Horikawa Manabu, Oshikiri Taro, Takiguchi Gosuke, Urakawa Naoki, Hasegawa Hiroshi, Yamamoto Masashi, Kanaji Shingo, Matsuda Yoshiko, Yamashita Kimihiro, Matsuda Takeru, Nakamura Tetsu, Suzuki Satoshi, Kakeji Yoshihiro
Division of Gastrointestinal Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan.
Division of Minimally Invasive Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan.
Surg Endosc. 2022 Apr;36(4):2680-2687. doi: 10.1007/s00464-021-08745-y. Epub 2021 Sep 27.
Retrosternal reconstruction is associated with a lower risk of mediastinitis, gastro-tracheal fistula, and hiatal hernia. Historically, traumatic manual creation of the retrosternal tunnel has been performed using one's fist. We report a novel and atraumatic laparoscopic procedure to create the retrosternal route.
We have laparoscopically created the retrosternal route in 25 thoracoscopic, mediastinoscopic, or robot-assisted minimally invasive esophagectomies since August 2019. Specifically, a peritoneal incision is started at the dorsal side of the xiphoid process. Through a 12-mm port inserted slightly to the right of and superior to the umbilical camera port, we dissect loose connective tissues from the caudal to the cranial side using behind the sternum and inside the internal thoracic vessels as landmarks. The time required to create the route was calculated. Then, the cumulative sum (CUSUM) method and the simple moving average of five cases were used to evaluate the learning curve of this novel procedure. Operative outcomes were analyzed according to the learning curve results and also compared with 25 cases of postmediastinal reconstruction counterparts.
Twenty-five patients were divided into the early group (six patients) and late group (19 patients) based on the peak of the CUSUM chart. The time required for route creation was 28.5 min (median) in the early and 15 min in the late group, indicating a significant difference (P = 0.038). The overall incidence of pleural injury was 20% (5 of 25 patients), with no significant difference between the groups. There was no significant difference in the incidence of perioperative complications. Also, there were no significant differences in perioperative complications or gastric conduit functions 1 year after surgery between the retrosternal and the postmediastinal reconstruction.
Laparoscopic creation of a retrosternal route for gastric conduit reconstruction is safe and feasible and has a short learning curve.
胸骨后重建与纵隔炎、胃气管瘘和食管裂孔疝的风险较低相关。历史上，胸骨后隧道的创伤性手动创建是用拳头进行的。我们报告一种新颖的、无创的腹腔镜手术来创建胸骨后路径。
自2019年8月以来，我们在25例胸腔镜、纵隔镜或机器人辅助的微创食管切除术中通过腹腔镜创建了胸骨后路径。具体而言，在剑突背侧开始做腹膜切口。通过一个插入到脐部摄像端口右侧稍上方的12毫米端口，我们以胸骨后和胸廓内血管内侧为标志，从尾侧向头侧解剖疏松结缔组织。计算创建路径所需的时间。然后，使用累积和（CUSUM）方法和五例的简单移动平均值来评估这一新颖手术的学习曲线。根据学习曲线结果分析手术结果，并与25例纵隔后重建的对应病例进行比较。
根据CUSUM图表的峰值，25例患者被分为早期组（6例患者）和晚期组（19例患者）。早期组创建路径所需时间为28.5分钟（中位数），晚期组为15分钟，差异有统计学意义（P = 0.038）。胸膜损伤的总体发生率为20%（25例患者中的5例），两组之间无显著差异。围手术期并发症的发生率无显著差异。此外，胸骨后重建和纵隔后重建术后1年的围手术期并发症或胃管道功能也无显著差异。
腹腔镜创建用于胃管道重建的胸骨后路径是安全可行的，且学习曲线短。
