Minimally invasive approach results in better outcome compared to open esophagectomy - A Propensity Score Matched Analysis

Abstract

Background Esophagectomy remains the mainstay treatment for esophageal cancer. Minimally invasive techniques have gained popularity in recent years. Whether minimally invasive methods result in equivalent or superior outcome to open esophagectomy or not is still controversial. The aim of the current study is to compare outcomes of minimally invasive and open esophagectomy from a single institution, using propensity score matching to lessen biases. Methods From 1994–2016, 724 patients with squamous cell cancer of the esophagus who underwent esophagectomy were studied. Data were retrieved from a prospectively collected database. Patients were divided into two groups: 453 had open esophagectomy (open group), and 271 had VATS esophagectomy with gastric mobilization either via laparotomy or laparoscopically (MIE group). A propensity score was generated for each patient based on age, gender, tumor level, use of neoadjuvant therapy, American Society of Anaesthesiologists (ASA) score, pathologic stage of disease, site of anastomosis, and residual tumour (R) categories and the two matched groups were compared in clinico-pathological features, morbidity and mortality rates, and long-term survival. All statistical calculations were performed with SPSS version 24 (SPSS, Chicago, IL). Results A total of 158 patients in MIE and 187 in open group are matched for comparison (1:3 matching). MIE resulted in less blood loss (220 vs 400ml, P < 0.001) but longer operative time (461 vs 305 mins, P < 0.001). Wound infection (3.7% vs 10.7%, P = 0.01) and respiratory complications (29% vs 55.1%, P < 0.001) were also less in MIE group. Except for a higher rate of conduit ischemia (6.3% vs 1.6%, P = 0.02), MIE had comparable surgical outcomes with open technique in rates of anastomotic leakage (5.7% vs 5.3%, P = 0.89), recurrent laryngeal nerve palsy (20.1% vs 18.7%, P = 0.10), reoperation (10.8% vs 8.6%, P = 0.49), and length of postoperative hospital stay (13 vs 14 days, P = 0.50). Lymph node harvest was significantly higher with MIE (35 vs 21, P < 0.001), a longer median survival was also evident compared to the open group (42.3 vs 24.7 months, P = 0.03). Conclusion Although requiring longer operative time, MIE led to less wound and respiratory complications without jeopardizing surgical and oncological outcome. The more comprehensive lymphadenectomy could potentially improve prognosis. Disclosure All authors have declared no conflicts of interest.