Optimal extent of lymphadenectomy improves prognosis and guides adjuvant chemotherapy in esophageal cancer: A propensity scorematched analysis

BACKGROUND The optimal extent of lymphadenectomy in esophageal squamous cell carcinoma(ESCC)patients remained debatable.AIM To explore the ideal number of cleared lymph nodes in ESCC patients undergoing upfront surgery.METHODS In this retrospective,propensity score-matched study,we included 1042 ESCC patients who underwent esophagectomy from November 2008 and October 2019.Patients who underwent neoadjuvant therapy were excluded.We collected pa-tients’clinicopathological features and information regarding lymph nodes,in-cluding the total number of resected lymph nodes(NRLN),and pathologically diagnosed positive lymph nodes(RPLN).SPSS and R software were used for statistical analysis.RESULTS Among the included 1042 patients,two cohorts:≤21(n=664)and>21 NRLN(n=378)were identified.The final prognostic model included four variables:T stage,N,venous thrombus,and the number of removed lymph nodes.Among them,NRLN>21 was determined as an independent prognosticator after surgery for esophageal cancer(hazards regression=0.66,95%confidence interval:0.50-0.87,P=0.004).A nomogram was created based on the regression coefficients of the variables in the final model.In the training cohort,the predictive model dis-played an uncorrected five-year overall survival C-index of 0.659,with a bootstrap-corrected C-index of 0.654.In the subgroup analysis,adjuvant chemotherapy was beneficial in the subgroup with NRLN>21 and RPLN≤0.16 and NRLN≤21 and RPLN>0.16.CONCLUSION NRLN>21 was an independent prognostic factor after ESCC surgery.The combination of NRLN and RPLN may provide a reference for adjuvant chemotherapy use in potential beneficiaries.

Laparoscopic right radical hemicolectomy: Central vascular ligation and complete mesocolon excision vs D3 lymphadenectomy - How I do it?

In colon cancer surgery,ensuring the complete removal of the primary tumor and draining lymph nodes is crucial.Lymphatic drainage in the colon follows the vascular supply,typically progressing from pericolic to paraaortic lymph nodes.While NCCN guidelines recommend the removal of 10-12 lymph nodes for ade-quate oncological resection,achieving complete oncological resection involves more than just meeting these numerical targets.Various techniques have been developed and studied over time to attain optimal oncological outcomes.A key technique central to this goal is identifying the ileocolic vessels at their origin from the superior mesenteric vessels.Complete excision of the visceral and parietal mesocolon ensures the intact removal of the specimen,while D3 lymphade-nectomy targets all draining regional lymph nodes.Although these principles emphasize different aspects,they ultimately converge to achieve the same goal of complete oncological resection.This article aims to simplify the surgical steps that align with the principle of central vascular ligation and mesocolon mobilization while ensuring adequate D3 dissection.

Evaluation of rational extent lymphadenectomy for local advanced gastric cancer

Based upon studies from randomized clinical trials, the extended （D2） lymph node dissection is now recommended as a standard procedure for local advanced gastric cancer worldwide. However, the rational extent lymphadenectomy for local advanced gastric cancer has remained a topic of debate in the past decades. Due to the limitation of low metastatic rate in para-aortic nodes （PAN） in JCOG9501, the clinical benefit of D2＋ para-aortic nodal dissection （PAND） for patients with stage T4 and/or stage N3 disease, which is very common in China and other countries except Japan and Korea, cannot be determined. Furthermore, the role of splenectomy for complete resection of No.10 and No.l I nodes has been controversial, and however, the final results from the randomized trial ofJCOG0110 have yet to be completed. Gastric cancer with the No.14 and No.13 lymph node metastasis is defined as MI stage in the current version of the Japanese classification. We propose that D2~No.14v and ＋No.13 lymphadenectomy may be an option in a potentially curative gastrectomy for tumors with apparent metastasis to the No.6 nodes or infiltrate to duodenum. The examined lymph node and extranodal metastasis are significantly associated with the survival of gastric cancer patients.

