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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 (04) : 209 -212. doi: 10.3877/cma.j.issn.2095-8773.2017.04.03

所属专题： 文献；

论著

食管癌根治性放化疗后挽救性手术的价值
郭旭峰1, 孙益峰1, 杨煜1, 叶波1, 杨洋1, 张晓彬1, 华荣1, 茅腾1, 李志刚1,†()   
  1. 1. 200030　上海交通大学附属胸科医院胸外科　上海交通大学食管疾病诊治中心
  • 收稿日期:2017-09-10 出版日期:2017-11-28
  • 通信作者: 李志刚
  • 基金资助:
    上海市科委西医引导课题(17411971200); 上海市卫计委局青课题(20154Y017)

The value of salvage esophagectomy after definitive chemoradiotherapy in esophageal cancer

Xufeng Guo1, Yifeng Sun1, Yu Yang1, Bo Ye1, Yang Yang1, Xiaobing Zhang1, Rong Hua1, Teng Mao1, Zhigang Li1,†()   

  1. 1. Department of Thoracic Surgery, Section of Esophageal Cancer, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai 200030, China
  • Received:2017-09-10 Published:2017-11-28
  • Corresponding author: Zhigang Li
  • About author:
    Corresponding author: Li Zhigang, Email:
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郭旭峰, 孙益峰, 杨煜, 叶波, 杨洋, 张晓彬, 华荣, 茅腾, 李志刚. 食管癌根治性放化疗后挽救性手术的价值[J]. 中华胸部外科电子杂志, 2017, 04(04): 209-212.

Xufeng Guo, Yifeng Sun, Yu Yang, Bo Ye, Yang Yang, Xiaobing Zhang, Rong Hua, Teng Mao, Zhigang Li. The value of salvage esophagectomy after definitive chemoradiotherapy in esophageal cancer[J]. Chinese Journal of Thoracic Surgery(Electronic Edition), 2017, 04(04): 209-212.

目的

探讨食管癌根治性放化疗(dCRT)后挽救性外科手术的安全性和有效性。

方法

回顾性分析上海交通大学附属胸科医院胸外科单一手术组2014年12月—2017年3月间连续收治的18例dCRT后行挽救性手术的食管癌患者的临床及病理资料，其中dCRT后肿瘤复发6例(33.3%)、肿瘤持续存在12例(66.7%)，结合患者随访结果进行分析。

结果

18例dCRT后行挽救性手术的食管癌患者均采用McKeown术式并行胸腹两野淋巴结清扫，其中胃代食管15例，结肠代食管3例。根治性切除(R0)12例，姑息性切除(R2)6例，术后病理提示病理完全缓解(pCR)4例。术后并发症发生率为61.1%(11/18)，其中肺部感染6例，吻合口瘘4例，切口感染2例，呼吸功能不全、喉返神经麻痹、乳糜胸和脓胸致主动脉出血各1例。围术期死亡1例(脓胸致主动脉出血)。随访时间2～26月，中位随访时间9个月，截至最后一次随访日期存活13例，死亡5例。除外围术期死亡1例，分别有2例死于局域性复发转移和远处转移。

结论

挽救性手术是食管癌dCRT后肿瘤复发或者持续存在的一种治疗选择。手术并发症发生率高，dCRT后准确的临床分期尤为重要，应避免ycT4、ycN＋等容易出现R2切除的患者。R0切除及较长的无瘤期后再复发是预后良好的因素。

关键词: 食管癌, 根治性放化疗, 挽救性手术
Objective

To evaluate the safety and efficacy of salvage esophagectomy.

Methods

A retrospective analysis of 18 consecutive cases of salvage esophagectomy after definitive chemoradiotherapy (dCRT) by the single operation group in the department of thoracic surgery, Shanghai Chest Hospital affiliated to Shanghai Jiao Tong University from December 2014 to March 2017.

Results

There were 6 cases (33.3%) and 12 cases (66.7%) of recurrent and persistent tumor after dCRT respectively. All the patients were treated with McKeown operation style combing thoracic and abdominal lymph nodes dissection. Among them, there were 15 cases of gastric esophagus and 3 cases of colon esophagus. Radical resection (R0) was performed in 12 cases, palliative resection (R2) in 6 cases. There were 4 cases of pathological complete response (pCR). The incidence of postoperative complications was 61.1% (11/18), including 6 cases of pulmonary infection, 4 cases of anastomotic leak, 2 cases of incision infection, 1 case of respiratory insufficiency, 1 case of recurrent laryngeal nerve paralysis, 1 case of chylothorax, 1 case of aortic bleeding caused by empyema. One patient died in perioperative period because of aortic bleeding due to empyema. The follow-up period was from 2 to 26 months, and the median follow-up time was 9 months. There were 13 patients survived and 5 patients died at the last follow-up date including 1 case died in perioperative period, 2 cases died of local-regional recurrence and metastasis respectively.

Conclusions

Salvage esophagectomy is a treatment option for the recurrent or persistent disease after dCRT, but the incidence of postoperative complications is high. Accurate clinical staging is especially important after dCRT and ycT4, ycN+ patients should be avoided. R0 resection and recurrence after long disease free period are favorable prognostic factors.

Key words: Esophageal cancer, Definitive chemoradiotherapy (dCRT), Salvage resection
表1 食管癌患者行挽救性手术参数分析
手术参数 病例数 百分比
手术方式 ? ?
? McKeown-胃代食管 15 83.3
? McKeown-结肠代食管 3 16.7
胸部操作 ? ?
? 开放手术 13 72.2
? 胸腔镜手术 5 27.8
切除分类 ? ?
? R0 12 66.7
? R1/R2 0/6 33.3
病理分期 ? ?
? pCR 4 22.2
? ypT0N1M0 2 11.1
? ypT2N0M0 1 5.6
? ypT3N0M0 6 33.3
? ypT4bN0M0 3 16.7
? ypT4bN2M0 2 11.1
表2 食管癌患者术中事件及围术期参数分析
围术期参数 病例数 百分比
术中事件 ? ?
? ? 前锯肌覆盖气管膜部 2 11.1
? ? 心包脂肪垫覆盖气管膜部 1 5.6
? ? 合并切除肿瘤侵犯的右下肺 1 5.6
术后并发症 ? ?
? 无 7 38.9
? 有 11 61.1
? ? 肺部感染 6 33.3
? ? 吻合口瘘 4 22.2
? ? 切口感染 2 11.1
? ? 呼吸功能不全 1 5.6
? ? 乳糜胸 1 5.6
? ? 喉返神经麻痹 1 5.6
? ? 脓胸致主动脉出血 1 5.6
围术期死亡 1 5.6
图1 18例挽救性手术患者生存分析
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