食管癌切除胃代食管术后胃肠功能相关症状调查
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摘要
第一部分
目的：了解食管癌切除胃代食管术后胃肠症状发生情况，为进一步改善患者术后生活质量服务。
方法：门诊随访2011年9月-2012年3月期间已行食管癌切除胃代食管术的1019例患者，采用自制的食管癌术后胃肠功能调查表调查患者最近一周的胃肠症状。
结果：1.食管癌切除胃代食管癌术后胃肠症状总的发生率为83.51%，症状包括食欲降低（58.58%）、食量减少（78.21%）、体重降低（76.84%）、吞咽困难（6.10%）、吻合口狭窄（3.05%）、胃食管反流（59.08%）、胃排空相关不适（30.23%）、进食相关不适（32.78%）、腹泻（20.71%）、便秘（1.08%）。2.症状缓解方式。吻合口狭窄：内镜下食管扩张（70.97%），食管支架置入（29.03%）；胃食管反流、胃排空相关不适症状、进食相关不适症状需要药物控制比例分别为82.72%、19.48%、8.38%。3.术后3月内、术后3-6月、术后6-9月、术后9-12月、术后1-2年、术后2年及以上胃肠症状发生情况。胃肠症状发生率分别为88.54%、85.83%、81.50%、85.98%、80.22%、77.55%；吞咽困难发生率分别为4.45%、4.33%、4.32%、4.67%、9.35%、10.20%；吻合口狭窄发生率分别为3.82%、2.76%、2.31%、2.94%、3.24%、4.08%；胃食管反流症状发生率分别为66.24%、59.84%、60.69%、55.14%、56.47%、51.02%；胃排空相关不适症状发生率分别为43.31%、37.80%、17.34%、29.11%、25.18%、26.53%；进食相关不适症状发生率分别为33.76%、31.10%、29.48%、36.45%、35.97%、22.45%；腹泻的发生率分别为18.47%、18.11%、20.81%、28.97%、21.58%、18.37%。
结论：1.食管癌切除胃代食管术后胃肠症状发生率83.51%，总体趋势随着时间的进展逐渐降低；2.吞咽困难症状发生率随时间有增加趋势，50%吞咽困难是吻合口狭窄所致；内镜下食管扩张对于70.97%吻合口狭窄是有效的；3.食管癌切除胃代食管术后胃食管反流症状发生率高，症状重，绝大部分需要药物治疗；4.胃排空相关不适、进食相关不适症状发生率较低，症状较轻，很少需要药物治疗；5.腹泻症状发生率波动在20.71%。
第二部分
目的：了解食管癌切除胃代食管术后吞咽困难影响因素。
方法：选择调查中出现吞咽困难症状的病例，确定性别、年龄、术前合并症等12个因素作为吞咽困难可能影响因素。单因素chi-square检验筛选出对吞咽困难有意义的影响因素，以a=0.05为统计学显著性差异的检验水准。多因素Logistic回归分析这些影响因素对吞咽困难的影响作用。
结果：1.吞咽困难单因素分析结果：术后吻合口瘘吞咽困难发生率远大于无吻合口瘘（P<0.001）；男性食管癌术后吞咽困难发生率高于女性（P=0.049）；吞咽困难发生率在术后2年及以上高于其他时段（Linear-by-Linear Association Test P=0.007）。年龄、术前合并症、手术入路、肿瘤部位、替代器官、吻合部位、吻合方法、吻合路径、TNM分期与食管癌术后吞咽困难发生率无关（P>0.05）。2.多因素Logistc回归分析结果：吞咽困难症状发生率与性别、术后时间（≥24月）有关。男性吞咽困难发生率高于女性；术后≥24月吞咽困难发生率高于其他时间段。
结论：1.食管癌术后吞咽困难发生率6.10%，食管扩张率3.05%。吻合口瘘、性别和术后时间是其影响因素；2.吻合口瘘患者术后吞咽困难发生率远大于无吻合口瘘患者；3.男性吞咽困难发生率高于女性，但食管扩张率与性别无关；4.术后2年及以上，吞咽困难发生率明显增加。
第三部分
目的：了解食管癌切除胃代食管术后胃食管反流影响因素。
方法：选择调查中出现胃食管反流症状的病例，确定性别、年龄、术前合并症等12个因素作为胃食管反流可能影响因素。单因素chi-square检验筛选出对胃食管反流有意义的影响因素，以a=0.05为统计学显著性差异的检验水准。多因素Logistic回归分析这些影响因素对胃食管反流的影响作用。
结果：1.胃食管反流单因素分析结果：肿瘤部位、替代器官（吻合方法）、吻合部位、术后时间（Linear-by-LinearAssociation Test）与食管癌术后胃食管反流发生率相关（P<0.05）；性别、年龄、术前合并症、手术入路、吻合路径、TNM分期、吻合口瘘与胃食管反流症状发生率无关（P>0.05）。2.多因素logistic回归分析结果：食管癌切除食管胃吻合术后胃食管反流症状发生率：食管上段癌>食管中段癌>食管下段癌；颈部吻合>弓下吻合>弓上吻合；全胃代食管（机械吻合）>窄胃代食管（手工吻合）。
结论：1.食管癌切除胃代食管术后胃食管反流症状发生率为54.56%，并随着术后时间进展逐渐降低，但是程度较重，大部分需要药物治疗；2.经食管床、窄胃代食管（手工吻合）主动脉弓上吻合可以有效降低胃食管反流症状发生率。
Objective:
1 To learn the incidence of symptoms with gastrointestinal functionfollowing esophagogastrostomy for patients with esophageal cancer.
