Minimally invasive oesophagectomy versus open surgery: is there an advantage?

Safety, efficacy, and cost-effectiveness of minimally invasive esophagectomies versus open esophagectomies: an umbrella review

Traditionally, esophageal oncological resections have been performed via open approaches with well-documented levels of morbidity and mortality complicating the postoperative course. In contemporary terms, minimally invasive approaches have garnered sustained support in all areas of surgery, and there has been an exponential adaptation of this technology in upper GI surgery with the advent of laparoscopic and robotic techniques. The current literature, while growing, is inconsistent in reporting on the benefits of minimally invasive esophagectomies (MIEs) and this makes it difficult to ascertain best practice. The objective of this review was to critically appraise the current evidence addressing the safety, efficacy, and cost-effectiveness of MIEs versus open esophagectomies. A systematic review of the literature was performed by searching nine electronic databases to identify any systematic reviews published on this topic and recommended Joanna Briggs Institute approach to critical appraisal, study selection, data extraction and data synthesis was used to report the findings. A total of 13 systematic reviews of moderate to good quality encompassing 143 primary trials and 36,763 patients were included in the final synthesis. Eleven reviews examined safety parameters and found a generalized benefit of MIE. Efficacy was evaluated by eight systematic reviews and found each method to be equivalent. There were limited data to judiciously appraise cost-effectiveness as this was only evaluated in one review involving a single trial. There is improved safety and equivalent efficacy associated with MIE when compared with open esophagectomy. Cost-effectiveness of MIE cannot be sufficiently supported at this point in time. Further studies, especially those focused on cost-effectiveness are needed to strengthen the existing evidence to inform policy makers on feasibility of increased assimilation of this technology into clinical practice.

Is there a relationship between two different anesthetic methods and postoperative length of stay during radical resection of malignant esophageal tumors in China?: a retrospective cohort study

BACKGROUND

Data providing a relationship between the anesthetic method and postoperative length of stay (PLOS) is limited. We aimed to investigate whether general anesthesia alone or combined with epidural anesthesia might affect perioperative risk factors and PLOS for patients undergoing radical resection of malignant esophageal tumors.

METHODS

The study retrospectively analyzed the clinical data of 680 patients who underwent a radical esophageal malignant tumor resection in a Chinese hospital from January 01, 2010, to December 31, 2020. The primary outcome measure was PLOS, and the secondary outcome was perioperative risk-related parameters that affect PLOS. The independent variable was the type of anesthesia: general anesthesia (GA) or combined epidural-general anesthesia (E-GA). The dependent variable was PLOS. We conducted univariate and multivariate logistic regression and propensity score matching to compare the relationships of GA and E-GA with PLOS and identify the perioperative risk factors for PLOS. In this cohort study, the confounders included sociodemographic data, preoperative chemotherapy, coexisting diseases, laboratory parameters, intraoperative variables, and postoperative complications.

RESULTS

In all patients, the average PLOS was 19.85 ± 12.60 days. There was no significant difference in PLOS between the GA group and the E-GA group either before or after propensity score matching (20.01 days ± 14.90 days vs. 19.79 days ± 11.57 days, P = 0.094, 18.09 ± 9.71 days vs. 19.39 ± 10.75 days, P = 0.145). The significant risk factors for increased PLOS were lung infection (β = 3.35, 95% confidence interval (CI): 1.54-5.52), anastomotic leakage (β = 25.73, 95% CI: 22.11-29.34), and surgical site infection (β = 9.39, 95% CI: 4.10-14.68) by multivariate regression analysis. Subgroup analysis revealed a stronger association between PLOS and vasoactive drug use, blood transfusions, and open esophagectomy. The results remained essentially the same (stable and reliable) after subgroup analysis.

CONCLUSIONS

Although there is no significant association between the type of anesthesia(GA or E-GA) and PLOS for patients undergoing radical esophageal malignant tumor resection, an association between PLOS and lung infection, anastomotic leakage, and surgical site infection was determined by multivariate regression analysis. A larger sample future study design may verify our results.

Margin Positivity in Resectable Esophageal Cancer: Are there Modifiable Risk Factors?

BACKGROUND

Patients with esophageal cancer have poor overall survival, with positive resection margins worsening survival. Margin positivity rates are used as quality measures in other malignancies, but modifiable risk factors are necessary to develop actionable targets for improvement. Our objectives were to (1) evaluate trends in esophageal cancer margin positivity, and (2) identify modifiable patient/hospital factors associated with margin positivity.

