McManus K, Anikin V, McGuigan J
Northern Ireland Regional Thoracic Surgical Department, Royal Victoria Hospital, Belfast, UK.
Eur J Cardiothorac Surg. 1999 Sep;16(3):261-5. doi: 10.1016/s1010-7940(99)00223-7.
Anastomotic recurrence is a major cause of late mortality following oesophago-gastrectomy (OG) for carcinoma of the oesophagus and oesophago-gastric junction using either the Ivor Lewis or left thoraco-abdominal approach with intra-thoracic anastomosis. The aim of this study was to determine whether the more extensive total thoracic oesophagectomy (TTO) with cervical anastomosis would reduce the anastomotic recurrence rate while maintaining acceptable operative morbidity and mortality.
From January 1988 to December 1996, 108 total thoracic oesophagectomies and 66 oesophago-gastrectomies were performed with curative intent in 174 patients (125 males, mean age 62.4 years) with carcinoma (squamous cell carcinoma in 34 and adenocarcinoma in 140) of the middle (31 patients) and lower (44 patients) oesophagus and oesophago-gastric junction (99 patients).
Minor complications occurred in 37 (34%) total thoracic oesophagectomy and 18 (27%) oesophago-gastrectomy patients, major complications in 15 (14%) and 5 (8%) and peri-operative death in 5 (4.6%) and 7 (11%) patients, respectively. Anastomotic leakage occurred in 10 (9%) total thoracic oesophagectomy and 5 (8%) oesophago-gastrectomy patients, and was fatal in 1 (1%) and 4 (6%). There was no incidence of tumour at or within 5 mm of the proximal limit in the total thoracic oesophagectomy group and this was reflected in the complete absence of anastomotic recurrence. In the oesophago-gastrectomy group there was a positive proximal resection margin in 13 (20%) and 13 anastomotic recurrences (22% of peri-operative survivors). The 5-year survival (including operative mortality) was 29% for total thoracic oesophagectomy compared with 21% for the other techniques (P = 0.028 log rank test). Median survival was 25.2 months after total thoracic oesophagectomy and 15.8 after oesophago-gastrectomy.
Total thoracic oesophagectomy can be performed in oesophageal cancer patients with comparable morbidity to that of lesser resections. Incomplete proximal resection and anastomotic recurrence did not occur in this series of 108 total thoracic oesophagectomies and this is reflected in an increased medium term survival. The improved survival is most apparent for tumours of the oesophago-gastric junction.
吻合口复发是采用艾弗·刘易斯（Ivor Lewis）术式或经左胸腹联合切口行胸内吻合的食管癌及食管胃交界癌食管胃切除术（OG）术后晚期死亡的主要原因。本研究的目的是确定更广泛的经胸全食管切除术（TTO）并进行颈部吻合是否能降低吻合口复发率，同时保持可接受的手术 morbidity 和 mortality。
1988年1月至1996年12月，对174例（125例男性，平均年龄62.4岁）患有中（31例）、下段（44例）食管癌及食管胃交界癌（99例）（34例鳞状细胞癌，140例腺癌）的患者进行了108例经胸全食管切除术和66例食管胃切除术，均为根治性手术。
经胸全食管切除术患者中有37例（34%）发生轻微并发症，食管胃切除术患者中有18例（27%）；严重并发症分别发生在15例（14%）和5例（8%）；围手术期死亡分别发生在5例（4.6%）和7例（11%）患者中。经胸全食管切除术患者中有10例（9%）发生吻合口漏，食管胃切除术患者中有5例（8%），其中1例（1%）和4例（6%）死亡。经胸全食管切除术组近端切缘5mm 以内或切缘处均无肿瘤发生，这也反映在完全没有吻合口复发上。食管胃切除术组有13例（20%）近端切缘阳性，13例吻合口复发（占围手术期存活者的22%）。经胸全食管切除术的5年生存率（包括手术死亡率）为29%，其他术式为21%（对数秩检验P = 0.028）。经胸全食管切除术后中位生存期为25.2个月，食管胃切除术后为15.8个月。
经胸全食管切除术可在食管癌患者中进行，其 morbidity 与较小切除手术相当。在这108例经胸全食管切除术系列中未发生近端切除不完全和吻合口复发，这也反映在中期生存率的提高上。生存率的提高在食管胃交界癌肿瘤中最为明显。
