Open Esophagectomy Group Research Articles

Comparative Analysis of Surgical Outcomes in Hybrid and Open Esophagectomy for Esophageal Cancer: A Regional Russian Cancer Centre Experience.

Surgery is pivotal in treating esophageal cancer; hybrid esophagectomy, which combines minimally invasive and open techniques, shows promising outcomes. This historical cohort study compared the surgical outcomes of standard open esophagectomy with hybrid esophagectomy. Overall, 58 patients who underwent either hybrid or open esophagectomy at the Ulyanovsk Regional Clinical Oncology Clinic, Russia, from January 2015 to December 2023 were included. Data on demographics, surgical details, and postoperative outcomes were analyzed. The primary measures were overall complications and anastomotic leakage rates. Statistical analysis was performed using Pearson's Chi square test and t test via StatTech software (version 2.8.8). The number of removed lymph nodes was higher in the hybrid group (24±9) than in the open group (15±7) (P<0.001). In addition, the hybrid esophagectomy group showed significant reductions in operational time and blood loss (P<0.001 and P=0.014, respectively). The need for blood transfusion was higher in the open esophagectomy group (P=0.043). The postoperative length of stay in the hospital did not differ significantly between the two groups (open=20±8 days, hybrid=17±7 days, P=0.178). Cardiac complications were more frequent after an open esophagectomy (P=0.044). Hybrid esophagectomy reduced postoperative cardiac complications and other adverse events while maintaining satisfactory oncological outcomes. It had advantages over standard open esophagectomy in terms of lymphadenectomy, operative time, blood loss, and transfusion requirements, suggesting its efficacy for esophageal cancer patients.

225. LONG-TERM ONCOLOGIC OUTCOMES OF ROBOT-ASSISTED VERSUS CONVENTIONAL OPEN ESOPHAGECTOMY FOR ESOPHAGEAL CANCER: PROPENSITY-SCORE MATCHED ANAYLSIS

Abstract Background This study aimed to compare the long-term oncologic outcomes of robot-assisted minimally invasive esophagectomy (RAMIE) with those of conventional open esophagectomy (OE) for esophageal cancer. Methods Between January 2006 and December 2021, 1,745 consecutive patients underwent esophagectomy for esophageal cancer at our institution. Among them, we retrieved 1,133 patients (mean age 63.1±7.8 years, 86 [7.6%] women, 1,100 [97.1%] squamous cell carcinomas), who were operated by a single surgeon. These patients were categorized into following two groups based on their surgical approaches: RAMIE (n = 497) and OE (n = 636). The RAMIE and OE groups were matched in a 1:1 ratio using propensity scores. Results Median follow-up was 51.8 months. Five-year overall survival (OS, 70.7% vs. 55.0%) and recurrence-free survival (RFS, 63.3% vs. 50.1%) rates were significantly higher in RAMIE than in OE group (P &amp;lt; 0.01). Following propensity-score matching, 886 patients (443 pairs) were successfully matched, demonstrating no significant intergroup differences. The RAMIE group consistently demonstrated enhanced OS (70.4% vs. 61.8%, P &amp;lt; 0.01) and RFS (62.8% vs. 55.8%, P=0.04) after five years, even after adjustment (Figure). The rate of noncancer mortality was significantly higher in the OE group (P &amp;lt; 0.01), whereas the esophageal cancer-related mortality showed no significant differences (P = 0.25). Conclusions RAMIE could be a safer and more feasible option for patients compared with conventional open esophagectomy with favorable long-term oncologic outcomes.

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

BackgroundThoracoscopic esophagectomy is a less invasive surgical procedure; however, evidence of its effect on long-term survival is limited. We evaluated long-term survival after the procedure in patients with esophageal carcinoma. MethodsThis retrospective multicenter study involved 1559 consecutive patients with esophageal carcinoma who underwent thoracoscopic esophagectomy or open esophagectomy between 2012 and 2019 at 2 Japanese high-volume cancer centers. Propensity score matching analysis was performed to compare short- and long-term outcomes. In addition, stage-specific survival rates were compared between the groups. ResultsThere were 313 patients who were matched and analyzed. The 1-, 3-, and 5-year overall survival rates were 84.5%, 60.5%, and 52.1%, respectively, in the matched open esophagectomy group; and 87.2%, 68.6%, and 61.8%, respectively, in the matched thoracoscopic esophagectomy group. The weighted Cox regression model showed significantly better survival in the thoracoscopic esophagectomy group than in the open esophagectomy group (hazard ratio, 0.74; 95% CI, 0.582-0.941). Deaths from other causes occurred more frequently in the open esophagectomy group than in the thoracoscopic esophagectomy group. Stratified analysis showed no significant survival differences between clinical stage I or II and pathologic stage 0 or I subgroups. However, the thoracoscopic esophagectomy groups with clinical stage III or IV and pathologic stage II, III, or IV had significantly better overall survival. ConclusionsThis study demonstrated the survival benefits of thoracoscopic esophagectomy, particularly for highly advanced esophageal carcinoma.

