不同食管胃吻合方式对术后并发症影响的Meta分析

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杨列, 郑轶峰, 姜建青, 俞永康, 李卫, 郑琇山. 不同食管胃吻合方式对术后并发症影响的Meta分析. 循证医学, 2013,13(3): 173-180
YANG Lie, ZHENG Yi-feng, JIANG Jian-qing, YU Yong-kang, LI Wei, ZHENG Xiu-shan. Comparison of Hand-Sewn and Stapled Esophagogastric Anastomoses： A Meta-Analysis. Journal of Evidence-Based Medicine,2013, 13(3): 173-180 复制到剪切板

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不同食管胃吻合方式对术后并发症影响的Meta分析

杨列, 郑轶峰, 姜建青, 俞永康, 李卫, 郑琇山

成都军区总医院心胸外科, 成都 610083

通讯作者: 姜建青,Tel：028-86570359; E-mail：yanglie1982@qq.com

作者简介: 杨列（1982-）,男,四川安岳人,硕士研究生,从事胸外科临床、基础研究。

摘要

目的探讨手工吻合与器械吻合（端侧吻合和侧侧吻合）对食管胃吻合术后吻合口并发症及死亡率的影响。方法计算机检索PubMed、Cochrane图书馆临床对照试验资料库,检索时间均从建库至2012年2月,收集比较手工吻合与器械吻合（端侧吻合和侧侧吻合）对食管胃吻合术后并发症的随机对照研究,对符合纳入标准的临床研究进行质量评价和资料提取后,采用RevMan 5.0软件进行Meta分析。结果共纳入11项研究,合计1 207例患者;所有的研究均是前瞻性研究,均未采用盲法,Jadad评分4分的 8篇,3分的3篇。各研究间无显著异质性,采用固定效应模型分析。11个研究报道了吻合口瘘发生率,术后吻合口瘘发生率差异无统计学意义（优势比1.07,95%可信区间0.67~1.73,P=0.77）。10个研究报道了术后良性吻合口狭窄率,环形吻合器吻合组吻合口狭窄率高于手工吻合组（优势比2.20,95%可信区间1.54~3.15,P<0.01）,差异有统计学意义。1个研究报道了侧侧吻合方法,吻合口瘘及狭窄发生率均显著低于环形吻合器吻合及手工吻合。7个研究报道了术后住院死亡率（优势比1.29,95%可信区间0.59~2.85,P=0.527）,不同吻合方式间术后住院死亡率差异无统计学意义。所有研究无明显发表偏倚。结论不同吻合方式（手工吻合、器械端侧吻合和器械侧侧吻合）对食管胃吻合术后吻合口瘘发生率、死亡率无显著影响,但环形吻合器行食管胃端侧吻合较手工吻合术后良性吻合口狭窄率显著增高。

关键词: 食管胃吻合; 手工吻合; 器械吻合; 侧侧吻合; Meta分析

中图分类号:R615 文献标识码:A

Comparison of Hand-Sewn and Stapled Esophagogastric Anastomoses： A Meta-Analysis

YANG Lie, ZHENG Yi-feng, JIANG Jian-qing, YU Yong-kang, LI Wei, ZHENG Xiu-shan

Department of Cardiothoracology, Chengdu Military General Hospital, Chengdu 610083, China

Abstract

Objective To investigate the impact of hand-sewn and stapled esophagogastric anastomoses on postoperative mortality, anastomostic leak and fibrosis stricture.Methods Such databases as PubMed and Central Register of Controlled Trials （from the date of their establishments to February 2012） were searched. Eligible studies accessed the postoperative complications after hand-sewn and stapled esophagogastric anastomoses of which randomized control trials were collected. Quality assessment and data extraction were performed in those clinical trials. RevMan 5.0 software was applied to carry out the meta-analysis.Results Eleven relevant studies with 1 207 patients were included. All the studies were prospective but unblinded because of performing surgery. There were 8 studies with Jadad score 4, and 3 studies with Jadad score 3. Eleven studies reported the incidence of anastomostic leak, no significant heterogeneity between the 11 trials and fixed model was used to analysis. The combined OR=1.07, 95%CI 0.67~1.73,P=0.77. There was no statistically difference between the incidences of postoperative anasotmostic leaks. Ten studies reported the incidence of anastomostic stricture, the combined OR=2.20,95%CI 1.54~3.15,P<0.01. The incidence of postoperative anasotmostic stricture in circular stapled anastomoses patients was statistically higher than that in hand-sewn anastomosed patients. Seven studies reported the postoperative mortality. The combined OR=1.29, 95%CI 0.59~2.85,P=0.52. There was no statistically difference between the mortality. Only one study compared side-side anastomosis and reported a lower incidence of postoperative anastomostic leak and stricture. No obvious publication bias existed.Conclusion Circular stapled esophagogastric anastomoses increased the incidence of postoperative anastomostic stricture comparing with the hand-sewn anastomosed.

