Clinical Pearls & Morning Reports
Published January 9, 2019
Mariette et al. conducted a prospective, randomized, controlled trial to test the hypothesis that hybrid minimally invasive esophagectomy would result in a lower incidence of major intraoperative and postoperative complications than open esophagectomy, without compromising rates of cancer recurrence. Read the latest NEJM original article here.
Q: Is the incidence of esophageal cancer increasing?
A: Esophageal cancer is among the cancers with the most rapidly increasing incidence in the Western world. Overall survival among patients with esophageal cancer remains poor; the 5-year survival rate is 10 to 15% among all patients but increases to 40% among patients who undergo curative surgery. Improvements in overall survival after esophagectomy have been observed in recent years because of centralization of practice to high-volume centers and the increased use of treatments involving multiple approaches.
Q: What are some possible advantages of hybrid minimally invasive esophagectomy for esophageal cancer?
A: In the current era, esophagectomy is most commonly a two-field (abdominal and thoracic) surgical procedure, and it remains unclear whether the maximal benefit of a minimally invasive approach is in the abdominal or thoracic phase. Hybrid minimally invasive esophagectomy combines a laparoscopic abdominal phase with an open thoracotomy, which may have specific advantages, including a lower rate of pulmonary complications, laparoscopic tumor dissection limiting potential tumor spillage, and easier reproducibility of the technique.
A: In the trial by Mariette et al., the primary end-point analysis showed that hybrid minimally invasive esophagectomy was associated with major intraoperative and postoperative morbidity at 30 days that was significantly lower than that with open esophagectomy (36% vs. 64%; P<0.001 by the chi-square test; odds ratio, 0.31; 95% confidence interval [CI], 0.18 to 0.55; P<0.001). After adjustment for age, sex, American Society of Anesthesiologists risk score, neoadjuvant therapy use, tumor location, histologic subtype, resection-margin status, pathological tumor and node stages, and trial center, the authors found that minimally invasive surgery was associated with a 77% lower risk of major intraoperative and postoperative complications within 30 days than open surgery (adjusted odds ratio, 0.23; 95% CI, 0.12 to 0.44; P<0.001).
A: Secondary end-point analysis showed no differences between the groups in postoperative mortality at 30 days, intraoperative and postoperative overall morbidity (major and minor) at 30 days, and surgical or medical morbidity. However, hybrid minimally invasive surgery was associated with a lower incidence of major pulmonary complications within 30 days than open surgery (18% vs. 30%). Other end points, including operative time and the median length of hospital stay, were similar in the two groups. The authors noted nonsignificant prolongations of overall survival and disease-free survival with minimally invasive surgery, as compared with open esophagectomy. It is important to note that this trial was not adequately powered to examine survival after esophagectomy, because the sample-size calculation was based on major complications as the primary end point. A trial design that is based on a survival end point remains an important area for future research.