SiewertⅡ型和Ⅲ型食管胃结合部腺癌经腹入路腹腔镜辅助和开腹根治术疗效及预后因素分析

Clinical effects and prognostic factors of transabdominal laparoscopic-assisted and open radical resection for Siewert type Ⅱ and Ⅲ adenocarcinoma of the esophagogastric junction

目的：探讨SiewertⅡ型和Ⅲ型食管胃结合部腺癌（AEG）经腹入路腹腔镜辅助和开腹根治术疗效及预后影响因素。方法：采用回顾性队列研究和病例对照研究方法。收集2014年1月至2017年1月厦门大学附属第一医院收治的84例SiewertⅡ型和Ⅲ型AEG患者的临床病理资料。84例患者中， 42例行腹腔镜辅助经腹入路AEG根治术，设为LARG 组；42例行开腹经腹入路AEG根治术，设为ORG组。观察指标：（1）两组患者术中和术后恢复情况比较。（2）随访和生存情况比较。（3）行经腹入路根治术Siewert Ⅱ型和Ⅲ型AEG患者预后因素分析。采用门诊和电话方式进行随访，了解患者术后生存情况和肿瘤复发、转移情况。随访时间截至2018年1月。正态分布的计量资料以x^-±s表示，组间比较采用t检验。偏态分布的计量资料以M（范围）表示。计数资料比较采用x2检验或Fisher确切概率法。等级资料组间比较采用Mann-Whitney U非参数检验。采用KaplanMeier法计算生存率和绘制生存曲线，采用Log-rank检验进行生存分析和单因素分析。多因素分析采用COX比例风险模型。结果：（1）两组患者术中和术后恢复情况比较：LARG组和ORG组Siewert Ⅱ型和Ⅲ型AEG患者均顺利完成经腹入路AEG根治术，无中转开胸患者。LARG组患者均采用圆形吻合器行食管空肠吻合术；ORG组行食管空肠吻合术采用圆形吻合器和直线切割闭合器患者分别为38例和4例。LARG组患者手术时间、术中出血量、切口长度、术后镇痛时间分别为（261±50）min、（119±111）mL、（7.8±1.6）cm、（2.1±1.3）d，ORG组患者上述指标分别为（216± 52）min、（230±178）mL、（17.3±1.8）cm、（3.4±1.2）d；LARG组患者术后Ⅰ～Ⅱ级并发症（吻合口出血、吻合口漏、腹腔出血、切口感染、肺部感染、腹腔感染、反流性食管炎）发生例数和术后住院时间分别为1、1、0、0、1、0、0例和（12.8±1.9）d，ORG组患者上述指标分别为2、0、2、2、2、1、2例和（18.4±15.3）d。两组患者上述指标比较，差异均有统计学意义（t=2.357，2.960，2.195，2.013， χ^2=5.486，t=2.125，P〈0.05）。所有并发症患者经对症处理后好转。（2）随访和生存情况比较：84例患者中，81例获得术后随访（其中LARG组 41例、ORG组40例），随访时间为6～48个月，中位随访时间为29个月。LARG组41例患者术后2年总体生存率、术后2年无瘤生存率分别为85.1%、82.1%，ORG组40例患者上述指标分别为83.1%、79.3%，两组患者生存情况比较，差异无统计学意义（χ^2=0.013，0.049，P〉0.05）。（3）行经腹入路根治术Siewert Ⅱ型和Ⅲ型AEG患者预后因素分析。单因素分析结果显示：肿瘤长径、肿瘤TNM分期、肿瘤T分期、肿瘤N分期、术后辅助化疗是影响行经腹入路根治术Siewert Ⅱ型和Ⅲ型AEG患者预后的相关因素（χ^2=8.349，14.376，9.732，17.250，8.012，P〈0.05）。多因素分析结果显示：肿瘤TNM分期、术后辅助化疗是影响行经腹入路根治术Siewert Ⅱ型和Ⅲ型AEG患者预后的独立因素（相对危险度=4.305，0.031，95%可信区间：1.858～9.977，0.004～0.246，P〈0.05）。结论：腹腔镜辅助经腹入路AEG根治术安全可行，具有显著微创优势，远期疗效与开腹手术相当。肿瘤TNM分期、术后辅助化疗是影响行经腹入路根治术Siewert Ⅱ型和Ⅲ型AEG患者预后的独立因素。

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 x^-±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, χ^2=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 （χ^2=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 （χ^2=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.