261. CONVERSION ESOPHAGECTOMY FOR CT4B ESOPHAGEAL CANCER - MIE VS OPEN -

Abstract Background and Aims The standard treatment for locally advanced unresectable esophageal cancer is definitive chemoradiotherapy (dCRT), however, after induction chemotherapy with a triplet chemotherapy regimen (docetaxel, cisplatin, and 5-FU: DCF) or dCRT, conversion surgery could be performed if esophageal cancer is considered resectable. Furthermore, minimally invasive surgery such as robot-assisted or thoracoscopic procedures are expected to improve the outcome of patients with advanced esophageal cancer. We investigated the feasibility of minimally invasive esophagectomy (MIE) in conversion surgery. Materials and Methods Sixty-six patients who underwent conversion thoracic esophagectomy for cT4b esophageal cancer from 2007 to 2023 were included. The short-term outcomes of 25 open esophagectomy group and 41 MIE group (8 robot-assisted and 33 thoracoscopic) were compared. Results No differences in age, gender, PS, tumor location, histology, cN, or cM were observed between the two groups. cT4b organs tended to be in the airway in the MIE group (airway 70.7% vs 44%, major vessels 19.5% vs 24%, both 9.7% vs 32%, p=0.04) and DCF therapy was significantly performed in the MIE group for induction therapy (DCF 87.8% vs 56%, dCRT 12.2% vs 44%, p&amp;lt;0.001). On the other hand, salvage surgery was significantly associated with open esophagectomy (24.3% vs. 52%, p=0.003). There was no difference in surgical outcomes regarding thoracic operation time (157 min vs. 180 min, p=0.09), whereas the total operation time was significantly shorter in the MIE group (392 min vs. 439 min, p=0.02). Blood loss was significantly lower in the MIE group (79 ml vs. 470 ml, p&amp;lt;0.001), and R0 resection rate did not differ (82.9% vs. 72%, p=0.357). There were no significant differences in postoperative complications including pneumonia (26.8% vs. 44%, p=0.183) and recurrent nerve palsy (21.9% vs. 36%, p=0.260), but anastomotic leakage was significantly lower in the MIE group (4.8% vs. 24%, p=0.04). There was no difference in median postoperative hospital stay (16 [11-20] vs. 16 [14-29] days), however, median ICU stay (3 [3-4] vs. 4 [3-4] days, p=0.03) and readmission within 1 month after discharge (2.4% vs. 16%, p=0.04) were significantly lower in the MIE group. In-hospital mortality was observed in 1 case in the MIE group and 3 in the open esophagectomy group. Conclusion Despite the bias associated with the transition of treatment modalities and surgical techniques, MIE may contribute to improved short-term outcomes in conversion surgery.

Safe Transition from Open to Total Minimally Invasive Esophagectomy for Cancer Utilizing Process Management Methodology.

Background: The global shift from open esophagectomy (OE) to minimally invasive esophagectomy (MIE) for treating esophageal cancer is well-established. Recent data indicate that transitioning from hybrid minimally invasive esophagectomy (hMIE) to total minimally invasive esophagectomy (tMIE) can be challenging due to concerns about higher leakage rates and lower lymph node counts, especially at the beginning of the learning curve. This study aimed to demonstrate that a safe transition from OE to tMIE for cancer is possible using process management methodology. Methods: A step-change approach was adopted in process management planning, with hMIE serving as an intermediate step between OE and tMIE. This single-center, case-control study included 150 patients who underwent the Ivor Lewis procedure with curative intent for esophageal cancer. Among these patients, 50 underwent OE, 50 hMIE (laparoscopic procedure followed by conventional right thoracotomy), and 50 tMIE (laparoscopic and thoracoscopic approach). A preceptored training scheme was implemented during execution, and treatment results were monitored and controlled to ensure a safe transition. Results: During the transition, the tMIE group was not worse than the hMIE and OE groups regarding operation duration (p = 0.135), overall postoperative complications (p = 0.020), anastomotic leakage rates (p = 0.773), 30-day mortality (p = 1.0), and oncological outcomes (based on R status (p = 0.628) and 2-year survival (p = 0.967)). Additionally, the tMIE group showed superior results in terms of major postoperative pulmonary complications (p = 0.004) and ICU stay duration (p < 0.001). Conclusions: Utilizing managerial methodology and practice in surgery, as a bridge between interdisciplinary and transdisciplinary approaches, demonstrated that transitioning from OE to tMIE, with hMIE as an intermediate step, is safe and feasible without compromising outcomes.

