Minimally Invasive Versus Open Esophagectomy for Esophageal Cancer: A Population-Based Analysis

Abstract

Background The objective of this study was to evaluate outcomes of minimally invasive approaches to esophagectomy using population-level data. Methods Multivariable regression modeling was used to determine predictors associated with the use of minimally invasive approaches for patients in the National Cancer Data Base who underwent resection of middle and distal clinical T13N03M0 esophageal cancers from 2010 to 2012. Perioperative outcomes and 3-year survival were compared between propensity-matched groups of patients with esophageal cancer who underwent minimally invasive esophagectomy (MIE) or open esophagectomy (OE). A subgroup analysis was performed to evaluate the impact of using robotic-assisted operations as part of the minimally invasive approach. Results Among 4,266 patients included, 1,308 (30.6%) underwent MIE. It was more likely to be used in patients treated at academic (adjusted odds ratio [OR], 10.1; 95% confidence interval [CI], 4.2–33.1) or comprehensive cancer facilities (adjusted OR, 6.4; 95% CI, 2.6–21.1). Compared with propensity-matched patients who underwent OE, patients who underwent MIE had significantly more lymph nodes examined (15 versus 13; p = 0.016) and shorter hospital lengths of stay (10 days versus 11 days; p = 0.046) but similar resection margin positivity, readmission, and 30-day mortality (all p > 0.05). Survival was similar between the matched groups at 3 years for both adenocarcinoma and squamous cell carcinoma (p > 0.05). Compared with MIE without robotic assistance, use of a robotic approach was not associated with any significant differences in perioperative outcomes (p > 0.05). Conclusions The use of minimally invasive techniques to perform esophagectomy for esophageal cancer is associated with modestly improved perioperative outcomes without compromising survival.

Oesophageal cancer

“…83,84 There are no major differences in survival between any of the established approaches. 31,80,82,85,86 Standardisation of the surgical approach might be a more important prognostic factor than selecting one specific procedure over another. 87 Alternatively, providing the surgeon has sufficient experience of various surgical approaches, the approach can be tailored depending on tumour and patient characteristics.…”

“…31,80 Earlier studies examining minimally invasive surgery showed a high risk of complications, possibly related to learning curve issues, while recent data show accelerated recovery, which has prompted its increased use. 81,82 On-going RCTs are comparing postoperative outcomes following minimally invasive procedures and open surgery, where HRQOL is a key outcome (ISRCTN59036820, NCT01544790, NTRTC2452). Transhiatal and minimally invasive surgery seem to be associated with fewer pulmonary complications compared to thoraco-abdominal approaches.…”

Robotic technological aids in esophageal surgery

“…Also postoperative morbidity rates, the length of stay in intensive care unit and the length of hospital stay did not significantly differ. Also Yerokun et al (21) recently failed to find any clear advantage of the robotassisted esophagectomy using population-level data. They compared perioperative outcomes and 3-year oncologic results obtained after open (n=2,958), standard minimally invasive esophagectomy without robotic assistance (n=1,077) and robot-assisted esophagectomy (n=231) for cT1-3N0-3M0 cancer of the middle or distal esophagus.…”

Robot-assisted Ivor-Lewis esophagectomy with intrathoracic robot-sewn anastomosis

“…Esophagectomy is technically challenging and is associated with high morbidity and mortality rates. Efforts to reduce these rates have spurred the adoption of minimally invasive techniques (2). The limitations of this approach, such as the two-dimensional (2D) view or movement restrictions, can, however, make a complex procedure such as esophagectomy difficult.…”