俯卧位胸内手工吻合在食管受累≥4 cm的食管胃结合部腺癌中的应用

doi:10.3877/cma.j.issn.1674-6899.2022.06.003

目的

探讨俯卧位胸内手工吻合治疗食管受累≥4 cm的食管胃结合部腺癌(adenocarcinoma of esophagogastric junction, AEG)的可行性。

方法

采用回顾性病例系列研究的方法，收集2019年3月至2020年12月期间，在郑州大学第一附属医院胃肠外科接受俯卧位完全微创食管胃胸内手工吻合的28例AEG患者的临床资料，分析手术情况和近期疗效等。

结果

28例患者均顺利完成手术，无中转开放手术。中位手术时间、中位消化道重建时间、中位术后住院时间分别为227.5(188~340)min、51(40~80)min、13(11~32)d。平均淋巴结清扫总数、平均近切缘长度分别为(27.5±3.8)枚、(5.3±1.4)cm，术后病理检查结果切缘均为阴性。术后并发症总发生率28.6%，其中吻合口并发症发生率7.1%(吻合口漏、吻合口狭窄各1例)、呼吸系统并发症发生率14.3%(胸腔积液2例、肺部感染1例、肺不张1例)、胃食管反流发生率7.1%(2例)，并发症严重程度以Clavien-Dindo Ⅱ级、Ⅲa级为主。中位随访时间14个月，随访期间患者均存活，其中2例发生肝转移。

结论

俯卧位胸内手工吻合治疗食管受累≥4 cm的AEG在技术上是安全、可行的，能保证足够的淋巴结清扫范围和清扫数及近端切缘长度。

关键词: 食管胃结合部腺癌, 完全微创手术, 胸内手工吻合, 俯卧位

Obsjection

To investigate the feasibility of intrathoracic hand-sewn anastomosis in prone position for adenocarcinoma of esophagogastric junction with esophageal involvement over 4 cm.

Methods

A descriptive case series study was conducted. The clinical data of 28 patients with AEG who underwent totally minimally invasive intrathoracic hand-sewn esophagogastric anastomosis in prone position from Mar.2019 to Dec. 2020 in the Department of gastrointestinal surgery of the First Affiliated Hospital of Zhengzhou University were collected, and analysis of short-term perioperative outcomes.

Results

Twenty-eight patients successfully completed the operation without conversion to open. The median operative time, esophagogastric anastomosis time and length of postoperative hospital stay were 227.5(188-340)min、51(40-80)min and 13(11-32)d, respectively. The mean total number of lymph nodes dissection and length of proximal margin were (27.5±3.8) cm and (5.3±1.4)cm, respectively, all proximal margins were negative. The overall postoperative morbidity was 28.6%, anastomotic complications rate was 7.1% (one anastomotic leakage and one anastomotic stenosis), respiratory complications rate was 14.3% (two pleural effusion, one pulmonary infection and one atelectasis), and gastroesophageal reflux rate was 7.1% (two cases). The severity of complications was mainly Clavien-Dindo Ⅱand Ⅲa. After a median follow-up of 14 months, all patients survived, and two cases occurred liver metastasis.

Conclusions

Intrathoracic hand-sewn anastomosis in prone position for adenocarcinoma of esophagogastric junction with esophageal involvement over 4 cm is technically safe and feasible, which can ensure sufficient extent and number of lymph node dissection and length of proximal margin.

Key words: Adenocarcinoma of esophagogastric junction, Totally minimally invasive surgery, Intrathoracic hand-sewn anastomosis, Prone position

图1 俯卧位完全微创食管胃胸内手工吻合手术注：A.腹部Trocar布局；B.打开食管裂孔，清扫下纵隔淋巴结；C.全腹腔镜下制作宽度3~4 cm的管胃；D.将管胃与近端残胃用丝线固定；E.胸部Trocar布局；F.清扫中纵隔淋巴结；G.胃管支撑下，食管管胃端端胸内手工吻合；H.吻合口展示

