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《中华消化外科杂志》2018年9月第17卷第9期论著·外科天地

单孔充气式纵隔镜联合腹腔镜食管癌根治术的应用价值

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引用本文:
何伟,乔志雄,何进喜,等.单孔充气式纵隔镜联合腹腔镜食管癌根治术的应用价值[J].中华消化外科杂志,2018,17(9):954-958.DOI:10.3760/cma.j.issn.1673-9752.2018.09.015.
【摘要】

目的:探讨单孔充气式纵隔镜联合腹腔镜食管癌根治术的应用价值。
方法:采用回顾性描述研究方法,收集2016 年9月至2018 年4月宁夏医科大学总医院收治的27例行单孔充气式纵隔镜联合腹腔镜食管癌根治术患者的临床病理资料。手术操作者分为两组,一组行颈部操作,一组行腹部操作。利用一根“Y”型管,给予纵隔及腹部同时进行CO2充气,气体压力值为12~16 mmHg(1 mmHg=0.133 kPa)。双侧相向游离食管并会师,剑突下作小切口,自贲门处离断食管,残胃制作直径3~5 cm管状胃,于管状胃最高点缝线,同时自颈部提出食管,食管上端吻合器头予以荷包缝合,经纵隔食管床将管状胃牵拉至左颈行胃食管手工吻合或器械吻合。观察指标:(1)手术和术后恢复情况。(2)随访和生存情况。采用电话或门诊方式随访,了解患者生存情况。随访时间截至2018年5月。正态分布的计量资料以±s表示,偏态分布的计量资料以M(范围)表示。
结果:(1)手术和术后恢复情况:27例患者顺利完成行单孔充气式纵隔镜联合腹腔镜食管癌根治术,无中转开胸,完整切除肿瘤;术中心电监测均未出现心律失常或心肌缺血, 27例患者中5例术中发生胸膜破裂,3例因显著的血流动力学变化而间断停用CO2充气。患者手术时间为(121±21)min,术中出血量为(100±30)mL。27例患者无胸部切口,术后疼痛明显降低,术后第1天下床活动。患者术后纵隔引流管引流量为(40±10)mL,常规进食1周后拔除纵隔引流管。27例患者中5例出现胸腔积液,给予穿刺引流后治愈;2例出现吻合口瘘,其中1例发生于术后12 d,颈部切口皮下少量积气,未予特殊治疗,患者继续经口进食后自愈,另1例发生于术后1个月,为患者进食硬质食物后出现颈部皮下少量积气,继续进食流质食物1周后愈合;1例出现吻合口狭窄,给予扩张后好转。全组患者术后病理学检查结果均为鳞癌,上下切缘无癌细胞浸润,纵隔清扫淋巴结数目为(9.5±2.2)枚,腹腔清扫淋巴结数目为(8.2±2.5)枚,阳性淋巴结数目为1枚(0~12枚);术后病理学分期为T1~3N0~1M0期。术后住院时间为13 d(11~21 d)。(2)随访和生存情况:27例患者术后随访1~20个月,中位随访时间10个月,随访期间无复发转移及死亡。
结论:单孔充气式纵隔镜联合腹腔镜食管癌根治术安全有效,适用于部分呼吸衰竭及封闭胸腔的患者。

【Abstract】

Objective:To explore the application value of single-port inflatable mediastinoscopy combined with laparoscopy in the radical resection of esophageal cancer.
Methods:The retrospective descriptive study was conducted. The clinicopathological data of 27 patients who underwent single-port inflatable mediastinoscopic and laparoscopic radical resection of esophageal cancer in the General Hospital of Ningxia Medical University between September 2016 and April 2018 were collected. The surgical operators were divided into neck operation group and abdomen operation group. A “Y” tube was used to inflate the abdomen and mediastinum simultaneously with CO2, and the gas pressure was 12-16 mmHg (1 mmHg=0.133 kPa). Bilateral exchange free and join forces with the esophagus and xiphoid process operating small incision, the severed esophagus cardia; residual stomach was made into a 3-5 cm tubular stomach and was sutured at the top point; at the same time, esophagus was brought up from the neck, with a pouch suture between upper esophageal and stapling head; the tubular stomach through mediastinum-esophagus bed was pulled to the left neck and then gastroesophageal anastomosis manually or instrument was performed. Observation indicators: (1) surgical and postoperative recovery; (2) follow-up and survival situations. Follow-up using outpatient examination and telephone interview was performed to detect postoperative survival up to May 2018. The measurement data with normal distribution were represented as ±s. The measurement data with skewed distribution were described as M (range).
Results:(1) Surgical and postoperative recovery: all the 27 patients underwent successful single-port inflatable mediastinoscopic and laparoscopic radical resection of esophageal cancer, with complete tumor resection and without conversion to open surgery. There was no arrhythmia or myocardial ischemia through intraoperative electrocardiography. Among 27 patients, 5 had intraoperative rupture of the pleura and 3 stopped intermittently inflation with CO2 due to obvious hemodynamic changes. The operation time and volume of intraoperative blood loss were (121±21)minutes and (100±30)mL. Twenty-seven patients had no thoracic incision, obviously decreased postoperative pain and out-of-bed activity at day 1 postoperatively. The volume of postoperative mediastinal drainage was (40±10)mL. The mediastinal drainage-tube was removed at 1 week after regular food intake. Of 27 patients, 5 with pleural effusion were cured by puncture drainage; 2 were complicated with anastomotic leakage, 1 of them with a small amount of subcutaneous gas under neck incision at 12 days postoperatively was cured spontaneously through oral food intake, without special treatment, and the other had a small amount of subcutaneous gas under neck incision after solid food intake at 1 month postoperatively and then was cured after 1-week fluid food intake; 1 with anastomotic stenosis was improved after dilation treatment. The squamous cell carcinoma was confirmed by postoperative pathological examination, without cancer cell infiltration in the upper and lower margins. The numbers of mediastinal lymph node dissected, abdominal lymph nodes dissected and positive lymph node, postoperative pathological staging and duration of hospital stay were respectively 9.5±2.2, 8.2±2.5, 1 (range, 0-12), T1-3N0-1M0 and 13 days (range, 11-21 days). (2) Follow-up and survival situations: 27 patients were followed up for 1-20 months, with a median time of 10 months. During the follow-up, there was no recurrence or metastasis and death.
Conclusion:The single-port inflatable mediastinoscopy combined with laparoscopy in the radical resection of esophageal cancer is safe and effective, and it is especially suitable for patients with partial respiratory failure and closed thoracic cavity.

DOI:10.3760/cma.j.issn.1673-9752.2018.09.015
基金项目:宁夏回族自治区自然科学基金(NZ15136)
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