Minimally invasive esophagectomy versus open esophagectomy: A systematic review and meta-analysis

Surgical complications after minimally invasive oesophagectomy compared to open oesophagectomy for oesophageal cancer: A population-based, nationwide study in Finland

INTRODUCTION

Evidence on the safety of minimally invasive oesophagectomy (MIO) compared to open oesophagectomy (OO) in nationwide practice is lacking. The aim of this study was to compare surgical complications after MIO and OO in a nationwide, population-based, unselected cohort.

MATERIALS AND METHODS

Descriptive statistics were used to report complications and complication categories defined by the Oesophagectomy Complications Consensus Group, major complications, reoperations and 90-day mortality in all patients undergoing MIO and OO in Finland during 2007-2016. Main outcomes were compared using logistic regression, adjusting for confounding.

RESULTS

Out of 699 patients, 295 (42 %) underwent MIO and 404 (58 %) underwent OO. Rates of anastomotic leakage (10 % vs 14 %, OR 0.47 (0.25-0.89)), intrathoracic abscesses (3 % vs 9 %, OR 0.13 (0.05-0.46)), major complications (35 % vs 47 %, OR 0.39 (0.25-0.60)) and reoperations (18 % vs 26 %, OR 0.43 (0.26-0.73)) were lower with MIO. Rates of pneumonia (16 % vs 27 %, OR 0.62 (0.38-1.03)), intra-abdominal abscesses (0.7 % vs 3.0 %, OR 0.20 (0.04-1.13)) and 90-day mortality (3.1 % vs 6.7 %, HR 0.48 (0.18-1.26)) were lower with MIO, but non-significant after adjustment. Pulmonary complications (36 % vs 46 %, OR 0.63 (0.41-0.96)) and infectious complications (11 % vs 22 %, OR 0.41 (0.23-0.73)) were less common with MIO, while rates of cardiac, gastrointestinal, urologic, thromboembolic, and neurologic complications were similar.

CONCLUSION

This study suggests a significant reduction in various surgical complications in patients undergoing MIO compared to OO and that implementing MIO into nationwide practice can be done safely.

Oncological outcomes of thoracic duct preservation and resection for esophageal carcinoma based on an understanding of its surgical microanatomy in the era of minimally invasive esophagectomy and neoadjuvant chemotherapy

BACKGROUND

Although the oncological benefits of thoracic duct (TD) resection have been reported, recent research has questioned its impact on survival. With advancements in minimally invasive esophagectomy (MIE) and a deeper understanding of the microanatomy, standardizing techniques for TD resection/preservation have become increasingly important. We demonstrated a minimally invasive surgical procedure for esophagectomy, with and without TD resection, in patients who received neoadjuvant chemotherapy.

METHODS

This multicenter, retrospective cohort study evaluated patients with cT1-3 thoracic esophageal cancer who underwent thoracoscopic McKeown esophagectomy after neoadjuvant chemotherapy at two Japanese cancer centers between 2012 and 2019. The effects of TD preservation and resection were compared using propensity score-matching. Short- and long-term outcomes were analyzed.

RESULTS

We showed the standard procedure for TD resection and preservation and demonstrated that recognizing membrane structures is crucial for precise resection of the esophagus and regional lymph nodes. After matching, 255 patients in each group were analyzed. The TD resection group showed no significant differences in short-term outcomes, complication rates, or thoracic lymph node harvest compared to the TD preservation group. Both groups had similar 5-year overall and recurrence-free survival rates, with no significant differences in recurrence patterns.

CONCLUSIONS

In the context of modern esophageal carcinoma treatment, in which MIE and neoadjuvant chemotherapy are standard practices, the impact of TD resection on prognosis is limited. Recognizing membrane structures is crucial for accurate esophagectomy using the MIE approach.

