Department of Upper Gastrointestinal and Oesophago-Gastric Surgery, Royal Bournemouth Hospital, Castle Lane East, Bournemouth, BH7 7DW, UK.
Department of General Surgery, Salisbury District Hospital, Odstock Road, Salisbury, SP2 8BJ, UK.
Surg Endosc. 2017 Sep;31(9):3681-3689. doi: 10.1007/s00464-016-5406-8. Epub 2017 Jan 11.
The trend towards laparoscopic surgery seen in other specialties has not occurred at the same pace in oesophagectomy. This stems from concerns regarding compromised oncological clearance, and complications associated with gastric tube necrosis and anastomotic failure. We present our experience of minimally invasive oesophagectomy (MIO) compared to open and hybrid surgery. We aim to ascertain non-inferiority of MIO by evaluating impact on survival, oncological clearance by resection margin and lymph node harvest and post-operative complications.
Data were sourced retrospectively 2008-2015. Three approaches were studied. MIO (3-stage Mckeown), hybrid (2-stage Ivor Lewis, laparoscopy, thoracotomy) and open (2-stage Ivor Lewis).
Five-year survival was 54.2%. Surgical approach had no significant impact on survival at any stage of disease (Stage 0/I p = 0.98; stage II p = 0.2; stage III p = 0.76). There was no statistically significant difference in oncological clearance by resection margins between procedures when compared by disease stage (p = 0.49). A higher number of nodes were harvested in hybrid [median 27.5 (6-65)] and open surgeries [median 26 (4-54)] than in MIO [median 20 (7-44)] (p > 0.01). Numbers of nodes resected did not impact risk of recurrence [recurrence, median 25 (6-54), no recurrence, 26 (4-65)] (p = 0.25). Anastomotic strictures (22.4%) and potential leaks (17.9%) were more common in MIO (strictures p > 0.01, leaks p = 0.08), although associated morbidity was lower. Respiratory complications were less common in MIO (2.9%) versus hybrid (13.3%) (p = 0.02). Wound infection and chyle leak were also lower (wound 1.5% MIO 3.5% open, p = 0.6; chyle leak 1.5% MIO, 6.7% hybrid, p = 0.2).
Our results show no negative impact of MIO on survival or oncological clearance. Respiratory and wound complications are lower in MIO, but rates of anastomotic strictures and potential anastomotic leaks are increased. This may be due to the longer length of conduit and subclinical ischaemia at the anastomosis and merits further evaluation.
在其他专业领域中，腹腔镜手术的趋势并没有在食管切除术上同步出现。这源于对肿瘤清除效果不佳以及胃管坏死和吻合口失败相关并发症的担忧。我们展示了我们在微创食管切除术（MIO）方面的经验，并与开放和杂交手术进行了比较。我们旨在通过评估对生存的影响、切除边缘和淋巴结采集的肿瘤学清除以及术后并发症来确定 MIO 的非劣效性。
数据来自 2008 年至 2015 年的回顾性资料。研究了三种方法：MIO（3 期 McKeown）、杂交（2 期 Ivor Lewis，腹腔镜，开胸）和开放（2 期 Ivor Lewis）。
5 年生存率为 54.2%。手术方式在疾病的任何阶段均未对生存产生显著影响（0/Ⅰ期 p=0.98；Ⅱ期 p=0.2；Ⅲ期 p=0.76）。当按疾病阶段比较时，各手术方法的切缘肿瘤学清除率无统计学差异（p=0.49）。与 MIO [中位数 20（7-44）]相比，杂交[中位数 27.5（6-65）]和开放手术[中位数 26（4-54）]采集的淋巴结数量更多（p>0.01）。切除的淋巴结数量并不影响复发的风险[复发，中位数 25（6-54），无复发，26（4-65）]（p=0.25）。吻合口狭窄（22.4%）和潜在漏诊（17.9%）在 MIO 中更为常见（狭窄 p>0.01，漏诊 p=0.08），尽管相关发病率较低。与杂交组相比，MIO 组的呼吸并发症较少（2.9%对 13.3%）（p=0.02）。MIO 组的伤口感染和乳糜漏发生率也较低（伤口 1.5%，MIO 3.5%，开放组，p=0.6；乳糜漏 1.5%，MIO 6.7%，杂交组，p=0.2）。
我们的结果表明 MIO 对生存或肿瘤学清除没有负面影响。MIO 组的呼吸和伤口并发症较低，但吻合口狭窄和潜在吻合口漏的发生率较高。这可能是由于吻合处的导管较长和亚临床缺血所致，值得进一步评估。
