Duan X F, He L H, Shang X B, Yue J, Ma Z, Chen C G, Zhang C, Qu D W, Jiang H J
Department of Minimally Invasive Esophageal Surgery, Tianjin Medical University Cancer Hospital and Institute, National Clinical Research Center for Cancer, Tianjin Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China.
Department of Cardiothoracic Surgery, the First People's Hospital of Wanzhou District, Chongqing 404100, China.
Zhonghua Wai Ke Za Zhi. 2022 May 1;60(5):461-465. doi: 10.3760/cma.j.cn112139-20210908-00427.
To examine the clinical value of routine contrast esophagram (RCE) for the diagnosis of anastomotic leakage (AL) after three-incision esophagectomy with cervical anastomosis. Clinical data of 1 022 patients with esophageal cancer who underwent McKeown three-incision esophagectomy with cervical anastomosis from January 2015 to December 2019 at Department of Minimally Invasive Esophageal Surgery, Tianjin Medical University Cancer Hospital and Institute were analyzed retrospectively. There were 876 males and 146 females, aging((IQR)) 48(16) years (range: 36 to 84 years). There were 253 patients (24.8%) with neoadjuvant therapy, and 817 patients (79.9%) with minimally invasive esophagectomy. According to the diagnosis and treatment habits of the attending surgeons, 333 patients were included in the RCE group, and RCE was performed on the 7 day postoperative, while 689 patients were included in the non-RCE group, and RCE was performed when the patients had suspicious symptoms. Taking clinical symptoms, RCE, CT, endoscopy and other methods as reference to the diagnosis of AL, the sensitivity and specificity were used to analyze and evaluate the efficacy of RCE for the diagnosis of AL. The data were compared by test or χ² test between groups. The incidence rate of AL after three-incision esophagectomy was 7.34% (75/1 022), including 30 cases in the RCE group and 45 cases in the non-RCE group (9.0%(30/333) 6.5%(45/689), χ²=2.027, =0.155). The diagnostic time of AL was 9(5) days postoperative (range: 4 to 30 days). Among them, 23 cases showed cervical leakages, 50 cases showed intro-thoracic leakages, and 2 cases both cervical and intro-thoracic leakages. The diagnostic time of patients with intro-thoracic leakages was longer than that of cervical leakages (10(4) days 6(3) days, =-2.517, =0.012). Among the 333 patients in the RCE group, 16 cases of RCE indicated leakages including 11 cases of true positive and 5 cases determined to be false positive, while 317 cases indicated no abnormalities including 19 cases developed leakages. The sensitivity and specificity of RCE to detect AL were 36.7%(11/30) and 98.3%(298/333), respectively. The Youden-index was 0.35, and the diagnostic accuracy was 92.8%(309/333). The positive and negative predictive value were 11/16 and 94.0%(298/317), respectively. Routine contrast esophagram after three-incision esophagectomy with cervical anastomosis has low sensitivity and high specificity in the diagnosis of AL. The diagnostic time of AL is the 9 day after surgery. It is necessary to prolong the observation time clinically, and combine RCE with CT, endoscopy and other inspection methods for diagnosis.
探讨常规食管造影（RCE）对三切口食管癌根治术颈部吻合术后吻合口漏（AL）的诊断价值。回顾性分析2015年1月至2019年12月在天津医科大学肿瘤医院微创食管外科行McKeown三切口食管癌根治术颈部吻合术的1022例食管癌患者的临床资料。其中男性876例，女性146例，年龄（四分位间距）48（16）岁（范围：36至84岁）。新辅助治疗患者253例（24.8%），微创食管癌根治术患者817例（79.9%）。根据主刀医生的诊疗习惯，将333例患者纳入RCE组，术后第7天行RCE检查，689例患者纳入非RCE组，患者出现可疑症状时行RCE检查。以临床症状、RCE、CT、内镜等方法诊断AL为参照，采用敏感度和特异度分析评价RCE对AL的诊断效果。组间数据比较采用t检验或χ²检验。三切口食管癌根治术后AL发生率为7.34%（75/1022），其中RCE组30例，非RCE组45例（9.0%（30/333）对6.5%（45/689），χ² = 2.027，P = 0.155）。AL诊断时间为术后9（5）天（范围：4至30天）。其中，颈部漏23例，胸内漏50例，颈部和胸内均漏2例。胸内漏患者的诊断时间长于颈部漏患者（10（4）天对6（3）天，t = -2.517，P = 0.012）。RCE组333例患者中，RCE提示漏16例，其中真阳性11例，假阳性5例；提示无异常317例，其中19例发生漏。RCE诊断AL的敏感度和特异度分别为36.7%（11/30）和98.3%（298/333）。约登指数为0.35，诊断准确率为92.8%（309/333）。阳性预测值和阴性预测值分别为11/16和94.0%（298/317）。三切口食管癌根治术颈部吻合术后常规食管造影诊断AL敏感度低、特异度高。AL诊断时间为术后第9天。临床需延长观察时间，并联合RCE与CT、内镜等检查方法进行诊断。
