本文關(guān)鍵詞：SiewertⅡ、Ⅲ型食管胃結(jié)合部腺癌兩種外科手術(shù)入路治療效果的研究，由筆耕文化傳播整理發(fā)布。

        目的：食管胃結(jié)合部腺癌（Adenocarcinoma of EsophagogastricJunction，AEG）是指發(fā)生于食管胃交界區(qū)域的腺癌，包括食管遠端腺癌和胃近端腺癌。近30年以來，胃遠端惡性腫瘤發(fā)病率明顯下降，而食管遠端和食管胃結(jié)合部惡性腫瘤的發(fā)病率呈明顯上升趨勢，尤以西方發(fā)達國家為著，亞洲亦有明顯上升趨勢，食管遠端和食管胃結(jié)合部惡性腫瘤已成為美歐醫(yī)學界研究的熱點領(lǐng)域。目前對于AEG尚無統(tǒng)一的分型標準，被廣泛應(yīng)用的是德國學者提出的Siewert分型，即將食管胃結(jié)合部（Esophagogastric Junction, EGJ或Gastroesophageal Junction，GEJ）連接線上下5cm范圍內(nèi)稱AEG。根據(jù)腫瘤中心位置不同進一步分為三型，Siewert Ⅰ型為食管遠端腺癌，指癌腫位于EGJ連接線上1-5cm范圍；Siewert Ⅱ型即為傳統(tǒng)意義的賁門癌，指EGJ連接線上1cm到連接線下2cm范圍內(nèi)，源自賁門上皮或食管胃結(jié)合處短段腸化生；Siewert Ⅲ型是賁門下癌，位于EGJ連接線下2-5cm范圍，可向上侵襲食管胃結(jié)合處及下端食管。相比于胃遠端癌和食管上段癌，AEG具有特殊的生物學行為，且5年生存率較低。以手術(shù)為主的綜合治療仍是目前主要的治療手段，但在手術(shù)入路、手術(shù)切除范圍、淋巴結(jié)的清掃、消化道重建等問題上觀點尚未統(tǒng)一。有文獻報道對于近側(cè)胃癌在經(jīng)胸或經(jīng)腹兩種手術(shù)入路之間術(shù)后5年生存率無明顯差異，但經(jīng)胸組術(shù)后并發(fā)癥率高于經(jīng)腹組。因此，何種手術(shù)入路治療效果更為合理值得探討。本文通過對Siewert Ⅱ、Ⅲ型AEG經(jīng)胸與經(jīng)腹兩種手術(shù)入路的臨床病歷資料進行回顧性分析，探討手術(shù)根治度、術(shù)后并發(fā)癥以及1、3、5年生存率等方面的差異，旨在對Siewert Ⅱ、Ⅲ型AEG患者的理想手術(shù)入路的選擇提供理論及臨床依據(jù)。方法：選擇2004-2007年河北醫(yī)科大學第四醫(yī)院行手術(shù)治療的SiewertⅡ、Ⅲ型AEG患者466例的臨床資料進行回顧性分析，其中男性382例,女性84例，男女比例：4.55：1。經(jīng)胸手術(shù)組298例,男238例，，女60例，男女比例：3.97：1，中位年齡58歲；經(jīng)腹手術(shù)組行168例，男144例，女24例，男女比例6：1，中位年齡60歲。入組標準：1.依據(jù)Siewert分型在2004-2007年河北醫(yī)科大學第四醫(yī)院胸外科及普外科行手術(shù)治療的患者中篩選出Siewert Ⅱ、Ⅲ型AEG的患者。2.患者臨床病例術(shù)前檢查、手術(shù)記錄、術(shù)后病理及相關(guān)信息均完整。3.患者術(shù)前均未進行化療。統(tǒng)計分析兩種手術(shù)徑路的手術(shù)時間、術(shù)中出血量、平均住院時間、上、下切緣殘端陽性率、平均清掃淋巴結(jié)數(shù)、各組淋巴結(jié)清掃數(shù)目及各組淋巴結(jié)轉(zhuǎn)移率、術(shù)后并發(fā)癥發(fā)生率、以及術(shù)后患者1年、3年、5年生存率。應(yīng)用SPSS19.0軟件對相關(guān)資料進行統(tǒng)計描述及統(tǒng)計分析，其中P<0.05提示差異有統(tǒng)計學意義。結(jié)果:1SiewertⅡ、Ⅲ型AEG患者手術(shù)情況1.1手術(shù)時間經(jīng)胸組平均手術(shù)時間339.81±79.088min，經(jīng)腹組平均手術(shù)時間204.17±86.598min，經(jīng)腹組手術(shù)時間較經(jīng)胸組短，兩組比較差異有統(tǒng)計學意義（P<0.05）。