Hybrid Minimally Invasive Esophagectomy Research Articles

Hybrid minimal invasive esophagectomy for esophageal cancer: a single center experience with 14 cases

AIM: To perform a retrospective evaluation of morbidity, early postoperative mortality rates, and the safety of the procedure in patients who underwent hybrid minimally invasive esophagectomy in our clinic. MATERIAL AND METHOD: The records of 14 patients with esophageal cancer operated using the minimally invasive esophagectomy technique in the general surgery clinic of the XXX Hospital between November 2015 and November 2022 were analyzed retrospectively. RESULTS: The mean age of the 14 cases was 55 ± 11.96 years (32-71). Ten patients (71%) were men and four (29%) were women. The tumor was located in the lower esophagus in 12 cases, in the middle esophagus in one, and in the upper esophagus in one. Near total esophagectomy – cervical anastomosis was performed in 13 cases. Pharyngogastric anastomosis was performed after total esophagectomy, bilateral total thyroidectomy, and laryngectomy in one patient with upper esophageal tumor. The mean operative time was 319.64 ± 76.28 (188-452) min. Mean intraoperative bleeding was 109.64 ± 58.58 (40-220) ml, and the mean length of hospital stay was 13.71 ± 3.72 (7-21) days. No early postoperative mortality was observed in any case. CONCLUSION: Our early postoperative results in cases in which we performed hybrid minimally invasive esophagectomy are consistent with the previous literature.

Short-term outcome of totally minimally invasive versus hybrid minimally invasive Ivor-Lewis esophagectomy.

For resectable esophageal cancer, the choice of total minimally invasive esophagectomy (TMIE) or hybrid minimally invasive esophagectomy (HMIE) remains controversial. The purpose of this study was to evaluate the short-term clinical outcomes of TMIE and HMIE under the Ivor-Lewis procedure. The data of 145 patients diagnosed with middle or lower esophageal cancer who underwent radical Ivor-Lewis esophagectomy in the Affiliated Hospital of Qingdao University between January 2018 and December 2019 were retrospectively analyzed. The short-term outcomes such as complications during surgery or within 30 days after surgery and postoperative pain were analyzed. All patients were divided into TMIE group (75 patients) and HMIE group (70 patients). No significant difference was observed in the baseline characteristics of the two groups. TMIE was associated with less blood loss than the HMIE group (p<0.05). A total of 54 (37.2%) patients had postoperative complications. Although the two groups were statistically similar in the incidence of major complications, patients in the HMIE group were more likely to have pneumonia compared with those in the TMIE group. The numeric rating scale for pain was significantly higher in the HMIE group (p=0.002) and more patients required an additional opioid analgesia after esophagectomy (p=0.282). In conclusion, according to perioperative outcomes, TMIE can benefit patients better than HMIE.

Hybrid Minimally Invasive Esophagectomy vs. Open Esophagectomy: A Retrospective Propensity Score Matched Comparison.

Background and Objectives: Though widely used, only limited data is available that shows the superiority of hybrid minimally-invasive esophagectomy (HMIE) compared to open esophagectomy (OE). The present study aimed to analyze postoperative morbidity, mortality, and compare lengths of hospital stay. Materials and Methods: A total of 174 patients underwent Ivor Lewis esophagectomy in our surgical department, of which we retrospectively created a matched population of one hundred (HMIE n = 50, OE n = 50). Morbidity and mortality data was categorized, analyzed, and risk factor analyzed for complications. Results: The oncological results were found to be comparable in both groups. A median of 23.5 lymphnodes were harvested during OE, and 21.0 during HMIE. Negative tumor margins were achieved in 98% of OE and 100% of HMIE. In-hospital mortality rate showed no significant difference between techniques (OE 14.0%, HMIE 4.0%, p = 0.160). Hospital (OE Median 23.00 days, HMIE 16.50 days, p = 0.004) and ICU stay (OE 5.50 days, HMIE 3.00 days, p = 0.003) was significantly shorter after HMIE. The overall complication rate was 50%, but complications in general (OE 70.00%, HMIE 30%, p < 0.001) as well as severe complications (Clavien Dindo ≥ III: HMIE 16.0%, OE 48.0%, p < 0.001) were significantly more common after OE. In multivariate stepwise regressions the influence of OE proved to be independent for said outcomes. We observed more pulmonary complications in the OE group (46%) compared to HMIE patients (26%). This difference was statistically significant after adjustment for sex, age, BMI, ASA classification, histology, neoadjuvant treatment or not, smoking status, cardiac comorbidities, diabetes mellitus, and alcohol abuse (p = 0.019). Conclusions: HMIE is a feasible technique that significantly decreases morbidity, while ensuring equivalently good oncological resection compared to OE. HMIE should be performed whenever applicable for patients and surgeons.

