Open Esophagectomy Research Articles

Survival Comparison Between Open and Thoracoscopic Upfront Esophagectomy in Patients With Esophageal Squamous Cell Carcinoma.

The survival outcomes of patients with esophageal squamous cell carcinoma (ESCC) after open or thoracoscopic upfront esophagectomy remained unclear. The aim of this retrospective study was to compare overall survival between open and thoracoscopic esophagectomy for ESCC patients without neoadjuvant chemodatiotherapy (CRT). The Taiwan Cancer Registry was investigated for ESCC cases from 2008 to 2016. We enrolled 2053 ESCC patients receiving open (n = 645) or thoracoscopic (n = 1408) upfront esophagectomy. One-to-two propensity score matching between the two groups was performed. Stage-specific survival was compared before and after propensity score matching. Univariate analysis and multivariate analysis were used to identify risk factors. After one-to-two propensity score matching, a total of 1299 ESCC patients with comparable clinic-pathologic features were identified. There were 433 patients in the open group and 866 patients in the thoracoscopic group. The 3-year overall survival of matched patients in the thoracoscopic group was better than that of matched patients in the open group (58.58% vs 47.62%, P = 0.0002). Stage-specific comparisons showed thoracoscopic esophagectomy is associated with better survival than open esophagectomy in patients with pathologic I/II ESCC. In multivariate analysis, surgical approach was still an independent prognostic factor before and after one-to-two propensity score matching. This propensity-matched study revealed that thoracoscopic esophagectomy could provide better survival than open esophagectomy in ESCC patients without neoadjuvant CRT.

Feasibility of conversion thoracoscopic esophagectomy after induction therapy for locally advanced unresectable esophageal squamous cell carcinoma.

Recently, patients with cT4b esophageal cancer often require conversion surgery following induction therapy, for which the standard procedure is open esophagectomy. However, thoracoscopic esophagectomy, including thoracoscopic esophagectomy in the prone position, is increasingly used. We compared short-term outcomes of thoracoscopic esophagectomy and open esophagectomy in this setting. We retrospectively analyzed 14 patients who underwent thoracoscopic esophagectomy, and 10 who underwent open esophagectomy, for locally advanced unresectable esophageal cancer after induction therapy between March 2007 and July 2020. The two groups did not significantly differ in patient background. Median total and thoracic surgical times were both significantly longer for open esophagectomy than for thoracoscopic esophagectomy. Median blood loss was also greater in the open esophagectomy group than in the thoracoscopic esophagectomy group. The thoracoscopic esophagectomy group also had significantly shorter median chest drain duration; and lower C-reactive protein levels on the second and third postoperative days. The two groups did not significantly differ in total complications or postoperative hospital stay. Thoracoscopic esophagectomy is as safe and feasible as open esophagectomy for conversion surgery after induction therapy for locally advanced unresectable esophageal squamous cell carcinoma.

Oncologic outcomes in minimally invasive esophagectomy for esophageal carcinoma

: Esophagectomy, with clear surgical margins and appropriate lymph node dissection, is the mainstay of curative intent treatment in esophageal cancer. Minimally invasive esophagectomy (MIE) including total MIE, hybrid and robotic approaches has become more frequent. Whether or not MIE offers the same oncologic outcomes as open esophagectomy (OE) is an unanswered question to be addressed in this review. A literature review was conducted using the search terms esophageal cancer, esophagectomy, outcomes, minimally invasive surgery, survival, lymph node assessment. Relevant studies were identified by two of the authors (NAD and GED). Studies reporting short terms outcomes consistently report decreased frequency of pneumonia, decreased blood loss and shorter length of stay. Margin status, appears to be similar while lymph node harvest is similar or better compared to open surgery. Overall survival (OS) is at least similar to open surgery but in several recent reports, survival after MIE is superior. Health-related quality of life (HRQOL) appears to be improved with MIE within the first 6 months but similar thereafter. MIE offers at least equivalent outcomes in terms of resection margins and lymph node harvest and long-term survival data. MIE offers earlier recovery from surgery with improved HRQOL within the first 6 months postoperatively.

