Study on changes in extravascular lung water during early postoperative periods in thoracic esophageal cancer--with special emphasis on their relation to postoperative renal function

Twenty-seven patients with esophageal cancer received an intrathoracic esophagectomy, lymphadenectomy and esophageal reconstruction performed in one stage. They were analyzed for respiratory and hemodynamic function parameters and also observed for the time course of extravascular lung water (EVLW), water balance, renal function as well as colloid osmotic pressure (COP) of plasma. And they were clarified the pathogenetic mechanism of post-operative pulmonary complications mainly from the aspects of pathophysiology of pulmonary edema and functional interrelationship of organs. Two groups of patients, i.e. those undergoing extended lymphadenectomy (particularly for lymph nodes of both sides of neck and upper mediastinum) and those of old age (70 years or above), were investigated for eventual characteristic features of postoperative changes in the parameters mentioned above. In the group of patients with postoperative pulmonary complications, a significant negative correlation was noted to exist between the plasma colloid osmotic pressure-pulmonary artery wedge pressure (COP-PAW) gradient and EVLW and between the former parameter and postoperative renal function (p less than 0.01). A postoperative lowering of renal function observed in the group with postoperative pulmonary complications was due mainly to depressed left ventricular function immediately following operation and assumed to play a significant role in the production of pulmonary edema as a hydrostatic factor subject to the Starling's low. In the group undergoing extended lymphadenectomy, extensive lymph node dissection reduced plasma colloid osmotic pressure. This reduction was thought to bring about a diminution of COP-PAW gradient, produce a transient depression of left ventricular function and augmentation of pulmonary edema, and to stimulate the formation of intrapulmonary shunting. In the old age group, their and renal function depressed immediately after operation because of advanced age. And for the maintenance of cardiac function massive water intake was required. They led to retention of water and thereby played a direct role in the causation of increase in EVLW and in intrapulmonary shunt. All these observations point to the necessity of initiating carefully planned management early in the postoperative period that takes these pathophysiologic features well into account.     

Respiratory function and pulmonary thromboxane release after total thoracic esophagectomy

In experimental studies using mongrel dogs, 60 minutes after total thoracic esophagectomy the dog lung transiently released into the systemic circulation up to about 6000 micrograms/ml of thromboxane A2(TXA2) measured by radioimmunoassay as its metabolite thromboxane B2(TXB2). To determine whether lung TX release had effects on pulmonary function, we measured the changes in extravascular lung water (EVLW), lung resistance (RL) before, 10, 30, and 60 minutes after total thoracic esophagectomy in 14 anesthetized dogs. In seven untreated dogs, EVLW and RL increased and CL decreased approximately twofold at 60 minutes after the surgery, which corresponded well with a large transpulmonary plasma concentration gradient of TXB2. In remaining 7 dogs pretreated with intravenous OKY-046 which was TXA2 synthetase inhibitor, increase in EVLW and RL and decrease in CL were minimal and plasma concentration of TXB2 remained low value of a preoperative level. In clinical studies, 20 patients with esophageal carcinoma were evaluated. All of these patients underwent total thoracic esophagectomy with extended lymph node dissection of a similar extent. In 5 control patients, significant increase in EVLW and pulmonary vascular resistance were noted at 60 minutes after surgery. On the other hand, while the patients who had intravenous OKY-046 administration during operation at a dose of 1 microgram/kg/min or 5 micrograms/kg/min showed significant decrease in EVLW and pulmonary vascular resistance at 60 minutes after surgery. Based on these results, it is concluded that TXA2 appears to be one of the most important factors to cause the postoperative pulmonary complication after total thoracic esophagectomy for esophageal cancer.     

