胸腹腔镜联合食管癌切除350例临床分析

目的：分析胸腹腔镜联合食管切除术（ TLE ）治疗食管癌的临床效果及学习曲线。方法回顾性分析2008年2月至2013年10月四川大学华西医院胸外科连续行TLE的350例患者临床资料,分析患者的术中及术后情况,评价该术式的临床疗效;根据患者接受TLE手术日期的顺序,将TLE开展的早期阶段150例病例平均分为3组,即TLE 1组、TLE 2组及TLE 3组,每组50例,比较3组间的围手术期指标,以分析该术式的学习曲线。结果全组无术中死亡病例,29例（8．3％）患者出现术中并发症,术中中转手术13例（3．7％,开胸9例、开腹4例）。全组手术时间为230～780（平均332．5） min,术中出血量为15～4000（平均160．8） ml。其中,R0切除333例（95．1％）,清扫淋巴结6～42（平均21．6）枚／例。术后住院时间为7～93（平均11．6） d。术后出现并发症75例（21．4％）,术后30 d内死亡3例（0．8％）。与TLE 1组比较,TLE 2组的手术时间、术中失血量、术后住院时间及术后并发症的发生率明显较低,淋巴结清扫数目明显较多（均P＜0．05）。TLE 3组除手术失血量明显少于TLE 2组外,两组间的其他围手术期指标差异均无统计学意义（均P＞0．05）。结论 TLE在技术上安全可行,且能够达到与传统食管癌手术相同的根治效果,是治疗食管癌的可选手术方式。开展TLE约50例后可基本掌握TLE的手术技巧。     

胸腹腔镜联合Ivor-Lewis食管癌根治术的临床应用

目的：探讨胸腹腔镜联合Ivor-Lewis食管癌根治术的可行性、安全性及近期临床效果。方法回顾性分析2011年10月—2013年6月安徽医科大学附属省立医院胸外科行胸腹腔镜联合Ivor-Lewis食管癌根治术146例（腔镜组)以及开放右胸上腹两切口食管癌根治术168例（开放组)患者的临床资料。比较两组手术时间、术中出血量、淋巴结清扫数目、术后住院时间及术后并发症的发生情况。结果与开放组相比,腔镜组的出血量少[（181．8±60．7)mL vs （205．7 ± 105．9)mL, t=－2．396],术后住院时间短[（11．5±5．5) d vs （13．0±7．4)d, t=－2．023],术后呼吸系统并发症发生率较低[8．2%（12/146) vs 22．0%（37/168),χ2=11．303],差异均有统计学意义（P值均<0．05);而手术时间、淋巴结清扫数目、循环和消化系统并发症发生率、二次手术率、近期总复发率及总生存率的差异均无统计学意义（P值均>0．05)。结论胸腹腔镜联合Ivor-Lewis食管癌根治术在技术上是安全可行的,且具有术中出血量少、术后肺部感染发生率低和住院时间短等优势;但其远期疗效需进一步随访观察。     

Patient reported outcomes (PROs) after minimally invasive and open esophagectomy

Esophagectomy for esophageal malignancies remains an operation with significant potential morbidity and mortality. However, surgical outcomes continue to improve over time and focus has shifted toward not just good outcomes, but quality of life post operatively. Patient reported outcomes (PROs) focus of quality of life measures via validated patient surveys has increasingly become a significant focus. While PROs do have their limitations, they represent a glimpse into the symptomatology, quality of life, and well-being of a patient undergoing a procedure with inherent morbidity. Working to improve outcomes from the perspective of the patient is not a new concept, but has becoming increasingly relevant as surgical quality for all procedures improves. The optimal approach to esophagectomy is controversial. Minimally invasive approaches attempt to avoid laparotomy and thoracotomy with the thought of improving post-operative quality of life by mitigating complications related to those open surgical approaches. The data in favor of laparoscopy and thoracoscopy is quite strong and multiple randomized controlled trials exist in this realm supporting minimally invasive approaches with regards to quality of life outcomes and more rapid return to patient’s preoperative baseline. The data in favor of a robotic approach for esophagectomy is not quite as robust, but more studies show that these approaches mirror the benefits of the laparoscopic and thoracoscopic approaches without robotic assistance.     

predictors for failure of stent treatment for benign esophageal perforations- a single center 10-year experience

