Messenger David E, Higgs Simon M, Dwerryhouse Simon J, Hewin David F, Vipond Mark N, Barr Hugh, Wadley Martin S
Department of General Surgery, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK,
Surg Endosc. 2015 Feb;29(2):417-24. doi: 10.1007/s00464-014-3689-1. Epub 2014 Jul 10.
The uptake of minimally invasive oesophagectomy (MIO) in the UK has increased dramatically in recent years. Post-oesophagectomy diaphragmatic hernias (PODHs) are rare, but may be influenced by the type of approach to resection. The aim of this study was to compare the incidence of symptomatic PODH following open and MIO in a UK specialist centre.
Consecutive patients undergoing oesophagectomy for malignant disease between 1996 and 2012 were included. A standardised, radical approach to the abdominal phase was employed, irrespective of the type of procedure undertaken. Patient demographics, details of surgery and post-operative complications were collected from patient records and a prospective database.
A total of 273 oesophagectomies were performed (205 open; 68 MIO). There were 62 hybrid MIOs (laparoscopic abdomen and thoracotomy) and six total MIOs. Seven patients required conversion and were analysed as part of the open cohort. Nine patients (13.2 %) developed a PODH in the MIO cohort compared with two patients (1.0 %) in the open cohort, (p < 0.001). Five patients developed hernias in the early post-operative period (days 2-10): all following MIO. Both PODHs in the open cohort occurred following transhiatal oesophagectomy. All PODHs were symptomatic and required surgical repair. CT thorax confirmed the diagnosis in 10 patients. Seven hernias were repaired laparoscopically, including two cases in the early post-operative period. PODHs were repaired using the following techniques: suture (n = 6), mesh reinforcement (n = 4) and omentopexy to the anterior abdominal wall without hiatal closure (n = 1). There were two recurrences (18 %).
The incidence of symptomatic PODH may be higher following MIO compared to open surgery. The reasons for this are unclear and may not be completely explained by the reduction in adhesion formation. Strategies such as fixation of the conduit to the diaphragm and omentopexy to the abdominal wall may reduce the incidence of herniation.
近年来，英国微创食管切除术（MIO）的采用率大幅上升。食管切除术后膈疝（PODH）较为罕见，但可能受切除方法类型的影响。本研究的目的是比较英国一家专科中心开放手术和MIO术后有症状PODH的发生率。
纳入1996年至2012年间因恶性疾病接受食管切除术的连续患者。无论采用何种手术方式，腹部阶段均采用标准化的根治性方法。从患者记录和前瞻性数据库中收集患者人口统计学资料、手术细节和术后并发症。
共进行了273例食管切除术（205例开放手术；68例MIO）。其中有62例混合MIO（腹腔镜腹部和开胸手术）和6例全MIO。7例患者需要中转手术，并作为开放手术队列的一部分进行分析。MIO队列中有9例患者（13.2%）发生了PODH，而开放手术队列中有2例患者（1.0%）发生了PODH，（p<0.001）。5例患者在术后早期（第2 - 1天）发生疝：均为MIO术后。开放手术队列中的2例PODH均发生在经裂孔食管切除术后。所有PODH均有症状，需要手术修复。胸部CT确诊10例患者。7例疝通过腹腔镜修复，包括2例术后早期病例。PODH采用以下技术修复：缝合（n = 6）、补片加强（n = 4）和大网膜固定于前腹壁而不关闭裂孔（n = 1）。有2例复发（18%）。
与开放手术相比，MIO术后有症状PODH的发生率可能更高。其原因尚不清楚，粘连形成减少可能无法完全解释这一现象。诸如将管道固定于膈肌和大网膜固定于腹壁等策略可能会降低疝形成的发生率。
