Is minimally invasive esophagectomy indicated for cancer?

Esophagectomy is an important component in the comprehensive treatment of esophageal cancer. The 5-year survival in patients who are treated with esophagectomy is approximately 35% compared with approximately 16% for all patients. However, esophagectomy is a complex operation with high (40-60%) morbidity and 5-20% mortality rates reported by many centers. Minimally invasive approaches to esophagectomy have been developed over the past decade; potential advantages of minimally invasive esophagectomy (MIE) include a reduced risk of perioperative morbidity and mortality with equivalent oncologic outcomes, including extent of lymphadectomy and survival. However, significant debate still exists regarding the role of MIE in the treatment of esophageal cancer, particularly given the limitations in the widespread implementation of this technically challenging operation. This review summarizes the current status of the use of minimally invasive surgery in treating esophageal cancer and seeks to answer the question of whether MIE is indicated in the treatment of esophageal cancer.     

Minimally invasive surgery for esophageal cancer

Esophageal cancer represents a major public health problem worldwide. Several minimally invasive esophagectomy (MIE) techniques have been described and represent a safe alternative for the surgical management of esophageal cancer in selected centers with high volume and expertise in them. This article reviews the most recent and largest series evaluating MIE techniques. Recent larger series have shown MIE to be equivalent in postoperative morbidity and mortality rates to conventional surgery. MIE has been associated with less blood loss, less postoperative pain, and decreased intensive care unit and hospital length of stay compared with conventional surgery. Despite limited data, conventional surgery and MIE have shown no significant difference in survival, stage for stage. The myriad of MIE techniques complicates the debate of defining the optimal surgical approach for treating esophageal cancer. Randomized controlled trials comparing MIE with conventional open esophagectomy are needed to clarify the ideal procedure with the lowest postoperative morbidity, best quality of life after surgery, and long-term survival.     

Long-term outcomes following minimally invasive and open esophagectomy in Finland: A population-based study

BackgroundStudies of long-term survival after minimally invasive and open esophagectomy are needed. The aim of this study was to compare long-term outcomes following minimally invasive and open esophagectomy for esophageal cancer at the population level.MethodsAll patients undergoing minimally invasive (n = 159) or open transthoracic (n = 431) esophagectomy for esophageal cancer in Finland between 2004 and 2014 were identified from nationwide registries. Propensity score matching was used to create groups of 150 minimally invasive and open esophagectomies with balanced baseline characteristics (sex, age, comorbidity, center volume, year of surgery, histology, stage (local or locally advanced), and neoadjuvant therapy). The primary outcome was 1-year survival after surgery. Secondary outcomes were the 3-year, 5-year, and 90-day survival.ResultsThe propensity matched 1-year survival rate was 85.3% after minimally invasive and 74.7% after open esophagectomy (adjusted HR 0.53, 95% CI 0.31–0.89; P = 0.0174). At 3 years, those were 68.7% and 55.6% (adjusted HR 0.62; 95% CI 0.43–0.91; P = 0.0144), respectively; at 5 years, survival rates were 61.8% and 51.9% (adjusted HR 0.68, 95% CI 0.47–0.97; P = 0.0347). The 30- and 90-day survival rates after minimally invasive and open surgery were 99.3% vs. 98.0% and 97.3% vs. 92.0%, respectively, without statistical significance.ConclusionsIn this population-based propensity matched study, minimally invasive esophagectomy was associated with improved long-term survival. Due to multiple confounding factors replication studies are needed.     

