食管胃交界部腺癌淋巴结转移特点及手术方式选择

目的研究不同分型食管胃交界部腺癌（AEG）的淋巴结转移规律，以指导各型手术方式的选择。方法回顾性分析2007—2012年在四川省肿瘤医院接受手术治疗的228例AEG患者的临床资料。按Siewert分型标准，Ⅰ型9例（3．9％），均采用上腹、左胸两切口入路；Ⅱ型121例（53．1％），其中经左胸入路12例，经上腹、左胸两切口人路48例．经腹入路61例；Ⅲ型98例（43％），其中经上腹、左胸两切口入路22例，经腹入路76例。分析各型淋巴结转移分布规律，比较不同手术入路对手术根治性的影响。结果228例AEG手术患者中有20例（8．8％）切缘阳性．其中Ⅱ型10例（8．3％），Ⅲ型10例（10．2％），差异无统计学意义（P〉0．05）。按手术入路。经腹组切缘阳性率为12．4％（17／137），经左胸组胃切缘阳性率16．7％（2／12），均高于经上腹、左胸两切口组的1．1％（1／88）（均P〈0．05）。159例患者（69．7％）发现有淋巴结转移：I型淋巴结转移率4／9．其中胸腔转移2例，上纵隔淋巴结未见转移。Ⅱ型淋巴结转移率66．9％（81／121），其中胸腔转移32例（26．4％），腹腔转移81例（66．9％）。IU型淋巴结转移率70．4％（69／98）。其中胸腔转移15例（15．3％）．腹腔转移69例（70．4％）。结论对于Ⅰ型AEG患者，由于其淋巴结转移规律符合食管下段癌，可选用经上腹、左胸两切口以方便清扫胸腔及腹腔淋巴结；对于Ⅱ型患者，由于其较高的胸内淋巴结转移率，应行上腹、左胸两切口以保证肿瘤切除范围及下段食管旁、膈上淋巴结清扫：对于Ⅲ型患者，经腹单一切口可因减少对呼吸功能影响而更具优势．但对于肿瘤病灶较大、外侵明显的病例，可加做开胸手术以保证手术根治性。

Characteristics of lymphatic metastasis and surgical approach of adenocarcinoma of the esophagogastric junction

Objective To investigate the characteristics of lymphatic metastasis in different types of adenocarcinoma of the esophagogastric junction （AEG） and provide guidance for surgical approach adoption. Methods Clinical data of 228 patients with AEG undergoing surgery were analyzed retrospectively. According to Siewert classification, there were 9 cases of type Ⅰ （3.9%） who all underwent left thoracoabdominal approach procedures. A total of 121 patients belonged to type Ⅱ （53.1%）, of whom 12 underwent left transthoracic approach, 48 left thoracoabdominal approach, and 61 transabdominal approach. Ninety-eight patients belonged to type Ⅲ （43%）, of whom 22 underwent left thoracoabdominal approach procedures and 76 transabdominal. The pattern of lymph node metastasis was analyzed and the association between surgical approach and oncological clearance was examined. Results The resection margin was positive in 20（8.8%） patients, including 10 with type Ⅱ （8.3%） and 10 with type Ⅲ （10.2%）, and the difference was not statistically significant （P〉0.05）. The rate of positive resection margin was 12.4%（17/137） in the transabdominal group and 16.7%（2/12） in the left transthoracic group, both significantly higher than the left thoracoabdominal group （1.1%, 1/88） （both P〈0.05）. Lymph node metastasis was found in 159（69.7%） patients. The metastasis was found in 4 of 9 patients with type Ⅰ cancer and two were thoracic metastasis, no metastasis was found in the upper mediastinum. For type Ⅱ cancer, the rate of lymph node metastasis was 66.9% （81/121）, including thoracic metastasis（n=32, 26.4%）and abdominal metastasis（n=81, 66.9%）. For typem cancer, the rate of lymph node metastasis was 66.9% （81/121）, including thoracic metastasis （n=15, 15.3% ） and abdominal metastasis （n=69, 70.4%）. Conclusions For type I AEG, left thoracoabdominal approach should be used because the pattern of lymph node metastasis is similar to that of the distal esophageal carcinoma. For type Ⅱ , left thoracoabdominal approach should be used to ensure adequate resection of the tumor and clearance of lymph node in the lower esophagus and upper mediastinum because of high rate of intrathoracic lymph node metastasis. For type m cancer, transabdominal incision offers better benefit with less impact on respiratory function. However, thoracic incision should be used to ensure adequate clearance for tumors of larger size and significant external invasion.