Glatz Torben, Marjanovic Goran, Kulemann Birte, Sick Olivia, Hopt Ulrich Theodor, Hoeppner Jens
Department of General and Visceral Surgery and Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany.
Langenbecks Arch Surg. 2017 Mar;402(2):323-331. doi: 10.1007/s00423-017-1550-4. Epub 2017 Jan 12.
In esophageal surgery, total minimally invasive techniques compete with hybrid and robot-assisted procedures. The benefit of the individual techniques for the patient remains vague. At our institution, the hybrid minimally invasive laparoscopic-thoracotomic esophagectomy (HMIE) has been routinely applied since 2013. We conducted this retrospective study to analyze the perioperative outcome.
Since 2013, 60 patients were operated in HMIE technique for esophageal cancer. Each of these patients was paired according to the criteria of gender, BMI, age, tumor histology, pulmonary preexisting conditions, and a history of smoking with a patient treated by open esophagectomy (OE). Perioperative parameters were extracted from our prospectively maintained database and compared among the groups.
The HMIE and OE groups were homogeneous in terms of patient- and tumor-related data. There was no difference in lymph nodes harvested (22 vs. 20, p = 0.459) and R0-resection rate (95 vs. 93%, p = 0.500). The operation time for the HMIE was significantly shorter (329 vs. 407 min, p < 0.001). There was no difference between the groups with respect to surgical complications (37 vs. 37%, p = 0.575), but the patients undergoing hybrid technique showed more delayed gastric emptying (23 vs. 10%, p = 0.042). Pulmonary morbidity was significantly reduced after HMIE (20 vs. 42%, p = 0.009). This affected both the occurrence of pneumonia and pleural effusions. The difference in the overall complication rate was not significant (50 vs. 60%, p = 0.179), but life-threatening complications (Clavien/Dindo 4/5) were less frequent (2 vs. 12%, p = 0.031). Overall, there was significantly less need for transfusion after HMIE (18 vs. 50%, p < 0.001), and hospital (and IMC) stay was significantly shorter (14 (6) vs. 18 (7) days, p = 0.002 (0.003)). The multivariate analysis confirms the surgical procedure as an independent risk factor for the development of pulmonary complications (OR 3.2, p = 0.011). Furthermore, preexisting pulmonary conditions were identified as a risk factor (OR 3.6, p = 0.006).
Our retrospective analysis shows that reduction of postoperative pulmonary morbidity, perioperative blood loss, and shortening of hospital stay can be achieved by HMIE. The procedure is safe, and the rate of surgical complications and oncological radicality is comparable to the conventional procedure.
在食管手术中，完全微创技术与杂交手术及机器人辅助手术相互竞争。这些技术对患者的益处仍不明确。自2013年起，我们机构常规应用杂交微创腹腔镜 - 开胸食管切除术（HMIE）。我们进行这项回顾性研究以分析围手术期结果。
自2013年起，60例患者接受了HMIE技术的食管癌手术。根据性别、BMI、年龄、肿瘤组织学、肺部基础疾病和吸烟史等标准，将这些患者与接受开放食管切除术（OE）的患者进行配对。围手术期参数从我们前瞻性维护的数据库中提取并在组间进行比较。
HMIE组和OE组在患者及肿瘤相关数据方面具有同质性。在淋巴结清扫数量（22枚对20枚，p = 0.459）和R0切除率（95%对93%，p = 0.500）方面无差异。HMIE的手术时间明显更短（329分钟对407分钟，p < 0.001）。两组在手术并发症方面无差异（37%对37%，p = 0.575），但接受杂交技术的患者胃排空延迟更多（23%对10%，p = 0.042）。HMIE术后肺部并发症显著减少（20%对42%，p = 0.009）。这对肺炎和胸腔积液的发生均有影响。总体并发症发生率的差异不显著（50%对60%，p = 0.179），但危及生命的并发症（Clavien/Dindo 4/5级）发生率较低（2%对12%，p = 0.031）。总体而言，HMIE术后输血需求显著减少（18%对50%，p < 0.001），住院（及重症监护）时间显著缩短（14（6）天对18（7）天，p = 0.002（0.003））。多因素分析证实手术方式是发生肺部并发症的独立危险因素（OR 3.2，p = 0.011）。此外，肺部基础疾病被确定为一个危险因素（OR 3.6，p = 0.006）。
我们的回顾性分析表明，HMIE可降低术后肺部并发症、减少围手术期失血并缩短住院时间。该手术是安全的，手术并发症发生率和肿瘤根治性与传统手术相当。
