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

Experiences in reverse sequence esophagectomy: a promising alternative for esophageal cancer surgery

OBJECTIVES

McKeown esophagectomy is a standard and significant component of multimodality therapy in esophageal cancer, however, experience in switching the resection and reconstruction sequence in esophageal cancer surgery is not available. Here, we have retrospectively reviewed the experience of reverse sequencing procedure at our institute.

METHODS

We retrospectively reviewed 192 patients who had undergone minimally invasive esophagectomy (MIE) with McKeown esophagectomy between August 2008 and Dec 2015. The patient's demographics and relevant variables were evaluated. The overall survival (OS) and disease-free survival (DFS) were analyzed.

RESULTS

Among the 192 patients, 119 (61.98%) received the reverse sequence MIE (the reverse group) and 73 patients (38.02%) received the standard operation (the standard group). Both patient groups had similar demographics. There were no inter-group differences existed in blood loss, hospital stay, conversion rate, resection margin status, operative complication, and mortality. The reverse group had shorter total operation time (469.83 ± 75.03 vs 523.63 ± 71.93, p < 0.001) and thoracic operation time (181.22 ± 42.79 vs 230.41 ± 51.93, p < 0.001). The 5-year OS and DFS for both groups were similar (44.77% and 40.53% in the reverse group vs 32.66% and 29.42% in the standard group, p = 0.252 and 0.261, respectively). Similar results were observed even after propensity matching.

CONCLUSIONS

The reverse sequence procedure had shorter operation times, especially in the thoracic phase. The reverse sequence MIE is a safe and useful procedure when postoperative morbidity, mortality, and oncological outcomes are considered.

Evolution of a minimally invasive oesophagectomy program - effective complication management is key

Introduction

Despite improvements in patient selection, operative technique, and postoperative care, oesophagectomy remains one of the most morbid oncologic resection types. Introduction of minimally invasive practice has been shown to have a greater marginal benefit for oesophagectomy than most of the other types of procedures.

Aim

To evaluate early surgical outcomes through the adoption of totally minimally invasive oesophagectomy and accumulating experience in perioperative management.

Material and methods

All patients with mid and distal oesophageal carcinoma who underwent oesophagectomy and gastric conduit construction between June 2004 and December 2021 were recorded prospectively. Demographic information, neoadjuvant treatment, operative data, and perioperative mortality/morbidity were evaluated. Patients were classified depending on the timeline and predominant surgical approach: Group 1 (2004-2011, open surgery), Group 2 (2011-2015, adoption period of minimally invasive surgery), and Group 3 (2015-2021, routine minimally invasive surgery).

Results

In total, 167 patients were identified (Group 1, n = 48; Group 2, n = 44; Group 3, n = 75). Group 3 was significantly older (59.5 ±11.6 vs. 54.1 ±10.6 years and 56.2 ±10.8 years; p = 0.031).The likelihood of successful completion of a totally minimally invasive esophagectomy was increased as well as the preference for intrathoracic anastomosis (p < 0.0001 for both). The major morbidity rate was stable across the groups, but 90-day mortality significantly decreased for the most recent cohort.

Conclusions

Accumulating experience led to enhanced success in completion of minimally invasive oesophagectomy, and intrathoracic anastomosis was increasingly the preferred modality. Surgical mortality decreased over time despite the older patients and comparable perioperative morbidity including anastomotic leaks. Improvement in the management of complications is an apparent contributor to good perioperative outcomes as well as technical development.

Determinants of survival outcomes among esophageal cancer patients at a national referral hospital in Kenya

Introduction

The overall 5-year survival rate for esophageal cancer patients in low- and middle-income countries was reported to be low, despite the availability of advanced treatments. Thus, this study aimed to assess determinants of survival outcomes among esophageal cancer patients in Kenya.

Methods

A retrospective cohort study was employed among 299 adult esophageal cancer patients. The data were collected using a data abstraction tool consisting of patients' clinical characteristics and survival outcome measuring parameters. Statistical Package for the Social Sciences (SPSS) statistical software (version 20.0, IBM. USA) was used to analyze the data. The Kaplan-Meier and Cox regression analyses were used to determine the survival outcome and determinants of mortality, respectively.

Results

The mortality rate was 43.1%, and 11.1% of patients demonstrated distant metastases in the follow-up period. Despite treatment, 20.1% had progressed disease, and 13.0% did not respond to treatment. Radiotherapy (AHR: 3.3, 95% CI: 1.4-7.8, p = 0.007), chemotherapy (AHR: 3.9, 95% CI: 1.2-6.1, p = 0.020), and chemoradiation (AHR: 5.6, 95%CI: 1.6-10.2, p = 0.006) were the significant determinants of survival in advanced stage (III and and IV) patients.

Conclusions

There was a high mortality rate, disease progression, and nonresponse of esophageal cancer patients. Hence, it is essential to improve the survival of patients through early detection and timely initiation of the available treatment options.

[Robot-assisted Minimally Invasive Oesophagectomy - Surgical Variants of Intrathoracic Circular Stapled Oesophagogastric Anastomosis]

INTRODUCTION

Anastomotic insufficiency after oesophagectomy contributes significantly to morbidity and mortality of affected patients. A safe surgical technique can reduce the incidence of such anastomotic insufficiencies.

INDICATION

In the treatment of oesophageal cancer, the German guideline recommends minimally invasive or hybrid surgical procedures. In most cases, Ivor-Lewis oesophagectomy and continuity reconstruction using a gastric sleeve are performed. Circular stapler anastomosis seems to be superior.

METHOD

The preparation of the anastomosis starts intra-abdominally with mobilisation of the stomach and sparing of the gastroepiploic vessels. After the subsequent intrathoracic mobilisation of the oesophagus, the actual anastomosis construction can take place. Here, the oesophagus is either transected with a stapler closure or openly with scissors. This is followed by a purse-string suture on the open oesophageal stump. Alternatively, partial oesophageal opening with prior purse-string suture may later facilitate insertion of the stapler anvil. The anvil is placed in the oesophageal stump via minithoracotomy or alternatively transorally using a special gastric tube system. Subsequently, the anvil is fixated using the previously performed purse-string suture. Now the gastric sleeve can be pulled into the thorax. The oesophagus and small gastric curvature are placed extrathoracically through the minithoracotomy and a circular stapler is inserted into the gastric tube via an opening of the small curvature. The anastomosis then must be placed remotely from the gastroepiploic arcade. After construction of the anastomosis, the gastric sleeve is separated using a linear stapler. Eventually, the oesophagus and small gastric curvature can be completely recovered. Optionally, an additional suturing over the anastomosis and dissection margin of the gastric sleeve can be performed.

CONCLUSION

In robot-assisted oesophagectomy, the reconstruction of continuity with a circular stapler anastomosis is quite possible and seems comparatively easier to learn. Nevertheless, variations are still possible within this procedure. However, there is no scientific evidence on the advantage for any method in a direct comparison.

Perineural Invasion Is a Significant Indicator of High Malignant Degree and Poor Prognosis in Esophageal Cancer: A Systematic Review and Meta-Analysis

Background

Perineural invasion (PNI) is a malignant metastatic mode of tumors and has been reported in many tumors including esophageal cancer (EC). However, the role of PNI in EC has been reported differently. This systematic review and meta-analysis aims to focus on the role of PNI in EC.

Methods

Eight databases of CNKI, VIP, Wanfang, Scopus, Wiley, ISI, PubMed, and EBSCO are used for literature search. The association of PNI with gender, pathological stages of T and N (pT and pN), lymphovascular invasion (LVI), lymph node metastasis, 5-year overall survival (OS), and 5-year disease-free survival (DFS) was examined in the meta-analysis by Revman5.0 Software. The pooled OR/HR and 95% CI were used to assess the risk and prognostic value.

Results

Sixty-nine published studies were screened for analysis of PNI in EC. The incidence of PNI in esophageal squamous carcinoma (ESCC) and esophageal adenocarcinoma (EAC) was different, but not statistically significant (p > 0.05). The PNI-positive patients had a significantly higher risk of pT stage (OR = 3.85, 95% CI = 2.45–6.05, p < 0.00001), pN stage (OR = 1.86, 95% CI = 1.52–2.28, p < 0.00001), LVI (OR = 2.44, 95% CI = 1.55–3.85, p = 0.0001), and lymph node metastasis (OR = 2.87, 95% CI = 1.56–5.29, p = 0.0007). Furthermore, the cumulative analysis revealed a significant correlation between PNI and poor OS (HR = 1.37, 95% CI = 1.24–1.51, p < 0.0001), as well as poor DFS (HR = 1.55, 95% CI = 1.38–1.74, p < 0.0001).

Conclusion

PNI occurrence is significantly related to tumor stage, LVI, lymph node metastasis, OS, and DFS. These results indicate that PNI can serve as an indicator of high malignant degree and poor prognosis in EC.

Risk stratification of cirrhotic patients undergoing esophagectomy for esophageal cancer: A single-centre experience

Background

Concomitant liver cirrhosis is a crucial risk factor for major surgeries. However, only few data are available concerning cirrhotic patients requiring esophagectomy for malignant disease.

Methods

From a prospectively maintained database of esophageal cancer patients, who underwent curative esophagectomy between 01/2012 and 01/2016, patients with concomitant liver cirrhosis (liver-cirrhotic patients, LCP) were compared to non-liver-cirrhotic patients (NLCP).

