束余声医生的科普号

扬州大学附属苏北人民医院束余声 石维平 史宏灿 陆世春 王康 孙超 缪乾兵 贺建胜摘要 目的 研究颈、胸、腹“三切口”食管癌根治术，对切除肿瘤的彻底性和防治主要并发症吻合口瘘的有利性。方法 回顾2000年1月至2011年1月11年中采用颈、胸、腹“三切口”行食管癌切除，全胃代食管术共2162例，介绍手术方法的改进，并发症的防治。结果 手术切除率97%，发生吻合口瘘207例，平均发生率为9.9%，围手术期死亡率为“0”。讨论 食管癌术后吻合口瘘是死亡的主要原因之一，颈、胸、腹“三切口”的吻合口不在胸腔内，一但发生瘘就不会像胸内瘘那样化学性和细菌性炎症对全身的影响大，治疗上不需禁食，保持颈部切口引流通畅，经换药1～2周左右多能自行愈合，采用胃管延期拔除 和术中安置十二指肠营养管术后早期给营养，处理起来更加得心应手。如果出现吻合口瘘以外的其它严重并发症，也有利于处理。一般认为该术式创伤大，并发症多，然而左胸“一切口”和左颈、胸“二切口”等其它术式采用了较大的后外侧切口，同时需切开膈肌，虽然少了切口，实际创伤更大。为了提高 “三切口”术式的安全性，降低手术死亡率必须注意以下几点：⑴颈部并发症的预防，手术操作应精细，尤其是防止喉返神经的损伤，采取左侧胸锁乳突肌斜切口，直视下解剖，经甲状腺外侧间隙进入食管后，在食管与脊柱之间钝性分离，胸内食管由此间隙拉出，尽可能避免拉钩牵引，疑是神经或血管组织应避免切断，基本上可以不损伤喉返神经；⑵颈部吻合口瘘破入胸腔也是较严重的并发症，采取游离胃上提至左颈的部分多一些，并用左颈部肌膜及右上纵隔胸膜与胃缝合固定使胸廓上口封闭，可杜绝这一并发症的发生；⑶替代器官胃保持“两头松中间紧”的方法，即胃在胸部紧，在颈、腹部松既可以预防吻合口瘘，又可以预防胃扩张和幽门功能不全；⑷既往有腹腔器官感染或有手术史的食管癌病人增多，其它手术迳路难以处理腹部器官的粘连，这种病人术后往往有肠功能不全，甚至发生肠梗阻，采用上腹正中切口处理腹部情况非常方便，必须充分游离胃周粘连，特别是幽门周围的粘连；（5）分组手术可以缩短手术时间，使用支气管插管麻醉，避免对肺部的挤压以减少肺挫伤、间质性肺水肿，这些都有利于防止肺部并发症。“三切口”术式的优点：⑴食管切除超过全长80%，食管组织再生癌的机会大大减少，复发病例主要为淋巴结转移；⑵切除率高，经右胸切除不受主动脉弓的影响，如果在左侧90度卧位的情况下操作则更为方便；⑶经右胸切口对于肿瘤外侵明显，需要行胸导管结扎的患者更加有利；⑷因为替代器官胃可纳入食管床，几乎不影响肺的扩张，同时减少了胃扩张等胸胃综合征的发生，胸腔积液量少，且发生率低；⑸不需切开膈肌，无膈疝发生，也使因为膈肌切开对呼吸功能的影响减少；⑹有利于颈、胸、腹三野淋巴结清除；⑺吻合口瘘发生率虽然高于胸内吻合，但死亡率低，本组无手术死亡。

【摘要】 目的 探讨大疱性肺气肿肺功能较差的食管癌病人，同期进行食管癌根治术和肺减容术的可行性和安全性。方法 我院1999年1月—2006年1月，共施行食管癌切除病人1082例，其中合并有大疱性肺气肿、肺功能较差的病人27例（占2.5%），有选择性手术入路进行了同期手术处理二种病变，右胸三切口食管癌切除19例，右胸一切口或二切口8例，颈部吻合22例，胸内吻合5例，同时行同侧肺楔形切除21例，单个或多个肺段切除4例，上肺叶切除2例。结果 无围手术期死亡，术后出现并发症18例，颈部吻合口瘘7例，肺部感染6例，肺创面漏气、气胸、皮下气肿10例，喉返神经损伤2例，咳痰无力，呼吸功能不全行气管切开呼吸机辅助呼吸6例，全部病人经积极处理无一例死亡，均恢复出院，平均住院18.6天。结论 术前精心设计手术方式，术中、后处理得当，对大疱性肺气肿肺功能差的食管癌患者一期行肿瘤切除和肺减容手术具有可行性和安全性。 关键词：食管癌，大疱性肺气肿，同期手术The simultaneous surgical treatment in patients with esophageal carcinoma company with bullous emphysemaThe clinical medical college of YangZhou university （225001） Shu yu-sheng Shi wei-ping Shi hong-can [ABSTRACT]:Objective To investigate the security and feasibility of the simultaneous operation of esophageal carcinoma and lung volume reduction in patients with esophageal carcinoma company with bullous emphysema.Methods