序贯三切口及选择性淋巴结清扫治疗食管癌1162例临床效果分析

目的 探讨食管癌外科治疗的手术方式、淋巴结清扫范围、术后综合治疗模式.方法 对1998年1月至2007年12月间收治的不同部位的食管癌1162例采用序贯的腹、胸、颈三切口的手术径路行食管肿瘤切除,应用术前影像、超声定位下穿刺细胞学检查和术中颈部淋巴结抽样活组织快速病理检查三步筛选方法行选择性一期三野淋巴结清扫,一期规范胸腹二野清扫和二期第三野颈部淋巴结清扫.同时,术后积极实施综合治疗.观察总的临床疗效和长期生存.结果 1162例食管癌手术中,手术切除率100％.根治性切除97.6％（1134/1162）.围手术期并发症发生率16.4％（191/1162）,吻合口瘘发生率为0.6％（7/1162）,术后30 d内死亡5例.全组淋巴结转移率52.6 ％（611/1162）,淋巴结转移度12.1％（3 092/25 564）.全组实施一期三野淋巴结清扫348例,阳性准确率为94.8％（330/348）,实施一期二野清扫814例,实施二期第三野颈部淋巴结清扫89例.三野清扫术后并发症明显高于二野清扫（23.6％比13.4％）（χ^2=18.37,P＜ 0.001）,但两者的1、3、5年生存率差异无统计学意义（P＞0.05）.一期三野清扫和二期第三野清扫患者1、3、5年生存率差异亦无统计学意义（P＞0.05）.但不同的淋巴结转移程度预后差异有统计学意义（χ^2=35.57,P＜ 0.001）,不同的分期决定着患者的预后.本组术后综合治疗实施率为87.2％,手术加术后综合治疗者总的1、3、5年生存率分别为92.1％、69.2％、49.6％.结论 序贯三切口切除食管肿瘤及应用三步筛选法选择性淋巴结清扫具有根治彻底、术后并发症少、患者生存质量高、长期生存率较好等优点,是食管癌外科治疗值得临床广泛应用的一种方法.术后积极的综合治疗是今后食管癌治疗的发展方向.

Clinical outcome efficacy analysis of three sequential incision and selective lymphadenectomy in treatment of 1162 cases with esophageal cancer

Objective To investigate the best models of esophageal cancer surgical approaches,lymphadenectomy ranges and postoperative comprehensive treatment.Methods From January 1998 to December 2007 in 10 years,1 162 cases of different parts with esophageal cancer were analysized which were treated with surgically adopting sequential abdomen,chest,neck three-incision approaches.Taking three-step screening way of preoperative imaging,preoperative ultrasound localigation fineneedle aspiration biopsy cytology and intraoperative rapid fieezing pathological examination were applied to make the selectivity of the first-times cervico-thoraco-abdominal three-field lymph node dissection （3FLND）,first-times standard thoracoabdominal two-field lymph node dissection （2FLND） and second-times third-field cervical lymphadenectomy.Meanwhile,we implemented actively postoperative comprehensive treatment and observed the overall clinical efficacy and long-term survival.Results In the group of 1 162 cases with esophageal cancer surgery.The operating resection rate was 100 %,Radical resection of 97.6 % （1 134/1 162）.Perioperative overall complication rate was 16.4 % （191/1 162）.Anastigmatic fistula was 0.6 % （7/1 162）.Five cases dead in 30 days after surgery.The whole group of lymph node metastasis rate was 52.6 % （611/1 162）,lymph node metastasis degree in 12.1% （3 092/25 564）.Full group of the first-times 3FLND was 348 cases.The positive rate was 94.8 % （330/348）,Implementing the first-times 2FLND was in 814 cases and the second-times thirdfield cervical lymph node dissection was performed in 89 cases.The postoperative complications of the 3FLND was significantly higher than that of 2FLND （23.6 % vs 13.4 %）.The difference was statistically significant （χ^2 =18.37,P 〈 0.001）.However,The difference was not statistically significant between 3FLND and 2FLND （P 〉 0.05）.There is no significant difference between the first-times 3FLND with the second-times 3FLND accumulating survival （P 〉 0.05?