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不同手术径路在Siewert Ⅱ型食管胃结合部腺癌根治术中的应用价值

张建锋, 田洋, 徐延昭, 吕会来, 黄超, 张帆, 田子强

张建锋, 田洋, 徐延昭, 等. 不同手术径路在Siewert Ⅱ型食管胃结合部腺癌根治术中的应用价值[J]. 中华消化外科杂志, 2021, 20(6): 675-682. DOI: 10.3760/cma.j.cn115610-20210407-00169
引用本文: 张建锋, 田洋, 徐延昭, 等. 不同手术径路在Siewert Ⅱ型食管胃结合部腺癌根治术中的应用价值[J]. 中华消化外科杂志, 2021, 20(6): 675-682. DOI: 10.3760/cma.j.cn115610-20210407-00169
Zhang Jianfeng, Tian Yang, Xu Yanzhao, et al. Application value of different surgical approaches in the radical resection of Siewert type adenocarcinoma of esophagogastric junction[J]. Chinese Journal of Digestive Surgery, 2021, 20(6): 675-682. DOI: 10.3760/cma.j.cn115610-20210407-00169
Citation: Zhang Jianfeng, Tian Yang, Xu Yanzhao, et al. Application value of different surgical approaches in the radical resection of Siewert type adenocarcinoma of esophagogastric junction[J]. Chinese Journal of Digestive Surgery, 2021, 20(6): 675-682. DOI: 10.3760/cma.j.cn115610-20210407-00169

不同手术径路在Siewert Ⅱ型食管胃结合部腺癌根治术中的应用价值

基金项目: 

河北省医学适用技术跟踪项目 GZ2020 20022

详细信息
    通讯作者:

    田子强,Email:tizq12@vip.163.com

Application value of different surgical approaches in the radical resection of Siewert type adenocarcinoma of esophagogastric junction

Funds: 

Hebei Provincial Medical Appropriate Technology Tracking Program GZ2020 20022

More Information
  • 摘要:
    目的 

    探讨不同手术径路在Siewert Ⅱ型食管胃结合部腺癌(AEG)根治术中的应用价值。

    方法 

    采用回顾性队列研究方法。收集2018年3月至2019年3月河北医科大学第四医院收治的84例Siewert Ⅱ型AEG病人的临床病理资料;男65例,女19例;中位年龄为66岁,年龄范围为43~82岁。84例病人中,24例采用经腹膈肌食管裂孔径路(TH)行AEG根治术设为TH组,32例采用经左胸径路(Sweet)行AEG根治术设为Sweet组,28例采用经腹右胸Ivor‑Lewis径路(RTA)行AEG根治术设为RTA组。观察指标:(1)3组Siewert Ⅱ型AEG病人手术及术后情况。(2)3组Siewert Ⅱ型AEG病人术后并发症情况。(3)随访情况。采用电话及门诊方式进行随访,了解病人术后生命质量、术后肿瘤复发及生存情况。随访时间截至2020年3月。正态分布的计量资料以x±s表示,组间比较采用单因素方差分析;偏态分布的计量资料以M(范围)表示,多组间比较采用Kruskal‑Wallis H检验,两两比较采用Dunn Bonferroni检验。计数资料以绝对数表示,组间比较采用χ²检验。

