胃部分切除术后食管癌的外科治疗

目的 探讨胃部分切除术后食管癌的手术方式及经验,方法 ８例胃大部切除术后食管癌行手术切除,选用３种不同的术式进行消化道重建。行右胸,上腹正中及左颈三口结肠代食管４例。在后外侧切口残胃脾胰尾移入胸腔,主动脉弓下食管残胃底端侧吻合２例,左后外侧切口食管下段残胃切除,食管空肠Ｒｏｕｘ－Ｙ吻合２例。结果 全组无手术死亡。     

改良胃食管吻合在食管癌切除术中的应用

目的探讨改良胃食管吻合术应用于食管癌切除术中预防吻合口狭窄的临床效果。方法将接受食管癌切除术98例病人分为两组,实验组49例施行改良胃食管吻合,对照组采用传统的方法,胃食管单纯吻合法,比较两组病人术后吻合口狭窄发生率。结果实验组49例病人术后随访3～30个月,通过食道吞钡或胃镜检查,提示无吻合口狭窄。对照组49例术后随访3～30个月,通过胃镜或食道吞钡摄片证实12例有不同程度的吻合口狭窄,其中吻合口宽度在0.5～0.7 cm之间8例,吻合口宽度在0.3～0.5 cm之间3例,吻合口宽度<0.3 cm有1例,吻合口狭窄发生率达24%。两组比较差异均有显著性(P<0.05),实验组发生吻合口狭窄明显低于对照组。结论改良胃食管吻合术有降低食管癌切除术后吻合口狭窄发生率的优点,有效减轻病员术后的痛苦,提高生存质量,值得临床上推广应用。     

高龄食管癌贲门癌患者术后并发症防治的临床观察

目的探讨高龄食管癌贲门癌患者术后并发症的病因与防治措施。方法对48例70岁以上高龄食管癌贲门癌切除术后出现不同并发症病人的临床资料进行回顾性分析。结果本组48例患者食管癌34例（70.8%）,贲门癌14例（29.2%）,术前合并其他脏器疾病35例（72.9%）,术式为癌切除胃食管吻合术,术后2 d至3个月出现不同并发症经综合治疗45例痊愈（治愈率93.75%）,死亡3例（死亡率6.25%）。结论高龄食管癌贲门癌患者手术后并发症以预防为主,针对其体质特点进行积极治疗,提高患者生活质量。     

食管癌切除食管胃端端分层吻合35例疗效分析

目的探讨食管癌切除食管胃端端分层吻合的手术疗效。方法选择眉山市人民医院2016年1月至2017年2月接受食管癌切除食管胃端端分层吻合术的35例食管癌患者作为观察组(端端组),将同期接受食管癌切除食管胃端侧分层吻合术的21例食管癌患者作为对照组(端侧组)。比较2组患者手术吻合时间、吻合口的张力大小、受压迫程度及吻合口瘘发生率,比较反酸、嗳气及进食梗阻发生率。结果端端组平均吻合时间(25.17±5.15)min,端侧组平均吻合时间(26.10±5.30)min,2组比较差异无统计学意义(P0.05)。端端组吻合口张力比端侧组小,且不受压迫而偏曲。端端组无吻合口瘘,端侧组有2例(9.52%)吻合口瘘,2组比较差异无统计学意义(P0.05)。进流食端端组患者无梗阻感,端侧组4例(19.05%)出现梗阻感,2组比较差异有统计学意义(P=0.016)。围手术期及术后6个月内,反酸、嗳气发生率组间差异均无统计学意义(P0.05)。术后6个月2组均无迟发吻合口瘘及需要扩张的吻合口狭窄。结论食管癌切除食管胃端端分层吻合因不需在管胃上另做切口,可避免管胃盲端挤压吻合口引起更多的不良反应。     