Treatment of Barrett’s esophagus with high-grade dysplasia

The incidence of esophageal adenocarcinoma is increasing in the USA, now accounting for at least 4% of US cancer-related deaths. Barrett’s esophagus is the main risk factor for the development of esophageal adenocarcinoma. The annual incidence of development of adenocarcinoma in Barrett’s esophagus is approximately 0.5% per year, representing at least a 30–40-fold increase in risk from the general population. High-grade dysplasia is known to be the most important risk factor for progression to adenocarcinoma. Traditionally, esophagectomy has been the standard treatment for Barrett’s esophagus with high-grade dysplasia. This practice is supported by studies revealing unexpected adenocarcinoma in 29–50% of esophageal resection specimens for high-grade dysplasia. In addition, esophagectomy employed prior to tumor invasion of the muscularis mucosa results in 5-year survival rates in excess of 80%. Although esophagectomy can result in improved survival rates for early-stage cancer, it is accompanied by significant morbidity and mortality. Recently, more accurate methods of surveillance and advances in endoscopic therapies have allowed scientists and clinicians to develop treatment strategies with lower morbidity for high-grade dysplasia. Early data suggests that carefully selected patients with high-grade dysplasia can be managed safely with endoscopic therapy, with outcomes comparable to surgery, but with less morbidity. This is an especially attractive approach for patients that either cannot tolerate or decline surgical esophagectomy. For patients that are surgical candidates, high-volume centers have demonstrated improved morbidity and mortality rates for esophagectomy. The addition of laparoscopic esophagectomy adds a less invasive surgical resection to the treatment armanentarium. Esophagectomy will remain the gold-standard treatment of Barrett’s esophagus with high-grade dysplasia until clinical research validates the role of endoscopic therapies. Current treatment strategies for Barrett’s esophagus with high-grade dysplasia will be reviewed.     

Technique and role of minimally invasive esophagectomy for premalignant and malignant diseases of the esophagus

Esophagectomy remains the standard of care in most centers for patients with resectable esophageal cancer. The choice of incision and conduit has remained the subject of much discussion. Open surgical approaches include the Ivor Lewis, transhiatal, left thoracoabdominal, three-hole, and left thoracoabdominal with left neck anastomosis. These techniques will be covered in the article by. Regardless of the approach, esophagectomy has been associated with considerable morbidity and mortality. Although modern anesthetic and surgical care has reduced the risks of esophagectomy, the incidence of major or minor complications is still approximately 70% to 80%, and the hospital mortality rate is 4% to 7% at experienced centers. In the hopes of reducing perioperative morbidity, minimally invasive techniques have been increasingly applied to esophageal surgery. Experience with laparoscopic antireflux surgery has allowed us to perform more and more complex surgery on the stomach and esophagus and, in 1995, surgeons began to report their experiences with minimally invasive esophagectomy using various techniques.     

微创食管癌切除术进展

随着食管手术技术的不断发展,很多国外的肿瘤中心相继开展了旨在减少食管癌手术并发症和死亡率的食管微创手术技术。本文综述了微创食管癌手术的概念、手术方式、淋巴结清扫状况、并发症和死亡率,以及术后的生存质量的情况。目前怎样界定小创伤或微创仍然是一个非常困难的事情,也就是说食管微创手术目前还没有一个统一的标准,但是很多的资料表明食管微创外科有着很多的优势。在手术入路方面,越来越多的进行食管微创手术的医生采取了与当前开放Ivor-Lewis 手术相似的方式,并获得了与开放手术相当甚至更好的淋巴结清扫。食管微创手术的术后生存质量的评价好于开放手术。在手术的并发症与死亡率方面与目前的开放手术相同。考虑到食管微创手术目前仍处于起步阶段,随着技术的不断完善,微创手术将获得更好的效果。当今的食管外科正在向着微创、彻底清扫的方向发展,可以预见在不远的将来,食管外科必将加入微创外科行列。      

食管癌外科治疗的现状与未来展望

外科手术仍是治疗食管癌的最重要手段,近10年来国内推荐对胸段食管癌经右胸路径,并渐成共识;微创食管切除术（minimally invasive esophagectomy,MIE）安全可行,有利于减少术后并发症,完全可以与传统开胸手术媲美。应用综合治疗提高预后已见成效,术前放化疗和术前化疗成为当前主要手段。食管癌快速康复策略获得同行的高度关注与评价。食管癌外科趋向微创化、个体化、综合化和规范化的发展方向。     

