RESUMEN
Objective:To investigate the influencing of inferior mediastinum and esophageal hiatus lymph node metastasis by submucosal different venous divisions of esophagogastric junction (EGJ) invaded in Siewert type Ⅱ adenocarcinoma of esophagogastric junction (AEG).Methods:The retrospective case-control study was conducted. The clinicopathological data of 547 patients with Siewert type Ⅱ AEG who were admitted to Shanxi Cancer Hospital from January 2018 to December 2021 were collected. There were 461 males and 86 females, aged 61 (range, 33?75)years. Observa-tion indicators: (1) lymph node metastasis rate in different groups; (2) influencing factors of inferior mediastinum lymph node metastasis in Siewert type Ⅱ AEG; (3) influencing factors of esophageal hiatus lymph node metastasis in Siewert type Ⅱ AEG. Measurement data with normal distribution were represented as Mean± SD, and comparison between groups was conducted using the t test. Measurement data with skewed distribution were represented as M(range) or M( Q1, Q3), and com-parison between groups was conducted using the Mann-Whitney U test. Count data were described as percentages or absolute numbers, and comparison between groups was conducted using the chi-square test. The univariate analysis was conducted using the corresponding statistical methods based on data type. The Logistic regression model was used for multivariate analysis. Results:(1) Lymph node metastasis rate in different groups. The lymph node metastasis rate in No. 1, 2, 3, 4sa, 4sb, 7, 8a, 9, 11,20, 108, 110 of the 547 patients was 17.37%(95/547), 6.76%(37/547), 46.44%(254/547), 1.65%(9/547), 1.10%(6/547), 23.22%(127/547), 4.39%(24/547), 3.11%(17/547), 3.47%(19/547), 3.66%(20/547), 0.55%(3/547), 4.20%(23/547), respectively. Of the 547 patients, there were 456 cases with proximal of AEG invading submucosal palisade venous of EGJ including 4 cases with inferior mediastinum lymph node metastasis and no case with media mediastinum or up media-stinum lymph node metastasis. There were 91 cases with proximal of AEG invading submucosal perforator venous of EGJ including 18 cases with inferior mediastinum lymph node metastasis, 3 cases with media mediastinum lymph node metastasis and no case with up mediastinum lymph node metastasis. (2) Influencing factors of inferior mediastinum lymph node metastasis in Siewert type Ⅱ AEG. Results of multivariate analysis showed that age, tumor invading submucosal perforator venous of EGJ and histological classification were independent influencing factors for inferior media-stinum lymph node metastasis of Siewert type Ⅱ AEG ( odds ratio=0.93, 23.33, 0.31, 95% confidence interval as 0.87?0.99, 4.18?130.28, 0.12?0.78, P<0.05). (3) Influencing factors of esophageal hiatus lymph node metastasis in Siewert type Ⅱ AEG. Tumor invading submucosal perforator venous of EGJ was an independent influencing factor for esophageal hiatus lymph node metastasis of Siewert type Ⅱ AEG ( odds ratio=14.95, 95% confidence interval as 2.46?90.76, P<0.05). Conclusion:Age, tumor invading submucosal perforator venous of EGJ and histological classification are independent influencing factors for inferior mediastinum lymph node metastasis of Siewert type Ⅱ AEG, and tumor invading submucosal perforator venous of EGJ is an independent influencing factor for esophageal hiatus lymph node metastasis.
RESUMEN
Objective:To investigate the clinical value of esophageal-jejunal OrVil TM anas-tomosis and Overlap anastomosis in laparoscopic radical total gastrectomy of adenocarcinoma of esophagogastric junction (AEG). Methods:The retrospective cohort study was conducted. The clinicopathological data of 112 patients with AEG who were admitted to the First Hospital of Jilin University from July 2017 to August 2022 were collected. There were 87 males and 25 females, aged (64±8)years. All 112 patients underwent laparoscopic total gastrectomy and D 2 lymphadenectomy, in which 61 cases with esophageal-jejunal OrVil TM anastomosis were divided into the OrVil TM group, 51 cases with esophageal-jejunal Overlap anastomosis were divided into the Overlap group. Observa-tion indicators: (1) surgical situations; (2) postoperative complications; (3) influencing factors for patients undergoing esophageal-jejunal OrVil TM anastomosis. Measurement data with normal distri-bution were represented as Mean± SD, and comparison between groups was conducted using the independent sample t test. Measurement data with skewed distribution were represented as M( Q1, Q3), and comparison between groups was conducted using the non-parameter test. Count data were described as absolute numbers, and comparison between groups was conducted using the chi-square test or Fisher exact probability. Logistic regression model was used for multivariate analysis. Results:(1) Surgical situations. The esophageal invasion length and tumor diameter was 1.0(0.7,2.0)cm and (6.3±2.7)cm in patients of the OrVil TM group, versus 0.2(0.1,0.5)cm and (4.7±2.2)cm, respectively, in patients of the Overlap group, showing significant differences in the above indicators between the two groups ( Z=?6.14, t=3.26, P<0.05). (2) Postoperative complications. Cases with complications ≥Ⅲa grade of Clavien-Dindo classification, cases with respiratory system complications, cases with hydrothorax were 13, 17, 13 in the OrVil TM group, versus 4, 5, 4 in the Overlap group, showing significant differences in the above indicators between the two groups ( χ2=3.91, 5.74, 3.91, P<0.05). Cases underwent readmission within postoperative 30 days were 3 and 1 in the OrVil TM group and the Overlap group, respectively, and all patients recovered after symptomatic treatment. There were 2 cases died after operation in the OrVil TM group and none of patients died after operation in the Overlap group. (3) Influencing factors for patients undergoing esophageal-jejunal OrVil TM anastomosis. Results of multivariate analysis showed that esophageal invasion length was an independent factor influencing for patients undergoing esophageal-jejunal OrVil TM anastomosis ( odds ratio=8.25, 95% confidence interval as 3.41?19.96, P<0.05). Conclusions:Compared with esophageal-jejunal Overlap anastomosis, choosing the esophageal-jejunal Orvil TM anastomosis during laparoscopic radical total gastrectomy can take benefit to the proximal margin of patients with AEG. However, the ratios of complications ≥ Ⅲa grade of Clavien-Dindo classification, respiratory system complications and hydrothorax associated to OrVil TM anastomosis are relatively increased. Esophageal invasion length is an independent influencing factor for patients undergoing esophageal-jejunal OrVil TM anastomosis.
RESUMEN
Objective:To investigate the clinicopathological characteristics and prognostic factors of Siewert Ⅱ and Ⅲ adenocarcinoma of esophagogastric junction (AEG).Methods:The retrospetcive cohort study was conducted. The clinicopathological data of 399 patients with AEG who were admitted to Peking University People′s Hospital from January 1998 to December 2015 were collected. There were 318 males and 81 females, aged 66(range, 19-87)years. Observation indicators: (1) clinicopathological characteristics of Siewert Ⅱ and Ⅲ AEG; (2) follow-up and survival; (3) prognostic factors analysis. Patients were followed up by telephone interview and outpatient examination to detect postoperative survival up to December 2018. Measurement data with normal distribution were represented as Mean±SD, and comparison between groups was conducted using the t test. Measurement data with skewed distribution were represented as M(range), and comparison between groups was conducted using the Mann-Whitney U test. Count data were described as absolute numbers, and comparison between groups was conducted using the chi-square test or Fisher exact probability. Kaplan-Meier method was used to draw survival curves and calculate survival rates. Log-rank test was used for survival analysis. Univariate and multivariate analyses were done using the COX proportional hazard model. Results:(1) Clinicopathological characteristics of Siewert Ⅱ and Ⅲ AEG. Of 399 patients, 198 cases were Siewert Ⅱ AEG and 201 cases were Siewert Ⅲ AEG. There were 130 cases undergoing transthoracic radical AEG surgery, 172 cases undergoing trans-abdominal proximal gastrectomy and 97 cases undergoing transabdominal total gastrectomy. The age, tumor diameter, cases with surgical method as transthoracic radical AEG surgery, transabdo-minal proximal gastrectomy and transabdominal total gastrectomy, the number of positive lymph nodes, cases in tumor TNM stage Ⅰ, Ⅱ, Ⅲ, Ⅳ were (65±10)years, (5.1±2.4)cm, 102, 68, 28, 17(range, 12?22), 20, 57, 117, 4 for patients with Siewert Ⅱ AEG, versus (62±12)years, (6.3±3.2)cm, 28, 104, 69,18(range, 14?27), 16, 41, 134, 10 for patients with Siewert Ⅲ AEG, showing significant differ-ences betweeen them ( t=2.83, ?3.82, χ2=66.97, U=17 407.05, 17 532.00, P<0.05). (2) Follow-up and survival. All 399 patients were followed up for 34(range, 2?160)months. The 5-year overall survival rate was 29.3% for patients with Siewert Ⅱ AEG, versus 37.0% for patients with Siewert Ⅲ AEG, showing no significant difference betweeen them ( χ2=1.46, P>0.05). The median survival time and 5-year overall survival rate were 29.0 months [95% confidence interval ( CI) as 23.4?34.6 months] and 22.9% for patients undergoing transthoracic radical AEG surgery, 43.0 months(95% CI as 33.9?52.1 months) and 34.7% for patients undergoing transabdominal proximal gastrectomy, 54.0 months (95% CI as 37.6?70.4 months)and 44.3% for patients undergoing transabdominal total gastrectomy, showing a significant difference in the survival among the 3 groups ( χ2=13.81, P<0.05). Of the 198 Siewert Ⅱ AEG patients, the 5-year overall survival rate was 24.6% for the 96 patients undergoing transabdominal surgery, versus 35.4% for the 102 patients undergoing transthoracic surgery, showing no significant difference in the survival between them ( χ2=3.10, P>0.05). Of the 201 Siewert Ⅲ AEG patients, the 5-year overall survival rate was 40.0% for the 173 patients undergoing transabdominal surgery, versus 16.1% for the 28 patients undergoing transthoracic surgery, showing a significant difference between them ( χ2=11.32, P<0.05). (3) Prognostic factors analysis. Results of univariate analysis showed that surgical method, pathological N staging, patholgical M staging were related factors for prognosis of Siewert Ⅱ and Ⅲ AEG ( hazard ratio=0.68, 1.25, 2.18, 95% CI as 0.54?0.86, 1.15?1.36, 1.28?3.73, P<0.05). Results of multivariate analysis showed that transthoracic approach, pathological stage N2?N3 and pathological stage M1 were independent risk factors for prognosis of Siewert Ⅱ and Ⅲ AEG ( hazard ratio=0.64, 1.25, 2.18, 95% CI as 0.51?0.80, 1.16?1.35, 1.28?3.70, P<0.05). Conclusions:Compared with Siewert Ⅲ AEG, Siewert Ⅱ AEG has a smaller tumor diameter, less positive lymph nodes, poorer prognosis. Transthoracic approach is preffered for the Siewert Ⅱ AEG. Transthoracic approach, pathological stage N2?N3 and pathological stage M1 are independent risk factors for prognosis of Siewert Ⅱ and Ⅲ AEG.
