腹腔镜辅助经腹食管裂孔入路治疗SiewertⅡ/Ⅲ型食管胃结合部腺癌围术期并发症分析(附50例报告)

The perioperative complications analysis of laparoscopic-assisted trans-hiatal esophagogastrectomy in the treatment of Siewert typeⅡ/Ⅲesophagogastric junction adenocarcinoma:with a report of 50 cases

目的:探讨腹腔镜辅助经腹食管裂孔入路清扫下纵隔治疗食管胃结合部腺癌围手术期并发症的发生机制及预防策略。方法:回顾2018年12月至2020年9月连续施行的经腹食管裂孔入路清扫下纵隔的50例SiewertⅡ/Ⅲ型食管胃结合部腺癌患者的临床资料,资料为前瞻性收集,总结分析手术资料及围术期并发症发生情况。结果:50例均顺利完成,其中46例采用OrvilTM完成吻合,4例OrvilTM吻合失败,中转其他吻合方式。手术时间265(265~302)min,术中出血量86(57.5~100)mL。4例(8.0%)发生术中并发症,2例(4.0%)心律失常,2例(4.0%)脾血管出血。14例(28.0%)发生术后并发症。心肺相关并发症包括胸腔积液10例(20.0%),肺部感染6例(12.0%),心律失常-心房颤动2例(4.0%),心包积脓1例(2.0%,经穿刺后缓解);吻合口相关并发症包括:吻合口漏5例(10.0%),其中4例经穿刺引流后治愈,1例因吻合口漏合并胸主动脉出血,最终死亡;吻合口狭窄1例(2.0%);其他并发症包括:下肢深静脉血栓3例(6.0%),呃逆2例(4.0%),腹腔感染2例(4.0%),乳糜瘘2例(4.0%),十二指肠残端瘘1例(2.0%),腹腔出血1例(2.0%)。无气胸、脓胸、吻合口出血、胰瘘、肠梗阻、切口感染等并发症发生。结论:腹腔镜辅助经腹食管裂孔入路清扫下纵隔治疗食管胃结合部腺癌围术期并发症发生率较高,且与传统全胃切除相关并发症有所不同,术者需对此有充分的认识与准备。

Objective:To explore the mechanism and preventive strategies of perioperative complications in laparoscopic-assisted trans-hiatal esophagogastrectomy and the lower mediastinum lymphadenectomy for the treatment of esophagogastric junction adenocarcinoma.Methods:This study reviewed 50 patients of Siewert typeⅡ/Ⅲesophagogastric junction adenocarcinoma who underwent continuous lymphadenectomy of the lower mediastinum through the trans-hiatal approach from Dec.2018 to Sep.2020.The data were prospectively collected.The the operation data and perioperative complications were summarized and analyzed.Results:All 50 cases completed the operation successfully.46 cases used OrvilTM to complete the anastomosis,OrvilTM anastomosis failed in 4 cases which were transferred to other anastomosis methods.The operation time was 265(265-320)min,and the intraoperative blood loss was 86(57.5-100)mL.Intraoperative complications occurred in 4 cases(8.0%),2 cases(4.0%)had arrhythmia,and 2 cases(4.0%)had splenic vascular bleeding.Postoperative complications occurred in 14 cases(28.0%).Cardiopulmonary complications included 10 cases of pleural effusion(20.0%),6 cases of pulmonary infection(12.0%),2 cases of arrhythmia-atrial fibrillation(4.0%),and 1 case of pericardial empyema(2.0%,the patient was relieved after puncture).Anastomotic complications included 5 cases of anastomotic leakage(10.0%,4 cases were cured after puncture and drainage,1 case was eventually declared dead due to anastomotic leakage combined with thoracic aortic bleeding).There was 1 case(2.0%)of anastomotic stenosis;other complications included:3 cases(6.0%)of deep vein thrombosis of lower limbs,2 cases(4.0%)of hiccups,2 cases(4.0%)of abdominal infection,2 cases(4.0%)of chyle fistula,1 case(2.0%)of duodenal stump fistula,and 1 case(2.0%)of abdominal hemorrhage.No pneumothorax,empyema,anastomotic bleeding,pancreatic fistula,intestinal obstruction,incision infection or other complications occurred.Conclusions:The complication incidence of laparoscopic-assisted lymphadenectomy of lower mediastinum through the trans-hiatal approach is higher and its type is different from traditional total gastrectomy,which requires the surgeon to have sufficient knowledge and preparation.