Efficacy analysis of laparoscopy-assisted total gastrectomy and proximal gastrectomy in treatment of adenocarcinoma of esophagogastric junction

目的 探讨腹腔镜辅助全胃切除术(LATG)和腹腔镜辅助近端胃切除术(LApG)治疗食管胃结合部腺癌(AEG)的临床疗效.方法 采用回顾性队列研究方法.收集2009年5月至2016年2月北京大学肿瘤医院收治的130例行腹腔镜辅助AEG根治术患者的临床病理资料.130例患者中,91例行LATG,设为LATG组;39例行LAPG,设为LAPG组.LATG组和LAPG组均按照日本《胃癌治疗指南》行D2淋巴结清扫术.腹腔镜下完成淋巴结清扫术后,取腹上区正中小切口辅助行消化道重建:LATG组患者采用食管空肠Roux-en-Y吻合术,LAPG组患者采用食管残胃吻合术.观察指标:(1)术中及术后情况:总体手术情况、中转开腹例数、手术时间、术中出血量、术中输血例数、淋巴结清扫数目、术后肛门排气时间、术后住院时间.(2)术后并发症情况:总体并发症、手术相关并发症(轻微和严重)、再次手术、内科系统并发症、术后30 d内手术相关并发症死亡.手术相关并发症严重程度按照Clavien-Dindo分级标准进行划分.(3)随访情况.采用门诊、电话或邮件形式进行随访,了解患者生存及肿瘤复发、转移情况.随访时间截至2016年8月31日.总体生存时间指患者自手术当日至末次随访或因该疾病死亡的时间.因2014年9月至2016年2月行手术治疗的48例患者至随访截止时,随访时间＜2年,故仅对2009年5月至2014年8月行手术治疗的82例患者进行生存分析.正态分布的计量资料以(x)±s表示,组间比较采用独立样本t检验,偏态分布的计量资料以M(范围)表示,组间比较采用非参数检验.计数资料比较采用x2检验,等级资料比较采用非参数检验.采用Kaplan-Meier法绘制生存曲线,采用Log-rank检验进行生存分析.结果 (1)术中及术后情况:130例AEG患者均顺利完成手术,中转开腹患者7例,中转原因主要为肿瘤局部进展侵犯邻近器官、腹腔粘连和过度肥胖.LATG组和LAPG组患者手术时间分别为(280±46) min和(258±57) min,淋巴结清扫数目分别为28枚(14～ 80枚)和23枚(14 ～46枚),两组患者上述指标比较,差异均有统计学意义(t=-2.305,Z=-4.168,P＜0.05).(2)术后并发症情况:LATG组和LAPG组患者总体并发症分别为18例和7例,手术相关轻微并发症中胃排空障碍、肠梗阻、淋巴液漏、切口感染分别为0、1、0、2例和1、0、1、0例,严重并发症中吻合口漏、十二指肠残端漏、吻合口出血、腹腔出血、腹腔感染分别为5、2、2、2、0例和3、0、0、0、1例,再次手术分别为5例和1例,内科系统并发症分别为7例和1例,术后30 d内手术相关并发症死亡分别为2例和0.两组患者上述指标比较,差异均无统计学意义(x2=0.059,0.111,0.000,0.000,0.514,0.024,P＞0.05).同一患者可合并多种并发症.发生并发症患者予再次手术或相应处理,1例吻合口出血和1例腹腔出血患者死亡,其余患者恢复顺利.(3)随访情况:130例患者中,128例获得术后随访.随访时间为1 ～82个月,中位随访时间为39个月.随访期间,28例患者死亡,其中因肿瘤复发死亡25例,非肿瘤死亡3例.纳入生存分析的82例AEG患者中,45例LATG患者3年总体生存率为77.9％,37例LAPG患者3年总体生存率为72.2％,两组患者比较,差异无统计学意义(x2=1.432,P＞0.05).结论 LATG和LAPG治疗AEG手术安全性相当,LATG淋巴结清扫数目更多.Objective To investigate the clinical efficacy of laparoscopy-assisted total gastrectomy (LATG) and laparoscopy-assisted proximal gastrectomy (LAPG) in treatment of adenocarcinoma of esophagogastric junction (AEG).Methods The retrospective cohort study was conducted.The clinicopathological data of 130 patients with AEG who underwent laparoscopy-assisted radical gastrectomy at the Peking University Cancer Hospital between May 2009 and February 2016 were collected.Among 130 patients,91 undergoing LATG were allocated into the LATG group and 39 undergoing LAPG were allocated into the LAPG group.D2 lymph node dissection was applied to patients in the 2 groups according to the Japanese gastric cancer treatment guidelines.Patients received digestive tract reconstruction though a small midline incision in the epigastric region after laparoscopy-assisted lymph node dissection:patients in the LATG group and LAPG group received respectively Roux-en-Y esophagojejunostomy and residual stomach-esophagus anastomosis.Observation indicators included:(1) intra-and post-operative situations:overall surgical situation,number of patients with conversion to open surgery,operation time,volume of intraoperative blood loss,number of patients with intraoperative blood transfusion,number of lymph node dissected,time to anal exsufflation and duration of postoperative hospital stay.(2) Occurrence of complications:overall complications,surgery-related complications (slight and severe complications),reoperation,medical complications and death from surgery-related complication within 30 days postoperatively.Severity of complications was evaluated according to Clavien-Dindo classification.