AIM:To investigate possible predictors for failed selfexpandable metallic stent(SEMS)therapy in consecutive patients with benign esophageal perforationrupture(EPR).METHODS:All patients between 2003-2013 treated for EPR at the Karolinska University Hospital,a tertiary referral center,were studied with regard to initial management with SEMS.Patients with malignancy as an underlying cause and those with anastomotic leakages were excluded.Sealing of the perforation with a covered SEMS was the primary strategy whenever feasible.Stent therapy failure was defined as a radical change of treatment strategy due to uncontrolled mediastinitis,which in this setting consisted of emergency esophagectomy with end-esophagostomy or death as a consequence of the perforation and subsequent uncontrolled sepsis.Patient and lesion characteristics were analyzed and are presented as median and interquartile range.Possible predictors for failed stent therapy were analyzed with uni-variate logistic regression,while variables with P<0.2 were further analyzed with multi-variate logistic regression.RESULTS:Of the total number of 48 patients presenting with EPR,40 patients(83.3%)were treated with SEMS at the time of admission,with an intention to heal the perforation.Twenty-three patients had Boerhaave’s syndrome(58%),16 had an iatrogenic perforation(40%)and 1 had external trauma to the esophagus(3%).The total in-hospital mortality,including the cases that had other initial treatments(n=8),was10.4%and 7.5%among those who were subjected to the SEMS-based strategy.In 33 of the 40 patients(82.5%)who were treated with stent,the EPR healed without further change in treatment strategy.Patients classified as treatment success received a SEMS at a median time of 1(1-1)d after the actual EPR,compared to 3(1-10)d among those where the initial treatment failed,P=0.039 in uni-variate analysis and P=0.052 in multi-variate analysis.No other significant factors emerged,indicating an increased risk for failure.Six of 7 patients,where stent treatment of the defect failed,underwent an emergency esophagectomy with end esophagostomy and one patient died.CONCLUSION:SEMS as an upfront therapeutic strategy seems to be a successful concept,when applied to an unselected group of patients with EPR.     

Impact of subcarinal dissection on short-term outcome and survival following esophagectomy

Background

The purpose of this study was to investigate the impact of subcarinal dissection on short-term outcomes and survival after esophagectomy in patients with thoracic esophageal squamous cell carcinoma.

Methods

Patients without subcarinal dissection were matched randomly to patients with subcarinal dissection in a 1:1 ratio according to 5 baseline variables (gender, pathologic stage, tumor location, histologic grade, and surgical approach) that may have major impacts on short-term outcomes and survival after esophagectomy in patients with thoracic esophageal squamous cell carcinoma. Preoperative clinical characteristics, short-term outcomes, and survival after esophagectomy of the 2 groups were compared.

Results

There were 128 patients included in each group. Blood loss, postoperative pleural drainage volume, and the incidences of postoperative complications and pulmonary complications in the nondissection group were significantly less than in the dissection group. The comparison of overall survival curves and disease-free survival curves between the 2 groups showed no significant difference (P > .05).

Conclusions

Subcarinal dissection might be futile for patients with thoracic esophageal squamous cell carcinoma.     

