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Re: Comparison of the Outcomes Between Open and Minimally Invasive Esophagectomy
With the development of the surgical technique, the minimally invasive esophagectomy, aiming to decrease the morbidity and mortality rates due to esophageal cancer, has been performed in more and more medical centers in China and worldwide. In this paper, the concept, technique, lymphadenectomy, complications and mortality, as well as the post-operative quality of life of the minimally invasive esophagectomy, are reviewed. Even though it is still difficult to define the minor wound or micro-trauma because there is not yet a unified standard for the minimally invasive esophagectomy, various clinical data have shown this surgical procedure enjoys a lot of advantages. In the operative approach of esophagectomy, more and more surgeons engaging in micro-traumatic surgery are adopting an operation mode similar to that of Ivor-Lewis operation mode, and have obtained as good or better results in lymphodenectomy as in open surgery. The post-operative quality of life of the patients undergoing this micro-traumatic surgery is better compared to those with open surgery. As for the morbidity and mortality rates, the minimally invasive esophagectomy showed satisfactory results as well, like the open surgery. As it is just in the beginning stages, the technique of minimally invasive esophagectomy will continue to be improved in the future.
Background:
Oesophageal resection is the main method of curative treatment for cancer of the oesophagus. Despite advances in surgical technology and postoperative care, the survival rate and prognosis of people undergoing oesophagectomy is still poor. The use of minimally invasive techniques in oesophageal surgery offers hope of reduced recovery time due to a reduction in surgical trauma. Although the first reports of thoracoscopy- and laparoscopy-assisted oesophagectomy emerged some 20 years ago, there is still no consensus that the outcomes are clearly superior to outcomes following conventional open surgery. Increasingly, some surgeons promote the use of minimally invasive techniques for oesophagectomy but questions remain over its safety and efficacy compared with open surgery.
Methods:
We conducted a systematic review of the literature to compare minimally invasive techniques for oesophagectomy to open surgery. The outcomes of interest for efficacy and safety included mortality, operative complications, recurrence, and quality of life.
Results:
There were 28 included comparative studies. No randomised controlled studies (RCTs) were available and therefore the data need to be interpreted with caution.
Conclusion:
Recommendations for future research are discussed. We argue that it is difficult to conduct an RCT for this procedure due to ethical considerations and suggest ways that future nonrandomised studies could be improved.
Open transthoracic oesophagectomy is the standard treatment for infracarinal resectable oesophageal carcinomas, although it is associated with high mortality and morbidity rates of 2 to 10% and 30 to 50%, respectively, for both the abdominal and thoracic approaches. The worldwide popularity of laparoscopic techniques is based on promising results, including lower postoperative morbidity rates, which are related to the reduced postoperative trauma. We hypothesise that the laparoscopic abdominal approach (laparoscopic gastric mobilisation) in oesophageal cancer surgery will decrease the major postoperative complication rate due to the reduced surgical trauma.
The MIRO trial is an open, controlled, prospective, randomised multicentre phase III trial. Patients in study arm A will receive laparoscopic-assisted oesophagectomy, i.e., a transthoracic oesophagectomy with two-field lymphadenectomy and laparoscopic gastric mobilisation. Patients in study arm B will receive the same procedure, but with the conventional open abdominal approach. The primary objective of the study is to evaluate the major postoperative 30-day morbidity. Secondary objectives are to assess the overall 30-day morbidity, 30-day mortality, 30-day pulmonary morbidity, disease-free survival, overall survival as well as quality of life and to perform medico-economic analysis. A total of 200 patients will be enrolled, and two safety analyses will be performed using 25 and 50 patients included in arm A.
Postoperative morbidity remains high after oesophageal cancer surgery, especially due to major pulmonary complications, which are responsible for 50% of the postoperative deaths. This study represents the first randomised controlled phase III trial to evaluate the benefits of the minimally invasive approach with respect to the postoperative course and oncological outcomes in oesophageal cancer surgery.
