现代二野淋巴结清扫食管癌切除术的疗效分析

Analysis of the therapeutic effect of esophagectomy with extended 2-field lymph node dissection for esophageal carcinoma

目的探讨食管癌切除现代二野淋巴结清扫的手术疗效及临床实际应用价值。方法1987年6月至2007年12月间，对1690例中下段及上段食管癌患者分别采用Ivor—Lewis术式和Akiyama术式进行现代淋巴结清扫治疗，总结胸腹二野淋巴结转移的发生率以及患者术后1、3、5和10年的生存率。结果全组患者中，有淋巴结转移713例，转移率为42．2％（713／1690）。胸部淋巴结转移665例，占39．3％（665／1690），其中右胸顶气管旁三角区淋巴结转移349例，占20．7％；后上纵隔淋巴结转移444例，占26．3％；下纵隔淋巴结转移307例，占18．2％。腹部淋巴结转移339例，占20．1％。全组患者术后有278例发生312例次各种并发症，并发症的发生率为16．4％（278／1690），其中以肺部并发症为主，共136例次，占43．6％。全组患者的手术死亡率为0．2％。全组患者术后1、3、5和10年生存率分别为88．2％（1388／1574）、63．5％（868／1367）、54．8％（705／1287）和30．8％（232／754）。无淋巴结转移患者的5年生存率为76．2％（448／588），有淋巴结转移患者的5年生存率为36．8％（257／699）。结论食管癌切除采用Ivor—Lewis和Akiyama术式可良好地显露胸腹二野，淋巴结清扫彻底，特别是对后上纵隔喉返神经旁、右胸顶气管旁三角区淋巴结的清扫尤为便利。对有淋巴结转移的食管癌患者施行现代二野淋巴结清扫十分必要，能显著提高患者的术后5年生存率。

Objective To summarize the surgical effect and clinical application value of esophagectomy with extended 2-field lymph node dissection for patients with esophageal carcinoma. Methods From June 1987 to December 2008, 1690 patients with esophageal cancer underwent esophagectomy with extended 2-field （thoracic and abdominal） dissection of lymph nodes. Patients with the middle and lower thoracic esophageal cancer underwent Ivor-Lewis esophagectomy, and patients with upper thoracic esophageal cancer underwent Akiyama esophagectomy. 2-field （thoracic and abdominal ） lymph node metastases information and the 1, 3, 5, 10-year survival rates were analyzed retrospectively. Results Lymph node metastases were found in 713 patients. The lymph node metastases rate was 42.2% （713/1690）. Thoracic lymph node metastasis rate was 39.3% （665/1690） , among which in the right pleura] apical para-tracheal triangle was 20.7% （349/1690）, in the posterior upper mediastinum was 26.3% （444/1690）, in the lower mediastinum was 18.2% （307/1690）. Abdominal lymph node metastasis rate was 20.1% （339/1690）. THE Postoperative complication rate was 16.4% （278/1690） , among which the pulmonary complication rate ranking the first, was 43.6% （136/312）. The operative mortality rate was 0.2%. The 1- year, 3-year, 5-year and 10-year survival rates were 88.2% （ 1388/1574）, 63.5% （868/1367）, 54.8% （705/1287） and 30.8% （232/754）, respectively. The 5-year survival rate in patients without lymph node metastasis was 76.2% （448/588）, but that in patients with lymph node metastases was 36.8% （257/669）. Conclusion The results of this study demonstrated that Ivor-Lewis and Akiyama esophagectomy with two-field lymph node dissection exposes the operation fields clearly and make radical lymphadenectomy thoroughly, especially the lymph nodes in the posterior upper mediastinum around the recurrent laryngeal nerve and in the right pleural apical para-tracheal triangle. It is essential that patients with esophageal carcinoma with lymph node metastases should undergo esophagectomy with extended 2-field dissection of lymph nodes. This can elevate the postoperative 5-year survival rate remarkably.