METHODS

Patients who underwent esophagectomy from 2004 to 2015 were identified from the National Cancer Database. Trends in margin positivity by time and hospital volume were evaluated using Cochrane-Armitage tests. Associations between patient/hospital factors and margin positivity were assessed by multivariable logistic regression.

RESULTS

Among 29,706 patients who underwent esophagectomy for cancer, 9.37% had positive margins. Margin positivity rates decreased over time (10.62% in 2004 to 8.61% in 2015; p < 0.001). Older patients (≥ 75 years) were more likely to have positive margins [odds ratio (OR) 2.04, 95% confidence interval (CI) 1.42-2.92], as were patients with a Charlson-Deyo Index ≥ 3 (OR 1.84, 95% CI 1.08-3.12). Patients who received neoadjuvant therapy were less likely to have positive margins (OR 0.37, 95% CI 0.29-0.47), while laparoscopic surgical approach was associated with increased margin positivity (OR 1.70, 95% CI 1.40-2.06). As the hospital annual esophagectomy volume increased, margin positivity rates decreased (7.76% in the fourth quartile vs. 11.39% in the first quartile; OR 0.70, 95% CI 0.49-0.99).

CONCLUSIONS

Use of neoadjuvant therapy, surgical approach, and hospital volume are modifiable risk factors for margin positivity in esophageal cancer. These factors should be considered in treatment planning, and margin positivity rates could be considered as a quality measure in esophageal cancer.

An Augmented Reality Endoscope System for Ureter Position Detection

Iatrogenic injury of ureter in the clinical operation may cause the serious complication and kidney damage. To avoid such a medical accident, it is necessary to provide the ureter position information to the doctor. For the detection of ureter position, an ureter position detection and display system with the augmented ris proposed to detect the ureter that is covered by human tissue. There are two key issues which should be considered in this new system. One is how to detect the covered ureter that cannot be captured by the electronic endoscope and the other is how to display the ureter position that provides stable and high-quality images. Simultaneously, any delayed processing of the system should disturb the surgery. The aided hardware detection method and target detection algorithms are proposed in this system. To mark the ureter position, a surface-lighting plastic optical fiber (POF) with the encoded light-emitting diode (LED) light is used to indicate the ureter position. The monochrome channel filtering algorithm (MCFA) is proposed to locate the ureter region more precisely. The ureter position is extracted using the proposed automatic region growing algorithm (ARGA) that utilizes the statistical information of the monochrome channel for the selection of growing seed point. In addition, according to the pulse signal of encoded light, the recognition of bright and dark frames based on the aided hardware (BDAH) is proposed to expedite the processing speed. Experimental results demonstrate that the proposed endoscope system can identify 92.04% ureter region in average.

Minimally invasive oesophagectomy versus open esophagectomy for resectable esophageal cancer: a meta-analysis

Background

Open esophagectomy (OE) is associated with significant morbidity and mortality. Minimally invasive oesophagectomy (MIO) reduces complications in resectable esophageal cancer. The aim of this study is to explore the superiority of MIO in reducing complications and in-hospital mortality than OE.

Methods

MEDLINE, Embase, Science Citation Index, Wanfang, and Wiley Online Library were thoroughly searched. Odds ratio (OR)/weighted mean difference (WMD) with a 95% confidence interval (CI) was used to assess the strength of association.

Results

Fifty-seven studies containing 15,790 cases of resectable esophageal cancer were included. MIO had less intraoperative blood loss, short hospital stay, and high operative time (P < 0.05) than OE. MIO also had reduced incidence of total complications; (OR = 0.700, 95% CI = 0.626 ~ 0.781, P_V < 0.05), pulmonary complications (OR = 0.527, 95% CI = 0431 ~ 0.645, P_V < 0.05), cardiovascular complications (OR = 0.770, 95% CI = 0.681 ~ 0.872, P_V < 0.05), and surgical technology related (STR) complications (OR = 0.639, 95% CI = 0.522 ~ 0.781, P_V < 0.05), as well as lower in-hospital mortality (OR = 0.668, 95% CI = 0.539 ~ 0.827, P_V < 0.05). However, the number of harvested lymph nodes, intensive care unit (ICU) stay, gastrointestinal complications, anastomotic leak (AL), and recurrent laryngeal nerve palsy (RLNP) had no significant difference.

Conclusions

MIO is superior to OE in terms of perioperative complications and in-hospital mortality.

