| BackgroundEsophageal cancer is one of the most common malignancies in human digestive system and the mortality rate of this disease ranks sixth among malignant tumors worldwide.About half of the new cases of esophageal cancer in the world occur in China every year.Surgery continues to play a key role in achieving locoregional control in patients with esophageal carcinoma.For a long time,the main operation type of the treatment for esophageal cancer is open esophagectomy(OE),which contains Sweet esophagectomy,Ivor Lewis esophagectomy,Mckeown esophagectomy,and so on.But patients with esophageal cancer suffered great trauma from these operation types because of the large incision.With the development of surgical skills,minimally invasive esophagectomy(MIE),compared with OE,has been a conventional procedure for the treatment of esophageal cancer,for it can reduce the incidence of perioperative complications and improve the postoperative quality of life effectively.At present,MIE mainly includes thoracoscopic laparoscopic esophagectomy with anastomosis in the neck(TLE-neck,MIE-Mckeown)and thoracoscopic laparoscopic esophagectomy with anastomosis in the chest(TLE-chest,MIE-Ivor Lewis).TLE-neck was performed earlier with uncomplicated steps,and it has been widely implemented in hospitals.Compared to TLE-neck,TLE-chest was performed late with more difficulty.However,it’s considered to be more minimally invasive because of the omission of incision in the neck.MIE-Ivor Lewis using the purse string-stapled anastomotic technique is a new type of TLE-chest,in which a purse string is hand sewn without the necessity of specialized devices,such as OrVil and Endo-Stitch.However,there are very few literature reports on the perioperative data of TLE-chest with this technique.In recent years,TLE-neck and TLE-chest using the purse string-stapled anastomotic technique were refined continuously by our operation teams,and many new skills and steps were added into these two operations.For the treatment of middle and lower esophageal cancer with minimally invasive surgery,it is still inconclusive that which operation is more suitable between the anastomosis in the neck and the anastomosis in the chest.Objectives1.The perioperative data of TLE-chest using the purse string-stapled anastomotic technique will be analysed in order to explore the feasibility,safety and treatment effect of this operation to middle and lower esophageal cancer.2.The improvement and experience of treating postoperative complications about TLE-chest and TLE-neck will be summarized.3.The perioperative data of these two refined operations will be compared,to provide evidence for the selection of minimally invasive surgery of middle and lower esophageal cancer.MethodsClinical and surgical data of 250 patients with esophageal cancer who underwent TLE-chest(n=110)and TLE-neck(n=140)in our department between January 2015and August 2017 were retrospectively analyzed.No patients received preoperative radiotherapy and chemotherapy.The general data of patients included age,gender,body mass index,smoking history,drinking history,the tumor location,pathology and preoperative clinical stage.The major indicators of analysis included operation time,the number of lymph nodes,conversion cases,mortality,volume of drainage,the retain days of thoracic tube,postoperative hospitalization days,cases of postoperative complications(leakage,upper gastrointestinal hemorrhage,pulmonary complications,recurrent laryngeal nerve injuries,chylothorax)and postoperative pathological stage.ResultsThere were 82(74.55%)men and 28(25.45%)women with a mean age of 64.05±8.38 years in the group of TLE-chest.The mean body mass index of this group was22.49±2.78 Kg/m~2.57 patients(50.18%)had smoking history,and 49(44.55%)patients had drinking history.The tumors were located in the middle esophagus in 73(66.36%)cases and the lower esophagus in 37(33.64%)cases.The percentage of squamous cell carcinoma was 92.73%.There were 100(71.43%)men and 40(28.57%)women with a mean age of 64.99±7.05 years in the group of TLE-neck.The mean body mass index of this group was 22.61±2.74 Kg/m~2.60patients(42.86%)had smoking history,and 51(36.43%)patients had drinking history.The tumors were located in the middle esophagus in 107(76.43%)cases and the lower esophagus in 33(23.57%)cases.The percentage of squamous cell carcinoma was 95.71%.There was no significant difference in all of general indicators between the two groups(P>0.05).The average operation time of TLE-chest group based on endoscopic purse-string suture technique was 273.71±48.85min,and the average number of lymph node dissection was 22.58±10.77.The average drainage volume after operation was2172.59±1130.03ml.Postoperative pathological stage:12 cases in stage Ia,15 cases in stage Ib,27 cases in stage IIa,12 cases in stage IIb,6 cases in stage IIIa,28 cases in stage IIIb,and 10 cases in stage IVa.The retain days of thoracic tube were 9.93±3.53,while the postoperative hospitalization days were 11.67±4.10.4 patients developed anastomotic leakage,and all of them were treated conservatively.2 patients experienced postoperative haemorrhage and 1 of them was cured with conservative treatment.The remaining patient was cured by endoscopic management using titanium clips.11 patients experienced postoperative pulmonary complications,and 4patients developed recurrent laryngeal nerve injuries.2 patient developed chyle leakage,and they were cured with conservative treatment.1 patient died from severe pulmonary infection during perioperative period.The average operation time of TLE-neck group was 254.23±58.78min,and the average number of lymph node dissection was 24.52±13.14.The average drainage volume after operation was2329.97±1587.39ml.Postoperative pathological stage:13 cases in stage Ia,23 cases in stage Ib,24 cases in stage IIa,18 cases in stage IIb,9 cases in stage IIIa,45 cases in stage IIIb,and 8 cases in stage IVa.The retain days of thoracic tube were 11.31±6.09,and the postoperative hospitalization days were 13.88±8.24.15 patients developed anastomotic leakage,and 14 of them were cured conservatively.7 patients experienced postoperative haemorrhage and all of them were cured with conservative treatment.24 patients experienced postoperative pulmonary complications,and 21patients developed recurrent laryngeal nerve injuries.3 patient developed chyle leakage,and 2 of them cured with conservative treatment.The remaining patient was found to be damaged in the chyle pool during laparotomy,and he was cured after surgery.2 patient died from pulmonary infection during perioperative period.1 of them deveolped anastomotic leakage,followed by esophageal tracheal fistula,respiratory failure.After the treatment by tracheotomy,mechanical ventilation,anti-infection,and so on,the patient developed severe pneumonia and ARDS.At last,the treatment was invalid and the patient died.There was no significant difference between the two groups(P>0.05)in operation time,the number of lymph nodes,conversion cases,mortality,volume of drainage,postoperative pathological stage,upper gastrointestinal hemorrhage,pulmonary complications and chylothorax.However,the retain days of thoracic tube,postoperative hospitalization days and the incidence of leakage and recurrent laryngeal nerve injuries were significantly lower in the TLE-chest group based on the laparoscopic pouch suture technique than in the TLE-neck group(P<0.05).Conclusions1.TLE-chest based on endoscopic purse-string suture technique is technically feasible,and the clinical treatment effect is satisfactory.It is safe when radical resection of tumor is ensured.2.The improvement and experience of treating postoperative complications about TLE-chest based on endoscopic purse-string suture technique and TLE-neck has been summarized.It can effectively improve the operability and contribute to the reduction of the incidence of postoperative complications.It is worth promoting in clinical application.3.TLE-chest based on endoscopic purse-string suture technique is a suitable choice for minimally invasive treatment of patients with middle and lower esophageal cancer. |
PDF Full Text Request