Ninomiya Itasu, Okamoto Koichi, Tsukada Tomoya, Oyama Katsunobu, Kinoshita Jun, Makino Isamu, Miyashita Tomoharu, Tajima Hidehiro, Fushida Sachio, Ohta Tetsuo
Department of Gastroenterological Surgery, Kanazawa University , Kanazawa, Ishikawa, Japan .
J Laparoendosc Adv Surg Tech A. 2016 Sep;26(9):715-20. doi: 10.1089/lap.2016.0056. Epub 2016 Apr 19.
Esophagectomy and esophageal reconstruction with organs other than the gastric tube are complicated and difficult surgical procedures. We developed a new method of thoracoscopic esophagectomy with intrathoracic esophagojejunostomy in the upper mediastinum when the gastric tube cannot be used as an esophageal substitute for reconstruction.
Total gastrectomy, preparation of pedicled jejunal conduit, and transhiatal lower mediastinal dissection were done under laparotomy. Upper and middle mediastinal dissection was performed thoracoscopically. After esophageal transection with a linear stapler above the arch of the azygos vein, an anvil was inserted transorally. A circular stapler-inserted jejunal conduit was introduced to the upper mediastinum via the transhiatal route with relaparotomy. Esophagojejunostomy was completed by double stapling technique.
We completed this procedure for 10 consecutive cases without conversion to thoracotomy. The median operation time, amount of blood loss, duration of intrathoracic anastomosis, and number of dissected total and thoracic nodes was 741 (665-1019) minutes, 835 (380-2090) ml, 94.5 (70-211) minutes, and 59 (16-165) and 30 (10-54) nodes, respectively. There was no anastomotic leakage, conduit necrosis, or hospital mortality. Two cases showed delayed anastomotic stenosis. The median body weight loss 3 months after surgery was 13.9%. The overall 5-year survival rate was 90% (stage I, 100% and stage III, 83.3%).
Thoracoscopic esophagectomy with intrathoracic esophagojejunostomy is safe and curative. This operation can be performed as a minimally invasive surgical procedure for esophageal cancer patients in whom the stomach cannot be used as a reconstruction conduit.
食管切除术及使用胃管以外的器官进行食管重建是复杂且难度较大的外科手术。当胃管不能用作食管替代物进行重建时，我们开发了一种在上纵隔进行胸腔镜食管切除术并胸腔内食管空肠吻合术的新方法。
在开腹手术下进行全胃切除术、带蒂空肠导管制备及经裂孔下纵隔解剖。胸腔镜下进行上纵隔和中纵隔解剖。在奇静脉弓上方用直线切割缝合器离断食管后，经口插入吻合器砧座。经裂孔途径并再次开腹将插入圆形吻合器的空肠导管引入上纵隔。通过双吻合器技术完成食管空肠吻合。
我们连续为10例患者完成了该手术，均未中转开胸。中位手术时间、失血量、胸腔内吻合持续时间、清扫的总淋巴结和胸段淋巴结数量分别为741（665 - 1019）分钟、835（380 - 2090）毫升、94.5（70 - 211）分钟，以及59（16 - 165）枚和30（10 - 54）枚。无吻合口漏、导管坏死或住院死亡情况。2例出现吻合口延迟狭窄。术后3个月中位体重减轻13.9%。总体5年生存率为90%（I期，100%；III期，83.3%）。
胸腔镜食管切除术并胸腔内食管空肠吻合术安全且具有根治性。对于不能使用胃作为重建管道的食管癌患者，该手术可作为一种微创手术进行。