Surgery and adjuvant therapy after esophagectomy

: Successful treatment of esophageal cancer requires a multidisciplinary approach consisting of surgery, chemotherapy, and radiotherapy. Esophagectomy is highly invasive with substantial morbidity and mortality. In order to reduce surgical invasiveness and improve outcomes, minimally invasive esophagectomy (MIE) and robot-assisted MIE were introduced. MIE reduces the incidence of postoperative complications, including pneumonia, when compared to open esophagectomy. In the last decade, several studies demonstrated that the modification of neoadjuvant and perioperative therapy could further improve outcomes. However, overall survival was still unsatisfactory: 5-year overall survival rate was 45% in the FLOT4 trial, 47% in the CROSS trial, and 55% in the JCOG9907 trial. Adjuvant therapy in combination with neoadjuvant chemotherapy may be a strategy to improve oncological outcomes. However, tolerability for adjuvant treatment is a concern as postoperative complications may delay recovery and hamper the application of adjuvant treatment. Secondly, not all patients likely benefit form adjuvant treatment. Individualization of treatment based on risk stratification of recurrent disease by new technologies is the future. Although further validation and interventional studies are required, liquid biopsies may be promising indicators to guide multidisciplinary treatment for esophageal cancer.

Minimally invasive or open oesophagectomy for localized oesophageal cancer: Results of the ROMIO phase 3 randomized controlled trial.

e16057 Background: Patients with localised oesophageal adenocarcinoma or squamous cell cancer are frequently offered surgery, usually with neoadjuvant treatment. Whether minimally invasive surgical approaches are superior to standard open procedures in terms of patient recovery and survival benefit is unclear. Well-designed and well-conducted pragmatic trials are limited. The ROMIO study compared laparoscopic abdominal surgery and thoracotomy (LAO) with open oesophagectomy (OO), to test the hypothesis that LAO allows faster recovery than OO whilst maintaining the survival benefit of surgery. Methods: A pragmatic multi-centre randomised controlled trial (1:1 LAO vs. OO) was conducted in 9 major cancer centres in the UK. Included were patients with localised adenocarcinoma or squamous cell cancer selected by a multi-disciplinary team for oesophagectomy with or without neoadjuvant treatment. Surgery was quality assured by provision of a protocol, pre-operative video assessment of the 40 participating surgeons and intra-operative photographs of key agreed surgical components. The primary outcome was the physical function scale of the EORTC QLQ-C30 assessed during the first 3 months. Results: At enrolment to ROMIO 447 (85%) of 526 participants were male, mean age was 67 years (SD 9), 469 (89%) had an adenocarcinoma, 368 (70%) had a clinically staged T3 or T4a tumour, 295 (56%) had clinically positive nodes, and 438 (83%) underwent neoadjuvant treatment. 263 were randomly allocated to each of the two procedures, with 241 (92%) undergoing their allocated open surgery and 237 (91%) undergoing their allocated LAO (hybrid) surgery. Analyses are underway and this presentation will include the primary outcome measure and other short-term clinical outcomes including key complications and survival during the first 90 days (clinical data >95% complete). Conclusions: ROMIO is the largest multi-centre randomised controlled surgical trial of minimal access versus open surgical approaches for oesophageal cancer. The provision of a surgical quality assessment tool will supplement trial data to provide for the first-time evidence of surgical standards of both approaches. Clinical trial information: ISRCTN10386621.

Learning Curve for Lymph Node Dissection Around the Recurrent Laryngeal Nerve in McKeown Minimally Invasive Esophagectomy.

BackgroundCompared to open esophagectomy (OE), minimally invasive esophagectomy (MIE) is associated with lower morbidity and mortality. However, lymph node (LN) dissection around the recurrent laryngeal nerve (RLN) is still an important factor that affects the length of the learning curve of MIE. This study aims to evaluate the surgical outcomes of the first nearly 5-year period and explore the learning curve for LN dissection around the RLN in McKeown MIE by a new single surgical team.MethodsA total of 285 consecutive patients who underwent McKeown MIE between March 2016 and September 2020 were included at our institution. According to the cumulative sum (CUSUM) analysis of LN dissection around the RLN, the patients were divided into three groups: exploration period, adjustment period, and stable period. We assessed the impact of surgical proficiency on postoperative outcomes and explored the learning curve for LN dissection around the RLN in McKeown MIE.ResultsThe CUSUM graph showed that a point of upward inflection for LN dissection around the RLN was observed in 151 cases. After 151 cases, LNs around the right and left RLNs were dissected thoroughly compared to the exploration and adjustment period (P = 0.010 and P = 0.012, respectively), and the postoperative incidence of hoarseness significantly decreased from 11.1 to 1.5% (P<0.001).ConclusionsOur study results revealed that not only are the LN, around the RLN, sufficiently dissected but also the incidence of hoarseness significantly decreased in the stable phase. Consequently, the learning curve length was approximately 151 cases for LN dissection around the RLN in McKeown MIE.

