微创食管癌切除Ivor-Lewis术与McKeown术的近期疗效比较及短期生活质量评价

发布时间：2018-06-27 22:09

本文选题：胸腔镜 + 腹腔镜　；参考：《山东大学》2016年博士论文

【摘要】：第一部分微创食管癌切除Ivor-Lewis术与McKeown术的近期疗效比较研究背景一直以来,传统的开胸食管癌切除Ivor-Lewis术与McKeown术是治疗食管中下段癌的主要治疗手术方式,然而,这些传统的开胸食管癌切除手术的缺点是创伤大,术后并发症的发生率和死亡率高。因此,微创食管切除手术越来越多的被用来治疗胸中下段食管癌,大量的回顾性研究和少量的前瞻性研究显示,微创食管癌切除手术能够明显改善传统开胸手术的不足之处。然而,这些研究主要集中于微创手术与开胸手术的比较,有关微创Ivor-Lewis术与McKeown术之间的比较非常少见,涉及微创Ivor-Lewis术的报道多数是回顾性的经验总结,有些虽然病例数较多,但缺乏与微创McKeown术进行比较研究；有少数与微创McKeown术的对照研究采用的是Orvil系统或直线切割缝合器进行的胸内吻合,颈部吻合时采用的是手工吻合,吻合方式缺乏一致性；对于颈部和胸内吻合均应用普通圆形吻合器进行吻合的微创Ivor-Lewis术和McKeown术的比较非常罕见,其结果是否与上述的吻合方式一致仍需进一步研究。目的本研究试图从手术的一般结果、围手术期的并发症发生率和死亡率等方面对应用普通圆形吻合器进行微创食管癌切除Ivor-Lewis术和McKeown术的疗效进行比较。方法回顾性分析2013年1月至2015年6月间在潍坊市人民医院胸外科接受微创食管癌切除Ivor-Lewis术与McKeown术的112例食管癌病人的临床和手术资料,比较两种手术病人的人口学特征、病理资料、手术方式、围手术期资料。微创食管癌切除Ivor-Lewis术的手术步骤：①腹腔镜游离胃,并清扫胃左动脉旁、腹腔干及肝总动脉旁淋巴结以及胃小弯侧脂肪和淋巴结组织。②胸腔镜游离胸段食管及肿瘤后清扫纵隔淋巴结,在食管靠近胸顶处行手工荷包缝合,在右胸顶应用强生普通圆形型吻合器完成食管-胃的端侧吻合,胃小弯组织用Echelon60钉仓切除做成管胃。微创食管癌切除McKeown的手术步骤：①胸腔镜游离胸段食管,并行系统性纵隔淋巴结清扫。②腹腔镜操作步骤与微创McKeown术相似。③沿左颈部胸锁乳突肌前缘开口游离颈部食管,经上腹部小切口将充分游离的食管、胃拉出腹腔,以直线切割缝合器平行胃大弯制作成直径约5cm左右的管型胃,经后纵隔将管胃拉至左侧颈部,用强生普通圆形吻合器与近端食管行端侧吻合,最后用直线切割缝合器将胃残端封闭。结果共有112个病人纳入本研究,其中50个病人接受了微创食管癌切除Ivor-Lewis术,62个病人接受了微创食管癌切除McKeown术。两组病人在人口统计学、病理资料、合并症等方面大致相同。两组的平均手术时间分别为276.8+17.3分钟vs.281.2士18.3分钟,(P0.05)；两组的失血量分别为143.7±84.1ml vs.159.1±95.1ml (P0.05);两组的平均淋巴结清扫数目分别为20.5+2.5枚vx.21.5士2.4枚,(P0.05)。与微创食管癌切除McKeown组相比,微创食管癌切除Nor-Lewis组在肺部并发症(18%vs.37.1%)、吻合口瘘(6%vs.19.4%)、吻合口狭窄(8%vs.22.6%)及喉返神经损伤(6%vs.21.0%)等方面有更低的发生率(P0.05)。两组间在乳糜胸(4%vs.8.1%)、心律失常(6%vs.12.5%)及胃排空延迟(10%vs.3.2%)等方面无统计学差异。2例(4%)微创食管癌切除Ivor-Lewis组的病人和3例(4.8%)微创食管癌切除McKeown组的病人因为乳糜胸需要再次手术。1例(2%)微创食管癌切除Ivor-Lewis组的病人和6例(9.7%)微创食管癌切除McKeown组的病人因为术后严重并发症被转入ICU继续治疗。在平均住院日方面,两组病人分别为23.5±9.5天vs.27.6+11.3天,(P0.05)。1例微创食管癌切除McKeown组病人因急性呼吸窘迫综合征、2例因气管食管瘘在术后90天内死亡,1例微创食管癌切除Ivor-Lewis组病人在术后90天内死于严重的肺部感染, 两组的90天死亡率分别为2%和4.8%。结论应用普通圆形吻合器进行微创食管癌切除Ivor-lewis术较McKeown术显示出更好的围手术期疗效及更少的并发症发生率。第二部分微创食管癌切除Ivor Lewis术与McKeown术后患者生活质量评价的对照研究研究背景传统的Ivor Lewis术与McKeown术是治疗食管癌的主要手术方式,但却伴随较高并发症发生率和死亡率,术后的生活质量低下。为减少并发症、提高病人的生活质量,微创食管切除术越来越多被应用于食管癌的治疗。已有的研究显示,微创食管切除术与开放手术相比能显著降低呼吸道并发症的发生率,从而提高病人的短期生活质量。然而,有比较性的研究显示,微创食管切除颈部吻合仍然伴随较高的吻合口瘘、吻合口狭窄及喉返神经损伤发生率,为此,微创食管切除Ivor Lewis术重新引起大家的兴趣,有关两种手术方式围手术期资料的比较有少量报道。然而,有关微创食管切除Ivor Lewis术与McKeown术之间生活质量评价的比较研究罕有报道。目的本研究的目的是评价微创食管癌切除Ivor Lewis术与McKeown术对中下段食管癌术后病人短期生活质量的影响。方法2013年1月至2015年6月间在潍坊市人民医院胸外科接受微创食管切除Ivor-Lewis术与McKeown术的112例食管癌病人纳入本研究。微创Ivor Lewis术包括腹腔镜游离胃并形成管胃和胸腔镜切除食管并胸内吻合两个步骤。微创McKeown术包括胸腔镜食管切除、腹腔镜游离胃及颈部吻合三个步骤。采用欧洲癌症研究与治疗组织(EORTC)开发的生活质量核心量表QLQ-C30(中文3.0版)和食管癌补充量表QLQ-OES18(中文版)进行生活质量评价。所有的病人分别在术前、术后2、4、12、24周通过口头、电话或书信进行调查问卷。为便于统计及比较,将调查所得的原始评分根据QLQ-C30评分手册转换为0-100分,功能性指标维度及总体健康状况维度评分越高说明功能越好、生活质量越高；QLQ-C30症状性指标维度及QLQ OES-18食管癌特有症状性指标维度越高说明症状越重、生命质量越差。结果共有112个病人纳入本研究,其中50个病人接受了微创食管癌切除Ivor-Lewis术,62个病人接受了微创食管癌切除McKeown术。两组病人在人口统计学、病理资料、合并症等方面大致相同。两组病人在手术时间,失血量,淋巴结清扫数目,平均住院日等方面没有明显差异。与微创McKeown术相比,微创食管切除Ivor Lewis术肺部并发症(18%vs.37.1%)、吻合口瘘(6%vs.19.4%)、吻合口狭窄(8%vs.22.6%)及喉返神经损伤(6%vs.21.0%)等方面有更低的发生率(P0.05)。在随访期间,微创Ivor Lewis组调查问卷的反馈率为有94%(235/250),而在微创McKeown组调查问卷的反馈率为95.2%(295/310)。两组病人术后生活质量评价中的总体健康状况、躯体功能、进食困难、咳嗽及言语等五个方面具有明显差异,然而其它的条目无明显差异。两组病人的总体健康状况和躯体功能分数都在手术后快速降低,然后从术后2周开始缓慢提高。微创Ivor Lewis组的病人在总体健康状况和躯体功能方面的恢复更快,在术后12周左右几乎达到术前水平。微创Ivor Lewis组的病人在进食困难方面的分数在手术后快速升高,然后在术后2周左右开始缓慢降低。相反地,微创McKeown组的病人在进食困难方面的分数在手术后略有升高,然后在4周后缓慢降低。结论微创Ivor Lewis组在术后短期内的总体健康状况、躯体功能、进食困难、咳嗽及言语等生活质量条目方面要明显优于微创McKeown组,但是两组病人在其它的生活质量条目方面未显示出明显不同,从长远来看,两组的生活质量有逐渐接近的趋势。
