SiewertⅡ、Ⅲ型食管胃结合部腺癌两种外科手术入路治疗效果的研究

  本文关键词：SiewertⅡ、Ⅲ型食管胃结合部腺癌两种外科手术入路治疗效果的研究，由笔耕文化传播整理发布。

        目的：食管胃结合部腺癌（Adenocarcinoma of EsophagogastricJunction，AEG）是指发生于食管胃交界区域的腺癌，包括食管远端腺癌和胃近端腺癌。近30年以来，胃远端恶性肿瘤发病率明显下降，而食管远端和食管胃结合部恶性肿瘤的发病率呈明显上升趋势，尤以西方发达国家为著，亚洲亦有明显上升趋势，食管远端和食管胃结合部恶性肿瘤已成为美欧医学界研究的热点领域。目前对于AEG尚无统一的分型标准，被广泛应用的是德国学者提出的Siewert分型，即将食管胃结合部（Esophagogastric Junction, EGJ或Gastroesophageal Junction，GEJ）连接线上下5cm范围内称AEG。根据肿瘤中心位置不同进一步分为三型，Siewert Ⅰ型为食管远端腺癌，指癌肿位于EGJ连接线上1-5cm范围；Siewert Ⅱ型即为传统意义的贲门癌，指EGJ连接线上1cm到连接线下2cm范围内，源自贲门上皮或食管胃结合处短段肠化生；Siewert Ⅲ型是贲门下癌，位于EGJ连接线下2-5cm范围，可向上侵袭食管胃结合处及下端食管。相比于胃远端癌和食管上段癌，AEG具有特殊的生物学行为，且5年生存率较低。以手术为主的综合治疗仍是目前主要的治疗手段，但在手术入路、手术切除范围、淋巴结的清扫、消化道重建等问题上观点尚未统一。有文献报道对于近侧胃癌在经胸或经腹两种手术入路之间术后5年生存率无明显差异，但经胸组术后并发症率高于经腹组。因此，何种手术入路治疗效果更为合理值得探讨。本文通过对Siewert Ⅱ、Ⅲ型AEG经胸与经腹两种手术入路的临床病历资料进行回顾性分析，探讨手术根治度、术后并发症以及1、3、5年生存率等方面的差异，旨在对Siewert Ⅱ、Ⅲ型AEG患者的理想手术入路的选择提供理论及临床依据。方法：选择2004-2007年河北医科大学第四医院行手术治疗的SiewertⅡ、Ⅲ型AEG患者466例的临床资料进行回顾性分析，其中男性382例,女性84例，男女比例：4.55：1。经胸手术组298例,男238例，，女60例，男女比例：3.97：1，中位年龄58岁；经腹手术组行168例，男144例，女24例，男女比例6：1，中位年龄60岁。入组标准：1.依据Siewert分型在2004-2007年河北医科大学第四医院胸外科及普外科行手术治疗的患者中筛选出Siewert Ⅱ、Ⅲ型AEG的患者。2.患者临床病例术前检查、手术记录、术后病理及相关信息均完整。3.患者术前均未进行化疗。统计分析两种手术径路的手术时间、术中出血量、平均住院时间、上、下切缘残端阳性率、平均清扫淋巴结数、各组淋巴结清扫数目及各组淋巴结转移率、术后并发症发生率、以及术后患者1年、3年、5年生存率。应用SPSS19.0软件对相关资料进行统计描述及统计分析，其中P<0.05提示差异有统计学意义。结果:1SiewertⅡ、Ⅲ型AEG患者手术情况1.1手术时间经胸组平均手术时间339.81±79.088min，经腹组平均手术时间204.17±86.598min，经腹组手术时间较经胸组短，两组比较差异有统计学意义（P<0.05）。1.2术中出血量经胸组术中出血量163.22±6.142ml，经腹组术中出血量147.58±7.781ml，两组比较差异无统计学意义（P>0.05）。1.3淋巴结清扫数经胸组平均淋巴结清扫数目17.39±2.237个，经腹组均淋巴结清扫数目22.78±4.588个，经胸组较经腹组平均清扫淋巴结数目少，两组比较差异有统计学意义（P<0.05）。1.4上下切缘残端阳性率经胸组下切缘残端阳性率6.04%（18/298），经腹组下切缘残端阳性率1.19%（2/168），两组下切缘残端阳性率比较，经腹组较经胸组低，两组比较差异有统计学意义（P<0.05）。经胸组上切缘残端阳性率1.34%（4/298），经腹组上切缘残端阳性率4.76%（8/168），两组上切缘残端阳性率比较，经腹组较经胸组高，但两组比较差异无统计学意义（P>0.05）。1.5肿瘤直径（cm）经胸组：5.84±2.479cm，经腹组：5.42±2.600cm，两组比较差异无统计学意义（P>0.05）。1.6术后并发症经胸组术后并发症发生率为26.85%（80/298），其中胸腔积液39例（13.09%）、肺部感染27例（9.06%）、吻合口漏5例（1.68%）、气胸4例（1.34%）、切口裂开5例（1.68%）。经腹组术后并发症发生率为4.17%（7/168），其中肺部感染9例（5.36%）、吻合口出血3例（1.79%）、胸腔积液3例（1.79%）。术后并发症发生率经胸组与经腹组比较，经腹术后并发症发生率较经胸组低，差异有统计学意义（χ~2=21.249P<0.05）。1.7住院时间经胸组平均住院时间16.82±6.142天，经腹组平均住院时间16.62±4.700天，平均住院时间经胸组与经腹组比较，差异无统计学意义（P>0.05）。2术后病理结果2.1分化程度经胸组：高中分化159例、低分化139例。经腹组：高中分化86例、低分化82例。两组比较差异无统计学意义（P>0.05）2.2大体分型（Borrmann分型）经胸组：Ⅰ型10例，Ⅱ型156例，Ⅲ型275例，Ⅳ型24例。经腹组：Ⅰ型7例，Ⅱ型104例，Ⅲ型170例，Ⅳ型17例。两组比较差异无统计学意义（P>0.05）。2.3各组淋巴结清扫个数及转移率经胸组各组淋巴结清扫个数及转移率：1组19.65%（207/1153）、2组32.02%（292/1012）、3组27.05%（221/917）、4组4.56%（15/329）、5组26.56%（12/406）、6组4.22%（3/71）、7组17.88%（59/330）、8组1.64%（2/122）、9组2.44%（1/41）、10组3.70%（2/54）、11组0%（0/63）、12组0%（0/136）、13组0%（0/9）、14组0%（0/5）、15组0%（0/4）、16组0%（0/9）、19组0%（0/0）、20组0%（0/0）、110组20.93%（18/86）、111组0%（0/9）、112组0%（0/3）。经腹组各组淋巴结清扫个数及转移率：1组47.26%（422/893）、2组33.79%（293/867）、3组29.03%（216/744）、4组5.43%（18/331）、5组38.69%（142/367）、6组13.70%（44/321）、7组35.03%（55/157）、8组23.19%（16/69）、9组34.78%（8/23）、10组23.81%（5/21）、11组32.39%（23/71）、12组0%（0/71）、13组0%（0/5）、14组0%（0/7）、15组0%（0/5）、16组0%（0/2）、19组0%（0/2）、20组0%（0/7）、110组14.29%（2/14）、111组0%（0/6）、112组0%（0/0）。经胸组与经腹组各组淋巴结转移率相比较：1组χ~2=202.954P=0.000；2组χ~2=5.317P=0.021；3组χ~2=5.153P=0.023；5组χ~2=154.306P=0.000；6组χ~2=4.954P=0.026；7组χ~2=17.459P=0.000；8组χ~2=23.976P=0.000；9组χ~2=10.216P=0.001；10组χ~2=5.042P=0.025。1-3组及5-8组淋巴结转移数经胸与经腹两组比较，经腹组转移率较经腹组高，差异有统计学意义（P<0.05）。其余各组淋巴结转移数，经胸组与经腹组比较，两组比较差异无统计学意义（P>0.05）。2.4pTNMⅠ期18例，Ⅱ期104例，Ⅲ期299例。经胸组：Ⅰ期11例，Ⅱ期69例，Ⅲ期189例。