Comparison of outcomes between minimally invasive oesophagectomy and open oesophagectomy for oesophageal cancer

How pragmatic are randomised controlled trials evaluating minimally invasive surgery for oesophageal cancer? A methodological review of trial design using the Pragmatic-Explanatory Continuum Indicator Summary-2 (PRECIS-2) tool

BACKGROUND

Surgical interventions are inherently complex and designing and conducting surgical randomised controlled trials (RCTs) can be challenging. Trial design impacts the applicability of trial results to clinical practice. Given the recent growth in numbers of surgical RCTs, there is a need to better understand the validity and applicability of trials in this field.

OBJECTIVES

To examine the applicability and validity of RCTs comparing minimally invasive and open surgery for oesophageal cancer and to delineate areas for future research.

ELIGIBILITY CRITERIA

RCTs comparing open with minimal invasive oesophagectomy, published January 2012-June 2023. Abstracts, pilot and feasibility studies, and systematic reviews were excluded.

SOURCES OF EVIDENCE

Three sequential searches of Ovid MEDLINE, Embase and CENTRAL electronic databases and clinical trials registry databases.

CHARTING METHODS

Two independent reviewers screened the articles and used appropriate, validated tools (Pragmatic-Explanatory Continuum Indicator Summary-2 (PRECIS-2) and Risk of Bias 2) to assess study quality. Trials were considered pragmatic if they were conducted in multiple centres and had a mean score of four or above on the PRECIS-2.

RESULTS

Nine RCTs were identified. One was judged to be pragmatic. The remaining eight were limited by narrow eligibility criteria, being single-centred or having strict intervention protocols. Two studies were low risk of bias, of which one was pragmatic, and three high, due to unblinded outcome assessment. The remaining four studies were of 'some concern' due to poor reporting.

CONCLUSIONS

Only one trial identified in this review was considered pragmatic. More lenient criteria, as used in other reviews, may increase the proportion. There is a need for clearer guidance on the cut-off values that define a trial as pragmatic. It is recommended that the intended purpose of the trial, whether explanatory or pragmatic, receives more attention during surgical trial study design and conduct.

Calcifications in the descending thoracic aorta predict postoperative anastomotic leakages after esophagectomy for cancer

BACKGROUND

Anastomotic leak is one of the most feared complications of esophagectomy. Previous studies have suggested a potential link between aortic calcifications detected on routine preoperative CT scans and increased risk of anastomotic leak after esophagectomy. This study aims to investigate whether clinicians' assessment of aortic calcifications can predict the occurrence of anastomotic leaks in patients undergoing esophagectomy for cancer.

METHODS

A long-term follow-up was conducted on consecutive patients with esophageal cancer who underwent elective open esophagectomy at a Finnish tertiary hospital. Aortic calcifications were evaluated based on CT scans and categorized on a 0-3 scale reflecting the number of calcifications in the affected segment of the aorta. Reviewers assessing the calcifications were blinded to clinical details and postoperative outcomes.

RESULTS

The study included 97 patients (median age: 64 years and range: 43-78; 20% female), with a median follow-up time of 1307 (2-1540) days. Among them, 22 patients (23%) had postoperative anastomotic leak. We observed a significant association between calcifications in the descending aorta and a higher risk of anastomotic leak (p = 0.007), as well as an earlier occurrence of leak postoperatively (p = 0.013). However, there was no association between aortic calcifications and increased mortality.

CONCLUSIONS

Presence of calcifications in the descending aorta is independently associated with an increased risk of anastomotic leaks following esophagectomy for cancer. Identifying patients at higher risk for this complication could facilitate appropriate pre- and postoperative interventions, as well as enable earlier diagnosis and treatment to mitigate the severity of the complication.

Robotic-Assisted Ivor Lewis Esophagectomy Is Safe and Cost Equivalent Compared to Minimally Invasive Esophagectomy in a Tertiary Referral Center

In recent decades, robotic-assisted minimally invasive esophagectomy (RAMIE) has been increasingly adopted for patients with esophageal cancer (EC) or cancer of the gastroesophageal junction (GEJ). However, concerns regarding its costs compared to conventional minimally invasive esophagectomy (MIE) have emerged. This study examined outcomes and costs of RAMIE versus total MIE in 128 patients who underwent Ivor Lewis esophagectomy for EC/GEJ at our department between 2017 and 2021. Surgical costs were higher for RAMIE (EUR 12,370 vs. EUR 10,059, p < 0.001). Yet, median daily (EUR 2023 vs. EUR 1818, p = 0.246) and total costs (EUR 30,510 vs. EUR 29,180, p = 0.460) were comparable. RAMIE showed a lower incidence of postoperative pneumonia (8% vs. 25%, p = 0.029) and a trend towards shorter hospital stays (15 vs. 17 days, p = 0.205), which may have equalized total costs. Factors independently associated with higher costs included readmission to the intensive care unit (hazard ratio [HR] = 7.0), length of stay (HR = 13.5), anastomotic leak (HR = 17.0), and postoperative pneumonia (HR = 5.4). In conclusion, RAMIE does not impose an additional financial burden. This suggests that RAMIE may be considered as a valid alternative approach for esophagectomy. Attention to typical cost factors can enhance postoperative care across surgical methods.

Evolving Perspectives on Esophagectomy Care: Clinical Update

Recent changes in perioperative care have led to new perspectives and important advances that have helped to improve outcomes among patients treated with esophagectomy for esophageal cancer.

Effect of thoracic cage width on surgery time and postoperative outcome in minimally invasive esophagectomy

INTRODUCTION

Minimally invasive esophagectomy (MIE) for esophageal cancer is a complex procedure that reduces postoperative morbidity in comparison to open approach. In this study, thoracic cage width as a factor to predict surgical difficulty in MIE was evaluated.

METHODS

All patients of our institution receiving either total MIE or robotic-assisted MIE (RAMIE) with intrathoracic anastomosis between February 2016 and April 2021 for esophageal cancer were included in this study. Right unilateral thoracic cage width on the level of vena azygos crossing the esophagus was measured by the horizontal distance between the esophagus and parietal pleura on preoperative computer tomography. Patients' data as well as operative and postoperative details were collected in a prospective database. Correlation between thoracic cage width with duration of the thoracic procedure and postoperative complication rates was analyzed.