Results

Of 170 patients, 14 cirrhotic patients with predominately low MELD scores (≤ 9, 64.3%) were identified. Perioperative outcome was significantly worse for LCP, as proofed by 30-day (57.1% vs. 7.7, p<0.001) and 90-day mortality (64.3% vs. 9.6%, p<0.001), anastomotic leakage rate (64.3 vs. 22.3%, p = 0.002) and sepsis (57.1 vs. 21.5%, p = 0.006). Even after adjustment for age, gender, comorbidities, and surgical approach, LCP revealed higher odds for 30-day and 90-day mortality compared to NLCP. Moreover, 5-year survival analysis showed a significantly poorer long-term outcome of LCP (p = 0.023). For risk stratification, none of the common cirrhosis scores proved prognostic impact, whereas components as Bilirubin (auROC 94.4%), INR (auROC = 90.0%), and preoperative ascites (p = 0.038) correlated significantly with the perioperative outcome.

Conclusion

Curative esophagectomy for cirrhotic patients is associated with a dismal prognosis and should be evaluated critically. While MELD and Child score failed to predict perioperative mortality, Bilirubin and INR proofed excellent prognostic capacity in this cohort.

Does thoracoscopic esophagectomy really reduce post-operative pneumonia in all cases?

It has been said that "thoracoscopy suppresses the occurrence of pneumonia in comparison to thoracotomy", but does it reflect real clinical practice? To resolve this clinical question, we compared the results of randomized controlled trials (RCTs) and retrospective cohort studies from limited institutes (CLIs) in which a large number of high-volume centers were the main participants to those of retrospective cohort studies based on nationwide databases (CNDs) in which both high-volume centers and low-volume hospitals participated. A systematic review and meta-analysis were conducted to compare the short-term outcomes of thoracoscopic to open esophagectomy for esophageal cancer in the three above-mentioned research formats. In total, 43 studies with 21,057 patients, which included 1 RCT with 115 patients, 38 CLIs with 6,126 patients and 4 CNDs with 14,816 patients, were selected. Pneumonia was one of the most important complications. Although significant superiority in thoracoscopic esophagectomy was observed in RCTs (p = 0.005) and CLIs (p = 0.003), no such difference was seen in findings using nationwide databases (p = 0.69). In conclusion, unlike RCTs and CLIs, CNDs did not show the superiority of thoracoscopic surgery in terms of post-operative pneumonia. RCTs and CLIs were predominantly performed by high-volume hospitals, while CNDs were often performed by low-volume hospitals. In actual clinical practice including various types of hospitals, the superiority of thoracoscopic over open esophagectomy regarding the incidence of pneumonia may, therefore, decrease.

Concurrent diagnosis of anxiety increases postoperative length of stay among patients receiving esophagectomy for esophageal cancer

OBJECTIVE

Psychiatric comorbidities disproportionately affect patients with cancer. While identified risk factors for prolonged length of stay (LOS) after esophagectomy are primarily medical comorbidities, the impact of psychiatric comorbidities on perioperative outcomes is unclear. We hypothesized that psychiatric comorbidities would prolong LOS in patients with esophageal cancer.

METHODS

The 2016 National Inpatient Sample (NIS) was used to identify patients with esophageal cancer receiving esophagectomy. Concurrent psychiatric illness was categorized using Clinical Classifications Software Refined for ICD-10, creating 34 psychiatric diagnosis groups (PDGs). Only PDGs with >1% prevalence in the cohort were included in the analysis. The outcome of interest was hospital LOS. Bivariable testing was performed to determine the association of PDGs and demographic factors on LOS using rank sum test. Multivariable regression analysis was performed using backward selection from bivariable testing (α ≤ 0.05).

RESULTS

We identified 1,730 patients who underwent esophagectomy for esophageal cancer in the 2016 NIS. The median LOS was 8 days (IQR 5-12). In bivariable testing, a concurrent diagnosis of anxiety was the only PDG associated with LOS (9 days (IQR 6-14) with anxiety diagnosis versus 8 days (IQR 5-12) with no anxiety diagnosis, p = 0.022). Multivariable modeling showed an independent association between anxiety diagnosis and increased LOS (OR 4.82 (1.25-25.23), p = 0.022). Anxiety was not associated with increased hospital cost or in-hospital mortality.

CONCLUSIONS

This analysis demonstrates an independent effect of anxiety prolonging postoperative LOS after esophagectomy in the United States. These findings may influence perioperative care, patient expectations, and resource allocation.

Effect of anastomotic leaks on long-term survival after oesophagectomy for oesophageal cancer: systematic review and meta-analysis

INTRODUCTION

Long-term survival after curative surgery for oesophageal cancer surgery remains poor, and the prognostic impact of anastomotic leak (AL) remains unknown. A meta-analysis was conducted to investigate the impact of AL on long-term survival.

METHODS

A systematic electronic search for articles was performed for studies published between 2001 and 2020 evaluating the long-term oncological impact of AL. Meta-analysis was performed using the DerSimonian-Laird random-effects model to compute hazard ratios and 95% confidence intervals.

RESULTS

Nineteen studies met the inclusion criteria, yielding a total of 9885 patients. Long-term survival was significantly reduced after AL (HR: 1.79, 95% CI: 1.33-2.43). AL was associated with significantly reduced overall survival in studies within hospital volume Quintile 1 (HR: 1.35, 95% CI: 1.12-1.63) and Quintile 2 (HR: 1.83, 95% CI: 1.35-2.47). However, no significant association was found for studies within Quintile 3 (HR: 2.24, 95% CI: 0.85-5.88), Quintile 4 (HR: 2.59, 95% CI: 0.67-10.07), and Quintile 5 (HR: 1.29, 95% CI: 0.92-1.81). AL was significantly associated with poor long-term survival in patients with associated overall Clavien Dindo Grades 1-5 (HR: 2.17, 95% CI: 1.31-3.59) and severe Clavien Dindo Grades 3-5 (HR: 1.42, 95% CI: 1.14-1.78) complications.

CONCLUSIONS

AL has a negative prognostic impact on long-term survival after restorative resection of oesophageal cancers, particularly in low-volume centers. Future efforts must be focused on strategies to minimize the septic and immunological response to AL with early recognition and treatment thus reducing the impact on long-term survival.

Minimally invasive techniques for transthoracic oesophagectomy for oesophageal cancer: systematic review and network meta-analysis

BACKGROUND

Oesophagectomy is a demanding operation that can be performed by different approaches including open surgery or a combination of minimal access techniques. This systematic review and network meta-analysis aimed to evaluate the clinical outcomes of open, minimally invasive and robotic oesophagectomy techniques for oesophageal cancer.

METHODS

A systematic literature search was conducted for studies reporting open oesophagectomy, laparoscopically assisted oesophagectomy (LAO), thoracoscopically assisted oesophagectomy (TAO), totally minimally invasive oesophagectomy (MIO) or robotic MIO (RAMIO) for oesophagectomy. A network meta-analysis of intraoperative (operating time, blood loss), postoperative (overall complications, anastomotic leaks, chyle leak, duration of hospital stay) and oncological (R0 resection, lymphadenectomy) outcomes, and survival was performed.

RESULTS

Ninety-eight studies involving 32 315 patients were included in the network meta-analysis (open 17 824, 55·2 per cent; LAO 1576, 4·9 per cent; TAO 2421 7·5 per cent; MIO 9558, 29·6 per cent; RAMIO 917, 2·8 per cent). Compared with open oesophagectomy, both MIO and RAMIO were associated with less blood loss, significantly lower rates of pulmonary complications, shorter duration of stay and higher lymph node yield. There were no significant differences between surgical techniques in surgical-site infections, chyle leak, and 30- and 90-day mortality. MIO and RAMIO had better 1- and 5-year survival rates respectively compared with open surgery.

CONCLUSION

Minimally invasive and robotic techniques for oesophagectomy are associated with reduced perioperative morbidity and duration of hospital stay, with no compromise of oncological outcomes but no improvement in perioperative mortality.

Predictive Value of the Age-Adjusted Charlson Comorbidity Index for Outcomes After Hepatic Resection of Hepatocellular Carcinoma

BACKGROUND

This study aimed to evaluate the impact of the age-adjusted Charlson comorbidity index (ACCI) on outcomes after hepatic resection for hepatocellular carcinoma (HCC).

METHODS

We assessed 763 patients who underwent hepatic resection for HCC. The ACCI scores were categorized as follows: ACCI ≤ 5, ACCI = 6, and ACCI ≥ 7.

RESULTS

A multivariate analysis showed that the odds ratios for postoperative complications in ACCI = 6 and ACCI ≥ 7 groups, with reference to ACCI ≤ 5 group, were 0.71 (p = 0.41) and 4.15 (p < 0.001), respectively. The hazard ratios for overall survival of ACCI = 6 and ACCI ≥ 7 groups, with reference to ACCI ≤ 5 group, were 1.52 (p = 0.023) and 2.45 (p < 0.001), respectively. The distribution of deaths due to HCC-related, liver-related, and other causes was 68.2%, 11.8%, and 20% in ACCI ≤ 5 group, 47.2%, 13.9%, and 38.9% in ACCI = 6 group, and 27.3%, 9.1%, and 63.6% in ACCI ≥ 7 group (p = 0.053; ACCI ≤ 5 vs. = 6, p = 0.19; ACCI = 6 vs. ≥ 7, p < 0.001; ACCI ≤ 5 vs. ≥ 7). In terms of the treatment for HCC recurrence in ACCI ≤ 5, ACCI = 6, and ACCI ≥ 7 groups, adaptation rate of surgical resection was 20.1%, 7.3%, and 11.1% and the rate of palliative therapy was 4.3%, 12.2%, and 22.2%, respectively.

