经右胸-切口入路食管切除重建术的临床疗效

Clinical efficacy of exclusive right-thoracic approach in esophageal surgery

目的探讨经右胸-切口入路食管切除重建术的手术适应证和临床疗效。方法回顾性分析2008年6月至2010年6月青岛大学医学院附属医院收治的35例采用经右胸-切口入路食管切除重建手术患者的临床资料。35例患者中食管癌患者21例，年龄均〉70岁，PaO2（70-L-9）mmHg（1mmHg=0．133kPa），最大通气量：51％±9％，第1秒肺活量：57％±11％；食管良性或低度恶性病变患者14例，PaO2：（96±13）mmHg，最大通气量：83％±11％，第1秒肺活量：91％±14％；均采用右胸-切口入路，根据病灶位置选择具体术式。患者采用门诊及电话方式进行随访，随访时间截至2012年4月。结果35例患者顺利完成手术，其中21例食管癌患者行食管部分切除＋胃食管右胸内吻合术；14例食管良性或低度恶性病变患者中，2例食管平滑肌瘤、3例食管间质瘤和1例食管平滑肌瘤患者行食管部分切除＋胃食管胸内吻合术，7例食管平滑肌瘤和1例食管间质瘤患者行单纯肿瘤摘除术。患者手术时间为（3．4±1．8）h，术中出血量为（160±44）m1。21例食管癌患者清扫淋巴结（14±5）枚，其中胃左动脉旁淋巴结（1．1±0．7）枚；术后无胸内吻合口瘘等并发症发生，无围手术期死亡，住院时间为（10±4）d。食管癌患者术后PaO2为（664-10）mmHg，最大通气量为50％±11％，第1秒肺活量为51％±13％；食管良性或低度恶性病变患者PaO2为（94±13）mmHg，最大通气量为80％±13％，第1秒肺活量为87％±16％。35例患者随访1～2年，患者术后进食良好，无明显进食梗阻，术后1年生存率为82．9％（29／35），术后2年生存率为77．1％（27／35）；死亡患者均为食管癌患者，1例死于心血管意外，7例死于肿瘤复发转移。结论经右胸-切口入路可选择性用于治疗部分食管良性或低度恶性病变患者和高龄、肺功能低的食管癌患者，其近期效果良好。

Objective To investigate the indications and clinical efficacy of an exclusive right-thoracic approach in esophageal surgery. Methods The clinical data of 35 patients with esophageal disease who underwent an exclusive right-thoracic approach operation from June 2008 to June 2010 at the Affiliated Hospital of Qingdao University were retrospectively analyzed. Of the 35 patients, 21 were with esophageal cancer, and their ages were above 70 years, the partial pressure of oxygen of arterial blood （ PaO2 ） , maximal voluntary ventilation and forced vital capacity of the first second were （70±9）mm Hg （1 mm Hg=0.133 kPa）, 51%±9% and 57%±11%, respectively. Fourteen patients were with benign esophageal disease or low grade malignancy, and their PaO2 maximal voluntary ventilation and forced vital capacity of the first second were （96 ± 13 ）mm Hg, 83 %± 11% and 91%± 14%, respectively. Exclusive right-thoracic approach was selected for all the patients, and surgical procedure was selected according to the location of the lesions. Patients were followed up by out-patient examination or phone call till April 2012. Results All the operations were carried out successfully, 21 patients with esophageal cancer underwent partial esophagus resection and stomach-esophagus intrathoracic anastomosis through a right-thoracic approach. Of the 14 patients with benign esophageal disease or low grade malignancy, 2 patients were with esophageal leiomyoma, 3 with esophageal stromal tumor and 1 with esophageal leiomyomatosis underwent partial esophagus resection ± intrathoracic anastomosis ; 7 patients with esophageal leiomyoma and 1 with esophageal stromal tumor underwent tumor extirpation. The operation time and operative blood loss were （3.4 ± 1.8）hours and （160±44） ml, respectively. The number of lymph node dissected of the 21 patients withesophageal tumor was 14 ± 5, including 1. 1 ± 0. 7 lymph nodes dissected near the left gastric artery. No anastomosis fistula and perioperative death were detected, and the duration of hospital stay was （ 10±4） days. The postoperative PaO2 , maximal voluntary ventilation and forced vital capacity of the first second were （66 ± 10） mm Hg, 50% ± 11% and 51% ± 15% for patients with esophageal cancer, and （94 ± 13） mm Hg, 80% ± 13% and 87% ± 16% for patients with benign esophageal disease or low grade malignancy. All the patients were followed up for 1-2 years, no eating obstruction was detected, and the postoperative 1- and 2-year survival rate were 82.9% （29/35） and 77.1% （27/35）, respectively. Of the 8 patients with esophageal cancer who died postoperatively, 1 died of cardiovascular diseases and 7 died of tumor recurrence and metastasis. Conclusion Exclusive rightthoracic appraoch could be used for patients with benign esophageal disease, low-grade malignancy and old esophageal cancer patients with poor oulmonarv function.