Name: 内窥镜真空疗法治疗食管空肠吻合术全胃切除术后吻合口漏 (视频) | JoVE Journal
Uploaded: 2025-08-22T13:55:00.000+00:00
Duration: 4 min 5 s
Description: 了解内镜真空疗法治疗全胃切除术后食管空肠吻合口漏的临床应用。该方法通过负压引流促进愈合，降低并发症风险，为消化道吻合口漏提供微创治疗方案。

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本工作获得了四川省重点临床专科建设项目 [ZX-2428-1]、吴阶平医学基金会 [320.6750.2024-07-3] 和科学技术局的资助 &amp;#38; 技术南充市 [22JCYJPT0007]

该方案遵循南充市中心医院人体研究伦理委员会的指南。
1. 准备
<ol>
	<li>通过CT、胃肠道造影或内镜检查评估漏出物大小及脓肿情况。</li>
	<li>与患者充分沟通，并取得患者的知情同意。</li>
	<li>EVT引流装置（EVTDD）：
	<ol>
		<li>选用经美国食品药品监督管理局（FDA）批准的医用级开孔聚氨酯醚泡沫材料，根据漏出部位或脓肿腔的大小和形态精确塑形。使用6.0 Fr/18胃管作为引流管。</li>
		<li>将泡沫牢固地包裹在引流管顶端，并用3-0聚丙烯缝线固定，确保完全覆盖所有侧孔。最后将引流管末端连接至负压引流系统，以实现有效引流（图2）。</li>
	</ol>
	</li>
</ol>
2. EVTDD 的放置
<ol>
	<li>对患者实施全身麻醉。</li>
	<li>润滑内镜后，经口插入食管，并推进至脓腔。用生理盐水冲洗吻合口瘘或脓腔，直至脓液完全清除且冲洗液变清亮。冲洗所用生理盐水的量取决于吻合口瘘的大小或脓腔的容积。</li>
	<li>在内镜引导下放置鼻空肠营养管（图3）。</li>
	<li>使用内镜钳夹住缝线，该缝线固定着管端和海绵，然后将海绵推入瘘腔内（图4）。</li>
	<li>在内镜引导下确认海绵已进入或附着于脓腔。</li>
	<li>将EVTDD引流管和鼻空肠营养管经同一鼻腔引出。</li>
	<li>将引流管连接至负压引流装置。</li>
	<li>将负压调节至-100至-125 mmHg的适宜范围。治疗期间每4–8小时检查一次压力稳定性及引流功能。</li>
	<li>用胶带将引流管和鼻空肠营养管固定于患者鼻部。</li>
</ol>
3. 替换 EVTDD
<ol>
	<li>每5-7天更换一次EVTDD，首先从吻合口漏出部位移除，然后再从患者身上移除。</li>
	<li>更换EVTDD时，通过内镜观察漏出部位的愈合情况。</li>
	<li>按照上述方法放置新的EVTDD。</li>
	<li>将受污染的海绵和液体放入可耐受高压灭菌的生物危害袋中，进行妥善处理。</li>
</ol>
4. 术后护理
<ol>
	<li>保持引流管通畅。记录引流液的量、颜色和性状。</li>
	<li>妥善处理并发症，包括腹痛、发热或出血等。</li>
</ol>
5. 术后随访
<ol>
	<li>密切评估治疗效果，并根据需要调整负压。采用CT、对比胃肠造影或内镜检查评估漏出部位的愈合情况。</li>
</ol>

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</ol>

作者声明无竞争利益。

内镜真空治疗（EVT）在吻合口漏的治疗中发挥着关键作用，可显著减少并发症并改善患者预后21。该治疗过程包括三个主要步骤：首先，术前通过CT扫描、胃肠道造影或内镜检查明确漏口位置及是否存在相关脓腔；在操作过程中，在直接内镜可视下将EVTDD装置置于漏口处；最后，将引流管的外端连接至负压装置，并调节以维持持续稳定的负压22。其中，决定手术成功最关键的步骤是海绵定位技术。内镜引导可确保治疗用海绵准确放置，完全覆盖缺损区域，从而实现有效的负压吸引治疗。
这种微创的EVT克服了传统治疗方法的局限性，使其成为研究和临床应用的重点。传统的保守治疗方法，如抗感染治疗和经皮引流，通常在控制感染和促进组织愈合方面效果较差23。一项荟萃分析显示，支架置入在治疗食管-肠吻合口漏方面的疗效不如EVT24。支架置入可能导致严重的不良事件，包括出血、穿孔、溃疡和组织增生10。...