Comparison of Up-Front Minimally Invasive Esophagectomy versus Open Esophagectomy on Quality of Life for Esophageal Squamous Cell Cancer

This study investigates whether minimally invasive esophagectomy (MIE) is a safe and effective way for patients with resectable esophageal cancer by comparing the short-term quality of life (QOL) after minimally invasive esophagectomy and open esophagectomy (OE). A total number of 104 patients who underwent esophagectomy from January 2013 to March 2014 were enrolled in this study. These patients were divided into two groups (MIE and OE group). Three scoring scales of quality of life were used to evaluate QOL before the operation and at the first, third, sixth and twelfth months after MIE or OE, which consist of Karnofshy performance scale (KPS), the European Organization for Research and Treatment questionnaire QLQC-30 (EORTC QLQC-30) and esophageal cancer supplement scale (OES-18). The MIE group was higher than the OE group in one-year survival rate (92.54% vs. 72.00%). Significant differences between the two groups were observed in intraoperative bleeding volume (158.53 ± 91.07 mL vs. 228.97 ± 109.33 mL, p = 0.001), and the incidence of postoperative pneumonia (33.33% vs. 58.62%, p = 0.018). The KPS of MIE group was significantly higher than the OE group at the first (80 vs. 70, p = 0.004 < 0.05), third (90 vs. 80, p = 0.006 < 0.05), sixth (90 vs. 80, p = 0.007 < 0.05) and twelfth months (90 vs. 80, p = 0.004 < 0.05) after surgery. The QLQC-30 score of MIE group was better than OE group at first and twelfth months after the operation. The OES-18 score of MIE group was significantly better than OE group at first, sixth and twelfth months after surgery. The short-term quality of life in MIE group was better than OE group.     

食管癌腔镜手术现状

传统的开放性食管癌手术创伤大、术后并发症发生率及死亡率较高.腔镜下食管癌手术具有创伤小、出血少、术后恢复快和术后并发症少等优点,越来越多地应用于临床.本文总结了国内外腔镜食管癌切除术的研究报道,分别从腔镜下食管癌手术的应用、手术方式、手术体位及优缺点等方面分析,就食管癌腔镜微创手术现状作一论述.     

Minimally invasive esophagectomy versus open esophagectomy: A systematic review and meta-analysis

The paradigm of the treatment of esophageal cancer has been changing with the increasing use of minimally invasive esophagectomy (MIE) in detriment of open esophagectomy (OE). We aimed to perform a meta-analysis to evaluate and compare these two techniques in terms of mortality and associated complications.The literature search was conducted in MEDLINE and U.S. National Library of Medicine Clinical Trials, considering eligible articles since 2015 to 2020. Clinical trials and observational studies were included. We presented results as mean differences with 95% confidence intervals and calculation of heterogeneity associated to the included studies.Thirty-one articles were included with a total of 34,465 participants diagnosed with esophageal adenocarcinoma or squamous cell carcinoma. MIE had tendency towards a decrease in 30- and 90- day mortality after surgery, but no statistically significative results were found. Major cardiovascular and respiratory complications were less frequent in the MIE group, despite high heterogeneity. Also, MIE might contribute to a decrease of minor post-operative complications, to an increase need of a second surgical intervention, to a greater risk for vocal cord lesions; but these results were not statistically significant. Additionally, no differences were found concerning risk of wound infection and for local and systemic recurrence.MIE may be more beneficial than OE, but these findings should be considered carefully.     

全腔镜与开放食管癌根治术的近期效果对比研究

目的 分析全腔镜与开放食管癌根治术在食管癌治疗中的近期效果.方法 回顾性分析接受全腔镜或开放食管癌根治术的94例食管癌患者的临床资料,根据手术方式的不同将患者分为全腔镜组和传统开放组,每组47例.比较两组患者的围手术期指标和术后指标.结果 全腔镜组患者的住院时间、术后下床时间及术后排气时间明显短于传统开放组,术中出血量明显少于传统开放组,胸部和腹部切口长度明显短于传统开放组,手术时间明显长于传统开放组,差异均有统计学意义(P﹤0.01).全腔镜组患者肺部感染的发生率低于传统开放组,差异有统计学意义(P﹤0.05).两组患者的局部复发率和远处转移率比较,差异均无统计学意义(P﹥0.05).结论 全腔镜食管癌根治术能够有效减轻手术创伤,缩短住院时间,可作为临床上食管癌外科治疗的良好术式.     

