| Background and ObjectiveEsophageal carcinoma is a common yet deadly cancer with a high morbidity rate.Although the incidence of esophageal cancer has decreased in recent years,but it is remains one of the most common forms of cancer threatening human health worldwide.Surgery is the gold standard for the treatment of esophageal carcinoma.One popular surgical approach is the minimally invasive McKeown esophagectomy.However,little is known about post-surgical complications,advantages,and disadvantages of this approach compared to a traditional left thoracotomy.What are the common complications of minimally invasive Mckeown esophagectomy? How can these complications be prevented? What are the advantages and disadvantages of minimally invasive Mckeown esophagectomy compared with traditional left thoracotomy(Sweet surgery)? How to choose the operation mode of esophageal carcinoma? Is there any pattern of lymph node metastasis in esophageal carcinoma patients and how to clean the lymph nodes according to the lymph node metastasis of esophageal carcinoma? At present,literature about the topic is still rare.The purpose of this study was to evaluate minimally invasive McKeown esophagectomy to effectively reduce the incidence of complications.In addition,we wanted todetermine criteria for the proper selection of the right recurrent laryngeal nerve(RLN)lymph node dissection and for the appropriate mode of operation for esophageal carcinoma.Materials and MethodsFrom August 2008 to June 2016,esophageal resection and lymph node dissections were performed on 620 patients with esophageal carcinoma.(Patients with esophagogastric junction were not included in the study).Of these,340 patients underwent a minimally invasive McKeown esophagectomy,and 280 patients underwent a left thoracotomy.Post-operative complications of minimally invasive McKeown esophagectomy were recorded,causes of complications were analyzed,and methods for avoiding complications were summarized.In addition,the metastatic pattern of the right RLN lymph nodes was studied.Subsequently,the two surgical methods were compared.Results? ? Post-operative complications of minimally invasive McKeown esophagectomyWe found that post-operative complications of minimally invasive McKeown esophagectomy included hepatic injury(2.1%);trachea and left main bronchus injury(0.9%);pulmonary infection(13.0%);respiratory failure(2.65%);recurrent laryngeal nerve injury(12%),of which 2.35% constituted bilateral recurrent laryngeal nerve injuries;cervical anastomotic leakage(11.47%);arrhythmia(9.41%);severe anastomotic stenosis(1.18%);thoracic bronchogastric and bronchial fistula(0.59%);post-operative burst bleeding,delayed gastric emptying,chylothorax,refractory hypotension and cerebral infarction(0.59%);and death(1.47%).The incidence of anastomotic leakage in the minimally invasive McKeown esophagectomy groupe performed three different cervical esophagogastrostomy were26.7%,27.2% and 7.9%,respectively.??Metastatic pattern of right recurrent laryngeal nerve(RLN)lymph nodesThe degree of metastasis of right RLN lymph nodes in esophageal carcinoma patients was 11.5%,and the metastasis rate was 17.1%.We next,evaluated the different factors involved in the metastasis of the right RLN lymph nodes: location,severity,length and differentiation status of lesions.1)Lesions were located in the upper,middle and lower segments of the thoracic esophagus,and the corresponding metastasis rates of the right RLN lymph nodes were 44.1%,12.05% and 8.2%,respectively.We found that the metastatic rate of the lesions located in the upper segment of the right RLN lymph node were significantly different compared with the middle and lower segments(p<0.01);2)The metastatic rate of the right RLN lymph node in esophageal carcinoma patients with the degree of invasion at T4,T3,T2 and T1,respectively were 100%,23.2%,13.2%and 0%.We observed significant differences between T4 and T3(p<0.05),T2(p<0.01)and T1(p<0.01);in addition,we observed a significant difference when T3 and T2 were compared with T1(p<0.01);3)The metastatic rate of right RLN lymph nodes in patients with the length of esophageal carcinoma >3 cm was 26.49%,and the metastatic rate of right RLN lymph nodes in patients with the length of esophageal carcinoma ? 3cm was 8.17%,and this difference was significant(p<0.01);4)The metastatic rates of right RLN lymph nodes in esophageal carcinoma patients with well-differentiated,moderately differentiated and poorly differentiated tumors were 5.4%,12.45% and 48.9%,respectively;the difference was significant between the patients with well and moderately differentiated tumors compared with poorly differentiated tumors(p<0.01).??Comparison between McKeown esophagecomy and left thoracotomyThe total rates of complication for the minimally invasive McKeown esophagectomy group and the left thoracotomy group were 51.72% and 37.86%,respectively.The rate of complications was significantly higher in the minimally invasive McKeown esophagectomy group than that in the left thoracotomy group(p<0.05).Specifically,the RLN injury and anastomotic leakage rates were high,8.97%/0.36% and 8.62%/1.43%,respectively,and the differences were significant between groups(p<0.01).Intraoperative blood loss(100±31.5 ml/300±44.7 ml)and the amount of drainage(260±40.2 ml/450±56.6 ml)on the first day post-operationwere both significantly lower in the minimally invasive McKeown esophagectomy group,compared with the left thoracotomy group(p<0.01).Although the operation time(210±26.7 min /165±18.2 min)and the length of stay in hospital(16.9±5.3d/14.6±2.7 d)were longer,and the cost(46000 yuan/37000 yuan)was higher in the minimally invasive McKeown esophagectomy group,we did not observe any statistical difference(p>0.05)in lymph node dissection between the two groups.Furthermore,we did not observe any statistical difference in pulmonary complications(pulmonary infection,respiratory failure and tracheotomy),chylothorax,delayed gastric emptying,tracheobronchial injury,arrhythmia,and gastric fistula(p>0.05)between the two groups.Conclusions??The common complications of minimally invasive esophageal carcinoma included recurrent laryngeal nerve injury,anastomotic leakage,pulmonary infection,arrhythmia,etc,its causes and preventive measures are more specific than those of open surgery for esophageal carcinoma.gastric tube tracheal-bronchial fistula,intractable hypotension were more common than open surgery.??We found that the rate of anastomotic leakage could be effectively reduced without embedding and hanging of the anastomotic stoma.??The metastasis of the right RLN lymph nodes correlated with the location,severity,length and degree of differentiation of the cancer cells,the correlation is the severity of invasion,the degree of differentiation of cancer cells,the location of lesion and the length of lesion from a high to a low order.? ? The total rates of complications in the minimally invasive McKeown esophagectomy group were higher than that in the left thoracotomy group(p<0.05),intraoperative blood loss and the amount of drainage on the first day postoperation were significantly lower than in the left thoracotomy group(p<0.01). |
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