经胸切口的食管切除术会增加肺部发病率。

Esophagectomies with thoracic incisions carry increased pulmonary morbidity.

机构信息

Providence Cancer Center, Portland, Oregon.

出版信息

JAMA Surg. 2013 Aug;148(8):733-8. doi: 10.1001/jamasurg.2013.2356.

DOI:10.1001/jamasurg.2013.2356

PMID:23784203

Abstract

IMPORTANCE

Thoracic incisions are not required for all esophagectomies and may increase pulmonary morbidity.

OBJECTIVE

To compare the pulmonary and overall morbidity of esophagectomies with and without thoracic incisions.

DESIGN

Observational study.

SETTING

Hospitals participating in the National Surgical Quality Improvement Project.

PARTICIPANTS

Patients without metastatic cancer undergoing nonemergency total esophagectomies with reconstruction from 2005 through 2010. Patients who underwent transhiatal esophagectomy (THE) were compared with a THORACIC group (Ivor Lewis and McKeown techniques).

MAIN OUTCOMES AND MEASURES

Pulmonary and overall morbidity, infection, and thromboembolic complications.

RESULTS

Of 1568 patients, 717 (45.7%) underwent THE, and 851 (54.3%) were in the THORACIC group (Ivor Lewis technique in 487 [31.1%] and McKeown technique in 364 [23.2%]). The population was 80.5% male, with a mean age of 62.9 years. Patients undergoing THE were older (P = .02). Diabetes mellitus was less common in the THORACIC group (11.2% vs 15.9% for THE; P = .02), and cancer was more common (91.0% vs 87.0%; P = .01). Morbidity was 49.2% and mortality was 3.3%, without differences between groups. The mean length of stay was 1.6 days shorter (P = .009) in the THE group. Multivariable analysis showed that thoracic incisions increased rates of pneumonia (odds ratio [OR], 1.47; P = .007), ventilator dependence (OR, 1.35; P = .04), and septic shock (OR, 1.86; P = .001) but not mortality. Compared with the Ivor Lewis technique, the McKeown technique worsened the odds of superficial wound infections (OR, 1.71; P = .02) but not septic shock (OR, 0.84; P = .47).

CONCLUSIONS AND RELEVANCE

Esophagectomies have an acceptable mortality rate but a significant morbidity rate. We demonstrated that rates of pneumonia, ventilator dependence, and septic shock are increased with the use of thoracic incision. Avoiding thoracic incisions may therefore decrease the risk of pulmonary morbidity and septic shock.

摘要

重要性

并非所有的食管癌切除术都需要开胸，开胸可能会增加肺部发病率。

目的

比较有无开胸的食管癌切除术的肺部和总体发病率。

设计

观察性研究。

地点

参与国家外科质量改进计划的医院。

参与者

无转移性癌症的患者在 2005 年至 2010 年间接受非紧急全食管切除术和重建。经胸食管切除术（THE）患者与胸腔组（Ivor Lewis 和 McKeown 技术）进行比较。

主要结果和测量指标

肺部和总体发病率、感染和血栓栓塞并发症。

结果

在 1568 名患者中，717 名（45.7%）接受了 THE，851 名（54.3%）在胸腔组（Ivor Lewis 技术 487 名[31.1%]，McKeown 技术 364 名[23.2%]）。人群中 80.5%为男性，平均年龄为 62.9 岁。接受 THE 的患者年龄更大（P = .02）。胸腔组糖尿病发病率较低（11.2%比 THE 组的 15.9%；P = .02），癌症发病率较高（91.0%比 87.0%；P = .01）。两组之间的发病率没有差异，发病率为 49.2%，死亡率为 3.3%。THE 组的平均住院时间缩短了 1.6 天（P = .009）。多变量分析显示，开胸增加了肺炎（比值比 [OR]，1.47；P = .007）、呼吸机依赖（OR，1.35；P = .04）和感染性休克（OR，1.86；P = .001）的发生率，但不增加死亡率。与 Ivor Lewis 技术相比，McKeown 技术增加了浅表伤口感染的几率（OR，1.71；P = .02），但不增加感染性休克的几率（OR，0.84；P = .47）。