RESULTS

Overall, 313 patients were eligible for this study. Thoracic width on vena azygos level ranged from 85 to 149 mm with a mean of 116.5 mm. In univariate analysis, a small thoracic width significantly correlated with longer duration of the thoracic procedure (p = 0.014). In multivariate analysis, small thoracic width and neoadjuvant therapy were identified as independent factors for long duration of the thoracic procedure (p = 0.006). Regarding postoperative complications, thoracic cage width was a significant risk factor for occurrence of postoperative pneumonia in the multivariate analysis (p = 0.045). Dividing the cohort into two groups of patients with narrow (≤ 107 mm, 19.5%) and wide thoraces (≥ 108 mm, 80.5%), the thoracic procedure was significantly prolonged by 17 min (204 min vs. 221 min, p = 0.014).

CONCLUSION

A small thoracic cage width is significantly correlated with longer operation time during thoracic phase of a MIE in Europe, which suggests increased surgical difficulty. Patients with small thoracic cage width may preferably be operated by MIE-experienced surgeons.

Safety, efficacy, and cost-effectiveness of minimally invasive esophagectomies versus open esophagectomies: an umbrella review

Traditionally, esophageal oncological resections have been performed via open approaches with well-documented levels of morbidity and mortality complicating the postoperative course. In contemporary terms, minimally invasive approaches have garnered sustained support in all areas of surgery, and there has been an exponential adaptation of this technology in upper GI surgery with the advent of laparoscopic and robotic techniques. The current literature, while growing, is inconsistent in reporting on the benefits of minimally invasive esophagectomies (MIEs) and this makes it difficult to ascertain best practice. The objective of this review was to critically appraise the current evidence addressing the safety, efficacy, and cost-effectiveness of MIEs versus open esophagectomies. A systematic review of the literature was performed by searching nine electronic databases to identify any systematic reviews published on this topic and recommended Joanna Briggs Institute approach to critical appraisal, study selection, data extraction and data synthesis was used to report the findings. A total of 13 systematic reviews of moderate to good quality encompassing 143 primary trials and 36,763 patients were included in the final synthesis. Eleven reviews examined safety parameters and found a generalized benefit of MIE. Efficacy was evaluated by eight systematic reviews and found each method to be equivalent. There were limited data to judiciously appraise cost-effectiveness as this was only evaluated in one review involving a single trial. There is improved safety and equivalent efficacy associated with MIE when compared with open esophagectomy. Cost-effectiveness of MIE cannot be sufficiently supported at this point in time. Further studies, especially those focused on cost-effectiveness are needed to strengthen the existing evidence to inform policy makers on feasibility of increased assimilation of this technology into clinical practice.

Selection of minimally invasive surgical approaches for treating esophageal cancer

Minimally invasive esophagectomy has gradually been accepted as an active treatment option for surgery of esophageal cancer. However, there is no consensus about how to perform the procedures in the thoracic and abdominal phase including anastomosis in the neck (McKeown) or chest (Ivor Lewis), VATS, robotic‐assisted or reduced port approaches or various endoscopic abrasion techniques. Further studies to investigate the roles of these novel techniques are required to treat the various patient populations.

Operative Outcomes of Minimally Invasive Esophagectomy versus Open Esophagectomy for Resectable Esophageal Cancer

Background There is a recent rise in the incidence of esophageal carcinoma in India. Surgical resection with or without neoadjuvant chemoradiation is the current treatment modality of choice. Postoperative complications, especially pulmonary complications, affect many patients who undergo open esophagectomy for esophageal cancer. Minimally invasive esophagectomy (MIE) could reduce the pulmonary complications and reduce the postoperative stay.

Methodology We performed a retrospective analysis of prospectively collected data of 114 patients with esophageal cancer in the department of surgical oncology at a tertiary cancer center in South India between January 2019 and March 2020. We included patients with resectable cancer of middle or lower third of the esophagus, and gastroesophageal junction tumors (Siewert I). MIE was performed in 27 patients and 78 patients underwent open esophagectomy (OE). The primary outcome measured was postoperative complications of Clavien–Dindo grade II or higher within 30 days. Other outcomes measured include overall mortality within 30 days, intraoperative complications, operative duration and the length of hospital stay.

Results A postoperative complication rate of 18.5% was noted in the MIE group, compared with 41% in the OE group ( p = 0.034). Pulmonary complications were noted in 7.4% in the MIE group compared to 25.6% in the OE group ( p = 0.044). Postoperative mortality rates, intraoperative complications, and other nonpulmonary postoperative complications were almost similar with MIE as with open esophagectomy. Although the median operative time was more in the MIE group (260 minutes vs. 180 minutes; p < 0.0001), the median length of hospital stay was shorter in patients undergoing MIE (9 days vs. 12 days; p = 0.0001).

Conclusions We found that MIE resulted in lower incidence of postoperative complications, especially pulmonary complications. Although, MIE was associated with prolonged operative duration, it resulted in shorter hospital stay.

Outcomes of robotic esophagectomy

Esophagectomy has long been considered the standard of care for early-stage (≤ T2N0) esophageal cancer. Minimally invasive esophagectomy (MIE), using a combined laparoscopic and thoracoscopic approach, was first performed in the 1990s and showed significant improvements over open approaches. Refinement of MIE arrived in the form of robotic-assisted minimally invasive esophagectomy (RAMIE) in 2004. MIE is a challenging procedure for which consensus on optimal technique is still elusive. Although nonrobotic MIE confers significant advantages over open approaches, MIE remains associated with stubbornly high rates of complications, including pneumonia, aspiration, arrhythmia, anastomotic leakage, surgical site infection, and vocal cord palsy. RAMIE was envisioned to improve operative-associated morbidity while achieving equivalent or superior oncologic outcomes to nonrobotic MIE. However, owing to RAMIE’s significant upfront costs, steep learning curve, and other requirements, adoption remains less than widespread and convincing evidence supporting its use from well-designed studies is lacking. In this review, we compare operative, oncologic, and quality-of-life outcomes between open esophagectomy, nonrobotic MIE, and RAMIE. Although RAMIE remains a relatively new and underexplored modality, several studies in the literature show that it is feasible and results in similar outcomes to other MIE approaches. Moreover, RAMIE has been associated with favorable patient satisfaction and quality of life.

