三切口食管癌切除术:胸腔镜与开放手术的术后并发症分析

目的比较胸腔镜三切口食管癌切除术(minimally invasive eaophagectomy,MIE)及开放三切口食管癌切除术(open esophagectomy,OE)术后并发症的发生情况,评判胸腔镜是否可以减少患者术后并发症的发生。方法采用回顾性分析研究,选取2015年1月至2016年3月间扬州市苏北人民医院胸心外科收治的接受三切口食管癌手术患者为研究对象,其中MIE患者153例(MIE组),OE患者178例(OE组)。比较两组患者的手术时间、术中出血量、淋巴结清扫数目及术后常见并发症的发生情况并进行统计分析。结果两组患者均顺利完成手术,无围手术期死亡。与OE组相比,MIE组的术中出血量明显减少[(123±38)ml vs(346±89)ml,P=0.000],清扫淋巴结数目增多[(29.2±6.3)枚vs(25.5±5.8)枚,P=0.032],术后并发症总体减少(55.6%vs 86.5%,P=0.000),其中肺部感染发生率明显降低(8.4%vs 20.2%,P=0.003)。结论三切口食管癌根治术,胸腔镜较开放手术而言,可以减少术后并发症的发生,尤其是在减少肺部感染的发生上有明显优势。     

胸腹腔镜联合食管癌切除食管胃胸内吻合术的初步临床应用

目的评价胸腹腔镜联合食管切除、食管胃胸内吻合术治疗食管癌新术式的可行性及安全性。方法回顾性对照分析2010年3月至2012年3月首都医科大学附属北京朝阳医院收治食管癌患者40例的临床资料,按照手术方式不同分为两组,采用胸腹腔镜联合食管切除食管胃胸内吻合术22例(腔镜手术组),同期经右胸腹食管癌切除术18例(开放手术组)。对比两组患者的手术时间、术中出血量、淋巴结清扫情况、术后并发症发生率、住院时间及住院费用等。结果腔镜手术组住院总费用较开放手术组显著增高[(78 181.5±8 958.8)元vs(.61 717.2±35 159.4)元,Z=4.078,P=0.000];腔镜手术组与开放手术组手术时间[(292.0±74.8)min vs(.256.1±41.0)min,t=1.838,P=0.074],术中出血量[(447.7±597.0)ml vs.(305.6±125.9)ml,Z=0.401,P=0.688)],淋巴结清扫总数(230枚vs.215枚,t=1.714,P=0.095),术后并发症发生率[22.7%(5/22)vs.33.3%(6/18),χ2=0.559,P=0.498],术后恢复进食时间[(8.5±3.5)d vs.(11.1±9.6)d,t=1.202,P=0.237],术后住院时间[(11.6±5.7)d vs.(13.3±9.4)d,t=0.680,P=0.501]等差异无统计学意义。腔镜手术组按开展该手术时间先后分为早期10例和后期12例,做分层分析,后期患者手术时间较早期患者显著缩短[(262.9±64.9)min vs(.327.5±73.0)min,t=2.197,P=0.040],与开放手术组差异无统计学意义[(262.9±64.9)min vs.(256.1±41.0)min,t=0.353,P=0.727]。后期患者术中出血量也较早期患者显著减少[(220.8±149.9)mlvs.(720.0±808.0)ml,Z=3.279,P=0.001)],与开放组相比也为少[(220.8±149.9)ml vs.(305.6±125.9)ml,Z=2.089,P=0.037]。结论胸腹腔镜联合食管切除食管胃胸内吻合术应用于食管癌治疗安全有效。     

