Does the Approach Matter? Comparing Survival in Robotic, Minimally Invasive, and Open Esophagectomies

Our objective was to determine how surgical approach impacts overall survival and postoperative outcomes when comparing robotic-assisted minimally invasive esophagectomy (RAMIE), minimally invasive esophagectomy (MIE), and open esophagectomy (OE).

The National Cancer Database was queried for patients diagnosed with pathologic Stage 0 to III esophageal cancer from 2010 to 2015. Primary outcome measures evaluated were length of stay, 30-day unplanned readmissions, mortality rates at 30 and 90 days, and overall survival rates. The surgical cohorts underwent 1:1 propensity score matching, and Kaplan-Meier survival estimates were compared by surgical approach. Cox proportional hazards regression was utilized to estimate factors associated with overall survival.

Of 5,553 patients that met criteria, 28.4% were MIE, 7.8% RAMIE, and 63.8% OE. From 2010 to 2015, an increasing trend was seen for both minimally invasive approaches, with MIE surpassing the number of OEs. Unplanned 30-day readmissions and 30-day and 90-day mortality rates were not significantly different between the different groups. Median length of stay was significantly shorter in MIE (9 [interquartile range (IQR), 8 to 14] days) and RAMIE (9 [IQR, 7 to 14] days), compared with OE (10 [IQR, 8 to 15] days; p < 0.001). MIE and RAMIE had comparable survival rates compared with OE, with no significant differences in median overall survival estimates after propensity score matching (log-rank p = 0.603), with a trend for increased survival in MIE (adjusted hazard ratio, 0.97; 95% confidence interval, 0.89 to 1.06; p = 0.530) and RAMIE (hazard ratio, 0.81; 95% confidence interval, 0.69 to 0.95; p = 0.012). Both minimally invasive approaches had a significantly higher median lymph node counts (MIE: 15 [IQR, 9 to 22]; RAMIE: 17 [IQR, 11 to 24]; OE: 13 [IQR, 8 to 20]), which may highlight important differences in postoperative upstaging.

Trends in MIE use is surpassing the open approach. Minimally invasive approaches are becoming the preferred approach, with noninferior long-term results compared with OEs. A significantly higher lymph node yield was seen for RAMIE and MIE.