食管癌外科治疗中联合腔镜的应用

Clinical application of combined thoracoscopic and laparoscopic esophagectomy for esophageal carcinoma

目的探讨食管癌根治性切除术中应用联合腔镜的可行性和近期疗效及手术适应证。方法回顾性分析2009年12月至2011年8月139例食管癌患者施行联合腔镜食管癌切除术的临床资料。食管癌位于上段者16例，中段107例，下段者16例。手术先用胸腔镜游离胸段食管并清扫淋巴结，再用腹腔镜游离胃行食管胃左颈部吻合。术后病理分期：I期25例（Ia期13例、Ib期12例），Ⅱ期71例，Ⅲ期31例（Ⅲa期16例、Ⅲb期15例），Ⅳ期12例。结果除4例中转开胸手术，中转率2．9％外，其余全部顺利完成手术。术后出现吻合口瘘6例、心律失常4例和乳糜胸、胃排空障碍各1例，均保守治愈；吻合口狭窄2例扩张治疗后治愈；肺部感染11例，3例气管切开、呼吸机辅助呼吸，其中1例死亡（0．7％）；10例声音嘶哑。130例随访1～20个月，10例死亡，其中癌转移6例、肺部感染和精神抑郁各1例、不明原因2例。24例患者1年生存率88．9％。结论胸、腹腔镜联合行食管癌根治术在技术上是安全可行的，近期疗效满意。不仅适应于早、中期食管癌，而且适用于部分晚期病例。

Objective To study the indication, feasibility and short-term efficacy of combined thoracoscopic and laparo- scopic radical esophagectomy for the treatment of esophageal cancer. Methods Retrospective medical records analysis was conducted for 139 esophageal cancer patients who underwent combined thoracoscopic and laparoscopic esophagectomy in our department from December 2009 to August 2011. The tumors were located in upper esophagus in 16 cases, middle esophagus in 107 cases, and lower esophagus in 16 cases. The surgery started with the thoracoscopic mobilization of thoracic esophagus and lymph nodes dissection, which were followed by the laparoscopic stomach mobilization and gastroesophageal anastomosis in left neck. Postoperative pathological staging identified stage I esophageal cancer in 25 cases （ stage I a ： 13 cases, stage I b ： 12 ca- ses ）, stage Ⅱ esophageal cancer in 71 cases, stage III esophageal cancer in 31 cases （ stage Ⅲa ： 16 cases, stage Ⅲ b ： 15 cases） and stage Ⅳ esophageal cancer in 12 cases. Results Except for open conversions in 4 cases （2.9%） , all surgical operations were completed smoothly. Postoperative anastomotic leak was found in 6 cases （4.3 % ）, chylothorax in 1 case （0.7 % ）, arrhythmia in 4 cases（2.9% ） , and dumping syndrome in 1 case（0.7% ）. All of these complicated cases fully recovered after conservative treatments. Postoperative lung infection was found 11 cases（7.9% ）, 3 of whom required tracheotomy and assisted ventilation and 1 case died as a result of the infection （ mortality rate ： 0.7% ）. Ten cases（7. ：2% ） presented with hoarseness postoperatively. Out of the 139 cases, 130 cases were successfully followed up with durations ranged from 1 to 20 months, dur- ing of time the esophageal cancer spread to liver in 2 cases, celiac lymph nodes in 4 cases, lung in 2 cases, and bone in 1 case. Ten cases died, and all remaining cases remained alive during the follow up. The one-year survival rate was 88.9% for these cases. Conclusion Combined thoracoscopic and laparoscopic radical esophagectomy is a technically safe and feasible treatment for esophageal cancer. The short-term efficacy results are Satisfactory. This technique is indicated not only for early and middle stage esophageal cancer, but also for some of the advanced esophageal cancer cases.