RESUMEN
Objective: The study aimed to investigate the safety and feasibility of intrathoracic modified overlap method in laparoscopic radical resection of Siewert type II adenocarcinoma of the esophagogastric junction (AEG). Methods: A descriptive case series study was conducted. The clinical data of 27 patients with Siewert type II AEG who underwent transthoracic single-port assisted laparoscopic total gastrectomy and intrathoracic modified overlap esophagojejunostomy in Guangdong Provincial Hospital of Chinese Medicine from May 2017 to December 2020 were retrospectively analyzed. The intrathoracic modified overlap esophagojejunostomy was performed as follows: (1) The Roux-en-Y loop was made; (2) The jejunum side was prepared extraperitoneal for overlap anastomosis; (3) The esophagus side was prepared intraperitoneal for overlap anastomosis; (4) The overlap esophagojejunostomy was performed; (5) The common outlet was closed after confirmation of anastomosis integrity without bleeding; (6) A thoracic drainage tube was inserted into the thoracic hole with the diaphragm incision closed. The intraoperative and postoperative results were reviewed. Results: All 27 patients were successfully operated, without mortality or conversion to laparotomy. The operative time, digestive tract reconstruction time and esophageal-jejunal anastomosis time were (327.5±102.0) minute, 50 (28-62) minute and (29.0±7.4) minute, respectively. The blood loss was 100 (20-150) ml. The postoperative time to flatus and postoperative hospital stay were (4.7±3.7) days and 9(6-73) days, respectively. Three patients (11.1%) developed postoperative grade III complications according to the Clavien-Dindo classification, including 1 case of anastomotic fistula with empyema, 1 case of pleural effusion and 1 case of pancreatic fistula, all of whom were cured by puncture drainage and anti-infective therapy. Conclusions: The intrathoracic modified overlap esophagojejunostomy is safe and feasible in laparoscopic radical resection of Siewert type II AEG.
Asunto(s)
Humanos , Adenocarcinoma/cirugía , Anastomosis Quirúrgica , Unión Esofagogástrica/cirugía , Estudios de Factibilidad , Gastrectomía/métodos , Laparoscopía/métodos , Estudios Retrospectivos , Neoplasias Gástricas/patologíaRESUMEN
A greater controversy remains in clinical diagnosis and treatment of Siewert type II adenocarcinoma of esophagogastric junction (AEG), compared with Siewert type I and III AEG. In 2018, the first edition of Chinese Expert Consensus on the Surgical Treatment for Adenocarcinoma of Esophagogastric Junction was published in the Chinese Journal of Gastrointestinal Surgery. In the past few years, the advance in minimally invasive thoracoscopic surgery has been proven to reduce thoracic trauma in Siewert type II AEG. Meanwhile, distal thoracic esophagectomy can achieve more complete resection, and upper abdomen-right thoracic approach can ensure the mediastinal lymph node dissection and improve long-term survival. The concept and practice of endoscopic surgery and the comprehensive treatment also give new supplements to the treatment regimen of Siewert type II AEG. More clinical researches should be conducted to address the surgical residual safety and lymph node dissection issues.
Asunto(s)
Humanos , Adenocarcinoma/patología , Neoplasias Esofágicas/cirugía , Unión Esofagogástrica/cirugía , Gastrectomía , Escisión del Ganglio Linfático , Estudios Retrospectivos , Neoplasias Gástricas/cirugía , Cirugía TorácicaRESUMEN
The incidence of Siewert type II adenocarcinoma of the esophagogastric junction (AEG) is increasing year by year. Due to its special anatomical location and biological behavior, the treatment of AEG is still controversial in terms of lymph node dissection, the esophageal resection margin, range of gastrectomy, and the choice of reconstruction modality for postoperative gastrointestinal tract. The advent of the minimally invasive era has brought the treatment of Siewert type II AEG to a stage of gradual improvement and standardization. Experts of China are also actively exploring the value of minimally invasive surgery in the treatment of AEG through multicenter trials (CLASS-10, etc.). It is believed that based on the active development of many clinical studies, basic experimental studies and large prospective clinical studies, the strengthening of communication and cooperation among various disciplines and the innovative application of new technologies can bring greater survival benefits to patients.