Video-Assisted Thoracic Surgery Intrathoracic Anastomosis Technique

The extracorporeal anastomosis technique for video-assisted thoracoscopic surgery (VATS) intrathoracic esophagogastric anastomosis is a convenient, easy technique to use in VATS esophagectomy. The surgeon can assess the viability and the status of the gastric conduit, and the introduction of a circular stapler can be easily done under direct vision extracorporeally, enabling easy and simple VATS intrathoracic anastomosis between the esophagus and the gastric conduit.

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

The paradigm of the treatment of esophageal cancer has been changing with the increasing use of minimally invasive esophagectomy (MIE) in detriment of open esophagectomy (OE). We aimed to perform a meta-analysis to evaluate and compare these two techniques in terms of mortality and associated complications. The literature search was conducted in MEDLINE and U.S. National Library of Medicine Clinical Trials, considering eligible articles since 2015 to 2020. Clinical trials and observational studies were included. We presented results as mean differences with 95% confidence intervals and calculation of heterogeneity associated to the included studies. Thirty-one articles were included with a total of 34,465 participants diagnosed with esophageal adenocarcinoma or squamous cell carcinoma. MIE had tendency towards a decrease in 30- and 90- day mortality after surgery, but no statistically significative results were found. Major cardiovascular and respiratory complications were less frequent in the MIE group, despite high heterogeneity. Also, MIE might contribute to a decrease of minor post-operative complications, to an increase need of a second surgical intervention, to a greater risk for vocal cord lesions; but these results were not statistically significant. Additionally, no differences were found concerning risk of wound infection and for local and systemic recurrence. MIE may be more beneficial than OE, but these findings should be considered carefully.

Minimally Invasive Versus Open McKeown for Patients with Esophageal Cancer: A Retrospective Study

INTRODUCTION

McKeown minimally invasive esophagectomy (McKeown-MIE) offers advantages in short-term outcomes compared with McKeown open esophagectomy (McKeown-OE); however, debate as to whether MIE is equivalent or better than OE regarding survival outcomes is ongoing.

OBJECTIVE

The aim of this study was to compare long-term survival between McKeown-MIE and McKeown-OE in a large cohort of esophageal cancer (EC) patients.

METHODS

We used a prospective database (independently managed by LinkDoc company) of the Thoracic Surgery Department at Henan Cancer Hospital and included patients who underwent McKeown-MIE and McKeown-OE for EC from 1 January 2015 to 6 January 2018. The perioperative data and overall survival (OS) rate in the two groups were retrospectively compared.

RESULTS

We included 502 patients who underwent McKeown-MIE (n = 306) or McKeown-OE (n = 196) for EC. The median age in the total patient population was 63 years. All baseline characteristics were well-balanced between the two groups. There was a significantly shorter mean operative time (269.76 min vs. 321.14 min, p < 0.001) in the OE group. The 30-day and in-hospital mortality rates were 0, and there was no difference in 90-day mortality (p = 0.053) between the groups. The postoperative stay was shorter in the MIE group and was 14 days and 18 days in the MIE and OE groups, respectively (p < 0.001). The OS at 60 months was 58.8% and 41.6% in the MIE and OE groups, respectively (p < 0.001) [hazard ratio 1.783, 95% confidence interval 1.347-2.359].

CONCLUSIONS

These results showed that McKeown-MIE was associated with better long-term survival than McKeown-OE for patients with resectable EC.

[Evidence in minimally invasive oncological surgery of the esophagus]

BACKGROUND

Thoracoabdominal esophagectomy still plays a major role in the oncological treatment for esophageal cancer. Minimally invasive procedures were developed to reduce the high rate of postoperative morbidity and mortality without negatively affecting the oncological outcome.

OBJECTIVE

What evidence supports minimally invasive oncological surgery of the esophagus? Do patients benefit from minimally invasive esophagectomy compared to an open approach? Is the reduction of surgical access trauma specifically advantageous?

MATERIAL AND METHODS

Review, evaluation and critical analysis of the international literature.

RESULTS

A reduction in postoperative morbidity by decreasing surgical trauma was confirmed by three prospective randomized clinical trials, while showing at least similar oncological outcomes. Diverse retrospective analyses and meta-analyses also came to the same result.

CONCLUSION

A minimization of surgical access trauma during thoracoabdominal esophagectomy reduces postoperative morbidity compared to conventional open surgery. Recent evidence suggests that oncological outcomes are not altered depending on the surgical approach.

The Impact of Prehabilitation on Post-operative Outcomes in Oesophageal Cancer Surgery: a Propensity Score Matched Comparison

BACKGROUND

Patients undergoing oesophageal cancer surgery are often frail with a high risk of post-operative complications. Prehabilitation has been shown to reduce post-operative complications in specific patient populations but evidence in oesophageal cancer patients is inconclusive.

METHODS

Between January 2016 and April 2019, all patients with resectable oesophageal cancer who underwent curative treatment at a specialist tertiary centre participated in a personalised, home-based, multimodal prehabilitation programme. Post-operative complications and hospital stay in this group were compared to a control sample. Propensity score matching was used to control for differences in baseline characteristics.

RESULTS

Seventy-two patients who completed prehabilitation and 39 control patients were studied; following propensity score matching, there were 38 subjects in each group. In comparison to matched controls, patients in the prehabilitation group had a lower incidence of post-operative pneumonia (prehabilitation = 26%; control = 66%; p = 0.001) and a shorter length of stay (prehabilitation = median 10 days, IQR 8-17 days; control = median 13 days, IQR 11-20 days; p = 0.018). On multivariate regression analysis, participation in prehabilitation was associated with a 77% lower incidence of post-operative pneumonia (OR 0.23, 95% CI 0.09 to 0.55 p = 0.001). There was no significant difference in the incidence of overall complications or severe complications.

