外阴恶性肿瘤保留大隐静脉的腹股沟淋巴结清扫术改良术式的探讨

背景与目的:外阴恶性肿瘤传统手术方式为外阴广泛切除术 双侧腹股沟淋巴结清扫术伴大隐静脉的结扎和切除,术后多种并发症的发生严重影响了患者的生存质量.本研究探讨外阴恶性肿瘤行腹股沟淋巴结清扫术保留大隐静脉对手术操作、预后及并发症的影响.方法:将1989年1月至2005年12月期间收住院并行双侧腹股沟淋巴结清扫术的64例外阴恶性肿瘤患者分为两组,31例行双侧腹股沟淋巴结清扫术时保留双侧大隐静脉主干(简称保留组),33例结扎、切除一段大隐静脉(简称切除组),对两组患者的手术时间、术中出血量、5年生存率、复发率及术后急慢性并发症进行比较.结果:(1)保留组中,双侧腹股沟淋巴结清扫术手术时间为130～170 min,中位时间155 min:出血量100～450 ml,中位出血量295 ml.切除组中,手术时间为120～170 min,中位时间140 min;出血量150～390 ml,中位出血量270 ml.两组比较,两个参数差异均无显著性,P值均＞0.05;(2)两组患者总的5年生存率为67.3%,切除组为66.7%,保留组为68.0%,两组比较差异无显著性,P＞0.05.随访至2006年3月,保留组共发现3例5侧腹股沟淋巴结复发,切除组5例7侧复发,复发率分别为8.9%(5/56)、12.1%(7/58),两者比较差异无显著性,P＞0.05;(3)保留组急性下肢静脉炎,急性下肢淋巴水肿的发生率分别为11.3%,43.5%;切除组分别为25.8%,66.7%,两组比较差异有显著性(P值分别＜0.05,＜0.01).保留组迟发性下肢水肿和下肢疼痛的发生率分别为25.0%,23.2%,切除组48.3%,46.6%,两组比较差异均具有非常显著性(P值均＜0.01);两组下肢蜂窝组织炎及感觉异常的发生率差异亦具有显著性(P值均＜0.05).结论:外阴恶性肿瘤行腹股沟淋巴结清扫术时保留双侧大隐静脉主干不延长手术时间,不增加手术难度,不降低患者长期生存率,但能明显降低术后并发症的发生率,提高患者的生活质量,是值得推广的手术方式.

Preservation of the saphenous vein during inguinal lymphadenectomy for vulval malignancies

BACKGROUND & OBJECTIVE: The conventional operation for the patients with vulval malignancies is radical vulvectomy and bilateral inguinal lymphadenectomy with partial saphenous vein trunk ligation and resection, but the quality of life of the patients was declined severely because of multiple postoperative complications. This study was to explore the influences of preserving the saphenous vein during inguinal lymphadenectomy for vulval malignancies on operation, prognosis, and complications. METHODS: A total of 64 patients with vulval malignancies, treated in Shandong Provincial Cancer Hospital from Jan. 1989 to Dec. 2005, were divided into 2 groups: the saphenous vein was preserved in 31 patients and ligated in 33 patients during inguinal lymphadenectomy. The operating time, intraoperative blood loss, 5-year survival rate, recurrence rate, and complications were compared between the 2 groups. RESULTS: The median operating time of bilateral inguinal lymphadenectomy was 155 min (130-170 min) in preservation group, and 140 min (120-170 min) in ligation group (P>0.05). The median intraoperative blood loss was 295 ml (100-450 ml) in preservation group, and 270 ml (150-390 ml) in ligation group (P>0.05). The 5-year overall survival rate was 67.3%; it was 68.0% in preservation group and 66.7% in ligation group (P>0.05). Till Mar. 2006, 5 sides of inguinal lymph nodes relapsed in 3 patients in preservation group, and 7 sides in 5 patients in ligation group; the recurrence rates were 8.9% (5/56), and 12.1% (7/58) (P>0.05). The occurrence rates of acute low extremity lymph edema, low extremity phlebitis, chronic low extremity edema, and chronic leg pain were significantly lower in preservation group than in ligation group (11.3% vs. 25.8%, P<0.05; 43.5% vs. 66.7%, P<0.01; 25.0% vs. 48.3%, P<0.01; 23.2% vs. 46.6%, P<0.01); the occurrence of leg cellulitis and sense abnormity were also less in preservation group than in ligation group (P<0.05). CONCLUSIONS: Preserving the saphenous vein trunk during inguinal lymphadenectomy for vulval malignancies reduces multiple postoperative complications without compromising treatment outcome. This modified operative modality is valuable to be recommended.