Full RAMIE vs Hybrid RAMIE: a retrospective study on outcomes evaluation and cost considerations

To compare the results of Minimally Invasive Esophagectomy performed with a Fully Robot-Assisted technique (F-RAMIE) and a Hybrid approach with laparoscopic abdominal phase (H-RAMIE). Multicentric retrospective analysis of patients who underwent F-RAMIE and H-RAMIE between 2018 and 2023. The primary endpoint was the rate of postoperative complications, secondary endpoints were clinical outcomes, oncological results and costs. Survival analyses were calculated according to the Kaplan-Meier method. The economic evaluation included costs related to operating room time, length of stay, surgical tools, and robotic system maintenance. A total of 100 patients from two experienced surgical centers were included: 64 H-RAMIE and 36 F-RAMIE. The two groups were comparable in baseline clinical conditions and staging. F-RAMIE was associated with longer operative time (434.7 ± 46.4 Vs. 477.3 ± 47.5 min, p < 0.001) and shorter length of Intensive Care Unit stay (1.1 ± 1.1 Vs. 2.3 ± 2.3 days, p = 0.002) than H-RAMIE. There were no significant differences in conversion rate, postoperative complications and length of stay. F-RAMIE demonstrated superior lymph node retrieval (43.8 ± 15.2 Vs. 22.4 ± 10.3, p < 0.001), but no differences in R0 resection rates. Overall survival and recurrences were comparable. Cost analysis revealed a slight economic advantage for F-RAMIE (20,556.3 ± 3,601.2 € Vs. 23,302.4 ± 5,894.5 € p = 0.012), mainly due to hospital stay-related cost (11,267.6 ± 5,912.8 € for H-RAMIE Vs. 8,360.3 ± 3,550.6 €, p = 0.007). F-RAMIE and H-RAMIE proved to be equally safe and effective in terms of postoperative complications and oncological outcomes.

Long-term Survival in Esophageal Cancer: Comparison of Minimally Invasive and Open Esophagectomy

BACKGROUND

Thoracoscopic esophagectomy is a less invasive surgical procedure; however, evidence of its effect on long-term survival is limited. We evaluated long-term survival after the procedure in patients with esophageal carcinoma.

METHODS

This retrospective multicenter study involved 1559 consecutive patients with esophageal carcinoma who underwent thoracoscopic esophagectomy or open esophagectomy between 2012 and 2019 at 2 Japanese high-volume cancer centers. Propensity score matching analysis was performed to compare short- and long-term outcomes. In addition, stage-specific survival rates were compared between the groups.

RESULTS

There were 313 patients who were matched and analyzed. The 1-, 3-, and 5-year overall survival rates were 84.5%, 60.5%, and 52.1%, respectively, in the matched open esophagectomy group; and 87.2%, 68.6%, and 61.8%, respectively, in the matched thoracoscopic esophagectomy group. The weighted Cox regression model showed significantly better survival in the thoracoscopic esophagectomy group than in the open esophagectomy group (hazard ratio, 0.74; 95% CI, 0.582-0.941). Deaths from other causes occurred more frequently in the open esophagectomy group than in the thoracoscopic esophagectomy group. Stratified analysis showed no significant survival differences between clinical stage I or II and pathologic stage 0 or I subgroups. However, the thoracoscopic esophagectomy groups with clinical stage III or IV and pathologic stage II, III, or IV had significantly better overall survival.

CONCLUSIONS

This study demonstrated the survival benefits of thoracoscopic esophagectomy, particularly for highly advanced esophageal carcinoma.

The comparison of uniportal versus multiportal video-assisted thoracic surgery for esophageal cancer: a propensity-weighted analysis

OBJECTIVES

The utilization of uniportal video-assisted thoracoscopic surgery (VATS) has become prevalent, notwithstanding, there are few studies exploring its application specifically in esophagectomy.

METHODS

A retrospective analysis was conducted on data collected from patients diagnosed with clinical stage T1-3/N0/M0 thoracic esophageal cancer, who underwent surgery between January 2017 and December 2020. To evaluate the outcomes, an analysis was conducted utilizing the inverse probability of treatment weighting (IPTW) method.

