McKeown食管切除术后胸骨后与后纵隔胃管重建的内镜可及性与管道通过性：一项回顾性队列研究

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中文摘要

背景： McKeown食管切除术后胃管重建的最佳路径仍不确定。既往比较主要关注吻合口漏和肺部并发症，而术后内镜可及性和临床明显的管道通过障碍则较少被充分描述。我们比较了胸骨后（RS）与后纵隔（PM）重建，重点关注这些功能性结局。
方法： 这项单中心回顾性队列纳入2025年3月至2026年4月期间由同一手术团队治疗的37例患者（RS，n=14；PM，n=23）。上消化道造影评估通常在约2周时进行，常规术后内镜在约3周时进行，除非内镜有禁忌或不可行。内镜时间和路径相关困难在检查层面进行评估。临床明显的通过障碍定义为吞咽困难伴食物滞留或食团通过受损，需要内镜确认或治疗，在3个月随访期间于患者层面进行评估。还评估了早期和晚期延迟胃管排空（DGCE）以及次要围手术期结局。所有比较均未校正，且为探索性。
结果： 在有记录时长的检查中（13例RS和24例PM），RS重建后的中位内镜时间更长[14.00（8.00，17.00）对7.50（6.00，11.00）分钟，P=0.01]。在4例RS检查中记录了内镜推进的路径相关困难或吻合口显示不完全，而在24例完成的PM检查中无一例记录。4例RS患者出现临床明显的通过障碍，伴吞咽困难和食物滞留，而PM患者无一例出现（4/14对0/23，P=0.02）。所有4起事件均与吻合口狭窄相关；滞留食物经内镜取出，随后3例患者接受扩张，1例患者接受支架置入，所有患者随后均恢复经口进食。吻合口狭窄发生于4/14例RS和1/23例PM患者（P=0.057）。早期DGCE（1/14对1/23；P>0.99）、晚期DGCE（2/14对0/23；P=0.14）或吻合口漏（1/14对2/23；P>0.99）均未观察到统计学上可检测的组间差异。
结论： 在这个小队列中，RS重建与检查层面更长的内镜时间以及4起狭窄相关通过障碍事件相关，而未观察到DGCE方面有统计学上可检测的路径相关差异。这些未校正的发现具有假设生成性，并不能确立任一路径的优越性。需要更大规模的前瞻性研究，纳入标准化内镜评估、路径几何测量、经过验证的吞咽困难工具以及纵向功能结局。

英文摘要

BACKGROUND: The optimal route for gastric-conduit reconstruction after McKeown esophagectomy remains uncertain. Previous comparisons have focused primarily on anastomotic leakage and pulmonary morbidity, whereas postoperative endoscopic accessibility and clinically evident conduit-passage disturbance have been less well characterized. We compared retrosternal (RS) and posterior mediastinal (PM) reconstruction, focusing on these functional outcomes.
METHODS: This single-center retrospective cohort included 37 patients treated by the same surgical team between March 2025 and April 2026 (RS, n=14; PM, n=23). Upper gastrointestinal contrast assessment was generally performed at approximately 2 weeks and routine postoperative endoscopy at approximately 3 weeks, unless endoscopy was contraindicated or not feasible. Endoscopy time and route-related difficulty were evaluated at the examination level. Clinically evident passage disturbance, defined as dysphagia with retained food or impaired bolus transit requiring endoscopic confirmation or treatment, was evaluated at the patient level during 3 months of follow-up. Early and late delayed gastric conduit emptying (DGCE) and secondary perioperative outcomes were also assessed. All comparisons were unadjusted and exploratory.
RESULTS: Among examinations with recorded duration (13 RS and 24 PM), median endoscopy time was longer after RS reconstruction [14.00 (8.00, 17.00) vs. 7.50 (6.00, 11.00) minutes, P=0.01]. Route-related difficulty in scope advancement or incomplete anastomotic visualization was documented in four RS examinations and in none of the 24 completed PM examinations. Four RS patients developed clinically evident passage disturbance with dysphagia and retained food, compared with no PM patients (4/14 vs. 0/23, P=0.02). All four events were associated with anastomotic stricture; retained food was removed endoscopically, followed by dilation in three patients and stent placement in one, and all subsequently resumed oral intake. Anastomotic stricture occurred in 4/14 RS and 1/23 PM patients (P=0.057). No statistically detectable between-group differences were observed for early DGCE (1/14 vs. 1/23; P>0.99), late DGCE (2/14 vs. 0/23; P=0.14), or anastomotic leakage (1/14 vs. 2/23; P>0.99).
CONCLUSIONS: RS reconstruction was associated with longer examination-level endoscopy time and four stricture-related passage-disturbance events in this small cohort, whereas no statistically detectable route-related difference in DGCE was observed. These unadjusted findings are hypothesis-generating and do not establish the superiority of either route. Larger prospective studies incorporating standardized endoscopic assessment, route-geometry measures, validated dysphagia instruments, and longitudinal functional outcomes are warranted.