CAJ | 학술논문

目的总结开展腔镜辅助下McKeown术式切除食管癌的经验体会.方法回顾性分析1997年8月至2012年12月507例施行腔镜辅助下McKeown术式切除食管癌的患者临床资料.男348例,女159例；年龄(60.5±10.6)岁.其中,食管肿瘤位于上段39例(7.69％),中段312例(61.54％),下段156例(30.77％),术前放、化疗21例(4.14％).TNM分期:0期55例(10.85％),Ⅰ期167例(32.94％),Ⅱ期203例(40.04％),Ⅲ期69例(13.61％),Ⅳ期13例(2.56％)；鳞癌463例(91.32％),腺癌及其他类型44例(8.68％).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281例(55.42％),胸腔镜+腹腔镜179例(35.31％),开胸+腹腔镜32例(6.31％),中转开胸/开腹15例(2.96％).结果 507例患者中腔镜辅助下完成McKeown食管癌切除手术492例(97.04％).胸腔镜下食管游离及胸腔淋巴结清扫(81.5±34.7) min,腹腔镜下胃游离及腹区淋巴结清扫(60.3 ±17.5) min.胸腔镜手术出血(105.2±73.1)ml,腹腔镜手术出血(43.5土21.4)ml.清扫淋巴结总数(23.7±11.5)枚/例,其中胸腔淋巴结清扫(14.6±7.7)枚/例,腹腔淋巴结清扫(8.7±5.2)枚/例,颈区淋巴结清扫(1.3±1.1)枚/例.198例经食管床、309例经胸骨后径路重建食管.全组术中无死亡.术中因非病灶原因胸导管损伤13例、心房颤动9例、食管切缘阳性R1切除者3例、奇静脉/脾脏损伤出血3例、电凝钩/超声刀误伤气管3例.术后早期主要并发症为肺部感染54例(10.65％),颈部吻合瘘39例(7.69％),心律失常25例(4.93％),胸腔积液需要置管19例(3.75％),喉返神经损伤17例(3.35％),术后乳糜胸12例(2.37％).术后早期死亡5例(0.99％).241例(47.53％)接受术后放化疗.458例随访(41.5±35.9)个月,1、3、5年生存率分别为81.9％ (324/396)、53.7％ (148/276)、47.6％ (63/132).结论腔镜辅助下McKeown术式切除食管肿瘤可行、有效,术后近、中期疗效可靠.
목적 총결개전강경보조하McKeown술식절제식관암적경험체회.방법 회고성분석1997년8월지2012년12월507례시행강경보조하McKeown술식절제식관암적환자림상자료.남348례,녀159례；년령(60.5±10.6)세.기중,식관종류위우상단39례(7.69％),중단312례(61.54％),하단156례(30.77％),술전방、화료21례(4.14％).TNM분기:0기55례(10.85％),Ⅰ기167례(32.94％),Ⅱ기203례(40.04％),Ⅲ기69례(13.61％),Ⅳ기13례(2.56％)；린암463례(91.32％),선암급기타류형44례(8.68％).수술채용강경보조하경우흉、상복、좌경입로,기중흉강경+개복281례(55.42％),흉강경+복강경179례(35.31％),개흉+복강경32례(6.31％),중전개흉/개복15례(2.96％).결과 507례환자중강경보조하완성McKeown식관암절제수술492례(97.04％).흉강경하식관유리급흉강림파결청소(81.5±34.7) min,복강경하위유리급복구림파결청소(60.3 ±17.5) min.흉강경수술출혈(105.2±73.1)ml,복강경수술출혈(43.5토21.4)ml.청소림파결총수(23.7±11.5)매/례,기중흉강림파결청소(14.6±7.7)매/례,복강림파결청소(8.7±5.2)매/례,경구림파결청소(1.3±1.1)매/례.198례경식관상、309례경흉골후경로중건식관.전조술중무사망.술중인비병조원인흉도관손상13례、심방전동9례、식관절연양성R1절제자3례、기정맥/비장손상출혈3례、전응구/초성도오상기관3례.술후조기주요병발증위폐부감염54례(10.65％),경부문합루39례(7.69％),심률실상25례(4.93％),흉강적액수요치관19례(3.75％),후반신경손상17례(3.35％),술후유미흉12례(2.37％).술후조기사망5례(0.99％).241례(47.53％)접수술후방화료.458례수방(41.5±35.9)개월,1、3、5년생존솔분별위81.9％ (324/396)、53.7％ (148/276)、47.6％ (63/132).결론 강경보조하McKeown술식절제식관종류가행、유효,술후근、중기료효가고.
