UPDATE 1-Minimally invasive esophagectomy may be better than open surgery

Last Updated: 2015-01-12

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By Lorraine L Janeczko

NEW YORK (Reuters Health) - Patients with esophagus and gastroesophageal junction cancers who have minimally invasive esophagectomy may live longer than those who have open or hybrid esophagectomy (OHE), according to new research.

"Minimally invasive esophagectomy (MIE) is increasingly used for the treatment of patients with cancer of the esophagus and gastroesophageal junction (EC). . . . This study supports MIE for EC as a superior procedure with respect to overall survival, perioperative mortality, and severity of postoperative complications," the study authors wrote online December 26 in Journal of the American College of Surgeons.

Dr. Francesco Palazzo of Thomas Jefferson University in Philadelphia and colleagues looked at their prospective database of patients who underwent esophagectomy for cancer over about 4.5 years.

All patients had adenocarcinoma or squamous cell carcinoma of the esophagus, gastroesophageal junction or gastric cardia. Patients diagnosed with high-grade dysplasia were excluded.

In the MIE (n=104) and OHE (n=68) groups, the average age was around 60, and most patients were male. The MIE group tended to have higher body mass index and earlier stage disease, and was less likely to receive neoadjuvant chemoradiotherapy (CRT). The MIE group also had lower operative mortality (3.9% vs 8.8%) and fewer major complications.

Patients in the MIE group underwent either a three-field thoracoscopy/laparoscopy/cervical McKeown esophagectomy or a laparoscopy/thoracoscopy Ivor Lewis esophagectomy.

The 13 participants who had the thoracic or abdominal components completed through an open approach, with the other completed through a minimally invasive approach, were considered as having a hybrid esophagectomy.

Patients who had laparoscopic or open transhiatal esophagectomies were excluded from the study.

The authors also reviewed the records of 55 patients who underwent an exclusively open approach (39 3-hole patients and 16 Ivor Lewis patients) who met these criteria and they compared data for this group as well. They jointly analyzed open and hybrid procedures and compared their outcomes with those of the MIE patients.

The authors used Kaplan-Meier statistics to compare survival and Cox regression to evaluate the impact of surgery type on mortality, adjusting for age, gender, total lymph nodes, lymph node ratio, CRT, and pathological stage.

The five-year survival between the groups differed significantly (MIE 64% vs OE 35%, p<0.001), and multivariate analysis showed that patients undergoing OHE had significantly worse survival than those having MIE, independent of age, lymph node ratio, CRT, and stage (hazard ratio=2.00, p=0.019).

"Several biases may have affected these results: earlier stage in the MIE group and disparity in timing of the procedures," the authors acknowledged. "These results will need to be confirmed in future prospective studies with longer follow-up."

While these results confirm the safety of the perioperative and postoperative outcomes of MIE and add to the knowledge of the oncologic efficacy of MIE, the authors wrote, they expect to learn more from the expected follow-up to the recent trials.

"In our opinion, all patients should be considered candidates for MIE today and only patients with true contraindications, such as extensive prior surgery, should be offered an open approach. Prior neoadjuvant therapy is not a contraindication to MIE," Dr. Palazzo told Reuters Health by email.

"This study is very relevant as there is not significant literature or level-1 data available on whether MIE affects the survival of patients with esophageal cancer, and if so, to what degree," he added. "While our study is a retrospective review and not a randomized clinical trial, it still provides very valuable data on survival advantage after MIE."

The authors reported no disclosures.

Source: http://bit.ly/14LM6bQ

J Am Coll Surgeons 2014.