[Abstract]:A comparative study of the short-term effect of Ivor-Lewis and McKeown in the first part of minimally invasive esophagectomy, the traditional surgical resection of esophagus carcinoma with Ivor-Lewis and McKeown is the main treatment for the middle and lower esophageal cancer. However, the shortcomings of these traditional surgical procedures are large trauma and postoperative complications. The incidence and mortality of the disease are high. Therefore, minimally invasive esophagectomy is becoming more and more used for the treatment of lower thoracic esophagus cancer. A large number of retrospective studies and a small number of prospective studies have shown that minimally invasive esophagectomy can significantly improve the shortcomings of traditional thoracotomy. However, these studies are mainly focused on minimally invasive surgery. Compared with open chest surgery, the comparison between minimally invasive Ivor-Lewis and McKeown is very rare. Most of the reports involving minimally invasive Ivor-Lewis are retrospective summary of experience. Although there are many cases, there is a lack of comparative study with minimally invasive McKeown, and a few comparative studies with minimally invasive McKeown are used in the Orvil system. The intrathoracic anastomosis performed by the traditional or linear cutting suture, the manual anastomosis and the lack of consistency during the neck anastomosis, and the comparison of the minimally invasive Ivor-Lewis and McKeown for the anastomosis of the neck and chest anastomoses with the common circular stapler are very rare, and the results are still in accordance with the same anastomosis. The purpose of this study is to compare the general results of the operation, the incidence of complications and mortality in the perioperative period, and to compare the efficacy of the common circular stapler for Ivor-Lewis and McKeown for minimally invasive esophagus carcinoma. Methods a retrospective analysis was made between January 2013 and June 2015 in the thoracic area of Weifang People's Hospital. The clinical and surgical data of 112 patients with esophageal cancer treated with minimally invasive esophagectomy with Ivor-Lewis and McKeown were compared. The demographic characteristics, pathological data, surgical methods, and perioperative data were compared in the two surgical patients. The procedure of Ivor-Lewis resection for minimally invasive esophagectomy was performed: (1) the laparoscopic free stomach, and the clearance of the left gastric artery, and the abdominal cavity The lymph nodes in the trunk and the hepatic para artery and the small bend side of the stomach and lymph nodes. 2. The thoracoscopic free thoracic esophagus and the tumor were swept through the mediastinal lymph nodes. The hand suture was sutured at the top of the esophagus. The end to side anastomosis of the esophagus and stomach was completed by the common circular stapler of Johnson on the right thoracic top, and the small bend tissue of the stomach was cut by Echelon60 nailing. In addition to the tube stomach. Minimally invasive esophagectomy for the resection of McKeown: (1) thoracoscopic free thoracic esophagus, parallel systematic mediastinal lymph node dissection. (2) the procedure of laparoscopic operation is similar to that of minimally invasive McKeown. 3. Free cervical esophagus is free of the esophagus and the stomach is pulled out of the stomach through a small incision in the upper abdomen. In the cavity, a tubular stomach with a diameter about 5cm of about 5cm was made by a straight line cutting suture. The tube stomach was pulled to the left neck through the posterior mediastinum, and the end to side of the proximal esophagus was anastomosed with the common circular stapler of Johnson. Finally, the gastric remnant was closed with a linear cutting suture. A total of 112 patients were included in this study, of which 50 patients accepted the study. The minimally invasive esophagus carcinoma