RESULTS

This study identified 55 patients who underwent uniportal VATS and 212 patients who underwent multiportal VATS. Postoperative complications classified as Clavien-Dindo grades 1-2 occurred less frequently after uniportal than multiportal VATS in both unadjusted and IPTW-adjusted analyses (10.1% versus 28.8%, respectively; P = 0.018). Upon IPTW analysis, it indicated that the rate of pneumonia (grades 1-2) in the uniportal VATS group was 7.3%, notably lower than the corresponding rate of 23.2% observed in the multiportal VATS group (P = 0.037). Patients in uniportal VATS group had a shorter postoperative length of stay comparing with those in multiportal VATS group (9 versus 10 days, P = 0.006 after IPTW). The visual analog scale (VAS) was administered within 7 days following surgery and scores were significantly lower in uniportal VATS group (P < 0.001). No surgery-related mortality was observed in uniportal VATS group. The survival benefit observed between two groups was comparable before (P = 0.320) and after IPTW analysis (P = 0.824), indicating no significant difference.

CONCLUSIONS

The utilization of uniportal VATS for esophagectomy demonstrated a reduced occurrence of postoperative complications, accompanied by mitigated postoperative pain, thereby presenting as a viable and practical approach for treating esophageal cancer patients.

Association of Preoperative Physical Fitness With Post-Esophagectomy Pneumonia in Older With Locally Advanced Esophageal Cancer: An Exploratory Prospective Study

BACKGROUNDS

Currently, there is a lack of evidence of prehabilitation during neoadjuvant chemotherapy (NAC) to prevent pneumonia of older patients. This study aimed to investigate the association of preoperative physical fitness after NAC with post-esophagectomy pneumonia in older patients with locally advanced esophageal cancer (LAEC).

METHODS

This single-center exploratory prospective cohort study included 80 patients aged ≥ 65 years with LAEC scheduled for curative esophagectomy after NAC between 2021 and 2023. The post-NAC short incremental shuttle walk test (ISWT) by sex was established using the Youden index. The association of the post-NAC short ISWT with postoperative pneumonia was investigated via Firth's penalized logistic regression model with statistical significance set as two-tailed p < 0.05.

RESULTS

A total of 69 patients were analyzed. The mean post-NAC ISWT values were 353.5 m. Short ISWT distance was defined as ≤ 395 and ≤ 195 m for men and women, respectively. Postoperative pneumonia developed in 17 (25%) patients. Short post-NAC ISWT distance was significantly associated with postoperative pneumonia (adjusted odds ratio: 1.840, 95%CI: 1.760-28.440, p = 0.004).

CONCLUSIONS

Decline in physical fitness was associated with post-esophagectomy pneumonia, which may be a key targeted factor of prehabilitation during NAC for older patients with LAEC.

Continuous Epidural Versus Non-Epidural Pain Management After Minimally Invasive Esophagectomy: A Real-Life, High-Case-Load Center Experience

Background/Objectives: Esophagectomy is a key component of esophageal cancer treatment, with minimally invasive esophagectomy (MIE) increasingly replacing open esophagectomy (OE). Effective postoperative pain management can be achieved through various analgesic modalities. This study compares the efficacy of thoracic epidural anesthesia (TEA) with non-TEA methods in managing postoperative pain following MIE. Methods: A retrospective review was conducted on 110 patients who underwent MIE between 2018 and 2023. 1. TEA vs. 2. intravenous patient-controlled analgesia (PCA) alone vs. 3. transversus abdominis plane (TAP) catheter with PCA vs. 4. single-shot TAP block with paravertebral catheter (PVB) in combination with PCA were compared. The primary outcome was postoperative pain within the first 72 h, assessed using the numeric rating scale. Secondary outcomes included postoperative surgical complications (Clavien-Dindo classification (CDC)), patient satisfaction, and duration of induction and emergence, among others. Results: The incidence of an NRS > 3 during movement was 47.1%, 51%, 60.1%, and 48.3% for TEA, PCA alone, TAP + PCA, and PVB + PCA, respectively. For pain at rest, the rates were 8.3%, 4.3%, 11.2%, and 5%, respectively. High surgical complication rates were observed across all groups (CDC IIIa-V 31.6% overall), with patient satisfaction similarly high, regardless of the analgesic modality used (85% satisfied or very satisfied). No differences in the other secondary outcomes were observed. Conclusions: PVB combined with PCA offered analgesic efficacy and patient satisfaction comparable to TEA in managing postoperative pain following MIE.