Key words: esophagogastric anastomosis; hand-sewn anastomosis; stapled anastomosis; side-side anastomosis; meta-analysis

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食管癌是常见肿瘤之一,2008年全球预计新发病例482 300例,预计死亡病例406 800例^{[ 1]},而我国属于食管癌高发带。尽管目前放化疗已取得了较大发展^{[ 2]},手术切除仍是食管癌治疗的主要手段^{[ 3]}。食管癌切除术中最常见的食管重建方法是通过胃代食管和食管胃吻合^{[ 4]}。吻合口瘘是食管胃吻合最常见的早期并发症^{[ 5]},它也是食管癌术后患者致残及死亡的主要原因^{[ 6]};文献报道,吻合口瘘的发生率在0%~24%^{[ 6, 7, 8]},约占总死亡病例的90%^{[ 9]}。良性吻合口狭窄是食管胃吻合的晚期主要并发症之一,其严重影响患者生活质量及手术效果;术后吻合口狭窄发生率在13.6%~40%^{[ 10, 11]}。

传统食管胃吻合方法是手工吻合,包括单层及分层缝合。1977年环形吻合器发明以后,器械吻合得到广泛使用^{[ 12]}。近年来,借助腔镜直线切割缝合器进行侧侧吻合的方法得到不少支持,被认为可以减少术后吻合口狭窄的发生^{[ 13, 14]}。但究竟哪一种吻合方法更有优势目前仍有争议,多数手术人员基于其个人对吻合技术的喜好来选择吻合方式^{[ 5]}。本文目的是系统评价目前的文献,评估不同食管胃吻合方法对术后吻合口并发症的影响。

1 资料和方法

1.1 文献纳入标准

研究对象：食管癌、贲门癌或其它食管良性疾病,接受食管癌或贲门癌切除、胃代食管、食管胃吻合术,年龄18周岁以上患者;干预措施：手工端侧吻合,环形吻合器端侧吻合,腔镜直线切割缝合器侧侧吻合方法;研究类型：前瞻性、随机临床试验（randomized clinical trial,RCT）;评价指标：术后死亡率、吻合口瘘及吻合口狭窄发生率。

1.2 检索策略

两名研究者分别对PubMed和Cochrane Library进行检索,检索时间从建库至2012年2月。我们使用自由词（“esophageal” OR “esophagus”OR“esophagastric”） AND （“anastomosis” OR “anastomoses” OR “anastomostic”）进行检索;对文献语言不予限制;同时手工检索相关文献及综述的参考文献。

1.3 资料收集和统计学方法

所有研究者都完整阅读每一篇纳入文献,并采用Jadad方法对每一篇文献进行RCT质量评估：①采用何种随机分配方法,方法是否正确（0~2分）;②是否进行分配隐藏,方法是否正确（0~2分）;③是否采用盲法,方法是否恰当（0~2分）;④有无失访和退出及理由（0~1分）。

数据由2名研究者提取并交叉核对,有争议时通过讨论解决。用优势比（odds ratio,OR）及其95%可信区间（confidence interval,CI）来分析各种计数资料,采用RevMan 5.0软件完成分析。通过以下两种方法检验纳入试验的异质性：χ²检验, P>0.1 提示没有异质性; I²检验, I²<50%提示低异质性可能。如果各研究没有显著异质性,采用固定效应模型（fixed effect model）分析;反之,如各研究存在显著异质性,则采用随机效应模型（random effect model）分析,并对可能导致异质性的因素进行亚组分析或敏感性分析。采用Begg漏斗图分析法（funnel plot）描述纳入文献的发表偏倚。

2 结果

2.1 文献筛选

初检出4 605篇文献,筛选后11篇随机对照研究纳入本系统评价,检索策略见图1。所有的研究均是前瞻性研究,纳入研究质量评价见表1。由于是手术研究,均未采用盲法,Jadad评分（满分7分）4分的8篇,3分的3篇,不能进行双盲及未描述随访分组方法、缺乏随机隐藏是文献评分低的主要原因。

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	图 1 文献检索流程图

表1 纳入11 项随机临床研究的质量评估

2.2 一般资料

纳入的研究中最早开始于1985年,最晚开始于2007年,其中6个研究纳入样本量大于100例。除Walther等^{[ 10]}的研究纳入了良性食管病变外,所有研究均仅纳入食管癌或贲门癌患者,10个研究报道了肿瘤部位及分期情况;3个研究明确纳入了术前放化疗患者。3个研究术中测量食管外径后进行了分层分组,并根据食管外径使用不同型号的环形吻合（最大使用31号吻合器）。除Valverde等^{[ 17]}的研究纳入了经裂孔手术患者外,所有研究均采用开胸入路或胸腹入路手术,4个研究进行了管状胃成形,Laterza、Hsu等^{[ 18, 21]}的两项研究中,颈部吻合患者移植胃经前纵隔上拉至颈部。所有研究均报道了术后吻合口瘘的发生率,1个研究未报道术后吻合口狭窄率。纳入研究的其它一般情况详见表2。

表2 纳入研究的基本情况

2.3 吻合口瘘

所有研究均报道了吻合口瘘的发生率,4个研究报道单层手工吻合术的吻合口瘘发生率为1.6%~6.7%;5个研究报道分层手工吻合术的吻合口瘘发生率为0.4%~22%;所有研究均有环形吻合器吻合组,吻合口瘘发生率为0%~26%。1个研究报道了侧侧吻合,45例侧侧吻合患者没有吻合口瘘发生。只有1个研究报道手工吻合与环形吻合器吻合组在吻合口瘘发生率上差异有统计学意义。所有研究异质性检验 P=0.79, I²=0%,研究间无统计学异质性,采用固定效应模型分析。Meta分析结果显示,合并OR=1.07,95%CI 0.67~1.73, P=0.77;两组在吻合口瘘发生率上差异无统计学意义。分层分析显示单层、双层手工吻合与环形吻合器吻合患者间吻合口瘘发生率差异均无统计学意义（ P>0.05）;不同吻合部位（颈部与胸内、颈部与颈部、胸内与胸内）对两种吻合方法术后吻合口瘘发生率无显著影响（ P>0.05）,见图2。