Anatomy and influence of the splenic artery in laparoscopic spleen-preserving splenic lymphadenectomy

AIM: To investigate the splenic hilar vascular anatomy and the influence of splenic artery(Sp A) type in laparoscopic total gastrectomy with spleen-preserving splenic lymphadenectomy(LTGSPL).METHODS:The clinical anatomy data of 317 patients with upper- or middle-third gastric cancer who underwent LTGSPL in our hospital from January 2011 to December 2013 were collected. The patients were divided into two groups(concentrated group vs distributed group) according to the distance between the splenic artery's furcation and the splenic hilar region. Then, the anatomical layout, clinicopathologic characteristics, intraoperative variables, and postoperative variables were compared between the two groups.RESULTS: There were 205 patients with a concentrated type(64.7%) and 112 patients with a distributed type(35.3%) Sp A. There were 22 patients(6.9%) with a single branch of the splenic lobar vessels, 250(78.9%) with 2 branches, 43(13.6%) with 3 branches, and 2 patients(0.6%) with multiple branches. Eighty sevenpatients(27.4%) had type?Ⅰ?splenic artery trunk, 211(66.6%) had type Ⅱ, 13(4.1%) had type Ⅲ, and 6(1.9%) had type Ⅳ. The mean splenic hilar lymphadenectomy time(23.15 ± 8.02 vs 26.21 ± 8.84 min; P = 0.002), mean blood loss resulting from splenic hilar lymphadenectomy(14.78 ± 11.09 vs 17.37 ± 10.62 m L; P = 0.044), and number of vascular clamps used at the splenic hilum(9.64 ± 2.88 vs 10.40 ± 3.57; P = 0.040) were significantly lower in the concentrated group than in the distributed group. However, the mean total surgical time, mean total blood loss, and the mean number of harvested splenic hilar lymph nodes were similar in both groups(P > 0.05 for each comparison). There were also no significant differences in clinicopathological and postoperative characteristics between the groups(P > 0.05).CONCLUSION: It is of value for surgeons to know the splenic hilar vascular anatomy when performing LTGSPL. Patients with concentrated type Sp A may be optimal patients for training new surgeons.

Laparoscopic spleen-preserving splenic hilar lymphadenectomy in 108 consecutive patients with upper gastric cancer

AIM: To evaluate the feasibility and short-term efficacy of laparoscopic spleen-preserving splenic hilar (No. 10) lymphadenectomy to treat advanced upper gastric cancer (AUGC).

Lymph node metastasis and lymphadenectomy of resectable adenocarcinoma of the esophagogastric junction

Based on Siewert classification, adenocarcinomas of the esophagogastric junction （AEGs） have different behaviors of perigastric-mediastinal nodal metastasis. Siewert type I AEGs have higher incidence of mediastinal nodal metastasis than those of type H or III, especially at middle-upper mediastinum. With regard to the necessity of mediastinal lymphadenectomy, theoretically, transthoracic esophagogastrectomy with complete mediastinal lymphadenectomy is suggested for Siewert type I AEGs, while transhiatal total gastrectomy with lower mediastinal and D2 perigastric lymphadenectomy is a standard surgery for type II-III AEGs. Nevertheless, the mediastinal nodal metastasis is an independent factor of poor prognosis for any type of AEG.

Lymphatic spreading and lymphadenectomy for esophageal carcinoma

Esophageal carcinoma(EC) is a highly lethal malignancywith a poor prognosis. One of the most important prognostic factors in EC is lymph node status. Therefore, lymphadenectomy has been recognized as a key that influences the outcome of surgical treatment for EC. However, the lymphatic drainage system of the esophagus, including an abundant lymph-capillary network in the lamina propria and muscularis mucosa, is very complex with cervical, mediastinal and celiac node spreading. The extent of lymphadenectomy for EC has always been controversial because of the very complex pattern of lymph node spreading. In this article, published literature regarding lymphatic spreading was reviewed and the current lymphadenectomy trends for EC are discussed.

