胸腹腔镜联合食管癌Ivor-Lewis术与McKeown术近期疗效比较

Short-term efficacy comparison between Ivor-Lewis approach and McKeown approach in minimally invasive esophagectom

目的：对比胸腹腔镜Ivor-Lewis术与McKeown术治疗食管癌的近期疗效。方法回顾性分析2010年12月至2014年3月福建医科大学附属协和医院胸外二科同一治疗组采用全腔镜食管癌根治术治疗的288例胸中下段食管癌患者临床资料。其中，Ivor-Lewis组103例，McKeown组185例，两种手术方式均进行胸腹部淋巴结清扫。对比观察两种术式的围术期情况。结果两组术中出血量、中转开胸或开腹率、术后拔管时间、术后进食时间、术后住院时间、清扫淋巴结总数的差异均无统计学意义（P＞0．05）；而Ivor-Lewis组手术时间较McKeown组缩短[（283．4±32．0） min比（303．6±43．7） min，P＜0．01]，住院总费用增高[（76492±18553）元比（68923±17331）元，P＜0．01）。McKeown组围手术期死亡1例（0．5％），Ivor-Lewis组无一例围手术期死亡。Ivor-Lewis组术后总并发症发生率为16．5％（17/103），明显低于McKeown组的31．4％（58/185）（P＜0．01），其中术后肺部并发症、吻合口瘘、吻合口狭窄、喉返神经损伤发生率均明显低于McKeown组（均P＜0．05）。结论全胸腹腔镜Ivor-Lewis术较McKeown术治疗胸中下段食管癌术后并发症发生率更低，但手术费用增加。

Objective To compare the perioperative complications between Ivor-Lewis approach and McKeown approach in minimally invasive esophagectomy and gastric tube reconstruction for the treatment of middle and lower thoracic esophageal cancer. Methods Retrospective analysis of clinical data was performed on 288 patients with middle and lower thoracic esophageal cancer who underwent completely minimally invasive esophagectomy by one surgical team in Fujian Medical University Union Hospital from December 2010 to March 2014. Among the 288 patients , 103 patients underwent combined laparoscopic and thoracoscopic esophagectomy and intrathoracic esophagogastric anastomosis using a transoral anvil （Orvil） （Ivor-Lewis group, 2-incision） and 185 patients underwent combined laparoscopic and thoracoscopic esophagectomy and cervical anastomosis （McKeown group, 3-incision）. Patients were stratified by surgical approach and perioperative outcomes were compared between the two groups. Results There were no statistical differences between two groups in intra-operative blood loss , conversion to open, extubation time, time to resume oral intake, postoperative hospital stay, the median number of lymph nodes resected. The operation time of Ivor-Lewis group was significantly shorter than that of McKeown group[（283.4±32.0） min vs. （303.6±43.7） min, P=0.003）. The hospital cost of Ivor-Lewis group was significantly higher than that of McKeown group [（76 492 ±18 553） yuan vs. （68 923 ±17 331） yuan, P〈0.01]. There were no statistical differences between two groups in chylothorax, delayed gastric emptying, atrial fibrillation, postoperative bleeding, admission to ICU, short-term postoperative mortality （P〉0.05）. The total postoperative complication morbidity of Ivor-Lewis group was significantly lower than that of McKeown group （16.5% vs. 31.4%, P〈0.01）. Ivor-Lewis group had lower pulmonary complication （8.7% vs. 25.9%, P〈0.01）, anastomotic leakage （1.9% vs. 13.0%, P〈0.01）, anastomotic stricture （0% vs. 4.9%, P〈0.05）, recurrent laryngeal nerve injury （1.0% vs. 7.0%, P〈0.05）. Conclusion Ivor-Lewis approach is associated with less postoperative complications, but higher cost as compared to McKeown approach in the treatment of middle and lower thoracic esophageal cancer.