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	图2 食管胃手工吻合与环形吻合器吻合对食管癌术后吻合口瘘影响的Meta 分析

2.4 良性吻合口狭窄

共有10个研究报道了良性吻合口狭窄发生率,其中6个研究以内镜下食管直径<10 mm为标准,1个研究以造影直径小于8 mm为标准, 2个研究以有需要扩张治疗的吞咽困难为诊断标准。3个研究吻合前对食管外径进行测量后根据食管外径进行分组,并根据食管直径使用了不同型号的吻合器。4个研究报道单层手工吻合吻合口狭窄发生率在9.1%~26.5%;6个研究报道分层手工吻合吻合口狭窄发生率在0%~14%;所有研究均有环形吻合器吻合组,吻合口狭窄发生率在5%~40%。只有1个研究报道了侧侧吻合,45例患者没有吻合口狭窄发生。4个研究报道手工吻合与环形吻合器吻合组在吻合口狭窄发生率上有统计学差异。10个研究异质性检验 P=0.25, I²=21%,研究间无统计学异质性,采用固定效应模型分析。Meta分析结果显示,合并OR=2.20,95%CI 1.54~3.15, P<0.01;提示环形吻合器吻合组吻合口狭窄发生率高于手工吻合组,差异有统计学意义。分层分析显示单层、双层手工吻合吻合口狭窄发生率均低于环形吻合器吻合（ P<0.01,见图3）。手工胸内吻合与环形吻合器胸内吻合比较,吻合口狭窄率明显下降;而颈部手工吻合与颈部、胸内环形吻合器吻合比较,吻合口狭窄率无显著差异（见图4）。

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	图3 食管胃手工吻合与环形吻合器吻合对食管癌术后吻合口狭窄影响的Meta分析

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	图4 吻合部位对食管胃手工吻合与环形吻合器吻合术后吻合口狭窄影响的Meta分析

2.5 住院死亡率

2个研究报告了术后30天死亡率和住院死亡率,5个研究报告了住院死亡率,3个研究报告了术后30天死亡率,1个研究未报道术后死亡情况。住院死亡率合并OR=1.29,95%CI 0.59~2.85, P=0.52,不同吻合方式间术后住院死亡率差异无统计学意义（见图5）。

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	图5 食管胃手工吻合与环形吻合器吻合对食管癌术后住院死亡率影响的Meta分析

2.6 敏感性分析

由于Hsu等的研究术后吻合口瘘发生率较高,且其术后住院时间长达40余天;而West Scotland小组的研究时间在1990年以前;两个研究可能受手术者学习曲线的影响较大,我们排除该两项研究以进一步分析。排除后吻合口瘘的合并OR=1.01,95%CI 0.59~1.72, P=0.98,无显著差异;吻合口狭窄的合并OR=2.27, 95%CI 1.57~3.30, P<0.01,差异仍有统计学意义。

2.7 发表偏倚

对11篇文献进行漏斗图检验,如图6所示,漏斗图对称,各试验均位于95%CI线内,显示无明显发表偏倚。

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	图6 纳入的11项随机临床试验漏斗图

3 讨论

尽管食管癌的多模式治疗有了较大进展^{[ 2]},但手术仍是早期食管癌的主要治疗手段。食管癌手术方式纷繁复杂,各有优劣;其术后并发症主要有吻合口瘘、吻合口狭窄、肿瘤复发转移以及肺部并发症等。其中吻合口瘘是术后早期死亡的主要原因,吻合口良性狭窄则是影响食管癌患者术后生活质量的主要因素。

吻合口瘘的主要原因包括：吻合技术不可靠,吻合口缺血以及术后吻合口张力过高。吻合口良性狭窄的主要原因有：吻合口瘘和吻合口瘢痕形成。吻合口对合不良是引起吻合口瘢痕形成原因之一,环形瘢痕形成则更容易引起狭窄^{[ 25]}。因此,不同的吻合方法可能对术后吻合口瘘及良性吻合口狭窄等并发症产生重要影响。大量的研究者尝试比较了食管切除术后不同吻合方法的效果;多个回顾性研究表明环形器械吻合降低了吻合口瘘的发生^{[ 26]},而其他一些研究未发现手工吻合和环形器械吻合间吻合口瘘发生率有显著差异^{[ 27]}。另有研究指出环形器械吻合增加了吻合口狭窄的发生率^{[ 28]},其原因可能是黏膜对位不良导致肉芽组织形成和过度纤维化形成^{[ 22]},而另一些研究则得到了相反的结论^{[ 29]}。

本文对不同吻合方法对术后吻合口并发症的影响进行了荟萃分析,以探讨不同吻合方法的优势。纳入的临床试验均为前瞻性随机临床试验,研究例数超过100例者有6个,研究总体质量较高,无显著发表偏倚。从11个临床随机对照试验来看,只有1个随机对照研究提示术后吻合口瘘在手工吻合与环形吻合器吻合间有差异;分析结果也提示：无论单层或双层手工吻合,术后吻合口瘘发生率与环形吻合器吻合并无差异。与环形吻合器吻合比较,手工吻合显著降低了吻合口狭窄的发生。尽管有研究认为,双层缝合较单层缝合更有优势^{[ 30]},但我们的分层研究提示双层缝合与单层缝合吻合口瘘发生率与环形吻合器吻合间均无差异,而两者吻合口狭窄发生率均较后者低。虽然分析提示吻合部位（颈部或胸内）对吻合口狭窄无显著影响,但针对这一问题纳入的研究数量较少,有待进一步研究比较。分析术后住院死亡率发现,两种手术方式对术后死亡率无明显影响。

