CAJ | 학술논문

目的：分析胸腹腔镜联合食管切除术（ TLE ）治疗食管癌的临床效果及学习曲线。方法回顾性分析2008年2月至2013年10月四川大学华西医院胸外科连续行TLE的350例患者临床资料，分析患者的术中及术后情况，评价该术式的临床疗效；根据患者接受TLE手术日期的顺序，将TLE开展的早期阶段150例病例平均分为3组，即TLE 1组、TLE 2组及TLE 3组，每组50例，比较3组间的围手术期指标，以分析该术式的学习曲线。结果全组无术中死亡病例，29例（8．3％）患者出现术中并发症，术中中转手术13例（3．7％，开胸9例、开腹4例）。全组手术时间为230～780（平均332．5） min，术中出血量为15～4000（平均160．8） ml。其中，R0切除333例（95．1％），清扫淋巴结6～42（平均21．6）枚／例。术后住院时间为7～93（平均11．6） d。术后出现并发症75例（21．4％），术后30 d内死亡3例（0．8％）。与TLE 1组比较，TLE 2组的手术时间、术中失血量、术后住院时间及术后并发症的发生率明显较低，淋巴结清扫数目明显较多（均P＜0．05）。TLE 3组除手术失血量明显少于TLE 2组外，两组间的其他围手术期指标差异均无统计学意义（均P＞0．05）。结论 TLE在技术上安全可行，且能够达到与传统食管癌手术相同的根治效果，是治疗食管癌的可选手术方式。开展TLE约50例后可基本掌握TLE的手术技巧。
목적：분석흉복강경연합식관절제술（ TLE ）치료식관암적림상효과급학습곡선。방법회고성분석2008년2월지2013년10월사천대학화서의원흉외과련속행TLE적350례환자림상자료，분석환자적술중급술후정황，평개해술식적림상료효；근거환자접수TLE수술일기적순서，장TLE개전적조기계단150례병례평균분위3조，즉TLE 1조、TLE 2조급TLE 3조，매조50례，비교3조간적위수술기지표，이분석해술식적학습곡선。결과전조무술중사망병례，29례（8．3％）환자출현술중병발증，술중중전수술13례（3．7％，개흉9례、개복4례）。전조수술시간위230～780（평균332．5） min，술중출혈량위15～4000（평균160．8） ml。기중，R0절제333례（95．1％），청소림파결6～42（평균21．6）매／례。술후주원시간위7～93（평균11．6） d。술후출현병발증75례（21．4％），술후30 d내사망3례（0．8％）。여TLE 1조비교，TLE 2조적수술시간、술중실혈량、술후주원시간급술후병발증적발생솔명현교저，림파결청소수목명현교다（균P＜0．05）。TLE 3조제수술실혈량명현소우TLE 2조외，량조간적기타위수술기지표차이균무통계학의의（균P＞0．05）。결론 TLE재기술상안전가행，차능구체도여전통식관암수술상동적근치효과，시치료식관암적가선수술방식。개전TLE약50례후가기본장악TLE적수술기교。
Objective To investigate the clinical efficacy and learning curve of thoracoscopic and laparoscopic esophagectomy (TLE) in the treatment of esophageal carcinoma. Methods Clinical data of 350 consecutive patients with esophageal carcinoma undergoing TLE in the West China Hospital between February 2008 and October 2013 were retrospectively analyzed. Patients in the early stage (n=150) were chronologically and evenly divided into three groups, and perioperative outcomes were compared between the three groups in order to evaluate the learning curve. Results There were no intraoperative deaths. Intraoperative complications occurred in 29 (8.3%) patients. Thirteen (3.7%) cases were converted to open operation including 9 thoracotomy and 4 laparotomy. The mean operative time was 332.5 (range 230-780) min and the mean blood loss was 160.8 (range 15-4000) ml. The tumor free resection margins (R0) were completely in 333 (95.1%) cases. The mean lymph nodes harvested was 21.6(range 6-42). The average length of postoperative hospital stay was 11.6(range 7-93) d. Postoperative complications occurred in 75(21.4%) patients, and 3(0.8%) patients died within 30 days after surgery. Compared with TLE 1 group, TLE 2 group presented shorter operative time, less blood loss, shorter postoperative hospital stay, lower postoperative complication rate, and more lymph nodes harvested (all P<0.05). Only blood loss was less in TLE 3 group as compared to TLE 2 group, and other perioperative results were found to be of no statistical differences between the two groups. There was no significant difference in 30-day mortality between the three groups. Conclusions TLE is a technically feasible and safe procedure and provides comparable oncological outcomes with open esophagectomy, thus suggesting that TLE is an alternative approach in the treatment of esophageal carcinoma. A plateau of TLE skill can be reached after 50 surgical procedures.