全胸腔镜与传统食管癌根治术治疗Ⅰ、Ⅱ期食管癌效果比较
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摘要
目的与开胸食管癌根治术对比,探讨全胸腔镜(VATS)下食管癌根治术治疗Ⅰ、Ⅱ期食管癌的安全性和有效性。方法2007,9~2010,3通过VATS食管癌切除术治疗Ⅰ、Ⅱ期食管癌患者,其中男22例,女14例,中位年龄60.5岁(38~78),方法为胸腔镜下经右胸游离胸段食管及肿瘤,清扫胸腔内淋巴结,上腹部正中切口完成胃的游离及清扫腹腔内淋巴结,颈部切口完成食管癌切除胃食管颈部吻合术。并与同时期接受传统开胸手术治疗的36例患者进行对比分析,对比两组术前、术中、术后近期情况。结果36例患者胸部手术均通过胸腔镜完成,无中转开胸,发生吻合口瘘2例,乳糜胸2例,无院内死亡病例,效果满意。两组在年龄、性别分布、术前主要合并症等方面差异无统计学意义(P>0.05)。VATS组与开胸组相比,胸部手术时间(110.56±36.41)min对(133.33±22.55)min(P<0.05);术中出血(125.82±47.82)ml对(215.28±46.99)ml(P<0.001);淋巴结清扫数目(11.47±5.91)对(16.19±8.54)(P<0.05);术后第一天胸引量(274.44±127.13)ml对(456.11±184.43)ml(P<0.001);术后胸引管带管时间(6.53±1.87)d对(9.89±2.61)d(P<0.001);术后36小时疼痛VAS(3.36±0.96)对(6.81±1.72)(P<0.001);术后胸部引流总量(1094.2±405.6)ml对(1687.9±689.6)ml(P<0.001);术后72小时右上肢功能恢复(5.08±1.27)cm对(16.00±3.62)cm(P<0.001);住院总花费(2.97±0.81)万元对(2.78±0.76)万元(P>0.05)。结论两种术式在治疗Ⅰ、Ⅱ期食管癌具有相似的完全性和彻底性,电视胸腔镜食管切除术在技术上是安全可行的。VATS食管癌根治术较开胸食管癌根治术的胸部手术出血量少,术后胸引流量少,术后疼痛轻微,上肢活动恢复快。但是VATS临床应用有局限性,不能完全代替常规开胸手术,对手术操作难度大的病变或较大的肿瘤仍选择常规开胸手术为宜。胸腔镜食管癌切除术有其适应证,对医生提出更高的技术要求,目前仍有争议,全盘否定或盲目应用都会影响胸外科的发展。
Objective To compare the results and safety between video-assisted thoracic surgery(VATS)radical operation and conventional thoractomy in patients with stageⅠ,Ⅱesophageal carcinoma. Methods From September 2007 to March 2010,video-assisted thoracoscopic esophagectomy was performed in 36 patients. There were 22 men , 14 women. Median age was 60.5 years ( range ,38 - 78) . Under thoracoscopy via thoracic and cervical incisions, the esophagus and tumor were disconnected and the intrathoracic lymph nodes were cleared through the right thorax. Then a median incision was made at the epigastrium. Through the incision the stomach was disconnected and intraabdominal lymph nodes were removed. Afterwards, esophagectomy and gastroesophagostomy were performed by way of the cervical incision. Retrospectively reviewed 72 patients with stageⅠ,Ⅱesophageal carcinoma underwent either VATS radical operation (VATS group,n=36) or standard radical operation via thoractomy (open group,n=36) . Patients’s operative characteristics and postoperative courses were comparable between two groups. Results The results were satisfactory and no operative mortality , anastomotic leak 2 case , chylothorax 2 case . The operative time was (110.56±36.41)min in the VATS group and (133.33±22.55)min in the open group(P<0.05);The number of mediastinal lymphonode resection was (11.47±5.91) and (16.19±8.54)(P<0.05);The time of postoperative chest tube was(6.53±1.87)d and(9.89±2.61)d(P<0.001);The postoperative pain(VAS) was (3.36±0.96) and(6.81±1.72)(P<0.001);The postoperative locomotor activity of right upper extremity was(5.08±1.27)cm and (16.00±3.62)cm(P<0.001). Conclusion Compare with thoractomy,VATS thoracic surgery for patients with stageⅠ,Ⅱesophageal carcinoma appears to be as effective but less morbid . Video-assisted thoracoscopic esophagectomy is technically feasible and safe. It has the potential to replace open esophagectomy in selected patients. However, the VATS can not fill the place of thoracotomy for its limitedness. Regular thoracotomy is preferable in cases of high risks or with larger tumor. Thoracoscope has its indications in treatment of the esophageus carcinoma. Strict requirement of the doctors thoracoscope skill must be performed. Dispute was exist in the use of thoracoscope. Total negation or blind application would holdback the development of thoracoscope surgery .
