DiPierro F V, Rice T W, DeCamp M M, Rybicki L A, Blackstone E H
Department of Thoracic and Cardiovascular Surgery, The Center for Swallowing and Esophageal Disorders, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195-5066, USA.
Eur J Cardiothorac Surg. 2000 Jun;17(6):702-9. doi: 10.1016/s1010-7940(00)00408-5.
Esophageal resection with diversion and staged reconstruction of the upper gastrointestinal (GI) tract is an option in the management of complex problems. This study characterizes circumstances, indications, outcomes and their predictors for staged reconstruction, and estimates the optimal timing for reconstruction.
Between October 1981 and March 1999, 43 patients were identified with planned staged reconstruction. Twenty-six had esophageal cancer, and 17 had complications of benign disease. Primary diversion with esophageal resection was needed in 16 patients, and secondary diversion with takedown of previous esophageal reconstruction was needed in 27. Common indications were failed esophageal anastomosis and esophageal perforation. Death before and death after reconstruction were considered as competing risks. Multivariable analyses were used to estimate the optimal timing of reconstruction.
The survival was 75, 21 and 9% at 3 months, 5 and 10 years, with survival only somewhat better (P=0. 06) among patients having benign versus malignant disease. A similar proportion of patients died before reconstruction as underwent reconstruction, resulting in only 17 reconstructions, typically 9 months after diversion. The risk factors for death included cancer and primary diversion. The survival was best for benign disease when reconstruction was early. The survival was poor after reconstruction in the few patients with malignant disease.
Patients requiring staged esophageal reconstruction are heterogeneous, with malignant or benign disease, and primary or secondary diversion. The outcome is poor, and is influenced by the pathology and timing of diversion. Patients with benign disease should be reconstructed as early as feasible; reconstruction is rarely indicated for patients with cancer.
食管切除并改行消化道转流术以及分期重建上消化道是处理复杂问题的一种选择。本研究描述了分期重建的情况、适应证、结局及其预测因素，并估计了重建的最佳时机。
在1981年10月至1999年3月期间，确定了43例计划分期重建的患者。其中26例患有食管癌，17例患有良性疾病并发症。16例患者需要行食管切除并一期转流术，27例患者需要行二次转流术并拆除先前的食管重建。常见适应证为食管吻合口失败和食管穿孔。重建前死亡和重建后死亡被视为竞争风险。采用多变量分析来估计重建的最佳时机。
3个月、5年和10年的生存率分别为75%、21%和9%，良性疾病患者的生存率仅略高（P=0.06）。重建前死亡的患者比例与接受重建的患者比例相似，最终仅17例进行了重建，通常在转流术后9个月。死亡的危险因素包括癌症和一期转流术。良性疾病患者早期重建时生存率最佳。少数恶性疾病患者重建后的生存率较差。
需要分期食管重建的患者具有异质性，包括恶性或良性疾病，以及一期或二期转流术。结局较差，且受转流术的病理情况和时机影响。良性疾病患者应尽早可行地进行重建；癌症患者很少需要重建。