Association of operative time and approach on postoperative complications for esophagectomy

Minimally invasive esophagectomy is associated with decreased postoperative complications compared with open esophagectomy. However, the risks of complications for minimally invasive esophagectomy compared with open esophagectomy may be affected by operative time. The objectives of this study are to (1) compare the incidence of postoperative complications for minimally invasive esophagectomy and open esophagectomy and (2) evaluate the association of postoperative complications on operative approach and operative time. A retrospective cohort analysis of patients who underwent an esophagectomy in the American College of Surgeons National Surgical Quality Improvement Program Procedure-Targeted Data File was performed from 2016 to 2020. For analysis, minimally invasive esophagectomy and open esophagectomy were stratified into tertiles of operative time. A bivariate analysis of postoperative complications comparing minimally invasive esophagectomy with open esophagectomy was performed. Multivariable Poisson regression models were estimated evaluating the association of the likelihood of postoperative complications with operative approach and operative time. In total, 8,574 patients who underwent esophagectomy were included: 5,369 patients underwent minimally invasive esophagectomy, and 3,205 patients underwent open esophagectomy. Median operative time was 402minutes for minimally invasive esophagectomy and 321minutes for open esophagectomy. The incidence of postoperative complications and 30-day mortality was lower in the minimally invasive esophagectomy group than the open esophagectomy group within the same tertiles of operative time. When we compared patients who underwent short open esophagectomy with those who underwent long minimally invasive esophagectomy, there were no significant differences in complications. There is no significant association of postoperative complications for short open esophagectomy compared with long minimally invasive esophagectomy. Patients should be selected for minimally invasive esophagectomy when there is appropriate surgeon experience and hospital resources.

Comparisons of short-term outcomes between robot-assisted, video-assisted, and open esophagectomy for resectable esophageal cancer after neoadjuvant treatment: a retrospective study.

Robot-assisted esophagectomy (RAE), video-assisted minimally invasive esophagectomy (VAMIE), and open esophagectomy (OE) all have significant roles in the management of esophageal cancer (EC). Few studies have compared efficacy and safety between RAE, VAMIE, and OE for resectable EC after neoadjuvant treatment. Therefore, this study aimed to explore the short-term outcomes between RAE, VAMIE, and OE for resectable EC after neoadjuvant treatment. Ninety-eight patients were consecutively enrolled who underwent esophagectomy. A retrospective study was performed including 98 consecutive patients treated from January 2021 to August 2022 who received neoadjuvant treatment (including immunochemotherapy and chemoradiotherapy) followed by RAE, VAMIE or OE. Evaluated endpoints in the present study consisted of pathological outcomes, intraoperative and postoperative outcomes, as well as postoperative complications. No significant differences were seen in the operating time, blood loss, length of intensive care unit (ICU) stay, R0 resection, and number of dissected lymph nodes between the three RAE, VAMIE, or OE groups. The achievement rate of right recurrent laryngeal nerve (RLN) lymph node removal (P=0.01) and the total cost (P<0.001) were higher in RAE. The postoperative hospital stay of OE was longer than the other two groups (P<0.05). There were no significant differences in postoperative complications. Compared to VAMIE, no clear benefit exists for RAE in the treatment of resectable EC after neoadjuvant therapy. OE resulted in a longer hospital stay. Although the rate of successful right RLN node removal was higher with RAE, the clinical relevance for this is yet unclear.

The influence of minimally invasive esophagectomy on wound infection in patients undergoing esophageal cancer surgery: A meta-analysis.

The impacts of minimally invasive esophagectomy (MIE) in comparison with open esophagectomy (OE) on postoperative complications, wound infections and hospital length of stay in patients with esophageal carcinoma (ESCA) using meta-analysis to provide reliable evidence for clinical practice. A search strategy was developed and computer searches were performed on Embase, Web of Science, PubMed, Cochrane Library, Wanfang, China Biomedical Literature Database and China National Knowledge Infrastructure databases for clinical studies that reported the effects of MIE in comparison with OE in patients with ESCA. The retrieval time was from their inception to October 2023. Two authors independently performed literature screening, and data extraction and literature quality evaluation were performed separately for the included studies. Meta-analysis was performed using Stata 17.0 software. Overall, 26 studies with 2427 ESCA patients were included in this study, of which 1203 were in the MIE group and 1224 were in the OE group. The results showed that, compared with OE, ESCA patients who underwent MIE were less likely to develop postoperative wound infections (odds ratio [OR] = 0.31, 95% confidence intervals [CIs]: 0.20-0.49, p < 0.001) and complications (OR = 0.23, 95% CI: 0.18-0.30, p < 0.001) and have a shorter hospital stay (standardized mean difference = -1.93, 95% CI: -2.38 to -1.48, p < 0.001). MIE has advantages over OE in terms of shorter hospital stay and reduced incidence of postoperative wound infections and complications.