Objective To compare the results and safety between video-assisted thoracic surgery(VATS)radical operation and conventional thoractomy in patients with stageⅠ,Ⅱesophageal carcinoma. Methods From September 2007 to March 2010,video-assisted thoracoscopic esophagectomy was performed in 36 patients. There were 22 men , 14 women. Median age was 60.5 years ( range ,38 - 78) . Under thoracoscopy via thoracic and cervical incisions, the esophagus and tumor were disconnected and the intrathoracic lymph nodes were cleared through the right thorax. Then a median incision was made at the epigastrium. Through the incision the stomach was disconnected and intraabdominal lymph nodes were removed. Afterwards, esophagectomy and gastroesophagostomy were performed by way of the cervical incision. Retrospectively reviewed 72 patients with stageⅠ,Ⅱesophageal carcinoma underwent either VATS radical operation (VATS group,n=36) or standard radical operation via thoractomy (open group,n=36) . Patients’s operative characteristics and postoperative courses were comparable between two groups. Results The results were satisfactory and no operative mortality , anastomotic leak 2 case , chylothorax 2 case . The operative time was (110.56±36.41)min in the VATS group and (133.33±22.55)min in the open group(P<0.05);The number of mediastinal lymphonode resection was (11.47±5.91) and (16.19±8.54)(P<0.05);The time of postoperative chest tube was(6.53±1.87)d and(9.89±2.61)d(P<0.001);The postoperative pain(VAS) was (3.36±0.96) and(6.81±1.72)(P<0.001);The postoperative locomotor activity of right upper extremity was(5.08±1.27)cm and (16.00±3.62)cm(P<0.001). Conclusion Compare with thoractomy,VATS thoracic surgery for patients with stageⅠ,Ⅱesophageal carcinoma appears to be as effective but less morbid . Video-assisted thoracoscopic esophagectomy is technically feasible and safe. It has the potential to replace open esophagectomy in selected patients. However, the VATS can not fill the place of thoracotomy for its limitedness. Regular thoracotomy is preferable in cases of high risks or with larger tumor. Thoracoscope has its indications in treatment of the esophageus carcinoma. Strict requirement of the doctors thoracoscope skill must be performed. Dispute was exist in the use of thoracoscope. Total negation or blind application would holdback the development of thoracoscope surgery .
引文
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1,王俊.电视胸腔镜在胸部疾病治疗中的应用现状[J].临床外科杂志, 2005, 13 (7) : 384～385.
2,李剑锋,王俊.电视胸腔镜手术的发展现状[J].腹腔镜外科杂志, 2001, 6 (2) : 117～119
3, L Solaini F,Prusciano P,Bagioni F,et al.Poddie video-assisted thoracic surgery(VATS) of the lung.Analysis of intraoperative and postoperative complications over 15 years and review of the literature[J]. Surg Endosc,2008,22:298-310.
4, Collard JM,,Lengele B,Otte JB, et al. Enbloc and standard esophagectomies by thoracoscopy[J]. AnnThorac Surg, 1993, 56 (3) : 675～679.
5, Gossot D, Fourquier P, CelerierM. Thoracoscopic esophagectomy: technique and initial results [J]. Ann Thorac Surg, 1993, 56 ( 3 ) : 667 -670.
6, Pellegrini C ,Wetter LA , Patti M , et al . Thoracoscopic esophagomyotomy. Initial experience with a new approach for the treatment of achalasia[J] . Ann Surg ,1992 ,216 :291-296
7,梁朝阳,周乃康,崔忠厚,等.胸腔镜食管切除术治疗食管癌[J].解放军医学杂志, 2002, 27 (12) : 1074 - 1075.
8,曲家骐,侯维平.电视胸腔镜食管癌切除术八例初步报告[J] .中华外科杂志, 1996 ,34 :84-86.
9, de- Hoyos A, Litle VR, Luketich JD. Minimally invasive esophagectomy[J]. Surg Clin N Am, 2005, 85 (3) : 631 - 647.
10, Inada K, Shirakusa T, Yoshinaga Y, et al. The role of video-assisted thoracic surgery for the treatment of lung cancer: lung lobectomy by thoracoscopy versus the standard thoracotomy approach [J]. Int Surg,,2000, 85 (1) : 6～12.
