总结腔镜辅助下McKeown术式切除食管癌的单中心18年经验体会。

回顾性分析1997年8月至2015年6月在温州医科大学附属台州医院胸外科行食管癌切除的639例患者的临床资料，其中在腔镜辅助下完成McKeown食管癌切除手术622例(97.34%)。食管肿瘤位于上、中、下段分别占7.98%、63.54%和28.48%，其中8.92%的患者术前接受放化疗。TNM分期中，0、Ⅰ、Ⅱ、Ⅲ、Ⅳ期分别占10.33%、29.26%、42.10%、15.02%和3.29%；病理检查为鳞癌占92.02%，腺癌及其他类型占7.98%。手术采用腔镜辅助下经右胸、上腹、左颈入路，其中胸腔镜＋开腹占44.60%，胸腔镜＋腹腔镜占47.26%，开胸＋腹腔镜占5.48%，非计划中转开胸或开腹占2.66%。

胸腔镜下食管游离及胸腔淋巴结清扫时间为(78.6±36.9)min，腹腔镜下胃游离及腹区淋巴结清扫时间为(55.4±19.5)min；胸腔镜手术出血量为(99.5±79.2)ml，腹腔镜手术出血量为(40.5±23.4)ml。每例患者平均清扫淋巴结总数为(24.1±12.4)枚，其中胸腔淋巴结清扫(14.9±8.1)枚，腹腔淋巴结清扫(9.1±5.5)枚，颈区淋巴结清扫(1.5±1.3)枚。全组术中无死亡病例，术中因奇静脉或脾脏损伤出血4例，电凝钩或超声刀误伤气管4例，非病灶原因胸导管损伤13例，心房纤颤11例，食管切缘阳性R₁切除者4例。术后早期并发症超过10例次的包括肺部感染(11.42%)、颈部吻合瘘(7.04%)、心律失常(4.85%)、胸腔积液需要置管(3.29%)、喉返神经损伤(3.13%)，术后乳糜胸(2.03%)。术后早期死亡6例(0.94%)，分别为术后呼吸衰竭3例、气管管胃瘘后肺部严重感染1例、难控性高血糖并颈部吻合口瘘迁延不愈及多器官衰竭1例、胸胃瘘或坏死致主动脉腐蚀破裂出血1例。术后接受放化疗307例(48.04%)；术后随访率为90.8%，平均随访时间(44.5±33.1)个月；术后1、2、3、5年的生存率分别为83.9%、69.7%、57.1%和45.5%。

腔镜辅助下McKeown术式食管癌切除在肿瘤R₀切除，以及术后近远期疗效上是可行且有效的。

To summarize the 18-year experience in video-assisted McKeown esophagectomy for esophageal cancer.

The clinical data of 639patients with esophageal cancer undergoing McKeown esophagectomy between August 1997 and June 2015 in Department of Thoracic Surgery, Taizhou Hospital affiliated to Wenzhou Medical University were retrospectively analyzed. Among these 639 patients, 622(97.34%) completed the surgery with video-assisted procedures. A total of 7.98% of esophageal tumors located in the upper segment, 63.54% in the middle segment, and 28.48% in the lower segment.Preoperative neoadjuvant chemoradiotherapy was done in 8.92% of patients. For TNM staging, stage 0 accounted for 10.33%, stage Ⅰ29.26%, stage Ⅱ 42.10%, stage Ⅲ15.02% and stage Ⅳ 3.29%. Pathological examinations demonstrated that there were 92.02% of squamous cancer and 7.98% of adenocarcinoma and other histological types.Surgery were completed by thoracoscopy and laparotomy(44.60%), thoracoscopy and laparoscopy(47.26%), thoracotomy and laparoscopy(5.48%), and conversion to thoracotomy or laparotomy (2.66%).

The time of esophagus freeing and pleural lymph node dissection under thoracoscope was (78.6±36.9)min, and the time of stomach freeing and abdominal lymph node dissection under laparoscope was (55.4±19.5) min. The volumes of blood loss in thoracoscopic surgery and laparoscopic surgery were (99.5±79.2) ml and (40.5±23.4) ml respectively. The mean total number of lymph node dissection was(24.1±12.4) per case, and the number of thoracic lymph node dissection was (14.9±8.1) per case, abdominal lymph node dissection (9.1±5.5) per case, and neck lymph node dissection (1.5±1.3) per case. There was no death during operation. There were 4 cases of intraoperative bleeding due to the azygos vein or spleen injury, 4 cases of accidental tracheal injury caused by cautery hook or ultrasound knife, 13 cases of thoracic duct injury of non-focal cause, 11 cases of atrial fibrillation and 4 cases of esophageal resection margin-positive R₁ resection. The major complications in the early postoperative period which occurred in more than 10 cases were lung infection(11.42%), neck anastomosis leak(7.04%), arrhythmia(4.85%), pleural effusion catheterization(3.29%), recurrent laryngeal nerve injury(3.13%) and chylothorax(2.03%). Six cases(0.94%) died early after operation. Among them, 3 died of postoperative respiratory failure, 1 severe pulmonary infection after tracheoesophageal fistula, 1 recurrent hyperglycemia complicated with neck anastomotic fistula uncured and multiple organ failure, and the other aorta rupture and bleeding caused by chest gastric fistula or necrosis. Three hundred and seven patients (48.04%) received postoperative radiotherapy and chemotherapy. The follow-up rate was 90.8%, and the mean follow-up time was (44.5 ± 33.1) months.The 1, 2, 3, and 5-year overall survival rates were 83.9%, 69.7%, 57.1%and 45.5%, respectively.

Video-assisted McKeown esophagectomy for esophageal cancer is feasible and effective in tumor R₀ resection and short-term and long-term effects.