Minimally invasive techniques for transthoracic oesophagectomy for oesophageal cancer: systematic review and network meta-analysis.

BACKGROUND: Oesophagectomy is a demanding operation that can be performed by different approaches including open surgery or a combination of minimal access techniques. This systematic review and network meta-analysis aimed to evaluate the clinical outcomes of open, minimally invasive and robotic oesophagectomy techniques for oesophageal cancer. METHODS: A systematic literature search was conducted for studies reporting open oesophagectomy, laparoscopically assisted oesophagectomy (LAO), thoracoscopically assisted oesophagectomy (TAO), totally minimally invasive oesophagectomy (MIO) or robotic MIO (RAMIO) for oesophagectomy. A network meta-analysis of intraoperative (operating time, blood loss), postoperative (overall complications, anastomotic leaks, chyle leak, duration of hospital stay) and oncological (R0 resection, lymphadenectomy) outcomes, and survival was performed. RESULTS: Ninety-eight studies involving 32 315 patients were included in the network meta-analysis (open 17 824, 55·2 per cent; LAO 1576, 4·9 per cent; TAO 2421 7·5 per cent; MIO 9558, 29·6 per cent; RAMIO 917, 2·8 per cent). Compared with open oesophagectomy, both MIO and RAMIO were associated with less blood loss, significantly lower rates of pulmonary complications, shorter duration of stay and higher lymph node yield. There were no significant differences between surgical techniques in surgical-site infections, chyle leak, and 30- and 90-day mortality. MIO and RAMIO had better 1- and 5-year survival rates respectively compared with open surgery. CONCLUSION: Minimally invasive and robotic techniques for oesophagectomy are associated with reduced perioperative morbidity and duration of hospital stay, with no compromise of oncological outcomes but no improvement in perioperative mortality.

ANTECEDENTES: La esofaguectomía es una operación muy exigente que puede ser realizada a través de diferentes abordajes que incluyen la cirugía abierta o una combinación de técnicas con acceso mínimamente invasivo. Esta revisión sistemática y metaanálisis en red se propuso evaluar los resultados clínicos de la esofaguectomía abierta y de las técnicas de esofaguectomía mínimamente invasiva y robótica para el cáncer de esófago. MÉTODOS: Se llevó a cabo una búsqueda sistemática de la bibliografía de estudios que describiesen esofaguectomía abierta, esofaguectomía asistida por laparoscopia (laparoscopic assisted oesophagectomy, LAO), esofaguectomía asistida por toracoscopia (thoracoscopic assisted oesophagectomy, TAO), esofaguectomía totalmente mínimamente invasiva (totally minimally invasive oesophagectomy, MIO) o MIO robótica (RAMIO). Se realizó un mataanálisis en red de resultados intraoperatorios (tiempo operatorio, pérdida de sangre), postoperatorios (complicaciones globales, fuga anastomótica, quilotórax, duración estancia hospitalaria), oncológicos (resección R0, linfadenectomía) y supervivencia. RESULTADOS: Se incluyeron 98 estudios con 32.296 pacientes en el metaanálisis en red (abierta: n = 17.824, 55%; LAO: n = 1.576, 5%; TAO: n = 2.421, 7%; MIO: n = 9.558, 30%; RAMIO: n = 917, 3%). En comparación con la vía abierta, tanto MIO y RAMIO se asociaron con menos pérdidas hemáticas, tasas significativamente menores de complicaciones pulmonares, estancia más corta y obtención de un mayor número de ganglos linfáticos. No hubo diferencias significativas entre las técnicas quirúrgicas en las infecciones del sitio quirúrgico, quilotórax y mortalidad a los 30 y 90 días. MIO y RAMIO se asociaron con mejores tasas de supervivencia a 1 y 5 años respectivamente, en comparación con la cirugía abierta. CONCLUSIÓN: Las técnicas mínimamente invasivas y robótica para la esofaguectomía se asociaron con menor morbilidad postoperatoria y estancia hospitalaria, sin comprometer los resultados oncológicos, pero sin mejoría en la mortalidad perioperatoria.

Anastomotic techniques for oesophagectomy for malignancy: systematic review and network meta-analysis.

BACKGROUND: Current evidence on the benefits of different anastomotic techniques (hand-sewn (HS), circular stapled (CS), triangulating stapled (TS) or linear stapled/semimechanical (LSSM) techniques) after oesophagectomy is conflicting. The aim of this study was to evaluate the evidence for the techniques for oesophagogastric anastomosis and their impact on perioperative outcomes. METHODS: This was a systematic review and network meta-analysis. PubMed, EMBASE and Cochrane Library databases were searched systematically for randomized and non-randomized studies reporting techniques for the oesophagogastric anastomosis. Network meta-analysis of postoperative anastomotic leaks and strictures was performed. RESULTS: Of 4192 articles screened, 15 randomized and 22 non-randomized studies comprising 8618 patients were included. LSSM (odds ratio (OR) 0·50, 95 per cent c.i. 0·33 to 0·74; P = 0·001) and CS (OR 0·68, 0·48 to 0·95; P = 0·027) anastomoses were associated with lower anastomotic leak rates than HS anastomoses. LSSM anastomoses were associated with lower stricture rates than HS anastomoses (OR 0·32, 0·19 to 0·54; P < 0·001). CONCLUSION: LSSM anastomoses after oesophagectomy are superior with regard to anastomotic leak and stricture rates.

