Department of General, Visceral and Cancer Surgery, University Hospital Cologne, Germany.
Department of General and Transplantation Surgery, University Hospital Zurich, Zurich, Switzerland.
Ann Surg. 2019 Nov;270(5):820-826. doi: 10.1097/SLA.0000000000003538.
OBJECTIVE: The aim of this study was to describe anastomotic techniques used for total minimally invasive transthoracic esophagectomy (ttMIE) and to analyze the associated morbidity. BACKGROUND: ttMIE faces increasing application in surgical treatment of esophageal cancer. For esophagogastric reconstruction, different anastomotic techniques are currently used, but their effect on postoperative anastomotic leakage and morbidity has not been investigated. PATIENTS AND METHODS: Patients were selected from a basic dataset, collected during a 5-year period from 13 international surgical high-volume centers. Endpoints were anastomotic leakage rate and postoperative morbidity in correlation to anastomotic techniques, measured by the Clavien-Dindo classification and the Comprehensive Complication Index (CCI). RESULTS: Five anastomotic techniques were identified in 966 patients after ttMIE: intrathoracic end-to-side circular-stapled technique in 427 patients (double-stapling n = 90, purse-string n = 337), intrathoracic (n = 109) or cervical (n = 255) side-to-side linear-stapled, and cervical end-to-side hand-sewn (n = 175). Leakage rates were similar in intrathoracic and cervical anastomoses (15.9% vs 17.2%, P = 0.601), but overall complications (56.7%% vs 63.7%, P = 0.029) and median 90-day CCI {21 [interquartile range (IQR) 0-36] vs 29 [IQR 0-40], P = 0.019} favored intrathoracic reconstructions. Leakage rates after intrathoracic end-to-side double-stapling (23.3%) and cervical end-to-side hand-sewn (25.1%) techniques were significantly higher compared with intrathoracic side-to-side linear (15.6%), end-to-side purse-string (13.9%), and cervical side-to-side linear-stapled esophagogastrostomies (11.8%) (P < 0.001). Multivariable analysis confirmed anastomotic technique as independent predictor of leakage after ttMIE. CONCLUSION: Results of this analysis present the current status of the technical evolution of ttMIE with anastomotic leakage as predominant surgical complication. However, technique-related morbidity requires cautious interpretation considering the long learning curve of this complex surgical procedure.
目的：本研究旨在描述全微创经胸食管切除术（ttMIE）中使用的吻合技术，并分析相关并发症。
背景：ttMIE 在食管癌的外科治疗中应用日益广泛。对于食管胃重建，目前使用不同的吻合技术，但尚未研究其对术后吻合口漏和并发症的影响。
患者和方法：从 13 个国际外科大容量中心收集的 5 年基本数据集，选择患者。研究终点是吻合口漏发生率和与吻合技术相关的术后并发症，通过 Clavien-Dindo 分类和综合并发症指数（CCI）进行测量。
结果：在 966 例 ttMIE 后确定了 5 种吻合技术：胸腔内端侧圆形吻合技术 427 例（双吻合 n = 90，荷包缝合 n = 337），胸腔内（n = 109）或颈部（n = 255）侧侧直线吻合，以及颈部端侧手工缝合（n = 175）。胸腔内和颈部吻合口的漏率相似（15.9%比 17.2%，P = 0.601），但总体并发症（56.7%比 63.7%，P = 0.029）和中位 90 天 CCI {21 [四分位距（IQR）0-36]比 29 [IQR 0-40]，P = 0.019}有利于胸腔内重建。胸腔内端侧双吻合（23.3%）和颈部端侧手工缝合（25.1%）技术的漏率明显高于胸腔内侧侧直线（15.6%）、端侧荷包缝合（13.9%）和颈部侧侧直线吻合（11.8%）（P < 0.001）。多变量分析证实吻合技术是 ttMIE 后吻合口漏的独立预测因素。
结论：本分析结果介绍了 ttMIE 技术演变的现状，吻合口漏是主要的手术并发症。然而，考虑到这种复杂手术的学习曲线较长，技术相关的发病率需要谨慎解释。
Surg Laparosc Endosc Percutan Tech. 2022-6-1
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