CONCLUSION

Prehabilitation was associated with a lower incidence of post-operative pneumonia and shorter hospital length of stay following oesophagectomy. This model of home based, personalised, and supervised prehabilitation is effective and relevant to centralised cancer services.

Minimal Invasive Esophagectomy-a New Dawn of EsophagealSurgery

Surgery is the mainstay of esophageal cancer. However, esophagectomy is a major surgical trauma on a patient with high morbidity and mortality. The intent of minimally invasive esophagectomy (MIE) is to decrease the degree of surgical trauma and perioperative morbidity associated with open surgery, and provide faster recovery and shorter hospital stay with the equivalent oncological outcome. It also allows for lesser pulmonary morbidity, less blood loss, less pain, and a better quality of life. MIE is safe and effective but has a steep learning curve with high technical expertise. Recently, it is increasingly accepted and adopted all over the globe. In this article, we discuss the safety, efficacy, short-term, and oncological outcomes of thoracoscopic- and laparoscopic-assisted minimally invasive esophagectomy and robotic surgery compared with open esophagectomy with a special focus on the Indian perspective.

Application of neck anastomotic muscle flap embedded in 3-incision radical resection of oesophageal carcinoma: A protocol for systematic review and meta analysis

BACKGROUND

Oesophageal cancer is one of the most common malignant tumors and has been identified as one of the leading causes of cancer death worldwide. Surgery is considered to be the optimal treatment for patients with resectable oesophageal cancer. Oesophagectomy for oesophageal cancer can significantly extend the survival period of patients and provide a potential opportunity for a cure. However, there is still controversy regarding application of neck anastomotic muscle flap embedded. This systematic review and meta-analysis will be performed to determine whether the application of neck anastomotic muscle flap embedded would benefit patients more.

METHODS

We will search PubMed, Web of Science, Embase, Cancerlit, the Cochrane Central Register of Controlled Trials, and Google Scholar databases for relevant clinical trials published in any language before October 1, 2020. Randomized controlled trials (RCTs), quasi-RCTs, propensity score-matched comparative studies, and prospective cohort studies of interest, published or unpublished, that meet the inclusion criteria will be included. Subgroup analysis of the type of operation, tumor pathological stage, and ethnicity will be performed. INPLASY registration number: INPLASY202080059.

RESULTS

The results of this study will be published in a peer-reviewed journal.

CONCLUSION

As far as we know, this study will be the first meta-analysis to compare the efficacy of the application of neck anastomotic muscle flap embedded in 3-incision radical resection of oesophageal carcinoma. Due to the nature of the disease and intervention methods, RCTs may be inadequate, and we will carefully consider inclusion in high-quality, non-RCTs, but this may result in high heterogeneity and affect the reliability of the results.

Minimally invasive esophagectomy: clinical evidence and surgical techniques

Background

Surgical esophagectomy plays a crucial role in the curative and palliative treatment of esophageal cancer. Thereby, minimally invasive esophagectomy (MIE) is increasingly applied all over the world. Combining minimal invasiveness with improved possibilities for meticulous dissection, robot-assisted minimal invasive esophagectomy (RAMIE) has been implemented in many centers.

Purpose

This review focuses on the development of MIE as well as RAMIE and their value based on evidence in current literature.

Conclusion

Although MIE and RAMIE are highly complex procedures, they can be performed safely with improved postoperative outcome and equal oncological results compared with open esophagectomy (OE). RAMIE offers additional advantages regarding surgical dissection, lymphadenectomy, and extended indications for advanced tumors.

Minimally invasive techniques for transthoracic oesophagectomy for oesophageal cancer: systematic review and network meta-analysis

BACKGROUND

Oesophagectomy is a demanding operation that can be performed by different approaches including open surgery or a combination of minimal access techniques. This systematic review and network meta-analysis aimed to evaluate the clinical outcomes of open, minimally invasive and robotic oesophagectomy techniques for oesophageal cancer.

METHODS

A systematic literature search was conducted for studies reporting open oesophagectomy, laparoscopically assisted oesophagectomy (LAO), thoracoscopically assisted oesophagectomy (TAO), totally minimally invasive oesophagectomy (MIO) or robotic MIO (RAMIO) for oesophagectomy. A network meta-analysis of intraoperative (operating time, blood loss), postoperative (overall complications, anastomotic leaks, chyle leak, duration of hospital stay) and oncological (R0 resection, lymphadenectomy) outcomes, and survival was performed.

RESULTS

Ninety-eight studies involving 32 315 patients were included in the network meta-analysis (open 17 824, 55·2 per cent; LAO 1576, 4·9 per cent; TAO 2421 7·5 per cent; MIO 9558, 29·6 per cent; RAMIO 917, 2·8 per cent). Compared with open oesophagectomy, both MIO and RAMIO were associated with less blood loss, significantly lower rates of pulmonary complications, shorter duration of stay and higher lymph node yield. There were no significant differences between surgical techniques in surgical-site infections, chyle leak, and 30- and 90-day mortality. MIO and RAMIO had better 1- and 5-year survival rates respectively compared with open surgery.

CONCLUSION

Minimally invasive and robotic techniques for oesophagectomy are associated with reduced perioperative morbidity and duration of hospital stay, with no compromise of oncological outcomes but no improvement in perioperative mortality.