管状胃替代食管对食管癌术后胃动力学的影响

目的 探讨食管癌手术最佳的胸腔胃解剖形态与蠕动排空功能的关系,以正确指导食管癌的手术治疗,减少术后消化道并发症和提高手术疗效.方法 将70例食管癌病例依据手术中胸胃剪切后胃的形状不同随机分为2组,管胃组35例和全胃组35例.利用食管胃功能测试仪在术前和术后对食管癌病例进行了胸胃静息压、蠕动收缩压和蠕动频率的检测,以及术后胸胃排空功能的X线消化道造影评价.结果 2组胸胃功能术后较术前均下降,管胃组术后胸胃的静息压为(6.20±1.55) mmHg,蠕动收缩压(36.40±3.86) mmHg,蠕动频率(5.30±1.95)次/分;全胃组分别为(4.70±1.42) mmHg,(27.50±3.63) mmHg和(4.60±1.26)次/分.前者静息压和收缩压数值明显大于后者,但蠕动频率两者无差异(P分别是0.012,0.000和0.373).管胃组术后胸胃的排空率明显高于全胃组(P＜0.05).结论 食管癌切除胃替代食管手术管状胃的胃动力学参数和胃排空功能等均优于全胃,管状胃的术后并发症也少于全胃,建议食管癌手术中尽量采取管状胃替代食管.     

右侧剖胸经膈肌裂孔“骨骼化”食管癌根治手术的临床应用

目的探讨右侧剖胸经膈肌裂孔“骨骼化”食管癌根治手术及其在胸中上段食管癌临床应用的可行性和优越性。方法右侧剖胸一或二切口，应用“电凝锐性解剖”将食管周围组织（包括局部区域淋巴结和结缔组织）连同食管整块切除，使食管周围不能切除的解剖结构“骨骼化”，经膈肌裂孔游离胃，使用吻合器作食管胃胸顶或颈部吻合。结果共有26例胸中上段食管癌采用本项技术完成手术治疗，无手术死亡，术后并发症2例（7．7％）。结论该术式切口少，保留膈肌的完整性，既达到减创的目的，同时应用“电凝锐性解剖”，强调食管周围不能切除的解剖结构的“骨骼化”，遵循无瘤原则，以提高术后长期存活率。     

食管癌左侧开胸颈部吻合200例临床分析

目的 研究和探讨胸中段以上食管癌根治手术的方法 改进,为临床胸中段以上食管癌患者提供另一个有效的手术方法.方法 对近三年来200例胸中段以上食管癌患者进行肿瘤根治性切除手术所采取的手术方法,进行总结和分析,进一步明确该手术方法 的有效性和可行性,结果 对200例胸中段以上食管癌患者行肿瘤根治性切除手术,采用左侧开胸,将胃沿食管床经主动脉弓后方向上提至颈部,在颈部左侧胸锁乳突肌内缘做一纵行切口,将胃和食管行端侧吻合,采用4-0的可吸收缝线连续缝合的方法 进行吻合,并将吻合口包埋入胃内,以减少术后吻合口返流,手术效果良好.结论 采用左胸左颈两切口,颈部食管胃端-侧可吸收线连续缝合,并将吻合口套入胃内以抗返流,术后吻合口瘘发生率低,吻合口狭窄发生率低,为一有效的手术方法.     

管状吻合器在食管癌根治颈部吻合术中的应用

目的：探讨管状吻合器在右径三切口食管癌根治术颈部吻合中的方法及效果。方法：对55例胸中上段食管癌采用右径三切口＋胸腹二野淋巴结清扫术,术中闭合器切除部分小弯侧胃制成管型胃,经裂口、食管床上提至颈部,管状吻合器行食管胃端侧吻合术, 间断全层加固吻合口。结果：术后吻合口瘘1例（1．8％）,吻合口狭窄2例（3．6％）,无吻合口出血及吻合口癌残留。结论：管状吻合器颈部胃食管吻合简便易行,降低了吻合口相关并发症的发生率,经验值得推广。     

70岁以上患者颈段及胸上段食管癌的外科治疗

目的探讨70岁以上患者颈段及胸上段食管癌的外科治疗。方法回顾性分析68例70岁以上颈段及胸上段食管癌患者的临床资料,全组患者均经左胸左颈二切口食管癌切除局部淋巴结清扫,食管-胃颈部吻合术。结果 68例患者均顺利完成手术切除食管肿瘤,死亡3例,其余病例恢复良好出院,术后主要并发症为心、肺并发症及吻合口瘘。结论高龄高位食管癌手术难度大、术后并发症多,经左胸左颈二切口颈部吻合手术方式能缩短手术时间,减少术后并发症,提高手术疗效。     

