A. Salem1, R. Shridhar2, K. Almhanna2, S. Hoffe2, K. Meredith3 3Florida State University College Of Medicine,Department Of Surgery,Tallahassee, FL, USA 1University Of Wisconsin,Department Of Surgery,Madison, WI, USA 2Moffitt Cancer Center And Research Institute,Department Of Surgery,Tampa, FL, USA
Introduction:
Surgery is pivotal in the management of patients with esophageal cancer. Recent prospective data demonstrates advantages of minimally invasive techniques compared to historical open cohorts. However, varying surgical techniques precludes the recommendation of a standard approach. We sought to examine our outcomes with differing approaches to minimally invasive esophagectomy.
Methods:
We queried a prospectively maintained esophageal database to identify patients who underwent minimally invasive esophagectomy (MIE) from 1994 to 2014. Surgical approaches included trans-hiatal (TH), Ivor Lewis (IVL), and robotic assisted Ivor Lewis (RAIL). Demographics, operative variables and post-operative complications were all compared and considered significant at p<=0.05.
Results:
We identified 280 patients who underwent MIE with a mean age of 65.65 ± 10.5 and a median follow-up of 48 months. Fifty-seven patients underwent IVL, 78 underwent TH, and 145 underwent RAIL. The length of operation was significantly longer in IVL and RAIL approaches compared to TH (TH=242 min, IVL=320 min, RAIL=415 min, p=0.001). Mean estimated blood loss did not differ between cohorts (TH=150 mL, IVL=125 mL, RAIL=158 mL, p=0.8). Rates of anastomotic leak, stricture, pneumonia, and wound infections were all higher in the TH compared to the trans-thoracic approaches p=0.04, p=0.02, p=0.01, and p<0.001 respectively (Table 1.). Operative mortality was low for each cohort and did not differ between approaches (TH=2.6%, IVL=0%, RAIL=2%, p=0.2). The median length of hospitalization also did not differ between groups (TH=10 days, IVL=8.5 days, RAIL=9 days, p=0.15). Oncologic outcomes were measured by completeness of resection and nodal harvest. There was decreased R1 resections in both the IVL and RAIL compared to TH (TH=8%, IVL=0%, and RAIL=0% p=0.04). Additionally, the mean number of lymph nodes harvested was lower in patients undergoing TH compared to IVL and RAIL groups (TH=9.2, IVL=12.8, and RAIL=20.6, p=0.05).
Conclusion:
In our large series comparing minimally invasive approaches to esophageal resection we have demonstrated improved operative outcomes in trans-thoracic approaches compared to trans-hiatal approach. Additionally, improved nodal harvest and increased R0 resection rates were improved with the trans-thoracic approaches. We recommend that patients undergoing minimally invasive esophagectomy be strongly considered for a trans-thoracic approach.