Ivor-Lewis经胸颈部机械吻合术治疗中段食管癌的前瞻性研究

目的 探讨Ivor-Lewis经胸颈部机械吻合术治疗中段食管癌的疗效.方法 前瞻性研究2005年3月至2013年3月两家医院收治的303例中段食管癌患者(江苏省如皋市博爱医院107例、江苏省如皋市人民医院196例)的临床资料,按患者入院先后顺序编号分为Ivor-Lewis组(151例),施行Ivor-Lewis径路经胸颈部机械吻合术;Sweet组(152例),施行Sweet径路经胸颈部机械吻合术.比较两组患者术中情况、围手术期并发症、淋巴结清扫和术后随访等情况.采用门诊复查方式随访,随访时间截至2012年12日.计量资料采用成组t检验,计数资料采用x2检验或Fisher确切概率法,等级资料采用Wilcoxon成组秩和检验.采用Kaplan-Meier法绘制生存曲线,COX比例风险模型分析术后死亡风险.结果 Ivor-Lewis组的手术时间和手术切除率分别为(239±21) min和98.68％(149/151),Sweet组分别为(188±30) min和92.76％(141/152),两组比较,差异有统计学意义(t=11.32,x2=6.45,P＜0.05).Ivor-Lewis组和Sweet组的食管上切缘阳性率分别为0.67％(1/149)和0.71％(1/141),术后并发症发生率分别为10.07％ (15/149)和11.35％(16/141),手术死亡率分别为0和0.71％(1/141),两组比较,差异均无统计学意义(P＞0.05).Ivor-Lewis组清扫的颈胸交界部、腹上区淋巴结数目以及颈胸交界部阳性淋巴结数目分别为(3.6±1.1)枚、(3.5±1.1)枚和(0.7±1.1)枚,Sweet组分别为(2.3±0.8)枚、(2.4±0.8)枚和(0.3±0.6)枚,两组比较,差异均有统计学意义(Z=9.96,9.02,3.26,P＜0.05).290例手术切除治疗的食管癌患者中273例获得术后随访,随访率为94.14％ (273/290),中位随访时间为28.0个月.Ivor-Lewis组患者术后第1、2、3年肿瘤复发、转移率分别为8.21％(11/134)、19.64％ (22/112)、29.35％(27/92),Sweet组分别为19.05％ (24/126)、35.24％ (37/105)、44.19％ (38/86),两组比较,差异有统计学意义(x2=6.55,7.33,5.03,P＜O.05).其中两组患者术后1、2、3年区域淋巴结复发率比较,差异有统计学意义(x2=7.03,9.68,6.87,P＜0.05).Ivor-Lewis组患者术后1、2、3年累积生存率分别为90.30％ (121/134)、80.36％ (90/112)、71.74％ (66/92),Sweet组分别为80.95％ (102/126)、59.05％ (62/105)、51.16％ (44/86),两组比较,差异均有统计学意义(x2=4.65,11.73,7.97,P＜0.05).结论 Ivor-Lewis经胸颈部机械吻合术治疗中段食管癌,手术切除率高、安全性好,术后患者生存获益明显.该术式可以作为治疗颈部无肿大可疑转移淋巴结的中段食管癌的优选手术方法.     

不同饮食护理对食管重建术后吻合口狭窄的影响

目的:研究不同饮食护理对食管重建术后吻合口狭窄的影响。方法:按照不同饮食护理方法,将食管重建术后病例分为A、B两组,每组842例,A组采用传统饮食护理,B组采用积极饮食护理。观察比较两组术后吻合口狭窄的发生率、吻合口瘘发生率、切口感染率、平均住院时间、上消化道炎症发生情况。结果:1吻合口狭窄A组60例,发生率7.13%,B组38例,发生率4.51%,差异有统计学意义(P﹤0.05);吻合口瘘A组8例,发生率0.95%,B组10例,发生率1.19%,差异无统计学意义(P﹥0.05)。比较切口感染率、平均住院时间、上消化道炎症发生率,差异均无统计学意义(P﹥0.05)。结论:积极饮食护理能够降低食管重建术后吻合口狭窄的发生率。     

食管重建--从全胃到管胃

胃是食管切除后重建的首选替代器官,但早期的全胃代食管有许多缺点。近年来,“管状胃”代食管被广大学者所接受。本文就胃代食管的解剖生理优势,全胃代食管的缺点,以及“管状胃”的改进作一总结,供大家参考。     

Copper-deficiency anemia after esophagectomy: A pitfall of postoperative enteral nutrition through jejunostomy

INTRODUCTION

Copper deficiency leads to functional disorders of hematopoiesis and neurological system. There have been some reports of copper deficiency occurring to the patients on enteral nutrition through a jejunostomy in long-term-care hospitals. However, it is extremely rare to find patients with copper deficiency several months after esophagectomy, regardless of enteral nutrition through the jejunostomy. To the best of our knowledge, this is the first case report of a patient who experienced copper-deficiency anemia after esophagectomy and subsequent enteral nutrition through the jejunostomy.

PRESENTATION OF CASE

A 73-year-old man presented with pulmonary failure after esophagectomy for esophageal cancer with video-assisted thoracoscopic surgery, and needed long-term artificial ventilator support. Nutritional management included enteral nutrition through a jejunostomy from the early postoperative period. Copper-deficiency anemia was detected 3 months postoperatively; therefore, copper supplementation with cocoa powder was performed, and both serum copper and hemoglobin levels subsequently recovered.

DISCUSSION

Copper-deficiency anemia has already been reported to occur in patients receiving enteral nutrition in long-term care hospitals. However, this is the first case report of copper deficiency after esophagectomy despite administration of standard enteral nutrition through the jejunostomy for several months.

CONCLUSION

It is extremely rare to find copper-deficiency anemia several months after esophagectomy followed by enteral nutrition through the jejunostomy. However, if anemia of unknown origin occurs in such patients, copper-deficiency anemia must be considered among the differential diagnoses.