CAJ | 학술논문

目的：食管癌患者术后营养支持至关重要，目前肠内营养在食管癌术后应用广泛，经鼻-空肠营养管是主要的肠内营养途径，具有无创、简便、安全、易行的特点。但目前为止，国内外鲜见报道上腹-右胸食管癌切除术中闭合式空肠营养管安置的文献。本研究中通过改进手术操作，探索Ivor-Lewis术中闭合式安置空肠营养管的方法。方法：2010年1月至2013年12月四川大学华西医院共连续实施85例Ivor-Lewis食管癌/贲门癌切除术患者，其中男72例，女13例，平均年龄59.7±7.5岁。每例患者均尝试闭合式安置空肠营养管。主要手术步骤包括：1）经腹游离胃，食管裂孔的扩大和幽门括约肌捏断术；2）经胸管胃制作，食管肿瘤切除和胃食管胸内吻合；3）在巡回护士协助下，术者进行空肠营养管的闭合式安置。结果：全组病例无术后死亡或营养管相关不良事件发生。营养管安置成功52例，总体安置成功率为61.2%（52/85），其中40例安置成功并成功实施术后全肠内营养支持；12例安置成功，但因其它原因无法实施肠内营养；安置失败（33例）的患者均进行肠外营养支持。肠内营养组与肠外营养组在术后住院时间、术后并发症方面差异无统计学意义（P>0.05），肠内营养组在营养制剂费用、营养制剂费用占总住院费用比例两项指标上显著低于肠外营养组（1469±741元vs.3223±917元，P<0.001；3.4%vs.7.2%，P<0.001）。结论：Ivor-Lewis食管癌切除术中闭合式空肠营养管安置，是一种无创、安全、简单可行的手术操作方式，可以为患者提供有效、经济的肠内营养支持方案。外科医生通过练习完全可以熟练实施Ivor-Lewis术中营养管闭合式安置。
목적：식관암환자술후영양지지지관중요，목전장내영양재식관암술후응용엄범，경비-공장영양관시주요적장내영양도경，구유무창、간편、안전、역행적특점。단목전위지，국내외선견보도상복-우흉식관암절제술중폐합식공장영양관안치적문헌。본연구중통과개진수술조작，탐색Ivor-Lewis술중폐합식안치공장영양관적방법。방법：2010년1월지2013년12월사천대학화서의원공련속실시85례Ivor-Lewis식관암/분문암절제술환자，기중남72례，녀13례，평균년령59.7±7.5세。매례환자균상시폐합식안치공장영양관。주요수술보취포괄：1）경복유리위，식관렬공적확대화유문괄약기날단술；2）경흉관위제작，식관종류절제화위식관흉내문합；3）재순회호사협조하，술자진행공장영양관적폐합식안치。결과：전조병례무술후사망혹영양관상관불량사건발생。영양관안치성공52례，총체안치성공솔위61.2%（52/85），기중40례안치성공병성공실시술후전장내영양지지；12례안치성공，단인기타원인무법실시장내영양；안치실패（33례）적환자균진행장외영양지지。장내영양조여장외영양조재술후주원시간、술후병발증방면차이무통계학의의（P>0.05），장내영양조재영양제제비용、영양제제비용점총주원비용비례량항지표상현저저우장외영양조（1469±741원vs.3223±917원，P<0.001；3.4%vs.7.2%，P<0.001）。결론：Ivor-Lewis식관암절제술중폐합식공장영양관안치，시일충무창、안전、간단가행적수술조작방식，가이위환자제공유효、경제적장내영양지지방안。외과의생통과연습완전가이숙련실시Ivor-Lewis술중영양관폐합식안치。
Objectives:To improve the surgical procedures and investigate the feasibility of the closed placement of nasojejunal tube during Ivor-Lewis esophagectomy. Methods:From January 2010 to December 2013, 85 patients (72 males and 13 females) with esophageal or gastric cardiac carcinoma underwent Ivor-Lewis esophagectomy in our department. Briefly, the general surgical proce-dures were performed as follows:1) stomach mobilization and enlargement of esophageal hiatus and pyloric sphincter digital fracture via laparotomy; 2) tubular stomach reconstruction, esophageal carcinoma resection, and intra-thoracic esophagogatrostomy via right posterolateral thoracotomy;and 3) forward closed placement of feeding tube through the nostrils and jejunum of patients under the guid-ance of a surgeon, who palpates the pylorus through the hiatus with the use of fingers. Results:No operative death or feeding tube-asso-ciated adverse event was observed. Among the 85 patients who have undergone Ivor-Lewis esophagectomy, feeding tube placement in-to the jejunum during surgery failed in 33 cases. The success rate of nasojejunal feeding tube placement was 61.2%(52/85). Twelve pa-tients with successful tube placement did not receive enteral feeding for several reasons and were thereby transferred to parenteral group. Significant differences were observed in terms of the nutritional cost and proportion between enteral feeding and parenteral groups (?1,469 ± 741 vs.?3,223 ± 917, P<0.001;3.4%vs. 7.2%, P<0.001). No differences in postoperative hospital stay and morbidi-ty were observed between the two groups (P>0.05). Conclusion:The novel forward closed placement of nasojejunal feeding tube dur-ing Ivor-Lewis esophagectomy provides a non-invasive, feasible, simple, and economical method for postoperative nutritional support. Surgeons could perform this novel technique successfully in practice.