Improved Survival Following Minimally Invasive Oesophagectomy Compared to Open Surgery

Oliver C Burdall, James Fullick, Alexander P Boddy, Jane Blazeby, Richard Krysztopik, Christopher Streets, Andrew Hollowood, Christopher P Barham, Daniel R Titcomb. Bristol Royal Infirmary.

INTRODUCTION Oesophageal cancer is one of the top ten most common cancers and increasing in incidence worldwide. As with other areas of surgery, minimally invasive techniques have been used to perform oesophagectomy, but concerns regarding these techniques remain. Since its description by Cuschiri in 1992 the use of minimally invasive oesophagectomy (MIO) has increased, but MIO was still only used 16% of resections in the UK in 2009. In particular, there has been reluctance to use minimally invasive (thoracoscopic and laparoscopic) techniques in more advanced cancers for fears regarding the adequacy of the oncological resection. In order to identify any factors that could affect survival, we undertook a retrospective analysis on all patients that underwent surgery in our department over an 8 year period.

METHODOLOGY A retrospective data analysis was undertaken on all patients who underwent oesophagectomy in a tertiary upper gastrointestinal surgery unit, from 2005 to 2012 inclusive. Data was collected from the departmental data base and case note review, with follow-up and survival data to time of data collection. The survival data was analysed using univariate and multivariate Cox proportional hazard regression models to determine which variables affected survival. Variables examined included age, tumour position, tumour stage (T0,1,2 vs T3,4), nodal stage (N0 vs N1), tumour histology, completeness of resection (R0 vs R1), use of neoadjuvant chemotherapy and operative technique (thoracoscopic/laparoscopic (MIO) vs laparoscopic abdomen/open chest (Lap assisted) vs Open)

RESULTS 340 patients underwent oesophagectomy between 2005 and 2012. Male to female ratio was 3.75:1, with a mean age of 64 years (range: 36-87). There were 83 open oesophagectomies, 189 laparoscopically assisted oesophagectomies and 68 minimally invasive oesophagectomies. Following univariate regression analysis the following factors were found to be correlated to survival: use of neoadjuvant chemotherapy (Hazard Ratio 2.889, 95% CI 1.737-4.806), T stage 3 or 4 (3.749, 2.475-5.72), Node positive (5.225, 3.561-7.665), R1 resection (2.182, 1.425-3.341), type of operation (MIO compared to open oesophagectomy) (0.293, 0.158-0.541). There was no significant relationship between age, tumour position or tumour histology and length of survival. When these factors were entered into a multivariate model, the independently significant factors correlated to survival were found to be: T stage 3 or 4 (HR 1.969, 1.248-3.105), Node positive (3.833, 2.548-5.766) and type of operation (MIO compared to open) (0.5186, 0.277-0.972).

CONCLUSION Multiple small studies have found reduced pulmonary complication rates and duration of hospital stay when using a minimally invasive approach compared to open. Concerns in the literature over long term outcomes, however, have led to limited utilization of this method, especially in advanced disease. The data from this large study shows significantly better survival following operations performed using minimally invasive techniques compared to open, although we have not adjusted for some known or unknown confounding factors. International and national randomised controlled trials are required to provide more information in due course.

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