Comparison of short-term outcomes between minimally invasive McKeown and Ivor Lewis esophagectomy for esophageal or junctional cancer: a systematic review and meta-analysis

Abstract

Purpose: Minimally invasive esophagectomy is increasingly performed for esophageal or gastroesophageal junctional cancer, with advantages of improved perioperative outcomes in comparison with open esophagectomy. McKeown and Ivor Lewis are widely used procedures of minimally invasive esophagectomy, and there have been controversies on which one is preferred for patients with resectable esophageal or junctional cancer.

Patients and methods: This review was registered at the International Prospective Register of Systematic Reviews (number CRD42017075989). Studies in PubMed, Embase, Web of Science, the Cochrane Library, and ClinicalTrials.gov were thoroughly investigated. Eligible studies included prospective and retrospective studies evaluating short-term outcomes of minimally invasive McKeown esophagectomy (MIME) vs minimally invasive Ivor Lewis esophagectomy (MILE) in patients with resectable esophageal or junctional tumors. Main parameters included anastomotic leak and 30-day/in-hospital mortality. Overall incidence rates (ORs)/weighted mean difference (WMD) with 95% confidence intervals (CIs) were calculated by employing random-effects models.

Results: Fourteen studies containing 3,468 cases were included in this meta-analysis. Age, male sex, and American Joint Committee on Cancer (AJCC) stage between the 2 groups were not statistically different. MIME led to more blood loss, longer operating time, and longer hospital stay than MILE. MIME was associated with higher incidence of pulmonary complications (OR =1.96, 95% CI =1.28-3.00) as well as total anastomotic leak (OR =2.55, 95% CI =1.40-4.63), stricture (OR =2.07, 95% CI =1.05-4.07), and vocal cord injury/palsy (OR =5.62, 95% CI =3.46-9.14). In addition, the differences of R0 resection rate, number of lymph modes retrieved, blood transfusion rate, length of intensive care unit stay, incidence of cardiac arrhythmia, and Chyle leak between MIME and MILE were not statistically significant. Notably, incidence of severe anastomotic leak (OR =1.28, 95% CI =0.73-2.24) and 30-day/in-hospital mortality (OR =1.76, 95% CI =0.92-3.36) as well as 90-day mortality (OR =2.22, 95% CI =0.71-6.98) between the 2 procedures were also not significantly different.

Conclusion: This study suggests that MIME and MILE are comparable with respect to clinical safety. MILE may be a better option when oncologically and clinically suitable. MIME is still a safe alternative procedure when clinically indicated. However, this evidence is at risk for bias; randomized controlled trials are needed to validate or correct our results.

Keywords: Ivor Lewis esophagectomy; McKeown esophagectomy; cervical anastomosis; intrathoracic anastomosis; minimally invasive esophagectomy (MIE).

Figure 1

PRISMA 2009 flow diagram. Abbreviation: PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Figure 2

Meta-analysis for anastomotic leak. Note: Weights are from random-effects analysis. Abbreviations: CI, confidence interval; MILE, minimally invasive Ivor Lewis esophagectomy; MIME, minimally invasive McKeown esophagectomy; OR, odds ratio.

Figure 3

Sensitivity analysis for anastomotic leak. Abbreviation: CI, confidence interval.

Figure 4

Meta-analysis for severe anastomotic leak. Note: Weights are from random-effects analysis. Abbreviations: CI, confidence interval; MILE, minimally invasive Ivor Lewis esophagectomy; MIME, minimally invasive McKeown esophagectomy; OR, odds ratio.

Figure 5

Meta-analysis for vocal cord injury/palsy. Note: Weights are from random-effects analysis. Abbreviations: CI, confidence interval; MILE, minimally invasive Ivor Lewis esophagectomy; MIME, minimally invasive McKeown esophagectomy; OR, odds ratio.

Figure 6

Meta-analysis for 30-day/in-hospital mortality. Note: Weights are from random-effects analysis. Abbreviations: CI, confidence interval; MILE, minimally invasive Ivor Lewis esophagectomy; MIME, minimally invasive McKeown esophagectomy; OR, odds ratio.

Figure 7

Meta-analysis for 90-day mortality. Note: Weights are from random-effects analysis. Abbreviations: CI, confidence interval; MILE, minimally invasive Ivor Lewis esophagectomy; MIME, minimally invasive McKeown esophagectomy; OR, odds ratio.