微创食管癌切除术能否替代开放性食管癌切除术？日本国家临床数据库 24233 例食管癌切除术的最新分析。

Can Minimally Invasive Esophagectomy Replace Open Esophagectomy for Esophageal Cancer? Latest Analysis of 24,233 Esophagectomies From the Japanese National Clinical Database.

机构信息

Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Chuoku, Kumamoto, Japan.

Division of Translational Research and Advanced Treatment Against Gastrointestinal Cancer, Kumamoto University, Chuoku, Kumamoto, Japan.

出版信息

Ann Surg. 2020 Jul;272(1):118-124. doi: 10.1097/SLA.0000000000003222.

DOI:10.1097/SLA.0000000000003222

PMID:30720501

Abstract

OBJECTIVE

We aimed to elucidate whether minimally invasive esophagectomy (MIE) can be safely performed by reviewing the Japanese National Clinical Database.

SUMMARY OF BACKGROUND DATA

MIE is being increasingly adopted, even for advanced esophageal cancer that requires various preoperative treatments. However, the superiority of MIE's short-term outcomes compared with those of open esophagectomy (OE) has not been definitively established in general clinical practice.

METHODS

This study included 24,233 esophagectomies for esophageal cancer conducted between 2012 and 2016. Esophagectomy for clinical T4 and M1 stages, urgent esophagectomy, 2-stage esophagectomy, and R2 resection were excluded. The effects of preoperative treatment and surgery on short-term outcomes were analyzed using generalized estimating equations logistic regression analysis.

RESULTS

MIE was superior or equivalent to OE in terms of the incidence of most postoperative morbidities and surgery-related mortality, regardless of the type of preoperative treatment. Notably, MIE performed with no preoperative treatment was associated with significantly less incidence of any pulmonary morbidities, prolonged ventilation ≥48 hours, unplanned intubation, surgical site infection, and sepsis. However, reoperation within 30 days in patients with no preoperative treatment was frequently observed after MIE. The total surgery-related mortality rates of MIE and OE were 1.7% and 2.4%, respectively (P < 0.001). Increasing age, low preoperative activities of daily living, American Society of Anesthesiologists physical status ≥3, diabetes mellitus requiring insulin use, chronic obstructive pulmonary disease, congestive heart failure, creatinine ≥1.2 mg/dL, and lower hospital case volume were identified as independent risk factors for surgery-related mortality.

CONCLUSIONS

The results suggest that MIE can replace OE in various situations from the perspective of short-term outcome.

摘要

目的

通过审查日本国家临床数据库，阐明微创食管切除术（MIE）是否可以安全实施。

摘要背景数据

即使对于需要各种术前治疗的晚期食管癌，MIE 的应用也在不断增加。然而，MIE 的短期结果与开放食管切除术（OE）相比的优势在一般临床实践中尚未得到明确确立。

方法

本研究纳入了 2012 年至 2016 年间进行的 24233 例食管癌食管切除术。排除临床 T4 和 M1 期、急诊食管切除术、两阶段食管切除术和 R2 切除术。使用广义估计方程逻辑回归分析，分析术前治疗和手术对短期结果的影响。

结果

无论术前治疗类型如何，MIE 在大多数术后并发症和手术相关死亡率的发生率方面均优于或等同于 OE。值得注意的是，无术前治疗的 MIE 与任何肺部并发症、通气时间延长≥48 小时、计划外插管、手术部位感染和脓毒症的发生率显著降低相关。然而，无术前治疗的患者在 MIE 后 30 天内经常需要再次手术。MIE 和 OE 的总手术相关死亡率分别为 1.7%和 2.4%（P<0.001）。年龄增长、术前日常生活活动能力低、美国麻醉医师协会身体状况≥3、需要胰岛素治疗的糖尿病、慢性阻塞性肺疾病、充血性心力衰竭、肌酐≥1.2mg/dL 和较低的医院病例量被确定为手术相关死亡率的独立危险因素。