Minimally invasive esophagectomy: A single center comparative study of outcomes with 638 esophagectomy for squamous cell cancer of the esophagus

Introduction: The optimal surgical approach for esophagectomy remains controversial. The advent of minimally invasive technique has generated more controversies with regards to its true value. The present study aimed to evaluate our results of minimally invasive esophagectomy compared with open surgery. Methods: From 1994 to 2013, 638 patients who underwent esophagectomy for squamous cell cancers of the esophagus were studied. They were divided into three groups: 85 had VATS esophagectomy (VATS group), 104 had VATS and laparoscopic gastric mobilization and cervical anastomosis (total MIE group), and 449 had open esophagectomy (Open group). Their clinical-pathological features, morbidity and mortality rates were compared. Long-term prognosis was studied with multivariate analysis to look at independent prognostic factors. Results: More patients in the total MIE group had neoadjuvant chemoradiation (64.4% vs. 44.7% for the VATS group and 42.8% in the Open group). This was because total MIE was started later in the series. Open esophagectomy resulted in more blood loss but a shorter operation duration. Wound infection rate was higher in the Open group. Total MIE had higher incidence of ischemic stomach compared with Open surgery (8.7% vs. 1.8%), and also a higher recurrent laryngeal nerve palsy rate (19.2% vs. 10.5%). These were believed to be related to a change in gastric tubularization method and more aggressive policy of RLN nodal dissection rather than the VATS or laparoscopic method per se. There was no significant difference in postoperative pneumonia. VATS group had higher mortality compared to the Open group (5.9% vs. 1.3%) while total MIE had intermediate result (4.8%). On pathological variables, total MIE group had most lymph node sampled, significantly more than the other groups.On multivariate analysis, gender, pT stage, number of lymph nodes sampled, number of involved nodes, and R-category were independent prognostic factors. Conclusions: Both minimally invasive surgery and Open surgery have relative merits. Selection biases and change in treatment strategy over time could explain many differences in outcome. Extended lymphadenectomy could improve outcome by increasing the number of lymph nodes harvested