Totally minimally invasive esophagectomy versus hybrid minimally invasive esophagectomy: systematic review and meta-analysis

Minimally invasive esophagectomy is increasingly performed for the treatment of esophageal cancer, but it is unclear whether hybrid minimally invasive esophagectomy (HMIE) or totally minimally invasive esophagectomy (TMIE) should be preferred. The objective of this study was to perform a meta-analysis of studies comparing HMIE with TMIE. A systematic literature search was performed in MEDLINE, Embase, and the Cochrane Library. Articles comparing HMIE and TMIE were included. The Newcastle-Ottawa scale was used for critical appraisal of methodological quality. The primary outcome was pneumonia. Sensitivity analysis was performed by analyzing outcome for open chest hybrid MIE versus total TMIE and open abdomen MIE versus TMIE separately. Therefore, subgroup analysis was performed for laparoscopy-assisted HMIE versus TMIE, thoracoscopy-assisted HMIE versus TMIE, Ivor Lewis HMIE versus Ivor Lewis TMIE, and McKeown HMIE versus McKeown TMIE. There were no randomized controlled trials. Twenty-nine studies with a total of 3732 patients were included. Studies had a low to moderate risk of bias. In the main analysis, the pooled incidence of pneumonia was 19.0% after HMIE and 9.8% after TMIE which was not significantly different between the groups (RR: 1.46, 95% CI: 0.97-2.20). TMIE was associated with a lower incidence of wound infections (RR: 1.81, 95% CI: 1.13-2.90) and less blood loss (SMD: 0.78, 95% CI: 0.34-1.22) but with longer operative time (SMD:-0.33, 95% CI: -0.59--0.08). In subgroup analysis, laparoscopy-assisted HMIE was associated with a higher lymph node count than TMIE, and Ivor Lewis HMIE was associated with a lower anastomotic leakage rate than Ivor Lewis TMIE. In general, TMIE was associated with moderately lower morbidity compared to HMIE, but randomized controlled evidence is lacking. The higher leakage rate and lower lymph node count that was found after TMIE in sensitivity analysis indicate that TMIE can also have disadvantages. The findings of this meta-analysis should be considered carefully by surgeons when moving from HMIE to TMIE.

Postoperative short-term outcomes of minimally invasive versus open esophagectomy for patients with esophageal cancer: An updated systematic review and meta-analysis

Background

We performed a systematic review and meta‐analysis to synthesize the available evidence regarding short‐term outcomes between minimally invasive esophagectomy (MIE) and open esophagectomy (OE).

Methods

Studies were identified by searching databases including PubMed, EMBASE, Web of Science and Cochrane Library up to March 2019 without language restrictions. Results of these searches were filtered according to a set of eligibility criteria and analyzed in line with PRISMA guidelines.

Results

There were 33 studies included with a total of 13 269 patients in our review, out of which 4948 cases were of MIE and 8321 cases were of OE. The pooled results suggested that MIE had a better outcome regarding all‐cause respiratory complications (RCs) (OR = 0.56, 95% CI = 0.41–0.78, P = <0.001), in‐hospital duration (SMD = −0.51; 95% CI = −0.78−0.24; P = <0.001), and blood loss (SMD = −1.44; 95% CI = −1.95−0.93; P = <0.001). OE was associated with shorter duration of operation time, while no statistically significant differences were observed regarding other outcomes. Additionally, subgroup analyses were performed for a number of different postoperative events.

Conclusions

Our study indicated that MIE had more favorable outcomes than OE from the perspective of short‐term outcomes. Further large‐scale, multicenter randomized control trials are needed to explore the long‐term survival outcomes after MIE versus OE.

Efficacy of hybrid minimally invasive esophagectomy vs open esophagectomy for esophageal cancer: A meta-analysis

BACKGROUND

The first line treatment regimen for esophageal cancer is still surgical resection and the choice of surgical scheme depends on surgeon. Now the efficacy comparison of hybrid minimally invasive esophagectomy (HMIE) and open esophagectomy (OE) is still controversial.

AIM

To compare the perioperative and postoperative outcomes of HMIE and OE in patients with esophageal cancer.

METHODS

PubMed, EMBASE, and Cochrane Library databases were searched for related articles. The odds ratio (OR) or standard mean difference (SMD) with a 95% confidence interval (CI) was used to evaluate the effectiveness of HMIE and OE.

RESULTS

Seventeen studies including a total of 2397 patients were selected. HMIE was significantly associated with less blood loss (SMD = -0.43, 95%CI: -0.66, -0.20; P = 0.0002) and lower incidence of pulmonary complications (OR = 0.72, 95%CI: 0.57, 0.90; P = 0.004). No significant differences were seen in the lymph node yield (SMD = 0.11, 95%CI: -0.08, 0.30; P = 0.26), operation time (SMD = 0.24, 95%CI: -0.14, 0.61; P = 0.22), total complications rate (OR = 0.68, 95%CI: 0.46, 0.99; P = 0.05), cardiac complication rate (OR = 0.91, 95%CI: 0.62, 1.34; P = 0.64), anastomotic leak rate (OR = 0.95, 95%CI: 0.67, 1.35; P = 0.78), duration of intensive care unit stay (SMD = -0.01, 95%CI: -0.21, 0.19; P = 0.93), duration of hospital stay (SMD = -0.13, 95%CI: -0.28, 0.01; P = 0.08), and total mortality rates (OR = 0.70, 95%CI: 0.47, 1.06; P = 0.09) between the two treatment groups.

CONCLUSION

Compared with the OE, HMIE shows less blood loss and pulmonary complications. However, further studies are necessary to evaluate the long-term oncologic outcomes of HMIE.

Right versus left thoracic approach oesophagectomy for oesophageal cancer: a systematic review and meta-analysis protocol

INTRODUCTION

Oesophageal cancer is one of the most common malignant tumours and has been identified as one of the leading causes of cancer death worldwide. Surgery is considered to be the optimal treatment for patients with resectable oesophageal cancer. Oesophagectomy for oesophageal cancer can significantly extend the survival period of patients and provide a potential opportunity for a cure. However, there is still controversy regarding which thoracic approach (right or left) during oesophagectomy for oesophageal cancer can lead to better surgical outcomes globally. This systematic review and meta-analysis will be performed to determine which thoracic approach during oesophagectomy will achieve longer patient survival and will be more beneficial for patients.

METHODS AND ANALYSIS

We will search PubMed, Web of Science, Embase, Cancerlit, the Cochrane Central Register of Controlled Trials and Google Scholar databases for relevant clinical trials published in any language before 1 October 2019. Randomised controlled trials (RCTs), quasi-RCTs, propensity score-matched comparative studies and prospective cohort studies of interest, published or unpublished, that meet the inclusion criteria will be included. Subgroup analysis of the type of operation, tumour pathological stage and ethnicity will be performed.