2 To determine the affecting factors of dysphagia followingesophagectomy.
3 To understand the influencing factors of symptoms withgastroesophageal reflux following esophagectomy.
Methods:
1 A total of 1019 patients with esophageal cancer receivedesophagogastrostomy were investigated from September 2011 to March2012 in the Affiliated Hospital of North Sichuan Medical College withself-made Gastrointestinal Function Questionnaire.
2 Uuivariate analyses and multivariate analysis were performed todetermine the affecting factors for dysphagia and symptoms forgastroesophageal reflux.
Results:
1 The total incidence of gastrointestinal symptoms following esophagectomy is 83.51%, which include decreased appetite(58.58%)、dietcut down(78.21%)、abspecken(76.84%)、dysphagia(6.10%)、anastomoticstricture(3.05%)、gastroesophageal reflux(59.08%)、chest stomachsyndrome(30.23%)、dumping syndrome(32.78%)、diarrhea(20.71%)、constipation (1.08%).
2 The anesis way of anastomotic stricture: esophageal dilatation(70.97%)、esophageal stent (29.03%); the incidence of gastroesophagealreflux、chest stomach syndrome and dumping syndrome need drug treatmentare 82.72%、19.48%、8.38% respectively.
3 The incidence of symptoms with gastrointestinal function in 3months、3-6months、6-9months、9-12months、12-24months、≥24monthsafter operation are 88.54%、85.83%、81.50%、85.98%、80.22%、77.55%respectively; dysphagia are 4.45%、4.33%、4.32%、4.67%、9.35%、10.20%respectively; anastomotic stricture are 3.82%、2.76%、2.31%、2.94%、3.24%、4.08% respectively; gastroesophageal reflux are 66.24%、59.84%、60.69%、55.14%、56.47%、51.02% respectively; chest stomach syndrome are 43.31%、37.80%、17.34%、29.11%、25.18%、26.53% respectively; dumping syndromeare 33.76%、31.10%、29.48%、36.45%、35.97%、22.45% respectively;diarrhea are 18.47%、18.11%、20.81%、28.97%、21.58%、18.37%respectively.
3 The results of oneway analysis of variance
3.1 Dysphagia
These patients who had anastomotic leak are much higher than thesewho did not have anastomotic leak at the incidence of dysphagia (P<0.001);males and patients whose postoperative time are above at 24 months havehigher incidence of dysphagia than females and the others time slot(P<0.005). The rest of the possible affect factors have nothing to do withdysphagia (P>0.005).
