胃食管连接部腺癌临床研究

发布时间：2018-06-19 17:46

本文选题：胃食管连接部腺癌 + 淋巴结转移　；参考：《安徽医科大学》2016年博士论文

【摘要】：胃食管连接部腺癌(esophagogastric junction adenocarcinoma,EGJA)作为独立病种越来越多的得到临床医生的关注。针对临床上关心的热点问题,本研究拟解决如下问题1.如何合理选择手术径路?2.EGJA淋巴结转移规律,各型肿瘤淋巴结清扫范围?3.EGJA术后常见并发症,并发症与所采取的治疗方法的关系,如何控制?4.EGJA预后分析及影响预后的主要因素。通过对2006年6月6日-2011年11月26日经手术治疗的EGJA患者共376例进行回顾性分析,了解EGJA的一般临床病理特征和淋巴结转移规律,SiewertI、II型淋巴结转移率占65.7%。而Siewert III型肿瘤淋巴结转移率占73.3%。Siewert I型EGJA隆突下淋巴结转移率5.68%、胸下段食管旁及下纵膈淋巴结转移率27.27%、贲门右淋巴结转移率为45.45%、贲门左淋巴结转移率为29.54%、胃小弯淋巴结转移率为43.18%、胃大弯淋巴结转移率为28.41%、胃左动脉旁及腹腔动脉周围淋巴结转移率为22%。Siewert II型EGJA隆突下淋巴结转移率3.54%、胸下段食管旁及下纵膈淋巴结转移率16.16%、贲门右淋巴结转移率为50.00%、贲门左淋巴结转移率为35.85%、胃小弯淋巴结转移率为42.93%、胃大弯淋巴结转移率为24.74%、胃左动脉旁及腹腔动脉周围淋巴结转移率为32.83%;Siewert III型EGJA胸下段食管旁及下纵膈淋巴结转移率3%、贲门右淋巴结转移率为45.45%、贲门左淋巴结转移率为29.54%、胃小弯淋巴结转移率为43.18%、胃大弯淋巴结转移率为28.41%、胃左动脉旁及腹腔动脉周围淋巴结转移率为22%。Siewert I、II型EGJA淋巴结转移胸腹双向性,主要转移至近端胃周和下纵膈,较少出现中上纵膈淋巴结转移,仅出现纵膈淋巴结转移而不伴有胃周淋巴结转移者很少。Siewert III型主要转移至胃周淋巴结。得出Siewert I、II型EGJA淋巴结清扫,应以涵盖下纵膈及近端胃周的两野淋巴结清扫为主,而不需清扫中上纵膈淋巴结;Siewert III型EGJA则仅需要清扫胃周淋巴结的结论。EGJA术后并发症谱发生了巨大的变化,吻合口瘘的发生率和死亡率已经大幅度下降,得到了较好的控制,但是,心肺并发症仍然保持很高的发生率和死亡率。本组经腹入路者术前伴有心肺疾患及糖尿病等严重合并症的比率高于经胸和胸腹联合者,术后心肺并发症比率低于经左胸及胸腹联合组,表现出经腹入路术后心肺并发症降低的趋向。通过对不同手术入路的比较和术后并发症的分析,得出了手术入路选择的方法,手术入路的选择应考虑R0切除和淋巴结清扫的需要,同时应兼顾考虑降低术后并发症及手术风险的要求。如果EGJA范围不大,SiewertI、II型者,心肺功能能耐受进胸手术,应使用左胸+膈肌径路以满足病变切除范围及常规淋巴结清扫的需要。对于高龄、心肺功能下降,预期术后心肺并发症发生率高者,或III型EGJA对下纵膈淋巴结清扫要求不高者,可考虑使用经腹入路。通过对2007年7月10日-2011年11月26日手术治疗EGJA281例患者进行随访和生存分析,表明手术径路的选择、病理T、N分期、病理分期以及切除程度和预后相关,手术径路选择和N分期是影响预后的独立性因素。
[Abstract]:Esophagogastric junction adenocarcinoma (EGJA), as an independent disease, has attracted more and more attention as an independent disease. In view of the hot issues concerned, this study is to solve the following problems: 1. how to choose the surgical path reasonably, the lymph node metastasis of 2.EGJA, the range of lymph node dissection of various types of tumor, 3.EGJA The common postoperative complications, the relationship between the complications and the treatment, how to control the 4.EGJA prognosis and the main factors affecting the prognosis. A total of 376 cases of EGJA patients who were treated by surgery on November June 6, 2006, 26 -2011, were retrospectively analyzed to understand a kind of clinicopathological features and lymph node metastasis of EGJA, Siewer TI, II type lymph node metastasis rate accounted for 65.7%. while the lymph node metastasis rate of Siewert III tumor accounted for 5.68% of 73.3%.Siewert I EGJA protuberance, 27.27% of subthoracic esophagus and lower mediastinal lymph node metastasis rate, 45.45% of cardiac right lymph node metastasis rate, 29.54% of cardia left lymph node transfer rate and 43.18% lymph node metastasis rate of 43.18% stomach. The rate of lymph node metastasis of large gastric curvature was 28.41%, the rate of lymph node metastasis around the left and the celiac artery was 3.54% of 22%.Siewert II EGJA protuberance, 16.16% of subthoracic esophagus and lower mediastinal lymph node, 50% of cardiac right lymph node metastasis, 35.85% of cardia left lymph node metastasis, and 35.85% of gastric cardia lymph node metastasis. The rate of migration was 42.93%, the rate of lymph node metastasis of large gastric curved lymph nodes