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食管癌是世界上最常见的恶性肿瘤之一,中国食管癌每年新增病例超过29万例,占全球食管癌新增病例的53%,男性病人的数量大约是女性病人的2倍[1-3]。目前,手术是治疗食管癌早中期的首选,但食管癌手术时间长、创伤大,手术复杂,即使手术方式和技术不断改进,术后并发症仍无法完全避免。术后吻合口瘘是食管癌常见的并发症,发病率高[4-5]。全腔镜微创McKeown食管癌根治术具有创伤小、术后恢复快、适应范围广等优势,逐渐成为食管癌的主要手术方式,但术后发生吻合口瘘的概率较传统手术无明显改善,并且目前对术后发生吻合口瘘的危险因素尚无共识[6-9]。因此,本研究回顾性分析行全腔镜McKeown手术治疗的食管癌病人的临床资料,探讨手术后吻合口瘘的相关危险因素,以期为以后的临床工作提供指导。
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160例中,31例发生吻合口瘘,未发现残胃瘘及其他位置的瘘口,26例在术后5~10 d内发生,经治疗后瘘口均愈合,愈合时间5~29 d;其中14例出现吻合口狭窄症状,经球囊扩张治疗后好转;无支架植入或死亡病例。单因素分析显示,肿瘤位置(上段)、术前未放化疗、肺部感染及术后第3天血清Alb < 30 g/L的病人在食管癌术后吻合口瘘的发生率较高(P < 0.05~P < 0.01)(见表 1)。多因素logistic回归分析显示,术后第3天血清Alb < 30 g/L和术后肺部感染是食管癌术后发生吻合口瘘的独立危险因素(P < 0.05)(见表 2)。
因素 无瘘
(n=129)有瘘
(n=31)χ2 P 性别 男
女86
4321
100.01 >0.05 年龄/岁 ≤65
>6557
7216
150.56 >0.05 饮酒史 有
无44
8514
171.32 >0.05 吸烟史 有
无57
7211
200.78 >0.05 糖尿病 有
无11
1185
260.87△ >0.05 高血压 有
无19
1106
250.41 >0.05 BMI/(kg/m2) ≤24
>2423
10610
213.18 >0.05 肿瘤直径/cm ≤3.5
>3.562
6714
170.08 >0.05 肿瘤位置 上段
中下段17
1129
224.62 < 0.05 术前放化疗 有
无20
10911
206.39 < 0.05 手术时间/min ≤300
>30077
5223
82.24 >0.05 吻合方式 机械吻合 42 13 手工吻合 9 4 — >0.05▲ 机械+手工吻合 78 14 做管状胃 有
无96
3326
51.23 >0.05 吻合口包埋 有
无125
428
31.25△ >0.05 吻合口悬吊 有
无23
1068
231.02 >0.05 术后第3天血清Alb/(g/L) ≥30
< 3074
556
2514.44 < 0.01 术后肺部感染 有
无21
10815
1614.78 < 0.01 病理学类型 鳞癌 104 27 腺癌 4 1 — >0.05▲ 其他 21 3 △示校正χ2值;▲示Fisher′s确切概率法 表 1 食管癌病人术后吻合口瘘的单因素分析(n)
因素 B SE Waldχ2 OR 95%CI P 肿瘤位置(上段) 0.231 1.002 0.053 1.259 0.177~8.968 >0.05 术前未放化疗 -1.792 1.443 1.541 0.167 0.010~2.821 >0.05 肺部感染 2.610 1.174 4.939 13.600 1.361~135.913 < 0.05 术后第3天Alb < 30 g/L 1.289 0.556 5.363 0.276 0.093~0.820 < 0.05 表 2 食管癌病人术后吻合口瘘的多因素分析
全腔镜食管癌根治McKeown术式发生吻合口瘘的危险因素分析
Analysis of the risk factors of anastomotic fistula after total endoscopic McKeown radical resection for esophageal cancer
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摘要:
目的探讨全腔镜McKeown术式治疗食管癌术后发生吻合口瘘的危险因素。 方法选取160例采用全腔镜McKeown术式治疗食管癌病人的临床资料,单因素分析病人性别、年龄、饮酒史、吸烟史、糖尿病病史、高血压病史、体质量指数、肿瘤直径、肿瘤位置、术前放化疗、手术时间、吻合方式、是否做管状胃、吻合口是否包埋、吻合口是否悬吊、术后第3天血清白蛋白含量、术后肺部感染及病理学类型与术后吻合口瘘的相关性,多因素logistics回归分析食管癌术后发生吻合口瘘的独立危险因素。 结果160例中,31例发生吻合口瘘,保守治疗后瘘口消失;14例出现吻合口狭窄,经球囊扩张治疗后均好转;无支架植入及死亡病例。单因素分析显示,肿瘤位置(上段)、术前未放化疗、肺部感染及术后第3天血清白蛋白 < 30 g/L的病人在食管癌术后吻合口瘘的发生率较高(P < 0.05~P < 0.01)。多因素logistic回归分析显示,术后第3天血清白蛋白 < 30 g/L和术后肺部感染是食管癌术后发生吻合口瘘的独立危险因素(P < 0.05)。 结论术后血清白蛋白 < 30 g/L和肺部感染是全腔镜食管癌根治McKeown术式后发生吻合口瘘的独立危险因素,通过改善营养状态及控制肺部感染能有效减少吻合口瘘的发生。 Abstract:ObjectiveTo explore the risk factors of anastomotic fistula after total endoscopic McKeown technique for esophageal cancer. MethodsThe clinical data of 160 patients with esophageal cancer treated with total endoscopic McKeown technique were selected.The correlation between postoperative anastomotic fistula and gender, age, drinking history, smoking history, diabetes mellitus history, hypertension history, body mass index, tumor diameter, tumor location, preoperative radiotherapy and chemotherapy, operation time, anastomotic mode, making tubular stomach or not, embedding anastomotic site or not, suspending anastomotic site or not, serum albumin content on the third day after, postoperative pulmonary infection, pathological types was analyzed by univariate analysis.The independent risk