Minimally Invasive Esophagectomy Provides Significant Survival Advantage Compared with Open or Hybrid Esophagectomy for Patients with Cancers of the Esophagus and Gastroesophageal Junction - 23/03/15

Doi : 10.1016/j.jamcollsurg.2014.12.023

Francesco Palazzo, MD, FACS ^a,^⁎ , Ernest L. Rosato, MD, FACS ^a, Asadulla Chaudhary, BS ^a, Nathaniel R. Evans, MD, FACS ^a, Jocelyn A. Sendecki, MSPH, MS ^b, Scott Keith, PhD ^b, Karen A. Chojnacki, MD, FACS ^a, Charles J. Yeo, MD, FACS ^a, Adam C. Berger, MD, FACS ^a
^a The Jefferson Gastro-Esophageal Center, the Department of Surgery, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA
^b Division of Biostatistics, Department of Clinical Pharmacology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA

^∗Correspondence address: Francesco Palazzo, MD, FACS, Department of Surgery, Thomas Jefferson University, 1100 Walnut St, 5th Floor, Philadelphia, PA 19107.

Abstract

Background

Minimally invasive esophagectomy (MIE) is increasingly being used to treat patients with cancer of the esophagus and gastroesophageal junction. We previously reported that oncologic efficacy may be improved with MIE compared with open or hybrid esophagectomy (OHE). We compared survival of patients undergoing MIE and OHE.

Study Design

Our contemporary series of patients who underwent MIE (2008 to 2013) was compared with a cohort undergoing OHE (3-hole [n = 39], Ivor Lewis [n = 16], hybrid [n = 13], 2000 to 2013). Summary statistics were calculated by operation type; Kaplan-Meier methods were used to compare survival. Cox regression was used to assess the impact of operation type (MIE vs OHE) on mortality, adjusting for age, sex, total lymph nodes, lymph node ratio (LNR), neoadjuvant chemoradiotherapy (CRT), and stage.

Results

The MIE (n = 104) and OHE (n = 68) groups were similar with respect to age and sex. The MIE group tended to have higher BMI, earlier stage disease, and was less likely to receive CRT. The MIE group experienced lower operative mortality (3.9% vs 8.8%, p = 0.35) and significantly fewer major complications. Five-year survival between groups was significantly different (MIE, 64%, OHE, 35%, p < 0.001). Multivariate analysis demonstrated that patients undergoing OHE had a significantly worse survival compared with MIE independent of age, LNR, CRT, and pathologic stage (hazard ratio 2.00, p = 0.019).

Conclusions

This study supports MIE for EC as a superior procedure with respect to overall survival, perioperative mortality, and severity of postoperative complications. Several biases may have affected these results: earlier stage in the MIE group and disparity in timing of the procedures. These results will need to be confirmed in future prospective studies with longer follow-up.

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Abbreviations and Acronyms : CRT, LNR, LOS, MIE, OHE