was 24.74%, the rate of lymph node metastasis around the left gastric artery and the celiac artery was 32.83%, the rate of Siewert III EGJA lower thoracic esophagus and lower mediastinal lymph node metastasis rate was 3%, the rate of cardiac right lymph node metastasis was 45.45%, the cardia left lymph node transfer rate was 29.54%, and the rate of lymph node metastasis of gastric small bend was 43.18%. The rate of lymph node metastasis in the large gastric curvature was 28.41%, the rate of lymph node metastasis around the left and the celiac artery was 22%.Siewert I, and the II type EGJA lymph node metastases to the chest and abdomen, mainly transferred to the proximal gastric and lower mediastinum, less middle and upper mediastinal lymph node metastasis, only the mediastinal lymph node metastases but not the lymph node metastases in the stomach. The less.Siewert III type is mainly transferred to the peri gastric lymph node. It is concluded that Siewert I and II EGJA lymph node dissection should be mainly two wild lymph node dissections that cover the lower mediastinum and the proximal gastric peri, without cleaning the middle and upper mediastinal lymph nodes; Siewert III EGJA only needs to clear the lymph nodes of the stomach, and the complication spectrum of the.EGJA is greatly changed. The incidence and mortality of anastomotic fistula have declined greatly and have been well controlled. However, the incidence and mortality of cardiopulmonary complications are still high. The rate of severe complications, such as cardiopulmonary disease and diabetes, is higher than those of the chest and abdomen combined with the low rate of postoperative cardiopulmonary complications in this group. In the combination of the left chest and the thoracic and abdominal groups, the trend of the decrease of the cardiopulmonary complications after the abdominal approach was shown. Through the comparison of the different surgical approaches and the analysis of the postoperative complications, the selection method of the surgical approach was obtained. The choice of the surgical approach should consider the needs of R0 resection and lymph node dissection, and should consider the reduction of postoperative complications. And the requirements of surgical risk. If the EGJA range is not large, the SiewertI, II type, cardiopulmonary function can tolerate the thoracic surgery, the left chest plus diaphragm should be used to meet the extent of diseased resection and the needs of conventional lymph node dissection. For the elderly, the decrease of cardiopulmonary function, the high incidence of postoperative cardiopulmonary and complication, or III EGJA to the inferior mediastinal lymph nodes Through the follow-up and survival analysis of the surgical treatment of EGJA281 patients in July 10, 2007 -2011, the selection of surgical pathways, pathological T, N staging, pathological staging, and the degree of resection were associated with the prognosis. The choice of hand approach and N staging are independent factors that affect the prognosis. Prime.
【学位授予单位】：安徽医科大学
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R735

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