| Objective: Adenocarcinoma of Esophagogastric Junction (AEG) is akind of adenocarcinoma which occurs in the region of the esophagogastricjunction, including adenocarcinoma of distal esophagus and adenocarcinomaof proximal stomach. During the recent30years, the incidence of malignanttumors of distal stomach has significantly decreased, while the incidence ofmalignant tumors of distal esophagus and esophagogastric junction has shownan obvious trend of going up, especially noticeable in developed westerncountries, and also apparent in Asia. Malignant tumors of distal esophagus andgastroesophageal junction have become the hotspots in medical research areaof the United States and Europe. There is no universal classification standardfor AEG, and the one that is widely used currently is the Siewert typing putforward by the German scholars, which defines AEG as the region within5cm below or above the esophagogastric junction (Esophagogastric Junction,EGJ or Gastroesophageal Junction, GEJ). According to the locations of tumorepicenter, it can be further divided into three subtypes. Siewert Type Ⅰis distalesophageal adenocarcinoma, whose tumor epicenter is located within1-5cmabove the esophagogastric junction (EGJ); Siewert Type II is whattraditionally known as cardia cancer, whose tumor epicenter lies within1cmabove the EGJ and2cm below the EGJ, and develops from cardia epitheliumor short segments of intestinal metaplasia in gastroesophageal junction;Siewert Type Ⅲis cancer below the cardia. With its tumor epicenter locatedwithin2-5cm below the EGJ, it can invade gastroesophageal junction andlower esophagus. Compared with tumors of distal stomach and upperesophagus cancer, AEG has special biological behavior and its5-year survivalrate is low. Combined treatment with focus on surgery is still the main treatment at present, but views on surgical approach, extent of surgicalresection, lymph node dissection, digestive tract reconstruction and otherissues haven’t been unified. Some literature reported that for proximal gastriccancer, there was no significant difference in5-year survival rates betweentransthoracic approach and transabdominal approach, but the rate ofpostoperative complications in the transthoracic approach group was higherthan that in the transabdominal group. Therefore, it is worth exploring whichoperative approach can bring more reasonable therapeutic effects. This paperis based on the retrospective analysis of clinical medical data of transthoracicapproach and transabdominal approach for patients with Siewert Type ⅡandIII AEG, discusses the differences between the two groups in the degree ofradical resection, postoperative complications,1year,3years and5yearssurvival rates and so forth, and aims to provide theoretical and clinical basisfor choosing an ideal surgical approach for patients with Siewert Type ⅡandIII AEG.Method: Chose and retrospectively analyzed the clinical data of466AEG Ⅱ, Ⅲpatients (382male cases and84female cases) who had undergonesurgery during2004to2007in the Fourth Affiliated Hospital of HebeiMedical University. The male to female ratio was4.55:1. The transthoracicapproach group had298cases, including238male cases and60female cases.The male to female ratio was3.97:1, and the median age was58years old.The transabdominal approach group had168cases, including144male casesand24female cases. The male to female ratio was6:1, and the median agewas60years old.The Inclusion Criteria:1. According to Siewert typing, selected AEG Ⅱ,Ⅲpatients who had undergone surgery by transthoracic approach ortransabdominal approach in the Department of Chest Surgery and Departmentof General Surgery in the Fourth Affiliated Hospital of Hebei MedicalUniversity during2004to2007.2. The patients’ data of preoperativeexamination, surgical records, postoperative pathological condition and relatedinformation was complete.3. The patients had not received chemotherapy before surgery.Statistical analysis was conducted on figures from the two surgicalapproach groups, including operation time, blood loss, average time ofhospital stay, positive rate of the upper and lower cut edge of the stump,average number of lymph node dissection, number of