本文選題：胸腔鏡 + 腹腔鏡　； 參考：《山東大學(xué)》2016年博士論文

【摘要】：第一部分微創(chuàng)食管癌切除Ivor-Lewis術(shù)與McKeown術(shù)的近期療效比較研究背景一直以來,傳統(tǒng)的開胸食管癌切除Ivor-Lewis術(shù)與McKeown術(shù)是治療食管中下段癌的主要治療手術(shù)方式,然而,這些傳統(tǒng)的開胸食管癌切除手術(shù)的缺點(diǎn)是創(chuàng)傷大,術(shù)后并發(fā)癥的發(fā)生率和死亡率高。因此,微創(chuàng)食管切除手術(shù)越來越多的被用來治療胸中下段食管癌,大量的回顧性研究和少量的前瞻性研究顯示,微創(chuàng)食管癌切除手術(shù)能夠明顯改善傳統(tǒng)開胸手術(shù)的不足之處。然而,這些研究主要集中于微創(chuàng)手術(shù)與開胸手術(shù)的比較,有關(guān)微創(chuàng)Ivor-Lewis術(shù)與McKeown術(shù)之間的比較非常少見,涉及微創(chuàng)Ivor-Lewis術(shù)的報(bào)道多數(shù)是回顧性的經(jīng)驗(yàn)總結(jié),有些雖然病例數(shù)較多,但缺乏與微創(chuàng)McKeown術(shù)進(jìn)行比較研究；有少數(shù)與微創(chuàng)McKeown術(shù)的對照研究采用的是Orvil系統(tǒng)或直線切割縫合器進(jìn)行的胸內(nèi)吻合,頸部吻合時(shí)采用的是手工吻合,吻合方式缺乏一致性；對于頸部和胸內(nèi)吻合均應(yīng)用普通圓形吻合器進(jìn)行吻合的微創(chuàng)Ivor-Lewis術(shù)和McKeown術(shù)的比較非常罕見,其結(jié)果是否與上述的吻合方式一致仍需進(jìn)一步研究。目的本研究試圖從手術(shù)的一般結(jié)果、圍手術(shù)期的并發(fā)癥發(fā)生率和死亡率等方面對應(yīng)用普通圓形吻合器進(jìn)行微創(chuàng)食管癌切除Ivor-Lewis術(shù)和McKeown術(shù)的療效進(jìn)行比較。方法回顧性分析2013年1月至2015年6月間在濰坊市人民醫(yī)院胸外科接受微創(chuàng)食管癌切除Ivor-Lewis術(shù)與McKeown術(shù)的112例食管癌病人的臨床和手術(shù)資料,比較兩種手術(shù)病人的人口學(xué)特征、病理資料、手術(shù)方式、圍手術(shù)期資料。微創(chuàng)食管癌切除Ivor-Lewis術(shù)的手術(shù)步驟：①腹腔鏡游離胃,并清掃胃左動脈旁、腹腔干及肝總動脈旁淋巴結(jié)以及胃小彎側(cè)脂肪和淋巴結(jié)組織。②胸腔鏡游離胸段食管及腫瘤后清掃縱隔淋巴結(jié),在食管靠近胸頂處行手工荷包縫合,在右胸頂應(yīng)用強(qiáng)生普通圓形型吻合器完成食管-胃的端側(cè)吻合,胃小彎組織用Echelon60釘倉切除做成管胃。微創(chuàng)食管癌切除McKeown的手術(shù)步驟：①胸腔鏡游離胸段食管,并行系統(tǒng)性縱隔淋巴結(jié)清掃。②腹腔鏡操作步驟與微創(chuàng)McKeown術(shù)相似。③沿左頸部胸鎖乳突肌前緣開口游離頸部食管,經(jīng)上腹部小切口將充分游離的食管、胃拉出腹腔,以直線切割縫合器平行胃大彎制作成直徑約5cm左右的管型胃,經(jīng)后縱隔將管胃拉至左側(cè)頸部,用強(qiáng)生普通圓形吻合器與近端食管行端側(cè)吻合,最后用直線切割縫合器將胃殘端封閉。結(jié)果共有112個(gè)病人納入本研究,其中50個(gè)病人接受了微創(chuàng)食管癌切除Ivor-Lewis術(shù),62個(gè)病人接受了微創(chuàng)食管癌切除McKeown術(shù)。兩組病人在人口統(tǒng)計(jì)學(xué)、病理資料、合并癥等方面大致相同。兩組的平均手術(shù)時(shí)間分別為276.8+17.3分鐘vs.281.2士18.3分鐘,(P0.05)；兩組的失血量分別為143.7±84.1ml vs.159.1±95.1ml (P0.05);兩組的平均淋巴結(jié)清掃數(shù)目分別為20.5+2.5枚vx.21.5士2.4枚,(P0.05)。與微創(chuàng)食管癌切除McKeown組相比,微創(chuàng)食管癌切除Nor-Lewis組在肺部并發(fā)癥(18%vs.37.1%)、吻合口瘺(6%vs.19.4%)、吻合口狹窄(8%vs.22.6%)及喉返神經(jīng)損傷(6%vs.21.0%)等方面有更低的發(fā)生率(P0.05)。兩組間在乳糜胸(4%vs.8.1%)、心律失常(6%vs.12.5%)及胃排空延遲(10%vs.3.2%)等方面無統(tǒng)計(jì)學(xué)差異。2例(4%)微創(chuàng)食管癌切除Ivor-Lewis組的病人和3例(4.8%)微創(chuàng)食管癌切除McKeown組的病人因?yàn)槿槊有匦枰俅问中g(shù)。1例(2%)微創(chuàng)食管癌切除Ivor-Lewis組的病人和6例(9.7%)微創(chuàng)食管癌切除McKeown組的病人因?yàn)樾g(shù)后嚴(yán)重并發(fā)癥被轉(zhuǎn)入ICU繼續(xù)治療。在平均住院日方面,兩組病人分別為23.5±9.5天vs.27.6+11.3天,(P0.05)。1例微創(chuàng)食管癌切除McKeown組病人因急性呼吸窘迫綜合征、2例因氣管食管瘺在術(shù)后90天內(nèi)死亡,1例微創(chuàng)食管癌切除Ivor-Lewis組病人在術(shù)后90天內(nèi)死于嚴(yán)重的肺部感染, 兩組的90天死亡率分別為2%和4.8%。結(jié)論應(yīng)用普通圓形吻合器進(jìn)行微創(chuàng)食管癌切除Ivor-lewis術(shù)較McKeown術(shù)顯示出更好的圍手術(shù)期療效及更少的并發(fā)癥發(fā)生率。第二部分微創(chuàng)食管癌切除Ivor Lewis術(shù)與McKeown術(shù)后患者生活質(zhì)量評價(jià)的對照研究研究背景傳統(tǒng)的Ivor Lewis術(shù)與McKeown術(shù)是治療食管癌的主要手術(shù)方式,但卻伴隨較高并發(fā)癥發(fā)生率和死亡率,術(shù)后的生活質(zhì)量低下。為減少并發(fā)癥、提高病人的生活質(zhì)量,微創(chuàng)食管切除術(shù)越來越多被應(yīng)用于食管癌的治療。已有的研究顯示,微創(chuàng)食管切除術(shù)與開放手術(shù)相比能顯著降低呼吸道并發(fā)癥的發(fā)生率,從而提高病人的短期生活質(zhì)量。然而,有比較性的研究顯示,微創(chuàng)食管切除頸部吻合仍然伴隨較高的吻合口瘺、吻合口狹窄及喉返神經(jīng)損傷發(fā)生率,為此,微創(chuàng)食管切除Ivor Lewis術(shù)重新引起大家的興趣,有關(guān)兩種手術(shù)方式圍手術(shù)期資料的比較有少量報(bào)道。然而,有關(guān)微創(chuàng)食管切除Ivor Lewis術(shù)與McKeown術(shù)之間生活質(zhì)量評價(jià)的比較研究罕有報(bào)道。目的本研究的目的是評價(jià)微創(chuàng)食管癌切除Ivor Lewis術(shù)與McKeown術(shù)對中下段食管癌術(shù)后病人短期生活質(zhì)量的影響。