National trends in operative approach to esophagectomy: utilization rates, outcomes, and overall survival

Although open esophagectomies (OE) have traditionally been favored, minimally invasive approaches are increasingly utilized and associated with improved outcomes. We investigated the adoption rates of robotic-assisted minimally invasive esophagectomy (RAMIE) and minimally invasive esophagectomy (MIE) compared with OE. Utilization rates by surgical approach, post-operative outcomes, and overall survival were analyzed.

The National Cancer Database was queried for patients who underwent OE, MIE, and RAMIE for esophageal cancer from 2010 to 2019. Adoption rates of RAMIE, MIE and OE were determined for all patients. Patients with primary cervical esophageal cancer, stage 4 disease, unknown staging, or missing follow-up data were excluded. Multivariable Cox regression models compared overall survival based on surgical approach.

A total of 17,765 patients underwent an esophagectomy for stage I, II, and III disease (OE: n = 10,039; MIE: n = 5388; RAMIE: n = 2338). Between 2010 and 2019, OE decreased by 52%, while MIE and RAMIE increased by 49% and 704%, respectively. The overall conversion rate of MIE and RAMIE to OE decreased significantly over the study time period. On multivariable analysis, the odds of 30-day and 90-day mortality was lower for MIE (p < 0.001; p < 0.001) and trended towards lower for RAMIE when compared to OE, though was not a statistically significant difference. Further, the overall 5-year survival was higher in the MIE and RAMIE cohort compared to the OE cohort. Like short-term survival, patients who underwent MIE had a significantly lower mortality (p < 0.001) while those who underwent RAMIE trended towards lower mortality.

This contemporary review of a national cohort demonstrates the rapid adoption of minimally invasive esophagectomy techniques, without compromise in short-term or long-term outcomes.