    结果 

    (1)3组Siewert Ⅱ型AEG病人手术及术后情况:TH组、Sweet组、RTA组Siewert Ⅱ型AEG病人手术时间分别为216 min(190~230 min)、174 min(152~185 min)、295 min(261~337 min),3组比较,差异有统计学意义(H=57.977,P<0.05),TH组分别与Sweet组、RTA组比较,差异均有统计学意义(P<0.05),Sweet组与RTA组比较,差异有统计学意义(P<0.05)。术中出血量分别为150 mL(100~163 mL)、150 mL(150~200 mL)、200 mL(150~263 mL),3组比较,差异有统计学意义(H=11.097,P<0.05),TH组与Sweet组比较,差异无统计学意义(P>0.05),TH组、Sweet组分别与RTA组比较,差异均有统计学意义(P<0.05)。淋巴结清扫数目分别为15枚(9~19枚)、17枚(10~21枚)、30枚(24~40枚),3组比较,差异有统计学意义(H=29.775,P<0.05),TH组与Sweet组比较,差异无统计学意义(P>0.05),TH组、Sweet组分别与RTA组比较,差异均有统计学意义(P<0.05)。胸腔淋巴结清扫数目分别为0、2枚(1~3枚)、6枚(3~9枚),3组比较,差异有统计学意义(H=48.140,P<0.05),TH组分别与Sweet组、RTA组比较,差异均有统计学意义(P<0.05),Sweet组与RTA组比较,差异有统计学意义(P<0.05)。腹腔淋巴结清扫数目分别为15枚(9~19枚)、12枚(8~19枚)、24枚(17~35枚),3组比较,差异有统计学意义(H=18.149,P<0.05),TH组与Sweet组比较,差异无统计学意义(P>0.05),TH组、Sweet组分别与RTA组比较,差异均有统计学意义(P<0.05)。阳性淋巴结清扫数目分别为2枚(0~3枚)、0(0~3枚)、5枚(1~6枚),3组比较,差异有统计学意义(H=7.729,P<0.05),TH组分别与Sweet组、RTA组比较,差异均无统计学意义(P>0.05),Sweet组与RTA组比较,差异有统计学意义(P<0.05)。TH组、Sweet组、RTA组Siewert Ⅱ型AEG病人术后肛门首次排气时间分别为3 d(3~4 d)、3 d(3~4 d)、4 d(3~5 d),3组比较,差异无统计学意义(H=3.125,P>0.05)。术后住院时间分别为16 d(14~17 d)、14 d(12~15 d)、19 d(18~21 d),3组比较,差异有统计学意义(H=35.244,P<0.05),TH组与Sweet组比较,差异无统计学意义(P>0.05),TH组、Sweet组分别与RTA组比较,差异均有统计学意义(P<0.05)。(2)3组Siewert Ⅱ型AEG病人术后并发症情况:TH组、Sweet组、RTA组Siewert Ⅱ型AEG病人术后发生心肺并发症、吻合口漏、AEG相关死亡例数分别为6例、6例、11例,1例、1例、2例,1例、0、1例,3组上述指标比较,差异均无统计学意义(χ²=3.263,0.754,1.595,P>0.05)。(3)随访情况:84例Siewert Ⅱ型AEG病人中,78例获得随访。随访时间为9.0~24.0个月,中位随访时间为16.6个月。TH组、Sweet组、RTA组Siewert Ⅱ型AEG病人术后3个月发生呼吸功能下降、胃食管反流、体质量下降例数分别为4例、3例、5例,3例、6例、7例,3例、2例、4例,3组上述指标比较,差异均无统计学意义(χ²=1.009,1.107,1.112,P>0.05)。3组病人术后1年肿瘤复发转移,生存例数分别为5例、7例、4例,19例、24例、25例,3组上述指标比较,差异均无统计学意义(χ²=0.897,1.261,P>0.05)。

    结论 

    Siewert Ⅱ型AEG根治术中手术径路选择RTA,其手术时间延长,术中出血量增多,术后住院时间延长,但RTA具有更好的淋巴结清扫优势。

    Abstract:
    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.