Minimally Invasive Transhiatal Esophagectomy Using Antegrade Inversion Technique in Esophageal Cancer: 10-Year Experience from a Tertiary Care Center

Background: Esophageal cancer surgery aims for curative intent but carries high complication rates. Transthoracic esophagectomy is the dominant approach, however, transhiatal esophagectomy (THE) offers selective advantages in certain clinical scenarios. Minimally invasive THE (MI-THE) is an evolving technique with limited data. Methods: This retrospective study reviewed 38 patients with esophageal cancer who underwent MI-THE using "Antegrade Inversion Technique" between 2013 and 2023 at a tertiary care center. Perioperative outcomes were analyzed. Data were presented as mean with standard deviation, median with interquartile range, and percentages. Results: Most patients (86.8%) had early-stage cancer. Median operative time was 375 minutes, hospital stay was 8 days, and intensive care unit stay was 3 days. All patients achieved a negative resection margin. Pleural effusion (57.9%) was the most common complication, followed by pneumothorax (31.6%) and surgical site infection (15.8%). Anastomotic leak rate was 13.2%. There was no mortality. Conclusions: MI-THE appears safe and feasible with encouraging perioperative outcomes, particularly for early-stage disease and high-risk patients. While potentially offering advantages over open THE, further research is needed to definitively establish its role compared to traditional approaches.

Clinical implementation of minimally invasive esophagectomy

BACKGROUND

Minimally invasive surgery is becoming the method of choice for the resection of esophageal cancer worldwide.

METHODS

Retrospective analysis of prospectively collected clinical data in a tertiary care center with a detailed description of the course of the program.

RESULTS

A total of 136 transthoracic esophageal resections were performed between 2010 and 2023. The study group included 116 operations, 69 of which were fully minimally invasive and 47 hybrid. 80.0% of the study group underwent surgery using a multimodality approach. The median operation time was 431 min (± 103). The R0 resection rate was 100%. Forty-two patients (36.2%) had no postoperative complications. The postoperative Clavien-Dindo > IIIb morbidity was 27%. The postoperative 90-d mortality rate was 1.7%. The average number of lymph nodes removed in the last quarter of cancer patients was 31. The anastomotic insufficiency rate for reoperation was 4% (Ivor-Lewis 4.2%, McKeown 5%).

CONCLUSIONS

With extensive expertise in high-end minimally invasive abdominal and thoracic surgery, implementation of a minimally invasive esophageal resection program with a clinical and oncologic outcome within generally accepted limits is feasible.

Association of operative time and approach on postoperative complications for esophagectomy

BACKGROUND

Minimally invasive esophagectomy is associated with decreased postoperative complications compared with open esophagectomy. However, the risks of complications for minimally invasive esophagectomy compared with open esophagectomy may be affected by operative time. The objectives of this study are to (1) compare the incidence of postoperative complications for minimally invasive esophagectomy and open esophagectomy and (2) evaluate the association of postoperative complications on operative approach and operative time.

METHODS

A retrospective cohort analysis of patients who underwent an esophagectomy in the American College of Surgeons National Surgical Quality Improvement Program Procedure-Targeted Data File was performed from 2016 to 2020. For analysis, minimally invasive esophagectomy and open esophagectomy were stratified into tertiles of operative time. A bivariate analysis of postoperative complications comparing minimally invasive esophagectomy with open esophagectomy was performed. Multivariable Poisson regression models were estimated evaluating the association of the likelihood of postoperative complications with operative approach and operative time.

