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内镜下置覆膜镍钛合金支架治疗食管瘘的护理

【摘要】 目的 探讨内镜下放覆膜镍钛合金支架治疗食管气管瘘、食管纵隔瘘的疗效及护理。 方法 对2001年1月-2009年3月收治的56例食管气管瘘、食管纵隔瘘患者，行内镜下置入覆膜记忆合金支架封堵瘘口的术前、术中、术后护理观察及疗效随访。 结果 所有患者均一次置放成功，瘘口全部封闭，无一例因为护理及饮食不当而导致失败。 结论 内镜下放覆膜镍钛合金支架是治疗食管气管瘘、食管纵隔瘘一种安全、有效、简便方法，能达到封闭瘘口，恢复进食，控制肺部感染，改善患者生活质量的目的。

The Value of Serum Dickkopf 1 Protein for Early Diagnosis of Esophageal Cancer

Abstract：　Objective　To explore the value of serum Dickkopf-related protein 1 （DKK1）for the early diagnosis of esophageal cancer， and provide theoretical evidence for the diagnosis and treatment of esophageal cancer.　Methods　A total of 145 patients who were admitted to the Affiliated Hospital of Jiangnan University between October 2009 and April 2011 were included in this study and divided into four groups. There were 72 patients in the esophageal cancer group　（54 males and 18 females with their median age of 60.4 years），13 patients in the precancerosis group （9 males and 4　females with their median age of 58.6 years），30 patients in the benign esophageal lesion group （23 males and 7 females with their median age of 56.4 years），and 30 healthy people in the volunteer group （19 males and 11 females with their median age of 58.6 years）. Serum DKK1 protein concentration was measured by enzyme linked immunosorbent assay （ELISA）. Receiver operating characteristics （ROC） curve was drawn to determine the cutoff level with optimal diagnostic accuracy.　Results Serum DKK1 protein levels were significantly higher in the esophageal cancer group and precancerosis group than those in the volunteer group and benign esophageal lesion group ［（37.5±2.8） μg/L， （19.7±2.7） μg/L vs. （5.7±0.8） μg/L， （6.5±0.8） μg/L，t=47.391， P＜0.05］. There was no statistical difference in serum DKK1 protein level between the　volunteer group and benign esophageal lesion group ［（6.5±0.8） μg/L vs. （5.7±0.8） μg/L， t=4.215，P=0.374］. When the level of serum DKK1 protein was 13.4 μg/L， the diagnostic sensitivity and specificity of esophageal cancer were 74.1% and 96.7%， respectively.　Conclusion　Overexpression of serum DKK1 protein could be related to the pathogenesis and progression　of esophageal cancer. DKK1 protein may be a potential serologic biomarker for the early diagnosis of esophageal cancer.

Pattern of lymph node metastasis in 177 thoracic esophageal cancer patients

Objective This study analyzed the pattern and influence factors of lymph node metastasis in thoracic esophageal cancer to provide a reference for the lymph node dissection for esophageal cancer. Methods Clinical data of 177 patients with thoracic esophageal cancer receiving the lymph node dissection in our department from 2015 to 2016 were retrospectively analyzed. There were 125 males and 52 females with a median age of 64 years, ranging from 18 to 86 years. We excluded cervical esophageal cancer and adenocarcinoma of the esophagogastric junction and analyzed the relationship between lymph node metastasis and tumor pathological type, depth of invasion, degree of differentiation and length. Results Of the 177 patients, 76 (42.9%) were found to have lymph node metastasis. In the 4 977 dissected lymph nodes, metastasis was identfied in 361 (7.3%) lymph nodes. The rate of lymph node metastasis in thoracic esophageal carcinoma was not related to the location and length of the tumor (P>0.05), but related to the depth of invasion and the degree of differentiation (P<0.05). Conclusion Lymph node metastasis is prone to present in the early stage of thoracic esophageal cancer. According to the characteristics of lymph node metastasis in thoracic esophageal carcinoma, we need have a standardized, systematic and focused lymph node dissection.

