改良Ivor-lewis与经左胸一切口手术治疗胸中段食管鳞癌的临床分析

Clinical analysis of modified Ivor-lewis esophagectomy and one-incision esophagectomy via left thoracic pathway in the treatment of middle thoracic esophageal squamous cell carcinoma

目的比较改良Ivor-lewis和经左胸一切口两种手术方式治疗胸中段食管鳞状细胞癌的疗效,并对两种手术方式进行临床评价。方法回顾性分析本院胸外科2004年3月~2006年8月间进行的273例食管中段鳞癌手术临床资料,改良Ivor-lewis术式（改良Ivor-lewis组）189例,经左胸一切口术式（经左胸组）84例。对两组的3年和5年生存率、3年肿瘤局部复发率、淋巴结清扫数目、切缘阳性率、围术期并发症、手术时间等进行对比研究。结果改良Ivor-lewis组3年生存率为59.5%,经左胸组为60.3%（P=0.312）,5年生存率分别为37%和38.1%（P=0.868）;改良Ivor-lewis组3年肿瘤局部复发率为33.9%,经左胸组为46.4%（P=0.048）;改良Ivor-lewis组和经左胸组平均清扫淋巴结数分别是（16.5±2.5）枚和（11.1±2.5）枚（P〈0.001）;上切缘阳性率分别为1.1%和7.1%（P=0.018）;改良Ivor-lewis组和经左胸组的并发症发生率分别是38.6%和44%（P=0.399）,其中改良Ivor-lewis组的胃潴留发生率较高（P=0.015）,而经左胸组的吻合口瘘发生率较高（P=0.040）;手术时间分别为（3.15±0.5）h和（3.07±0.49）h（P=0.216）。结论改良Ivor-lewis术式和经左胸一切口术式均可作为胸中段食管鳞癌的候选手术方式,但在3年肿瘤局部复发率、平均清扫淋巴结的数目、切缘阳性率及术后吻合口瘘严重并发症发生率方面,改良Ivor-lewis手术有一定优势。

Objective To compare the modified Ivor-lewis esophagectomy and one-incision esophagectomy via left thoracic pathway in the treatment of middle thoracic esophageal squamous cell carcinoma,and evaluate the clinical efficacy of the two different surgical methods.Methods The clinical data of 273 patients with middle thoracic esophageal squamous cell carcinoma between March 2004 and August 2006 in our hospital were retrospectively analyzed.A total of 189 patients received modified Ivor-lewis esophagectomy and 84 patients received one-incision esophagectomy via left thoracic pathway.The 3-year and 5-year survival rates,the 3-year recurrence rate of local carcinoma,the number of lymph node dissection,the surgical margin-positive rate,the perioperative complications and the operation duration were comparatively studied.Results The 3-year survival rates of the modified Ivor-lewis esophagectomy and one-incision esophagectomy via left thoracic pathway were 59.5% and 60.3%（P=0.312）.The 5-year survival rates of the modified Ivor-lewis esophagectomy and one-incision esophagectomy via left thoracic pathway were 37% and 38.1%（P=0.868）.The 3-year recurrence rates of local carcinoma of the modified Ivor-lewis esophagectomy and one-incision esophagectomy via left thoracic pathway were 33.9% and 46.4%（P=0.048）.The numbers of lymph node dissection of the modified Ivor-lewis esophagectomy and one-incision esophagectomy via left thoracic pathway were 16.5±2.5 and 11.1±2.5（P〈0.001）.The surgical margin-positive rates of the modified Ivor-lewis esophagectomy and one-incision esophagectomy via left thoracic pathway were 1.1% and 7.1%（P=0.018）.The rates of perioperative complication of the modified Ivor-lewis esophagectomy and one-incision esophagectomy via left thoracic pathway were 38.6% and 44%（P=0.399）,in which the gastric retention was higher in modified Ivor-lewis esophagectomy（P=0.015） and the anastomotic leakage was higher in one-incision esophagectomy via left thoracic pathway（P=0.040）.Operation duration of the modified Ivorlewis esophagectomy and one-incision esophagectomy via left thoracic pathway were 3.15±0.5 h and 3.07±0.49 h（P=0.216）.Conclusion Both the modified Ivor-lewis esophagectomy and one-incision esophagectomy via left thoracic pathway are feasible alternatives in the treatment of middle thoracic esophageal squamous cell carcinoma,but the modified Ivor-lewis esophagectomy has some advantages in the 3year recurrence rate of local carcinoma,the average number of lymph node dissection,the surgical margin-positive rate and complication rate of serious postoperative anastomotic leakage.