术中非计划事件对于微创食管癌根治术患者术后早期康复的影响

Impact of unplanned events during minimally invasive esophagectomy on early postoperative recovery

目的探讨术中非计划事件发生对于微创食管癌根治术（MIE）患者术后早期康复的影响.方法回顾性分析上海交通大学附属胸科医院2011年1月至2015年12月单-手术组连续收治的303例MIE患者的临床资料,根据患者术中有无发生非计划事件分为非计划事件组（UG组,85例）和无非计划事件组（PG组,218例）,比较两组患者术后并发症发生率的差异.结果（1）MIE术中非计划事件（89例次）以胸腔和（或）腹腔粘连（28/89,31.5%）、术中意外发现肿瘤外侵明显（sT4a＋T4b,25/89,28.1%）最为多见.（2）UG组患者术后呼吸系统并发症（57.6%）和神经系统并发症（10.6%）、感染（32.9%）和乳糜胸（8.2%）发生率均显著高于PG组（8.3%、2.8%、5.0%和0.9%）,差异有统计学意义（χ2=12.138、8.026、10.336、8.325,均P〈0.05）.（3）中转开胸或开腹最常见原因为胸腔和（或）腹腔粘连（9/38,23.7%）,以及损伤血管大出血（7/38,18.4%）.（4）非根治性切除最常见原因为肿瘤侵犯气管和（或）总支气管（7/21,33.3%）及主动脉（5/21,23.8%）.结论术中非计划事件的发生增加了MIE术后并发症的发生率.随着学习曲线的延长,术中非计划事件发生率会明显下降;术前对原发肿瘤和转移淋巴结的准确分期有助于降低MIE术中非计划事件的发生.

Objective To investigate the impact of unplanned events during minimally invasive esophagectomy（MIE） on early postoperative recovery. Methods The clinical data of 303 consecutive patients undergoing MIE by the same operation group in Department of Thoracic Surgery, Shanghai Chest Hospital affiliated to Shanghai Jiaotong University between January 2011 and December 2015 were retrospectively analyzed. Patients were divided into unplanned group（85 cases） and planned group（218 cases） based on the presence and absence of unplanned events during operation, and the incidences of postoperative complications were compared between two groups. Results （ 1 ） The most common unplanned events during MIE were pleural or/and peritoneal adhesion （28/89, 31. 5%）. Intraoperative accidental discovery of deep tumor invasion （sT4a ＋ T4b） ranked second （25/89, 28. 1%） . （2 ） The incidences of respiratory system complications （57.6%）, nervous system complications （10.6%）, postoperative infection （32.9%）and chylothorax （8.2%） in unplanned group were significantly higher than those in planned group（8.3% , 2.8%, 5.0%, 0.9%, respectively） = 12.138, 8.02 6,10.336, 8.325,respectively; P 〈0 . 0 5 ） . （ 3） The most common reasons for transference from MIE to thoracotomy or laparotomy were pleural/peritoneal adhesion （9/38,23. 7%） and bleeding （ 7/38, 18.4%）. （4） The main reasons for R2 resection were tumor invasions of trachea/bronchus （7/21, 33.3%） and aorta（5/21, 23.8%）.Conclusions The unplanned events during MIE increases the incidence of postoperative complications. With the increase in experience for MIE, unplanned events will decrease. Preoperative accurate clinical TNM staging can reduce the incidence of unplanned events during MIE.