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Ivor-Lewis经胸颈部机械吻合术治疗中段食管癌的前瞻性研究

Ivor-Lewis stapled cervical esophagogastrostomy via thorax for middle esophageal carcinoma: a prospective cohort study

摘要:

目的 探讨Ivor-Lewis经胸颈部机械吻合术治疗中段食管癌的疗效.方法 前瞻性研究2005年3月至2013年3月两家医院收治的303例中段食管癌患者(江苏省如皋市博爱医院107例、江苏省如皋市人民医院196例)的临床资料,按患者入院先后顺序编号分为Ivor-Lewis组(151例),施行Ivor-Lewis径路经胸颈部机械吻合术;Sweet组(152例),施行Sweet径路经胸颈部机械吻合术.比较两组患者术中情况、围手术期并发症、淋巴结清扫和术后随访等情况.采用门诊复查方式随访,随访时间截至2012年12日.计量资料采用成组t检验,计数资料采用x2检验或Fisher确切概率法,等级资料采用Wilcoxon成组秩和检验.采用Kaplan-Meier法绘制生存曲线,COX比例风险模型分析术后死亡风险.结果 Ivor-Lewis组的手术时间和手术切除率分别为(239±21) min和98.68%(149/151),Sweet组分别为(188±30) min和92.76%(141/152),两组比较,差异有统计学意义(t=11.32,x2=6.45,P<0.05).Ivor-Lewis组和Sweet组的食管上切缘阳性率分别为0.67%(1/149)和0.71%(1/141),术后并发症发生率分别为10.07% (15/149)和11.35%(16/141),手术死亡率分别为0和0.71%(1/141),两组比较,差异均无统计学意义(P>0.05).Ivor-Lewis组清扫的颈胸交界部、腹上区淋巴结数目以及颈胸交界部阳性淋巴结数目分别为(3.6±1.1)枚、(3.5±1.1)枚和(0.7±1.1)枚,Sweet组分别为(2.3±0.8)枚、(2.4±0.8)枚和(0.3±0.6)枚,两组比较,差异均有统计学意义(Z=9.96,9.02,3.26,P<0.05).290例手术切除治疗的食管癌患者中273例获得术后随访,随访率为94.14% (273/290),中位随访时间为28.0个月.Ivor-Lewis组患者术后第1、2、3年肿瘤复发、转移率分别为8.21%(11/134)、19.64% (22/112)、29.35%(27/92),Sweet组分别为19.05% (24/126)、35.24% (37/105)、44.19% (38/86),两组比较,差异有统计学意义(x2=6.55,7.33,5.03,P<O.05).其中两组患者术后1、2、3年区域淋巴结复发率比较,差异有统计学意义(x2=7.03,9.68,6.87,P<0.05).Ivor-Lewis组患者术后1、2、3年累积生存率分别为90.30% (121/134)、80.36% (90/112)、71.74% (66/92),Sweet组分别为80.95% (102/126)、59.05% (62/105)、51.16% (44/86),两组比较,差异均有统计学意义(x2=4.65,11.73,7.97,P<0.05).结论 Ivor-Lewis经胸颈部机械吻合术治疗中段食管癌,手术切除率高、安全性好,术后患者生存获益明显.该术式可以作为治疗颈部无肿大可疑转移淋巴结的中段食管癌的优选手术方法.

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abstracts:

Objective To investigate the efficacy of the Ivor-Lewis cervical stapled esophagogastrostomy via thorax in the treatment of middle esophageal carcinoma.Methods The clinical data of 303 patients with middle esophageal carcinoma who were admitted to the Rugao Boai Hospital (107 patients) and the Rugao People's Hospital (196 patients) from March 2005 to March 2013 were prospectively analyzed.All the patients received Ivor-Lewis stapled cervical esophagogastrectomy (Ivor-Lewis group,151 patients) or Sweet stapled cervical esophagogastrostomy (Sweet group,152 patients) according to the admission order.The intraoperative condition,perioperative complications,lymph node dissection and postoperative follow-up of the 2 groups were analyzed.All the patients were followed up via out-patient examination till December 2012.The measurement data,enumeration data and the ranked data were analyzed using the independent samples t-test,chi-square test or Fisher exact probability and Wilcoxon rank sum test,respectively.The survival curve was drawn by the Kaplan-Meier method,and the postoperative mortality rate was analyzed using the Cox proportional hazard model.Results The operation time of the Ivor-Lewis group was (239 ± 21)minutes,which was significantly longer than (188 ± 30)minutes of the Sweet group (t =11.32,P < 0.05).The surgical resection rate of the Ivor-Lewis group was 98.68% (149/151),which was significantly higher than 92.76% (141/152) of the Sweet group (x2 =6.45,P < 0.05).The positive rate of the upper resection margin of the esophagus,postoperative morbidity rate and operative were 0.67%(1/149),10.07% (15/149) and 0 in the Ivor-Lewis group,and 0.71% (1/141),11.35% (16/141) and 0.71%(1/141) in the Sweet group,with no significant difference between the 2 groups (P > 0.05).The number of lymph nodes dissected from the cervical-thoracic junction and the upper abdomen were 3.6 ± 1.1 and 3.5 ± 1.1 in the Ivor-Lewis group,which were significantly greater than 2.3 ± 0.8 and 2.4 ± 0.8 in the Sweet group (Z =9.96,9.02,P < 0.05).The number of positive lymph nodes dissected from the cervical-thoracic junction was 0.7 ± 1.1 in the Ivor-Lewis group,which was greater than 0.3 ± 0.6 of the Sweet group,with significant difference between the 2 groups (Z =3.26,P < 0.05).Of the 290 patients who received surgical treatment,273 were followed up with the follow-up rate of 94.14% (273/290),and the median time for follow-up was 28.0 months.The 1-,2-,3-year tumor recurrence rates were 8.21% (11/134),19.64% (22/112) and 29.35% (27/92) of the Ivor-Lewis group,which was significantly lower than 19.05% (24/126),35.24% (37/105) and 44.19%(38/86) of the Sweet group (x2=6.55,7.33,5.03,P < 0.05).There were significant differences in the 1-,2-,3-year locoregional recurrence rate of the lymph nodes between the 2 groups (x2 =7.03,9.68,6.87,P <0.05).The 1-,2-,3-year accumulative survival rates of the Ivor-Lewis group were 90.30% (121/134),80.36%(90/112) and 71.74% (66/92),which were significantly higher than 80.95% (102/126),59.05% (62/105)and 51.16% (44/86) of the Sweet group (x2=4.65,1 1.73,7.97,P < 0.05).Conclusion Ivor-Lewis stapled cervical esophagogastrostomy via thorax has advantages of high resection rate,better safety and better quality of life of patients,and it could be an optimized design of the treatment for patients with middle esophageal cancer without intumescent lymph node of neck.

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