1.2術(shù)中出血量經(jīng)胸組術(shù)中出血量163.22±6.142ml，經(jīng)腹組術(shù)中出血量147.58±7.781ml，兩組比較差異無統(tǒng)計學意義（P>0.05）。1.3淋巴結(jié)清掃數(shù)經(jīng)胸組平均淋巴結(jié)清掃數(shù)目17.39±2.237個，經(jīng)腹組均淋巴結(jié)清掃數(shù)目22.78±4.588個，經(jīng)胸組較經(jīng)腹組平均清掃淋巴結(jié)數(shù)目少，兩組比較差異有統(tǒng)計學意義（P<0.05）。1.4上下切緣殘端陽性率經(jīng)胸組下切緣殘端陽性率6.04%（18/298），經(jīng)腹組下切緣殘端陽性率1.19%（2/168），兩組下切緣殘端陽性率比較，經(jīng)腹組較經(jīng)胸組低，兩組比較差異有統(tǒng)計學意義（P<0.05）。經(jīng)胸組上切緣殘端陽性率1.34%（4/298），經(jīng)腹組上切緣殘端陽性率4.76%（8/168），兩組上切緣殘端陽性率比較，經(jīng)腹組較經(jīng)胸組高，但兩組比較差異無統(tǒng)計學意義（P>0.05）。1.5腫瘤直徑（cm）經(jīng)胸組：5.84±2.479cm，經(jīng)腹組：5.42±2.600cm，兩組比較差異無統(tǒng)計學意義（P>0.05）。1.6術(shù)后并發(fā)癥經(jīng)胸組術(shù)后并發(fā)癥發(fā)生率為26.85%（80/298），其中胸腔積液39例（13.09%）、肺部感染27例（9.06%）、吻合口漏5例（1.68%）、氣胸4例（1.34%）、切口裂開5例（1.68%）。經(jīng)腹組術(shù)后并發(fā)癥發(fā)生率為4.17%（7/168），其中肺部感染9例（5.36%）、吻合口出血3例（1.79%）、胸腔積液3例（1.79%）。術(shù)后并發(fā)癥發(fā)生率經(jīng)胸組與經(jīng)腹組比較，經(jīng)腹術(shù)后并發(fā)癥發(fā)生率較經(jīng)胸組低，差異有統(tǒng)計學意義（χ~2=21.249P<0.05）。1.7住院時間經(jīng)胸組平均住院時間16.82±6.142天，經(jīng)腹組平均住院時間16.62±4.700天，平均住院時間經(jīng)胸組與經(jīng)腹組比較，差異無統(tǒng)計學意義（P>0.05）。2術(shù)后病理結(jié)果2.1分化程度經(jīng)胸組：高中分化159例、低分化139例。經(jīng)腹組：高中分化86例、低分化82例。兩組比較差異無統(tǒng)計學意義（P>0.05）2.2大體分型（Borrmann分型）經(jīng)胸組：Ⅰ型10例，Ⅱ型156例，Ⅲ型275例，Ⅳ型24例。經(jīng)腹組：Ⅰ型7例，Ⅱ型104例，Ⅲ型170例，Ⅳ型17例。兩組比較差異無統(tǒng)計學意義（P>0.05）。2.3各組淋巴結(jié)清掃個數(shù)及轉(zhuǎn)移率經(jīng)胸組各組淋巴結(jié)清掃個數(shù)及轉(zhuǎn)移率：1組19.65%（207/1153）、2組32.02%（292/1012）、3組27.05%（221/917）、4組4.56%（15/329）、5組26.56%（12/406）、6組4.22%（3/71）、7組17.88%（59/330）、8組1.64%（2/122）、9組2.44%（1/41）、10組3.70%（2/54）、11組0%（0/63）、12組0%（0/136）、13組0%（0/9）、14組0%（0/5）、15組0%（0/4）、16組0%（0/9）、19組0%（0/0）、20組0%（0/0）、110組20.93%（18/86）、111組0%（0/9）、112組0%（0/3）。