食管胃结合部癌的分型思考与手术径路探讨

Controversy over classifications and surgical approaches for esophagogastric junction carcinomas

食管胃结合部癌由于其肿瘤部位的特殊性,外科手术需要同时满足淋巴结清扫范围、切缘及重建安全性,因此在分型方式、手术径路等方面存在争议.传统的Siewert及Nishi分型以肿瘤中心作为分型的主要依据,这种分型没有考虑到肿瘤的上下切缘,尤其是对食管下端的浸润距离缺乏直观的精准的术前术中评估,因此这种分型对食管胃结合部癌手术方式、淋巴结清扫范围及重建方式的指导作用受到了一定的限制.本文系统分析了传统的Siewert及Nishi分型优缺点,阐述了不同分型的规范化淋巴结清扫范围及重建方式,并提出了一种以食管浸润长度为核心的食管胃结合部肿瘤分型的设想.

Due to the specific tumor site,the surgical resection and reconstruction of esophagogastric junction carcinoma needs radical lymphadenectomy and the safety of anastomotic stoma.The classification and surgical approaches for esophagogastric junction carcinoma are still under debate.The Siewert classification and Nishi classification focus on the center of the tumor,and do not take the proximal or distal margin into account.The lack of accurate preoperative or intraoperative assessment of the infiltration distance of the distal esophagus may limit the decision on the surgical approach,lymphadenectomy,and reconstruction.The purpose of this paper is to put forward a new classification for esophagogastric junction carcinoma,which includes the proximal and distal margins within 5 cm from the dentate line,with the proximal margin used as the main classification basis.Tumors with a distance from the proximal margin to the dentate line more than 3 cm are classified as typeⅠ,those less than 3 cm are classified as typeⅡ,and those with the proximal margin below the dentate line are classified as typeⅢ.