lymph node dissectionin each group, metastasis rate of lymph node in each group, incidence ofpostoperative complications, patients’1-year,3-year and5-year survival ratesafter the surgery. SPSS19.0software was applied to statistically describe andanalyze the relevant data, if P<0.05, then the difference was statisticallysignificant.Results:1. The Operative Situations of Siewert Ⅱ, Ⅲ AEG Patients1.1Operation Time:The transthoracic approach group: the average operation time339.81±79.088min. The transabdominal approach group: the average operation time204.17±86.598min. The operation time of the transabdominal approachgroup was shorter than that of the transthoracic approach group. Thedifference was statistically significant (P <0.05).1.2Blood Loss:The transthoracic approach group: the average blood loss163.22±6.142ml. The transabdominal approach group: the average blood loss147.58±7.781ml. The difference was not statistically significant (P>0.05).1.3Number of Lymph Node DissectionThe transthoracic approach group: the average number of lymph nodedissection was17.39±2.237. The transabdominal approach group: theaverage number of lymph node dissection was22.78±4.588. The averagenumber of lymph node dissection was lower in the transthoracic approachgroup than that in the transabdominal approach group. The difference wasstatistically significant (P <0.05).1.4Positive Rate of the Upper and Lower Cut Edge of the StumpThe positive rate of the lower cut edge of the stump in the transthoracic approach group was6.04%(18/298). The positive rate of the lower cut edge ofthe stump in transabdominal approach group was1.19%(2/168). Comparedwith the transthoracic approach group, the transabdominal approach group hadthe lower positive rate of the lower cut edge of the stump. The difference wasstatistically significant (P<0.05). The positive rate of the upper cut edge of thestump of the transthoracic approach group was1.34%(4/298). The positiverate of the upper cut edge of the stump of the transabdominal approach groupwas4.76%(8/168). Compared with the transthoracic approach group, thetransabdominal group had the higher positive rate of the upper cut edge of thestump. But the difference was not statistically significant (P>0.05).1.5Tumor Diameter (cm)The transthoracic approach group:(5.84±2.479) cm. The transabdominalapproach group:5.42±2.600cm. The difference was not statisticallysignificant (P>0.05).1.6Postoperative Complications:The transthoracic approach group: the postoperative complication ratewas26.85%(80/298), including39cases in postoperative pleural effusion,27cases in postoperative pulmonary infection,5case in postoperativeanastomotic fistula,4cases in pneumothorax,5cases in postoperativeinfection of incisional wound. The transabdominal approach group: thepostoperative complication rate was4.17%(7/168), including9case inpostoperative pulmonary infection,3case in postoperative anastomoticbleeding,3case in postoperative pleural effusion. Compared with theincidence of postoperative complications in transthoracic approach group, thetransabdominal approach group had the lower postoperative complications.The difference was statistically significant (P <0.05).1.7Time of Hospital StayThe transthoracic approach group: the average time of hospital stay was16.82±6.142days. The transabdominal approach group: the average time ofhospital stay was16.62±4.700days. Comparison of the average time ofhospital stay in the two groups showed no statistically significant difference (P>0.05).2Postoperative Pathological Results2.1Degree of Differentiation:The transthoracic approach group:159cases in well and moderatedifferentiation,139cases in poor differentiation. The transabdominal approachgroup:86cases in well and moderate differentiation,82cases in poordifferentiation. The difference was not statistically significant (P>0.05).2.2General Classification (Borrmann Typing):The transthoracic approach group:10cases of typeⅠ,156cases of typeII,275cases of type Ⅲ,24cases of type Ⅳ. The transabdominal approachgroup:7cases of typeⅠ,104cases of type II,170cases of type Ⅲ,17casesof type Ⅳ. The differencewas not statistically significant (P>0.05).2.3The Number of Lymph Node Dissection