原发性食管淋巴上皮瘤样癌二例

胸腹腔镜联合食管癌切除颈部吻合术30例疗效分析

目的探讨胸腹腔镜联合食管癌切除术的临床疗效。 方法回顾性分析2010年1月至2012年12月在江苏南通医学院附属丹阳医院胸心外科接受食管癌切除术的53例T3N1M0内食管癌患者的临床资料，其中行胸腹腔镜联合食管癌切除颈部吻合术30例（腔镜组，男16例、女14例），年龄（62.3±7.6）岁；右侧开胸三切口食管癌切除手术23例（开胸组，男13例、女10例），年龄（63.1±6.9）岁。比较两组胸部及腹部手术时间、术中出血量、手术淋巴结清扫数目、住ICU时间、术后疼痛评分、镇痛药用量、围手术期并发症。 结果与开胸组相比，腔镜组患者胸部手术时间更短[（98±35）min vs.（115±45）min，P=0.000]，胸部出血量更少[（65±30）ml vs.（142±53）ml，P=0.000]，胸部淋巴结清扫数量更多[（14.8±4.8）枚/例vs.（12.6±3.5）枚/例，P=0.002]，术后住ICU时间更短[（1.2±0.4）d vs.（3.3±1.2）d，P=0.001]，疼痛视觉模拟评分更低[（2.5±1.3）vs.（4.8±1.2），P=0.000]，镇痛药用量更少[（142±32）mg vs（.368±62）mg，P=0.000]，围手术期呼吸循环系统并发症发生率明显降低（16.7% vs.47.8%，P＜0.05）。 结论掌握手术适应证行胸腹腔镜联合食管癌切除颈部吻合术，具有创伤小、出血少、疼痛轻、住ICU时间短、肺部并发症发生率低等优点。

肺功能不全食管癌患者的围手术期处理

目的 探讨肺功能不全食管癌患者围手术期的治疗措施，总结治疗经验。 方法 回顾性分析武钢总医院2001年1月至2009年1月手术治疗76例肺功能不全食管癌患者的临床资料，其中男52例，女24例；年龄49～80岁，平均年龄62.5岁。术前经戒烟、预防和控制呼吸道感染、呼吸道雾化吸入或应用解痉化痰药物，呼吸功能锻炼和氧疗以改善肺功能。行左后外侧切口食管癌根治术26例，右胸前外侧切口、上腹部正中切口手术（Ivorlewis术式）33例，颈、胸、腹三切口手术17例，术后施行静脉自控镇痛(PCIA)、抗感染、解痉化痰、保持呼吸道通畅、营养支持和氧疗；部分患者予以呼吸支持。 结果 全组76例中，19例术后行机械通气支持，术后发生肺部并发症9例，心律失常5例，颈部吻合口漏1例；无围术期死亡，所有患者均痊愈出院。术后均获得随访，随访时间3～6个月，均恢复良好，无手术相关并发症。 结论 严谨的围手术期处理和肺保护是肺功能不全食管癌患者手术成功的重要因素。

食管癌术后消化道瘘的个体化治疗

目的 总结食管癌术后消化道瘘的治疗经验，探讨其个体化治疗方法。 方法 2004年1月至2009年11月中山市人民医院收治食管癌患者并行食管癌切除、胃食管吻合术338例，术后出现消化道瘘22例(6.51%)，全组患者均为男性，年龄44~77岁，中位年龄62岁。颈部吻合口瘘8例，胸内吻合口瘘11例，胸胃瘘3例。再次手术治疗5例，植入食管支架2例，保守治疗15例。 结果 治疗时间5~181 d，平均47.0 d，主要并发症为肺部感染11例、呼吸衰竭5例、败血症3例；死亡7例，病死率31.8％（7/22）。5例再次手术治疗，其中死亡3例，治愈1例，再发生瘘1例，改保守治疗后治愈；2例经支架治疗均治愈；保守治疗15例，其中10例治愈，治疗时间20~73 d，平均46.3 d。 结论 对食管癌术后消化道瘘的局部处理，应根据患者瘘发生的时间、部位、瘘口大小和局限程度等给予个体化治疗。

