胸腔镜改良喉返神经旁淋巴结清扫对Ⅱ~Ⅲ期下段食管鳞状细胞癌三野手术治疗患者预后的影响

Influence of thoracoscopic modified para-recurrent laryngeal nerve dissection on prognosis of patients with stageⅡ-Ⅲlower esophageal squamous cell carcinoma treated with three-field surgery.

目的探讨胸腔镜三野清扫食管癌根治术中采用改良喉返神经旁淋巴结清扫在TNM分期Ⅱ期、Ⅲ期下段食管鳞状细胞癌治疗中的效果。方法采用临床前瞻性随机研究,选取2016年3月至2018年12月空军军医大学第二附属医院胸外科采取手术治疗的98例下段食管鳞状细胞癌患者,按照随机分组原则分为改良组、传统组,各49例,两组均采用胸腔镜三野清扫食管癌根治术,改良组术中采用改良喉返神经旁淋巴结清扫术,传统组采用传统的淋巴清扫方式。比较两组的围手术期指标、淋巴结清扫效果、生存质量情况、并发症发生率、3年随访结局差异。结果改良组患者的手术出血量、手术时间、术后引流管留置时间、住院时间与传统组比较,差异均无统计学意义(P>0.05);改良组患者的喉返神经淋巴结清扫数目为[(6.8±1.6)个],多于传统组[(5.7±1.4)个],差异有统计学意义(P<0.05)。改良组患者的手术并发症率6.1%,低于传统组(22.5%),差异有统计学意义(P<0.05)。术前,改良组和传统组患者的生存质量均较差,两组患者的生存质量各个维度评分差异无统计学意义(P>0.05);术后3个月再次评估,改良组患者的吞咽困难、进食、咳嗽三个维度的评分为(66.9±8.2)、(58.1±7.4)、(56.3±6.3)分,均高于传统组[(61.3±7.8)、(52.8±8.4)、(53.7±6.6)分],差异均有统计学意义(P<0.05)。术后随访3年,改良组患者的生存率为65.3%,传统组患者的生存率为53.1%,两组差异无统计学意义(P>0.05);改良组患者的中位生存时间与传统组比较,差异无统计学意义(P>0.05)。结论TNM分期Ⅱ期、Ⅲ期下段食管鳞状细胞癌患者胸腔镜三野清扫食管癌根治术中采用改良喉返神经旁淋巴结清扫方式,能更加彻底清扫淋巴结,减少对喉返神经的损伤,降低手术并发症,提高手术后患者的生存质量,但是对患者预后的延长不明显,可能需要进一步延长观察时间进行分析。

Objective To investigate the effect of modified lymph node dissection near the recurrent laryngeal nerve in the treatment of TNM stageⅡandⅢlower segment esophageal squamous cell carcinoma during thoracoscopic three-field dissection for esophageal cancer radical resection.Methods A prospective randomized clinical study was used to select 98 patients with lower esophageal squamous cell carcinoma who underwent surgery in the Department of Thoracic Surgery,the Second Affiliated Hospital of Air Force Military Medical University from March 2016 to December 2018.There were 49 cases in each group,both groups were treated with thoracoscopic three-field dissection for esophageal cancer radical resection,the modified group was treated with modified lymph node dissection next to the recurrent laryngeal nerve,and the traditional group was treated with traditional lymph node dissection.The perioperative indicators,lymph node dissection effect,quality of life,complication rate,and 3-year follow-up outcomes were compared between the two groups.Results Compared with the traditional group,there were no significant differences in the amount of surgical blood loss,operation time,postoperative drainage tube indwelling time,and hospital stay in the modified group(P>0.05),the number of lymph node dissections of the recurrent laryngeal nerve in the modified group were[(6.8±1.6)pieces],which were more than those in the traditional group[(5.7±1.4)pieces],and the differences were statistically significant(P<0.05).The surgical complication rate of the modified group was 6.1%,which was lower than that of the traditional group(22.5%),and the difference was statistically significant(P<0.05).The quality of life of the patients in the traditional group was poor,and there was no significant difference in the scores of each dimension of the quality of life between the two groups(P>0.05);re-evaluated 3 months after surgery,the scores of dysphagia,eating,and coughing in the modified group were(66.9±8.2),(58.1±7.4),and(56.3±6.3)points,which were higher than those in the traditional group[(61.3±7.8),(52.8±8.4),(53.7±6.6)points],the differences were statistically significant(P<0.05).After 3 years of follow-up,the survival rate of the modified group was 65.3%,and the survival rate of the traditional group was 53.1%.There was no significant difference between the two groups(P>0.05).There was no significant difference in the median survival time between the modified group and the traditional group(P>0.05).Conclusion In patients with TNM stageⅡandⅢlower segment esophageal squamous cell carcinoma,the modified method of lymph node dissection next to the recurrent laryngeal nerve is used in thoracoscopic three-field dissection for esophageal cancer radical resection,which can more thoroughly dissect the lymph nodes,reduce the damage to the recurrent laryngeal nerve,and reduce the risk of surgery.Complications can improve the quality of life of patients after surgery,but the prolongation of the prognosis of patients is not obvious,and it may be necessary to further extend the observation time for analysis.