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摘要:目的 探究微创McKeown食管癌切除术中应用腹腔镜下空肠造瘘的安全性和临床价值。方法 回顾性收集2013年1月至2020年6月北京协和医院胸外科行微创McKeown食管癌切除术患者的临床资料，根据术后营养支持方式分为经口营养组(2013年1月至2017年10月)、空肠造瘘组(2017年11月至2020年6月)。比较两组手术时间、术后住院时间、并发症、围术期营养状况与生活质量。结果 共入选符合纳入和排除标准的食管癌患者190例。其中空肠造瘘组128例、经口营养组62例。与经口营养组比较，空肠造瘘组术后住院时间[11(9, 13)d比14(13, 20)d, P＜0.001]更短，术后辅助化疗完成率更高(95.16%比75.00%, P=0.005), 两组手术时间[335(300，374)min比330(310, 370)min, P=0.750]、手术相关并发症发生率(28.13%比35.48%，P=0.748)无显著差异。与经口营养组比较，空肠造瘘组术后1个月[(23.3±3.5)kg/m2比(21.7±3.9)kg/m2, P=0.006]、3个月[(22.6±3.5)kg/m2比(20.6±4.0)kg/m2, P＜0.001]体质量指数均增高，术后1个月[(3.9±2.2)%比(10.3±3.5)%, P＜0.001]、3个月[(6.5±3.1)%比(15.7±4.8)%, P＜0.001]体质量下降率均降低。与术前比较，两组患者术后7 d时生活质量症状量表评分均升高，功能量表评分及总体生活质量评分均急剧降低，术后1个月时各评分均有不同程度改善。与经口营养组比较，空肠造瘘组术后7 d与术后1个月时症状量表评分(术后1个月时疼痛评分除外)均降低，功能量表评分及总体生活质量评分均升高(P均＜0.05)。结论 相较于经口营养，腹腔镜下空肠造瘘在食管癌患者术后营养支持、生活质量恢复方面更具优势，且不增加手术相关并发症，安全性高。
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关键词:
- 空肠造瘘 /
- McKeown食管癌切除术 /
- 肠内营养 /
- 腹腔镜
Abstract:Objective To evaluate the safety and clinical value of laparoscopic jejunostomy in minimal invasive McKeown esophagectomy.Methods The clinical data of the patients undergoing minimally invasive McKeown esophagectomy in the Department of Thoracic Surgery, Peking Union Medical College Hospital from January 2013 to June 2020 were retrospectively included, and according to postoperative nutritional support they were divided into oral intake group (January 2013 to October 2017) and jejunostomy group (November 2017 to June 2020). The operation time, postoperative hospital stay, complications, perioperative nutritional status and quality of life scores were compared between the two groups.Results A total of 190 patients with esophageal cancer who met the inclusion and exclusion criteria were enrolled. There were 128 cases in jejunostomy group and 62 cases in oral intake group. Compared with the patients in oral intake group, those in jejunostomy group had shorter postoperative hospitalization time [11(9, 13)d vs. 14(13, 20)d, P < 0.001], the completion rate of postoperative adjuvant chemotherapy in the jejunostomy group was higher(95.16% vs. 75.00%, P=0.005). The operation time [335(300, 374)min vs. 330(310, 370)min, P=0.750] and the incidence of surgery-related complications(28.13% vs. 35.48%, P=0.748) showed no significant difference between the two groups. The body mass index in jejunostomy group was higher 1 month [(23.3 ± 3.5)kg/m2 vs. (21.7±3.9)kg/m2, P=0.006] and 3 months[(22.6±3.5)kg/m2 vs. (20.6±4.0)kg/m2, P < 0.001] after surgery, and the body weight decreasing rate was lower 1 month [(3.9 ± 2.2)% vs. (10.3±3.5)%, P < 0.001] and 3 months[(6.5±3.1)% vs. (15.7 ± 4.8)%, P < 0.001] after surgery than those in oral intake group. The quality of life symptom scores in both groups were increased and the physical functioning and summary scores were sharply decreased at day 7 after operation, and all scores were improved in different degrees 1 month after operation. Compared with the measurements in oral intake group, the symptom scores (except pain score 1 month after operation) were decreased, and the physical functioning and summary scores were increased in the jejunostomy group 7 days and 1 month after operation (all P < 0.05).Conclusion Compared with oral nutrition, total laparoscopic jejunostomy has greater advantages in postoperative nutritional support and quality of life recovery in patients with esophageal cancer. It is also safe and unlikely to increase surgery-related complications. -
作者贡献：赵珞负责数据收集、统计分析、论文撰写；何嘉、秦应之、韩志军负责研究实施；刘洪生、李单青、李力参与研究设计、论文修订。利益冲突：所有作者均声明不存在利益冲突
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表 1 两组患者基线资料比较
指标 空肠造瘘组(n=128) 经口营养组(n=62) 年龄[M(P25, P75), 岁] 63(57, 67) 60(54, 67) 性别[n(%)] 男 108(84.38) 54(87.10) 女 20(15.62) 8(12.90) TNM分期[n(%)] Ⅰ 33(25.78) 16(25.81) Ⅱ 44(34.38) 22(35.48) Ⅲ 41(32.03) 19(30.65) Ⅳ 10(7.81) 5(8.06) 肿瘤部位[n(%)] 食管上段 13(10.16) 9(14.52) 食管中段 71(55.47) 30(48.39) 食管下段 44(34.37) 23(37.09) 术前新辅助治疗[n(%)] 45(35.16) 20(32.26) 术后辅助化疗[n(%)] 62(48.44) 28(45.16) 
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表 2 两组患者治疗相关指标比较
指标 空肠造瘘组(n=128) 经口营养组(n=62) P值 手术时间[M(P25, P75), min] 335(300，374) 330(310, 370) 0.750 术后住院时间[M(P25, P75), d] 11(9, 13) 14(13, 20) ＜0.001 有吻合口漏 20(15, 32) 36(28, 80) 0.040 无吻合口漏 10(9, 12) 14(13, 18) ＜0.001 完成术后辅助化疗[n(%)] 59(95.16) 21(75.00) 0.005 手术相关并发症[n(%)] 36(28.13) 22(35.48) 0.748 吻合口漏 10(7.81) 7(11.29) 0.431 喉返神经损伤 12(9.38) 7(11.29) 0.680 呼吸系统并发症 6(4.69) 5(8.06) 0.350 心血管系统并发症 5(3.91) 2(3.23) 0.816 乳糜漏 2(1.56) 1(1.61) 0.975 术后30 d内死亡 1(0.78) 0(0) 0.485
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表 3 两组患者围术期营养指标比较(x±s)
指标 空肠造瘘组(n=128) 经口营养组(n=62) P值 白蛋白(g/L) 术前 39.6±4.5 39.7±4.9 0.951 术后7 d 34.2±4.5 33.2±5.0 0.171 总蛋白(g/L) 术前 56.1±5.6 56.8±4.6 0.430 术后7 d 52.9±5.7 51.7±4.4 0.147 BMI(kg/m2) 术前 24.2±3.4 24.3±3.8 0.804 术后1个月 23.3±3.5 21.7±3.9 0.006 术后3个月 22.6±3.5 20.6±4.0 ＜0.001 体质量下降率(%) 术后1个月 3.9±2.2 10.3±3.5 ＜0.001 术后3个月 6.5±3.1 15.7±4.8 ＜0.001 BMI：体质量指数
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