Gillinov A M, Heitmiller R F
Division of Thoracic Surgery, Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA.
Dis Esophagus. 2017 Nov 1;11(1):43-47. doi: 10.1093/dote/11.1.43.
By eliminating a thoracotomy, transhiatal esophagectomy (THE) is purported to reduce postoperative pulmonary complications. However, data from many early series do not support this contention, documenting pulmonary complications in up to 50% of patients and pneumonia in 5%-20%. Since 1990, we have implemented a management strategy designed to maximize airway protection in the postoperative period. The purpose of this study was to determine the current incidence of pulmonary complications after transhiatal esophagectomy without thoracotomy.
From 1990 to 1995, 101 consecutive patients underwent THE. Surgical indications were esophageal carcinoma (90 patients) and Barrett mucosa with high-grade epithelial dysplasia (11 patients). Mean age was 60.2 ± 1.2 years; 89 patients were male. Eighty-two patients were smokers and 26 had chronic obstructive pulmonary disease (COPD). Sixty-five patients were American Society of Anesthesiologists risk score 3 or 4. Postoperatively, all patients were managed according to a standardized clinical pathway that included overnight mechanical ventilation, chest physiotherapy, video pharyngo-esophagram postoperative day 6 or 7, and graduated post-esophagectomy therapeutic diet after acceptable esophagram.
Pulmonary complications were classified as major or minor depending upon whether or not a change in therapy was required. Ten patients (10%) had 11 major pulmonary complications. These included pneumonia (3), pleural effusion requiring drainage (4), exacerbation of COPD (2), and mucus plug requiring bronchoscopy or intubation (2). Minor pulmonary complications identified by chest film were atelectasis (97), pleural effusion (85), and pneumothorax (3). Patients with major pulmonary complications were older (69.3 ± 9.8 vs. 59.2 ± 12.1 years, p < .02) and more likely to have COPD (70% vs. 21%, p < .005) than those with only minor complications. There were 3 operative deaths; 2 caused by pneumonia and 1 by fungal sepsis in a patient who had exacerbation of COPD. Mean hospital length of stay was 13.1 ± 1.4 days.
Minor pulmonary complications identified by chest film occur in nearly all patients undergoing THE. Strict adherence to a management protocol designed to maximize airway protection in the postoperative period results in a 10% incidence of major pulmonary complications. Older patient age and COPD are risk factors for major pulmonary complications after THE. Although pneumonia is uncommon, it remains the most frequent cause of death after THE.
经裂孔食管切除术（THE）通过避免开胸手术，据称可减少术后肺部并发症。然而，许多早期系列研究的数据并不支持这一观点，报告显示高达50%的患者出现肺部并发症，5% - 20%的患者发生肺炎。自1990年以来，我们实施了一种管理策略，旨在最大限度地保护术后气道。本研究的目的是确定非开胸经裂孔食管切除术后肺部并发症的当前发生率。
1990年至1995年，连续101例患者接受了THE手术。手术指征为食管癌（90例）和伴有高级别上皮发育异常的巴雷特黏膜（11例）。平均年龄为60.2±1.2岁；89例为男性。82例患者吸烟，26例患有慢性阻塞性肺疾病（COPD）。65例患者美国麻醉医师协会风险评分为3或4级。术后，所有患者均按照标准化临床路径进行管理，包括过夜机械通气、胸部物理治疗、术后第6或7天进行视频咽喉食管造影，以及在食管造影结果满意后逐步进行食管切除术后治疗性饮食。
根据是否需要改变治疗方案，将肺部并发症分为严重或轻微。10例患者（10%）出现11例严重肺部并发症。其中包括肺炎（3例）、需要引流的胸腔积液（4例）、COPD加重（2例）以及需要支气管镜检查或插管的黏液栓（2例）。胸部X线片发现的轻微肺部并发症包括肺不张（97例）、胸腔积液（85例）和气胸（3例）。与仅有轻微并发症的患者相比，发生严重肺部并发症的患者年龄更大（69.3±9.8岁对59.2±12.1岁，p<.02），且更有可能患有COPD（70%对21%，p<.005）。有3例手术死亡；2例因肺炎死亡，1例因COPD加重患者发生真菌败血症死亡。平均住院时间为13.1±1.4天。
几乎所有接受THE手术的患者都会出现胸部X线片显示的轻微肺部并发症。严格遵循旨在最大限度保护术后气道的管理方案，严重肺部并发症的发生率为10%。患者年龄较大和患有COPD是THE术后发生严重肺部并发症的危险因素。虽然肺炎并不常见，但它仍然是THE术后最常见的死亡原因。
