食管癌术后吻合口瘘的临床分析
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摘要
目的：总结食管癌术后发生吻合口瘘的危险因素、原因及防治方法。
方法：自2005年8月至2009年8月我院共施行317例食管癌切除术,对这些病例进行回顾性分析：①选择11个可能对食管癌切除术疗效产生影响的非重复性特征性临床因素,包括性别、年龄、是否合并糖尿病、术前血清白蛋白水平、吻合方式、吻合部位、手术时间、术前是否有放疗史、颈部吻合途径、是否有呼吸系统疾病史及高血压史进行分组。将各病例的上述因子有关资料进行量化赋值,进行单因素分析发现吻合口瘘发生的危险因素；再采用逐步Logistic回归分析,找出对吻合口瘘有影响的主要危险因素。②分析吻合口瘘的临床表现,CT、胃镜、泛影葡胺造影结果。③对发生在不同时期、部位的吻合口瘘的治疗方法进行分析。
结果：术后发生吻合口瘘17例,发生率5.36%,死亡4例,病死率23.53%。经分析确定4个与吻合口瘘相关的因素：颈部吻合经胸骨后途径(OR=8.990)、术前血清白蛋白水平小于35g/L(OR=7.542)、术前有放疗史(OR=7.422)、有呼吸系统疾(OR=7.410)。依据发热、胸痛、咳嗽、切口红肿感染、服用美兰、泛影葡胺造影可确诊,少数较小瘘还需CT、胃镜明确诊断。17例病例中二次手术者9例,占发生吻合口瘘病例52.9%,对早期瘘、胸腔感染轻的较小瘘行单纯修补；对中后期胸腔感染较重的瘘行手术同期支架置入术,颈段食管造口胃、空肠造瘘术,开胸清除病灶、引流术。手术同期支架置入术4例,颈段食管造口胃、空肠造瘘3例,单纯修补1例,开胸清除病灶、引流1例,7例治愈／好转,2例死亡,二次手术病死率22.2%。保守治疗(包括单纯支架置入)7例,占发生吻合口瘘病例41.2%,6例单纯颈部瘘病例痊愈/好转,1例单纯支架置入病例死亡,保守治疗病死率14.3%。放弃治疗1例,死亡。
结论：(1)胸骨后径路发生吻合口瘘比例较食管床路径高。(2)术前放疗、低蛋白血症、呼吸系统病史是吻合口瘘发生的危险因素。(3)颈部瘘处理以保守治疗为主,预后好；胸内瘘处理以二次手术为主,似乎手术同期支架置入术预后更佳。
Objective The purpose of this study was to investigate the causes, risk factors, prevention and treatment of anastomotic fistula after esophagectomy for esophageal carcinoma.
Methods The clinical data of 317 patients underwent esophagectomy for esophageal carcinoma from August 2005 to August 2009 was analyzed retrospectively. 11 non-repetitive and characteristic clinical factors, including gender, age, history of diabetes, preoperative serum albuminous level, anastomotic mode, anastomotic site, operation time, preoperative history of radiotherapy, cervical anastomotic pathway, history of respiratory diseases and hypertension, were investigated. The risk factors potentially affecting the anastomotic fistula were analyzed by single factor analysis. Logistic regression analysis was used to study which variables were main risk factor of influencing the anastomotic fistula after esophagectomy. We evaluated the patients' clinical characteristics, preoperative CT, endoscopy, diatrizoate contrast findings.
Results 17 cases out of 317 patients underwent esophagectomy for esophageal carcinoma had anastomotic fistula (5.36%).1 case out of 17 patients with anastomotic fistula died, the mortality rate was 23.53%. The analysis disclosed the following 4 risk factors affecting the anastomotic fistula:cervical anastomosis through the substernal approach (OR=8.990), preoperative serum albuminous level less than 35g/L (OR=7.542), history of preoperative radiotherapy (OR=7.422), and respiratory illness (OR=7.410). Anastomotic fistula can be diagnosed via clinical symptoms, such as fever, chest pain, cough, wound swelling and infection, methylene blue or diatrizoate contrast. CT or endoscopy may be needed in a small fistula.9 (52.9%)cases out of 17 patients with anastomotic fistula accept secondary surgery. The neoplasty was applicable to the early small fistula with light chest infection, whereas the late fistula with heavy chest infection needed the neoplasty combined with stent placement(4 cases), cervical esophagostomy with gastrostomy or jejunostomy(3 cases), thoracotomy debridement or drainage(1 cases). Neoplasty combined with stent placement in 4 cases, cervical esophagostomy with gastrostomy or jejunostomy in 3 cases, thoracotomy debridement or drainage in 1 cases, neoplasty only in 1 cases.7 cases were cured,2 cases were dead, the mortality rate of secondary surgery rate of 22.2%.7(41.2%)cases out of 17 patients with anastomotic fistula underwent conservative treatment (include stent placement only),6 cases of cervical anastomotic fistula only were cured and 1 case of stent placement was dead. The mortality rate of conservative treatment was 14.3%.1 case gave up treatment and died.
Conclusion Reconstruction of Esophagus through esophageal bed after esophagectomy for esophageal carcinoma was apt to occur anastomotic fistula more often than that through substernal pathway. Compared with stapling anastomosis, manual anastomosis was prone to anastomotic fistula. The risk factors for anastomotic fistula are preoperative radiotherapy, hypoproteinemia and history of respiratory disease. Cervical anastomotic fistula can be cured via conservative treatment, although thoracic anastomotic fistula was treated maily with the second surgery. Neoplasty combined with simultaneously stent placement seems to achieve better prognosis.
