腹腔镜全胃切除术后食管空肠吻合口漏危险因素分析
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摘要
目的探讨腹腔镜全胃切除术后食管空肠吻合口漏的危险因素及处理措施。方法回顾性分析2006年4月至2016年12月南方医科大学南方医院收治的440例行腹腔镜全胃切除切缘阴性的胃癌病人的临床病理学资料。对照分析影响术后食管空肠吻合口漏的危险因素及相对应的处理措施。结果 440例病人术后并发食管空肠吻合口漏者12例(2.7%),平均发生时间为术后4(1～8)d。单因素分析显示:性别、年龄、新辅助化疗、吻合方式(全腹腔镜吻合、辅助切口吻合)、联合器官切除(胰体尾、脾脏、胆囊)、侵犯食管是影响腹腔镜全胃切除术后并发食管空肠吻合口漏的危险因素(P<0.05)。多因素分析结果显示:年龄、新辅助化疗、吻合方式、联合器官切除、侵犯食管是影响腹腔镜全胃切除术后并发食管空肠吻合口漏的独立危险因素。结论对高龄(>65岁)、接受新辅助化疗、肿瘤侵犯食管、行全腹腔镜吻合方式、联合器官切除病人,行腹腔镜下全胃切除须警惕食管空肠吻合口漏发生。内镜下覆膜支架置入使食管空肠吻合口漏病人预后快且创伤小,但有脱落风险。
Objective To identify the risk factors of esophagojejunal anastomotic leakage and its intervention measures of gastric cancer patients after laparoscopic total gastrectomy. Methods The clinical and follow-up data of 440 gastric cancer patients who underwent laparoscopic total gastrectomy with negative margins at the Department of General Surgery, Nanfang Hospital of Southern Medical University from April 2006 to December 2016 were analyzed retrospectively. Risk factors of esophagojejunal anastomotic leakage and intervention measures of patients were analyzed respectively. Results Esophagojejunal anastomotic leakage occurred in 12 of 440 patients(2.7%). The leakage was diagnosed at a median of 4(range,1 to 8) days after surgery. Univariate analysis showed that gender, age, neoadjuvant chemotherapy, anastomosis method, combined organ resection, invasion of the esophagus were risk factors affecting esophagojejunal anastomotic leakage after laparoscopic total gastrectomy, with statistically significant differences(P<0.05). Multivariate analysis showed that age, neoadjuvant chemotherapy, anastomosis method, combined organ resection,invasion of the esophagus were independent risk factors affecting esophagojejunal anastomotic leakage after laparoscopic total gastrectomy, with statistically significant differences(P<0.05). Conclusion For the elderly patients, who are older than 65 years old, received neoadjuvant chemotherapy, had tumor invasion of the esophagus, undergone total laparoscopic anastomosis, combined organ resection, when they are treating with laparoscopic total gastrectomy, esophagojejunal anastomosis should be careful about. Esophagojejunal anastomotic leakage can be treated effectively with self-expanding metalstents, but the risk of migration still exists.
Objective To identify the risk factors of esophagojejunal anastomotic leakage and its intervention measures of gastric cancer patients after laparoscopic total gastrectomy. Methods The clinical and follow-up data of 440 gastric cancer patients who underwent laparoscopic total gastrectomy with negative margins at the Department of General Surgery, Nanfang Hospital of Southern Medical University from April 2006 to December 2016 were analyzed retrospectively. Risk factors of esophagojejunal anastomotic leakage and intervention measures of patients were analyzed respectively. Results Esophagojejunal anastomotic leakage occurred in 12 of 440 patients(2.7%). The leakage was diagnosed at a median of 4(range,1 to 8) days after surgery. Univariate analysis showed that gender, age, neoadjuvant chemotherapy, anastomosis method, combined organ resection, invasion of the esophagus were risk factors affecting esophagojejunal anastomotic leakage after laparoscopic total gastrectomy, with statistically significant differences(P<0.05). Multivariate analysis showed that age, neoadjuvant chemotherapy, anastomosis method, combined organ resection,invasion of the esophagus were independent risk factors affecting esophagojejunal anastomotic leakage after laparoscopic total gastrectomy, with statistically significant differences(P<0.05). Conclusion For the elderly patients, who are older than 65 years old, received neoadjuvant chemotherapy, had tumor invasion of the esophagus, undergone total laparoscopic anastomosis, combined organ resection, when they are treating with laparoscopic total gastrectomy, esophagojejunal anastomosis should be careful about. Esophagojejunal anastomotic leakage can be treated effectively with self-expanding metalstents, but the risk of migration still exists.