Minimally invasive esophagectomy/ gastroesophagectomy for cancer - Long term results from a single institution

Background: Esophagectomy is a complex operation. Minimally invasive esophagectomy (MIE) may decrease the morbidity and mortality of resection. The aim of this study was to produce long term outcome of MIE from a single center in Nepal. Methods: Patients with squamous cell carcinoma and adenocarcinoma of esophagus/ gastroesophageal junction who underwent MIE between 2001-2018 were analyzed. Results: 215 patients were taken for MIE during 2001-2018. There was 11.2% conversion rate. Totally MIE approach was performed in 43% cases and hybrid MIE in 57% cases. Mean operative time, intra operative blood loss, anastomotic leak, pulmonary infection, recurrent laryngeal nerve injury and in-hospital mortality were 246 min, 286 ml, 13.1%, 9%, 6.8% and 3%, respectively. Final histopathology revealed most common Stages III and IV in 51.2% and 36.1%, respectively. The median survival was 34 months and 5-OS was 27%. 5-OS was 27% and o% for R0 and R+ resection (p&lt;.001). Median survival after radical and non-radical lymphadenectomy was 36 months and 25 months (p=.003), respectively. Responders to neoadjuvant treatment had the best survival. Conclusion: MIE has got acceptable post operative morbidities. R0 resection, early stage of disease, radical lymphadenectomy and responders to neoadjuvant treatment had got the best survival results

Population-Based Cohort Study from a Prospective National Registry: Better Long-Term Survival in Esophageal Cancer After Minimally Invasive Compared with Open Transthoracic Esophagectomy.

Recent research indicates long-term survival benefits of minimally invasive esophagectomy (MIE) compared with open esophagectomy (OE) for patients with esophageal and gastroesophageal junction (GEJ) cancers, but there is a need for more population-based studies. We conducted a prospective population-based nationwide cohort study including all patients in Sweden diagnosed with esophageal or junctional cancer who underwent a transthoracic esophagectomy with intrathoracic anastomosis. Data were collected from the Swedish National Register for Esophageal and Gastric Cancer in 2006-2019. Patients were grouped into OE and MIE including hybrid MIE (HMIE) and totally MIE (TMIE). Overall survival and short-term postoperative outcomes were compared using Cox regression and logistic regression models, respectively. All models were adjusted for age, sex, American Society of Anesthesiologists (ASA) score, clinical T and N stage, neoadjuvant therapy, year of surgery, and hospital volume. Among 1404 patients, 998 (71.1%) underwent OE and 406 (28.9%) underwent MIE. Compared with OE, overall survival was better following MIE (hazard ratio [HR] 0.72, 95% confidence interval [CI] 0.55-0.94), TMIE (HR 0.67, 95% CI 0.47-0.94), and possibly also after HMIE (HR 0.76, 95% CI 0.56-1.02). MIE was associated with shorter operation time, less intraoperative bleeding, higher number of resected lymph nodes, and shorter hospital stay compared with OE. MIE was also associated with fewer overall complications (odds ratio [OR] 0.70, 95% CI 0.47-1.03) as well as non-surgical complications (OR 0.64, 95% CI 0.40-1.00). MIE seems to offer better survival and similar or improved short-term postoperative outcomes in esophageal and GEJ cancers compared with OE in this unselected population-based cohort.

Effect of Phased Implementation of Totally Minimally Invasive Ivor Lewis Esophagectomy for Esophageal Cancer after Previous Adoption of the Hybrid Minimally Invasive Technique: Results from a French Nationwide Population-Based Cohort Study