148. COMPARISON OF EARLY POSTOPERATIVE OUTCOME BETWEEN OPEN AND MINIMALLY INVASIVE TRANSTHORACIC ESOPHAGECTOMY FOR ESOPHAGEAL CANCER: A RETROSPECTIVE STUDY

Abstract Background Esophagectomy is a highly invasive surgical procedure for esophageal cancer, with open thoracotomy associated with a significant risk of pulmonary complications. Minimally invasive techniques, such as minimally invasive esophagectomy (MIE), are expected to reduce these complications and enhance postoperative recovery. This study aimed to compare the early postoperative outcomes of patients who underwent open esophagectomy versus MIE. Methods We conducted a retrospective study using a single-center database from January 1, 2010, to February 28, 2023, including patients aged 18–90 years with a resectable lesion of the esophagus or esophagogastric junction who underwent either open transthoracic esophagectomy or MIE (thoracoscopic/robotic-assisted). Patient data, surgical procedures, interventions, and early outcomes (within 30 days of operation) were collected and analyzed. The study included a total of 76 patients, with 50 patients in open esophagectomy group and 26 patients in MIE group. The primary outcome was the incidence of pulmonary complications during the hospital stay, and logistic regression was used for data analysis. Results The overall incidence of pulmonary complications was 37 cases (74%) in the open esophagectomy group and 14 cases (53.8%) in the MIE group, with the incidence of pulmonary infection occurring in 19 cases (38%) and 8 cases (30.8%), respectively. Perioperative mortality was 1 cases (2%) in the open esophagectomy group and 0 cases (0%) in the MIE group. After adjusting for age, sex, BMI, smoking, COPD, and operative time, the open esophagectomy group had a 4.29 times higher risk of pulmonary complications than the MIE group (odds ratio 4.29, 95% confidence interval 1.30–14.16; p = 0.017). Conclusion Our study demonstrates that MIE is associated with a lower incidence of pulmonary complications, reduced blood loss, and shorter ICU stays compared to open esophagectomy. Rates of anastomosis leakage, vocal cord paralysis, and hospital stays were comparable. These findings support the feasibility and safety of MIE, potentially improving surgical outcomes and enhancing postoperative recovery for the treatment of esophageal cancer.

231. ROBOT-ASSISTED TRANSMEDIASTINAL (TRANSCERVICAL &amp; TRANSHIATAL) ESOPHAGECTOMY FOR ESOPHAGEAL CANCER

Abstract Background Esophagectomy is still main treatment mode for esophageal cancer, though it is known to be associated with severe surgical invasiveness resulting in high morbidity and mortality. Minimally invasive esophagectomy (MIE), which consisted of thoracoscopic and/or laparoscopic procedure, has been widely performed to diminish those disadvantages of open procedure. Recent reports, however, show insufficient effects of the conventional MIE. Therefore, additional improvements are needed to overcome those problems. Methods We developed the robot-assisted transmediastinal esophagectomy (RATME) in 2012 to prevent the postoperative complications. It is the combination of transcervical and transhiatal approach without one lung ventilation anesthesia and body change during surgery. Upper mediastinal lymphadenectomy along left recurrent laryngeal nerve (RLN) is perfomed by transcervical mediastinoscopic procedure under pneumo-mediastinum. Laparoscopic abdominal LN dissection is performed in parallel with the cervical procedure. Remnant lower and middle LN dissections, including subcarinal and main bronchus, are done using robotic procedure in which robotic arms are inserted through hiatus from abdomen. Finally, bilateral pleura can be preserved. Results To date, 275 RATMEs have been performed. Among them, post-operative pneumonia occurred in 33 cases (12%), and mortality is zero. Oncological outcomes, e.g., the numbers of harvested LNs, post-operative QOL, e.g., post-operative pulmonary function, were observed and reported to be better in RATME group as compared to open esophagectomy group. Survival after surgery is, also, not at all inferior. Conclusion RATME is a promising minimally invasive technique, overcoming the disadvantages of conventional procedures. For the patients with previous thoracic surgery, and/or impaired respiratory function who are unable to undergo transthoracic esophagectomy, RATME can offer a valuable alternative surgery as a radical treatment.