微创Ivor-Lewis食管切除术与Sweet手术治疗Siewert Ⅱ型食管胃结合部腺癌的前瞻性对比研究

目的探讨微创Ivor-Lewis食管切除术(minimally invasive Ivor-Lewis esophagectomy,MI-ILE)与Sweet手术治疗SiewertⅡ型食管胃结合部腺癌(adenocarcinoma of esophagogastric junction,AEG)的疗效。方法选择2017年12月～2019年3月SiewertⅡ型AEG 82例,按照前瞻性非随机方法分为2组,行MI-ILE手术41例,Sweet手术41例,2组术前一般资料差异无显著性(P0.05)。比较2组手术指标、术后并发症及短期生存和复发率。结果 MI-ILE组手术时间长于Sweet组[(244.0±39.5)min vs.(186.9±24.8)min,t=7.840,P=0.000],但术中出血量少[(88.9±34.1)ml vs.(107.7±42.4)ml,t=-2.211,P=0.030],术后第1天胸腔引流量少[(205.9±73.3)ml vs.(287.7±126.3)ml,t=-3.587,P=0.001],胸腔引流时间短[(6.2±2.2)d vs.(8.8±2.8)d,t=-4.666,P=0.000],术后排气早[(3.0±1.0)d vs.(3.7±1.3)d,t=-2.739,P=0.008],术后住院时间短[(9.2±3.2)d vs.(11.2±2.6)d,t=-2.982,P=0.004]。MI-ILE组清扫淋巴结(28.6±10.0)枚,其中胸腔清扫(7.2±4.4)枚,腹腔清扫(21.4±8.9)枚,均高于Sweet组的(22.2±7.3)、(4.8±4.0)、(17.4±7.3)枚(P均0.05)。2组胸腔、腹腔淋巴结转移数目差异无显著性(P0.05)。随访1年,2组均无死亡;MI-ILE复发1例(2.5%),Sweet组复发3例(7.3%)(χ~2=1.051,P=0.305)。结论 MI-ILE治疗SiewertⅡ型AEG安全、可行,与Sweet手术比较,不增加风险,近期疗效满意。     

开放手术与腔镜下根治切除术治疗胸段食管鳞癌的病例对照研究

目的对比胸段食管鳞癌行胸、腹腔镜根治切除术与开放手术的安全性及手术效果。方法回顾性分析2014年6月到2015年6月我科125例胸段食管鳞癌患者的临床资料,其中经左颈、右胸、上腹行食管癌切除+食管胃颈部吻合术(Mc Keown术)18例(开放组,男13例、女5例),行腔镜下Mc Keown术107例(腔镜组,男77例、女30例),比较两组患者手术资料及术后并发症情况。结果腔镜组手术时间、住ICU时间、喉返神经旁淋巴结清扫个数与开放组[(333.58±72.84)min vs.(369.17±91.24)min,P=0.067;(2.84±1.44)d vs.(6.44±13.46)d,P=0.272;(4.71±3.87)个vs.(3.89±3.97)个,P=0.408]差异均无统计学意义。腔镜组术中出血量少于开放组[(222.62±139.77)ml vs.(427.78±276.65)ml,P=0.006]。腔镜组淋巴结清扫总数、淋巴结组数多于开放组[(19.62±9.61)个vs.(14.61±8.07)个,P=0.038;(3.70±0.99)组vs.(3.11±1.13)组,P=0.024],差异具有统计学意义。腔镜组总并发症发生率为32.7%,开放组38.9%,差异无统计学意义(P=0.608)。腔镜组肺部感染率明显低于开放组(2.8%vs.16.7%),差异具有统计学意义(P=0.011)。两组吻合口瘘、心脏并发症、左侧胸腔积液、右侧气胸、声音嘶哑、切开感染发生率差异均无统计学意义。结论与开放手术相比,针对胸段食管鳞癌行腔镜下Mc Keown术清扫淋巴结彻底、出血量少,肺部感染发生率优于开放手术,符合食管癌切除安全性和肿瘤根治性原则。     

功能型助手在腹腔镜胃癌根治术中的作用

目的:比较腹腔镜辅助胃癌根治术中功能型助手与支架型助手的作用。方法:回顾分析2017年1月至2019年12月收治的122例行腹腔镜辅助胃癌根治术(全胃切除,食管-空肠Roux-en-Y吻合术)患者的临床资料。其中,60例为支架型助手组(对照组),62例为功能型助手组(研究组)。对比分析两组围手术期及近期随访情况。结果:入组患者均顺利完成手术,无围手术期死亡病例。与支架型助手组相比,功能型助手组手术时间短[(208.1±34.8)min vs.(259.4±37.9)min,P<0.001],淋巴结清扫数量多[(30.2±7.4)枚vs.(26.0±6.4)枚,P=0.001],术中出血量少[(115.0±61.9)mL vs.(200.5±71.5)mL,P<0.001],切口短[(6.7±0.8)cm vs.(8.1±0.6)cm,P<0.001],首次进食流质早[(4.7±1.1)d vs.(5.2±1.3)d,P=0.033];两组首次排气时间[(3.8±0.9)d vs.(4.1±1.2)d,P=0.116]、引流管拔除时间[(9.0±2.5)d vs.(8.2±2.8)d,P=0.096]及术后住院时间[(10.7±2.8)d vs.(9.9±2.5)d,P=0.107]差异均无统计学意义。结论:功能型助手在腹腔镜辅助胃癌根治术中优势明显,与支架型助手相比,具有创伤小、出血少、手术时间短、淋巴结清扫更彻底等优势,近期效果显著。     