经腹组：Ⅰ期7例，Ⅱ期35例，Ⅲ期110例。两组比较差异无统计学意义（P>0.05）。2.5浸润深度粘膜层5例，粘膜下层3例，肌层47例，浆膜层155例，浆膜外256例。其中，经胸组：粘膜层3例，粘膜下层2例，肌层27例，浆膜层91例，浆膜外175例；经腹组：粘膜层2例，粘膜下层1例，肌层20例，浆膜层46例，浆膜外81例。两组比较差异无统计学意义（P>0.05）。3Siewert Ⅱ、Ⅲ型AEG患者预后情况随访时间截至2012年12月，随访率为73.39%（342/466），单纯经胸手术组和经腹手术组患者1年生存率分别为78.00%和79.75%（χ~2=0.219P=0.640），3年生存率分别为36.95%和42.36%（χ~2=0.562P=0.435），5年生存率分别为17.98%和20.33%（χ~2=0.883P=0.347），经胸手术组和经腹手术组患者术后5年总生存率两组比较，差异无统计学意义（P=0.123P>0.05）。结论：本组资料通过对Siewert Ⅱ、Ⅲ型AEG经胸与经腹两种手术入路466例病例的临床对照研究，对其手术情况及预后进行对比分析，现小结如下：1手术根治度方面:经腹组的下切缘癌残端阳性率较经胸组低；上残端阳性率两组比较无差异；经腹组较经组胸平均清扫淋巴结数目多；经腹组较经胸组在腹腔淋巴结清扫数目上具优势。2经胸组比经腹组创伤大、时间长术后并发症发生率高。3经胸手术组和经腹手术组患者术后生存率两组比较无明显差异。

    Objective: Adenocarcinoma of Esophagogastric Junction (AEG) is akind of adenocarcinoma which occurs in the region of the esophagogastricjunction, including adenocarcinoma of distal esophagus and adenocarcinomaof proximal stomach. During the recent30years, the incidence of malignanttumors of distal stomach has significantly decreased, while the incidence ofmalignant tumors of distal esophagus and esophagogastric junction has shownan obvious trend of going up, especially noticeable in developed westerncountries, and also apparent in Asia. Malignant tumors of distal esophagus andgastroesophageal junction have become the hotspots in medical research areaof the United States and Europe. There is no universal classification standardfor AEG, and the one that is widely used currently is the Siewert typing putforward by the German scholars, which defines AEG as the region within5cm below or above the esophagogastric junction (Esophagogastric Junction,EGJ or Gastroesophageal Junction, GEJ). According to the locations of tumorepicenter, it can be further divided into three subtypes. Siewert Type Ⅰis distalesophageal adenocarcinoma, whose tumor epicenter is located within1-5cmabove the esophagogastric junction (EGJ); Siewert Type II is whattraditionally known as cardia cancer, whose tumor epicenter lies within1cmabove the EGJ and2cm below the EGJ, and develops from cardia epitheliumor short segments of intestinal metaplasia in gastroesophageal junction;Siewert Type Ⅲis cancer below the cardia. With its tumor epicenter locatedwithin2-5cm below the EGJ, it can invade gastroesophageal junction andlower esophagus. Compared with tumors of distal stomach and upperesophagus cancer, AEG has special biological behavior and its5-year survivalrate is low. Combined treatment with focus on surgery is still the main treatment at present, but views on surgical approach, extent of surgicalresection, lymph node dissection, digestive tract reconstruction and otherissues haven’t been unified. Some literature reported that for proximal gastriccancer, there was no significant difference in5-year survival rates betweentransthoracic approach and transabdominal approach, but the rate ofpostoperative complications in the transthoracic approach group was higherthan that in the transabdominal group. Therefore, it is worth exploring whichoperative approach can bring more reasonable therapeutic effects. This paperis based on the retrospective analysis of clinical medical data of transthoracicapproach and transabdominal approach for patients with Siewert Type ⅡandIII AEG, discusses the differences between the two groups in the degree ofradical resection, postoperative complications,1year,3years and5yearssurvival