Comment on: Health-related quality of life following total minimally invasive, hybrid minimally invasive or open oesophagectomy: a population-based cohort study.

Comment on: Health-related quality of life following total minimally invasive, hybrid minimally invasive or open oesophagectomy: a population-based cohort study.

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

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

The modern approach to esophagectomy-review of the shift towards minimally invasive surgery.

The treatment of esophageal cancer has significantly advanced in the last 10 years and now includes multimodal treatment with a continued emphasis on surgical management. Minimally invasive esophagectomy (MIE) has been performed for almost 25 years and, in comparison to open esophagectomy techniques, MIE has shown to be equivalent or better in terms of its perioperative and oncologic outcomes. This paper reviews the evidence for MIE and recommends it should be offered as the first approach for esophagectomy surgery in the modern era.

Laparoscopic transhiatal esophagectomy in esophageal cancer patients with high-risk post-operative complications.

Surgical treatment of esophageal cancer is challenging, due to considerable morbidity, especially in high surgical risk patients. While transhiatal esophagectomy leads to good oncological outcomes and reduced postoperative complications, less invasive techniques might further improve outcomes. Our goal was to compare results of laparoscopic transhiatal esophagectomy (LTE) with open transhiatal esophagectomy (OTE) in esophageal cancer patients at high surgical risk. From 2014 to 2020, 128 patients were identified. Seventy received OTE while 51 received LTE. After propensity score matching (1:1), postoperative complications, analysis of overall and disease-free survival, and survival-related prognostic factors were assessed in two groups of 48 patients. Ninety-one (77%) patients were men with a mean age of 65 ± 10.3 years. Those who underwent OTE experienced more clinical and surgical complications. In LTE patients, the number of mean resected lymph nodes was 25.9, and in patients who had OTE, it was 17.4 (P < 0.001). Overall survival was 56.0% in the LTE group and 33.6% (P = 0.023) in the OTE group. In multivariable analysis of overall survival, open surgery and incomplete pathological response were seen as worse negative factors. In multivariable analysis, metastatic lymph nodes, incomplete pathologic response, surgical complications, and a Charlson's index > 2 (P = 0.014) were associated with poor prognosis. Both surgical methods are safe with similar morbidity and mortality; however, LTE was associated with fewer complications, a higher number of resected lymph nodes, better overall survival, and more prognostic factors related to global and disease-free overall survival in high-risk patients.

A long-term follow-up study of minimally invasive Ivor Lewis esophagectomy with linear stapled anastomosis

Minimally invasive esophagectomy (MIE) is increasingly performed to expect lower complication rate compared to open esophagectomy. Studies of minimally invasive Ivor Lewis esophagectomy (MIILE) with circular staplers have reported better outcomes compared to MIE with cervical anastomosis, but frequent anastomotic complications have also been reported. MIILE with linear staplers is a promising alternative, but the long-term functional and oncological outcomes are uncertain. To evaluate the functional and oncological outcomes of MIILE with linear stapled anastomosis, a retrospective cohort study was performed in 104 patients who underwent MIILE with linear stapled anastomosis for esophageal malignant tumors. The primary endpoints were the overall complication and anastomotic leak rates. The secondary endpoints were late complications, overall and disease-free survival, and nutritional status at 6 and 12months after MIILE. Anastomotic leak occurred in 4 patients (3.8%). The short-term complication rate of grade IIIb or higher was 6.7%. During a median 57-month follow-up period, anastomotic stricture occurred in one patient, 7 required hiatal hernia repair, and 2 underwent conduit revision surgery. The 5-year overall survival and disease-free survival rates were 69.3% and 59.5%, respectively. Status of reflux esophagitis at the time of most recent evaluation was grade N/A/B/C/D in 52/10/10/13/8 among 93 patients who had follow-up endoscopy. The mean body weight loss at 6 and 12months after MIILE was 11.3 and 11.8% with maintenance of the serum albumin level. MIILE with linear stapled anastomosis is a safe procedure with a low anastomotic complication rate and favorable long-term functional and survival outcomes.

