Esophagus and cardia cancer resection after use stapling line gastrointestinal reconstruction in domestic has a wide application [1 ~ 3], and achieved good clinical effects. June 1996 – February 1999, I adopted American Johnson &johnson production CDH/SDH type one-time digestive tract stomach stapling do Esophagus 85 cases of colorectal anastomosis and esophagus, preliminary results and experience will be reported as follows.
1 clinical data
1.1 generally
85 cases, male 19.88% 73 cases, women in 12 cases, the age of 38-82, average age of 70 years old, 61.3 above 25 cases. 71 cases of Esophagus cancer diagnose cardia cancer, 13 cases and Esophagus corrosion after 1 scar stricture. 71 cases of Esophagus cancer, located in middle and lower 51 cases of 20 cases, According to Ⅱ: a TNM staging 15 cases, Ⅱ b 47, Ⅲ 9 cases, and 3 patients were in 30 years, 2 years and stomach ulcer did three years ago because most excision, roche Ⅰ type 1 and type 2 Ⅱ stomach jejunum anastomosis, Cases of gastric cardia cancer and stomach wall corner and after, and has nearly 2 cm involving the esophagus, Esophagus corrosion of alkali injuries were created by stomach injury, mouth, Esophagus swallowed feeding food in the aorta barium see scar stricture, inferior plane is linear change by dilute barium. All cases were routine preoperative preparation.
1.2 surgery mode
All the cases are in the endotracheal tube surgery under anesthesia. Esophagus cancer cases in the aorta rear part do right lateral chest, cardia cancer cases using epigastric midline incision and lower part of them left sternal elevation YanWei or chest, the joint incision cases were left after the chest outside the incision. Esophagus tumor resection, or scar esophagus anastomosis 82 cases do Esophagus stomach, chest aorta on top and anastomosis of 45 patients, bow next 24 cases, 13 cases of cardia cancer in Esophagus hiatal department or within the left breast. Most already 3 patients with stomach esophagus colon and 2 cases, jejunum, respectively in the right chest top 2 and anastomosis of the left breast anastomosis. With CDH 25 type anastomosis 32 cases, SDH 25 type 1 patients are identical, 53, smooth completion times no mechanical fault occurs. After all inspection organization anastomosis anastomosis intact, neat cutting ring at both ends, incomplete cardia cancer, one that left front leg sleeve, and given above nail suture needle number, light touch anastomotic soft and smooth. Nasogastric tube will put the anastomotic stomach for gastrointestinal decompression, close mouth. Put stapling Sixty-two cases of recent anastomotic front wall of gastric package.2 results
The group of 85 cases occurred, stomach fistula in 1 (1.17%) and anastomotic fistula in 1 case (1.17%). This is the case in the first postoperative fistula in 13 days after the first half flow diet, 21 days did fiber Esophagus bronchoscopy see anastomotic smooth, in the anterior wall stomach from anastomotic about 2.5 cm a 1.5 cm necrosis breaches the thorax, closed drainage, nutrition support conservative treatment in March, after death. Anastomotic fistula in 1 case of cardia cancer and diabetes, the first three days after surgery, again see anastomotic left side a about 1.3 cm fistula, necrotic tissue after suturing and trim the intercostal muscle flap embedding repair, postoperative recovery smoothly. Other cases restored smoothly. The group without anastomotic stenosis. Four patients with early without anastomotic embedding cases, after eating hypothesis has regurgitation, including one symptom aggravating, six months after taking the drug, alleviate acid were no particular discomfort. Postoperative esophagus anastomosis of barium swallow check back chang, see, smooth, 2 patients have barium reflux hypothesis. After three weeks, 10 cases were Esophagus dynamic testing and 24 h pH. Results: the esophagus anastomosis mouth pressures for 1.24 kPa (9.3 1.85 ~ ~ ~ -13.9 mmHg), average 1.52 kPa (11.4 mmHg stomach, chest) pressure is 0.33 kPa (250 ~ ~ ~ 1.64 12.3 mmHg), average 0.94 kPa (7.08 mmHg), 24 h pH determination: according to Meester score 8 cases of normal De (< 14.72), Two cases of more than normal, respectively, and the 138.8 amounts.
3 discussion
Tubular gastrointestinal surgery in the application of Esophagus stapling technique in China for many years history, which is consistent and reliable, low incidence anastomotic fistula, operation time is short and get more extensive application, is an inevitable trend in the development of Esophagus surgery. Through the clinical use, we have the following experience.
