腔镜辅助下McKeown术式切除食管癌18年经验总结

Video-assisted McKeown esophagectomy for esophageal cancer:18-year experience in a single institution

目的总结腔镜辅助下McKeown术式切除食管癌的单中心18年经验体会。方法回顾性分析1997年8月至2015年6月在温州医科大学附属台州医院胸外科行食管癌切除的639例患者的临床资料,其中在腔镜辅助下完成McKeown食管癌切除手术622例(97.34%)。食管肿瘤位于上、中、下段分别占7.98%、63.54%和28.48%,其中8.92%的患者术前接受放化疗。TNM分期中,0、Ⅰ、Ⅱ、Ⅲ、Ⅳ期分别占10.33%、29.26%、42.10%、15.02%和3.29%;病理检查为鳞癌占92.02%,腺癌及其他类型占7.98%。手术采用腔镜辅助下经右胸、上腹、左颈入路,其中胸腔镜+开腹占44.60%,胸腔镜+腹腔镜占47.26%,开胸+腹腔镜占5.48%,非计划中转开胸或开腹占2.66%。结果胸腔镜下食管游离及胸腔淋巴结清扫时间为(78.6±36.9)min,腹腔镜下胃游离及腹区淋巴结清扫时间为(55.4±19.5)min;胸腔镜手术出血量为(99.5±79.2)ml,腹腔镜手术出血量为(40.5±23.4)ml。每例患者平均清扫淋巴结总数为(24.1±12.4)枚,其中胸腔淋巴结清扫(14.9±8.1)枚,腹腔淋巴结清扫(9.1±5.5)枚,颈区淋巴结清扫(1.5±1.3)枚。全组术中无死亡病例,术中因奇静脉或脾脏损伤出血4例,电凝钩或超声刀误伤气管4例,非病灶原因胸导管损伤13例,心房纤颤11例,食管切缘阳性R1切除者4例。术后早期并发症超过10例次的包括肺部感染(11.42%)、颈部吻合瘘(7.04%)、心律失常(4.85%)、胸腔积液需要置管(3.29%)、喉返神经损伤(3.13%),术后乳糜胸(2.03%)。术后早期死亡6例(0.94%),分别为术后呼吸衰竭3例、气管管胃瘘后肺部严重感染1例、难控性高血糖并颈部吻合口瘘迁延不愈及多器官衰竭1例、胸胃瘘或坏死致主动脉腐蚀破裂出血1例。术后接受放化疗307例(48.04%);术后随访率为90.8%,平均随访时间(44.5±33.1)个月;术后1、2、3、5年的生存率分别为83.9%、69.7%、57.1%和45.5%。结论腔镜辅助下McKeown术式食管癌切除在肿瘤R0切除,以及术后近远期疗效上是可行且有效的。

[Abstract ] Objective To summarize the 18-year experience in video-assisted McKeown esophagectomy for esophageal cancer.Methods The clinical data of 639patients with esophageal cancer undergoing McKeown esophagectomy between August 1997 and June 2015 in Department of Thoracic SurgeryTaizhou Hospital affiliated to Wenzhou Medical University were retrospectively analyzed. Among these 639 patients62297.34% completed the surgery with video-assisted procedures.A total of 7.98% of esophageal tumors located in the upper segment63.54% in the middle segmentand 28.48% in the lower segment.Preoperative neoadjuvant chemoradiotherapy was done in 8.92% of patients.For TNM stagingstage 0 accounted for 10.33%stage Ⅰ29.26%stage Ⅱ 42.10%stageⅢ15.02% and stage Ⅳ 3.29%.Pathological examinations demonstrated that there were 92.02% of＆amp;nbsp;squamous cancer and 7.98% of adenocarcinoma and other histological types.Surgery were completed by thoracoscopy and laparotomy44.60%thoracoscopy and laparoscopy47.26%thoracotomy and laparoscopy5.48%and conversion to thoracotomy or laparotomy 2.66%.Results The time of esophagus freeing and pleural lymph node dissection under thoracoscope was78.6±36.9minand the time of stomach freeing and abdominal lymph node dissection under laparoscope was55.4±19.5min. The volumes of blood loss in thoracoscopic surgery and laparoscopic surgery were99.5±79.2ml and40.5±23.4 ml respectively.The mean total number of lymph node dissection was24.1±12.4 per caseand the number of thoracic lymph node dissection was 14.9 ± 8.1 per caseabdominal lymph node dissection9.1±5.5 per caseand neck lymph node dissection1.5±1.3 per case.There was no death during operation.There were 4 cases of intraoperative bleeding due to the azygos vein or spleen injury4 cases of accidental tracheal injury caused by cautery hook or ultrasound knife13 cases of thoracic duct injury of non-focal cause11 cases of atrial fibrillation and 4 cases of esophageal resection margin-positive R1 resection.The major complications in the early postoperative period which occurred in more than 10 cases were lung infection11.42%neck anastomosis leak7.04%arrhythmia4.85%pleural effusion catheterization3.29%recurrent laryngeal nerve injury3.13% and chylothorax2.03%.Six cases0.94% died early after operation. Among them 3 died of postoperative respiratory failure 1 severe pulmonary infection after tracheoesophageal fistula 1 recurrent hyperglycemia complicated with neck anastomotic fistula uncured and multiple organ failureand the other aorta rupture and bleeding caused by chest gastric fistula or necrosis.Three hundred and seven patients 48.04% received postoperative radiotherapy and chemotherapy.The follow-up rate was 90.8%and the mean follow-up time was 44.5 ± 33.1 months.The 123and 5-year overall survival rates were 83.9%69.7%57.1% and 45.5%respectively.Conclusions Video-assisted McKeown esophagectomy for esophageal cancer is feasible and effective in tumor R0 resection and short-term and long-term effects.