was excised by Ivor-Lewis, and 62 patients received minimally invasive esophageal cancer resection McKeown. The two groups were roughly the same in demography, pathological data, and complication. The average operation time of the two groups was 276.8+17.3 minutes vs.281.2 18.3 minutes respectively, (P0.05), and the two groups were 143.7 + 84.1ml vs.159.1 + 95, respectively. .1ml (P0.05); the average number of lymph node dissections in the two groups was 2.4 20.5+2.5 vx.21.5 men, respectively, (P0.05). Compared with the McKeown group of minimally invasive esophagectomy, the Nor-Lewis group of the minimally invasive esophagectomy in the Nor-Lewis group had such aspects as pulmonary complications (18%vs.37.1%), anastomotic fistula (6%vs.19.4%), anastomotic stenosis (8%vs.22.6%) and recurrent laryngeal nerve injury (6%vs.21.0%). Lower incidence (P0.05). There was no statistical difference between two groups in chylothorax (4%vs.8.1%), arrhythmia (6%vs.12.5%) and gastric emptying delay (10%vs.3.2%),.2 (4%) patients with minimally invasive esophagus resection in the Ivor-Lewis group and 3 (4.8%) patients with minimally invasive esophagus resection in the McKeown group because the chylothorax needed to be reoperated in.1 (2%) minimally invasive esophagus Patients with cancer resection Ivor-Lewis and 6 (9.7%) patients in group McKeown of minimally invasive esophagus cancer were transferred to ICU for severe postoperative complications. On average hospitalization days, two groups of patients were 23.5 + 9.5 days vs.27.6+11.3 days, and (P0.05).1 cases of minimally invasive esophagus cancer resection McKeown patients due to acute respiratory distress syndrome, 2 patients were caused by acute respiratory distress syndrome. Tracheoesophageal fistula died within 90 days after operation. 1 cases of minimally invasive esophagus carcinoma group Ivor-Lewis died of severe pulmonary infection within 90 days after operation. The mortality rate of 90 days in the two group was 2% and 4.8%., respectively. Conclusion the common circular stapler for minimally invasive esophagus cancer resection Ivor-lewis was better than McKeown. The incidence of fewer complications. A comparative study of the quality of life of patients with minimally invasive resection of the esophagus with Ivor Lewis and McKeown after McKeown. Background traditional Ivor Lewis and McKeown are the main surgical methods for the treatment of esophageal cancer, but the incidence and mortality of higher complications are accompanied by low quality of life. Complications to improve the quality of life of the patients, minimally invasive esophagectomy is increasingly used in the treatment of esophageal cancer. Previous studies have shown that minimally invasive esophagectomy can significantly reduce the incidence of respiratory complications and improve the patient's short-term quality of life compared with open surgery. However, a comparative study shows that the minimally invasive esophagus is a minimally invasive esophagectomy. Cervical anastomosis is still associated with higher anastomotic fistula, anastomotic stenosis and recurrent laryngeal nerve injury, and minimally invasive esophagectomy Ivor Lewis regenerates interest. There are a few reports about the perioperative data of the two surgical methods. However, the relationship between minimally invasive esophagectomy and Ivor Lewis and McKeown is the result of minimally invasive esophagectomy. The purpose of this study was to evaluate the effect of Ivor Lewis and McKeown on the short-term quality of life of the patients after middle and lower esophageal cancer resection. Methods from January 2013 to June 2015, minimally invasive esophagectomy was received