食管胃结合部腺癌手术方式的选择

目的探讨食管胃结合部腺癌（AEG）合理的手术方式。方法检索2004年1月至2013年12月第三军医大学西南医院实施手术治疗的AEG病例资料，按年份分析AEG的发病趋势，AEG3种亚型的构成比，Siewert分型与手术路径、切除范围、消化道重建方式的关系，以及机械吻合器和腹腔镜技术介入后AEG手术方式的变化情况。结果共纳入AEG患者563例，男443例，女120例；年龄15～91岁，平均年龄59岁。AEG在所有胃腺癌中所占比例约为25．897％（563／2174）。2004—2013年，AEG在当年胃腺癌中所占比例分别为18．89％（27／143）、14．81％（20／135）、17．06％（29／170）、14．21％（28／197）、19．78％（36／182）、33．64％（72／214）、31．17％（72／231）、29．31％（85／290）、30．42％（87／286）、37．15％（107／288）。SiewertI型AEG患者52例（9．24％）、Ⅱ型424例（75．31％）、11I型87例（15．45％）。手术路径：52例SiewertI型AEG患者均采用经胸路径；424例SiewertU型AEG患者中，采用经胸路径45例（10．61％）、经胸腹联合路径12例（2．83％）、经腹路径367例（86．56％）；87例Siewert111型AEG患者均采用经腹路径。切除范围：52例SiewertI型AEG患者均行食管下段及近端胃切除；424例Siewert1I型AEG患者中，行近端胃切除167例（39．39％0）、全胃切除257例（含残胃癌27例，60．61％）；87例SiewertⅢ型AEG患者均行全胃切除。消化道重建方式：52例SiewertI型AEG患者均行经胸食管胃吻合；424例SiewertII型AEG患者中，行食管胃吻合62例（14．62~70），保留远端残胃的双通道吻合55例（12．97％），食管空肠Roux-en-Y吻合248例（58．49％0）、食管空肠Braun吻合59例（13．92％）；87例Siewert111型AEG患者中，行食管空肠Roux-en-Y吻合61例（70．11％）、食管空肠Braun吻合26例（29．89％）。食管胃吻合、食管空肠吻合基本采用机械吻合器完成。自2005年起，腹腔镜技术介入AEG手术，腹腔镜下实施SiewertII型AEG手术239例、SiewertⅢ型AEG手术59例。结论SiewertI型AEG主要采用经胸路径，Siewert1I、11I型AEG手术路径由经胸路径向经腹路径转移，全胃切除比例上升，但尚未形成标准的手术方式。AEG手术方式应从手术的安全性、根治的彻底性、术后生命质量、手术的简约性以及腹腔镜技术的熟练程度等进行合理选择。

Selection of surgical treatment methods for adenocarcinoma of the esophagogastric junction

Objective To investigate the reasonable surgical treatment methods for adenocarcinoma of the esophagogastric junction （AEG）. Methods The clinical data of patients with AEG who received surgical treat- ment at the Southwest Hospital from Janual7 2004 to December 2013 were retrieved. The epidemiological trends of AEG, the proportion of 3 types of AEG, relationship between the type of AEG and surgical procedures, resection ranges, methods of digestive tract reconstruction were analyzed. The changes of surgical treatment methods after the application of stapler and laparoseopic instruments were recorded. Results The clinical data of 563 AEG pa- tients were retrieved, including 443 males and 120 females. The mean age was 59 years （range, 15-91 years）. The proportion of AEG in all the gastric adenocarcinoma was 25. 897 % （563/2 174 ）. The proportions of AEG from the year 2004 to 2013 were 18.89% （27/143）, 14.81% （20/135）, 17.06% （29/170）, 14.21% （28/197）, 19.78% （36/182）, 33.64% （72/214）, 31.17% （72/231）, 29.31% （85/290）, 30.42% （87/286）, 37.15% （ 107/288 ）. The numbers of patients with Siewert type I , ]I and m were 52 （9.24%）, 424 （75.31% ） and 87（ 15.45% ）. Fifty-two patients with Siewert type I AEG were treated by transthoracic approach. Of the 424 patients with Siewert type U AEG, 45（ 10.61% ） were treated by transthoraeic approach, 12（2.83% ） by thoracoabdo- minal approach, and 367 （86.56%） by transabdominal approach. Eighty-seven patients with Siewert type DI AEG were treated by transabdominal approach. Fifty-two patients with Siewert type I AEG received resection of lower esophagus and proximal gastrectomy. Of the 424 patients with Siewert type lI AEG, 167 （ 39. 39% ） reeeived proximal gastreetomy, 257 （60.61% , including 27 patients with gastric stump cancer） received total gastreetomy. Eighty-seven patients with Siewert type m received total gastrectomy. Fifty-two patients with Siewert type I received intrathoracic esophagogastric anastomosis. Of the 424 patients with Siewert type II AEG, 62 patients （ 14.62% ） received esophagogastric anastomosis, 55 （ 12.97% ） received dual channel anastomosis with preservation of distal gastric stump, 248 patients （58.49%） received esophagojejunal Roux-en-Y anastomosis, 59 patients （ 13.92% ） received esophagojejunal Braun anastmosis. Of the 87 patients with Siewcrt type Ill AEG, 61 patients （70.11% ） reeeived esophagojejunal Roux-en-Y anastomosis, 26 patients （29.89%） received esophago- jejunal Braun anastomosis. Most of the esophagogastrie anastomosis and esophagojejunal anastmosis were done with staplers Since 2005, 239 patients with Siwert type 11 AEG and 59 patients with Siewert type m AEG received surgery under laparoscope. Conclusions Most patients with Siewert type I AEG were treated by transthoracic approach, while for patients with Siewert type lI ,III AEG, surgeons tend to select transabdominal approach rather than transthoracic approach. No consensus on the standard surgical procedures is reached. Surgeons should delib- erate on the surgical treatment in terms of safety of the operation, thoroughness of resection, postoperative life quality, simplicity of operation and technique proficiency.