胃切除联合根治性胰体尾和脾切除或联合姑息性胰腺楔形切除治疗侵犯胰腺的食管胃交界部腺癌的效果比较

Gastrectomy with either wedge resection of the pancreas or pancreaticosplenectomy for adenocarcinoma of the esophagogastric junction invading the pancreas: a comparison study

目的比较胃切除联合根治性胰体尾和脾切除和联合胰腺楔形切除治疗食管胃交界部腺癌侵犯胰腺的效果。方法回顾性分析2005年5月至2015年12月于河北医科大学第四医院胸外科接受手术治疗的连续64例食管胃交界部腺癌侵犯胰腺患者的临床资料,男性53例,女性11例,平均年龄60.2岁(范围:39~77岁)。根据AJCC第8版食管癌和胃癌分期系统,T4bN0M0期27例,T4bN1M0期18例,T4bN2M0期9例,T4bN3M0期10例。39例患者接受胃切除联合胰体尾和脾切除(联合脾胰切除组),25例接受胃切除联合受侵部位胰腺楔形切除(联合楔形切除组)。术后每半年随访一次。两组间定量资料比较采用t检验,分类资料采用χ^2检验、Fisher确切概率法或Wilcoxon秩和检验,生存率比较采用Kaplan-Meier法,单因素分析采用Log-rank检验,多因素分析采用Cox风险回归模型。结果联合脾胰切除组患者术后发生切口感染5例,吻合口瘘、腹腔感染、肺栓塞各1例;联合楔形切除组患者术后发生呼吸衰竭和腹腔感染各1例;术后并发症发生率两组无差异(8/39比2/25,P=0.292)。无手术后死亡患者。57例患者获得随访,随访率为89.1%。联合脾胰切除组5年总体生存率为32.3%,联合楔形切除组为0(χ^2=4.484,P=0.034)。术后辅助化疗组5年总体生存率为32.3%,高于单纯手术组的17.2%(χ^2=4.186,P=0.041)。结论胃切除联合脾胰体尾切除能够达到R0切除的食管胃交界部腺癌侵犯胰腺患者,通过手术可获得生存受益。手术后应辅助化疗。

Objective To compare the outcomes of gastrectomy with either wedge resection of the pancreas or pancreaticosplenectomy for adenocarcinoma of the esophagogastric junction (AEG) invading pancreas. Methods From May 2005 to December 2015, a total of 64 patients with AEG invading pancreas underwent gastrectomy with either wedge resection of pancreas (n=25) or pancreaticosplenectomy (n=39) at Department of Thoracic Surgery, Fourth Hospital, Hebei Medical University. There were 53 males and 11 females, with a mean age of 60.2 years (range: 39 to 77 years). According to the AJCC esophageal cancer staging system, 8th edition, there were 27 patients in phase T4N0M0, 18 in phase T4bN1M0, 9 in phase T4bN2M0 and 10 in phase T4bN3M0. Follow-up was carried out every 6 months. The t-test for the measurement data and the χ^2 test, Fisher exact test or Wilcoxon ran-sum test for the enumeration data were used between the two groups. Survival curves were generated using the Kaplan-Meier method, and compared using the Log-rank test. Multivariate analysis was undertaken using the Cox proportional hazard model (forward stepwise regression). Results In 39 patients who underwent pancreaticosplenectomy, incision infection occurred in 5 patients, anastomotic leak, peritoneal infection, lung infarction each occurred in 1 patient. There was 1 respiratory failure and 1 peritoneal infection in 25 patients undergoing wedge resection of the pancreas. There were no significant difference in the incidence of postoperative complications between the 2 groups (8/39 vs. 2/25, P=0.292), and no postoperative death in the study. Fifty-seven patients were followed up, with a follow-up rate of 89.1%. The 5-year overall survival rate was 32.3% in patients who underwent simultaneous gastrectomy and pancreaticosplenectomy, compared to 0 in those who underwent gastrectomy and wedge resection of the pancreas (χ^2=4.484, P=0.034). The 5-year overall survival rate for patients who undergoing adjuvant chemotherapy was 32.3%, compared to 17.2% in whom underwent surgery alone (χ^2=4.186, P=0.041). Conclusions Survival benefit from R0 resection by simultaneous gastrectomy and pancreaticosplenectomy for AEG invading the pancreas can be achieved. Adjuvant chemotherapy is necessary for these patients.