Similar Quality of Life After Conventional and Robotic Transhiatal Esophagectomy

BackgroundPatient-reported outcomes (PROs) for minimally invasive esophagectomy (MIE) have demonstrated benefits compared with open transthoracic or 3-hole esophagectomy. PROs, including quality of life (QoL) and fear of recurrence (FoR), comparing open transhiatal esophagectomy (THE) and transhiatal robotic-assisted MIE (Th-RAMIE) have been limited. MethodsAt a single, high-volume academic center, patients undergoing THE and Th-RAMIE with gastric conduit for clinical stage I to III esophageal cancer from 2013 to 2018 were evaluated. The European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ-C30), the EORTC Quality of Life Questionnaire in Esophageal Cancer (QLQ-OES18), and the FoR survey were administered preoperatively and at 1, 6, and 12 months postoperatively. Linear mixed-effects models were used for QoL and FoR score comparisons. Perioperative outcomes were also compared. ResultsA total of 309 patients (212 in the group and 97 in the Th-RAMIE group) were included. The Th-RAMIE cohort had a significantly higher number of lymph nodes harvested (14 ± 0.8 vs 11.2 ± 0.4; P = .01), a shorter length of stay (days, 10.0 ± 6.7 vs 12.1 ± 7.0; P = .03), lower rates of postoperative ileus (5% vs 15%; P = .02), and fewer opioids prescribed at discharge (71% vs 85%; P = .03). After adjustment, there were no significant differences in QLQ-C30, QLQ-OES18, and FoR scores between the groups out to 1 year postoperatively. ConclusionsThere were no clear patient-reported benefits of Th-RAMIE over THE for esophageal cancer. However, Th-RAMIE conferred several perioperative benefits.

Reply to Comment on Health-related quality of life following total minimally invasive, hybrid minimally invasive or open oesophagectomy: a population-based cohort study by Li et al.

Reply to Comment on Health-related quality of life following total minimally invasive, hybrid minimally invasive or open oesophagectomy: a population-based cohort study by Li et al.

The Presence of Metastatic Thoracic Duct Lymph Nodes in Western Esophageal Cancer Patients: A Multinational Observational Study

BackgroundThe thoracic lymphadenectomy during an esophagectomy for esophageal cancer includes resection of the thoracic duct (TD) compartment containing the TD lymph nodes (TDLNs). The role of TD compartment resection is still a topic of debate since metastatic TDLNs have only been demonstrated in squamous cell carcinomas in Eastern esophageal cancer patients. Therefore, the aim of this study was to assess the presence and metastatic involvement of TDLNs in a Western population, in which adenocarcinoma is the predominant type of esophageal cancer. MethodsFrom July 2017 to May 2020, all consecutive patients undergoing an open or robot-assisted transthoracic esophagectomy with concurrent lymphadenectomy and resection of the TD compartment in the University Medical Center Utrecht in Utrecht, the Netherlands, and the Città della Salute e della Scienza University Hospital in Turin, Italy, were included. The TD compartment was resected en bloc and was separated in the operation room by the operating surgeon after which it was macroscopically and microscopically assessed for (metastatic) TDLNs by the pathologist. ResultsA total of 117 patients with an adenocarcinoma (73%) or squamous cell carcinoma (27%) of the esophagus were included. In 61 (52%) patients, TDLNs were found, containing metastasis in 9 (15%) patients. No major complications related to TD compartment resection were observed. ConclusionsThis study demonstrates the presence of metastatic TDLNs in adenocarcinomas of the esophagus. This result provides a valid argument to routinely extend the thoracic lymphadenectomy with resection of the TD compartment during an esophagectomy for esophageal cancer.

Hypotension Associated with MTS is Aggravated by Early Activation of TEA During Open Esophagectomy.