3.2 Gastroesophageal Reflux
Tumor location、replacement organs(anastomosis methods)、anastomosis place、postoperative time(linear-by-linear association test) areassociation with gastroesophageal reflux (P<0.005). The rest of the possiblefactors have nothing to do with gastroesophageal reflux (P>0.005).
4 The results of multiple logistic regressions
4.1 Dysphagia
The incidences of dysphagia are association with gender andpostoperative time (≥24 months). Males and patients whose postoperativetimes are above at 24 months have much higher incidence of dysphagia thanfemales and the others time slot. 4.2 Gastroesophageal Reflux
The incidence of gastroesophageal reflux following esophagectomy:upper esophageal cancer>middle-third esophageal cancer>lower esophagealcancer; anastomosis in neck>anastomosis in subaortic arch>anastomosis insupra-aortic arch; use the whole stomach to instead esophagus (mechanicalanastomosis)>use a narrow stomach to replace esophagus (handseamanastomosis).
Conclusions:
1 The total incidence of gastrointestinal symptoms followingesophagectomy is 83.51%, and it will reduced gradually as times; theincidence of dysphagia will increased gradually. half of the dysphagias areanastomotic stricture, and 70.97% of these can be cured by esophagealdilatation; according to the gastrointestinal symptoms, the incidence is highand the symptom is critical, most of these patients need drug treatment; andcontrary to the chest stomach syndrome and dumping syndrome, theincidence is low and the symptoms are slight, little patients need drugtreatment; the incidence of diarrhea is 20.71%.
2 The incidence of dysphagia is 6.10%, half of dysphagia (3.05%) needesophageal dilatation. anastomotic leak、gender and postoperative time (≥24months) are the affect factors of dysphagia. These patients who hadanastomotic leak had much more chance to get dysphagia than these who did not have anastomotic leak; males have higher incidence of dysphagia thanfemales, but both the males and the females are the same incidence inesophageal dilatation; the patients whose postoperative time are above at 24months have a higher incidence of dysphagia than the others time slot, thatmay be association with the tumor recurrence.
3 The incidence of gastroesophageal reflux following esophagectomy is54.56%, and which reduced gradually as times, but the symptom is alwayscritical, most of these patients need drug treatment; use a narrow stomach toinstead esophagus(handmade anastomosis)、go through esophageal bed andanastomosis in supra-aortic arch can effectively reduce the incidence ofgastroesophageal reflux symptoms.