11,杜贾军,孟龙,陈景寒,等.胸段食管癌的微创手术治疗附145例报告[J].山东医药, 2005, 45 (27) : 9 - 10.
12,Thomas P, Doddoli C, Yena S, et al. VATS is an adequate oncological operation for stage I non small cell lung cancer[J]. Eur J Cardiothorac Surg, 2002, 21 (6) : 1094～1099.
13, Li JH, Liang YP, Lu M, et al. Video-assisted thoracoscopic surgery in treatment of chest diseases[J]. Journal of Fourth Military Medical University, 2003, 24 (4) : 382～383.
14, Akaishi T, Kaneda I, Higuchi N, et al. Thoracoscopic en bloc total esophagectomy with radical mediastinal lymphadenectomy[J].Thorac Cardiovasc Surg, 1996, 112 (3) : 1533 - 1541.
15,谢彤,刘德森,祝家兴,等.电视辅助VATS手术对外周血HCT、WBC的影响[J].中国内镜杂志, 2000, 6 (5) : 18 - 19.
16,林雨冬,王明元,吴和康,等.食管癌切除颈部吻合对患者肺功能的影响[J].临床肿瘤学杂志, 2001, 6 (1) : 48～49.
17 , Craig SR,Leaver HA,Yap PL,et al. Acute phase responses following minimal access and conventional thoracic surgery[J] .Eur J Cardiothorac Surg,2001,20(3):455-463。
18,宁玉林,郭金成,赵国强.胸腔镜下食管癌手术对术后早期肺功能影响的临床研究[J].中国内镜杂志, 2007, 13 (3) : 302 - 304.
19, Taguchi S, Osugi H, Higashino M, et al. Comparison of three-ield esophagectomy for esophageal cancer incorporating open or thoracoscopic thoracotomy[J]. Surg Endosc, 2003, 17 (9) : 1445 - 1450.
20, Osugi H, Takemura M, Higashino M, et al. Learning curve of video-assisted thoracoscopic esophagectomy and extensive lymphadenectomy for squamous cell cancer of the thoracic esophagus and results[J]. Surg Endosc, 2003, 17 (3) : 515 - 519.
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22, Watanabe A, koyanagi T, Ohsawa H, et al. Systmatic node dissection by VATS is not inferior to that through an open thoracotomy: a comparative clinicopathologic retrospective study[J]. Surgery,2005, 138(3): 510-517
23, Luketich JD , Meehan M , Nguyen NT , et al . Minimally invasive surgical staging for esophageal cancer[J]. Surg Endosc , 2000 , 14 : 700.
24, Roviaro GC , Varoli F , Vergani C , et al . State of the art in thoracoscopic surgery : a personal experience of 2000 video-thoracoscopic procedures and an overview of the literature[J] . Surg Endosc , 2002 , 16 : 881.
25,陆江,张立国,许寿霞,等.胸腔镜下食管癌切除术[J].中国微创外科杂志, 2006, 6 (8) : 571 - 572.
26,朱成楚,陈仕林,叶敏华,等.电视VATS下行食管癌手术胸部淋巴结清扫[J].中华外科杂志, 2005, 43 (10) : 628 - 630.
27, Lin TS, Kuo SJ, Lai CY, et al. Combination of video-assisted thoracoscopic surgery and hand-assisted laparoscopic surgery for early cancer of the thoracic esophagus[J]. International surgery, 2004, 89 (3) : 131 -135.
28,叶中瑞,朱成楚,叶加洪,等.电视VATS食管癌切除术[J].中国微创外科杂志, 2005, 5 (8) : 609 - 610.
29, Alberto de Hoyos,Virginia R. Litle, James D. Luketich. Minimally invasive esophagectomy[J]. Surg Clin N Am, 2005, 85 (3) : 631～647.
30, Mafune K, Tanaka Y,Makuuchi M. Video2assisted esophagectomy for carcinoma of the esophagus , using thoracoscopy or mediastinoscopy [J] . Gan To Kagaku Ryoho , 1997 , 24 : 525-531.
31, Collard JM ,Lengele B , Ot te JB , et al . En bloc and standard esophagectomies by thoracoscopy[J] . Ann Thorac Surg ,1993 ,56 :675-679.
32, Law S , Fok M ,Chu KM , et al . Thoracoscopic esophagectomy for esophageal cancer [J] . Surgery ,1997 ,122 :8214.