Esophageal surgery in minimally invasive era

The widespread popularity of new surgical technologies such as laparoscopy, thoracoscopy and robotics has led many surgeons to treat esophageal diseases with these methods. The expected benefits of minimally invasive surgery (MIS) mainly include reductions of postoperative complications, length of hospital stay, and pain and better cosmetic results. All of these benefits could potentially be of great interest when dealing with the esophagus due to the potentially severe complications that can occur after conventional surgery. Moreover, robotic platforms are expected to reduce many of the difficulties encountered during advanced laparoscopic and thoracoscopic procedures such as anastomotic reconstructions, accurate lymphadenectomies, and vascular sutures. Almost all esophageal diseases are approachable in a minimally invasive way, including diverticula, gastro-esophageal reflux disease, achalasia, perforations and cancer. Nevertheless, while the limits of MIS for benign esophageal diseases are mainly technical issues and costs, oncologic outcomes remain the cornerstone of any procedure to cure malignancies, for which the long-term results are critical. Furthermore, many of the minimally invasive esophageal operations should be compared to pharmacologic interventions and advanced pure endoscopic procedures; such a comparison requires a difficult literature analysis and leads to some confounding results of clinical trials. This review aims to examine the evidence for the use of MIS in both malignancies and more common benign disease of the esophagus, with a particular emphasis on future developments and ongoing areas of research.

Superiority of Minimally Invasive Oesophagectomy in Reducing In-Hospital Mortality of Patients with Resectable Oesophageal Cancer: A Meta-Analysis

Background

Compared with open oesophagectomy (OE), minimally invasive oesophagectomy (MIO) proves to have benefits in reducing the risk of pulmonary complications for patients with resectable oesophageal cancer. However, it is unknown whether MIO has superiority in reducing the occurrence of in-hospital mortality (IHM).

Objective

The objective of this meta-analysis was to explore the effect of MIO vs. OE on the occurrence of in-hospital mortality (IHM).

Data Sources

Sources such as Medline (through December 31, 2014), Embase (through December 31, 2014), Wiley Online Library (through December 31, 2014), and the Cochrane Library (through December 31, 2014) were searched.

Study Selection

Data of randomized and non-randomized clinical trials related to MIO versus OE were included.

Interventions

Eligible studies were those that reported patients who underwent MIO procedure. The control group included patients undergoing conventional OE.

Study Appraisal and Synthesis Methods

Fixed or random -effects models were used to calculate summary odds ratios (ORs) or relative risks (RRs) for quantification of associations. Heterogeneity among studies was evaluated by using Cochran’s Q and I² statistics.

Results

A total of 48 studies involving 14,311 cases of resectable oesophageal cancer were included in the meta-analysis. Compared to patients undergoing OE, patients undergoing MIO had statistically reduced occurrence of IHM (OR=0.69, 95%CI =0.55 -0.86). Patients undergoing MIO also had significantly reduced incidence of pulmonary complications (PCs) (RR=0.73, 95%CI = 0.63-0.86), pulmonary embolism (PE) (OR=0.71, 95%CI= 0.51-0.99) and arrhythmia (OR=0.79, 95%CI = 0.68-0.92). Non-significant reductions were observed among the included studies in the occurrence of anastomotic leak (AL) (OR=0.93, 95%CI =0.78-1.11), or Gastric Tip Necrosis (GTN) (OR=0.89, 95%CI =0.54-1.49).

Limitation

Most of the included studies were non-randomized case-control studies, with a diversity of study designs, demographics of participants and surgical intervention.

Conclusions

Minimally invasive oesophagectomy (MIO) has superiority over open oesophagectomy (OE) in terms of the occurrence of in-hospital mortality (IHM) and should be the first-choice surgical procedure in esophageal surgery.

[Mini-invasive technologies in complex treatment of esophagus cancer]

It was evaluated mini-invasive endovideosurgical technologies using in complex treatment of esophagus cancer. The investigation included 28 patients with thoracic esophagus cancer. Age of patients operated in terms from April 2012 to December 2013 was from 42 to 74 years (mean 61.7 ± 8.7 years). Only surgical treatment was used in 10 patients. Neoadjuvant chemotherapy and radiotherapy were performed in 18 patients. Hybrid mini-invasive esophagectomy (laparoscopic stomach mobilization and right-side thoracotomy) were used in 14 cases. The frequency of postoperative complications was 35.5%. Mini-invasive endovideosurgical esophagectomy was done in 14 patients. The frequency of postoperative complications was 57.1%. There were not deaths. Our experience demonstrates good results of mini-invasive technologies using in treatment of patients with esophagus cancer. Endovideosurgical methods permit to perform adequate volume of surgery in case of oncological diseases.

