DeMeester T R, Zaninotto G, Johansson K E
Department of Surgery, School of Medicine, Creighton University, Omaha, Neb. 68131.
J Thorac Cardiovasc Surg. 1988 Jan;95(1):42-54.
The role of curative en bloc resection for carcinoma of the lower esophagus and cardia is still controversial. The experience with a selective approach in 52 patients with cancer in this location is reviewed. Thirty-two of the cancers were squamous cell, 13 adenocarcinoma, and seven adenocarcinoma associated with Barrett's esophagus. In 19, the tumor was not resectable and all of these patients died within a year. In 19 patients, a palliative resection could be done. Actuarial survival was 31% at 1 year. Only one patient was alive after 5 years. Initially, 16 patients with noncircumferential lesions on endoscopy and/or no evidence of spread to mediastinal lymph nodes on computed tomographic scan were considered to have potentially curable lesions. All were less than 75 years old and had a forced expiratory volume in 1 second greater than 1.5 L and a resting ejection fraction greater than 40%. A curative resection consisting of an en bloc thoracic esophagectomy, mediastinal lymphadenectomy, and an 80% gastrectomy with abdominal lymphadenectomy was performed in 14. The left colon was used to reestablish the gastrointestinal continuity. Two patients had more extensive disease discovered at operation, and the curative en bloc resection was abandoned. Absence of full wall penetration or involvement of four or fewer regional nodes, or both, was correctly predicted by preoperative and intraoperative staging in 86% of the patients. Operative mortality of a curative en bloc resection was 7% (1/14), and the actuarial survival rates were 76%, 66%, and 53% at 1, 2, and 5 years. Inferences are made from these results on tumor characteristics associated with survival, the extent of resection necessary for cure, the difficulty of accomplishing a curative en bloc resection by the transhiatal approach, the contraindication to curative en bloc resection, and the need for a surveillance program for patients with Barrett's esophagus.
根治性整块切除在下段食管癌和贲门癌治疗中的作用仍存在争议。本文回顾了对52例该部位癌症患者采用选择性治疗方法的经验。其中32例为鳞状细胞癌，13例为腺癌，7例为与巴雷特食管相关的腺癌。19例患者的肿瘤无法切除，所有这些患者均在1年内死亡。19例患者可行姑息性切除。1年的精算生存率为31%。5年后仅有1例患者存活。最初，16例在内镜检查时病变非环周且/或计算机断层扫描未显示纵隔淋巴结转移迹象的患者被认为具有潜在可治愈性病变。所有患者年龄均小于75岁，第1秒用力呼气量大于1.5L，静息射血分数大于40%。14例患者接受了包括整块胸段食管切除术、纵隔淋巴结清扫术以及80%胃切除术加腹部淋巴结清扫术的根治性切除。采用左结肠重建胃肠道连续性。2例患者在手术中发现病情更为广泛，放弃了根治性整块切除。术前和术中分期对86%的患者正确预测了无全层穿透或累及区域淋巴结数少于4个或两者均无。根治性整块切除的手术死亡率为7%（1/14），1年、2年和5年的精算生存率分别为76%、66%和53%。根据这些结果对与生存相关的肿瘤特征、治愈所需的切除范围、经裂孔途径完成根治性整块切除的难度、根治性整块切除的禁忌证以及对巴雷特食管患者进行监测计划的必要性进行了推断。