and Metastasis Rate in EachGroupThe number of lymph node dissection and metastasis rate in eachtransthoracic approach group: No.119.65%(207/1153), No.232.02%(292/1012), No.27.05%(221/917), No.44.56%(15/329), No.526.56%（12/406）, No.64.22%（3/71）, No.717.88%（59/330）, No.81.64%(2/122),No.92.44%(1/41), No.103.70%(2/54), No.110%(0/63), No.120%(0/136),No.130%(0/9), No.140%(0/5), No.150%(0/40), No.160%(0/9), No.190%(0/0), No.200%(0/0), No.11020.93%(18/86), No.1110%(0/9), No.1120%(0/3).The number of lymph node dissection and metastasis rate in eachtransabdominal approach group:No.147.26%(422/893), No.233.79%(293/867), No.329.03%(216/744),No.45.43%(18/331), No.538.69%(142/367), No.613.70%(44/321), No.735.03%(55/157), No.823.19%(16/69), No.934.78%(8/23), No.1023.81%(5/21), No.1132.39%(23/71), No.120%(0/71), No.130%(0/5), No.140%(0/7), No.150%(0/5), No.160%(0/2), No.190%(0/2), No.200%(0/7),No.11014.29%(2/14), No.1110%(0/6), No.1120%(0/0).Comparison of lymph node metastasis rates in each transthoracic and transabdominal group: No.1χ~2=202.954P=0.000; No.2χ~2=5.317P=0.021;No.3χ~2=5.153P=0.023; No.5χ~2=154.306P=0.000; No.6χ~2=4.954P=0.026;No.7χ~2=17.459P=0.000; No.8χ~2=23.976P=0.000; No.9χ~2=10.216P=0.001;No.10χ~2=5.042P=0.025. Compared with the transthoracic approach group,the transabdominal approach group had a higher lymph node metastasis rate inNo.1-3and No.5-8(P <0.05). The difference was statistically significant. Butin the rest groups, the two approaches showed no statistically significantdifference in the number of lymph node metastasis (P>0.05).2.4pTNMpTNM:18cases of stageⅠ,104cases ofstage Ⅱ,299cases ofstage Ⅲ.The transthoracic approach group:11cases of stage Ⅰ,69cases ofstage II,189cases of stage Ⅲ. The transabdominal approach group:7cases ofstageⅠ,35cases ofstage Ⅱ,110cases ofstage Ⅲ. Thedifference was notstatistically significant (P>0.05).2.5Infiltration DepthInfiltration Depth:5cases of mucous layer,3cases of submucosa,47cases of muscularis layer,155cases of serosa layer,256cases of serousmembrane layer, with3cases of mucous layer,2cases of submucosa,27casesof muscularis layer,91cases of serosa layer,175cases of serous membranelayer in the transthoracic approach group and2cases of the mucous layer,1case of submucosa,20cases of muscularis layer,46cases of serosa layer,81cases of serous membrane layer in the transabdominal approach group. Thedifference was not statistically significant (P>0.05).3The Prognosis of AEG II, III PatientsThe follow-up time ended in December,2012, and the follow-up rate was73.39%(342/466). The1-year survival rates of patients in the transthoracicapproach group and the transabdominal approach group were78.00%and79.75%(χ~2=0.219P=0.640);3-year survival rates were36.95%and42.36%(χ~2=0.562P=0.435); and5-year survival rates ware17.98%and20.33%(χ~2=0.883P=0.347). The comparison of the overall survival rates ofthe transthoracic approach and the transabdominal approach showed that the difference between the two groups was not statistically significant (P=0.123P>0.05).Conclusion:This research conducted a clinical controlled study on466Siewert Ⅱ, ⅢAEG cases by transthoracic approach or transabdominal approach, comparedand analyzed their operative situations and prognosis, and concluded asummary as follows:1In terms of radical degree: the positive rate of the lower cut edge of thestump was lower in the transabdominal approach group than that in thetransthoracic approach group; the positive rate of the upper cut edge of thestump of the two groups showed no difference; the average number of lymphnode dissection was higher in the transabdominal approach group than that inthe transthoracic approach group; and compared with the transthoracicapproach group, the transabdominal approach group had an advantage inclearing more abdominal lymph nodes.2The transthoracic approach group was more traumatic, took longertime in operation and had higher incidence of postoperative complicationsthan the transabdominal approach group.3There was no significant difference in the postoperative survival ratesbetween the transthoracic approach group and the transabdominal approachgroup. |
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