Short-and Mid-term Outcomes of Patients with Esophageal Cancer after Subtotal Esophagectomy via Thoracoscopy in Lateral Prone Position, Left Lateral Position, or Prone Position: A randomized Controlled Trial

ObjectiveTo compare the short-and mid-term outcomes of patients with esophageal cancer after subtotal esophagectomy via thoracoscopy in lateral prone position, prone position, or left lateral position. MethodsThis randomized prospectively controlled study was conducted in 121 patients receiving subtotal esophagectomy via thoracoscopy between January 2010 and February 2013. The patients were randomly assigned into three groups to underwent esophagectomy in lateral prone position, prone position, or left lateral position, respectively. Forty-three patients (24 males, 19 females, 61.5±1.5 years) underwent surgery in lateral prone position, 39 patients (21 males, 18 females, 63.2±1.7 years) in prone position and other 39 patients (22 males, 17 females, 60.1±1.6 years) in left lateral position. Esophagogastric anastomosis was performed in the left neck. ResultsThe median operative time in the three groups was 232 (165-296) min, 230 (170-310) min, and 280 (190-380) min, respectively (P < 0.05). The median perioperative bleeding was 262 (185-330) ml, 275 (100-320) ml and 350 (120-560) ml, respectively (P > 0.05). The average number of harvested lymph nodes was 19.1 (9-26), 18.4 (11-23), 10.9 (6-21), respectively (P < 0.05). The postoperative medical complications occurred in 10, 9 and 11 patients in three groups, respectively, with no statistical difference. Twenty patients died in the lateral prone position group after a median follow-up period of 19.2 (6-31) months, 18 patients died in the prone position group after a median follow-up period of 20.7 (8-29) months, and 21 patients died in the left lateral position group after a median follow-up period of 18.5 (12-33) months. ConclusionThe results confirm the feasibility and safety of this minimally invasive esophagectomy via thoracoscopy in lateral prone position, prone position, or left lateral position for patients with esophageal carcinoma. A possible advantage of lateral prone technique is that in case of an emergency, precious time could be saved in changing the position of the patient.

食管肉瘤样癌诊治现状

食管肉瘤样癌是一种十分罕见的食管恶性肿瘤，无特异性临床症状及体征，主要表现为吞咽梗阻、胸骨后疼痛等；其生长速度较快，常呈息肉样生长；具有上皮性癌和梭性肉瘤样细胞 2 种成分，并以肉瘤样成分占优势，其发病原因及病理组织起源目前尚未明确；免疫组织化学检测癌成分常见细胞角蛋白及上皮膜抗原表达，肉瘤样成分常见波形纤维蛋白表达；治疗方式以手术为主，对放射治疗、化学疗法（化疗）较敏感，常用化疗方案为铂类联合氟尿嘧啶类或紫杉类的双药联合方案，其早期预后较食管鳞状细胞癌好。

Application of Domestic Stapler and Suture Device in Digestive Tract Reconstruction of Esophageal Cancer

目的 评价国产吻合器和闭合器在食管癌消化道重建术中的应用价值。 方法 回顾性分析2005年3月-2008年4月期间收治的387例食管癌手术患者的临床资料，根据不同消化道重建方式分为手工吻合组（n=172）和器械吻合组（n=215），对两组患者吻合时间、术中出血量及术后并发症发生情况进行对比分析。 结果 全组无手术死亡。器械吻合组和手工吻合组术中出血量的差别无统计学意义（Pgt;0.05），但前者的吻合时间、住院时间均少于后者（Plt;0.05）。手工吻合组术后吻合口出血多于器械吻合组（5.2%比1.4%，Plt;0.05），发生吻合口漏亦多于器械吻合组（6.4%比2.8%，Plt;0.05）。随访1.5～2年，排除失访患者后，器械吻合组吻合口狭窄发生率低于手工吻合组（4.6%比10.3%，Plt;0.05）。 结论 国产吻合器与和缝合器用于食管癌的消化道重建安全有效，值得在基层医院推广应用。