引文
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[11]Watanabe M,Miyata H,Gotoh M,et al.Total gastrectomy risk model:data from 20,011 Japanese patients in a nationwide internet-based database[J].Ann Surg,2014,260(6):1034-1039.
[12]冯兴宇,王伟,臧潞,等.全腹腔镜下圆形吻合器与直线切割闭合器行食管空肠吻合疗效对照研究[J].中国实用外科杂志,2016,36(12):1288-1292.
[13]所剑,李国新,苏向前,等.全腹腔镜全胃切除术消化道重建方式选择--圆形还是侧侧吻合?[J].中国实用外科杂志,2016,36(9):955-957.
[14]Kunisaki C,Makino H,Oshima T,et al.Application of the transorally inserted anvil(OrVil)after laparoscopy-assisted total gastrectomy[J].Surg Endosc,2011.25(4):1300-1305.
[15]Li X,Hong L,Ding D,et al.Comparison of OrVilTM and RPD in laparoscopic total gastrectomy for gastric cancer[J].Surg Endosc,2017,31(11):4773-4779.
[16]Cianchi F,Giuseppe M,Indennitate G,et al.Laparoscopic total gastrectomy using the transorally inserted anvil(OrVil?):Apreliminary,single institution experience[J].Springerplus,2014,3(1):1-6.
[17]Fujitani K,Ajani JA,Crane CH,et al.Impact of induction chemotherapy and preoperative chemoradiotherapy on operative morbidity and mortality in patients with locoregional adenocarcinoma of the stomach or gastroesophageal junction[J].Ann Surg Oncol,2007,14(7):2010-2017.
[18]Okajima K,Isozaki H.Splenectomy for treatment of gastric cancer:Japanese experience[J].World J Surg,1995,19(4):537-540.
[19]Monig SP,Collet PH,Baldus SE,et al.Splenectomy in proximal gastric cancer:frequency of lymph node metastasis to the splenic hilus[J].J Surg Oncol,2001,76(2):89-92.
[20]中国医师协会内镜医师分会腹腔镜外科专业委员会.中国腹腔镜胃癌根治手术质量控制专家共识(2017版)[J].中华消化外科杂志,2017,16(6):539-547.
[21]Usui S,Tashiro M,Haruki S,et al.Spleen preservation versus splenectomy in laparoscopic total gastrectomy with D 2 lymphadenectomy for gastric cancer:A comparison of short-term outcomes[J].Asian J Endosc Surg,2016,9(1):5-13.
[22]Yu W,Choi GS,Chung HY.Randomized clinical trial of splenectomy versus,splenic preservation in patients with proximal gastric cancer[J].Br J Surg,2010,93(5):559-563.
[23]Shim CN,Kim HI,Hyung WJ,et al.Self-expanding metal stents or nonstent endoscopic therapy:which is better for anastomotic leaks after total gastrectomy?[J].Surg Endosc,2014,28(3):833-840.
[24]Cipolletta L,Bianco MA,Rotondano G,et al.Endoscopic clipping of perforation following pneumatic dilation of esophagojejunal anastomotic strictures[J].Endoscopy,2000,32(9):720-722.
[25]Ta?demir O,Kü?ükaksu DS,Karag?z H,et al.Beneficial effects of fibrin glue on esophageal perforation[J].Ann Thorac Surg,1996,61(5):1589.
[26]Oh HJ,Lim CH,Yoon SB,et al.Temporary self-expandable metallic stent placement in post-gastrectomy complications[J].Gastric Cancer,2018:1-6.
[27]Raimondo D,Sinagra E,Facella T,et al.Self-expandable metal stent placement for closure of a leak after total gastrectomy for gastric cancer:report on three cases and review of the literature[J].Case Rep Gastrointest Med,2014,2014(2014):409283.
[28]Persson S,Rouvelas I,Kumagai K,et al.Treatment of esophageal anastomotic leakage with self-expanding metal stents:analysis of risk factors for treatment failure[J].Endosc Int Open,2016,4(4):E420-E426.