ObjectiveA mesenteric traction syndrome (MTS) is elicited by prostacyclin (PGI2)-induced vasodilation and identified by facial flushing, tachycardia, and hypotension during abdominal surgery. We evaluated whether thoracic epidural anesthesia (TEA) influences the incidence of MTS.DesignRandomized, blinded controlled trial.SettingSingle-center university hospital.ParticipantsFifty patients undergoing open esophagectomy.InterventionsPatients were randomized to either early (EA, after induction of general anesthesia) or late activation of TEA (LA, after re-established gastric continuity). Plasma 6-keto-PGF1α, a stable metabolite of PGI2 and interleukine-6 (IL6) were measured in plasma during surgery along with hemodynamic variables and MTS graded according to facial flushing together with plasma C-reactive protein on the third post-operative day.ResultsForty-five patients met the inclusion criteria. Development of MTS tended to be more prevalent with EA (n=13/25 [52%]) than with LA TEA (n=5/20 [25%], p=0.08). For patients who developed MTS, there was a transient increase in plasma 6-keto-PGF1α by 15 min of surgery and plasma IL6 (p<0.001) as C-reactive protein (P<0.009) increased. EA TEA influenced the amount of phenylephrine needed to maintain mean arterial pressure >60 mmHg in patients who developed MTS (0.16 [0.016–0.019] mg/min vs MTS and LA TEA 0.000 [0.000–0.005] mg/min, p<0.001).ConclusionThe incidence of MTS is not prevented by TEA in patients undergoing open esophagectomy. On the contrary, the risk of hypotension is increased in patients exposed to TEA during surgery, and the results suggest that it is advantageous to delay activation of TEA. Also, MTS seems to be associated with a systemic inflammatory response, maybe explaining the aggravated post-operative outcome.

A Propensity Score–Matched Analysis of Thoracolaparoscopic vs Open McKeown’s Esophagectomy

BackgroundThe effectiveness and survival benefit of minimally invasive esophagectomy compared to open esophagectomy (OE) remain controversial. The aim of this study was to evaluate the safety, efficacy, and oncologic outcomes of McKeown’s total minimally invasive esophagectomy (tMIE) and McKeown’s OE in the treatment of patients with esophageal squamous cell carcinoma. MethodsA series of 917 consecutive patients (306 OE and 611 tMIE) who underwent McKeown’s esophagectomy for esophageal squamous cell carcinoma in the Department of Thoracic Surgery at Sun Yat-sen University Cancer Center from January 2011 to December 2016 were evaluated. We performed propensity matching between the tMIE and OE groups on the basis of estimated propensity scores for each patient. ResultsAfter propensity-matched analysis, 288 patients were selected from each group. The rate of postoperative complications, such as pneumonia, respiratory insufficiency, cervical anastomotic leakage, and wound infection, in the OE group was significantly higher than that in the tMIE group. Intraoperative blood loss and operative duration were not significantly different between the matched groups, whereas the tMIE group had a shorter length of intensive care unit stay and postoperative hospital stay than the OE group. The R0 resection rate and the number of lymph nodes harvested were not significantly different between groups. There was no significant difference in median overall survival between the 2 groups after matching. ConclusionsMcKeown’s tMIE was shown to be a safe and effective procedure with long-term survival comparable to that of OE for the patients with esophageal squamous cell carcinoma.

Propensity matched analysis of short term oncological and perioperative outcomes following robotic and thoracolaparoscopic esophagectomy for carcinoma esophagus- the first Indian experience.

Thoracolaparoscopic esophagectomy (TLE) for carcinoma esophagus has better short-term outcomes compared to open esophagectomy. The precise role of robot-assisted laparoscopic esophagectomy (RALE) is still evolving. Single center retrospective analysis of TLE and RALE performed for carcinoma esophagus between January 2015 and September 2018. Propensity score matching was done between the groups for age, gender, BMI, ASA grade, tumor location, neoadjuvant therapy, the extent of surgical resection (Ivor Lewis or McKeown’s), histopathological type (squamous cell carcinoma or adenocarcinoma), clinical T and N stages. The primary outcome parameter was lymph node yield. Secondary outcome parameters were resection margin status, duration of surgery, blood loss, conversion to open procedure, length of hospital stay, length of ICU stay, complications, 90-day mortality and cost. There were 90 patients in TLE and 25 patients in RALE group. After propensity matching, there were 22 patients in each group. The lymph node yield was similar in both the groups (23.95 ± 8.23 vs 22.73 ± 11.63; p = 0.688). There were no conversions or positive resection margins in either group. RALE was associated with longer operating duration (513.18 ± 91.23 min vs 444.77 ± 64.91 min; p = 0.006) and higher cost ($5271.75 ± 456.46 vs $4243.01 ± 474.64; p < 0.001) than TLE. Both were comparable in terms of blood loss (138.86 ± 31.20 ml vs 133.18 ± 34.80 ml; p = 0.572), Clavien-Dindo grade IIIa and above complications (13.64% vs 9.09%; p = 0.634), hospital stay (12.18 ± 6.35 days vs 12.73 ± 7.83 days; p = 0.801), ICU stay (4.91 ± 5.22 days vs 4.77 ± 4.81 days; p = 0.929) and mortality (0 vs 4.55%; p = 0.235). RALE is comparable to TLE in terms of short-term oncological and perioperative outcomes except for longer operating duration when performed for carcinoma esophagus. RALE is costlier than TLE.