微创食管切除术

背景与目的：剖胸食管切除术常能引起严重并发症，并延长患者恢复正常活动的时间。微创手术能减少并发症，目前国内鲜有报道。本文探讨胸腔镜结合腹腔镜治疗食管疾病的可行性，并介绍手术具体操作方法。方法：自2001年11月至2005年10月，本科为20位患者行胸腔镜下食管切除术。男性16例，女性4例，48～70岁，食管中下段癌，病理学诊断为鳞状细胞癌。5例由胸腔镜结合腹腔镜，颈部切口完成。其余15例均为胸腔镜下切除食管，开腹和颈部切口完成。结果：手术时间为6～14．5小时，在ICU监护时间为1天，手术及院内死亡率为0，无并发症。结论：在有着丰富的微创手术及剖胸术的经验的医院开展胸腔镜下食管切除是安全可行的。     

Age and Charlson Comorbidity Index score are not independent risk factors for severe complications after curative esophagectomy for esophageal cancer: a Dutch population-based cohort study

BackgroundThe number of older patients undergoing curative esophagectomy for esophageal cancer is increasing, and minimally invasive techniques are being increasingly used. The aim of this study is to compare postoperative outcomes after curative esophagectomy between older and younger patients.MethodsData was retrieved from the Dutch Upper Gastrointestinal Cancer Audit (DUCA), a national surgical outcome registry. The primary outcome was severe complications, defined as complications graded Clavien-Dindo ≥ 3. The secondary outcomes were postoperative complications, reintervention rates, length of hospital stays, and mortality. Outcomes were compared between patients aged ≥75 and < 75 years. We performed additional subgroup analyses between these age groups after totally minimally invasive esophagectomy (TMIE) and in patients with severe complications. We adjusted for the following parameters: gender, BMI, Charlson Comorbidity Index score (CCI), ASA score, histology, type of neoadjuvant therapy, and surgical technique.ResultsOf all 3775 included patients, 455 (12.1%) were aged ≥75 years and 3302 (87.9%) were aged <75 years. Overall, severe complications occurred in 184 (40.4%) older and in 1140 (34.5%) younger patients (CI = 1.009–1.080). After TMIE, severe complications occurred in 150 (42.1%) older and in 891 (35.8%) younger patients (CI = 1.007–1.088). In patients with severe complications, rates of complications, reinterventions, mortality, and ICU stays were comparable between older and younger patients. After adjustment for casemix, age and CCI score were not independent risk factors for (severe) complications and mortality.ConclusionsAge and Charlson Comorbidity Index are not adequate predictors of postoperative morbidity and mortality after curative esophagectomy for esophageal cancer.     

Chemoradiation: A Superior Alternative for the Primary Management of Esophageal Carcinoma

There have been no randomized studies of esophagectomy versus chemoradiation as primary management of esophageal cancer. Review of the literature indicates esophagectomy alone has limited applicability, significant morbidity, higher mortality, and a lesser chance for cure than chemoradiation for patients with squamous cell cancer of the esophagus. The majority of patients with esophageal cancer have disease extending through the esophageal wall or nodal involvement and the prognosis for such patients treated by esophagectomy alone is quite poor, with 5-year survival rate of 10% or less. Recent studies indicate 5-year survival rates with chemoradiation is 20% to 25%. Local failure rates are similar with chemoradiation versus esophagectomy, but swallowing function is superior with chemoradiation. Salvage surgery is possible following chemoradiation for the small percentage of patients who have local-only failure. Chemoradiation is preferred to esophagectomy for patients with squamous cell cancer of the esophagus, and offers significant palliation and the chance for cure for patients with adenocarcinoma of the esophagus as well.     

