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Transition from open to minimally invasive en bloc esophagectomy can be achieved without compromising surgical quality

  • 2020 SAGES Oral
  • Published:
Surgical Endoscopy Aims and scope Submit manuscript

Abstract

Background

En bloc esophagectomy results in higher lymph node (LN) retrieval than standard esophagectomy. Minimally invasive esophagectomy (MIE) has gained traction due to improved short-term outcomes, but many large series report LN yields well below the international benchmark of 23. We sought to determine if an established approach to open en bloc resection can be safely transferred to MIE using LN yield as a quality benchmark.

Methods

An open approach to en bloc esophagectomy (OE) was established over 5 years (~ 300 cases) before en bloc MIE was introduced in 2010. Patients undergoing curative-intent en bloc Ivor-Lewis and McKeown esophagectomy for cancer from 2010 to 2019 by a single surgeon with formal minimally invasive surgery training were identified from a prospectively collected database. Mann–Whitney U and χ2 tests and cumulative sum analysis were used for statistical analysis. “Failure” was defined as LN yield less than AJCC’s 8th edition guidelines: 10 LNs for pT1 cancers, 20 for pT2 and 30 for pT3–4.

Results

A total of 269 esophageal resections met inclusion criteria [193(72%) OE; 76(28%) MIE]. Age, sex, BMI and comorbidities were comparable between groups. Tumors were larger and more often locally advanced in OE. Median LN retrieval was sufficient by international standards in both groups [OE:34(27–46); MIE:28(22–39); p = 0.01]. “Failures” occurred in 33(17%) of OE and 12(16%) MIE cases (p = 0.63). No learning effect was observed for LN yield. R0 resection rate was comparable [OE:191(99%); MIE:73(96%); p = 0.90]. Operative time was longer for MIE [275(246–300)] than OE [240(210–270) minutes], p < 0.0001, while estimated blood loss (OE:350(250–500)mL; MIE:300(200–400)mL; p = 0.02] and length of stay [OE:8(6–13); MIE7(6–9) days; p = 0.02] were higher for OE. Morbidity and mortality were comparable between groups and LN yield did not impact survival.

Conclusions

Under appropriate conditions, an established approach to open en bloc esophagectomy can be safely transferred to MIE without compromising surgical quality.

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Acknowledgements

We would like to thank Aya Siblini for assisting with securing research ethics review board approval and Samantha Lancione for obtaining mortality data.

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Authors and Affiliations

  1. Division of Thoracic and Upper Gastrointestinal Surgery, McGill University Health Centre, Montreal, Quebec, Canada

    Anitha Kammili, Jonathan Cools-Lartigue, David Mulder, Lorenzo E. Ferri & Carmen L. Mueller

  2. Division of General Surgery, McGill University Health Centre, Montreal, Quebec, Canada

    Liane S. Feldman, Lorenzo E. Ferri & Carmen L. Mueller

Authors
  1. Anitha Kammili
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  2. Jonathan Cools-Lartigue
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Correspondence to Anitha Kammili.

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Drs. Carmen L. Mueller, Lorenzo E. Ferri, Liane S. Feldman, David Mulder, Jonathan Cools-Lartigue and Anitha Kammili have no conflicts of interest or financial ties to disclose.

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Kammili, A., Cools-Lartigue, J., Mulder, D. et al. Transition from open to minimally invasive en bloc esophagectomy can be achieved without compromising surgical quality. Surg Endosc 35, 3067–3076 (2021). https://doi.org/10.1007/s00464-020-07696-0

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