1	国际食管疾病学会中国分会食管胃结合部疾病跨界联盟，中国医师协会内镜医师分会腹腔镜外科专业委员会，中国医师协会外科医师分会上消化道外科医师专业委员会，等．食管胃结合部腺癌外科治疗中国专家共识(2018年版)[J]．中华胃肠外科杂志，2018，21(9):961-975.
2	Liu K, Yang K, Zhang W, et al.Changes of esophagogastric junctional adenocarcinoma and gastroesophageal reflux disease among surgical patients during 1988-2012: a single-institution, high-volume experience in china[J]．Ann Surg，2016，263(1):88-95.
3	Matsuno K, Ishihara R, Ohmori M, et al.Time trends in the incidence of esophageal adenocarcinoma, gastric adenocarcinoma, and superficial esophagogastric junction adenocarcinoma[J]．J Gastroenterol，2019，54(9):784-791.
4	郑民华，臧潞，马君俊，等．Siewert Ⅱ型食管胃结合部腺癌腔镜手术治疗中国专家共识(2019版)[J]．中国实用外科杂志，2019，39(11):1129-1135.
5	Merritt RE, Kneuertz PJ, D'Souza DM, et al.An analysis of outcomes after transition from open to minimally invasive ivor lewis esophagectomy[J]．Ann Thorac Surg，2021，111(4):1174-1181.
6	Mariette C, Markar SR, Dabakuyo-Yonli TS, et al.Hybrid minimally invasive esophagectomy for esophageal cancer[J]．N Engl J Med，2019，380(2):152-162.
7	Gottlieb-Vedi E, Kauppila JH, Mattsson F, et al.Long-term survival in esophageal cancer after minimally invasive esophagectomy compared to open esophagectomy[J]．Ann Surg，2021，276(6):744-748.
8	郑民华，余佩武，赵永亮，等．腹腔镜胃癌手术操作指南(2016版)[J]．中华消化外科杂志，2016，15(9):851-857.
9	Amin MB, Edge S, Greene F, et al.AJCC cancer staging manual[M].8th ed.New York：Springer，2017.
10	李子禹，吴舟桥，季加孚．中国胃肠肿瘤外科术后并发症诊断登记规范专家共识(2018版)[J]．中国实用外科杂志，2018，38(6):589-595.
11	Yamashita H, Seto Y, Sano T, et al.Results of a nation-wide retrospective study of lymphadenectomy for esophagogastric junction carcinoma[J]．Gastric Cancer，2017，20(1):69-83.
12	Nishiwaki N, Noma K, Matsuda T, et al.Risk factor of mediastinal lymph node metastasis of Siewert type Ⅰ and Ⅱ esophagogastric junction carcinomas[J]．Langenbecks Arch Surg，2020，405(8):1101-1109.
13	Kurokawa Y, Takeuchi H, Doki Y, et al.Mapping of lymph node metastasis from esophagogastric junction tumors: a prospective nationwide multicenter study[J]．Ann Surg，2021，274(1):120-127.
14	Deng J, Liu J, Wang W, et al.Validation of clinical significance of examined lymph node count for accurate prognostic evaluation of gastric cancer for the eighth edition of the american joint committee on cancer (AJCC) TNM staging system[J]．Chin J Cancer Res，2018，30(5):477-491.
15	Japanese Gastric Cancer A．Japanese gastric cancer treatment guidelines 2018 (5th edition)[J]．Gastric Cancer，2021，24(1):1-21.
16	韩逸超，张亚杰，李鹤成．不同食管胃胸内吻合方式在食管癌手术中的应用[J]．中华胃肠外科杂志，2018，21(9):995-1000.
17	Kamarajah SK, Bundred JR, Singh P, et al.Anastomotic techniques for oesophagectomy for malignancy: systematic review and network meta-analysis[J]．BJS open，2020，4(4):563-576.
18	Deng XF, Liu QX, Zhou D, et al.Hand-sewn vs linearly stapled esophagogastric anastomosis for esophageal cancer: a meta-analysis[J]．World J Gastroenterol，2015，21(15):4757-4764.
19	Patel K, Abbassi O, Tang CB, et al.Completely minimally invasive esophagectomy versus hybrid esophagectomy for esophageal and gastroesophageal junctional cancer: clinical and short-term oncological outcomes[J]．Ann Surg Oncol，2021，28(2):702-711.
20	Charalabopoulos A, Davakis S, Syllaios A, et al.Intrathoracic hand-sewn esophagogastric anastomosis in prone position during totally minimally invasive two-stage esophagectomy for esophageal cancer[J]．Dis Esophagus，2021，34(6): 106.

