Hybrid minimally invasive esophagectomy associated with lower complication rates compared to open esophagectomy

1. A hybrid minimally invasive esophagectomy approach (Ivor-Lewis esophagectomy) was found to have lower rates of intraoperative and postoperative complications after 30 days as compared to an open esophagectomy approach.

2. Disease-free survival and overall survival, though not statistically significant, trended towards higher rates with the minimally invasive hybrid approach.

Evidence Rating Level: 1 (Excellent)

Study Rundown: New surgical approaches to treat esophageal cancer have recently been proposed and are under study for their safety and efficacy. In this randomized control trial, researchers compared the efficacy of a hybrid minimally invasive surgical approach in which surgeons combine a laparoscopic abdominal access route and open thoracotomy to a traditional open esophagectomy procedure for patients that had squamous-cell carcinoma or adenocarcinoma of the middle or lower third of the esophagus. Both procedures were assessed for their rates of intraoperative or postoperative complications, with special attention given to rates of pulmonary complications. Overall, researchers found that the hybrid approach resulted in lower rates of intraoperative and postoperative complications, as well as lower rates of pulmonary complications. Overall survival and disease-free survival rates trended towards being higher in the in the hybrid surgery group, though not significant.

While more investigation is needed, these findings suggest there is merit in considering adoption of this minimally invasive approach when surgically treating esophageal cancer. Strengths of the study include its randomized design, measures taken in attempt to standardize surgical technique, and robust clinical follow-up. Limitations include the small sample size and inclusion of only notably experienced surgeons affecting generalizability.

Click to read the study in NEJM

Relevant Reading: Minimally invasive versus open oesophagectomy for patients with oesophageal cancer: a multicentre, open-label, randomised controlled trial

In-Depth [randomized controlled trial]:  This multicenter, open-label, intention-to-treat randomized controlled trial enrolled 207 patients from 2009 to 2012. Using a stratified block-randomization scheme, patients were enrolled into one of two procedure arms: 103 patients underwent the hybrid Ivor-Lewis esophagectomy procedure and 104 underwent an open esophagectomy. The primary outcome of this study was the incidence of any major complications either during the procedure or within 30 days after surgery. The severity of complications was graded using the Clavien-Dindo scale (grade II or higher were considered major complications). The incidence of pulmonary-specific complications within 30 days, disease-free survival, and overall survival were also analyzed. Results showed that 36% of patients in the hybrid surgery group and 64% in the open esophagectomy group experienced major complications (OR, 0.31; 95% confidence interval [CI], 0.18 to 0.55; P<0.001). After adjusting for confounders, researchers noted that the hybrid approach was associated with a 77% lower risk of major complications compared to the open approach within 30 days of surgery (aOR 0.23; 95% CI, 0.12 to 0.44; P<0.001). The risk of pulmonary complications was also lower in the hybrid group (OR, 0.50, 95% CI, 0.26 to 0.96). Overall survival at 3 years was 67% (95% CI, 57 to 75%) in the hybrid group as compared to 55% in the open esophagectomy group (95% CI, 45 to 64%). Disease-free survival at 3 years was 57% in the hybrid group (95% CI, 47 to 66%) and 48% in the open group (95% CI, 38 to 57%).

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