本文選題：胃食管連接部腺癌 + 淋巴結(jié)轉(zhuǎn)移��； 參考：《安徽醫(yī)科大學(xué)》2016年博士論文

【摘要】：胃食管連接部腺癌(esophagogastric junction adenocarcinoma,EGJA)作為獨(dú)立病種越來越多的得到臨床醫(yī)生的關(guān)注。針對(duì)臨床上關(guān)心的熱點(diǎn)問題,本研究擬解決如下問題1.如何合理選擇手術(shù)徑路?2.EGJA淋巴結(jié)轉(zhuǎn)移規(guī)律,各型腫瘤淋巴結(jié)清掃范圍?3.EGJA術(shù)后常見并發(fā)癥,并發(fā)癥與所采取的治療方法的關(guān)系,如何控制?4.EGJA預(yù)后分析及影響預(yù)后的主要因素。通過對(duì)2006年6月6日-2011年11月26日經(jīng)手術(shù)治療的EGJA患者共376例進(jìn)行回顧性分析,了解EGJA的一般臨床病理特征和淋巴結(jié)轉(zhuǎn)移規(guī)律,SiewertI、II型淋巴結(jié)轉(zhuǎn)移率占65.7%。而Siewert III型腫瘤淋巴結(jié)轉(zhuǎn)移率占73.3%。Siewert I型EGJA隆突下淋巴結(jié)轉(zhuǎn)移率5.68%、胸下段食管旁及下縱膈淋巴結(jié)轉(zhuǎn)移率27.27%、賁門右淋巴結(jié)轉(zhuǎn)移率為45.45%、賁門左淋巴結(jié)轉(zhuǎn)移率為29.54%、胃小彎淋巴結(jié)轉(zhuǎn)移率為43.18%、胃大彎淋巴結(jié)轉(zhuǎn)移率為28.41%、胃左動(dòng)脈旁及腹腔動(dòng)脈周圍淋巴結(jié)轉(zhuǎn)移率為22%。Siewert II型EGJA隆突下淋巴結(jié)轉(zhuǎn)移率3.54%、胸下段食管旁及下縱膈淋巴結(jié)轉(zhuǎn)移率16.16%、賁門右淋巴結(jié)轉(zhuǎn)移率為50.00%、賁門左淋巴結(jié)轉(zhuǎn)移率為35.85%、胃小彎淋巴結(jié)轉(zhuǎn)移率為42.93%、胃大彎淋巴結(jié)轉(zhuǎn)移率為24.74%、胃左動(dòng)脈旁及腹腔動(dòng)脈周圍淋巴結(jié)轉(zhuǎn)移率為32.83%;Siewert III型EGJA胸下段食管旁及下縱膈淋巴結(jié)轉(zhuǎn)移率3%、賁門右淋巴結(jié)轉(zhuǎn)移率為45.45%、賁門左淋巴結(jié)轉(zhuǎn)移率為29.54%、胃小彎淋巴結(jié)轉(zhuǎn)移率為43.18%、胃大彎淋巴結(jié)轉(zhuǎn)移率為28.41%、胃左動(dòng)脈旁及腹腔動(dòng)脈周圍淋巴結(jié)轉(zhuǎn)移率為22%。Siewert I、II型EGJA淋巴結(jié)轉(zhuǎn)移胸腹雙向性,主要轉(zhuǎn)移至近端胃周和下縱膈,較少出現(xiàn)中上縱膈淋巴結(jié)轉(zhuǎn)移,僅出現(xiàn)縱膈淋巴結(jié)轉(zhuǎn)移而不伴有胃周淋巴結(jié)轉(zhuǎn)移者很少。Siewert III型主要轉(zhuǎn)移至胃周淋巴結(jié)。得出Siewert I、II型EGJA淋巴結(jié)清掃,應(yīng)以涵蓋下縱膈及近端胃周的兩野淋巴結(jié)清掃為主,而不需清掃中上縱膈淋巴結(jié);Siewert III型EGJA則僅需要清掃胃周淋巴結(jié)的結(jié)論。EGJA術(shù)后并發(fā)癥譜發(fā)生了巨大的變化,吻合口瘺的發(fā)生率和死亡率已經(jīng)大幅度下降,得到了較好的控制,但是,心肺并發(fā)癥仍然保持很高的發(fā)生率和死亡率。本組經(jīng)腹入路者術(shù)前伴有心肺疾患及糖尿病等嚴(yán)重合并癥的比率高于經(jīng)胸和胸腹聯(lián)合者,術(shù)后心肺并發(fā)癥比率低于經(jīng)左胸及胸腹聯(lián)合組,表現(xiàn)出經(jīng)腹入路術(shù)后心肺并發(fā)癥降低的趨向。通過對(duì)不同手術(shù)入路的比較和術(shù)后并發(fā)癥的分析,得出了手術(shù)入路選擇的方法,手術(shù)入路的選擇應(yīng)考慮R0切除和淋巴結(jié)清掃的需要,同時(shí)應(yīng)兼顧考慮降低術(shù)后并發(fā)癥及手術(shù)風(fēng)險(xiǎn)的要求。如果EGJA范圍不大,SiewertI、II型者,心肺功能能耐受進(jìn)胸手術(shù),應(yīng)使用左胸+膈肌徑路以滿足病變切除范圍及常規(guī)淋巴結(jié)清掃的需要。對(duì)于高齡、心肺功能下降,預(yù)期術(shù)后心肺并發(fā)癥發(fā)生率高者,或III型EGJA對(duì)下縱膈淋巴結(jié)清掃要求不高者,可考慮使用經(jīng)腹入路。通過對(duì)2007年7月10日-2011年11月26日手術(shù)治療EGJA281例患者進(jìn)行隨訪和生存分析,表明手術(shù)徑路的選擇、病理T、N分期、病理分期以及切除程度和預(yù)后相關(guān),手術(shù)徑路選擇和N分期是影響預(yù)后的獨(dú)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.
【學(xué)位授予單位】：安徽醫(yī)科大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2016
【分類號(hào)】：R735

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