SiewertI型食管胃结合部腺癌的手术径路及预后分析

Surgical approaches and prognostic analysis of Siewert type I adenocarcinoma of the esophagogastric junction

目的探讨SiewertI型食管胃结合部腺癌（AEG）合理的手术径路及影响患者预后的因素。方法回顾性分析2005年1月至2009年12月上海交通大学医学院附属仁济医院收治的103例SiewertI型AEG患者的临床资料。根据手术径路将患者分为2组：单纯经胸手术组（61例），胸腹联合手术组（42例）。两组患者术中腹腔淋巴结清扫和术后并发症情况比较分别采用X2检验（例数〈1时采用Fisher确切概率法）及￡检验。Kaplan—Meier法绘制生存曲线，Log—rank检验分析生存情况。患者预后分析采用单因素方差分析，多因素分析采用COX回归模型。结果两组患者均无围手术期死亡。单纯经胸手术组和胸腹联合手术组患者在腹腔淋巴结清扫和转移数目两方面比较，差异有统计学意义（t=2．18，2．29，P〈0．05）；术中脾脏损伤比较，差异无统计学意义（P〉0．05）；术后出血、吻合口瘘、吻合口狭窄、胃食管反流、肺部感染、切口处骨髓炎等并发症发生率方面比较，差异无统计学意义（X2=0．07，0．94，0．22，1．41，0．17，P〉0．05）。全组患者随访率为94．2％（97／103），术后中位生存时间为26个月，术后3年生存率为35．9％。单纯经胸手术组和胸腹联合手术组患者术后3年生存率分别为32．8％和40．2％，两组比较，差异无统计学意义（X2=0．37，P〉0．05）。单因素分析结果表明，患者的3年生存率与手术方式、TNM分期、N分期、肿瘤直径、淋巴结转移率、根治程度有关（X2=21．07，26．0d，22．42，6．26，32．20，20．80，P〈0．05）。多因素分析结果表明，TNM分期、淋巴结转移率及根治程度是影响患者预后的独立危险因素（Wald=12．01，8．75，10．03，P〈0．05）。结论胸腹联合入路是SiewertI型AEG患者更为合理的手术径路选择。TNM分期、淋巴结转移率、根治程度是影响患者预后的独立危险因素。

Objective To investigate rational surgical approaches for Siewert type I adenocarcinoma of the esophagogastric junction （ AEG）, and analyze the prognostic factors. Methods The clinical data of 103 patients with Siewert type I AEG who were admitted to the Renji Hospital from January 2005 to December 2009 were retro- spectively analyzed. All patients were divided into transthoracic approach group （61 patients） and thoracoabdominal approach group （42 patients）. The incidences of numbers of lymph node dissected and postoperative complications of the 2 groups were compared using the chi-square test, Fisher exact probability or the t test. The survival curve was drawn by the Kaplan-Meier method and the survival was analyzed using the Log-rank test. Prognostic factors were analyzed using the one-way analysis of variance and Cox regression model. Results No perioperative death was observed in the 2 groups. There were significant differences in the number of lymph node dissected and number of metastatic lymph node between the 2 groups （t =2. 18, 2.29, P 〈 0.05 ）. There was no significant difference in splenic injury between the 2 groups （ P 〉 0.05 ）. There were no significant differences in postoperative bleed- ing, anastomotic fistula and stricture, esophagogastric reflux, pulmonary infection and osteomyelitis between the 2 groups （X2 =0.07, 0.94, 0.22, 1.41, 0.17, P〉0 up. The mean postoperative survival time was 26 months. 05）. Of the 103 patients, 97 （ 94.2% ） were followed The median survival time was 26 months, and the 3-year survival rate was 35.9%. The 3-year survival rates of transthoracic approach group and thoracoabdominal approach group were 32.8% and 40.2% , with no significant difference between the 2 groups （X2 = 0.37, P 〉 0, 05 ）. The results of univariate analysis showed that radical or palliative resection, TNM stage, lymph node metastasis stage, tumor diameter and metastasis rate, degree of radical resection were independent factors influencing the prognosis of patients with Siewert type I AEG （X2 =21.07, 26.04, 22.42, 6.26, 32.20, 20.80, P 〈0.05）. The results of muhivariate analysis showed that degree of TNM stage, lymph node metastasis rate and radical resection were independent factors influencing the prognosis of patients （ Wald = 12. 01, 8. 75, 10. 03, P 〈 0.05 ）. Conclusions Thoracoabdominal approach is a reasonable selection for patients with Siewert type I AEG. Degree of TNM stage, lymph node metastasis rate and radical resection were independent risk factors influencing the prognosis of patients.