筋膜引导下根治性食管切除术的技术要点与短期结局：单中心回顾性数据库分析

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中文摘要

背景： 近年来，基于胚胎发育及组织学证实的食管周围筋膜层的“同心结构模型”为根治性食管切除术提供了新的解剖定位。然而，对筋膜引导下食管切除术的技术要点及短期结局仍缺乏全面评价。本研究旨在阐明该手术的关键技术方面，并初步评估其短期安全性和可行性。
方法： 我们回顾性分析了2023年1月至12月期间接受筋膜解剖引导下微创食管切除术的88例胸段食管鳞状细胞癌患者的临床资料。利用“同心结构模型”和组织学验证的筋膜平面，在上、中、下纵隔以及腹腔沿这些解剖平面进行食管游离和整块淋巴结清扫。分析术后病理结果和并发症（采用Clavien-Dindo分类分级）。
结果： 队列包括67例男性患者（76.1%），平均年龄61.3岁，平均BMI为22.0 kg/m2。49例患者（55.7%）接受了新辅助治疗。平均总手术时间为274.6分钟，平均胸部阶段持续时间为120.5分钟。平均估计失血量为53.6 mL。R0切除率为97.7%。平均清扫淋巴结总数为51.1枚，其中胸部区域平均清扫38.0枚淋巴结。术后总体并发症发生率（Clavien-Dindo分级≥II级）为28.4%，主要并发症发生率（Clavien-Dindo分级≥IIIa级）为14.8%。具体并发症包括肺炎（17.0%）、喉返神经麻痹（10.2%）和吻合口漏（3.4%）。术后90天死亡率为1.1%。
结论： 筋膜引导下根治性食管切除术提供了清晰的解剖游离平面，便于整块淋巴结清扫，并显示出可接受的短期安全性和可行性；然而，这些发现需要在更大规模、前瞻性、对照研究中加以确认，并延长随访以评估肿瘤学结局。

英文摘要

BACKGROUND: In recent years, the "concentric structural model" based on embryonic development and histologically confirmed periesophageal fascial layers has provided a new anatomical orientation for radical esophagectomy. However, a comprehensive evaluation of the technical key points and short-term outcomes of fascia-guided esophagectomy remains lacking. This study aims to elucidate the key technical aspects of this procedure and preliminarily assess its short-term safety and feasibility.
METHODS: We retrospectively analyzed the clinical data of 88 patients with thoracic esophageal squamous cell carcinoma who underwent minimally invasive esophagectomy guided by fascial anatomy between January and December 2023. Utilizing the "concentric structural model" and histologically validated fascial planes, esophageal mobilization and en bloc lymph node dissection were performed along these anatomical planes in the upper, middle, and lower mediastinum, as well as the abdominal cavity. Postoperative pathological results and complications (graded using the Clavien-Dindo classification) were analyzed.
RESULTS: The cohort comprised 67 male patients (76.1%), with a mean age of 61.3 years and a mean BMI of 22.0 kg/m2. Neoadjuvant therapy was administered to 49 patients (55.7%). The mean total operative time was 274.6 min, with a mean thoracic phase duration of 120.5 min. The mean estimated blood loss was 53.6 mL. The R0 resection rate was 97.7%. The mean total number of harvested lymph nodes was 51.1, with a mean of 38.0 lymph nodes retrieved from the thoracic region. The overall postoperative complication rate (Clavien-Dindo grade ≥ II) was 28.4%, and the major complication rate (Clavien-Dindo grade ≥ IIIa) was 14.8%. Specific complications included pneumonia (17.0%), recurrent laryngeal nerve palsy (10.2%), and anastomotic leakage (3.4%). The 90-day postoperative mortality rate was 1.1%.
CONCLUSION: Fascia-guided radical esophagectomy provides a clear anatomical dissection plane, facilitates en bloc lymph node dissection, and demonstrates acceptable short-term safety and feasibility, however, these findings warrant confirmation in larger, prospective, controlled studies with extended follow-up for oncologic outcomes.