| [Background]The morbidity and mortality of esophageal carcinoma in countries are very different. China is one of the countries with the highest esophagus cancer risk in the world. Esophageal carcinoma is a common digestive tract cancer in our country, incidence of more men than women, more than 40 years of age or more. The incidence of esophageal cancer was about 31.66/100 thousand men, women about 15.93/100 thousand, representing various parts of cancer deaths second only to gastric cancer. Morbidity and mortality of esophageal carcinoma in China now ranks first in the world. The number of patients with esophageal carcinoma in China is nearly 60% of the total incidence in the world. The number of annual growth of about 15 million people died in China, about 300 thousands people worldwide succumb to esophageal cancer each year.The general treatment of esophageal carcinoma including:surgical treatment, radiotherapy, chemotherapy and combined therapy (two and/or more treatments applied simultaneously or successively called comprehensive treatment). The results showed that the combined treatment is better. Surgery is the preferred method of treatment of esophageal cancer.1) Indications for surgery:the body in good condition and has good cardiopulmonary reserve, no obvious signs of distant metastasis, could be considered surgery. Cervical cancer, generally the length<3cm, upper thoracic cancer length<4cm, length of the lower thoracic cancer<5cm have greater chance of removal. However, there are not too big but the tumor has been with the major organs, such as the aorta, trachea, and not removed by close adhesion. Squamous cell carcinoma of the larger estimate is unlikely that the patient removed the body in good condition, could be used preoperative radiotherapy and chemotherapy, to be reduced further after tumor surgery.2) surgical contraindications:①General condition is poor, has shown cachexia, or serious heart, lung or liver and kidney dysfunction.②Lesions violations range, or foreign invasion and perforation have been obvious signs, such as has occurred hoarseness or those who have esophago-tracheal fistula.③Have distant metastasis.3) Surgical approach:Left chest one incision, Left chest and left cervical two incisions, Right chest and abdominal two incisions or cervical, thoracic and abdominal three incisions.4) Surgical methods:radical resection should pay attention to the length and breadth. In principle most of the esophagus should be removed. Length should be removed from the tumor margin in the upper and lower 5-8cm above. Breadth should include the removal of fibrous tissue around the tumor and all lymph nodes (in the middle and upper esophageal carcinoma should pay particular attention to the neck, chest top of the mediastinum, esophagus and trachea carina around; lower esophageal cancer should be noted that the around cardia, lesser curvature of stomach, around the left gastric artery and abdominal aortic lymph node dissection, etc.). Anastomosis:The lower esophageal cancer, esophagus often consistent with the substitutive organ in superior the aortic arch; and middle or upper esophageal cancer should be consistent in the neck. Substitutive organs are commonly used stomach, sometimes colon or jejunum is used. Common postoperative complications are anastomotic leakage and anastomotic stenosis.In terms of resectable esophageal cancer, esophageal cancer resection, regional lymph node dissection and reconstruction of digestive tract is still the optimal therapeutic method. But the open resection of esophageal cancer, especially traditional three incision esophagectomy, is large trauma and high postoperative complications and mortality. Even though, due to development of the surgical technique and instruments recent years, a variety of postoperative complication rate has dropped, but hospital mortality rate was still as high as 6% to 7%.That causes the patients to fear of surgery, and some patients those should to accept surgical treatment give up the opportunity.In order to reduce invasive trauma, improved postoperative quality of life, with the development of endoscopic surgery, thoracoscoe, laparoscope and mediastinoscope has started used in esophagectomy. In 1991, Collard and Gossot carried out the first VATS resection of esophageal cancer. In 1996, by domestic Qu Jia-Qi et al first reported thoracoscopic resection of esophageal carcinoma. The early endoscopic esophageal cancer surgery can be divided into VATS assisted small incision in resection of esophageal cancer, hand-assisted thoracoscopic resection of esophageal cancer, a simple thoracoscopic esophagectomy and mediastinoscope associate with laparotomy or laparoscopy esophagectomy for cancer. Hand-assisted thoracoscopic resection of esophageal cancer still need to open surgery, surgical trauma is still large, and the