方法2013年1月至2015年6月間在濰坊市人民醫(yī)院胸外科接受微創(chuàng)食管切除Ivor-Lewis術(shù)與McKeown術(shù)的112例食管癌病人納入本研究。微創(chuàng)Ivor Lewis術(shù)包括腹腔鏡游離胃并形成管胃和胸腔鏡切除食管并胸內(nèi)吻合兩個(gè)步驟。微創(chuàng)McKeown術(shù)包括胸腔鏡食管切除、腹腔鏡游離胃及頸部吻合三個(gè)步驟。采用歐洲癌癥研究與治療組織(EORTC)開發(fā)的生活質(zhì)量核心量表QLQ-C30(中文3.0版)和食管癌補(bǔ)充量表QLQ-OES18(中文版)進(jìn)行生活質(zhì)量評價(jià)。所有的病人分別在術(shù)前、術(shù)后2、4、12、24周通過口頭、電話或書信進(jìn)行調(diào)查問卷。為便于統(tǒng)計(jì)及比較,將調(diào)查所得的原始評分根據(jù)QLQ-C30評分手冊轉(zhuǎn)換為0-100分,功能性指標(biāo)維度及總體健康狀況維度評分越高說明功能越好、生活質(zhì)量越高；QLQ-C30癥狀性指標(biāo)維度及QLQ OES-18食管癌特有癥狀性指標(biāo)維度越高說明癥狀越重、生命質(zhì)量越差。結(jié)果共有112個(gè)病人納入本研究,其中50個(gè)病人接受了微創(chuàng)食管癌切除Ivor-Lewis術(shù),62個(gè)病人接受了微創(chuàng)食管癌切除McKeown術(shù)。兩組病人在人口統(tǒng)計(jì)學(xué)、病理資料、合并癥等方面大致相同。兩組病人在手術(shù)時(shí)間,失血量,淋巴結(jié)清掃數(shù)目,平均住院日等方面沒有明顯差異。與微創(chuàng)McKeown術(shù)相比,微創(chuàng)食管切除Ivor Lewis術(shù)肺部并發(fā)癥(18%vs.37.1%)、吻合口瘺(6%vs.19.4%)、吻合口狹窄(8%vs.22.6%)及喉返神經(jīng)損傷(6%vs.21.0%)等方面有更低的發(fā)生率(P0.05)。在隨訪期間,微創(chuàng)Ivor Lewis組調(diào)查問卷的反饋率為有94%(235/250),而在微創(chuàng)McKeown組調(diào)查問卷的反饋率為95.2%(295/310)。兩組病人術(shù)后生活質(zhì)量評價(jià)中的總體健康狀況、軀體功能、進(jìn)食困難、咳嗽及言語等五個(gè)方面具有明顯差異,然而其它的條目無明顯差異。兩組病人的總體健康狀況和軀體功能分?jǐn)?shù)都在手術(shù)后快速降低,然后從術(shù)后2周開始緩慢提高。微創(chuàng)Ivor Lewis組的病人在總體健康狀況和軀體功能方面的恢復(fù)更快,在術(shù)后12周左右?guī)缀踹_(dá)到術(shù)前水平。微創(chuàng)Ivor Lewis組的病人在進(jìn)食困難方面的分?jǐn)?shù)在手術(shù)后快速升高,然后在術(shù)后2周左右開始緩慢降低。相反地,微創(chuàng)McKeown組的病人在進(jìn)食困難方面的分?jǐn)?shù)在手術(shù)后略有升高,然后在4周后緩慢降低。結(jié)論微創(chuàng)Ivor Lewis組在術(shù)后短期內(nèi)的總體健康狀況、軀體功能、進(jìn)食困難、咳嗽及言語等生活質(zhì)量條目方面要明顯優(yōu)于微創(chuàng)McKeown組,但是兩組病人在其它的生活質(zhì)量條目方面未顯示出明顯不同,從長遠(yuǎn)來看,兩組的生活質(zhì)量有逐漸接近的趨勢。
[Abstract]:A comparative study of the short-term effect of Ivor-Lewis and McKeown in the first part of minimally invasive esophagectomy, the traditional surgical resection of esophagus carcinoma with Ivor-Lewis and McKeown is the main treatment for the middle and lower esophageal cancer. However, the shortcomings of these traditional surgical procedures are large trauma and postoperative complications. The incidence and mortality of the disease are high. Therefore, minimally invasive esophagectomy is becoming more and more used for the treatment of lower thoracic esophagus cancer. A large number of retrospective studies and a small number of prospective studies have shown that minimally invasive esophagectomy can significantly improve the shortcomings of traditional thoracotomy. However, these studies are mainly focused on minimally invasive surgery. Compared with open chest surgery, the comparison between minimally invasive Ivor-Lewis and McKeown is very rare. Most of the reports involving minimally invasive Ivor-Lewis are retrospective summary of experience. Although there are many cases, there is a lack of comparative study with minimally invasive McKeown, and a few comparative studies with minimally invasive McKeown are used in the Orvil system. The intrathoracic anastomosis performed by the traditional or linear cutting suture, the manual anastomosis and the lack of consistency during the neck anastomosis, and the comparison of the minimally invasive Ivor-Lewis and McKeown for the anastomosis of the neck and chest anastomoses with the common circular stapler are very rare, and the results are still in accordance with the same anastomosis. The purpose of this study is to compare the