Objective To assess our outcomes after McKeown minimally invasive esophagectomy(MMIE) for the treatment of esophageal cancer.Methods From August 1997 to December 2012,MMIE was performed in 507 patients.Esophageal tumors located in the upper in 39(7.69％),middle in 312(61.54％),lower in 156(30.77％).Preoperative neoadjuvant chemoradiotherapy was used in 21 cases (4.14 ％).Resection was performed for squamous cancer (463 cases,91.32 ％),adenocarcinoma and other histologic types (44 cases,8.68％) in patients with stages 0 (55,10.85％),Ⅰ (167,32.94％),Ⅱ (203,40.04％),Ⅲ (69,13.61％),and Ⅳ (13,2.56％) disease.Surgery were completed by thoracoscopic and laparotomy(281 cases,55.42％),total thoracoscopic/laparoscopic approach(179 cases,35.31％),thoracotomy and laparoscopic (32 cases,6.31％),conversion to thoracotomy/laparotomy (15 cases,2.96％).Results MMIE was successfully completed in 492(97.04％) patients.The operative time of thoracoscopic the esophagus free and pleural lymph node dissection was(81.5 ±34.7)min(60-180 min),laparoscopic stomach free and abdominal area lymphadenectomy was 60.3 ± 17.5)min(40-105 min).The blood loss of thoracoscopic surgery was(105.2 ±73.1) m1(55-1080 ml),laparoscopic surgery (43.5 ±21.4)m1(30-350ml).The total number of lymph node dissection was 5-48[(23.7 ± 11.5)/case],the number of thoracic lymph node dissection was 3-32 [(14.6 ± 7.7)/case],abdominal lymph node dissection 2-29 [(8.7 ±5.2)/case)],and neck lymph node dissection 0-7 [(1.3 ± 1.1)/case].198 cases of esophageal reconstruction after esophageal bed,309 cases through the sternum approach.The whole group were no deaths,intraoperative bleeding in 3 cases due to the azygos vein/spleen injury,the hook cautery/ultrasound surgery the knife accidentally injure trachea 3 cases,the non-focal cause 13 cases of thoracic duct injury,9 cases of atrial fibrillation,esophageal resection margin-positive R1 resection in 3 cases.Major complications in the early postoperative period,lung infection rate was 10.65％ (n =54),the neck anastomosis leak rate was 7.69％ (n =39),arrhythmia rate was 4.93％ (n =25),pleural effusion catheter rate was 3.75％ (n =19),recurrent laryngeal nerve injury rate was 3.35 ％ (n =17),c hylothorax rate was 2.37％ (n =12).Mortality rate of early postoperative rate was 0.99％ (n =5).241 patients(47.53％) received postoperative radiotherapy and chemotherapy.The postoperative group average follow-up time was (41.5 ± 35.9) months(1-96 months),a successful follow-up of 458 cases,follow-up rate of 90.3％.The 1-year survival rate was 81.9％ (324/396),3-year survival rate was 53.7％ (148/276),and 5-year survival rate was 47.6％ (63/132).Conclusion The surgical and oncologic outcomes of the MMIE procedure for esophageal cancer in our center were acceptable and comparable with those of reported the open-McKeown esophagectomy.The operation was shown to be feasible and safe,and these properties will be consolidated by experience.