[Clinical value of routine contrast esophagram in the diagnosis of anastomotic leakage for three-incision esophagectomy with cervical anastomosis].

Objective: To examine the clinical value of routine contrast esophagram (RCE) for the diagnosis of anastomotic leakage (AL) after three-incision esophagectomy with cervical anastomosis. Methods: Clinical data of 1 022 patients with esophageal cancer who underwent McKeown three-incision esophagectomy with cervical anastomosis from January 2015 to December 2019 at Department of Minimally Invasive Esophageal Surgery, Tianjin Medical University Cancer Hospital and Institute were analyzed retrospectively. There were 876 males and 146 females, aging(M(IQR)) 48(16) years (range: 36 to 84 years). There were 253 patients (24.8%) with neoadjuvant therapy, and 817 patients (79.9%) with minimally invasive esophagectomy. According to the diagnosis and treatment habits of the attending surgeons, 333 patients were included in the RCE group, and RCE was performed on the 7th day postoperative, while 689 patients were included in the non-RCE group, and RCE was performed when the patients had suspicious symptoms. Taking clinical symptoms, RCE, CT, endoscopy and other methods as reference to the diagnosis of AL, the sensitivity and specificity were used to analyze and evaluate the efficacy of RCE for the diagnosis of AL. The data were compared by U test or χ² test between groups. Results: The incidence rate of AL after three-incision esophagectomy was 7.34% (75/1 022), including 30 cases in the RCE group and 45 cases in the non-RCE group (9.0%(30/333) vs. 6.5%(45/689), χ²=2.027, P=0.155). The diagnostic time of AL was 9(5) days postoperative (range: 4 to 30 days). Among them, 23 cases showed cervical leakages, 50 cases showed intro-thoracic leakages, and 2 cases both cervical and intro-thoracic leakages. The diagnostic time of patients with intro-thoracic leakages was longer than that of cervical leakages (10(4) days vs. 6(3) days, Z=-2.517, P=0.012). Among the 333 patients in the RCE group, 16 cases of RCE indicated leakages including 11 cases of true positive and 5 cases determined to be false positive, while 317 cases indicated no abnormalities including 19 cases developed leakages. The sensitivity and specificity of RCE to detect AL were 36.7%(11/30) and 98.3%(298/333), respectively. The Youden-index was 0.35, and the diagnostic accuracy was 92.8%(309/333). The positive and negative predictive value were 11/16 and 94.0%(298/317), respectively. Conclusions: Routine contrast esophagram after three-incision esophagectomy with cervical anastomosis has low sensitivity and high specificity in the diagnosis of AL. The diagnostic time of AL is the 9th day after surgery. It is necessary to prolong the observation time clinically, and combine RCE with CT, endoscopy and other inspection methods for diagnosis.目的： 探讨三切口食管癌切除颈部吻合术后常规食管造影在诊断吻合口漏方面的临床应用价值。 方法： 回顾性分析2015年1月至2019年12月于天津医科大学肿瘤医院食管肿瘤微创外科接受McKeown三切口食管癌切除颈部吻合术的1 022例食管癌患者资料。男性876例，女性146例，年龄［M（IQR）］48（16）岁（范围：36~84岁）。253例接受新辅助治疗，817例接受微创食管切除术。依据主诊医师的诊疗习惯，333例于术后常规行食管造影，其他689例患者则根据临床表现适时选择造影等检查手段。以临床症状、食管造影、CT、内镜等方法确诊的吻合口漏为参考，在常规造影组中评价食管造影诊断吻合口漏的灵敏度和特异度。组间比较采用U检验或χ²检验。 结果： 全部患者术后吻合口漏发生率为7.34%（75/1 022），常规食管造影组和非常规造影组吻合口漏发生率的差异无统计学意义［9.0%（30/333）比6.5%（45/689），χ²=2.027，P=0.155］。吻合口漏的诊断时间为术后第9（5）天（范围：第4~30天）。常规造影组333例患者中，16例造影检查结果提示吻合口漏，其中11例为真阳性，5例为假阳性；317例提示吻合口愈合良好，其中298例为真阴性，19例为假阴性；常规食管造影诊断吻合口漏的灵敏度和特异度分别为36.7%（11/30）和98.3%（298/303），约登指数为0.35，诊断准确率为92.8%（309/333），阳性预测值和阴性预测值分别为11/16和94.0%（298/317）。 结论： 三切口食管癌切除颈部吻合术后常规食管造影诊断吻合口漏的灵敏度低而特异度高。吻合口漏的中位发生时间为术后第9天，临床上需延长观察时间，并联合应用食管造影、CT、内镜等多种检查手段。.