Department of Surgical Oncology, Manipal Comprehensive Cancer Care Center, Kasturba Medical College, Manipal Academy of Higher Education (MAHE), Manipal, Karnataka, 576104, India.
Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, 400012, India.
Langenbecks Arch Surg. 2021 May;406(3):613-621. doi: 10.1007/s00423-020-02020-9. Epub 2020 Nov 26.
This study compares the short- and long-term outcomes between the left thoraco-abdominal and trans-abdominal approaches for radical resection of adenocarcinoma of the gastro-esophageal junction (GEJ) (Siewert types II and III) following neo-adjuvant chemotherapy.
A retrospective analysis of a prospectively maintained database of patients from May 2008 to December 2016. Demographic variables, perioperative outcomes, and survival were compared between two approaches.
Of the 792 patients, who underwent total/proximal gastrectomy during the specified time interval, 162 had Siewert's type II/III lesions, of which 147 received neoadjuvant chemotherapy and were included in the study. Ninety-two and 55 patients underwent definitive surgery through trans-abdominal and left thoraco-abdominal approach respectively. On baseline endoscopy, 81.8% of patients in the left thoraco-abdominal group had lower esophageal mucosal infiltration as compared to 41.3% in the trans-abdominal group (p < 0.001). Both groups were comparable in terms of duration of surgery, blood loss, complications, severity of complications (Clavien-Dindo grade), duration of hospital stay, R0 resection rate, length of proximal margin, and lymph node yield. At a median follow-up of 24 months, there was no difference in recurrence rate and survival between the groups.
Both left thoraco-abdominal and trans-abdominal are comparable surgical approaches for tumors involving the GEJ in terms of morbidity, perioperative, and long-term oncological outcomes. In patients with lower esophageal involvement, the left thoraco-abdominal approach is a feasible alternative with no added overall morbidity or mortality and can be preferred especially in cases, where a safe proximal margin and anastomosis is deemed technically challenging.
本研究比较了新辅助化疗后根治性切除胃食管交界腺癌（Siewert Ⅱ型和Ⅲ型）左胸腹联合入路与经腹入路的短期和长期疗效。
回顾性分析 2008 年 5 月至 2016 年 12 月期间前瞻性维护的数据库中的患者资料。比较两种入路的围手术期结果和生存情况。
在指定的时间间隔内，792 例患者接受了全胃/近端胃切除术，其中 162 例患有 Siewert Ⅱ/Ⅲ型病变，其中 147 例接受了新辅助化疗并纳入研究。92 例和 55 例患者分别通过经腹和左胸腹联合入路行确定性手术。基线内镜检查时，左胸腹联合组 81.8%的患者食管下段黏膜浸润，而经腹组为 41.3%（p < 0.001）。两组在手术时间、出血量、并发症、并发症严重程度（Clavien-Dindo 分级）、住院时间、R0 切除率、近端切缘长度和淋巴结检出数方面均无差异。中位随访 24 个月时，两组复发率和生存率无差异。
左胸腹联合入路与经腹入路在手术并发症、围手术期和长期肿瘤学结果方面相似。对于累及胃食管交界部的肿瘤，在食管下段受累的患者中，左胸腹联合入路是一种可行的替代方法，不会增加总体发病率或死亡率，并且可以优先选择，特别是在近端切缘和吻合被认为在技术上具有挑战性的情况下。