[29]Lee SR,Kim HO,Park JH,et al.Clinical outcomes of endoscopic metal stent placement for esophagojejunostomy leakage after total gastrectomy for gastric adenocarcinoma[J].Surg Laparosc Endosc Percutan Tech,2018.28(2):1.
[30]Salminen P,Gullichsen R,Laine S.Use of self-expandable metal stents for the treatment of esophageal perforations and anastomotic leaks[J].Surg Endosc,2009,23(7):1526-1530.
[31]Bakken JC,Song LMWK,Groen PCD,et al.Use of a fully covered self-expandable metal stent for the treatment of benign esophageal diseases[J].Gastrointest Endosc,2010,72(4):712-720.
[32]Kim YJ,Shin SK,Lee HJ,et al.Endoscopic management of anastomotic leakage after gastrectomy for gastric cancer:how efficacious is it?[J].Scand J Gastroenterol,2013,48(1):111-118.
[33]Schubert D,Scheidbach H,Kuhn R,et al.Endoscopic treatment of thoracic esophageal anastomotic leaks by using silicone-covered,self-expanding polyester stents[J].Gastrointest Endosc,2005,61(7):891-896.
[34]Akashi Y,Hiki N,Nunobe S,et al.Safe management of anastomotic leakage after gastric cancer surgery with enteral nutrition via a nasointestinal tube[J].Langenbecks Arch Surg,2012,397(5):737-744.
[2]Japanese Gastric Cancer Association.Japanese gastric cancer treatment guidelines 2010(ver.3)[J].Gastric Cancer.2011,14(2):113-123.
[3]Sierzega M,Kolodziejczyk P,Kulig J,et al.Impact of anastomotic leakage on long-term survival after total gastrectomy for carcinoma of the stomach[J].Br J Surg,2010,97(7):1035-1042.
[4]Markar S,Gronnier C,Duhamel A,et al.The impact of severe anastomotic leak on long-term survival and cancer recurrence after surgical resection for esophageal malignancy[J].Ann Surg2015,262(6):972-980.
[5]Yoo HM,Lee HH,Shim JH,et al.Negative impact of leakage on survival of patients undergoing curative resection for advanced gastric cancer[J].J Surg Oncol,2011,104(7):734-740.
[6]Lerut T,Moons J,Coosemans W,et al.Postoperative complications after transthoracic esophagectomy for cancer of the esophagus and gastroesophageal junction are correlated with early cancer recurrence:role of systematic grading of complications using the modified Clavien classification[J].Ann Surg,2009,250(5)798-807.
[7]Hu Y,Huang C,Sun Y,et al.Morbidity and mortality of laparoscopic versus open D2 distal gastrectomy for advanced gastric cancer:A randomized controlled trial[J].J Clin Oncol,2016.34(12):1350-1357.
[8]Edge SB,Compton CC.AJCC cancer staging manual(7th ed)[M].New York,NY:Springer,2010.
[9]Yuichiro K,Seiji S,Koichi S,et al.Critical factors that influence the early outcome of laparoscopic total gastrectomy[J].Gastric Cancer,2015,18(3):662-668.
[10]Oshi M,Kunisaki C,Miyamoto H,et al.Risk factors for anastomotic leakage of esophagojejunostomy after laparoscopy-assisted total gastrectomy for gastric cancer[J].Dig Surg,2017,35(1):28-34.
[11]Watanabe M,Miyata H,Gotoh M,et al.Total gastrectomy risk model:data from 20,011 Japanese patients in a nationwide internet-based database[J].Ann Surg,2014,260(6):1034-1039.
[12]冯兴宇,王伟,臧潞,等.全腹腔镜下圆形吻合器与直线切割闭合器行食管空肠吻合疗效对照研究[J].中国实用外科杂志,2016,36(12):1288-1292.
[13]所剑,李国新,苏向前,等.全腹腔镜全胃切除术消化道重建方式选择--圆形还是侧侧吻合?[J].中国实用外科杂志,2016,36(9):955-957.
[14]Kunisaki C,Makino H,Oshima T,et al.Application of the transorally inserted anvil(OrVil)after laparoscopy-assisted total gastrectomy[J].Surg Endosc,2011.25(4):1300-1305.
[15]Li X,Hong L,Ding D,et al.Comparison of OrVilTM and RPD in laparoscopic total gastrectomy for gastric cancer[J].Surg Endosc,2017,31(11):4773-4779.
