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Hybrid esophagectomy results in fewer major complications without compromising survival outcomes

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January 9, 2019

Patients with esophageal cancer who underwent a hybrid minimally invasive esophagectomy had a lower incidence of intraoperative and postoperative major complications than patients who underwent open surgery, according to results of a randomized, phase 3 trial published in The New England Journal of Medicine.

Further, the hybrid procedure did not appear to compromise survival over 3 years.

“Esophageal cancer is among the cancers with the most rapidly increasing incidence in the Western world,” Guillaume Piessen, MD, PhD, gastrointestinal surgeon in the department of digestive and oncologic surgery at Claude Huriez University Hôpital in Lille, France, and colleagues wrote. “Overall survival among patients with esophageal cancer remains poor ... [but] 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.”

Researchers randomly assigned 207 patients (median age, 61 years; range, 23-78; men, n = 175) with esophageal cancer from 13 centers in France to undergo a hybrid minimally invasive esophagectomy (n = 103) or a transthoracic open esophagectomy (n = 104). The hybrid procedure included laparoscopic gastric mobilization and open thoracotomy.

A total of 152 patients underwent either neoadjuvant chemotherapy (n = 86) or chemoradiotherapy (n = 66).

Primary endpoints included intraoperative or postoperative complications of grade 2 or higher — according to the five-grade Clavien-Dindo classification system — within 30 days.

Median follow-up as assessed by reverse Kaplan-Meier method was 48.8 months (95% CI, 46.9-52.2).

Researchers observed 312 serious adverse events among 110 patients. A total of 37 patients (36%) in the hybrid surgery group experienced a major intraoperative or postoperative complication compared with 67 patients (64%) in the open surgery group (OR = 0.31, 95% CI; 0.18-0.55). More patients in the open surgery group (n = 31) had a major pulmonary complication than in the hybrid surgery group (n = 18).

Results showed 3-year OS of 67% (95% CI, 57-75) in the hybrid surgery group and 55% (95% CI, 45-64) in the open surgery group. Three-year DFS was 57% (95% CI, 47-66) with hybrid surgery and 48% (95% CI, 38-57) with open surgery.

Other endpoints, such as operative time and median length of hospital stay, appeared similar between the two groups.

“In parallel to previous findings regarding colorectal resection and gastrectomy, we found that a minimally invasive approach ... was associated with substantially lower morbidity, specifically pulmonary morbidity,” Piessen and colleagues wrote. “This result was most probably mediated by the reduction in surgical trauma, with less postoperative pain and a lower incidence of diaphragmatic splinting and thus less basal lung atelectasis and fewer major pulmonary complications.” – by John DeRosier

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Disclosure s : The French National Cancer Institute funded this study. Piessen reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.

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This study included 207 patients with localized middle- and lower-esophageal cancer randomly assigned to treatment with open esophagectomy or a hybrid minimally invasive esophagectomy with an intrathoracic anastomosis using laparoscopy and thoracotomy. The hybrid procedure group experienced fewer perioperative complications (36% vs. 64%) and had superior 3-year OS and disease-specific survival. Lymph node harvest, rate of positive margins and length of stay were equivalent. 
Researchers of the TIME trial conducted in the Netherlands randomly assigned 115 patients with esophageal cancer to open surgery or minimally invasive surgery with laparoscopy and thoracoscopy. In two-thirds of cases, clinicians performed a cervical anastomosis. The minimally invasive group experienced fewer episodes of pneumonia, less blood loss and fewer cases of recurrent laryngeal nerve paralysis — which is particularly a risk with a cervical anastomosis. Importantly, the minimally invasive group showed superior quality of life on several measures.
These trials, in combination with a multitude of comparative reports, would suggest that the question regarding the superiority of a minimally invasive approach to cancers of the middle and lower esophagus has been answered. The next areas that need to be addressed are process improvement to reduce complications and improve postoperative quality of life, a better understanding of the benefit of a robotic approach, and a focus on cost reduction. 
The well-established relationship between higher surgical volume and improved outcomes also would suggest that unanswered questions remain regarding how esophageal surgery care should be organized, to provide patients with the benefits of regionalization — and care at a higher-volume facility — while minimizing their need for travel.
Reference:
Straatman J, et al. Ann Surg. 2017;doi:10.1097/SLA.0000000000002171.

 

Jonathan C. Salo, MD, FACS

Levine Cancer Institute at Atrium Health

Disclosure: Salo reports no relevant financial disclosures.