食管癌切除术后吻合口漏的围手术期危险因素：胸段硬膜外镇痛的影响

Perioperative risk factors for anastomotic leakage after esophagectomy: influence of thoracic epidural analgesia.

作者信息

Michelet Pierre, D'Journo Xavier-Benoit, Roch Antoine, Papazian Laurent, Ragni Jacques, Thomas Pascal, Auffray Jean-Pierre

机构信息

Département d'Anesthésie Réanimation, Marseille, France.

出版信息

Chest. 2005 Nov;128(5):3461-6. doi: 10.1378/chest.128.5.3461.

DOI:10.1378/chest.128.5.3461

PMID:16304300

Abstract

STUDY OBJECTIVES

Anastomotic leakage after esophagectomy is associated with high postoperative morbidity and mortality. The most important predisposing factors for anastomotic leaks are ischemia of the gastric conduit and low blood oxygen content. The aim of this study was to evaluate the influence of thoracic epidural analgesia (TEA) on the incidence of anastomotic leakage after esophagectomy.

DESIGN

Retrospective study.

SETTING

A thoracic surgery and anesthesia department in a teaching hospital.

PATIENTS

Two hundred seven patients who underwent one-stage esophagectomy between 1998 and 2003.

INTERVENTIONS

The effects of perioperative factors and postoperative complications on the incidence of anastomotic leakage were analyzed. Leakage was defined as an anastomotic disruption detected by an ionic x-ray contrast study and confirmed by upper endoscopy in the postoperative period. Analyzed factors included effective TEA placed before the surgical procedure.

MEASUREMENTS AND RESULTS

Anastomotic leakage occurred in 23 patients (11%). This complication was associated with a significant increase in length of stay in the ICU and in the hospital (mean, 19 +/- 16 days vs 9 +/- 7 days [+/- SD], p = 0.008; and 43 +/- 27 days vs 23 +/- 11 days, respectively; p < 0.001). Mortality in patients presenting anastomotic leakage was 26%, compared with 5.4% in the remainder (p = 0.002). Factors independently associated with the incidence of leakage included estimated blood loss per milliliter during the surgical procedure (odds ratio [OR], 1.004; 95% confidence interval [CI], 1.001 to 1.007), the cervical location for anastomosis (OR, 5.4; 95% CI, 1.3 to 22.9), and the development of an ARDS in the postoperative period (OR, 4.1; 95% CI, 2.6 to 176.5). Ninety-three patients benefited from an effective TEA for 4.4 +/- 0.8 days. The use of TEA was independently associated with a decrease in the incidence of anastomotic leakage (OR, 0.13; 95% CI, 0.02 to 0.71).

CONCLUSIONS

The results of this retrospective study suggest that TEA is associated with a decrease in occurrence of anastomotic leakage.

摘要

研究目的

食管切除术后吻合口漏与术后高发病率和死亡率相关。吻合口漏最重要的诱发因素是胃管道缺血和低血氧含量。本研究的目的是评估胸段硬膜外镇痛（TEA）对食管切除术后吻合口漏发生率的影响。

设计

回顾性研究。

地点

一家教学医院的胸外科和麻醉科。

患者

1998年至2003年间接受一期食管切除术的207例患者。

干预措施

分析围手术期因素和术后并发症对吻合口漏发生率的影响。漏出定义为离子X线造影检查发现并经术后上消化道内镜检查证实的吻合口破裂。分析的因素包括手术前放置有效的TEA。

测量与结果

23例患者（11%）发生吻合口漏。这种并发症与ICU住院时间和住院时间显著延长相关（平均，19±16天对9±7天[±标准差]，p = 0.008；分别为43±27天对23±11天；p < 0.001）。发生吻合口漏的患者死亡率为26%，其余患者为5.4%（p = 0.002）。与漏出发生率独立相关的因素包括手术期间每毫升估计失血量（比值比[OR]，1.004；95%置信区间[CI]，1.001至1.007）、吻合口的颈部位置（OR，5.4；95%CI，1.3至22.9）以及术后发生急性呼吸窘迫综合征（ARDS）（OR，4.1；95%CI，2.6至176.5）。93例患者受益于有效的TEA，时间为4.4±0.8天。TEA的使用与吻合口漏发生率的降低独立相关（OR，0.13；95%CI，0.02至0.71）。