持续冲洗联合胸腔闭式引流用于食管空肠吻合口瘘合并纵隔和胸腔及腹腔感染的治疗效果

摘要

目的 探讨持续冲洗联合胸腔闭式引流治疗全胃切除术后食管空肠吻合口瘘(EJAF)合并纵隔、胸腔及腹腔感染临床疗效.方法 回顾性分析2012年6月至2018年5月期间,在解放军联勤保障部队第九○一医院普通外科接受根治性全胃切除术后发生EJAF合并纵隔、胸腔及腹腔感染的22例患者临床资料.病例纳入标准:(1)术前内镜病理确诊为胃腺癌,并行根治性全胃切除且无严重器官功能不全;(2)术后影像学明确诊断为EJAF合并纵隔、胸腔及腹腔感染,CT和超声均证实存在胸腔积液.其中10例采用单纯胸腔闭式引流(单纯引流组),12例除行胸腔闭式引流外,同时于同一窦道内胸腔闭式引流管旁另置橡胶导尿管,予以0.9%氯化钠溶液持续滴注冲洗,滴速为50～100 ml/h(持续冲洗加引流组).比较两组感染指标、吻合口瘘愈合时间及其相关临床指标.结果 单纯引流组10例患者中男性5例,年龄(61.9±10.7)岁,腹腔镜手术4例,开腹手术6例,EJAF分级Ⅲ级者6例,Ⅳ级者4例;持续冲洗加引流组12例患者中男性6例,年龄(61.7± 11.0)岁,腹腔镜手术7例,开腹手术5例,EJAF分级Ⅲ级者6例,Ⅳ级者6例.两组患者性别、年龄、基础疾病、术前血液学检查指标、手术方式、肿瘤TNM分期、EJAF分级等基线资料的比较,差异均无统计学意义(均P＞0.05);术后出现EJAF合并纵隔、胸腔及腹腔感染时,两组患者白细胞总数、降钙素原、C反应蛋白等生化指标的差异无统计学意义(P＞0.05),具有可比性.两组患者均达到临床治愈,无死亡病例出现.经胸腔闭式引流后,与单纯引流组比较,持续冲洗加引流组感染指标恢复至正常水平的时间明显较少[白细胞计数:(6.8±2.0) d比(10.5±3.0) d,t=4.062,P＜0.001;降钙素原:(7.5±1.0) d比(9.2±1.9) d,t=3.236,P=0.040;C-反应蛋白:(8.8±1.0) d比(11.2±1.5) d,t=5.177, P＜0.001];外科重症监护室的入住时间[(4.9±2.5) d比(9.9±6.7) d,t=2.935,P=0.006]、瘘的愈合时间[(42.9±12.5) d比(101.8±53.2) d,t=4.187,P=0.001]以及术后总住院时间[(62.3±15.8) d比(119.7±59.4) d,t=3.634,P=0.002]明显较短;总住院费用明显较低(中位数 8.6 万元比 12.4万元,Z=2.063,P=0.040).结论 以0.9%氯化钠溶液持续冲洗的胸腔闭式引流方式可以加速EJAF合并纵隔和胸腔及腹腔感染患者的感染控制和缓解,缩短吻合口瘘愈合时间.%Objective To investigate the clinical efficacy of continuous irrigation combined with closed thoracic drainage for esophagojejunal anastomotic fistula (EJAF) complicated with mediastinal, thoracic and abdominal infection after total gastrectomy. Methods Clinical data of 22 EJAF patients complicated with mediastinal, thoracic and abdominal infection after radical gastrectomy at Department of General Surgery of the 901th Hospital of PLA from June 2012 to May 2018 were retrospectively analyzed. Case inclusion criteria: (1) gastric adenocarcinoma confirmed by preoperative endoscopic pathology undergoing radical total gastrectomy without severe organ dysfunction; (2)EJAF complicated with mediastinal, thoracic and abdominal infections diagnosed by postoperative radiography, the presence of pleural effusion confirmed by CT and ultrasound. Among them, 10 cases were treated with simple thoracic closed drainage (single drainage group); 12 cases received same closed thoracic drainage, and a rubber catheter was placed next to the closed thoracic drainage tube in the same sinus. A 0.9% sodium chloride solution was applied in continuous drip irrigation with drip velocity at 50 to 100 ml/h (continuous flushing plus drainage group). Infection indicators, anastomotic fistula healing time and related clinical indicators were compared between the two groups. Results In the simple drainage group, 5 cases were males, age was (61.9 ±10.7) years old, 4 cases received laparoscopic surgery, 6 cases received open surgery, 6 cases were EJAF grade Ⅲ, 4 cases were EJAF IV. In continuous flushing and drainage group, 6 cases were males, age was (61.7±11.0) years old, 7 cases received laparoscopic surgery, 5 cases received open surgery, 6 cases were EJAF grade Ⅲ, and 6 cases were EJAF grade IV. Baseline data including gender, age, underlying diseases, preoperative hematological examination indexes, surgical methods, tumor TNM stage and EJAF grade were not significantly different between the two groups (all P＞0.05). When postoperative EJAF was complicated with mediastinal, thoracic and abdominal infection, biochemical parameters including white blood cell, procalcitonin, C-reactive protein were not significantly different between two groups (all P＞0.05). All patients of both groups achieved clinical cure without death. Compared with the simple drainage group after closed thoracic drainage, the continuous irrigation plus drainage group had significantly shorter duration of infection parameters returning to normal levels [white blood cell count: (6.8 ± 2.0) days vs. (10.5±3.0) days, t=4.062, P＜0.001; procalcitonin: (7.5±1.0) days vs.(9.2±1.9) days, t=3.236, P=0.040; C-reactive protein: (8.8±1.0) days vs.(11.2±1.5) days, t=5.177, P＜0.001], meanwhile time in surgical ICU [(4.9±2.5) days vs.(9.9±6.7) days, t=2.935, P=0.006], healing time of fistula [(42.9±12.5) days vs.(101.8±53.2) days, t=4.187, P=0.001] and total postoperative hospital stay [(62.3±15.8) days vs.(119.7 ±59.4) days, t=3.634, P=0.002] were significantly shorter, and total hospitalization cost was significantly lower (median 86 000 yuan vs. 124 000 yuan, Z=2.063, P=0.040) in the continuous irrigation plus drainage group. Conclusion The continuous closed thoracic drainage with 0.9% sodium chloride solution can accelerate infection control and remission of EJAF patients complicated with mediastinal, thoracic and abdominal infections, and shorten the healing time of anastomotic fistula.