摘要
目的探讨不同宽度的管状胃对行Ivor-Lewis术后食管癌患者生活质量的影响。方法采用回顾性队列研究方法，选取2015年1月至2016年6月在南京医科大学鼓楼临床医学院心胸外科行Ivor-Lewis术式的188例食管癌患者的临床资料及术后随访资料。研究对象的纳入标准为年龄〈75岁且基础情况较好、无远处转移、术后1年随访资料完整的食管中一下段鳞状细胞癌患者。以术中裁剪成形的管状胃宽度作为分组依据，其中细管状胃组有92例（管状胃宽度≥2em且〈4cm），亚组再分为：较细组（44例，管状胃宽度为≥2cm且〈3cm）和中细组（48例，管状胃宽度为≥3cm且〈4cm）；粗管状胃组有96例（管状胃宽度≥4cm），亚组再分为：中粗组（50例，管状胃宽度为≥4cm且〈5cm）和更粗组（46例，宽度为≥5cm）。对术后患者进行为期1年的电话或门诊随访，满1年后进行住院复查，包括复查肺功能、进行食管测压、食管24hpH监测检查（pH〈4．0的总次数、pH〈4．0持续5min以上的次数、pH〈4．0的最长持续时间以及pH〈4．0总时间百分比）以及管胃扩张度测量（CT测量的管胃宽度减去术中测量的管胃宽度）。住院复查期间，填写生活质量评定表进行术后生活质量测评。比较不同宽度管状胃患者的术后1年复查指标状况．并绘制线图表示不同宽度管状胃患者的复查指标变化趋势。结果细管状胃组和粗管状胃组患者术前基线资料、术后病理及术后并发症（残胃漏、吻合口漏、吻合口狭窄、肺部并发症、房颤及乳糜胸）发生情况的比较，差异均无统计学意义（均P〉0．05）。与粗管状胃组比较，细管状胃组术后肺功能各项指标，包括术后肺活量百分比[（76．4±6．8）％比（73．2±7．7）％，t=2．168，P=0．033]，术后最大通气量百分比[（72．7±6．4）％比（69．3±6．8）％，t=2．409，P=0．018]以及术后第1秒用力呼气容积百分比[（69．2±5．0）％比（66．7±6．2）％，t=2．033，P=0．045]均较高，吻合口平面压力较大[（5．4±3．1）mmHg比（4．2±2．4）mmHg，t=2．083，P=0．038]，术后管胃扩张度更大[（1．0±0．4）cm比（O．5±0．3）cm，t=5．888，P=0．000]，24h食管pH监测指标包括pH〈4总次数[（228．3±65．3）次比（280．8±103．9）次，t=-2．920，P=0．004]、pH〈4持续5min以上的次数[（19．9±8．5）次比（30．6±15．6）次，t=4．127，P=0．000]、pH〈4最长持续时间[（32．5±9．4）min比（37．9±13．6）min，t=-2．232，P=0．028]、pH〈4总时间百分比[（23．4±10．2）％比（28．4±10．6）％，t=-2．303，P=0．024]均较低。但两组在生活质量评分的差异尚未达到统计学意义（P=0．051）。各亚组间两两比较显示，较细组术后1年肺功能指标、吻合口平面压力、术后管胃扩张度、食管pH检测指标及术后生活质量评分均优于更粗组（均P〈0．05）。较细组和中细组、中粗组和更粗组术后复查指标的比较，差异均无统计学意义（均P〉0．05）。通过线图显示，管状胃宽度越大，术后肺功能越差，胃食管反流程度越严重；管状胃宽度越小，术后管胃扩张程度越大。结论管状胃裁制宽度在2～4cm之间时，可以改善Ivor-Lewis术后食管癌患者的生活质量．且不增加术后并发症发生风险。
Objective To explore the impact of the gastric tube diameter on quality of lite of esophagus cancer patients after Ivor-Lewis esophagectomy. Methods Clinical and tollow-up data of 188 esophageal cancer patients who underwent lvor-Lewis esophagectomy at Department of Cardio-Thoracic Surgery, Drum Tower Clinical Medicine College, Nanjing Medical University from January 2015 to June 2016 were retrospectively analyzed. Inclusion criteria included age 〈75 years old, good foundation health situation, no distant metastasis, complete tbllow-up data for one-year alter surgery, and middle- lower esophageal squamous cell carcinoma （ESCC）. According to the diameter of gastric tube formed during operation, 92 patients were assigned to narrow gastric tube group （NGT group, ≥ 2 cm to 〈4 cm）, which were further divided into narrower group （≥2 cm to 〈3 cm, n=44） and medium narrow group （≥3 cm to 〈4 cm, n=48） ; 96 patients were assigned to wide gastric tube gruup （WGT group, ≥4 cm）, which were further divided into medium wide group （≥4 cm to 〈5 cm, n=50） and wider group （≥ 5 era, n=46）. Postoperative patients were followed up by telephone or outpatient service for one year and then re-hospitalized to receive associated examinations, including lung function test, esophageal pressure measurement, 24-hour esophageal dynamic pH monitoring （total number of pH〈4, number of pH〈4 lasting more than 5 minutes, maximum duration