CONCLUSIONS

The ACCI predicted the short-term and long-term outcomes after hepatic resection of HCC. These findings will help physicians establish a treatment strategy for HCC patients with comorbidities.

The Impact of Hybrid Minimally Invasive Esophagectomy with Neck-Abdominal First Approach on the Short- and Long-Term Outcomes for Esophageal Squamous Cell Carcinoma

BACKGROUND

Currently, there is no consensus for an optimal minimally invasive esophagectomy (MIE) approach. This study aimed to compare hybrid MIE (hMIE) with neck-abdominal first approach to standard open esophagectomy (OE).

METHODS

Data from a cohort of 301 patients were retrospectively analyzed. All participants received either hMIE or OE for the treatment of esophageal squamous cell carcinoma at Tokyo Medical and Dental University between January 2003 and December 2013. Analyses included propensity score matching and the Kaplan-Meier statistical method to determine overall survival (OS) and disease-free survival (DFS) of the cohort.

RESULTS

After one-to-one propensity score matching, there were 68 patient pairs. The hMIE group had significantly lower incidence of severe postoperative complications (20.1% vs. 7.4%; p = 0.026) and severe respiratory complications (7.4% vs. 0%; p = 0.058) than the OE group. The 5-year oncological outcomes of the two groups were almost equivalent (OS: OE, 55.0%; hMIE, 69.0%; p = 0.063 and DFS: OE, 54.0%; hMIE, 62.0%; p = 0.28).

CONCLUSIONS

This study compared hMIE with neck-abdominal first approach to standard OE. The results showed significantly less severe postoperative complications for hMIE with neck-abdominal first approach in comparison with OE, without a compromise in long-term oncological outcomes.

Long-term oncological outcomes following completely minimally invasive esophagectomy versus open esophagectomy

Open esophagectomy (OE) for esophageal and gastroesophageal junctional cancers is associated with high morbidity. Completely minimally invasive esophagectomy (CMIE) techniques have evolved over the last two decades and significantly reduce surgical trauma compared to open surgery. Despite this, long-term oncological outcomes following CMIE compared to OE remain unclear. This systematic review and meta-analysis aimed to compare overall 5-year survival (OFS) and disease-free 5-year survival (DFFS) between CMIE and OE. It was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive electronic literature search from MEDLINE, EMBASE, Web of Science, Scopus and the Cochrane Central Register of Controlled Trials was conducted. The PROSPERO database was also searched for studies comparing OFS and DFFS between CMIE and OE. The Newcastle Ottawa Scale was used to assess study quality for included studies. Overall, seven studies (containing 949 patients: 527 OE and 422 CMIE) were identified from screening. On pooled meta-analysis, there was no significant difference in OFS or DFFS between CMIE and OE cohorts ([odds ratio 1.12; 95% CI: 0.85 to 1.48; P = 0.41] and [odds ratio 1.34; 95% CI: 0.81-2.22; P = 0.25] respectively). Sensitivity and subgroup analysis with high-quality studies, three highest sample sized studies, and three most recent studies also revealed no difference in long-term oncological outcomes between the two operative groups. This review demonstrates long-term oncological outcomes following CMIE appear equivalent to OE based on amalgamation of existing published literature. Limited high-level evidence comparing OFS and DFFS between CMIE and OE exists. Further research with a randomized controlled trial is required to clinically validate these findings.

Postoperative short-term outcomes of minimally invasive versus open esophagectomy for patients with esophageal cancer: An updated systematic review and meta-analysis

Background

We performed a systematic review and meta‐analysis to synthesize the available evidence regarding short‐term outcomes between minimally invasive esophagectomy (MIE) and open esophagectomy (OE).

Methods

Studies were identified by searching databases including PubMed, EMBASE, Web of Science and Cochrane Library up to March 2019 without language restrictions. Results of these searches were filtered according to a set of eligibility criteria and analyzed in line with PRISMA guidelines.

Results

There were 33 studies included with a total of 13 269 patients in our review, out of which 4948 cases were of MIE and 8321 cases were of OE. The pooled results suggested that MIE had a better outcome regarding all‐cause respiratory complications (RCs) (OR = 0.56, 95% CI = 0.41–0.78, P = <0.001), in‐hospital duration (SMD = −0.51; 95% CI = −0.78−0.24; P = <0.001), and blood loss (SMD = −1.44; 95% CI = −1.95−0.93; P = <0.001). OE was associated with shorter duration of operation time, while no statistically significant differences were observed regarding other outcomes. Additionally, subgroup analyses were performed for a number of different postoperative events.

Conclusions

Our study indicated that MIE had more favorable outcomes than OE from the perspective of short‐term outcomes. Further large‐scale, multicenter randomized control trials are needed to explore the long‐term survival outcomes after MIE versus OE.

Risk factors and outcomes associated with anastomotic leaks following esophagectomy: a systematic review and meta-analysis

Anastomotic leaks (AL) are a major complication after esophagectomy. This meta-analysis aimed to determine identify risks factors for AL (preoperative, intra-operative, and post-operative factors) and assess the consequences to outcome on patients who developed an AL. This systematic review was performed according to PRISMA guidelines, and eligible studies were identified through a search of PubMed, Scopus, and Cochrane CENTRAL databases up to 31 December 2018. A meta-analysis was conducted with the use of random-effects modeling and prospectively registered with the PROSPERO database (Registration CRD42018130732). This review identified 174 studies reporting outcomes of 74,226 patients undergoing esophagectomy. The overall pooled AL rates were 11%, ranging from 0 to 49% in individual studies. Majority of studies were from Asia (n = 79). In pooled analyses, 23 factors were associated with AL (17 preoperative and six intraoperative). AL were associated with adverse outcomes including pulmonary (OR: 4.54, CI95%: 2.99-6.89, P < 0.001) and cardiac complications (OR: 2.44, CI95%: 1.77-3.37, P < 0.001), prolonged hospital stay (mean difference: 15 days, CI95%: 10-21 days, P < 0.001), and in-hospital mortality (OR: 5.91, CI95%: 1.41-24.79, P = 0.015). AL are a major complication following esophagectomy accounting for major morbidity and mortality. This meta-analysis identified modifiable risk factors for AL, which can be a target for interventions to reduce AL rates. Furthermore, identification of both modifiable and non-modifiable risk factors will facilitate risk stratification and prediction of AL enabling better perioperative planning, patient counseling, and informed consent.

Postoperative complications of minimally invasive esophagectomy for esophageal cancer

Minimally invasive esophagectomy (MIE) has been performed increasingly more frequently for the treatment of esophageal cancer, ever since it was first described in 1992. However, the incidence of postoperative complications of MIE has not yet been well-characterized, because (a) there are few reports of studies with a sufficient sample size, (b) a variety of minimally invasive surgical techniques are used, and (c) there are few reports in which an established system for classifying the severity of complications is examined. According to an analysis performed by the Esophageal Complications Consensus Group, the most common complications of MIE are pneumonia, arrhythmia, anastomotic leakage, conduit necrosis, chylothorax, and recurrent laryngeal nerve palsy. Therefore, we decided to focus on these complications. We selected 48 out of 1245 reports of studies (a) that included more than 50 patients each, (b) in which the esophagectomy technique used was clearly described, and (c) in which the complications were adequately described. The overall incidences of the postoperative complications of MIE for esophageal cancer were analyzed according to the MIE technique adopted, that is, McKeown MIE, Ivor Lewis MIE, robotic-assisted McKeown MIE, robotic-assisted Ivor Lewis MIE, or mediastinoscopic transmediastinal esophagectomy. Pneumonia, arrhythmia, anastomotic leakage, and recurrent laryngeal nerve palsy occurred at an incidence rate of about 10% each; Ivor Lewis MIE was associated with a relatively low incidence of recurrent laryngeal nerve palsy. It is important to recognize that the incidences of complications of MIE are influenced by the MIE technique adopted and the extent of lymph node dissection.

Impact of the Charlson Comorbidity Index on the treatment strategy and survival in elderly patients after non-curative endoscopic submucosal dissection for esophageal squamous cell carcinoma: a multicenter retrospective study

BACKGROUND

In elderly patients with superficial esophageal squamous cell carcinoma (ESCC), the optimal treatment strategy after non-curative endoscopic submucosal dissection (ESD) remains unclear. We aimed to evaluate the validity of additional treatments after non-curative ESD and post-ESD survival predictors in elderly patients with ESCC.

METHODS

Elderly patients (age > 75 years) treated with ESD for ESCC between January 2010 and July 2014 at six tertiary referral hospitals in Japan were retrospectively investigated and stratified according to lymph node metastasis risk, based on histological findings (high-risk factors: positive lymphovascular invasion, submucosal invasion, and positive/indeterminate vertical margin) and post-ESD treatment strategy: group A (287 patients; low risk), group B (41 patients; high risk, without additional treatment), and group C (32 patients; high risk, with additional treatment). We evaluated 3- and 5-year overall survival and disease-specific survival, and prognostic factors for post-ESD survival.

RESULTS

At a median follow-up of 38, 40, and 49 months, respectively, there was 1 esophageal cancer-related death in group A, 1 in group B, and none in group C, whereas 22, 9, and 3 patients in groups A, B, and C died of other diseases. The groups differed significantly in overall survival (92.4%; 87.6%; 93.4%, p = 0.022), although not in disease-specific survival (99.4%; 96.3%; 100%, p = 0.217). On multivariate analysis, Charlson Comorbidity Index (CCI) ≥ 2 was the only independent risk factor for post-ESD death (hazard ratio 7.92; 95% confidence interval 3.42-18.3; p < 0.001).

