完全腹腔镜经腹经膈肌裂孔入路在SiewertⅡ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2020年12月浙江大学医学院附属杭州市第一人民医院收治的45例Siewert Ⅱ型AEG病人的临床病理资料;男28例, 女17例;中位年龄为64岁, 年龄范围为35~85岁。病人均行完全腹腔镜经腹经膈肌裂孔入路AEG根治术;消化道吻合选择近端胃切除双通道吻合或全胃切除食管空肠吻合;消化道重建行食管空肠经膈肌裂孔高位Overlap吻合。观察指标:(1)手术及术后情况。(2)术后组织病理学检查情况。(3)随访及生存情况。采用门诊、电话方式进行随访, 了解病人生存情况及肿瘤复发、转移情况。随访时间截至2021年3月。正态分布的计量资料以x±s表示, 偏态分布的计量资料以M(范围)表示。结果 (1)手术及术后情况:45例病人均成功施行完全腹腔镜经腹经膈肌裂孔入路SiewertⅡ型AEG根治术, 其中35例行全胃切除食管空肠吻合, 10例行近端胃切除双通道吻合。45例病人总手术时间为(235±32)min, 下纵隔淋巴结清扫时间为(25±8)min, 食管空肠高位Overlap吻合时间为(45±10)min, 术中出血量为(70±13)mL;术后下床活动时间为(20±8)h, 术后肛门首次排气时间为(2.3±0.2)d, 术后首次恢复流质食物时间为(2.6±0.8)d, 术后引流管留置时间为(6.2±1.1)d。45例病人中, 11例术后发生并发症, 无围手术期死亡病例。45例病人术后住院时间为(10±3)d。(2)术后组织病理学检查情况:45例病人手术上切缘均为阴性;食管切缘长度为(2.5±0.5)cm, 肿瘤长径为(2.9±0.8)cm, 淋巴结清扫数目为(35.0±4.0)枚, 其中下纵隔淋巴结清扫数目为(2.4±0.8)枚。45例病人术后组织病理学检查均为腺癌, 病理学TNM分期:ⅠB期5例、ⅡA期8例、ⅡB期21例、ⅢA期11例。(3)随访及生存情况:45例病人均获得随访, 随访时间为3~46个月, 中位随访时间为26个月。随访期间, 45例病人中, 8例死亡。37例生存病人中, 肝转移3例, 骨转移、肺转移、腹膜转移各1例。结论完全腹腔镜经腹经膈肌裂孔入路治疗Siewert Ⅱ型AEG安全、可行, 临床疗效满意。

Objective To investigate the application value of totally laparoscopic trans-abdominal-hiatal approach in the radical resection of Siewert type Ⅱ adenocarcinoma of esophago-gastric junction(AEG).Methods The retrospective and descriptive study was conducted.The clinicopathological data of 45 patients with Siewert type II AEG who were admitted to the Afiliated Hangzhou First People's Hospital,Zhejiang University School of Medicine from May 2017 to December 2020 were collected.There were 28 males and 17 females,aged from 35 to 85 years,with a median age of 64 years.All patients underwent radical resection of AEG by totally laparoscopic trans-abdominal-hiatal approach with gastrointestinal anastomosis using proximal gastrectomy with double-tract anastomosis or total gastrectomy with esophagojejunointestinal anastomosis and digestive reconstruction using transdiaphragmatic-hiatal superior overlap esophagojejunostomy.Observation indicators:(1)surgical and postoperative situations;(2)postoperative histopathological examination;(3)follow-up and survival situations.Follow-up using outpatient examination and telephone interview was performed to detect survival of patients and tumor recurrence and metastasis up to March 2021.Measurement data with normal distribution were presented as Mean±SD and measure-ment data with skewed distribution were presented as M(range).Results(1)Surgical and post-operative situations:all 45 patients underwent radical resection of AEG by totally laparoscopic transabdominal-hiatal approach successfully,including 35 cases undergoing total gastrectomy with esophagojejunointestinal anastomosis and 10 cases undergoing proximal gastrectomy with double-tract anastomosis.The total operation time,time of lower mediastinal lymph node dissection,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 to drainage tube removal of the 45 patients were(235±32)minutes,(25±8)minutes,(45±10)minutes,(70±13)ml,(20±8)hours,(2.3±0.2)days,(2.6±0.8)days and(6.2±1.1)days,respectively.Eleven of 45 patients under-went postoperative complications and none of patient died during perioperative period.The post-operative duration of hospital stay of 45 patients was(10±3)days.(2)Postoperative histopatho-logical examination:all 45 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 nodes harvested were(2.5±0.5)cm,(2.9±0.8)cm,35.0±4.0 and 2.4±0.8,respectively.Patholo-gical examination showed adenocarcinoma in all 45 patients with pTNM staging as 5 cases of stage ⅠB,8 cases ofstage Ⅱ A,21 cases of stage ⅡB and 11 cases of stageⅢ A.(3)Follow-up and survival.situations:45 patients were followed up for 3 to 46 months,with a median follow-up time of 26 months.During follow-up,8 of 45 patients died.Of the 37 patients survived,3 cases underwent liver metastasis and 3 cases underwent bone metastasis,lung metastasis or peritoneal metastasis respec-tively.Conclusion Total laparoscopic transabdominal-hiatal approach is safe and feasible in the treatment of Siewert type II AEG with a satisfactory clinical efficacy.