  • 食管胃结合部腺癌(adenocarcinoma of esopha⁃gogastric junction,AEG)是指肿瘤中心位于食管胃交界线上下5 cm范围内并跨越或接触食管胃交界线的腺癌,肿瘤中心位于食管胃交界线上方1 cm至下方2 cm范围为Siewert Ⅱ型AEG。目前AEG的病因尚不清楚,可能与肥胖症、胃食管反流、个体遗传易感性及环境因素有关[13]。由于Siewert Ⅱ型AEG肿瘤位置特殊及淋巴结转移路径复杂,其诊断与治疗一直是困扰胃肠外科医师和胸外科医师的共同难点。其手术径路选择、淋巴结清扫范围等尚缺乏统一标准[4]。目前Siewert Ⅱ型AEG手术径路选择较多,主要包括经腹膈肌食管裂孔径路(abdominal transhiatal approach,TH)、经左胸径路(Sweet)、经腹右胸Ivor‑Lewis径路(right thoraco⁃abdominal approach,RTA)、经左胸腹联合切口径路等[5]。不同手术径路各有优势与不足[68]。本研究回顾性分析2018年3月至2019年3月我科收治的84例Siewert Ⅱ型AEG病人的临床病理资料,探讨不同手术径路在Siewert Ⅱ型AEG根治术中的应用价值。

    采用回顾性队列研究方法。收集84例Siewert Ⅱ型AEG病人的临床病理资料;男65例,女19例;中位年龄为66岁,年龄范围为43~82岁。84例病人中,24例采用TH行AEG根治术设为TH组,32例采用Sweet行AEG根治术设为Sweet组,28例采用RTA行AEG根治术设为RTA组。3组病人性别、年龄、BMI、Charlson合并症指数评分、美国麻醉医师协会分级、肿瘤长径、上侵食管长度、肿瘤分化程度、临床TNM分期、病理学T分期、病理学TNM分期比较,差异均无统计学意义(P>0.05),具有可比性。见表1。本研究通过我院医学伦理委员会审批,批号为2020kt393。病人及家属均签署知情同意书。

    表  1  TH组、Sweet组和RTA组Siewert Ⅱ型食管胃结合部腺癌病人一般资料比较
    Table  1.  Comparison of general data in Siewert type Ⅱ adenocarcinoma of esophagogastric junction patients among the abdominal transhiatal approach group, the Sweet approach group and the right thoracoabdominal approach group
    组别例数性别(例)年龄(例)体质量指数(x±s,kg/m2Charlson合并症指数评分(例)美国麻醉医师协会分级(例)
    ≤60岁>60岁1~2分≥3分Ⅰ级Ⅱ级
    TH组24159101423.5±2.7231213
    Sweet组3228472523.1±3.1284311
    RTA组2822642424.5±2.9262262
    统计值χ²=4.931χ²=5.437F=1.833χ²=1.184χ²=1.825
    P>0.05>0.05>0.05>0.05>0.05
    注:TH组病人采用经腹膈肌食管裂孔径路行食管胃结合部腺癌根治术,Sweet组病人采用经左胸径路行食管胃结合部腺癌根治术,RTA组病人采用经腹右胸Ivor‑Lewis径路行食管胃结合部腺癌根治术
    下载: 导出CSV 
    | 显示表格

    纳入标准:(1)CT、消化道造影及胃镜活组织病理学检查证实为Siewert Ⅱ型AEG。(2)术前系统评估可行手术及D2淋巴结清扫术。(3)无胸部及腹上区手术史。(4)未行新辅助放化疗等抗肿瘤治疗。(5)临床病理资料完整。

    排除标准:(1)合并其他肿瘤。(2)有肿瘤病史。(3)术前组织病理学检查证实为鳞癌。(4)术后病理学检查证实为多原发癌。(5)随访期间非AEG原因死亡。(6)临床病理资料缺失。

    手术均由同一主刀医师团队完成。TH组:取上腹部正中切口,行近端胃切除术或全胃切除+D2淋巴结清扫术。Sweet组:取左胸后外侧切口第7肋间进入胸腔,打开膈肌后,行近端胃切除+D2淋巴结清扫术。根据术中探查情况,须行全胃切除向腹部延长切口行全胃切除+D2淋巴结清扫术。RTA组:先取上腹正中切口,完成胃游离、腹腔淋巴结清扫、管状胃制作或全胃切除,再取左侧卧位,于右侧第5肋间进入胸腔,清扫胸腔淋巴结。所有近端胃切除术行食管胃弓下或膈下吻合,全胃切除术行食管空肠Roux‑en‑Y吻合。

