微创Ivor-Lewis食管切除术与传统左开胸手术治疗SiewertⅠ型食管胃交界部腺癌的对比研究

微创Ivor-Lewis食管切除术与传统左开胸手术治疗SiewertⅠ型食管胃交界部腺癌的对比研究

李建

四川省泸州市合江县人民医院  四川合江  646200

【摘要】目的：对比研究微创Ivor-Lewis食管切除术与传统左开胸手术治疗SiewertⅠ型食管胃交界部腺癌（AEG）的临床效果。方法：选入我院2019年1月~2022年1月收治的SiewertⅠ型AEG患者94例，根据手术方式不同分为微创组（微创Ivor-Lewis食管切除术）和开放组（传统左开胸手术），每组47例。评价两组的治疗效果、术后并发症等指标，并进行统计比较。结果：微创组术中出血量、胸腔引流时间、术后肛门排气时间、术后进流食时间及术后住院时间显著低于开放组（P＜0.05），手术时间和淋巴结清扫总数明显高于开放组（P＜0.05）；微创组切口感染率和肺部感染率明显低于开放组（P＜0.05）。结论：对于SiewertⅠ型AEG，微创Ivor-Lewis食管切除术虽然比传统左开胸手术操作时间长，但淋巴结清扫效果好、术中出血少、术后恢复快，且并发症少。

【关键词】微创Ivor-Lewis食管切除术；传统左开胸手术；食管胃交界部腺癌；SiewertⅠ型；疗效

A comparative study of minimally invasive Ivor Lewis esophagectomy and traditional left thoracotomy in the treatment of Siewert Ⅰtype esophageal gastric junction adenocarcinoma

[Abstract] Objective:To compare the clinical effects of minimally invasive Ivor Lewis esophagectomy and traditional left thoracotomy in the treatment of Siewert type I esophageal gastric junction adenocarcinoma (AEG).Methods:94 patients with Siewert type I AEG admitted to our hospital from January 2019 to January 2022 were pided into minimally invasive group (minimally invasive Ivor Lewis esophagectomy) and open group (traditional left thoracotomy) according to different surgical methods, with 47 patients in each group. The therapeutic effect and postoperative complications of the two groups were evaluated and compared statistically.Results:The amount of bleeding during operation, the time of thoracic drainage, the time of anal exhaust, the time of feeding and hospitalization after operation in the minimally invasive group were significantly lower than those in the open group (P; The wound infection rate and lung infection rate in the minimally invasive group were significantly lower than those in the open group (P<0.05).Conclusion:For Siewert type I AEG, although minimally invasive Ivor Lewis esophagectomy takes longer than traditional left thoracotomy, it has good lymph node dissection effect, less intraoperative bleeding, faster postoperative recovery, and fewer complications.

[Keywords]:

Minimally invasive Ivor Lewis esophagectomy; Traditional left thoracotomy; Adenocarcinoma at the junction of esophagus and stomach; Siewert I type; Curative effect

食管胃交界部腺癌（adenocarcinoma of esophagogastric junction，AEG）是指横跨食管远端和胃近端贲门交界处区域的腺癌性病变[1]，根据Siewert分型（即肿瘤中心所处位置不同）分为Siewert Ⅰ型、Ⅱ型、Ⅲ型3种类型。SiewertⅠ型AEG是发生于远端食管的腺癌，位于齿状线上1~5cm，对于该类型癌，手术及治疗均与食管下段癌类似。近年来，随着外科技术及腔镜微创器械的发展，胸、腹腔镜联合微创Ivor-Lewis食管切除术以创伤小、术后恢复快等优势被越来越多的用于AEG的临床治疗[2]，但关于该手术的安全性和治疗恶性肿瘤的彻底性仍存在争议。鉴于此，本研究对比了微创Ivor-Lewis食管切除术与传统左开胸手术治疗SiewertⅠ型AEG的临床效果，以期为临床治疗提供参考，现报告如下。