在这些研究中也存在一些问题,首先评价吻合口狭窄的标准不统一,有的是根据症状,有的根据内镜下标准进行评价,影响了荟萃分析结果。其次,有研究显示,大直径食管器械吻合术后吻合口狭窄的发生率与手工吻合差异无统计学意义,而小直径食管两者间有显著差异;在所有的11个研究中,只有5 个研究根据食管外径进行分组,并采用了相匹配的环形吻合器。第三,部分研究随访时间较短。Hsu等^{[ 21]}的长期术后随访显示,术后12个月内,吻合口狭窄的患者逐渐增多;因此过短的随访时间将导致对术后吻合口狭窄评价的不准确。第四,部分研究吻合口狭窄随访排除了术后吻合口瘘患者,虽然术后吻合口瘘发生率在各组间均差异不显著,但仍可能影响术后吻合口狭窄发生率的计算。

管状胃成形在有的研究中被报道,有研究证实,胃管状成形后,胃壁缺血面积明显减少^{[ 31]},可有效减少肺部并发症,减少胃潴留,因此管状胃成形已在食管癌手术中得到广泛应用。管状胃成形也可能对吻合口并发症产生影响,本文纳入的研究中只有4篇文献报告了管状胃成形情况。不同移植胃路径也可能对吻合口血供等造成影响,从而影响吻合口愈合,本文中2个研究的移植路径是胃从前纵隔上提至颈部,其余采用后纵隔食管床上提胃。这些因素均有可能影响本研究评价的客观性。

近年来有不少利用线性吻合器进行侧侧吻合的研究^{[ 13, 14, 32]}。食管胃侧侧吻合从理论上有可能避免术后吻合口狭窄的发生：一是扩大了吻合口直径;二是吻合口对合相对整齐;三是吻合口未处于同一平面,避免了环形瘢痕的形成。贲晓松等的研究表明,侧侧吻合可显著降低颈部、胸内食管胃吻合口瘘及狭窄的发生率^{[ 14, 32]}。但只有1篇关于侧侧吻合的随机对照研究,尽管研究结果显示侧侧吻合在吻合口瘘及吻合口狭窄方面均有优势,但试验例数偏少,术后随访时间只有3个月。仍有待进一步的随机对照研究证实。

部分研究报道的术中吻合时间,手工吻合所用绝对时间较器械吻合长;但我们的研究认为,手工吻合较环形吻合器吻合在预防术后吻合口良性狭窄方面有一定优势。而侧侧吻合等其它吻合方法的效果有待进一步研究明确。

The authors have declared that no competing interests exist.