Several randomized controlled trials (RCTs) have demonstrated improved short-term outcomes of totally minimally invasive esophagectomy (TMIE) compared with open esophagectomy (OE); however, to what extent these outcomes can be extrapolated to a national level remains debatable. The aim of this study was to evaluate, on a nationwide basis, the short-term outcomes of TMIE and to analyze these results within the context of previously implemented hybrid minimally invasive esophagectomy (HMIE). All consecutive patients who underwent a curative Ivor Lewis esophagectomy in France between 2017 and 2019 were included in this retrospective cohort study. The primary endpoint was to compare 90-day postoperative mortality (POM) between OE, HMIE, and TMIE, while secondary endpoints were defined as the rate of postoperative complications. A matched and multivariate analysis was adjusted for confounding factors. Overall, 2675 patients were included (1003 OE vs. 1498 HMIE vs. 174 TMIE). In every center where TMIE was performed, HMIE had been previously adopted. The matched 90-day POM rate in the TMIE group was significantly lower compared with the OE group (2.3% vs. 6.3%, p=0.046) but not compared with the HMIE group (2.3% vs. 4.9%, p=0.156). There was no significant difference between TMIE and OE, or TMIE and HMIE, regarding the 30-day fistula rate (21.8% vs. 17%, p=0.176; and 21.8% vs. 21.3%, p=0.88, respectively). TMIE was associated with a reduced rate of pulmonary complications compared with OE (33.9% vs. 44%, p=0.027) and HMIE (33.9% vs. 42.8%, p=0.05). Low-volume centers were identified as a negative predictive factor for 90-day POM (odds ratio 1.89, 95% confidence interval 1.3-2.75, p=0.001). TMIE is associated with a lower 90-day POM rate compared with OE and offers reduced rates of pulmonary complications compared with OE and HMIE. After previous adoption of the HMIE technique, TMIE can be safely implemented in high-volume centers nationwide.

Five-Year Survival Outcomes of Hybrid Minimally Invasive Esophagectomy in Esophageal Cancer

Available data comparing the long-term results of hybrid minimally invasive esophagectomy (HMIE) with that of open esophagectomy are conflicting, with similar or even better results reported for the minimally invasive esophagectomy group. To evaluate the long-term, 5-year outcomes of HMIE vs open esophagectomy, including overall survival (OS), disease-free survival (DFS), and pattern of disease recurrence, and the potential risk factors associated with these outcomes. This randomized clinical trial is a post hoc follow-up study that analyzes the results of the open-label Multicentre Randomized Controlled Phase III Trial, which enrolled patients from 13 different centers in France and was conducted from October 26, 2009, to April 4, 2012. Eligible patients were 18 to 75 years of age and were diagnosed with resectable cancer of the middle or lower third of the esophagus. After exclusions, patients were randomized to either the HMIE group or the open esophagectomy group. Data analysis was performed on an intention-to-treat basis from November 19, 2019, to December 4, 2020. Hybrid minimally invasive esophagectomy (laparoscopic gastric mobilization with open right thoracotomy) was compared with open esophagectomy. The primary end points of this follow-up study were 5-year OS and DFS. The secondary end points were the site of disease recurrence and potential risk factors associated with DFS and OS. A total of 207 patients were randomized, of whom 175 were men (85%), and the median (range) age was 61 (23-78) years. The median follow-up duration was 58.2 (95% CI, 56.5-63.8) months. The 5-year OS was 59% (95% CI, 48%-68%) in the HMIE group and 47% (95% CI, 37%-57%) in the open esophagectomy group (hazard ratio [HR], 0.71; 95% CI, 0.48-1.06). The 5-year DFS was 52% (95% CI, 42%-61%) in the HMIE group vs 44% (95% CI, 34%-53%) in the open esophagectomy group (HR, 0.81; 95% CI, 0.55-1.17). No statistically significant difference in recurrence rate or location was found between groups. In a multivariable analysis, major intraoperative and postoperative complications (HR, 2.21; 95% CI, 1.41-3.45; P < .001) and major pulmonary complications (HR, 1.94; 95% CI, 1.21-3.10; P = .005) were identified as risk factors associated with decreased OS. Similarly, multivariable analysis of DFS identified overall intraoperative and postoperative complications (HR, 1.93; 95% CI, 1.28-2.90; P = .002) and major pulmonary complications (HR, 1.85; 95% CI, 1.19-2.86; P = .006) as risk factors. This study found no difference in long-term survival between the HMIE and open esophagectomy groups. Major postoperative overall complications and pulmonary complications appeared to be independent risk factors in decreased OS and DFS, providing additional evidence that HMIE may be associated with improved oncological results compared with open esophagectomy primarily because of a reduction in postoperative complications. ClinicalTrials.gov Identifier: NCT00937456.

