保留喉功能的非开胸食管拔脱下咽颈段食管癌切除术

【摘要】目的探讨保留喉功能的非开胸食管拔脱切除颈段食管癌及胃上提、结肠上徙代食管的治疗经验。方法 非开胸食管拔脱切除颈段食管癌24例，其中T2N02例,T2N11例,T3N05例,T3N16例,T4N05例,T4N15例,均为鳞状细胞癌。17 例保留喉功能。重建食管用胃上提(19例)或结肠上徙(5例)。24例均清扫颈部及上纵隔气管食管旁淋巴结, 7例喉侵犯严重者做全喉切除,甲状腺叶切除术15例。术前或术后给予放疗。结果 T2期3和5年生存率者分别为3/3例、1/1例,T3、4期患者3和5年生存率分别为8/19例和3/8例。17例保留喉功能,喉功能保留率77.3%(17/22),术后拔管率75.0 %(12/16)。并发症发生率为29.2%,包括咽瘘2例次,颈部吻合口狭窄1例次,吻合口瘘1例次,腹壁刀口裂开1例次,胸腔积液、气胸各1例次。结论　颈段食管癌可以行非开胸食管拔脱一期切除肿瘤及周围受侵组织,并尽可能保留喉功能。利用胃上提、结肠上徙重建食管,联合放射治疗,可以提高患者的术后生存率和生存质量。 【关键词】 颈段食管癌／外科手术；食管成型术;胃;结肠　Substituting esophagus with stomach or colon without chest break in the treatment of cervical esophagus carcinoma with laryngeal function preserved DU Xiaodong*, SHUChang*,YOU Qingjun*.*Fourth Hospital of Shuzhou University,Wuxi 214062. Abstract　Objective To study the feasibility and effect of substituting esophagus with stomach　or colon without chest break in the treatment of cervical esophagus carcinoma. Methods Twenty-four patients with cervical esophageal carcinoma were  retrospetive studied,including 22 males and 2 females.There were 2 patients in  T2N0,1 in T2N1,5 in T3N0,6 in T3N1,5 in T4N0,5 in T4N1. The esophaguses were resected and substituted with 19 stomach pulling-up and 5 colon interposition. Nineteen patients received radio therapy postoperatively(dose50-70Gy).Results Twenty two patients’follow-up was over 3 years.Three and one patient in T2 survived 3 and 5 years. Three and five year survival rates for T3-4 were 8/19 and 3/8. The laryngeal function  preservation rate was 77.27% (17/24)and the decannulation rate was 75.00 %(12/16).The incidence of complication was 29.17%,including pharyngeal fistulas in 2cases,cervical stomal fistula in 1,cervical stomal stenosis in 1, splitting of abdominal wall in 1,hydrothorax in 1 and pneumothorax in 1. Conclusions Surgical resection of cervical esopphageal carcinoma and resolvation of the extraesophageal invasion is possible.The continuity of the esophagus is restored by stomach transposition and colon interposition, Three fourth of the patients’laryngeal function can be preserved.Combined with radio therapy,the resectability, survival rate and life quality of the cervical esophageal carcinoma can be improved. Cervical esophageal cancer must be managed by otolaryngeal head and neck surgeons under the support of thoracic and abdominal surgeons and radiotherapists. Key words:Cervical esophagus carcinoma; Esophagoplasty;Stomach;Colon 近年来，我科在治疗晚期下咽癌基础上，发挥专科特长,与胸外科合作，开展了保留喉功能的非开胸食管拔脱一期切除颈段食管癌手术，采用胃上提、结肠上徙等方法重建食管, 取得了较为满意的生存率和术后生存质量,使手术成为颈段食管癌的首选治疗方法。现将24例颈段食管癌的治疗情况报告如下。 临床资料 1994年7月～2007年4月间，我院耳鼻咽喉科-头颈外科和胸外科共收治颈段食管癌37例,其中行非开胸食管拔脱治疗24例。男22例,女2例；年龄33～73岁,平均57.8岁。TNM分期：T2N02例,T2N11例,T3N05例,T3N16例,T4N05例,T4N15例,全部患者均无远处转移。 手术方法：24例患者中，行气管切开术21例,未行气管切开术1例,术前曾患喉癌已做全喉切除气管造瘘术2例。颈廓清术后,切除患侧甲状软骨后1/2～1/3,由梨状窝进入下咽腔,从上界开始切除肿瘤,安全切缘1.5cm,如果侵犯喉部,则根据情况做相应喉部分切除或全喉切除，喉部分切除修复材料:带状肌筋膜、单蒂或双蒂胸骨舌骨肌肌瓣、颈前肌皮瓣、甲状软骨膜加带状肌。清扫上纵隔的气管食管旁淋巴结后，四周分离食管床。切除肿瘤采用非开胸食管拔脱法,其中内翻拔脱23例，外翻拔脱1例。重建食管采用胃上提(19例)或结肠上徙(5例)代食管。胃上提代食管者经食管床18例,经胸骨后1例;结肠上徙代食