Minimally invasive versus open esophagectomy for cancer: a systematic review and meta-analysis

Evidence on the benefits of minimally invasive surgery over open procedures in gastrointestinal surgery is continuing to accumulate. This is also the case for esophageal surgery. Esophageal cancer often requires extensive surgery and is, therefore, considered to be one of the most invasive elective gastrointestinal procedures. Clinical studies investigating means to reduce the invasive nature of the surgery are currently being received with great interest. A systematic review and meta-analysis of present literature was performed to evaluate the effects of minimally invasive esophagectomy (MIE) versus open esophagectomy on outcome. All comparative studies comparing MIE with open esophagectomy for cancer were included. Eligible studies were identified from three electronic databases (Medline, Embase, Cochrane) and through a cross-reference search. Three comparative groups were created for (meta-) analysis: 1) total MIE verus open transthoracic esophagectomy (TTE); 2) thoracoscopy and laparotomy versus open TTE; 3) laparoscopy versus open transhiatal esophagectomy. Ten studies were identified after a comprehensive search. One controlled clinical trial and 9 case-control studies, comprising 1061 patients, were retrieved. Trends were observed in the various studies in favour of MIE for the following outcome parameters: major morbidity, pulmonary complications, anastomotic leakage, mortality, length of hospital stay, operating time and blood loss. The meta-analysis in group 1 showed no significant differences between the groups for major morbidity or pulmonary complications OR 0.88 (95% CI 0.35-2.14, P=0.78) and OR 1.05 (95% CI 0.42-2.66, P=0.91) respectively. In group 2 significantly fewer cases of anastomotic leakage were reported in the MIE group OR 0.51 (95% CI 0.28-0.95, P=0.03). In both group 1 and 2 a trend toward a reduced mortality was seen in the MIE group, although no statistical significance was reached (group 1: OR 0.58 (95 % CI 0.06-5.56, P=0.64), group 2: OR 0.59 (95% CI 0.20-1.76, P=0.34)). No meta-analysis could be performed for group 3 due to incomplete data of the selected outcome parameters in the various studies. A faster postoperative recovery and, therefore, a reduction in morbidity can be achieved with MIE. Furthermore, less mortality with the implementation of MIE can be realised. MIE is investigated in case-control studies and bias may have been introduced simply by study design. Therefore, randomized trials comparing MIE with open esophagectomy are necessary in order to evaluate outcome more efficiently.