| BackgroundEsophageal cancer, one of the most common malignant tumors in the world, has the highest morbidity and mortality in China. At the present, the treatment for esophageal cancer patients is still conventional surgery, assisted with radiotherapy and chemotherapy. Several studies have shown that two-field or three-field lymph node dissection by surgery through right thorax (two-incision esophagectomy through right abdomen &thorax and three-incision esophagectomy through right thorax, abdomen &cervix) could improve the five-year survival rate for patients significantly. Therefore, these two surgical methods are now preferred. However, thoracotomy causes big traumas, obvious pain and poor quality of life after surgery with a high incidence of postoperative complications and mortality. By the middle of 1990s, minimally invasive techniques that represented by laparoscope and thoracoscope have been gradually applied to many fields of thoracic surgery. Endoscopic surgery has changed some previous large-incision or severe-trauma operations fundamentally. Minimally invasive techniques have won vast approval because of the advantages as little trauma, clear vision, speedy recovery and less bleeding. But laparoscopic esophagectomy combined with thoracoscope is difficult to operate. The surgeons are required not only to have rich experience in conventional open esophagectomy, but also to be proficient in thoracoscopic and laparoscopic operation. The learning curve is relatively long. Although there are much controversy to lymphadenectomy and the safety of tumors, minimally invasive esophagectomy has been adopted by more and more scholars at home and abroad as technology matures and experience grows. Large-sample retrospective studies have also shown the advantages of minimally invasive esophagectomy.Objective1. Discuss the therapeutic effect of esophageal carcinoma resection and cervical esophagogastrostomy combined with thoracoscopic and laparoscopic techniques, and sum up the relevant surgical experience and the treatment in operative complications.2. Analyze the influence of operator’s experience in the early results of esophageal carcinoma resection and cervical esophagogastrostomy combined with thoracoscopic and laparoscopic techniques and study the learning curve of minimally invasive esophagectomy.MethodsRetrospective summary has analyzed 144 surgical cases of esophageal carcinoma resection and cervical esophagogastrostomy combined with thoracoscopic and laparoscopic techniques, finished from Apr 2010 to Dec 2011 by the same surgeon in the general thoracic surgery department of the first affiliated hospital of Anhui Medical University. The major indicators of analysis include surgery time, blood loss during operation, volume of blood transfusion, complication, the number of surgeries converted to open, postoperative indwelling time of thoracic duct, total flow of postoperative drainage, postoperative complications (recurrent laryngeal nerve injury, chylothorax, anastomotic fistula and pulmonary infection), the treatment thereof, hospital stay after operation and pathologic data of patients after operation (including tumor location, pathologic findings of anastomotic stoma, pathological type, total lymph nodes, number of positive lymph nodes and pathological TNM stage). Meanwhile, the cases of esophagectomy combined with thoracoscopic and laparoscopic techniques are to be sorted in chronological order. In the order of operations dates,144 patients are divided into 4 groups, i.e. Group A, B, C and D with 36 patients for each. Compare the operation dates, bleeding volume during operation, total lymph nodes, rate of surgery converted to open, complication rate, length of hospital stay and operation frequency of groups with each other to discuss the surgical effects at different stages. Analyze the influence of operator’s experience in the early results of esophageal carcinoma resection and cervical esophagogastrostomy combined with thoracoscopic and laparoscopic techniques and study the learning curve of minimally invasive esophagectomy.Results1. There are 144 patients in the group, among which 111 are male and 33 are female. They are aged from 40 to 78 with an average of 62.1±6.6 years old. ASA classification:there are 45 cases for Grade I,99 cases for Grade II and no case above Grade III. The serum albumin level in biochemical test before operation is 31.7-55g/L with an average of 43.0±3.7g/l. The operations in the group were all accomplished smoothly. There are 5 cases of complications during operation and surgeries convertied to open, among which 3 cases are converted to laparotomy for spleen bleeding,1 converted to thoracotomy repair for left principal bronchus injury during operation and 1 converted to thoracotomy repair for inferior vena