There were 27 cases who suffered esophageal carcinoma company with bullous emphysema and all be treated with the simultaneous operation of esophageal carcinoma and lung volume reduction. Results No death in this group. The main postoperative complications were anastomotic leak and respiratory complications.There were 7 cases suffered with anastomotic leak,6 cases suffered with pneumonia and 10 cases suffered with pneumothorax, subcutaneous emphysema and air leak of the wound of lung. Conclusions It is safe and feasible that the simultaneous operation of esophageal carcinoma and lung volume reduction in patients with esophageal carcinoma company with bullous emphysema. It is very important to enhance the management of respiratory treat in the patients’ perioperative period and the choice of different opperative methods. Key words：esophageal carcinoma，simultaneous surgical treatment， bullous emphysema 为探讨合并有大疱性肺气肿的食管癌病人，同期进行手术治疗的可行性。作者自1999年1月—2006年1月有选择性地施行了此类手术27例，占整个食管切除手术病人的2.5%，取得了满意效果，现报告如下：1、资料与方法1.1一般资料：本组27例，男21例，女6例，年龄52—71岁，平均63.5岁，均有不同程度的进食梗阻感，上消化道钡餐以及胃镜检查证实，食管上段癌7例，中段癌16例，下段癌4例，病理证实均为鳞状细胞癌。有慢性支气管炎，肺气肿病史3—10年不等，胸片以及胸部CT检查提示。大疱性肺气肿，右上肺为主19例，左上肺为主8例，肺功能检查：MVV占预计值百分比：50%—60%22例，50%以下5例，FEV1占预计值百分比：50%—60%24例，50%以下3例，FEV1：1.0—1.5L21例，1.0L以下6例，手指脉搏氧（SaO2）85%—90%5例，90%—95%22例。1.2手术处理：全组病人术前常规行物理治疗，抗生素应用控制肺部炎症，间断低流量吸氧，进行咳嗽、呼吸功能锻炼。均采用胸段硬膜外麻醉及双腔气管插管静脉复合麻醉，桡动脉测压。19例行右胸、左颈、上腹部三切口常规行食管中上段癌根治术，胸胃予以管状成形，行走于食管床颈部吻合22例，胸内吻合5例。根据手术前胸片以及CT检查并结合术中所见，确定切除进胸侧肺上叶的大小，其中行肺叶切除2例，肺上叶楔形切除21例，单个或多个肺段切除4例，约占上肺叶的1/3—1/2。使用胃残端关闭器，放置在预计切割线上，尽可能沿肺段进行切除病变肺组织，肺创面常规再用3—0Prolene线来回交锁关闭，针孔漏气处应用生物蛋白胶封闭。常规放置上下两根胸引管，进行闭式引流，不使用负压吸引。胃肠减压管5—6天拔除后进行流质饮食，根据胸片及胸腔引流情况决定拔除胸引管，一般在术后4—7天，可先后拔除，如果持续漏气可以延长拔管时间。术后强调应用胸段硬膜外麻醉镇痛，第3—5天，拔除硬膜外导管，加强术后呼吸道管理，呼吸困难或面罩吸氧不能改善，痰多，咳痰无力，则早期行气管切开，必要时机械通气支持。2、结果：全组无手术及围手术期死亡。7例发生颈部吻合口瘘，无胸内吻合口瘘，肺部感染6例，肺创面漏气、气胸、皮下气肿10例，其中1例持续漏气达4周，喉返神经损伤2例、2例发生室上性心动过速，6例呼吸功能不全行气管切开并机械通气支持，全组病人经积极对症治疗，均恢复出院，平均住院18.6天。3、讨论：食管癌在我国是常见肿瘤。目前手术切除仍被许多胸外科专家认为是中、早期食管癌治疗的首选治疗方式，并且外科治疗趋势之一是手术适应症的逐渐扩大。但是食管癌术后因胸部创伤、胸腔胃、呼吸道感染等，疼痛的刺激使呼吸功能下降，潮气量和肺泡有效通气减少而引起呼吸功能衰竭，常常是致命性并发症 [1] 。