Ministry of Health Holdings Singapore, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
University Surgical Cluster, National University Hospital, Singapore.
Surg Oncol. 2024 Apr;53:102042. doi: 10.1016/j.suronc.2024.102042. Epub 2024 Feb 1.
Transhiatal esophagectomy (THE) avoids thoracotomy but sacrifices mediastinal lymphadenectomy. Mediastinoscopy-assisted transhiatal esophagectomy (MATHE) allows for visualisation and en-bloc dissection of mediastinal lymph nodes while retaining the benefits of THE. However, given its novel inception, there is a paucity of literature. This study aimed to conduct the first meta-analysis to explore the efficacy of MATHE and clarify its role in the future of esophagectomy.
Four databases (PubMed, EMBASE, Scopus, and Cochrane Library) were searched from inception to May 1, 2023. Studies were included if they reported outcomes for patients with esophageal cancer who underwent MATHE. Meta-analyses of proportions and pooled means were performed for the outcomes of intraoperative blood loss, lymph node (LN) harvest, mean hospital length of stay (LOS), mean operative time, R0 resection, conversion rates, 30-day mortality rate, 5-year OS, and surgical complications (anastomotic leak, cardiovascular [CVS] and pulmonary complications, chyle leak and recurrent laryngeal nerve palsy [RLN]). Sensitivity analyses were performed for outcomes with substantial statistical heterogeneity.
The search yielded 223 articles; 28 studies and 1128 patients were included in our analysis. Meta-analyses of proportions yielded proportion rates: 30-day mortality (0 %, 95 %CI 0-0), 5-year OS (60.5 %, 95 %CI 47.6-72.7), R0 resection (100 %, 95 %CI 99.3-100), conversion rate (0.1 %, 95 %CI 0-1.2). Among surgical complications, RLN palsy (14.6 %, 95 %CI 9.5-20.4) were most observed, followed by pulmonary complications (11.3 %, 95 %CI 7-16.2), anastomotic leak (9.7 %, 95 %CI 6.8-12.8), CVS complications (2.3 %, 95 %CI 0.9-4.1) and chyle leak (0.02 %, 95 %CI 0-0.8). Meta-analysis of pooled means yielded means: LN harvest (18.6, 95 %CI 14.3-22.9), intraoperative blood loss (247.1 ml, 95 %CI 173.6-320.6), hospital LOS (18.1 days, 95 %CI 14.4-21.8), and operative time (301.5 min, 95 %CI 238.4-364.6). There was moderate-to-high statistical heterogeneity. Findings were robust to sensitivity analyses.
MATHE is associated with encouraging post-operative mortality and complication rates, while allowing for radical mediastinal lymphadenectomy with reasonable lymph node harvest.
经食管裂孔切除术（THE）避免了开胸手术，但牺牲了纵隔淋巴结清扫术。胸内镜辅助经食管裂孔切除术（MATHE）允许可视化和整块切除纵隔淋巴结，同时保留 THE 的优点。然而，由于其新颖的设计，相关文献很少。本研究旨在进行首次荟萃分析，以探讨 MATHE 的疗效，并阐明其在未来食管癌手术中的作用。
从 1990 年 1 月至 2023 年 5 月 1 日，我们在 PubMed、EMBASE、Scopus 和 Cochrane Library 四个数据库中进行了检索。纳入报告了接受 MATHE 的食管癌患者结局的研究。我们对术中出血量、淋巴结（LN）采集、平均住院时间（LOS）、平均手术时间、R0 切除率、转化率、30 天死亡率、5 年总生存率和手术并发症（吻合口漏、心血管[CVS]和肺部并发症、乳糜漏和喉返神经麻痹[RLN]）的结局进行了比例和合并均值的荟萃分析。对具有显著统计学异质性的结局进行敏感性分析。
检索到 223 篇文章；28 项研究和 1128 名患者纳入了我们的分析。比例荟萃分析得出了比例率：30 天死亡率（0%，95%CI 0-0），5 年总生存率（60.5%，95%CI 47.6-72.7），R0 切除率（100%，95%CI 99.3-100），转化率（0.1%，95%CI 0-1.2）。在手术并发症中，RLN 麻痹（14.6%，95%CI 9.5-20.4）最为常见，其次是肺部并发症（11.3%，95%CI 7-16.2），吻合口漏（9.7%，95%CI 6.8-12.8），CVS 并发症（2.3%，95%CI 0.9-4.1）和乳糜漏（0.02%，95%CI 0-0.8）。合并均值的荟萃分析得出了平均值：LN 采集（18.6，95%CI 14.3-22.9），术中出血量（247.1ml，95%CI 173.6-320.6），住院 LOS（18.1 天，95%CI 14.4-21.8）和手术时间（301.5 分钟，95%CI 238.4-364.6）。存在中度到高度统计学异质性。敏感性分析结果稳健。
MATHE 术后死亡率和并发症发生率令人鼓舞，同时允许进行合理的纵隔淋巴结清扫术并获得合理的淋巴结采集。
