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中华胸部外科电子杂志

中华胸部外科电子杂志 ›› 2017, Vol. 04 ›› Issue (01) : 7 -12. doi: 10.3877/cma.j.issn.2095-8773.2017.01.02

所属专题： 文献；

论著

食管癌根治术常规清扫隆突下淋巴结的价值
周瑜1, 田东1, 严高武2, 李利发3, 施贵冬1, 陆宇海1, 付茂勇1,†()   
  1. 1. 637000　南充，川北医学院附属医院胸心外科
    2. 637000　南充，川北医学院附属医院放射科
    3. 637000　南充，川北医学院附属医院胃肠外科
  • 收稿日期:2016-09-25 出版日期:2017-02-28
  • 通信作者: 付茂勇
  • 基金资助:
    川北医学院2014年科研发展计划项目(CBY14-A-ZD03)

Value of routine subcarinal lymph node dissection in radical resection of esophageal cancer

Yu Zhou1, Dong Tian1, Gaowu Yan2, Lifa Li3, Guidong Shi1, Yuhai Lu1, Maoyong Fu1,†()   

  1. 1. Department of Cardiothoracic Surgery, Affiliated Hospital of North Sichuan Medical College, Nanchong 637000, China
    2. Department of Radiology, Affiliated Hospital of North Sichuan Medical College, Nanchong 637000, China
    3. Department of Gastrointestinal Surgery, Affiliated Hospital of North Sichuan Medical College, Nanchong 637000, China
  • Received:2016-09-25 Published:2017-02-28
  • Corresponding author: Maoyong Fu
  • About author:
    Corresponding author: Fu Maoyong, Email:
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周瑜, 田东, 严高武, 李利发, 施贵冬, 陆宇海, 付茂勇. 食管癌根治术常规清扫隆突下淋巴结的价值[J]. 中华胸部外科电子杂志, 2017, 04(01): 7-12.

Yu Zhou, Dong Tian, Gaowu Yan, Lifa Li, Guidong Shi, Yuhai Lu, Maoyong Fu. Value of routine subcarinal lymph node dissection in radical resection of esophageal cancer[J]. Chinese Journal of Thoracic Surgery(Electronic Edition), 2017, 04(01): 7-12.

目的

探讨食管癌根治术是否需要常规清扫隆突下淋巴结。

方法

回顾性分析川北医学院附属医院2013年3月至2016年3月行食管癌根治术患者的临床资料，根据是否行隆突下淋巴结清扫分为清扫组(n＝294)和未清扫组(n＝308)两组。比较两组患者的基本特征，Logistic回归分析食管癌隆突下淋巴结转移的影响因素，并比较清扫组和未清扫组患者的围手术期差异。

结果

共纳入病例602例，平均清扫淋巴结11.75枚，其中淋巴结转移202例(33.6%)。清扫组患者平均清扫隆突下淋巴结2.87枚，其中转移20例(6.8%)。单因素分析显示：Tis/T1、T2、T3、T4期食管癌隆突下淋巴结转移率分别为0、1.4%、10.2%、13.6%(χ2＝16.407，P < 0.01)；N0、N1、N2、N3期食管癌隆突下淋巴结转移率分别为0、12.9%、20.5%、60.0%(χ2＝46.099，P < 0.01)；肿瘤长度≤3.0 cm、3.1～5.0 cm、>5.0 cm食管癌隆突下淋巴结转移率分别为2.0%、7.5%、13.3%(χ2＝8.253，P < 0.05)；隆突下淋巴结转移与年龄、性别、手术路径、肿瘤位置、肿瘤分化程度以及淋巴结清扫数目无关(均P>0.05)。多因素分析显示：食管癌隆突下淋巴结转移与T分期及肿瘤浸润深度有关(均P<0.05)。清扫组患者肺部及胸腔并发症发生率高于未清扫组，手术时间长于未清扫组(均P< 0.05)。

结论

食管癌隆突下淋巴结转移与肿瘤浸润深度及N分期有关。因此，对于胸段食管癌当肿瘤侵及食管纤维膜时建议行隆突下淋巴结清扫，但可能会增加肺部及胸腔并发症发生率并延长手术时间。

关键词: 食管癌, 外科治疗, 隆突下, 淋巴结清扫
Objective

To investigate the value of routine subcarinal lymph node dissection in radical resection of esophageal cancer.

Methods

The clinical data of patients undergoing radical resection of esophageal cancer in Affiliated Hospital of North Sichuan Medical College between March 2013 and March 2016 were retrospectively analyzed. Patients were divided into dissection group (with subcarinal lymph node dissection, n=294) and non-dissection group (without subcarinal lymph node dissection, n=308). The basic characteristics were compared between two groups. The influencing factors of subcarinal lymph node metastasis were explored by Logistic regression analysis, and the perioperative parameters were compared between two groups.