如果术前合并有大疱性肺气肿、肺功能检查提示：中一重度通气功能减退，通气储备功能低，这组病人常常被认为手术禁忌而失去最佳的手术治疗机会。有文献报告[2]：凡术前肺功能检查：FEV1占预计值百分比<50%，MVV占预计值百分比<50%，则作为进胸手术禁忌。FEV1<1.5L，FEV1占预计值百分比<60%，则手术需慎重考虑。本组病人有慢支，肺气肿病史3—10年不等，肺功能检查示中一重度通气功能障碍，早期我们对此类病人都习惯于选择放疗而不施行手术。近年来，随着静脉全麻复合硬膜外麻醉开展，围手术期管理水平的提高，特别是对肺减容手术认识的提高，我们对这类病人采取外科手术一期进行食管癌根治及同侧肺减容术，取得了较满意的效果。我们的体会是：1、充分的术前准备：Craig报道，食管癌术后第1天病人的肺活量和最大通气量分别较术前降低30%、27.5%，加之食管癌患者因进食困难常出现消瘦，营养不良，机体抵抗力下降，低蛋白血症出现引起肺间质水肿，肺内分流增多，再合并慢支、肺气肿、肺通气、换气功能减低而导致低氧血症。因此术前适合的病例选择，综合的肺功能评估，合理的术前治疗甚为重要。戒烟，呼吸道物理治疗，雾化吸入，呼吸功能锻炼，术前一周抗生素应用，补充营养，可间断少量输血浆、白蛋白治疗，使病人处于最佳状态下进行手术。作者自1999年1月—2006年1月有选择性地施行了食管癌合并有大疱性肺气肿病人27例，同期手术，取得满意效果，其理论基础[3]就是：肺减容术，切除了无功能的肺气肿组织靶区，减少了无效肺组织体积，使胸腔压力下降，负压恢复，肺弹性回缩力改善，小气道张力恢复，气道阻力下降，胸廓的弹性回缩力改善，膈肌、胸壁有效运动幅度增大，残余肺舒缩状态改善，FEV1明显增高。手术过程中我们强调尽量简化手术操作难度，缩短手术时间，可分成胸腹部二组同时进行探查，肿瘤可以切除、腹腔代食管的胃条件正常，就在膈上切断食管，结扎两断端牵引，向上游离食管肿瘤，清扫淋巴结，向下回送腹段食管及贲门，游离胃体。注意胃体做成管状，置入食管床，尽量减少对肺及气管的牵拉和机械挫伤，保护好喉返神经。作颈部吻合时就可以同时进行肺减容手术。具体做法是：结合手术前胸片及CT检查以及术中具体所见，行楔行切除或多段切除，要求达到上肺叶的20—30%左右，有2例由于先天性右上肺发育不良囊性纤维化改变而行肺叶切除。在作楔行切除或肺段切除时，我们应用残胃关闭器多次作上肺叶切线方向关闭切割，然后再用3—0Prolene线来回交锁缝合，既考虑了经济因素又能达到防止漏气的效果。手术结束，常规放置两根胸引管闭式引流，不主张负压吸引，关胸之前，观察肺膨胀完全，拔气管插管前彻底吸出呼吸道分泌物。除2例病人需带气管插管回ICU外，其余病人均在手术室清醒，恢复肌力，自主呼吸幅度好，血氧饱和度满意后拔管。重视胸引管的管理，少量漏气可以不作处理，要保证胸引管通畅，负压随呼吸波动。如较多漏气或出现皮下气肿根据胸片情况有局限性气胸可以考虑再放置一根胸引管引流，纵隔气肿行上纵隔切开引流。本组22例病人在一周内都能拔除上下胸引管，4例病人第2周拔除，1例病人持续漏气，延长至4周方才愈合。其中6例病人出现呼吸功能不全，缺氧，予以气管切开，机械辅助通气，经及时处理，并加强呼吸道的管理，全部病人均得以康复，无1例死亡病例。另一方面，我们也强调术后胸段硬膜外麻醉镇痛，鼓励病人自主咳嗽排痰，有效雾化吸入和拍背等物理治疗，良好的营养支持也甚为重要。总之，我们的感受是：食管癌合并有大疱性肺气肿可以通过外科手术一期进行食管癌切除及肺减容术，不增加手术的死亡率，具有可行性和安全性，但术后远期肺功能的改善及生活质量状况还有待于作进一步随访和深入研究。【参考文献】 1 姚玉春，胥永忠，赵雍凡.食管癌患者围手术期死亡的高危因素分析.中国胸心血管外科临床杂志，2002，4（9）：311-312.2 Gairssert,HA.Trulock,EP.cooper,JD.et,al Comparison of early functional resuolt after volume reduction or Lung trausplantation for chronic obstructive pulmonary disease.J thorac Careliovasc surg 1996;111∶2963 Demeester SR.Patterson GA.Sundaresan RS et al.Lobectomy combined with volume reduction for patients with lung cancer and advanced emphysema［J］.J Thorac Cardiovasc Surg,1998;115:681-8.