Asunto(s)
Humanos , Adenocarcinoma/patología , Neoplasias Esofágicas/cirugía , Unión Esofagogástrica/cirugía , Gastrectomía , Escisión del Ganglio Linfático , Procedimientos Quirúrgicos Mínimamente Invasivos , Estudios Prospectivos , Estudios Retrospectivos , Neoplasias Gástricas/patologíaRESUMEN
Objective:To investigate the clinical efficacy of proximal gastrectomy and total gastrectomy in the treatment of Siewert type Ⅱ and Ⅲ adenocarcinoma of esophagogastric junction (AEG).Methods:The retrospective cohort study was conducted. The clinicopathological data of 170 patients with Siewert type Ⅱ and Ⅲ AEG who were admitted to Guangdong Provincial People′s Hospital from January 2010 to December 2018 were collected. There were 125 males and 45 females, aged from 30 to 85 years, with a median age of 64 years. Of the 170 patients, 82 cases undergoing proximal gastrectomy were allocated into the proximal gastrectomy group and 88 cases undergoing total gastrectomy were allocated into the total gastrectomy group. Observation indica-tors: (1) surgical and postoperative situations; (2) follow-up and survival; (3) analysis of prognostic factors. Follow-up was conducted using telephone interview and outpatient examination to detect survival of patients up to December 2021. Measurement data with normal distribution were represented as Mean± SD, and comparison between groups was analyzed using the t test. Measure-ment data with skewed distribution were represented as M( Q1, Q3) or M(range), and comparison between groups was analyzed using the Mann-Whitney U test. Count data were described as absolute numbers or percentages, and comparison between groups was analyzed using the chi-square test or Fisher exact probability. Comparison of ordinal data was analyzed using the rank sum test. Kaplan-Meier method was used to draw survival curves, and Log-Rank test was used for survival analysis. COX proportional hazard model was used for univariate and multivariate analyses. Variables with P<0.1 in univariate analysis were included for multivariate analysis. Results:(1) Surgical and postoperative situations. Cases with surgical approach as transthoracic or thoraco-abdominal approach, transabdominal approach, the operation time, cases with volume of intra-operative blood loss ≤100 mL or >100 mL, cases with length of proximal margin ≤1.5 cm or >1.5 cm, cases with radical surgery outcome as R 0, R 1, R 2, the number of lymph nodes harvest, cases with anastomotic leakage, cases with anastomotic stricture, cases with incision infection, cases with pleural infection or effusion, cases with abdominal infection or ascites were 61, 21, (211±18)minutes, 46, 36, 44, 38, 73, 6, 3, 15(9,22), 5, 2, 2, 4, 2 in the proximal gastrectomy group, respec-tively. The above indicators were 12, 76, (263±15)minutes, 27, 61, 45, 43, 82, 4, 2, 23(18,32), 4, 1, 3, 1, 4 in the total gastrectomy group, respectively. There were significant differences in the surgical approach, operation time, volume of intraoperative blood loss and the number of lymph nodes harvest between the two groups ( χ2=63.94, t=-25.50, χ2=11.19, Z=-5.62, P<0.05). There was no significant difference in the length of proximal margin or radical surgery outcome between the two groups ( χ2=0.11, Z=-0.95, P>0.05) and there was no significant difference in the anastomotic leakage, anastomotic stricture, incision infection, pleural infection or effusion, abdominal infection or ascites between the two groups ( P>0.05). (2) Follow-up and survival. All the 170 patients were followed up for 89(64,106)months. Of the 170 patients, the 5-year overall survival rates were 43.8% and 35.5% of the Siewert type Ⅱ and Ⅲ AEG patients, respectively, showing no significant difference between them ( χ2=0.87, P>0.05). Of the patients with Siewert type Ⅱ AEG, the 5-year overall survival rates were 41.7% and 54.3% in the patients with proximal gastrectomy and the total gastrectomy, respectively, showing no significant difference between them ( χ2=1.05, P>0.05). Of the patients with Siewert type Ⅲ AEG, the 5-year overall survival rates were 31.3% and 37.5% in the patients with proximal gastrectomy and the total gastrectomy, respectively, showing no significant difference between them ( χ2=0.33, P>0.05). The 5-year overall survival rates were 39.0% and 44.2% in the proximal gastrectomy group and the total gastrectomy group, respectively, showing no significant difference between the two groups ( χ2=0.63, P>0.05). Of the patients in TNM stage Ⅰ, stage Ⅱ, stage Ⅲ, the 5-year overall survival rates were 65.3%, 36.3%, 27.1% in the proximal gastrectomy group, versus 83.3%, 48.0%, 39.7% in the total gastrectomy group, showing no signifi-cant difference between the two groups ( χ2=0.02, 1.50, 1.21, P>0.05). (3) Analysis of prognostic factors. Results of univariate analysis showed that pathological N staging, degree of tumor differen-tiation and radical surgery outcome were related factors influencing prognosis of AEG patients ( hazard ratio=1.71, 1.70, 2.85, 95% confidence interval as 1.16-2.60, 1.15-2.50, 1.58-5.14, P<0.05). Results of multivariate analysis showed that pathological N staging and radical surgery outcome were independent factors influencing prognosis of AEG patients ( hazard ratio=1.55, 2.18, 95% confidence interval as 1.05-2.31, 1.18-4.02, P<0.05). Conclusions:There is no significant difference in the prognosis of Siewert type Ⅱ and Ⅲ AEG patients undergoing proximal gastrectomy or total gastrectomy. Proximal gastrectomy can be used for the treatment of advanced Siewert type Ⅱ and Ⅲ AEG.
RESUMEN
Objective:To investigate the clinical value of computer tomography (CT)-based three-section formula in identification of Siewert types of adenocarcinoma of esophagogastric junction (AEG).Methods:The retrospective and descriptive study was conducted. The clinicopatho-logical data of 62 AEG patients who were admitted to two medical centers, including 33 patients from Peking University Cancer Hospital and 29 patients from the First Affiliated Hospital of Amy Medical University, between January 2019 and January 2021 were collected. There were 53 males and 9 females, aged (66±9)years. All patients underwent CT examination to obtain the coronal and axial images and determine the upper and lower edges of the tumor and the esophagogastric junction, which were imported into the formula for Siewert classification. Observation indicators: (1) results of CT examination and pathological examination; (2) consistence of judgements for CT examination between doctors; (3) consistence of judgements between CT examination and patholo-gical examination. Results of pathological examination came from intraoperative surgical observa-tion and postoperative histopathological examination. Measurement data with normal distribution were represented as Mean± SD, and count data were described as absolute numbers or percentages. The consistency coefficient Kappa ( κ) was used to evaluate the consistency of diagnosis between resear-chers. The κ≥0.75 was regarded as excellent consistency, 0.40< κ<0.75 as good consistency, κ ≤0.40 as poor consistency. Wilcoxon rank sum test was used to evaluate the statistical difference between results of the CT-based three-section formula method and the pathological examination. Taking the results of histopathological examination as standard, the sensitivity, specifi-city, accuracy and 95% confidence interval of the CT-based three-section formula method were calculated. Results:(1) Results of CT examination and pathological examination: all the 62 patients underwent CT examination successfully to obtain the coronal and axial images and determine the upper and lower edges of the tumor and the esophagogastric junction, which were used for Siewert classifica-tion. There were 3 cases with AEG of Siewert type Ⅰ, 47 cases with AEG of Siewert type Ⅱ and 12 cases with AEG of Siewert type Ⅲ according to doctor's judgement from the Peking University Cancer Hospital, and there were 3 cases with AEG of Siewert type Ⅰ, 49 cases with AEG of Siewert type Ⅱ and 10 cases with AEG of Siewert type Ⅲ according to doctor's judgement from the First Affiliated Hospital of Amy Medical University, respectively. After arbitration, there were 2 cases with AEG of Siewert type Ⅰ, 48 cases with AEG of Siewert type Ⅱ and 12 cases with AEG of Siewert type Ⅲ determined by the CT based three-section formula. There were 7 cases of stage T1, 10 cases of stage T2, 24 cases of stage T3, 14 of stage T4a and 7 cases of stage T4b of pathological T staging. There were 2 cases with AEG of Siewert type Ⅰ, 48 cases with AEG of Siewert type Ⅱ and 12 cases with AEG of Siewert type Ⅲ determined by pathological examination. (2) Consistence of judgements for CT examination between doctors: the consistency of Siewert classification determined by CT-based three-section formula between 2 doctors was good ( κ=0.74, P<0.001). (3) Consistence of judgements between pathological examination and CT examination: with Siewert classification determined by pathological examination as reference, the accuracy of Siewert classification determined by CT based three-section formula was 90.3%( κ=0.73, P<0.001). The sensitivity and specificity of CT-based three-section formula were 66.7%(95% confidence interval as 20.8%-93.9%) and 100.0%(95% confidence interval as 93.9%-100.0%) for AEG of Siewert type Ⅰ, 97.7%(95% confidence interval as 88.2%-99.6%) and 72.2%(95% confidence interval as 49.1%-87.5%) for AEG of Siewert type Ⅱ, 73.3%(95% confidence interval as 48.0%-89.1%) and 97.9%(95% confidence interval as 88.9%-99.9%) for AEG of Siewert type Ⅲ, respectively. Conclusion:The CT-based three-section formula can be used for identification of Siewert types of AEG, with a high accuracy.
