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目的:改进食管、贲门癌的手术入路,提高手术切除率,降低残端癌发生率、手术死亡率等。方法:1990年3月～2008年3月对667例食管、贲门癌患者,分别采用左胸后外侧切口152例,左胸后外侧+左颈部切口150例,左胸腹联合切口76例,右胸后外侧+右颈+上腹切口52例。右胸后外侧+左颈+上腹切口38例,右胸后外侧+颈U形+上腹切口12例,右胸后外侧+上腹切口36例,右胸前外侧+上腹切口137例,右胸腹联合切口8例,右胸腹联合+右颈切口2例,上腹正中切口4例。结果:食管切端癌发生率1.2%(8/667)吻合口瘘5.25%(35/667),术后心、肺、脑、肾并发症11.39%(76/667),手术病死率2.25%(15/667),手术切除667例中姑息性切除489例73.31%(489/667)。结论:右胸、颈、腹三切口可彻底清扫颈、胸、腹各组区域淋巴结,能有效减少切端癌的发生,其三野淋巴结清扫是外科治疗的方向。术中摇床的右胸前外侧切口及右胸腹联合切口,减少了切口,且避免了术中变换体位对病人的打击小,提倡同道试用。贲门癌上腹正中切口因术后切端癌、吻合口瘘发生率高应废弃,选左胸腹联合切口为佳。另外,食管CT增强扫描是选择手术入路的有效措施。
Objective: To improve the surgical approach of esophageal and cardiac cancer, improve the surgical resection rate, reduce the incidence of stump cancer, operative mortality and so on. Methods: From March 1990 to March 2008, 667 patients with esophageal and cardiac cancer were treated with left thoracotomy, 152 with left thoracotomy, 150 with left thoracotomy, left thoracic incision, 76 with left thoracoabdominal incision, Right chest right lateral + right incision in 52 cases. Right chest thoracotomy + left neck + upper abdominal incision in 38 cases, right thoracic outside + neck U-shaped + upper abdominal incision in 12 cases, right thoracic outside + upper abdominal incision in 36 cases, right thoracic lateral + abdominal incision in 137 cases , Right thoracoabdominal incision in 8 cases, right thoracoabdominal + right cervical incision in 2 cases, the median incision in 4 cases. Results: The incidence rate of endoscopic esophagectomy was 1.2% (8/667) and 5.25% (35/667) respectively. The postoperative cardiac, lung, brain and renal complications were 11.39% (76/667) and the operative mortality was 2.25% 15/667). Of the 667 surgically resected patients, 489 (73.31%) had palliative resection (489/667). Conclusion: The right thoracic, cervical and abdominal incision can completely clean the cervical, thoracic and abdominal regional lymph nodes, which can effectively reduce the incidence of end-cancer. The three-node lymphadenectomy is the direction of surgical treatment. Intraoperative intra-cranial right anterior chest thoracotomy and right thoracotomy incision, reducing the incision, and to avoid intraoperative change positions on the patient’s small, advocating fellow trial. Cardiac cancer abdominal incision due to postoperative cut end of cancer, high incidence of anastomotic leakage should be abandoned, choose the left thoracoabdominal incision better. In addition, esophageal CT enhanced scan is an effective measure to choose the surgical approach.