机器人辅助下食管肿瘤全系膜切除与胸导管旁淋巴结转移规律

Robot-assisted total mesoesophageal excision for esophageal cancer and metastasis of thoracic duct lymph nodes

目的总结上海交通大学附属胸科医院近期开展的机器人辅助食管肿瘤全系膜切除术的手术经验,分析胸导管旁淋巴结分布规律、转移概率和影响因素,为该项术式的临床应用提供数据支持。方法回顾上海交通大学附属胸科医院2020年1—3月于机器人辅助下行食管肿瘤全系膜切除手术治疗的鳞状细胞癌患者的临床资料。总结和分析患者的一般情况、术前治疗方案、手术过程,以及术后病理学检查结果,分析术后并发症发生情况和胸导管旁淋巴结转移规律。结果共纳入26例患者,其中男24例、女2例,年龄为(65.9±6.8)岁,肿瘤位置以食管中下段为主(21/26,80.8%);肿瘤临床T分期以T 3为主(15/26,57.7%);临床淋巴结N分期阳性患者占88.5%(23/26);TNM分期以Ⅲ期病变为主(16/26,61.5%)。术前13例(50%)患者接受了新辅助治疗[诱导化学治疗(简称化疗)2例、诱导放射治疗(简称放疗)+化疗5例、诱导化疗+免疫治疗6例]。患者术后3 d内引流的胸腔积液为(209±196)mL/d,术后胸腔引流管拔除时间为4(3,5)d,术后住院时间为8(7,10)d,所有患者住院期间无死亡病例。术后并发症总体发生率为38.5%(10/26),Clavien-Dindo分级Ⅲ级以上患者为3.8%(1/26),喉返神经麻痹发生率为19.2%(5/26),乳糜胸发生率为11.5%(3/26),无吻合口瘘。术后病理学检查结果显示57.7%(15/26)的患者在胸导管旁发现淋巴结,中位直径为0.4(0.2,0.8)cm,19.2%(5/26)患者胸导管旁淋巴结转移(TDLN)呈阳性。肿瘤退缩分级1级患者占69.2%(9/13),病理完全缓解率为53.8%(7/13)。分析TDLN阳性和TDLN阴性两组患者,TDLN阳性多发生于食管下段病变(P=0.071);两组患者临床和病理学T分期的差异无统计学意义(P=0.628、0.330)。比较两组患者临床和病理学N分期,TDLN阴性组临床N 0~1分期患者人数占总人数的比例为71.4%,N 2~3分期比例为28.6%,病理学N 0~1分期比例为85.7%,N 2~3分期比例为14.3%;而TDLN阳性组临床和病理学N 2~3分期患者的比例均为100.0%;两组患者分期的差异均有统计学意义(P=0.007、0.001)。两组患者在淋巴结清扫总数、胸部淋巴结数量和淋巴结尺寸方面比较的差异无统计学意义(P值均>0.05);TDLN阳性组患者转移淋巴结个数显著多于TDLN阴性组(P=0.003)。结论机器人辅助下行食管肿瘤全系膜切除术治疗食管肿瘤安全可行。对于中下段进展期食管肿瘤患者推荐行包含胸导管在内的全系膜切除术,但其远期生存率是否可以因此获益需进一步研究证实。

Objective To summarize the experience of robot-assisted total mesoesophageal excision in patients with esophageal cancer,and to analyze the incidence,pattern and risk factors for metastasis of lymph nodes along the thoracic duct.Methods Clinical data of patients with esophageal squamous cell carcinoma who underwent robot-assisted total meso-esophageal excision in Shanghai Chest Hospital,Shanghai Jiao Tong University from January 2020 to March 2020 were retrospectively analyzed.Patient’s general information,preoperative therapy,surgical procedure and postoperative pathological results were collected.The incidence and patterns of lymphatic metastasis along the thoracic duct were analyzed.Results A total of 26 patients were enrolled in this study.There were 24 males and 2 females,with a mean age of(65.9±6.8)years.The middle-lower esophagus was mainly involved(21/26,80.8%).Fifteen patients(57.7%)were in clinical T 3 and sixteen patients(61.5%)were classified into TNM stageⅢ.Lymph node metastasis was positive in 23 patients(88.5%).Thirteen(50%)patients received neoadjuvant therapy(chemotherapy in 2 patients,chemoradiotherapy in 5,and chemotherapy plus immunotherapy in 6).The mean pleural effusion was(209±196)mL/d within 3 days after surgery.The median time of thoracic drainage tube removal was 4(3,5)days,and the median time of hospital stay was 8(7,10)days.No patient died in the hospital.The overall incidence of postoperative complications was 38.5%(10/26).The rate of Clavien-Dindo classification above gradeⅢwas 3.8%(1/26),recurrent laryngeal nerve palsy was 19.2%(5/26),and chylothorax was 11.5%(3/26).No anastomotic fistula occurred.Lymph nodes along thoracic duct 0.4 cm(0.2,0.8 cm)were observed in 15(57.7%)patients,and 5(19.2%)patients had lymph node metastasis(TDLN+).Tumor regression grade(TRG)1 accounted for 69.2%(9/13)of patients,and the rate of pathological complete response was 53.8%(7/13).TDLN+mostly occurred in patients with lower esophageal cancer(P=0.071).There was no significant difference in the clinical or pathological stage T between TDLN+patients and TDLN-patients(P=0.628,0.330).In TDLN-patients,71.4%were in clinical stage N 0-1 and 28.6%in clinical stage N 2-3;85.7%were in pathological stage N 0-1 and 14.3%in pathological stage N 2-3.All the TDLN+patients were in both clinical and pathological stage N 2-3.There were significant differences in the clinical and pathological stage N between TDLN+patients and TDLN-patients(P=0.007,0.001).However,there was no significant difference in the total amount of removed lymph nodes,the amount of thoracic lymph nodes,or the size of lymph nodes between TDLN+patients and TDLN-patients(P>0.05).TDLN+patients had more metastatic lymph nodes than TDLN-patients(P=0.003).Conclusion Robot-assisted total mesoesophageal excision is safe and feasible for the esophageal squamous cell carcinoma.For the middle-lower advanced esophageal cancer,total meso-esophageal excision with thoracic duct resection is recommended;however,the survival needs to be confirmed by long-term results.