The epidemiology, diagnosis, and treatment of Barrett's carcinoma

BACKGROUND

Roughly 3000 new cases of Barrett's carcinoma arise in Germany each year. In view of recent advances in the epidemiology, diagnosis, and treatment of this disease, an update of the clinical recommendations is in order.

METHODS

This review is based on selected relevant publications, including current reviews, meta-analyses, and guidelines.

RESULTS

The risk of progression of Barrett's esophagus to carcinoma lies between 0.10% and 0.15% per year. Risk factors for progression include male sex, age over 50 years, obesity, longstanding and frequent reflux symptoms, smoking, length of the Barrett's esophagus, and intraepithelial neoplasia. Well-differentiated carcinomas that are confined to the esophageal mucosa can be resected endoscopically with a cure rate above 90%. For more advanced, but still locally confined tumors, surgical resection is the treatment of choice. In stages cT3/4, the prognosis can be improved with neo-adjuvant chemo - therapy or combined radiotherapy and chemotherapy. Metastatic Barrett's carcinoma can be treated by endoscopic, chemotherapeutic, radiotherapeutic, and palliative methods.

CONCLUSION

Early carcinoma can often be cured by endoscopic resection. Locally advanced carcinoma calls for multimodal treatment. Current research focuses on means of preventing the progression of Barrett's esophagus, the scope of applicability of endoscopic techniques, and the optimization of multimodal treatment strategies for advanced disease.

The feasibility of a randomized controlled trial of esophagectomy for esophageal cancer--the ROMIO (Randomized Oesophagectomy: Minimally Invasive or Open) study: protocol for a randomized controlled trial

BACKGROUND

There is a need for evidence of the clinical effectiveness of minimally invasive surgery for the treatment of esophageal cancer, but randomized controlled trials in surgery are often difficult to conduct. The ROMIO (Randomized Open or Minimally Invasive Oesophagectomy) study will establish the feasibility of a main trial which will examine the clinical and cost-effectiveness of minimally invasive and open surgical procedures for the treatment of esophageal cancer.

METHODS/DESIGN

A pilot randomized controlled trial (RCT), in two centers (University Hospitals Bristol NHS Foundation Trust and Plymouth Hospitals NHS Trust) will examine numbers of incident and eligible patients who consent to participate in the ROMIO study. Interventions will include esophagectomy by: (1) open gastric mobilization and right thoracotomy, (2) laparoscopic gastric mobilization and right thoracotomy, and (3) totally minimally invasive surgery (in the Bristol center only). The primary outcomes of the feasibility study will be measures of recruitment, successful development of methods to monitor quality of surgery and fidelity to a surgical protocol, and development of a core outcome set to evaluate esophageal cancer surgery. The study will test patient-reported outcomes measures to assess recovery, methods to blind participants, assessments of surgical morbidity, and methods to capture cost and resource use. ROMIO will integrate methods to monitor and improve recruitment using audio recordings of consultations between recruiting surgeons, nurses, and patients to provide feedback for recruiting staff.

DISCUSSION

The ROMIO study aims to establish efficient methods to undertake a main trial of minimally invasive surgery versus open surgery for esophageal cancer.

TRIAL REGISTRATION

The pilot trial has Current Controlled Trials registration number ISRCTN59036820(25/02/2013) at http://www.controlled-trials.com; the ROMIO trial record at that site gives a link to the original version of the study protocol.

Role of endoscopic stents and selective minimal access drainage in oesophageal leaks: feasibility and outcome

BACKGROUND

Leaks following oesophageal surgery are considered to be amongst the most dreaded complications and contributory to postoperative mortality. Controversies still exist regarding the best option for the management of oesophageal leaks due to lack of standardized treatment protocols. This study was designed to analyse the feasibility outcome and complications associated with placement of removable, fully covered, self-expanding metallic stents for oesophageal leaks with concomitant minimally invasive drainage when appropriate.

METHODS

The study group included 32 patients from a prospectively maintained database of oesophageal leaks, with the majority being anastomotic leaks after minimally invasive oesophagectomy (n = 28), followed by laparoscopic cardiomyotomy (n = 3) and extended total gastrectomy (n = 1). The procedures took place between March 2007 and April 2013.

