Objective To investigate the long-term outcomes of splenic hilar lymphadenectomy (SPL) in patients with Siewert type Ⅱ and Ⅲ adenocarcinoma of esophagogastric junction (AEG) and a tumor diameter≥ 4 cm after radical total gastrectomy.Methods The retrospectively cohort study was conducted.The clinicopathological data of 412 patients with Siewert type Ⅱ and Ⅲ AEG and a tumor diameter≥4 cm who were admitted to the Fnjian Medical University Union Hospital from December 2007 to December 2013 were collected.Transabdominal and open or laparoscopic radical total gastrectomies were applied to 412 patients by surgeons in the same team.Of 412 patients,154 receiving spleen-preserving SPL in situ were allocated into the SPL group and 258 who didn't receive SPL were allocated into the non-SPL group.Observation indicators included:(1) surgical situations,(2) follow-up situations,(3) postoperative survival factors analysis in patients with Siewert type Ⅲ AEG and a tumor diameter ≥ 4 cm.Follow-up using outpatient examination,door-to-door visit,correspondence and telephone interview was performed once every 3 months within 2 years postoperatively and once every 6 months within 3-5 years postoperatively up to June 2015.Follow-up included regular physical examination,laboratory examinations (levels of CA19-9,CA72-4 and CEA),chest X-ray,total abdomen color Doppler ultrasonography or computed tomography (CT) scan and annual gastroscopy.The overall survival was from operation to the last follow-up or death or deadline of follow-up database (loss to follow-up and dying of other diseases).Measurement data with normal distribution were represented as (x) ± s and comparison between groups was analyzed using the t test.Measurement data with skewed distribution were described as M (range) and comparison between groups was analyzed using the Mann-Whitney U test.Count data were analyzed using the chi-square test or Fisher exact probability.The survival rate and survival comparison were respectively done by the Kaplan-Meier method and the Log-rank test.The univariate analysis and multivariate analysis were done using the chi-square test and COX regression model.Results (1) Surgical situations:operation time,volume of intraoperative blood loss and number of lymph node dissected were (217 ±65) minutes,50 mL (range,10-1 000 mL),38 ± 13 in the SPL group and (204 ±54)minutes,50 mL (range,5-2 000 mL),31 ± 10 in the non-SPL group,respectively,with no statistically significant difference in volume of intraoperative blood loss between the 2 groups (Z =1.495,P ＞ 0.05) and with statistically significant differences in operation time and number of lymph node dissected between the 2 groups (t =2.140,5.400,P ＜ 0.05).Lymph node metastasis rate in the SPL group was 8.3％ (5/60) in patients with Siewert type Ⅱ AEG and 20.2％ (19/94) in patients with Siewert type Ⅲ AEG,with a statistically significant difference (x2 =3.930,P ＜ 0.05).Overall incidence of postoperative complications in the SPL group and non-SPL group was respectively 20.13％ (31/154) and 13.95％ (36/258),with no statistically significant difference between the 2 groups (x2 =2.700,P ＞ 0.05).(2) Follow-up situations:384 patients were followed up for48 months (range,17-89 months).The 3-year overall survival rate and disease-free survival rate were respectively 72.7％,67.4％ in the SPL group and 54.4％,48.5％ in the non-SPL group,with statistically significant differences between the 2 groups (x2 =7.580,12.380,P ＜ 0.05).Stratified analysis showed that 3-year overall survival rate and disease-free survival rate in patients with Siewert type Ⅱ AEG were 72.9％,63.7％ in the SPL group and 65.1％,59.4％ in the non-SPL group,with no statistically significant difference between the 2 groups (x2=0.280,0.580,P ＞0.05).Among patients with Siewert type Ⅲ AEG,3-year overall survival rate and disease-free survival rate which were 72.4％ and 68.3％ in the SPL group were significantly higher than that which were 48.3％ and 42.2％ in the non-SPL group (x2 =8.990,14.030,P ＜ 0.05).