superior abdominal incision impact on respiratory function is similar to thoracotomy, and the occurrence of postoperative pneumonia was still high, even of some patients postoperative abdominal wound dehiscence caused by coughing. Therefore, the common endoscopic surgical treatment of esophageal cancer not fully reflects the advantages of minimally invasive. In 2000, Luketich first reported thoracoscopy combined with laparoscopy in 77 cases of esophageal resection, so called totally endoscopic Ivor Lewis esophagectomy. As the joint use of thoracoscopic and laparoscopic techniques, the lower traumas to the thoracic and abdominal, with fewer traumas and little effect on respiratory function, the advantages of rapid recovery, the early results is good. However, there are still some shortcomings in this surgical procedure. First, the stomach pass through esophageal bed, and anastomose with esophageal stump, the intrathoracic stomach oppress on the pulmonary and effect postoperative respiratory function of the patients; Secondly, the presence of intrathoracic stomach is not conducive to postoperative radiotherapy, because radiotherapy inevitably lead to damage to the stomach.With a variety of endoscopic surgical techniques of esophageal cancer in-depth study of, so increasingly accepted by everyone. On this basis, combining all the advantages of endoscopic esophagectomy, in 2009, we began to explore and successfully carried out the thoracoscopic and laparoscopic esophagectomy for cancer and mechanical cervical esophagogastric anastomosis via retrosternal route. The surgical operation uses the previous thoracoscopic resection of esophageal cancer. The abdominal surgical operation using the laparoscopic technique, dissociate stomach and abdominal esophagus, while dissociating lymph node located abdominal surgical field(around cardia, lesser curvature of stomach, around the left gastric artery); stomach pass through the retrosternal tunnel pull-up to the neck, and practice mechanical cervical esophagogastric anastomosis. The advantages of this surgical procedure:First, thoracoscopic esophagectomy combined laparoscopic technique; in recent years, studies have shown that thoracoscopic resection of esophageal cancer can reduce pulmonary function injury. Small incision, especially in the chest only four 0.5-1.0cm hole, not cut off the chest wall muscles, not braced ribs, the muscle related to respiratory function damaged little, no significant effect on the thoracic respirations; the same time, the abdominal incision is only 4-5cm, help to reduce abdominal pain and the impact of abdominal breathing. After operation coughing, sputum was markedly increased. Second, the original stomach pass through retrosternal tunnel raised to the neck; the benefits of stomach pass through substernal tunnel path:1). stomach placed in the retrosternal chest to avoid the stomach oppress on the lung tissue, in order to protect the lung function better; 2). Made without the stomach tube, and maintained the original size of the stomach, the impact on the function of the stomach is small; 3) stomach through esophageal bed is not conducive to patients in need of postoperative radiotherapy and reduce radiation complications. Third, mechanical cervical esophagogastric anastomosis reduces the postoperative incidence of anastomotic leakage and stricture. A number of retrospective studies are that the technology of mechanical cervical esophagogastric anastomosis could significantly reduce the incidence of esophageal fistula and anastomotic stricture. Because most of the anastomotic stricture due to anastomosis fistula. If the anastomotic fistula happened, opening the cervical incision and draining can easily limited the infection, to avoid emphysema. Surgical trauma, faster postoperative recovery, shorter hospital stay, plays more fully the advantages of minimally invasive endoscopic surgery.But it's unknown to us that the safety and treatment effectiveness of these surgical procedures, quality of life of these patients surpassed those patients undergone the three incisions open surgery, there is no literature in this area. Purpose of this study was to evaluate the clinical effect of this surgical procedure and postoperative quality of life of patients.The research content includes two aspects:Chapter 1 Analysis of clinical short term effect of thoracoscopic and laparoscopic esophagectomy for cancer and mechanical cervical esophagogastric anastomosis via retrosternal route in patients with esophageal carcinoma[Objectives]To compare the clinical short term effect in patients with esophageal carcinoma after thoracoscopic and laparoscopic esophagectomy for cancer and mechanical cervical esophagogastric anastomosis via retrosternal route or cervicothoracic-abdominal three-incision surgery.