中国实用外科杂志

中国实用外科杂志 ›› 2022, Vol. 42 ›› Issue (04): 423-428.DOI: 10.19538/j.cjps.issn1005-2208.2022.04.12

• 论蓍 • 上一篇    下一篇

基于倾向性评分匹配对比腹腔镜辅助经腹膈肌裂孔入路与经胸腹联合入路治疗Siewert Ⅱ型食管胃结合部腺癌疗效

宋奇赢a，李雄广a，吴    迪a，李    硕a，张沥予a，乌日力格b，王鑫鑫a   

  1. 中国人民解放军总医院第一医学中心 a.普通外科  b.大数据中心，北京100853 
  • 出版日期:2022-04-01 发布日期:2022-04-04

  • Online:2022-04-01 Published:2022-04-04

摘要： 目的    比较腹腔镜辅助经腹膈肌裂孔入路与经胸腹联合入路治疗Siewert Ⅱ型食管胃结合部腺癌（AEG）的手术疗效。方法    回顾性分析2014年1月至2019年12月中国人民解放军总医院第一医学中心收治的行根治性手术治疗的425例Siewert Ⅱ型AEG病人的临床资料。其中腹腔镜辅助经腹膈肌裂孔入路（经腹组）363例，腹腔镜辅助经胸腹联合入路（胸腹联合组）62例。采用1∶1倾向性评分匹配后对比分析两组病人近、远期疗效。结果    两组各匹配61例，匹配后基线资料差异均无统计学意义（P<0.05）。与胸腹联合组相比，经腹组病人术中失血量少［150（100，200）mL vs. 200（150，200）mL，Z=-2.973，P=0.003］，手术时间短［220（188，250）min vs. 293（257，350）min，Z=-6.427，P<0.001］，且术后下床活动［2（1，3） d vs. 3（2，4）d，Z=-3.992，P<0.001］和进食流食时间［5（3，6）d vs. 8（6，9）d，Z=-5.522，P<0.001］更早，术后住院时间缩短［10（9，14）d vs. 13（12，16）d，Z=-3.966，P<0.001］，差异均有统计学意义；胸腹联合组在近端切缘距离、淋巴结清扫总数以及纵隔淋巴结清扫数目方面优于经腹组（P<0.05）；两组术后并发症发生率及分布差异均无统计学意义（P>0.05）。术后随访时间为3～84个月，两组病人在术后3年总体生存率（OS）和无瘤生存率（DFS）方面差异无统计学意义（OS：72.6% vs. 83.2%，χ2=0.379，P=0.538；DFS：58.8% vs. 73.2%，χ2=2.900，P=0.089）。亚组分析显示，在进展期病人中，胸腹联合组3年DFS显著高于经腹组（57.1% vs. 73.7%，χ2=0.5280，P=0.022）。结论    对于Siewert Ⅱ型AEG病人，腹腔镜辅助经胸腹联合入路手术风险高，病人术后恢复时间长，且未能延长术后生存时间，建议选择经腹膈肌裂孔入路；而对于进展期病人，腹腔镜经胸腹联合入路可能存在生存获益。

关键词: 食管胃结合部腺癌, Siewert Ⅱ型, 腹腔镜辅助, 经腹入路, 经胸腹联合入路

Abstract: Comparison based on Propensity Score Matching for Siewert type Ⅱ adenocarcinoma of the esophagogastric junction between laparoscopic-assisted abdominal-transhiatal approach and thoracoabdominal approach                  SONG Qi-ying*，LI Xiong-guang，WU Di，et al. *Department of General Surgery，Chinese PLA General Hospital，Beijing 100853，China 
Corresponding author：WANG Xin-xin，E-mail：301wxx@sina.com
Abstract    Objective    To compare the efficacy between laparoscopic-assisted abdominal-transhiatal(LTH) approach and thoracoabdominal(LTA) approach for Siewert type II adenocarcinoma of the esophagogastric junction(AEG). Methods    The clinical data of 425 Siewert type II AEG patients who underwent surgery from January 2014 to December 2019 at the First Medical Center of PLA General Hospital in China were analyzed retrospectively. All patients were classified into LTH group(n=363) and LTA group(n=62). Using 1∶1 propensity score matching(PSM)，the perioperative outcomes and prognosis were compared between the LTH and LTA groups. Results    61 cases matched in each group. The clinicopathological characteristics between the two groups had no statistical difference after the PSM(P<0.05). Compared with the LTA group，the LTH group had less intraoperative blood loss［150(100，200)mL vs. 200(150，200) mL，Z=-2.973，P=0.003］，shorter operation time［220(188，250)min vs. 293(257，350)min，Z=-6.427，P<0.001］，earlier postoperative ambulation ［2(1，3)d vs. 3(2，4)d，Z=-3.992，P<0.001］，earlier liquid feeding time［5(3，6)d vs. 8(6，9)d，Z=-5.522，P<0.001］ and shorter length of stay after surgery［10(9，14)d vs. 13(12，16)d，Z=-3.966，P<0.001］；the length of the proximal margin，number of harvested lymph nodes (LNs) and mediastinal LNs in the LTA group were significantly better than those of the LTH group (P<0.05)；and there were no significant differences in the incidence and distribution of postoperative complications between the two groups(P>0.05). Postoperative follow-up showed that there were no significant differences between the two groups of patients in terms of 3-year overall survival rate and disease-free survival(DFS) rate (OS:72.6% vs. 83.2%，χ2=0.379，P=0.538；DFS:58.8% vs. 73.2%，χ2=2.900，P=0.089). Subgroup analysis showed that the 3-year DFS of the LTA group was significantly higher than that of the LTH group(57.1% vs. 73.7%，χ2=0.5280，P=0.022) for advanced patients. Conclusion    For patients with Siewert type Ⅱ AEG，the LTA approach has high surgical risk，long postoperative recovery time，and fails to improve the survival time of the patients，the LTH approach is recommended. For advanced patients，the LTA approach may have survival benefits. 

Key words: adenocarcinoma of the esophagogastric junction, Siewert type Ⅱ, laparoscopic-assisted, abdominal-transhiatal, thoracoabdominal