全腔镜下经腹膈入路全胃切除治疗SiewertⅡ型食管胃交界部腺癌的围手术期疗效分析
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摘要
目的探讨全腹腔镜下经腹切开膈肌扩大食管裂孔入路的根治性全胃切除治疗SiewertⅡ型食管胃交界部腺癌的围手术期疗效。方法回顾性分析2017年4月—2017年12月解放军总医院第六医学中心普通外科开展的全腹腔镜下经腹膈肌入路行D2淋巴结清扫和消化道重建的10例SiewertⅡ型食管胃交界部腺癌患者的围手术期资料。10例均行全胃切除,并行食管-空肠消化道重建,其中8例使用圆型吻合器吻合,2例使用直线吻合器吻合。结果 10例患者均顺利完成手术,平均手术时间250(230～290) min,消化道重建时间52(40～70) min,术中出血量160(80～350) m L,无中转开腹。术后切缘全部为阴性,平均肿瘤直径5. 4(3. 5～7. 1) cm,侵及食管长度2. 0(1. 5～4. 2) cm,平均淋巴结清扫个数32. 5(26～40)个。术后1例患者出现吻合口瘘及肺部感染,经治疗后痊愈出院。术后平均随访时间为6个月,无明显食管反流、进食困难等并发症发生。结论对SiewertⅡ型食管胃交界部腺癌行全腹腔镜下经腹膈肌入路淋巴结清扫和食管-空肠消化道重建可行并可以达到根治性手术的切除要求,但手术方式较新,远期疗效需要更大规模的研究证实。
Objective We aim to evaluate the perioperative efficacy of application of an intra-abdominal diaphragmic incision( IADI) technique to enlarge esophageal-hiatus in totally laparoscopic total gastrectomy( TLTG) for lymph node dissection and esophagojejunostomy( EJ) in patients with Siewert Ⅱ adenocarcinoma of esophagogastric junction( AEGJ). Methods Ten individuals with Siewert Ⅱ AEGJ that underwent TLTG with D2 lymph node dissection and EJ via IADI approach were recruited between April 2017 and December 2017 retrospectively. Among them,eight cases were anastomosed through circular stapler and two cases through linear stapler. Results The operations of the 10 patients were completed successfully. The average operative time was 250( 230～ 290) minutes,the time of digestive tract reconstruction was 52( 40 ～ 70) minutes and intraoperative bleeding was 160( 80 ～ 350) m L. No conversions to open surgery occurred. The margins of resection were free of tumor in the specimens of all patients,the average diameter of tumors was 5. 4( 3. 5～7. 1) centimeters,the average length of the esophagus invaded was 2. 0( 1. 5～4. 2) centimeters and the average number of the lymph nodes dissected was 32. 5( 26 ～ 40). Post-operative EJ leakage with pulmonary infection was observed in one patient,which was managed non-operatively and the patient was cured and discharged. No complications of esophageal reflux and difficulty in eating were observed during a mean follow-up time of 6 months. Conclusion The method of lymph node dissection and EJ in TLTG by using IADI approach is feasible and safe for patients with SiewertⅡ AEGJ,which can achieve the request of radical surgery excision. However,the long-term efficacy of this new method needs to be confirmed by larger studies.
Objective We aim to evaluate the perioperative efficacy of application of an intra-abdominal diaphragmic incision( IADI) technique to enlarge esophageal-hiatus in totally laparoscopic total gastrectomy( TLTG) for lymph node dissection and esophagojejunostomy( EJ) in patients with Siewert Ⅱ adenocarcinoma of esophagogastric junction( AEGJ). Methods Ten individuals with Siewert Ⅱ AEGJ that underwent TLTG with D2 lymph node dissection and EJ via IADI approach were recruited between April 2017 and December 2017 retrospectively. Among them,eight cases were anastomosed through circular stapler and two cases through linear stapler. Results The operations of the 10 patients were completed successfully. The average operative time was 250( 230～ 290) minutes,the time of digestive tract reconstruction was 52( 40 ～ 70) minutes and intraoperative bleeding was 160( 80 ～ 350) m L. No conversions to open surgery occurred. The margins of resection were free of tumor in the specimens of all patients,the average diameter of tumors was 5. 4( 3. 5～7. 1) centimeters,the average length of the esophagus invaded was 2. 0( 1. 5～4. 2) centimeters and the average number of the lymph nodes dissected was 32. 5( 26 ～ 40). Post-operative EJ leakage with pulmonary infection was observed in one patient,which was managed non-operatively and the patient was cured and discharged. No complications of esophageal reflux and difficulty in eating were observed during a mean follow-up time of 6 months. Conclusion The method of lymph node dissection and EJ in TLTG by using IADI approach is feasible and safe for patients with SiewertⅡ AEGJ,which can achieve the request of radical surgery excision. However,the long-term efficacy of this new method needs to be confirmed by larger studies.
引文
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[12]Polkowski WP,van Lanschot JJ.Proximal margin length with transhiatal gastrectomy for Siewert typeⅡandⅢadenocarcinomasof the oesophagogastric junction(Br J Surg2013;100:1050-1054)[J].Br J Surg,2014,101(6):735.