cava injury. The operation time is 150-480min with an average of 276.6±62.6min; the blood loss during operation is 10-850ml with an average of 128.3±124.2ml; there are 14 cases of upper esophageal cancer,116 cases of middle esophageal cancer and 14 cases of lower esophageal cancer. One patient with middle esophageal cancer got a high-grade intraepithelial neoplasia below the epithelium of anastomotic stoma (R1 resection) and the other 143 patients got RO reduction. The pathological types include 137 cases of squamous-cell carcinoma and 7 cases of squamous epithelium high-grade intraepithelial neoplasia. The average number of lymph nodes is 15.97±7.77 and that of positive lymph nodes is 1.24±2.37. Postoperative TNM stage:1 case for stage 0,42 for stage Ⅰ,52 for stage Ⅱ,42 for stage III and 7 for stage IV.2. Postoperative indwelling time of thoracic duct is 2-25 days with an average of 7.60 ±3.10 days; total postoperative drainage flow of thoracic duct is 390-7040ml with an average of 1785.37±998.42ml; there are postoperative complications in 19 patients, including 2 mild chylothorax patients,5 anastomotic fistula,9 pulmonary infection after operation and 7 postoperative hoarse voice (4 patients developed pulmonary infection and hoarse voice concurrently); no perioperative death occurred; length of hospital stay after operation is 6-38 days with an average of 13.05±4.63 days.3. Group study finds that the surgical experience of operators could improve various indexes of the patients at perioperative period significantly and the indexes grow more stable as the operation frequency increases gradually. The operation time of group Ais (339.1±56.5) min, significantly longer than that of group B-(240.7± 58.2) min, group C-(255.4±45.7) min or group D-(269.9±45.4) min (P=0.000). The bleeding volume during operation of group A is (218.6±142.9) min, much more than that of group B-(106.4±76.0) min, group C-(75.5±48.7) min or group D-(100.5±91.9)min (P=0.000). The number of lymph nodes in group A is (10.6 ±5.6), significantly less than that in group B-(15.6±7.7), group C-(18.3±6.9) or group D-(18.4±8.7) (P=0.000). There is no significant difference in the rate of surgeries converted to open (P=0.399), the incidence of complication (P=0.753) and the length of hospital stay after operation (P=0.611) for 4 groups of patients.Conclusion1. The esophageal carcinoma resection and cervical esophagogastrostomy combined with thoracoscopic and laparoscopic techniques are safe and feasible technically.2. The surgical experience of operators could improve various indexes of the patients at perioperative period significantly and the indexes grow more stable as the operation frequency increases gradually. There are 36 cases of esophageal carcinoma resection and cervical esophagogastrostomy combined with thoracoscopic and laparoscopic techniques forming the learning curve.BackgroundFast-track surgery (FTS) is a series of optimization measures taken for patients undergoing selective operation during the perioperation on the basis of medical basis so as to reduce or relieve the psychological &physical injury, stress response and complications, enhance recovery after surgery, shorten the length of hospital stay and reduce hospitalization expenses. The most important is to reduce stress response, including psychological guidance before surgery, minimal invasive surgical therapy, anesthesia improvement, attention for intraoperative warming, reduction of water-sodium retention, effective analgesia after surgery, early extubation and early ambulation. The relative measures are taken throughout the perioperative period. In recent years, FTS measures have been widely used for the treatment of diseases in urinary surgery, general surgery, obstetrics-gynecology, cardiac surgery, orthopedics and general thoracic surgery, among which the most successful application is in the colorectal resection operation. FTS is a multi-disciplinary collaboration system, involving the active participation of surgeon, anesthetist, rehabilitation therapist, nurse, patient and the family members of patient. At the same time, FTS depends on the good integration of the therapies during the vital perioperative period. In the concept of FTS, minimally invasive is an important factor.China has the highest morbidity and mortality of esophageal cancer in the world. Each year, approximately half of the new esophageal cancer patients in the world are Chinese and the high incidence areas are relatively backward in economy with scare medical resources. And currently the treatment for esophageal cancer patients is still surgical therapy. Thus it is of special significance to bring the idea of FTS to the treatment of esophagus cancer. Currently, the application of FTS in esophagus cancer operation is rarely reported so