Recent surgical treatment of thoracic esophageal carcinoma]

Nowadays, surgery for a thoracic esophageal carcinoma is accomplished safely, however, there still remain many problems concerning curative resection. Cancerous recurrences of the lymph node is still high against to lymph node dissection around thoracoabdominal region. Therefore, surgery should endeavour to prevent such lymphatic recurrences. In the patients with a carcinoma in the upper or middle third of the esophagus, who underwent extended radical esophagectomy, a significantly high incidence of metastasis in the recurrent nerve lymphatic chain was noted in comparison with that in patients with that in those who underwent standard radical resection. Complete resection of the recurrent nerve lymphatic chain is generally difficult through the thoracic approach alone, and such approach might be the factor causing the poor prognosis after standard radical surgery for an upper or middle thoracic esophageal carcinoma. Accordingly, extended radical surgery by the cervicothoracoabdominal approach can produced improved surgical curability for an upper or middle thoracic esophageal carcinoma. On the other hand, pulmonary complications are still a major postoperative complication following radical esophagectomy due to extended radical lymphadenectomy around the paratracheobronchial region. So, it is now clear that we should preserve the right bronchial artery and pulmonary nerves branched from the vagus nerve during the thoracic procedure, if these unaffected by cancerous invasion. Adopting this procedure resulted in a marked decrease in the incidence rate of postoperative severe pulmonary complications. Finally, in the near future we expect to develop criteria to select the best treatment for each specific individual based on preoperative studies of the biological characteristics of the carcinoma.     

Complication-free early extubation following abdomino-thoracic esophagectomy

The combined thoracoabdominal procedure for patients with esophageal cancer is still associated with a high rate of pulmonary complications. Many institutions believe prophylactic postoperative mechanical ventilation to be the most effective measure against pulmonary complications. On the other hand, the duration of mechanical ventilation can have a significant influence on the incidence of pulmonary complications, which are increased after prolonged ventilatory support. Interstitial pulmonary edema is a frequent pathological finding with a poor prognosis after esophageal surgery. Increased water retention in the lung means a greater risk of atelectasis or pneumonia. At the St. Clara Hospital, Basle, patients with esophagectomy were extubated on the day of surgery. Despite early extubation there was a very low rate of minor pulmonary complications. To clarify possible factors contributing to this uncomplicated postoperative course, 20 patients with thoracoabdominal resection of the esophagus were evaluated. All patients were operated upon using a combination of thoracic epidural and light general anesthesia. At the end of the operation all were breathing spontaneously. After a short period of pressure support ventilation and continuous positive airway pressure (CPAP), the mean extubation time was 3 h 10 min postoperatively. Local anesthetics and morphine given by the epidural route and the simultaneous use of nonsteroidal anti-inflammatory drugs made possible an uneventful and pain-free postoperative course. Early extubation, the immediate use of a CPAP mask system 2-3-hourly and an effective cough were the main points of respiratory therapy.(ABSTRACT TRUNCATED AT 250 WORDS)     

管状胃在胸腹腔镜联合食管癌根治术中的应用探讨

目的探讨管状胃在胸腹腔镜联合食管癌根治术中的临床应用价值。方法选取2011年1月至2015年12月在我院行胸腹腔镜联合食管癌根治术治疗的胸段食管癌患者160例,将其分为两组,分别采用管状胃代食管手术和传统全胃缝缩术治疗。记录两组患者手术完成情况、比较两组患者淋巴结清扫个数、失血量、手术时间、胸管留置时间、术后引流量、围手术期和随访期间并发症发生率、记录并发症处理情况、比较两种手术方法的总体疗效。结果两种术式在胸部淋巴结清扫个数、术中失血量、胸管留置时间和术后引流量方面无明显差异(P0.05);管状胃代食管术手术时间、腹部淋巴结清扫个数明显多于全胃缝缩术(P0.05)。管状胃代食管术的并发症发生率明显低于全胃缝缩术(P0.05)。管状胃代食管术住院时间、术后进食时间、复发和转移率、2年生存率和生活质量均明显优于全胃缝缩术(P0.05)。两组1年生存率无明显差异(P0.05)。结论管状胃代食管术可有效减少食管癌术后并发症,提高患者生活质量和生存率,安全可靠。     

Changes in cardiorespiratory function after radical esophagectomy by bilateral thoracotomy approach in dogs