Surgical outcomes after totally minimally invasive Ivor Lewis esophagectomy. A systematic review and meta-analysis

BackgroundA transthoracic esophagectomy is associated with high rates of morbidity. Minimally invasive esophagectomy has emerged to decrease such morbidity. The aim of this study was to accurately determine surgical outcomes after totally minimally invasive Ivor-Lewis Esophagectomy (TMIE).MethodsA systematic literature search was performed to identify original articles analyzing patients who underwent TMIE. Main outcomes included overall morbidity, major morbidity, pneumonia, arrhythmia, anastomotic leak, chyle leak, and mortality. A meta-analysis was conducted to estimate the overall weighted proportion and its 95% confidence interval (CI) for each analyzed outcome.ResultsA total of 5619 patients were included for analysis; 4781 (85.1%) underwent a laparoscopic/thoracoscopic esophagectomy and 838 (14.9%) a robotic-assisted esophagectomy. Mean age of patients was 63.5 (55–67) years and 75.8% were male. Overall morbidity and major morbidity rates were 39% (95% CI, 33%–45%) and 20% (95% CI, 13%–28%), respectively. Postoperative pneumonia and arrhythmia rates were 10% (95% CI, 8%–13%) and 12% (95% CI, 8%–17%), respectively. Anastomotic leak rate across studies was 8% (95% CI, 6%–10%). Chyle leak rate was 3% (95% CI, 2%–5%). Mortality rate was 2% (95% CI, 2%–2%). Median ICU stay and length of hospital stay were 2 (1–4) and 11.2 (7–20) days, respectively.ConclusionsTotally minimally invasive Ivor-Lewis esophagectomy is a challenging procedure with high morbidity rates. Strategies to enhance postoperative outcomes after this operation are still needed.     

Local recurrence after total or subtotal esophagectomy for esophageal cancer

Cancer recurrence is a common problem after esophagectomy for esophageal cancer. Local recurrence is especially problematic because it often negates the palliative benefit of esophagectomy. We conducted a retrospective review to assess the effect of extent of esophageal resection (subtotal or total esophagectomy) on local cancer recurrence. Seventy-four consecutive patients with esophageal cancer underwent esophagectomy at our institution over a four-year period. Their charts were reviewed retrospectively and data was collected on age, gender, histology, stage, tumor location, operation, resection margin status, anastomotic leaks, operative mortality, adjuvant therapy, cancer survival, and local recurrence. Total esophagectomy was done in 19 patients (transhiatal - 3; McKeown - 16) and subtotal esophagectomy was done in the other 55 patients (Lewis - 25; left thoracoabdominal - 30). The two groups were similar with respect to age, gender, histology, stage, anastomotic leaks, operative mortality, adjuvant therapy, and overall survival. Resection margins were positive for residual tumor in 2 out of 19 (11%) total esophagectomies and 9 out of 55 (16%) subtotal esophagectomies (p=0.42). Local recurrence occurred in 3 of 19 (16%) patients treated with total esophagectomy and 23 out of 55 (42%) patients treated with subtotal esophagectomy (p=0.04). We conclude that total esophagectomy is associated with fewer local cancer recurrences than subtotal esophagectomy. We, therefore, recommend total esophagectomy for the surgical treatment of esophageal cancer.     

Dissection of lymph node metastases in esophageal cancer

There has been much recent debate regarding the best surgical procedure to treat esophageal cancer, in particular with regard to the optimum extent of lymphadenectomy to improve survival while minimizing morbidity. No results obtained by prospective, randomized studies on the comparison of radical esophagectomy and extended lymphadenectomy with limited or less invasive resections following neoadjuvant therapy with regard to perioperative morbidity and prognosis are available to date. Until now, there has been no evidence suggesting the usefulness of sentinel lymph node navigation in esophageal cancers, regardless of the cell type. Furthermore, the question as to the benefits and risks of two-field and three-field lymphadenectomy in esophageal cancer has not yet been conclusively answered. This article will discuss the recent status of lymph node-dissection procedures stage-dependently according to the two different tumor entities and with regard to minimally invasive esophagectomy, including the novel 2010 Tumor, Node, Metastasis-staging system.     