局部进展期食管癌新辅助治疗后微创手术可行性分析的病例对照研究

目的探讨局部进展期食管癌新辅助治疗后行微创手术的安全性和有效性。方法回顾性分析上海交通大学附属胸科医院胸外科2015~2016年连续收治的新辅助治疗后行手术治疗局部进展期食管癌患者56例的临床资料,男51例、女5例。将患者分为开放手术组[OE组,25例,年龄61(50~73)岁]和微创手术组[MIE组,31例,60(55~79)岁]两组。结果行新辅助同步放化疗28例,新辅助化疗28例。新辅助同步放化疗患者的病理完全缓解(p CR)率明显高于新辅助化疗患者(21.4%vs.10.7%,P0.05)。MIE组手术时间、术中失血量、R2切除率及淋巴结清扫数量比OE组有明显优势,差异有统计学意义(P0.05)。两组双侧喉返神经旁淋巴结清扫数量和淋巴结转移比例差异无统计学意义(P0.05)。MIE组术后呼吸系统并发症发生率低于OE组,差异有统计学意义(P=0.041)。两组患者其它并发症、二次手术、再入ICU、术后住院时间及术后30 d死亡率差异均无统计学意义(P0.05)。新辅助放化疗联合OE组1例患者因术后食管气管瘘胃液窒息而死亡。结论新辅助治疗联合MIE治疗局部进展期食管癌安全可行且能够达到与OE相当的肿瘤学根治效果。     

双通道吻合技术在早期胃癌腹腔镜近端胃切除术消化道重建中的应用价值

目的:探讨双通道法应用于早期胃癌近端胃切除术中的临床价值及疗效。方法:回顾分析2015年1月至2016年12月接受腹腔镜胃癌D2根治术的41例胃癌患者的临床资料,其中19例于近端胃切除术中采用双通道法行消化道重建(双通道组),22例于全胃切除术中采用空肠食管吻合法行消化道重建(传统组)。对比分析两组手术时间、消化道重建时间、出血量、术后并发症、术后进食时间及住院时间。结果:两组均顺利完成手术,无一例中转开腹,双通道组消化道重建吻合时间[(33.76±6.95)min vs.(34.5±5.12)min]、术中出血量[(91.59±19.28)mL vs.(93.40±21.14)mL]、淋巴结清扫数量[(28.00±5.21)枚vs.(27.40±4.47)枚]、术后排气时间[(4.24±1.75)d vs.(4.25±2.10)d]及术后住院时间[(12.53±3.28)d vs.(13.60±3.62)d]与传统组相比差异均无统计学意义;两组术后并发症发生率[5.3%(1/19)vs.31.8%(7/22)]差异有统计学意义(P<0.05)。术后平均随访(23±11)个月,双通道组出现肠梗阻1例(5.3%),无远期并发症发生;传统组出现反流性食管炎2例(9.1%),营养不良5例(22.7%);两组均无肿瘤复发及死亡病例。结论:近端胃切除术中采用双通道吻合法较空肠食管(Roux-en-Y)吻合法更具优势,值得进一步推广应用。     