in Department of thoracic surgery, Weifang People's Hospital, and McKeown 112 cases of esophageal cancer were included in this study. Minimally invasive Ivor Lewis included laparoscopic free stomach and two steps to form a tube stomach and a thoracoscopic resection of the esophagus and intrathoracic anastomosis. Minimally invasive McKeown included thoracoscopic esophagectomy, laparoscopic free stomach and neck anastomosis, three steps. The European continent cancer research and treatment organization (EORTC) was developed. Quality of life core scale QLQ-C30 (Chinese version 3) and esophageal cancer supplement QLQ-OES18 (Chinese version) were used to evaluate the quality of life. All the patients were examined before the operation, 2,4,12,24 weeks after the operation by oral, telephone or letter. In order to facilitate statistics and comparison, the original score of the investigation was converted to the QLQ-C30 manual. 0-100 points, the higher the functional index dimension and the overall health status dimension score, the better the function, the higher the quality of life; the higher the symptomatic dimension of QLQ-C30 and the higher the symptomatic indicator dimension of QLQ OES-18 esophageal cancer, the worse the symptoms and the worse the quality of life. The results were included in the study, of which 50 patients accepted the micro. 62 patients underwent minimally invasive esophageal cancer resection (Ivor-Lewis). The two groups were roughly the same in the demography, pathological data, and complication in the two group. The two groups had no significant differences in the operation time, the amount of blood loss, the number of lymph nodes, the average days of hospitalization, and so on. Compared with the minimally invasive McKeown The incidence of pulmonary complications (18%vs.37.1%), anastomotic fistula (6%vs.19.4%), anastomotic stenosis (8%vs.22.6%) and recurrent laryngeal nerve injury (6%vs.21.0%) was lower (P0.05). During the follow-up period, the feedback rate of the minimally invasive Ivor Lewis group was 94% (235/250), while the feedback rate of the minimally invasive McKeown group survey questionnaire was 94%. For 95.2% (295/310). The overall health status, physical function, eating difficulty, cough and speech were significantly different in the two groups of patients' postoperative quality of life assessment, but there were no significant differences in other items. The overall health status and body function scores of the two groups were rapidly reduced after the operation and then from the beginning of the 2 week after the operation. Slow improvement. The patients in the minimally invasive Ivor Lewis group recovered faster in the overall health and body function, and almost reached the preoperative level in the 12 weeks after the operation. The scores of the patients in the minimally invasive Ivor Lewis group increased rapidly after the operation, and then began to slow down at the left right 2 weeks after the operation. On the contrary, the minimally invasive McKeown group The scores of patients with difficulty in eating increased slightly after the operation and then slowed down slowly after 4 weeks. Conclusion the minimally invasive Ivor Lewis group was significantly better than the minimally invasive McKeown group in the short term overall health status, physical function, eating difficulties, cough and speech, but the two groups were in the other life quality. There was no significant difference in quantity items. In the long run, the quality of life of the two groups was gradually approaching.
【学位授予单位】：山东大学
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R735.1

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