参考文献

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[1]	Jemal A, Bray F, Center MM, et al. Global cancer statistics[J]. CA Cancer J Clin, 2011, 61(2): 69-90. [本文引用:1] [JCR: 153.459]
[2]	Quiros RM, Bui CL. Multidisciplinary approach to esophageal and gastric cancer[J]. Surg Clin North Am, 2009, 89(1): 79-96. [本文引用:2] [JCR: 2.019]
[3]	Stein HJ, Sendler A, Fink U, et al. Multidisciplinary approach to esophageal and gastric cancer[J]. Surg Clin North Am, 2000, 80(2): 659-682;discussions683-656. [本文引用:1]
[4]	Urschel JD, Blewett CJ, Bennett WF, et al. Hand sewn or stapled esophagogastric anastomoses after esophagectomy for cancer: Meta-analysis of rand omized controlled trials[J]. Dis Esophagus, 2001, 14(3-4): 212-217. [本文引用:1] [JCR: 1.642]
[5]	Urschel JD. Esophagogastrostomy anastomotic leaks complicating esophagectomy: A review[J]. Am J Surg, 1995, 169(6): 634-640. [本文引用:2] [JCR: 2.516]
[6]	Martin LW, Swisher SG, Hofstetter W, et al. Intrathoracic leaks following esophagectomy are no longer associated with increased mortality[J]. Ann Surg, 2005, 242(3): 392-399;discussion399-402. [本文引用:1]
[7]	Ercan S, Rice TW, Murthy SC, et al. Does esophagogastric anastomotic technique influence the outcome of patients with esophageal cancer?[J]. J Thorac Cardiovasc Surg, 2005, 129(3): 623-631. [本文引用:1]
[8]	Behzadi A, Nichols FC, Cassivi SD, et al. Esophagogastre- ctomy: The influence of stapled versus hand -sewn anastomosis on outcome[J]. J Gastrointest Surg, 2005, 9(8): 1031-1040;discussion1040-1042. [本文引用:1]
[9]	Dewar L, Gelfand G, Finley RJ, et al. Factors affecting cervical anastomotic leak and stricture formation following esophagogastrectomy and gastric tube interposition[J]. Am J Surg, 1992, 163(5): 484-489. [本文引用:1] [JCR: 2.516]
[10]	Walther B, Johansson J, Johnsson F, et al. Cervical or thoracic anastomosis after esophageal resection and gastric tube reconstruction: A prospective rand omized trial comparing sutured neck anastomosis with stapled intrathoracic anastomosis[J]. Ann Surg, 2003, 238(6): 803-812;discussion812-814. [本文引用:1]
[11]	Blackmon SH, Correa AM, Wynn B, et al. Propensity-matched analysis of three techniques for intrathoracic esophagogastric anastomosis[J]. Ann Thorac Surg, 2007, 83(5): 1805-1813; discussion1813. [本文引用:1]
[12]	Ravitch MM, Steichen FM. A stapling instrument for end-to-end inverting anastomoses in the gastrointestinal tract[J]. Ann Surg, 1979, 189(6): 791-797. [本文引用:1] [JCR: 6.329]
[13]	沈祯云, 王可毅, 宋金涛, 等. 应用直线型缝合器行食管胃侧侧吻合术[J]. 中国现代手术学杂志, 2009, 13(6): 434-438. [本文引用:1]
[14]	贲晓松, 陈刚, 唐继鸣, 等. 食管-胃颈部侧侧机械吻合法在三切口食管癌切除术中的应用[J]. 中国癌症杂志, 2010, 20(2): 130-133. [本文引用:1]
[15]	West of Scotland Highland Anastomosis Study Group. Suturing or stapling in gastrointestinal surgery: A prospective rand omized study[J]. Br J Surg, 1991, 78(3): 337-341. [本文引用:1] [JCR: 1.291]
[16]	Law S, Fok M, Chu KM, et al. Comparison of hand -sewn and stapled esophagogastric anastomosis after esophageal resection for cancer: A prospective rand omized controlled trial[J]. Ann Surg, 1997, 226(2): 169-173. [本文引用:1] [JCR: 6.329]
[17]	Valverde A, Hay JM, Fingerhut A, et al. Manual versus mechanical esophagogastric anastomosis after resection for carcinoma: A controlled trial[J]. Surgery, 1996, 120(3): 476-483. [本文引用:1] [JCR: 3.373]
[18]	Laterza E, de＇ Manzoni G, Veraldi GF, et al. Manual compared with mechanical cervical esophagogastric anastomosis: A rand omised trial[J]. Eur J Surg, 1999, 165(11): 1051-1054. [本文引用:1] [JCR: 0.782]
[19]	Craig SR, Walker WS, Cameron EW, et al. A prospective rand omized study comparing stapled with hand sewn esophagogastric anastomoses[J]. J R Coll Surg Edinb, 1996, 41(1): 17-19. [本文引用:1] [JCR: 0.903]
[20]	Okuyama M, Motoyama S, Suzuki H, et al. Hand -sewn cervical anastomosis versus stapled intrathoracic anastomosis after esophagectomy for middle or lower thoracic esophageal cancer: A prospective rand omized controlled study[J]. Surg Today, 2007, 37(11): 947-952. [本文引用:1] [JCR: 0.963]
[21]	Hsu HH, Chen JS, Huang PM, et al. Comparison of manual and mechanical cervical esophagogastric anastomosis after esophageal resection for squamous cell carcinoma: A prospective rand omized controlled trial[J]. Eur J Cardiothorac Surg, 2004, 25(6): 1097-1101. [本文引用:2]
[22]	Luechakiettisak P, Kasetsunthorn S. Comparison of hand -sewn and stapled in esophagogastric anastomosis after esophageal cancer resection: A prospective rand omized study[J]. J Med Assoc Thai, 2008, 91(5): 681-685. [本文引用:1]
[23]	Zhang YS, Gao BR, Wang HJ, et al. Comparison of anastomotic leakage and stricture formation following layered and stapler esophagogastric anastomosis for cancer: A prospective rand omized controlled trial[J]. J Int Med Res, 2010, 38(1): 227-233. [本文引用:1] [JCR: 0.958]
[24]	马瑞东, 张文通, 许起荣, 等. 食管胃侧侧吻合预防吻合口狭窄的临床随机对照研究[J]. 中华外科杂志, 2010, 48(8): 577-581. [本文引用:1]
[25]	戒铁华, 刘广森, 黄植蕃, 等. 食管癌和贲门癌术后吻合口狭窄的外科治疗[J]. 癌症, 1995, 14(4): 280-282. [本文引用:1]
[26]	Cooke DT, Lin GC, Lau CL, et al. Analysis of cervical esophagogastric anastomotic leaks after transhiatal esophagectomy: Risk factors, presentation, and detection[J]. Ann Thorac Surg, 2009, 88(1): 177-184;discussion184-185. [本文引用:1]
[27]	Zhu ZJ, Zhao YF, Chen LQ, et al. Clinical application of layered anastomosis during esophagogastrostomy[J]. World J Surg, 2008, 32(4): 583-588. [本文引用:1] [JCR: 2.228]
[28]	Honkoop P, Siersema PD, Tilanus HW, et al. Benign anastomotic strictures after transhiatal esophagectomy and cervical esophagogastrostomy: Risk factors and management[J]. J Thorac Cardiovasc Surg, 1996, 111(6): 1141-1146;discussion1147-1148. [本文引用:1]
[29]	Blackmon SH, Correa AM, Wynn B, et al. Propensity-matched analysis of three techniques for intrathoracic esophagogastric anastomosis[J]. Ann Thorac Surg, 2007, 83(5): 1805-1813; discussion1813. [本文引用:1]
[30]	侯建彬, 梅平, 师晓天, 等. 食管胃颈部可吸收线连续分层吻合180例临床分析[J]. 中国肿瘤临床与康复, 2003, 10(4): 335-336. [本文引用:1]
[31]	Korenaga D, Toh Y, Maekawa S, et al. Intra-operative measurement of the tissue blood flow for evaluating blood supply to the gastric tube for esophageal reconstruction[J]. Hepatogastroenterology, 1998, 45(24): 2179-80. [本文引用:1]
[32]	Raz DJ, Tedesco P, Herbella FA, et al. Side-to-side stapled intra-thoracic esophagogastric anastomosis reduces the incidence of leaks and stenosis[J]. Dis Esophagus, 2008, 21(1): 69-72. [本文引用:2] [JCR: 1.642]

2011

153.459

0.0

Jemal

, Bray

, Center

, et al. Global cancer statistics[J]. CA Cancer J Clin, 2011, 61(2): 69-90.