factors of anastomotic fistula after operation for esophageal cancer were analyzed by multivariate logistic regression analysis. ResultsAmong the 160 esophageal cancer cases, 31 cases had anastomotic fistula, which disappeared after conservative treatment; anastomotic stenosis occurred in 14 cases, and all improved after balloon dilatation; no stent implantation and death cases were found.Univariate analysis showed that the incidence of anastomotic fistula was higher in patients with tumor location of upper segment, no preoperative radiotherapy and chemotherapy, pulmonary infection and serum albumin < 30 g/L on the third day after operation (P < 0.05 to P < 0.01).Multivariate logistic regression analysis showed that serum albumin < 30 g/L on the third day after operation and postoperative pulmonary infection were the independent risk factors for anastomotic fistula after esophageal cancer operation (P < 0.05). ConclusionsPostoperative serum content of albumin content < 30 g/L and postoperative pulmonary infection are the independent risk factors for anastomotic fistula after total endoscopic McKeown radical resection for esophageal cancer.The occurrence of anastomotic fistula can be effectively reduced by improving nutritional status and controlling pulmonary infection. -
Key words:
- esophageal neoplasms /
- McKeown technique /
- anastomotic fistula /
- risk factors
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表 1 食管癌病人术后吻合口瘘的单因素分析(n)
因素 无瘘
(n=129)有瘘
(n=31)χ2 P 性别 男
女86
4321
100.01 >0.05 年龄/岁 ≤65
>6557
7216
150.56 >0.05 饮酒史 有
无44
8514
171.32 >0.05 吸烟史 有
无57
7211
200.78 >0.05 糖尿病 有
无11
1185
260.87△ >0.05 高血压 有
无19
1106
250.41 >0.05 BMI/(kg/m2) ≤24
>2423
10610
213.18 >0.05 肿瘤直径/cm ≤3.5
>3.562
6714
170.08 >0.05 肿瘤位置 上段
中下段17
1129
224.62 < 0.05 术前放化疗 有
无20
10911
206.39 < 0.05 手术时间/min ≤300
>30077
5223
82.24 >0.05 吻合方式 机械吻合 42 13 手工吻合 9 4 — >0.05▲ 机械+手工吻合 78 14 做管状胃 有
无96
3326
51.23 >0.05 吻合口包埋 有
无125
428
31.25△ >0.05 吻合口悬吊 有
无23
1068
231.02 >0.05 术后第3天血清Alb/(g/L) ≥30
< 3074
556
2514.44 < 0.01 术后肺部感染 有
无21
10815
1614.78 < 0.01 病理学类型 鳞癌 104 27 腺癌 4 1 — >0.05▲ 其他 21 3 △示校正χ2值;▲示Fisher′s确切概率法 表 2 食管癌病人术后吻合口瘘的多因素分析
因素 B SE Waldχ2 OR 95%CI P 肿瘤位置(上段) 0.231 1.002 0.053 1.259 0.177~8.968 >0.05 术前未放化疗 -1.792 1.443 1.541 0.167 0.010~2.821 >0.05 肺部感染 2.610 1.174 4.939 13.600 1.361~135.913 < 0.05 术后第3天Alb < 30 g/L 1.289 0.556 5.363 0.276 0.093~0.820 < 0.05 -
[1] SIEGEL RL, MILLER KD, JENAL A. Cancer statistics, 2020[J]. CA Cancer J Clin, 2020, 70(1): 7. doi: 10.3322/caac.21590 [2] BRAY F, FERLAY J, SOERJOMATARAM I, et al. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries[J]. CA Cancer J Clin, 2018, 68(6): 394. doi: 10.3322/caac.21492 [3] 郑荣寿, 孙可欣, 张思维, 等. 2015年中国恶性肿瘤流行情况分析[J]. 中华肿瘤杂志, 2019, 41(1): 19. doi: 10.3760/cma.j.issn.0253-3766.2019.01.005 [4] DENT B, GRIFFIN SM, JONES R, et al. Management and outcomes of anastomotic leaks after oesophagectomy[J]. Brit J Surg, 2016, 103(8): 1033. doi: 10.1002/bjs.10175 [5] MESSAGER M, WARLAUMONT M, RENAUD F, et al. Recent improvements in the management of esophageal anastomotic leak after surgery for cancer[J]. Eur J Surg Onc, 2017, 43(2): 258. doi: 10.1016/j.ejso.2016.06.394 [6] SUN HB, LI Y, LIU XB, et al. Early oral feeding following McKeown minimally invasive esophagectomy[J]. Ann Surg, 2018, 267(3): 435. doi: 10.1097/SLA.0000000000002304 [7] 邱龙, 李向楠, 赵松, 等. 