(3) Postoperative survival factors analysis in patients with Siewert type Ⅲ AEG and a tumor diameter ≥4 cm:results of univariate analysis showed that age,American Society of Anesthesiologists (ASA) score,tumor differentiation,splenic hilar dissection,T stage,N stage and TNM stage were factors affecting postoperative 3-year overall survival rate in patients with Siewert type Ⅲ AEG and a tumor diameter≥4 cm (x2 =8.825,7.485,6.766,8.996,14.024,26.002,19.461,P ＜0.05).There were correlations among age,splenic hilar dissection,N stage,TNM stage and postoperative 3-year disease-free survival rate in patients with Siewert type Ⅲ AEG and a tumor diameter ≥ 4 cm (x2=6.743,14.038,26.596,21.285,P ＜ 0.05).Results of multivariate analysis showed that age ≥ 65 years,without splenic hilar dissection,T stage and N stage were independent risk factors affecting postoperative 3-year overall survival rate in patients with Siewert type Ⅲ AEG and a tumor diameter ≥4 cm [HR =1.817,0.458,1.613,1.312,95％ confidence interval (CI):1.117-2.955,0.292-0.721,1.129-2.304,1.004-1.714,P ＜ 0.05].Age ≥ 65 years,without splenic hilar dissection and TNM stage were independent risk factors affecting postoperative 3-year disease-free survival rate in patients with Siewert type Ⅲ AEG and a tumor diameter ≥4 cm (HR =1.807,0.442,1.799,95％ CI:1.258-2.596,0.228-0.679,1.004-3.224,P ＜ 0.05).Conclusions SPL should be performed to patients with Siewert type Ⅲ AEG and a tumor diameter≥4 cm due to higher lymph node metastasis rate,and it will be beneficial to survival of patients.%目的 探讨脾门淋巴结清扫对肿瘤长径≥4 cm的Siewert Ⅱ型和Ⅲ型食管胃结合部腺癌(AEG)患者行根治性全胃切除术后远期疗效的影响.方法 采用回顾性队列研究方法.收集2007年12月至2013年12月福建医科大学附属协和医院收治的412例肿瘤长径≥4 cm的Siewert Ⅱ型和Ⅲ型AEG患者的临床病理资料.患者由同一组医师施行经腹开腹或腹腔镜根治性全胃切除术,其中154例患者行保脾原位脾门淋巴结清扫术设为脾门清扫组;258例患者未行脾门淋巴结清扫术设为未清扫组.观察指标:(1)手术情况.(2)随访情况.(3)影响肿瘤长径≥4 cm Siewert Ⅲ型AEG患者术后生存因素分析.术后采用门诊、登门拜访、信件及电话等方式进行随访.2年内每3个月随访1次,3～5年每6个月随访1次.随访内容为:常规体格检查,实验室检查(CA19-9、CA72-4、CEA水平),胸部X线片,全腹彩色多普勒超声或CT检查,每年行1次胃镜检查.总生存时间为自手术至末次随访时间,或死亡时间,或随访数据库截止时间(如失访、死于其他疾病等).随访时间截至2015年6月.正态分布的计量资料采用(x)±s表示,组间比较采用t检验.偏态分布的计量资料以M(范围)表示,组间比较采用Mann-Whitney U检验.计数资料采用x2检验或Fisher确切概率检验.Kaplan-Meier法计算生存率,生存情况比较采用Log-rank检验.预后单因素分析采用x2检验,多因素分析采用COX风险回归模型.结果 (1)手术情况:154例脾门清扫组患者手术时间、术中出血量、淋巴结清扫数目分别为(217±65) min、50 mL(10～1 000 mL)、(38±13)枚;258例未清扫组患者分别为(204±54) min、50 mL(5 ～2 000mL)、(31±10)枚.两组患者术中出血量比较,差异无统计学意义(Z=1.495,P ＞0.05).两组患者手术时间和淋巴结清扫数目比较,差异均有统计学意义(t=2.140,5.400,P＜0.05).154例脾门清扫组患者中,Siewert Ⅱ型和Ⅲ型脾门淋巴结转移率分别为8.3％ (5/60)和20.2％ (19/94),两者比较,差异有统计学意义(x2=3.930,P ＜0.05).脾门清扫组患者术后总体并发症发生率为20.13％ (31/154),未清扫组为13.95％(36/258),两组患者比较,差异无统计学意义(x2=2.700,P＞0.05).(2)随访情况:384例患者获得随访,随访时间为48个月(17～ 89个月).脾门清扫组和未清扫组患者3年总体生存率分别为72.7％和54.4％,无病生存率分别为67.4％和48.5％,两组患者比较,差异均有统计学意义(x2=7.580,12.380,P＜0.05).分层分析显示:Siewert Ⅱ型患者中,脾门清扫组3年总体生存率及无病生存率分别为72.9％和63.7％,未清扫组分别为65.1％和59.4％,两组患者比较,差异均无统计学意义(x2=0.280,0.580,P＞0.05).SiewertⅢ型患者中,脾门清扫组3年总体生存率及无病生存率分别为72.4％和68.3％,高于未清扫组的48.3％和42.2％,两组患者比较,差异均有统计学意义(x2=8.990,14.030,P＜0.05).(3)影响肿瘤长径≥4 cm Siewert Ⅲ型AEG患者术后生存因素分析:单因素分析结果显示:患者年龄、美国麻醉医师协会(ASA)评分、肿瘤分化、脾门清扫、T分期、N分期、TNM分期是肿瘤长径≥4 cm Siewert Ⅲ型AEG患者术后3年总体生存率的影响因素(x2=8.825,7.485,6.766,8.996,14.024,26.002,19.461,P＜0.05);年龄、脾门清扫、N分期、TNM分期与肿瘤长径≥4 cm Siewert Ⅲ型AEG患者术后3年无病生存率密切相关(x2=6.743,14.038,26.596,21.285,P＜0.05).多因素分析结果显示:年龄≥65岁、未行脾门清扫、T分期、N分期是肿瘤长径≥4 cm Siewert Ⅲ型AEG患者术后3年总体生存率的独立影响因素(HR=1.817,0.458,1.613,1.312,95％可信区间:1.117～2.955,0.292 ～0.721,1.129 ～2.304,1.004 ～1.714,P＜0.05).年龄≥65岁、未行脾门清扫、TNM分期是肿瘤长径≥4 cm Siewert Ⅲ型AEG患者术后3年无病生存率的独立影响因素(HR=1.807,0.442,1.799,95％可信区间:1.258～2.596,0.228～0.679,1.004～3.224,P＜0.05).结论 肿瘤长径≥4 cm的Siewert Ⅲ型AEG患者脾门淋巴结转移率高,对该类患者行脾门淋巴结清扫可使其生存获益.
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