general results of the operation, the incidence of complications and mortality in the perioperative period, and to compare the efficacy of the common circular stapler for Ivor-Lewis and McKeown for minimally invasive esophagus carcinoma. Methods a retrospective analysis was made between January 2013 and June 2015 in the thoracic area of Weifang People's Hospital. The clinical and surgical data of 112 patients with esophageal cancer treated with minimally invasive esophagectomy with Ivor-Lewis and McKeown were compared. The demographic characteristics, pathological data, surgical methods, and perioperative data were compared in the two surgical patients. The procedure of Ivor-Lewis resection for minimally invasive esophagectomy was performed: (1) the laparoscopic free stomach, and the clearance of the left gastric artery, and the abdominal cavity The lymph nodes in the trunk and the hepatic para artery and the small bend side of the stomach and lymph nodes. 2. The thoracoscopic free thoracic esophagus and the tumor were swept through the mediastinal lymph nodes. The hand suture was sutured at the top of the esophagus. The end to side anastomosis of the esophagus and stomach was completed by the common circular stapler of Johnson on the right thoracic top, and the small bend tissue of the stomach was cut by Echelon60 nailing. In addition to the tube stomach. Minimally invasive esophagectomy for the resection of McKeown: (1) thoracoscopic free thoracic esophagus, parallel systematic mediastinal lymph node dissection. (2) the procedure of laparoscopic operation is similar to that of minimally invasive McKeown. 3. Free cervical esophagus is free of the esophagus and the stomach is pulled out of the stomach through a small incision in the upper abdomen. In the cavity, a tubular stomach with a diameter about 5cm of about 5cm was made by a straight line cutting suture. The tube stomach was pulled to the left neck through the posterior mediastinum, and the end to side of the proximal esophagus was anastomosed with the common circular stapler of Johnson. Finally, the gastric remnant was closed with a linear cutting suture. A total of 112 patients were included in this study, of which 50 patients accepted the study. The minimally invasive esophagus carcinoma was excised by Ivor-Lewis, and 62 patients received minimally invasive esophageal cancer resection McKeown. The two groups were roughly the same in demography, pathological data, and complication. The average operation time of the two groups was 276.8+17.3 minutes vs.281.2 18.3 minutes respectively, (P0.05), and the two groups were 143.7 + 84.1ml vs.159.1 + 95, respectively. .1ml (P0.05); the average number of lymph node dissections in the two groups was 2.4 20.5+2.5 vx.21.5 men, respectively, (P0.05). Compared with the McKeown group of minimally invasive esophagectomy, the Nor-Lewis group of the minimally invasive esophagectomy in the Nor-Lewis group had such aspects as pulmonary complications (18%vs.37.1%), anastomotic fistula (6%vs.19.4%), anastomotic stenosis (8%vs.22.6%) and recurrent laryngeal nerve injury (6%vs.21.0%). Lower incidence (P0.05). There was no statistical difference between two groups in chylothorax (4%vs.8.1%), arrhythmia (6%vs.12.5%) and gastric emptying delay (10%vs.3.2%),.2 (4%) patients with minimally