Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA.
Department of Surgery, University Hospitals Research in Surgical Outcomes & Effectiveness Center (UH-RISES), University Hospitals Cleveland Medical Center, Cleveland, OH, USA.
Dis Esophagus. 2020 Oct 12;33(10). doi: 10.1093/dote/doaa017.
Despite excellent short-term outcomes of minimally invasive esophagectomy (MIE), there is minimal data on long-term outcomes compared to open esophagectomy. MIE's superior visualization may have improved lymphadenectomy and complete resection rate and therefore improved long-term outcomes. We hypothesized that MIE would have superior long-term survival. Patients undergoing an esophagectomy for cancer between 2010 and 2016 were identified in the National Cancer Database. MIE included laparoscopic/robotic approach, and conversions were categorized as open. A 1:1 propensity match was performed. Lymphadenectomy and margin status were compared between MIE and open using Stuart Maxwell marginal homogeneity and Wilcoxon matched-pair signed-rank test. Survival was compared using log-rank test. 13,083 patients were identified: 8,906 (68%) open and 4,177 (32%) MIE. Propensity matching identified 3,659 'pairs' of MIE and open esophagectomy patients. Among them, MIE was associated with higher number lymph nodes examined (16 vs. 14, P < 0.001) and similar number of positive lymph nodes (0 vs. 0, P = 0.33). MIE had higher rate of negative pathologic margin (95 vs. 93.5%, P < 0.001). MIE was also associated with shorter hospitalization (9 vs. 10 days, P < 0.001). Survival was improved among MIE patients (46.6 vs. 41.4 months for open, P = 0.003) and among pathologic node-negative patients (71.4 vs. 61.5 months, P = 0.005). These data suggest that MIE has improved short-term outcomes (improved lymphadenectomy, pathologic margins, and length of stay) and also associated improved overall survival. The etiology of superior overall survival is likely secondary to many factors related and unrelated to surgical approach.
尽管微创食管切除术（MIE）具有出色的短期治疗效果，但与开放食管切除术相比，其长期治疗效果的数据很少。MIE 卓越的可视化效果可能提高了淋巴结清扫和完全切除率，从而改善了长期治疗效果。我们假设 MIE 具有更优的长期生存率。在国家癌症数据库中，确定了 2010 年至 2016 年间因癌症而行食管切除术的患者。MIE 包括腹腔镜/机器人方法，转化为开放手术的则归入开放手术。然后进行了 1:1 倾向评分匹配。使用 Stuart Maxwell 边界同质性和 Wilcoxon 匹配对符号秩检验比较 MIE 和开放手术之间的淋巴结清扫和切缘状态。使用对数秩检验比较生存率。共确定了 13083 例患者：8906 例（68%）行开放手术，4177 例（32%）行 MIE。倾向评分匹配确定了 3659 对 MIE 和开放食管切除术患者。其中，MIE 组检查的淋巴结数量更多（16 个 vs. 14 个，P<0.001），阳性淋巴结数量相似（0 个 vs. 0 个，P=0.33）。MIE 组阴性病理切缘的比例更高（95% vs. 93.5%，P<0.001）。MIE 组的住院时间也更短（9 天 vs. 10 天，P<0.001）。MIE 患者的生存率提高（MIE 组为 46.6 个月 vs. 开放组为 41.4 个月，P=0.003），病理淋巴结阴性患者的生存率提高（MIE 组为 71.4 个月 vs. 开放组为 61.5 个月，P=0.005）。这些数据表明，MIE 改善了短期治疗效果（改善了淋巴结清扫、病理切缘和住院时间），并与整体生存率的提高相关。整体生存率较高的原因可能是与手术方法相关和不相关的多种因素共同作用的结果。
