【作者】 田界勇；

【导师】 魏大中；

【作者基本信息】 安徽医科大学 ， 外科学， 2008， 硕士

【摘要】 目的观察右胸及上腹两切口术式与左径胸术式治疗食管中段癌的近远期疗效,探讨右胸及上腹两切口术式在食管中段癌手术中的临床应用价值。方法回顾性分析2003年2月至2006年2月共320例食管中段癌手术患者的临床资料,其中214例采用右胸及上腹两切口径路,106例采用左胸径路(左经胸一切口主动脉弓上吻合或左胸及左颈两切口颈部吻合),所有病例采用胃作为食管替代物,术后病理类型均为鳞状细胞癌。总结患者临床及病理学特点,比较两组病例在手术时间、术中出血量、住院时间、清扫淋巴结数目、术后并发症发生率及术后1,2,3年生存率上的差异并进行分析。数据处理采用SPSS13.0统计软件包,计量资料采用独立样本t检验,计数资料采用χ2检验或Fisher’s确切概率检验,生存率计算采用Kaplan-Meier法,生存比较采用log-rank检验,P值小于0.05为差异有显著性意义。结果两组病例临床病理学特点及分期差异无显著性。右胸及上腹两切口径路较左胸径路手术时间延长(5.5±2.0小时和4.5±1.2小时)(P<0.01);术中出血量、住院时间差异无显著性;淋巴结清扫总数更多(32±5个19±7个)(P<0.01),总的转移率42.5%,其中纵隔淋巴结数(19±6个和11±5个) (P<0.01)、腹部淋巴结数(13±4个和8±4个) (P<0.01),差异均有显著性;吻合口瘘、吻合口狭窄及喉返神经损伤发生率低分别为(0.5%和4.7%、1.4%和7.6%、0%和5.7%)(P<0.01),其它并发症比较差异无显著性。右胸及上腹两切口径路和左胸径路术后1年、2年、3年生存率比较,分别为(92.4%、73.1%、64.2%和90.5%、67.2%、53.2% ) (χ2=12.991 P=0.00);N0患者的术后3年生存率分别为68.2%和50.4% (χ2=4.199 P=0.04);N1患者的术后3年生存率分别为60.3%和40.63%(χ2=43.921 P=0.00);差异均具有显著性。结论右胸及上腹两切口术式治疗食管中段癌与左径胸术式比较具有术野暴露好,癌肿切除及淋巴结清扫彻底,易于实现食管次全切除,食管、胃吻合确切可靠,保证吻合口无张力,吻合口瘘、吻合口狭窄、喉返神经损伤等并发症发生率低,术后生活质量较高,远期效果较好,是目前食管中段癌根治较理想的术式。更多还原

【Abstract】 Objective To compare the short-term or long-term effect of right thoracal upper abdominal double incisions and left chest incision in the treatment of mid-esophageal cancer, and to investigate the advantage and clinical application of right thoracal and upper abdominal double incisions in the treatment of mid-esophageal cancer.Method Retrospective analysis the clinical data of 320 cases of mid-esophageal cancer from February 2003 to February 2006, of which 214 cases were used right thoracal upper abdominal double incisions approach, 106 cases were used one left chest incision (the anastomosis on the thoracic aortic arch through left thorax or the anastomosis of two incisions of left thorax and left neck on the neck), all cases’esophageal used stomach as a substitute, the pathological types are squamous cell carcinoma. Summing up the clinical and pathological features, comparing the operative time, blood loss volume, duration of hospitalization, the number of lymph node dissection, and the incidence of postoperative complications, and survival rate after operation 1, 2, 3-year between two groups patients. SPSS13.0 software package was used for statistical data processing. Measurement data using independent sample t-test, count information was usedχ2 test or Fisher’s exact probability test. Survival rate was calculated using Kaplan-Meier method, Comparison of survival rate by log-rank test. P value of less than 0.05 was for the significant difference.Results The difference of the clinical and pathological features of two groups of cases was not significant. right thoracal and upper abdominal double incisions approach had longer operation time than left thorax approach (5.5±2.0hours and 4.5±1.2hours) (P <0.01); bleeding volume, duration of hospitalization have no significant difference; more total lymph node dissection (32±5, 19±7) (P <0.01), the overall transfer rateis 42.5%, the number of mediastinum lymph node (19±6 and 11±5) (P <0.01), the number of abdominal lymph node (13±4 and 8±4)(P<0.01), the differences were significant; the incidence of anastomotic fistula, anastomotic stenosis and recurrent laryngeal nerve injury was low (0.5% and 4.7%, 1.4% and 7.6%, 0% and 5.7%, P <0.01), but the other complications have no significant difference. The survival rate of 1, 2, 3-year postoperation of right thoracal and upper abdominal double incisions approach and left thorax approach, were 92.4%, 73.1%, 64.2% and 90.5%, 67.2%, 53.2% (χ2=12.991, P =0.00); the survival rates of the N0 patients after 3-year were 68.2% and 50.4% (χ2=4.199, P=0.04); the survival rates of the N1 patients after 3-year were 60.3% and 40.63% (χ2=43.921, P=0.00), the differences were significant.Conclusion The right thoracal and upper abdominal double incisions approach has a wide operative exposed field, complete tumor excision and lymph node dissection, and easy to achieve the total removal of esophagus, getting a precise and reliable esophageal stomach anastomosis, and ensuring anastomosis tension-free. The rate of complications of anastomotic fistula, anastomotic stenosis, and recurrent laryngeal nerve injury were low. The right thoracal and upper abdominal double incisions approach has a better long-term effect, and is a better therapy for curing mid-esophageal cancer.更多还原