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.

Outcomes of curative esophageal cancer surgery in elderly: A meta-analysis.

BACKGROUNDAn increasing number of older patients is undergoing curative, surgical treatment of esophageal cancer. Previous meta-analyses have shown that older patients suffered from more postoperative morbidity and mortality compared to younger patients, which may lead to patient selection based on age. However, only studies including patients that underwent open esophagectomy were included. Therefore, it remains unknown whether there is an association between age and outcome in patients undergoing minimally invasive esophagectomy.AIMTo perform a systematic review on age and postoperative outcome in esophageal cancer patients undergoing esophagectomy.METHODSStudies comparing older with younger patients with primary esophageal cancer undergoing curative esophagectomy were included. Meta-analysis of studies using a 75-year age threshold are presented in the manuscript, studies using other age thresholds in the Supplementary material. MEDLINE, Embase and the Cochrane Library were searched for articles published between 1995 and 2020. Risk of bias was assessed with the Newcastle-Ottawa Scale. Primary outcomes were anastomotic leak, pulmonary and cardiac complications, delirium, 30- and 90-d, and in-hospital mortality. Secondary outcomes included pneumonia and 5-year overall survival.RESULTSSeven studies (4847 patients) using an age threshold of 75 years were included for meta-analysis with 755 older and 4092 younger patients. Older patients (9.05%) had higher rates of 90-d mortality compared with younger patients (3.92%), (confidence interval = 1.10-5.56). In addition, older patients (9.45%) had higher rates of in-hospital mortality compared with younger patients (3.68%), (confidence interval = 1.01-5.91). In the subgroup of 2 studies with minimally invasive esophagectomy, older and younger patients had comparable 30-d, 90-d and in-hospital mortality rates. CONCLUSIONOlder patients undergoing curative esophagectomy for esophageal cancer have a higher postoperative mortality risk. Minimally invasive esophagectomy may be important for minimizing mortality in older patients.

Minimal invasive versus open esophagectomy for patients with esophageal squamous cell carcinoma after neoadjuvant treatments

BackgroundAlthough previous studies have discussed whether the minimally invasive esophagectomy (MIE) is superior to open surgery, the data concerning esophageal squamous cell carcinoma (ESCC) patients underwent neoadjuvant treatment followed by radical resection is limited. The purpose of our study was to compare the short- and long-term clinical outcomes of the two surgical approaches in treating ESCC patients.MethodsBetween January 2010 and December 2016, ESCC patients who had received neoadjuvant therapy and underwent Mckeown esophagectomy at our institute were eligible. The baseline characteristics, pathological data, short-and long-term outcomes of these patients were collected and compared based on the surgical approach.ResultsA total of 195 patients was included in the current study. Compared to patients underwent open surgery, patients underwent MIE had shorter operative time and less intraoperative bleeding (390 min vs 330 min, P = 0.001; 204 ml vs 167 ml, P = 0.021). In addition, the risk of anastomotic leakage was decreased in MIE group (20.0% vs 3.3%, P < 0.001), while the occurrence of other complications did not have statistical significance between two groups. Overall survival (OS) and disease-free survival (DFS) was no difference in patients received neoadjuvant chemotherapy between the two approaches. For the patients underwent neoadjuvant chemoradiotherapy, OS was significantly better in the MIE group (log rank = 6.197; P = 0.013).ConclusionMinimally invasive Mckeown esophagectomy is safe and feasible for ESCC patients who underwent neoadjuvant therapy. MIE approach presented better perioperative results than open esophagectomy. The effect of surgical approaches on survival was depending on the scheme of neoadjuvant treatment.