食管空肠吻合口漏是全胃切除术后一种严重且可能危及生命的并发症。它不仅延长住院时间，还显著增加医疗费用1,2,3。全胃切除术后吻合口漏的发生率为1%至14%4,5,6,7,8。
传统治疗方法主要包括保守治疗、支架置入，以及在某些情况下的手术修复9。保守治疗通常包括营养支持、抗炎治疗和引流。覆膜支架可将脓肿腔与胃肠道管腔隔离开。然而，保守治疗和支架置入往往无法有效引流脓液或坏死组织渗出物。尽管手术修复可直接处理漏口，但其手术并发症风险较高。相比之下，EVT&#160;在持续引流吻合口漏或脓肿腔以及促进愈合方面，已显示出优于保守治疗、支架置入或手术治疗的疗效10,11。
随着内镜技术的进步，Weidenhagen R. 等人于2008年首次报道了使用内镜下负压治疗（EVT）来处理直肠前切除术后吻合口漏12。该方法源于常用于开放性创面愈合的负压辅助闭合（VAC）技术。VAC 治疗通过将开放孔隙的海绵敷料置于创面，用粘性胶带密封后施加可控的低于大气压的压力，从而减轻慢性水肿，增强局部血流，并促进肉芽组织形成13。EVT 将内镜技术与 VAC 治疗相结合，在内镜引导下，将负压精准作用于瘘管或渗漏部位，有效清除渗出液和细菌，减少感染源。此外，该方法还能刺激组织细胞增殖与迁移，加速创面愈合，并降低并发症风险14,15。然而，EVT 的标准化操作方案报道较少。
多项研究已证实，使用EVT&#160;治疗上消化道渗漏具有显著优势16,17,18。Pattynama等人报道，采用EVT治疗术后上消化道吻合口渗漏的成功率为74%，在38例患者中有28例实现闭合16。在一项多中心回顾性研究中，Momblán等人评估了102例上消化道缺损患者，其中包括89例吻合口渗漏和13例穿孔，成功闭合了84例（82%）17。此外，do Monte Junior等人进行的一项荟萃分析表明，与支架置入相比，EVT可使上消化道透壁性缺损的渗漏闭合率提高21%，死亡率降低12%，治疗时间缩短14至22天，不良事件发生率减少24%18。这些研究结果凸显了EVT在管理上消化道缺损方面的有效性。
EVT&#160;已成为上消化道渗漏的标准治疗方法。其主要临床适应证包括上消化道肿瘤切除术后吻合口漏以及医源性穿孔19，而禁忌证则包括完全性管腔梗阻或内镜无法到达的病变20。该操作应由具备高级内镜技术经验的内镜医师实施。EVT 包括在吻合口漏部位或相关脓肿腔内通过内镜置入特制的聚氨酯海绵，并在整个治疗过程中使用负压装置维持 -100 至 -125 mmHg 的负压。
本研究展示了一例使用内镜真空治疗（EVT）处理吻合口漏的代表性病例。一名74岁男性因食管胃结合部癌（Siewert III型）在另一家医院接受了全胃切除术及食管空肠吻合术。术后第7天，计算机断层扫描（CT）提示存在吻合口漏。尽管进行了包括抗炎治疗、营养支持及其他保守治疗措施，病情未见明显改善。术后第20天，患者出现吻合口出血，遂转至我院。上消化道造影证实存在渗漏，显示造影剂从吻合口右下方外渗（图1）。重复CT扫描显示腹腔内存在气腹。随后，患者被安排接受内镜真空治疗（EVT）。

<table><tbody><tr><td>一次性外接吸液连接管</td><td>Henna Tuoren Best Medical Equipment Co., Ltd.</td><td>Type II-2.0</td><td></td></tr><tr><td>一次性负压引流装置</td><td>Henna Tuoren Best Medical Equipment Co., Ltd.</td><td>Type II-1&amp;ndash;2000 mL</td><td></td></tr><tr><td>引流管</td><td>扬州华为医疗器械有限公司</td><td>6.0 mm (Fr18)</td><td></td></tr><tr><td>内窥镜</td><td>Olympus</td><td>GIF-H170</td><td></td></tr><tr><td>内镜活检钳</td><td>常州九鸿医疗器械有限公司</td><td>JHY-FB-23-160-O-O</td><td></td></tr><tr><td>鼻空肠营养管</td><td>Fresenius kabi AG</td><td>CH/FR 15,100 CM</td><td></td></tr><tr><td>开孔型聚氨酯海绵</td><td>广东美济生物科技有限公司</td><td>MJ-03B4</td><td></td></tr><tr><td>聚丙烯不可吸收缝合线</td><td>ETHICON</td><td>8522H</td><td></td></tr></tbody></table>

