胸腔镜微创与开放食管癌根治术围手术期并发症和淋巴结清扫情况的回顾性比较

Retrospective comparative study of preoperative complications and lymphadenectomy between thoracoscopic esophagectomy and open procedure

目的 比较胸腔镜微创与开放食管切除术治疗食管癌患者的围手术期并发症和淋巴结清扫情况差异.方法 回顾性分析2012年10月至2014年4月间207例在天津肿瘤医院行手术治疗的食管癌患者资料,胸腔镜微创食管癌切除术125例（胸腔镜组）,开放食管癌切除术82例（开放组）.胸腔镜组中109例行单纯胸腔镜加开腹手术,16例行胸腹全腔镜联合手术.结果 与开放组相比,胸腔镜组患者术后需要有创治疗的肺不张[0.8％ （1/125）比7.3％ （6/82）]、胸腔积液[0（0/125）比4.9％ （4/82）]及急性呼吸窘迫[0（0/125）比6.1％（5/82）]等严重呼吸系统并发症发生率下降;术中可疑胸导管损伤结扎[3.2％（4/125）比15.9％ （13/82）]、喉返神经损伤[19.2％（24/125）比32.9％ （27/82）]以及术后乳糜胸发生率[0（0/125）比4.9％ （4/82）]降低;清扫右喉返神经链淋巴结数[（1.91±0.73）枚比（1.12±0.81）枚]及成功率[97.6％（122/125）比89.0％ （73/82）]增加;但清扫左喉返神经链淋巴结枚数[（0.93±0.71）比（1.76±0.84）]及成功率[52％（65/125）比76.8％ （63/82）]降低;差异均有统计学意义（P＜0.05）.两组间术后肺部感染、吻合口瘘、脓胸、食管气管瘘、二次开腹、二次开胸、伤口感染、心律失常、心力衰竭、肾功能衰竭、肝功能不全和脑梗塞等发生率及病死率的差异无统计学意义（P＞0.05）;食管旁、隆凸下及肺门淋巴结清扫亦无统计学差异（均P＞0.05）.结论 胸腔镜微创食管癌手术能够降低严重呼吸系统并发症发生,减少胸导管及喉返神经损伤,清扫右喉返神经链淋巴结优势明显,但清扫左侧喉返神经链淋巴结难度大,仍存在改进提升空间.

Objective To analyze the differences in paraoperative morbidity and lymph node dissection between thoracoscopic esophagectomy and open procedure.Methods From October 2012 to April 2014,207 patients with esophageal cancer underwent surgery.125 patients underwent video-assisted esophagectomy,and 82 underwent open procedure.In the minimally invasive group,there were 109 thoracoscopic cases and 16 thoracolaparoscopic cases.Results There were significant differences between the thoracoscope group and the open group in atelectasis（0.8％ vs.7.3％,P ＜ 0.05）,pleural effusion （0 vs.4.9％,P ＜ 0.05）,acute respiratory distress （0 vs.6.1％,P ＜ 0.05）,ligation of thoracic duct （3.2％ vs.15.9 ％,P ＜ 0.05）,recurrent laryngeal nerve paralysis （19.2％ vs.32.9％,P ＜ 0.05）,c hylothorax （0 vs.4.9％,P ＜ 0.05）,number of lymphonode along the right recurrent laryngeal nerve lymphatic chains[1.91 ± 0.73 vs.1.12 ± 0.81,P ＜ 0.05）] and achievement ratio（97.6％ vs.89.0％,P ＜0.05） and number of lymphonode along the left recurrent laryngeal nerve lymphatic chains （0.93 ± 0.71 vs.1.76 ± 0.84,P ＜ 0.05） and achievement ratio（52％ vs.76.8％,P ＜ 0.05）.No significant differences were observed in pneumonia,anastomotic leak,thoracic abscess,esophago-tracheal fistula,re-laparotomy,re-thoracotomy,wound infection,arrhythmia,cardia failure,renal failure,hepatic inadequacy,cerbral infarction,and mortality（P ＞ 0.05）.There were also no significant differences in number of lymphonode and achievement ratio of periesophagel lymph nodes,subcarinal lymph nodes and hilar lymph nodes （all P ＞ 0.05）.Conclusion The thoracoscopic esophagectomy has some obvious advantage associated with less pulmonary complications,lower injury of thoracic duct and recurrent laryngeal nerve,more lymphonode and higher achievement ratio along the right recurrent laryngeal nerve lymphatic chains.But it has still a larger space for improvement of lymphadenectomy along the left recurrent laryngeal nerve lymphatic chains.