Minimally invasive versus open esophagectomy for cancer: a systematic review and meta-analysis.
ABSTRACT Evidence on the benefits of minimally invasive surgery over open procedures in gastrointestinal surgery is continuing to accumulate. This is also the case for esophageal surgery. Esophageal cancer often requires extensive surgery and is, therefore, considered to be one of the most invasive elective gastrointestinal procedures. Clinical studies investigating means to reduce the invasive nature of the surgery are currently being received with great interest. A systematic review and meta-analysis of present literature was performed to evaluate the effects of minimally invasive esophagectomy (MIE) versus open esophagectomy on outcome. All comparative studies comparing MIE with open esophagectomy for cancer were included. Eligible studies were identified from three electronic databases (Medline, Embase, Cochrane) and through a cross-reference search. Three comparative groups were created for (meta-) analysis: 1) total MIE verus open transthoracic esophagectomy (TTE); 2) thoracoscopy and laparotomy versus open TTE; 3) laparoscopy versus open transhiatal esophagectomy. Ten studies were identified after a comprehensive search. One controlled clinical trial and 9 case-control studies, comprising 1061 patients, were retrieved. Trends were observed in the various studies in favour of MIE for the following outcome parameters: major morbidity, pulmonary complications, anastomotic leakage, mortality, length of hospital stay, operating time and blood loss. The meta-analysis in group 1 showed no significant differences between the groups for major morbidity or pulmonary complications OR 0.88 (95% CI 0.35-2.14, P=0.78) and OR 1.05 (95% CI 0.42-2.66, P=0.91) respectively. In group 2 significantly fewer cases of anastomotic leakage were reported in the MIE group OR 0.51 (95% CI 0.28-0.95, P=0.03). In both group 1 and 2 a trend toward a reduced mortality was seen in the MIE group, although no statistical significance was reached (group 1: OR 0.58 (95 % CI 0.06-5.56, P=0.64), group 2: OR 0.59 (95% CI 0.20-1.76, P=0.34)). No meta-analysis could be performed for group 3 due to incomplete data of the selected outcome parameters in the various studies. A faster postoperative recovery and, therefore, a reduction in morbidity can be achieved with MIE. Furthermore, less mortality with the implementation of MIE can be realised. MIE is investigated in case-control studies and bias may have been introduced simply by study design. Therefore, randomized trials comparing MIE with open esophagectomy are necessary in order to evaluate outcome more efficiently.
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ABSTRACT: Background There is a need for evidence of the clinical effectiveness of minimally invasive surgery for the treatment of esophageal cancer, but randomized controlled trials in surgery are often difficult to conduct. The ROMIO (Randomized Open or Minimally Invasive Oesophagectomy) study will establish the feasibility of a main trial which will examine the clinical and cost-effectiveness of minimally invasive and open surgical procedures for the treatment of esophageal cancer. Methods/Design A pilot randomized controlled trial (RCT), in two centers (University Hospitals Bristol NHS Foundation Trust and Plymouth Hospitals NHS Trust) will examine numbers of incident and eligible patients who consent to participate in the ROMIO study. Interventions will include esophagectomy by: (1) open gastric mobilization and right thoracotomy, (2) laparoscopic gastric mobilization and right thoracotomy, and (3) totally minimally invasive surgery (in the Bristol center only). The primary outcomes of the feasibility study will be measures of recruitment, successful development of methods to monitor quality of surgery and fidelity to a surgical protocol, and development of a core outcome set to evaluate esophageal cancer surgery. The study will test patient-reported outcomes measures to assess recovery, methods to blind participants, assessments of surgical morbidity, and methods to capture cost and resource use. ROMIO will integrate methods to monitor and improve recruitment using audio recordings of consultations between recruiting surgeons, nurses, and patients to provide feedback for recruiting staff. Discussion The ROMIO study aims to establish efficient methods to undertake a main trial of minimally invasive surgery versus open surgery for esophageal cancer. Trial registration The pilot trial has Current Controlled Trials registration number ISRCTN59036820(25/02/2013) at http://www.controlled-trials.com; the ROMIO trial record at that site gives a link to the original version of the study protocol.Trials 06/2014; 15(1):200. DOI:10.1186/1745-6215-15-200 · 2.12 Impact Factor
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ABSTRACT: Management of esophageal cancer has evolved since the two last decades. Esophagectomy remains the primary treatment for early stage esophageal cancer although its specific role in superficial cancers is still under debate since the development of endoscopic mucosal treatment. To date, there is strong evidence to consider that locally advanced cancers should be recommended for a multimodal treatment with a neoadjuvant chemotherapy or a combined chemoradiotherapy (CRT) followed by surgery. For locally advanced squamous cell carcinoma or for a part of adenocarcinoma, some centers have proposed treating with definitive CRT to avoid related-mortality of surgery. In case of persistent or recurrent disease, a salvage esophagectomy remains a possible option but this procedure is associated with higher levels of perioperative morbidity and mortality. Despite the debate over what constitutes the best surgical approach (transthoracic versus transhiatal), the current question is if a minimally procedure could reduce the periopertive morbidity and mortality without jeopardizing the oncological results of surgery. Since the last decade, minimally invasive esophagectomy (MIE) or hybrid operations are being done in up to 30% of procedures internationally. There are some consistent data that MIE could decrease the incidence of the respiratory complications and decrease the length of hospital-stay. Nowadays, oncologic outcomes appear equivalent between open and minimally invasive procedures but numerous phase III trials are ongoing.
Cancer Forum 01/2011; 35(3):166-170.