目的：了解食管癌切除胃代食管术后胃肠症状发生情况，为进一步改善患者术后生活质量服务。
方法：门诊随访2011年9月-2012年3月期间已行食管癌切除胃代食管术的1019例患者，采用自制的食管癌术后胃肠功能调查表调查患者最近一周的胃肠症状。
结果：1.食管癌切除胃代食管癌术后胃肠症状总的发生率为83.51%，症状包括食欲降低（58.58%）、食量减少（78.21%）、体重降低（76.84%）、吞咽困难（6.10%）、吻合口狭窄（3.05%）、胃食管反流（59.08%）、胃排空相关不适（30.23%）、进食相关不适（32.78%）、腹泻（20.71%）、便秘（1.08%）。2.症状缓解方式。吻合口狭窄：内镜下食管扩张（70.97%），食管支架置入（29.03%）；胃食管反流、胃排空相关不适症状、进食相关不适症状需要药物控制比例分别为82.72%、19.48%、8.38%。3.术后3月内、术后3-6月、术后6-9月、术后9-12月、术后1-2年、术后2年及以上胃肠症状发生情况。胃肠症状发生率分别为88.54%、85.83%、81.50%、85.98%、80.22%、77.55%；吞咽困难发生率分别为4.45%、4.33%、4.32%、4.67%、9.35%、10.20%；吻合口狭窄发生率分别为3.82%、2.76%、2.31%、2.94%、3.24%、4.08%；胃食管反流症状发生率分别为66.24%、59.84%、60.69%、55.14%、56.47%、51.02%；胃排空相关不适症状发生率分别为43.31%、37.80%、17.34%、29.11%、25.18%、26.53%；进食相关不适症状发生率分别为33.76%、31.10%、29.48%、36.45%、35.97%、22.45%；腹泻的发生率分别为18.47%、18.11%、20.81%、28.97%、21.58%、18.37%。
结论：1.食管癌切除胃代食管术后胃肠症状发生率83.51%，总体趋势随着时间的进展逐渐降低；2.吞咽困难症状发生率随时间有增加趋势，50%吞咽困难是吻合口狭窄所致；内镜下食管扩张对于70.97%吻合口狭窄是有效的；3.食管癌切除胃代食管术后胃食管反流症状发生率高，症状重，绝大部分需要药物治疗；4.胃排空相关不适、进食相关不适症状发生率较低，症状较轻，很少需要药物治疗；5.腹泻症状发生率波动在20.71%。
第二部分
目的：了解食管癌切除胃代食管术后吞咽困难影响因素。
方法：选择调查中出现吞咽困难症状的病例，确定性别、年龄、术前合并症等12个因素作为吞咽困难可能影响因素。单因素chi-square检验筛选出对吞咽困难有意义的影响因素，以a=0.05为统计学显著性差异的检验水准。多因素Logistic回归分析这些影响因素对吞咽困难的影响作用。
结果：1.吞咽困难单因素分析结果：术后吻合口瘘吞咽困难发生率远大于无吻合口瘘（P<0.001）；男性食管癌术后吞咽困难发生率高于女性（P=0.049）；吞咽困难发生率在术后2年及以上高于其他时段（Linear-by-Linear Association Test P=0.007）。年龄、术前合并症、手术入路、肿瘤部位、替代器官、吻合部位、吻合方法、吻合路径、TNM分期与食管癌术后吞咽困难发生率无关（P>0.05）。2.多因素Logistc回归分析结果：吞咽困难症状发生率与性别、术后时间（≥24月）有关。男性吞咽困难发生率高于女性；术后≥24月吞咽困难发生率高于其他时间段。
结论：1.食管癌术后吞咽困难发生率6.10%，食管扩张率3.05%。吻合口瘘、性别和术后时间是其影响因素；2.吻合口瘘患者术后吞咽困难发生率远大于无吻合口瘘患者；3.男性吞咽困难发生率高于女性，但食管扩张率与性别无关；4.术后2年及以上，吞咽困难发生率明显增加。
第三部分
目的：了解食管癌切除胃代食管术后胃食管反流影响因素。
方法：选择调查中出现胃食管反流症状的病例，确定性别、年龄、术前合并症等12个因素作为胃食管反流可能影响因素。单因素chi-square检验筛选出对胃食管反流有意义的影响因素，以a=0.05为统计学显著性差异的检验水准。多因素Logistic回归分析这些影响因素对胃食管反流的影响作用。
结果：1.胃食管反流单因素分析结果：肿瘤部位、替代器官（吻合方法）、吻合部位、术后时间（Linear-by-LinearAssociation Test）与食管癌术后胃食管反流发生率相关（P<0.05）；性别、年龄、术前合并症、手术入路、吻合路径、TNM分期、吻合口瘘与胃食管反流症状发生率无关（P>0.05）。2.多因素logistic回归分析结果：食管癌切除食管胃吻合术后胃食管反流症状发生率：食管上段癌>食管中段癌>食管下段癌；颈部吻合>弓下吻合>弓上吻合；全胃代食管（机械吻合）>窄胃代食管（手工吻合）。
结论：1.食管癌切除胃代食管术后胃食管反流症状发生率为54.56%，并随着术后时间进展逐渐降低，但是程度较重，大部分需要药物治疗；2.经食管床、窄胃代食管（手工吻合）主动脉弓上吻合可以有效降低胃食管反流症状发生率。
Objective:
1 To learn the incidence of symptoms with gastrointestinal functionfollowing esophagogastrostomy for patients with esophageal cancer.
