腔镜微创食管癌切除术的学习过程分析

Analysis of learning process of video-assisted minimally invasive esophagectomy for thoracic esophageal carcinoma

目的总结腔镜微创食管癌切除术（MIE）的学习过程。方法选取同一组医生连续完成的MIE手术100例，按手术时间顺序分为3组：第1、2组各25例行胸腔镜并常规开腹手术，第3组50例行胸腹腔镜手术．分别记录手术时间、出血量、正常结构保护及并发症发生情况、术后ICU观察时间、住院时间、术后肿瘤病理及淋巴结清扫情况等临床资料，比较各组之间的差异。结果全组中96例患者顺利完成MIE，4例患者中转开胸，无中转开腹。中位手术时间310min，中位失血量200ml，中位清扫淋巴结22枚，总体并发症发生率50％。第1组与第2组比较，在保留奇静脉弓（P=0．010）、保留支气管动静脉（P=0．038）及左侧喉返神经胸段术中暴露率（P=0．048）方面的差异有统计学意义。前50例与后50例比较，在胸部手术时间（P=0．000）、失血量（P=0．025）、保留奇静脉弓（P=0．001）、保留支气管动静脉（P=0．000）、胸野淋巴结清扫（P=0．022）、左喉返神经链淋巴结清扫（P=0．000）及该神经起始部术中暴露率（P=0．002）方面的差异有统计学意义。结论MIE学习过程较长．应循序渐进。随着经验的积累和手术技巧的提升．MIE将逐渐显示其独特的优势并替代传统开胸食管癌切除术。

Objective To evaluate the learning process of video-assisted minimally invasive esophagectomy （MIE）. Methods One hundred consecutive patients with thoracic esophageal carcinoma were treated by a same team of surgeons, and were divided into 3 groups in chronological order. The former two groups both consisted of 25 patients with thoracoscopy plus laparotomy. The remaining 50 patients were enrolled in the third group with thoracoscopy plus laparoscopy. Clinieopathological data including operative time, blood loss, protection of normal structures, complications, length of ICU stay, postoperative stay, and lymph nodes harvest, were collected and compared between groups. Results Procedures were accomplished successfully in 96 patients. Only 4 cases were converted to open thoracotomy and none to laparotomy. The median operative time was 310 min and blood loss was 200 ml. The median number of lymph node harvest was 22. The overall complication rate was 50%. Comparison of first two groups revealed that significant differences existed in the preservation rate of arch of azygos vein （P=0.010）, bronchial vessels （P=0.038）, and exposure rate of thoracic part of left recurrent laryngeal nerve （P=0.048）. Comparison of the former and latter 50 patients revealed that significant differences existed in thoracic operative time （P〈0.001）, blood loss （P=0.025）, preservation rate of arch of azygos vein （P=0.001） and bronchial vessels （P〈0.001）, the number of lymph node harvest in thoracoscopy（P=0.022） and in left recurrent laryngeal nerve chain（P〈0.001 ）, and exposure rate of initiate part of left recurrent laryngeal nerve （P=0.002）. Conclusion The learning curve of MIE is long and beginners should proceed step by step.