411 LEARNING CURVES IN MINIMALLY INVASIVE ESOPHAGECTOMY: A SYSTEMATIC REVIEW

Abstract Minimally invasive techniques are being increasingly used in the treatment of esophageal cancer. The learning curve for minimally invasive esophagectomy (MIE) is variable and can have an impact upon training delivered within residency and fellowship programmes. The aims of this review are to critically appraise current literature on the learning curve for MIE, identify what parameter(s) is used to quantify achieving competence and determine if there is evidence of resultant impact on surgical training. Methods A search of the major reference databases (MEDLINE, EMBASE, Cochrane) was performed with no time limits up to the date of the search (February 2020). Results were screened in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and study quality assessed using the Newcastle-Ottawa Scale for cohort studies. Results Twenty-one studies comprising 2720 patients were included- 17 studies reported on a combination of thoracoscopic, hybrid and total MIE, 3 studies reported robotic assisted alone and 1 study evaluated robotic assisted and thoracoscopic esophagectomy. 3 studies used a cumulative sum (CUSUM) analysis to define learning, 1 study used CUSUM and another parameter and 17 studies used one or more parameters. Quantification of surgical competence was variable and ranged from 12–80 cases for robotic surgery and 12–60 cases for other modes of MIE. One study reported trainees achieving MIE skills quicker if mentoring surgeons had attained proficiency on the learning curve. Conclusion Learning curves in MIE remain ill-defined with limited evidence on impact upon training received by residents and fellows. Additionally, the parameters used to define achievement of surgical competency is heterogenous. As minimally invasive techniques are increasingly adopted, specific standards to help define competence need to be identified and agreed on. This could help in designing training programmes and improve the rate of achieving competency.

The Impact of Hybrid Minimally Invasive Esophagectomy with Neck-Abdominal First Approach on the Short- and Long-Term Outcomes for Esophageal Squamous Cell Carcinoma.

Currently, there is no consensus for an optimal minimally invasive esophagectomy (MIE) approach. This study aimed to compare hybrid MIE (hMIE) with neck-abdominal first approach to standard open esophagectomy (OE). Data from a cohort of 301 patients were retrospectively analyzed. All participants received either hMIE or OE for the treatment of esophageal squamous cell carcinoma at Tokyo Medical and Dental University between January 2003 and December 2013. Analyses included propensity score matching and the Kaplan-Meier statistical method to determine overall survival (OS) and disease-free survival (DFS) of the cohort. After one-to-one propensity score matching, there were 68 patient pairs. The hMIE group had significantly lower incidence of severe postoperative complications (20.1% vs. 7.4%; p = 0.026) and severe respiratory complications (7.4% vs. 0%; p = 0.058) than the OE group. The 5-year oncological outcomes of the two groups were almost equivalent (OS: OE, 55.0%; hMIE, 69.0%; p = 0.063 and DFS: OE, 54.0%; hMIE, 62.0%; p = 0.28). This study compared hMIE with neck-abdominal first approach to standard OE. The results showed significantly less severe postoperative complications for hMIE with neck-abdominal first approach in comparison with OE, without a compromise in long-term oncological outcomes.

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

SummaryMinimally 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.

Essential Updates 2018/2019: Essential Updates for esophageal cancer surgery.

Key papers to treatment of esophageal cancer surgery and reduction of postoperative complications after esophagectomy published between 2018 and 2019 were reviewed. Within this review there was a focus on minimally invasive esophagectomy (MIE), robot‐assisted MIE (RAMIE), and centralization to high‐volume center. Advantages of MIE, irrespectively of hybrid or total MIE, to prevent postoperative complications, especially pneumonia, were shown in comparison to open procedure. However, whether total MIE has evident effects or not, as compared to hybrid MIEs, still remains unclear. Differences between RAMIE and MIE were reported to be marginal, though the advantage of lymphadenectomy, especially along recurrent laryngeal nerve, has been suggested. Centralization to high‐volume center evidently benefits esophageal cancer patients by improving short‐term outcomes. The definition of high‐volume center has not been established yet, though institutional structure and quality are thought to be important. Transmediastinal esophagectomy, currently developed, has a potential to be one radical option of MIE for esophageal cancer.

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

BACKGROUNDThe 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.AIMTo compare the perioperative and postoperative outcomes of HMIE and OE in patients with esophageal cancer.METHODSPubMed, 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.RESULTSSeventeen 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.CONCLUSIONCompared 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.