Results

A total of 602 patients were included, with an average of 11.75 dissected lymph nodes in each patient. There were 202 cases of lymph node metastasis, which accounted for 33.6%. The mean number of dissected lymph nodes in each patient in dissection group was 2.87, and there were 20 patients (6.8%) with lymph node metastasis in dissection group. Univariate analysis indicated that the rates of subcarinal lymph node metastasis in patients staged Tis/T1, T2, T3 and T4 were 0, 1.4%, 10.2% and 13.6%, respectively (χ2=16.407, P<0.01), the rates of subcarinal lymph node metastasis in those staged N0, N1, N2 and N3 were 0, 12.9%, 20.5% and 60.0%, respectively (χ2=46.099, P< 0.01), the rates of subcarinal lymph node metastasis in those with different length of esophageal cancers (≤3.0 cm, 3.1 to 5.0 cm, >5.0 cm) were 2.0%, 7.5% and 13.3%, respectively (χ2=8.253, P<0.05), and the rate of subcarinal lymph node metastasis was not significantly related to age, gender, tumor location, surgical path, tumor differentiation and number of dissected lymph nodes (P>0.05). Multivariate analysis indicated that T staging and infiltration depth of esophageal cancer were related to subcarinal lymph node metastasis (P<0.05). The incidence of pulmonary and thoracic cavity complications and operation time in dissection group were higher and longer than those in non-dissection group (P<0.05).

Conclusions

Tumor infiltration depth and N staging are related to subcarinal lymph node metastasis of esophageal cancer. Subcarinal lymph nodes may be dissected routinely in esophageal cancer patients with esophageal fiber membrane infiltration, however, it may also increase the incidence of complications and operation time.

Key words: Esophageal neoplasm, Surgical treatment, Subcarinal, Lymph node dissection
表1 294例食管癌隆突下淋巴结清扫结果单因素分析
因素 总例数 清扫淋巴结数(枚，±s) 隆突下淋巴结数(枚，±s) 单因素分析
隆突下淋巴结转移[例(%)] χ2值 P值
年龄(岁) ? ? ? ? 0.263 0.608
? <60 88 15.0±6.1 3.1±3.0 7(8.0) ? ?
? ≥60 206 13.6±7.2 2.8±2.2 13(6.3) ? ?
性别 ? ? ? ? 0.052 0.819
? 男性 199 14.4±7.1 2.8±2.4 14 (7.0) ? ?
? 女性 95 13.3±6.7 3.0±2.7 6 (6.3) ? ?
肿瘤位置 ? ? ? ? 4.081 0.130
? 胸上段 27 13.6±8.1 3.0±2.7 0(0) ? ?
? 胸中段 220 13.7±6.6 2.8±3.3 16(7.3) ? ?
? 胸下段 47 15.8±7.7 3.2±2.9 4(8.5) ? ?
手术入路 ? ? ? ? 1.069 0.546
? 经左胸 241 13.9±6.8 2.9±2.5 18 (7.5) ? ?
? 经右胸 53 14.5±7.5 2.9±2.2 2 (3.8) ? ?
T分期 ? ? ? ? 16.407 0.001
? Tis-T1 49 13.0±6.7 2.4±2.1 0(0) ? ?
? T2 73 12.6±6.7 3.0±2.6 1(1.4) ? ?
? T3 128 14.6±6.7 3.1±2.6 13(10.2) ? ?
? T4 44 16.0±7.7 2.7±2.3 6 (13.6) ? ?
N分期 ? ? ? ? 46.099 <0.001
? N0 180 13.0±6.9 2.9±2.6 0(0) ? ?
? N1 70 15.3±7.1 2.9±2.5 9(12.9) ? ?
? N2 39 16.0±6.7 2.4±1.7 8 (20.5) ? ?
? N3 5 20.8±8.4 3.6±2.3 3(60.0) ? ?
肿瘤直径(cm) ? ? ? ? 8.253 0.016
? ≤3.0 100 12.7±6.9 3.2±2.6 2(2.0) ? ?
? 3.1～5.0 134 14.5±6.2 2.6±2.1 10(7.5) ? ?
? > 5.0 60 15.2±8.2 3.0±2.9 8(13.3) ? ?
肿瘤分化程度 ? ? ? ? 4.358 0.113
? 高分化 125 14.5±7.7 3.1±2.6 5(4.0) ? ?
? 中分化 112 14.2±6.21 2.8±2.1 12(10.7) ? ?
? 低分化 57 12.6±6.6 2.5±2.7 3(5.3) ? ?
淋巴结清扫数目 ? ? ? ? 0.267 0.605
? <12枚 119 7.7±2.5 2.1±1.3 7(5.9) ? ?
? ≥12枚 175 18.3±5.6 3.4±2.9 13 (7.4) ? ?
表2 294例食管癌隆突下淋巴结转移多因素Logistic回归分析
因素 SE Sig EXP(B)(95% CI)
肿瘤浸润深度 0.623 0.017 0.226(0.067～0.766)
N分期 0.354 0.000 0.227(0.113～0.453)
肿瘤直径 0.679 0.298 0.493(0.130～1.866)
表3 清扫组和未清扫组围手术期指标比较[例(%)]
项目 未清扫组(308例) 清扫组(294例) 检验值 P值
肺部及胸腔并发症① 47(15.3) 81(27.5) χ2＝13.574 <0.001
吻合口瘘及残胃瘘 22(7.1) 25(8.5) χ2＝0.387 0.534
切口感染 34(11.0) 30(10.2) χ2＝0.110 0.740
胃排空障碍 6(1.9) 5(1.7) χ2＝0.051 0.821
手术时间(min，±s) 194.5±14.9 205.9±25.8 t＝84.689 <0.001
术中失血量(ml，±s) 194.1±17.7 195.6±17.0 t＝15.211 0.294
图1 食管癌隆突下淋巴结转移患者的淋巴结病理检查结果(HE×400)。A：左下角包膜不完整，不排除制片时破坏或术中清扫淋巴结时破坏包膜；B：左下角肿瘤细胞直接从包膜侵犯淋巴结
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