Current opinion on lymphadenectomy in pancreatic cancer surgery

BACKGROUND:Adenocarcinoma of the pancreas exhibits aggressive behavior in growth,inducing an extremely poor prognosis with an overall median 5-year survival rate of only 1%-4%.Curative resection is the only potential therapeutic opportunity. DATA SOURCES:A PubMed search of relevant articles published up to 2009 was performed to identify information about the value of lymphadenectomy and its extent in curative resection of pancreatic adenocarcinoma. RESULTS:Despite recent advances in chemotherapy,radio-therapy or even immunotherapy,surgery still remains the major factor that affects the outcome.The initial promising performance in Japan gave conflicting results in Western countries for the extended and more radical pancreatectomy; it has failed to prove beneficial.Four prospective,randomized trials on extended versus standard lymphadenectomy during pancreatic cancer surgery have shown no improvement in long-term survival by the extended resection.The exact lymph node status,including malignant spread and the total number retrieved as well as the lymph node ratio,is the most important prognostic factor.Positive lymph nodes after pancreatectomy are present in 70%.Paraaortic lymph node spread indicates poor prognosis. CONCLUSIONS:Undoubtedly,a standard lymphadenectomy including>15 lymph nodes must be no longer preferred in patients with the usual head location.The extended lymphadenectomy does not have any place,unless in randomized trials.In cases with body or tail location,the radical antegrade modular pancreatosplenectomy gives promising results.Nevertheless,accurate localization and detailed examination of the resected specimen are required for better staging.

Learning curve of laparoscopy-assisted distal gastrectomy with systemic lymphadenectomy for early gastric cancer

AIM: To evaluate the nature of the 'learning curve' for laparoscopy-assisted distal gastrectomy (LADG) with systemic lymphadenectomy for early gastric cancer. METHODS: The data of 90 consecutive patients with early gastric cancer who underwent LADG with systemic lymphadenectomy between April 2003 and November 2004 were reviewed. The 90 patients were divided into 9 sequential groups of 10 cases in each group and the average operative time of these 9 groups were determined. Other learning indicators, such as transfusion requirements, conversion rates to open surgery, postoperative complication, time to first flatus, and postoperative hospital stay, were evaluated. RESULTS: After the first 10 LADGs, the operative time reached its first plateau (230-240 min/operation) and then reached a second plateau (＜200 min/operation) for the final 30 cases. Although a significant improvement in the operative time was noted after the first 50 cases, there were no significant differences in transfusion requirements, conversion rates to open surgery, postoperative complications, time to first flatus, or postoperative hospital stay between the groups. CONCLUSION: Based on operative time analysis, this study show that experience of 50 cases of LADG with systemic lymphadenectomy for early gastric cancer is required to achieve optimum proficiency.

Prognostic impact of D2-plus lymphadenectomy and optimal extent of lymphadenectomy in advanced gastric antral carcinoma: Propensity score matching analysis

