Wong J, Cheung H, Lui R, Fan Y W, Smith A, Siu K F
Surgery. 1987 Apr;101(4):408-15.
The circular stapler has lowered the leakage rate of an esophageal anastomosis to a level hitherto achieved by only a few surgeons performing hand anastomosis on selected patients with carcinoma of the esophagus. However, the esophageal anastomosis performed with a stapler is also associated with a high stricture rate. Our prospective study was conducted to determine the leakage rate and the incidence of stricture after esophagogastric anastomosis was performed with a stapler, the relationship of stricture to the size of the stapler, and the risk of stricture in relation to time. In a group of 174 patients with carcinoma of the thoracic esophagus, resection was performed, and a one-stage esophagogastric anastomosis was constructed. There were 33 hand anastomoses, 64 anastomoses with an EEA stapler (U.S. Surgical Corp., Norwalk, Conn.), and 77 anastomoses with an ILS stapler (Ethicon Ltd., Edinburgh, U.K.). The anastomotic leakage rate was 3.4% (6/174); 3% with the hand technique and 3.5% with the stapler technique (4.7% for the EEA and 2.6% for the ILS). After leakages and hospital deaths were excluded, 133 discharged patients were evaluated for the occurrence of anastomotic strictures. Only those who complained of dysphagia were investigated. The incidence of stricture for hand anastomosis was 8.7%-EEA 20% and ILS 10%; the overall incidence of anastomoses with a stapler was 14.5%. The true incidence would probably be higher if all patients were assessed by endoscopic or radiologic examination after operation. All three sizes of EEA staplers had a high incidence of stricture. For the ILS stapler the 25 mm size had the highest stricture rate (28.6%) of all groups, but for the 29 and 33 mm sizes, the incidences were 5.3% and 0%, respectively. Actuarial analysis showed an increasing risk of stricture with a reduction in the size of stapler used and was 32.5% and 35%, respectively, for the ILS 25 mm and EEA 25 mm staplers at 131/2 months. The risk of stricture occurrence was highest in the first 4 months. Treatment by bougienage was satisfactory. In conclusion, esophagogastric anastomosis performed with a stapler is a very safe procedure with respect to leakage but is associated with a high risk of stricture, except when the largest ILS staplers are used. However, dilatation readily overcomes the stricture occurrence and adequately compensates for the reduced leakage rate and its attendant serious consequences.
圆形吻合器已将食管吻合口漏率降低到了此前只有少数外科医生在为特定食管癌患者进行手工吻合时才能达到的水平。然而，使用吻合器进行的食管吻合也伴随着较高的狭窄率。我们开展了一项前瞻性研究，以确定使用吻合器进行食管胃吻合后的漏率和狭窄发生率、狭窄与吻合器尺寸的关系以及狭窄发生风险与时间的关系。在一组174例胸段食管癌患者中，进行了切除手术，并构建了一期食管胃吻合。其中有33例手工吻合、64例使用EEA吻合器（美国外科公司，康涅狄格州诺沃克）进行的吻合以及77例使用ILS吻合器（英国爱丁堡Ethicon有限公司）进行的吻合。吻合口漏率为3.4%（6/174）；手工技术组为3%，吻合器技术组为3.5%（EEA为4.7%，ILS为2.6%）。在排除吻合口漏和医院死亡病例后，对133例出院患者进行了吻合口狭窄发生情况的评估。仅对那些主诉吞咽困难的患者进行了调查。手工吻合的狭窄发生率为8.7%——EEA为20%，ILS为10%；使用吻合器进行吻合的总体发生率为14.5%。如果术后对所有患者进行内镜或放射学检查，实际发生率可能会更高。所有三种尺寸的EEA吻合器狭窄发生率都很高。对于ILS吻合器，25毫米尺寸在所有组中狭窄率最高（28.6%），但对于29毫米和33毫米尺寸，发生率分别为5.3%和0%。精算分析显示，使用的吻合器尺寸越小，狭窄风险越高，在13.5个月时，ILS 25毫米和EEA 25毫米吻合器的狭窄风险分别为32.5%和35%。狭窄发生风险在最初4个月最高。通过探条扩张治疗效果良好。总之，就吻合口漏而言，使用吻合器进行食管胃吻合是一种非常安全的手术，但与较高的狭窄风险相关，除非使用最大尺寸的ILS吻合器。然而，扩张很容易克服狭窄的发生，并充分弥补漏率降低及其带来的严重后果。
