腔镜食管癌切除术的现状.ppt

食管癌的微创切除术MinimallyInvasiveEsophagectomy,提纲,1.指导思想1)以分期为基础2)以功能保护为手段3)提高手术产出为目标2.腔镜食管癌切除术的现状3.腔镜食管癌切除术展望和思考,指导思想-以分期为基础,准确的分期，才有合理的治疗。食管癌不同的分期，有不同的微创治疗方法，熟练掌握其技巧并严格掌握其适应证，才能真正体现“以病人为中心”的现代人文关怀之理念。,食管癌的微创治疗,一、食管癌EMR/ESD（T1a1bN0）二、食管拨脱术（Ia/Ib-T1-2N0）三、胸腔镜食管癌切除术（T13N02？）四、食管支架置入术(部分IIIc/IV期)？,sm3,日本食管疾病学会按癌灶的浸润深度进一步把粘膜内癌（mm癌）与粘膜下癌（sm癌）各细分为三个亚型。ep，上皮层；lpm，固有膜层；lmm，粘膜肌层；sm，粘膜下层。,粘膜内癌与粘膜下癌的亚型,早期食管癌内镜治疗（T1aN0）,已具备良好的诊治技术的基础1)放大电视内镜、色素内镜2)内镜超声检查(EUS)微型超声探头EUS引导下细针穿刺吸引活检(FNAB）3)多种治疗技术的联合应用放疗、EMR/APC/PTD可保全解剖及生理功能,.,食管拨脱术（Ia/Ib-T1-2N0）,一个体位（截石位最优）创伤比VATS更小较适合低位颈段、胸腔入口、腹段食管肺功能较差者不开胸，不破坏胸廓,不能清扫淋巴结,ABCDEFA自制食管支架BWCEPC国产钛镍合金支架DGaiturcoZ-stentEUltraflexFWallstent,食管支架置入术(部分IIIc/IV期),MIE的发展历史,1994McAnena胸腔镜游离食管1995Depaula腹腔镜制作管状胃1998Lukitech胸腔镜联合腹腔镜食管癌根治术,McAnenaOJ,RogersJ,WilliamsNS.Rightthoracoscopicallyassistedoesophagectomyforcancer.BrJSurg1994;81:236-238DePaulaAL,HashibaK,FerreiraEA,etal.Laparoscopictranshiatalesophagectomywithesophagogastroplasty.SurgLaparoscEndosc1995;5:1-5LuketichJD,NguyenNT,WeigelT,etal.Minimallyinvasiveapproachtoesophagectomy.JSLS1998;2:243-247,MIE的种类,经胸腔食管切除术（TransthoracicEsophagectomy,TTE)胸腔镜+常规开腹腹腔镜+常规开胸全腔镜（颈部或右胸顶吻合）经膈裂孔食管切除术（TranshiatalEsophagectomy,THE)腹腔镜纵隔镜+常规开腹纵隔镜+腹腔镜,Orvil,Nguyenetal.(California)AnnThoracSurg2008;86:98993,适应证,与开放相似技术为基础学习曲线,胸部体位,腹部体位,麻醉,双腔单腔+Forgantyballoon单腔+人工气胸,质量控制,1.肿瘤完全切除的观念长度/径向淋巴结的范围(解剖边界)及个数2.无瘤观念(标本的取否?)3.外科技术4.良好的设备,.,3-field,Dissectionfield,1,2,推荐6nodes:UICC食管癌分期6th版本（2002）推荐12nodes:AJCC食管癌分期7th版本（2009）推荐15nodes:BollschweilerE,etal.JSurgOncol.2006;94:355-363.推荐18nodesGreensteinAJ,etal.Cancer.2008;112:1239-1246RizkN,etal.JThoracCardiovascSurg.2006;132:1374-1381.推荐19nodesBogoevskiD,etal.AnnSurg.2008;247:633-641.其他23nodesPeyreCG,etal.AnnSurg.2008;248:549-556.30nodesSchwarzRE,etal.JGastrointestSurg.2007;11:1384-139340nodesAltorkiNK,etal.AnnSurg.2008;248:221-226.,淋巴结切除个数与预后的相关研究,AnnSurgOncol(2010)17:19011911Hao-XianYang,Jian-HuaFu,etal,临界点的界定,长期生存率,EsophagectomywithSuperextended2-fieldLND,Inf.thyroidealartery,Right.phrenicnerve,Rightrecurrentnerve,Es,Tra,Mediastinallymphnodedissection,Rt.bronchialartery,Thoracicduct,Leftrecurrentnerve,Ao,Tra,Vagusnerve,Esophagus,Lymphnodedissectionalongtherecurrentnerves,不同MIE的手术并发症,DeckerG,CoosemansW,DeLeynP,etal.Minimallyinvasiveesophagectomyforcancer.EurJCardiothoracSurg2009;35:13-20;discussion20-11,OR：0.58（95%CI：0.35-0.98）,OR：0.52（95%CI：0.32-0.84）,NagpalK,AhmedK,VatsA,etal.Isminimallyinvasivesurgerybeneficialinthemanagementofesophagealcancer?Ameta-analysis.SurgEndosc2010;24:1621-1629,HybridSurgeryVSOpenSurgery,MIE的淋巴结清扫,NagpalK,AhmedK,VatsA,etal.Isminimallyinvasivesurgerybeneficialinthemanagementofesophagealcancer?Ameta-analysis.SurgEndosc2010;24:1621-1629VerhageRJ,HazebroekEJ,BooneJ,etal.Minimallyinvasivesurgerycomparedtoopenproceduresinesophagectomyforcancer:asystematicreviewoftheliterature.MinervaChir2009;64:135-146,UrsZingg,MD,etal.AnnThoracSurg2009;87:9119,生存率比较(MIEv.sOE),Jang-MingLeeetal.(Taiwan)WorldJSurg(2011)35:790797,MIE对生存率有无影响？,MIE,Open,P=0.826,ZinggU,McQuinnA,DiValentinoD,etal.Minimallyinvasiveversusopenesophagectomyforpatientswithesophagealcancer.AnnThoracSurg2009;87:911-919LeeJM,ChengJW,LinMT,etal.Isthereanybenefittoincorporatingalaparoscopicprocedureintominimallyinvasiveesophagectomy?Theimpactonperioperativeresultsinpatientswithesophagealcancer.WorldJSurg2011;35:790-797,MIE的评价,MIE可安全替代开胸手术，其优点：减少术后并发症，特别是呼吸道并发症缩短住院时间，失血量减少清扫范围与开放手术相同不影响长期生存仍需前瞻性临床对照研究,在中国提高疗效?,左右胸N0左右胸,左/右胸入路生存比较癌症2009，28（12）：12601264,DFS,OS,Complicationsofrightorleftsideapproach(74pairsT1-3N0M0,Case-math1:1,65y),SYSUCC,功能保护(一),功能保护(二),右主支气管动脉,奇静脉/支气管动脉的保护,功能保护(三),选择性隆突下淋巴结清扫?,各种临床病理因素与隆突下淋巴结转移状态的关系,生存曲线,胸上段患者清扫组与未清扫组生存分析(48.8vs45.0%，P=0.568),清扫与不清扫隆突下淋巴结对围术期的影响,a.包括：肺部感染、气胸、肺不张、ARDS、脓胸、痰堵。,Traditionalinvasivevs.minimallyinvasiveesophagectomy:amulti-center,randomizedtrial(TIME-trial)Trialregistration(NetherlandsTrialRegister)NTR2452,Secondaryendpoint:qualityofthespecimensurvivalbloodlossconversiontoo