PROSPERO REGISTRATION NUMBER

CRD42019124133.

ETHICS AND DISSEMINATION

Because this study will be based on published or unpublished records and studies, there is no need for ethics approval. The results of the study will be published in a peer-reviewed journal.

Effects of preoperative sarcopenia on postoperative complications of minimally invasive oesophagectomy for oesophageal squamous cell carcinoma

Background

Sarcopenia is closely associated with surgical complications in patients with certain cancers. In this study we assessed the relationship between sarcopenia and postoperative complications in patients with oesophageal squamous cell carcinoma.

Methods

We retrospectively analysed of patients who underwent thoracoscopic combined with laparoscopic radical resection of oesophageal cancer. Preoperative computed tomography to evaluate skeletal muscle mass to diagnose sarcopenia and to evaluate associations with age, body mass index (BMI), lung function and postoperative complications.

Results

Among 141 patients, 73 presented with sarcopenia (sarcopenia group) and 68 did not (non-sarcopenia group). The mean skeletal muscle index in all patients was 49.5±9.0 cm²/m²; median, 49.3 cm²/m². The sarcopenia group included a higher proportion of men (P=0.039) and had a lower BMI than the non-sarcopenia group (P=0.001). There were no significant differences in any other clinical and pathological features. The incidences of postoperative complications in the sarcopenia and non-sarcopenia groups were 63.0% and 36.8%, respectively (P=0.002). The incidences of pulmonary infections and postoperative pleural effusions were 28.8% vs. 11.8% (P=0.011) and 38.4% vs. 20.6% (P=0.020) in the sarcopenia and non-sarcopenia groups, respectively. The incidences of other complications were not significantly different between the two groups. Univariate and multivariate analyses of pulmonary infection-related clinical factors revealed that sarcopenia and forced expiratory volume in the first second as a percent of forced vital capacity (FEV1.0%) were independent risk factors for pulmonary infection after minimally invasive surgery.

Conclusions

Preoperative sarcopenia is an independent risk factor for pulmonary infection after minimally invasive oesophagectomy (MIE). Evaluation of preoperative sarcopenia will thus help to prevent postoperative complications.

Matched-pair comparisons of minimally invasive esophagectomy versus open esophagectomy for resectable esophageal cancer: A systematic review and meta-analysis protocol

BACKGROUND

Open esophagectomy (OE) with radical lymphadenectomy is known as one of the most invasive digestive surgeries with the high rate of complications. Minimally invasive esophagectomy (MIE) has developed very rapidly and has formed several available technical approaches. This systematic review and meta-analysis is aiming at how beneficial, and to what extent MIE resection really will be.

METHODS

A systematic literature search will be performed through May 31, 2018 using MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and Google Scholar for relevant articles published in any language. Randomized controlled trials, prospective cohort studies, and propensity score matched comparative studies will be included. If data are sufficient, subgroup analyses will be conducted in different surgical procedures of MIE.

RESULTS

The results of this systematic review and meta-analysis will be published in a peer-reviewed journal.

CONCLUSION

This will be the first systematic review and meta-analysis using data of randomized controlled, prospective, and propensity score matched comparative studies to compare the outcomes between MIE and OE updating to May 31, 2018.

Prognostic value of the number of negative lymph nodes in esophageal carcinoma without lymphatic metastasis

Background

The impact of the number of negative lymph nodes (LNs) on survival in patients with esophageal cancer remains a controversial issue. This study investigated the association between the number of resected LNs and the prognosis of patients with node‐negative esophageal carcinoma.

Methods

A retrospective review was performed of the data of 429 patients who underwent esophagectomy with modern two‐field lymphadenectomy for the treatment of esophageal cancer between January 1998 and December 2008. Histopathology showed no LN involvement in the patient sample. The prognostic impact of the number of negative LNs and the clinicopathological factors were analyzed.

Results

The overall median survival time and the one, three, and five‐year overall survival rates were 63.0 months and 78.5%, 64.0%, and 51.2%, respectively. Survival analysis confirmed that the number of negative LNs and the depth of tumor invasion were independent prognostic factors. Patients with a high number of negative LNs had a better overall survival rate than patients with a low number of negative LNs (P < 0.001). Patients with dissected LNs > 14 for pT1 tumors (P < 0.001) and > 19 for pT2–3 tumors (P < 0.001 and P = 0.001, respectively) had better long‐term survival outcomes.

Conclusions

The number of negative LNs is an independent prognostic factor for node‐negative esophageal carcinoma. Extended LN dissection is recommended to improve the survival of patients with node‐negative esophageal carcinoma.

The Era of the Large Databases: Outcomes After Gastroesophageal Surgery According to NSQIP, NIS, and NCDB Databases. Systematic Literature Review

BACKGROUND

The term big data refers to databases that include large amounts of information used in various areas of knowledge. Currently, there are large databases that allow the evaluation of postoperative evolution, such as the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), the Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS), and the National Cancer Database (NCDB). The aim of this review was to evaluate the clinical impact of information obtained from these registries regarding gastroesophageal surgery.

METHODS

A systematic review using the Meta-analysis of Observational Studies in Epidemiology guidelines was performed. The research was carried out using the PubMed database identifying 251 articles. All outcomes related to gastroesophageal surgery were analyzed.

RESULTS

A total of 34 articles published between January 2007 and July 2017 were included, for a total of 345 697 patients. Studies were analyzed and divided according to the type of surgery and main theme in (1) esophageal surgery and (2) gastric surgery.

CONCLUSIONS

The information provided by these databases is an effective way to obtain levels of evidence not obtainable by conventional methods. Furthermore, this information is useful for the external validation of previous studies, to establish benchmarks that allow comparisons between centers and have a positive impact on the quality of care.

Is closed thoracic drainage tube necessary for minimally invasive thoracoscopic-esophagectomy?

Background

Closed thoracic drainage tube (CTDT) is a conventional treatment after esophagectomy, even after minimally invasive esophagectomy. Here, we report a single-center, retrospective study to explore the safety and necessity of CTDT after thoracoscopic-esophagectomy.

