Alldinger Ingo, Sisic Leila, Hochreiter Marcel, Weichert Wilko, Blank Susanne, Burian Maria, Grenacher Lars, Bruckner Tom, Werner Jens, Büchler Markus W, Ott Katja
Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, INF 110, 69120, Heidelberg, Germany,
Langenbecks Arch Surg. 2015 Jan;400(1):9-18. doi: 10.1007/s00423-014-1257-8. Epub 2014 Nov 20.
Esophagectomy for esophageal cancer remains a challenge with relatively high morbidity. We analyzed outcome, complications, and mortality after abdominothoracic esophagectomy with intrathoracic anastomosis. No routine preoperative risk stratification was performed.
One hundred eighty-seven consecutive patients (105 AEG I, 21 AEG II, 58 SCC, and 3 other entities) underwent standardized right abdominothoracic esophagectomy with intrathoracic anastomosis and two field lymphadenectomy between 2003 and 2009. Reconstruction was performed mostly with a gastric tube (n = 126) or a fundus rotation gastroplasty (n = 57). Seventy-four patients underwent neoadjuvant treatment (36 patients chemotherapy; 38 patients chemoradiotherapy).
Postoperative morbidity was high (73.2 %). Ninety-two patients (49.2 %) suffered from surgical complications, 50 patients had major (26.7 %), and 42 minor (22.5 %) complications. Thirty-day mortality was 9/187 (4.8 %) while in-hospital mortality was doubled with 9.6 %. Six of 19 of the patients died without surgical complications. Preoperative treatment did not increase morbidity or mortality. Surgical complications with subsequent death were tracheobronchial fistula (2/3), ischemia of the gastric tube (3/6), anastomotic leakage (6/30), chylothorax (1/6), and intraoperative bleeding from the aorta (1/1). The median overall survival was 25.0 months. The occurrence of surgical or medical complications did not influence overall survival. In multivariate analysis, cT-category, pN-category, R-category, and re-intubation were independent prognostic factors.
Abdominothoracic esophagectomy with intrathoracic anastomosis without preoperative patient selection is associated with a high risk for complications and subsequent death but ranges still within the upper range of published data. Strict patient selection is accepted to reduce postoperative morbidity and mortality but excludes a subgroup of patients from potentially curative resection.
食管癌的食管切除术仍然是一项挑战，其发病率相对较高。我们分析了经胸腹部食管切除术并进行胸内吻合术后的结果、并发症及死亡率。术前未进行常规风险分层。
2003年至2009年间，187例连续患者（105例AEG I型、21例AEG II型、58例鳞状细胞癌及3例其他类型）接受了标准化的经右胸腹部食管切除术并进行胸内吻合及两野淋巴结清扫术。重建大多采用胃管（n = 126）或胃底旋转胃成形术（n = 57）。74例患者接受了新辅助治疗（36例化疗；38例放化疗）。
术后发病率较高（73.2%）。92例患者（49.2%）出现手术并发症，50例为严重并发症（26.7%），42例为轻微并发症（22.5%）。30天死亡率为9/187（4.8%），而住院死亡率翻倍，为9.6%。19例患者中有6例死于无手术并发症。术前治疗未增加发病率或死亡率。导致后续死亡的手术并发症有气管支气管瘘（2/3）、胃管缺血（3/6）、吻合口漏（6/30）、乳糜胸（1/6）及术中主动脉出血（1/1）。中位总生存期为25.0个月。手术或内科并发症的发生不影响总生存期。多因素分析显示，cT分期、pN分期、R分期及再次插管是独立的预后因素。
未经术前患者选择的经胸腹部食管切除术并胸内吻合术并发症及后续死亡风险较高，但仍处于已发表数据的较高范围。接受严格的患者选择以降低术后发病率和死亡率，但会将一部分患者排除在可能的根治性切除之外。