经腋乳入路与胸乳入路行腔镜甲状腺癌切除术的比较研究

目的:通过与胸乳入路腔镜甲状腺癌切除术对比,探讨腋乳入路腔镜甲状腺癌切除术的临床疗效及安全性。方法:回顾分析2019年1月1日至2020年1月1日行腔镜甲状腺癌切除术患者的临床资料,其中经腋乳入路、胸乳入路各40例,比较两组围手术期相关指标、并发症。结果:腋乳入路组与胸乳入路组术后住院时间[(4.6±1.2)d vs.(4.9±1.4)d,P=0.307]、淋巴结清扫数量[(4.5±3.2)vs.(3.6±2.7),P=0.178]、并发症发生率(7.5%vs. 12.5%,P=0.709)差异无统计学意义,手术时间[(156.3±30.2)min vs.(172.6±35.3)min,P=0.029]、术中出血量[(15.8±6.5)mL vs.(23.4±8.6)mL,P0.001]、术后总引流量[(107.9±34.7)mL vs.(124.6±30.5)mL,P=0.025]差异有统计学意义。两组术后随访1年,无局部复发、淋巴结转移及远处转移。结论:腋乳入路切口隐蔽,对于单侧甲状腺癌是安全、有效、可推荐的手术路径。     

腔镜胃癌保脾脾门淋巴结清扫术的临床应用研究

目的:探讨腹腔镜保脾脾门淋巴结清扫术在胃上部癌根治术中的临床疗效与可行性。方法:2012年5月至2014年10月为70例进展期胃上部癌患者行根治性全胃切除联合保脾脾门淋巴结清扫术。其中33例行腹腔镜手术(腹腔镜组),37例行常规开腹手术(开腹组)。对比分析两组患者术中出血量、手术时间、术后住院时间、淋巴结清扫数量及术后并发症发生率等情况。结果:两组患者均成功完成手术。两组患者手术时间[(250.97±51.21)min vs.(226.57±44.61)min]、术中出血量[(203.94±99.06)ml vs.(276.22±148.61)ml]、术后肛门排气时间[(4.64±1.11)d vs.(5.35±1.46)d]、术后住院时间[(12.09±2.65)d vs.(13.95±3.72)d]差异均有统计学意义(P0.05)。两组脾门淋巴结清扫数量分别为(1.2±1.2)枚与(1.2±1.3)枚,差异无统计学意义(P0.05);腹腔镜组与开腹组患者术后并发症发生率分别为9.09%与13.51%,差异无统计学意义(P0.05)。结论:腹腔镜保脾脾门淋巴结清扫术能达到与开腹手术相同的根治效果,且具有安全、术后康复快等优点。     

浸润深度对接受左侧开胸手术的pT1期胸中段食管癌患者预后的影响北大核心CSCD

目的探讨浸润深度对接受左侧开胸手术的pT1期胸中段食管癌患者预后的影响。方法回顾性分析139例符合入组条件的食管胸中段癌术后pT1N0M0期患者的临床病历资料。首先分析全组患者的预后及其影响因素,并比较pT1a期和pT1b期患者预后、局部区域复发和远处转移的差异,同时分析不同浸润深度对患者预后及治疗失败的影响。应用SPSS 25.0软件进行统计学分析。结果全组患者1、3、5年总生存率(OS)和无病生存率(DFS)分别为95.0%、87.8%、82.0%和91.4%、84.2%、77.0%。pT1a和pT1b期患者1、3、5年OS(χ^(2)=7.500,P=0.006)和DFS(χ^(2)=7.354,P=0.007)差异均有统计学意义。Cox多因素分析结果显示pT分期和病理类型为患者OS和DFS的独立性预后影响因素(P<0.05)。pT1a期肿瘤各不同浸润深度的OS(χ^(2)=0.734,P=0.693)和DFS(χ^(2)=0.7690,P=0.681)差异均无统计学意义;pT1b期肿瘤各不同浸润深度的1、3、5年OS(χ^(2)=15.368,P<0.001)和DFS(χ^(2)=27.470,P<0.001)差异均有统计学意义。pT1b期的复发率(23.8%)显著高于pT1a期(5.3%)患者(χ^(2)=5.274,P=0.022);前者的远处转移率(10.9%)亦显著性高于后者(0)(χ^(2)=4.494,P=0.034)。pT1b期患者不同浸润深度之间的局部区域复发率(χ^(2)=17.051,P<0.001)和远处转移率(χ^(2)=15.460,P<0.001)差异均有统计学意义。影响pT1b期患者治疗后失败的logistic多因素分析结果显示浸润深度为影响其出现局部区域复发的独立性因素(P<0.001);病理类型(P=0.003)和浸润深度(P=0.027)为影响其出现远处转移的独立性因素。结论pT1a期和pT1b期患者的预后及治疗后失败模式不尽相同,且pT1b期患者的不同浸润深度与患者的预后及其治疗后失败模式显著相关,浸润深度为影响pT1b期患者治疗后失败的独立性影响因素,建议临床医师应该重视pT1b期患者的术后辅助治疗。此结论需要大宗病例前瞻性研究结果证实。     