rates and so forth, and aims to provide theoretical and clinical basisfor choosing an ideal surgical approach for patients with Siewert Type ⅡandIII AEG.Method: Chose and retrospectively analyzed the clinical data of466AEG Ⅱ, Ⅲpatients (382male cases and84female cases) who had undergonesurgery during2004to2007in the Fourth Affiliated Hospital of HebeiMedical University. The male to female ratio was4.55:1. The transthoracicapproach group had298cases, including238male cases and60female cases.The male to female ratio was3.97:1, and the median age was58years old.The transabdominal approach group had168cases, including144male casesand24female cases. The male to female ratio was6:1, and the median agewas60years old.The Inclusion Criteria:1. According to Siewert typing, selected AEG Ⅱ,Ⅲpatients who had undergone surgery by transthoracic approach ortransabdominal approach in the Department of Chest Surgery and Departmentof General Surgery in the Fourth Affiliated Hospital of Hebei MedicalUniversity during2004to2007.2. The patients’ data of preoperativeexamination, surgical records, postoperative pathological condition and relatedinformation was complete.3. The patients had not received chemotherapy before surgery.Statistical analysis was conducted on figures from the two surgicalapproach groups, including operation time, blood loss, average time ofhospital stay, positive rate of the upper and lower cut edge of the stump,average number of lymph node dissection, number of lymph node dissectionin each group, metastasis rate of lymph node in each group, incidence ofpostoperative complications, patients’1-year,3-year and5-year survival ratesafter the surgery. SPSS19.0software was applied to statistically describe andanalyze the relevant data, if P<0.05, then the difference was statisticallysignificant.Results:1. The Operative Situations of Siewert Ⅱ, Ⅲ AEG Patients1.1Operation Time:The transthoracic approach group: the average operation time339.81±79.088min. The transabdominal approach group: the average operation time204.17±86.598min. The operation time of the transabdominal approachgroup was shorter than that of the transthoracic approach group. Thedifference was statistically significant (P <0.05).1.2Blood Loss:The transthoracic approach group: the average blood loss163.22±6.142ml. The transabdominal approach group: the average blood loss147.58±7.781ml. The difference was not statistically significant (P>0.05).1.3Number of Lymph Node DissectionThe transthoracic approach group: the average number of lymph nodedissection was17.39±2.237. The transabdominal approach group: theaverage number of lymph node dissection was22.78±4.588. The averagenumber of lymph node dissection was lower in the transthoracic approachgroup than that in the transabdominal approach group. The difference wasstatistically significant (P <0.05).1.4Positive Rate of the Upper and Lower Cut Edge of the StumpThe positive rate of the lower cut edge of the stump in the transthoracic approach group was6.04%(18/298). The positive rate of the lower cut edge ofthe stump in transabdominal approach group was1.19%(2/168). Comparedwith the transthoracic approach group, the transabdominal approach group hadthe lower positive rate of the lower cut edge of the stump. The difference wasstatistically significant (P<0.05). The positive rate of the upper cut