1Vice President, Surveillance Research, American Cancer Society, Atlanta, GA 2Deputy Head, Section of Cancer Information, International Agency for Research on Cancer, Lyon, France 3Epidemiologist, Surveillance Research, American Cancer Society, Atlanta, GA 4Informatics Officer, Section of Cancer Information, International Agency for Research on Cancer, Lyon, France 5National Vice President, Intramural Research, American Cancer Society, Atlanta, GA 6Head, Section of Cancer Information, International Agency for Research on Cancer, Lyon, France *Surveillance Research, American Cancer Society, 250 Williams Street, NW, Atlanta, GA 30303-1002

The global burden of cancer continues to increase largely because of the aging and growth of the world population alongside an increasing adoption of cancer-causing behaviors, particularly smoking, in economically developing countries. Based on the GLOBOCAN 2008 estimates, about 12.7 million cancer cases and 7.6 million cancer deaths are estimated to have occurred in 2008; of these, 56% of the cases and 64% of the deaths occurred in the economically developing world. Breast cancer is the most frequently diagnosed cancer and the leading cause of cancer death among females, accounting for 23% of the total cancer cases and 14% of the cancer deaths. Lung cancer is the leading cancer site in males, comprising 17% of the total new cancer cases and 23% of the total cancer deaths. Breast cancer is now also the leading cause of cancer death among females in economically developing countries, a shift from the previous decade during which the most common cause of cancer death was cervical cancer. Further, the mortality burden for lung cancer among females in developing countries is as high as the burden for cervical cancer, with each accounting for 11% of the total female cancer deaths. Although overall cancer incidence rates in the developing world are half those seen in the developed world in both sexes, the overall cancer mortality rates are generally similar. Cancer survival tends to be poorer in developing countries, most likely because of a combination of a late stage at diagnosis and limited access to timely and standard treatment. A substantial proportion of the worldwide burden of cancer could be prevented through the application of existing cancer control knowledge and by implementing programs for tobacco control, vaccination (for liver and cervical cancers), and early detection and treatment, as well as public health campaigns promoting physical activity and a healthier dietary intake. Clinicians, public health professionals, and policy makers can play an active role in accelerating the application of such interventions globally. CA Cancer J Clin 2011. © 2011 American Cancer Society, Inc.

... 食管癌是常见肿瘤之一,2008年全球预计新发病例482 300例,预计死亡病例406 800例^[1],而我国属于食管癌高发带 ...

2009

2.019

0.0

Quiros

, Bui

CL.

Multidisciplinary approach to esophageal and gastric cancer[J]. Surg Clin North Am, 2009, 89(1): 79-96.

The incidence of esophageal and gastric malignancies has increased over the last decade. Historically, surgery has been considered the best treatment for these cancers. However, long-term survival after surgery is fair at best, because of the tendency of disease to recur locally and distantly. Presently, the management of these cancers involves surgery, chemotherapy, and radiation therapy. This article discusses various treatment strategies that employ these modalities either alone or in combination, in an attempt to improve survival rates for patients who have gastroesophageal malignancies.

... 尽管目前放化疗已取得了较大发展^[2],手术切除仍是食管癌治疗的主要手段^[3] ...

... 3 讨论尽管食管癌的多模式治疗有了较大进展^[2],但手术仍是早期食管癌的主要治疗手段 ...

0.0

... 尽管目前放化疗已取得了较大发展^[2],手术切除仍是食管癌治疗的主要手段^[3] ...

2001

1.642

0.0

Urschel

, Blewett

, Bennett

, et al. Hand sewn or stapled esophagogastric anastomoses after esophagectomy for cancer: Meta-analysis of rand omized controlled trials[J]. Dis Esophagus, 2001, 14(3-4): 212-217.

Department of Surgery, McMaster University, Hamilton, Ontario, Canada * Dr J. D. Urschel St. Joseph's Hospital, 50 Charlton Avenue East, Hamilton, Ontario L8N 4A6, Canada. Tel: (+1) 905 522 0118; Fax: (+1) 905 521 6190; E-mail: <a href="mailto:urschelj@mcmaster.ca" title="Link to email address" shape="rect">urschelj@mcmaster.ca</a>