胸腔镜腹腔镜联合手术与开放手术治疗食管癌的同期临床对照研究

目的 探讨和评价胸腔镜腹腔镜联合手术治疗食管癌的可行性、安全性、根治性以及近期临床疗效.方法 回顾性分析2007年7月至2009年10月收治的行电视胸腔镜、腹腔镜联合食管癌根治术(即微创组67例)和常规三切口开放食管癌根治术(即开放组38例)食管癌患者临床资料.比较两组手术指标、肿瘤学指标以及近期临床疗效.结果 两组患者性别组成、年龄结构、肺功能等差异无统计学意义,临床资料具有可比性.两组总手术时间以及胸、腹部手术时间差异无统计学意义,但微创组胸部及腹部术中出血量少于开放组(胸部112.3 ml比175.3 ml,P=0.035;腹部31.4 ml比100.5 ml,P=0.026),组间差异有统计学意义.术后转入ICU例数(P=0.042)和术后第3天疼痛情况(P=0.005)组间差异均有统计学意义.术后微创组呼吸系统并发症发生率低(10.4%比26.3%,P=0.046),开放组出现不完全性肠梗阻概率较大(0比8.6%,P=0.045),差异有统计学意义.微创组平均清扫淋巴结20.9枚,转移率为26.9%,开放组平均清扫淋巴结20.1枚,转移率为47.4%,组间淋巴结清扫数量差异无统计学意义.术后平均随访(14.0±2.2)个月,微创组和开放组患者总复发率分别为7.7%和10.8%,生存率分别为89.2%和86.5%,差异均无统计学意义.结论 电视胸腔镜腹腔镜联合食管癌手术具有明显微创优势,安全可行,近期疗效可靠,符合肿瘤外科根治原则.     

Thoracic Duct Resection During Esophagectomy Does Not Contribute to Improved Prognosis in Esophageal Squamous Cell Carcinoma: A Propensity Score Matched-Cohort Study

Purpose

Esophagectomy with extended lymphadenectomy remains the mainstay of treatment for localized esophageal squamous cell carcinoma (ESCC). Thoracic duct (TD) resection has been recommended as part of extended lymphadenectomy, although its merits are unclear. The aim of this two-institutional, matched-cohort study is to clarify whether TD resection improves prognosis in esophagectomy for ESCC.

Patients and Methods

In this two-institutional, matched-cohort study of 399 patients with ESCC who underwent McKeown esophagectomy between 2010 and 2014, the primary outcomes were overall survival (OS), disease-free survival (DFS), and cause-specific survival (CSS). Secondary outcomes were perioperative results and recurrence patterns.

Results

Based on a propensity score, 122 TD-resected or 122 TD-preserved patients in all stages were selected (median follow-up 4.5 years). The 5-year OS, DFS, and CSS rates in the TD-resected versus TD-preserved groups were 49% versus 60%, 53% versus 57%, and 58% versus 70%, respectively, without any significant differences. Operative time for the thoracic procedure was significantly longer and the number of retrieved mediastinal nodes was significantly higher in the TD-resected group (P = 0.009 and 0.005, respectively). The rates of chylothorax and left recurrent laryngeal nerve (RLN) palsy were significantly higher in the TD-resected group (P = 0.041 and 0.018, respectively). There were no significant differences in rates of local or distant metastases between the two groups.

Conclusions

TD resection does not contribute to improve OS, DFS, or CSS in ESCC but increases incidence of chylothorax and left RLN palsy. Prophylactic TD resection should be avoided in esophagectomy for ESCC.

