Original article
General thoracic
Outcomes With Open and Minimally Invasive Ivor Lewis Esophagectomy After Neoadjuvant Therapy

https://doi.org/10.1016/j.athoracsur.2015.09.062Get rights and content

Background

Neoadjuvant therapy is integral in the treatment of locally advanced esophageal cancer. Despite increasing acceptance of minimally invasive approaches to esophagectomy, there remain concerns about the safety and oncologic soundness after neoadjuvant therapy. We examined outcomes in patients undergoing open and minimally invasive (MIE) Ivor Lewis esophagectomy after neoadjuvant therapy.

Methods

This was a retrospective series of 130 consecutive patients with esophageal cancer undergoing Ivor Lewis esophagectomy with curative intention after neoadjuvant therapy at a tertiary academic center (2008 to 2012).

Results

An open procedure was performed in 74 patients (56.9%), and 56 (43.1%) underwent MIE after neoadjuvant therapy. MIE patients had shorter median intensive care unit (p = 0.002) and hospital lengths of stay (p < 0.0001). The incidence of postoperative complications was similar (open: 54.8% vs MIE: 41.1%, p = 0.155). However, observed respiratory complications were significantly reduced after MIE (8.9%) compared with open (29.7%; p = 0.004). Anastomotic leak rates were similar (open: 1.4% vs. MIE: 0%, p = 1.00). Mortality at 30 and 90 days was comparable (open: 2.7% and 4.1% vs MIE: 0% and 1.8%, p = 0.506 and p = 0.634, respectively). Complete resection rates and the number of collected lymph nodes was similar. Overall survival rates at 5 years were similar (open: 61% vs MIE: 50%, p = 0.933). MIE was not a significant predictor of overall survival (hazard ratio, 1.07; 95% confidence interval, 0.61 to 1.87; p = 0.810).

Conclusions

MIE proves its safety after neoadjuvant therapy because it leads to faster progression during the early postoperative period while reducing pulmonary complications. Open and MIE approaches appear equivalent with regards to perioperative oncologic outcomes after neoadjuvant therapy. Long-term outcomes need further validation.

Section snippets

Patients

The study population included 130 consecutive patients undergoing Ivor Lewis esophagectomies with curative intent after having received neoadjuvant therapy at the Massachusetts General Hospital between January 2008 and December 2012. Operations performed with an open or MIE approach were included. All patients were evaluated with computed tomography of the chest, abdomen and pelvis. Most patients underwent staging with positron emission tomography and endoscopic ultrasound, if feasible.

Baseline Characteristics

There were 74 patients (56.9%) receiving an open Ivor Lewis esophagectomy and 56 (43.1%) who underwent MIE after neoadjuvant therapy. Baseline patient characteristics are reported in Table 1. Patients in the open and MIE groups were comparable in gender, age, smoking history, body mass index, comorbidities, and preoperative pulmonary function tests. However, patients in the MIE group presented more frequently with a history of chronic obstructive pulmonary disease, and patients in the open

Comment

Patients with locally advanced esophageal cancer should be evaluated in a multidisciplinary fashion and considered for neoadjuvant therapy, regardless of the planned surgical approach to resection 12, 13, as currently strongly recommended by clinical practice guidelines for the management of esophageal cancer [14], including those published by The Society of Thoracic Surgeons [4]. Therefore, an increase is expected in the number of patients presenting for esophagectomy who have received

References (15)

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