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目的探讨如何提高食管癌手术根治性、减少术后复发以改善食管癌治疗长期疗效。方法104例胸段食管鳞癌病人,56例按传统术式行食管切除+肿大淋巴结摘除术,48例行系统性胸腹二野淋巴结清扫术。3例手术死亡(2.9%),余101例病人中29例术后接受顺铂+氟脲嘧啶辅助化疗,其中15例为传统术式病例,14例为二野清扫病例。结果胸腹二野清扫手术时间虽然较传统术式延长,但手术出血量、术后并发症及病死率未见增高。二野清扫组清扫淋巴结组数(10.5组对3.2组,P<0.001)及转移淋巴结检出组数(1.1组对0.6组,P=0.038)均显著多于传统术式组。通过淋巴结清扫发现,双侧喉返神经旁(16.8%)、食管旁(22.9%)和胃左动脉旁(16.8%)淋巴结为胸段食管癌常见转移部位,10.4%病例存在跳跃性淋巴结转移,上纵隔(20.8%)与中下纵隔(31.3%)及上腹部(25.0%)3个区域间淋巴结转移频度差异无统计学意义。二野清扫组25.0%病例因扫除了传统术式可能遗漏的转移淋巴结使手术根治性提高,另有12.5%病例手术病理分期因此由pN0上升至pN1。术后辅助化疗病人中86.2%完成2个以上疗程,平均化疗3.1个疗程,无严重毒副作用或死亡。淋巴结清扫组5年生存率显著高于传统术式组(36.4%对24.9%,P=0.049),术后化疗组显著高于未化疗组(44.8%对20.7%,P=0.023),接受淋巴结清扫及术后化疗者5年生存率最高(46.2%),显著高于单纯进行传统手术且未行化疗的病例(19.4%,P=0.018)。结论系统的胸腹二野淋巴结清扫有助于提高食管癌手术根治性和病理分期准确性,淋巴结清扫与术后辅助化疗相结合的优化治疗方法有助于提高胸段食管鳞癌的长期疗效。
Objective To explore how to improve the curative effect of esophageal cancer and reduce the recurrence after esophagectomy to improve the long-term curative effect of esophageal cancer. Methods A total of 104 patients with thoracic esophageal squamous cell carcinoma underwent esophageal resection and enlarged lymph node dissection in 56 patients, and 48 patients underwent lymphadenectomy of 48 cases. Three patients died of surgery (2.9%). Of the remaining 101 patients, 29 received cisplatin + fluorouracil adjuvant chemotherapy after surgery. Of these, 15 were conventional surgical procedures and 14 were Second Field surgical procedures. Results Although the operation time of chest, abdomen and two fields was longer than that of traditional operation, the amount of bleeding, postoperative complications and mortality did not increase. There were significantly more lymph node dissection groups (10.5 vs 3.2, P <0.001) and lymph node metastasis group (1.1 vs 0.6, P = 0.038) than those in the conventional surgery group. Lymphadenopathy (16.8%), paraesophageal (22.9%) and paravaginal para-aortic (16.8%) lymph nodes were common metastatic sites of thoracic esophageal cancer by lymph node dissection, with leaking lymph node metastasis in 10.4% There was no significant difference in the frequency of lymph node metastasis between the mediastinum (20.8%) and the mediastinum (31.3%) and the upper abdomen (25.0%). In the second field operation group, 25.0% of the cases were cured by removing the metastatic lymph nodes which may be missed by the traditional surgical procedures, and another 12.5% of the cases were surgically stained with pN0. 86.2% of postoperative adjuvant chemotherapy patients completed more than 2 courses of treatment, with an average of 3.1 courses of chemotherapy without any serious side effects or death. The 5-year survival rate of lymph node dissection group was significantly higher than that of the conventional operation group (36.4% vs. 24.9%, P = 0.049). The postoperative chemotherapy group was significantly higher than the non-chemotherapy group (44.8% vs. 20.7%, P = 0.023) The 5-year survival rate was the highest (46.2%) in patients who underwent surgery and postoperative chemotherapy, which was significantly higher than those who underwent conventional surgery without chemotherapy (19.4%, P = 0.018). Conclusions The systematic lymphadenectomy of the thoracoabdominal and second abdominal region can help improve the radical and pathological staging accuracy of esophageal cancer operation. The optimized treatment combining lymph node dissection and postoperative adjuvant chemotherapy can help to improve the long-term efficacy of thoracic esophageal squamous cell carcinoma.