CONCLUSIONS

A follow-up strategy without additional treatment after ESD for ESCC may be acceptable in high-risk elderly patients, especially for CCI ≥ 2.

Can we perform esophagectomy for esophageal cancer patients with concomitant liver cirrhosis? A comprehensive systematic review and meta-analysis

Liver cirrhosis is sometimes encountered in esophageal cancer patients intended for surgery. However, the impact of liver cirrhosis on patients with surgically treated esophageal cancer remains unclear. Therefore, we conducted the first meta-analysis focusing on current topic. We comprehensively searched relevant studies in Pubmed, Embase, and Web of Science on September 3, 2018. Data for analysis included both short-term (including morbidity and mortality rates) and long-term (5-year survival rate) outcomes. Our meta-analysis was conducted by using the STATA 12.0 package. We finally included a total of six cohort studies involving a total of 1426 patients (161 cirrhotic patients and 1265 noncirrhotic patients). Meta-analysis showed that cirrhotic patients had a significantly higher morbidity rate (risk ratio (RR) = 1.226; 95% Confidence interval (CI) = [1.043, 1.442]; P = 0.014) than noncirrhotic patients. For specific complications, cirrhotic patients had a significantly higher rate of pulmonary complications (RR = 2.354; 95%CI = [1.376, 4.026]; P = 0.002) and pleural effusion (RR = 2.414; 95%CI = [1.482, 3.613]; P < 0.001) than noncirrhotic patients and there was a trend toward a higher rate of anastomotic leak (RR = 1.759; 95%CI = [0.945, 3.274]; P = 0.075) in cirrhotic patients. Moreover, cirrhotic patients also had a significantly higher mortality rate (RR = 2.529; 95%CI = [1.480, 4.324]; P = 0.001) than noncirrhotic patients. Cirrhotic patients tended to yield a lower 5-year survival rate than those noncirrhotic patients after surgical resection of esophageal cancer (RR = 0.715; 95%CI = [0.492, 1.039]; P = 0.079). In conclusion, liver cirrhosis was significantly correlated with high morbidity and mortality rates. However, there was no sufficient evidence of unfavorable survival in cirrhotic patients. Esophagectomy can be performed for certain esophageal cancer patients with concomitant liver cirrhosis with acceptable operative risks, providing that careful preoperative evaluation and patient selection have been achieved.

Thoracoscopy in prone position with two-lung ventilation compared to conventional thoracotomy during Ivor Lewis procedure: a multicenter case-control study

BACKGROUND

Intraoperative management based on thoracoscopy, prone position and two-lung ventilation could decrease the rate of postoperative pulmonary complications after esophagectomy. The aim of this study was to compare this multifaceted approach (MIE-PP) and conventional thoracotomy for Ivor Lewis procedure after a systematic laparoscopic dissection.

METHODS

Data from 137 consecutive patients undergoing Ivor Lewis procedures between 2010 and 2017 at two tertiary centers was analyzed retrospectively. The outcomes of patients who underwent MIE-PP (n = 58; surgeons group 1) were compared with those of patients undergoing conventional approach (n = 79; surgeons group 2). Our primary outcome was major postoperative pulmonary complications. Our main secondary outcomes were anastomotic leak, quality of resection and mortality.

RESULTS

Female patients were more prevalent in the MIE-PP group (p = 0.002). Other patient characteristics, cTNM staging and neoadjuvant treatment rate were not different between groups. Major postoperative pulmonary complications were significantly lower in the MIE-PP group compared to Conventional group (24 vs. 44%; p = 0.014). Anastomotic leak occurred in 31 versus 18% in MIE-PP group and Conventional groups, respectively (p = 0.103). Complete resection rate (98 vs. 95%; p = 0.303) and mean number of harvested lymph nodes (16 (4-40) vs. 18 (3-37); p = 0.072) were similar between the two groups. Postoperative mortality rates were 0 versus 2% at day 30 (p = 0.508) and 0 versus 7.6% at day 90 (p = 0.038).

CONCLUSION

Short-term outcomes of minimally invasive Ivor Lewis using thoracoscopy, prone position and two-lung ventilation are at least equivalent to the hybrid approach. Anastomotic leak after MIE-PP remains a major concern.

Recent advances in thoracoscopic esophagectomy for esophageal cancer

Technical advances and developments in endoscopic equipment and thoracoscopic surgery have increased the popularity of minimally invasive esophagectomy (MIE). However, there is currently no established scientific evidence supporting the use of MIE as an alternative to open esophagectomy (OE). To date, a number of single-institution studies and several meta-analyses have demonstrated acceptable short-term outcomes of thoracoscopic esophagectomy for esophageal cancer, and we recently reported one of the largest propensity score-matched comparison studies between MIE and OE for esophageal cancer, based on a nationwide Japanese database. We found that, in general, MIE had a longer operative time and less blood loss than OE. Moreover, compared to OE, MIE was associated with a lower rate of pulmonary complications such as pneumonia, and both methods had similar mortality rates. Although MIE may reduce the occurrence of postoperative respiratory complications, MIE and OE seem to have comparable short-term outcomes. However, the oncological benefit to patients undergoing MIE remains to be scientifically proven, as no randomized controlled trials have been conducted to verify each method's impact on the long-term survival of cancer patients. An ongoing randomized phase III study (JCOG1409) is expected to determine the impact of each method with regard to short- and long-term outcomes.

Minimally invasive esophagectomy may contribute to long-term respiratory function after esophagectomy for esophageal cancer

Evidence suggests that minimally invasive esophagectomy has several advantages with regard to short-term outcomes, compared to open esophagectomy in esophageal cancer patients. However, the impact of minimally invasive esophagectomy on long-term respiratory function remains unknown. The objective of this study is to assess the association between use of the minimally invasive esophagectomy and long-term respiratory dysfunction in esophageal cancer patients after esophagectomy. This retrospective single institution study using prospectively collected data included 87 consecutive esophageal cancer patients who had undergone esophagectomy. All patients underwent a respiratory function test before, and one year after esophagectomy. Logistic regression analysis was used to compute the hazard ratio for long-term respiratory dysfunction. Minimally invasive esophagectomies were performed in 53 patients, and open esophagectomies in 34 patients. The two groups showed no significant differences in terms of postoperative complications and postoperative course. Nor were any differences observed between the two groups in terms of volume capacity (L) and forced expiratory volume 1.0 (L) before esophagectomy (P > 0.34). However, one year after esophagectomy, the decreases in volume capacity and forced expiratory volume 1.0 were significantly less in the minimally invasive esophagectomy group than in the open esophagectomy group (P = 0.04 and P = 0.007, respectively). Multivariate analyses revealed that minimally invasive esophagectomy was an independent favorable factor for maintenance of forced expiratory volume 1.0 (hazard ratio = 0.17, 95% confidence interval 0.04-0.71; P = 0.01). Minimally invasive esophagectomy may be an independent favorable factor for maintenance of long-term respiratory function in esophageal cancer patients after esophagectomy.

Robot assisted esophagectomy for esophageal squamous cell carcinoma

Background

This study aims to report our experience with robot assisted esophagectomy (RAE) for the treatment of resectable esophageal squamous cell carcinoma (ESCC).

Methods

A series of 249 consecutive patients diagnosed with ESCC who underwent RAE from November 2015 to December 2017 at Shanghai Chest Hospital were evaluated, and their clinical data were reviewed retrospectively. One hundred patients were equally divided into four groups according to the surgery order, and the short-term outcomes in each group were analyzed.

Results

Overall, 249 patients (201 males and 48 females) with a mean age of 63.4±7.3 years who underwent RAE were analyzed. The thoracic procedure was successfully performed with the assistance of a robot. The mean total duration was 250.6±58.4 mins, and the estimated blood loss was 215.5±87.6 mL. R0 resection was performed in 232 (93.2%) patients with a mean total number of dissected lymph nodes of 18.5±9.1 and mean yield of lymph nodes along the recurrent laryngeal nerve (RLN) of 4.4±3.2. The median postoperative hospital stay was 11 days, and no 90-day mortality was observed. Forty-five (18.1%) patients experienced pulmonary complications, and the recurrent laryngeal nerve injury were observed in 38 (15.3%) patients. A significant reduction in thoracic duration was observed after the initial 25 cases (P<0.001). After 50 cases, the dissection of total lymph nodes, mediastinum lymph nodes and lymph nodes along the RLN were significantly improved (P<0.001, P<0.001, P=0.001, respectively) with a shorter postoperative hospital stay (P=0.005).

Conclusions

RAE is a safe and feasible alternative surgical approach for resectable esophageal carcinoma and is associated with a large yield of lymph nodes, especially along the RLN. The surgeon will reach a plateau of operative duration after 25 cases and a plateau of lymphadenectomy after 50 cases.

Perioperative management and outcomes of minimally invasive esophagectomy: case study of a high-volume tertiary center in Taiwan

Background

Mortality and complication rates for surgical esophagectomy remain high despite progress in surgical techniques and perioperative care. Minimally invasive surgery and intraoperative goal-directed fluid management are gaining popularity in Taiwan; however, perioperative complications and short-term outcomes have been rarely reported. In this retrospective study, we analyzed the surgical procedures performed as well as the perioperative outcomes and treatments after esophagectomy in a high-volume medical center in Taiwan. The goals of this study are to compare the complications and the following treatment between different surgical procedures and to analyze if any preoperative coexisting disease and anesthesia conduct might be associated with postoperative complications and hospitalization course.