Robotic versus open Ivor-Lewis esophagectomy: A more accurate lymph node dissection without burdening the leak rate.

Robotic-assisted minimally invasive esophagectomy (RAMIE) combines the beneficial effects of minimally invasive surgery on postoperative complications, especially on pulmonary ones, with the safety of the anastomosis performed in open surgery. Moreover, RAMIE could allow a more accurate lymphadenectomy. We reviewed our database to identify all patients with adenocarcinoma of the esophagus treated by Ivor-Lewis esophagectomy in the period January 2014 to June 2022. Patients were divided according to the thoracic approach into RAMIE and open esophagectomy (OE) groups. We compared the groups for early surgical outcomes, 90-day mortality as well as R0 rate, and the number of lymph nodes harvested. We identified 47 patients in RAMIE and 159 patients in theOE group. Baseline characteristics were comparable. Operative time was significantly longer for RAMIE procedures (p < 0.01); however, we did not observe the difference in overall (RAMIE 55.5% vs.OE 61%, p = 0.76) and severe complications rate (RAMIE 17% vs.OE 22.6%, p = 0.4). The anastomotic leak rate was 2.1% after RAMIE and 6.9% after OE (p = 0.56). We did not report the difference in 90-day mortality (RAMIE 2.1% vs.OE 1.9%, p = 0.65). In theRAMIE group, we observed a significantly higher number of thoracic lymph nodes harvested, with a median of 10 lymph nodes in theRAMIE group versus 8 in theOE group (p < 0.01). In our experience, RAMIE has morbimortality rates comparable to OE. Moreover, it allows a more accurate thoracic lymphadenectomy which results in a higher thoracic lymph nodes retrieval rate.

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 versus open esophagectomy for resectable thoracic esophageal cancer (NST 1502): a multicenter prospective cohort study

BackgroundWhether minimally invasive esophagectomy (MIE) is superior to open esophagectomy (OE) in the treatment of esophageal squamous cell carcinoma (ESCC) is still uncertain. Therefore, this multicenter prospective study aimed to compare MIE with OE in postoperative parameters and long-term survival. MethodsAll hospitalized patients with cT1b-3N0–1M0 thoracic ESCC treated by MIE or OE were enrolled from 19 selected centers from April 1, 2015 to December 31, 2018. The propensity score matching (PSM) was performed to minimize the selection bias. The basic clinicopathological characteristics and 3-year overall survival (OS) as well as disease-free survival (DFS) of two groups were compared by R version 3.6.2. ResultsMIE were performed in 1,387 patients and OE in 335 patients. 335 cases in each group were finally matched by PSM, and no significant differences in the essential demographic characteristics were observed between the MIE and OE groups after PSM. Compared with OE, MIE had significantly less intraoperative bleeding, less total drainage volume, shorter postoperative hospital stay, and harvested significantly more lymph nodes (LNs) (all P < 0.001). There were no significant differences in the major postoperative complications and death rates between MIE and OE. The 3-year OS and DFS were 77.0% and 68.1% in the MIE group versus 69.3% and 60.9% in the OE group (OS: P = 0.03; DFS: P = 0.09), and the rates were 75.1% and 66.5% in the MIE group versus 66.9% and 58.6% in the OE group for stage cII patients (OS: P = 0.04, DFS: P = 0.09), respectively. ConclusionsCompared with OE, MIE is a safe and effective treatment approach with similar mortality and morbidity. It has the advantages in harvesting more LNs, improving postoperative recovery and survival of stage cII ESCC patients.

Patterns of Recurrence and Long-Term Survival of Minimally Invasive Esophagectomy Versus Open Esophagectomy for Locally Advanced Esophageal Cancer Treated with Neoadjuvant Chemotherapy: a Propensity Score–Matched Analysis