Objective: To investigate the prognostic impact of D2-plus lymphadenectomy including the posterior(No. 8 p,No. 12 b/p, No. 13, and No. 14 v), and para-aortic(No. 16 a2, and No. 16 b1) lymph nodes(LNs) in subtotal gastrectomy for advanced gastric antral carcinoma.Methods: A total of 203 patients with advanced gastric cancer(GC) located in the antrum, who underwent R0 gastrectomy with D2 or D2-plus lymphadenectomy between January 2003 and December 2011 were enrolled.Propensity score matching was used to reduce the strength of the confounding factors to accurately evaluate prognoses. The therapeutic value index(TVI) was calculate to evaluate the survival benefit of dissecting each LN station.Results: Of 102 patients with D2-plus lymphadenectomy, 21(20.59%) were pathologically identified as having LN metastases beyond the extent of D2 lymphadenectomy. After matching, the overall survival(OS) was significantly better in the D2-plus than the D2 group(P=0.030). In the multivariate survival analysis, D2-plus lymphadenectomy(hazard ratio, 0.516;P=0.006) was confirmed to significantly improve the survival rate. In the logistic regression analysis, p N stage [odds ratio(OR), 2.533;95% confidence interval(95% CI), 1.368-4.691;P=0.003] and extent of LNs metastasis(OR, 5.965;95% CI, 1.335-26.650;P=0.019) were identified as independent risk factors for LN metastases beyond the extent of D2 lymphadenectomy. The TVI of patient with metastasis to LNs station was 7.1(No. 8p), 5.7(No. 12p), 5.1(No. 13), and 7.1(both No. 16a2 and No. 16b1), respectively.Conclusions: D2-plus lymphadenectomy may improve the prognoses of some patients with advanced GC located in the antrum, especially for No. 8p, No. 12b, No. 13, and No. 16.

Effect of lymphadenectomy extent on advanced gastric cancer located in the cardia and fundus

AIM： To analyze the prognostic impact of lymphade-nectomy extent in advanced gastric cancer located in the cardia and fundus. METHODS： Two hundred and thirty-six patients with advanced gastric cancer located in the cardia and fundus who underwent D2 curative resection were analyzed retrospectively. Relationships between the numbers of lymph nodes （LNs） dissected and survival was analyzed among different clinical stage subgroups. RESULTS： The 5-year overall survival rate of the entire cohort was 37.5%. Multivariate prognostic variables were total LNs dissected （P 〈 0.0001; or number of negative LNs examined, P 〈 0.0001）, number of positive LNs （P 〈 0.0001）, T category （P 〈 0.0001） and tumor size （P = 0.015）. The greatest survival differences were observed at cutoff values of 20 LNs resected for stage Ⅱ（p = 0.0136）, 25 for stage Ⅲ（P 〈 0.0001）, 30 for stage Ⅳ（P = 0.0002）, and 15 for all patients （P = 0.0024）. Based on the statistically assumed linearity as best fit, linear regression showed a significant survival enhancement based on increasing negative LNs for patients of stages Ⅲ （P = 0.013） and Ⅳ（P = 0.035）. CONCLUSION： To improve the long-term survival of patients with advanced gastric cancer located in the cardia and fundus, removing at least 20 LNs for stage Ⅱ,25 LNs for stage Ⅲ, and 30 LNs for stage N patients during D2 radical dissection is recommended.

Clinical significance of lymphadenectomy in patients with gastric cancer

Approximately thirty percent of patients with gastric cancer undergo an avoidable lymph node dissection with a higher rate of postoperative complication. Comparing the D1 and D2 dissections,it was found that there is a significant difference in morbidity,favoured D1 dissection without any difference in overall survival. Subgroup analysis of patients with T3 tumor shows a survival difference favoring D2 lymphadenectomy,and there is a better gastric cancer-related death and non-statistically significant improvement of survival for node-positive disease in patients with D2 dissection. However,the extended lymphadenectomy could improve stage-specific survival owing to the stage migration phenomenon. The deployment of centralization and application of national guidelines could improve the surgical outcomes. The Japanese and European guidelines enclose the D2 lymphadenectomy as the gold standard in R0 resection. In the individualized,stageadapted gastric cancer surgery the Maruyama computer program(MCP) can estimate lymph node involvement preoperatively with high accuracy and in addition the Maruyama Index less than 5 has a better impact on survival,than D-level guided surgery. For these reasons,the preoperative application of MCP is recommended routinely,with an aim to perform "low Maruyama Index surgery". The sentinel lymph node biopsy(SNB) may decrease the number of redundant lymphadenectomy intraoperatively with a high detection rate(93.7%) and an accuracy of 92%. More accurate stage-adapted surgery could be performed using the MCP and SNB in parallel fashion in gastric cancer.