     

胸腔镜与开放食管癌根治术中纵隔淋巴结清扫情况的比较

目的：比较胸腔镜食管癌根治术与开放手术的纵隔淋巴结清扫情况,探讨胸腔镜手术的根治性及安全性。方法回顾性分析2009年6月至2011年6月间四川省肿瘤医院胸外科经左颈右胸上腹食管癌根治术治疗304例患者的临床资料。其中199例行传统开放三切口食管癌根治术（开放组）,105例行胸腹腔镜三切口食管癌根治术（腔镜组）,比较两组患者术中淋巴结清扫情况及围手术期并发症发生情况。结果腔镜组清扫纵隔淋巴结数目为（10．1±5．5）枚,明显少于开放组的（13．3±7．5）枚（P＜0．01）;但匹配术后病理分期后,各期腔镜组和开放组的胸内淋巴结清扫数目差异并无统计学意义（均P＞0．05）。开放组和腔镜组左喉返神经旁淋巴结平均清扫数分别为（2．7±0．2）枚和（1．4±0．2）枚,下段食管旁分别为（1．0±0．1）枚和（0．6±0．1）枚,病灶旁分别为（1．7±0．2）枚和（0．7±0．1）枚,差异均有统计学意义（均P＜0．01）;其他区域两组淋巴结清扫数目差异均无统计学意义（均P＞0．05）。腔镜组围手术期并发症发生率为28．6％（30/105）,低于开放组的41．2％（82/199）（P＜0．05）,但喉返神经麻痹发生率[12．4％（13/105）]明显高于开放组[2．5％（5/199）,P＜0．01）。结论胸腔镜食管癌根治术安全可行。但在行胸腔镜纵隔淋巴结清扫时,应加强对喉返神经旁、下段食管旁和病灶旁淋巴结的清扫,并注意喉返神经的保护。     

肝内胆管癌根治性切除术中淋巴结清扫价值研究

目的 通过分析海军军医大学东方肝胆外科医院7年间诊断肝内胆管癌（ICC）并接受手术治疗病人的治疗及预后情况,探讨术中淋巴结清扫的意义。方法 回顾性分析2010年1月至2017年12月于海军军医大学东方肝胆外科医院经手术治疗的265例ICC病人资料。结果 共纳入265例病人,男性175例,女性90例。年龄22~86岁,中位年龄56.5岁。中位随访时间33.5个月。全部病人1、2、3年无瘤存活率分别为50%、29%、20%,中位无瘤生存时间11.9个月;1、2、3年总存活率分别为 77%、47%、36%,总中位生存时间22.8个月。COX多因素分析结果显示病人无瘤生存的影响因素包括糖尿病史、术前CA19-9高水平、肿瘤直径≥5 cm、肿瘤周边子灶、淋巴结是否清扫;病人总体生存的影响因素包括术前CA19-9高水平、肿瘤直径≥5 cm、血管侵犯、淋巴结是否清扫。分组对比经倾向评分匹配（PSM）后,淋巴结清扫组及未清扫组各77例。1、2、3年无瘤存活率:清扫组68%、47%、36% vs.未清扫组31%、13%、6%（P＜0.05）,中位无瘤生存时间：清扫组22.2个月 vs.未清扫组9.2个月。1、2、3年总存活率：清扫组91%、75%、56% vs.未清扫组71%、30%、21%（P＜0.05）,中位总生存时间：清扫组46.8个月vs.未清扫组17.0个月。剔除清扫组淋巴结阳性病人,比较清扫组中淋巴结病理学诊断阴性与未清扫病人生存情况,PSM后：清扫淋巴结阴性组及未清扫组各50例。1、2、3年无瘤存活率：清扫淋巴结阴性组77%、60%、52% vs.未清扫组32%、22%、15%（P＜0.05）,中位无瘤生存时间：清扫淋巴结阴性组38.1个月vs.未清扫组9.0个月。1、2、3年总存活率：清扫淋巴结阴性组94%、82%、74% vs.未清扫组68%、40%、28%,（P＜0.05）,中位总生存时间：清扫淋巴结阴性组54.0个月vs.未清扫组18.9个月。病人发生淋巴结转移的影响因素分析显示,肿瘤直径≥5 cm、术前CA19-9高水平是影响病人淋巴结转移的独立危险因素。结论 术中淋巴结清扫可改善ICC病人预后。术前无法明确淋巴结转移,但评估肿瘤可行根治性切除的ICC病人,伴随术前CA19-9水平较高、肿瘤直径较大时,术中应积极常规进行淋巴结清扫。     