Health-related Quality of Life Following Hybrid Minimally Invasive Versus Open Esophagectomy for Patients With Esophageal Cancer, Analysis of a Multicenter, Open-label, Randomized Phase III Controlled Trial

Hybrid minimally invasive esophagectomy (HMIE) has been shown to reduce major postoperative complications compared with open esophagectomy (OE) for esophageal cancer. The aim of this study was to compare short- and long-term health-related quality of life (HRQOL) following HMIE and OE within a randomized controlled trial. We performed a multicenter, open-label, randomized controlled trial at 13 study centers between 2009 and 2012. Patients aged 18 to 75 years with resectable cancers of the middle or lower third of the esophagus were randomized to undergo either transthoracic OE or HMIE. Patients were followed-up every 6 months for 3 years postoperatively and global health assessed with EORTC-QLQC30 and esophageal symptoms assessed with EORTC-OES18. The short-term reduction in global HRQOL at 30 days specifically role functioning [-33.33 (HMIE) vs -46.3 (OE); P = 0.0407] and social functioning [-16.88 (HMIE) vs -35.74 (OE); P = 0.0003] was less substantial in the HMIE group. At 2 years, social functioning had improved following HMIE to beyond baseline (+5.37) but remained reduced in the OE group (-8.33) (P = 0.0303). At 2 years, increases in pain were similarly reduced in the HMIE compared with the OE group [+6.94 (HMIE) vs +14.05 (OE); P = 0.018]. Postoperative complications in multivariate analysis were associated with role functioning, pain, and dysphagia. Esophagectomy has substantial effects upon short-term HRQOL. These effects for some specific parameters are, however, reduced with HMIE, with persistent differences up to 2 years, and maybe mediated by a reduction in postoperative complications.

Hybrid Minimally Invasive Esophagectomy-Surgical Technique and Results.

Background: Hybrid minimally invasive esophagectomy (HMIE) has been proven to be superior when compared with open esophagectomy, with a significant reduction of postoperative morbidity. In HMIE, the laparotomy is replaced by a minimally invasive laparoscopic approach. The radical mediastinal resection plus reconstruction is performed by a thoracic approach through a muscle-sparing thoracotomy. In this instructional article, we describe the surgical technique of HMIE in detail in order to facilitate possible adoption of the procedure by other surgeons. In addition, we give the monocentric results of our own practice. Methods: Between 2013 and 2018, HMIE was performed in 157 patients. The morbidity and mortality data of the procedure is shown in a retrospective monocentric analysis. Results: Overall, 54% of patients had at least one perioperative complication. Anastomotic leak was evident in 1.9%, and a single patient had focal conduit necrosis of the gastric pull-up. Postoperative pulmonary morbidity was 31%. Pneumonia was found in 17%. The 90 day mortality was 2.5%. Wound infection rate was 3%, and delayed gastric emptying occurred in 17% of patients. In follow up, 12.7% presented with diaphragmatic herniation of the bowel, requiring laparoscopic hernia reduction and hiatal reconstruction and colopexy several months after surgery. Conclusion: HMIE is a highly reliable technique, not only for the resection part but especially in terms of safety in reconstruction and anastomosis. For esophageal surgeons with experience in minimally invasive anti-reflux procedures and obesity surgery, HMIE is easy and fast to learn and adopt.

Morbidity in open versus minimally invasive hybrid esophagectomy (MIOMIE): Long-term results of arandomized controlled clinical study.

SummaryBackgroundThe minimally invasive esophagectomy (MIE) for esophageal cancer was introduced assuming a reduction of morbidity and operation time. After implementation of MIE at our institution, a randomized controlled trial was designed.MethodsThis is a prospective randomized controlled study comparing open (OE) and laparoscopic gastric tube (MIE) formation in Ivor Lewis esophagectomy. Primary endpoints were morbidity and 30-day mortality. Secondary endpoints included the duration of intensive care unit stay, length of hospital stay, operative time as well as relapse-free and overall survival.ResultsTwenty patients (76.9%) were male, median age was 63 years (40–77). Median operation time was 290 (215–385) minutes in OE and 292.5 (200–450) minutes in MIE group, p = 0.421. Major complications occurred in 4 (33.3%) patients in the OE group and in 6 (35.7%) patients in the MIE group. Anastomotic leakage was seen in 2 (16.6%) and 3 (21.4%) patients, respectively (OR 1.364; CI = 0.188–9.912; p = 0.759). Due to an alarming number of consecutive anastomotic leakages, the trial was stopped after inclusion of 26 patients. Median follow-up was 41.5 (1–62.6) months. 5‑year survival rate was 50%. Thirty-eight percent developed recurrence of disease in the study period. There was no significant difference in overall and relapse-free survival regarding the type of surgery.ConclusionThis study shows that hybrid MIE is a feasible alternative for esophageal resection. Morbidity, mortality, and oncological long-term results were equal in both groups, but the interpretation has to be done carefully due to premature termination of the trial. Interrupting a trial because of patient benefit should not be a reason to discard results but rather to improve technical aspects and strive for novel studies.