Twenty eight dogs (10-16 kg) were anesthetized with pentobarbital sodium, buprenorphine and pancuronium bromide followed by endotracheal intubation in the supine position. Twenty eight dogs were divided into two groups. Group 1 (n = 14) underwent thoracic esophagectomy with regional lymph nodes dissection under the right thoracotomy. Group 2 (n = 14) underwent the same manner of group 1. And left thoracotomy was added in the 5th intercostal space to completely dissect the left side regional lymph nodes. During surgical procedure, lactated Ringer's solution (L-R) were administered, L-R and Dextran 40 were given for postoperative fluid therapy. Cardiac output (CO), pulmonary arterial pressure (PAP), pulmonary wedge pressure (PWP), mean arterial pressure (AP), heart rate (PR), extravascular lung water (EVLW), blood gas analysis, pulmonary shunt rate (Qs/Qt), lung resistance (RL), dynamic lung compliance (CL) and colloid osmotic pressure (COP) were measured at preoperative phase and 1, 3, 6, 12 hrs after surgery. Significant differences were found in the left ventricular stroke work index (LVSWI), RL and the dosage of L-R between these dogs in groups 1 and 2. From these results, extended radical esophagotomy by bilateral thoracotomy approach for clinical cases seems to be possible under the exact indication and intensive perioperative care.     

腔镜辅助下McKeown术式切除食管癌18年经验总结

目的总结腔镜辅助下McKeown术式切除食管癌的单中心18年经验体会。 方法回顾性分析1997年8月至2015年6月在温州医科大学附属台州医院胸外科行食管癌切除的639例患者的临床资料,其中在腔镜辅助下完成McKeown食管癌切除手术622例(97.34%)。食管肿瘤位于上、中、下段分别占7.98%、63.54%和28.48%,其中8.92%的患者术前接受放化疗。TNM分期中,0、Ⅰ、Ⅱ、Ⅲ、Ⅳ期分别占10.33%、29.26%、42.10%、15.02%和3.29%;病理检查为鳞癌占92.02%,腺癌及其他类型占7.98%。手术采用腔镜辅助下经右胸、上腹、左颈入路,其中胸腔镜＋开腹占44.60%,胸腔镜＋腹腔镜占47.26%,开胸＋腹腔镜占5.48%,非计划中转开胸或开腹占2.66%。 结果胸腔镜下食管游离及胸腔淋巴结清扫时间为(78.6±36.9)min,腹腔镜下胃游离及腹区淋巴结清扫时间为(55.4±19.5)min;胸腔镜手术出血量为(99.5±79.2)ml,腹腔镜手术出血量为(40.5±23.4)ml。每例患者平均清扫淋巴结总数为(24.1±12.4)枚,其中胸腔淋巴结清扫(14.9±8.1)枚,腹腔淋巴结清扫(9.1±5.5)枚,颈区淋巴结清扫(1.5±1.3)枚。全组术中无死亡病例,术中因奇静脉或脾脏损伤出血4例,电凝钩或超声刀误伤气管4例,非病灶原因胸导管损伤13例,心房纤颤11例,食管切缘阳性R₁切除者4例。术后早期并发症超过10例次的包括肺部感染(11.42%)、颈部吻合瘘(7.04%)、心律失常(4.85%)、胸腔积液需要置管(3.29%)、喉返神经损伤(3.13%),术后乳糜胸(2.03%)。术后早期死亡6例(0.94%),分别为术后呼吸衰竭3例、气管管胃瘘后肺部严重感染1例、难控性高血糖并颈部吻合口瘘迁延不愈及多器官衰竭1例、胸胃瘘或坏死致主动脉腐蚀破裂出血1例。术后接受放化疗307例(48.04%);术后随访率为90.8%,平均随访时间(44.5±33.1)个月;术后1、2、3、5年的生存率分别为83.9%、69.7%、57.1%和45.5%。 结论腔镜辅助下McKeown术式食管癌切除在肿瘤R₀切除,以及术后近远期疗效上是可行且有效的。     

Experimental studies on the effect of total thoracic esophagectomy on cardiorespiratory functions and the plasma concentration of chemical mediators

