不同手术径路在SiewertⅡ型食管胃结合部腺癌根治术中的应用价值

Application value of different surgical approaches in the radical resection of Siewert type Ⅱ adenocarcinoma of esophagogastric junction

目的探讨不同手术径路在SiewertⅡ型食管胃结合部腺癌(AEG)根治术中的应用价值。方法采用回顾性队列研究方法。收集2018年3月至2019年3月河北医科大学第四医院收治的84例SiewertⅡ型AEG病人的临床病理资料;男65例,女19例;中位年龄为66岁,年龄范围为43~82岁。84例病人中,24例采用经腹膈肌食管裂孔径路(TH)行AEG根治术设为TH组,32例采用经左胸径路(Sweet)行AEG根治术设为Sweet组,28例采用经腹右胸Ivor-Lewis径路(RTA)行AEG根治术设为RTA组。观察指标:(1)3组SiewertⅡ型AEG病人手术及术后情况。(2)3组SiewertⅡ型AEG病人术后并发症情况。(3)随访情况。采用电话及门诊方式进行随访,了解病人术后生命质量、术后肿瘤复发及生存情况。随访时间截至2020年3月。正态分布的计量资料以x±s表示,组间比较采用单因素方差分析;偏态分布的计量资料以M(范围)表示,多组间比较采用Kruskal-Wallis H检验,两两比较采用Dunn Bonferroni检验。计数资料以绝对数表示,组间比较采用χ^(2)检验。结果(1)3组SiewertⅡ型AEG病人手术及术后情况:TH组、Sweet组、RTA组SiewertⅡ型AEG病人手术时间分别为216 min(190~230 min)、174 min(152~185 min)、295 min(261~337 min),3组比较,差异有统计学意义(H=57.977,P<0.05),TH组分别与Sweet组、RTA组比较,差异均有统计学意义(P<0.05),Sweet组与RTA组比较,差异有统计学意义(P<0.05)。术中出血量分别为150 mL(100~163 mL)、150 mL(150~200 mL)、200 mL(150~263 mL),3组比较,差异有统计学意义(H=11.097,P<0.05),TH组与Sweet组比较,差异无统计学意义(P>0.05),TH组、Sweet组分别与RTA组比较,差异均有统计学意义(P<0.05)。淋巴结清扫数目分别为15枚(9~19枚)、17枚(10~21枚)、30枚(24~40枚),3组比较,差异有统计学意义(H=29.775,P<0.05),TH组与Sweet组比较,差异无统计学意义(P>0.05),TH组、Sweet组分别与RTA组比较,差异均有统计学意义(P<0.05)。胸腔淋巴结清扫数目分别为0、2枚(1~3枚)、6枚(3~9枚),3组比较,差异有统计学意义(H=48.140,P<0.05),TH组分别与Sweet组、RTA组比较,差异均有统计学意义(P<0.05),Sweet组与RTA组比较,差异有统计学意义(P<0.05)。腹腔淋巴结清扫数目分别为15枚(9~19枚)、12枚(8~19枚)、24枚(17~35枚),3组比较,差异有统计学意义(H=18.149,P<0.05),TH组与Sweet组比较,差异无统计学意义(P>0.05),TH组、Sweet组分别与RTA组比较,差异均有统计学意义(P<0.05)。阳性淋巴结清扫数目分别为2枚(0~3枚)、0(0~3枚)、5枚(1~6枚),3组比较,差异有统计学意义(H=7.729,P<0.05),TH组分别与Sweet组、RTA组比较,差异均无统计学意义(P>0.05),Sweet组与RTA组比较,差异有统计学意义(P<0.05)。TH组、Sweet组、RTA组SiewertⅡ型AEG病人术后肛门首次排气时间分别为3 d(3~4 d)、3 d(3~4 d)、4 d(3~5 d),3组比较,差异无统计学意义(H=3.125,P>0.05)。术后住院时间分别为16 d(14~17 d)、14 d(12~15 d)、19 d(18~21 d),3组比较,差异有统计学意义(H=35.244,P<0.05),TH组与Sweet组比较,差异无统计学意义(P>0.05),TH组、Sweet组分别与RTA组比较,差异均有统计学意义(P<0.05)。(2)3组SiewertⅡ型AEG病人术后并发症情况:TH组、Sweet组、RTA组SiewertⅡ型AEG病人术后发生心肺并发症、吻合口漏、AEG相关死亡例数分别为6例、6例、11例,1例、1例、2例,1例、0、1例,3组上述指标比较,差异均无统计学意义(χ^(2)=3.263,0.754,1.595,P>0.05)。(3)随访情况:84例SiewertⅡ型AEG病人中,78例获得随访。随访时间为9.0~24.0个月,中位随访时间为16.6个月。TH组、Sweet组、RTA组SiewertⅡ型AEG病人术后3个月发生呼吸功能下降、胃食管反流、体质量下降例数分别为4例、3例、5例,3例、6例、7例,3例、2例、4例,3组上述指标比较,差异均无统计学意义(χ^(2)=1.009,1.107,1.112,P>0.05)。3组病人术后1年肿瘤复发转移,生存例数分别为5例、7例、4例,19例、24例、25例,3组上述指标比较,差异均无统计学意义(χ^(2)=0.897,1.261,P>0.05)。结论SiewertⅡ型AEG根治术中手术径路选择RTA,其手术时间延长,术中出血量增多,术后住院时间延长,但RTA具有更好的淋巴结清扫优势。

Objective To investigate the application value of different surgical approaches in the radical resection of Siewert typeⅡadenocarcinoma of esophagogastric junction[AEG].Methods The retrospective cohort study was conducted.The clinicopathological data of 84 patients with Siewert Ⅱ AEG who were admitted to the Fourth Hospital of Hebei Medical University from March 2018 to March 2019 were collected.There were 65 males and 19 females,aged from 43 to 82 years,with a median age of 66 years.Of 84 patients,24 cases undergoing radical resection of AEG via abdominal transhiatal approach[TH]were allocated into TH group,32 cases undergoing radical resection of AEG via left thoracic approach[Sweet]were allocated into Sweet group,28 cases undergoing radical resection of AEG via right thoracoabdominal approach[RTA]were allocated into RTA group.Observation indicators:[1]surgical and postoperative conditions of Siewert It AEG patients in the 3 groups;[2]postoperative complications of SiewertⅡAEG patients in the 3 groups.