食管空肠吻合术后全胃切除术吻合口漏的内镜下负压治疗

Endoscopic Vacuum Therapy for the Treatment of Anastomotic Leakage after Total Gastrectomy with Esophagojejunostomy

内镜下负压治疗（EVT）为吻合口漏的治疗提供了一种有效的替代方案。目前针对吻合口漏的治疗选择包括保守治疗、支架置入或再次手术。然而，保守治疗通常恢复缓慢，在严重病例中常无效。支架置入存在移位或堵塞等风险，且保守治疗和支架均常无法充分引流脓液或坏死组织渗出物。此外，再次手术与较高的手术并发症风险相关。EVT 通过自然腔道采用持续负压，清除脓液和坏死组织渗出物。该方法还可促进瘘管或漏口部位的肉芽组织形成，从而加速愈合过程。临床实践中，EVT 已显示出显著降低感染、出血及吻合口狭窄等并发症的潜力。它不仅改善了患者的预后，还减少了额外侵入性操作的需求，并缩短了住院时间。总之，EVT 是处理复杂胃肠道漏的一种具有前景且创新的方法。

在此代表性病例中，患者接受了三次EVTDD置换。每次EVTDD置入的平均操作时间为37分钟，患者在该医疗机构的总住院时间为21天。EVT手术期间及术后均未观察到并发症。
首次内镜真空治疗（EVT）过程中，内镜检查发现食管-空肠吻合口处存在一处1 cm × 1.5 cm的瘘口，周围覆盖黄色-白色脓性苔膜，可见缝线痕迹及血管夹（图5）。操作中正确置入EVTDD装置，确保了充分引流（图6）。术后EVT引流功能良好，保持通畅，患者双侧腹腔引流管引流出少量脓性液体。第二次EVT操作时，内镜显示瘘口已缩小，边缘可见轻微黏膜出血（图7）。患者腹腔引流管每日引流量逐渐减少，最终降至0 mL。第三次EVT操作时，瘘口显著缩小，难以准确评估其大小（图8）。患者经EVT治疗后病情明显改善，术后4天出院。出院1个月后，上消化道造影证实无造影剂外漏（<strong cla...

本文介绍了一种用于治疗全胃切除术联合食管空肠吻合术后吻合口漏的内镜下负压治疗（EVT）方案。

内镜下真空治疗（EVT）为吻合口漏的治疗提供了一种有效的替代方案。目前针对漏症的治疗选择包括……

我们的研究聚焦于全胃切除术后食管空肠吻合口漏的内镜下负压治疗。旨在评估该疗法的有效性，明确治疗方案，评价其安全性，并衡量其临床疗效。内镜下负压治疗在吻合口漏、消化道瘘及穿孔的处理中是一项重大突破。近年来的进展包括临床适应证的拓展以及治疗方案的优化，以实现更精准的治疗。同时，我们团队正在研究其在结直肠吻合口漏中的应用，以进一步优化其临床使用。内镜下载体治疗是一种针对胃肠道吻合口漏的高效微创治疗方法。进行传统操作时，该方法可加快操作速度，降低并发症风险，并减少再次手术的需求。采用标准化操作流程可进一步提高其安全性和有效性。首先，选择经美国食品药品监督管理局（FDA）批准的开孔聚醚型聚氨酯泡沫材料。将其塑形以适配漏出部位或脓肿腔，并准备一根6.0 French或18号胃引流管。然后，将泡沫材料牢固地包裹在引流管顶端，使用3-0聚丙烯缝线固定，确保所有引流侧孔均被完全覆盖。在对患者进行麻醉并润滑内窥镜后，经口腔将内窥镜插入食管，并推进至脓肿腔。用生理盐水冲洗吻合口漏处或脓肿腔，直至完全清除内容物且流出液变清亮。随后，在内镜引导下放置鼻空肠营养管。使用内镜钳夹住缝合线，固定管子和海绵的顶端。然后将海绵推入渗漏腔内。在内镜引导下，确认海绵已进入或附着于脓肿腔内。然后，通过同一鼻腔引流出EVTDD管和鼻空肠喂养管。首次内镜检查发现食管-空肠吻合口处存在一个1 cm × 1.5 cm的瘘口，周围覆盖黄色白色脓性渗出物，可见缝线痕迹和血管夹。在首次操作中，内镜下真空负压双引流装置被成功置入，以确保有效引流。第二次手术期间的内镜检查显示，瘘口尺寸已缩小，边缘仅见少量黏膜出血。至第三次手术时，瘘口已显著缩小，难以测量其大小。出院一个月后，上消化道造影证实无造影剂外渗，表明缺损已完全闭合。

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食管空肠吻合术后全胃切除术吻合口漏的内镜下负压治疗

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