Problems faced by evidence-based medicine in evaluating lymphadenectomy for gastric cancer

Gastric cancer surgical management differs between Eastern Asia and Western countries. Extended lymphadenectomy (D2) is the standard of care in Japan and South Korea since decades, while the majority of United States patients receive at most a limited lymphadenectomy (D1). United States and Northern Europe are considered the scientific leaders in medicine and evidence-based procedures are the cornerstone of their clinical practice. However, surgeons in Eastern Asia are more experienced, as there are more new cases of gastric cancer in Japan (107898 in 2012) than in the entire European Union (81592), or in South Korea (31269) than in the entire United States (21155). For quite a long time evidence-based medicine (EBM) did not solve the question whether D2 improves long-term prognosis with respect to D1. Indeed, eastern surgeons were reluctant to perform D1 even in the frame of a clinical trial, as their patients had a very good prognosis after D2. Evidence-based surgical indications provided by Western trials were questioned, as surgical procedures could not be properly standardized. In the present study we analyzed indications about the optimal extension of lymphadenectomy in gastric cancer according to current scientific literature (2008-2012) and surgical guidelines. We searched PubMed for papers using the key words “lymphadenectomy or D1 or D2” AND “gastric cancer” from 2008 to 2012. Moreover, we reviewed national guidelines for gastric cancer management. The support to D2 lymphadenectomy increased progressively from 2008 to 2012: since 2010 papers supporting D2 have achieved a higher overall impact factor than the other papers. Till 2011, D2 was the procedure of choice according to experts’ opinion, while three meta-analyses found no survival advantage after D2 with respect to D1. In 2012-2013, however, two meta-analyses reported that D2 improves prognosis with respect to D1. D2 lymphadenectomy was proposed as the standard of care for advanced gastric cancer by Japanese National Guidelines since 1981 and was adopted as the standard procedure by the Italian Research Group for Gastric Cancer since the Nineties. D2 is now indicated as the standard of surgical treatment with curative intent by the German, British and ESMO-ESSO-ESTRO guidelines. At variance American NCCN guidelines recommend a D1+ or a modified D2 lymph node dissection. In conclusion, D2 lymphadenectomy, originally developed by Eastern surgeons, is now becoming the procedure of choice also in the West. In gastric cancer surgery EBM is lagging behind national guidelines, rather than preceding and orienting them. To eliminate this lag, EBM should value to a larger extent Eastern Asian literature and should evaluate not only the quality of the study design but also the quality of surgical procedures.

Techniques and feasibility of laparoscopic extended right hemicolectomy with D3 lymphadenectomy

AIM: To illustrate the critical techniques and feasibility of laparoscopic extended right hemicolectomy (LERH), according to our previous experience.

Vagina vasorum dissection during D2 lymphadenectomy for gastric carcinoma

AIM: To explore the relationship between metastasis and vagina vasorum in the progress of gastric carcinoma and to find some facts and references for gastric surgeons. METHODS: One hundred and seven specimens of left or right gastric arteries (55 left and 52 right) were gathered from 59 patients undergoing radical gastrectomy for gastric carcinoma. All the frozen specimens were cut into 3 μm-thick sections and stained with hematoxylin-eosin (HE) and immunohistochemical method separately. Cytokeratin (CK) and mesothelial cells (MC) were stained with immunohistochemical method. Cancer cells inside vagina vasorum were detected and the structure of artery wall was observed under microscope. RESULTS: Metastatic cancer cells or tubercles were found inside vagina vasorum in some stage Ⅲ or Ⅳ specimens, but not in stageⅠor Ⅱ specimens. Tumor cells in vagina vasorum were CK positive in 26 specimens of 14 tumors. Among them, stage Ⅲ was found in 4 specimens of 2 tumors, and stage Ⅳ in 22 specimens of 12 tumors. None of these specimens was positive for MC. The positive rate of CK increased with TNM staging. Compared with the lower part, tumors in the upper and middle parts of stomach were more likely to metastasize into vagina vasorum. CONCLUSION: Vagina vasorum dissection should be performed during D2 lymphadenectomy for TNM stage Ⅲ or Ⅳ gastric carcinoma.

