Booka Eisuke, Takeuchi Hiroya, Morita Yoshifumi, Hiramatsu Yoshihiro, Kikuchi Hirotoshi
Department of Surgery Hamamatsu University School of Medicine Hamamatsu Japan.
Department of Perioperative Functioning Care and Support Hamamatsu University School of Medicine Hamamatsu Japan.
Ann Gastroenterol Surg. 2023 May 2;7(4):553-564. doi: 10.1002/ags3.12685. eCollection 2023 Jul.
Thoracic esophagectomy is a particularly invasive and complicated surgical procedure, with a reconstruction of the gastrointestinal tract, such as the stomach, jejunum, or colon. The posterior mediastinal, retrosternal, and subcutaneous routes are the three possible esophageal reconstruction routes. Each route has advantages and disadvantages, and the optimal reconstruction route after esophagectomy remains controversial. Additionally, the best anastomotic techniques after esophagectomy in terms of location (Ivor Lewis or McKeown) and suturing (manual or mechanical) are debatable. Our meta-analysis investigating postoperative complications after esophagectomy between the posterior mediastinal and retrosternal routes revealed that the posterior mediastinal route was associated with a significantly lower anastomotic leakage rate than the retrosternal route (odds ratio = 0.78, 95% confidence interval: 0.70-0.87, < 0.0001). Conversely, pulmonary complications (odds ratio = 0.80, 95% confidence interval: 0.58-1.11, = 0.19) and mortality between the posterior mediastinal and retrosternal routes (odds ratio = 0.79, 95% confidence interval: 0.56-1.12, = 0.19) were not significantly different. However, the incidence of pneumonia may be lower when using the retrosternal route rather than the posterior mediastinal route for performing minimally invasive esophagectomy. The McKeown procedure is oncologically necessary for tumors located above the carina to dissect upper mediastinal and cervical lymph nodes; however, the Ivor Lewis procedure offers perioperative and oncological safety for tumors located under the carina. An individualized treatment strategy for selecting the optimal reconstruction procedure can be proposed in future studies based on oncological and patient risk factors considering mid- to long-term quality of life.
胸段食管癌切除术是一种创伤特别大且复杂的外科手术，需要重建胃肠道，比如胃、空肠或结肠。后纵隔、胸骨后和皮下途径是三种可能的食管重建途径。每种途径都有优缺点，食管癌切除术后的最佳重建途径仍存在争议。此外，食管癌切除术后在吻合位置（艾弗·刘易斯或麦克尤恩）和缝合方式（手工或机械）方面的最佳吻合技术也存在争议。我们对后纵隔途径和胸骨后途径食管癌切除术后的并发症进行的荟萃分析显示，后纵隔途径的吻合口漏发生率显著低于胸骨后途径（优势比=0.78，95%置信区间：0.70 - 0.87，P<0.0001）。相反，后纵隔途径和胸骨后途径之间的肺部并发症（优势比=0.80，95%置信区间：0.58 - 1.11，P=0.19）和死亡率（优势比=0.79，95%置信区间：0.56 - 1.12，P=0.19）没有显著差异。然而，在进行微创食管癌切除术时，采用胸骨后途径而非后纵隔途径时肺炎的发生率可能更低。对于位于隆突上方的肿瘤，为了清扫上纵隔和颈部淋巴结，麦克尤恩手术在肿瘤学上是必要的；然而，对于位于隆突下方的肿瘤，艾弗·刘易斯手术提供了围手术期和肿瘤学安全性。未来的研究可以基于肿瘤学和患者风险因素，并考虑中长期生活质量，提出一种个性化的治疗策略来选择最佳的重建手术。
