Department of Surgery, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL 322246, USA.
Surg Endosc. 2011 Dec;25(12):3865-9. doi: 10.1007/s00464-011-1811-1. Epub 2011 Jun 24.
Transhiatal (two-field) esophagectomy reduces cardiopulmonary complications by avoiding thoracic access, but requires blind mediastinal dissection. The authors developed a minimally invasive esophagectomy (MIE) technique applying single-incision laparoscopy technology to better visualize the thoracic esophageal dissection. This is performed using laparoscopy and simultaneous transcervical videoscopic esophageal dissection (TVED). Our aim is to demonstrate feasibility of two-field MIE with TVED and improve recovery in high-risk patients.
We performed a retrospective cohort study of eight patients who underwent two-field MIE with TVED over 10 months. The majority were male (N = 6) with mean age of 63 ± 12 years. Mean body mass index (BMI) was 30.2 ± 5.1 kg/m(2). Indications for operation were: high-grade dysplasia (N = 2), adenocarcinoma (N = 6) with one receiving neoadjuvant chemoradiation. Using the Charlson comorbidity index, three patients were low risk and five were high risk. TVED was performed with a modified single-incision access device across the left neck. The mediastinal esophagus was dissected distally and circumferentially with simultaneous transabdominal laparoscopy for gastric conduit creation and distal esophageal dissection.
Mean operative time was 292 min (range 194-375 min). Three obese patients required temporary abdominal desufflation to avoid extrinsic mediastinal compression. Mean estimated blood loss was 119 mL (range 25-400 mL). A median of 23 lymph nodes (range 13-29) was harvested. Median intensive care unit (ICU) stay was 1 day (range 1-5 days), and median overall stay was 7 days (range 5-16 days). The three low-risk patients had no major complications. Three of five high-risk patients had major complications, including two cervical anastomotic leaks. Major complications were seen in three of four obese patients (BMI >30 kg/m(2)). There were no mortalities.
The TVED approach may avoid the morbidity of transthoracic esophageal dissection by improving esophageal visualization. Complications with TVED appear to correlate with obesity and comorbidities. Although TVED appears feasible, a larger experience is required.
经胸（两野）食管切除术通过避免开胸来减少心肺并发症，但需要进行盲目纵隔解剖。作者开发了一种微创食管切除术（MIE）技术，应用单切口腹腔镜技术更好地可视化胸段食管的解剖。这是通过腹腔镜和同时经颈腔镜食管解剖（TVED）来完成的。我们的目的是展示使用 TVED 进行两野 MIE 的可行性，并改善高危患者的康复情况。
我们对 10 个月内接受 TVED 两野 MIE 的 8 例患者进行了回顾性队列研究。大多数为男性（N=6），平均年龄为 63±12 岁。平均体重指数（BMI）为 30.2±5.1kg/m²。手术指征为：高级别异型增生（N=2）、腺癌（N=6），其中 1 例接受新辅助放化疗。使用 Charlson 合并症指数，3 例患者为低危，5 例为高危。TVED 通过改良的单切口进入装置在左侧颈部进行。用腹腔镜同时进行胃管的创建和远端食管的解剖，对纵隔食管进行远端和周向解剖。
平均手术时间为 292 分钟（范围 194-375 分钟）。3 例肥胖患者需要临时腹部放气以避免纵隔外压迫。平均估计出血量为 119ml（范围 25-400ml）。中位数采集 23 个淋巴结（范围 13-29 个）。中位数 ICU 住院时间为 1 天（范围 1-5 天），中位数总住院时间为 7 天（范围 5-16 天）。3 例低危患者无重大并发症。5 例高危患者中有 3 例发生重大并发症，包括 2 例颈部吻合口漏。3 例肥胖患者（BMI>30kg/m²）中有 4 例出现重大并发症。无死亡病例。
TVED 方法可通过改善食管可视化来避免经胸食管解剖的发病率。TVED 的并发症似乎与肥胖和合并症有关。尽管 TVED 似乎可行，但需要更多的经验。