RESUMEN
Objective:To investigate the influencing factors and regularity of inferior mediastinal lymph node metastasis in Siewert type Ⅱ and Ⅲ adenocarcinoma of esophagogastric junction (AEG).Methods:The retrospective case-control study was conducted. The clinicopatho-logical data of 185 Siewert type Ⅱ and Ⅲ AEG patients in two medical centers (113 cases in Changzhi People's Hospital Affiliated to Changzhi Medical College and 72 cases in Heji Hospital Affiliated to Changzhi Medical College) from January 2017 to January 2022 were collected. There were 143 males and 42 females, aged (64±8)years. Patients underwent radical resection of AEG combined with inferior mediastinal lymph node dissection. Observation indicators: (1) clinicopathological charac-teristics of Siewert type Ⅱ and Ⅲ AEG patients; (2) analysis of influencing factors for inferior mediastinal lymph node metastasis in Siewert type Ⅱ and Ⅲ AEG; (3) regularity of inferior mediastinal lymph node metastasis in Siewert type Ⅱ and Ⅲ AEG. Measurement data with normal distribution were represented as Mean± SD, and comparison between groups was analyzed using the t test. Measurement data with skewed distribution were represented as M(range), and comparison between groups was analyzed using the Mann-Whitney U test. Count data were represented as absolute numbers or percentages, and comparsion between groups was analyzed using the chi-square test or Fisher exact probability. Comparison of ordinal data was analyzed using the rank sum test. Univariate and multivariate analyses were conducted using the Logistic regression model. Results:(1) Clinicopathological characteristics of Siewert type Ⅱ and Ⅲ AEG patients. Pathologic staging as stage Ⅰ, Ⅱ, Ⅲ and Ⅳ, degree of tumor invasion as stage T1, T2, T3 and T4, length of esophageal invasion ≤1 cm, >1 cm and ≤2 cm, >2 cm and ≤3 cm, >3 cm and ≤4 cm were found in 30, 61, 75, 7, 3, 41, 79, 50, 101, 46, 18, 8 cases of the Siewert type Ⅱ and Ⅲ AEG patients without inferior mediastinal lymph node metastasis, respectively, versus 0, 2, 10, 0, 0, 0, 5, 7, 4, 3, 2, 3 cases of the Siewert type Ⅱ and Ⅲ AEG patients with inferior mediastinal lymph node metastasis, showing a significant differences between them ( Z=?2.21, ?2.49, ?2.22, P<0.05). (2) Analysis of influencing factors for inferior mediastinal lymph node metastasis in Siewert type Ⅱ and Ⅲ AEG. Results of univariate analysis showed that pathological staging, depth of tumor invasion and length of esophageal invasion were related factors affecting inferior mediastinal lymph node metastasis in Siewert type Ⅱ and Ⅲ AEG ( odds ratio=2.48, 3.26, 2.03, 95% confidence intervals as 1.02?6.01, 1.21?8.80, 1.18?3.51, P<0.05). Results of multivariate analysis showed that depth of tumor invasion and length of esophageal invasion were independent influening factors affecting inferior mediastinal lymph node metastasis in Siewert type Ⅱ and Ⅲ AEG ( odds ratio=4.01, 2.26, 95% confidence interval as 1.35?11.96, 1.26?4.06, P<0.05). The inferior mediastinal lymph node metastasis probability of AEG patients with the length of esophageal invasion >3 cm and ≤4 cm was 9.47 times that of AEG patients with the length of esophageal invasion ≤1 cm. (3) Regularity of inferior mediastinal lymph node metastasis in Siewert type Ⅱ and Ⅲ AEG. The number of inferior mediastinal lymph nodes including No.110, No.111 and No.112 dissected in 185 patients of Siewert type Ⅱ and Ⅲ AEG were 127, 50 and 27. The number of lymph nodes dissected and the number of metastatic lymph nodes in No.110 and No.111 of patients with length of esophageal invasion ≤1 cm, >1 cm and ≤2 cm, >2 cm and ≤3 cm, >3 cm and ≤4 cm were 69, 4, 42, 4, 4, 1, 12, 4 and 23, 0, 17, 0, 7, 2, 3, 0, respectively. There were significant differences in metastatic lymph nodes in No.110 and No.111 of patients with length of esophageal invasion ≤1 cm, >1 cm and ≤2 cm, >2 cm and ≤3 cm, >3 cm and ≤4 cm ( χ2=8.45, 7.30, P<0.05). Of the 185 patients of Siewert type Ⅱ and Ⅲ AEG, the ratio of cases with inferior mediastinal lymph nodes metastasis was 6.49%(12/185). The ratio of inferior mediastinal lymph nodes metastasis in cases with length of esophageal invasion ≤1 cm, >1 cm and ≤2 cm, >2 cm and ≤3 cm, >3 cm and ≤4 cm were 3.81%(4/105), 6.12%(3/49), 10.00%(2/20), 27.27%(3/11), respectively. The ratio of No.110 lymph nodes metastasis in cases with length of esophageal invasion ≤1 cm, >1 cm and ≤2 cm, >2 cm and ≤3 cm, >3 cm and ≤4 cm were 2.86%(3/105), 6.12%(3/49), 5.00%(1/20), 27.27%(3/11), respectively, showing a significant difference among them ( χ2=8.26, P<0.05). Conclusions:Depth of tumor invasion and length of esophageal invasion are independent influening factors affecting inferior mediastinal lymph node metastasis in Siewert type Ⅱ and Ⅲ AEG. The rate of inferior mediastinal lymph node metastasis increases with the increase of the length of esophageal invasion.
RESUMEN
With the continuous update and improvement of minimally invasive techni-ques, laparoscopic and robotic surgeries have increased significantly for the surgical treatment of adenocarcinoma of esophagogastric junction (AEG). Due to the anatomical particularity and biolo-gical characteristics of Siewert type Ⅱ AEG, surgical approach, the range of resection, lymph node dissection and digestive tract reconstruction cannot be unified at present, which is also the contro-versy between gastrointestinal surgery and thoracic surgery. Laparoscopic minimally invasive techni-que may be more conducive to lower mediastinal lymph node dissection. Laparoscopic surgery of AEG after neoadjuvant chemotherapy is safe and feasible. Robotic surgery may be the direction of minimally invasive surgery in the future. The authors mainly investigate strategies of minimally invasive surgery for the surgical treatment of AEG, and look forward to more clinical trials on Siewert type Ⅱ AEG surgery to guide surgical treatment.
RESUMEN
Due to the particularity of tumor location, the surgery of esophagogastric junc-tion(EGJ) carcinoma needs to meet the safety of negative tumor margin, lymph node dissection and digestive tract reconstruction at the same time, which attracted more and more attention of esopha-gogastric surgeons. The current Siewert and Nishi classifications are based on the tumor epicenter, which is difficult to be accurately evaluated and measured before and during operation, and also lack of significance in determining the surgical methods and approach and lymph node dissection. The authors systematically analyze the limitations of Siewert and Nishi classification, discuss the relationship between esophageal invasion length and mediastinal lymph node metastasis and the role of esophageal invasion length on selection of surgical approach, and propose a modified classi-fication based on esophageal invasion length, including (1) malignant tumors with the upper or lower edge of tumor involving the zone of EGJ are defined as EGJ carcinoma; (2) EGJ carcinoma with the upper edge of tumor located 3.0 cm above the EGJ is classified as type Ⅰ; (3) EGJ carcinoma with the upper edge of tumor located 0?3.0 cm above the EGJ is classified as type Ⅱ; (4) EGJ carcinoma with the upper edge of tumor located 0?2.0 cm below the EGJ is classified as type Ⅲ.
RESUMEN
Objective: Surgical operation is the main treatment for advanced adenocarcinoma of esophagogastric junction (AEG). Due to its special anatomic location and unique lymph node reflux mode, the surgical treatment of Siewert II AEG is controversial. Lower mediastinal lymph node dissection is one of the most controversial points and a standard technique has not yet been established. This study is aim to explore the safety and feasibility of five-step maneuver of transthoracic single-port assisted laparoscopic lower mediastinal lymph node dissection for Siewert type II AEG. Methods: A descriptive case series study was conducted. The intraoperative and postoperative data of 25 patients with Siewert type II AEG who underwent five-step maneuver of transthoracic single-port assisted laparoscopic lower mediastinal lymph node dissection in Guangdong Provincial Hospital of Traditional Chinese Medicine from January 2019 to April 2021 were retrospectively analyzed. Five-step maneuver was as follows: In the first step, the subcardiac sac was exposed; the right pulmonary ligament lymph nodes and the anterior thoracic paraaortic lymph nodes were dissected cranial to inferior pericardium, left to left edge of thoracic aorta. In the second step, the left diaphragm was opened, and a 12 mm trocar was placed through the 6-7 rib in the left anterior axillary line. The supra-diaphragmatic nodes were dissected through the thoracic operation hole. In the third step, the left inferior pulmonary ligament was severed. The anterior fascia of thoracic aorta was incised to join the anterior space of thoracic aorta formed in the first step and then the lymphatic tissue was dissected upward until the exposure of left inferior pulmonary vein. In the fourth step, the posterior pericardium was denuded retrogradely from ventral side to oral side to the level of left inferior pulmonary vein, right to right pleura, and then the right pulmonary ligament lymph nodes were completely removed. In the fifth step, the esophagus was denuded, and the esophagus was transected 5 cm above the tumor using a linear stapler to complete the dissection of lower thoracic paraesophageal lymph nodes. Results: Operations were successfully completed in 25 patients without conversion, intra-operative complication and perioperative death. Total gastrectomy was performed in 19 cases and proximal gastrectomy in 6 cases. The mean operative time was (268.7±85.6) minutes, the mean estimated blood loss was (90.4±44.2) ml, the mean time of lower mediastinal lymph node dissection was (38.6±10.3) minutes, and the mean harvested number of lower mediastinal lymph node was 5.9±2.9. The length of esophageal invasion was >2 cm in 7 cases and ≤ 2 cm in 18 cases. Eight patients (33.0%) had lower mediastinal lymph node metastasis, including 3 cases with esophageal invasion >2 cm and 5 cases with esophageal invasion ≤ 2 cm. The mean time to postoperative first flatus was (5.5±3.1) days. The average time of postoperative thoracic drainage was (5.9±2.9) days. The mean hospital stay was (9.7±3.1) days. Two patients (8.0%) developed postoperative grade IIIa complications according to the Clavien-Dindo classification, including 1 case of pancreatic fistula and 1 case of pleural effusion, both of whom were cured by puncture drainage. Conclusions: Five-step maneuver of transthoracic single-port assisted laparoscopic lower mediastinal lymph nodes dissection for Siewert type II AEG is safe and feasible. Which can ensure sufficient lower mediastinal lymph node dissection to the level of left inferior pulmonary vein.