[3]Follow-up.Follow-up using outpatient examination and telephone interview was conducted to detect postoperative life quality,tumor recurrence and survival of patients up to March 2020.Measurement data with normal distribution were represented as Mean±SD,and comparison between groups was analyzed using the ANOVA.Measurement data with skewed distribution were represented as M[range],comparison among multiple groups was analyzed using the Kruskal-Wallis H test,and comparison between two groups was analyzed using the Dunn Bonferroni test.Count data were described as absolute numbers,and comparison between groups was analyzed using the chi-square test.Results[1]Surgical and postoperative conditions of Siewert Ⅱ AEG patients in the 3 groups:the operation time for Siewert typeⅡAEG patients in TH group,Sweet group and RTA group were 216 minutes[range,190-230 minutes],174 minutes[range,152-185 minutes]and 295 minutes[range,261-337 minutes],respectively,showing a significant difference among the 3 groups[H=57.977,P<0.05].There were significant differences between the TH group and the Sweet group,between the TH group and the RTA group,respectively[P<0.05].There was also a significant difference between the Sweet group and the RTA group[P<0.05].The volume of intraoperative blood loss for Siewert type H AEG patients in TH group.Sweet group and RTA group were 150 mL[range,100-163 mL],150 mL[range,150-200 mL]and 200 mL[range,150-263 mL],respectively,showing a significant difference among the 3 groups[H=11.097,P<0.05].There was no significant difference between the TH group and the Sweet group[P>0.05].There were significant differences between the TH group and the RTA group,between the Sweet group and the RTA group,respectively[P<0.05].The number of lymph node dissected for Siewert type Ⅱ AEG patients in TH group,Sweet group and RTA group were 15[range,9-19],17[range,10-21]and 30[range,24-40],respectively,showing a significant difference among the 3 groups[H=29.775,P<0.05].There was no significant difference between the TH group and the Sweet group[P>0.05].There were significant differences between the TH group and the RTA group,between the Sweet group and the RTA group,respectively[P<0.05].The number of thoracic lymph node dissected for Siewert type Ⅱ AEG patients in TH group,Sweet group and RTA group were 0,2[range,1-3]and 6[range,3-9],respectively,showing a significant difference among the 3 groups[H=48.140,P<0.05].There were significant differences between the TH group and the Sweet group,between the TH group and the RTA group,respectively[P<0.05].There was also a significant difference between the Sweet group and the RTA group[P<0.05].The number of abdominal lymph node dissected for Siewert type Ⅱ AEG patients