病理T1b期食管鳞状细胞癌外科治疗的结果分析

目的 探讨外科手术治疗病理T1b期食管鳞状细胞癌(鳞癌)的预后生存状况及预后影响因素.方法 回顾性分析兰州大学第二医院2012～2015年接受经右胸路径食管癌根治性切除且术后病理为鳞癌T1b期95例患者的临床资料,其中男78例(78.3％)、女17例(21.7％),平均年龄(61.4±7.4)岁.结果 35例(36.8...     

食管鳞癌新辅助治疗研究进展

新辅助治疗是食管癌综合治疗的重要部分,使病人能够生存获益.目前一些新辅助治疗的临床试验虽然取得令人欣喜的结果,但仍存在诸多问题亟待解决.本文针对食管鳞癌,围绕新辅助放化疗、新辅助化疗和免疫治疗,就不同治疗方案的疗效、方案之间的比较和新辅助治疗后手术时机的选择等热点问题,结合最新相关研究做一综述.     

同时化疗和放疗后手术切除对T4期食管鳞状细胞癌的治疗

手术技术及围手术期处理的进步提高了食管癌的切除率和长期生存率，并降低了病死率。但单纯的手术并不能改善T4食管鳞癌的不良预后，因此为了改善属于局部进展期的食管癌的预后，尚需一种多方式治疗。近来已发展有多方式治疗，来控制食管癌局部复发和远处转移，从而延长生存期，最有希望的是手术前予以同时化疗和效疗。术前化疗放疗的理论基础为：①术前治疗可提高肿瘤切除可能。     

食管外科进展

食管外科近年在微创技术普及和围手术期综合治疗方面发展迅猛,但对于传统的食管良性疾病和危重症处理却鲜见报道.本文系统地将食管外科技术划分为修复、切除、重建、淋巴结清扫4个部分,全面阐述每一领域的外科治疗进展,希望对从事食管外科临床工作的医生有所帮助.     

食管鳞癌DNA含量与临床病理及预后的关系

应用自动化图像分析仪对５０例食管鳞癌进行细胞ＤＮＡ定量分析，结合临床资料，发现肿瘤分化越差、外侵越严重，ＤＮＡ含量越高。淋巴结转移组ＤＮＡ含量高于非转移组。二倍体或近二倍体组１、３、５年生存率明显高于异倍体组（Ｐ＜０．０１）。表明ＤＮＡ含量的测定可从核酸代谢的分子水平揭示食管癌恶性生物学行为，同时可作为估计手术预后的客观定量指标。     

机器人辅助食管癌的微创外科切除：上海市胸科医院75例临床报道

目的通过回顾国内最大的一组单中心达芬奇机器人辅助食管癌(RAE)手术治疗结果,报道上海市胸科医院RAE根治术的早期结果和相关技术学习曲线。 方法回顾上海市胸科医院自2015年11月至2016年8月开展的所有RAE患者,共75例。研究内容包括患者的一般资料、术前肿瘤病理分期、手术过程、肿瘤切除结果和术后恢复情况。 结果75例RAE患者中,男性53例,女性22例。平均年龄(62.1±8.0)岁。术前诱导4例(5.3%),R0切除率73/75(97.3%),平均出血量(230.7±73.5)ml。全组平均手术时间(275.2±56.8)min,胸部手术时间(95.6±27.5)min。最早20例与之后55例比较：全部手术时间分别为(318.0±48.1)min和(259.7±51.8)min(t＝ 4.391,P<0.001);胸部手术时间分别为(115.1±29.0)min和(88.6±23.5)min(t＝ 4.057,P＝0.001)。平均切除淋巴结总数为(15.9±11.0)枚,切除胸部淋巴结个数为(9.8±6.9)枚,切除喉返神经旁淋巴结个数为(3.3±2.6)枚。以手术日期为分界,20例为组,对75例患者行亚分组后,上纵隔淋巴结采样率分别为85.0%、100.0%、100.0%和100.0%(χ²＝8.594,P＝0.049),其中左喉返神经旁淋巴结采样率分别为65.0%、95.0%、95.0%和100.0%(χ²＝13.920,P＝0.006)。术后主要并发症包括呼吸功能不全5例(6.7%)、乳糜胸2例(2.7%)、气管食管瘘1例(1.3%)、肺栓塞1例(1.3%)、喉返神经麻痹(VCP)11例(14.7%)。以手术日期为界,25例为组,对75例患者行亚分组后发现,VCP发生率明显下降,但差异无统计学意义(24.0%、12.0%和8.0%;χ²＝2.770,P＝0.250)。患者中位住院时间12 d,无术后30 d内死亡病例。 结论RAE根治术安全、可靠。经过20例左右的学习曲线后,术者可熟练掌握胸部机器人手术操作和纵隔淋巴结清扫,尤其是双侧喉返神经旁可获得明显改善,而喉返神经损伤率也能明显降低。     

