Division of Cardiothoracic Surgery, Washington University, St. Louis, Mo.
Division of Cardiothoracic Surgery, Wayne State University, Detroit Medical Center, Karmanos Cancer Center, Detroit, Mich.
J Thorac Cardiovasc Surg. 2017 Oct;154(4):1450-1458. doi: 10.1016/j.jtcvs.2017.04.012. Epub 2017 Apr 13.
Severe postesophagectomy gastric conduit dysfunction refractory to standard endoscopic intervention is rare, with few published reports discussing timing, technique, or results of reoperation. This case series examines assessment and management of severe conduit dysfunction and details techniques for conduit revision.
We retrospectively reviewed patients who underwent esophagectomy between September 2008 and October 2015 and studied patients who underwent conduit revision.
More than 400 patients underwent Ivor Lewis or transhiatal esophagectomies during this 7-year period. Eight patients underwent reoperation for conduit revision. The strategy for initial anastomosis and management of the pylorus were variable. Symptoms included dysphagia, delayed emptying, aspiration, and weight loss. Evaluation and management included esophagram, computed tomography, repeated esophagoscopy with pyloric intervention, and selective anastomotic dilation. Two patients also had associated paraconduit hiatal hernias. Average time to reoperation was 3.8 years (range 2 weeks to 6.5 years). All revisions were performed through a thoracotomy with either laparoscopy or laparotomy. Revisions were completed in 7 patients. Average length of stay was 9.9 days (range 4-21). Average follow up was 10.1 months (range 1-36). The completed revisions led to restoration of a regular diet with improved patient satisfaction.
Severe gastric conduit dysfunction after esophagectomy is rare. Symptoms, esophagram findings, and response to interventional esophagoscopy guide the decision to revise the conduit. Principles of conduit revision include reducing paraconduit hernias, reducing redundant conduit, tubularizing a dilated conduit, and ensuring adequate gastric drainage. Selective revision was performed with minimal morbidity and durable improvement in subjective symptoms of dysphagia and reflux.
严重的食管切除术后胃管功能障碍对标准内镜干预无反应较为罕见，且很少有文献报道讨论再手术的时机、技术或结果。本病例系列研究了严重胃管功能障碍的评估和处理方法，并详细介绍了胃管修正技术。
我们回顾性分析了 2008 年 9 月至 2015 年 10 月期间接受食管切除术的患者，并研究了接受胃管修正术的患者。
在这 7 年期间，超过 400 例患者接受了 Ivor Lewis 或经胸食管切除术。8 例患者因胃管修正而接受再次手术。初始吻合策略和幽门管理方法多种多样。症状包括吞咽困难、排空延迟、吸入和体重减轻。评估和管理包括食管造影、计算机断层扫描、反复食管镜检查和幽门干预以及选择性吻合扩张。2 例患者还伴有胃旁疝。再次手术的平均时间为 3.8 年（范围为 2 周至 6.5 年）。所有修正均通过开胸手术完成，腹腔镜或剖腹手术均可。7 例患者完成了修正术。平均住院时间为 9.9 天（范围为 4-21 天）。平均随访时间为 10.1 个月（范围为 1-36 个月）。完成的修正术使患者恢复正常饮食，提高了患者满意度。
食管切除术后胃管功能严重障碍较为罕见。症状、食管造影发现和对介入性食管镜检查的反应指导着修正胃管的决策。胃管修正的原则包括减少胃旁疝、减少多余的胃管、使扩张的胃管管状化以及确保充分的胃排空。选择性修正术具有较小的发病率，并且对吞咽困难和反流等主观症状的改善具有持久效果。
