van Workum Frans, Berkelmans Gijs H, Klarenbeek Bastiaan R, Nieuwenhuijzen Grard A P, Luyer Misha D P, Rosman Camiel
Department of surgery, Radboudumc, Nijmegen, the Netherlands.
Department of surgery, Catharina hospital, Eindhoven, the Netherlands.
J Thorac Dis. 2017 Jul;9(Suppl 8):S826-S833. doi: 10.21037/jtd.2017.03.173.
Minimally invasive esophagectomy (MIE) has consistently been associated with improved perioperative outcome and similar oncological safety compared to open esophagectomy. However, it is currently unclear what type of MIE is preferred for patients with resectable esophageal cancer.
Literature was searched in Medline, Embase and the Cochrane library combining relevant search terms. Articles that included patients undergoing totally minimally invasive esophagectomy (TMIE) or hybrid minimally invasive esophagectomy (HMIE) and compared McKeown with Ivor Lewis procedures were included. Studies were excluded if they included >10% of patients undergoing a procedure other than MIE McKeown or MIE Ivor Lewis (i.e., transhiatal resections). The primary outcome parameter was anastomotic leakage. Secondary outcome parameters were: other complications, reinterventions, reoperations, hospital length of stay, ICU length of stay, postoperative mortality, operative time, blood loss, R0 resection rate, lymph nodes examined, quality of life and costs.
Five studies with a total of 1,681 patients undergoing TMIE were included. There were no studies comparing HMIE McKeown versus HMIE Ivor Lewis. There were no randomized controlled trials and all included studies were cohort studies with a moderate risk of bias. No meta-analysis could be performed for R0 resection rate, survival, quality of life and costs because there was insufficient data available for these parameters. The incidence of anastomotic leakage did not differ between the groups [relative risk (RR) =1.39, 95% confidence interval (CI) =0.90-10.38, P=0.14]. TMIE Ivor Lewis was associated with a lower incidence of recurrent laryngeal nerve (RLN) trauma (RR =6.70, 95% CI =3.09-14.55, P<0.001), a shorter hospital length of stay [standardized mean difference (SMD) =0.17, 95% CI =0.06-0.28, P=0.002] and less blood loss (SMD =0.69, 95% CI =0.25-1.12, P=0.002).
TMIE Ivor Lewis is associated with improved outcome regarding RLN trauma, hospital length of stay and blood loss as compared to TMIE-McKeown, but the incidence of anastomotic leakage is not different. The evidence is limited, of low quality and at risk for bias. A randomized controlled trial is currently being performed in order to demonstrate whether a McKeown or Ivor Lewis procedure should be preferred in patients undergoing MIE.
与开放食管切除术相比，微创食管切除术（MIE）一直与围手术期结局改善及相似的肿瘤学安全性相关。然而，目前尚不清楚对于可切除食管癌患者，哪种类型的MIE更为可取。
在Medline、Embase和Cochrane图书馆中检索文献，组合相关检索词。纳入包含接受完全微创食管切除术（TMIE）或杂交微创食管切除术（HMIE）且比较了麦克尤恩手术与艾弗·刘易斯手术的患者的文章。如果研究纳入了超过10%接受MIE麦克尤恩手术或MIE艾弗·刘易斯手术以外的其他手术（即经裂孔切除术）的患者，则将其排除。主要结局参数为吻合口漏。次要结局参数包括：其他并发症、再次干预、再次手术、住院时间、重症监护病房（ICU）住院时间、术后死亡率、手术时间、失血量、R0切除率、检查的淋巴结、生活质量和费用。
纳入了5项研究，共1681例接受TMIE的患者。没有比较HMIE麦克尤恩手术与HMIE艾弗·刘易斯手术的研究。没有随机对照试验，所有纳入研究均为队列研究，存在中度偏倚风险。由于这些参数的数据不足，无法对R0切除率、生存率、生活质量和费用进行荟萃分析。两组之间吻合口漏的发生率无差异[相对危险度（RR）=1.39，95%置信区间（CI）=0.90 - 10.38，P = 0.14]。TMIE艾弗·刘易斯手术与喉返神经（RLN）损伤发生率较低相关（RR = 6.70，95% CI = 3.09 - 14.55，P < 0.001），住院时间较短[标准化均数差（SMD）= 0.17，95% CI = 0.06 - 0.28，P = 0.002]，失血量较少（SMD = 0.69，95% CI = 0.25 - 1.12，P = 0.002）。
与TMIE - 麦克尤恩手术相比，TMIE艾弗·刘易斯手术在RLN损伤发生率、住院时间和失血量方面结局更好，但吻合口漏的发生率没有差异。证据有限，质量低且存在偏倚风险。目前正在进行一项随机对照试验，以证明在接受MIE的患者中，麦克尤恩手术还是艾弗·刘易斯手术更为可取。