BackgroundThe use of minimally invasive esophagectomy (MIE) as a treatment for patients with esophageal cancer has recently become more common worldwide. However, differences in the pattern of recurrence between MIE and open esophagectomy (OE) using the transthoracic approach have not been fully investigated, particularly in patients treated with neoadjuvant chemotherapy. MethodsWe searched the prospective databases of two institutes for patients with esophageal cancer who underwent neoadjuvant chemotherapy followed by esophagectomy between 2011 and 2018. Propensity score–matched analysis was performed to reduce bias from confounding patient-related variables. Operative outcomes, regionally harvested lymph nodes (LNs), recurrence pattern, and prognosis were investigated in two groups. ResultsWe identified 410 patients who underwent OE (n = 263) and MIE (n = 147). After propensity score matching, 131 pairs of patients were selected. There were no significant differences in baseline characteristics after matching. The total number of harvested LNs in both groups was similar (55.1 vs. 58.9, P = 0.132). The incidence of LN recurrence in the MIE group was significantly lower than that in the OE group (27% vs. 15%, P = 0.010). In particular, the incidence of mediastinal LN recurrence in the MIE group was significantly lower than that in the OE group (16% vs. 6%, P = 0.017). There were no significant differences between the two groups in hematogenous (19% vs.12%, P = 0.173), dissemination (5% vs. 4%, P = 0.769), local (4% vs. 1%. P = 0.213), and other recurrence (3% vs. 3%, P = 1.000). The 3-year disease-free and overall survival of MIE were significantly better than OE (71.4% vs. 50.5%, P = 0.004 and 80.3% vs. 61.2%, P = 0.002, respectively). Multivariate analysis showed that the thoracic approach (OE vs. MIE) (HR 1.93, P = 0.004) was an independent prognostic factor, along with the pathological N stage (HR 3.05, P < 0.001). ConclusionsMIE has less intramediastinal LN recurrence than OE and may lead to a better long-term prognosis in patients with advanced esophageal cancer who underwent neoadjuvant chemotherapy.

Comparisons of minimally invasive esophagectomy and open esophagectomy in lymph node metastasis/dissection for thoracic esophageal cancer.

The study aimed to clarify the characteristics of lymph node metastasis (LNM) and to compare the oncologic outcomes of minimally invasive esophagectomy (MIE) with open esophagectomy (OE) in terms of lymph node dissection (LND) in thoracic esophageal cancer patients. The data from esophageal cancer patients who underwent MIE or OE from January 2016 to January 2019 were retrospectively reviewed. The characteristics of LNM in thoracic esophageal cancer were discussed, and the differences in numbers of LND, LND rate, and LNM rate/degree of upper mediastinum between MIE and OE were compared. For overall characteristics of LNM in 249 included patients, the highest rate of LNM was found in upper mediastinum, while LNM rate in middle and lower mediastinum, and abdomen increased with the tumor site moving down. The patients were divided into MIE ( n = 204) and OE groups ( n = 45). In terms of number of LND, there were significant differences in upper mediastinum between MIE and OE groups (8 [5, 11] vs. 5 [3, 8], P < 0.001). The comparative analysis of regional lymph node showed there was no significant difference except the subgroup of upper mediastinal 2L and 4L group (3 [1, 5] vs. 0 [0, 2], P < 0.001 and 0 [0, 2] vs. 0, P = 0.012, respectively). Meanwhile, there was no significant difference in terms of LND rate except 2L (89.7% [183/204] vs. 71.1% [32/45], P = 0.001) and 4L (41.2% [84/204] vs . 22.2% [10/45], P = 0.018) groups. For LNM rate of T3 stage, there was no significant difference between MIE and OE groups, and the comparative analysis of regional lymph node showed that there was no significant difference except 2L group (11.1% [5/45] vs . 38.1% [8/21], P = 0.025). The LNM degree of OE group was significantly higher than that of MIE group (27.2% [47/173] vs . 7.6% [32/419], P < 0.001), and the comparative analysis of regional LNM degree showed that there was no significant difference except 2L (34.7% [17/49] vs . 7.7% [13/169], P < 0.001) and 4L (23.8% [5/21] vs . 3.9% [2/51], P = 0.031) subgroups. MIE may have an advantage in LND of upper mediastinum 2L and 4L groups, while it was similar to OE in other stations of LND.

Robotic Esophagectomy Compared With Open Esophagectomy Reduces Sarcopenia within the First Postoperative Year: A Propensity Score-Matched Analysis

IntroductionSarcopenia is a known risk factor for adverse outcomes after esophageal cancer (EC) surgery. Robot-assisted minimally invasive esophagectomy (RAMIE) offers numerous advantages, including reduced morbidity and mortality. However, no evidence exists to date comparing the development of sarcopenia after RAMIE and open esophagectomy (OE). The objective was to evaluate whether the development of sarcopenia within the first postoperative year after esophagectomy is associated with the surgical approach: RAMIE versus OE. MethodsA total of 168 patients with EC were analyzed who either underwent total robotic or fully open Ivor Lewis esophagectomy in a propensity score-matched analysis. Sarcopenia was assessed using the skeletal muscle index (cm2/m2) and psoas muscle thickness per height (mm/m) on axial computed tomography scans during the first postoperative year; in total 540 computed tomography scans were evaluated. ResultsAfter 1-to-1 propensity score matching for confounders, 67 patients were allocated to RAMIE and OE groups, respectively. Skeletal muscle index in the OE group was significantly lower compared with the RAMIE group at the third (43.2 ± 7.6 cm2/m2 versus 49.1 ± 6.9 cm2/m2, p = 0.001), sixth (42.7 ± 7.8 cm2/m2 versus 51.5 ± 8.2 cm2/m2, p < 0.001) and ninth (43.0 ± 7.0 cm2/m2 versus 49.9 ± 6.6 cm2/m2, p = 0.015) postoperative month. Similar results were recorded for psoas muscle thickness per height. ConclusionsTo our knowledge, this study is the first to suggest a substantial benefit of RAMIE compared with open esophagectomy in terms of postoperative sarcopenia. These results add further evidence to support the implementation of the robotic approach in multimodal therapy of EC.

