Bartella I, Brinkmann S, Fuchs H, Leers J, Schlößer H A, Bruns C J, Schröder W
Department of General, Visceral and Cancer Surgery, University of Cologne, Kerpener Str. 32, 50937, Cologne, Germany.
Surg Endosc. 2021 Mar;35(3):1182-1189. doi: 10.1007/s00464-020-07485-9. Epub 2020 Mar 12.
Ivor-Lewis esophagectomy (ILE) is the standard surgical care for esophageal cancer patients but postoperative morbidity impairs quality of life and reduces long-term oncological outcome. Two-stage ILE separating the abdominal and thoracic phase into two distinct surgical procedures has proven to enhance microcirculation of the gastric conduit and therefore most likely reduces complications. However, two-stage ILE has not been evaluated systematically in selected groups of patients scheduled for this procedure. This investigation aims to demonstrate the feasibility of two-stage ILE in high-risk patients.
In this retrospective analysis of data obtained from a prospective database, a consecutive series of 275 hybrid ILE (hILE) were included. Patients were divided into two groups based on one- or two-stage hILE. Postoperative complications were assessed according to ECCG (Esophageal Complication Consensus Group) criteria and compared using the Clavien-Dindo score. Indication for two-stage esophagectomy was classified as pre- or intraoperative decision.
34 out of 275 patients (12.7%) underwent two-stage hILE. Patients of the two-stage group were significantly older. In 21 of 34 patients (61.8%) the decision for a two-stage procedure was made prior to esophagectomy, in 13 (38.2%) patients intraoperatively after completion of the laparoscopic gastric mobilization. The most frequent preoperative reason to select the two-stage procedure was a stenosis of the coeliac trunc and superior mesenteric artery (n = 10). The predominant cause for an intraoperative change of strategy was a laparoscopically diagnosed hepatic fibrosis/cirrhosis (n = 5).Overall morbidity and major' complications (CD > IIIa) were comparable for both groups (11.7% in both groups). The overall anastomotic leak rate was 12.4% and was non-significant lower for the two-stage procedure.
Two-stage hILE is a feasible concept to individualize the surgical treatment of patients with well-defined clinical risk factors for postoperative morbidity. It can also be applied after completion of the abdominal phase of IL esophagectomy without compromising the patient safety.
艾弗-刘易斯食管切除术（ILE）是食管癌患者的标准手术治疗方法，但术后并发症会影响生活质量并降低长期肿瘤学疗效。分两阶段进行的ILE将腹部和胸部手术阶段分为两个不同的手术操作，已被证明可增强胃管道的微循环，因此很可能减少并发症。然而，两阶段ILE尚未在计划进行该手术的特定患者群体中进行系统评估。本研究旨在证明两阶段ILE在高危患者中的可行性。
在对前瞻性数据库中获取的数据进行的这项回顾性分析中，纳入了连续的275例混合ILE（hILE）病例。根据单阶段或两阶段hILE将患者分为两组。根据食管并发症共识小组（ECCG）标准评估术后并发症，并使用Clavien-Dindo评分进行比较。两阶段食管切除术的指征分为术前或术中决定。
275例患者中有34例（12.7%）接受了两阶段hILE。两阶段组的患者年龄明显更大。34例患者中有21例（61.8%）在食管切除术之前就决定采用两阶段手术，13例（38.2%）患者在腹腔镜胃游离完成后术中决定。选择两阶段手术最常见的术前原因是腹腔干和肠系膜上动脉狭窄（n = 10）。术中改变策略的主要原因是腹腔镜诊断的肝纤维化/肝硬化（n = 5）。两组的总体发病率和主要并发症（CD＞IIIa）相当（两组均为11.7%）。总体吻合口漏率为12.4%，两阶段手术的漏率无显著降低。
两阶段hILE是一种可行的概念，可针对具有明确术后发病临床风险因素的患者进行个体化手术治疗。它也可在ILE食管切除术的腹部阶段完成后应用，而不影响患者安全。
