Thoracic: Esophageal Cancer
Minimally invasive surgery is associated with decreased postoperative complications after esophagectomy

https://doi.org/10.1016/j.jtcvs.2022.11.026Get rights and content

Abstract

Background

Although some studies have compared esophagectomy outcomes by technique or approach, there is opportunity to strengthen our knowledge surrounding these outcomes. We aimed to perform a comprehensive comparison of esophagectomy postoperative complications.

Methods

We retrospectively reviewed the American College of Surgeons National Surgical Quality Improvement Program database (2007-2018). Esophagectomies were identified using Current Procedural Terminology codes and grouped by operative technique (Ivor Lewis, transhiatal, McKeown) and surgical approach (minimally invasive vs open esophagectomy). Twelve postoperative complications were compared. Significant complications underwent risk adjustment using multivariate logistic regression.

Results

Analysis was performed on 13,457 esophagectomies: 11,202 (83.2%) open and 2255 (16.8%) minimally invasive. There were 7611 (56.6%) Ivor Lewis, 3348 (24.9%) transhiatal, and 2498 (18.6%) McKeown procedures. There were significant differences among the surgical techniques in 6 of 12 risk-adjusted complications. When comparing the outcomes of minimally invasive techniques, there were only significant differences in 2 of 12 complications: overall morbidity (minimally invasive Ivor Lewis 30.5%, minimally invasive transhiatal 43.4%, minimally invasive McKeown 40.3%, P = .0009) and infections (minimally invasive Ivor Lewis 15.4%, minimally invasive transhiatal 26.0%, minimally invasive McKeown 25.3%, P = .0003). Patients who underwent minimally invasive surgery were less likely to have overall morbidity (odds ratio, 0.68; 95% confidence interval, 0.62-0.75), respiratory complications (odds ratio, 0.77; 95% confidence interval, 0.68-0.87), urinary tract infection (odds ratio, 0.61; 95% confidence interval, 0.43-0.88), renal complications (odds ratio, 0.52; 95% confidence interval, 0.34-0.81), bleeding complications (odds ratio, 0.36; 95% confidence interval, 0.30-0.43), and nonhome discharge (odds ratio, 0.54; 95% confidence interval, 0.45-0.64), and had shorter length of stay (9.7 vs 13.2 days, P < .0001).

Conclusions

Patients undergoing minimally invasive esophagectomy have lower rates of postoperative complications regardless of esophagectomy techniques. The minimally invasive approach was associated with reduced complication variance among 3 common esophagectomy techniques.

Section snippets

Ethical Oversight

The Colorado Multiple Institutional Review Board determined this study exempt from review because it used publicly available deidentified data.

Patient Population and Data

This was a retrospective review of the prospectively collected American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2007 to 2018. The ACS-NSQIP database includes audited, systematically sampled data on patients who underwent surgery, reporting preoperative, intraoperative, and 30-day postoperative data from

Results

We identified 13,587 patients undergoing esophagectomies within the ACS-NSQIP database. Of those, we excluded 130 (1.0%) for undergoing emergency operations, having preoperative sepsis, or requiring a ventilator preoperatively, leaving a total of 13,457 patients (99.0%) for inclusion. Figure 1 shows the visual abstract. There were 11,202 (83.2%) OEs and 2255 (16.8%) MIEs. There were 7611 (56.6%) ILEs, 3348 (24.9%) THEs, and 2498 (18.6%) MKEs. Table 1 shows the demographic information of the

Discussion

We performed a comprehensive analysis of esophagectomy comparing open and minimally invasive approaches of the 3 most common surgical techniques. Patients who underwent MIE had a shorter length of stay and lower risk-adjusted rates of several postoperative complications than patients who underwent OE. Among the esophagectomy techniques, ILE had the lowest rate of complications, followed by THE and then MKE. Among the individual techniques, MIS was associated with lower complications rates for

Conclusions

Patients undergoing MIE have lower rates of adjusted postoperative complications than those undergoing OE. This remained true on subgroup analysis comparing MIE with OE for each of the 3 common surgical techniques evaluated. Given the differences in complication profiles among the 3 techniques when comparing MIE with OE, the benefit of a MIS approach likely stems from a minimally invasive transthoracic approach. Although the rates of most complications were lowest in ILE and highest in MKE, the

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    This work was supported by an internal grant from the Department of Surgery, University of Colorado School of Medicine. The funding organization had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Drs Dyas and Meguid had full data access to all of the data in the study and take full responsibility for its integrity and the accuracy of analysis. The ACS-NSQIP and participating hospitals are the source of these data; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors.

    The Colorado Multiple Institutional Review Board determined this study exempt from review because it used publicly available deidentified data.

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