Abstract: Objective:To investigate clinical effects and prognostic factors of transabdominal laparoscopicassisted and open radical resection for Siewert type Ⅱ and Ⅲ adenocarcinoma of the esophagogastric junction (AEG).
Methods:The retrospective cohort and casecontrol studies were conducted. The clinicopathological data of 84 patients with Siewert type Ⅱ and Ⅲ AEG who were admitted to the First Affiliated Hospital of Xiamen University from January 2014 to January 2017 were collected. Among 84 patients, 42 undergoing transabdominal laparoscopicassisted radical gastectomy (LARG) were allocated into LARG group and 42 undergoing transabdominal open radical gastectomy (ORG) were allocated into ORG group. Observation indicators: (1) comparison of intraoperative and postoperative recovery situations between groups; (2)comparison of followup and survival situations between groups; (3) prognostic analysis of patients with Siewert type Ⅱ and Ⅲ AEG undergoing transabdominal radical resection. Followup using outpatient examination and telephone interview was performed to detect postoperative survival situations, tumor recurrence and metastasis of patients up to January 2018. Measurement data with normal distribution were representde as ±s, and comparison between groups was analyzed using the t test. Measurement data with skewed distribution were described as M (range). Comparison of count data were analyzed using the chisquare test or Fisher exact probability. Ordinal data were compared between groups using the MannWhitney U nonparametric test. The survival rate and curve were respectively calculated and drawn by the KaplanMeier method, and Logrank test was used for survival and univariate analyses. Multivariate analysis was done by COX proportional hazard model.
Results:(1)Comparison of intraoperative and postoperative recovery situations between groups: patients with Siewert type Ⅱ and Ⅲ AEG in the LARG and ORG group underwent successful transabdominal radical resection, without conversion to thoracotomy. All patients in the LARG group underwent esophagojejunostomy with circular stapler device, 38 and 4 patients in the ORG group underwent esophagojejunostomy with circular stapler and linear cut stapler respectively. Operation time, volume of intraoperative blood loss, length of incision, time of postoperative analgesia, cases with anastomotic bleeding, anastomotic leakage, abdominal bleeding, incisional infection, pulmonary infection, abdominal infection and reflux esophagitis of grade Ⅰ~Ⅱ postoperative complications and duration of postoperative stay were respectively (261±50)minutes, (119±111)mL, (7.8±1.6)cm, (2.1±1.3)days, 1, 1, 0, 0, 1, 0, 0 , (12.8±1.9)days in LARG group and (216±52)minutes, (230±178)mL, (17.3±1.8)cm, (3.4±1.2)days, 2, 0, 2, 2, 2, 1, 2, (18.4±15.3)days in ORG group, with statistically significances between groups (t=2.357, 2.960, 2.195, 2.013, x²=5.486, t=2.125, P<0.05). All patients with complications were improved by symptomatic treatment. (2) Comparison of followup and survival situations between groups: 81 of 84 patients including 41 in LARG group and 40 in ORG group were followed up for 6-48 months, with a median time of 29 months. The postoperative 2year overall and tumorfree survival rates were respectively 85.1% and 82.1% of 41 patients in LARG group and 83.1% and 79.3% of 40 patients in ORG group, with no statistically significance between groups (x²=0.013, 0.049, P>0.05). (3) Prognostic analysis of patients with Siewert type Ⅱ and Ⅲ AEG undergoing transabdominal radical resection: results of univariate analysis showed that tumor diameter,tumor TNM staging, tumor T staging, tumor N staging and postoperative adjuvant chemotherapy were related factors affecting prognosis of patients with Siewert type Ⅱ and Ⅲ AEG undergoing transabdominal radical resection (x²=8.349, 14.376, 9.732, 17.250, 8.012, P<0.05). Results of multivariate analysis showed that tumor TNM staging and postoperative adjuvant chemotherapy were independent factors affecting prognosis of patients with Siewert type Ⅱ and Ⅲ AEG undergoing transabdominal radical resection (risk ratio=4.305, 0.031, 95% confidence interval: 1.858-9.977, 0.004-0.246, P<0.05).
Conclusions:Transabdominal laparoscopicassisted radical resection for AEG is safe and feasible, with advantage of minimally invasiveness, having equivalent longterm effects compared to open surgery. Tumor TNM staging and postoperative chemotherapy are independent factors affecting prognosis of patients with Siewert type Ⅱ and Ⅲ AEG undergoing transabdominal radical resection.