Asunto(s)
Humanos , Adenocarcinoma/cirugía , Unión Esofagogástrica , Laparoscopía , Escisión del Ganglio Linfático , Estudios RetrospectivosRESUMEN
Objective: To investigate the effectiveness, safety, and prognosis of neoadjuvant chemoradiotherapy (nCRT) for Siewert type II and III adenocarcinomas of the esophagogastric junction (AEG). Methods: This study is a prospective randomized controlled clinical study (NCT01962246). AEG patients who were treated at the Third Department of Surgery of the Fourth Hospital of Hebei Medical University from February 2012 to June 2016 were included. All of the enrolled patients were diagnosed with type II or III locally advanced AEG gastric cancer (T2-4N0-3M0 or T1N1-3M0) by gastroscopy and CT before operation; the longitudinal axis of the lesion was ≤ 8 cm; no anti-tumor treatment was previously given and no contraindications of chemotherapy and surgery were found. Case exclusion criteria: serious diseases accompanied by liver and kidney, cardiovascular system and other vital organs; allergy to capecitabine or oxaliplatin drugs or excipients; receiving any form of chemotherapy or other research drugs; pregnant or lactating women; patients with diseases resulting in difficulty to take capecitabine or with concurrent tumors. Based on sample size estimation, a total of 150 AEG patients were enrolled. Using the random number table method, the enrolled patients were divided into the nCRT group and the direct operation group with 75 cases in each group. The nCRT group received XELOX chemotherapy (capecitabine+ oxaliplatin) before surgery and concurrent radiotherapy (45 Gy, 25 times, 1.8 Gy/d, 5 times/week). Clinical efficacy of the nCRT group was evaluated by the solid tumor efficacy evaluation standard (RECIST1.1) and the tumor volume reduction rate was measured on CT. After completing the preoperative examination in the direct operation group, and 8-10 weeks after the end of nCRT in the nCRT group, surgery was performed. Laparoscopic exploration was initially performed. According to the Japanese "Regulations for the Treatment of Gastric Cancer", a transabdominal radical total gastrectomy combined with perigastric lymph node dissection was performed. The primary outcome was the 3-year overall survival (OS) and disease-free survival rate (DFS); the secondary outcomes were R0 resection rate, the toxicity of chemotherapy, and surgical complications. The follow-up ended on December 31, 2019. The postoperative recurrence, metastasis and survival time of the two groups were collected. Results: After excluding patients with incomplete clinical data, patients or family members requesting to withdraw informed consent, and those failing to follow the treatment plan, 63 cases in the nCRT group and 69 cases in the direct operation group were finally enrolled in the study. There were no statistically significant differences in baseline characteristics of the two groups (all P>0.05). Sixty-three patients in the nCRT group were evaluated by RECIST1.1 after treatment, the image based effective rate was 42.9% (27/63), and the stable disease rate was 98.4% (62/63); the tumor volume before and after nCRT measured on CT was (58.8±24.4) cm(3) and (46.6±25.7) cm(3), respectively, the effective rate of tumor volume reduction measured by CT was 47.6% (30/63). Incidences of neutrophilopenia [65.1% (41/63) vs. 40.6% (28/69), χ(2)=7.923, P=0.005], nausea [81.0% (51/63) vs. 56.5% (39/69), χ(2)=9.060, P=0.003] and fatigue [74.6% (47/63) vs. 42.0% (29/69), χ(2)=14.306, P=0.001] in the nCRT group were significantly higher than those in the direct surgery group. Radiation gastritis/esophagitis and radiation pneumonia were unique adverse reactions in the nCRT group, with incidences of 52.4% (33/63) and 15.9%(10/63), respectively. The classification of tumor regression of 63 patients in nCRT group presented as 11 cases of grade 0 (17.5%), 20 cases of grade 1 (31.7%), 28 cases of grade 2 (44.4%), and 5 cases of grade 3 (7.9%). Eleven (17.5%) patients achieved pathologic complete response. Sixty-one (96.8%) patients in the nCRT group underwent R0 resection, which was higher than 87.0% (60/69) in the direct surgery group (χ(2)=4.199, P=0.040). The mean number of harvested lymph nodes in the specimens in the nCRT group and the direct operation group was 27.6±12.4 and 26.8±14.6, respectively, and the difference was not statistically significant (t=-0.015, P=0.976). The pathological lymph node metastasis rate and lymph node ratio in the two groups were 44.4% (28/63) vs. 76.8% (53/69), and 4.0% (70/1 739) vs. 21.9% (404/1 847), respectively with statistically significant differences (χ(2)=14.552, P<0.001, and χ(2)=248.736, P<0.001, respectively). During a median follow-up of 52 (27-77) months, the 3-year DFS rate in the nCRT group and the direct surgery group was 52.4% and 39.1% (P=0.049), and the 3-year OS rate was 63.4% and 52.2% (P=0.019), respectively. According to whether the tumor volume reduction rate measured by CT was ≥ 12.5%, 63 patients in the nCRT group were divided into the effective group (n=30) and the ineffective group (n=33). The 3-year DFS rate of these two subgracps was 56.6% and 45.5%, respectively without significant difference (P=0.098). The 3-year OS rate was 73.3% and 51.5%,respectively with significant difference (P=0.038). The 3-year DFS rate of patients with the tumor regression grades 0, 1, 2 and 3 was 81.8%, 70.0%, 44.4%, and 20.0%, repectively (P=0.024); the 3-year OS rate was 81.8%, 75.0%, 48.1% and 40.0%, repectively (P=0.048). Conclusion: nCRT improves treatment efficacy of Siewert type II and III AEG patients, and the long-term prognosis is good.
Asunto(s)
Humanos , Adenocarcinoma/terapia , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Capecitabina/administración & dosificación , Quimioradioterapia Adyuvante , Unión Esofagogástrica/cirugía , Gastrectomía , Escisión del Ganglio Linfático , Terapia Neoadyuvante , Estadificación de Neoplasias , Oxaliplatino/administración & dosificación , Pronóstico , Estudios Prospectivos , Estudios Retrospectivos , Neoplasias Gástricas/terapiaRESUMEN
Objective:To investigate the application value of totally laparoscopic trans-abdominal-hiatal approach in the radical resection of Siewert type Ⅱ adenocarcinoma of esophago-gastric junction (AEG).Methods:The retrospective and descriptive study was conducted. The clinicopathological data of 45 patients with Siewert type Ⅱ AEG who were admitted to the Affiliated Hangzhou First People′s Hospital, Zhejiang University School of Medicine from May 2017 to December 2020 were collected. There were 28 males and 17 females, aged from 35 to 85 years, with a median age of 64 years. All patients underwent radical resection of AEG by totally laparoscopic trans-abdominal-hiatal approach with gastrointestinal anastomosis using proximal gastrectomy with double-tract anastomosis or total gastrectomy with esophagojejunointestinal anastomosis and digestive reconstruction using transdiaphragmatic-hiatal superior overlap esophagojejunostomy. Observation indicators: (1) surgical and postoperative situations; (2) postoperative histopathological examination; (3) follow-up and survival situations. Follow-up using outpatient examination and telephone interview was performed to detect survival of patients and tumor recurrence and metastasis up to March 2021. Measurement data with normal distribution were presented as Mean± SD and measure-ment data with skewed distribution were presented as M(range). Results:(1) Surgical and post-operative situations: all 45 patients underwent radical resection of AEG by totally laparoscopic transabdominal-hiatal approach successfully, including 35 cases undergoing total gastrectomy with esophagojejunointestinal anastomosis and 10 cases undergoing proximal gastrectomy with double-tract anastomosis. The total operation time, time of lower mediastinal lymph node dissection, time of superior overlap esophagojejunostomy, volume of intraoperative blood loss, time for initial out-of-bed activities, time to first flatus, time to initial liquid diet intake, time to drainage tube removal of the 45 patients were (235±32)minutes, (25±8)minutes, (45±10)minutes, (70±13)mL, (20±8)hours, (2.3±0.2)days, (2.6±0.8)days and (6.2±1.1)days, respectively. Eleven of 45 patients under-went postoperative complications and none of patient died during perioperative period. The post-operative duration of hospital stay of 45 patients was (10±3)days. (2) Postoperative histopatho-logical examination: all 45 patients had negative upper surgical margin. The length of proximal margin, tumor diameter, total number of lymph lodes harvested and number of lower mediastinal lymph nodes harvested were (2.5±0.5)cm, (2.9±0.8)cm, 35.0±4.0 and 2.4±0.8, respectively. Patholo-gical examination showed adenocarcinoma in all 45 patients with pTNM staging as 5 cases of stage ⅠB, 8 cases of stage ⅡA, 21 cases of stage ⅡB and 11 cases of stage ⅢA. (3) Follow-up and survival situations: 45 patients were followed up for 3 to 46 months, with a median follow-up time of 26 months. During follow-up, 8 of 45 patients died. Of the 37 patients survived, 3 cases underwent liver metastasis and 3 cases underwent bone metastasis, lung metastasis or peritoneal metastasis respec-tively.Conclusion:Total laparoscopic transabdominal-hiatal approach is safe and feasible in the treatment of Siewert type II AEG with a satisfactory clinical efficacy.