保留乳头乳晕复合体的乳腺癌改良根治术预后的相关因素分析

目的探究影响保留乳头乳晕复合体(NAC)的乳腺癌改良根治术(NSM)预后的相关因素。 方法回顾性分析2011年1月至2014年12月84例早期原发性乳腺癌并接受NAC的NSM患者临床病理资料。使用统计软件SPSS 20.0进行数据分析,采用K-M生存曲线评估术后无病生存(DFS)及总生存(OS),采用单因素分析和Cox多因素分析影响NSM术后患者DFS和OPS的影响因素。P<0.05差异有统计学意义。 结果术后局部复发8例,远处转移6例,术后5年DFS为83.3%,OS为91.7%。多因素分析显示,肿瘤最大径、肿瘤距乳头乳晕距离(TND)、腋窝淋巴结状态、组织学类型及Her-2阳性是影响DFS的独立危险因素(P<0.05);而腋窝淋巴结状态是影响术后OS的独立危险因素(P<0.05)。 结论肿瘤最大径、TND、腋窝淋巴结状态、组织学类型及Her-2阳性是DFS的独立危险因素,腋窝淋巴结状态是OS的独立危险因素;腋窝淋巴结情况同时影响患者术后DFS和OS,术前系统、精准地评估并妥善处理特殊腋窝淋巴结可提高乳腺癌患者预后。     

Survival and quality of life after minimally invasive esophagectomy: a single-surgeon experience

Background

Reports on quality of life (QOL) after minimally invasive esophagectomy (MIE) have been limited. This report compares perioperative outcomes, survival, and QOL after MIEs with open transthoracic esophagectomy (TTE) and open transhiatal esophagectomy (THE).

Methods

After institutional review board approval, retrospective review of a prospectively maintained database identified patients who underwent esophageal resection for esophageal cancer at Creighton University between August 2003 and August 2010. Patients with preoperative stage 4 disease, emergent procedures, laparoscopic transhiatal esophagectomies, or esophagojeujunostomies were excluded from the study. The study patients were categorized as having undergone open TTE, open THE, or MIE. Overall survival (OS) was the interval between diagnosis and death or follow-up assessment. Disease-free survival (DFS) was the interval between surgery and recurrence, death, or follow-up assessment. For the patients who survived at least 1?year after surgery, QOL was assessed using European Organization for Research and Treatment of Cancer (EORTC-QLQ, version 3.0) and esophageal module (EORTC-QLQ OES 18) questionnaires.

Results

The study criteria were satisfied by 104 patients. Lymph node harvest with MIE (median = 20) was similar to that with open TTEs (median = 19) and significantly higher (P?P?Conclusions MIEs offer a safe and viable alternative to open esophagectomies because they reduce the need and volume of intraoperative blood product transfusion and postoperative respiratory complications without compromising oncological clearance, survival, and QOL.     

Minimally invasive esophagectomy for esophageal cancer: an updated review

Purpose

The surgical, postoperative and oncologic outcomes of minimally invasive esophagectomy (MIE) for esophageal cancer were reviewed to clarify the benefits of this surgical modality.

Methods

A systematic literature search was performed using synonyms for minimally invasive or thoracoscopic esophagectomy. There were 18 retrospective cohort studies and 3 meta-analyses retrieved in this review.

Results

There are several minimally invasive approaches for esophageal cancer. Total MIE using both the thoracoscopic and laparoscopic approach is increasingly performed. A longer operative time and less blood loss are observed with MIE in comparison to open esophagectomy (OE). Although the benefit of MIE for reducing morbidity and mortality rates is still under debate, a shorter hospital stay was common among the studies. The oncologic outcomes of MIE were not inferior to OE, while the number of retrieved lymph nodes was greater in MIE than OE in several studies.

Conclusion

Total MIE using a combined thoracoscopic and laparoscopic approach can be performed safely, although the benefits for short-term outcomes are still controversial. Oncologic outcomes are favorable and MIE may have an advantage in lymph node dissection over OE. The benefits of MIE should therefore be confirmed by randomized controlled trials.     

Open Versus Thoracoscopic Esophagectomy in Patients with Esophageal Squamous Cell Carcinoma

Background

The impact of minimally invasive esophagectomy on patient prognosis, particularly disease-free survival (DFS), has not been well addressed. We compared the clinical outcomes of open and thoracoscopic esophagectomy in patients with esophageal squamous cell carcinoma (ESCC).