經(jīng)腹組各組淋巴結(jié)清掃個數(shù)及轉(zhuǎn)移率：1組47.26%（422/893）、2組33.79%（293/867）、3組29.03%（216/744）、4組5.43%（18/331）、5組38.69%（142/367）、6組13.70%（44/321）、7組35.03%（55/157）、8組23.19%（16/69）、9組34.78%（8/23）、10組23.81%（5/21）、11組32.39%（23/71）、12組0%（0/71）、13組0%（0/5）、14組0%（0/7）、15組0%（0/5）、16組0%（0/2）、19組0%（0/2）、20組0%（0/7）、110組14.29%（2/14）、111組0%（0/6）、112組0%（0/0）。經(jīng)胸組與經(jīng)腹組各組淋巴結(jié)轉(zhuǎn)移率相比較：1組χ~2=202.954P=0.000；2組χ~2=5.317P=0.021；3組χ~2=5.153P=0.023；5組χ~2=154.306P=0.000；6組χ~2=4.954P=0.026；7組χ~2=17.459P=0.000；8組χ~2=23.976P=0.000；9組χ~2=10.216P=0.001；10組χ~2=5.042P=0.025。1-3組及5-8組淋巴結(jié)轉(zhuǎn)移數(shù)經(jīng)胸與經(jīng)腹兩組比較，經(jīng)腹組轉(zhuǎn)移率較經(jīng)腹組高，差異有統(tǒng)計學意義（P<0.05）。其余各組淋巴結(jié)轉(zhuǎn)移數(shù)，經(jīng)胸組與經(jīng)腹組比較，兩組比較差異無統(tǒng)計學意義（P>0.05）。2.4pTNMⅠ期18例，Ⅱ期104例，Ⅲ期299例。經(jīng)胸組：Ⅰ期11例，Ⅱ期69例，Ⅲ期189例。經(jīng)腹組：Ⅰ期7例，Ⅱ期35例，Ⅲ期110例。兩組比較差異無統(tǒng)計學意義（P>0.05）。2.5浸潤深度粘膜層5例，粘膜下層3例，肌層47例，漿膜層155例，漿膜外256例。其中，經(jīng)胸組：粘膜層3例，粘膜下層2例，肌層27例，漿膜層91例，漿膜外175例；經(jīng)腹組：粘膜層2例，粘膜下層1例，肌層20例，漿膜層46例，漿膜外81例。兩組比較差異無統(tǒng)計學意義（P>0.05）。3Siewert Ⅱ、Ⅲ型AEG患者預后情況隨訪時間截至2012年12月，隨訪率為73.39%（342/466），單純經(jīng)胸手術(shù)組和經(jīng)腹手術(shù)組患者1年生存率分別為78.00%和79.75%（χ~2=0.219P=0.640），3年生存率分別為36.95%和42.36%（χ~2=0.562P=0.435），5年生存率分別為17.98%和20.33%（χ~2=0.883P=0.347），經(jīng)胸手術(shù)組和經(jīng)腹手術(shù)組患者術(shù)后5年總生存率兩組比較，差異無統(tǒng)計學意義（P=0.123P>0.05）。結(jié)論：本組資料通過對Siewert Ⅱ、Ⅲ型AEG經(jīng)胸與經(jīng)腹兩種手術(shù)入路466例病例的臨床對照研究，對其手術(shù)情況及預后進行對比分析，現(xiàn)小結(jié)如下：1手術(shù)根治度方面:經(jīng)腹組的下切緣癌殘端陽性率較經(jīng)胸組低；上殘端陽性率兩組比較無差異；經(jīng)腹組較經(jīng)組胸平均清掃淋巴結(jié)數(shù)目多；經(jīng)腹組較經(jīng)胸組在腹腔淋巴結(jié)清掃數(shù)目上具優(yōu)勢。2經(jīng)胸組比經(jīng)腹組創(chuàng)傷大、時間長術(shù)后并發(fā)癥發(fā)生率高。3經(jīng)胸手術(shù)組和經(jīng)腹手術(shù)組患者術(shù)后生存率兩組比較無明顯差異。

    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型食管胃結(jié)合部腺癌兩種外科手術(shù)入路治療效果的研究

摘要4-9ABSTRACT9-15前言16資料與方法16-18結(jié)果18-23附圖23-28附表28-31討論31-35結(jié)論35-36參考文獻36-39綜述 食管胃結(jié)合部腺癌病因、治療的研究進展39-53    參考文獻48-53致謝53-54個人簡歷54

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