Abstract

Background

Ivor-Lewis esophagectomy (ILE) is the standard surgical care for esophageal cancer patients but postoperative morbidity impairs quality of life and reduces long-term oncological outcome. Two-stage ILE separating the abdominal and thoracic phase into two distinct surgical procedures has proven to enhance microcirculation of the gastric conduit and therefore most likely reduces complications. However, two-stage ILE has not been evaluated systematically in selected groups of patients scheduled for this procedure. This investigation aims to demonstrate the feasibility of two-stage ILE in high-risk patients.

Patients and methods

In this retrospective analysis of data obtained from a prospective database, a consecutive series of 275 hybrid ILE (hILE) were included. Patients were divided into two groups based on one- or two-stage hILE. Postoperative complications were assessed according to ECCG (Esophageal Complication Consensus Group) criteria and compared using the Clavien–Dindo score. Indication for two-stage esophagectomy was classified as pre- or intraoperative decision.

Results

34 out of 275 patients (12.7%) underwent two-stage hILE. Patients of the two-stage group were significantly older. In 21 of 34 patients (61.8%) the decision for a two-stage procedure was made prior to esophagectomy, in 13 (38.2%) patients intraoperatively after completion of the laparoscopic gastric mobilization. The most frequent preoperative reason to select the two-stage procedure was a stenosis of the coeliac trunc and superior mesenteric artery (n = 10). The predominant cause for an intraoperative change of strategy was a laparoscopically diagnosed hepatic fibrosis/cirrhosis (n = 5).Overall morbidity and major’ complications (CD > IIIa) were comparable for both groups (11.7% in both groups). The overall anastomotic leak rate was 12.4% and was non-significant lower for the two-stage procedure.

Conclusion

Two-stage hILE is a feasible concept to individualize the surgical treatment of patients with well-defined clinical risk factors for postoperative morbidity. It can also be applied after completion of the abdominal phase of IL esophagectomy without compromising the patient safety.

中文翻译：

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两阶段混合 Ivor-Lewis 食管切除术作为降低高危患者术后发病率的手术策略

摘要

背景

Ivor-Lewis 食管切除术 (ILE) 是食管癌患者的标准手术治疗，但术后发病率会损害生活质量并降低长期肿瘤学结果。已证明将腹腔和胸腔分为两个不同的外科手术的两阶段 ILE 可增强胃导管的微循环，因此最有可能减少并发症。然而，尚未在计划进行此手术的选定患者组中系统地评估两期 ILE。本研究旨在证明两期 ILE 在高危患者中的可行性。

患者和方法

在对从前瞻性数据库获得的数据进行的回顾性分析中，包括了 275 个混合 ILE (hILE) 的连续系列。根据一期或二期 hILE 将患者分为两组。根据 ECCG（食管并发症共识组）标准评估术后并发症，并使用 Clavien-Dindo 评分进行比较。两阶段食管切除术的适应症被分类为术前或术中决定。

结果

275 名患者中有 34 名 (12.7%) 接受了两期 hILE。两阶段组的患者年龄显着增加。34 名患者中有 21 名（61.8%）在食管切除术前决定进行两阶段手术，13 名（38.2%）患者在完成腹腔镜胃动员后在术中做出决定。选择两阶段手术的最常见的术前原因是腹腔干和肠系膜上动脉狭窄（n  = 10）。术中改变策略的主要原因是腹腔镜诊断为肝纤维化/肝硬化（n = 5). 两组的总体发病率和主要并发症 (CD > IIIa) 具有可比性（两组均为 11.7%）。总吻合口漏率为 12.4%，两阶段手术的低不显着。

结论

两期 hILE 是一种可行的概念，可以对具有明确定义的术后并发症临床危险因素的患者进行个体化手术治疗。它也可以在完成 IL 食管切除术的腹部期后应用，而不会影响患者的安全。