摘要
目的比较经胸与经腹入路手术治疗SiewertⅡ型食管胃结合部腺癌(AEG)的远期生存结局。方法合并2006—2014年期间四川大学华西医院食管癌外科和胃癌外科病例登记数据库,回顾性收集接受手术切除的SiewertⅡ型AEG病例,病例纳入标准:(1)胃镜及活检确诊为腺癌;(2)肿瘤累及食管胃交界线;(3)肿瘤位于食管胃交界线上下5 cm范围内,且肿瘤中心位于食管胃交界线上1 cm至线下2 cm之间;(4)在胸外科或胃肠外科接受了手术切除;(5)随访资料完整。胸外科病例采用经左胸、经右胸、或经胸腹联合入路;实施食管下段加近端胃大部切除;二野淋巴结或选择性三野淋巴结清扫;重建采用食管-残胃或食管-管状残胃主动脉弓下或弓上吻合,手工缝合或器械完成吻合。胃肠外科采用经腹(膈肌裂孔径路)、或经胸腹联合入路;实施全胃切除或近端胃大部切除;进行D1+、D2或D2+淋巴结清扫;重建采用食管-单管空肠或空肠储袋Roux-en-Y吻合,或食管-残胃或食管-管状残胃吻合,均采用器械完成吻合。随访截止时间为2018年1月。采用国际抗癌联盟(UICC)第8版食管癌TNM分期系统,生存表法测算3年总体生存率(OS)及95%可信区间(CI),生存分析采用log-rank检验,Cox回归分析远期生存的危险因素并报道危险比(HR)及其95%CI。结果共纳入443例符合SiewertⅡ型AEG标准的病例,其中经胸入路手术组89例(含3例经胸腹联合入路),经腹入路手术组354例。中位随访时间为50.0(四分位数:26.4~70.2)月。经胸入路手术组与经腹入手术路组临床病理特征基线可比,但食管受累高度差异有统计学意义[经腹入路手术组食管受累高度<3 cm者有354例(100%),经胸入路手术组为44例(49.4%),差异有统计学意义(χ^2=199.23,P<0.001)]。胸外科和胃肠外科的中位淋巴结清扫数目分别为12.0(四分位数:9.0~17.0)枚和24.0(四分位数:18.0~32.5)枚(Z=11.29,P<0.001)。经腹入路手术组与经胸入路手术组术后3年OS分别为69.2%(95%CI:64.1%~73.7%)和55.8%(95%CI:44.8%~65.4%),log-rank检验总体生存率差异无统计学意义(P=0.059),但Ⅲ期亚组分析提示,经腹入路手术患者的生存结局更优[3年OS分别为:经腹入路手术组78.1%(95%CI:70.5~84.0),经胸入路手术组46.3%(95%CI:31.0~60.3);P=0.001]。经Cox多因素分析提示,经胸入路手术组总体生存结局倾向为劣(HR=2.45,95%CI:1.30~4.64,P=0.006)。结论经腹入路手术总体生存倾向为优,尤其在Ⅲ期病例。可能与SiewertⅡ型AEG腹部淋巴结转移率更高,彻底清扫获益更多有关。
Objective To compare the long-term survival outcomes of SiewertⅡadenocarcinoma of esophagogastric junction(AEG)between transthoracic(TT)approach and transabdominal(TA)approach.Methods The databases of Gastrointestinal Surgery Department and Thoracic Surgery Department in West China Hospital of Sichuan University from 2006 to 2014 were integrated.Patients of SiewertⅡAEG who underwent resection were retrospectively collected.Inclusion criteria:(1)adenocarcinoma confirmed by gastroscopy and biopsy;(2)tumor involvement in the esophagogastric junction line;(3)tumor locating from lower 5 cm to upper 5 cm of the esophagogastric junction line,and tumor center locating from upper 1 cm to lower 2 cm of esophagogastric junction line;(4)resection performed at thoracic surgery department or gastrointestinal surgery department;(5)complete follow-up data.Patients at thoracic surgery department received trans-left thoracic,trans-right thoracic,or transabdominothoracic approach;underwent lower esophagus resection plus proximal subtotal gastrectomy;selected two-field or three-field lymph node dissection;underwent digestive tract reconstruction with esophagus-remnant stomach or esophagus-tubular remnant stomach anastomosis above or below aortic arch using hand-sewn or stapler instrument to perform anastomosis.Patients at gastrointestinal surgery department received transabdominal(transhiatal approach),or transabdominothoracic approach;underwent total gastrectomy or proximal subtotal gastrectomy;selected D1,D2 or D2 lymph node dissection;underwent digestive tract reconstruction with