    观察指标:(1)3组Siewert Ⅱ型AEG病人手术及术后情况:手术时间、术中出血量、淋巴结清扫数目、阳性淋巴结数目、术后肛门首次排气时间、术后住院时间。(2)3组Siewert Ⅱ型AEG病人术后并发症情况:心肺并发症、吻合口漏、AEG相关死亡。(3)随访情况:术后生命质量(呼吸功能下降、胃食管反流、体质量下降),术后肿瘤复发及生存情况。

    评价标准:上侵食管长度为肿瘤上极至齿状线的直线距离。TNM分期参照第八版国际抗癌联盟/美国癌症联合委员会癌症分期。参照日本食管肿瘤研究会进行淋巴结分区划分与清扫。AEG相关死亡为术后1个月内并发症导致的死亡。呼吸功能下降为术后3个月时测第1 s用力呼气容量与术前比较下降≥20%。体质量下降值为术后3个月时体质量与术前体质量比较下降。

    采用电话及门诊方式进行随访,了解病人术后生命质量、肿瘤复发及生存情况。随访时间截至2020年3月。

    应用SPSS 26.0统计软件进行分析。正态分布的计量资料以x±s表示,组间比较采用单因素方差分析;偏态分布的计量资料以M(范围)表示,多组间比较采用Kruskal‑Wallis H检验,两两比较采用Dunn Bonferroni检验。计数资料以绝对数表示,组间比较采用χ²检验。P<0.05为差异有统计学意义。

    TH组、Sweet组、RTA组Siewert Ⅱ型AEG病人手术时间分别为216 min(190~230 min)、174 min(152~185 min)、295 min(261~337 min),3组比较,差异有统计学意义(H=57.977,P<0.05),TH组分别与Sweet组、RTA组比较,差异均有统计学意义(P<0.05),Sweet组与RTA组比较,差异有统计学意义(P<0.05)。术中出血量分别为150 mL(100~163 mL)、150 mL(150~200 mL)、200 mL(150~263 mL),3组比较,差异有统计学意义(H=11.097,P<0.05),TH组与Sweet组比较,差异无统计学意义(P>0.05),TH组、Sweet组分别与RTA组比较,差异均有统计学意义(P<0.05)。淋巴结清扫数目分别为15枚(9~19枚)、17枚(10~21枚)、30枚(24~40枚),3组比较,差异有统计学意义(H=29.775,P<0.05),TH组与Sweet组比较,差异无统计学意义(P>0.05),TH组、Sweet组分别与RTA组比较,差异均有统计学意义(P<0.05)。胸腔淋巴结清扫数目分别为0、2枚(1~3枚)、6枚(3~9枚),3组比较,差异有统计学意义(H=48.140,P<0.05),TH组分别与Sweet组、RTA组比较,差异均有统计学意义(P<0.05),Sweet组与RTA组比较,差异有统计学意义(P<0.05)。腹腔淋巴结清扫数目分别为15枚(9~19枚)、12枚(8~19枚)、24枚(17~35枚),3组比较,差异有统计学意义(H=18.149,P<0.05),TH组与Sweet组比较,差异无统计学意义(P>0.05),TH组、Sweet组分别与RTA组比较,差异均有统计学意义(P<0.05)。阳性淋巴结清扫数目分别为2枚(0~3枚)、0(0~3枚)、5枚(1~6枚),3组比较,差异有统计学意义(H=7.729,P<0.05),TH组分别与Sweet组、RTA组比较,差异均无统计学意义(P>0.05),Sweet组与RTA组比较,差异有统计学意义(P<0.05)。TH组、Sweet组、RTA组Siewert Ⅱ型AEG病人术后肛门首次排气时间分别为3 d(3~4 d)、3 d(3~4 d)、4 d(3~5 d),3组比较,差异无统计学意义(H=3.125,P>0.05)。术后住院时间分别为16 d(14~17 d)、14 d(12~15 d)、19 d(18~21 d),3组比较,差异有统计学意义(H=35.244,P<0.05),TH组与Sweet组比较,差异无统计学意义(P>0.05),TH组、Sweet组分别与RTA组比较,差异均有统计学意义(P<0.05)。

