Nishikawa Katsunori, Fujita Tetsuji, Hasegawa Yako, Tanaka Yujiro, Matsumoto Akira, Mitsumori Norio, Yanaga Katsuhiko
Department of Surgery, The Jikei University School of Medicine, 3-25-8 Nishi-Shinbashi Minato-ku, Tokyo, 105-8461, Japan.
Esophagus. 2018 Oct;15(4):231-238. doi: 10.1007/s10388-018-0619-7. Epub 2018 May 31.
The purpose of this study was to investigate modifiable predisposing factors associated with anastomotic leak in the anterior mediastinal (AM) reconstruction route.
We reviewed the data on 154 patients who underwent esophagectomy and gastric tube reconstruction using the AM route between 2008 and 2016. The data included computed tomography (CT) scans with sagittal reconstruction of the thoracic section. The level of the esophagogastric anastomosis (LEA) and pretracheal distance (PTD) was measured from sagittal reconstructed CT images. Vascularization of the gastric tube was evaluated by postoperative endoscopy. Variables associated with anastomotic leak were determined using univariate and multivariate analyses.
Anastomotic leak developed in 13 patients (8%). The cut-off level at which the anastomosis was less likely to develop a leak, as determined by Chi-square tests, was 1.5 cm for LEA and 1.3 cm for PTD. On univariate analysis, the factors that were significantly associated with the risk of anastomotic leak included diabetes, hand-sewn anastomosis, the LEA ≥ 1.5 cm, and severe mucosal degeneration. On multivariate analysis, diabetes (OR 4.7, 95% CI 1.29-17.2), LEA ≥ 1.5 cm (OR 20.1, 95% CI 3.15-128), and severe mucosal degeneration (OR 7.2, 95% CI 1.42-36.8) were found to be statistically significant independent risk factors.
Use of the AM route to place the cervical anastomosis within 1.5 cm above the suprasternal notch might avoid excessive pressure on the gastric tube from the surrounding structures, resulting in a reduction in the risk of an anastomotic leak.
本研究旨在调查前纵隔（AM）重建路径中与吻合口漏相关的可改变诱发因素。
我们回顾了2008年至2016年间154例行食管切除术并采用AM路径进行胃管重建患者的数据。数据包括胸部矢状面重建的计算机断层扫描（CT）图像。从矢状面重建的CT图像上测量食管胃吻合水平（LEA）和气管前距离（PTD）。通过术后内镜评估胃管的血管化情况。使用单因素和多因素分析确定与吻合口漏相关的变量。
13例患者（8%）发生吻合口漏。通过卡方检验确定的吻合口不易发生漏的临界水平，LEA为1.5 cm，PTD为1.3 cm。单因素分析显示，与吻合口漏风险显著相关的因素包括糖尿病、手工缝合吻合、LEA≥1.5 cm和严重黏膜变性。多因素分析发现，糖尿病（OR 4.7，95%CI 1.29 - 17.2）、LEA≥1.5 cm（OR 20.1，95%CI 3.15 - 128）和严重黏膜变性（OR 7.2，95%CI 1.42 - 36.8）是具有统计学意义的独立危险因素。
采用AM路径将颈部吻合口置于胸骨上切迹上方1.5 cm以内，可能避免周围结构对胃管的过度压迫，从而降低吻合口漏的风险。