Robot-Assisted Hybrid Esophagectomy Is Associated with a Shorter Length of Stay Compared to Conventional Transthoracic Esophagectomy: A Retrospective Study.

Aim To compare the peri- and postoperative data between a hybrid minimally invasive esophagectomy (HMIE) and the conventional Ivor Lewis esophagectomy. Methods Retrospective comparison of perioperative characteristics, postoperative complications, and survival between HMIE and Ivor Lewis esophagectomy. Results 216 patients were included, with 160 procedures performed with the conventional and 56 with the HMIE approach. Lower perioperative blood loss was found in the HMIE group (600 ml versus 200 ml, p < 0.001). Also, a higher median number of lymph nodes were harvested in the HMIE group (median 28) than in the conventional group (median 23) (p = 0.002). The median length of stay was longer in the conventional group compared to the HMIE group (11.5 days versus 10.0 days, p = 0.03). Patients in the HMIE group experienced fewer grade 2 or higher complications than the conventional group (39% versus 57%, p = 0.03). The rate of all pulmonary (51% versus 43%, p = 0.32) and severe pulmonary complications (38% versus 18%, p = 0.23) was not statistically different between the groups. Conclusions The HMIE was associated with lower intraoperative blood loss, a higher lymph node harvest, and a shorter hospital stay. However, the inborn limitations with the retrospective design stress a need for prospective randomized studies. Registration number is DRKS00013023.

Is There Any Benefit to Incorporating a Laparoscopic Procedure into Minimally Invasive Esophagectomy? The Impact on Perioperative Results in Patients with Esophageal Cancer

The benefit of using the laparoscopic approach in minimally invasive esophagectomy (MIE) has not been established. We therefore compared the outcome of esophagectomy for patients with esophageal cancer performed with open surgery, video-assisted thoracic surgery (VATS)/laparotomy (hybrid MIE), and VATS/ laparoscopy (total MIE). Patients with esophageal cancer undergoing tri-incisional esophagectomy with three different approaches between 2005 and 2009 were analyzed from a prospective database. Three groups of patients underwent esophagectomy by open surgery (n = 64), hybrid MIE (n = 44), and total MIE (n = 30). The total MIE group had significantly longer operative times but had shorter postoperative ventilator usage times postoperative hospital stay, and they began jejunostomy feeding sooner (P < 0.05, compared with the other groups). There was a significant trend toward a decrease in postoperative pulmonary complications and anastomotic leakage in parallel to the proportion of minimally invasive procedures for esophagectomy (P < 0.05 for the trend test), with a significant difference between the open surgery and total MIE groups (30% vs. 6.7%, and 28% vs. 6.7%, respectively; P < 0.05). Use of a laparoscopic procedure in MIE for patients with esophageal cancer might provide benefit by facilitating postoperative recovery and reducing the rates of post-esophagectomy pulmonary complications and anastomotic leakage.

Is minimally invasive surgery beneficial in the management of esophageal cancer? A meta-analysis

Open esophagectomy for cancer is a major oncological procedure, associated with significant morbidity and mortality. Recently, thoracoscopic procedures have offered a potentially advantageous alternative because of less operative trauma compared with thoracotomy. The aim of this study was to utilize meta-analysis to compare outcomes of open esophagectomy with those of minimally invasive esophagectomy (MIE) and hybrid minimally invasive esophagectomy (HMIE). Literature search was performed using Medline, Embase, Cochrane Library, and Google Scholar databases for comparative studies assessing different techniques of esophagectomy. A random-effects model was used for meta-analysis, and heterogeneity was assessed. Primary outcomes of interest were 30-day mortality and anastomotic leak. Secondary outcomes included operative outcomes, other postoperative outcomes, and oncological outcomes in terms of lymph nodes retrieved. A total of 12 studies were included in the analysis. Studies included a total of 672 patients for MIE and HMIE, and 612 for open esophagectomy. There was no significant difference in 30-day mortality; however, MIE had lower blood loss, shorter hospital stay, and reduced total morbidity and respiratory complications. For all other outcomes, there was no significant difference between the two groups. Minimally invasive esophagectomy is a safe alternative to the open technique. Patients undergoing MIE may benefit from shorter hospital stay, and lower respiratory complications and total morbidity compared with open esophagectomy. Multicenter, prospective large randomized controlled trials are required to confirm these findings in order to base practice on sound clinical evidence.