可以在不影响手术质量的情况下，从开放性整块食管切除术向微创整块切除术过渡。
Transition from open to minimally invasive en bloc esophagectomy can be achieved without compromising surgical quality.
机构信息
Division of Thoracic and Upper Gastrointestinal Surgery, McGill University Health Centre, Montreal, Quebec, Canada.
Division of General Surgery, McGill University Health Centre, Montreal, Quebec, Canada.
出版信息
Surg Endosc. 2021 Jun;35(6):3067-3076. doi: 10.1007/s00464-020-07696-0. Epub 2020 Jun 15.
BACKGROUND
En bloc esophagectomy results in higher lymph node (LN) retrieval than standard esophagectomy. Minimally invasive esophagectomy (MIE) has gained traction due to improved short-term outcomes, but many large series report LN yields well below the international benchmark of 23. We sought to determine if an established approach to open en bloc resection can be safely transferred to MIE using LN yield as a quality benchmark.
METHODS
An open approach to en bloc esophagectomy (OE) was established over 5 years (~ 300 cases) before en bloc MIE was introduced in 2010. Patients undergoing curative-intent en bloc Ivor-Lewis and McKeown esophagectomy for cancer from 2010 to 2019 by a single surgeon with formal minimally invasive surgery training were identified from a prospectively collected database. Mann-Whitney U and χ tests and cumulative sum analysis were used for statistical analysis. "Failure" was defined as LN yield less than AJCC's 8th edition guidelines: 10 LNs for pT1 cancers, 20 for pT2 and 30 for pT3-4.
RESULTS
A total of 269 esophageal resections met inclusion criteria [193(72%) OE; 76(28%) MIE]. Age, sex, BMI and comorbidities were comparable between groups. Tumors were larger and more often locally advanced in OE. Median LN retrieval was sufficient by international standards in both groups [OE:34(27-46); MIE:28(22-39); p = 0.01]. "Failures" occurred in 33(17%) of OE and 12(16%) MIE cases (p = 0.63). No learning effect was observed for LN yield. R0 resection rate was comparable [OE:191(99%); MIE:73(96%); p = 0.90]. Operative time was longer for MIE [275(246-300)] than OE [240(210-270) minutes], p < 0.0001, while estimated blood loss (OE:350(250-500)mL; MIE:300(200-400)mL; p = 0.02] and length of stay [OE:8(6-13); MIE7(6-9) days; p = 0.02] were higher for OE. Morbidity and mortality were comparable between groups and LN yield did not impact survival.
CONCLUSIONS
Under appropriate conditions, an established approach to open en bloc esophagectomy can be safely transferred to MIE without compromising surgical quality.
背景
整块切除术比标准食管切除术获得更多的淋巴结（LN）。微创食管切除术（MIE）由于短期结果改善而得到广泛应用，但许多大型系列报告的 LN 产量远低于 23 的国际基准。我们旨在确定一种已建立的开放整块切除术方法是否可以通过 LN 产量作为质量基准安全地转移到 MIE 中。
方法
在 2010 年引入整块 MIE 之前，我们在 5 年内（~300 例）建立了一种开放的整块食管切除术（OE）方法。从 2010 年至 2019 年，由一位接受过正式微创外科培训的外科医生对接受根治性整块 Ivor-Lewis 和 McKeown 食管切除术治疗癌症的患者进行了前瞻性收集数据库。使用 Mann-Whitney U 和 χ 检验和累积和分析进行统计分析。“失败”定义为 LN 产量低于 AJCC 第 8 版指南：pT1 癌症 10 个 LN，pT2 癌症 20 个 LN，pT3-4 癌症 30 个 LN。
结果
共有 269 例食管切除术符合纳入标准[193（72％）OE；76（28％）MIE]。两组之间的年龄、性别、BMI 和合并症相似。OE 组的肿瘤更大且更常局部晚期。两组的 LN 检索均达到国际标准[OE：34（27-46）；MIE：28（22-39）；p=0.01]。OE 中有 33（17％）例和 MIE 中有 12（16％）例发生“失败”（p=0.63）。没有观察到 LN 产量的学习效应。RO 切除率相当[OE：191（99％）；MIE：73（96％）；p=0.90]。MIE 的手术时间较长[275（246-300）分钟]，而 OE 为[240（210-270）分钟]，p<0.0001，而估计出血量（OE：350（250-500）mL；MIE：300（200-400）mL；p=0.02）和住院时间（OE：8（6-13）天；MIE：7（6-9）天；p=0.02）较长。两组的发病率和死亡率相当，LN 产量并不影响生存。
结论
在适当的条件下，一种已建立的开放整块切除术方法可以安全地转移到 MIE 中，而不会影响手术质量。
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