臺灣博碩士論文加值系統

背景
佔據癌症死亡原因第九位的食道癌，患者在總體存活率及疾病預後上相比於其他癌症較差。除了疾病復發問題外，手術後的併發症亦是影響患者恢復品質的重要課題。最常見的術後併發症為吻合處狹窄。對於術後吻合處產生狹窄的病患而言，往往衍生出醫療照護成本增加以及生活品質低落等問題。但截至目前為止，對於相關因素影響食道癌術後吻合處產生狹窄的研究結論尚未相當具有共識，尤其針對台灣食道癌特性與西方國家不同下，較少研究探討食道癌術後狹窄因素。

目的
本研究將針對某醫學中心之受術後食道癌個案資料進行回溯性病歷資料收集，以探討影響食道癌術後狹窄的相關因素。



材料與方法
為探討可能影響術後吻合處狹窄的相關因素，本研究以單一醫學中心，以病歷回溯方式，自2011年10月5日至2018年10月4日間，收集分析共258名患者的資料，進行包括生理特徵、疾病史、腫瘤特性及手術相關因子在內，對於吻合處發生狹窄或非狹窄間的比較。考量發生術後狹窄時間，本研究利用Cox等比例風險回歸(Cox proportional hazards regression)分析方法，找出與術後吻合處狹窄相關的影響因子。

結果
本研究總收案數258名患者，術後發生窄化須進行食道擴張的患者有124名(48%)；患者平均年齡為55.1歲；男性佔絕大多數，有95.3%。以一年為觀察時間，兩個月內發生狹窄為最高峰，其次隨著時間增加而發生率下降。透過卡方檢定可以發現年齡大於等於55歲患者術後產生狹窄的比例較高(54% vs 42%, p=0.045)；患者有接受過術前化學治療，其術後產生狹窄的比例則會較低(32% vs 55%, p<0.001)；同樣較低比例的吻合處狹窄也發生在接受過術前放射線治療的患者(36% vs 54%, p=0.007)。在調整其他相關危險因子後，多變項Cox等比例風險回歸分析顯示有接受過術前化學治療的患者對於術後狹窄的發生有顯著且獨立的降低發生食道癌術後吻合處產生狹窄危險(風險比 0.47, 95%信賴區間 0.23-0.99; p=0.0456)。

結論
根據本研究資料顯示，以一年為觀察時間，兩個月內發生狹窄為最高峰，其次隨著時間增加而發生率下降。發生食道癌術後吻合處狹窄在食道癌手術達48%。調整個人暴露因素及術前及術後因素後，與沒有接受過術前化學治療的患者比較，術前有接受化療者，顯著降低食道癌術後吻合處狹窄發生風險。

Background
Esophageal cancer, which accounts for the ninth leading cause of cancer death, has a poor overall survival rate and disease prognosis in comparison with other cancers. In addition to the concern of recurrence, the postoperative complication is also an important issue that affects the recovery. The most common postoperative complication is the stricture of anastomosis. For patients who suffered from the stricture of anastomosis, their costs in medical care will increase and the quality of life will become poor absolutely. The specific factors affecting anastomotic stricture for postoperative esophageal cancer is still controversial, especially for the esophageal cancer in Taiwan whose clinicopathological features id different from other western countries.

Purpose
This study aimed to explore those related factors affecting the anastomotic stricture based on those post-esophagectomy patients with reconstruction for esophageal cancer based on Taiwanese hospital-based data.

Methods
In order to explore the possible factors related to the incidence of anastomotic stricture, we retrospectively reviewed the data of 258 patients from October 2011 to October 2018, including physiological characteristics, personal history, clinicopathological features of disease and surgical related factors, from a single institute of medical center, and all these factors were analyzed to estimate their relationship to occurrence of anastomotic stricture. By means of Cox Proportional Hazards Mode, we try to find out the significantly independent factors that were related to the incidence of anastomotic stricture based on those post-esophagectomy patients.

Results
Of the 258 patients, 124 (48%) patients had endoscopic dilatation after surgery within our observational period; the average age of all the patients was 55.1 years; the majority of patients were male, which accounts for 95.3%; and the BMI of the whole patient was low as 22.1. By chi-square test, patients aged equal to or older than 55 years are more likely to have anastomotic stricture than patients aged younger than 55 (54% vs 42%, p ≤ 0.045). The patients who had preoperative chemotherapy were lower in the incidence of anastomotic stricture (32% vs 55%, p < 0.001). The lower incidence of anastomotic stricture was also shown in the patients who had preoperative radiation therapy (36% vs 54%, p ≤ 0.007). In the analysis of Cox Proportional Hazards Mode, the factor of having preoperative chemotherapy were significantly correlated with the occurrence of anastomotic stricture (hazard ratio 0.47, 95% of confidence interval 0.23 - 0.99; p = 0.0456).

Conclusion
The benign anastomotic stricture is common in patients undergoing esophagectomy and reconstruction for esophageal cancer. For Patients without preoperative chemotherapy, more rigorous medical care and more intensive follow-ups should be recommended to prevent the higher incidence of postoperative anastomotic stricture

目錄
長庚大學碩(博)士論文指導教授推薦書
口試委員審定書
致謝-------------------------------------------------------------------------------iii
中文摘要-------------------------------------------------------------------------iv
英文摘要-------------------------------------------------------------------------vi
目錄-------------------------------------------------------------------------------ix
表目錄----------------------------------------------------------------------------xi
圖目錄----------------------------------------------------------------------------xii
第一章 緒論 - 1 -
第一節 研究背景與動機 - 1 -
第二節 研究目的 - 2 -
第二章 文獻探討 - 3 -
第一節 食道癌臨床處置概述 - 3 -
第二節 食道癌術後狹窄之醫療處置及預後 - 7 -
第三節 吻合處狹窄相關因子探討 - 11 -
第三章 材料與方法 - 16 -
第一節 研究設計 - 16 -
第二節 研究對象 - 17 -
第三節 資料來源 - 18 -
第四節 研究變項說明 - 18 -
第五節 統計分析方法 - 20 -
第四章 研究結果 - 22 -
第一節 研究基本資料描述 - 22 -
第二節 描述性統計分析 - 26 -
第三節 單變項與多變項描述統計分析 - 30 -
第四節 食道癌術後狹窄因素分析 - 33 -
第五節 研究限制 - 37 -
第五章 討論與結論 - 38 -
第一節 討論 - 38 -
第二節 結論 - 45 -
第三節 管理意涵 - 46 -
參考資料 - 47 -


圖目錄

圖4-1 (A). 發生第一次窄化事件之風險分佈圖(全部個案之追蹤時間)-------------------------------------------------------------------------33
圖4-1(B). 發生第一次窄化事件之風險分佈圖(365天追蹤時間)-----34
圖4-1(C). 發生第一次窄化事件之風險分佈圖(180天追蹤時間)-----34
圖4-2. 有術前化療及無術前化療之發生第一次窄化事件之風險分佈(180天追蹤時間)-------------------------------------------------------35
圖4-3. 有術前化療及無術前化療之開刀至窄化發生分析--------------36

表目錄

表2-1. 吞嚥困難程度分級-----------------------------------------------------10
表3-1. 研究設計圖--------------------------------------------------------------17
表4-1. 基本資料佔率分析-----------------------------------------------------24
表4-2. 食道癌術後狹窄相關因素資料分析--------------------------------27
表4-3. 食道癌術後狹窄相關因素單變項及多變項分析-----------------31

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