腹腔镜手术治疗在老年Siewert II、III型食管胃结合部腺癌患者中的研究进展

Research Progress of Laparoscopic Surgery in Elderly Patients with Siewert Type II and III Esophageal and Gastric Junction Adenocarcinoma

近年来,我国老年性食管胃结合部腺癌(Adenocarcinoma of Esophagogastric Junction, AEG)的发病率逐年走高,八成以上的AEG患者在确诊时已处于晚期,且患者的5年生存率不到30%。根据2022年国家癌症中心最新发布的《2022年全国癌症报告》显示,胃癌和食管癌的新发病数在我国癌症发病数中居第三和第六,分别为39.7万和25.3万,占全球总发病数的33%及49.7%。显然,我国亟需解决这一重大公共卫生问题,以提高我国人民健康水平。目前,国内外学者对AEG的研究主要集中在外科治疗策略上,尤其是淋巴结的转移及清扫上面研究得较为深入。目前,外科手术切除仍是治疗AEG的最重要的方式。多中心研究发现,腹腔镜辅助AEG根治术能达到与传统开腹方式相同的根治目的,且能取得明显地微创优势。AEG可选择的入路分别有经上腹右胸入路、经左胸入路、颈胸腹三切口术式、胸腹联合切口入路、经腹及膈肌裂孔入路等术式。此外,AEG分为Siewert I、II、III型,东亚人的患病类型主要为Siewert II、III型。目前I型AEG治疗手术多由胸外科进行,本文暂不作叙述。II型及III型AEG手术路径主要为食管裂孔路径(transhiatal approach, TH)。但是,老年患者因其术前基础疾病多,手术耐受能力较差,高龄等被视为大部分传统腹部手术的危险因素。因此,腹腔镜手术是否适用于老年患者还有待进一步探索。因此,本文就腹腔镜手术治疗在老年Siewert II、III型食管胃结合部腺癌患者中的研究从腹腔镜下淋巴结清扫、胃切除范围、以及消化道重建方式及吻合方法四个方面展开综述,以提高对该疾病的认识,寻求老年患者更加合理的外科治疗策略。

In recent years, the incidence rate of elderly adenocarcinoma of esophagogastric junction (AEG) in China has increased year by year. More than 80% of AEG patients were in advanced stage when they were diagnosed, and the 5-year survival rate of patients was less than 30%. According to the latest National Cancer Report 2022 released by the National Cancer Center in 2022, the number of new cases of gastric cancer and esophageal cancer ranked third and sixth in the number of cancer cases in China, with 397,000 and 253,000 respectively, accounting for 33% and 49.7% of the total num-ber of global cases. Obviously, China urgently needs to solve this major public health problem in order to improve the health level of our people. At present, domestic and foreign scholars’ research on AEG mainly focuses on surgical treatment strategies, especially on lymph node metastasis and dissection. At present, surgical resection is still the most important way to treat AEG. Multi-center studies have found that laparoscopy-assisted AEG radical surgery can achieve the same goal as tra-ditional laparotomy, and can achieve obvious minimally invasive advantages. The AEG can be se-lected through the upper abdominal right chest approach, the left chest approach, the three-incision approach of the neck, chest and abdomen, the combined thoracoabdominal approach, and the abdominal and diaphragmatic hiatus approach. In addition, AEG is divided into Siewert I, II and III, and the main types of disease in East Asians are Siewert II and III. At present, the treatment of type I AEG is mostly performed by thoracic surgery, which will not be described in this article. The main surgical pathway of type II and type III AEG is esophageal hiatal approach (TH). However, the elderly patients are regarded as the risk factors of most traditional abdominal surgery because of many basic diseases before surgery, poor surgical tolerance, and old age. Therefore, whether lap-aroscopic surgery is suitable for elderly patients remains to be further explored. Therefore, this ar-ticle reviews the study of laparoscopic surgery in elderly patients with Siewert type II and III esophageal and gastric junction adenocarcinoma from four aspects: laparoscopic lymph node dis-section, scope of gastrectomy, and digestive tract reconstruction and anastomosis methods, in order to improve the understanding of the disease and seek more reasonable surgical treatment strate-gies for elderly patients.