Methods

We retrospectively reviewed the data of all patients who had undergone esophagectomy and reconstruction in 2015. Patient characteristics, type of surgery performed, method of anesthesia, postoperative hospitalization course, and additional surgical interventions were reviewed and analyzed.

Results

In total, 64 patients were included. Among them, 58 patients (90.6%) were reported squamous cell carcinoma, 33 patients (51.6%) received McKeown minimally invasive esophagectomy (MIE), and 20 (31.3%) received Ivor-Lewis MIE. The most common postoperative complications were pulmonary complications (18.7%), such as empyema and pleural effusion, dysrhythmias (14.1%), anastomosis leakage (14.1%), vocal cord paralysis (9.4%), gastric tube stenosis (4.7%), chyle leakage (4.7%), and acute kidney injury (AKI, 4.7%). Twenty-five percent of patients received secondary operative interventions for the aforementioned complications. Postoperative arrhythmia (P=0.042), pulmonary complications (P=0.009), and AKI (P=0.015) were significantly associated with prolonged intensive care unit (ICU) stays. Thirty-day and 90-day mortality rates were 3.1% and 4.7% respectively. Patients with preoperative arrhythmias have a higher risk of developing post-operative dysrhythmia (P=0.013) and lung complications (P=0.036). Patients with an underlying heart disease are at higher risk of post-op AKI (P=0.002) and second surgical intervention (P=0.013). Chronic kidney diseases are associated with post-op dysrhythmia (P=0.013), lung complications (P=0.036) and post-op AKI (P≤0.01). Although McKeown MIE bore a significantly longer surgical time and higher intraoperatively-infused crystalloid than did Ivor Lewis MIE, there were no significant differences regarding postoperative cardiothoracic complications and patient outcomes.

Conclusions

Postoperative outcomes of McKeown MIE and Ivor-Lewis MIE were comparable in our center and short term outcomes were similar to those in previous reports. However, despite neoadjuvant concurrent chemoradiation therapy (CCRT), the use of minimally invasive techniques, and well-controlled anesthesia, the incidence of perioperative complications remains high. Our results suggest that patients with preoperative comorbidity of arrhythmia, heart diseases, and CKD are associated with more common post-operative complications. Furthermore, postoperative dysrhythmias, pulmonary complications, and AKI warrant special anesthetic and surgical care to prevent prolonged ICU stay.

Impact of surgical approach on perioperative and long-term outcomes following esophagectomy for esophageal cancer

BACKGROUND

Surgical resection remains a critical component of esophageal cancer treatment with curative-intent. The aim of this study was to compare open (OE) to minimally invasive Ivor Lewis esophagectomy (MIE) with respect to perioperative and oncologic outcomes.

METHODS

Retrospective single-institution review of MIE and OE patients operated between 2001 and 2015 was conducted. Univariable and multivariable models were created using Cox regression. The Kaplan-Meier method was used to compare oncologic outcomes. Propensity score matching was used to compare oncological outcomes in MIE and OE patients.

RESULTS

Of 210 esophageal resection patients, 47% had OE (137/291) and 25% had MIE (73/291). The MIE and OE groups were comparable with respect to patient factors and operative details. Fewer OE patients received neoadjuvant chemoradiation. MIE was associated with improved lymph node yield, (MIE = 30 [IQR:22-39]; OE = 14 [IQR:7-19], p < 0.001), less intraoperative blood loss (MIE = 312 mL [100-400]; OE = 657 mL [350-700], p < 0.001), and shorter median length of stay (MIE = 10 days [IQR = 8-14]; OE = 14 days [IQR = 11-22] p < 0.01). The OE group had significantly more adverse events resulting in reoperation or intensive care unit admission (MIE = 21%; OE = 34%; p < 0.01). On multivariable analysis, age and positive resection margins were associated with decreased odds of survival. The number of lymph nodes retrieved, positive resection margins, and pathologic stage were significant predictors of disease-free survival. Analysis of 69 matched pairs showed equivalent median overall survival (MIE = 49 months [18-67]; OE = 29 months [17-69]; p = 0.26) and disease-free survival (MIE = 9 [6-22]; OE = 13 [6-22]; p = 0.45) between the two groups.

CONCLUSIONS

Although long-term oncologic outcomes appear to be similar, MIE is associated with significantly less intraoperative blood loss, improved lymph node yield, less risk of severe postoperative adverse events, and shorter length of stay.

Are Thoracotomy and/or Intrathoracic Anastomosis Still Predictors of Postoperative Mortality After Esophageal Cancer Surgery?: A Nationwide Study

BACKGROUND

Intrathoracic (vs cervical) anastomosis and a thoracotomy (vs absence) have previously been associated with increasing postoperative mortality (POM). Recent improvements in surgical practices and perioperative management may have changed these dogmas.

OBJECTIVES

The aim of this study was to evaluate the impact of performing intrathoracic anastomosis and/or thoracotomy on POM after esophageal cancer surgery in recent years.

METHODS

All consecutive patients who underwent esophageal cancer surgery with reconstruction between 2010 and 2012 in France were included (n = 3286). Patients with a thoracoscopic approach were excluded (n = 4). We compared 30-day POM between patients having received intrathoracic (vs cervical) anastomosis and between those having received a thoracotomy or not. Multivariate analyses and propensity score matching were used to adjust for confounding factors.

RESULTS

Patients had either cervical (n = 548) or intrathoracic (n = 2738) anastomosis. Thirty-day POM was higher after cervical anastomosis (8.8% vs 4.9%, P < 0.001). Having received a thoracotomy (n = 3061) was associated with a decreased risk of 30-day POM (5.3% vs 9.3%, P = 0.011). After adjustment for confounding factors, cervical anastomosis was associated with 30-day POM [odds ratio (OR) 1.71; 95% confidence interval (CI) 1.05-2.77); P = 0.032], whereas performing a thoracotomy was not associated with 30-day POM (OR 0.97; 95% CI 0.51-1.84; P = 0.926).

CONCLUSIONS

Nowadays, intrathoracic anastomosis provides a lower 30-day POM rate compared to cervical anastomosis, and performing a thoracotomy is not associated with POM. Systematic anastomosis neck placement or thoracotomy avoidance is not a relevant argument anymore to decrease POM.

Improved treatment decisions in patients with esophageal cancer

BACKGROUND

Patients with esophageal cancer seldom achieve long-term survival. This prospective cohort study investigated the selection of patients likely to benefit from curative treatment and whether information on patients' health-related quality of life (HRQL) would assist treatment decisions in the multidisciplinary team.

METHODS

Consecutive patients completed HRQL assessments and clinical data were collected before start of treatment. Logistic regression analyses identified clinical factors associated with treatment intent in patients with stage-III disease. Kaplan-Meier method was used for survival analyses and Cox proportional hazards models were used to assess the impact of clinical factors and HRQL on survival in patients planned for curative treatment.

RESULTS

Patients with curative treatment intent (n = 90) were younger, had better WHO performance status and less fatigue than patients with palliative treatment intent (n = 89). Median survival for the total cohort (n = 179) and patients with palliative or curative treatment intent was nine, five and 19 months, respectively. In multivariate Cox regression analyses, performance status (0-1 favorable) and comorbidity (ASA I favorable) were factors of importance for survival, whereas measures of HRQL were not.

CONCLUSIONS

Patients performance status and comorbidity must be considered in addition to stage of disease to avoid extensive curative treatment in patients with short life expectancy. This study did not provide evidence to support that information on patients HRQL adds value to the multidisciplinary team's treatment decision process.

Minimally invasive esophagectomy is a safe surgical treatment for locally advanced pathologic T3 esophageal squamous cell carcinoma

Background

Previous studies have shown that minimally invasive esophagectomy (MIE) is safe and feasible. However, several of these studies had selection bias because they included more patients with early-stage cancer, and no study has compared the outcomes of locally advanced pathologic T3 (pT3) esophageal carcinoma between MIE and open surgery.

Methods

This retrospective analysis included 229 patients with stage pT3 esophageal squamous cell carcinoma (ESCC) who underwent esophagectomy from January 2013 to June 2015. The outcomes included operative outcomes, postoperative complications, recurrence, and mid-term survival.

Results

Sixty-six patients underwent MIE and 163 patients underwent open surgery. No significant difference was noted in blood loss or resection completeness (R0) between the two groups. The operative duration was longer in the MIE than open surgery group (266.5±52.5 vs. 218.1±47.4, P<0.01), and the number of lymph nodes dissected was higher in the MIE than open surgery group (15.2±5.3 vs. 12.9±7.3, P=0.01). There was no significant difference in the length of stay or 30-day mortality rate between the two groups, but the intensive care unit stay was shorter in the MIE group (3 vs. 4, P=0.01). No difference in complications or recurrence was noted between the two groups. The 2-year overall survival (OS) rate was 72.8% for MIE and 69.4% for open surgery, and the 2-year disease-free survival (DFS) rate was 69.4% for MIE and 57.2% for open surgery.

Conclusions

For patients with locally advanced stage pT3 ESCC, MIE has perioperative outcomes comparable to those of open surgery without compromising recurrence or survival.

A non-randomized retrospective observational study on the subcutaneous esophageal reconstruction after esophagectomy: is it feasible in high-risk patients?