33, Higashino M , Takemura M. Indication and limitation of endoscopic surgicalprocedure for esophageal cancer [J] . Gan To Kagaku Ryoho ,2004 ,31 :1481-1484.
34,张明.电视胸腔镜食管癌切除术16例报告[J] .中国微创科杂志,2004 ,4 :189-190.
35, Higashino M, Takemura M. Indication and limitation of endoscopicsurgical procedure for esophageal cancer[J]. Gan To Kagaku Ryoho,2004, 31 (10) : 1481 - 1484.
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39杜贾军,孟龙,陈景寒,等.手辅助电视胸腔镜行食管癌切除术[J] .中华外科志,2005 ,43 :351-353.
40, Okushiba S ,Ohno K, Itoh K,et al . Hand-assisted endoscopic esophagectomy for esophageal cancer [J] . Surg Today , 2003 ,33 :158-161.
41, Swanstrom LL, Hansen P. Laparoscopic total esophagectomy[J]. Arch Surg, 1997, 132 (9) : 943～949.
42, Luketich JD, Nguyen NT, Schauer PR. Laparoscopic transhiatal esophagectomy for Barrett’s esophagus with high grade dysp lasia [J]. JSLS, 1998, 2 (1) : 75～77.
43, Luketich JD, Alvelo-Rivera M, Buenaventura PO, et al. Minimally invasive esophagectomy: outcomes in 222 patients [J]. Ann Surg,2003, 238 (4) : 486～494.
44, Okushiba S, Ohno K, Itoh K. Hand-assisted endoscopic esophagectomy for esophageal cancer[J]. Surg Today, 2003, 33 ( 2 ) :158 - 161.
45, Swanstrom LL, Hansen P. Laparoscopic total esophagectomy[J]. Arch Surg, 1997, 132 (9) : 943～949.
46, Okada M, Sakamoto T, Yuki T, et al. Hybrid surgical approach of video-assistedminithoracotomy for lung cancer. Siginificance of direct visualization on quality of surgery[J]. Chest, 2005, 128 ( 4 ) :2696– 2701.
47, Law S,Wong J. Use of minimally invasive oesophagectomy for cancer of the oesophagus[J]. Lancet Oncol, 2002, 3 (4) : 215～222.
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5, Gossot D, Fourquier P, CelerierM. Thoracoscopic esophagectomy: technique and initial results [J]. Ann Thorac Surg, 1993, 56 ( 3 ) : 667 -670.
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7,梁朝阳,周乃康,崔忠厚,等.胸腔镜食管切除术治疗食管癌[J].解放军医学杂志, 2002, 27 (12) : 1074 - 1075.
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13, Li JH, Liang YP, Lu M, et al. Video-assisted thoracoscopic surgery in treatment of chest diseases[J]. Journal of Fourth Military Medical University, 2003, 24 (4) : 382～383.
14, Akaishi T, Kaneda I, Higuchi N, et al. Thoracoscopic en bloc total esophagectomy with radical mediastinal lymphadenectomy[J].Thorac Cardiovasc Surg, 1996, 112 (3) : 1533 - 1541.
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18,宁玉林,郭金成,赵国强.胸腔镜下食管癌手术对术后早期肺功能影响的临床研究[J].中国内镜杂志, 2007, 13 (3) : 302 - 304.
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42, Luketich JD, Nguyen NT, Schauer PR. Laparoscopic transhiatal esophagectomy for Barrett’s esophagus with high grade dysp lasia [J]. JSLS, 1998, 2 (1) : 75～77.
43, Luketich JD, Alvelo-Rivera M, Buenaventura PO, et al. Minimally invasive esophagectomy: outcomes in 222 patients [J]. Ann Surg,2003, 238 (4) : 486～494.
44, Okushiba S, Ohno K, Itoh K. Hand-assisted endoscopic esophagectomy for esophageal cancer[J]. Surg Today, 2003, 33 ( 2 ) :158 - 161.
45, Swanstrom LL, Hansen P. Laparoscopic total esophagectomy[J]. Arch Surg, 1997, 132 (9) : 943～949.
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49, Mckenna RJ,Houck W,Fuller CB. Video-assisted thoracic surgery lobectomy: experience with 1100 cases[J] .Ann Thorac Surg , 2006 , 81:421-425.
50, Shigermura N,Akashi A ,Funaki S,et al.Long-term outcomes after a variety of video-assisted thoracic laparoscopic lobectomy approaches for clinical stage IA lung cancer: a multi-institutional study[J]. Thorac Cardiovasc Surg, 2006, 132: 507-512.
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