电视胸腔镜治疗食管黏膜下肿物20年经验

Video-assisted Thoracoscopic Surgery for Esophageal Submucosal Tumors: Experience of 20 Years

目的探讨食管黏膜下肿物的临床特点、术式选择和中长期疗效。方法回顾性分析1996年9月-2016年2月20年共89例外科治疗食管黏膜下肿物的资料,分析临床资料、影像学资料、内镜资料、病理资料、治疗方式、治疗经过及术后随访资料。男57例,女32例,男∶女约为2∶1。年龄（44.1±11.0）岁。行肿瘤切除术85例（95.5%）,其中胸腔镜手术（video-assisted thoracoscopic surgery,VATS）69例（77.5%）,VATS中转开胸4例（4.5%）,直接开胸5例（5.6%）,经颈部切口5例（5.6%）,腹腔镜2例（2.2%）;行食管切除重建术3例（3.4%）;仅行活检1例（1.1%）。结果全组围手术期无死亡,无食管漏发生,1例乳糜胸,保守治疗治愈。病理诊断平滑肌瘤74例（83.1%）,胃肠道间质瘤（gastrointestinal stromal tumor,GIST）6例（6.7%）,神经纤维瘤、包涵囊肿各3例（3.4%）,血管瘤、脂肪肉瘤和原始神经外胚层肿瘤（primitive neurotodermal tumour,PNET）各1例（1.1%）。60例（67.4%）术后随访10-224个月,（72.3±47.6）月。1例高危型GIST术后24个月复发,未进一步治疗,术后60个月带瘤生存,其余5例GIST随访63-185个月,（143.6±55.4）月,未见复发。1例脂肪肉瘤术后70个月死于合并卵巢癌,其余53例无复发、死亡。结论食管黏膜下肿物是一组以良性和低度恶性为主的间质来源肿瘤,术前超声内镜检查、术中冰冻检查能帮助术者明确诊断。胸腔镜食管肿物切除术安全可行,适用于绝大部分患者,且长期效果良好,可作为治疗该病的标准术式。

Objective To explore the clinical characteristics of esophageal submucosal tumors and to summarize the choice of operative methods and observe the intermediate and long-term curative effects. Methods From September 1996 to February 2016,a total of 89 patients diagnosed with esophageal submucosal tumors and receiving surgical resection in the department were retrospectively analyzed. The clinical data,endoscopic findings,radiographic appearance,the histologic and immunohistologic characteristics of the tumors,details of treatment and postoperative follow-up data were collected. There were 57 men and 32 women in this group,with an average age of 44. 1 ± 11. 0 years old. Among them,69 cases（ 77. 5%） underwent video-assisted thoracoscopic surgery（ VATS）,4cases（ 4. 5%） required a conversion to open surgery,5 cases（ 5. 6%） received traditional thoracotomy directly,5 cases（ 5. 6%）underwent cervical operation,2 cases（ 2. 2%） underwent laparoscopy,3 cases（ 3. 4%） underwent esophageal resection and reconstruction,and 1 case（ 1. 1%） only biopsy. Results There was no perioperative death or esophageal leakage. One patient was diagnosed as chylothorax after operation,and was cured after conservative treatment. The diagnosis of all cases were confirmed by immunohistochemistry after operation,including 74 cases（ 83. 1%） of leiomyoma,6 cases（ 6. 7%） of gastrointestinal stromal tumor（ GIST）,3 cases（ 3. 4%） of schwannoma,3 cases（ 3. 4%） of inclusion cyst,and 1 case（ 1. 1%） of each of hemangioma,liposarcoma,and primitive neurotodermal tumour（ PNET）,respectively. There were 60 cases（ 67. 4%） receiving successful followup. The mean follow-up period was 72. 3 ± 47. 6 months（ range,10- 224 months）. At 24 months after surgery,a high risk type GIST patient was confirmed as having recurrence by CT scanning. Without any further treatment,at 60 months after surgery,the patient survived. The follow-up period of the rest of 5 GIST patients were 143. 6 ± 55. 4 months（ range,63- 185 months）,and there was no evidence of relapse. One case of liposarcoma died of ovarian cancer at 70 months after operation. The rest of 53 cases had no recurrence or death. Conclusions The esophageal submucosal tumors are mainly composed of benign leiomyoma and low-grade malignant GIST. Preoperative endoscopic ultrasonography and intraoperative frozen section examination can help the differential diagnosis of these diseases. It is safe and feasible to perform enucleation by VATS,which is suitable for the majority of patients and has good long-term effects. It can be used as the standard for the treatment of esophageal submucosal tumors.