CAJ | 학술논문

目的：比较胸腔镜食管癌根治术与开放手术的纵隔淋巴结清扫情况，探讨胸腔镜手术的根治性及安全性。方法回顾性分析2009年6月至2011年6月间四川省肿瘤医院胸外科经左颈右胸上腹食管癌根治术治疗304例患者的临床资料。其中199例行传统开放三切口食管癌根治术（开放组），105例行胸腹腔镜三切口食管癌根治术（腔镜组），比较两组患者术中淋巴结清扫情况及围手术期并发症发生情况。结果腔镜组清扫纵隔淋巴结数目为（10．1±5．5）枚，明显少于开放组的（13．3±7．5）枚（P＜0．01）；但匹配术后病理分期后，各期腔镜组和开放组的胸内淋巴结清扫数目差异并无统计学意义（均P＞0．05）。开放组和腔镜组左喉返神经旁淋巴结平均清扫数分别为（2．7±0．2）枚和（1．4±0．2）枚，下段食管旁分别为（1．0±0．1）枚和（0．6±0．1）枚，病灶旁分别为（1．7±0．2）枚和（0．7±0．1）枚，差异均有统计学意义（均P＜0．01）；其他区域两组淋巴结清扫数目差异均无统计学意义（均P＞0．05）。腔镜组围手术期并发症发生率为28．6％（30/105），低于开放组的41．2％（82/199）（P＜0．05），但喉返神经麻痹发生率[12．4％（13/105）]明显高于开放组[2．5％（5/199），P＜0．01）。结论胸腔镜食管癌根治术安全可行。但在行胸腔镜纵隔淋巴结清扫时，应加强对喉返神经旁、下段食管旁和病灶旁淋巴结的清扫，并注意喉返神经的保护。
목적：비교흉강경식관암근치술여개방수술적종격림파결청소정황，탐토흉강경수술적근치성급안전성。방법회고성분석2009년6월지2011년6월간사천성종류의원흉외과경좌경우흉상복식관암근치술치료304례환자적림상자료。기중199례행전통개방삼절구식관암근치술（개방조），105례행흉복강경삼절구식관암근치술（강경조），비교량조환자술중림파결청소정황급위수술기병발증발생정황。결과강경조청소종격림파결수목위（10．1±5．5）매，명현소우개방조적（13．3±7．5）매（P＜0．01）；단필배술후병리분기후，각기강경조화개방조적흉내림파결청소수목차이병무통계학의의（균P＞0．05）。개방조화강경조좌후반신경방림파결평균청소수분별위（2．7±0．2）매화（1．4±0．2）매，하단식관방분별위（1．0±0．1）매화（0．6±0．1）매，병조방분별위（1．7±0．2）매화（0．7±0．1）매，차이균유통계학의의（균P＜0．01）；기타구역량조림파결청소수목차이균무통계학의의（균P＞0．05）。강경조위수술기병발증발생솔위28．6％（30/105），저우개방조적41．2％（82/199）（P＜0．05），단후반신경마비발생솔[12．4％（13/105）]명현고우개방조[2．5％（5/199），P＜0．01）。결론흉강경식관암근치술안전가행。단재행흉강경종격림파결청소시，응가강대후반신경방、하단식관방화병조방림파결적청소，병주의후반신경적보호。
Objective To compare thoracoscopic esophagectomy with traditional esophagectomy in radical mediastinal lymphadenectomy for esophageal cancer , and to explore the feasibility and safety of thoracoscopic mediastinal lymphadenectomy for esophagectomy. Methods Clinical data associated with perioperation and mediastinal lymph nodes clearance of 304 patients undergoing radical operation of esophageal cancer via left neck-right chest-upper abdomen in our department from June 2009 to June 2011 were analyzed retrospectively. Among 304 cases, 199 received traditional open radical resection and 105 thoracoscopic esophagectomy. The intrathoracic mediastinal lymph node metastasis rate , extent of metastasis, time of operation, blood loss and complications between two groups were compared. Results All the 304 cases completed their operations successfully. A total of 3724 mediastinal lymph nodes were removed, mean 12.3±7.0 per case, including 1065 in thoracoscopic group, mean 10.1±5.5 per case, and 2659 in open group, mean 13.3 ±7.5 per case, whose difference was significant. But further analysis according to the postoperative pathologic staging showed no significant difference of above lymph nodes removed between two groups. Mediastinal lymph node metastasis was found in 126 patients with a rate of 41.4%, which was 35.6% and 44.7% in thoracoscopic and open groups respectively without significant difference (P>0.05). The left laryngeal recurrent nerve lymph node metastasis rate in open group and thoracoscopic group was 16.1% and 6.7% respectively , and the difference was significant (P<0.05). Differences of lymph node metastasis rate in other regions were not significant between the two groups. There were 365 positive lymph nodes , and the lymph node metastasis degree was 9.8%. which was 8.2% and 10.5% in thoracoscopic group and open group respectively (P<0.05), besides metastasis degree of open group was much higher in right laryngeal recurrent nerve and subcarinal lymph node region. The overall complication rate was 36.8%, which was 28.6% in thoracoscopic group and 41.2% in open group respectively with significant difference (P<0.05). There were no significant differences in operative time and blood loss between the two groups (both P>0.05). Conclusion Radical mediastinal lymphadenectomy with thoracoscopic esophagectomy is technically safe and feasible for early to moderate stage esophageal cancer with similar lymph nodes removed and lower complication morbidity. In the early period of carrying out thoracoscopic radical mediastinal lymphadenectomy, laryngeal recurrent nerve and subcarinal lymph node region should be identified to prevent incidental injury.