that the joint application of FTS and esophagectomy combined with thoracoscopic &laparoscopic techniques will provide new idea and basis for further exploring the treatment of esophagus cancer and postoperative rapid recovery.Objective1. Observe the safety, feasibility and clinical effects of FTS measures in esophageal carcinoma resection and cervical esophagogastrostomy combined with thoracoscopic and laparoscopic techniques.2. Explore the safer, more reasonable and effective FTS procedures carried out after esophageal cancer operation.MethodsMake a retrospective analysis on 80 surgical cases of esophageal carcinoma resection and cervical esophagogastrostomy combined with thoracoscopic and laparoscopic techniques, finished from Jan 2012 to Apr 2013 by the same surgeon in the general thoracic surgery department of the first affiliated hospital of Anhui Medical University. The 80 patients are divided into 2 groups with 40 patients for each. The experimental group (FTS group including 40 cases) is treated with FTS measures during the perioperative period, while the control group (conventional group including 40 cases) is with conventional perioperative treatment. The major indicators of analysis include surgery time, blood loss during operation, total lymph nodes, the placement of gastric tube, abdominal cavity drainage tube &cervical latex drainage tubing after surgery, the volume of postoperative intravenous fluid, urinary catheter indwelling time, thoracic duct indwelling time, pharyngalgia, emesis, pathological type, pTNM stages, time for postoperative drinking, duration of ventilation, length of postoperative hospital stay, the occurrence of complications within 1 month after surgery and the rehospitalization rate within 30 days.Results1. There was no statistically significant difference (p>0.05) between the two groups of patients in the age, gender, ASA grade, tumor location and serum protein level before surgery.2. The blood loss during operation and the number of lymph nodes did not show evident difference between the two groups of patients. The operation time of the patients in group FTS was much shorter than that in conventional group (217(150-290)min vs 242(173-383)min, p<0.05). The patients in group FTS were all treated without gastric tube, abdominal cavity drainage tube &cervical latex drainage tubing during operation, while the 40 patients in conventional group were in routine use of gastric tube, abdominal cavity drainage tube &cervical latex drainage tubing.3. By comparison, the volume of postoperative intravenous fluid in group FTS is much shorter than that in conventional group (2.11L vs 2.8L), a statistically significant difference (p=0.000). The retention time of thoracic duct after surgery in group FTS is much shorter than that in conventional group (3(2-4)d vs 8(6-9.75)d. There was no significant statistical difference (p=0.20) between the two groups of patients in postoperative emesis. Yet the occurrence rate of pharyngalgia after surgery in group FTS is much less than that in conventional group (17 vs 40 p=0.000). The time for postoperative drinking of the patients in group FTS is obviously earlier than that in conventional group (2(2-3)d vs 9(8-10)d) with statistical significance (p=0.000). Compared with the conventional group, the duration of postoperative ventilation(3(3-4)d vs 6(6-7)d) and the length of hospital stay (7(6-9)d vs 12(10-16.5)d) in group FTS are remarkably shortened with statistical significance (p<0.001). There was no statistical difference (p>0.05) between the two groups of patients in postoperative pTNM stages, pathological type, the retention time of catheter after surgery and the rehospitalization rate within 30 days. There was no significant difference (p>0.05) between the two groups of patients in the occurrence of postoperative complications.Conclusion1. The application of FTS measures during the perioperative period in esophageal carcinoma resection and cervical esophagogastrostomy combined with thoracoscopic and laparoscopic techniques is safe, effective and feasible.2. The FTS measures applied in esophageal carcinoma resection and cervical esophagogastrostomy combined with thoracoscopic and laparoscopic techniques during the perioperative period could enhance the recovery of gastrointestinal function after surgery, shorten the length of hospital stay, speed up the recovery rate and add comfort. Compared with the esophageal carcinoma resection and cervical esophagogastrostomy combined with thoracoscopic and laparoscopic techniques dealt with the conventional perioperation therapy, the occurrence rate of postoperative complications has not yet increased. Therefore, the FTS measures taken during the perioperative period have certain advantages. |
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