(3) Follow-up situations.Patients were followed up by outpatient examination,telephone interview and correspondence up to August 31,2016.Follow-up included the tumor recurrence and metastasis.Overall survival time was counted from operation date to end of follow-up or time of death.Because follow-up time of 48 patients who underwent surgery from September 2014 to February 2016 was less than 2 years,survival analysis of the other 82 patients who underwent surgery from May 2009 to August 2014 was done.Measurement data with normal distribution were represented as (x) ± s and comparison between groups was analyzed using the independent-sample t test.Measurement data with skewed distribution were represented as M (range) and comparison between groups was analyzed using the nonparametric test.Comparison of count data was analyzed using the chi-square test,and ranked data was analyzed using the nonparametric test.Survival curve was drawn by the Kaplan-Meier method,and survival analysis was done using the Log-rank test.Results (1) Intra-and post-operative situations:all the 130 patients underwent successful radical gastrectomy,and 7 patients converted to open surgery due to local tumor progression invading adjacent organs,abdominal adhesions and obesity.Operation time and number of lymph node dissected were (280 ±46)minutes,28 (range,14-80) in the LATG group and (258 ±57)minutes,23 (range,14-46) in the LAPG group,respectively,with statistically significant differences between the 2 groups (t =-2.305,Z =-4.168,P ＜0.05).(2) Postoperative complications situations:18 patients in the LATG group and 7 patients in the LAPG group had overall complications.Delayed gastric emptying,intestinal obstruction,endolymphatic leakage and wound infection of slight complications were respectively detected in 0,1,0,2 patients in the LATG group and 1,0,1,0 patients in the LAPG group.Anastomotic leakage,duodenal stump leakage,anastomotic bleeding,intra-abdominal bleeding and intra-abdominal infection of severe complications were respectively detected in 5,2,2,2,0 patients in the LATG group and 3,0,0,0,1 patients in the LAPG group.Reoperation,medical complications and death from surgery-related complication within 30 days postoperatively were respectively detected in 5,7,2 patients in the LATG group and 1,1,0 patients in the LAPG group,with no statistically significant differences in above indicators between the 2 groups (x2 =0.059,0.111,0.0300,0.000,0.514,0.024,P ＞ 0.05).The same patients may have multiple complications.Patients with complications received reoperation or corresponding treatment,1 with anastomotic bleeding and 1 with intra-abdominal bleeding died and other patients had a smooth recovery.(3) Follow-up situations:128 of 130 patients were followed up for 1-82 months with a median time of 39 months.During the follow-up,28 patients died,including 25 dying of tumor recurrence and 3 dying of non-tumor causes.Of 82 patients in survival analysis,3-year overall survival rate was 77.9％ in 45 patients of LATG group and 72.2％ in 37 patients of LAPG group,showing no statistically significant difference between the 2 groups (x2=1.432,P ＞ 0.05).Conclusion Safety of LATG in treatment of AEG is equal to that of LAPG,and LATG can dissect more lymph nodes.国家高技术研究发展计划(863计划); 国家自然科学基金; 首都临床特色应用研究; 北京市医院管理局临床医学发展专项(XM201309)National High-tech Research & Development Program of China (863 Program); National Natural Science Foundation of China; Clinical Distinctive Application Program of the Capital; Special Funds for Development of Clinical Medicine of Beijing Municipal Administration of Hospitals中文核心期刊要目总览(PKU)中国科技核心期刊(ISTIC)中国科学引文数据库(CSCD)111062-10671