食管癌术后颈部食管胃吻合口瘘的危险因素分析[J]. 中华消化外科杂志, 2017, 5(16): 483. [8] ZHU XD, WU HR, LIU CQ, et al. Covering the gastric tube with the mediastinal pleura during minimally invasive McKeown esophagectomy can reduce the incidence of anastomotic fistulae[J]. Wideochir Inne Tech Maloinwazyjne, 2021, 16(3): 612. [9] CHENG L, FU SQ, LIU JH, et al. Modified layered hand-sewn cervical end-to-side anastomosis for minimally invasive McKeown esophagectomy[J]. J Surg Oncol, 2021, 124(7): 1031. doi: 10.1002/jso.26622 [10] MOON DH, LEE JM, JEON JH, et al. Clinical outcomes of video-assisted thoracoscopic surgery esophagectomy for esophageal cancer: a propensity score-matched analysis[J]. J Thorac Dis, 2017, 9(9): 3005. doi: 10.21037/jtd.2017.08.71 [11] 代磊, 任自学, 张安庆, 等. McKeown食管癌术后吻合口瘘的危险因素分析及预测模型建立[J]. 中国胸心血管外科临床杂志, 2020, 27(12): 1436. [12] ZHANG J, WANG R, LIU S, et al. Refinement of minimally invasive esophagectomy techniques after 15 years of experience[J]. J Gastrointest Surg, 2012, 16(9): 1768. doi: 10.1007/s11605-012-1950-2 [13] DEPYPERE L, COOSEMANS W, NAFTEUX P, et al. Video-assisted thoracoscopic surgery and open chest surgery in esophageal cancer treatment: present and future[J]. J Vis Surg, 2017, 3: 30. doi: 10.21037/jovs.2017.01.02 [14] VAN DAELE E, VAN DE PUTTE D, CEELEN W, et al. Risk factors and consequences of anastomotic leakage after Ivor Lewis oesophagectomy[J]. Interact Cardiov Thoracic, 2015, 22(1): 32. [15] 徐俊, 胡坚. 老年食管癌患者术后吻合口瘘危险因素临床分析[J]. 中华老年医学杂志, 2016, 35(8): 876. doi: 10.3760/cma.j.issn.0254-9026.2016.08.019 [16] 周晓, 吴君旭, 曹炜, 等. 胸腹腔镜联合食管癌切除并左侧颈部吻合术的效果及对病人营养水平的影响[J]. 蚌埠医学院学报, 2018, 43(4): 494. [17] GAO C, XU G, WANG C, et al. Evaluation of preoperative risk factors and postoperative indicators for anastomotic leak of minimally invasive McKeown esophagectomy: a single-center retrospective analysis[J]. J Cardiothorac Surg, 2019, 14(1): 1. doi: 10.1186/s13019-018-0811-9 [18] GOENSE L, VAN ROSSUM P SN, TROMP M, et al. Intraoperative and postoperative risk factors for anastomotic leakage and pneumonia after esophagectomy for cancer[J]. Dis Esophagus, 2016, 30(1): 10. [19] DENT B, GRIFFIN SM, JONES R, et al. Management and outcomes of anastomotic leaks after oesophagectomy[J]. Brit J Surgery, 2016, 103(8): 1033. doi: 10.1002/bjs.10175 [20] SUN HB, LI Y, LIU XB, et al. Early oral feeding following McKeown minimally invasive esophagectomy: an open-label, randomized, controlled, noninferiority trial[J]. Ann Surg, 2017, 267(3): 435. [21] YU HM, TANG CW, FENG WM, et al. Early enteral nutrition versus parenteral nutrition after resection of esophageal cancer: a retrospective analysis[J]. Indian J Surg, 2017, 79(1): 13. doi: 10.1007/s12262-015-1420-7 [22] WANG G, CHEN H, LIU J, et al. A comparison of postoperative early enteral nutrition with delayed enteral nutrition in patients with esophageal cancer[J]. Nutrients, 2015, 7(6): 4308. doi: 10.3390/nu7064308 [23] HAN H, PAN M, TAO Y, et al. Early enteral nutrition is associated with faster post-esophagectomy recovery in Chinese esophageal cancer patients: a retrospective cohort study[J]. Nutr Cancer, 2018, 70(2): 221.