NCT00937456 (ClinicalTrials.gov).
Oesophagectomy is one of the most challenging surgeries. Potential for morbidity and mortality is high. Minimally invasive techniques have been introduced in an attempt to reduce postoperative complications and recovery times. Debate continues over whether these techniques are beneficial to morbidity and whether oncological resection is compromised. This review article will analyse the different techniques employed in minimally invasive oesophagectomy (MIO) and critically evaluate commonly reported outcome measures from the available literature.
Medline, Embase, Science Citation Index, Current Contents, and PubMed databases were used to search English language articles published on MIO. Thirty-one articles underwent thorough analysis and the data were tabulated where appropriate. To date, only level III evidence exists. Where appropriate, comparisons are made with a meta-analysis on open oesophagectomy.
Positive aspects of MIO include at least comparable postoperative recovery data and oncological resection measures to open surgery. Intensive care unit requirements are lower, as is duration of inpatient stay. Respiratory morbidity varies. Negative aspects include increased technical skill of the surgeon and increased equipment requirements, increased operative time and limitation with respect to local advancement of cancer. With increasing individual experience, improvements in outcome measures and the amenability of this approach to increasing neoplastic advancement has been shown.
MIO has outcome measures at least as comparable to open oesophagectomy in the setting of benign and nonlocally advanced cancer. Transthoracic oesophagectomy provides superior exposure to the thoracic oesophagus compared to the transhiatal approach and is currently preferred. No multicentre randomised controlled trials exist or are likely to come into fruition. As with all surgery, careful patient selection is required for optimal results from MIO.
Complications after an esophagectomy are a serious problem. It is important to minimize the risk, but there are few major randomized controlled trials that address the prevention. The efforts must be concentrated not only on improvement of the survival, but also on the prevention of complications. © 2009 The Editorial Committee of Annals of Thoracic and Cardiovascular Surgery.
Perhaps there is no more important issue in the care of surgical patients than the appropriate use of minimally invasive surgery (MIS) for patients with cancer. Important advances in surgical technique have an impact on early perioperative morbidity, length of hospital stay, pain management, and quality of life issues, as clearly proved with MIS. However, for oncology patients, historically, the most important clinical questions have been answered in the context of prospective randomized trials. Important considerations for MIS and cancer have been addressed, such as what are the important immunologic consequences of MIS versus open surgery and what is the role of laparoscopy in the staging of gastrointestinal cancers? This review article discusses many of the key controversies in the minimally invasive treatment of cancer using the pro-con debate format.
Early efforts with minimally invasive esophagectomy (MIE) were hybrid approaches. No conclusive benefit was seen with this approach compared with the standard open procedure. Total MIE has demonstrated its advantages in single institution series. The drawbacks of total MIE include the steep learning curve and the high cost of the disposable instrumentation. We sought to determine the feasibility of modifying the surgical technique involved in the hybrid approach in an effort to decrease the cost of the surgery without compromising the outcome. From December 2007 to September 2008, the modified McKeown procedure (thoracoscopic esophageal mobilization three-incision esophagectomy) was performed in 30 cases. The median operative time was 225 minutes (range, 195 -290 minutes) and the median average time of VATS was 70 minutes (range, 50 -130 minutes). Median lymph node retrieval was 25.6 +/- 4.8 nodes (15.1 +/- 3.4 intrathoracic) per patient. The median postoperative hospital stay was 17.1 +/- 6.3 days. There was no in-hospital (30 days) mortality. Postoperative complications occurred in 9 patients (30%), including 2 (6.7%) pneumonia, 1 (3.3%) chylothorax, 1 (3.3%) delayed gastric emptying, 1 (3.3%) vocal cord palsy, 2 (6.7%) neck anastomotic leaks, and 2 (6.7%) arrhythmias. This procedure is technically feasible and safe with lower mortality and mobility. The short-term surgical outcomes are comparable with most of the total MIE reports. Performing the gastric mobilization and spontaneous neck anastomosis first greatly facilitate and simplifies the VATS maneuver.