Regional lymphadenectomy strongly recommended in T1b gallbladder cancer

This article discusses the adequate treatment of early gallbladder cancer （Tla, Tlb） and is based on published studies extending over nearly 3 decades. Ran- domized studies and meta analyses comparing different surgical treatments do not exist. The literature shows that in up to 20% of patients lymph node metastasis are found in Tlb gallbladder cancer. Due to high malignancy with early angiolymphatic spread and resistance to chemotherapy and radiation on the one hand, and the relative low operative risk of extended cholecystectomy （cholecystectomy and regional lymphadenectomy） on the other hand, we believe that this procedure is mandatory in early gallbladder cancer.

Extended lymphadenectomy in hilar cholangiocarcinoma: What it will bring?

Lymph node dissection is always a hot issue in radical resection of hilar cholangiocarcinoma(HCCA).There are still controversies regarding whether some lymph nodes should be dissected,of which the para-aortic lymph nodes are the most controversial.This review synthesized findings in the literature using the PubMed database of articles in the English language published between 1990 and 2019 on the effectiveness of extended lymphadenectomy including paraaortic lymph nodes dissection in radical resection of HCCA.Hepatobiliary surgeons have basically achieved a consensus that enough lymph nodes should be obtained to accurately stage HCCA.Only a very small number of studies have focused on the effectiveness of extended lymphadenectomy including para-aortic nodes dissection on HCCA.They reported that extended lymphadenectomy can bring some survival benefits for patients with potential para-aortic lymph node metastasis and more lymph nodes can be obtained to make the patient's tumor staging more accurate without increasing the related complications.Extended lymphadenectomy should not be adopted for HCCA patients with intraoperatively confirmed distant lymph node metastases.For these patients,radical resection combined with postoperative adjuvant chemotherapy seems to be a better choice.A prospective,multicenter,randomized,controlled clinical study of regional lymphotomy and extended lymphadenectomy in HCCA should be conducted to guide clinical practice.A standardized extended lymphadenectomy may help to more accurately stage HCCA.Future studies are required to further assess whether extended lymphadenectomy can improve long-term survival in negative celiac,superior mesenteric,and para-aortic lymph node diseases.

Postoperative mortality and morbidity after D2 lymphadenectomy for gastric cancer:A retrospective cohort study

BACKGROUND Surgery for gastric cancer is a complex procedure and lymphadenectomy is often mandatory.Postoperative mortality and morbidity after curative gastric cancer surgery is not insignificant.AIM To evaluate the factors determining mortality and morbidity in a population of patients undergoing R0 resection and D2 lymphadenectomy for gastric cancer.METHODS A retrospective analysis of clinical data and pathological characteristics(age,sex,primary site of the tumor,Lauren histotype,number of positive lymph nodes resected,number of negative lymph nodes resected,and depth of invasion as defined by the standard nomenclature)was conducted in patients with gastric cancer.For each patient we calculated the Kattan’s score.We arbitrarily divided the study population of patients into two groups based on the nomogram score(<100 points or≥100 points).Prespecified subgroups in these analyses were defined according to age(≤65 years or>65 years),and number of lymph nodes retrieved(≤35 lymph nodes or>35 lymph nodes).Uni-and multivariate analysis of clinical and pathological findings were performed to identify the factors affecting postoperative mortality and morbidity.RESULTS One-hundred and eighty-six patients underwent a curative R0 resection with D2 lymphadenectomy.Perioperative mortality rate was 3.8%(7 patients);a higher mortality rate was observed in patients aged>65 years(P=0.002)and in N+patients(P=0.04).Following univariate analysis,mortality was related to a Kattan’s score≥100 points(P=0.04)and the presence of advanced gastric cancer(P=0.03).Morbidity rate was 21.0%(40 patients).Surgical complications were observed in 17 patients(9.1%).A higher incidence of morbidity was observed in patients where more than 35 lymph nodes were harvested(P=0.0005).CONCLUSION Mortality and morbidity rate are higher in N+and advanced gastric cancer patients.The removal of more than 35 lymph nodes does not lead to an increase in mortality.