Comparison of complications and long-term survival after minimally invasive esophagectomy versus open esophagectomy in patients with esophageal cancer and chronic obstructive pulmonary disease

ObjectiveTo compare the complications and long-term survival of esophageal cancer patients with chronic obstructive pulmonary disease (COPD) after minimally invasive esophagectomy (MIE) versus open esophagectomy (OE) using propensity score matching (PSM).MethodsEsophageal cancer patients who underwent esophagectomy at the Thoracic Surgery Department of the First Affiliated Hospital of Hebei North University from January 2010 to December 2018 were retrospectively enrolled. The incidence of postoperative complications and prognosis of the MIE (n = 132) and OE (n = 138) groups were compared. To reduce bias, 1:1 PSM was adopted for the analysis.ResultsThe median disease-free survival (DFS) of the MIE and OE groups were 24 months and 26 months, respectively, and neither group reached median survival. There was no significant difference between the two groups in terms of 3-year DFS and overall survival (OS). The stratification of the patients on the basis of the percentage of estimated forced expiratory volume in the first second (%FEV1) did not result in significant differences in the survival rates. A total of 42 patients (50%) in the MIE group and 55 patients (65.48%) in the OE group experienced complications, and the difference was statistically significant (OR=0.527, 95% CI: 0.283–0.981, P=0.042). The incidence of acute COPD exacerbation (OR=0.213, 95% OR, CI: 0.068–0.666, P=0.004) and pulmonary atelectasis requiring bronchoscopic aspiration (OR=0.232, 95% OR, CI: 0.082–0.659, P=0.004) were significantly higher in the OE versus the MIE group. In addition, the distribution of the various grades of complications also differed significantly between the two groups (P=0.016). While the incidence of minor complications (≤Grade II) was similar in both groups (P=0.503), that of severe complications (≥Grade III) was markedly higher in the OE group (P=0.002) and the Grade-IIIa complications were predominant (P=0.001). The severity of complications was correlated with the postoperative duration of hospital stay in both groups (r=0.187, P=0.015). No significant difference was observed in the incidence of minor complications (≤Grade II) between the two groups following stratification on the basis of %FEV1, whereas severe complications were more frequent in the OE group among patients with %FEV1 between 60% and 70% (P=0.001<0.05).ConclusionThere was no significant difference in the postoperative DFS and OS of esophageal cancer patients with COPD after undergoing MIE or OE. However, MIE significantly reduced the incidence of severe postoperative complications among patients with %FEV1 between 60% and 70%.

565. MOVING FROM OPEN ESOPHAGECTOMY TO MINIMALLY INVASIVE ESOPHAGECTOMY: A PARADIGM SHIFT IN AN UPPER GASTROINTESTINAL CENTER

Abstract Esophagectomy is a complex procedure that is traditionally associated with high morbidities. Minimally invasive esophagectomy (MIE) has the benefits of reduced post-op complications and improved quality of life in comparison to open esophagectomy (OE). This study aimed to compare the outcomes of MIE vs OE since the advocation of MIE as the standard approach in an upper gastrointestinal center. A retrospective review of prospectively collected data from the institutional online databank. OE was the main approach for esophageal cancer between year 2015 to 2017, while MIE was the standard approach in 2020 to 2021. Patient’s demography, tumour’s characteristics, operative approach, perioperative outcomes such as operation time, blood loss, post-op length of hospital stay, number of lymph node yield, post-op morbidities and mortality were compared between the OE (Jan 2015 – Dec 2017) and the MIE (Jan 2020 – Dec 2021) group. 28 patients were included in this study, 15 in the OE group while 13 in the MIE group. Mean age was similar in both groups (60.4vs59.4). 46.7% were of squamous cell carcinoma in the OE group vs 76.9% of adenocarcinoma in the MIE group. Ivor-Lewis approach was more common in the OE group (53.3%vs38.5%). MIE was associated with shorter mean operative time (489.38minutes vs 526minutes), less blood loss (110ml vs 250ml), shorter length of stay post-op (10.38days vs 24.67days) and higher number of lymph node yield (44vs31.67). Post-op morbidity was lower in MIE (30.7%vs73.3%) with Clavien-dindo grade-III and above complication rate of 7.69% vs 26.67%. 90-day mortality was 0 in the MIE vs 1 in the OE group. MIE was associated with shorter operative time, higher number of lymph node yield, reduced post-op morbidity, mortality and shorter post-operative hospital stay in patients with esophageal cancer. The encouraging results marked the paradigm shift from OE to MIE in our center.

