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近年来,食管胃结合部腺癌(AEG)发病率呈上升趋势,手术为该病的主要治疗手段,但目前国人对该病概念较模糊,导致手术选择(包括手术入路、切除范围、淋巴结清扫范围等方面)多样,甚至存在争议。对肿瘤进行充分的分型、分期评估,遵循个体化治疗原则,是为病人选择科学合理的术式的前提和基础。对于SiewertI型AEG病人可行经胸经裂孔食管下段切除术、经颈、胸、腹三切口手术等;SiewertⅡ型AEG病人术式选择和手术入路存在较多的争议,经腹行全胃切除+腹部及纵隔淋巴结清扫被认为是进展期SiewertⅡ型AEG的首选术式,只有全胃切除才能保证进展期AEG足够无瘤切缘和淋巴结清扫范围,早期SiewertⅡ型AEG病人可行近端胃切除及相应淋巴结清扫;Ⅲ型AEG则按近端胃癌手术原则处理。进展期AEG是否联合脾切除尚存争议。目前不建议行常规脾切除术,只有在脾门受侵或有明确的淋巴结转移时,才考虑行脾切除。

Selection of surgical procedures for the patients with resectable adenocarcinoma of the esophagogastric junction

In resent years,the incidence of adenocarcinoma of the esophagogastric junction(AEG) is increasing.Surgery is the main method of treatment.However,the concept of the disease remains unclear in China,so that surgical procedures are diverse and even controversy.Adequate assessment of the classification and stage of AEG before operation,as well as following the principle of individual therapy play an important role in selecting suitable surgical procedures for the patients.For AEG I tumor,transthorasic and transhiatal resection of the distal esophagus or 3-field lymph node dissection(cervical,mediastinal,and abdominal lymph node dissection) can be performed;Total gastrectomy with transhiatal resection of the distal esophagus(transhiatally extended gastrectomy) plus abdominal and mediastinal lymphadenectomy is the best approach for AEG Ⅱ tumors.Only performing total gastrectomy can ensure a negative resection margin and enough scope of lympha node dissection.Proximal gastrectomy is acceptable by early AEG.Selecting surgical procedure for AEG Ⅲ tumor should obey the surgical principle of proximal gastric cancer.Splenectomy is not recommended in routine AEG operation.Splenectomy is only performed in patients with definited lymph node metastases or infiltration of the splenic hilum.