Abstract objective: To study the advantages and evaluate the curative effect of three incisions and cervical esophagogastrostomy for treatment of middle and upper esophageal carcinoma. Methods From 1998 to 2008, there were 1226 patients with thoracic esophageal carcinoma undergone esophagogastrostomy and lyphadenectomy through right chest, upper abdomen and left neck and. Results: This operative method can radically remove carcinoma and extensive lymph nodes. Although cervical anastomosis leakage has higher incidence, the management of this complication is relatively easy and the satisfactory results can be achieved.Conclusions: Three incisions and cervical esophagogastrmy is more advantageous and effective and can reduce the patients mortality rate and raise survival rate.Keywords: esophageal carcinoma; three incisions; cervical esophagogastrmyPresently, the surgical operation is still the main treatment method of esophageal carcinoma; however the surgical approaches are several and have advantages and disadvantages respectively. The reasonable approach can get better anatomical exposure for radical operation and lymph node dissection. From 1998 to 2008, there were 1226 patients with thoracic esophageal carcinoma undergone esophagogastrostomy and lyphadenectomy through right chest, upper abdomen and left neck, the results were satisfied.1. Data and Method Clinical dataThere were 1226 patients in this group, 829 males and 397 females. Their mean age was 56.6 years old and from 33 to 78 years old, 413 patients had upper esophageal carcinoma, 645 patients had middle esophageal carcinoma, 168 patients had upper and middle esophageal carcinoma. Their were 263 patients in I stage,362 patients in II stage,454 patients in III stage,147 patients in Ⅳ stage. They were all final diagnosed by gastrofiberscopy. In this group, the resection rate was 95.3 %( 1226/1287), 995 patients had radical operation, 231 patients had palliated operation. All of their pathological diagnosis was squamous cell carcinoma. Operation methodAfter anaesthetized successfully，we raised the patients’ right chests to 60 degrees, changed their heads to right. If the resection of the tumor was difficulty for the tumor’s largeness, we raised the patient’s left chest to 90 degrees .The operation staff was divided into two groups. The fourth interspaces’ thoracotomy was performed by one group to determine the resection of tumor; the abdomen was entered through a midline incision by another group to assure no celiac organic metastasis. Then two groups operated at the same time. The arch of the azygous vein was divided, and the tumor-bearing esophagus was resected with completed dissection of lymph nodes in the mediastinum. We cut down esophagus from cardia, the proximal end was bonded up with sterile gloves, and the distal end was transfixed and pulled into abdominal cavity from esophageal hiatus. From the left-sided neck incision, we liberated esophagus and pulled it out the left-sided neck incision. Another group cut down left triangular ligament of liver, thoroughly liberated stomach and reserved right gastric artery and right gastroepiploic artery, and thoroughly solute anterior part of pylorus and the first segment of duodenum, then regularly cleared up paracardiac nodes and left gastric artery nodes and peripheral adipose tissue, and then reconstructed the stomach into a gastric tube. The gastric tube is then positioned in the posterior mediastinum in the original esophageal bed and was anastomized to the cervical esophagus.2. ResultsIn this group, no residual carcinoma was found at below incised edges, but residual carcinoma was found at 14 upper incised edges.389 cases were masculine in three field lymph node pathoscopy;231 cases were complicated by cervical infection;117 cases were complicated by cervical anastomotic fistula, and 3 cases died of severe mediastinal and thoracic infection caused by anastomotic fistula;18 cases were complicated by empyema;86 cases were complicated by thoracic fluidify;32 cases were complicated by recurrent laryngeal nerve injury ,but all recovered in three months.62 cases were complicated by hypopnoea caused by pulmonary infection and atelectasis,46 of them were improved after sputum suction with nasal catheter, the other 16 cases were undertaken tracheotomy and supported by breathing machine, and all of them recoverd.14 cases were complicated with gastric retention. In