胸段食管鳞癌外科治疗及预后分析(附2 766例报告)

目的探讨胸段食管鳞癌外科治疗及预后。方法采用回顾性队列研究方法。收集2010年1月至2017年12月四川省肿瘤医院收治的2 766例胸段食管鳞癌患者的临床病理资料;男2 256例, 女510例;年龄为(62±8)岁。患者均行外科手术治疗。观察指标:(1)治疗情况。(2)术后并发症情况。(3)术后生存情况。正态分布的计量资料以x±s表示, 偏态分布的计量资料以M(Q1, Q3)表示。计数资料以绝对数或百分率表示。采用Kaplan-Meier法绘制生存曲线并计算生存率, Log-Rank检验进行生存分析。结果 (1)治疗情况。2 766例患者中, 新辅助治疗52例;1 444例行开放手术(其中44例中转开胸手术), 1 322例行微创食管切除术;手术方式为McKeown、Ivor-Lewis、Sweet分别为1 991、729、46例;术后辅助治疗1 271例。2 766例患者淋巴结转移数目为2.1(0, 3.0)枚, 淋巴结清扫数目为(22±12)枚, R0切除率为94.722%(2 620/2 766), 手术时间为(237±66)min。(2)术后并发症情况。2 766例患者术后总并...     

食管鳞癌新辅助治疗后淋巴结阳性病人行特瑞普利单克隆抗体辅助治疗的多中心、前瞻性、随机对照临床研究设计

新辅助治疗已成为局部进展期食管癌首选治疗方式,但行新辅助治疗后淋巴结阳性（ypN+）病人的预后较差,且缺乏有效辅助治疗手段。程序性死亡受体-1（PD-1）抗体治疗晚期食管癌可获得较好临床疗效。笔者设计针对行新辅助化疗联合手术切除食管鳞癌病人,接受特瑞普利单克隆抗体（抗PD-1）辅助治疗的多中心、前瞻性、随机对照临床研究...     

微创食管切除术治疗食管癌的研究进展

食管癌是全世界8大常见恶性肿瘤之一,外科手术仍为最主要的治疗方案。传统开放食管切除术术后并发症发生率高,患者生活质量较差。为减少手术并发症、提高患者的生活质量,微创食管切除术逐渐被胸外科医师接受并应用于食管癌的治疗当中。目前,多数研究认为微创食管切除术是安全、可行的,同时术后并发症发生率等短期效果优于开放食管切除术,而总生存率等远期效果并不低于开放食管切除术。随着研究的不断细化深入,食管癌的精准微创治疗将得到进一步的发展和推广。     

The first series of completely robotic esophagectomies with three-field lymphadenectomy: initial experience

Background This study investigated the use of robotics to perform extended esophageal resection in a series of patients. Methods A total of 14 patients with a median age of 64 years underwent esophagectomy using the da Vinci robot. At presentation, there were 12 cases of cancer, staged at T2N1 (n = 2), T3N0 (n = 2), T3N1 (n = 6), T4N1 (n = 1), and M1a (n = 1); 2 cases of high-grade dysplasia; 8 cases of adenocarcinoma; and 4 cases of squamous cell cancer; as well as 2 middle third, 9 lower third, and one gastroesophageal junction tumor. Nine patients had undergone preoperative chemoradiotherapy, and six had undergone prior abdominal surgery. The patients were categorized into three chronological groups according to the procedure performed. Group 1 consisted of the first three patients in the series, whose surgery was thoracic only (robotically assisted esophagectomy). Group 2, the next three patients, had robotically assisted thoracic esophagectomy plus thoracic duct ligation using a laparoscopic gastric conduit. Group 3, the last eight patients, underwent completely robotic esophagectomy. Results For Group 3, the total operating room time was 11.1 ± 0.8 h (range, 11.3–13.2 h), with a console time of 5.0 ± 0.5 h (range, 4.8–5.8 h). The estimated blood loss was 400 ± 300 ml (range, 200–950 ml). One patient in group 1 had a thoracic duct leak. In groups 2 and 3, thoracic duct ligation resulted in no further leaks. Other postoperative complications included severe pneumonia (1 case), atrial fibrillation (5 cases), cervical anastomotic leak (2 cases), wound infection (1 case), and bilateral vocal cord paresis requiring tracheostomy (1 case). In seven of the cases, no intensive care unit time was required. There was one death from pneumonia 72 days after the procedure. The rate of disease-free survival was 87%. Conclusion The robotic approach facilitates an extended three-field esophagolymphadenectomy even after induction therapy and abdominal surgery. Larger scale trials are needed to define the role of this technique.     