edge of thestump of the transthoracic approach group was1.34%(4/298). The positiverate of the upper cut edge of the stump of the transabdominal approach groupwas4.76%(8/168). Compared with the transthoracic approach group, thetransabdominal group had the higher positive rate of the upper cut edge of thestump. But the difference was not statistically significant (P>0.05).1.5Tumor Diameter (cm)The transthoracic approach group:(5.84±2.479) cm. The transabdominalapproach group:5.42±2.600cm. The difference was not statisticallysignificant (P>0.05).1.6Postoperative Complications:The transthoracic approach group: the postoperative complication ratewas26.85%(80/298), including39cases in postoperative pleural effusion,27cases in postoperative pulmonary infection,5case in postoperativeanastomotic fistula,4cases in pneumothorax,5cases in postoperativeinfection of incisional wound. The transabdominal approach group: thepostoperative complication rate was4.17%(7/168), including9case inpostoperative pulmonary infection,3case in postoperative anastomoticbleeding,3case in postoperative pleural effusion. Compared with theincidence of postoperative complications in transthoracic approach group, thetransabdominal approach group had the lower postoperative complications.The difference was statistically significant (P <0.05).1.7Time of Hospital StayThe transthoracic approach group: the average time of hospital stay was16.82±6.142days. The transabdominal approach group: the average time ofhospital stay was16.62±4.700days. Comparison of the average time ofhospital stay in the two groups showed no statistically significant difference (P>0.05).2Postoperative Pathological Results2.1Degree of Differentiation:The transthoracic approach group:159cases in well and moderatedifferentiation,139cases in poor differentiation. The transabdominal approachgroup:86cases in well and moderate differentiation,82cases in poordifferentiation. The difference was not statistically significant (P>0.05).2.2General Classification (Borrmann Typing):The transthoracic approach group:10cases of typeⅠ,156cases of typeII,275cases of type Ⅲ,24cases of type Ⅳ. The transabdominal approachgroup:7cases of typeⅠ,104cases of type II,170cases of type Ⅲ,17casesof type Ⅳ. The differencewas not statistically significant (P>0.05).2.3The Number of Lymph Node Dissection and Metastasis Rate in EachGroupThe number of lymph node dissection and metastasis rate in eachtransthoracic approach group: No.119.65%(207/1153), No.232.02%(292/1012), No.27.05%(221/917), No.44.56%(15/329), No.526.56%（12/406）, No.64.22%（3/71）, No.717.88%（59/330）, No.81.64%(2/122),No.92.44%(1/41), No.103.70%(2/54), No.110%(0/63), No.120%(0/136),No.130%(0/9), No.140%(0/5), No.150%(0/40), No.160%(0/9), No.190%(0/0), No.200%(0/0), No.11020.93%(18/86), No.1110%(0/9), No.1120%(0/3).The number of lymph node dissection and metastasis rate in eachtransabdominal approach group:No.147.26%(422/893), No.233.79%(293/867), No.329.03%(216/744),No.45.43%(18/331), No.538.69%(142/367), No.613.70%(44/321), No.735.03%(55/157), No.823.19%(16/69), No.934.78%(8/23), No.1023.81%(5/21), No.1132.39%(23/71), No.120%(0/71), No.130%(0/5), No.140%(0/7), No.150%(0/5), No.160%(0/2), No.190%(0/2), No.200%(0/7),No.11014.29%(2/14), No.1110%(0/6), No.1120%(0/0).Comparison of lymph node metastasis rates in each transthoracic and