RESUMEN
Objective:To investigate the application value of different surgical approaches in the radical resection of Siewert type Ⅱ adenocarcinoma of esophagogastric junction (AEG).Methods:The retrospective cohort study was conducted. The clinicopathological data of 84 patients with Siewert Ⅱ AEG who were admitted to the Fourth Hospital of Hebei Medical University from March 2018 to March 2019 were collected. There were 65 males and 19 females, aged from 43 to 82 years, with a median age of 66 years. Of 84 patients, 24 cases undergoing radical resection of AEG via abdominal transhiatal approach (TH) were allocated into TH group, 32 cases undergoing radical resection of AEG via left thoracic approach (Sweet) were allocated into Sweet group, 28 cases undergoing radical resection of AEG via right thoracoabdominal approach (RTA) were allocated into RTA group. Observation indicators: (1) surgical and postoperative conditions of Siewert Ⅱ AEG patients in the 3 groups; (2) postoperative complications of Siewert Ⅱ AEG patients in the 3 groups. (3) Follow-up. Follow-up using outpatient examination and telephone interview was conducted to detect postoperative life quality, tumor recurrence and survival of patients up to March 2020. Measurement data with normal distribution were represented as Mean± SD, and comparison between groups was analyzed using the ANOVA. Measurement data with skewed distribution were represented as M (range), comparison among multiple groups was analyzed using the Kruskal-Wallis H test, and comparison between two groups was analyzed using the Dunn Bonferroni test. Count data were described as absolute numbers, and comparison between groups was analyzed using the chi-square test. Results:(1) Surgical and postoperative conditions of Siewert Ⅱ AEG patients in the 3 groups: the operation time for Siewert type Ⅱ AEG patients in TH group, Sweet group and RTA group were 216 minutes (range, 190-230 minutes), 174 minutes (range, 152-185 minutes) and 295 minutes (range, 261-337 minutes), respectively, showing a significant difference among the 3 groups ( H=57.977, P<0.05). There were significant differences between the TH group and the Sweet group, between the TH group and the RTA group, respectively ( P<0.05). There was also a significant difference between the Sweet group and the RTA group ( P<0.05). The volume of intraoperative blood loss for Siewert type Ⅱ AEG patients in TH group, Sweet group and RTA group were 150 mL (range, 100-163 mL), 150 mL (range, 150-200 mL) and 200 mL (range, 150-263 mL), respectively, showing a significant difference among the 3 groups ( H=11.097, P<0.05). There was no significant difference between the TH group and the Sweet group ( P>0.05). There were significant differences between the TH group and the RTA group, between the Sweet group and the RTA group, respectively ( P<0.05). The number of lymph node dissected for Siewert type Ⅱ AEG patients in TH group, Sweet group and RTA group were 15 (range, 9-19), 17 (range, 10-21) and 30 (range, 24-40), respectively, showing a significant difference among the 3 groups ( H=29.775, P<0.05). There was no significant difference between the TH group and the Sweet group ( P>0.05). There were significant differences between the TH group and the RTA group, between the Sweet group and the RTA group, respectively ( P<0.05). The number of thoracic lymph node dissected for Siewert type Ⅱ AEG patients in TH group, Sweet group and RTA group were 0, 2 (range, 1-3) and 6 (range, 3-9), respec-tively, showing a significant difference among the 3 groups ( H=48.140, P<0.05). There were significant differences between the TH group and the Sweet group, between the TH group and the RTA group, respectively ( P<0.05). There was also a significant difference between the Sweet group and the RTA group ( P<0.05). The number of abdominal lymph node dissected for Siewert type Ⅱ AEG patients in TH group, Sweet group and RTA group were 15 (range, 9-19), 12 (range, 8-19), and 24 (range, 17-35), respectively, showing a significant difference among the 3 groups ( H=18.149, P<0.05). There was no significant difference between the TH group and the Sweet group ( P>0.05). There were significant differences between the TH group and the RTA group, between the Sweet group and the RTA group, respectively ( P<0.05). The number of positive lymph node for Siewert type Ⅱ AEG patients in TH group, Sweet group and RTA group were 2 (range, 0-3), 0 (range, 0-3), and 5 (range, 1-6), respectively, showing a significant difference among the 3 groups ( H=7.729, P<0.05). There was no significant difference between the TH group and the Sweet group, between the TH group and the RTA group, respectively ( P>0.05). There was a significant difference between the Sweet group and the RTA group ( P<0.05). The time to postoperative first flatus of Siewert type Ⅱ AEG patients in TH group, Sweet group and RTA group were 3 days (range, 3-4 days), 3 days (range, 3-4 days), and 4 days (range, 3-5 days), respectively, showing no significant difference among the 3 groups ( H=3.125, P>0.05). The duration of postoperative hospital stay for Siewert type Ⅱ AEG patients in TH group, Sweet group and RTA group were 16 days (range, 14-17 days), 14 days (range, 12-15 days), and 19 days (range, 18-21 days), respectively, showing a significant difference among the 3 groups ( H=35.244, P<0.05). There was no significant difference between the TH group and the Sweet group ( P>0.05). There were significant differences between the TH group and the RTA group, between the Sweet group and the RTA group, respectively ( P<0.05). (2) Postoperative complications of Siewert Ⅱ AEG patients in the 3 groups: there were 6, 6, 11 Siewert type Ⅱ AEG patients of the TH group, Sweet group and RTA group with cardiopulmonary complication, respectively, 1, 1, 2 patients with anastomotic leakage and 1, 0, 1 patients with AEG-related death, showing no significant difference in the above indicators among the 3 groups ( χ2=3.263, 0.754, 1.595, P>0.05). (3) Follow-up: 78 of 84 Siewert type Ⅱ AEG patients were followed up for 9.0 to 24.0 months, with a median follow-up time of 16.6 months. Cases with reduced respiratory function at postoperative 3 months for the TH group, Sweet group and RTA group were 4, 3, 5, respectively. Cases with gastroesophageal reflux at postoperative 3 months for the 3 groups were 3, 6, 7, respectively. Cases with weight loss at post-operative 3 months for the 3 groups were 3, 2, 4, respectively. There was no significant difference in the above indicators among the 3 groups ( χ2=1.009, 1.107, 1.112, P>0.05). Cases tumor recurrence and metastasis in the TH group, Sweet group and RTA group were 5, 7, 4, cases who survived at postoperative 1 year in the 3 groups were 19, 24, 25, respectively. There was no significant difference in the above indicators among the 3 groups ( χ2=0.897, 1.261, P>0.05). Conclusion:RTA appiled in Siewert type Ⅱ AEG patients has a longer postoperative operation time, increased intra-operative blood loss and longer hospital stay, while has better advantages in lymph node dissection.