[1]	童洪杰, 陈琨, 潘飞艳, 倪红英. 俯卧位通气对静脉-静脉体外膜肺氧合支持的急性呼吸窘迫综合征患者病死率影响的Meta分析[J]. 中华危重症医学杂志(电子版), 2022, 15(04): 312-317.
[2]	邹庆涛, 张洪贞, 尹作文, 喻军, 张鹏. 食管胃结合部腺癌根治术三种消化道重建方式的临床效果评价[J]. 中华普外科手术学杂志(电子版), 2022, 16(05): 545-548.
[3]	邹庆涛, 张洪贞, 尹作文, 喻军, 张鹏. 腹腔镜辅助全胃切除术与近端胃切除术治疗SiewertⅡ型食管胃结合部腺癌的近期及远期效果对比研究[J]. 中华普外科手术学杂志(电子版), 2022, 16(04): 395-398.
[4]	李东亮, 王伟, 周家杰, 杜瑞, 王峰, 佟贵繁, 丁旭, 汪刘华, 汤东, 王道荣. 自带抗反流装置管型胃在SiewertⅡ型和Ⅲ型食管胃结合部腺癌中临床疗效分析[J]. 中华普外科手术学杂志(电子版), 2021, 15(02): 157-161.
[5]	杨恒, 张家伟, 苏容万, 邓天星. 分腿俯卧位完成女性膀胱前壁肿瘤电切术十例报告[J]. 中华腔镜泌尿外科杂志(电子版), 2022, 16(05): 454-455.
[6]	黄华生, 郑哲明, 陈早庆, 郁兆存, 方钟进, 谢永康. 斜仰卧截石位与俯卧位经中上盏入路微通道经皮肾镜的比较[J]. 中华腔镜泌尿外科杂志(电子版), 2021, 15(04): 299-303.
[7]	陶莎, 鲁静, 沈玥, 帅维正, 王振华. 俯卧位无创机械通气治疗AECOPD的临床分析[J]. 中华肺部疾病杂志(电子版), 2022, 15(06): 792-795.
[8]	冯芸, 刘娟, 周圣哲, 程绩. 俯卧位通气时间对急性呼吸窘迫综合征病死率影响的Meta分析[J]. 中华肺部疾病杂志(电子版), 2020, 13(04): 524-526.
[9]	朱天宇, 李瑞欣, 王国俊. 俯卧位与侧卧位胸腔镜食管癌根治术的对照研究[J]. 中华腔镜外科杂志(电子版), 2022, 15(04): 206-210.
[10]	胡志豪, 李瑞欣, 王国俊. 食管胃结合部腺癌的微创外科治疗现状与展望[J]. 中华腔镜外科杂志(电子版), 2021, 14(03): 181-186.
[11]	李东亮, 王伟, 周家杰, 杜瑞, 王峰, 佟贵繁, 丁旭, 汪刘华, 汤东, 王道荣. 腹腔镜辅助下Overlap法管型胃食管吻合在食管胃结合部腺癌中临床疗效分析[J]. 中华腔镜外科杂志(电子版), 2020, 13(06): 357-361.
[12]	李东亮, 周家杰, 杜瑞, 王峰, 佟贵繁, 丁旭, 张琪, 汪刘华, 王伟, 汤东, 王道荣. 腹腔镜辅助下三种消化道重建方式在食管胃结合部腺癌中的临床疗效分析[J]. 中华腔镜外科杂志(电子版), 2020, 13(03): 159-165.
[13]	马璐, 刘松桥, 康焰, 吴志雄, 李晓青, 徐翠荣. 高龄新型冠状病毒肺炎患者重症护理：防“危”杜渐[J]. 中华重症医学电子杂志, 2022, 08(03): 211-215.
[14]	吴晓燕, 杨志祥, 於江泉, 郑瑞强. 扬州地区老年COVID-19患者临床特征分析及俯卧位通气疗效评价[J]. 中华重症医学电子杂志, 2022, 08(03): 216-222.
[15]	鲁卫华, 王涛, 秦雪梅, 徐前程, 姜小敢. 早期清醒俯卧位联合经鼻高流量氧疗治疗重型新型冠状病毒肺炎一例[J]. 中华重症医学电子杂志, 2022, 08(01): 85-89.

阅读次数

全文

摘要

选择文件类型/文献管理软件名称

选择包含的内容

Application of intrathoracic hand-sewn anastomosis in prone position for adenocarcinoma of esophagogastric junction with esophageal involvement over 4 cm

模态框（Modal）标题

选择文件类型/文献管理软件名称

选择包含的内容

Application of intrathoracic hand-sewn anastomosis in prone position for adenocarcinoma of esophagogastric junction with esophageal involvement over 4 cm