改良Ivor-Lewis经胸颈部机械吻合术治疗中段食管癌的双向性队列研究

Improved Ivor-Lewis Cervical Stapled Esophagogastrostomy via Thorax for Middle Esophageal Carcinoma:An Ambispective Cohort Study

目的探讨腹腔镜辅助腋下小切口改良Ivor-Lewis经胸颈部机械吻合术对中段食管癌手术疗效的影响。方法以术前检查颈部无可疑转移淋巴结的中段食管癌患者为研究对象。将2010年4月至2012年12月行Ivor-Lewis经胸颈部机械吻合术治疗的55例作为历史性队列[A组,男36例、女19例,年龄（65±8）岁],2013年1月至2015年3月行改良Ivor-Lewis经胸颈部机械吻合术治疗的46例作为前瞻性队列[B组,男31例、女15例,年龄（66±7）岁],比较两组的围手术期观察指标、淋巴结清扫效果和手术后1年的随访情况。结果与A组比较,B组患者胸部手术时间短（t=5.94,P〈0.05）、术后呼吸系统并发症发生率及总体并发症发生率更低（χ^2=3.08,4.30,P〈0.05）、恢复肛门自动排气时间缩短（t=2.08,P〈0.05）、术后住院时间缩短（t=3.20,P〈0.05）。两组与外科技术相关的吻合口瘘、喉返神经损伤、乳糜胸的发生率差异无统计学意义（P〉0.05）。两组颈胸交界（包括颈段食管旁）、纵隔、上腹部淋巴结转移率（χ^2=0.03,0.15,0.08,P〉0.05）和淋巴结转移度（χ^2=0.01,0.71,0.01,P〉0.05）的差异均无统计学意义。两组术后1年的肿瘤复发转移率（χ^2=0.04,P〉0.05）和生存率（χ^2=0.13,P〉0.05）差异也无统计学意义。结论改良Ivor-Lewis经胸颈部机械吻合术是一种更好的以经胸径路替代经颈径路清扫颈部淋巴结治疗中段食管癌的手术方法。

Objective To determine if laparoscopic assisted Ivor-Lewis cervical stapled esophagogastrostomy via a minor subaxillary incising enables better perioperative and medium-term outcome than Ivor-Lewis cervical stapled esophagogastrostomy via thorax for middle esophageal carcinoma without intumescent lymphnode of neck.Methods The perioperative and medium-term outcome of a series of 55 patients underwent Ivor-Lewis cervical stapled esophagogastrostomy via thorax between April 2010 and December 2012 were as a historic cohort（group A,36 males,19 females at age of 65±8 years）.And 46 patients underwent laparoscopic assisted Ivor-Lewis cervical stapled esophagogastrostomy via a minor subaxillary incising between January 2013 and March 2015 were as a prospective cohort（group B,31 males,15 females at age of 66 ±7 years）.Perioperative indexes,lymphadenectomy,and result at end of one year following up were compared.Results Compared with group A,there was shorter thoracic operation time（t=5.94,P〈0.05）,shorter time of restored anus exhaust（t=2.08,P〈0.05）,less pulmonary complication（χ~2=3.08,P〈0.05） and less total perioperative complications（χ~2=4.30,P〈0.05）,shorter postoperative hospital stay（t=3.20,P〈0.05） in the group B.While no statistically significant difference was found between the two group in postoperative morbidity of circulation or digestive and associated with surgical techniques（all P〈0.05）,lymph node metastasis rate of cervico-thoracic（include cervical paraesophageal） or mediastinum or abdominal cavity（χ~2=0.03,0.15,0.08,all P〈0.05）,lymph node ratio（LNR） of cervical thoracic（include cervical paraesophageal） or mediastinum or abdominal cavity（χ~2=0.01,0.71,0.01,all P〈0.05）,recurrence rate of tumour（χ~2=0.04,P〈0.05）,or survival rate（χ~2=0.13,P〈0.05） one year after the surgery.Conclusion Laparoscopic assisted IvorLewis cervical stapled esophagogastrostomy via a minor subaxillary incising is a more rational surgery of cervicothoracic and cervical paraesophageal lymph nodes dissection via intrathoracic instead of cervical approach for middle esophageal carcinoma.