D. Lee1, P. Briceno2, R. Shridhar3, S. Kucera4, K. L. Meredith2 1Florida State University College Of Medicine,Sarasota, FL, USA 2Florida State University College Of Medicine/Sarasota Memorial Health Care System,Gastrointestinal Oncology,Sarasota, FL, USA 3University Of Central Florida,Radiation Oncology,Orlando, FL, USA 4Florida State University College Of Medicine/Sarasota Memorial Health Care System,Endoscopic Oncology,Sarasota, FL, USA
Introduction: The long-term survival for patients with locally advanced esophageal cancer remains poor despite improvements in multi-modality care over the last several decades. Surgical resection remains piviotal in the management of patients with esophageal cancer. We report our experience with esophageal cancer patients undergoing esophagectomy from a large prospectively maintained database.
Methods: A prospectively managed esophagectomy database was queried for patients undergoing esophagectomy 1996 and 2015. Basic demographics, tumor characteristics, operative details, and post-operative outcomes were recorded. Continuous variables were compared using the Kruskal Wallis or the ANOVA tests as appropriate. Pearson’s Chi-square test was used to compare categorical variables. All statistical tests were two-sided and an α (type I) error <0.05 was considered statistically significant.
Results: We identified 856 patients who underwent esophagectomy with a mean age of 64 ± 10 years, mean BMI of 28.6 ± 6, and a mean follow up of 48 ± 13 months. There were 717 (83.8%) males and 139 (16.2%) females. Neoadjuvant therapy was administered in 543 (63.4%) patients. There were 475 (55.5 %) open Ivor Lewis (OIL), 69 (8.1%) open trans-hiatal (OTH), 10 (1.2%) open Mckeown, 95 (11.0%) minimally invasive esophagectomies (MIE) via Ivor Lewis approach (MIE IVL), 63 (7.4%) MIE TH and 144 (16.8%) robotic assisted Ivor Lewis esophagectomies (RAIL). There were 504 (58.8%) open esophagectomies and 302 (35.2%) MIE. Complications occurred less frequent in patients undergoing RAIL and MIE IVL: 145 (30.5%) OIL, 28 (40.6%) OTH, 28 (29.5%) MIE IVL, 31 (49.2%) MIE TH, and 34 (23.6%) RAIL (p=0.003). Pulmonary complications also occurred less frequently in RAIL and MIE IVL: 72 (15.2%) OIL, 12 (17.4%) OTH, 18 (28.6%) MIE TH, 8 (8.4%) MIE IVL, and 10 (6.9%) RAIL, p<0.001. Anastomotic leaks were less common in patients who underwent IVL either open or minimally invasive compared to trans-hiatal approaches: 23 (4.8%) OIL, 4 (4.2%) MIE IVL, 4 (2.8%) RAIL, versus 9 (13.0%) OTH, 4 (6.3%) MIE TH, p=0.03. There were 13 (1.5%) mortalities and this did not differ among techniques, p= 0.6. Oncologic quality as indicated by R0 resections and mean lymph node harvest were improved in patients undergoing RAIL: 449 (94.7%) and10±6 OIL, 62 (89.9%) and 8±5 OTH, 60 (96.8%) and 9±6 MIE TH, 86 (93.5%) and 14±7 MIE IVL, and 144 (100%) and 20±9 RAIL, p=0.04 and p=0.001. Median length of hospitalization was 9 days in both RAIL and MIE IVL and 10 days in all other groups, p=0.2.
Conclusion: We report our experience with varying approaches to esophageal resections from a large esophagectomy database. Minimally invasive and robotic Ivor Lewis techniques demonstrated substantial benefits in post-operative complications. Oncologic outcomes similarly favor MIE IVL and RAIL. Pulmonary outcomes were not reduced by trans-hiatal approaches.