本文選題：食管癌　切入點：吻合口瘺　出處：《吉林大學》2017年碩士論文

【摘要】：研究目的:結(jié)合文獻,綜合分析食管癌根治術后影響胸內(nèi)吻合口瘺發(fā)生的主要相關因素。探究“改良式食管-管狀胃吻合”與“環(huán)式套入包埋”聯(lián)合應用的手術技巧對于預防胸內(nèi)吻合口瘺發(fā)生是否有積極的作用。研究方法:采用具有前瞻性的隨機對照試驗方式,納入我院胸外科自2014年11月至2016年11月行Sweet術式的胸中下段食管癌鱗癌患者共200例。將所有入選患者隨機分為對照組和試驗組兩個組別:對照組于管狀胃切割閉合線近側(cè)端下方平行于長軸切開管狀胃,置入吻合器行食管-管狀胃端側(cè)吻合,對吻合環(huán)行漿肌層多點式加強縫合,常規(guī)閉合胃壁造口,對造口全層包埋縫合,100例,男92例,女8例;試驗組于管狀胃頂端垂直于管胃長軸另造口,置入吻合器,反折管狀胃胃底與食管殘端行端側(cè)吻合,切割閉合器閉合并切除管狀胃頂端造口及周圍胃壁,全層包埋縫合后,將管狀胃輕輕上提套住吻合口,使胃壁折疊約2-3cm,在胃壁折疊的最高點與食管下段行環(huán)式漿肌層包埋縫合加固,100例,男94例,女6例。兩組患者術中均預置食管床引流管;術后均給予早期腸內(nèi)營養(yǎng)。兩組患者自術后第4天至第7天每日均給予口服亞甲藍檢測,凡有一次出現(xiàn)胸引管或縱隔引流管藍染的,判定為發(fā)生吻合口瘺;對于兩組中行4次亞甲藍試驗均陰性的患者,于拔除引流管前再行亞甲藍試驗一次,5次亞甲藍試驗均為陰性者,判定未發(fā)生吻合口瘺。主要對發(fā)生術后胸內(nèi)吻合口瘺的患者的組別、人數(shù)、性別、病理分期進行記錄和對比分析。病理分期參照食管癌TNM國際分期第7版。采用SPSS 21.0統(tǒng)計軟件對各項數(shù)據(jù)進行分析,以α=0.05為檢驗標準,P0.05表示差異有統(tǒng)計學意義。結(jié)果:兩組患者一般狀況相當(P0.05),無統(tǒng)計學差異,有可比性。同等條件下性別不同對術后胸內(nèi)吻合口瘺的發(fā)生沒有統(tǒng)計學差異(P0.05)。試驗組對吻合和包埋的改進,能明顯降低術后胸內(nèi)吻合口瘺的發(fā)生率,與對照組的差別有統(tǒng)計學意義(P0.05)。同等條件下,病理分期對吻合口瘺的發(fā)生率有影響,分期越晚,瘺發(fā)生率越高,差異有統(tǒng)計學意義(P0.05)。研究結(jié)論:本研究所采用的“改良式食管-管狀胃吻合”和對吻合口的“環(huán)式套入包埋”,能有效預防Sweet術式食管癌根治術術后胸內(nèi)吻合口瘺的發(fā)生,與術中預置的食管床引流管,共同構成了對于Sweet術后胸內(nèi)吻合口瘺的三位一體式的預防措施,改善了吻合口血供,降低了吻合口的張力,為吻合口營造了良好的局部愈合環(huán)境,措施全面,技巧簡單,效果顯著,應予推廣。
[Abstract]:Objective: to combine the literature, The main factors related to the occurrence of intrathoracic anastomotic fistula after radical resection of esophageal cancer were analyzed. The combined application of "modified esophagojejunostomy" and "ring embedding" was explored to prevent intrathoracic anastomosis. Whether oral fistula has a positive effect. Methods: a prospective randomized controlled trial was used. From November 2014 to November 2016, 200 patients with squamous cell carcinoma of middle and lower thoracic esophageal carcinoma underwent Sweet operation in our hospital. All the patients were randomly divided into two groups: the control group and the experimental group. The proximal end of the closure line is parallel to the long axis incision of the tube stomach. The esophagojejunostomy was performed with stapler. The anastomosed circular serous myometrium was sutured with multiple points, and the gastric wall was routinely closed. 100 cases (92 males and 8 females) were buried and sutured in the whole layer of anastomosis. In the test group, the tip of the tube stomach was perpendicular to the long axis of the tube stomach, and a stapler was inserted. The stomach fundus of the tube was anastomosed with the esophageal stump by end-to-side anastomosis. The cut-closure device closed and removed the orifice of the top of the tube stomach and the surrounding gastric wall. After the whole layer was buried and sutured, The tubular stomach was gently lifted up to cover the anastomotic site, and the gastric wall was folded about 2-3 cm. 100 cases (94 males and 6 females) were strengthened with circular sarcoplasmic muscular layer embedding at the highest point of gastric wall folding and the subesophagus segment. All patients in both groups were preplaced with esophageal bed drainage tube during the operation. The patients in both groups were given oral methylene blue test from the 4th to 7th day after operation. If there was a blue staining of the thoracic drainage tube or the mediastinal drainage tube, the anastomotic leakage was determined. For the two groups of patients who were negative for 4 methylene blue tests, one methylene blue test and five methylene blue tests were all negative before the drainage tube was removed. The group, number and sex of patients with intrathoracic anastomotic fistula after operation were determined. The pathological stages were recorded and compared with each other. The pathological staging was based on the seventh edition of TNM international staging of esophageal carcinoma. The data were analyzed by SPSS 21.0 software. Results: the general condition of the two groups was similar to that of P0.05, and there was no statistical difference between the two groups. There was no significant difference in the incidence of intrathoracic anastomotic leakage between the two groups under the same conditions. The improvement of anastomosis and embedding in the trial group could significantly reduce the incidence of postoperative intrathoracic anastomotic leakage. Under the same conditions, pathological staging had an effect on the incidence of anastomotic leakage, and the later the stage was, the higher the incidence of fistula was. The difference was statistically significant (P 0.05). Conclusion: the modified esophagojejunostomy and the loop embedding of anastomosis can effectively prevent the occurrence of intrathoracic anastomotic leakage after radical resection of esophageal carcinoma by Sweet. Together with the pre-inserted esophageal bed drainage tube during the operation, the three-in-one preventive measures for intrathoracic anastomotic leakage after Sweet were formed, which improved the blood supply of the anastomotic site, reduced the tension of the anastomotic site, and created a good local healing environment for the anastomotic site. The measure is comprehensive, the skill is simple, the effect is remarkable, should be popularized.
【學位授予單位】：吉林大學
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R735.1

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