Substitute or coexistence? Mediastinoscopy-assisted versus thoracoscope-assisted esophagectomy in esophageal cancer: a meta-analysis of perioperative outcomes and long-term survival

Abstract

Background: Currently, mediastinoscopy-assisted esophagectomy (MAE) and thoracoscope-assisted esophagectomy (TAE) represent two prevalent forms of minimally invasive esophagectomy extensively employed in the management of esophageal cancer (EC). The aim of this meta-analysis is to assess and compare these two surgical approaches concerning perioperative outcomes and long-term survival, offering valuable insights for refining surgical strategies and enhancing patient outcomes in this field.

Methods: Adhering to PRISMA guidelines, the authors systematically searched PubMed, Web of Science, Cochrane Library, Embase, and CNKI databases until 1 March 2024, for studies comparing MAE and TAE. Outcomes of interest included perioperative outcomes (intraoperative outcomes, postoperative recovery, postoperative complications) and survival rates. Statistical analyses were performed using RevMan 5.4, with heterogeneity dictating the use of fixed or random-effects models.

Results: A total of 21 relevant studies were finally included. MAE was associated with significantly shorter operation times [mean difference (MD)=-59.58 min, 95% CI: -82.90 to -36.26] and less intraoperative blood loss (MD=-68.34 ml, 95% CI: -130.45 to -6.23). However, MAE resulted in fewer lymph nodes being dissected (MD=-3.50, 95% CI: -6.23 to -0.78). Postoperative recovery was enhanced following MAE, as evidenced by reduced hospital stays and tube times. MAE significantly reduced pulmonary complications [odds ratio (OR)=0.59, 95% CI: 0.44, 0.81] but increased the incidence of recurrent laryngeal nerve injury (OR=1.84, 95% CI: 1.30, 2.60). No significant differences were observed in anastomotic leakage, chylothorax, cardiac complications, wound infections, and gastric retention between MAE and TAE. The long-term survival outcomes showed no statistical difference [hazard ratio (HR)=1.05, 95% CI: 0.71, 1.54].

Conclusions: MAE offers advantages in reducing operation time, blood loss, and specific postoperative complications, particularly pulmonary complications, with a shorter recovery period compared to TAE. However, it poses a higher risk of recurrent laryngeal nerve injury and results in fewer lymph nodes being dissected. No difference in long-term survival was observed, indicating that both techniques have distinct benefits and limitations. These findings underscore the need for personalized surgical approaches in EC treatment, considering individual patient characteristics and tumor specifics.

Figure 1

The flow diagram showing the process of study selection.

Figure 2

Forest plots of studies evaluating MDs of MAE versus TAE on intraoperative outcomes of esophageal cancers, stratified by (A) operation time; (B) hemorrhage in operation; (C) number of lymph nodes dissected. MAE, mediastinoscopy-assisted esophagectomy; TAE, thoracoscope-assisted esophagectomy.

Figure 3

Forest plots of studies evaluating MDs of MAE versus TAE on (A) hospital days; (B) postoperative tube time; (C) 24 h postoperative drainage volume; (D) 72 h postoperative drainage volume; and (E) postoperative lCU days of esophageal cancers. MAE, mediastinoscopy-assisted esophagectomy; TAE, thoracoscope-assisted esophagectomy.

Figure 4

Forest plots of studies evaluating ORs of MAE versus TAE on postoperative complications of esophageal cancers, stratified by (A) pulmonary complications; (B) anastomotic leakage; and (C) recurrent laryngeal nerve injury. MAE, mediastinoscopy-assisted esophagectomy; TAE, thoracoscope-assisted esophagectomy.

Figure 5

Forest plots of studies evaluating ORs of MAE versus TAE on (A) chylothorax; (B) cardiac complications; (C) wound infections; and (D) gastric retention of esophageal cancers. MAE, mediastinoscopy-assisted esophagectomy; TAE, thoracoscope-assisted esophagectomy.

Figure 6

Forest plots of ORs for pulmonary complications in esophageal cancer patients who underwent MAE compared with TAE stratified by (A) cancer type; (B) treatment methods; and (C) methods of TAE. EC, esophageal cancer; ESCC, esophageal squamous cell cancer; MAE, mediastinoscopy-assisted esophagectomy; TAE, thoracoscope-assisted esophagectomy.

Figure 7

Forest plots of ORs for anastomotic leakages in esophageal cancer patients who underwent MAE compared with TAE stratified by (A) cancer type; (B) treatment methods; and (C) methods of TAE. EC, esophageal cancer; ESCC, esophageal squamous cell cancer; MAE, mediastinoscopy-assisted esophagectomy; TAE, thoracoscope-assisted esophagectomy.

Figure 8

Forest plots of ORs for recurrent laryngeal nerve injury in esophageal cancer patients who underwent MAE compared with TAE stratified by (A) cancer type; (B) treatment methods; and (C) methods of TAE. EC, esophageal cancer; ESCC, esophageal squamous cell cancer; MAE, mediastinoscopy-assisted esophagectomy; TAE, thoracoscope-assisted esophagectomy.

Figure 9

Forest plots of studies evaluating HRs of MAE versus TAE on overall survival of esophageal cancers. MAE, mediastinoscopy-assisted esophagectomy; TAE, thoracoscope-assisted esophagectomy.

Figure 10

Sensitivity analysis for meta-analysis of mediastinoscopy-assisted esophagectomy compared with thoracoscope-assisted esophagectomy on (A) pulmonary complications; (B) anastomotic leakage; (C) recurrent laryngeal nerve injury; (D) overall survival.

Figure 11

Funnel plots of publication bias for meta-analysis of mediastinoscopy-assisted esophagectomy compared with thoracoscope-assisted esophagectomy for (A) pulmonary complications; (B) anastomotic leakage; (C) recurrent laryngeal nerve injury; (D) overall survival.