摘要目的 探讨不留置胃肠减压管和早期经口进食加速康复外科在微创食管癌根治术中的应用价值.方法 采用回顾性队列研究方法.收集2016年3月至2017年10月南部战区总医院收治的126例行微创食管癌根治性切除+胃代食管颈部吻合术患者的临床病理资料;男80例,女46例;平均年龄为64岁,年龄范围为52～ 82岁.126例患者中,82例胃食管吻合采用“李氏”吻合法,不留置胃肠减压管,术后早期经口进食,设为免管免禁组;44例胃食管吻合采用管型吻合器行端侧吻合,常规留置胃肠减压管,术后1周开始经口进食,设为传统治疗组.观察指标:(1)手术及术后恢复情况.(2)病理学检查情况.(3)随访情况.采用门诊和电话方式进行随访,了解患者术后肿瘤复发及转移情况.随访时间截至2018年10月.正态分布的计量资料以Mean±SD表示,组间比较采用独立样本t检验;偏态分布的计量资料以M(范围)表示,组间比较采用秩和检验.计数资料以绝对数或百分比表示,组间比较采用x2检验.等级资料比较采用秩和检验.结果 (1)手术及术后恢复情况:两组患者均顺利完成微创食管癌根治性切除+胃代食管颈部吻合术.免管免禁组患者手术时间、术中出血量、吻合口瘘发生率、肺部并发症发生率、术后住院时间分别为(326±41) min、(225±96) mL、7.3％(6/82)、24.4％ (20/82)、10 d(6～90 d),传统治疗组患者上述指标分别为(317±37)min、(214±66) mL、9.1％(4/44)、20.5％(9/44)、14 d(10～42 d),两组术后住院时间比较,差异有统计学意义(Z=-7.129,P＜O.05);而两组患者手术时间、术中出血量、吻合口瘘发生率、肺部并发症发生率比较,差异均无统计学意义(t=1.311,0.703,x2=0.000,0.077,P＞O.05).(2)病理学检查情况:免管免禁组患者淋巴结清扫数目和术后肿瘤TNM分期Ⅰ、Ⅱ、Ⅲ期分别为(27±5)枚和12、55、15例,传统治疗组患者上述指标分别为(26±5)枚和9、28、7例,两组比较,差异均无统计学意义(t=0.549,Z=-0.747,P＞O.05).(3)随访情况:116例患者(免管免禁组76例、传统治疗组40例)获得随访,随访时间为12～31个月,中位随访时间为20个月.随访期间,116例患者均未发现肿瘤复发及转移.结论 不留置胃肠减压管和早期经口进食加速康复外科应用于微创食管癌根治性切除术安全、可行,与传统治疗比较,能缩短术后住院时间.

abstractsObjective To investigate the application value of enhanced recovery after surgery with no gastrointestinal decompression tube and with early postoperative oral feeding in minimally invasive radical resectionof esophageal cancer.Methods The retrospective cohort study was conducted.The clinicopathological data of 126 patients who underwent minimally invasive McKeown surgery in the General Hospital of Southern Theatre Command of PLA between March 2016 and October 2017 were collected.There were 80 males and 46 females,aged from 52 to 82 years,with an average age of 64 years.Of 126 patients,82 undergoing "li's anastomosis" with no gastrointestinal decompression tube and receiving early postoperative oral feeding were allocated into non-tube no fasting group,and 44 undergoing end-to-side gastroesophageal anastomosis with tubular stapler,conventionally indwelling gastrointestinal decompression tube,and beginning oral feeding at 1 week after surgery were allocated into traditional treatment group.Observation indicators:(1) surgical and postoperative recovery situations;(2) results of pathological examination;(3) follow-up.Follow-up using outpatient examination and telephone interview was performed to detect the postoperative tumor recurrence and metastasis up to October 2018.Measurement data with normal distribution were represented as Mean ± SD,and comparison between groups was analyzed using independent sample t test.Measurement data with skewed distribution were expressed as M (range),and comparison between groups was analyzed by rank sum test.Count data were described as absolute number or percentage,and comparison between groups was analyzed using chi-square test.Ordinal data were analyzed by rank sum test.Results (1) Surgical and postoperative recovery situations:patients in the two groups underwent minimally invasive McKeown surgery successfully.Operation time,volume of intraoperative blood loss,incidence of anastomotic fistula,incidence of pulmonary complications,and duration of postoperative hospital stay were respectively (326±41) minutes,(225±96) ml,7.3 ％ (6/82),24.4％ (20/82),and 10 days (range,6-90 days) in the non-tube no fasting group and (317± 37) minutes,(214 ± 66) mL,9.1％ (4/44),20.5％ (9/44),and 14 days (range,10-42 days) in the traditional treatment group;there was a statistically significant difference in duration of postoperative hospital stay between the two groups (Z =-7.129,P ＜ 0.05) and no statistically significant difference in operation time,volume of intraoperative blood loss,incidence of anastomotic fistula,and incidence of pulmonary complications between the two groups (t =1.311,0.703,x2 =0.000,0.077,P＞0.05).(2) Results of pathological examination:the number of lymph node dissected,cases in postoperative TNM stage Ⅰ,Ⅱ and Ⅲ were respectively 27±5,12,55,15 in the non-tube no fasting group and 26±5,9,28,7 in the traditional treatment group,with no statistically significant difference between the two groups (t =0.549,Z =-0.747,P＞0.05).(3) Follow-up:of 126 patients,116 were followed up for 12-31 months,with a median time of 20 months,including 76 in the non-tube no fasting group and 40 in the traditional treatment group.During the follow-up,no tumor recurrence or metastasis was found in the 116 patients.Conclusion The enhanced recovery after surgery with no gastrointestinal decompression tube and with early postoperative oral feeding is safe and feasible in the McKeown surgery,which can significantly shorten the postoperative hospitalization time compared with the traditional treatment.