RESUMEN
Objective:To investigate the application value of individualized full-course nutritional intervention in neoadjuvant concurrent chemoradiotherapy (nCRT) for locally advanced Siewert type Ⅱ and Ⅲ adenocarcinoma of esophagogastric junction (AEG).Methods:The perspec-tive randomized control study was conducted. The clinicopathological data of 90 patients with locally advanced Siewert type Ⅱ and Ⅲ AEG who underwent nCRT in the Fourth Hospital of Hebei Medical University from February 2012 to December 2018 were selected. Patient were divided into two groups with 1:1 according to random number table. Patients undergoing nCRT combined with individualized full-course nutritional intervention were allocated into experimental group, and patients undergoing nCRT combined with common nutritional intervention were allocated into control group. Observation indicators: (1) grouping situations of the enrolled patients; (2) changing situations of nutritional status and quality of life of patients in nCRT and preoperative waiting period; (3) efficacy evaluation and adverse effects of nCRT; (4) surgical and recovery situations. Measurement data with normal distribution were represented as Mean± SD, and comparison between groups was conducted using the t test. Measurement date with skewed distribution were represented as M ( P25, P75) or M (range), and comparison between groups was conducted using the Mann-Whitney U test. Count data were represented as absolute numbers or percentages, and comparison between groups was conducted using the chi-square test or Fisher exact probability. Comparison of ordinal data was conducted using the non-parameter rank sum test. Repeated measurement data were analyzed using the repeated ANOVA. Results:(1) Grouping situations of the enrolled patients: a total of 90 patients were selected for eligibility. There were 77 males and 13 females, aged from 26 to 74 years, with a median age of 62 years. Of 90 patients, there were 45 cases in the experimental group and 45 cases in the control group. (2) Changing situations of nutritional status and quality of life of patients in nCRT and preoperative waiting period: ① during the nCRT treatment (week 3, week 6) and the preoperative waiting period (week 9, week 12, week 15), the body mass was (67±10)kg, (66±9)kg, (67±10)kg, (68±10)kg, (70±10)kg for the experi-mental group, respectively, and (65±9)kg, (59±8)kg, (62±8)kg, (64±8)kg, (66±9)kg for the control group. The multivariate test was conducted based on the mauchly's test of sphericity for the body mass ( χ2=195.010, P<0.05). There were significant differences in the time effect, interaction effect, intervention effect of body mass changing between the two groups ( F=93.974, 60.638, 4.144, P<0.05). ② During the nCRT treatment (week 3, week 6) and the preoperative waiting period (week 9, week 12, week 15), the total protein was (66±4)g/L, (65±4)g/L, (65±4)g/L, (68±4)g/L, (71±5)g/L for the experimental group, respectively, and (65±4)g/L, (62±5)g/L, (63±5)g/L, (65±5)g/L, (67±6)g/L for the control group. The multivariate test was conducted based on the mauchly's test of sphericity for the total protein ( χ2=652.524, P<0.05). There were significant differences in the time effect, interaction effect, interven-tion effect of total protein changing between the two groups ( F=672.507, 6.424, 5.057, P<0.05). ③ During the nCRT treatment (week 3, week 6) and the preoperative waiting period (week 9, week 12, week 15), the albumin was (40±3)g/L, (38±4)g/L, (38±4)g/L, (39±4)g/L, (40±4)g/L for the experimental group, respectively, and (39±4)g/L, (35±5)g/L, (36±4)g/L, (36±4)g/L, (37±5)g/L for the control group. The multivariate test was conducted based on the mauchly's test of sphericity for the albumin ( χ2=289.324, P<0.05). There were significant differences in the time effect, interaction effect, intervention effect of albumin changing between the two groups ( F=4 210.683, 5.013, 7.330, P<0.05). ④ During the nCRT treatment (week 3, week 6) and the preoperative waiting period (week 9, week 12, week 15), the prealbumin was (228±41)mg/L, (222±56)mg/L, (223±47)mg/L, (227±46)mg/L, (233±53)mg/L for the experimental group, respectively, and (202±49)mg/L, (174±68)mg/L, (179±54)mg/L, (185±51)mg/L, (193±57)mg/L for the control group. The multi-variate test was conducted based on the mauchly's test of sphericity for the prealbumin ( χ2=297.324, P<0.05). There were significant differences in the time effect, interaction effect, intervention effect of prealbumin changing between the two groups ( F=871.545, 6.111, 14.426, P<0.05). ⑤ During the nCRT treatment (week 3, week 6) and the preoperative waiting period (week 9, week 12, week 15), the hemoglobin was (124±14)g/L, (121±14)g/L, (125±13)g/L, (127±13)g/L, (128±13)g/L for the experimental group, respectively, and (121±18)g/L, (114±14)g/L, (116±14)g/L, (117±16)g/L, (118±22)g/L for the control group. The multivariate test was conducted based on the mauchly's test of sphericity for the hemoglobin ( χ2=257.560, P<0.05). There were significant differences in the time effect, interaction effect, intervention effect of hemoglobin changing between the two groups ( F=2 533.553, 4.142, 4.985, P<0.05). ⑥ During the nCRT treatment (week 3, week 6) and the preopera-tive waiting period (week 9, week 12, week 15), the patient-generated subjective global assessment (PG-SGA) score was 4.4±1.2,6.3±1.4, 5.5±1.4, 4.3±1.4, 3.4±1.7 for the experimental group, respec-tively, and 4.9±1.2, 7.4±1.7, 7.3±1.6, 6.3±1.4, 6.0±1.5 for the control group. The multivariate test was conducted based on the mauchly's test of sphericity for the PG-SGA score ( χ2=289.543, P<0.05). There were significant differences in the time effect, interaction effect, intervention effect of PG-SGA score changing between the two groups ( F=648.583, 41.906, 26.098, P<0.05). ⑦ During the nCRT treatment (week 3, week 6) and the preoperative waiting period (week 9, week 12, week 15), the quality of life questionnaire of stomach (QLQ-ST022) score was 13±3, 16±6, 16±4, 14±4, 12±5 for the experimental group, respectively, and 15±4, 21±6, 20±4, 17±4, 15±5 for the control group. The multivariate test was conducted based on the mauchly's test of sphericity for the QLQ-STO22 ( χ2=279.865, P<0.05). There were significant differences in the time effect, interaction effect, interven-tion effect of QLQ-STO22 changing between the two groups ( F=710.238, 7.261, 16.794, P<0.05). (3) Efficacy evaluation and adverse effects of nCRT: there were 25 patients and 20 cases of the experimental group with partial response and stable disease, showing the objective response rate and disease control rate as 55.6%(25/45)and 100.0%(45/45). There were 18 patients and 27 cases of the control group with partial response and stable disease, showing the objective response rate and disease control rate as 40.0%(18/45)and 100.0%(45/45). There was no significant difference in the nCRT efficacy between the two groups ( P>0.05). Cases with leukopenia, neutropenia, anemia, nausea, and loss of appetite were 27, 25, 19, 30, 34 for the experimental group, versus 37, 34, 29, 39, 42 for the control group, showing significant differences between the two groups ( χ2=5.409, 3.986, 4.464, 5.031, 5.414, P<0.05). (4) Surgical and recovery situations: patients of the experimental group underwent surgeries successfully. Two patients of the control group diagnosed with peritoneal metastasis after laparoscopic exploration underwent conversion therapy and no surgery, the other 43 patients underwent surgeries. The time to postoperative gastric tube removal, time to postopera-tive drainage tube removal, time to postoperative first flatus, time to postoperative first defecation, duration of postoperative hospital stay were 2.0 days (1.5 days, 3.0 days), 6.0 days (5.0 days,11.0 days), 2.0 days (1.5 days, 2.5 days), 2.0 days (1.5 days, 2.5 days), 7.0 days (6.0 days,14.0 days) for the experimental group, versus 3.0 days (2.0 days,4.0 days), 7.0 days (5.5 days,14.0 days), 2.0 days (1.5 days,3.0 days), 3.0 days (2.0 days,3.5 days), 8.0 days (6.0 days, 17.0 days) for the control group, showing significant differences between the two groups ( Z=-3.477, -4.398, -3.068, -5.786, -3.395, P<0.05). Conclusion:For AEG patients undergoing nCRT, the individualized full-course nutrition intervention involving nutritionists is beneficial to improve the nutritional status, reduce adverse reactions, and improve the quality of life of the patients, promote postoperative short-term recovery. Registry: this study was registered at clinicaltrials.gov in United States, with the registry number of NCT01962246.
RESUMEN
Objective:To explore the characteristics of Siewert classification and microsatellite instability(MSI) and HER2 expression in adenocarcinoma of esophagogastric junction (AEG).Methods:The clinicopathological data of gastric adenocarcinoma from May 2019 to November 2020 were retrospectively analyzed. The patients were divided into two groups: AEG group and non AEG group. The composition ratio of Siewert type of AEG was counted, and the relationship between tumor size and Siewert type was analyzed. The MSI status and HER2 expression status of AEG and non AEG were statistically compared. The measurement data of normal distribution were expressed as mean ± standard deviation( Mean± SD), the comparison between groups were by t test, the comparison of count data between groups were by Chi-square test. Results:A total of 328 consecutive cases of gastric adenocarcinoma were collected, including 242 cases of AEG and 86 cases of non AEG. The Siewert classification of AEG was mainly type Ⅱ (151 cases, 62.40%), followed by type Ⅲ (86 cases, 35.54%) and type Ⅰ (5 cases, 2.07%). The analysis of the relationship between the size of the tumor length and the number of Siewert type showed that the number of Siewert type Ⅱ cases decreased and the number of Siewert type Ⅲ cases increased with the increase of the tumor size. MSI status was detected non selectively in 192 cases of gastric adenocarcinoma (140 cases of AEG and 52 cases of non AEG). There were 12 cases of MSI (6.25%), 2 cases of MSI-H (1.04%) and 10 cases of MSI-L (5.21%). There was no significant difference in MSI ratio between AEG group and non AEG group ( P>0.05). All MSI cases were negative or weakly positive for PMS2. The expression of HER2 was detected by immunohistochemistry in 313 cases of gastric adenocarcinoma, except 15 cases of PTIS/T1a. There were 30 cases (9.58%) with HER2 expression 3+ . Thirty-two cases (10.22%) expressed HER2 (2+ ), of which 7 cases were detected by fluorescence in situ hybridization (FISH), and 3 cases were positive. The proportion of HER2 (3+ ) in AEG was significantly higher than that in non AEG group ( P<0.05). Conclusions:The main type of AEG was Siewert type Ⅱ. AEG may mostly occur between 1 cm above the esophagogastric junction and 2 cm below the esophagogastric junction; For endoscopic screening of early AEG, more attention should be paid to this area of stomach. Siewert type Ⅲ may be derived from the development of Siewert type Ⅱ. The incidence of microsatellite instability in gastric cancer is low. Compared with other gastric adenocarcinoma, AEG has no specificity in MSI. The MSI of AEG was mainly the expression defect of PMS2. Compared with other gastric adenocarcinoma, there are more HER2 overexpression in AEG.