To examine the effects of total thoracic esophagectomy on cardiorespiratory functions and the responses of the body to surgery, changes in the cardiorespiratory parameters and plasma concentrations of chemical mediators were examined before and after surgery in 21 mongrel dogs inflicted with 3 types of surgical damage. Group 1 underwent a simple thoracotomy, Group 2 an ablation around the thoracic esophagus and pulmonary hilus, and Group 3 a total thoracic esophagectomy with extended lymphnode dissection around the tracheobronchial region. In Group 3, lung resistance and extravascular lung water increased by 108 per cent and 83 per cent, respectively, while lung compliance decreased by 71 per cent. Among the cardiovascular parameters, pulmonary arterial pressure and pulmonary wedge pressure increased by 40 per cent and 89 per cent, respectively, these values being significantly higher in this group than in the other two groups. With regard to the plasma chemical mediators, renin-angiotensin-aldosterone, antidiuretic hormone, catecholamine, serotonin, histamine, and thromboxane B2 levels were significantly higher in Group 3 than in Group 1. The increase in thromboxane B2 was particularly notable in Group 3, being about 6,000 pg/ml 60 minutes after surgery. The results of this study showed how total thoracic esophagectomy lead to a marked deterioration in respiratory function caused by division of the pulmonary nerves and changes in plasma chemical medicator concentrations which induced constriction of the pulmonary vessels and/or increased the vascular permeability. The disturbance of pulmonary lymph flow due to surgical disruption of the lymphatic system also contributed to the deteriorated lung function.     

Surgical Treatment of Cancer of the Thoracic Esophagus in Association With a Major Pulmonary Operation

Background: Pulmonary complications have been a major cause of mortality after operations for cancer of the thoracic esophagus. Although the risk involved in esophagectomy associated with a major pulmonary operation is expected to be high, it has seldom been evaluated on the basis of clinical experience.

Study Design: Of 408 patients who underwent esophagectomy, 8 had previously undergone major pulmonary operation (7 for tuberculosis and 1 for pulmonary cancer) and 10 underwent concurrent major pulmonary resection (7 for pulmonary invasion of esophageal cancer, 2 for synchronous pulmonary cancer, 1 for extensive bronchiectasia). All patients underwent systematic lymph node dissection for esophageal cancer, except one patient with mucosal cancer. To prevent postoperative complications, the operative approach and dissection procedures for esophageal cancer were modified according to the associated pulmonary operation and the extent of cancer invasion. All thoracotomies for esophagectomy were performed on the same side as the major pulmonary operation. Additional median sternotomy was performed when necessary. In the most recent 8 patients who underwent major pulmonary resection concurrent with esophagectomy, the bronchial stump was covered with a pedicle flap.

Results: Of the 18 patients who underwent pulmonary operation, postoperative complications developed in 13 of the 18 object patients, but none was fatal. The 3-year survival rate was 45%. All deaths were caused by esophageal cancer or another cancer.

Conclusions: Aggressive esophagectomy associated with major pulmonary operation is not contraindicated in patients with fair risk conditions. The operative procedures for esophagectomy should be appropriately modified to minimize the effect of the associated pulmonary operation. Special care should be taken with respect to the approach for mediastinal dissection and closure of the bronchial stump.     

Thoracoscopic resection of esophageal cancer with a tracheal diverticulum

Tracheal diverticulum, a benign entity characterized by single or multiple invaginations of the tracheal wall, is commonly asymptomatic and detected incidentally. We report the case of a 76-year-old man with a tracheal diverticulum who underwent thoracoscopic esophagectomy with a three-field lymphadenectomy for middle thoracic esophageal cancer. The tracheal diverticulum was located at the right posterolateral region of the trachea, which overlapped the region of dissection of the right recurrent laryngeal nerve lymph nodes. Paratracheal lymph node dissection is an important surgical procedure for thoracic esophageal cancer. In such cases, there is a risk of misidentifying a tracheal diverticulum as an enlarged lymph node and injuring it. Injury of a tracheal diverticulum causes serious complications such as mediastinal emphysema, mediastinitis, and pulmonary fistula. It is important to recognize its existence preoperatively and perform accurate lymph node dissection by taking full advantage of the magnified visual effect provided by thoracoscopic surgery.     

