腹腔镜经腹入路与胸腹腔镜联合入路治疗食管胃连接部腺癌预后效果的对照研究

Comparative study on the prognostic effects between laparoscopic transabdominal approach and thoracoscopic laparoscopic combined approach in treatment of adenocarcinoma of esophagogastric junction

摘要:

目的 比较腹腔镜经腹入路与胸腹腔镜联合入路治疗食管胃连接部腺癌（AEG）的预后效果。方法 选择2021年12月－2023年12月该院行AEG切除术，并行淋巴结清扫的患者110例。根据手术方式，将患者分为腹腔镜组（n = 62）和胸腹腔镜联合组（n = 48）。采用倾向评分匹配（PSM）平衡组间差异，减少潜在混杂因素后，比较两组患者的一般资料、围手术期指标、营养状态指标、术后并发症和术后生存情况；采用广义估计方程（GEE），构建两组患者治疗前后的营养状态相关指标模型；采用Cox比例风险模型，分析治疗方式对AEG患者预后的影响。结果 PSM前，两组患者性别、年龄、体重指数（BMI）、TNM分期、肿瘤最大直径和食管侵犯长度比较，差异均有统计学意义（P < 0.05）。PSM后，两组患者一般资料比较，差异无统计学意义（P > 0.05）；胸腹腔镜联合组手术时间、术后卧床时间、术后住院时间明显长于腹腔镜组（P < 0.05），术中出血量明显多于腹腔镜组（P < 0.05），术后24 h视觉模拟评分法（VAS）明显高于腹腔镜组（P < 0.05），淋巴结清扫数量、阳性淋巴结数量、纵隔淋巴结清扫数量和腹腔淋巴结清扫数量明显多于腹腔镜组（P < 0.05），血红蛋白（Hb）、白蛋白（ALB）、前白蛋白（PAB）、转铁蛋白（TRF）和体重（W）术前术后差值明显大于腹腔镜组（P < 0.05），两组患者术后并发症总发生率和1年生存率比较，差异均无统计学意义（P > 0.05）；GEE分析结果显示，腹腔镜治疗对Hb和TRF指标影响更大，胸腹腔镜联合治疗对ALB、PAB和W指标影响更大；腹腔镜治疗方式是AEG患者预后良好的保护因素（P < 0.05）。结论 腹腔镜治疗在手术时间、术后卧床时间、术后住院时间、术中出血量、24 h VAS和术后营养方面占优势；胸腹腔镜联合治疗在淋巴结清扫数量、阳性淋巴结数量，纵隔淋巴结清扫数量和腹腔淋巴结清扫数量方面占优势。综合考虑，腹腔镜治疗的短期预后更好。

Abstract:

Objective To compare the prognosis effects between laparoscopic transabdominal approach and thoracoscopic laparoscopic combined approach in treatment of adenocarcinoma of esophagogastric junction (AEG).Methods 110 patients who underwent AEG resection and lymph node dissection from December 2021 to December 2023 were selected and divided into laparoscopic group (n = 62) and thoracoscopic laparoscopic combined group (n = 48) according to treatment methods. After propensity score matching (PSM) was used to balance the difference between the two groups and reduce potential confounding factors, the general data, perioperative indexes, nutritional status indexes, postoperative complications, and postoperative survival of the two groups were analyzed. The generalized estimating equation (GEE) analysis was used to construct the nutritional status related index model of the two groups of patients before and after treatment. The Cox proportional risk model was used to analyse the effect of treatment on the prognosis of AEG patients.Results Before PSM, there were statistically significant differences in gender, age, body mass index (BMI), TNM grade, maximum tumor diameter and esophageal invasion length between the laparoscopic group and the thoracoscopic laparoscopic combined group (P < 0.05). After PSM, the results showed that there were no statistical significances in the comparison of general clinical data between the laparoscopic group and thoracoscopic laparoscopic combined group (P > 0.05). The operation time, postoperative bed time and postoperative hospital stay in the thoracoscopic laparoscopic combined group were significantly longer than those in the laparoscopic group (P < 0.05), the intraoperative blood loss was significantly more than that in the laparoscopic group (P < 0.05), and 24 h postoperative visual analogue scale (VAS) was significantly higher than that of laparoscopic group (P < 0.05). The number of lymph node dissection, the number of positive lymph nodes, the number of mediastinal lymph nodes dissection and the number of abdominal lymph nodes dissection were significantly more than those in the laparoscopic group (P < 0.05). The differences of hemoglobin (Hb), albumin (ALB), prealbumin (PAB), transferrin (TRF) and weight (W) before and after surgery were significantly higher than those in laparoscopic group (P < 0.05). And there were no statistically significant differences in postoperative complications and 1-year survival rate between the two groups (P > 0.05). The GEE analysis results showed that laparoscopic treatment had a greater impact on Hb and TRF, while thoracoscopic laparoscopic combined treatment had a greater impact on ALB, PAB and W. Laparoscopic treatment was a protective factor for good prognosis in AEG patients (P < 0.05).Conclusion The laparoscopic treatment has advantages in operation time, postoperative bed time, postoperative hospital stay, intraoperative blood loss, 24 h VAS and postoperative nutritional indexes. The thoracoscopic laparoscopic combined treatment has advantages in the number of lymph node dissection, the number of positive lymph node, the number of mediastinal lymph nodes dissection and the number of abdominal lymph nodes dissection. Considering the therapeutic effect comprehensively, the short-term prognosis of laparoscopic treatment is better.