BACKGROUND

Esophageal reconstruction after esophagectomy is a complex procedure with high morbidity and mortality. Anastomotic leakage is more severe and frequent in patients with preoperative comorbidities and may present with septic conditions. Considering the possibility of an easier management of such cases, we evaluated the safety and feasibility of subcutaneous esophageal reconstruction in patients with high operative risks.

METHODS

We performed a non-randomized retrospective observational study on the 75 (subcutaneous: 21, intrathoracic: 54) esophageal cancer patients who underwent esophageal reconstruction either through subcutaneous or intrathoracic route between January 2003 and February 2015. Preoperative data including the estimated reasons for the selection of the subcutaneous route were obtained from medical charts. Clinical outcomes were evaluated and compared between the two groups.

RESULTS

The mean postoperative hospital stay was longer in the subcutaneous group than the overall group. Anastomotic leakage occurred more frequently in the subcutaneous group [10 (47.6%) vs. 7 (13%), P=0.004]. Three major leakages resulted in chronic cutaneous fistula, but were successfully treated by lower neck reconstruction using radial forearm fasciocutaneous free flap (RFFF). There was no in-hospital mortality in the subcutaneous group.

CONCLUSIONS

Subcutaneous esophageal reconstruction in high-risk patients showed a higher rate of anastomotic leakage. However, easier correction without fatal septic conditions could be obtained by primary repair or flap reconstruction resulting in lower perioperative mortality. Therefore, esophageal reconstruction through the subcutaneous route is not recommended as a routine primary option. However, in highly selected patients with unfavorable preoperative comorbidities or intraoperative findings, especially those with poor blood supply to the graft, graft hematoma or edema, or gross tumor invasion to surrounding tissues, esophageal reconstruction through the subcutaneous route may carefully be considered as an alternative to the conventional surgical techniques.

Morbidity analysis in minimally invasive esophagectomy for oesophageal cancer versus conventional over the last 10 years, a single institution experience

BACKGROUND

There has been an increasing inclination towards minimally invasive esophagectomies (MIEs) at our institute recently for resectable oesophageal cancer.

OBJECTIVES

The purpose of the present study is to report peri-operative and long-term procedure specific outcomes of the two groups and analyse their changing pattern at our institute.

METHODS

All adult patients with a diagnosis of oesophageal cancer managed at our institute from 2005 to 2015 were included in this retrospective study. Patients' demographic and clinical characteristics were recorded through our hospital information system. The cohort of esophagectomies was allocated into two groups, conventional open esophagectomy (OE) or total laparoscopic MIE; hybrid esophagectomies were taken as a separate group. The short-term outcome measures are an operative time in minutes, length of hospital and Intensive Care Unit (ICU) stay in days, post-operative complications and 30 days in-hospital mortality. Complications are graded according to the Clavien-Dindo classification system. Long-term outcomes are long-term procedure related complications over a minimum follow-up of 1 year. Trends were analysed by visually inspecting the graphic plots for mean number of events in each group each year.

RESULTS

Our results showed no difference in mortality, length of hospital and ICU stays and incidence of major complications between three groups on uni- and multi-variate analysis (P > 0.05). The operative time was significantly longer in MIE group (odds ratio [OR]: 1.66, confidence interval [CI]: 2.4-11.5). The incidence of long-term complication was low for MIE (OR: 1.0, CI: 133-1.017). However, all post-operative surgical outcomes trended to improve in both groups over the course of this study and stayed better for MIE group except for the operative time.

CONCLUSION

MIE has overall comparable surgical outcomes to its conventional counterpart. Furthermore, the peri-operative outcomes tend to improve in our centre with the maturation of program and experience.

The effect of postoperative complications on survival of patients after minimally invasive esophagectomy for esophageal cancer

BACKGROUND

Minimally invasive esophagectomy (MIE) has been shown to be a feasible technique for the treatment of esophageal cancer; however, its postoperative morbidity remains high. This retrospective study aimed to evaluate the effect of postoperative complications on long-term outcomes in patients who have undergone MIE for esophageal squamous cell carcinoma (ESCC).

METHODS

This retrospective study enrolled patients who had undergone MIE for ESCC between September 2009 and November 2014; all procedures were performed by a single surgical team. Relevant patient characteristics and postoperative variables were collected and evaluated. The disease-free survival (DFS) and disease-specific survival (DSS) were determined by the Kaplan-Meier method, and compared by log-rank tests. Possible predictors of survival were subjected to univariate analysis and multivariate Cox proportional hazard regression analysis.

RESULTS

In all, data on 214 patients with ESCC were analyzed, including 170 men and 44 women. All study subjects had undergone thoracoscopic or thoracoscopic-laparoscopic esophagectomy and cervical esophagogastric anastomosis. One hundred and thirty patients (60.7%) had postoperative complications (Grades 1-4). The overall DFS and DSS rates were 80.0 and 88.9% at 1 year, 48.6 and 54.2% at 3 years, and 43.2 and 43.5% at 5 years, respectively. Univariate analysis and multivariate Cox proportional hazard regression analysis showed that T stage, N stage, and tumor grade were independent prognostic factors for long-term survival; however, postoperative complications had no significant effect on the DFS or DSS of this patient cohort (log-rank test, p = 0.354 and 0.160, respectively).

CONCLUSIONS

Postoperative complications have no significant effect on long-term survival in patients who have undergone MIE for ESCC.

Surgical and long-term outcomes following oesophagectomy in oesophageal cancer patients with comorbidity

INTRODUCTION

The elucidation of the clinical impact of comorbidities is important to optimize the treatment and follow-up strategy in oesophageal cancer. We aimed to clarify the surgical and long-term outcomes following oesophagectomy in oesophageal cancer patients with comorbidity.

METHODS

A total of 658 consecutive patients who underwent oesophagectomy for oesophageal cancer between 1985 and 2008 at our institution were enrolled. Based on the criteria of comorbidity as we defined it, we retrospectively reviewed and compared the surgical outcomes and survival between the comorbid (n = 251) and non-comorbid group (n = 407).

RESULTS

Postoperative morbidity and mortality were not significantly different between the two groups. The 5-year overall survival rate of the comorbid group was significantly lower (39.3% vs. 45.2%, adjusted HR = 1.31, 95% CI: 1.07-1.62) but the 5-year disease-specific survival rate was not significantly different between the comorbid and non-comorbid groups (53.9% vs. 53.1%, adjusted HR = 1.11, 95% CI: 0.86-1.42). The 5-year incidence rate of death from other diseases in the comorbid group was significantly higher than that in the non-comorbid group (26.7% vs. 14.8%, P < 0.01). The leading cause of death from other diseases was pneumonia.

CONCLUSIONS

Oesophagectomy in oesophageal cancer patients with comorbidity can be safely performed. However, the overall survival after oesophagectomy in these patients was unfavorable because of the high incidence of death from other diseases, especially pneumonia.

Pathologic Complete Response Is an Independent Predictor of Improved Survival Following Neoadjuvant Chemoradiation for Esophageal Adenocarcinoma

INTRODUCTION

Reports of improved survival in patients with pathologic complete response (pCR) to neoadjuvant therapy for esophageal and gastroesophageal junction (GEJ) adenocarcinoma is extrapolated from heterogeneous studies that include squamous cell histology. We sought to determine if pCR is associated with a survival advantage in a homogenous group of patients with esophageal adenocarcinoma.

METHODS

This is a single institution analysis of all patients with T2-T4 or node positive esophageal adenocarcinoma treated with neoadjuvant chemoradiotherapy and esophagectomy between 2004 and 2014. Patients were divided into two groups based on pathological response, pCR vs. incomplete pathological response (iPR). Survival outcomes were evaluated using standard Kaplan-Meier methods and multivariable Cox regression models.

RESULTS

A total of 205 patients were included in the study: 38 (19 %) patients with pCR and 167 patients (81 %) with iPR. The two groups were similar with respect to clinical stage, age, gender, comorbid conditions, ECOG status, smoking, and alcohol use. Patients in the pCR group had a higher percentage of tumors located in middle third of esophagus (11 vs. 2 %, p = 0.04) while tumor grade was similar in both groups. Median follow-up was 50 months, range 2-109 months. The 3-year overall (OS) and recurrence-free survival (RFS) for iPR was 48 and 39 %, respectively, vs. 86 and 80 % for pCR group, respectively.

CONCLUSION

This analysis of a cohort of homogeneous patients with esophageal adenocarcinoma undergoing multimodality therapy showed that pCR is an independent predictor of improved RFS and OS. This data contributes to a growing body of evidence highlighting the benefits of neoadjuvant therapy specific to esophageal adenocarcinoma particularly when pCR is achieved.

Incidence and impact of postoperative atrial fibrillation after minimally invasive esophagectomy

Atrial fibrillation (AF) following open esophagectomy has been associated with increased rates of pulmonary and anastomotic complications, and mortality. This study seeks to evaluate effects of AF after minimally invasive esophagectomy (MIE). A retrospective review of patients consecutively treated with MIE for esophageal carcinoma, dysplasia. and benign disease from November 2006 to November 2011 was performed. One hundred twenty-one patients underwent MIE. Median age was 65 years (range 26-88) with 85% being male. Thirty-eight (31.4%) patients developed AF postoperatively. Of these 38 patients, 7 (18.4%) had known AF preoperatively. Patients with postoperative AF were significantly older than those without postoperative AF (68.7 vs. 62.8 years, P = 0.008) and more likely to be male (94.7% vs. 80.7%, P = 0.04). Neoadjuvant chemoradiation showed a trend toward increased risk of AF (73.7% vs 56.6%, P = 0.07). Sixty-day mortality was 2 of 38 (5.3%) in patients with AF and 4 of 83 (6.0%) in the no AF cohort (P = 1.00). The group with AF had increased length of hospitalization (13.4 days vs. 10.6 days P = 0.02). No significant differences in rates of pneumonia (31.6% vs. 21.7% P = 0.24), stricture (13.2% vs. 26.5% P = 0.10), or leak requiring return to operating room (13.2% vs. 8.4% P = 0.51) were noted between groups. We did not find an increased rate of AF in our MIE cohort compared with prior reported rates in open esophagectomy populations. AF did result in an increased length of stay but was not a predictor of other short-term morbidities including anastomotic leak, pulmonary complications, stenosis, or 60-day mortality.