Methods

From October 2015 and August 2016, 50 patients were enrolled and underwent thoracoscopic-esophagectomy in semi-prone position by same surgical team. Perioperative demographic and surgical parameters, and patients' satisfaction with or without CTDT after thoracoscopic-esophagectomy were collected and analyzed.

Results

All eligible patients (18 patients without CTDT and 32 patients with CTDT) were successfully underwent thoracoscopic procedures without conversion to open approach or major intraoperative complications and perioperative death. The two groups, with similar demographic parameters, had no statistically difference in thoracic operation time, blood loss, ICU stay, postoperative mobilization and oral feeding, and hospital stay. Also, the incidence of postoperative complications was similar with or without CTDT after esophagectomy. But, no-CTDT group had better post-operative satisfaction, including less pain scale scoring and better Norton scoring.

Conclusions

This study demonstrated that the treatment of no-CTDT after the minimally invasive thoracoscopic-esophagectomy is safe and feasible, might reduce the work intensity of medical stuff and lead to a better patients' experience.

Fully robotic da Vinci Ivor-Lewis esophagectomy in four-arm technique-problems and solutions

The aim of this technical note is a step-by-step description of a fully robotic abdominothoracic esophagectomy with an intrathoracic esophagogastrostomy. We report on our technique and short-term results of 75 patients undergoing an Ivor-Lewis esophagectomy using a fully robotic 4-arm approach in the abdominal and thoracic phase with a hand-sewn intrathoracic anastomosis. There are several important steps and differences to consider compared to the conventional minimal invasive approach (patient's positioning, anaesthesiological set up, port placement, gastric conduit pull up, technique of esophagostrostomy). Mean operative time was 392 minutes (240-610) with a 94% R0 resection status. Conversion to open procedure occurred in 2 (2.6%) in the abdominal, and 14 (18.2%) in the thoracic phase. Main reasons for conversion were problems during the lifting of the gastric conduit and difficulties in the construction of the esophagogastrostomy. The rate dropped during the last 20 patients (1/20 (10%). Our results suggest that the reported technique is safe and feasible. It satisfies the oncological principles and provides the advantages of robotic assisted minimal invasive surgery.

[Endoscopic and surgical treatment of early gastric and esophageal carcinoma]

BACKGROUND

The treatment of early gastric (EGC) and esophageal carcinomas (EEC) is an interdisciplinary challenge. The risk of lymph node metastasis (LNM) is the crucial point in choosing the correct treatment option.

OBJECTIVE

This article gives an overview of the current treatment options and provides help in choosing the correct therapy.

METHOD

Current concepts and therapy algorithms are presented on the basis of a literature review and data from our own center.

RESULTS

Endoscopic submucosal dissection (ESD) is recommended for mucosal gastric cancer with good or moderate differentiation (G1,2) without macroscopic ulceration, in elevated type lesions smaller than 2 cm in size or depressed lesions smaller than 1 cm in size. In additional chromoendoscopy should be carried out. The extent of surgical resection is defined by the location of the tumor. A safety margin of at least 3 cm should be applied in distal gastric resections whereas the first line goal in gastrectomy is to achieve an R0 resection. In cN0 tumors a D1 lymphadenectomy (LA) seems to be sufficient. Minimally invasive techniques currently show promising results especially for a subtotal resection. The treatment strategy in EEC differs depending on the tumor entity. Mucosal squamous cell carcinoma with high risk factors (L1,V1) and all cN0 submucosal tumors without the detection of LNM should be referred to primary surgical resection. Early stage cN+ squamous cell carcinomas should be preoperatively treated with chemoradiotherapy. Adenocarcinoma with infiltration of the deeper submucosa (sm2,3) and high-risk sm1 tumors require surgical treatment. The standard operating procedure for EEC is an Ivor Lewis esophagectomy with 2‑field LA preferably performed as a hybrid or by a completely minimally invasive procedure. The procedure of choice in endoscopic resection of EEC is resection with the suck and cut technique.

Costs and benefits of different methods of esophagectomy for esophageal cancer

Background A minimally invasive approach to esophagectomy is being used increasingly, but concerns remain regarding the feasibility, safety, cost, and outcomes. We performed an analysis of the costs and benefits of minimally invasive, hybrid, and open esophagectomy approaches for esophageal cancer surgery. Methods The data of 83 consecutive patients who underwent a McKeown's esophagectomy at Prince of Songkla University Hospital between January 2008 and December 2014 were analyzed. Open esophagectomy was performed in 54 patients, minimally invasive esophagectomy in 13, and hybrid esophagectomy in 16. There were no differences in patient characteristics among the 3 groups Minimally invasive esophagectomy was undertaken via a thoracoscopic-laparoscopic approach, hybrid esophagectomy via a thoracoscopic-laparotomy approach, and open esophagectomy by a thoracotomy-laparotomy approach. Results Minimally invasive esophagectomy required a longer operative time than hybrid or open esophagectomy ( p = 0.02), but these patients reported less postoperative pain ( p = 0.01). There were no significant differences in blood loss, intensive care unit stay, hospital stay, or postoperative complications among the 3 groups. Minimally invasive esophagectomy incurred higher operative and surgical material costs than hybrid or open esophagectomy ( p = 0.01), but there were no significant differences in inpatient care and total hospital costs. Conclusion Minimally invasive esophagectomy resulted in the least postoperative pain but the greatest operative cost and longest operative time. Open esophagectomy was associated with the lowest operative cost and shortest operative time but the most postoperative pain. Hybrid esophagectomy had a shorter learning curve while sharing the advantages of minimally invasive esophagectomy.

Hybrid minimally invasive esophagectomy vs. open esophagectomy: a matched case analysis in 120 patients

PURPOSE

In esophageal surgery, total minimally invasive techniques compete with hybrid and robot-assisted procedures. The benefit of the individual techniques for the patient remains vague. At our institution, the hybrid minimally invasive laparoscopic-thoracotomic esophagectomy (HMIE) has been routinely applied since 2013. We conducted this retrospective study to analyze the perioperative outcome.