transabdominal group: No.1χ~2=202.954P=0.000; No.2χ~2=5.317P=0.021;No.3χ~2=5.153P=0.023; No.5χ~2=154.306P=0.000; No.6χ~2=4.954P=0.026;No.7χ~2=17.459P=0.000; No.8χ~2=23.976P=0.000; No.9χ~2=10.216P=0.001;No.10χ~2=5.042P=0.025. Compared with the transthoracic approach group,the transabdominal approach group had a higher lymph node metastasis rate inNo.1-3and No.5-8(P <0.05). The difference was statistically significant. Butin the rest groups, the two approaches showed no statistically significantdifference in the number of lymph node metastasis (P>0.05).2.4pTNMpTNM:18cases of stageⅠ,104cases ofstage Ⅱ,299cases ofstage Ⅲ.The transthoracic approach group:11cases of stage Ⅰ,69cases ofstage II,189cases of stage Ⅲ. The transabdominal approach group:7cases ofstageⅠ,35cases ofstage Ⅱ,110cases ofstage Ⅲ. Thedifference was notstatistically significant (P>0.05).2.5Infiltration DepthInfiltration Depth:5cases of mucous layer,3cases of submucosa,47cases of muscularis layer,155cases of serosa layer,256cases of serousmembrane layer, with3cases of mucous layer,2cases of submucosa,27casesof muscularis layer,91cases of serosa layer,175cases of serous membranelayer in the transthoracic approach group and2cases of the mucous layer,1case of submucosa,20cases of muscularis layer,46cases of serosa layer,81cases of serous membrane layer in the transabdominal approach group. Thedifference was not statistically significant (P>0.05).3The Prognosis of AEG II, III PatientsThe follow-up time ended in December,2012, and the follow-up rate was73.39%(342/466). The1-year survival rates of patients in the transthoracicapproach group and the transabdominal approach group were78.00%and79.75%(χ~2=0.219P=0.640);3-year survival rates were36.95%and42.36%(χ~2=0.562P=0.435); and5-year survival rates ware17.98%and20.33%(χ~2=0.883P=0.347). The comparison of the overall survival rates ofthe transthoracic approach and the transabdominal approach showed that the difference between the two groups was not statistically significant (P=0.123P>0.05).Conclusion:This research conducted a clinical controlled study on466Siewert Ⅱ, ⅢAEG cases by transthoracic approach or transabdominal approach, comparedand analyzed their operative situations and prognosis, and concluded asummary as follows:1In terms of radical degree: the positive rate of the lower cut edge of thestump was lower in the transabdominal approach group than that in thetransthoracic approach group; the positive rate of the upper cut edge of thestump of the two groups showed no difference; the average number of lymphnode dissection was higher in the transabdominal approach group than that inthe transthoracic approach group; and compared with the transthoracicapproach group, the transabdominal approach group had an advantage inclearing more abdominal lymph nodes.2The transthoracic approach group was more traumatic, took longertime in operation and had higher incidence of postoperative complicationsthan the transabdominal approach group.3There was no significant difference in the postoperative survival ratesbetween the transthoracic approach group and the transabdominal approachgroup.

SiewertⅡ、Ⅲ型食管胃结合部腺癌两种外科手术入路治疗效果的研究

摘要4-9ABSTRACT9-15前言16资料与方法16-18结果18-23附图23-28附表28-31讨论31-35结论35-36参考文献36-39综述 食管胃结合部腺癌病因、治疗的研究进展39-53    参考文献48-53致谢53-54个人简历54

  本文关键词：SiewertⅡ、Ⅲ型食管胃结合部腺癌两种外科手术入路治疗效果的研究，由笔耕文化传播整理发布。