van Lanschot J J, Hop W C, Voormolen M H, van Deelen R A, Blomjous J G, Tilanus H W
Department of General Surgery, University Hospital Rotterdam-Dijkzigt, The Netherlands.
J Am Coll Surg. 1994 Dec;179(6):705-13.
After "curative" resection of carcinoma of the esophagus, late secondary dysphagia almost invariably indicates locoregional tumor recurrence. The retrosternal reconstruction route is advocated to prevent ingrowth of tumor recurrence in the neoesophagus.
To evaluate the quality of palliation after "curative" resection of carcinoma of the esophagus and the possible benefit of the retrosternal reconstruction route, we retrospectively analyzed the records of patients who had resection of a malignant tumor of the esophagus, or the gastroesophageal junction, and a prevertebral reconstruction. The extra-anatomic route would have been only beneficial for patients with intrathoracic tumor recurrence distant from the anastomosis and causing gastrointestinal symptoms.
Between 1983 and 1989, 209 patients (mean age of 61.3 years at the time of operation) had "curative" resection and prevertebral reconstruction in the institution of this study. Seventy-three patients (35 percent) had locoregional tumor recurrence. Univariate and multivariate analysis of various risk factors for locoregional recurrence showed that the presence of positive lymph nodes (pN1), especially if located at the celiac trunk (pM1), and a macroscopically non-radical R2 resection were the most important risk factors. Forty-six patients (22 percent) had secondary dysphagia as a result of locoregional tumor recurrence, mostly (18 percent) within two years postoperatively. Dysphagia lasted on average 5.3 months (range of 0.3 to 21.5 months) before the patients died. In 27 patients (13 percent), dysphagia would probably have been prevented by using a retrosternal reconstruction route.
These data are an argument in favor of the extra-anatomic, retrosternal reconstruction route after limited transthoracic or transhiatal resection in the presence of positive lymph nodes. This method seems especially indicated if the nodes are located at the celiac trunk and in case of a macroscopically nonradical R2 resection.
在食管癌“根治性”切除术后，晚期继发性吞咽困难几乎总是提示局部区域肿瘤复发。提倡采用胸骨后重建路径以防止肿瘤复发向内生长至新食管。
为评估食管癌“根治性”切除术后的姑息治疗质量以及胸骨后重建路径可能带来的益处，我们回顾性分析了行食管或胃食管交界恶性肿瘤切除及椎体前重建患者的记录。解剖外路径仅对吻合口远处胸内肿瘤复发并引起胃肠道症状的患者有益。
1983年至1989年期间，本研究机构中有209例患者（手术时平均年龄61.3岁）接受了“根治性”切除及椎体前重建。73例患者（35%）出现局部区域肿瘤复发。对局部区域复发的各种危险因素进行单因素和多因素分析显示，阳性淋巴结（pN1）的存在，尤其是位于腹腔干处（pM1），以及宏观上非根治性的R2切除是最重要的危险因素。46例患者（22%）因局部区域肿瘤复发出现继发性吞咽困难，大多数（18%）发生在术后两年内。吞咽困难平均持续5.3个月（0.3至21.5个月不等），直至患者死亡。在27例患者（13%）中，采用胸骨后重建路径可能预防吞咽困难。
这些数据支持在存在阳性淋巴结的情况下，经有限的开胸或经裂孔切除术后采用解剖外的胸骨后重建路径。如果淋巴结位于腹腔干处以及宏观上为非根治性的R2切除时，这种方法似乎尤为适用。