Significant understaging is seen in clinically staged T2N0 esophageal cancer patients undergoing esophagectomy

This study aimed to determine the impact of preoperative staging on the treatment of clinical T2N0 (cT2N0) esophageal cancer patients undergoing esophagectomy. We reviewed a retrospective cohort of 27 patients treated at a single institution between 1999 and 2011. Clinical staging was performed with computed tomography, positron emission tomography, and endoscopic ultrasound. Patients were separated into two groups: neoadjuvant therapy followed by surgery (NEOSURG) and surgery alone (SURG). There were 11 patients (41%) in the NEOSURG group and 16 patients (59%) in the SURG group. In the NEOSURG group, three of 11 patients (27%) had a pathological complete response and eight (73%) were partial or nonresponders after neoadjuvant therapy. In the SURG group, nine of 16 patients (56%) were understaged, 6 (38%) were overstaged, and 1 (6%) was correctly staged. In the entire cohort, despite being clinically node negative, 14 of 27 patients (52%) had node-positive disease (5/11 [45%] in the NEOSURG group, and 9/16 [56%] in the SURG group). Overall survival rate was not statistically significant between the two groups (P = 0.96). Many cT2N0 patients are clinically understaged and show no preoperative evidence of node-positive disease. Consequently, neoadjuvant therapy may have a beneficial role in treatment.

Laparoscopic versus open transhiatal oesophagectomy for oesophageal cancer

BACKGROUND

Surgery is the preferred treatment for resectable oesophageal cancers, and can be performed in different ways. Transhiatal oesophagectomy (oesophagectomy without thoracotomy, with a cervical anastomosis) is one way to resect oesophageal cancers. It can be performed laparoscopically or by open method. With other organs, laparoscopic surgery has been shown to reduce complications and length of hospital stay compared to open surgery. However, concerns remain about the safety of laparoscopic transhiatal oesophagectomy in terms of post-operative complications and oncological clearance compared with open transhiatal oesophagectomy.

OBJECTIVES

To assess the benefits and harms of laparoscopic versus open oesophagectomy for people with oesophageal cancer undergoing transhiatal oesophagectomy.

SEARCH METHODS

We electronically searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, Science Citation Index Expanded, and trials registers until August 2015. We also searched the references of included trials to identify further trials.

SELECTION CRITERIA

We considered randomised controlled trials and non-randomised studies comparing laparoscopic with open transhiatal oesophagectomy in patients with resectable oesophageal cancer, regardless of language, blinding, or publication status for the review.

DATA COLLECTION AND ANALYSIS

Three review authors independently identified trials, assessed risk of bias and extracted data. We calculated the risk ratio (RR) or hazard ratio (HR) with 95% confidence intervals (CI), using both fixed-effect and random-effects models, with RevMan 5, based on intention-to-treat analyses.

MAIN RESULTS

We found no randomised controlled trials on this topic. We included six non-randomised studies (five retrospective) that compared laparoscopic versus open transhiatal oesophagectomy (334 patients: laparoscopic = 154 patients; open = 180 patients); five studies (326 patients: laparoscopic = 151 patients; open = 175 patients) provided information for one or more outcomes. Most studies included a mixture of adenocarcinoma and squamous cell carcinoma and different stages of oesophageal cancer, without metastases. All the studies were at unclear or high risk of bias; the overall quality of evidence was very low for all the outcomes.The differences between laparoscopic and open transhiatal oesophagectomy were imprecise for short-term mortality (laparoscopic = 0/151 (adjusted proportion based on meta-analysis estimate: 0.5%) versus open = 2/175 (1.1%); RR 0.44; 95% CI 0.05 to 4.09; participants = 326; studies = 5; I² = 0%); long-term mortality (HR 0.97; 95% CI 0.81 to 1.16; participants = 193; studies = 2; I² = 0%); anastomotic stenosis (laparoscopic = 4/36 (11.1%) versus open = 3/37 (8.1%); RR 1.37; 95% CI 0.33 to 5.70; participants = 73; studies = 1); short-term recurrence (laparoscopic = 1/16 (6.3%) versus open = 0/4 (0%); RR 0.88; 95% CI 0.04 to 18.47; participants = 20; studies = 1); long-term recurrence (HR 1.00; 95% CI 0.84 to 1.18; participants = 173; studies = 2); proportion of people who required blood transfusion (laparoscopic = 0/36 (0%) versus open = 6/37 (16.2%); RR 0.08; 95% CI 0.00 to 1.35; participants = 73; studies = 1); proportion of people with positive resection margins (laparoscopic = 15/102 (15.8%) versus open = 27/111 (24.3%); RR 0.65; 95% CI 0.37 to 1.12; participants = 213; studies = 3; I² = 0%); and the number of lymph nodes harvested during surgery (median difference between the groups varied from 12 less to 3 more lymph nodes in the laparoscopic compared to the open group; participants = 326; studies = 5).The proportion of patients with serious adverse events was lower in the laparoscopic group (10/99, (10.3%) compared to the open group = 24/114 (21.1%); RR 0.49; 95% CI 0.24 to 0.99; participants = 213; studies = 3; I² = 0%); as it was for adverse events in the laparoscopic group = 37/99 (39.9%) versus the open group = 71/114 (62.3%); RR 0.64; 95% CI 0.48 to 0.86; participants = 213; studies = 3; I² = 0%); and the median lengths of hospital stay were significantly less in the laparoscopic group than the open group (three days less in all three studies that reported this outcome; number of participants = 266). There was lack of clarity as to whether the median difference in the quantity of blood transfused was statistically significant favouring laparoscopic oesophagectomy in the only study that reported this information. None of the studies reported post-operative dysphagia, health-related quality of life, time-to-return to normal activity (return to pre-operative mobility without caregiver support), or time-to-return to work.

AUTHORS' CONCLUSIONS

There are currently no randomised controlled trials comparing laparoscopic with open transhiatal oesophagectomy for patients with oesophageal cancers. In observational studies, laparoscopic transhiatal oesophagectomy is associated with fewer overall complications and shorter hospital stays than open transhiatal oesophagectomy. However, this association is unlikely to be causal. There is currently no information to determine a causal association in the differences between the two surgical approaches. Randomised controlled trials comparing laparoscopic transhiatal oesophagectomy with other methods of oesophagectomy are required to determine the optimal method of oesophagectomy.

A Newly Designed Enterocutaneous Esophageal Fistula Model in the Pig

Background Fistulas after esophagectomy are a significant cause of morbidity and mortality. Several endoscopic treatments have been attempted, with varying success. An experimental model that could validate new approaches such as cellular therapies is highly desirable. The aim of this study was to create a chronic esophageal enterocutaneous fistula model in order to study future experimental treatment options. Methods Eight pigs (six 35-kg young German and two 50-kg adult Yucatan pigs) were used. Through a left and right cervicotomy, under endoscopic view, 1 (group A, n = 6) or 2 (group B, n = 7) plastic catheters were introduced into the esophagus 30 cm from the dental arches bilaterally and left in place for 1 month. Radiologic and endoscopic fistula tract evaluations were performed at postoperative day (POD; 30) and at sacrifice (POD 45). Results Three fistulas were excluded from the study because of early (POD 5) dislodgment of the catheter, with complete fistula closure. At catheter removal (POD 30), the external orifice was larger in group B (5.2 ± 1.1 mm vs 2.6 ± 0.4 mm) with more severe inflammation (72% vs 33%). At POD 45, the external orifice was closed in all fistulas in group A and in 1/7 in group B. At necropsy, the fistula tract was still present in all animals. Yucatan pigs showed more complex tracts, with a high level of necrosis and substantial fibrotic infiltration. Conclusions In this article, we show a reproducible, safe, and effective technique to create an esophagocutaneous fistula model in a large experimental animal.

Laparoscopic Gastric Mobilization Reduces Postoperative Mortality After Esophageal Cancer Surgery: A French Nationwide Study

OBJECTIVE

This study was designed to investigate the impact of laparoscopic gastric mobilization (LGM) on 30-day postoperative mortality (POM) after surgery for esophageal cancer (EC).

BACKGROUND

Meta-analyses of nonrandomized studies have failed to demonstrate any significant benefit of hybrid minimally invasive esophagectomy on POM, potentially due to small population samples. Moreover, none of the published randomized trials have been designed to answer this question.

METHODS

All consecutive patients who underwent EC resection between 2010 and 2012 in France were included in this nationwide study (n = 3009). Data were extracted from the French National Health Service Database with internal and external quality controls. Patients treated with LGM (LGM group, n = 663) were compared with those treated with open approach (open group, n = 2346). Propensity score matching and multivariable analyses were used to compensate for the differences in baseline characteristics.