Gastric transposition with esophagogastric anastomosis is a common method of reconstruction after esophagectomy for cancer. The anastomosis can be fashioned using a handsewn or stapled technique. The choice of anastomotic technique is often debated but there is little evidence to support the use of one method over the other. We performed a meta-analysis of randomized controlled trials (RCTs) to determine the effect of esophagogastric anastomotic method (handsewn or circular stapled) on patient outcomes. Medline and manual searches were done (completed independently and in duplicate) to identify all published RCTs that addressed the issue of handsewn or stapled esophagogastric anastomosis after esophagectomy for cancer. The selection process was inclusive; no trials were excluded. Trial validity assessment was done and a trial quality score was assigned. Major outcomes for quantitative data synthesis included operative mortality, anastomotic leaks, anastomotic strictures, cardiac morbidity, and pulmonary morbidity. A random-effects model was used and relative risk was the principal measure of effect. Systematic qualitative review was used for other outcomes such as duration of operation and time to complete the anastomosis. Data on cancer survival were not available in the RCTs. Five RCTs were selected with quality scores ranging from 2 to 3 (5-point Jadad scale). Selection and validity agreement was strong. Relative risk (95% confidence interval, CI; P-value), expressed as handsewn vs. stapled (treatment vs. control), was 0.45 (0.20, 1.00; P=0.05) for operative mortality, 0.79 (0.44, 1.42; P=0.43) for anastomotic leaks, 0.60 (0.27, 1.33; P=0.21) for anastomotic strictures, 0.99 (0.55, 1.77; P=0.97) for cardiac morbidity, and 0.93 (0.63, 1.37; P=0.72) for pulmonary morbidity. Data synthesized from existing RCTs show that handsewn and circular stapled esophagogastric anastomotic techniques give similar results for anastomotic outcomes, such as leaks and strictures. The stapled anastomotic method appears to increase operative mortality (P=0.05). Although it is difficult to explain this finding, it should not be dismissed. Several hypotheses are discussed.

... 食管癌切除术中最常见的食管重建方法是通过胃代食管和食管胃吻合^[4] ...

1995

2.516

0.0

... 吻合口瘘是食管胃吻合最常见的早期并发症^[5],它也是食管癌术后患者致残及死亡的主要原因^[6] ...

... 但究竟哪一种吻合方法更有优势目前仍有争议,多数手术人员基于其个人对吻合技术的喜好来选择吻合方式^[5] ...

0.0

... 吻合口瘘是食管胃吻合最常见的早期并发症^[5],它也是食管癌术后患者致残及死亡的主要原因^[6] ...

2005

0.0

1992

2.516

0.0

... 文献报道,吻合口瘘的发生率在0%~24%^[6,7,8],约占总死亡病例的90%^[9] ...

0.0

... 除Walther等^[10]的研究纳入了良性食管病变外,所有研究均仅纳入食管癌或贲门癌患者,10个研究报道了肿瘤部位及分期情况 ...

1813

0.0

Blackmon

, Correa

, Wynn

, et al. Propensity-matched analysis of three techniques for intrathoracic esophagogastric anastomosis[J]. Ann Thorac Surg, 2007, 83(5): 1805-1813; discussion1813.

Background

A cervical side-to-side stapled esophagogastric anastomosis appears to decrease morbidity compared with traditional hand-sewn techniques. We evaluated our experience with this novel technique in intrathoracic anastomoses and compared the outcome with circular-stapled or hand-sewn techniques.

Methods

All patients undergoing transthoracic esophagectomy from 1999 to 2005 for esophageal cancer with gastric replacement were reviewed. A prospective quality improvement database, telephone interview, and chart review were used to collect data. A side-to-side stapled anastomosis was done in 44 patients, circular-stapled anastomosis in 147, and hand-sewn anastomosis in 23. Propensity scores were generated from 14 variables, which were then used to generate 23 patient triplets. End points included leak, dysphagia, stricture, other major complications, and overall survival. Follow-up was available on all patients.

Results

For matched triplet comparison, no significant difference was noted in anastomotic leaks (8.7% with side-to-side stapled, 4.3% with circular-stapled, and 4.3% with hand-sewn; p = 0.78). Postoperative dysphagia was significantly higher in hand-sewn anastomoses at 56.5% versus 26.1% with side-to-side stapled and 21.7% with circular-stapled (p = 0.04). Stricture requiring esophageal dilation was also increased in hand-sewn at 34.8% versus 8.7% with side-to-side stapled and 8.7% with circular-stapled (p = 0.04). No difference was noted in perioperative mortality, long-term survival, or locoregional recurrences between techniques.

Conclusions

In this carefully matched group of patients, intrathoracic use of the side-to-side stapled esophagogastric anastomosis in esophageal cancer patients is safe and effective. Postoperative dysphagia and need for stricture dilation may be decreased using a stapled compared with a traditional hand-sewn anastomosis.

1979

6.329

0.0

... 1977年环形吻合器发明以后,器械吻合得到广泛使用^[12] ...

2009

0.0

2010

0.0

... 贲晓松等的研究表明,侧侧吻合可显著降低颈部、胸内食管胃吻合口瘘及狭窄的发生率^[14,32] ...

1991

1.291

0.0

West of

Scotland

Highland Anastomosis Study

Group

. Suturing or stapling in gastrointestinal surgery: A prospective rand omized study[J]. Br J Surg, 1991, 78(3): 337-341.

University Department of Surgery, Western Infirmary, Glasgow, Gartnavel General Hospital, Glasgow, Raigmore Hospital, Inverness, Crosshouse Hospital, Kilmarnock, Inverclyde Royal Hospital, Greenock and Royal Alexandra Hospital, Paisley, UK *University Department of Surgery, Western Infirmary, Glasgow G11 6NT, UK

A prospective randomized study of 1004 patients is reported, comparing surgical stapling and manual suturing techniques in the construction of gastrointestinal anastomoses. The incidence of clinical leaks was similar between the two groups (sutured 3·2 per cent, stapled 4·7 per cent; P = 0·22), while for radiological leaks the incidence was significantly higher in the sutured group (12·2 per cent versus 4·1 per cent, P<0·05). Stapling instruments afforded significantly quicker anastomoses, mean(s.e.m.) 28·1(0·7) versus 14·3(0·5) min (P<0·001), and quicker operations, 115·5(2·4) versus 103·8(2·2) min (P < 0·001). The two groups were found to be comparable in other respects such as operative mortality, requirements for blood transfusion, incidence of infective complications, recovery of gastrointestinal function and postoperative hospital stay.