METHODS

Since 2013, 60 patients were operated in HMIE technique for esophageal cancer. Each of these patients was paired according to the criteria of gender, BMI, age, tumor histology, pulmonary preexisting conditions, and a history of smoking with a patient treated by open esophagectomy (OE). Perioperative parameters were extracted from our prospectively maintained database and compared among the groups.

RESULTS

The HMIE and OE groups were homogeneous in terms of patient- and tumor-related data. There was no difference in lymph nodes harvested (22 vs. 20, p = 0.459) and R0-resection rate (95 vs. 93%, p = 0.500). The operation time for the HMIE was significantly shorter (329 vs. 407 min, p < 0.001). There was no difference between the groups with respect to surgical complications (37 vs. 37%, p = 0.575), but the patients undergoing hybrid technique showed more delayed gastric emptying (23 vs. 10%, p = 0.042). Pulmonary morbidity was significantly reduced after HMIE (20 vs. 42%, p = 0.009). This affected both the occurrence of pneumonia and pleural effusions. The difference in the overall complication rate was not significant (50 vs. 60%, p = 0.179), but life-threatening complications (Clavien/Dindo 4/5) were less frequent (2 vs. 12%, p = 0.031). Overall, there was significantly less need for transfusion after HMIE (18 vs. 50%, p < 0.001), and hospital (and IMC) stay was significantly shorter (14 (6) vs. 18 (7) days, p = 0.002 (0.003)). The multivariate analysis confirms the surgical procedure as an independent risk factor for the development of pulmonary complications (OR 3.2, p = 0.011). Furthermore, preexisting pulmonary conditions were identified as a risk factor (OR 3.6, p = 0.006).

CONCLUSION

Our retrospective analysis shows that reduction of postoperative pulmonary morbidity, perioperative blood loss, and shortening of hospital stay can be achieved by HMIE. The procedure is safe, and the rate of surgical complications and oncological radicality is comparable to the conventional procedure.

[Oncologic esophageal resection and reconstruction : Open, hybrid, minimally invasive or robotic?]

Minimally invasive resections are increasingly employed in oncologic surgery for esophageal carcinoma. The new German S3 guideline states that esophagectomy, as well as reconstruction of the esophagus, can be performed minimally invasively or in combination with open techniques (hybrid). However, the current value of different techniques - ranging from complete minimally invasive esophagectomy over hybrid to robotic surgery - remains unregarded.This review provides a critical comparison of these techniques based on current evidence. Minimally invasive procedures of oncologic esophageal resection are safe in experienced hands and show numerous advantages with regard to postoperative reconvalescence. Laparoscopic gastrolysis with intra-abdominal lymphadenectomy and muscle sparing as well as anterolateral mini-thoracotomy (also via VATS as single-port technique) as a hybrid method also result in a relevant reduction of postoperative mortality and offer the possibility of extended mediastinal lymphadenectomy, which requires a high level of expertise when performed thoracoscopically. At present, robotic esophagectomy is applied in only a few clinics in Germany. A lack of evidence based on studies for esophageal surgery, as well as high acquisition and operating costs of the robotic system, have to be taken into account.

Comparison of short-term outcomes and three yearsurvival between total minimally invasive McKeown and dual-incision esophagectomy

Background

The aim of this study was to compare the short‐term outcomes and three‐year survival between dual‐incision esophagectomy (DIE) and total minimally invasive McKeown esophagectomy (MIME) for esophageal cancer patients with negative upper mediastinal lymph nodes requiring esophagectomy and neck anastomosis.

Methods

One hundred and fifty patients underwent DIE, while 361 patients received total MIME. Perioperative outcomes and three‐year survival were compared in unmatched and propensity score matched data between two groups.

Results

Both unmatched and matched analysis demonstrated that there were no significant differences in the number of lymph nodes harvested, or major or minor complication rates between the DIE and MIME groups. Compared with patients who underwent DIE, patients who underwent total MIME had longer operation duration (310 minutes vs. 345 minutes; P = 0.002). However, there was significantly less intraoperative blood loss in the total MIME compared with the DIE group (191 mL vs. 287 mL, respectively; P < 0.001). Kaplan‐Meier analysis demonstrated a trend that patients who underwent MIME had longer overall (79.5% vs. 64.1%; P = 0.063) and disease‐free three‐year survival (65.3% vs. 82.8%; P = 0.058) compared with patients who underwent DIE.

Conclusions

Both total MIME and DIE are feasible for the surgical treatment of esophageal cancer patients with negative upper mediastinal lymph nodes requiring esophagectomy and neck anastomosis. However, MIME was associated with better overall and disease‐free three‐year survival compared with DIE.

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

Background and objectives

The safety and effectiveness of minimally invasive esophagectomy (MIE) in comparison with the open esophagectomy (OE) remain uncertain in esophageal cancer treatment. The purpose of this meta-analysis is to compare the outcomes of the two surgical modalities.

Methods

Searches were conducted in MEDLINE, EMBASE, and ClinicalTrials.gov with the following index words: “esophageal cancer”, “VATS”, “MIE”, “thoracoscopic esophagectomy”, and “open esophagectomy” for relative studies that compared the effects between MIE and OE. Random-effect models were used, and heterogeneity was assessed.

Results

A total of 20 studies were included in the analysis, consisting of four randomized controlled trials and 16 prospective studies. MIE has reduced operative blood loss (P=0.0009) but increased operation time (P=0.009) in comparison with OE. Patients get less respiratory complications (risk ratio =0.74, 95% CI =0.58–0.94, P=0.01) and better overall survival (hazard ratio =0.54, 95% CI =0.42–0.70, P<0.00001) in the MIE group than the OE group. No statistical difference was observed between the two groups in terms of lymph node harvest, R0 resection, and other major complications.

Conclusion

MIE is a better choice for esophageal cancer because patients undergoing MIE may benefit from reduced blood loss, less respiratory complications, and also improved overall survival condition compared with OE. However, more randomized controlled trials are still needed to verify these differences.