[13]Hosoda K,Yamashita K,Moriya H,et al.Optimal treatment for Siewert typeⅡandⅢadenocarcinoma of the esophagogastric junction:a retrospective cohort study with longterm follow-up[J].World J Gastroenterol,2017,23(15):2723-2730.
[14]Papachristou DN,Fortner JG.Adenocarcinoma of the gastric cardia.The choice of gastrectomy[J].Ann Surg,1980,192(1):58-64.
[15]Facy O,Arru L,Azagra JS.Intestinal anastomosis after laparoscopic total gastrectomy[J].J Visc Surg,2012,149(3):e179-e184.
[16]Inaba K,Satoh S,Ishida Y,et al.Overlap method:novel intracorporeal esophagojejunostomy after laparoscopic total gastrectomy[J].J Am Coll Surg,2010,211(6):e25-e29.
[17]Bracale U,Marzano E,Nastro P,et al.Side-to-side esophagojejunostomy during totally laparoscopic total gastrectomy for malignant disease:a multicenter study[J].Surg Endosc,2010,24(10):2475-2479.
[18]Okabe H,Obama K,Tanaka E,et al.Intracorporeal esophagojejunal anastomosis after laparoscopic total gastrectomy for patients with gastric cancer[J].Surg Endosc,2009,23(9):2167-2171.
[2]Drahos J,Wu M,Anderson WF,et al.Regional variations in esophageal cancer rates by census region in the United States,1999-2008[J].PLoS One,2013,8(7):e67913.
[3]Lubin JH,Cook MB,Pandeya N,et al.The importance of exposure rate on odds ratios by cigarette smoking and alcohol consumption for esophageal adenocarcinoma and squamous cell carcinoma in the Barrett’s Esophagus and Esophageal Adenocarcinoma Consortium[J].Cancer Epidemiol,2012,36(3):306-316.
[4]Cook MB,Corley DA,Murray LJ,et al.Gastroesophageal reflux in relation to adenocarcinomas of the esophagus:a pooled analysis from the Barrett’s and Esophageal Adenocarcinoma Consortium(BEACON)[J].PLoS One,2014,9(7):e103508.
[5]Takiguchi S,Miyazaki Y,Shinno N,et al.Laparoscopic mediastinal dissection via an open left diaphragm approach for advanced Siewert typeⅡadenocarcinoma[J].Surg Today,2016,46(1):129-134.
[6]Siewert JR,Stein HJ.Classification of adenocarcinoma of the oesophagogastric junction[J].Br J Surg,1998,85(11):1457-1459.
[7]Feith M,Stein HJ,Siewert JR.Adenocarcinoma of the esophagogastric junction:surgical therapy based on 1602consecutive resected patients[J].Surg Oncol Clin N Am,2006,15(4):751-764.
[8]Mariette C,Piessen G,Briez N,et al.Oesophagogastric junction adenocarcinoma:which therapeutic approach?[J].Lancet Oncol,2011,12(3):296-305.
[9]Wei MT,Zhang YC,Deng XB,et al.Transthoracic vs transhiatal surgery for cancer of the esophagogastric junction:a meta-analysis[J].World J Gastroenterol,2014,20(29):10183-10192.
[10]Kurokawa Y,Hiki N,Yoshikawa T,et al.Mediastinal lymph node metastasis and recurrence in adenocarcinoma of the esophagogastric junction[J].Surgery,2015,157(3):551-555.
[11]Barbour AP,Rizk NP,Gonen M,et al.Lymphadenectomy for adenocarcinoma of the gastroesophageal junction(GEJ):impact of adequate staging on outcome[J].Ann Surg Oncol,2007,14(2):306-316.
[12]Polkowski WP,van Lanschot JJ.Proximal margin length with transhiatal gastrectomy for Siewert typeⅡandⅢadenocarcinomasof the oesophagogastric junction(Br J Surg2013;100:1050-1054)[J].Br J Surg,2014,101(6):735.
[13]Hosoda K,Yamashita K,Moriya H,et al.Optimal treatment for Siewert typeⅡandⅢadenocarcinoma of the esophagogastric junction:a retrospective cohort study with longterm follow-up[J].World J Gastroenterol,2017,23(15):2723-2730.
[14]Papachristou DN,Fortner JG.Adenocarcinoma of the gastric cardia.The choice of gastrectomy[J].Ann Surg,1980,192(1):58-64.
[15]Facy O,Arru L,Azagra JS.Intestinal anastomosis after laparoscopic total gastrectomy[J].J Visc Surg,2012,149(3):e179-e184.
[16]Inaba K,Satoh S,Ishida Y,et al.Overlap method:novel intracorporeal esophagojejunostomy after laparoscopic total gastrectomy[J].J Am Coll Surg,2010,211(6):e25-e29.
[17]Bracale U,Marzano E,Nastro P,et al.Side-to-side esophagojejunostomy during totally laparoscopic total gastrectomy for malignant disease:a multicenter study[J].Surg Endosc,2010,24(10):2475-2479.
[18]Okabe H,Obama K,Tanaka E,et al.Intracorporeal esophagojejunal anastomosis after laparoscopic total gastrectomy for patients with gastric cancer[J].Surg Endosc,2009,23(9):2167-2171.