RESUMEN
Objective To investigate the safety and feasibility of totally laparoscopic transabdominalhiatal approach in the treatment of Siewert type Ⅱ adenocarcinoma of esophagogastric junction (AEG).Methods The retrospective and descriptive study was conducted.The clinicopathological data of 11 patients with Siewert type Ⅱ AEG who were admitted to Affiliated Hangzhou First People's Hospital of Zhejiang University School of Medicine from May 2017 to July 2018 were collected.There were 8 males and 3 females,aged 56-72 years,with an average age of 63 years.Patients underwent radical resection of AEG by totally laparoscopic transabdominalhiatal approach.Observation indicators:(1) surgical situations and postoperative recovery;(2) postoperative pathological examination;(3) follow-up and survival situations.Follow-up using outpatient examination and telephone interview was performed to detect postoperative adjuvant chemotherapy,complications,food intake,anastomosis patency,tumor recurrence and metastasis,and survival up to December 2018.Measurement data with normal distribution were presented as Mean±SD,measurement data with skewed distribution were presented as M (range),and count data were represented as absolute number or percentage.Results (1) Surgical situations and postoperative recovery:all the patients underwent totally laparoscopic radical resection of Siewert type Ⅱ AEG by transabdominal-hiatal approach,without conversion to open surgery or perioperative death.Of the 11 patients,8 underwent total gastrectony including 3 combined with splenic hilar lymph node dissection and 3 underwent proximal gastrectomy with double-tract reconstruction.Operation time,time of superior overlap esophagojejunostomy,volume of intraoperative blood loss,time for initial out-of-bed activities,time to first flatus,time to initial liquid diet intake,time of drainage tube removal were respectively (245± 39)minutes,(60± 12) minutes,(75±23) mL,(24± 8) hours,(2.4± 0.5) days,(3.5 ± 0.8) days,(8.2 ± 1.3) days respectively.There was no serious complication including postoperative hemorrhage,anatomotic fistula or death.Three patients had left pleural effusion,and were cured after thoracic drainage.The duration of postoperative hospital stay was (11.0±3.0) days.(2) Postoperative pathological examination:all the 11 patients had negative upper surgical margin.The length of proximal margin,tumor diameter,total number of lymph lodes harvested,and number of lower mediastinal lymph lodes harvested were (2.1 ±0.2) cm,(2.6±0.9) cm,(36.0±4.0)/case and (2.3± 0.8)/case.Pathological examination showed adenocarcinoma in all the 11 patients.pTNM staging:2 cases were in stage Ⅰ B,4 cases in stage Ⅱ A,3 cases in stage Ⅱ B and 2 cases in stage Ⅲ A.(3) Follow-up and survival situations:11 patients were follow-up for 6-19 months,with a median time of 9 months.Chemotherapy regimeus were formulated according to the pathological examination.Nine patients received postoperative adjuvant chemotherapy,and 2 in stage Ⅱ B received no postoperative adjuvant chemotherapy.During the follow-up,11 patients had no obvious reflux symptom or choking feeling,and the anastomosis was patent as evaluated by oral contrast agent and gastroscopy.There was no tumor recurrence and metastasis or death in the 11 patients.Conclusion Totally laparoscopic transabdominal-hiatal approach applied in the radical resection is safe and feasible for the treatment of Siewert type Ⅱ AEG,with good short-term outcomes.
RESUMEN
Objective To investigate the pattern of lymph node metastasis and analyze prognostic factors of Siewert type Ⅱ adenocarcinoma of esophagogastric junction (AEG).Methods The retrospective case-control study was conducted.The clinicopathological data of 368 patients with Siewert type Ⅱ AEG who were admitted to Tianjin Medical University Cancer Institute and Hospital from June 2010 and November 2015 were collected.There were 323 males and 45 females,aged from 35 to 80 years,with an average age of 64 years.Of 368 patients,209 underwent left transthoracic surgery,1 12 underwent thoracoabdominal surgery,and 47 underwent Ivor-Lewis surgery.Observation indicators:(1) total lymph node metastasis and metastasis of various lymph node stations;(2) follow-up and survival;(3) prognostic factors analysis;(4) influencing factors affecting thoracic lymph node metastasis.Follow-up using outpatient examination and telephone interview was performed to detect survival of patients up to November 2018.Measurement data with skewed distribution were represented as M (range).Count data were represented as absolute number or percentage.The survival time and rate were calculated using the Kaplan-Meier method.The univariate and multivariate analyses were done by the COX proportional hazard model.Results (1) Total lymph node metastasis and metastasis of various lymph node stations:the total lymph node metastasis rate was 66.58％ (245/368) in 368 patients.The metastasis rates of abdominal lymph nodes,thoracic lymph nodes,lower mediastinal lymph nodes,and upper mediastinal lymph nodes were 65.49％ (241/368),12.77％ (47/368),12.23％ (45/368),and 1.09％ (4/368),respectively.The order of metastasis rate of various lymph node stations from high to low was 51.99％(170/237) of No.7 left gastric artery,34.23％(89/260) of No.1 right paracardial region,33.88％ (83/245) of No.2 left paracardial region,28.91％ (85/294) of No.3 lesser curvature,27.10％(29/107) of No.1 1 splenic artery,19.75％(16/81) of No.9 celiac trunk,15.25％(36/236) of No.E8Lo lower paraesophageal region,11.94％ (16/134) of No.4 greater curvature,11.76％ (6/51) of No.E8M middle paraesophageal region,11.1 1％(10/90) of No.8 common hepatic artery,4.65％(4/86) of No.E9L left inferior pulmonary ligament and 3.39％ (2/59) of No.E7 subcarinal region.(2) Follow-up and survival:of the 368 patients,309 were followed up for 1-103 months,with a median follow-up time of 38 months.The survival time of 309 patients was 0.7-101.9 months,and the median survival time was 35.9 months.During the followup,the postoperative l-,2-,3-year overall survival rates were 85.9％,68.6％,and 58.7％,respectively.(3) Prognostic factors analysis.Results of univariate analysis showed that tumor differentiation degree,presence of thoracic lymph node metastasis,number of metastatic lymph nodes,T staging,tumor diameter,and length of esophageal invasion were associated factors affecting prognosis of patients (x2 =8.776,26.582,46.057,18.679,22.460,9.158,P＜0.05).Results of multivariate analysis showed that presence of thoracic lymph node metastasis,number of metastatic lymph nodes,T staging,and tumor diameter were independent influencing factors for prognosis of patients [odds ratio (OR) =1.699,1.271,1.422,1.238,95％ confidence interval:1.102-2.621,1.019-1.481,1.090-1.856,0.971-1.481,P＜0.05].(4) Influencing factors affecting thoracic lymph node metastasis:results of univariate analysis showed that tumor diameter,length of esophageal invasion,number of lymph lodes harvested in thorax were related factors for thoracic lymph node metastasis (x2 =5.129,43.140,10.605,P＜0.05).Results of multivariate analysis showed that length of esophageal invasion ≥2 cm,number of lymph lodes harvested in thorax ≥ 4 were independent risk factors for thoracic lymph node metastasis (OR =6.321,1.097,95％ confidence interval:2.982-13.398,1.026-1.173,P＜0.05).Conclusion Lymph node metastasis of Siewert type Ⅱ AEG spreads two regions,mainly at abdominal lymph nodes,followed by the thoracic lymph nodes.Presence of thoracic lymph node metastasis,number of metastatic lymph nodes,T staging,and tumor diameter are independent influencing factors for prognosis of patients.Presence of thoracic lymph node metastasis indicates poor prognosis of patients.Length of esophageal invasion ≥ 2 cm and number of lymph lodes harvested in thorax ≥4 are independent risk factors for thoracic lymph node metastasis.
RESUMEN
In recent years,the incidence of gastric cancer has been decreasing year by year in the world,but the incidence of adenocarcinoma of esophagogastric junction (AEG) has shown a significant upward trend,especially in western countries such as Europe and America.The prognosis of AEG is poor,therefore,it is extremely necessary to establish AEG's best diagnosis and treatment strategies to improve the long-term outcome of AEG.Nowadays,the most commonly used AEG classification is the Siewert classification proposed by German scholars in 1987,which is based on the anatomical features of the esophagogastric junction.It provides guidance for the choice of surgical methods.Compared with European and American countries,Siewert type Ⅱ or type Ⅲ are more common in Asian countries,and are mainly treated as the proximal gastric cancer.Compared with gastric tumors in other areas,AEG has obvious differences and specialities in anatomy,physiology and pathology,and there is still much controversy in the field of surgical and comprehensive treatment.