Impact of Comorbidity on Outcomes and Overall Survival After Open and Minimal Invasive Esophagectomy for Locally Advanced Esophageal Cancer.

James P Dolan, MD, Taranjeet Kaur, MBBS, Brian S Diggs, PhD, Renato A Luna, MD, Paul Schipper, MD, Brandon Tieu, MD, Brett C Sheppard, MD, John G Hunter, MD

Oregon Health & Science University

Introduction: Minimally invasive esophagectomy (MIE) was introduced with the intent of lessening the mortality and morbidity related to esophagectomy as compared to the open approach. More recently, comparisons have been made in regard to oncological equivalence between the two approaches. The aim of this study was to examine the impact of the Charlson Comorbidity Index on predicting outcomes and overall survival after Open and MIE.

Methods: We conducted a retrospective analysis of a prospective database between1995 and 2011. All patients who underwent esophagectomy for locally advanced esophageal cancer (stage II and III) were selected. A total of 146 patients were analyzed and separated into two groups, Open esophagectomy (Open) and MIE. Risk adjustment for each patient was performed using Charlson Comorbidity Index-Grade (CCI-G). The outcomes of interest were operative time, intraoperative estimated blood loss (EBL), lymph node harvest, length of hospital stay (LOS), major complications, 30-day mortality and overall survival. Multivariate linear, logistic and cox proportional hazard models were used to adjust for the effect of approach, age, gender, BMI, and CCI-G on the outcomes.

Results: Sixty four patients (44%) underwent Open while seventy one (49%) had MIE. An additional eleven (7%) had to be converted and were classified with the MIE for further analysis. There was no significant difference between MIE and Open in terms of operative time but MIE had less intraoperative EBL (mean 234 mL, p < 0.001). Lymph node harvest was also higher (mean 7 nodes, p < 0.001) and LOS was shorter for MIE (ratio 0.80, p = 0.018). Major complications occurred in 33% of patients in the MIE and 33% of patients in the Open group (p = 0.988) while 30-day mortality was 2% in MIE and 5% in Open (p = 0.459). Estimated survival at 3 years was 52% for MIE, 48% for Open and at 5 years 42% for MIE and 37% for Open (p = 0.513). Age, gender and BMI did not have any significant effect on the outcomes or overall survival. Charlson Comorbidity Index-Grade influenced outcomes with the operative time (mean 129 minutes, p = 0.004), LOS (ratio 2.3, p < 0.001), and major complications (odds ratio 10.1, p = 0.048) worse for CCI-G 3 compared to CCI-G 0. Overall survival was worse for CCI-G 1 in comparison with CCI-G 0 (hazard ratio 1.99, p = 0.027).

Conclusions: MIE is a safe alternative to Open esophagectomy for treatment of locally advanced esophageal cancer. Compared with Open esophagectomy, MIE decreases intraoperative EBL and LOS without increasing operative time, morbidity, or mortality related to the procedure. In addition, presence of comorbidities, as measured by CCI-G, increases operative time, length of hospital stay and post-operative complications while worsening overall survival.

Session: Podium Presentation

Program Number: S046