[16]Cianchi F,Giuseppe M,Indennitate G,et al.Laparoscopic total gastrectomy using the transorally inserted anvil(OrVil?):Apreliminary,single institution experience[J].Springerplus,2014,3(1):1-6.
[17]Fujitani K,Ajani JA,Crane CH,et al.Impact of induction chemotherapy and preoperative chemoradiotherapy on operative morbidity and mortality in patients with locoregional adenocarcinoma of the stomach or gastroesophageal junction[J].Ann Surg Oncol,2007,14(7):2010-2017.
[18]Okajima K,Isozaki H.Splenectomy for treatment of gastric cancer:Japanese experience[J].World J Surg,1995,19(4):537-540.
[19]Monig SP,Collet PH,Baldus SE,et al.Splenectomy in proximal gastric cancer:frequency of lymph node metastasis to the splenic hilus[J].J Surg Oncol,2001,76(2):89-92.
[20]中国医师协会内镜医师分会腹腔镜外科专业委员会.中国腹腔镜胃癌根治手术质量控制专家共识(2017版)[J].中华消化外科杂志,2017,16(6):539-547.
[21]Usui S,Tashiro M,Haruki S,et al.Spleen preservation versus splenectomy in laparoscopic total gastrectomy with D 2 lymphadenectomy for gastric cancer:A comparison of short-term outcomes[J].Asian J Endosc Surg,2016,9(1):5-13.
[22]Yu W,Choi GS,Chung HY.Randomized clinical trial of splenectomy versus,splenic preservation in patients with proximal gastric cancer[J].Br J Surg,2010,93(5):559-563.
[23]Shim CN,Kim HI,Hyung WJ,et al.Self-expanding metal stents or nonstent endoscopic therapy:which is better for anastomotic leaks after total gastrectomy?[J].Surg Endosc,2014,28(3):833-840.
[24]Cipolletta L,Bianco MA,Rotondano G,et al.Endoscopic clipping of perforation following pneumatic dilation of esophagojejunal anastomotic strictures[J].Endoscopy,2000,32(9):720-722.
[25]Ta?demir O,Kü?ükaksu DS,Karag?z H,et al.Beneficial effects of fibrin glue on esophageal perforation[J].Ann Thorac Surg,1996,61(5):1589.
[26]Oh HJ,Lim CH,Yoon SB,et al.Temporary self-expandable metallic stent placement in post-gastrectomy complications[J].Gastric Cancer,2018:1-6.
[27]Raimondo D,Sinagra E,Facella T,et al.Self-expandable metal stent placement for closure of a leak after total gastrectomy for gastric cancer:report on three cases and review of the literature[J].Case Rep Gastrointest Med,2014,2014(2014):409283.
[28]Persson S,Rouvelas I,Kumagai K,et al.Treatment of esophageal anastomotic leakage with self-expanding metal stents:analysis of risk factors for treatment failure[J].Endosc Int Open,2016,4(4):E420-E426.
[29]Lee SR,Kim HO,Park JH,et al.Clinical outcomes of endoscopic metal stent placement for esophagojejunostomy leakage after total gastrectomy for gastric adenocarcinoma[J].Surg Laparosc Endosc Percutan Tech,2018.28(2):1.
[30]Salminen P,Gullichsen R,Laine S.Use of self-expandable metal stents for the treatment of esophageal perforations and anastomotic leaks[J].Surg Endosc,2009,23(7):1526-1530.
[31]Bakken JC,Song LMWK,Groen PCD,et al.Use of a fully covered self-expandable metal stent for the treatment of benign esophageal diseases[J].Gastrointest Endosc,2010,72(4):712-720.
[32]Kim YJ,Shin SK,Lee HJ,et al.Endoscopic management of anastomotic leakage after gastrectomy for gastric cancer:how efficacious is it?[J].Scand J Gastroenterol,2013,48(1):111-118.
[33]Schubert D,Scheidbach H,Kuhn R,et al.Endoscopic treatment of thoracic esophageal anastomotic leaks by using silicone-covered,self-expanding polyester stents[J].Gastrointest Endosc,2005,61(7):891-896.
[34]Akashi Y,Hiki N,Nunobe S,et al.Safe management of anastomotic leakage after gastric cancer surgery with enteral nutrition via a nasointestinal tube[J].Langenbecks Arch Surg,2012,397(5):737-744.