Methods

Sixty-three and 66 patients, nonrandomized, underwent open and thoracoscopic esophagectomies for ESCC between 2008 and 2011 were included. The clinicopathological data were reviewed retrospectively. Perioperative outcome, overall survival (OS), DFS, and the recurrence sites after open and thoracoscopic esophagectomy were compared.

Results

The open and thoracoscopic groups were comparable with regard to the total number of harvested lymph nodes and the percentage patients undergoing R0 resection. Fewer patients in the thoracoscopic group had pneumonia and wound complications. Intensive care unit (ICU) stay also was shorter in the thoracoscopic group. The recurrence pattern was similar in the two groups. In the open and thoracoscopic groups, the 3-year OS rates were 47.6 and 70.9 % (p = 0.031), respectively, and the 3-year DFS rates were 35 and 62.4 % (p = 0.007), respectively. However, the trends in better OS and DFS in the thoracoscopic group were not significant after stratification according to pathologic stage.

Conclusions

The perioperative benefit of thoracoscopic esophagectomy included fewer postoperative complications and shorter ICU stays. Mid-term OS and DFS associated with thoracoscopic techniques are at least equivalent to those associated with open procedures.     

全胸腔镜肺叶切除术治疗周围型肺癌的临床分析

目的探讨全胸腔镜肺叶切除术在治疗周围型肺癌患者中的应用。方法回顾性分析2009年7月至2011年12月安徽医科大学附属省立医院应用全胸腔镜肺叶切除术治疗90例周围型肺癌患者的临床资料,其中男55例,女35例;年龄33～79(62.5±11.5)岁。观察术中淋巴结清扫组数、手术时间、术中出血量、术后胸腔引流时间、术后住院时间、并发症发生率和疼痛评分。结果围术期无死亡。手术时间(135.0±32.5)min,术中出血量(230.0±80.4)ml,术后胸腔引流时间(4.8±2.1)d,术后第3 d疼痛评分(5.3±1.2)分。共清扫淋巴结520组,1 568枚,5.8组/例、17.4枚/例;淋巴结有转移71组,阳性率13.7%(71/520)。术后发生声音嘶哑2例;乳糜胸3例,经相应的治疗均治愈。随访90例,随访时间1～24个月,随访期间因肿瘤转移死亡4例;其余生存患者生活质量良好。结论对周围型肺癌患者采用全胸腔镜肺叶切除术治疗,具有创伤小、恢复快和疼痛轻等优点。手术安全性、根治性与开胸手术相似,可作为治疗周围型肺癌患者的手术方式。     

Endoscopic Tumor Length Is an Independent Prognostic Factor in Esophageal Squamous Cell Carcinoma

Purpose

To investigate the impact of endoscopic esophageal tumor length on survival for patients with resected esophageal squamous cell carcinoma (ESCC).

Methods

We retrospectively reviewed the clinicopathologic characteristics of 244 ESCC patients who underwent curative resection as the primary treatment at Taipei Veterans General Hospital between January 2000 and November 2010. The endoscopic tumor length was defined as a uniform measurement before completion of the esophagectomy. The impact of endoscopic tumor length on a patient??s overall survival (OS) and disease-free survival (DFS) were assessed. A Cox regression model was used to identify prognostic factors.

Results

The 1-, 3-, and 5-year OS rates were 81.2, 48.2, and 39.6%, respectively, with a median survival time of 18.0?months. The 1-, 3-, and 5-year DFS rates were 66.2, 34.7, and 32.4%, respectively, with a median DFS of 15.0?months. Endoscopic tumor length correlated with pathologic tumor length [Pearson correction (r)?=?0.621; P?4?cm to identify patients with decreased long-term survival. In multivariate survival analysis, endoscopic tumor length (more or less than 4?cm) remained an independent prognostic factor for both OS (P?=?0.006) and DFS (P?=?0.002).

Conclusions

Endoscopic tumor length could have a significant impact on both the OS and DFS of patients with resected ESCC and may provide additional prognostic value to the current tumor, node, and metastasis staging system before patients receive any cancer-specific treatment.