腔镜微创食管癌切除术的学习过程分析

目的总结腔镜微创食管癌切除术（MIE）的学习过程。方法选取同一组医生连续完成的MIE手术100例,按手术时间顺序分为3组：第1、2组各25例行胸腔镜并常规开腹手术,第3组50例行胸腹腔镜手术．分别记录手术时间、出血量、正常结构保护及并发症发生情况、术后ICU观察时间、住院时间、术后肿瘤病理及淋巴结清扫情况等临床资料,比较各组之间的差异。结果全组中96例患者顺利完成MIE,4例患者中转开胸,无中转开腹。中位手术时间310min,中位失血量200ml,中位清扫淋巴结22枚,总体并发症发生率50％。第1组与第2组比较,在保留奇静脉弓（P=0．010）、保留支气管动静脉（P=0．038）及左侧喉返神经胸段术中暴露率（P=0．048）方面的差异有统计学意义。前50例与后50例比较,在胸部手术时间（P=0．000）、失血量（P=0．025）、保留奇静脉弓（P=0．001）、保留支气管动静脉（P=0．000）、胸野淋巴结清扫（P=0．022）、左喉返神经链淋巴结清扫（P=0．000）及该神经起始部术中暴露率（P=0．002）方面的差异有统计学意义。结论MIE学习过程较长．应循序渐进。随着经验的积累和手术技巧的提升．MIE将逐渐显示其独特的优势并替代传统开胸食管癌切除术。     

Laparoscopic esophagectomy in the palliative treatment of advanced esophageal cancer after radiochemotherapy

Background Esophageal cancer is associated with a poor long-term prognosis. Only a 10% 5-year survival rate is reported. This article aims to evaluate the feasibility and efficacy of laparoscopic esophagectomy for the palliative treatment of advanced esophageal cancer (T3-T4 Nx-N1) after neoadjuvant therapy.Methods From March 1998 to July 2002, 35 patients (mean age, 64.6 years; range, 35–72 years) affected by advanced cancer of the middle lower third of the esophagus came to the authors observation. All received neoadjuvant radiochemotherapy. Of the 35 patients, 22 (62.9%) showed a positive response to treatment (50% reduction of maximal cross-sectional area of the tumor), and surgical intervention was performed 4 weeks after the end of the therapy. The operations were accomplished through the laparoscopic approach and left lateral cervicotomy.Results The mean operative time was 160 min (range, 120–260 min). One patient (4.5%) experienced a cervical anastomotic leak. Three patients (13.6%) died in the postoperative period: one of myocardial infarction and two of acute respiratory failure. The mean postoperative hospital stay was 12.1 days (range, 9–23 days). After a mean follow-up period of 20.2 months (range, 10–40 months), 13 patients (68.4%) were alive.Conclusions The laparoscopic approach seems to be effective for the palliative treatment of advanced esophageal cancer. Further trials will be necessary to evaluate the advantages of this technique.     

胸腔镜下食管癌切除术50例临床分析

目的总结胸腔镜下食管癌根治术的临床经验及体会,评价其近期疗效。方法回顾性分析2011-09—2013-07间行胸腔镜食管癌根治术50例患者的临床资料。结果本组患者无围手术期死亡,中转开胸2例。胸腔镜手术组平均淋巴结清扫个数更多(13.5±3.6)/例:(10.7±2.4)/例;胸部手术失血量更少(150.5±20.5)mL:(280.7±35.6)mL;术后胸管拔管时间更短(3.7±1.6)d:(4.8±2.3)d;肺部并发症更少(6.4%):(14.7%);总体住院时间更短(12.5±3.3)d:(15.2±6.3)d;但胸部手术时间更长(100.5±37.6)/例:(70.4±22.8)/例。结论胸腔镜下食管癌切除术与传统三切口手术相比,具有淋巴清扫彻底,创伤小,并发症少,术后恢复快等优点,近期效果满意。     

微创手术治疗食管癌160例临床分析

目的探讨微创手术治疗食管癌的可行性、安全性及临床应用价值。方法回顾性分析2008年2月至2011年12月四川大学华西医院采用微创手术完成的160例食管癌病例的临床资料。结果160例病例中男140例,女20例．平均年龄59．6岁。行胸腔镜腹腔镜联合食管切除术139例．腹腔镜纵隔镜联合食管切除术3例,腹腔镜辅助lvor—Lewis术15例．胸腹腔镜联合Ivor．Lewis3例。手术时间230～780（平均364．0）min,术中出血量20～4000（平均286．2）ml;获得R0切除152例（95．0％）,清扫淋巴结6。39（平均19．4）枚。中转开放手术11例（6．9％）,其中开胸9例。开腹2例：术中并发症发生率为11．3％（18／160）。重症监护室监护时间0。430h（平均22．1）h。术后住院时间7-93（平均13．1）d：术后并发症发生率34．4％（55／160）,术后30d内死亡率1．2％（2／160）。住院死亡率2．5％（4／160）。结论微创手术治疗食管癌在技术上安全可行,可取得相当于甚至优于传统手术的治疗效果。     