电视引导下用胸腔镜行食管癌根治手术的配合

1997年2月～8月我院胸外科共进行电视引导下用胸腔镜行食管癌手术10例,现将手术期间施械和巡回护士准备工作、与术者的配合及注意事项小结如下.1 资料与方法1.1 资料 男性8例,女性2例,年龄41～70岁.中段食管癌7例,下段食管2例,贲门1例.7例行左颈、左胸、腹部三切口食管癌切除;有两例(下段食管癌和贲门癌1例)经左胸用吻合器行食管癌切除及主动脉弓下食管吻合术;1例因癌肿浸润右下肺静脉及心包而改为剖胸手术.手术过程顺利.手术时间150～210分钟,术中出血量300～400毫升.1.2 方法 麻醉采用静脉诱导,吸入氧化亚氮-氧-七氟醚维持,用双腔气管导管行肺隔离术,以保证术中术侧肺萎陷及健肺通气.手术分三步进行(1)经右胸在胸腔镜直视下游离全胸段食管及清除淋巴结;(2)腹部正中切口开腹,游离胃体并切断食管;(3)经左颈部切口游离出食管并切除,行食管-胃吻合.     

Mid-term outcomes of side-to-side stapled anastomosis in cervical esophagogastrostomy

This study was conducted to evaluate the mid-term results of cervical esophagogastric anastomosis using a side-to-side stapled anastomosis method for treatment of patients with malignant esophageal disease. A total of 13 patients were reviewed retrospectively from January 2001 to November 2005 who underwent total esophagectomy through a right thoracotomy, gastric tube formation through a midline laparotomy and finally a cervical esophagogastric anastomosis. Average patient age was 62.6 yr old and the male to female ratio was 11:2. The mean anastomosis time was measured to be about 32.5 min; all patients were followed for about 22.8+/-9.9 months postoperatively. There were no early or late mortalities. There were no complications of anastomosis site leakage or conduit necrosis. A mild anastomotic stricture was noted in one patient, and required two endoscopic bougination procedures at postoperative 4th month. Construction of a cervical esophagogastric anastomosis by side-to-side stapled anastomosis is relatively easy to apply and can be performed in a timely manner. Follow up outcomes are very good. We, therefore, suggest that the side-to-side stapled anastomosis could be used as a safe and effective option for cervical esophagogastric anastomosis.     

A case of large cell neuroendocrine carcinoma exhibiting rhabdoid features in the esophagogastric junction

We report a case of large cell neuroendocrine carcinoma with rhabdoid features in the esophagogastric junction. An 81‐year‐old man presented to Saku Central Hospital Advanced Care Center with a tumor in the esophagogastric junction. During upper gastrointestinal endoscopy, an ulcerative tumor, measuring 4 × 3 cm in diameter, was observed. Computed tomography revealed lymph node metastasis, but no metastasis to other organs was observed. A thoracoscopic subtotal esophagectomy was performed. Histopathologically, anaplastic large cells exhibited a solid growth pattern with focal and geographic necrosis. Approximately half of the tumor cells exhibited large nuclei with conspicuous nucleoli; an eosinophilic “rhabdoid” cytoplasmic inclusion; and a nucleus displaced eccentrically by the cytoplasmic inclusion body. Immunohistochemically, tumor cells, including rhabdoid cells, were focally positive for pan‐cytokeratin and diffusely positive for vimentin and synaptophysin. Additionally, electron microscopy identified dense‐core granules in the tumor cells. Therefore, a diagnosis of large cell neuroendocrine carcinoma with rhabdoid features was made. A few cases of esophageal neuroendocrine tumors with rhabdoid features have been reported in the lung and pancreas; however, this is the first report of large cell neuroendocrine carcinoma with rhabdoid features in the esophagogastric junction.     

Tubular duplication of the esophagus. Contribution of magnetic resonance imaging in anatomical analysis before surgery

The authors report a tubular duplication of the thoracic esophagus in a 17-year-old male. This anomaly, rare in the adult, can be explained either by a failure of esotracheal compartmentalisation, or a notochordodysraphy or more probably by an error during vacuolisation of the esophagus. The anatomical characteristics of the duplication were clearly seen on MRI. This investigation showed the intramural duplication, with only a thin barrier without muscle, between the esophageal lumen and the duplication channel: two communications were present between the esophageal lumen and the duplication. The esophagus was accessed by right thoracotomy. The close contact between the duplication and the esophagus did not allow them to be separated. A subtotal esophagectomy was necessary, with digestive continuity being restored by coloplasty after a left cervicotomy and a laparotomy. The anatomy seen on the MRI should have predicted that an esophagectomy was necessary and that a thoracotomy could have been avoided by performing the procedure with a closed thorax.     

