Yu Lei, Wu Ji-Xiang, Gao Yu-Shun, Li Jian-Ye, Zhang Yun-Feng, Ke Ji
Department of Thoracic Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China.
Department of Surgery, Beijing Tongren Hospital, Capital Medical University, No. 1 Dongjiaominxiang Street, Dongcheng District, Beijing, 100730, China.
Surg Endosc. 2016 Jun;30(6):2382-9. doi: 10.1007/s00464-015-4488-z. Epub 2015 Sep 28.
Controversies on how to treat upper esophageal carcinoma have existed for several decades. With the application of minimally invasive techniques, surgical treatment to upper esophageal carcinoma tends to show more advantages and attract more patients. Up to now, most hospitals adopted the combined thoracoscopic and laparoscopic esophagectomy (CTLE) as the way of minimally invasive surgery for upper esophageal carcinoma. But CTLE to treat upper esophageal carcinoma has its drawbacks, such as demanding certain pulmonary function and severe postoperative regurgitation. In 2011, we developed the gasless laparoscopic transhiatal esophagectomy (LTE) to treat upper esophageal carcinoma, which showed some advantages. The aim of this article was to compare LTE with CTLE in treating upper thoracic or cervical esophageal carcinoma and assess the value of LTE.
From 2009 to 2014, esophagectomy has been performed by the introduction of minimally invasive surgery in a total of 83 patients with upper thoracic or cervical esophageal carcinoma. Among these patients, LTE was performed in 27 cases (Group 1), while CTLE was performed in the other 56 (Group 2). Neoadjuvant chemotherapy was done in patients of Group 1.
There were no operation-related deaths and conversion to open procedure. There was no significant difference in postoperative complications, ventilation time, ICU stay, hospital stay, and anastomotic leak rates between the two groups. But LTE was associated with shorter operative time and less intraoperative blood loss. In Group 2, 21 (37.5 %) patients had postoperative pulmonary complications, while in Group 1, there were 6 (22.2 %) patients having pulmonary complications at least one time. Results of 24-h pH monitoring and manometry showed that postoperative laryngo-pharyngeal reflux (PLPR) was more severe in Group 2 patients than in Group 1; for Group 1, PLPR mainly occurred on sleep stage, while for Group 2, PLPR might exist all the day with short intervals and last longer at night. The median overall survival was 27.2 months after CTLE and 30.8 months after LTE (P = 0.962). There was no significant difference in survival at 2, 3 and 4 years between the two groups.
Compared with CTLE, LTE is a more minimally invasive approach to effectively treat patients with upper esophageal carcinoma. Laryngo-pharyngeal reflux after LTE was less severe than that after CTLE, which might lower incidence of pulmonary complications. For the elderly patients, LTE seems more suitable.
关于如何治疗上段食管癌的争议已经存在了几十年。随着微创技术的应用，上段食管癌的手术治疗往往显示出更多优势，并吸引了更多患者。到目前为止，大多数医院采用胸腔镜联合腹腔镜食管癌切除术（CTLE）作为上段食管癌的微创手术方式。但CTLE治疗上段食管癌有其缺点，如对肺功能要求较高和术后严重反流。2011年，我们开展了非气腹腹腔镜经裂孔食管癌切除术（LTE）治疗上段食管癌，显示出一些优势。本文旨在比较LTE与CTLE治疗胸上段或颈段食管癌的效果，并评估LTE的价值。
2009年至2014年，共有83例胸上段或颈段食管癌患者接受了微创手术食管癌切除术。其中，27例患者接受了LTE（第1组），另外56例接受了CTLE（第2组）。第1组患者接受了新辅助化疗。
无手术相关死亡及中转开腹病例。两组术后并发症、通气时间、ICU停留时间、住院时间及吻合口漏发生率无显著差异。但LTE手术时间更短，术中出血量更少。第2组有21例（37.5%）患者发生术后肺部并发症，而第1组有6例（22.2%）患者至少发生过一次肺部并发症。24小时pH监测和测压结果显示，第2组患者术后喉咽反流（PLPR）比第1组更严重；第1组PLPR主要发生在睡眠阶段，而第2组PLPR可能全天存在，间隔时间短，夜间持续时间长。CTLE术后总生存期中位数为27.2个月，LTE术后为30.8个月（P = 0.962）。两组在2年、3年和4年生存率方面无显著差异。
与CTLE相比，LTE是一种更微创的方法，可有效治疗上段食管癌患者。LTE术后喉咽反流比CTLE术后轻，这可能降低肺部并发症的发生率。对于老年患者，LTE似乎更合适。
