胸腔镜下系统纵隔淋巴结清扫在食管癌外科治疗中的临床价值

Clinical value of thoracoscopic extensive mediastinal lymphadenectomy in the surgical treatment of esophageal carcinoma

目的：探讨胸腔镜下系统纵隔淋巴结清扫的安全性和可行性。方法回顾性分析2009年5月至2011年12月间四川大学华西医院采用胸腹腔镜联合食管切除术治疗的125例食管癌患者的临床资料。根据患者是否行系统纵隔淋巴结清扫分为系统清扫组（72例）和非系统清扫组（53例），比较两组的围手术期指标。结果与非系统清扫组相比，系统清扫组胸部手术失血量减少[（140．6±62．1） ml比（167．7±69．2） ml，P＜0．05]，胸部淋巴结清扫数目增多[（12．2±4．2）枚比（9．0±4．1）枚，P＜0．01]。系统纵隔淋巴结清扫可使每例患者额外清扫出（2．4±1．5）枚喉返神经旁淋巴结，其阳性率为23．6％（17/72），其中7例（9．7％）患者术后TNM分期升级。两组患者在胸部手术时间、ICU监护时间、术后住院时间、术后并发症发生率及围手术期死亡率方面的差异均无统计学意义（P＞0．05）。结论胸腔镜下系统纵隔淋巴结清扫术安全可行，不仅可以增加纵隔淋巴结清扫的数目、提高术后TNM分期的准确性，而且并不会增加围手术期并发症发生率和病死率。

Objective To explore the safety and feasibility of extensive mediastinal lymphadenectomy during thoracoscopic esophagectomy in the treatment of esophageal carcinoma. Methods Clinical data of 125 patients with esophageal carcinoma undergoing thoracoscopic and laparoscopic esophagectomy （TLE） in West China Hospital of Sichuan University between May 2009 and December 2011 were retrospectively analyzed . Patients were divided into 2 groups： non-extensive mediastinal lymphadenectomy group （non-extensive group, n=53） and extensive mediastinal lymphadenectomy group （extensive group, n=72）. Perioperative outcomes of these two groups were compared. Results No significant differences were found in the time of thoracic operation , length of intensive care unit stay and postoperative hospital stay , postoperative complication and the overall mortality between the two groups. Compared with non-extensive group , extensive group showed less blood loss during thoracic operation[（140.6±62.1） ml vs. （167.7±69.2） ml, P=0.023], more thoracic lymph nodes harvested （12.2 ±4.2 vs. 9.0 ±4.1, P〈0.01）. Seventeen patients （23.6%） in extensive group were found to have positive recurrent laryngeal nerve lymph nodes , which resulted in upstaging of TNM in 7 patients （9.7%）. The incidence of recurrent laryngeal nerve palsy was higher in extensive group as compared to non-extensive group, but the difference was not statistically significant （6.9% vs. 1.9%, P=0.240）. Conclusion Extensive mediastinal lymphadenectomy during thoracoscopic esophagectomy is a feasible and safe procedure for esophageal carcinoma patients , which can increase the number of harvested lymph node and the accuracy of tumor staging.