this group, one-year survival rate was 85.1%, and three-year survival rate was 57.3%.3. DiscussionsGreat controversy remains on the extent of resection and the typer of surgical access and lymphadenonectomy. Transhiatal esophagectomy without thoracotomy was developed because of the pulmonary and intrathoracic leak complications associated with the thoracotomy required for transthoracic and en bloc esophagectomies,but the resection of lymph nodes couldn’t be completed; transthoracic esophagectomy couldn’t dissect the lymph nodes outside of the chest cavity. So Akigama claimed that when the tumor invaded out of mucous layer, better operation effect could be got if we undertake three field (neck, chest and abdomen) lymph node dissections.From 1998, there were 1226 patients with thoracic esophageal carcinoma undergone esophagogastrostomy through right chest, upper abdomen and left neck and three field lyphadenectomy, the results were satisfied. This type of operation had some bellowing advantages:(1) The rate of tumor resection was improved. Because the middle and upper segment of esophageal lies on the right side of spine without the block of aortic arch, this type of the operation is convenient for tumor resection when the tumor invades the tissue behind aortic arch and the membranous part of trachea or azygous vein, and we can obviate injury when we dissect the tumor under direct vision.(2)The tumor can be dissected thoroughly. Because esophageal carcinoma is multicentric and metastasize continuously or skip toward up and down two directions, the safety margin we often chosen is five centimeters far from the edge of the tumor, but carcinoma still remains on some resection margin. The En bloc esophagectomy can diminish stump cancer, multicentric cancer and wall-inside metastasis. (3)The ligation of thoracic duct is convenient when the tumor invades obviously.(4)Because the succedaneous gastric tube is positioned in the original esophageal bed and without influence to pulmonary ecstasy, gastroectasia and pleural effusion can be reduced.(5)The lymph nodes of three fields(neck, chest and abdomen) can be dissected thoroughly. Now ,It is known that the lymphatic metastasis of esophageal carcinoma is two-way, any segment of esophageal carcinoma can metastasize to Para-esophageal lymph nodes, carinal lymph nodes, subclavicular lymph nodes,paracardial lymph nodes，left gastric lymph nodes and celiac lymph nodes. Esophagogastrostomy through right chest, upper abdomen and left neck is convenient to resect cervical lymph nodes and left gastric lymph nodes. It is reported that the five year survival rate after operation was 12.6% to 18.9% in the patients with lymph node metastasis ,while the patients were undertaken extensive lymph node resection, the rate could be raised to 31.7%.In this group, pathologic analysis after operation verified that 389 cases were masculine in three field lymph node pathoscopy,so the latent metastasis was cleared and the recurrence was diminished, and so the survival rate after operation was elevated(one year survival rate to 85.1% and three year survival rate to57.3%).(6)The Complications after operation can be treated conveniently. Anastomotic fistula is the frequent and severe complication after esophagogastrostomy, if this complication happens in the chest cavity, serious toxic symptoms can always be found and the mortality is about 50%; although the incidence rate of cervical anastomotic fistula is about 15%, this complication can be found early and cured by thorough drainage, the patient can go on taking food to improve nutrition without life threaten. In two years, the incidence rate of cervical anastomotic fistula was decreased obviously. We have improved our techniques in the bellowing respects:①The longevity of the gastric tube must be sure sufficient, and pylorus should be dissociated thoroughly, the posterior peritoneum of duodenum may be cut open, the pyloroplasty should be taken if it is necessary.②When we position the gastric tube, we must be sure there is no gastric volvulus and anastomotic tension. The retro-lateral gastric wall was always fixed to prevertebral fascia with three sutures just below anastomotic stoma, the upper mediastinal pleura was sutured and fixed.