Minimally invasive esophagectomy (MIE) compared with open esophagectomy (OE) has been shown to have clinical advantages, but selection bias is present.
All patients undergoing MIE or OE for cancer between 1999 and 2007 were eligible for analysis. To minimize selection bias, only patients who also met the selection criteria for the thoracoscopic approach were included in the open esophagectomy group.
Fifty-six patients underwent MIE and 98 OE. No significant differences in demographics or pathologic data between groups occurred, with the exception of thoracic epidural analgesia (OE 98%, MIE 71.1%, p < 0.001), and neoadjuvant treatment (OE 50.5%, MIE 71.4%, p = 0.016). Morbidity and in-hospital death were not significantly different. Duration of surgery was longer in MIE (250 vs 209 minutes, p < 0.001) and blood loss less (320 mL vs 857 mL, p < 0.001). Intensive care unit stay was shorter in MIE (3.0 vs 6.8 days, p = 0.022). The relative risk (RR) for in-hospital death was 0.57 (p = 0.475) if the patients underwent MIE. After adjusting for thoracic epidural analgesia, the RR was 0.29 (p = 0.213) for the MIE group. The RR for surgical morbidity was 1.47 (p = 0.154) for patients undergoing MIE. Neoadjuvant treatment increased the RR for surgical morbidity to 1.78 (p = 0.028). No difference between the two groups concerning survival occurred.
The MIE is comparable with the OE. In MIE, neoadjuvant treatment increased the risk of surgical morbidity. Thoracic epidural analgesia in MIE reduced the risk of in-hospital death and should be considered for all patients undergoing esophagectomy.
This article reviews the use of minimally invasive surgical and endoscopic techniques in the field of surgical oncology. It reviews the indications and techniques of the use of minimally invasive surgery for several oncologic indications in general surgery. In particular, it reviews the currently published literature discussing the oncologic outcomes of these techniques.
Conventional esophagectomy requires either a laparotomy or a thoracotomy. Currently, the minimally invasive esophagectomy is an evolving alternative to the open technique.
Assess and evaluate the early outcomes of the authors' experiences with the minimally invasive esophagectomy for esophageal cancer.
Outcome data were collected prospectively from 28 consecutive patients, 22 men and six women with a mean age of 63 years and a range of 36-77 years.
Thoracoscopic esophageal mobilizations were successful in 17 patients. Four patients were converted to open thoracotomy. Laparoscopic gastric mobilizations were successful in eight patients and only one patient was converted to laparotomy. Mortality was one (3.5%), and perioperative morbidity was nine (32%), including pneumonia, pleural effusion, wound infection, anastomosic leakage, and hoarseness.
Minimally invasive esophagectomy is feasible and can be performed at the Prince of Songkla University Hospital. Optimal results require appropriate patient selection and surgeon experience.
Regarding the surgical treatment of esophageal cancer, a question was raised by the introduction of minimally invasive surgery, because of the technical complexity of the techniques involved and its uncertain benefits. We evaluated the impact of laparoscopic esophagectomy on the surgical approach to esophageal cancer.
From January 2002 to March 2006, 22 non-randomized patients were recruited to undergo esophagectomy for neoplastic disease. The esophagectomy and esophagogastroplasty were performed using the laparoscopic transhiatal technique (THE) in 9 cases, while a combined laparoscopic gastric mobilisation and right transthoracic incision (TT/LE) was performed in the other 13.
Mean follow up was 21+/-3.23 months, range 2-46 months. Overall cumulative survival was 84.0% at 12 months, 61.3% at 24 months, 51.0% at 36 months. THE achieved better results than TT/LE on the ground with regard to the time it took to complete the procedure (p=0.046) and the hospital stay times (p=0.039), and the time in ICU, postoperative oral feeding resumption, number of retrieved lymph nodes.