RESULTS

In total, 8,574 patients who underwent esophagectomy were included: 5,369 patients underwent minimally invasive esophagectomy, and 3,205 patients underwent open esophagectomy. Median operative time was 402 minutes for minimally invasive esophagectomy and 321 minutes for open esophagectomy. The incidence of postoperative complications and 30-day mortality was lower in the minimally invasive esophagectomy group than the open esophagectomy group within the same tertiles of operative time. When we compared patients who underwent short open esophagectomy with those who underwent long minimally invasive esophagectomy, there were no significant differences in complications.

CONCLUSION

There is no significant association of postoperative complications for short open esophagectomy compared with long minimally invasive esophagectomy. Patients should be selected for minimally invasive esophagectomy when there is appropriate surgeon experience and hospital resources.

Comparative study of acute and chronic pain after inflatable videoasisted MediastinoscopicTranshiatal esophagectomy and minimally invasive McKeown Esophagectomy:A propensity score matching analysis

Objective

The short-term quality of life of patients can be enhanced by performing Inflatable Video-Assisted Mediastinoscopic Transhiatal Esophagectomy (IVMTE). Nevertheless, there is limited research on how it impacts postoperative acute and chronic pain in individuals diagnosed with esophageal cancer.Hence, this research aimed to examine the impact of IVMTE and minimally invasive Mckeown esophagectomy (MIME) on the occurrence of acute and chronic pain following surgery in individuals diagnosed with esophageal cancer.

Methods

A retrospective, propensity score matching analysis was adopted. In total, 133 patients with esophageal cancer who underwent IVMTE and MIME between January 2020 and December 2021 were part of the study. Among them, 38 patients underwent IVMTE and 95 patients underwent MIME. Following the propensity score matching analysis, 36 patients were included in each group. Patients' postoperative pain was evaluated using the numerical rating scale (NRS).

Results

The IVMTE group (Group A) had significantly reduced operation time and intraoperative blood loss compared to the MIME group (Group B) (P < 0.05). NRS scores on the 1st, 2nd, 3rd, and 7th days after surgery, as well as on the 3rd and 6th months post-surgery, were notably reduced in the IVMTE group (Group A) compared to the MIME group (Group B) (P < 0.05). Univariate and multivariate analysis showed that chronic pain occurred postoperative 3rd months was related to the operation methods (P < 0.05). Univariate analysis showed that chronic pain occurred postoperative 6th months was related to the operation time, postoperative 14th days NRS scores and operation methods (P < 0.05). Multivariate analysis showed that chronic pain occurred postoperative 6th months was related to the operation methods (P < 0.05).

Conclusion

The results showed that the operation methods were the main risk factors for postoperative chronic pain. The compared with MIME, IVMTE can further reduce the acute and chronic pain of patients with esophageal cancer.

A comparative assessment of ACS NSQIP-predicted and actual surgical risk outcomes of robotic transhiatal esophagectomy for esophageal adenocarcinoma resection at a high volume institution

Esophageal adenocarcinoma incidence is increasing in Western nations. There has been a shift toward minimally invasive approaches for transhiatal esophagectomy (THE). This study compares the outcomes of robotic THE for esophageal adenocarcinoma resection at our institution with the predicted metrics from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). With Institutional Review Board (IRB) approval, we prospectively followed 83 patients who underwent robotic THE from 2012 to 2023. Predicted outcomes were determined using the ACS NSQIP Surgical Risk Calculator. Our outcomes were compared with these predicted outcomes and with general outcomes for transhiatal esophagectomy reported in ACS NSQIP, which includes a mix of surgical approaches. The median age of patients was 70 years, with a body mass index (BMI) of 26.4 kg/m2 and a male prevalence of 82%. The median length of stay was 7 days. The rates of any complications and in-hospital mortality were 16% and 5%, respectively. Seven patients (8%) were readmitted within a 30-day postoperative window. The median survival is anticipated to surpass 95 months. Our outcomes were generally aligned with or surpassed the predicted ACS NSQIP metrics. The extended median survival of over 95 months highlights the potential effectiveness of robotic THE in the resection of esophageal adenocarcinoma. Further exploration into its long-term survival benefits and outcomes is warranted, along with studies that provide a more direct comparison between robotic and other surgical approaches.