    TH组、Sweet组、RTA组Siewert Ⅱ型AEG病人术后发生心肺并发症、吻合口漏、AEG相关死亡例数分别为6例、6例、11例,1例、1例、2例,1例、0例、1例,3组上述指标比较,差异均无统计学意义(χ²=3.263,0.754,1.595,P>0.05)。

    84例Siewert Ⅱ型AEG病人中,78例获得随访。随访时间为9.0~24.0个月,中位随访时间为16.6个月。

    TH组、Sweet组、RTA组Siewert Ⅱ型AEG病人术后3个月发生呼吸功能下降、胃食管反流、体质量下降例数分别为4例、3例、5例,3例、6例、7例,3例、2例、4例,3组上述指标比较,差异均无统计学意义(χ²=1.009,1.107,1.112,P>0.05)。3组病人术后1年肿瘤复发,生存例数分别为5例、7例、4例,19例、24例、25例,3组上述指标比较,差异均无统计学意义(χ²=0.897,1.261,P>0.05)。

    目前AEG分型普遍采用Siewert分型系统[911]。SiewertⅠ型AEG经胸手术切除和Siewert Ⅲ型AEG经腹手术切除已达成共识,但Siewert Ⅱ型AEG手术径路、切除范围及淋巴结清扫范围等尚不明确,仍需进一步探索[1218]。Siewert Ⅱ型AEG手术径路的选择需综合肿瘤位置、安全切缘、合理淋巴结清扫范围等因素[1719]。日本的一项前瞻性多中心研究根据淋巴结转移率及上侵食管长度确定AEG淋巴结清扫范围及手术径路[20]。已有研究结果显示:肿瘤上侵食管长度<3 cm时,从手术安全性及远期疗效考虑首选TH[14]

    淋巴结清扫是影响Siewert Ⅱ型AEG病人预后的重要因素, Siewert Ⅱ型AEG的淋巴结主要集中于腹腔淋巴结及下纵隔区[2123]。一项单中心回顾性研究结果显示:对于Siewert Ⅱ型AEG,TH比Sweet有利于扩大淋巴结清扫范围[24]。李国雷等[25]的前瞻性研究结果显示:微创Ivor‑Lewis组与Sweet组比较,淋巴结清扫总数,胸、腹腔淋巴结清扫数目均多于Sweet组,但两组胸、腹腔淋巴结转移数目比较,差异均无统计学意义。段晓峰等[26]回顾性分析101例SiewertⅡ型AEG病人的资料,其研究结果显示:RTA组淋巴结清扫总数及胸腔淋巴结清扫数目均多于Sweet组。但2019年的一项Meta分析结果显示:RTA与TH的淋巴结清扫总数比较,差异无统计学意义[27]。本研究结果显示:RTA组淋巴结清扫总数,胸、腹腔淋巴结清扫数目均多于TH组和Sweet组,RTA兼具胸、腹腔淋巴结清扫优势。RTA组腹腔淋巴结检出数目多于TH组,可能与本研究样本量较少有关。由于手术视野、暴露程度受限以及胸、腹腔解剖特点等原因,TH组与Sweet组胸腔淋巴结清扫数目少于RTA组。