1 资料和方法

1.1 一般资料

选入我院2019年1月~2022年1月收治的SiewertⅠ型AEG患者94例，根据手术方式不同分为微创组和开放组，每组47例。微创组中，男36例，女11例；年龄42~78岁，平均年龄（63.18±8.61）岁；肿瘤长度1.5~6cm，平均（3.64±1.31）cm；肿瘤分化程度：低分化23例，中分化15例，高分化9例；TNM分期：Ⅰ期8例，Ⅱ期26例，Ⅲ期13例。开放组中，男37例，女10例；年龄39~77岁，平均年龄（63.05±9.17）岁；肿瘤长度2~6cm，平均（3.58±1.22）cm；肿瘤分化程度：低分化24例，中分化13例，高分化10例；TNM分期：Ⅰ期9例，Ⅱ期24例，Ⅲ期14例。两组一般资料比较，P＞0.05，具有可比性。

1.2 纳入及排除标准

纳入标准：（1）经CT、胃镜、病理活检等诊断为SiewertⅠ型AEG；（2）术前检查未见明显肿瘤侵犯周围组织及远处转移；（3）非复发AEG；（4）行微创Ivor-Lewis食管切除术或左开胸手术治疗；（5）ASA分级Ⅰ~Ⅱ级；（6）既往无食管及胃部手术史，且入组前未接受任何抗癌症治疗；（7）病历资料完整，且对本研究内容知情同意。

排除标准：（1）Siewert Ⅱ型或Ⅲ型AEG，或已发生远处转移或与周围组织广泛浸润而无法进行手术者；（2）有胸腹部手术史、其他恶性肿瘤病史或已接收放化疗、中药治疗、免疫治疗等抗肿瘤治疗；（3）胸腔或腹腔粘连致密需开放手术，或因消化道出血、梗阻等肿瘤并发症行急诊手术；（4）病历资料不全、依从性差等影响疗效判定者。

1.3 治疗方法

1.3.1 术前准备

血液常规检查、食管钡餐造影检查、电子胃镜、心电图、胸腹部影像学检查等，明确病变情况，排除手术禁忌；术前1d行肠道准备，予温盐水冲洗胃和食管，禁食、禁饮12h；均采用双腔气管插管（左主支气管置管，单肺通气、右肺塌陷）+静脉复合全身麻醉。

1.3.2 手术操作

微创组：采用微创Ivor-Lewis食管切除术治疗，即采用胸腹腔镜下右胸和上腹部二切口行食管切除、食管-胃右胸内吻合术治疗，具体操作：（1）平卧位行腹腔镜操作，腹部5个Trocar呈“V”字形放置，根据《腹腔镜胃癌手术操作指南》游离胃和清扫腹腔淋巴结。胃小弯侧距离胃角切迹4cm，以直线切割闭合器制作宽度3~5cm管状胃，保持食管与管状胃的连接，保留部位为胃小囊，为胸部吻合创造条件；适当打开食管裂孔，清扫腹段食管及食管裂孔周围淋巴组织；（2）改左侧卧位行胸腔镜手术：右胸4孔法，分别为位于腋后线第6肋间（5~6cm）的主操作孔，位于腋中线第7肋间（1cm）、腋前线第4肋间（1cm）和肩胛前缘第5肋间（1cm）的辅助操作孔，左肺通气，制造人工气胸；常规游离食管至安全距离（距离食管近端病变3cm以上），根据实际情况清扫胸段、食管周围、支气管淋巴结；在胸腔内离断食管，置入钉砧，利用保留的胃小囊置入吻合器，完成胸内食管和胃的端侧吻合，并用3-0可吸收线全层加固残胃闭合口及吻合口6针，并行食管胃套叠减少术后反酸。置入胃管及十二指肠营养管，置胸腔引流后逐层关胸、关腹。

开放组：采用传统左开胸Sweet手术，患者取右侧卧位，经左胸第7肋间做15~20cm斜切口，松解下肺韧带，游离食管到主动脉弓，清扫胸腔淋巴结，打开膈肌，分离腹段食管，游离胃大小弯，并清扫腹腔各站淋巴结，制作管胃，后续操作同微创组。                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  