invasive esophagus resection in the Ivor-Lewis group and 3 (4.8%) patients with minimally invasive esophagus resection in the McKeown group because the chylothorax needed to be reoperated in.1 (2%) minimally invasive esophagus Patients with cancer resection Ivor-Lewis and 6 (9.7%) patients in group McKeown of minimally invasive esophagus cancer were transferred to ICU for severe postoperative complications. On average hospitalization days, two groups of patients were 23.5 + 9.5 days vs.27.6+11.3 days, and (P0.05).1 cases of minimally invasive esophagus cancer resection McKeown patients due to acute respiratory distress syndrome, 2 patients were caused by acute respiratory distress syndrome. Tracheoesophageal fistula died within 90 days after operation. 1 cases of minimally invasive esophagus carcinoma group Ivor-Lewis died of severe pulmonary infection within 90 days after operation. The mortality rate of 90 days in the two group was 2% and 4.8%., respectively. Conclusion the common circular stapler for minimally invasive esophagus cancer resection Ivor-lewis was better than McKeown. The incidence of fewer complications. A comparative study of the quality of life of patients with minimally invasive resection of the esophagus with Ivor Lewis and McKeown after McKeown. Background traditional Ivor Lewis and McKeown are the main surgical methods for the treatment of esophageal cancer, but the incidence and mortality of higher complications are accompanied by low quality of life. Complications to improve the quality of life of the patients, minimally invasive esophagectomy is increasingly used in the treatment of esophageal cancer. Previous studies have shown that minimally invasive esophagectomy can significantly reduce the incidence of respiratory complications and improve the patient's short-term quality of life compared with open surgery. However, a comparative study shows that the minimally invasive esophagus is a minimally invasive esophagectomy. Cervical anastomosis is still associated with higher anastomotic fistula, anastomotic stenosis and recurrent laryngeal nerve injury, and minimally invasive esophagectomy Ivor Lewis regenerates interest. There are a few reports about the perioperative data of the two surgical methods. However, the relationship between minimally invasive esophagectomy and Ivor Lewis and McKeown is the result of minimally invasive esophagectomy. The purpose of this study was to evaluate the effect of Ivor Lewis and McKeown on the short-term quality of life of the patients after middle and lower esophageal cancer resection. Methods from January 2013 to June 2015, minimally invasive esophagectomy was received in Department of thoracic surgery, Weifang People's Hospital, and McKeown 112 cases of esophageal cancer were included in this study. Minimally invasive Ivor Lewis included laparoscopic free stomach and two steps to form a tube stomach and a thoracoscopic resection of the esophagus and intrathoracic anastomosis. Minimally invasive McKeown included thoracoscopic esophagectomy, laparoscopic free stomach and neck anastomosis, three steps. The European continent cancer research and treatment organization (EORTC) was developed. Quality of life core scale QLQ-C30 (Chinese version 3) and esophageal cancer supplement QLQ-OES18 (Chinese version) were used to evaluate the quality of life. All the patients were examined before the operation, 2,4,12,24 weeks after the operation by oral, telephone or letter. In order to facilitate statistics and comparison, the original score of the investigation was converted to the QLQ-C30 manual. 