Ahmed Zuhair, Elliott Jessie A, King Sinead, Donohoe Claire L, Ravi Narayanasamy, Reynolds John V
Department of Surgery, Trinity Centre for Health Sciences, Trinity College Dublin and St. James's Hospital, Dublin 8, Ireland.
World J Surg. 2017 Feb;41(2):487-497. doi: 10.1007/s00268-016-3746-0.
Benign anastomotic strictures occur frequently after esophagectomy, and impact on postoperative recovery, nutritional status, and quality of life. This large cohort study explored the incidence of stricture after transthoracic (2- and 3-stage) and transhiatal resections with uniform single-layer sutured anastomotic technique, and aimed to identify independent risk factors.
Patients undergoing esophagectomy with gastric conduit reconstruction between February 2001 and October 2014 were studied prospectively. Symptomatic anastomotic stricture was defined as dysphagia requiring endoscopic dilatation, and refractory strictures as those requiring >5 dilatations. Multivariable logistic regression was performed to determine factors independently associated with stricture development.
Five-hundred and twenty-four patients, 77 % with adenocarcinoma, underwent esophagectomy [2-stage, n = 328 (62.6 %); 3-stage, n = 129 (23.3 %); transhiatal, n = 74 (14.1 %)], with an overall inhospital mortality rate of 2.7 %. 58.5 % of patients received neoadjuvant therapy [chemotherapy only, n = 119 (22.7 %); chemoradiation, n = 188 (35.9 %)]. Anastomotic stricture developed in 125 patients (24.5 %), was refractory in 20 (3.9 %) and required a median of 2 dilatations (range 1-18). On multivariable analysis, ASA grade (P < 0.05), cervical anastomosis (P < 0.001), and a significant postoperative cardiac event (P < 0.05) were independently associated with stricture risk. Refractory strictures were independently associated with anastomotic leak (P = 0.01) and transhiatal resections (P < 0.001).
Benign anastomotic strictures are common, particularly with cervical reconstruction, and after transhiatal resection. Refractory strictures are rare. Where fitness and oncologic equivalence apply, a thoracic anastomosis provides significant advantages compared with a cervical anastomosis in terms of anastomotic stricture risk.
良性吻合口狭窄在食管切除术后频繁发生，影响术后恢复、营养状况和生活质量。这项大型队列研究探讨了采用统一单层缝合吻合技术的经胸（两阶段和三阶段）和经裂孔切除术术后狭窄的发生率，并旨在确定独立危险因素。
对2001年2月至2014年10月期间接受食管切除并胃代食管重建术的患者进行前瞻性研究。有症状的吻合口狭窄定义为需要内镜扩张的吞咽困难，难治性狭窄定义为需要超过5次扩张的狭窄。进行多变量逻辑回归以确定与狭窄发生独立相关的因素。
524例患者接受了食管切除术，其中77%为腺癌[两阶段，n = 328例（62.6%）；三阶段，n = 129例（23.3%）；经裂孔，n = 74例（14.1%）]，总体住院死亡率为2.7%。58.5%的患者接受了新辅助治疗[仅化疗，n = 119例（22.7%）；放化疗，n = 188例（35.9%）]。125例患者（24.5%）发生了吻合口狭窄，20例（3.9%）为难治性狭窄，扩张次数中位数为2次（范围1 - 18次）。多变量分析显示，美国麻醉医师协会（ASA）分级（P < 0.05）、颈部吻合（P < 0.001）和术后严重心脏事件（P < 0.05）与狭窄风险独立相关。难治性狭窄与吻合口漏（P = 0.01）和经裂孔切除术（P < 0.001）独立相关。
良性吻合口狭窄很常见，尤其是在颈部重建和经裂孔切除术后。难治性狭窄很少见。在身体状况和肿瘤学等效的情况下，与颈部吻合相比，胸部吻合在吻合口狭窄风险方面具有显著优势。