③When anastomosis was finished, the cervical incision was soaked t with hypo-concentration Iodophors solution for one minutes and then washed by Sodium Chloride. In order to prevent anastomotic fistula succeeded by infection, we replaced a latex tubing with vacuum aspiration instead of a flap through the port-hole pinked below the cervical incision to drain the anastomotic stoma.(7)The operational time in the chest cavity is reduced obviously.Two groups operate in chest and abdomen at the same time; when anastomosis was finished, the upper mediastinal pleura was sutured and abdominal and chest incisions were closed timely, so the operation time was always reduced into three hours and even two hours. There is no incision in diaphragm and less interference to heart and lung, so the post-operation pulmonary function is reserved and the patient can cough and expectorate easily after operation. References1. Altorki NK, Lerut T. Three-field lymph node dissection for cancer of the esophagus. Pearson FG, Cooper JD, Deslauriers J, Ginsberg RJ, Hiebert CA, Patterson GA, and Urschel HC Jr (eds): Esophageal Surgery, 2nd Edition. New York, Churchill Livingstone, 2002. 2. Altorki NK, Kent M, Ferrara CA, Port JP. Three-field lymph node dissection for squamous cell and adenocarcinoma of the esophagus. Ann Surg 2002; 236:177-83. 3. Akiyama H, Tsuramara M, Udagawa H, et al. Radical lymph node dissection for cancer of thoracic esophagus. Ann Surg,1994,220(3):3464. Kuwano H,et al.Univariate andmultivariate analyses of the prognostic significance of discontinuous intramural metastasis in patients with esophageal cancer,J Surg Oncol.1994,57:17

【摘要】 目的：探讨减少颈胸腹三切口食管癌手术颈部吻合口瘘的方法。方法：回顾性分析2007年2月至2010年5月成功在我科行改良法经左颈、右胸、腹部三切口食管癌根治手术的675例患者的颈部吻合口瘘的情况。结果：675例患者均顺利完成手术，术后发生吻合口瘘42例，瘘发生率为6.22%，无1例瘘入胸腔，住院时间12.5±8天。结论：改良法经颈胸腹三切口食管癌根治术能减少颈部吻合口瘘的发生，且治疗方便，愈合周期短。【关键词】食管癌 三切口 颈部吻合口瘘食管癌是一种多中心性的肿瘤,有人认为有时呈多灶性及跳跃式转移【 1，2】。三切口手术术野显露清楚,能有效地清除沿食管纵轴呈区域、双向、连续或跳跃式的颈、胸、腹部淋巴结【3】，特别是术后发生吻合口瘘处理简单，病死率明显低于胸内吻合口瘘。我们回顾性研究2007年2月至2010年5月在我科行改良法行左颈、右胸、腹部三切口食管癌根治术的675例患者的吻合口瘘的情况，以探讨吻合口瘘的防治，取得了较好效果，现介绍体会如下。1．资料与方法 1.1一般资料本组病人共675例，其中男471例，女204例，平均年龄64.4±11岁，病变位于中段565例（83.7%），上段42例（6.2%），下段68例(10.1%)，术前均未行放化疗，均经胃镜检查，病理学检查鳞癌672例，小细胞癌2例，肉瘤1例。1.2 手术过程 全麻成功后，手术分胸腹两组同时进行。患者取左侧卧位，右侧胸部抬高300。经右侧第4肋前外侧切口，进胸探查，探查显示肿瘤可以切除时，上腹部正中切口进入腹腔探查，无明显腹腔转移时，胸组沿肿瘤周围作锐性分离，逐一结扎切断食管的营养血管，清扫上纵隔淋巴结、双侧喉返神经淋巴结、气管隆突下淋巴结、食管旁淋巴结。胸段食管全部游离后，于膈上平面切断食管，并用碘伏消毒后双7号丝线分别结扎食管近远侧，食管上残端用胶皮套保护，食管下残端从裂孔推入腹腔。沿颈部左胸锁乳突肌前缘作斜切口，胸锁乳突肌向外牵开，显露甲状腺，在甲状腺后方显露并分离颈部食管，将胸部食管从颈部切口牵出。腹部手术组依次分离胃大弯及小弯，注意保护胃右及胃网膜右血管弓，常规清扫胃周及胃左淋巴结，沿胃小弯切除部分胃体及胃底形成“管形胃”。扩张食管裂孔，经裂孔将胃经纵隔食管床上提至颈部切口作吻合，行胃及食管双层手工吻合，缝合上纵隔胸膜，使“管形胃”置于纵隔食管床内，颈部肌层间断舒松缝合置入引流皮片保持引流通畅。2．结果 675例患者均完成食管次全切除、食管胃颈部吻合，术后发生吻合口瘘42例，瘘发生率为42/675(6.22%)，均瘘到颈部外，无1例瘘入胸腔，均经换药、营养支持、对症处理痊愈，平均住院时间延长12.5±8天，无1例围手术期死亡。3.讨论 根治性手术是食管癌的主要治疗手段。因食管癌发生、发展具有病灶多点起源和淋巴结双向、跳跃性转移的特点，常规食管癌切除有较高的局部复发率及远处转移率，而颈部、上纵隔淋巴结转移常是食管癌术后首发转移部位【4】。因此为提高手术后5年生存率，彻底切除病灶，清扫淋巴结很有必要。颈段及胸上段和部分中段食管癌与气管、喉返神经、主动脉弓等重要器官毗邻，手术创伤大、术后并发症多、死亡率高、远期疗效差，对外科医生要求较高。但三切口食管癌根治术，具有不切开膈肌，分离肿瘤不受主动脉弓影响，可避免对周围器官的损伤，对上纵隔及气管旁淋巴结清扫彻底，手术切除率高等优点，特别是术后发生吻合口瘘处理简单，病死率明显低于胸内吻合口瘘。国内报道颈部吻合口瘘为10%-20.6%【5,7】，本组患者颈部吻合口瘘发生率42/675(6.22%)。吻合口瘘发生率明显较低。对于吻合口瘘发生的原因，文献【6】认为食管癌术后吻合口瘘的发生主要和胃及食管的血运及吻合口张力有关。提高手术技巧及加强围手术期管理可以减少吻合口瘘的发生。我们的体会是：①术中注意保护胃网膜右血管弓及胃右血管，不要损失血管弓并保证血管弓不扭曲，保证胃的血供；②胃做成管状，文献【8】认为管状胃不仅能减少术后呼吸系统并发症的发生，而且能增加胃的长度、减少吻合口的张力及增加残胃的血运；③进腹后尽量吸尽胃内容物，减少胃的捻挫伤及吻合时涌出的胃液污染颈部切口；④粘膜对合良好及吻合口无皱缩是吻合口愈合良好的重要因素，胃食管颈部吻合时，胃壁上的切口一定要在最高点以减少吻合口的张力，胃壁上切口和食管的直径等长，使吻合口对合良好，缝合胃浆肌层及食管后壁3至4针后，先缝合食管及胃两侧角并留作牵引，由助手轻轻向两侧提起牵引线，以确保食管后壁和胃后壁无皱折，等距离缝合4至6针，特别注意进针时少带粘膜层多带肌层及外膜层已确保粘膜对合良好，同时注意线结不宜结扎过紧，以免造成胃及食管壁的切伤及影响吻合口血运，同法缝合前层，浆肌层缝合加固；⑤减少吻合口张力及增加吻合口的活动度是减少吻合口瘘的主要原因，我们在缝合胸顶时通常固定胃浆肌层4至5针于纵隔胸膜上，一般不缝合吻合口的胃壁与颈前筋膜，因为胃纵隔胸膜缝合足以对抗胃的重力引起的下降影响，并不会增加吻合口的张力，而胃壁未和颈前筋膜缝合，胃底有较好的升展性，使吻合口有足够的活动空间，减少了吻合口的张力；⑥颈部半片乳胶管引流，有不易堵塞，清洗方面等特点，一般放置4-6天，并每日用清洁棉签伸入颈部切口去除颈部分泌物，保证了引流通畅，有利于减少炎性渗出物对吻合口的侵蚀，并减少感染的发生率，且能较早发现吻合口瘘从而及时拆除颈部切口下方缝线，敞开切口以充分引流。在吻合口瘘引流治疗过程中，可从胃管或置入的十二指肠管注入营养液以促进胃肠功能的恢复，从而增强了患者的体质，缩短了吻合口瘘愈合时间。作者：束余声，男，汉，主任医师、硕士生导师，主要从事胸部肿瘤的研究。E-mail:shuyusheng65@163.com.参 考 文 献【1】王永岗,汪良骏,张德超等. 胸段食管鳞癌淋巴结转移特点及临床意义. 中华肿瘤杂志, 2000, 22 (3) : 241 - 243.【2】Stein HJ, Sendler A, Fink U, et al. Multidisciplinary approach to esophageal and gastric cancer. Surg Clin North Am, 2000, 80(2) : 659 - 682.【3 】万仁平,易云峰. 三切口食管癌切除术420例分析. 中国综合临床, 2006, 22 (4) : 372 - 373.【4】段红兵.63例食管癌三野根治术临床分析.福建医药杂志，2005，27（3）：59.【5】王敬华，刘增坤，辛绍平.食管贲门癌切除吻合方式与吻合口并发症关系的研究.肿瘤防治杂志，2002，9(1):74-75.【6】 张文山，潘开云，戴益智.三切口食管癌切除术后颈部吻合口瘘16例分析.福建医药杂志，2006,28(5)：78-79.【7】贲晓松，陈刚，唐继鸣,等.食管-胃颈部侧侧机械吻合法在三切口食管癌切除术中的应用.中国癌症杂志，2010,20(2):130-133【8】王家利，昂春臣，赵恒贻.胃管状成形术在三切口食管癌切除术中的应用.中国肿瘤临床与康复，2008,15(5)：434-435.