1.3.3 术后处理

术后密切监测生命体征，并积极行抗感染、补液、维持水、电解质及酸碱平衡等对症支持治疗；术后2d开始肠内营养支持，术后7d食管造影未无异常后可开始经口进食流食，并逐步向正常饮食过度。

1.4 观察指标

观察记录两组的手术时间、术中出血量、淋巴结清扫总数、胸腔引流时间、术后肛门排气时间、术后进流食时间及术后住院时间，同时予以3个月的随访，统计术后并发症情况。

1.5 统计学方法

建立Excel数据库，采用SPSS 21.0统计软件分析、处理；对计量资料进行t检验，计数资料采用χ2检验，P<0.05表示差异有统计学意义。

2 结果

2.1 两组围术期情况比较

微创组术中出血量、胸腔引流时间、术后肛门排气时间、术后进流食时间及术后住院时间显著低于开放组（P＜0.05），手术时间和淋巴结清扫总数明显高于开放组（P＜0.05），具体见表1所示。

表1 两组围术期情况比较（x—±s）

2.2 两组并发症情况比较

微创组切口感染率和肺部感染率明显低于开放组（P＜0.05），见表2。

表2 两组并发症情况比较[n(%)]

3 讨论

AEG是消化道常见恶性肿瘤，具有发病率日益增加、解剖位置及肿瘤生物学特殊、预后不佳等特性。由于AEG跨越不同解剖部位，其诊断和治疗一直是困扰腹部外科和胸外科医师的共同难点。由于SiewertⅠ型AEG与食管癌的肿瘤生物学行为及淋巴转移方式类似，其外科治疗争议较II/III 型少，普遍认为应行食管次全切除联合近端胃切除[3]。传统的左开胸手术安全成熟，但在右胸及腹腔淋巴结清扫方面，劣势明显，并可出现扩大切口、肋骨骨折等不良情况[4]。经右胸和上腹正中切口术（Ivor-Lewis）可实现肿瘤的整块切除和完全二野淋巴结清扫，但需胸腹两切口，创伤大、术中出血多。随着外科技术及腔镜微创器械的发展，胸、腹腔镜联合微创Ivor-Lewis食管切除术应运而生，并较传统开放手术表现出巨大的优势。

本研究对比了微创Ivor-Lewis食管切除术与传统左开胸手术在SiewertⅠ型AEG中的治疗效果，结果显示：微创组术中出血量、胸腔引流时间、术后肛门排气时间、术后进流食时间及术后住院时间显著低于开放组（P＜0.05），切口感染率和肺部感染率亦明显低于开放组（P＜0.05），而手术时间和淋巴结清扫总数明显高于开放组（P＜0.05）。究其原因：（1）胸腹腔镜的放大作用使得解剖更加精细，游离食管和胃更方便，能够减少不必要的组织损伤和出血，有利于术后恢复；且手术切口小，大大减少了术区暴露，避免了肺部感染及切口感染的发生几率；（2）Ivor-Lewis 术经右胸入路，有效避开主动脉弓遮挡，便于游离在主动脉弓后的病灶及被侵犯的有关结构，利于提高肿瘤切除的彻底性[5]；（3）微创组手术时间较开放组长，考虑与微创Ivor-Lewis食管切除术需较多器械、术中体位变动、二次消毒有关。

综上所述，与传统左开胸手术相比，微创Ivor-Lewis食管切除术在提高SiewertⅠ型AEG淋巴清扫效果、减少术中出血及术后并发症、促进术后恢复方面更具优势。但其后者操作时间较长，笔者认为这种差距会随着微创术式的不断优化、操作技术的不断熟练而越来越小。

参考文献

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[4] 张连福, 陈明会. Ivor-Lewis手术用于Siewert Ⅱ型食管胃结合部腺癌的疗效及对淋巴结清扫和术后并发症的影响[J]. 中国临床研究, 2019, 32(1): 71-74.

[5] 赵康超, 李国雷, 徐志峰, 等. 微创Ivor-Lewis食管切除术与传统左开胸手术治疗SiewertⅠ型食管胃交界部腺癌的对比研究[J].中国微创外科, 2021, 21(1): 9-12.