微创食管癌根治术105例临床分析

Minimally Invasive Esophagectomy:a Report of 105 Cases

目的探讨微创食管癌根治术的安全性及可行性。方法回顾性分析2011年9月～2014年10月105例微创食管癌根治术的临床资料,均在胸腔镜下游离食管,2011年9月～2013年9月行开腹游离胃54例,2013年9月～2014年10月行腹腔镜下游离胃51例,制作管状胃行左颈部机械吻合术。结果无围手术期死亡,中转开放手术4例,其中开胸3例,开腹1例。胸腔镜手术时间50～100 min,平均80.4 min;腹腔镜手术时间30～80 min,平均50.6 min;颈部手术时间30～50min,平均40.3 min。胸腔镜手术出血量60～210 ml,平均100.6 ml;腹腔镜手术出血量30～100 ml,平均50.2 ml。清扫淋巴结13～27枚,平均19.4枚。术后胸腔总引流量250～700 ml,平均340.7 ml。术后住院时间11～42 d,平均13.0 d。术后病理诊断均为鳞状细胞癌,T1～3N0～1M0,切缘阴性。术中并发症：主动脉食管支动脉出血1例（中转开胸）,支气管动脉出血2例（中转开胸）;胸导管损伤3例（2例术中结扎,1例术后第10天二次手术腔镜结扎）;胃左血管损伤1例（中转开腹手术）。术后并发症：术后急性肾功能损伤1例,急性肝功能损伤1例,急性胃排空障碍2例,吻合口漏3例,肺部感染8例,术后喉返神经损伤10例（随访6个月恢复）,术后吻合口狭窄2例（内镜下扩张3次后治愈）。105例随访1～35个月（中位随访时间16个月）,3例均因肿瘤广泛转移分别于术后6、12、14个月死亡,均为低分化鳞状细胞癌伴胸腔或腹腔淋巴结转移,余102例均健在。结论微创食管癌术在技术上是安全可行的。

Objective To explore of safety and feasibility of minimally invasive esophagectomy in the treatment of esophageal carcinoma. Methods A retrospective analysis was made on 105 patients receiving minimally invasive esophagectomy between September 2011 and October 2014. The esophageal was disconnected under thoracoscopy. The stomach mobilization was performed under open surgery in 54 cases from September 2011 to September 2013,and under laparoscope in 51 cases from September 2013 to October 2014. Then a tube-like stomach was created and anastomosed to the cervical part of esophagusy by stapling. Results No perioperative death was observed in the group. Conversions to open surgery were required in 4 cases,including 3 cases of open chest surgery and 1 case of open abdominal surgery. The operation time for thoracoscopy was 50- 100 min（ mean,80. 4 min）,and the operation time for laparoscopy was 30- 80 min（ mean,50. 6 min）. The operation time for neck operation was 30- 50 min（ mean,40. 3 min）. The thoracic blood loss ranged from 60 ml to 210 ml（ mean,100. 6 ml） and the abdominal blood loss ranged from 30 ml to 100 ml（ mean,50. 2 ml）. The number of mediastinal lymph node dissected was 13- 27（ mean,19. 4）. The postoperative thoracic drainage was 250- 700 ml（ mean,340. 7 ml）. The postoperative hospital stay was 11- 42 days（ mean,13. 0 days）. All the patients were diagnosed as having esophageal squamous cell cancer after operation. According to the AJCC（ the seventh edition） TNM staging guideline of esophageal cancer,the samples were staged as T0- T3,N0- N2,and M0. The edge of the tumor was negative.Intraoperative complications included aortic esophageal artery bleeding in 1 case（ conversion to open surgery）,bronchial arterial hemorrhage in 2 cases（ conversions to open surgery）,thoracic duct injury in 3 cases（ intraoperative ligation in 2 cases,and secondary thoracoscopic surgery after 10 days postoperatively in 1 case）,and left gastric blood vessel damage in 1 case（ conversion to open surgery）. Postoperative complications included acute renal dysfunction in 1 case,acute liver dysfunction in 1 case,acute gastric emptying disorder in 2 cases,anastomotic leakage in 3 cases,pulmonary infection in 8 cases,postoperative recurrent laryngeal nerve injury in 10 cases（ recovered during 6 months of follow-ups）,and anastomotic stricture in 2 cases（ cured after endoscopic dilation for3 times）. The 105 patients were followed up for 1- 35 months（ median,16 months）. Three patients died of extensive metastases of tumor at 6,12,and 14 months after surgery,respectively,all of which were poorly differentiated squamous cell carcinoma with pleural or abdominal lymph node metastases. The remaining 102 patients survived. Conclusion Minimally invasive esophagectomy is technically feasible and safe.