[Methods]A total of 63 patients with middle-upper esophageal carcinoma who underwent radical surgical resection by the same surgical group in Thoracic surgery of our hospital from January 2009 to October 2010 were enrolled in this study. Thirty three patients followed thoracoscopic and laparoscopic esophagectomy for cancer and mechanical cervical esophagogastric anastomosis via retrosternal route. Thirty patients followed three-incision surgery (25 cases with hand-sewn,5 cases with mechanical cervical esophagogastric anastomosis)[Results]There was no significant difference in the clinical data of the two groups except anastomosis method (P> 0.05). Two groups are comparable. In the endoscopic group, there are 1 case of leakage (3.0%,1/33),1 case of postoperative neck wound infection (3.0%,1/33), and 1 case of stricture (3.0%,1/33). In the cervicothoracic-abdominal three-incision surgery group,8 patients had leakage (26.7%,8/30),2 patients had stricture (6.7%,2/30),1 patient had neck wound infection (3.0%,1/33), and 6 patients had pulmonary infection (20.0%). All of the patients were cured by conservative treatment. The hospital day was significantly longer in the open group (21.10±17.31d)than in the endoscopic group (13.15±3.17d) (t=-2.478, P=0.019); The Open group had significant higher total hospital costs (101054.70±114359.62 Yuan), drugs costs (34156.48±16158.53 Yuan), bed costs (1961.69±1114.81Yuan) than the endoscopic Group (57084.18±8685.53 Yuan) (t=-2.100, P=0.044), (20534.47±5525.41 Yuan) (t=-4.390, P=0.000), (1210.86±302.84 Yuan) (t=-3.571, P=0.001). no significant difference in the other dimensions (P>0.05). During a follow-up for 3-20 months, none of the patients was found recurrence or metastasis after surgery. No patients died.[Conclusions]Cervical stapling technique significantly decreases the rate of leakage as well as hospital stay and hospital expenses. Due to mini-invasive, low incidence of postoperative complications, shorter hospital stay, low hospital expense, thoracoscopic and laparoscopic esophagectomy for cancer and mechanical cervical esophagogastric anastomosis via retrosternal route is safe and effective method. Chapter 2 Quality of life in patients with esophageal carcinoma undergoing thoracoscopic and laparoscopic esophagectomy and mechanical cervical esophagogastric anastomosis via retrosternal route[Objectives]To evaluate the quality of life (QOL) in patients with esophageal carcinoma after thoracoscopic and laparoscopic esophagectomy for cancer and mechanical cervical esophagogastric anastomosis via retrosternal route or cervicothoracic-abdominal three-incision surgery.[Methods]A total of 63 patients with middle-upper esophageal carcinoma who underwent radical surgical resection by the same surgical group in Thoracic surgery of our hospital from January 2009 to October 2010 were enrolled in this study. Thirty three patients followed thoracoscopic and laparoscopic esophagectomy for cancer and mechanical cervical esophagogastric anastomosis via retrosternal route. Thirty patients followed cervicothoracic-abdominal three-incision surgery (25 cases with hand-sewn,5 cases with mechanical cervical esophagogastric anastomosis).The EORTC questionnaire QLQ-C30 together with QLQ-OES18 were applied to evaluate the QOL of the all patients.[Results]There was no significant difference in the clinical data of the two groups except anastomosis method (P> 0.05). In the endoscopic group, there are one patient had leakage and 1 case of postoperative neck wound infection, cured by conservative treatment, and 1 case of stricture, ameliorated by endoscopic dilatation twice. In the open group,8 patients had leakage,2 patients had stricture,1 patient had neck wound infection, and 6 pulmonary infection. All of the patients were cured by conservative treatment. The postoperative QOL scores of dysphasia, food intake, pain, obstruction, dyspnea, anorexia, fatigue, financial difficulties, physical function, role function, emotional function, cognitive function, social function and global quality level were higher in eodoscopic group than open group (P<0.05), no significant difference in the other dimensions.[Conclusions]The postoperative symptoms of dysphasia, food intake, obstruction, anorexia, pain, dyspnea, fatigue were common in open group than eodoscopic group. Cervical stapling technique significantly decreases the rate of leakage as well as hospital stay and hospital expenses. The two groups differed in physical function, role function, emotional function, cognitive function, social function and global health level were more favorable in the endoscopy group (P<0.05). Due to mini-invasive, low incidence of postoperative complications, shorter hospital stay, low hospital expense, the postoperative quality of life is improved in endoscopic group compared with the open group. |
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