Does an extended mediastinal lymphadenectomy improve outcome after R0 resection in lung cancer?

Objective： This retrospective study was conducted to investigate the impact of more extended mediastinal lymphadenectomy on the outcome of lung cancer patients treated with R0 resection. Methods： During the investigation period, 325 lung cancer cases were enlisted and 278 cases entered the analysis. The patients were divided into Control group （n=116） and Research group （n=162） according to the different extents of mediastinal lymph node clearance at different time periods. Three major parameters were retrospectively assessed to compare the quality of surgical care： extent of lymph node clearance, resection volume, and postoperative recovery process and common complications. Comparison of the outcome between two groups was carried out. Results： Research group showed a significant quality improvement of lymphadenectomy, such as more mediastinal node stations investigated （more than 3 N2 stations investigated： Research group, 90.7% vs. Control group, 55.2%; P=0.001） and more nodes collection （total nodes 26.1±10.0 vs. 19.1±8.3, P=0.000; N2 nodes 15.5±7.2 vs. 9.8±5.6, P=0.000）. However, overall survival （OS） and disease-free survival （DFS） were not significantly different either between two groups （5-year OS： Control group, 56.4±4.6% vs. Research group, 62.6±4.3%; P=0.271） or between subgroups from stage I to IIIa. TNM stage and histology were significant factors associated with OS and DFS in multivariate analysis; extent of mediastinal lymphadenectomy was not associated with OS or DFS. Conclusions： More radical mediastinal lymphadenectomy may not lead to an improved oncological outcome for lung cancer treated with R0 resection.

Ivor Lewis subtotal esophagectomy with two-field lymphadenectomy for squamous cell carcinoma of the lower thoracic esophagus

AIM： To evaluate the clinical outcome of Ivor Lewis subtotal esophagectomy with two-field lymphadenectomy for patients with squamous cell carcinoma of the lower thoracic esophagus. METHODS： From January 1998 to December 2001, 73 patients with lower thoracic esophageal carcinoma underwent Ivor-Lewis subtotal esophagectomy with two-field lymphadenectomy. Clinicopathological information, postoperative complications, mortality and long term survival of all these patients were analyzed retrospectively. RESULTS： The operative morbidity and mortality was 15.1% and the mortality was 2.7%. Lymph node metastases were found in 52 patients （71.2%）. Nodal metastases to the upper, middle, lower mediastini and upper abdomen were found in 13 （17.8%）, 15 （20.5%）, 30 （41.1%）, and 25 （34.2%） patients, respectively. Postoperative staging was as follows： stage Ⅰ in 5 patients, stage Ⅱ in 34 patients, stage Ⅲ in 32 patients, and stage Ⅳ in 2 patients, respectively. The overall 5-year survival rate was 23.3%. For NO and N1 patients, the 5-year survival rate was 38.1% and 17.3%, respectively （X^2 = 22.65, P 〈 0.01）. The 5-year survival rate for patients in stages Ⅱ a, Ⅱ b and Ⅲ was 31.2%, 27.8% and 12.5%, repsectively （X^2 = 29.18, P 〈 0.01）. CONCLUSION： Ivor Lewis subtotal esophagectomy with two-field （total mediastinum） lymphadenectomy is a safe and appropriate operation for squamous cell carcinoma of the lower thoracic esophagus.