ANTECEDENTES: La evidencia actual sobre los beneficios de diferentes técnicas de anastomosis, incluyen la técnica manual (hand-sewn, HS), la sutura mecánica circular (circular stapled, CS), la sutura mecánica triangular (triangular stapler, TS) o la sutura mecánica lineal/semi-mecánica (linear stapler/semi-mechanical., LSSM) tras una esofaguectomía es contradictoria. El objetivo de este estudio fue evaluar la evidencia referente a las técnicas de anastomosis esofagogástrica (oesophagogastric, OG) y su impacto sobre los resultados perioperatorios. MÉTODOS: Se efectuó una revisión sistemática y metaanálisis en red, basados en una búsqueda sistemática en las bases de datos PubMed, EMBASE y Cochrane Library de estudios aleatorizados y no aleatorizados que describiese técnicas para la anastomosis OG. Se llevó a cabo un metaanálisis en red para los resultados de fugas anastomóticas y estenosis postoperatorias. RESULTADOS: De los 4.192 artículos revisados, se incluyeron 15 estudios aleatorizados y 22 no aleatorizados con un total de 8.618 pacientes. Las anastomosis con LSSM (razón de oportunidades, odds ratio, OR 0,49, i.c. del 95%: 0,33-0,74, P = 0,001) y las anastomosis con CS (OR 0,68, i.c. del 95%: 0.48-0,95, P = 0,027) se asociaron con tasas de fugas anastomóticas más bajas que las anastomosis con HS. Las anastomosis con LSSM se asociaron con unas tasas más bajas de estenosis (OR 0,15, i.c. del 95%: 0,08-0,28, P < 0,001), frente a las anastomosis con TS y HS. CONCLUSIONES: Las anastomosis con LSSM después de esofaguectomía son superiores en relación a las tasas de fugas anastomóticas y estenosis.

Impact of postoperative complications on survival after oesophagectomy for oesophageal cancer.

BACKGROUND: Recent evidence suggests that complications after oesophagectomy may decrease short- and long-term survival of patients with oesophageal cancer. This study aimed to analyse the impact of complications on survival in a Western cohort. METHODS: Complications after oesophagectomy were recorded for all patients operated on between January 2006 and February 2017, with severity defined using the Clavien-Dindo classification. Associations between complications and overall and recurrence-free survival were assessed using univariable and multivariable Cox regression models. RESULTS: Of 430 patients, 292 (67·9 per cent) developed postoperative complications, with 128 (39·8 per cent) classified as Clavien-Dindo grade III or IV. No significant associations were detected between Clavien-Dindo grade and either tumour (T) (P = 0·071) or nodal (N) status (P = 0·882). There was a significant correlation between Clavien-Dindo grade and ASA fitness grade (P = 0·032). In multivariable analysis, overall survival in patients with Clavien-Dindo grade I complications was similar to that in patients with no complications (hazard ratio (HR) 0·97, P = 0·915). However, patients with grade II and IV complications had significantly shorter overall survival than those with no complications: HR 1·64 (P = 0·007) and 1·74 (P = 0·013) respectively. CONCLUSION: Increasing severity of complications after oesophagectomy was associated with decreased overall survival. Prevention of complications should improve survival.

Meta-analysis of the influence of a positive circumferential resection margin in oesophageal cancer.

Background: The evidence regarding the prognostic impact of a positive circumferential resection margin (CRM) in oesophageal cancer is conflicting, and there is global variability in the definition of a positive CRM. The aim of this study was to determine the impact of a positive CRM on survival in patients undergoing oesophagectomy for oesophageal cancer. Methods: A systematic review and meta-analysis was performed. PubMed and Embase databases were searched for articles to May 2018 examining the effect of a positive CRM on survival. Cohort studies written in English were included. Meta-analyses of univariable and multivariable hazard ratios (HRs) were performed using both Royal College of Pathologists (RCP) and College of American Pathologists (CAP) criteria. Risk of bias was assessed using the Newcastle-Ottawa Scale. Egger regression, and Duval and Tweedie trim-and-fill statistics were used to assess publication bias. Results: Of 133 studies screened, 29 incorporating 6142 patients were finally included for analysis. Pooled univariable HRs for overall survival in patients with a positive CRM were 1·68 (95 per cent c.i. 1·48 to 1·91; P < 0·001) and 2·18 (1·84 to 2·60; P < 0·001) using RCP and CAP criteria respectively. Subgroup analyses demonstrated similar results for patients by T category, neoadjuvant therapy and tumour type. Pooled HRs from multivariable analyses suggested that a positive CRM was independently predictive of a worse overall survival (RCP: 1·41, 1·21 to 1·64, P < 0·001; CAP: 2·37, 1·60 to 3·51, P < 0·001). Conclusion: A positive CRM is associated with a worse prognosis regardless of classification system, T category, tumour type or neoadjuvant therapy.