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. 2022 Dec 13:12:858660.
doi: 10.3389/fonc.2022.858660. eCollection 2022.

Left versus right approach for middle and lower esophageal squamous cell carcinoma: A propensity score-matched study

Xining Zhang  1 , Kang Qi  1 , Weiming Huang  1 , Jingwei Liu  1 , Gang Lin  1 , Jian Li  1
Affiliations

Left versus right approach for middle and lower esophageal squamous cell carcinoma: A propensity score-matched study

Xining Zhang et al. Front Oncol. .

Abstract

Background: Despite superior short-term outcomes, there is considerable debate about the oncological efficacy of the left approach esophagectomy for middle and lower squamous esophageal carcinoma (ESCC). A propensity score-matched retrospective study was conducted to evaluate the left approach's short- and long-term effects.

Methods: We recorded data from patients with ESCC who underwent curative resection via the left or right approach between January 2010 and December 2015. Propensity score matching (PSM) was performed, and maximally selected rank statistics (MSRS) were utilized to determine the appropriate number of lymph nodes to resect during esophagectomy.

Results: One hundred and forty-eight ESCC patients underwent esophagectomy via the right approach, and 108 underwent the left approach esophagectomy. After PSM, the left approach esophagectomy showed statistically significant superiority in operative time and time to oral intake, and there was a trend toward a shorter length of hospital stay. Fewer cervical, upper thoracic, and recurrent laryngeal nerve lymph nodes were harvested via the left approach than the right approach; the total number of lymph nodes harvested via the left and right approaches was similar. Similar long-term survival outcomes were achieved. MSRS suggested that at least 25 lymph nodes are needed to be resected during esophagectomy to improve survival in N0 patients.

Conclusions: The left approach esophagectomy might facilitate postoperative recovery in patients with middle and lower ESCC. With adequate lymphadenectomy, the left approach esophagectomy might achieve similar long-term outcomes for middle and lower ESCC patients.

Keywords: Ivor-Lewis procedure; McKeown procedure; Sweet procedure; esophageal squamous cell carcinoma; lymphadenectomy.

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Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Figures

Figure 1
Figure 1
Intraoperative images of critical lymph node exposure and dissection. (A), The exposure and dissection of 4L station (thoracic) lymph nodes. Note that the proper traction of adjacent hilar structures could facilitate exposure of 4L station nodes. (B), The exposure and dissection of seven station (abdominal) lymph nodes after the left gastric vessels are dissected via the transhiatal approach. In this region, keeping the stomach empty and anterior traction of it could help expose the celiac structure. (C), The exposure and dissection of recurrent laryngeal nerve lymph nodes (left side), the SCM muscle, and the carotid artery could be gently tracked so the exposure of the peri-esophageal region could be more readily exposed. AO, Aortic artery. CA, Carotid artery. ESO, Esophagus. LMB, Left main bronchus. RLN, Recurrent laryngeal nerve. RLNLN, Recurrent laryngeal nerve lymph nodes. SCM, Sternocleidomastoid muscle. SPA, Splenic artery.
Figure 2
Figure 2
Split-violin plots of amount of lymph nodes resected by the Sweet and the right approaches in the PS-matched cohort. (A), the total amount of lymph nodes resected. (B), the amount of the upper thoracic lymph nodes resected. (C), the amount of the middle and lower thoracic lymph nodes resected. (D), the number of abdominal lymph nodes resected. (E), the number of cervical lymph nodes resected. (F), the amount of recurrent laryngeal nerve lymph nodes resected. PS, propensity score.
Figure 3
Figure 3
The long-term survival of N-negative and N-positive patients grouped by cutoff points calculated using the MSRS. (A), The OS of N-negative patients divided by the cutoff points of 25 lymph nodes. (B), The RFS of N-negative patients divided by the cutoff points of 25 lymph nodes. (C), The OS of N-positive patients divided by the cutoff points of 27 lymph nodes. (D), The RFS of N-positive patients, divided by the cutoff points of 27 lymph nodes. MSRS, maximally selected rank statistics. OS, overall survival. RFS, recurrence-free survival.
Figure 4
Figure 4
The long-term survival of unmatched and PS-matched cohorts. (A), The OS of unmatched patients in the left and right groups. (B), the RFS of unmatched patients in the left and the right groups. (C), The OS of matched patients in the left and right groups. (D), the RFS of matched patients in the left and the right groups. PS, propensity score. OS, overall survival. RFS, recurrence-free survival.
Figure 5
Figure 5
The stratified long-term survival of unmatched and PS-matched cohorts. (A), The OS of unmatched stage T1-2 patients. (B), The RFS of unmatched stage T1-2 patients. (C), The OS of unmatched stage T3-4 patients. (D), The RFS of unmatched stage T3-4 patients. (E), The OS of matched stage T1-2 patients. (F), The RFS of matched stage T1-2 patients. (G), The OS of matched stage T3-4 patients. (H), The RFS of matched stage T3-4 patients. OS, overall survival. RFS, recurrence-free survival.
Figure 6
Figure 6
The cumulative incidence functions of the PS-matched left and right groups; neither the recurrence rate of the cervical and mediastinal lymph nodes region nor the other region showed a statistically significant difference. LN, lymph nodes. PS, propensity score.
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