Is Minimally Invasive Surgery Preferred? Peri-operative Outcomes of Varying Esophagectomy Approaches in the Treatment of Esophageal Malignancy

Abstract Purpose Minimally invasive surgery is becoming widely adopted to decrease surgical morbidity and mortality, however data is still evolving and the optimal approach remains an area of controversy. We compared our unique single-institution experience with transhiatal, transthoracic, and minimally invasive approaches to examine survival and toxicity outcomes among patients treated for esophageal cancer. Methods Consecutive patients undergoing esophagectomy for esophageal or gastroesophageal junction (GEJ) cancer at a single institution between 2008 and 2017 were retrospectively reviewed. The patients were stratified by surgical approach. The Kaplan-Meier method was performed using the log-rank test to calculate two-year overall survival (OS) and two-year progression-free survival (PFS). Results A total of 198 consecutive patients were identified: 118 transhiatal esophagectomy (THE), 34 Ivor Lewis esophagectomy (ILE), and 46 minimally invasive esophagectomy (MIE) with a median follow-up of 30.0 months (range, 0.5-136.9 months). Most tumors were adenocarcinoma (89.9%) located in the distal esophagus and GEJ (94%). Neoadjuvant chemoradiotherapy was received by 75.8% of patients. Length of hospitalization, readmission rate, perioperative adverse events, reoperation rates, tracheoesophageal fistula, anastomotic leak, anastomotic stenosis, and 30-day mortality were comparable. Two-year overall survival rates for MIE, THE, and ILE were 71.7%, 67.8%, and 58.8%, respectively (p = 0.003). Progression-free survival at 2 years for MIE, THE, and ILE were 69.6%, 58.5%, and 35.3%, respectively (p = 0.002). Conclusion Minimally invasive esophagectomy is an effective approach which results in comparable perioperative complications and long-term survival outcomes to a transhiatal approach. Minimally invasive esophagectomy can safely be performed and should continue to be studied prospectively.