0-100 points, the higher the functional index dimension and the overall health status dimension score, the better the function, the higher the quality of life; the higher the symptomatic dimension of QLQ-C30 and the higher the symptomatic indicator dimension of QLQ OES-18 esophageal cancer, the worse the symptoms and the worse the quality of life. The results were included in the study, of which 50 patients accepted the micro. 62 patients underwent minimally invasive esophageal cancer resection (Ivor-Lewis). The two groups were roughly the same in the demography, pathological data, and complication in the two group. The two groups had no significant differences in the operation time, the amount of blood loss, the number of lymph nodes, the average days of hospitalization, and so on. Compared with the minimally invasive McKeown The incidence of pulmonary complications (18%vs.37.1%), anastomotic fistula (6%vs.19.4%), anastomotic stenosis (8%vs.22.6%) and recurrent laryngeal nerve injury (6%vs.21.0%) was lower (P0.05). During the follow-up period, the feedback rate of the minimally invasive Ivor Lewis group was 94% (235/250), while the feedback rate of the minimally invasive McKeown group survey questionnaire was 94%. For 95.2% (295/310). The overall health status, physical function, eating difficulty, cough and speech were significantly different in the two groups of patients' postoperative quality of life assessment, but there were no significant differences in other items. The overall health status and body function scores of the two groups were rapidly reduced after the operation and then from the beginning of the 2 week after the operation. Slow improvement. The patients in the minimally invasive Ivor Lewis group recovered faster in the overall health and body function, and almost reached the preoperative level in the 12 weeks after the operation. The scores of the patients in the minimally invasive Ivor Lewis group increased rapidly after the operation, and then began to slow down at the left right 2 weeks after the operation. On the contrary, the minimally invasive McKeown group The scores of patients with difficulty in eating increased slightly after the operation and then slowed down slowly after 4 weeks. Conclusion the minimally invasive Ivor Lewis group was significantly better than the minimally invasive McKeown group in the short term overall health status, physical function, eating difficulties, cough and speech, but the two groups were in the other life quality. There was no significant difference in quantity items. In the long run, the quality of life of the two groups was gradually approaching.
【學(xué)位授予單位】：山東大學(xué)
【學(xué)位級別】：博士
【學(xué)位授予年份】：2016
【分類號】：R735.1

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9 楊志剛,夏晉;術(shù)前CT檢查判斷食管癌切除可能性的臨床意義[J];中國煤炭工業(yè)醫(yī)學(xué)雜志;2004年01期

10 韓振國,辛華,王巖,楊斌;食管癌切除頸部食管胃側(cè)側(cè)吻合術(shù)[J];中華胸心血管外科雜志;2004年02期

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1 韓佳s，

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