CDH/SDH type stapling operation simple and convenient, is easy to grasp, reliable performance, safety, and its safety switch and closed with consistent and best one.the pointer (blue line mark safe limits inside), and only when the pointer of safety switch security range can be identical, therefore, open complete can avoid the errors caused by improper operation. But in the specific application, the following aspects: (1) the correct selection note, CDH/SDH stapling models respectively, and bending type two straight, each have different size (23; 25; 27; 29; 31 mm) specifications for selection. We feel bending type (CDH) identical prices higher than vertical, but to reveal the deep and poorer parts of the application. Good, and revealed more shallow parts choose vertical (SDH). Group of 32 cases of pleural top and Esophagus stage, using CDH type, type selection SDH are obtained satisfactory effect; anastomosis, 2 the esophagus, should pouch suture, Esophagus stump ligation left organization is unfavorable and overmuch, lest affect anastomosis, had better use autocratic pouch clamp and suture line, 3 the residue free length is esophagus anastomosis slightly shorter for manual, facilitate suture embedding can; (after the agreement should be gentle slowly, avoid injury anastomotic, close mouth should reduce stapling placement and avoid to anastomotic ministry force, preventing anastomotic tear. 5 after cutting in agreement whether complete inspection organization, smooth and to push to anastomotic situation.
Anastomosis (the machinery in the agreement, its incidence is ignored in 1% ~ 2% [4], 85 cases 19.88% anastomotic fistula in 1 and stomach. Anastomosis (happened with the following factors: could not skillful technical operation link, mainly in the attention of Esophagus residue free of reserves; muscle membrane, The agreement should be moderate, firmness one.the causes too tight anastomosis of the organization department, too loose nails trauma and after anastomotic and close close and avoid to remove stapling pine is too long, in order to avoid damage in nail base cap out anastomosis. For patients with diabetes, because of organization, loose nails and healing may have certain effect. In cases of anastomosis (19.88% with diabetes mellitus, see the organization is broken Esophagus residue with omental embedding anastomotic failed to smooth healing, fistula may occur with diabetes patients and the organization joint anti-infection ability weak, so there must be in such patients, with no mechanical anastomosis advisable or anastomotic with surrounding tissue embedding reinforcement, can avoid anastomosis (occurs.
Anastomotic stenosis is the main shortcomings, stapling homebred stapling anastomosis stricture rate of 2% ~ 4% [5], and lip length, tantalum nail anastomosis and coarse, few long pole, cutting center, cause less organization DuiGe mucosal anastomotic granulomas is bad, and excessive growth type/SDH CDH lip short, while stapling nail number, titanium, cutting center stem width, DuiGe mucosa tissue, texture is soft, therefore, have reason that the incidence of postoperative anastomotic stricture may reduce. But we should realize the esophagus, pouch suture needle shoulds not be too long, lest Esophagus mucosa and retract and insufficiency, nail excessive growth of granulation tissue while anastomosis stricture. Barium swallow 19.88% postoperative esophagus anastomosis unobstructed, check see no narrow, but less number of cases and short time, still need to further observation.
Postoperative observation results of relevant Esophagus dynamics are not all the same. WangJiZhang [6] report residual Esophagus motility basic disappeared, and stomach esophagus is a “common”. Okada [7] observation are identical 5.33 kPa (40 mmHg) around the high. We [8] 41 cases of Esophagus anastomosis of fold type detection: the esophagus anastomosis of gastric ministry is high, average for (1.49 ± 0.60 kPa) 11.17 [(47) mmHg], ± than normal Esophagus pressure at LESP (low) sphincter, but can maintain with thoracic cavity residual stomach esophagus within the cavity pressure difference has certain effect of regurgitation. There two distinct observation results, with its main operation. Anastomosis WangJiZhang [6] are adopted, and the single Okada [7] and I adopted the method of the agreement on the stomach of bag, with increasing pressure anastomosis. Anastomotic After using stapling causese of stomach, esophagus bag bottom wall can increase the pressure on anastomotic, plays a certain role against reflux. 10 cases of Esophagus pressure measurement for the average anastomosis area kPa (1.53 pressure 11.46 mmHg), nearly identical level of undergraduate course manual fold. But the two cases of patients are still not luggage mild regurgitation, Esophagus pressure lower than normal, 24 h scores were also DeMeester pH higher than normal. Therefore, additional stomach esophagus bag, will play a certain set of regurgitation.
Because of this, for one-time use stapling under the condition of higher prices. Should master a certain indication, can give full play to its advantages.