全腔镜下超二野淋巴结清扫食管鳞癌根治术临床疗效分析

Minimally invasive esophagectomy combined with super-extended two-field lymph node dissection for squamous cell esophageal carcinoma:early results

目的探讨全腔镜下超二野淋巴结清扫食管鳞癌切除术的安全性和早期肿瘤学效果。方法收集2012年5月至2013年12月在我院行全腔镜食管癌手术患者资料。手术方式均为McKeown三切口食管鳞癌根治术（右胸、腹部、左颈部），淋巴结清扫范围包括全纵隔、双侧下颈段食管旁、腹腔。结果全组患者共49例，其中男性44例，女性5例，年龄45～78岁，中位年龄58岁。I期患者共16例（32．7％）。R。切除48例（98．0％）。术后并发症发生率36．7％（18／49），吻合口瘘9例（18．4％），喉返神经麻痹7例（14．3％）。术后早期死亡1例。平均淋巴结清扫个数18枚，淋巴结转移率42．9％（21／49），其中上纵隔及下颈部食管旁淋巴结转移者占28．6％（6／21）。随访超过1年的18例患者中复发者7例，复发率为38．9％，区域淋巴结转移和血行转移分别为5例和2例。结论超二野微创食管切除技术获得美国国立综合癌症网络（NCCN）推荐的淋巴结清扫效果，手术安全；但近期随访结果提示区域淋巴结复发率高于远处转移，提示纵隔淋巴结清扫应更为彻底。

Objective To assess the safety and early oncologic results of minimally invasive esophagectomy （MIE） combined with super-extended two-field lymph node dissection for treating esophageal squamous cell carcinoma. Methods A total of 49 patients who underwent MIE through McKeown approach （right chest, left neck, and abdomen） between May 2012 and Dec. 2013 were enrolled in this study. Lymph node dissection fields included whole mediastinum, lower para-esophagus via thoracoscope route, and abdomen. Results The patients included 44 males and 5 females, with an age range of 45-78 years old and a median of 58 years old. Sixteen （32.7%） patients were at Stage I . Forty-eight （98.0%） patients received complete resection, and 18 （36.7%） patients had post-operation complications, including 9（18.4%） with neck leakage and 7 （14.3%） with vocal cord paralysis. Post-operative early death occurred in one case. The mean number of removed lymph nodes was 18 and the lymph node metastasis rate was 42. 9% （21/49）; 28. 6% （6/21）of the positive nodes were found in the upper mediastinum and lower para-esophagus areas. Seven of the 18 patients who were followed up had recurrence, with a recurrent rate of 38.9 %. The 7 cases included 5 in the locoregional areas and 2 in distant organs. Conclusion MIE combined with super two-field dissection can achieve the lymphadenectomy effect recommended by National Comprehensive Cancer Network （NCCN）, with satisfactory safety. Short-term follow-up indicates that the locoregional recurrence is more frequent than distant metastases, demanding more thorough mediastinal lymph node dissection.