Tubular duplication of the esophagus. Contribution of magnetic resonance imaging in anatomical analysis before surgery

The authors report a tubular duplication of the thoracic esophagus in a 17-year-old male. This anomaly, rare in the adult, can be explained either by a failure of esotracheal compartmentalisation, or a notochordodysraphy or more probably by an error during vacuolisation of the esophagus. The anatomical characteristics of the duplication were clearly seen on MRI. This investigation showed the intramural duplication, with only a thin barrier without muscle, between the esophageal lumen and the duplication channel two communications were present between the esophageal lumen and the duplication. The esophagus was accessed by right thoracotomy. The close contact between the duplication and the esophagus did not allow them to be separated. A subtotal esophagectomy was necessary, with digestive continuity being restored by coloplasty after a left cervicotomy and a laparotomy. The anatomy seen on the MRI should have predicted that an esophagectomy was necessary and that a thoracotomy could have been avoided by performing the procedure with a closed thorax.     

Overexpression of p53 protein associates decreased response to chemoradiotherapy in patients with esophageal carcinoma.

Induction chemoradiotherapy before esophagectomy for esophageal carcinoma seems to improve patient survival. Given the toxicity of this regimen, it would be useful to predict those patients likely to benefit. p53 is known to mediate apoptosis in response to DNA damage, but there are few data evaluating the relationship between p53 expression and chemoradiosensitivity in human tissues. We immunohistochemically evaluated p53 protein expression in 95 biopsy specimens from patients with esophageal carcinoma before chemoradiotherapy. p53 expression was correlated to the pathologic response identified in subsequent esophagectomy specimens. p53 immunoreactivity was recorded semiquantitatively using the following scale: neg, < 5%; 1+, 5-25%; 2+, 26-50%; 3+, 51-75%; 4+, > or = 76%. Pathologic response in esophagectomy specimens was categorized as overt residual tumor (ORT), minimal residual tumor, and no residual tumor. Of the 95 patients, 64 had adenocarcinoma, and 31 had squamous cell carcinoma. Of those with adenocarcinoma, 46 (72%) of 64 were positive for p53. Thirty-seven (80%) of 46 p53+ patients had ORT, compared with 4 (22%) of 18 p53- patients (P < .001). There was no correlation between the degree of p53 staining and pathologic response. Of those with squamous cell carcinoma, 13 (42%) of 18 were positive for p53. Three (23%) of 13 p53+ patients had ORT, compared with 4 (22%) of 18 p53- patients (P = .96). Our data indicate that overexpression of p53 protein is associated with decreased responsiveness to induction chemoradiotherapy in patients with esophageal adenocarcinoma but that no such association exists in patients with esophageal squamous cell carcinoma.     

Parameters predicting lymph node metastasis in patients with superficial esophageal squamous cell carcinoma

Endoscopic resection is a less invasive treatment than esophagectomy for superficial esophageal squamous cell carcinoma, but patients with lymph node metastasis need additional treatment after endoscopic resection. The purpose of this study was to establish a set of indicators to identify superficial esophageal squamous cell carcinoma patients at a high risk of metastasis. In all, 271 superficial esophageal squamous cell carcinoma esophagectomy cases were reviewed retrospectively. The relationships between clinicopathological parameters and immunohistochemical findings (p53, cyclin D1, EGFR and VEGF) on tissue microarrays, on the one hand, and lymph node metastasis were assessed by univariate and multivariate logistic regression analyses. Patients with intraluminal masses and ulcerated masses had a high risk of lymph node metastasis. Patients with superficial esophageal squamous cell carcinoma (1) thinner than 1200?μm; (2) confined to the mucosa; (3) with submucosal invasion <250?μm; (4) with submucosal invasion ≥250?μm but with negative VEGF expression and well/moderately differentiated or basaloid histology; or (5) with submucosal invasion ≥250?μm but with weak VEGF expression and well-differentiated histology had almost no risk of lymph node metastasis. We recommend endoscopic resection for all erosive, papillary and plaque-like superficial esophageal squamous cell carcinomas where endoscopic resection is clinically feasible, and esophagectomy for all other erosive, papillary and plaque-like cases and all intraluminal masses and ulcerated tumors. No additional treatment is needed for endoscopic resection cases with superficial esophageal squamous cell carcinoma (1) thinner than 1200?μm; (2) confined to the mucosa; (3) with submucosal invasion <250?μm; (4) with submucosal invasion ≥250?μm but with negative VEGF expression and well/moderately differentiated or basaloid histology; or (5) with submucosal invasion ≥250?μm but with weak VEGF expression and well-differentiated histology. These clinical and pathological criteria should enable more accurate selection of patients for these procedures.     

