腹腔镜辅助根治性全胃切除术后食管空肠吻合口漏诊治方法的改进

摘要

Objective Esophagojejunal anastomosis leakage is one of the severe complications after laparoscopic total gastrectomy and affects the long-term survival rate. Our aim is to explore an effective draninage approach to shorten treatment period. Method 3 patients who developed esophagojejunal anastomosis after laparoscopic total gastrectomy in Chinese Academy of Medical Sciences and Peking Union Medical College were identified and investigated. The diagnosis was established by changes of drainage, exit of methylene blue through the drain, upper digestive tract radiography and abdominal computed tomography (CT) scan on the 4th, 5th and 6th postoperative day respectively. Combined with other comprehensive treatment including fasting, continuous gastrointestinal decompression, parenteral and enteral nutrition, and broad-spectrum antibiotics, the effective management of drainage tube was achieved through the method of "T-tube drainage of the bile duct". The drainage tube can be clamped if the patient's body temperature was normal after two weeks. And after 24 ~ 48 hours later, oral feeding could be allowed. Then we clamped the drainage tube intermittently and retreated 1~2 cm every 3~5 days until the removal of drainage tube. Result 3 patients were all cured and discharged. The mean time of oral feeding was 20 days (range: 16 ~ 23 days) after diagnosis of anastomotic leakage; the mean time of removal of drainage tube was 28 days (range: 25 ~ 33 days); the hospitalization time was 30 days (range: 27 ~ 34 days). All 3 patients were followed up 3 ~ 16 months and no recurrent fever and abdominal pain were observed. Conclusion On the basis of fasting, continuous gastrointestinal decompression, parenteral and enteral nutrition, and broad-spectrum antibiotics, the effective management of drainage tube is achieved through the method of"T-tube drainage of the bile duct", which shortened the cure time of esophagojejunal anastomotic leakage.%目的 食管空肠吻合口漏是腹腔镜根治性全胃切除术后的严重并发症之一,影响患者的预后.本研究旨在探索有效的引流方法,以期缩短食管空肠吻合口漏的治愈时间.方法 总结分析中国医学科学院肿瘤医院3例腹腔镜根治性全胃切除术后食管空肠吻合口漏患者的临床诊治过程.3例患者分别于腹腔镜根治性全胃切除术后第4、5、6天,根据引流液性状改变、上消化道造影、腹部CT及美兰试验明确诊断为食管空肠吻合口漏.在禁食禁水、胃肠减压、肠内外营养支持及抗感染治疗的基础上,按照"胆管T管引流"的理念和原则管理引流管.在引流通畅、患者无发热后,诊断吻合口漏满2周即可试行夹闭腹腔引流管,观察24~48小时,如患者无不适,则可进水、进食,并间断夹闭引流管,每3~5天退管1~2 cm,若未见引流量和性质明显变化,逐渐退管直至拔除引流管.结果 3例患者吻合口漏均治愈,拔除引流管后顺利出院.3例患者平均进食时间为诊断吻合口漏后20天(16~23天);平均拔除引流管时间为诊断吻合口漏后28天(25~33天);诊断吻合口漏后住院天数为30天(27~34天).随访3~16个月,3例患者术后均无长期发热、腹胀、腹痛等不适.结论 在禁食禁水、对症支持治疗及抗感染治疗的基础上,通过"胆管T管引流"的方法进行有效的引流管管理,缩短了食管空肠吻合口漏的治愈时间.