Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Genetics, Peking University Cancer Hospital & Institute, Beijing, People's Republic of China.
Chinese Preventive Medicine Association, Beijing, People's Republic of China.
Int J Surg. 2024 Feb 1;110(2):675-683. doi: 10.1097/JS9.0000000000000897.
The objective was to compare the long-term overall survival (OS) of right versus left thoracic esophagectomy, and to evaluate whether surgical quality impacts comparison result.
Controversy regarding the optimal thoracic esophagectomy approach persists for esophageal squamous cell carcinoma (ESCC). No study has assessed the effect of surgical quality in comparison between right and left approaches.
The authors consecutively recruited 5556 operable ESCC patients from two high-volume centers in China, of whom 2220 and 3336 received right and left thoracic esophagectomy, respectively. Cumulative sum was used to evaluate the learning curve for operation time of right approach, as the indicator of surgical proficiency.
With a median follow-up of 83.1 months, right approach, harvesting more lymph nodes, tended to have a better OS than left approach (Mean: 23.8 vs. 16.7 nodes; adjusted hazard ratio (HR)=0.93, 95% CI: 0.85-1.02). Subset analysis by the extent of lymphadenectomy demonstrated that right approach with adequate lymphadenectomy (≥15 nodes) resulted in statistically significant OS benefit compared with left approach (adjusted HR=0.86, 95% CI: 0.77-0.95), but not with limited lymphadenectomy. Subset analysis by surgical proficiency showed that proficient right approach conferred a better OS than left approach (adjusted HR=0.75, 95% CI: 0.64-0.88), but improficient right approach did not have such survival advantage.
Surgical quality plays a crucial role in survival comparison between surgical procedures. Right thoracic esophagectomy performed with adequate lymphadenectomy and surgical proficiency, conferring more favorable survival than left approach, should be recommended as the preferred surgical procedure for localized ESCC.
比较右胸与左胸食管切除术的长期总生存率（OS），并评估手术质量是否影响比较结果。
对于食管鳞癌（ESCC），最佳的胸段食管切除术方法仍存在争议。尚无研究评估手术质量对左右入路比较的影响。
作者连续从中国两个高容量中心招募了 5556 例可手术的 ESCC 患者，其中 2220 例和 3336 例分别接受了右胸和左胸食管切除术。累积和用于评估右入路手术时间的学习曲线，作为手术熟练程度的指标。
中位随访 83.1 个月后，右入路、清扫更多淋巴结，OS 倾向于优于左入路（中位数：23.8 比 16.7 枚；调整后的危险比（HR）=0.93，95%可信区间：0.85-1.02）。根据淋巴结清扫程度的亚组分析表明，对于充分的淋巴结清扫（≥15 枚），右入路与左入路相比，具有统计学显著的 OS 获益（调整后的 HR=0.86，95%可信区间：0.77-0.95），但对于有限的淋巴结清扫并非如此。根据手术熟练程度的亚组分析显示，熟练的右入路较左入路具有更好的 OS（调整后的 HR=0.75，95%可信区间：0.64-0.88），但不熟练的右入路没有这种生存优势。
手术质量在手术方法的生存比较中起着至关重要的作用。对于局限性 ESCC，应推荐进行充分淋巴结清扫和手术熟练程度的右胸食管切除术，其生存获益优于左入路。
