I.R.C.C.S Ospedale Galeazzi - Sant'Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Milan, Italy.
Upper Gastrointestinal Surgery Unit, IRCCS Humanitas Research Hospital, Milan, Italy.
Ann Surg Oncol. 2024 Oct;31(10):6699-6709. doi: 10.1245/s10434-024-15770-3. Epub 2024 Jul 20.
Radical esophagectomy, including thoracic duct resection (TDR), has been proposed to improve regional lymphadenectomy and possibly reduce the risk of locoregional recurrence. However, because of its impact on immunoregulation, some authors have expressed concerns about its possible detrimental effect on long-term survival. The purpose of this review was to assess the influence of TDR on long-term survival.
PubMed, MEDLINE, Scopus, and Web of Science databases were searched through 15 March 2024. Overall survival (OS), cancer specific survival (CSS), and disease-free survival (DFS) were primary outcomes. Restricted mean survival time difference (RMSTD), risk ratio (RR), standardized mean difference (SMD), and 95% confidence intervals (CI) were used as pooled effect size measures. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) methodology was employed to evaluate the certainty of evidence.
The analysis included six studies with 5756 patients undergoing transthoracic esophagectomy. TDR was reported in 49.1%. Patients' ages ranged from 27 to 79 years and 86% were males. At 4-year follow-up, the multivariate meta-analysis showed similar results for the comparison noTDR versus TDR in term of OS [- 0.8 months, 95% confidence interval (CI) - 3.1, 1.3], CSS (0.1 months, 95% CI - 0.9, 1.2), and DFS (1.5 months, 95% CI - 2.6, 5.5). TDR was associated with a significantly higher number of harvested mediastinal lymph nodes (SMD 0.57, 95% CI 0.01-1.13) and higher risk of postoperative chylothorax (RR = 1.32; 95% CI 1.04-2.23). Anastomotic leak and pulmonary complications were comparable.
TDR seems not to improve long-term OS, CSS, and DFS regardless of tumor stage. Routine TDR should not be routinely recommended during esophagectomy.
根治性食管切除术，包括胸导管切除术（TDR），已被提议用于改善区域淋巴结清扫，并可能降低局部区域复发的风险。然而，由于其对免疫调节的影响，一些作者对其对长期生存的潜在不利影响表示担忧。本综述的目的是评估 TDR 对长期生存的影响。
通过 2024 年 3 月 15 日检索 PubMed、MEDLINE、Scopus 和 Web of Science 数据库。总生存期（OS）、癌症特异性生存期（CSS）和无病生存期（DFS）是主要结局。限制性平均生存时间差异（RMSTD）、风险比（RR）、标准化平均差异（SMD）和 95%置信区间（CI）被用作汇总效应量测量。采用推荐评估、制定与评价分级（GRADE）方法评估证据的确定性。
该分析纳入了 6 项研究，共 5756 例接受经胸食管切除术的患者。TDR 报告率为 49.1%。患者年龄从 27 岁至 79 岁不等，86%为男性。在 4 年随访时，多变量荟萃分析显示，在 OS（-0.8 个月，95%CI-3.1，1.3）、CSS（0.1 个月，95%CI-0.9，1.2）和 DFS（1.5 个月，95%CI-2.6，5.5）方面，无 TDR 与 TDR 比较的结果相似。TDR 与采集的纵隔淋巴结数量显著增加（SMD 0.57，95%CI0.01-1.13）和术后乳糜胸风险升高（RR=1.32；95%CI1.04-2.23）相关。吻合口漏和肺部并发症相似。
无论肿瘤分期如何，TDR 似乎都不能改善长期 OS、CSS 和 DFS。根治性食管切除术中不应常规推荐常规 TDR。
