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.
- [Show abstract] [Hide abstract]
ABSTRACT: Esophageal cancer is a devastating diagnosis with very dire long-term survival rates. This is largely due to its rather insidious progression, which leads to most patients being diagnosed with advanced disease. Recently, however, a greater understanding of the pathogenesis of esophageal malignancies has afforded surgeons and oncologists with new opportunities for intervention and management. Coupled with improvements in imaging, staging, and medical therapies, surgeons have continued to enhance their knowledge of the nuances of esophageal resection, which has resulted in the development of minimally invasive approaches with similar overall oncologic outcomes. This marriage of more efficacious induction therapy and diminished morbidity after esophagectomy offers new promise to patients diagnosed with this aggressive form of cancer. The following review will highlight these most recent advances and will offer insight into our own approach to patients with resectable esophageal malignancy.Journal of thoracic disease. 03/2014; 6(3):249-257.
- [Show abstract] [Hide abstract]
ABSTRACT: Worldwide an increasing part of oncologic oesophagectomies is performed in a minimally invasive way. Over the past decades multiple reports have addressed the perioperative outcomes and oncologic safety of minimally invasive oesophageal surgery. Although many of these (retrospective) case-control studies identified minimally invasive oesophagectomy as a safe alternative to open techniques, the clear benefit remained subject to debate. Recently, this controversy has partially resolved due to the results of the first randomized controlled trial that compared both techniques. In this trial short-term benefits of minimally invasive oesophagectomy were demonstrated in terms of lower incidence of pulmonary infections, shorter hospital stay and better postoperative quality of life. However, the current lack of long-term data on recurrence rate and overall survival precludes a comprehensive comparison of minimally invasive and open oesophagectomy. Proclaiming minimally invasive oesophagectomy as the standard of care for patients with resectable oesophageal cancer would therefore be a premature decision.Best practice & research. Clinical gastroenterology 02/2014; 28(1):41-52. · 2.48 Impact Factor
- [Show abstract] [Hide abstract]
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.Journal of thoracic disease. 05/2014; 6(Suppl 2):S253-S264.