Milestones in the History of Esophagectomy: From Torek to Minimally Invasive Approaches

The history of esophagectomy reflects a journey of dedication, collaboration, and technical innovation, with ongoing endeavors aimed at optimizing outcomes and reducing complications. From its early attempts to modern minimally invasive approaches, the journey has been marked by perseverance and innovation. Franz J. A. Torek's 1913 successful esophageal resection marked a milestone, demonstrating the feasibility of transthoracic esophagectomy and the potential for esophageal cancer cure. However, its high mortality rate posed challenges, and it took almost two decades for similar successes to emerge. Surgical techniques evolved with the left thoracotomy, right thoracotomy, and transhiatal approaches, expanding the indications for resection. Mechanical staplers introduced in the early 20th century transformed anastomosis, reducing complications. The advent of minimally invasive techniques in the 1990s aimed to minimize complications while maintaining oncological efficacy. Robot-assisted esophagectomy further pushed the boundaries of minimally invasive surgery. Collaborative efforts, particularly from the Worldwide Esophageal Cancer Collaboration and the Esophageal Complications Consensus Group, standardized reporting and advanced the understanding of outcomes. The introduction of risk prediction models aids in making informed decisions. Despite significant improvements in survival rates and postoperative mortality, anastomotic leaks remain a concern, with recent rates showing an increase. Prevention strategies include microvascular anastomosis and ischemic preconditioning, yet challenges persist.

Minimally invasive versus open esophagectomy after neoadjuvant therapy for esophageal cancer: a meta-analysis

OBJECTIVES

Neoadjuvant therapy and minimally invasive esophagectomy (MIE) are widely used in the comprehensive treatment of esophageal cancer. This study aimed to investigate the advantages of MIE for esophageal cancer after neoadjuvant therapy.

METHODS

Published clinical studies were reviewed and survival data and safety data were extracted. We compared the long-term survival and safety of MIE versus open esophagectomy after neoadjuvant surgery in a series of meta-analyses.

RESULTS

6 retrospective studies were included. Overall, MIE could significantly improve the overall survival of patients with esophageal cancer after neoadjuvant therapy compared with open esophagectomy [hazard ratio (HR) = 0.86, 95% confidence interval (CI) (0.75, 0.98)]. Compared with open esophagectomy, MIE could significantly reduce intraoperative blood loss and operative time [mean difference (MD) = -40.28.78, 95% CI (- 62.98, - 17.58); MD = -28.78, 95% CI (- 42.48, - 15.07), respectively]. There was no significant difference in 30-day and 90-day mortality between MIE and open esophagectomy [odds ratio (OR) = 0.42, 95% CI (0.09, 2.01); OR 0.80, 95% CI (0.25, 2.60), respectively]. MIE could not significantly reduce the incidence of anastomotic leakage, recurrent laryngeal nerve palsy and chylothorax [OR 0.70, 95% CI (0.37, 1.32); OR 1.43, 95% CI (0.33, 6.25); HR = 1.79, 95% CI (0.67, 4.75), respectively], but the incidence of pneumonia was significantly reduced [HR = 0.43, 95% CI (0.22, 0.82)]. In addition, the length of hospital stay and the incidence of total complications were significantly reduced after MIE [MD = -2.61, 95% CI (- 3.10, - 2.12); HR = 0.66, 95% CI (0.45, 0.98), respectively].