胸腹腔镜联合手术治疗食管癌81例

目的 评估应用胸、腹腔镜联合手术治疗食管癌的可行性和疗效.方法 回顾分析2007年7月至2009年12月,81例在电视胸腔镜、腹腔镜联合辅助下经右胸、腹、左颈,行食管次全切除术及纵隔区、腹区两野淋巴结清扫术病人的临床资料.结果 所有病例均在胸、腹腔镜联合下完成食管癌根治术.全组总手术196～315 min,平均每例270.5 min,腹腔镜下胃游离及腹区淋巴结清扫40～90 min,平均约64.5 min;胸腔镜食管游离及纵隔淋巴结清扫60～125 min,平均81.2 min.全组共清扫淋巴结1652枚,平均每例20.4枚(5～41枚),转移率30.9%(25/81例);纵隔区淋巴结1012枚,平均每例12.5枚;清扫腹区淋巴结591枚、平均每例7.3枚.术中无大出血,腹腔出血30～100 ml,平均42.4 ml;胸腔出血60～300 ml,平均121.5 ml.术后住院8～45天,平均9.2天.术后早期并发症发生率为27.2%,呼吸衰竭1例死亡.肺部感染10例、喉返神经损伤5例、颈部吻合口瘘3例、乳糜胸2例、管状胃瘘1例和胸胃扩张各1例.术后79例随访2～31个月,平均14.2个月;死亡7例,总体生存率为91.1%.近中期并发症发生率为27.8%,其中反流性食管炎12例、复发或转移6例、吻合口狭窄5例.结论 胸、腹腔镜联合手术治疗食管癌创伤小,并发症低,生活质量改善.该术式技术上可行,其达到肿瘤根治目的 及临床疗效方面是有效的.

Abstract：

Objective To assess the feasibility and clinical efficacy of minimally invasive esophagectomy for esophageal cancer.Methods From July 2007 to December 2009,eighty-one patients with esophageal cancer received combined thoracoscopic and laparoscopic esophagectomy with anastomosis in the neck.All clinical data were retrospectively reviewed.Results The median operative time was 270.5 min (range 196-315 min).The median time of gastric mobilization and abdominal lymph node dissection was 64.5 min,and the median time of esophageal dissection and mediastinall lymph node dissection was 81.2 min.The median blood loss was 121.5 ml for the thoracic phase and 42.4 ml for abdomen phase.The mean number of disected lymph nodes was 20.4 (range 5-41) with metastastic rate of 30.9% (25/81).The mean harvest lymph node was 12.5 in chest and 7.3 in abdomen.Perioperative complications rate was 27.2%,including respiratory failure in 1 case,pulmonary infection in 10,anastomotic leak in 3,chylothorax in 2,gastric tube dilatation in 1,gastric tube leak in 1.And recurrent laryneal nerve injury in 5 .Seventy-nine patients were followed up withmMean follow up time of 14.2 months( range 2-31 months).The overall one-year survival rate was 91.1%.Postoperative complications included anastomotic stenosis in 5 cases (6.3%),reflux esophagitis in 12 (15.2%) and recurrence or metastasis in 6 (7.6%).Conclusion Minimally invasive esophagectomy for esophageal cancer can mimimus trauma,reduce post-operative complications,improve the quality of life,which is feasible and effective from the point of the clinical efficacy and the purpose of tumor therapy.     