esophagus-single tube jejunum or esophagus-jejunal pouch Roux-en-Y anastomosis,or esophagus-remnant stomach or esophagus-tubular remnant stomach anastomosis;completed all the anastomoses with stapler instruments.The follow-up ended in January 2018.The TNM stage system of the 8th edition UICC was used for esophageal cancer staging;survival table method was applied to calculate 3-year overall survival rate and 95%cofidence interval(CI);log-rank test was used to perform survival analysis;Cox regression was applied to analyze risk factors and calculate hazard ratio(HR)and 95%CI.Results A total of 443 cases of SiewertⅡAEG were enrolled,including 89 cases in TT group(with 3 cases of transabdominothoracic approach)and 354 cases in TA group.Median follow-up time was 50.0 months(quartiles:26.4-70.2).The baseline data in TT and TA groups were comparable,except the length of esophageal invasion[for length<3 cm,TA group had 354 cases(100%),TT group had 44 cases(49.4%),χ^2=199.23,P<0.001].The number of harvested lymph node in thoracic surgery department and gastrointestinal surgery department were 12.0(quartiles:9.0-17.0)and 24.0(quartiles:18.0-32.5)respectively with significant difference(Z=11.29,P<0.001).The 3-year overall survival rate of TA and TT groups was 69.2%(95%CI:64.1%-73.7%)and 55.8%(95%CI:44.8%-65.4%)respectively,which was not significantly different by log-rank test(P=0.059).However,the stageⅢsubgroup analysis showed that the survival of TA group was better[the 3-year overall survival in TA group and TT group was 78.1%(95%CI:70.5-84.0)and 46.3%(95%CI:31.0-60.3)resepectively(P=0.001)].Multivariate Cox regression analysis revealed that the TT group had poor survival outcome(HR=2.45,95%CI:1.30-4.64,P=0.006).Conclusion The overall survival outcomes in the TA group are better,especially in stageⅢpatients,which may be associated with the higher metastatic rate of abdominal lymph node and the more complete lymphadenectomy via TA approach.
作者
杨世界
袁勇
胡皓源
李睿哲
刘凯
张维汉
杨昆
杨玉赏
白丹
陈心足
周总光
陈龙奇
Yang Shijie;Yuan Yong;Hu Haoyuan;Li Ruizhe;Liu Kai;Zhang Weihan;Yang Kun;Yang Yushang;Bai Dan;Chen Xinzu;Zhou Zongguang;Chen Longqi(Department of Gastrointestinal Surgery & Laboratory of Gastric Cancer,West China Hospital,Sichuan University,Chengdu 610041,China;Department of Thoracic Surgery,West China Hospital,Sichuan University,Chengdu 610041,China;Western China Gastric Cancer Surgery Research Volunteers Team, West China Hospital,Sichuan University,Chengdu 610041,China;Class 2016,Chengdu No.7 Middle School,Chengdu 610000,China;Class 2015,Huaxi College of Clinical Medicine,Sichuan University, Chengdu 610041,China;West China LongquanHospital,Sichuan University,Chengdu 610100,China)
出处
《中华胃肠外科杂志》
CAS
CSCD
北大核心
2019年第2期132-142,共11页
Chinese Journal of Gastrointestinal Surgery
