The Disccusion Of The Therapeutic Effects Of Different Surgical Approaches And Lymphatic Metastasis For Siewert Type Ⅱ Adenocarcinoma Of Esophagogastric Junction

Objective:To explore the therapeutic effect of different surgical approach of Siewert type II adenocarcinoma of esophagogastric junction(AEG) and its lymphatic metastasis.Methods:We retrospectively evaluated type II AEG who received surgery in our center between 2005 and 2012.Surgical approaches were divided into transthoracic approach and transabdominal approach. Surgical procedures were composed with transthoracic esophagectomy, transhiatal proximal gastrectomy and transhital gastrectomy. Clinicopathologic factors, operation factors postoperative in-hostpital mortality,postoperative complications,radical resction,lymphatic dissection and survival information were compared.And we also analyzed the lymphatic metastasis of type II AEG. Results: Of the 126 patients,86 underwent operation via transthoracic approach and 40 via transabdominal approach. 32 underwent proximal gastrectomy and 8 underwent gastrectomy. Security:1. average operation time: transthoracic approach 108±44.29 min, transabdominal approach(proximal gastrectomy) 169±52.37 min, transabdominal approach(total gastrectomy) 202±37.19 min. The operation time of the transthoracic approach group was shorter than that of the transabdominal approach group.(p<0.001). 2. Hospitalization days: transthoracic approach 17±8days. Transabdominal approach(proximal gastrectomy) 18±6days. Transabdominal approach(total gastrectomy) 23±4days. The hospitalization days of the transthoracic approach group was shorter than that of the total gastrectomy group.(p<0.05). 3.There are no difference among groups in blood loss, pulmonary complications, circulation system complications, anastomotic leakage and hospital mortality days. Resction&Prognosis: 1.Proximal oesophageal length with transthoracic approach(4.80±1.18cm) is greater than proximal gastrectomy( 2.87±1.01cm) and total gastrectomy( 2.52±0.84cm)(p<0.0001). 2.Positive oesophageal margins of transabdominal approach are higher than transthoracic approach(p<0.0001). 3.The number of lymph node dissection are greater in transabdominal approach(p=0.012). The number are less in proximal gastrectomy than in total gastrectomy( p=0.018). There are no difference in lymphadenectomy of paracardia and left gastric between two groups. Dissection of paracardia, left gastric, less curvature and lower mediastinal nodal are focusd on transthoracic approach. Dissection of paracardia, left gastric, less curvature, common hepatic artery,celiac trunk, greater curvature are focusd on transabdominal approach. 4. The median survival of transthoracic group were 39 months and the ratio of 5-year survival was 37.5%. The median survival of transabdominal group were 53 months and the ratio was 33.6%. There are no difference between two groups in the ratio of 5-year survival(p=0.353). Lymphatic metastasis: Lymph node metastasis often occur in paracardia(38.9%), left gastric(41.3%) and less curvature(28.9%). Lower mediastinal nodal(18.8%), subcarinal(15%)Conclusion: There are no different among groups in security and survival. Single surgical approach has its limited in resection and lymphadenectomy. For those preoperative evaluation of tumor volume are larger, lymphatic metastasis occurs in multiple stations the combination of two approaches would be a better choice.