Lerut T, Coosemans W, Decker G, De Leyn P, Moons J, Nafteux P, Van Raemdonck D
Department of Thoracic Surgery, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium.
J Surg Oncol. 2005 Dec 1;92(3):218-29. doi: 10.1002/jso.20363.
Adenocarcinoma of the esophagus and gastroesophageal junction (GEJ) has shown a remarkable increase during recent decades. Most patients are present with advanced stage disease, reflecting transmural growth and metastasis to lymph nodes at the time of diagnosis. Moreover, the pattern of lymph node dissemination is chaotic and difficult to predict, and despite the use of modern technology (e.g., spiral CT, EUS, FDG-PET), clinical staging remains suboptimal. These shortcomings in staging, as well as in different attitudes toward extent of resection and lymphadenectomy, are reflected by a great variation in surgical techniques, which are discussed in this review. As to the results, primary surgery can currently be performed with low mortality, below 5% in high volume centers. Hospital mortality and morbidity are mainly related to pulmonary complications and anastomotic leaks, the latter mostly resolving under conservative treatment. Overall 5-year survival varies between 10% and 59%. As expected the most important prognostic determinants are completeness of resection (R0 vs. R1-R2) and lymph node status (N0, N1). R0 resection currently offers 5-year survival rates of over 40%. Five-year survival figures for node-negative (N0) patients exceed 70%, and even for node-positive (N1), patients reach 25%. It is not known whether performing a three-field lymph node dissection is beneficial for patients with adenocarcinoma of the distal esophagus. With overall 5-year survival currently exceeding 30%-40%, these figures should be the gold standard against which all other therapeutic modalities are compared.
近几十年来，食管及胃食管交界（GEJ）腺癌的发病率显著上升。大多数患者就诊时已处于疾病晚期，这反映出在诊断时肿瘤已穿透管壁生长并发生淋巴结转移。此外，淋巴结转移模式混乱且难以预测，尽管使用了现代技术（如螺旋CT、超声内镜、氟代脱氧葡萄糖正电子发射断层显像），临床分期仍不尽人意。分期方面的这些不足，以及对切除范围和淋巴结清扫态度的差异，导致手术技术存在很大差异，本文将对此进行讨论。就手术结果而言，目前进行原发性手术的死亡率较低，在大型医疗中心低于5%。医院死亡率和发病率主要与肺部并发症和吻合口漏有关，后者大多在保守治疗下得以缓解。总体5年生存率在10%至59%之间。正如预期的那样，最重要的预后决定因素是切除的完整性（R0与R1 - R2）和淋巴结状态（N0、N1）。目前R0切除的5年生存率超过40%。淋巴结阴性（N0）患者的5年生存率超过70%，即使是淋巴结阳性（N1）患者也能达到25%。对于远端食管腺癌患者，进行三野淋巴结清扫是否有益尚不清楚。鉴于目前总体5年生存率超过30% - 40%，这些数据应成为所有其他治疗方式对比的金标准。
