Quality of Life after Minimally Invasive Versus Open Esophagectomy.

Abstract

More than 10 years ago, the very successful Dutch clinical trial network published the pivotal trial demonstrating that trans-hiatal esophagectomy was associated with significant advantages compared with traditional transthoracic resection, above all when it came to respiratory complications [1] and the facilitation of the postoperative course. These achievements were not reached at the expense of a less complete operation from a pure oncological perspective. It can be argued that this study represented the first and scientifically well substantiated step towards a less invasive surgical strategy to reduce the post-esophagectomy complication rates. Within the scenario of postoperative complications, those of respiratory nature are the most clinically prevalent and significant. During the same time period, clinical research also delivered convincing data to show that the post-esophagectomy rehabilitation was not only very slow and protracted but expressed itself also as a significant impairment in the patient’s health-related quality of life [2, 3]. In this respect, it also became obvious that the immediate postoperative complications had a detrimental effect on the patient’s quality of life, even when assessed up to 1 year after surgery. The second critically important step towards the dissemination of the minimally invasive approach to esophageal cancer treatment (MIE) was taken when a corresponding trial network, again organized and chaired from the Netherlands, conducted a randomized trial to compare the MIE with the traditional open technique [4]. It is important to bear in mind that this trial was powered to detect a clinically relevant difference in respiratory complication and nothing else. Again the investigators found that MIE offered advantages in terms of fewer complications without jeopardizing the surgical-oncological principles (as reflected by, for example, the lymph node yield in the resected specimens). In parallel, a corresponding trial has been completed in France comparing a hybrid MIE with the conventional thoraco-abdominal open operation (Mariette et al., abstract ISDE World Congress, 2013); we await the final results, being under review. The preceding uncontrolled observations again support the hybrid MIE strategy [5]. Now the multicenter RCT comparing MIE with open surgery presents the 1-year follow-up data, with particular emphasis on quality of life. The outcome is very clear; the early advantages of MIE, which could be seen during the first 6 weeks of the operation [4], are basically maintained when assessed 1 year later. These observations accord well with the observations previously presented to show the critical importance of minimizing the perioperative complications to reach even long-term benefits from these achievements. These aspects have of course a particular bearing on patients with disease states where the long-term prognosis is greatly threatened by the inborn nature of the cancer manifestation. We are close to a situation in which one can argue that MIE is ready for prime time in the curative treatment of invasive esophageal cancer. If we critically analyse the level and grading of evidence, the current situation concerning MIE and hybrid MIE is far better than was the case when laparoscopic cholecystectomy, anti-reflux surgery, and bariatric surgery were introduced into clinical practice. L. Lundell (&) Gastrocentrum, Centre for Digestive Diseases, Karolinska University Hospital, 141 86 Stockholm, Sweden e-mail: lars.lundell@karolinska.se