【摘要】目的 探讨电视纵隔镜下经颈小切口行胸腺切除治疗小儿重症肌无力的可行性和有效性。方法 选取2008年6月至2010年6月收治的12例重症肌无力合并胸腺增生或胸腺瘤形成的患儿行电视纵隔镜下经颈小切口行胸腺切除。 结果 12例患儿均经电视纵隔镜下颈部小切口完整切除胸腺及前纵隔脂肪，无1例患儿因出血或无法完整切除胸腺而中转开胸。术后随访6个月以上，症状均明显改善。 结论 电视纵隔镜下经颈小切口行胸腺切除治疗小儿重症肌无力具有创伤小，术后疼痛轻，并发症少，住院时间短等优点，是一种安全有效的手术方式。关键词：电视纵隔镜，胸腺切除，小儿重症肌无力Thymectomy through video-mediastinoscopy in the treatment of pediatric myasthenia gravisShu Yusheng, Sun Chao, Lu shichuenThe clinical medical college of YangZhou university （225001）[Abstract]:Objective To investigate the feasibility and effect of thymectomy through video-mediastinoscopy in the treatment of pediatric myasthenia gravis. Methods During June 2008 to June 2010,12 cases of pediatric myasthenia gravis company with thymic hyperplasia or thymoma were treated by thymectomy through video-mediastinoscopy. Results All the thymectomy could be done through video-mediastinoscopy. Thymus and fat in anterior mediastinum were ectomized completely.Follow-up was obtained above 6 months and symptoms were improved obviously. Conclusions Thymectomy through video-mediastinoscopy in the treatment of pediatric myasthenia gravis have many merits such as tiny wound,slight pain postoperation,few complications,short length of stay,etc.It is a safe and effective modus operandi.Key words: video-mediastinoscopy, thymectomy, pediatric myasthenia gravis 外科手术切除胸腺在治疗小儿重症肌无力方面有一定价值，但对胸腺切除术的手术指征及采取的手术径路仍然未取得共识。纵隔镜手术起初只用于颈部和上纵隔的活检和探查，摄像系统和纵隔镜的完美结合，即电视纵隔镜(video-mediastinoscopy,VM)，已不仅用于活检诊断，还用于纵隔疾病的治疗。我们从2008年6月至2010年6月,为12例重症肌无力合并胸腺增生或胸腺瘤形成的小儿患者行电视纵隔镜下经颈小切口胸腺切除，旨在探讨电视纵隔镜下经颈小切口胸腺切除治疗小儿重症肌无力的可行性和有效性。1.资料与方法1.1临床资料选取2008年6月至2010年6月收治的12例小儿重症肌无力合并胸腺增生或胸腺瘤形成的患儿作为研究对象。其中男性7例，女性5例，年龄8-15岁；9例为眼肌型，3例为眼肌型合并延髓型。术前胸部CT检查提示12名患儿均合并胸腺增生，其中4例伴有胸腺瘤形成，肿瘤直径2.3±1.1cm。所有患儿均经神经内科明确诊断及服用吡啶斯的明药物治疗，3例患儿接受长效类固醇药物治疗。术前行血常规，血糖，肝、肾功能，肺功能，心电图，腹部B超等常规检查，均未见明显异常。术前患儿服用常规剂量的吡啶斯的明（60mg.Q6-8h）。1.2手术方法患儿选择全麻气管插管。取仰卧位，手臂固定于两侧，肩背部垫高，头过度后仰, 使颈部充分伸展。按胸骨正中手术切口消毒铺巾，在胸骨切迹上2 cm处做3～4 cm横切口,逐层切开皮肤、皮下及颈阔肌至胸骨后间隙，沿此间隙置入纵隔镜，游离显露胸腺左右上极，分别使用双7号线结扎牵引，用自制胸骨悬吊拉钩牵引胸骨上端，充分暴露前纵隔，并使用光导纤维头灯帮助术野照明。利用“花生米”分离胸腺，并判断其质地，有无实质性肿瘤及与周围组织之间关系。首先游离胸腺后壁，解剖并显露无名静脉，找出胸腺动静脉，予钛夹钳闭或结扎后切断。此时需经颈置入纵隔镜，游离胸腺双下极及前纵隔脂肪，牵拉胸腺组织，将胸腺及前纵隔脂肪完整切除。仔细检查胸腺床有无活动性出血，并证实被切除胸腺组织的完整性，确认无名静脉、上腔静脉及主动脉弓上缘无残留胸腺和脂肪组织。切除胸腺大小平均约6.8cm×8.1cm。冲洗手术野，置入止血纱布，不需放置引流，分层关闭手术切口。