方法：自2005年8月至2009年8月我院共施行317例食管癌切除术,对这些病例进行回顾性分析：①选择11个可能对食管癌切除术疗效产生影响的非重复性特征性临床因素,包括性别、年龄、是否合并糖尿病、术前血清白蛋白水平、吻合方式、吻合部位、手术时间、术前是否有放疗史、颈部吻合途径、是否有呼吸系统疾病史及高血压史进行分组。将各病例的上述因子有关资料进行量化赋值,进行单因素分析发现吻合口瘘发生的危险因素；再采用逐步Logistic回归分析,找出对吻合口瘘有影响的主要危险因素。②分析吻合口瘘的临床表现,CT、胃镜、泛影葡胺造影结果。③对发生在不同时期、部位的吻合口瘘的治疗方法进行分析。
结果：术后发生吻合口瘘17例,发生率5.36%,死亡4例,病死率23.53%。经分析确定4个与吻合口瘘相关的因素：颈部吻合经胸骨后途径(OR=8.990)、术前血清白蛋白水平小于35g/L(OR=7.542)、术前有放疗史(OR=7.422)、有呼吸系统疾(OR=7.410)。依据发热、胸痛、咳嗽、切口红肿感染、服用美兰、泛影葡胺造影可确诊,少数较小瘘还需CT、胃镜明确诊断。17例病例中二次手术者9例,占发生吻合口瘘病例52.9%,对早期瘘、胸腔感染轻的较小瘘行单纯修补；对中后期胸腔感染较重的瘘行手术同期支架置入术,颈段食管造口胃、空肠造瘘术,开胸清除病灶、引流术。手术同期支架置入术4例,颈段食管造口胃、空肠造瘘3例,单纯修补1例,开胸清除病灶、引流1例,7例治愈／好转,2例死亡,二次手术病死率22.2%。保守治疗(包括单纯支架置入)7例,占发生吻合口瘘病例41.2%,6例单纯颈部瘘病例痊愈/好转,1例单纯支架置入病例死亡,保守治疗病死率14.3%。放弃治疗1例,死亡。
结论：(1)胸骨后径路发生吻合口瘘比例较食管床路径高。(2)术前放疗、低蛋白血症、呼吸系统病史是吻合口瘘发生的危险因素。(3)颈部瘘处理以保守治疗为主,预后好；胸内瘘处理以二次手术为主,似乎手术同期支架置入术预后更佳。
Objective The purpose of this study was to investigate the causes, risk factors, prevention and treatment of anastomotic fistula after esophagectomy for esophageal carcinoma.
Methods The clinical data of 317 patients underwent esophagectomy for esophageal carcinoma from August 2005 to August 2009 was analyzed retrospectively. 11 non-repetitive and characteristic clinical factors, including gender, age, history of diabetes, preoperative serum albuminous level, anastomotic mode, anastomotic site, operation time, preoperative history of radiotherapy, cervical anastomotic pathway, history of respiratory diseases and hypertension, were investigated. The risk factors potentially affecting the anastomotic fistula were analyzed by single factor analysis. Logistic regression analysis was used to study which variables were main risk factor of influencing the anastomotic fistula after esophagectomy. We evaluated the patients' clinical characteristics, preoperative CT, endoscopy, diatrizoate contrast findings.
Results 17 cases out of 317 patients underwent esophagectomy for esophageal carcinoma had anastomotic fistula (5.36%).1 case out of 17 patients with anastomotic fistula died, the mortality rate was 23.53%. The analysis disclosed the following 4 risk factors affecting the anastomotic fistula:cervical anastomosis through the substernal approach (OR=8.990), preoperative serum albuminous level less than 35g/L (OR=7.542), history of preoperative radiotherapy (OR=7.422), and respiratory illness (OR=7.410). Anastomotic fistula can be diagnosed via clinical symptoms, such as fever, chest pain, cough, wound swelling and infection, methylene blue or diatrizoate contrast. CT or endoscopy may be needed in a small fistula.9 (52.9%)cases out of 17 patients with anastomotic fistula accept secondary surgery. The neoplasty was applicable to the early small fistula with light chest infection, whereas the late fistula with heavy chest infection needed the neoplasty combined with stent placement(4 cases), cervical esophagostomy with gastrostomy or jejunostomy(3 cases), thoracotomy debridement or drainage(1 cases). Neoplasty combined with stent placement in 4 cases, cervical esophagostomy with gastrostomy or jejunostomy in 3 cases, thoracotomy debridement or drainage in 1 cases, neoplasty only in 1 cases.7 cases were cured,2 cases were dead, the mortality rate of secondary surgery rate of 22.2%.7(41.2%)cases out of 17 patients with anastomotic fistula underwent conservative treatment (include stent placement only),6 cases of cervical anastomotic fistula only were cured and 1 case of stent placement was dead. The mortality rate of conservative treatment was 14.3%.1 case gave up treatment and died.
Conclusion Reconstruction of Esophagus through esophageal bed after esophagectomy for esophageal carcinoma was apt to occur anastomotic fistula more often than that through substernal pathway. Compared with stapling anastomosis, manual anastomosis was prone to anastomotic fistula. The risk factors for anastomotic fistula are preoperative radiotherapy, hypoproteinemia and history of respiratory disease. Cervical anastomotic fistula can be cured via conservative treatment, although thoracic anastomotic fistula was treated maily with the second surgery. Neoplasty combined with simultaneously stent placement seems to achieve better prognosis.
引文
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