in TH group,Sweet group and RTA group were 15[range,9-19],12[range,8-19],and 24[range,17-35],respectively,showing a significant difference among the 3 groups[H=18.149,P<0.05].There was no significant difference between the TH group and the Sweet group[P>0.05].There were significant differences between the TH group and the RTA group,between the Sweet group and the RTA group,respectively[P<0.05].The number of positive lymph node for Siewert type E AEG patients in TH group,Sweet group and RTA group were 2[range,0-3],0[range,0-3],and 5[range,1-6],respectively,showing a significant difference among the 3 groups[H=7.729,P<0.05].There was no significant difference between the TH group and the Sweet group,between the TH group and the RTA group,respectively[P>0.05].There was a significant difference between the Sweet group and the RTA group[P<0.05].The time to postoperative first flatus of Siewert typeⅡAEG patients in TH group,Sweet group and RTA group were 3 days[range,3-4 days],3 days[range,3-4 days],and 4 days[range,3-5 days],respectively,showing no significant difference among the 3 groups[H=3.125,P>0.05].The duration of postoperative hospital stay for Siewert typeⅡAEG patients in TH group,Sweet group and RTA group were 16 days[range,14-17 days],14 days[range,12-15 days],and 19 days[range,18-21 days],respectively,showing a significant difference among the 3 groups[H=35.244,P<0.05].There was no significant difference between the TH group and the Sweet group[P>0.05].There were significant differences between the TH group and the RTA group,between the Sweet group and the RTA group,respectively[P<0.05].[2]Postoperative complications of Siewert 1 AEG patients in the 3 groups:there were 6,6,11 Siewert type Ⅱ AEG patients of the TH group,Sweet group and RTA group with cardiopulmonary complication,respectively,1,1,2 patients with anastomotic leakage and 1,0,1 patients with AEG-related death,showing no significant difference in the above indicators among the 3 groups[χ^(2)=3.263,0.754,1.595,P>0.05].[3]Follow-up:78 of 84 Siewert typeⅡAEG patients were followed up for 9.0 to 24.0 months,with a median follow-up time of 16.6 months.Cases with reduced respiratory function at postoperative 3 months for the TH group,Sweet group and RTA group were 4,3,5,respectively.Cases with gastroesophageal reflux at postoperative 3 months for the 3 groups were 3,6,1,respectively.Cases with weight loss at postoperative 3 months for the 3 groups were 3,2,4,respectively.There was no significant difference in the above indicators among the 3 groups [χ^(2)=1.009,1.107,1.112,P>0.05].Cases tumor recurrence and metastasis in the TH group,Sweet group and RTA group were 5,7,4,cases who survived at postoperative 1 year in the 3 groups were 19,24,25,respectively.There was no significant difference in the above indicators among the 3 groups [χ^(2)=0.897/1.261,P>0.05].Conclusion RTA appiled in Siewert type H AEG patients has a longer postoperative operation time,increased intraoperative blood loss and longer hospital stay,while has better advantages in lymph node dissection.