*Department of General and Transplantation Surgery, University Hospital Zurich, Zurich, Switzerland †Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands ‡Department of Thoracic Surgery, University Ziekenhuisen Leuven, Leuven, Belgium §Division of Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden ¶Department of General Thoracic and Esophageal Surgery, Helsinki University Hospital, Helsinki, Finland ||Department of Surgery, Thomas Jefferson University, Philadelphia, PA **Department of Surgery, IRCCS Policlinico San Donato, University of Milan, Milan, Italy ††Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands ‡‡Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands §§Department of General, Visceral and Cancer Surgery, University Hospital Cologne, Cologne, Germany ¶¶Department of Surgery, University Center Ghent, Ghent, Belgium ||||Department of Upper GI Surgery, Queen Alexandra Hospital, Portsmouth, United Kingdom ***Department of General, Visceral and Transplant Surgery, University Medical Center, Mainz, Germany.
Ann Surg. 2017 Nov;266(5):814-821. doi: 10.1097/SLA.0000000000002445.
To define "best possible" outcomes in total minimally invasive transthoracic esophagectomy (ttMIE).
TtMIE, performed by experts in patients with low comorbidity, may serve as a benchmark procedure for esophagectomy.
From a cohort of 1057 ttMIE, performed over a 5-year period in 13 high-volume centers for esophageal surgery, we selected a study group of 334 patients (31.6%) that fulfilled criteria of low comorbidity (American Society of Anesthesiologists score ≤2, WHO/ECOG score ≤1, age ≤65 years, body mass index 19-29 kg/m). Endpoints included postoperative morbidity measured by the Clavien-Dindo classification and the comprehensive complication index. Benchmark values were defined as the 75th percentile of the median outcome parameters of the participating centers to represent best achievable results.
Benchmark patients were predominantly male (82.9%) with a median age of 58 years (53-62). High intrathoracic (Ivor Lewis) and cervical esophagogastrostomy (McKeown) were performed in 188 (56.3%) and 146 (43.7%) patients, respectively. Median (IQR) ICU and hospital stay was 0 (0-2) and 12 (9-18) days, respectively. 56.0% of patients developed at least 1 complication, and 26.9% experienced major morbidity (≥grade III), mostly related to pulmonary complications (25.7%), anastomotic leakage (15.9%), and cardiac events (13.5%). Benchmark values at 30 days after hospital discharge were ≤55.7% and ≤30.8% for overall and major complications, ≤18.0% for readmission, ≤3.1% for positive resection margins, and ≥23 for lymph node yield. Benchmarks at 30 and 90 days were ≤1.0% and ≤4.6% for mortality, and ≤40.8 and ≤42.8 for the comprehensive complication index, respectively.
This outcome analysis of patients with low comorbidity undergoing ttMIE may serve as a reference to evaluate surgical performance in major esophageal resection.
定义全微创经胸食管切除术（ttMIE）的“最佳”结果。
在低合并症患者中由专家进行的 ttMIE 可以作为食管切除术的基准程序。
在 13 个食管外科手术的高容量中心进行的为期 5 年的 1057 例 ttMIE 中，我们选择了一个符合低合并症标准的研究组（334 例患者（31.6%），美国麻醉医师协会评分≤2，世界卫生组织/东部合作肿瘤学组评分≤1，年龄≤65 岁，体重指数 19-29kg/m）。终点包括术后并发症，采用 Clavien-Dindo 分类和综合并发症指数进行评估。基准值定义为参与中心的中位数结果参数的第 75 个百分位数，以代表最佳可实现的结果。
基准患者主要为男性（82.9%），中位年龄为 58 岁（53-62 岁）。高胸腔内（Ivor Lewis）和颈段食管胃吻合术（McKeown）分别在 188 例（56.3%）和 146 例（43.7%）患者中进行。中位（IQR）重症监护病房和住院时间分别为 0（0-2）和 12（9-18）天。56.0%的患者至少发生了 1 种并发症，26.9%发生了主要并发症（≥III 级），主要与肺部并发症（25.7%）、吻合口漏（15.9%）和心脏事件（13.5%）有关。出院后 30 天的基准值为总并发症和主要并发症分别为≤55.7%和≤30.8%，再入院率≤18.0%，阳性切缘率≤3.1%，淋巴结产量≥23。出院后 30 天和 90 天的基准值分别为死亡率≤1.0%和≤4.6%，综合并发症指数分别为≤40.8%和≤42.8%。
本研究对低合并症患者进行 ttMIE 的结果分析，可为评估主要食管切除术的手术效果提供参考。