CONCLUSION

MIE after neoadjuvant therapy is effective and safe. Compared with open esophagectomy, MIE can improve the long-term survival and reduce the incidence of postoperative complications of esophageal cancer patients.

Minimally invasive surgery is associated with decreased postoperative complications after esophagectomy

BACKGROUND

Although some studies have compared esophagectomy outcomes by technique or approach, there is opportunity to strengthen our knowledge surrounding these outcomes. We aimed to perform a comprehensive comparison of esophagectomy postoperative complications.

METHODS

We retrospectively reviewed the American College of Surgeons National Surgical Quality Improvement Program database (2007-2018). Esophagectomies were identified using Current Procedural Terminology codes and grouped by operative technique (Ivor Lewis, transhiatal, McKeown) and surgical approach (minimally invasive vs open esophagectomy). Twelve postoperative complications were compared. Significant complications underwent risk adjustment using multivariate logistic regression.

RESULTS

Analysis was performed on 13,457 esophagectomies: 11,202 (83.2%) open and 2255 (16.8%) minimally invasive. There were 7611 (56.6%) Ivor Lewis, 3348 (24.9%) transhiatal, and 2498 (18.6%) McKeown procedures. There were significant differences among the surgical techniques in 6 of 12 risk-adjusted complications. When comparing the outcomes of minimally invasive techniques, there were only significant differences in 2 of 12 complications: overall morbidity (minimally invasive Ivor Lewis 30.5%, minimally invasive transhiatal 43.4%, minimally invasive McKeown 40.3%, P = .0009) and infections (minimally invasive Ivor Lewis 15.4%, minimally invasive transhiatal 26.0%, minimally invasive McKeown 25.3%, P = .0003). Patients who underwent minimally invasive surgery were less likely to have overall morbidity (odds ratio, 0.68; 95% confidence interval, 0.62-0.75), respiratory complications (odds ratio, 0.77; 95% confidence interval, 0.68-0.87), urinary tract infection (odds ratio, 0.61; 95% confidence interval, 0.43-0.88), renal complications (odds ratio, 0.52; 95% confidence interval, 0.34-0.81), bleeding complications (odds ratio, 0.36; 95% confidence interval, 0.30-0.43), and nonhome discharge (odds ratio, 0.54; 95% confidence interval, 0.45-0.64), and had shorter length of stay (9.7 vs 13.2 days, P < .0001).

CONCLUSIONS

Patients undergoing minimally invasive esophagectomy have lower rates of postoperative complications regardless of esophagectomy techniques. The minimally invasive approach was associated with reduced complication variance among 3 common esophagectomy techniques.

Outcomes of Minimally Invasive and Robot-Assisted Esophagectomy for Esophageal Cancer

Simple Summary

This is an invited review for the special edition, “Minimally Invasive Surgery for Cancer: Indications and Outcomes.” Indications to perform minimally invasive techniques for esophagectomy rather than the classic open technique do not exist. This review outlines the current research by comparing outcomes among minimally invasive esophagectomy, robot-assisted esophagectomy, and open esophagectomy. After determining the benefits of each technique in terms of each outcome, the discussion focuses on how surgeons may use the presented information to determine which approach is most appropriate. We hope this study provides a comprehensive review of the current state of the literature regarding minimally invasive esophagectomy, as well as a guide for surgeons who treat patients with esophageal cancer.

Abstract

With the evolution of minimally invasive esophagectomy (MIE) and robot-assisted minimally invasive esophagectomy (RAMIE), questions remain regarding the benefits and indications of these methods. Given that set indications do not exist, this article aims first to review the reported outcomes of MIE, RAMIE, and open esophagectomy. Then, considerations based on the reported outcomes are discussed to guide surgeons in selecting the best approach. MIE and RAMIE offer the potential to improve outcomes for esophagectomy patients; however, surgeon experience as well as individual patient factors play important roles when deciding upon the surgical approach.

