Résumé
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.
Résumé
Objective To investigate the clinical efficacy of jejunal interposed single-tract and doubletract reconstruction after proximal gastrectomy for Siewert type Ⅱ and Ⅲ adenocarcinoma of the esophagogastric junction (AEG).Methods The prospective study was conducted.The clinicopathological data of 108 patients with Siewert type Ⅱ and Ⅲ AEG who were admitted to the Affiliated Tumor Hospital of Shanxi Medical University between August 2013 and November 2016 were collected.All the patients underwent proximal gastrectomy and were allocated into the 2 groups by random number table,including patients using single-tract jejunal interposition reconstruction in the single-tract group and patients using double-tract jejunal interposition reconstruction in the double-tract group.Digestive tract reconstruction:after end-to-side anastomosis between distal jejunum and esophagus and side-to-side anastomosis between posterior wall of the gastric remnant and jejunum,single-tract jejunal reconstruction was done through ligating jejunum at 3 cm below the anastomotic stoma,and then side-to-side anastomosis between proximal jejunum and jejunum was performed in the single-tract group.Patients in the double-tract group used the same digestive tract reconstruction,but jejunum was not ligated.The postoperative pathological examinations showed that patients with positive lymph nodes or tumor invading all layers of gastric wall underwent chemotherapy.Observation indicators:(1) intra-and post-operative situations;(2) follow-up situations.Follow-up using telephone interview was performed to detect postoperative complication,gastrointestinal function and body mass index (BMI) up to November 2017.Measurement data with normal distribution were represented as-x± s and comparison between groups was analyzed using t test.Measurement data with skewed distribution were described as M (range),and comparison between groups was analyzed using the nonparametric test.Repeated measurement data were analyzed by the repeated measures ANOVA.Comparisons of count data were done using chi-square test.Ordinal data were analyzed by the Kruskal Wallis H test.Results One hundred and eight patients were screened for eligibility,including 55 in the single-tract group and 53 in the double-tract group.(1) Intra-and post-operative situations:total operation time,digestive tract reconstruction time,volume of intraoperative blood loss,time to initial anal exsufflation,postoperative complications,cases with gastroesophageal reflux,intestinal obstruction and Visick grading ＞ Ⅱ and duration of postoperative hospital stay were respectively (145±26) minutes,(30±6) minutes,(181±37) mL,(53± 16) hours,1,1,1,(10.0±2.4) days in the singletract group and (139±29)minutes,(26±3)minutes,(176±31)mL,(50±17) hours,3,0,3,(9.4±l.4)days in the double-tract group,with no statistically significant difference between groups (t =0.725,0.219,0.162,-0.576,x2 =2.960,5.830,t =-0.993,P＞0.05).Four patients with gastroesophageal reflux received motilium and omeprazole therapy for 2 weeks,and were improved by symptomatic treatment such as increasing the solid food intake.One patient in the single-tract group had internal hernia-induced intestinal obstruction and was cured by reoperation.There was no anastomotic leakage,bleeding,infection,dumping syndrome and gallstone between groups.Of 108 patients,71 underwent 6-cycle SOX chemotherapy,including 67 with perigastric lymph node metastasis and 4 with tumor invading all layers of gastric wall.(2) Follow-up situations:108 patients were followed up for 12.0-48.0 months,with a median time of 28.6 months.During the follow-up,bowel sound in the double-tract group and single-tract group was 8 times / minute (range,5-12 times / minute) and 3 times /minute (range,2-5 times/ minute),with a statistically significant difference between groups (Z=-0.692,P＜0.05).The single food intake,serum gastrin level,ratio of serum pepsinogen Ⅰ and Ⅱ levels and BMI from preoperation to postoperative 12 months were from (1 117± 129)mL to (817± 127)mL,from (12±5)pmol/L to (41±13) pmol/L,from 11.3±2.8 to 5.1±2.2,(65±7)kg to (63±5) kg in the single-tract group and from (1 095±118)mL to (783±80)mL,from (10±4)pmol/L to (40±10)pmol/L,from 12.4±2.9 to 4.2±1.3,from (63±6) kg to (58±6)kg in the double-tract group,respectively,with no statistically significant difference in single food intake,serum gastrin level and ratio of serum pepsinogen Ⅰ and Ⅱ levels between groups (F =0.468,0.108,0.161,P＞0.05).There was a statistically significant difference in changing trend of BMI between groups (F=24.930,P＜0.05).Conclusion Jejunal interposed single-tract and double-tract reconstruction after proximal gastrectomy for Siewert type Ⅱ and Ⅲ AEG have the same surgical safety and don't affect secretion function of gastric remnant,but there are frequent bowel sounds and obvious weight loss.