2 To determine the affecting factors of dysphagia followingesophagectomy.
3 To understand the influencing factors of symptoms withgastroesophageal reflux following esophagectomy.
Methods:
1 A total of 1019 patients with esophageal cancer receivedesophagogastrostomy were investigated from September 2011 to March2012 in the Affiliated Hospital of North Sichuan Medical College withself-made Gastrointestinal Function Questionnaire.
2 Uuivariate analyses and multivariate analysis were performed todetermine the affecting factors for dysphagia and symptoms forgastroesophageal reflux.
Results:
1 The total incidence of gastrointestinal symptoms following esophagectomy is 83.51%, which include decreased appetite(58.58%)、dietcut down(78.21%)、abspecken(76.84%)、dysphagia(6.10%)、anastomoticstricture(3.05%)、gastroesophageal reflux(59.08%)、chest stomachsyndrome(30.23%)、dumping syndrome(32.78%)、diarrhea(20.71%)、constipation (1.08%).
2 The anesis way of anastomotic stricture: esophageal dilatation(70.97%)、esophageal stent (29.03%); the incidence of gastroesophagealreflux、chest stomach syndrome and dumping syndrome need drug treatmentare 82.72%、19.48%、8.38% respectively.
3 The incidence of symptoms with gastrointestinal function in 3months、3-6months、6-9months、9-12months、12-24months、≥24monthsafter operation are 88.54%、85.83%、81.50%、85.98%、80.22%、77.55%respectively; dysphagia are 4.45%、4.33%、4.32%、4.67%、9.35%、10.20%respectively; anastomotic stricture are 3.82%、2.76%、2.31%、2.94%、3.24%、4.08% respectively; gastroesophageal reflux are 66.24%、59.84%、60.69%、55.14%、56.47%、51.02% respectively; chest stomach syndrome are 43.31%、37.80%、17.34%、29.11%、25.18%、26.53% respectively; dumping syndromeare 33.76%、31.10%、29.48%、36.45%、35.97%、22.45% respectively;diarrhea are 18.47%、18.11%、20.81%、28.97%、21.58%、18.37%respectively.
3 The results of oneway analysis of variance
3.1 Dysphagia
These patients who had anastomotic leak are much higher than thesewho did not have anastomotic leak at the incidence of dysphagia (P<0.001);males and patients whose postoperative time are above at 24 months havehigher incidence of dysphagia than females and the others time slot(P<0.005). The rest of the possible affect factors have nothing to do withdysphagia (P>0.005).
3.2 Gastroesophageal Reflux
Tumor location、replacement organs(anastomosis methods)、anastomosis place、postoperative time(linear-by-linear association test) areassociation with gastroesophageal reflux (P<0.005). The rest of the possiblefactors have nothing to do with gastroesophageal reflux (P>0.005).
4 The results of multiple logistic regressions
4.1 Dysphagia
The incidences of dysphagia are association with gender andpostoperative time (≥24 months). Males and patients whose postoperativetimes are above at 24 months have much higher incidence of dysphagia thanfemales and the others time slot. 4.2 Gastroesophageal Reflux
The incidence of gastroesophageal reflux following esophagectomy:upper esophageal cancer>middle-third esophageal cancer>lower esophagealcancer; anastomosis in neck>anastomosis in subaortic arch>anastomosis insupra-aortic arch; use the whole stomach to instead esophagus (mechanicalanastomosis)>use a narrow stomach to replace esophagus (handseamanastomosis).
Conclusions:
1 The total incidence of gastrointestinal symptoms followingesophagectomy is 83.51%, and it will reduced gradually as times; theincidence of dysphagia will increased gradually. half of the dysphagias areanastomotic stricture, and 70.97% of these can be cured by esophagealdilatation; according to the gastrointestinal symptoms, the incidence is highand the symptom is critical, most of these patients need drug treatment; andcontrary to the chest stomach syndrome and dumping syndrome, theincidence is low and the symptoms are slight, little patients need drugtreatment; the incidence of diarrhea is 20.71%.