    术中情况及术后短期并发症是评价AEG病人近期疗效的重要指标。Duan等[28]对不同手术径路治疗Siewert Ⅱ型AEG的研究结果显示:RTA较Sweet并未增加术中出血量和吻合口漏、肺部感染、呼吸衰竭及切口液化或感染等术后并发症发生率,但手术时间明显长于Sweet。Heger等[27]及毛承毅[29]等的研究结果与上述研究一致。Tosolini等[30]的研究结果显示:RTA较TH有更高的术后并发症发生率,但两组住院期间病死率与90 d病死率比较,差异均无统计学意义。Xing等[31]比较RTA与TH对Siewert Ⅱ型AEG病人的近、远期疗效,结果显示:TH比RTA有更好的短期疗效及肿瘤学效果。本研究结果显示:与TH组和Sweet组比较,RTA组手术时间延长,术中出血量增多,术后住院时间延长,但心肺并发症、吻合口漏、AEG相关死亡情况及术后肛门首次排气时间与TH组和Sweet组比较,差异均无统计学意义。

    雷力强和董剑宏[32]的研究结果显示:SiewertⅡ型和Ⅲ型AEG病人采用经胸和经腹两种手术径路病人呼吸功能下降、术后胃食管反流发生率及体质量下降比较,差异均无统计学意义。这与本研究结果一致。一项纳入443例Siewert Ⅱ型AEG病人的胸外科与胃肠外科联合研究结果显示:经腹径路比经胸径路总体生存倾向更优[33]。Blank等[17]的研究结果显示:RTA术后生存时间明显长于TH。本研究中3种手术径路术后1年复发情况及生存情况比较,差异均无统计学意义,这可能与本研究随访时间较短有关。

    RTA对Siewert Ⅱ型AEG病人具有较好的淋巴结清扫优势,且未增加术后并发症发生率,术后生命质量与其他手术径路比较差异均无统计学意义,这证明RTA的安全性及可行性。但由于不同医疗机构手术熟练程度及围术期管理等存在差异,外科医师应根据病人个体情况及临床分期审慎选择手术径路。本研究不足为纳入病例数较少和随访时间较短,RTA在Siewert Ⅱ型AEG手术中的应用价值仍需更大样本、更长随访研究结果进一步论证。

    综上,Siewert Ⅱ型AEG根治术中手术径路选择RTA,其手术时间延长,术中出血量增多,术后住院时间延长,但RTA具有更好的淋巴结清扫优势。

    所有作者均声明不存在利益冲突
    张建锋, 田洋, 徐延昭, 等. 不同手术径路在Siewert Ⅱ型食管胃结合部腺癌根治术中的应用价值[J]. 中华消化外科杂志, 2021, 20(6): 675-682. DOI: 10.3760/cma.j.cn115610-20210407-00169.

    http://journal.yiigle.com/LinkIn.do?linkin_type=cma&DOI=10.3760/cma.j.cn115610-20210407-00169

  • 表  1   TH组、Sweet组和RTA组Siewert Ⅱ型食管胃结合部腺癌病人一般资料比较

    Table  1   Comparison of general data in Siewert type Ⅱ adenocarcinoma of esophagogastric junction patients among the abdominal transhiatal approach group, the Sweet approach group and the right thoracoabdominal approach group

    组别例数性别(例)年龄(例)体质量指数(x±s,kg/m2Charlson合并症指数评分(例)美国麻醉医师协会分级(例)
    ≤60岁>60岁1~2分≥3分Ⅰ级Ⅱ级
    TH组24159101423.5±2.7231213
    Sweet组3228472523.1±3.1284311
    RTA组2822642424.5±2.9262262
    统计值χ²=4.931χ²=5.437F=1.833χ²=1.184χ²=1.825
    P>0.05>0.05>0.05>0.05>0.05
    注:TH组病人采用经腹膈肌食管裂孔径路行食管胃结合部腺癌根治术,Sweet组病人采用经左胸径路行食管胃结合部腺癌根治术,RTA组病人采用经腹右胸Ivor‑Lewis径路行食管胃结合部腺癌根治术
    下载: 导出CSV
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  • 收稿日期:  2021-04-06
  • 网络出版日期:  2024-07-18
  • 刊出日期:  2021-06-19

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