完全腹腔镜经腹经膈肌裂孔入路在Siewert Ⅱ型食管胃结合部腺癌根治术中的应用价值

Application value of totally laparoscopic transabdominal-hiatal approach in the radical resection of Siewert type Ⅱ adenocarcinoma of esophagogastric junction

目的探讨完全腹腔镜经腹经膈肌裂孔入路在Siewert Ⅱ型食管胃结合部腺癌(AEG)根治术中的应用价值。方法采用回顾性描述性研究方法。收集2017年5月至2018年7月浙江大学医学院附属杭州市第一人民医院收治的11例Siewert Ⅱ型AEG患者的临床病理资料;男8例,女3例;平均年龄为63岁,年龄范围为56~72岁。患者均行完全腹腔镜经腹经膈肌裂孔入路AEG根治术。观察指标:(1)手术及术后情况。(2)术后病理学检查情况。(3)随访及生存情况。采用门诊或电话方式进行随访,了解患者术后辅助化疗情况、并发症情况、进食情况、吻合口通畅情况、肿瘤复发转移和生存情况。随访时间截至2018年12月。正态分布的计量资料以Mean±SD表示,偏态分布的计量资料以M(范围)表示。计数资料以绝对数或百分比表示。结果(1)手术及术后情况:11例患者均成功施行完全腹腔镜经腹经膈肌裂孔入路Siewert Ⅱ型AEG根治术,其中8例行全胃切除术(3例同时行脾门淋巴结清扫),3例行近端胃切除术(双通道吻合)。无中转开腹和围术期死亡患者。11例患者手术时间为(245±39)min,食管空肠高位Overlap吻合时间为(60±12)min,术中出血量为(75±23)mL,术后首次下床活动时间为(24±8)h,术后首次肛门排气时间为(2.4±0.5)d,术后首次进食流质食物时间为(3.5±0.8)d,术后引流管拔除时间为(8.2±1.3)d。11例患者术后无出血、吻合口瘘、死亡等严重并发症发生,3例术后出现左侧胸腔积液,经胸腔置管引流后痊愈。11例患者术后住院时间为(11.0±3.0)d。(2)术后病理学检查情况:11例患者上切缘均为阴性,食管切缘长度为(2.1±0.2)cm,肿瘤直径为(2.6±0.9)cm,淋巴结清扫数目为(36.0±4.0)枚/例,其中下纵隔淋巴结清扫数目为(2.3±0.8)枚/例。11例患者病理学检查均为腺癌,病理学TNM分期:ⅠB期2例、ⅡA期4例、ⅡB期3例、ⅢA期2例。(3)随访及生存情况:11例患者均获得随访,随访时间为6~19个月,中位随访时间为9个月。术后根据病理学检查情况制订化疗方案,9例患者行术后辅助化疗,2例ⅠB期患者未行术后辅助化疗。随访期间患者无明显胃食管反流症状,无进食哽噎感,术后口服水性造影剂及胃镜检查示11例患者吻合口均通畅。11例患者均无胃癌术后复发、转移和死亡。结论完全腹腔镜经腹经膈肌裂孔入路Siewert Ⅱ型AEG根治术安全、可行,近期疗效满意。

Objective To investigate the safety and feasibility of totally laparoscopic transabdominal-hiatal approach in the treatment of Siewert type Ⅱ adenocarcinoma of esophagogastric junction (AEG). Methods The retrospective and descriptive study was conducted. The clinicopathological data of 11 patients with Siewert type Ⅱ AEG who were admitted to Affiliated Hangzhou First People′s Hospital of Zhejiang University School of Medicine from May 2017 to July 2018 were collected. There were 8 males and 3 females, aged 56-72 years, with an average age of 63 years.Patients underwent radical resection of AEG by totally laparoscopic transabdominal-hiatal approach. Observation indicators:(1) surgical situations and postoperative recovery;(2) postoperative pathological examination;(3) follow-up and survival situations. Follow-up using outpatient examination and telephone interview was performed to detect postoperative adjuvant chemotherapy, complications, food intake, anastomosis patency, tumor recurrence and metastasis, and survival up to December 2018. Measurement data with normal distribution were presented as Mean±SD, measurement data with skewed distribution were presented as M (range), and count data were represented as absolute number or percentage. Results (1) Surgical situations and postoperative recovery: all the patients underwent totally laparoscopic radical resection of Siewert type Ⅱ AEG by transabdominal-hiatal approach, without conversion to open surgery or perioperative death. Of the 11 patients, 8 underwent total gastrectomy including 3 combined with splenic hilar lymph node dissection and 3 underwent proximal gastrectomy with double-tract reconstruction. Operation time, time of superior overlap esophagojejunostomy, volume of intraoperative blood loss, time for initial out-of-bed activities, time to first flatus, time to initial liquid diet intake, time of drainage tube removal were respectively (245±39)minutes,(60±12)minutes,(75±23)mL,(24±8)hours,(2.4±0.5)days,(3.5±0.8)days,(8.2±1.3)days respectively. There was no serious complication including postoperative hemorrhage, anatomotic fistula or death. Three patients had left pleural effusion, and were cured after thoracic drainage. The duration of postoperative hospital stay was (11.0±3.0) days.(2) Postoperative pathological examination: all the 11 patients had negative upper surgical margin. The length of proximal margin, tumor diameter, total number of lymph lodes harvested, and number of lower mediastinal lymph lodes harvested were (2.1±0.2)cm,(2.6±0.9)cm,(36.0±4.0)/case and (2.3±0.8)/case. Pathological examination showed adenocarcinoma in all the 11 patients. pTNM staging: 2 cases were in stage ⅠB, 4 cases in stage ⅡA, 3 cases in stage ⅡB and 2 cases in stage ⅢA.(3) Follow-up and survival situations: 11 patients were follow-up for 6-19 months, with a median time of 9 months. Chemotherapy regimeus were formulated according to the pathological examination. Nine patients received postoperative adjuvant chemotherapy, and 2 in stage ⅡB received no postoperative adjuvant chemotherapy. During the follow-up, 11 patients had no obvious reflux symptom or choking feeling, and the anastomosis was patent as evaluated by oral contrast agent and gastroscopy. There was no tumor recurrence and metastasis or death in the 11 patients. Conclusion Totally laparoscopic transabdominal-hiatal approach applied in the radical resection is safe and feasible for the treatment of Siewert type Ⅱ AEG, with good short-term outcomes.