The clinical benefits of minimally invasive techniques regard the time it takes to complete the procedure, the time in ICU, postoperative oral feeding resumption and the hospital stay times. Minimally invasive surgery might be not less curative and effective than open surgical procedures, as found in our small non-randomzed series of patients. Larger series should confirm these results.
To evaluate outcomes after minimally invasive or thoracolaparoscopic esophagectomy (TLE) with thoracoscopic mobilization of the esophagus and mediastinal esophagectomy in prone position. Esophagectomies are being performed increasingly by a minimally invasive route with decreased morbidity and shorter hospital stay compared with conventional esophagectomy. Most series report thoracoscopic mobilization of the esophagus and mediastinal lymphadenectomy in the left lateral position with respiratory complications up to 8% and prolonged operative time, probably because of inadequate stance of the surgeon during the thoracoscopic part. This study shows the potential of the thoracoscopic part of the procedure in prone position to ease these difficulties.
From January 1997 through April 2005, TLE was performed in 130 patients. All patients had histologically proved squamous cell carcinoma of the middle third of the esophagus. Only one (0.77%) patient received neoadjuvant chemotherapy. The thoracoscopic part of the procedure was performed in prone position with excellent ergonomics, translating into less operative time and better respiratory results. We performed a minilaparotomy to retrieve the specimen owing to bulky tumors. Feeding jejunostomy and pyloromyotomy were performed in all patients.
There were 102 men and 28 women. Median age was 67.5 years (range 38 to 78 years). There was no conversion to open method. Median ICU stay was 1 day (range 1 to 32 days) and median hospital stay was 8 days (range 4 to 68 days). Perioperative mortality was 1.54% (n = 2). Anastomotic leak rate was 2.31% (n = 3). There was no incidence of tracheal or lung injury and a very low incidence of postoperative pneumonia. At mean followup of 20 months (range 2 to 70 months), stage-specific survival was similar to open and other minimally invasive series.
TLE with thoracoscopic part in prone position is technically feasible, with a low incidence of respiratory complications and less operative time required. It provides comparable outcomes with other techniques of minimally invasive esophagectomy and most open series. In our experience, we observed a low mortality rate (1.54%), hospital stay of 8 days, and low incidence of postoperative pneumonia. It has the potential to replace conventional and other techniques of minimally invasive esophagectomy.
We report patient outcomes from esophageal resection with respect to morbidity and cancer survival comparing open thoracotomy and laparotomy (Open), with a thoracoscopic/laparotomy approach (Thoracoscopic-Assisted) and a total thoracoscopic/laparoscopic approach (Total MIE).
From a prospective database of all patients managed with cancer of the esophagus or esophagogastric junction, patients who had a resection using one of three techniques were analyzed to assess postoperative variables, adequacy of cancer clearance, and survival.
The number of patients for each procedure was as follows: Open, 114; Thoracoscopic-Assisted, 309; and Total MIE, 23. The groups were comparable with respect to preoperative variables. The differences in the postoperative variables were: less median blood loss in the Thoracoscopic-Assisted (400 mL) and Total MIE (300 mL) groups versus Open (600 mL); longer time for Total MIE (330 minutes) versus Thoracoscopic-Assisted (285 minutes) and Open (300 minutes); longer median time in hospital for Open (14 days) versus Thoracoscopic-Assisted (13 days), Total MIE (11 days) and less stricture formation in the Open (6.1%) versus Thoracoscopic-Assisted (21.6%), Total MIE (36%). There were no differences in lymph node retrieval for each of the approaches. Open had more stage III patients (65.8%) versus Thoracoscopic-Assisted (34.4%), Total MIE (52.1%). There was no difference in survival when the groups were compared stage for stage for overall median or 3-year survival.
Minimally invasive techniques to resect the esophagus in patients with cancer were confirmed to be safe and comparable to an open approach with respect to postoperative recovery and cancer survival.