2 The incidence of dysphagia is 6.10%, half of dysphagia (3.05%) needesophageal dilatation. anastomotic leak、gender and postoperative time (≥24months) are the affect factors of dysphagia. These patients who hadanastomotic leak had much more chance to get dysphagia than these who did not have anastomotic leak; males have higher incidence of dysphagia thanfemales, but both the males and the females are the same incidence inesophageal dilatation; the patients whose postoperative time are above at 24months have a higher incidence of dysphagia than the others time slot, thatmay be association with the tumor recurrence.
3 The incidence of gastroesophageal reflux following esophagectomy is54.56%, and which reduced gradually as times, but the symptom is alwayscritical, most of these patients need drug treatment; use a narrow stomach toinstead esophagus(handmade anastomosis)、go through esophageal bed andanastomosis in supra-aortic arch can effectively reduce the incidence ofgastroesophageal reflux symptoms.
引文
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[1] Pierie JP, Goedegebuure S, Schuerman FA, et al.Relation between functionaldysphagia and vocal cord palsy after transhiatal oesophagectomy.Eur J Surg, 2000,166:207-209.
[2] Berrisford RG,Page RD,Donnelly RJ.Stapler design and strictures at theesophagogastric anastomosis[J].Thorac Cardiovasc Surg,1996,111:142-146.
[3] Dan HL,Bai Y,Meng H,et al.A new three-layerfunnel-shaped esophagogastricanastomosis for surgical treatment of esophageal carcinoma. World J Gastroenterol,2003, 9:22-25.
[4] Devaney EJ, Lannettoni MD, Orringer MB, et al.Esophagectomy for achalasia:patient selection and clinical experience. Ann Thorac Surg, 2001, 72:854-858.
[5] Petrin G,Ruol A,Battaglia G,et al.Anastomotic stenoses occurring after circularstapling in esophageal cancer surgery.Surg Endosc,2000,14:670-674.
[6] Blackmon SH, Correa AM, Wynn B, et al.Propensity-matched analysis of threetechniques for intrathoracic esophagogastric anastomosis. Ann Thorac Surg, 2007,83:1805-1813.
[7] Van Heijl M, Gooszen JA, Fockens P, et al.Risk factors for development of benigncervical strictures after esophagectomy. Ann Surg, 2010, 251:1064-1069.
[8] D’Journo XB, Martin J, Rakovich G, et al.Mucosal damage in the esophagealremnant after esophagectomy and gastric transposition. Ann Surg, 2009,249:262-268.
[9] Sutcliffe RP,Forshaw MJ,Tandon R,et al.Anastomotic strictures and delayed gastricemptying after esophagectomy: incidence, risk factors and management. DisEsophagus, 2008, 21:712-717.
[10] Law S,Suen DT,Wong KH,et al.A single-layer,continuous, hand-sewn method foresophageal anastomosis:prospective evaluation in 218 patients.Arch Surg,2005,140:33-39.
[11] Briel JW,Tamhankar AP,Hagen JA,et al.Prevalence and risk factors for ischemia,leak,and stricture of esophageal anastomosis:gastric pull-up versus coloninterposition[J].Am Coll Surg,2004,198:536-541.
[12] De Giacomo T,Francioni F,Venuta F,et al.Complete mechanical cervical anastomosisusing a narrow gastric tube after esophagectomy for cancer.Eur J CardiothoracSurg,2004,26:881-884.
[13] Liu Wenlie, Han Xueli.Clinic Field of Saccule Cluctus Dilatation TreatmentAnastomotic Constrictive o f the Old Esophag us Car cinoma Posto perative [J].Chinese Journal of Geriatrics, 1999, 7(9):210-211.
[14] Thomas W.Rice, MD.Anastomotic Stricture Complicating Esophagectomy. ThoracSurg Clin, 2006, (16):63-73.
[15] Schuchert MJ, Luketich JD, Fernando HC.Complications of minimally invasiveesophagectomy.Semin Thorac Cardiovasc Surg, 2004, 16:133-141.
[16] Orringer MB,Marshall B,Iannettoni MD.Eliminating the cervical esophagogastricanastomotic leak with a side-to-side stapled anastomosis[J].Thorac CardiovascSurg,2000,119:277-288.
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