Bussières Jean S
Laval University, Anesthesiologist, University Heart and Lung Institute, Laval Hospital, Quebec City, P.Q., G1V 4G5, Canada.
Curr Opin Anaesthesiol. 2009 Feb;22(1):56-60. doi: 10.1097/ACO.0b013e32831cef4b.
Since the beginning of the 1990s, the use of minimally invasive esophagectomy instead of the open technique has increased. Should this type of approach change the way we manage anesthesia for a patient undergoing esophagectomy for cancer?
Because valid direct comparisons with open surgery are lacking, one cannot make definitive statements regarding the potential benefits of minimally invasive surgery. Rough comparisons with recent reports on open surgery suggest that reduced mortality, respiratory complications and blood loss, plus a more rapid return to a good quality of life are areas in which minimally invasive surgery might prove superior. Leak rates were similar to those reported with open procedures. Surprisingly, length of hospital stay and overall morbidity are similar with both techniques. Reported operating times appear longer than one might expect for open operations, which mirrors the experience of laparoscopic procedures in other areas.
The implantation of minimally invasive esophagectomy seems inevitable in spite of the absence of randomized, controlled trials. The use of the prone position with one lung ventilation during minimally invasive esophagectomy seems positive. Protective ventilation during one lung ventilation may help to prevent pulmonary complications. Finally, the well accepted use of thoracic epidural anesthesia now has a new positive role following esophagectomy, improving the perfusion at the anastomotic level.
自20世纪90年代初以来，微创食管切除术的应用取代开放技术的情况有所增加。这种手术方式是否应该改变我们对接受食管癌切除术患者的麻醉管理方式？
由于缺乏与开放手术的有效直接比较，无法就微创手术的潜在益处做出明确表述。与近期开放手术报告的粗略比较表明，降低死亡率、减少呼吸并发症和失血，以及更快恢复到良好生活质量是微创手术可能更具优势的方面。吻合口漏发生率与开放手术报告的相似。令人惊讶的是，两种技术的住院时间和总体发病率相似。报告的手术时间似乎比开放手术预期的要长，这与其他领域腹腔镜手术的经验相符。
尽管缺乏随机对照试验，但微创食管切除术的应用似乎不可避免。微创食管切除术期间采用俯卧位单肺通气似乎有积极作用。单肺通气期间的保护性通气可能有助于预防肺部并发症。最后，目前广泛应用的胸段硬膜外麻醉在食管切除术后有了新的积极作用，可改善吻合口水平的灌注。
