胸、腹腔镜联合手术治疗食管癌

Combination of Thoracoscopy and Laparoscopy for Treatment of Esophageal Carcinoma

目的探讨胸、腹腔镜联合下食管癌根治术技术上的可行性和安全性。方法对23例食管癌行电视胸腔镜联合腹腔镜下食管癌根治术:先左侧卧位行胸腔镜胸段食管的游离及淋巴结清扫;胸部手术完成后改平卧膀胱截石位行腹腔镜胃的游离及淋巴结清扫;胃游离后剑突下小切口完成管状胃的制作,再将管状胃从食管床拉至颈部与颈段食管间断吻合。结果中转开腹1例,无中转开胸。总手术时间:240～330min,平均270min;腹腔镜手术时间38～90min,平均65min;胸腔镜手术时间50～100min,平均70min。术中无大出血,总出血量100～300ml,平均225ml,其中腹腔出血10～50ml,平均20.4ml。共清扫纵隔淋巴结225枚,平均每例9.8枚;清扫胃左动脉旁、贲门左右淋巴结65枚,平均每例2.8枚。术后住院8～12d,平均9.2d。住院期间病人无死亡。术后并发症:肺部感染3例,颈部吻合口漏1例(术后第8天),乳糜胸1例(开胸行乳糜管结扎后治愈),声音嘶哑3例。23例随访1～11个月,平均7.7月,死亡1例,1例纵隔淋巴结广泛转移。结论胸、腹腔镜联合、颈部吻合的食管癌切除技术上是可行的,并且是安全的。

Objective To explore the feasibility and safety of combination of thoracoscopy and laparoscopy for the treatment of esophageal carcinoma. Methods Combining thoracoscopic and laparoscopic esophagectomy was attempted in 23 patients with esophageal cancer between August 2007 and July 2008. Being placed at a left lateral decubitus position, the patients received right thoracoscopic mobilization of the intrathoracic esophagus as well as lymph node dissection; then with lithotomy position, laparoscopic mobilization of the stomach and lymph node dissection were carried out, followed by creation of a gastric tube through a small incision under the xiphoid; finally we pulled out the gastric tube from the esophageal bed to the neck and made an intermittent gastroesophageal anastomosis. Results One of the patients was converted to open abdominal surgery, whereas no one was converted to open thoracic operation. The total operation time ranged from 240 to 330 minutes with a mean of 270 minutes, the operation time for laparoscopy was 38 -90 minutes （mean, 65 minutes）, and for thoracoscopy was 55 - 100 minutes （mean, 70 minutes）. No massive hemorrhage occurred during the operation, the total blood loss ranged from 100 to 300 ml （mean, 225 ml） , of which 10 to 50 ml were intra- abdominal blood loss （ mean, 20.4 ml）. Totally 225 lymph nods were removed （9.8 per patient in average）. Of the resected lymph nodes, 65 were para-left gastric arterial or pericardial lymph nodes （2.8 per case）. The mean hospital stay in this series was 9.2 days （range： 8 -12 days）. During the hospitalization, no patient died; postoperative complications included pulmonary infection （3 cases） , cervical anastomotic leak （one case, occurred in 8 days after the surgery） , ehylothorax （1 patient, cured by ligation via open thoracic surgery） , and hoarseness （3 cases）. Of the patient, 23 received an follow-up for 1 to 11 months （mean, 7.7 months） , during which, 1 patient died and 1 patient showed extensive metastasis to the mediastinal lymph node. Conclusion Combination of thoracoscopy and laparoscopy with cervical anastomosis is feasible and safe for the treatment of esophageal carcinoma.