385. OUTCOME FOLLOWING MINIMAL INVASIVE VERSUS OPEN ESOPHAGECTOMY FOR ESOPHAGEAL CARCINOMA PATIENTS WITH LIVER CIRRHOSIS: A PROPENSITY SCORE-MATCHED ANALYSIS

Abstract Although minimally invasive esophagectomy (MIE) has advanced into a safe and effective alternative to open esophagectomy (OE), its utility in cirrhotic esophageal cancer (EC) patients remained unknown. This study analyzed the perioperative outcomes of MIE for EC with LC compared with open esophagectomy (OE). We retrospectively reviewed the clinical charts of patients treated with esophagectomy for EC who had a concomitant diagnosis of LC. Of the 74 patients identified from our records, 43 underwent MIE and 31 OE. The two treatment groups underwent propensity scores (PS) matching using a logistic model that included the following covariates: type of preoperative therapy, Charlson comorbidity index, Child-Pugh class, and elective versus emergency surgery. Following PS matching, the MIE and OE groups consisted of 40 and 20 patients, respectively. Patients treated with MIE less frequently showed severe pneumonia (7.5% versus 30%, respectively, p = 0.049) and had a shorter length of stay (median: 16 versus 22 days, respectively, p = 0.009), albeit at the expense of a longer operating time (median: 465.5 versus 403 min, respectively, p = 0.015). Compared with OE, MIE was associated with a lower in-hospital mortality (25% versus 2.5%, respectively, p = 0.013). Moreover, MIE did not compromise the quality of resected specimens with similar R0 resection rate. EC patients with LC showed more favorable mortality figures and lower rates of severe pneumonia after MIE compared with those who underwent OE. MIE may serve as a safe and feasible alternative for selected EC patients with LC.

A retrospective study of preoperative malnutrition based on the Controlling Nutritional Status score as an associated marker for short-term outcomes after open and minimally invasive esophagectomy for esophageal cancer.

Preoperative malnutrition is a significant risk factor for post-esophagectomy morbidity. The Controlling Nutritional Status (CONUT) is an index used to assess nutritional status, and it has been suggested to predict post-esophagectomy morbidity. However, the difference in the predictive value of CONUT in estimating morbidities between open esophagectomy (OE) and minimally invasive esophagectomy (MIE) has not yet been elucidated. This study included patients who underwent a three-incision esophagectomy for esophageal cancer between April 2005 and August 2021. The patients were further divided into two groups according to their preoperative CONUT scores: normal and light malnutrition and moderate and severe malnutrition. Short-term outcomes between these groups were retrospectively compared in the OE and MIE groups. A total of 674 patients who underwent OE (296) and MIE (378) were analyzed. Moreover, 32 patients of the OE group and 16 of the MIE group were classified as having moderate and severe malnutrition, respectively. Moderate and severe malnutrition was significantly associated with a low body mass index, poor performance status, poor American Society of Anesthesiologists physical status, advanced cancer stage, and frequent preoperative treatment. These patients also experienced significantly more frequent morbidities of grade ≥ IIIb according to the Clavien-Dindo classification (CDc), respiratory, and cardiovascular morbidities after OE. Moreover, moderate and severe malnutrition in CONUT was an independent risk factor for morbidity of CDc ≥ IIIb (odds ratio [OR] vs. normal and light malnutrition = 3.38; 95% confidence interval [CI], 1.225-9.332; p = 0.019), respiratory (OR = 3.00; 95% CI, 1.161-7.736; p = 0.023), and cardiovascular morbidities (OR = 3.66; 95% CI, 1.068-12.55; p = 0.039) after OE. Meanwhile, moderate and severe malnutrition in CONUT did not increase the incidence of postoperative morbidities after MIE. Preoperative malnutrition in CONUT reflects various disadvantageous clinical factors and could be a predictor of worse short-term outcomes after OE, but it has no value in MIE. The low invasiveness of MIE might reduce the effect of preoperative malnutrition on worse short-term outcomes.