RESULTS

The 30-day POM rate was 5.2%, significantly lower after LGM, compared with open surgery (3.3% vs 5.7%, P = 0.005), as well as in-hospital (5.6% vs 8.1%, P = 0.028), and 90-day POM (6.9% vs 10.0%, P = 0.016). After propensity score matching, 30-day POM rates were 3.3% versus 5.9%, respectively (P = 0.029). By multivariable analysis, age ≥60 years, malnutrition and cardiovascular comorbidity were independently associated with higher POM, whereas LGM was associated with a decrease in POM (OR 0.60, 95% CI 0.37-0.98, P = 0.041).

CONCLUSIONS

This all-inclusive nationwide study strongly suggests that POM is significantly reduced after LGM for EC. This is high valuable evidence that helps decision making regarding the optimal approach for EC surgery.

Minimally Invasive Versus Open Esophagectomy for Esophageal Cancer: A Comparison of Early Surgical Outcomes From The Society of Thoracic Surgeons National Database

BACKGROUND

Open esophagectomy results in significant morbidity and mortality. Minimally invasive esophagectomy (MIE) has become increasingly popular at specialized centers with the aim of improving perioperative outcomes. Numerous single-institution studies suggest MIE may offer lower short-term morbidity. The two approaches are compared using a large, multiinstitutional database.

METHODS

The Society of Thoracic Surgeons (STS) National Database (v2.081) was queried for all resections performed for esophageal cancer between 2008 and 2011 (n = 3,780). Minimally invasive approaches included both transhiatal (n = 214) and Ivor Lewis (n = 600), and these were compared directly with open transhiatal (n = 1,065) and Ivor Lewis (n = 1,291) procedures, respectively. Thirty-day outcomes were examined using nonparametric statistical testing.

RESULTS

Both open and MIE groups were similar in terms of preoperative risk factors. Morbidity and all-cause mortality were equivalent at 62.2% and 3.8%. MIE was associated with longer median procedure times (443.0 versus 312.0 minutes; p < 0.001), but a shorter median length of hospital stay (9.0 versus 10.0 days; p < 0.001). Patients who underwent MIE had higher rates of reoperation (9.9% versus 4.4%; p < 0.001) and empyema (4.1% versus 1.8%; p < 0.001). Open technique led to an increased rate of wound infections (6.3% versus 2.3%; p < 0.001), postoperative transfusion (18.7% versus 14.1%; p = 0.002), and ileus (4.5% versus 2.2%; p = 0.002). Propensity score-matched analysis confirmed these findings. High- and low-volume centers had similar outcomes.

CONCLUSIONS

Early results from the STS National Database indicate that MIE is safe, with comparable rates of morbidity and mortality as open technique. Longer procedure times and a higher rate of reoperation following MIE may reflect a learning curve.

Does minimally invasive oesophagectomy provide a benefit in hospital length of stay when compared with open oesophagectomy?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was: 'in patients undergoing oesophagectomy, does a minimally invasive approach convey a benefit in hospital length of stay (LOS), when compared to an open approach?' A total of 647 papers were identified, using an a priori defined search strategy; 24 papers represented the best evidence to answer the clinical question. The authors, journal, date, country of publication, patient group, study type, relevant outcomes and key results are tabulated. Of the studies identified, data from two randomized controlled trials were available. The first randomized study compared the use of open thoracotomy and laparotomy versus thoracoscopy and laparoscopy. Those undergoing minimally invasive oesophagectomy (MIO) left hospital on average 3 days earlier than those treated with the open oesophagectomy (OO) technique (P = 0.044). The other randomized trial, which compared thoracotomy with thoracoscopy and laparoscopy, demonstrated a reduction of 1.8 days in the LOS when employing the MIO technique (P < 0.001). With the addition of the remaining 22 non-randomized studies, comprising 3 prospective and 19 retrospective cohort studies, which are heterogeneous with regard to their design, study populations and outcomes; data are available representing 3173 MIO and 25 691 OO procedures. In total, 13 studies (including the randomized trials) demonstrate a significant reduction in hospital LOS associated with MIO; 10 suggest no significant difference between techniques; and only 1 suggests a significantly greater length of stay associated with MIO. The only two randomized trials comparing MIO and OO demonstrated a reduction in length of stay in the MIO group, without compromising survival or increasing complication rates. All bar one of the non-randomized studies demonstrated either a significant reduction in length of stay with MIO or no difference. The benefit in reduced length of stay was not at the cost of worsened survival or increased complications, and conversion rates in all studies were low.

Combined thoracoscopic-laparoscopic esophagectomy versus open esophagectomy: a meta-analysis of outcomes

OBJECTIVES

At present there is controversy regarding the optimal surgical method for esophageal cancer. Specifically, whether combined thoracoscopic-laparoscopic esophagectomy is superior to open esophagectomy with respect to the surgical wound, perioperative morbidities and mortality, and the overall survival rate is of great concern. This article aimed to compare thoracoscopic-laparoscopic esophagectomy versus open esophagectomy on the perioperative morbidities and long-term survival.

METHODS

PubMed, Embase, and Google Scholar databases were searched for relevant studies comparing combined thoracoscopic-laparoscopic esophagectomy with open esophagectomy using the Preferred Reporting Items for Systemic Reviews and Meta-Analyses standards. Odds ratios were extracted to give pooled estimates of the perioperative effect of the two surgical procedures. Hazard ratios were extracted to compare overall survival between the two surgical procedures.

RESULTS

Thirteen studies involving 1549 patients were included in this meta-analysis. We found that patients that underwent combined thoracoscopic-laparoscopic esophagectomy had lower total complication rates (relative risk 1.20; 95 % CI 1.08-1.34; p = 0.0009), wound infection rates, pulmonary complications, and less intraoperative blood loss. Moreover, our study also showed combined thoracoscopic-laparoscopic esophagectomy did not compromise the 5-year survival rate (hazard risk 0.920; 95 % CI 0.720-1.176; p = 0.505) and even improved 2-year survival rate. The 30-day mortality and other common morbidities, including anastomotic leakage, anastomotic stricture, pulmonary infection, chylothorax, arrhythmia, or recurrent laryngeal nerve injury, were not significantly different between combined thoracoscopic-laparoscopic esophagectomy and traditional open esophagectomy (p > 0.05).

CONCLUSIONS

Combined thoracoscopic-laparoscopic esophagectomy is a feasible and reliable surgical procedure that can achieve uncompromising long-term survival rates and reduce perioperative complications.

Transthoracic Extracorporeal Gastric Conduit Preparation for Minimally Invasive Ivor-Lewis Esophagectomy

OBJECTIVE

During totally minimally invasive esophagectomy (MIE), the gastric conduit is typically constructed via laparoscopy. Trauma from laparoscopic instruments, inability to palpate the gastroepiploic arcade, and challenges in optimal positioning of the stomach for intra-abdominal stapling have led to the widespread use of laparotomy as part of hybrid MIE procedures. Our objective was to evaluate the safety of transthoracic extracorporeal gastric conduit preparation. We hypothesize that this alternative technique is equivalent in safety to the laparoscopic approach.

METHODS

This is a retrospective comparison of laparoscopic and transthoracic extracorporeal gastric conduit preparation with regard to anastomotic and respiratory outcomes.

RESULTS

During a 3-year period, 30 patients underwent MIE with a right intrathoracic anastomosis (extracorporeal conduit, 15; laparoscopic conduit, 15). Mean age (58.6 vs 67 years, P = 0.59), tumor location (gastroesophageal junction vs middle and lower esophageal, P = 0.27), and histology (adenocarcinoma vs other 26.7%, P = 0.68) were similar between groups. Anastomotic technique and operating surgeon were the same for all patients. Patients in the laparoscopic gastric conduit group were more likely to have undergone induction chemoradiotherapy (40% vs 80%, P = 0.030). There was no significant difference between groups with respect to anastomotic complications, including anastomotic leak and anastomotic stricture (20% vs 13.3%, P = 0.70). Transthoracic gastric conduit preparation was not associated with increased respiratory complications (8% vs 12%, P = 0.09).

CONCLUSIONS

Transthoracic gastric conduit preparation is a simple, minimally invasive alternative laparotomy for gastric conduit preparation during MIE. No additional incision is required. The technique may help surgeons overcome shortcomings of the laparoscopic approach without impacting perioperative risk.

Oncological and surgical outcomes of minimally invasive versus open esophagectomy for esophageal squamous cell carcinoma: a matched-pair comparative study

Only a few series have demonstrated the safety and efficacy of minimally invasive esophagectomy (MIE) for esophageal squamous cell carcinoma and the benefits of this approach. This report describes the results of a pair-matched comparative study between minimally invasive and open esophagectomy (OE) for esophageal squamous cell carcinoma. Patients were retrospectively matched in pairs for the following criteria: age, sex, American Society of Anesthesiology (ASA) score, clinical TNM stage, tumor location, and type of resection. A total of 97 patients undergoing MIE were compared with patients undergoing OE during the same period. Operative, postoperative, and oncologic outcomes were compared. Significantly less bleeding was observed in the MIE group (P = 0.001). Transfusion was required for three patients in the MIE group and ten patients in the OE group (P = 0.044). Overall morbidity was similar in the two groups. The hospital stay was significantly shorter for the patients undergoing MIE (P = 0.027). The surgical margin and tumor stage were not affected by MIE. The overall survival rates in the MIE group were 54% at 5 years and 46% in the OE group (P = 0.631). The disease-free survival rates in the MIE group were 45% at 5 years, 41% in the OE group (P = 0.704). In summary, MIE for esophageal squamous cell carcinoma for selected patients gave a better postoperative outcome without oncologic consequences.