Laparoscopic Versus Open Pancreatoduodenectomy: Cost-Effectiveness Analysis

Background and Objectives: The role of laparoscopy during a pancreatoduodenectomy (PD) is not clearly defined. The purpose of this study was thus to compare the cost-effectiveness between laparoscopic pancreatoduodenectomy (LPD) and open pancreatoduodenectomy (OPD). Materials and Methods: From 2010 to 2019, 140 patients underwent PD (60 LPD and 80 OPD). After 60-60 matching, the clinical-pathological characteristics, surgical technique, and type of rehabilitation were identical in both groups. Complications, R0 resection, and cost were compared. Results: Complication rates were 48% (12% Clavien-Dindo grade 3-4) in the LPD group and 64% (22% Clavien-Dindo grade 3-4) in the OPD group. The LPD group had significantly fewer pulmonary complications (6%) than the OPD group (20%) (P = .04). The oncological quality of the R0 resection did not differ between the two groups. The operating time was 312 ± 50 minutes in the OPD group and 392 ± 75 minutes in the LPD group (P < .001). The mean length of hospital stay was significantly shorter for the LPD group (13 ± 10) days compared to the OPD group (19 ± 8) days (P = .02). The average cost of total hospital stay was significantly lower for the LPD group compared to the OPD group (P = .02). Conclusions: Despite longer operative times, LPD had fewer (pulmonary) complications and reduced hospital costs.

Long-term effect of hospital volume on the postoperative prognosis of 158,618 patients with esophageal squamous cell carcinoma in China

Background

The impact of hospital volume on the long-term survival of esophageal squamous cell carcinoma (ESCC) has not been well assessed in China, especially for stage I-III stage ESCC. We performed a large sample size study to assess the relationships between hospital volume and the effectiveness of ESCC treatment and the hospital volume value at the lowest risk of all-cause mortality after esophagectomy in China.

Aim

To investigate the prognostic value of hospital volume for assessing postoperative long-term survival of ESCC patients in China.

Methods

The date of 158,618 patients with ESCC were collected from a database (1973-2020) established by the State Key Laboratory for Esophageal Cancer Prevention and Treatment, the database includes 500,000 patients with detailed clinical information of pathological diagnosis and staging, treatment approaches and survival follow-up for esophageal and gastric cardia cancers. Intergroup comparisons of patient and treatment characteristics were conducted with the X² test and analysis of variance. The Kaplan-Meier method with the log-rank test was used to draw the survival curves for the variables tested. A Multivariate Cox proportional hazards regression model was used to analyze the independent prognostic factors for overall survival. The relationship between hospital volume and all-cause mortality was assessed using restricted cubic splines from Cox proportional hazards models. The primary outcome was all-cause mortality.

Results

In both 1973-1996 and 1997-2020, patients with stage I-III stage ESCC who underwent surgery in high volume hospitals had better survival than those who underwent surgery in low volume hospitals (both P<0.05). And high volume hospital was an independent factor for better prognosis in ESCC patients. The relationship between hospital volume and the risk of all-cause mortality was half-U-shaped, but overall, hospital volume was a protective factor for esophageal cancer patients after surgery (HR<1). The concentration of hospital volume associated with the lowest risk of all-cause mortality was 1027 cases/year in the overall enrolled patients.

Conclusion

Hospital volume can be used as an indicator to predict the postoperative survival of ESCC patients. Our results suggest that the centralized management of esophageal cancer surgery is meaningful to improve the survival of ESCC patients in China, but the hospital volume should preferably not be higher than 1027 cases/year.

Core tip

Hospital volume is considered to be a prognostic factor for many complex diseases. However, the impact of hospital volume on long-term survival after esophagectomy has not been well evaluated in China. Based on a large sample size of 158,618 ESCC patients in China spanning 47 years (1973-2020), We found that hospital volume can be used as a predictor of postoperative survival in patients with ESCC, and identified hospital volume thresholds with the lowest risk of death from all causes. This may provide an important basis for patients to choose hospitals and have a significant impact on the centralized management of hospital surgery.