Page Richard D, Shackcloth Michael J, Russell Glenn N, Pennefather Stephen H
Department of Thoracic Surgery, The Cardiothoracic Centre, Thomas Drive, Liverpool L14 3PE, UK.
Eur J Cardiothorac Surg. 2005 Feb;27(2):337-43. doi: 10.1016/j.ejcts.2004.10.053.
To determine the optimum management of anastomotic leaks after oesophagectomy.
We undertook a retrospective review of 23 patients who developed anastomotic leakage, out of 389 patients undergoing oesophagectomy with gastric interposition. The presentation, diagnosis, and treatment of the leaks, and patient outcomes are analysed.
Leaks occurred from 3 to 23 (median=7.5) days after surgery. Clinical features included fever (57%), leucocytosis (52%), dysphagia (4%), coughing bile (4%), wound infection (13%), pneumothorax (35%), pleural effusion (70%) and septicaemia (70%). All but one leak was due to variable degree of gastric tip necrosis. Contrast swallow showed leakage in only 14 (61%) patients, whereas oesophagoscopy confirmed all the leaks. Surgical treatment (resection of necrotic stomach and either immediate or staged re-anastomosis, or end-oesophageal exteriorisation) was the primary treatment in 17 patients of whom 15 survived to discharge. Two out of the 6 patients treated non-surgically died.
Diagnosis of anastomotic leakage after oesophagectomy is difficult due to its variable presentation and the unreliability of contrast swallow. Gastric tip necrosis is by far the most common cause. We feel our preferred strategy of immediate surgical treatment of symptomatic leaks is justified by the favourable outcome in the majority of patients.
确定食管癌切除术后吻合口漏的最佳处理方法。
我们对389例行胃代食管食管癌切除术患者中的23例发生吻合口漏的患者进行了回顾性研究。分析了漏口的表现、诊断、治疗及患者预后。
漏口发生在术后3至23天(中位数=7.5天)。临床特征包括发热(57%)、白细胞增多(52%)、吞咽困难(4%)、咳出胆汁(4%)、伤口感染(13%)、气胸(35%)、胸腔积液(70%)和败血症(70%)。除1例漏口外,其余均因不同程度的胃底坏死所致。食管造影仅14例(61%)显示有漏口,而食管镜检查证实了所有漏口。手术治疗(切除坏死胃组织并立即或分期重新吻合,或食管末端外置)是17例患者的主要治疗方法,其中15例存活出院。6例非手术治疗的患者中有2例死亡。
由于食管癌切除术后吻合口漏的表现多样且食管造影不可靠,其诊断较为困难。胃底坏死是迄今为止最常见的原因。我们认为,对于有症状的漏口立即进行手术治疗的首选策略在大多数患者中取得了良好的效果,是合理的。