Open transthoracic or transhiatal esophagectomy versus minimally invasive esophagectomy in terms of morbidity, mortality and survival

Background Surgical treatment of esophageal cancer is associated with a high rate of morbidity and mortality even in specialized centers. Minimally invasive surgery has been proposed to decrease these complications. Methods The authors present their results regarding postoperative complications and the survival rate at 3 years, comparing the classic open procedures (transthoracic or transhiatal esophagectomy) with minimally invasive surgery. Surgical procedures were performed according to procedures published elsewhere. Results The study enrolled 166 patients who underwent surgery between 1990 and 2003. Open transthoracic surgery was performed for 60 patients. In this group of patients, postoperative mortality was observed in 11% of the cases. Major, minor, and late complications were observed in 61.6% of the patients, and the 3-year survival rate was 30% for this group. Open transhiatal surgery was performed for 59 patients. The morbidity, mortality, and 3-year rate were almost the same as for the transthoracic surgery group. For the 47 patients submitted to minimally invasive procedures (thoracoscopic and laparoscopic), the complications and mortality rates were significantly reduced (38.2% and 6.4%, respectively). For the patients submitted to minimally invasive surgery, the 3-year survival rate was 45.4%. It is important to clarify that the patients submitted to minimally invasive surgery manifested early stages of the diseases, and that this the reason why the morbimortality and survival rates were better. Conclusions The transthoracic and transhiatal open approaches have similar early and late results. Minimally invasive surgery is an option for patients with esophageal carcinoma, with reported results similar to those for open surgery. This approach is indicated mainly for selected patients with early stages of the disease. Presented as a “free paper” during the 9th World Congress of Endoscopic Surgery, Cancun, Mexico, 4-7 February, 2004     

First experience with robot-assisted thoracoscopic esophagolymphadenectomy for esophageal cancer

Background Transthoracic esophagectomy with extended lymph node dissection is associated with higher morbidity rates than transhiatal esophagectomy. This morbidity rate could be reduced by the use of minimally invasive techniques. The feasibility of robot-assisted thoracoscopic esophagectomy (RTE) with mediastinal lymphadenectomy was assessed prospectively. Methods This study investigated 21 consecutive patients with esophageal cancer who underwent RTE using the Da Vinci™ robotic system. Continuity was restored with a gastric conduit and a cervical anastomosis. Results A total of 18 (86%) procedures were completed thoracoscopically. The operating time for the thoracoscopic phase was 180 min (range, 120–240 min), and the median blood loss was 400 ml (range, 150–700 ml). A median of 20 (range, 9–30) lymph nodes were retrieved. The median intensive care unit stay was 4 days (range, 1–129 days), and the hospital stay was 18 days (range, 11–182 days). Pulmonary complications occurred in 10 patients (48%), and one patient (5%) died of a tracheoneoesophageal fistula. Conclusions In this initial experience, robot-assisted thoracoscopic esophagectomy was found to be feasible, providing an effective lymphadenectomy with low blood loss. Standardization of the technique and increased experience should reduce the complication rate, which is in the range of the rate for open transthoracic dissection.     

Minimally invasive surgical staging for esophageal cancer

Background: The incidence of esophageal adenocarcinoma is increasing in the United States, and the 5-year survival rate is dismal. Preliminary data suggest that conventional imaging is inaccurate in staging esophageal cancer and could limit accurate assessment of new treatments. The objective of this study was to compare minimally invasive surgical staging (MIS) with conventional imaging for staging esophageal cancer. Methods: Patients with potentially resectable esophageal cancer were eligible. Staging by conventional methods used computed tomography (CT) scan of the chest and abdomen, and endoscopic ultrasound (EUS), whereas MIS used laparoscopy and videothoracoscopy. Conventional staging results were compared to those from MIS. Results: In 53 patients, the following stages were assigned by CT scan and EUS: carcinoma in situ (CIS; n= 1), I (n= 1), II (n= 23), III (n= 20), IV (n= 8). In 17 patients (32.1%), MIS demonstrated inaccuracies in the conventional imaging, reassigning a lower stage in 10 patients and a more advanced stage in 7 patients. Conclusions: In 32.1% of patients with esophageal cancer, MIS changed the stage originally assigned by CT scan and EUS. Therefore, MIS should be applied to evaluate the accuracy of new noninvasive imaging methods and to assess new therapies for esophageal cancer. Received: 5 April 1999/Accepted: 15 March 2000/Online publication: 12 July 2000