Minimally Invasive Versus Open Esophagectomy for Esophageal Cancer: A Population-Based Analysis

Abstract

Background: The objective of this study was to evaluate outcomes of minimally invasive approaches to esophagectomy using population-level data.

Methods: Multivariable regression modeling was used to determine predictors associated with the use of minimally invasive approaches for patients in the National Cancer Data Base who underwent resection of middle and distal clinical T13N03M0 esophageal cancers from 2010 to 2012. Perioperative outcomes and 3-year survival were compared between propensity-matched groups of patients with esophageal cancer who underwent minimally invasive esophagectomy (MIE) or open esophagectomy (OE). A subgroup analysis was performed to evaluate the impact of using robotic-assisted operations as part of the minimally invasive approach.

Results: Among 4,266 patients included, 1,308 (30.6%) underwent MIE. It was more likely to be used in patients treated at academic (adjusted odds ratio [OR], 10.1; 95% confidence interval [CI], 4.2-33.1) or comprehensive cancer facilities (adjusted OR, 6.4; 95% CI, 2.6-21.1). Compared with propensity-matched patients who underwent OE, patients who underwent MIE had significantly more lymph nodes examined (15 versus 13; p = 0.016) and shorter hospital lengths of stay (10 days versus 11 days; p = 0.046) but similar resection margin positivity, readmission, and 30-day mortality (all p > 0.05). Survival was similar between the matched groups at 3 years for both adenocarcinoma and squamous cell carcinoma (p > 0.05). Compared with MIE without robotic assistance, use of a robotic approach was not associated with any significant differences in perioperative outcomes (p > 0.05).

Conclusions: The use of minimally invasive techniques to perform esophagectomy for esophageal cancer is associated with modestly improved perioperative outcomes without compromising survival.

Fig 1

Forest plot of factors associated with use of minimally invasive esophagectomy (MIE). Black squares represent odds ratios for the independent association of each factor with using MIE; 95% confidence interval bounds are represented by the corresponding horizontal lines. Factors to the right of the vertical line at 1.0 are independently associated with using MIE. Patients receiving care at an academic or comprehensive institution are associated with use of minimally invasive esophagectomies, whereas patients with cT2 and cT3 tumors were associated with use of open esophagectomy (OE).

Fig 2

Survival of open esophagectomy (OE) versus minimally invasive esophagectomy (MIE) and standard minimally invasive esophagectomy (SMIE) versus robotic-assisted minimally invasive esophagectomy (RAMIE), stratified by histologic type. (A) Adenocarcinoma: OE versus MIE; (B) adenocarcinoma: SMIE versus RAMIE; (C) squamous cell carcinoma: OE versus MIE; (D) squamous cell carcinoma: SMIE versus RAMIE.