Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the esophagus
Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the esophagus
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DOI：
10.1056/nejmoa022343
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发表时间：
2002-11-21
影响因子：
158.5
通讯作者：
van Lanschot, JJB
中科院分区：
文献类型：
--
作者：
Hulscher, JBF;van Sandick, JW;van Lanschot, JJB
背景：食管癌的最佳手术治疗存在争议。方法：我们随机选择220例食管中远端腺癌或贲门腺癌累及食管远端患者，分别行经裂口食管切除术或经胸食管切除术合并扩大整体淋巴结切除术。主要终点是总生存和无病生存。还确定了早期发病率和死亡率、获得的质量调整生命年数和成本效益。结果：106例患者行经食管切除术，114例患者行经胸食管切除术。两组患者的人口学特征和肿瘤特征相似。经胸食管切除术围手术期发病率较高，住院死亡率差异无统计学意义（P=0.45）。在中位4.7年的随访后，142例患者死亡——74例（70%）经食管切除，68例（60%）经胸腔切除（P=0.12）。虽然生存率的差异在统计学上并不显著，但在5年的时间里，延长治疗方法的生存率有提高的趋势：经食管切除术组的无病生存率为27%，而经胸食管切除术组为39%（差异的95%置信区间为-1至24%[负值表明经食管切除术生存率更高]），而总生存率为29%，而39%（差异的95%置信区间为-3至23%）。结论：经食道食管切除术的发病率低于经胸食管切除术合并扩大整体淋巴结切除术。虽然中位总生存率、无病生存率和质量调整生存率在两组间没有统计学差异，但延长经胸入路有改善5年长期生存率的趋势。
Background: Controversy exists about the best surgical treatment for esophageal carcinoma.Methods: We randomly assigned 220 patients with adenocarcinoma of the mid-to-distal esophagus or adenocarcinoma of the gastric cardia involving the distal esophagus either to transhiatal esophagectomy or to transthoracic esophagectomy with extended en bloc lymphadenectomy. Principal end points were overall survival and disease-free survival. Early morbidity and mortality, the number of quality-adjusted life-years gained, and cost effectiveness were also determined.Results: A total of 106 patients were assigned to undergo transhiatal esophagectomy, and 114 to undergo transthoracic esophagectomy. Demographic characteristics and characteristics of the tumor were similar in the two groups. Perioperative morbidity was higher after transthoracic esophagectomy, but there was no significant difference in in-hospital mortality (P=0.45). After a median follow-up of 4.7 years, 142 patients had died -- 74 (70 percent) after transhiatal resection and 68 (60 percent) after transthoracic resection (P=0.12). Although the difference in survival was not statistically significant, there was a trend toward a survival benefit with the extended approach at five years: disease-free survival was 27 percent in the transhiatal-esophagectomy group, as compared with 39 percent in the transthoracic-esophagectomy group (95 percent confidence interval for the difference, -1 to 24 percent [the negative value indicates better survival with transhiatal resection]), whereas overall survival was 29 percent as compared with 39 percent (95 percent confidence interval for the difference, -3 to 23 percent).Conclusions: Transhiatal esophagectomy was associated with lower morbidity than transthoracic esophagectomy with extended en bloc lymphadenectomy. Although median overall, disease-free, and quality-adjusted survival did not differ statistically between the groups, there was a trend toward improved long-term survival at five years with the extended transthoracic approach.