RESULTS

Most patients had an intrathoracic leak (n = 22), with a mean time to detection of the leak following surgery of 7.50 days (SD = 2.23). Subsequent to endoscopic stenting, enteral feeding via a nasojejunal tube was started on the second day and oral feeding was delayed until the 14th day (n = 31). Six patients underwent thoracoscopic (n = 5) or laparoscopic drainage (n = 1) along with stenting for significant mediastinal and intra-abdominal contamination. The stent migration rate of our study was 8.54%. The overall success in terms of preventing mortality was 96%.

CONCLUSION

Endoscopic stenting should be considered a primary option for managing oesophageal leaks. Delayed oral intake may reduce the incidence of stent migration. Larger stents (bariatric or colorectal stents) serve as a useful option in case of migrated stents. Combined minimally invasive procedures can be safely adapted in appropriate clinical circumstances and may contribute to better outcomes.

Impact of comorbidity on outcomes and overall survival after open and minimally invasive esophagectomy for locally advanced esophageal cancer

Background

The aim of this study was to examine the impact of the Charlson Comorbidity Index-Grade (CCI-G) on predicting outcomes and overall survival after open and minimally invasive esophagectomy (MIE).

Methods

One hundred and forty-six patients who underwent esophagectomy between 1995 and 2011 for stage II and III cancer were selected and separated into open esophagectomy (Open) and MIE groups. Risk adjustment was performed using the CCI-G. The outcomes of interest were operative time, estimated blood loss (EBL), lymph node harvest, length of hospital stay (LOS), major complications, 30-day mortality, and overall survival.

Results

Sixty-four patients (44 %) underwent Open while 71 (49 %) had MIE. An additional (7 %) were converted and classified with MIE. There was no significant difference between MIE and Open in terms of operative time. MIE had less EBL (mean difference = 234 mL, p < 0.001), higher lymph node harvest (mean = 7.4 nodes, p < 0.001), and shorter LOS (median = 1.5 days, p = 0.02). Atrial arrhythmias were the most frequent complication, occurring in 33 % of patients in both the MIE and the Open group (p = 0.988). Thirty-day mortality was 2 % for MIE and 5 % for Open (p = 0.459). Five-year survival was 41 % for MIE and 33 % for Open (p = 0.513). Operative approach, age, gender, BMI, clinical stage, and neoadjuvant therapy did not have any significant effect on the outcomes or overall survival. CCI-G influenced outcomes with operative time, LOS, cardiovascular complication, and anastomotic leak rate, favoring CCI-G 0 compared to CCI-G 3. Overall survival was worse for CCI-G 1 in comparison with CCI-G 0 [hazard ratio (HR) 1.99, p = 0.027].

Conclusions

MIE is a safe alternative to open esophagectomy for the treatment of locally advanced esophageal cancer. The presence of comorbidities increased operative time, length of hospital stay, and postoperative complications while worsening overall survival.

Influence of laparoscopic carbon dioxide pneumoperitoneum on neonate circulation and respiration

Objective

This study investigated the influence of laparoscopic carbon dioxide (CO2) pneumoperitoneum on neonate circulation and respiration.

Methods

The study included neonates undergoing elective laparoscopic abdominal surgery. CO2 insufflation pressure was maintained within 8–14 mmHg for pneumoperitoneum creation. Heart rate (HR), mean arterial pressure (MAP), peripheral oxygen saturation (SpO2), partial pressure of end-tidal carbon dioxide ( PETCO2) and maximum inspiratory pressure were monitored continuously. Arterial blood samples were collected: 5 min before pneumoperitoneum creation (baseline); 5, 10, and 20 min after CO2 insufflation; 10 min after CO2 exsufflation; 10 min after surgery. pH, partial pressure of CO2 (PaCO2) and arterial oxygen saturation (SaO2) were also measured.

Results

Thirty-six neonates were included. HR and MAP significantly increased after pneumoperitoneum creation, then decreased to baseline after CO2 exsufflation. PaCO2 and PETCO2 were significantly higher after pneumoperitoneum creation, whereas pH was significantly lower 20 min after pneumoperitoneum creation compared with baseline. No significant differences were observed in SpO2 and SaO2.

Conclusion

CO2 pneumoperitoneum had a significant effect on neonatal circulation and respiration, suggesting that the pneumoperitoneal pressure should be limited within a certain range in neonates undergoing laparoscopic surgery.