胸腹腔镜联合手术治疗食管癌81例

目的 评估应用胸、腹腔镜联合手术治疗食管癌的可行性和疗效.方法 回顾分析2007年7月至2009年12月,81例在电视胸腔镜、腹腔镜联合辅助下经右胸、腹、左颈,行食管次全切除术及纵隔区、腹区两野淋巴结清扫术病人的临床资料.结果 所有病例均在胸、腹腔镜联合下完成食管癌根治术.全组总手术196～315 min,平均每例270.5 min,腹腔镜下胃游离及腹区淋巴结清扫40～90 min,平均约64.5 min;胸腔镜食管游离及纵隔淋巴结清扫60～125 min,平均81.2 min.全组共清扫淋巴结1652枚,平均每例20.4枚(5～41枚),转移率30.9%(25/81例);纵隔区淋巴结1012枚,平均每例12.5枚;清扫腹区淋巴结591枚、平均每例7.3枚.术中无大出血,腹腔出血30～100 ml,平均42.4 ml;胸腔出血60～300 ml,平均121.5 ml.术后住院8～45天,平均9.2天.术后早期并发症发生率为27.2%,呼吸衰竭1例死亡.肺部感染10例、喉返神经损伤5例、颈部吻合口瘘3例、乳糜胸2例、管状胃瘘1例和胸胃扩张各1例.术后79例随访2～31个月,平均14.2个月;死亡7例,总体生存率为91.1%.近中期并发症发生率为27.8%,其中反流性食管炎12例、复发或转移6例、吻合口狭窄5例.结论 胸、腹腔镜联合手术治疗食管癌创伤小,并发症低,生活质量改善.该术式技术上可行,其达到肿瘤根治目的 及临床疗效方面是有效的.     

胸腹腔镜联合手术治疗食管癌81例

目的 评估应用胸、腹腔镜联合手术治疗食管癌的可行性和疗效.方法 回顾分析2007年7月至2009年12月,81例在电视胸腔镜、腹腔镜联合辅助下经右胸、腹、左颈,行食管次全切除术及纵隔区、腹区两野淋巴结清扫术病人的临床资料.结果 所有病例均在胸、腹腔镜联合下完成食管癌根治术.全组总手术196～315 min,平均每例270.5 min,腹腔镜下胃游离及腹区淋巴结清扫40～90 min,平均约64.5 min;胸腔镜食管游离及纵隔淋巴结清扫60～125 min,平均81.2 min.全组共清扫淋巴结1652枚,平均每例20.4枚(5～41枚),转移率30.9%(25/81例);纵隔区淋巴结1012枚,平均每例12.5枚;清扫腹区淋巴结591枚、平均每例7.3枚.术中无大出血,腹腔出血30～100 ml,平均42.4 ml;胸腔出血60～300 ml,平均121.5 ml.术后住院8～45天,平均9.2天.术后早期并发症发生率为27.2%,呼吸衰竭1例死亡.肺部感染10例、喉返神经损伤5例、颈部吻合口瘘3例、乳糜胸2例、管状胃瘘1例和胸胃扩张各1例.术后79例随访2～31个月,平均14.2个月;死亡7例,总体生存率为91.1%.近中期并发症发生率为27.8%,其中反流性食管炎12例、复发或转移6例、吻合口狭窄5例.结论 胸、腹腔镜联合手术治疗食管癌创伤小,并发症低,生活质量改善.该术式技术上可行,其达到肿瘤根治目的 及临床疗效方面是有效的.     

VATS食管癌切除胸部淋巴结清扫术的效果及对术后生存质量的影响

目的探讨在食管癌胸部淋巴结清扫术中使用电视辅助胸腔镜(VATS)手术的效果及术后生存质量的影响。 方法回顾性分析2014年3月至2016年5月期间行食管癌根治术75例食管癌患者。按照手术方式不同分为行VATS术38例(VATS组)和行传统开胸手术37例(传统组)，采用软件SPSS18.0分析数据，术中术后各项指标和生命质量评价以( ±s)表示，采用独立t检验；术后并发症及1年生存率采用χ²检验，以P<0.05为差异有统计学意义。 结果VATS组从淋巴结清扫数、术中出血量、住院时间、术后引流量、自主下床活动时间方面比较，均优于传统组(P<0.01)。VATS组肺部感染、切口感染(胸腹部)、吻合口漏等术后并发症明显低于传统组(P<0.01)。两组患者1年期生存率VATS组与传统组分别为(73.68%比67.57%)差异无统计学意义(P>0.05)。生存质量评分在术后第1周、12周时两组吞咽困难症状得分均明显降低，VATS组在疲劳、体力功能、术后疼痛、综合生命质量等生命质量维度得分显著优于传统组(P<0.05)。 结论食管癌胸部淋巴结清扫使用VATS手术时有着治疗效果好，术后恢复快、术后并发症少，能显著改善患者术后生存质量，临床中值得推广。     

