不同手术入路对Ⅱ、Ⅲ型食管胃结合部腺癌患者术后生活质量及生存的影响

Effect of different surgical approaches on postoperative quality of life and survival of patients with Ⅱ, Ⅲ type adenocarcinoma of the esophagogastric junction

目的 前瞻性分析Ⅱ、Ⅲ型食管胃结合部腺癌（AEG）经胸入路与经腹食管裂孔切开入路根治术对患者近期生活质量及总生存期等的影响,探讨Ⅱ、Ⅲ型AEG手术入路的合理选择.方法 2012年3月至2012年9月间山西省肿瘤医院前瞻性研究入组Ⅱ、Ⅲ型AEG患者139例,其中经胸入路组（经胸组）64例,经腹食管裂孔切开入路组（经腹组）75例,分别对两组的手术时间、切缘癌残留阳性率、平均清扫淋巴结数目、术后平均住院天数、胃肠功能恢复所需平均天数、围手术期心肺并发症发生率、吻合口瘘发生率、术后出血发生率、围手术期死亡率、术后1年内呼吸功能下降率、术后1年内体质量下降平均值、术后1年内反流率、术后1年复发转移率、1年生存率等指标进行统计对比分析.结果 139例患者中,26例失访,失访率为18.7％,随访病例113例.经胸组和经腹组患者的术后平均住院时间分别是（20.2±8.9）d、（17.1±6.4）d,两组间差异有统计学意义（P＜0.05）;两组平均清扫淋巴结数目分别为（15.2±7.5）个、（23.0±13.0）个,两组间差异有统计学意义（P＜0.05）.两组病例的手术时间、切缘癌残留阳性率、胃肠功能恢复平均天数、围手术期心肺并发症发生率、吻合口瘘发生率、术后出血发生率、围手术期死亡率、术后1年内呼吸功能下降率、术后1年内体质量下降平均值、术后1年内反流发生率、术后1年复发转移率及术后1年生存率差异均无统计学意义（均P＞0.05）.结论 Ⅱ、Ⅲ型AEG手术入路以经腹经食管裂孔切开根治术式为优先选择.经腹入路清扫淋巴结数目较经胸入路多,对预后可能有一定影响.

Objective To analyze the postoperative quality of life index and survival of Ⅱ,Ⅲ type adenocarcinoma of the esophagogastric junction （AEG） patients who were implemented radical surgery through the transthoracic approach or abdominal transhiatal approach.To explore the reasonable operative approach of Ⅱ,Ⅲ type AEG.Methods 139 cases of patients with Ⅱ,Ⅲ type AEG were prospectively enrolled into the group in Shanxi Cancer Hospital during March 2012 to September 2012.64 cases of them were in transthoracic approach （TT） group,and 75 cases in abdominal transhiatal approach （TH） group.The operative time,the residual incision margin cancer rate,the average number of lymph node dissection,postoperative hospital stay,the average number of days required for gastrointestinal function recovery,the incidence of cardiopulmonary complications,anastomotic leakage rate,postoperative bleeding rate,perioperative mortality,postoperative respiratory function decline rate within 1 year,the average weight loss after 1 year,postoperative reflux rate within 1 year,recurrence and metastasis rate within 1 year,and 1-year survival rate of two groups were respectively compared.Results Statistical analysis was done on the perioperative data of 139 patients,and regular follow-up was carried out for these 139 patients after they discharged from hospital,of which 26 cases were lost,the lost rate was 18.7 %,so the followed-up cases were 113 cases.Postoperative hospital stay in transthoracic approach group was longer than abdominal transhiatal approach group with significant difference,（20.2±8.9） d vs （17.1±6.4） d （P 〈 0.05）,the average number of lymph node dissection in transthoracic approach group （15.2±7.5） was less than abdominal transhiatal approach group （23.0±13.0） with significant difference （P 〈 0.05）.No significant difference were observed in the operative time,the residual incision margin cancer rate,the average number of days required for gastrointestinal function recovery,the incidence of cardiopulmonary complications,anastomotic leakage rate,postoperative bleeding rate,perioperative mortality,postoperative respiratory function decline rate within 1 year,the average weight loss after 1 year,postoperative reflux rate within 1 year,recurrence and metastasis rate within 1 year,and 1-year survival rate of the two operation approaches （all P 〉 0.05）.Conclusions Abdominal approach,through the esophageal hiatus radical surgery is a preferred operative approach of Ⅱ,Ⅲ type AEG.The average number of lymph node dissection in abdominal transhiatal approach group was more than transthoracic approach group.It may have some influence on the prognosis.