Paraneoplastic vasculitis associated with esophageal carcinoma

We report a case of esophageal carcinoma associated with paraneoplastic vasculitis. A 69-year-old man suffered from low-grade fever and numbness of the lower limbs for 3 months before esophageal and gastric carcinomas were detected. Concurrent infection or collagen disease was ruled out following clinical and laboratory examinations. In April 1996, the gastric carcinoma was completely removed by endoscopic mucosal resection, but the symptoms remained. Three weeks later esophagectomy was performed for esophageal carcinoma after which time the fever and numbness disappeared. The esophageal carcinoma was a well-differentiated squamous cell carcinoma invading into the submucosal layer. Twenty-two lymph node metastases were found in 68 resected lymph nodes. Latent thyroid cancer was found. Histologically, vasculitis was detected in the esophagus, stomach and serratus anterior muscle. The distribution and degree of vasculitis were most pronounced in the esophagus. The concurrent onset and spontaneous resolution of fever and numbness after the removal of the esophageal carcinoma suggested a paraneoplastic origin. The majority of patients with malignant neoplasm-associated vasculitis had hematologic neoplasms. Cases of esophageal carcinoma associated with paraneoplastic vasculitis are extremely rare.     

Can surgeon’s hand be replaced with a smart surgical instrument in esophagectomy?

Esophageal cancer is the eighth most common cancer in the world. The most common surgical procedures for esophageal cancer are transhiatal esophagectomy and transthoracic esophagectomy. Thoracic esophagectomy involves an abdominal incision and a thoracotomy, but transhiatal esophagectomy involves both an abdominal incision and a cervical incision. It can reduce postoperative morbidities and fast recovery. In transhiatal esophagectomy, part of dissection is blind and lack of sufficient vision during operation increases the dangers of this kind of surgery. In this paper, we propose a hypothesis about replacing surgeon’s hand with surgical instrument in esophagectomy. The proposed instrument is one-forth of surgeon’s hand volume and it can surround the esophagus radially. So, it would be able to sheer and dissect all the adhesive tissues around the esophagus. For determining possible threshold of causing traumas in delicate tissues during esophagectomy, various tactile sensors can be incorporated into the surgical instrument to detect and control the contact force of the instrument with delicate biological structures. For evaluating the proposed hypothesis, we analyzed the function of the instrument with finite element method and finally we constructed an initial prototype of the designed instrument.     

Prevalence and characteristics of Barrett esophagus in patients with adenocarcinoma of the esophagus or esophagogastric junction

The prevalence and characteristics of Barrett esophagus in patients with adenocarcinoma of the esophagus or esophagogastric junction are uncertain. We studied 61 consecutive esophagogastrectomy specimens with adenocarcinoma, which were subjected to extensive histopathologic examination. Barrett esophagus was found in 64% of the cases (39 of 61), but had been recognized in only 38% of the patients with Barrett-associated carcinoma who had undergone preoperative endoscopy with biopsy (13 of 34). The median extent of Barrett esophagus with adenocarcinoma was 5 cm (range, 1 cm to 12 cm), and distinctive-type ("specialized") Barrett mucosa predominated (35 of 39; 90%). The Barrett adenocarcinomas were centered in the distal esophagus 2 cm +/- 0.3 cm above the esophagogastric junction. The patients with Barrett adenocarcinoma showed a striking predominance of white men (34 of 39; 87%) in contrast to gastric adenocarcinoma cases (21 of 69; 30%) and to Barrett patients without carcinoma or dysplasia (75 of 149; 50%), but similar to patients having adenocarcinoma of the esophagus or esophagogastric junction without demonstrable Barrett esophagus (16 of 22; 73%). Our findings suggest that most adenocarcinomas of the esophagus or esophagogastric junction are Barrett carcinomas, rather than gastric cardiac cancers or other types of esophageal adenocarcinoma; most Barrett adenocarcinomas occur in short segments of Barrett esophagus, which may be difficult to detect at endoscopy; and white men with Barrett esophagus may constitute a clinically identifiable at-risk group suitable for surveillance.