The significance of the extensive systematic lymphadenectomy for thoracic esophageal carcinoma

1. Materials: One hundred and seventy nine patients with thoracic esophageal carcinoma who underwent an intrathoracic esophagectomy combined with systematic lymphadenectomy were investigated. They were roughly classified into two groups, i.e., those who received extensive lymphadenectomy in bilateral cervical and upper mediastinal regions (A group: 78 subjects), and those who underwent ordinary limited dissection of the lymph nodes in the left cervical and upper mediastinum (B group: 101 subjects). 2. Results: Cumulative 5-year survival rate of advanced cancer patients was 31.3% in A and 22.5% in B, the difference being of significance (p less than 0.05). The rate of postoperative mortality showed no difference between both groups, i.e., 3.8% in A and 4.9% in B groups. However, the incidence of postoperative pulmonary complication was 17.9% in A and 13.9% in B. Recurrent nerve palsy developed in frequencies of 39.7% and 17.8% in A and B groups respectively. 3. Conclusion: The degree of extended lymph node metastasis in carcinoma of the thoracic esophagus was closely correlated with its prognosis, and hence it is extremely important to perform intrathoracic esophagectomy with extensive systematic lymphadenectomy aiming at the favorable result in surgical treatment. It is also required to take preventive measures against postoperative complications.     

Bilateral approach for thoracoscopic esophagectomy with lymph node dissection in the dorsal area of the thoracic aorta in patients with esophageal cancer: A report of two cases

IntroductionThe incidence of lymph node metastasis in the dorsal area of the thoracic aorta (DTA) is relatively low in patients with esophageal cancer. It is difficult to approach the DTA using surgical procedures, such as an open thoracotomy and thoracoscopy in the left decubitus position.Case presentationCase 1: A 70-year-old man with esophageal cancer underwent thoracoscopic esophagectomy with mediastinal lymph node dissection via a right thoracoscopic approach, followed by lymphadenectomy in the DTA via left thoracoscopy in the prone position. Microscopic findings revealed two metastatic lymph nodes in the DTA. The definitive diagnosis was squamous cell carcinoma of the esophagus, and the pathological stage was T2N3M0 (Union for International Cancer Control [UICC], 7th edition). The patient showed lung metastasis 8 months after the surgery. Case 2: A 72-year-old man with esophageal cancer underwent esophagectomy via a bilateral approach in the prone position, using a similar procedure as in case 1. The definitive diagnosis was squamous cell carcinoma of the esophagus, and the pathological stage was T3N2M0. The patient showed a metastatic mediastinal lymph node 4 months after the surgery.ConclusionBilateral thoracoscopic esophagectomy in the prone position can be safely performed, and it might be an alternative curative surgery for esophageal cancer. However, both our cases showed metastasis in the early postoperative period. The long-term outcome and significance of dissection of lymph nodes in the DTA in patients with esophageal cancer remains controversial. Further studies are required to establish the indications and efficacy of this therapeutic approach.     

胸、腹腔镜下食管癌根治术与传统开放手术的疗效比较分析

目的:探讨胸、腹腔镜下食管癌根治术的安全性与可行性。方法:2011年6月至2016年6月为80例患者行完全胸、腹腔镜下联合食管癌根治术,选择同期行传统食管癌开放手术的80例患者作为研究对象。比较两组手术相关指标及术后随访情况。结果:胸、腹腔镜联合组手术时间较开放组长,失血量、术后第1天胸腔引流量少于开放组,术后拔管时间、ICU观察时间、住院时间均短于开放组(P0.05)。两组术中淋巴结清扫数量、阳性淋巴结数量、术后并发症发生率、术后随访例数、随访时间、复发或转移、总生存率差异无统计学意义(P0.05)。结论:与传统开放食管癌根治术相比,胸、腹腔镜食管癌根治术能达到相似的疗效,可实现手术的根治性与微创效果。     