1997

6.329

0.0

1996

3.373

0.0

... 除Valverde等^[17]的研究纳入了经裂孔手术患者外,所有研究均采用开胸入路或胸腹入路手术,4个研究进行了管状胃成形,Laterza、Hsu等^[18,21]的两项研究中,颈部吻合患者移植胃经前纵隔上拉至颈部 ...

1999

0.782

0.0

1996

0.903

0.0

2007

0.963

0.0

Okuyama

, Motoyama

, Suzuki

, et al. Hand -sewn cervical anastomosis versus stapled intrathoracic anastomosis after esophagectomy for middle or lower thoracic esophageal cancer: A prospective rand omized controlled study[J]. Surg Today, 2007, 37(11): 947-952.

Purpose

The type of anastomosis and its outcome can affect postoperative morbidity, mortality, and quality of life after esophagectomy. We compared the outcomes of cervical hand-sewn anastomosis (CHS) and intrathoracic stapled anastomosis (ITS) performed after esophagectomy and gastric reconstruction.

1.Akita University School of Medicine Department of Surgery 1-1-1 Hondo Akita 010-8543 Japan 2.Suzuki Clinic Akita Japan 3.Municipal Sakata Hospital Sakata Japan

2004

0.0

... Hsu等^[21]的长期术后随访显示,术后12个月内,吻合口狭窄的患者逐渐增多 ...

2008

0.0

... 另有研究指出环形器械吻合增加了吻合口狭窄的发生率^[28],其原因可能是黏膜对位不良导致肉芽组织形成和过度纤维化形成^[22],而另一些研究则得到了相反的结论^[29] ...

2010

0.958

0.0

2010

0.0

1995

0.0

... 吻合口对合不良是引起吻合口瘢痕形成原因之一,环形瘢痕形成则更容易引起狭窄^[25] ...

0.0

... 多个回顾性研究表明环形器械吻合降低了吻合口瘘的发生^[26],而其他一些研究未发现手工吻合和环形器械吻合间吻合口瘘发生率有显著差异^[27] ...

2008

2.228

0.0

Zhu

, Zhao

, Chen

, et al. Clinical application of layered anastomosis during esophagogastrostomy[J]. World J Surg, 2008, 32(4): 583-588.

The aim of this study was to compare the operative results in regard to reducing anastomotic leakage and stricture formation using a newly designed layered manual esophagogastric anastomosis versus a stapler esophagogastrostomy versus the conventional hand-sewn whole-layer anastomosis after resection for esophageal or gastric cardiac carcinoma. From January 2004 to September 2006, a total of 1024 patients with esophageal or gastric cardia carcinoma underwent a layered esophagogastric anastomosis with the assistance of a three-leaf clipper in a single university medical center. The mucosal layers of the esophagus and stomach were sutured continuously with 4/0 Vicryl plus antibacterial suture (polyglyconate). From May 2002 to December 2003, there were also 170 patients and 69 patients who underwent stapler and conventional whole-layer anastomosis, respectively; they served as control groups. The results were analyzed retrospectively. The operative mortality rate was 0.7% in the layered group compared to 5.9% and 7.2% for the stapler group and the whole-layer group (p < 0.01), The anastomotic leakage rates were 0%, 3.5%, and 5.8% for the layered group, stapler group, and whole-layer group, respectively (p < 0.01). All patients were followed postoperatively. Six patients in the layered group (0.6%) developed mild stricture formation compared to 16 patients in stapled group (9.9%) and 5 patients in the conventional whole-layer group (7.8%) (p < 0.01). The application of layered esophagogastric anastomosis could reduce the incidence of anastomotic leakage and stricture after esophagectomy compared with the stapler and whole-layer manual anastomoses. It is easy to apply and could be used as an alternative for esophagogastric anastomosis after resection for esophageal or cardiac carcinoma.

1.Department of Thoracic and Cardiovascular Surgery, West China Hospital, Sichuan University, 37 Guoxuexiang, Chengdu, Sichuan 610041, China

... 多个回顾性研究表明环形器械吻合降低了吻合口瘘的发生^[26],而其他一些研究未发现手工吻合和环形器械吻合间吻合口瘘发生率有显著差异^[27] ...

0.0

1813

0.0

Blackmon

, Correa

, Wynn

, et al. Propensity-matched analysis of three techniques for intrathoracic esophagogastric anastomosis[J]. Ann Thorac Surg, 2007, 83(5): 1805-1813; discussion1813.

Background

Methods

Results

Conclusions

2003

0.0

... 尽管有研究认为,双层缝合较单层缝合更有优势^[30],但我们的分层研究提示双层缝合与单层缝合吻合口瘘发生率与环形吻合器吻合间均无差异,而两者吻合口狭窄发生率均较后者低 ...

1998

0.0

... 管状胃成形在有的研究中被报道,有研究证实,胃管状成形后,胃壁缺血面积明显减少^[31],可有效减少肺部并发症,减少胃潴留,因此管状胃成形已在食管癌手术中得到广泛应用 ...

2008

1.642

0.0

... 近年来有不少利用线性吻合器进行侧侧吻合的研究^[13,14,32] ...

... 贲晓松等的研究表明,侧侧吻合可显著降低颈部、胸内食管胃吻合口瘘及狭窄的发生率^[14,32] ...