Minimally invasive versus open esophagectomy for cancer: A systematic review and meta-analysis
Department of Surgery, VU Medical Center, Amsterdam, the Netherlands. Minerva chirurgica
(Impact Factor: 0.68).
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.
Available from: PubMed Central
- "This study is also a longer follow-up study in the evaluation of oncological outcomes of MIE. Based on our experience and an analysis of the current literature –, the McKeown MIE was associated with lower morbidity and mortality than the conventional open esophagectomy, especially for patients with early esophageal cancer –. More importantly, the former ensures the transection of the esophagus with a cancer-negative margin, and shows a favorable oncological outcome compared to traditional open surgery in terms of lymph node dissection. "
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ABSTRACT: To achieve decreased invasiveness and lower morbidity, minimally invasive esophagectomy (MIE) was introduced in 1997 for localized esophageal cancer. The combined thoracoscopic-laparoscopic esophagectomy (left neck anastomosis, defined as the McKeown MIE procedure) has been performed since 2007 at our institution. From 2007 to 2011, our institution subsequently evolved as a high-volume MIE center in China. We aim to share our experience with MIE, and have evaluated the outcomes of 142 patients.
We retrospectively reviewed 142 consecutive patients who had presented with esophageal cancer undergoing McKeown MIE from July 2007 to December 2011. The procedure, surgical outcomes, disease-free and overall survival of these cases were assessed.
The average total procedure time was 270.5±28.1 min. The median operation time for thoracoscopy was 81.5±14.6 min and for laparoscopy was 63.8±9.1 min. The average blood loss associated with thoracoscopy was 123.8±39.2 ml, and for laparoscopic procedures was 49.9±14.3 ml. The median number of lymph nodes retrieved was 22.8. The 30 day mortality rate was 0.7%. Major surgical complications occurred in 24.6% and major non-surgical complications occurred in 18.3% of these patients. The median DFS and OS were 36.0±2.6 months and 43.0±3.4 months respectively.
Surgical and oncological outcomes following McKeown MIE for esophageal cancer were acceptable and comparable with those of open-McKeown esophagectomy. The procedure was both feasible and safe - properties that can be consolidated by experience.
Available from: Marike Schaaf, van der
- "In the literature advanced age, neoadjuvant chemo-radiotherapy, pulmonary dysfunction and poor pre-operative general performance are described as pre-operative risk factors. Intraoperative risk reduction is caused by recent advances in anaesthetic and surgical techniques (Biere et al., 2009; Decker et al., 2009; Grotenhuis et al., 2010). Whereas patients in the intervention group had more potential risk factors to develop a post-operative complication, such as neoadjuvant chemo-radiotherapy, history of cigarette smoking and longer surgery, the incidence of postoperative complications was not significantly higher than in the CC group. "
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ABSTRACT: Patients undergoing oesophageal surgery have a high risk for post-operative complications including pulmonary infections. Recently, physical therapy has shifted from the post-operative to the pre-operative phase to diminish post-operative complications and to shorten hospital stay. The purpose of this pilot study was to investigate the feasibility and initial effectiveness of pre-operative inspiratory muscle training (IMT) on the incidence of pneumonia in patients undergoing oesophagectomy.
A pragmatic non-randomized controlled trial was conducted among all patients who underwent an oesophagectomy between January 2009 and February 2010. Patients in the intervention group received IMT prior to surgery. Feasibility was assessed on the basis of the occurrence of adverse effects during testing or training and patient satisfaction. Initial effectiveness on respiratory function was evaluated by maximal inspiratory pressure (MIP) and endurance, the incidence of post-operative pneumonia and length of hospital stay.
Eighty-three patients were included, of which 44 received pre-operative IMT. No adverse effects were observed. IMT was well tolerated and appreciated. In the intervention group, the median MIP and endurance improved significantly after IMT by 32% and 41%, respectively (p < 0.001). The incidence of post-operative pneumonia and the length of hospital stay were comparable for the intervention and the conventional care groups (pneumonia, 25% vs. 23% [p = 0.84]; hospitalization, 13.5 vs. 12 days [p = 0.08]).
Pre-operative IMT is feasible in patients with oesophageal carcinoma and significantly improves respiratory muscle function. This, however, did not result in a reduction of post-operative pneumonia in patients undergoing oesophagectomy. Copyright
Available from: George A Sarosi
- "Additionally, Biere et al. published their findings of a metaanalysis in which 1 controlled clinical trial and 9 case-control studies were included in the final study (n = 1, 061). Trends were observed in favor of MIE for the following outcomes: major morbidity, pulmonary complications, anastomotic leakage, mortality, length of stay, operating time, and blood loss, but statistical significance was not reached . "
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ABSTRACT: Esophagectomy is a complex operation with significant morbidity and mortality. Minimally invasive esophagectomy (MIE) was described in the 1990s in an effort to reduce operative morbidity. Since then many institutions have adopted and described their series with this technique. This paper reviews the literature on the variety of MIE techniques, clinical and quality of life outcomes with open versus MIE, and controversies surrounding MIE-such as prone positioning, stapling techniques, size of the gastric conduit, and robotic techniques.
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