Objective To investigate the application value of different surgical approaches in the radical resection of Siewert type Ⅱ adenocarcinoma of esophagogastric junction (AEG).

Methods The retrospective cohort study was conducted. The clinicopathological data of 84 patients with Siewert Ⅱ AEG who were admitted to the Fourth Hospital of Hebei Medical University from March 2018 to March 2019 were collected. There were 65 males and 19 females, aged from 43 to 82 years, with a median age of 66 years. Of 84 patients, 24 cases undergoing radical resection of AEG via abdominal transhiatal approach (TH) were allocated into TH group, 32 cases undergoing radical resection of AEG via left thoracic approach (Sweet) were allocated into Sweet group, 28 cases undergoing radical resection of AEG via right thoracoabdominal approach (RTA) were allocated into RTA group. Observation indicators: (1) surgical and postoperative conditions of Siewert Ⅱ AEG patients in the 3 groups; (2) postoperative complications of Siewert Ⅱ AEG patients in the 3 groups. (3) Follow-up. Follow-up using outpatient examination and telephone interview was conducted to detect postoperative life quality, tumor recurrence and survival of patients up to March 2020. Measurement data with normal distribution were represented as Mean±SD, and comparison between groups was analyzed using the ANOVA. Measurement data with skewed distribution were represented as M (range), comparison among multiple groups was analyzed using the Kruskal-Wallis H test, and comparison between two groups was analyzed using the Dunn Bonferroni test. Count data were described as absolute numbers, and comparison between groups was analyzed using the chi-square test.

Results (1) Surgical and postoperative conditions of Siewert Ⅱ AEG patients in the 3 groups: the operation time for Siewert type Ⅱ AEG patients in TH group, Sweet group and RTA group were 216 minutes (range, 190-230 minutes), 174 minutes (range, 152-185 minutes) and 295 minutes (range, 261-337 minutes), respectively, showing a significant difference among the 3 groups (H=57.977, P<0.05). There were significant differences between the TH group and the Sweet group, between the TH group and the RTA group, respectively (P<0.05). There was also a significant difference between the Sweet group and the RTA group (P<0.05). The volume of intraoperative blood loss for Siewert type Ⅱ AEG patients in TH group, Sweet group and RTA group were 150 mL (range, 100-163 mL), 150 mL (range, 150-200 mL) and 200 mL (range, 150-263 mL), respectively, showing a significant difference among the 3 groups (H=11.097, P<0.05). There was no significant difference between the TH group and the Sweet group (P>0.05). There were significant differences between the TH group and the RTA group, between the Sweet group and the RTA group, respectively (P<0.05). The number of lymph node dissected for Siewert type Ⅱ AEG patients in TH group, Sweet group and RTA group were 15 (range, 9-19), 17 (range, 10-21) and 30 (range, 24-40), respectively, showing a significant difference among the 3 groups (H=29.775, P<0.05). There was no significant difference between the TH group and the Sweet group (P>0.05). There were significant differences between the TH group and the RTA group, between the Sweet group and the RTA group, respectively (P<0.05). The number of thoracic lymph node dissected for Siewert type Ⅱ AEG patients in TH group, Sweet group and RTA group were 0, 2 (range, 1-3) and 6 (range, 3-9), respec-tively, showing a significant difference among the 3 groups (H=48.140, P<0.05). There were significant differences between the TH group and the Sweet group, between the TH group and the RTA group, respectively (P<0.05). There was also a significant difference between the Sweet group and the RTA group (P<0.05). The number of abdominal lymph node dissected for Siewert type Ⅱ AEG patients in TH group, Sweet group and RTA group were 15 (range, 9-19), 12 (range, 8-19), and 24 (range, 17-35), respectively, showing a significant difference among the 3 groups (H=18.149, P<0.05). There was no significant difference between the TH group and the Sweet group (P>0.05). There were significant differences between the TH group and the RTA group, between the Sweet group and the RTA group, respectively (P<0.05). The number of positive lymph node for Siewert type Ⅱ AEG patients in TH group, Sweet group and RTA group were 2 (range, 0-3), 0 (range, 0-3), and 5 (range, 1-6), respectively, showing a significant difference among the 3 groups (H=7.729, P<0.05). There was no significant difference between the TH group and the Sweet group, between the TH group and the RTA group, respectively (P>0.05). There was a significant difference between the Sweet group and the RTA group (P<0.05). The time to postoperative first flatus of Siewert type Ⅱ AEG patients in TH group, Sweet group and RTA group were 3 days (range, 3-4 days), 3 days (range, 3-4 days), and 4 days (range, 3-5 days), respectively, showing no significant difference among the 3 groups (H=3.125, P>0.05). The duration of postoperative hospital stay for Siewert type Ⅱ AEG patients in TH group, Sweet group and RTA group were 16 days (range, 14-17 days), 14 days (range, 12-15 days), and 19 days (range, 18-21 days), respectively, showing a significant difference among the 3 groups (H=35.244, P<0.05). There was no significant difference between the TH group and the Sweet group (P>0.05). There were significant differences between the TH group and the RTA group, between the Sweet group and the RTA group, respectively (P<0.05). (2) Postoperative complications of Siewert Ⅱ AEG patients in the 3 groups: there were 6, 6, 11 Siewert type Ⅱ AEG patients of the TH group, Sweet group and RTA group with cardiopulmonary complication, respectively, 1, 1, 2 patients with anastomotic leakage and 1, 0, 1 patients with AEG-related death, showing no significant difference in the above indicators among the 3 groups (χ²=3.263, 0.754, 1.595, P>0.05). (3) Follow-up: 78 of 84 Siewert type Ⅱ AEG patients were followed up for 9.0 to 24.0 months, with a median follow-up time of 16.6 months. Cases with reduced respiratory function at postoperative 3 months for the TH group, Sweet group and RTA group were 4, 3, 5, respectively. Cases with gastroesophageal reflux at postoperative 3 months for the 3 groups were 3, 6, 7, respectively. Cases with weight loss at post-operative 3 months for the 3 groups were 3, 2, 4, respectively. There was no significant difference in the above indicators among the 3 groups (χ²=1.009, 1.107, 1.112, P>0.05). Cases tumor recurrence and metastasis in the TH group, Sweet group and RTA group were 5, 7, 4, cases who survived at postoperative 1 year in the 3 groups were 19, 24, 25, respectively. There was no significant difference in the above indicators among the 3 groups (χ²=0.897, 1.261, P>0.05).

Conclusion RTA appiled in Siewert type Ⅱ AEG patients has a longer postoperative operation time, increased intra-operative blood loss and longer hospital stay, while has better advantages in lymph node dissection.