Robot-assisted and conventional minimally invasive esophagectomy are associated with better postoperative results compared to hybrid and open transthoracic esophagectomy

BackgroundCurrently 4 surgical techniques are performed for transthoracic esophagectomy (open esophagectomy (OE), hybrid esophagectomy (HE), conventional minimally invasive esophagectomy (MIE) and robot assisted minimally invasive esophagectomy (RAMIE). Aim of this study was to compare these 4 different esophagectomy approaches regarding postoperative complications and short term oncologic outcomes.MethodsBetween 2008 and 2019, consecutive patients who underwent esophagectomy with gastric conduit reconstruction were included in this single center study. The primary outcome of this study was the incidence of postoperative complications.ResultsOverall 422 patients (OE (n = 107), HE (n = 101), MIE (n = 91) and RAMIE (n = 123)) were evaluated. Uncomplicated postoperative course was observed in 27% (OE), 34% (HE), 53% (MIE), and 63% (RAMIE) of patients (p < 0.001). Pulmonary complications were observed in 57% (OE), 44% (HE), 28% (MIE), and 21% (RAMIE) of patients (p < 0.001). Cardiac complications were present in 25% (OE), 23% (HE), 9% (MIE), and 11% (RAMIE) of patients (p < 0.001). MIE and RAMIE were associated with fewer wound infections (p < 0.001). Median hospital stay after MIE (13 days) and RAMIE (12 days) was shorter compared to OE (20 days) and HE (17 days) (p < 0.001). A median number of 21 (OE), 23 (HE), 23 (MIE), and 31 (RAMIE) lymph nodes was harvested (p < 0.001).ConclusionTotal minimally invasive esophagectomy (MIE, RAMIE) was associated with a lower overall, pulmonary, cardiac and wound complication rate as well as a shorter hospital stay compared to open or hybrid approach (OE, HE). RAMIE resulted in higher lymph node harvest than MIE.     

Sex differences in the prognosis after surgery for esophageal squamous cell carcinoma and adenocarcinoma

Some investigations suggest a better prognosis in women compared to men with esophageal cancer but these differences are uncertain. The aim of our study was to clarify whether sex influences the prognosis after esophagectomy for esophageal squamous cell carcinoma and esophageal adenocarcinoma. A population-based and nationwide cohort study included almost all patients who underwent esophagectomy for esophageal cancer in Sweden in 1987–2010, with follow-up until 2016. Patients’ sex was analyzed in relation to risk of mortality. Multivariable Cox regression provided hazard ratios (HR) with 95% confidence intervals (CI), adjusted for calendar period, age, education, comorbidity, tumor stage, neoadjuvant therapy, and surgeon volume. Among 1,816 participants, 1,024 (56%) had esophageal squamous cell carcinoma (355 [35%] women), and 792 (44%) had esophageal adenocarcinoma (103 [13%] women). Compared to men, women had a decreased overall all-cause mortality in esophageal squamous cell carcinoma (HR = 0.73, 95% CI 0.63–0.85). Stratified analyses showed decreased mortality limited to women aged >55 years (HR = 0.71, 95% CI 0.61–0.83), but in all tumor stages, particularly stages 0-I (HR = 0.54, 95% CI 0.37–0.79). Women also had decreased 90-day all-cause mortality, 5-year all-cause mortality, and 5-year disease-specific mortality in esophageal squamous cell carcinoma compared to men. For esophageal adenocarcinoma, no sex differences were found for any of the mortality outcomes. Thus, women who undergo esophagectomy for esophageal squamous cell carcinoma seem to have better prognosis than men, especially those with early tumor stages, whereas no sex differences in prognosis were found for esophageal adenocarcinoma.