摘要
目的手术是进展期食管胃结合部腺癌(AEG)的主要治疗方式。由于其特殊的解剖位置及独特的淋巴结回流方式,SiewertⅡ型AEG外科治疗方式存在争议,下纵隔淋巴结清扫是其中最主要的争议点之一,目前尚没有形成规范的手术方式。本文旨在介绍一种新的胸腔单孔辅助腹腔镜"五步法"下纵隔淋巴结清扫的手术技术,并分析其安全性和可行性。方法采用描述性病例系列研究方法。收集2019年1月至2021年4月期间,广东省中医院胃肠外科针对SiewertⅡ型食管胃结合部腺癌患者,完成的25例采用胸腔单孔辅助腹腔镜"五步法"下纵隔淋巴结清扫术的病例资料,进行术中及术后情况的回顾性分析。"五步法"操作步骤:第1步,显露心下囊,清扫右肺韧带淋巴结和胸主动脉前方淋巴结,头侧至心包下方,左侧至胸主动脉左侧缘;第2步,打开左侧膈肌,经左腋前线第6、7肋间隙置入12 mm Trocar,通过胸腔主操作孔清扫膈上淋巴结;第3步,离断左肺下韧带,切开胸主动脉前方筋膜,与第1步胸主动脉前间隙汇合,继续向头侧清扫至显露左肺下静脉;第4步,由腹侧向口侧逆行裸化心包后壁至左下肺静脉水平,向右至右侧胸膜,完整清扫No.112pulR(右肺韧带淋巴结);第5步:裸化食管,距肿瘤上方5 cm处使用切割闭合器离断食管,完成下胸部食管旁淋巴结清扫。结果25例患者均顺利完成手术,无中转开腹,无围手术期死亡。19例行全胃切除术,6例行近端胃切除术,术中出血量(90.4±44.2)ml,手术时间(268.7±85.6)min,下纵隔淋巴结清扫时间为(38.6±10.3)min,下纵隔淋巴结清扫数为(5.9±2.9)枚。肿瘤侵犯食管长度>2 cm者7例,≤2 cm者18例;25例患者中有8例(33.0%)出现下纵隔淋巴结转移,其中3例为肿瘤侵犯食管长度>2 cm者,5例为≤2 cm者。恢复全流饮食时间为术后(5.5±3.1)d。术后留置胸腔引流管的时间为(5.9±2.9)d。术后住院时间(9.7±3.1)d。2例(8.0%)患者出现Clavien-DindoⅢa级术后并发症,其中1例胰漏,1例为胸腔积液,均通过穿刺引流治愈。结论胸腔单孔辅助腹腔镜"五步法"下纵隔淋巴结清扫术治疗SiewertⅡ型AEG安全可行,可使下纵隔淋巴结清扫水平达到左肺下静脉。
Objective Surgical operation is the main treatment for advanced adenocarcinoma of esophagogastric junction(AEG).Due to its special anatomic location and unique lymph node reflux mode,the surgical treatment of Siewert II AEG is controversial.Lower mediastinal lymph node dissection is one of the most controversial points and a standard technique has not yet been established.This study is aim to explore the safety and feasibility of five-step maneuver of transthoracic single-port assisted laparoscopic lower mediastinal lymph node dissection for Siewert type II AEG.Methods A descriptive case series study was conducted.The intraoperative and postoperative data of 25 patients with Siewert type II AEG who underwent five-step maneuver of transthoracic single-port assisted laparoscopic lower mediastinal lymph node dissection in Guangdong Provincial Hospital of Traditional Chinese Medicine from January 2019 to April 2021 were retrospectively analyzed.Five-step maneuver was as follows:In the first step,the subcardiac sac was exposed;the right pulmonary ligament lymph nodes and the anterior thoracic paraaortic lymph nodes were dissected cranial to inferior pericardium,left to left edge of thoracic aorta.In the second step,the left diaphragm was opened,and a 12 mm trocar was placed through the 6-7 rib in the left anterior axillary line.The supra-diaphragmatic nodes were dissected through the thoracic operation hole.In the third step,the left inferior pulmonary ligament was severed.The anterior fascia of thoracic aorta was incised to join the anterior space of thoracic aorta formed in the first step and then the lymphatic tissue was dissected upward until the exposure of left inferior pulmonary vein.In the fourth step,the posterior pericardium was denuded retrogradely from ventral side to oral side to the level of left inferior pulmonary vein,right to right pleura,and then the right pulmonary ligament lymph nodes were completely removed.In the fifth step,the esophagus was denuded,and the esophagus was transected 5 cm above the tumor using a linear stapler to complete the dissection of lower thoracic paraesophageal lymph nodes.Results Operations were successfully completed in 25 patients without conversion,intra-operative complication and perioperative death.Total gastrectomy was performed in 19 cases and proximal gastrectomy in 6 cases.The mean operative time was(268.7±85.6)minutes,the mean estimated blood loss was(90.4±44.2)ml,the mean time of lower mediastinal lymph node dissection was(38.6±10.3)minutes,and the mean harvested number of lower mediastinal lymph node was 5.9±2.9.The length of esophageal invasion was>2 cm in 7 cases and≤2 cm in 18 cases.Eight patients(33.0%)had lower mediastinal lymph node metastasis,including 3 cases with esophageal invasion>2 cm and 5 cases with esophageal invasion≤2 cm.The mean time to postoperative first flatus was(5.5±3.1)days.The average time of postoperative thoracic drainage was(5.9±2.9)days.The mean hospital stay was(9.7±3.1)days.Two patients(8.0%)developed postoperative grade IIIa complications according to the Clavien-Dindo classification,including 1 case of pancreatic fistula and 1 case of pleural effusion,both of whom were cured by puncture drainage.Conclusions Five-step maneuver of transthoracic single-port assisted laparoscopic lower mediastinal lymph nodes dissection for Siewert type II AEG is safe and feasible.Which can ensure sufficient lower mediastinal lymph node dissection to the level of left inferior pulmonary vein.
作者
罗思静
熊文俊
陈妍
李峥宇
李恩
曾海平
郑燕生
罗立杰
李金
崔梓铭
万进
王伟
Luo Sijing;Xiong Wenjun;Chen Yan;Li Zhengyu;Li En;Zeng Haiping;Zheng Yansheng;Luo Lijie;Li Jin;Cui Ziming;Wan Jin;Wang Wei(The Second Clinical College,Guangzhou University of Traditional Chinese Medicine,Guangzhou 510405,China;Department of Gastrointestinal Surgery,Guangdong Hospital of Traditional Chinese Medicine,Guangzhou 510120,China;Department of Surgery,Taishan People's Hospital,Guangdong Taishan 529200,China;Department of Surgery,Meizhou People's Hospital,Guangdong Meizhou 514031,China)
出处
《中华胃肠外科杂志》
CSCD
北大核心
2021年第8期684-690,共7页
Chinese Journal of Gastrointestinal Surgery
基金
"双一流"与高水平大学学科协同创新团队立项课题(2021xk48)
广东省中医院院内专项(YN10101911)
广东省医学科学技术研究基金(A20211095)。
关键词
食管胃结合部腺癌
SiewertⅡ型
下纵隔淋巴结清扫
五步法
腹腔镜手术
Adenocarcinoma of the esophagogastric junction,Siewert type II
Lower mediastinal lymph node dissection,five-step maneuver
Laparoscopic surgery
作者简介
通信作者:王伟,Email:wangwei16400@163.com。