Evaluation of neck lymph node dissection for thoracic esophageal carcinoma

We studied a series of 150 patients treated for thoracic esophageal carcinoma at our institution. The patients were divided into two matched groups. Group B underwent transthoracic esophagectomy with mediastinal and abdominal lymphadenectomy only; group A also underwent bilateral neck lymph node dissection. The rates of operative mortality and operative complications did not differ significantly between the two groups. The 5-year survival rate was 38.7% overall (48.7% in group A and 33.7% in group B). Group A had a significantly better survival curve than group B. Twenty patients (26.0%) in group A had metastasis in the dissected neck lymph nodes. The 4-year survival rate of these patients was 47.9%. The significantly better survival of group A and the satisfactory prognosis in the patients with positive cervical lymph nodes demonstrates the effectiveness of neck lymph node dissection in radical operation for thoracic esophageal carcinoma.     

全腔镜手术联合加速康复外科理念指导的呼吸功能锻炼在食管癌围手术期的应用

目的探讨全腔镜手术联合加速康复外科（ERAS）理念的呼吸功能锻炼对食管癌患者术后肺部并发症、术后疼痛、下床时间、胸腔引流量、拔管时间以及住院时间的影响。 方法选择2018年6月至2020年6月在扬州大学附属医院行食管癌手术的160例患者,随机分为4组,每组40例。A组患者采用全腔镜食管癌手术,术前行ERAS理念宣教和呼吸功能锻炼;B组采用传统开放手术,术前行ERAS理念宣教和呼吸功能锻炼;C组采用全腔镜食管癌手术,术前行常规入院宣教和护理指导,常规呼吸功能锻炼,无术前ERAS理念宣教;D组采用传统开放手术,行常规入院宣教和护理指导,常规呼吸功能锻炼,无术前ERAS理念宣教。记录4组患者术后肺部并发症的发生数量、术后疼痛、下床时间、拔管时间及住院时间。 结果与B、C两组比较,A组肺部并发症发生率明显降低,下床时间、拔管时间和住院时间明显缩短;A组较B组术后疼痛明显减轻,差异均有统计学意义（P<0.05）。与D组比较,B组肺部并发症发生率、下床时间、拔管时间和住院时间明显减少,差异均有统计学意义（P<0.05）。与D组比较,C组术后疼痛、肺部并发症发生率均降低,下床时间、拔管时间和住院时间均缩短,差异有统计学意义（P<0.05）。 结论对于食管癌手术患者,ERAS理念指导下的呼吸功能锻炼联合全腔镜手术可有效降低肺部并发症的发生率和术后疼痛,缩短下床时间、拔管时间以及住院时间。     

Mortality and morbidity rates, postoperative course, quality of life, and prognosis after extended radical lymphadenectomy for esophageal cancer. Comparison of three-field lymphadenectomy with two-field lymphadenectomy.

PURPOSE: The authors evaluated the efficacy of extended radical (three-field) lymphadenectomy for esophageal cancer compared with less radical (two-field) lymphadenectomy. STUDY SUBJECTS AND ANALYTIC METHODS: The mortality and morbidity rates, postoperative courses, and survival rates were compared between 63 patients who underwent three-field lymph node dissection and 65 who underwent two-field lymph node dissection at Kurume University Hospital from 1986 to 1991. Long-term quality of life after surgery was compared between 37 patients who underwent three-field dissection and 35 who underwent two-field dissection from 1980 to 1991. RESULTS: Three-field dissection resulted in better survival for patients with positive lymph node metastasis from a carcinoma in the upper thoracic or midthoracic esophagus compared with two-field dissection. The mortality rates, postoperative courses and quality of life were the same for both procedures. CONCLUSIONS: Three-field dissection is preferred for upper thoracic or midthoracic esophageal cancer because of improved survival, acceptable mortality and morbidity rates, and good postoperative course and quality of life.