of pH〈4 and time percentage of pH〈4） and dilatation measurement of gastric tube （the diameter measured by CT minus the diameter measured in surgery）. During follow-up, postoperative quality of life （QoL） was assessed by questionnaire. These contents were compared and plotted as a chart. Results There were no statistically significant differences between NGT group and WGT group regard to preoperative baseline information, postoperative pathology and postoperative complications （residual gastric leakage, anastomotic leakage, anastomotic stenosis, pulmonary complications, atrial fibrillation and chylothorax） （all P〉0.05）. Compared with WGT group, the NGT group had better postoperative lung function, including percentage of vital capacity [（76.4±6.8）% vs. （73.2±7.7）%, t=2.168, P=0.0331, percentage of maximal voluntary ventilation [（72.7±6.4）% vs. （69.3±6.8）%, t=2.409, P=0.018] and percentage of forced expiratory volume in the first second [（69.2±5.0）% vs. （66.7±6.2）%, t=2.033, P=0.0451, higher plane pressure of anastomotic stoma [ （5.4±3.1） mmHg vs. （4.2±2.4） mmHg, t=2.083, P=0.038], greater dilatation of gastric tube [（1.0±0.4） cm vs. （0.5±0.3） cm, t=5.888, P=0.000], milder gastroesophageal reflux according to the indices of 24-hour esophageal dynamic pH monitoring, including the total numher of pH〈4 （228.3±65.3 vs. 280.8±103.9, t=-2.920,P=0.004）, the number of pH〈4 lasting more than 5 minutes （19.9±8.5 vs. 30.6±15.6, t=-4.127,P=O.O00）, the maximum duration of pH〈4[（32.5±9.4） minutes vs. （37.9±13.6） minutes, t=-2.232,P=0.028] and the time percentage of pH〈4 [ （23.4±10.2）% vs. （28.4±10.6）%, t=-2.303, P=0.024]. However, no significant difference was found in the scores of postoperative QoL between the two groups （P=0.051）. According to the pairwise comparisons among the fimr subgroups, narrower group showed better performance on postoperative lung function, plane pressure of anastomotic stnma, the dilatation of gastric tube, indices of 24-hour esophageal dynamic pH monitoring and scores of postoperative QoL as compared to wider group （all P〈0.05）. There were no statistically significant difl＇erences among medium narrow group, medium wide group and wider group. Line charts showed that the larger of the gastric tube diameter, the worse of the postoperative lung function, the more severe of gastroesophageal reflux and the smaller degree of gastric tube dilatation. Conclusion Narrow gastric tube with a diameter of 2-4 cm can improve the postoperative QoL of esophagus cancer patients aider Ivor-Lewis esophagectomy without increasing the risk of postoperative complications.
作者
何晓峰
史敏科
曹彬
He Xiaofeng;Shi Minke;Cao Bin(Department of Thoracic-Cardio Surgery,Drum Tower Clinical Medicine College Affiliated to Nanjing Medical University,Nanjing 210008,China)
出处
《中华胃肠外科杂志》
CAS
CSCD
北大核心
2018年第9期1001-1007,共7页
Chinese Journal of Gastrointestinal Surgery