2.结果12例患儿均顺利切除胸腺及前纵隔脂肪组织，无中转开胸，手术时间为112±20分钟，平均出血量约50ml。手术结束后，所有患儿均顺利拔除气管插管，术后继续使用吡啶斯的明药物治疗。患儿术后第一天便可下床活动，术后平均住院天数为3.5天。无切口感染、膈神经损伤、纵隔炎症及肺部感染等并发症的发生。术后随访6个月以上，根据陈志明的分级标准，术后患儿疗效分为优、良、中、差四级，本组4例患者术后疗效达到优，8例达到良。3.讨论重症肌无力是一种累及神经肌肉接头处突触后膜上乙酰胆碱受体，主要以乙酰胆碱受体抗体（AchRAb）介导，细胞免疫依赖并有补体参与的自身免疫性疾病【1】，与胸腺增生关系密切，重症肌无力患者约有15％伴有胸腺瘤或胸腺增生【2】。内科治疗主要包括应用抗胆碱酯酶药物，肾上腺皮质激素冲击，辅以免疫抑制剂治疗，但有效率较低，而胸腺切除术【3】【4】配合药物治疗是公认的治疗重症肌无力合并胸腺增生或胸腺瘤的主要方法,文献报道，其有效率可达80％【5】。通常采用正中全胸骨劈开切口，但此种手术方式创伤大，出血多，费用高，恢复慢，给病儿造成的心理影响也大。我们自2008年6月至2010年6月，采用电视纵隔镜下经颈小切口胸腺切除治疗小儿重症肌无力12例，经临床观察，我们认为该术式安全有效，值得推广。现在，对这一技术存在着争议主要是手术技术的可行性和疗效的可靠性。因无论采取哪一种手术方式，术中均要求完全切除胸腺和清除前纵隔脂肪组织才能达到治疗重症肌无力的目的。本组患儿均能通过颈部小切口电视纵隔镜下完成操作，证明此术式是可行的。无名静脉上方胸腺及胸腺动静脉各支均可在光导纤维头灯辅助下直视完成，纵隔镜主要使用于游离胸腺下极及前纵隔脂肪组织，保证胸腺的完全切除。本术式因不破坏胸部骨性支架及减少术后疼痛，这有利于重症肌无力使用糖皮质激素影响胸骨正中切口愈合的患儿。此外，本术式出血少，恢复快，费用低，住院时间缩短，减少切口感染、膈神经损伤、纵隔炎症及肺部感染等并发症的发生。与胸腔镜下胸腺切除术相比，解决了颈部胸腺上极无法完全切除的弊端【6】；而且患儿选择全麻气管插管时仅需要单腔气管导管，而不需要双腔气管导管，因为患儿太小无法行双腔气管插管；本术式不需要进入胸膜腔；术后不需要行胸腔闭式引流术，减少了术后患者行动的不便及胸腔粘连的发生，因此，这一术式经临床应用后不仅证明是安全可行的，而且较传统的正中切口及胸腔镜手术显示出其优越性。但此术式同时也有一定局限性，如胸腺肿瘤较大，一般大于4cm的情况下，或者胸腺与周围组织间隙不清则应慎重，此时需考虑胸骨正中切口。手术疗效与胸腺和纵隔脂肪组织是否完全清除干净有一定关系，但是否必须完全清除胸腺和纵隔脂肪组织才能达到最佳效果？经解剖学研究发现，异位胸腺组织广泛分布于前纵隔、后纵隔、颈部甚至到达腰部【7】【8】，故理论上完全消除异位胸腺组织是外科技术所不能达到的，所谓扩大切除术都是相对的。本组病例颈部小切口下纵隔镜辅以电视显示系统行胸腺扩大切除术均能完整切除胸腺及前纵隔脂肪，切除范围与胸部正中切口术式相仿，术后随访6月以上，症状均有效缓解，证明此术式对于治疗小儿重症肌无力合并胸腺增生或胸腺瘤是有效的。综上所述，电视纵隔镜下经颈小切口行胸腺切除治疗小儿重症肌无力在技术上是可行的，疗效是可靠的，是一项很有前景的技术，完全可以取代一部分传统开胸手术。参考文献1. 刘爱余,李柱一,张金妮,等.重症肌无力患者病情变化对单纤维肌电图jitter的影响[J].中国临床神经科学,2005,13(4):348-351.2. 侯熙德.神经病学[M].北京：人民卫生出版社，1996.204-2073.Jaretzki A, Steinglass KM, Sonett JR. Thymectomy in the management of myasthenia gravis. Semin Neurol,2004,24(1):49-624．潘文标，曹子昂，顾旭东等. 135例胸腺瘤的诊断和外科治疗[J].现代医学，2010,38（3）：260-2625. Prokakis C, Koletsis E, Salakou S, et al. Modified maximal thymectomy for myasthenia gravis: effect of maximal resection on late neurologic outcome and predictors of disease remission. The Annals of thoracic surgery.2009,88(5):1638-16456. 马山,于磊,景筠等.3种不同术式治疗重症肌无力的比较[J].中国微创外科杂志，2008，8（11）：967-9697. Zielinski M, Kuzdzal J, Szlubowski A,et al.Transcervical- subxiphoid-videothoracoscopic“maximal”thymectomy-operative technique and early results. Ann Thorac Surg, 2004,78(2):404-4098.张其刚，胡永校，李玉，等.61例重症肌无力病人前纵隔内异位胸腺分布规律[J].中华胸心血管外科杂志，1999，15（1）：39－40