SiewertⅡ型和Ⅲ型食管胃结合部腺癌经胸与经腹食管裂孔手术的疗效比较

目的探讨经胸与经腹食管裂孔两种不同手术路径治疗SiewertⅡ、Ⅲ型食管胃结合部腺癌（AEG）患者的疗效。方法回顾性分析2007年7月至2012年7月青岛大学附属医院收治的334例SiewertⅡ、Ⅲ型AEG患者的临床资料。胸外科收治的140例SiewertⅡ、Ⅲ型患者均经胸路径行全胃及近端胃切除、第2站淋巴结清扫术（经胸手术组），普通外科收治的194例SiewertⅡ、Ⅲ型患者均经腹食管裂孔路径行全胃及近端胃切除、第2站淋巴结清扫术（经腹食管裂孔手术组）。分析两组患者术中情况、近期和远期疗效。患者采用电话或门诊复查方式进行随访。随访时间截至2013年7月。计量资料采用t检验，计数资料采用，检验和Fisher确切概率法，等级资料采用非参数秩和检验。生存曲线绘制采用Kaplan-Meier法，生存率的比较采用Log-rank检验。结果经胸手术组患者和经腹食管裂孔手术组患者手术时间、食管切除长度、清扫淋巴结总数、术后疼痛评分、术后住院时间、抗生素应用时间、术后总体并发症发生率、住院总费用分别为（202±34）min、（4．1±1．1）em、（17±7）枚、（5．9±1．8）分、（13±6）d、（6．8±2．4）d、27．14％（38／140）、（4．7-4-1．8）万元和（153±48）min、（3．8-4-1．1）cm、（224-7）枚、（4．84-1．6）分、（114-6）d、（2．3±1．1）d、15．46％（30／194）、（4．54-1．5）万元，两组上述指标比较，差异有统计学意义（t=3．126，2．634，5．417，4．662，2．030，9．384，置。=6．841，t=2．398，P〈0．05）。302例SiewertⅡ、Ⅲ型AEG患者获得术后随访，随访率为90．42％（302／334），获得随访的AEG患者术后中位生存时间为38个月（2～72个月）。经胸手术组和经腹食管裂孔手术组患者术后5年生存率分别为35．3％和40．3％，两组比较，差异无统计学意义（矿=2．311，P〉0．05）。按TNM分期进行分层分析，经胸手术组和经腹食管裂孔手术组TNMⅢ期患者总生存率分别为25．7％和37．2％，两组比较，差异有统计学意义（∥=4．127，P〈0．05）。结论SiewertⅡ、Ⅲ型AEG患者经胸路径和经腹食管裂孔路径施行根治性全胃、近端胃切除术5年总生存率差异无统计学意义，经腹食管裂孔路径手术治疗AEG患者其近期临床疗效更具优势。

Comparison of clinical outcome of transthoracic and transabdominal hiatal approaches for the treatment ofSiewert type lI and HI adenocarcinoma of the esophagogastric junction

Objective To compare the clinical outcome of transthoracic and transabdominal hiatal approa- ches for the treatment of Siewert type [[ and m adenocareinoma of the esophagogastric junction （AEG）. Methods The clinical data of 334 patients with Siewert type II and ]][ AEG who were admitted to the Affiliated Hospital of Qingdao University from July 2007 to July 2012 were retrospectively analyzed. There were 140 patients received transthoraeic total or proximal gastrectomy ＋ No. 2 lymph node dissection （transthoracic group） , and 194 patients received transabdominal hiatal total or proximal gastreetomy ＋ No. 2 lymph node dissection （ transabdominal hiatal group）. The intraoperative and short-term conditions of the patients in the 2 groups were analyzed. Patients were followed up via phone call or out-patient examination till July 2013. All data were analyzed using the t test, chi-square test, Fisher exact probability or Kruskal Wallis test. The survival curve was drawn by Kaplan-Meier method, and the survival rate was analyzed using the Log-rank test. Results The operation time, lengths of esophagus resected, number of lymph node dissected, postoperative pain scores, duration of postoperative hospital stay, time of antibiotics usage, incidences of postoperative complications and total costs were （ 202 _＋ 34） minutes,（4.1 ~ 1.1）cm, 17 -＋7, 5.9 -＋ 1.8, （13 _＋6）days, （6.8 -＋ 2.4） days, 27.14% （38/140） and （4.7 _＋ 1.8）x 104 yuan in the transthoraeic group, and （153 -＋ 48）minutes, （3.8 ＋ 1.1 ）cm, 22 -＋ 7, 4.8 -＋ 1.6, （11 -＋ 6）days, （2.3 -＋ 1.1 ）days, 15.46% （30/194） and （4.5 -＋ 1.5）~ 104 yuan in the transabdominal hiatal group, with signi- ficant differences between the 2 groups （ t = 3. 126, 2. 634, 5. 417, 4. 662, 2. 030, 9. 384, X2 = 6. 841, t = 2. 398, P 〈 0.05）. A total of 302 patients were followed up, with the follow-up rate of 90.42% （302/334）. The median survival time of the patients was 38 months （range, 2- 72 months）. The 5-year survival rates of patients in the transthoracic group and the transabdominal hiatal group were 35.3% and 40.3% , with no significant differ- ence between the 2 groups （X2=2. 311, P 〉0.05）. The overall survival rates of patients in TNM stage H1 of the transthoracic group and the transabdominal hiatal group were 25.7% and 37.2% , with significant difference （X~= 4. 127, P 〈 0.05 ）. Conclusions There was no significant difference in the 5-year survival rates between transthoracic and transabdominal hiatal approaches for the treatment of patients with Siewert type II and 111 AEG. The short-term outcome of transabdominal hiatal approach is superior to that of transthoracic approach.