Safety, efficacy, and cost-effectiveness of minimally invasive esophagectomies versus open esophagectomies: an umbrella review.

Traditionally, esophageal oncological resections have been performed via open approaches with well-documented levels of morbidity and mortality complicating the postoperative course. In contemporary terms, minimally invasive approaches have garnered sustained support in all areas of surgery, and there has been an exponential adaptation of this technology in upper GI surgery with the advent of laparoscopic and robotic techniques. The current literature, while growing, is inconsistent in reporting on the benefits of minimally invasive esophagectomies (MIEs) and this makes it difficult to ascertain best practice. The objective of this review was to critically appraise the current evidence addressing the safety, efficacy, and cost-effectiveness of MIEs versus open esophagectomies. A systematic review of the literature was performed by searching nine electronic databases to identify any systematic reviews published on this topic and recommended Joanna Briggs Institute approach to critical appraisal, study selection, data extraction and data synthesis was used to report the findings. A total of 13 systematic reviews of moderate to good quality encompassing 143 primary trials and 36,763 patients were included in the final synthesis. Eleven reviews examined safety parameters and found a generalized benefit of MIE. Efficacy was evaluated by eight systematic reviews and found each method to be equivalent. There were limited data to judiciously appraise cost-effectiveness as this was only evaluated in one review involving a single trial. There is improved safety and equivalent efficacy associated with MIE when compared with open esophagectomy. Cost-effectiveness of MIE cannot be sufficiently supported at this point in time. Further studies, especially those focused on cost-effectiveness are needed to strengthen the existing evidence to inform policy makers on feasibility of increased assimilation of this technology into clinical practice.

Early postoperative pulmonary complications after minimally invasive esophagectomy in the prone position: incidence and perioperative risk factors from the perspective of anesthetic management.

OBJECTIVES: To investigate the incidence of and the risk factors for early postoperative pulmonary complications (PPC) after minimally invasive esophagectomy (MIE) in the prone position from the perspective of anesthetic management. METHODS: We conducted a historical cohort study of patients who underwent MIE in the prone position between September 2010 and August 2018. PPC was defined as pneumonia, atelectasis, acute respiratory distress syndrome (ARDS), respiratory failure, and pulmonary embolism (Clavien-Dindo Classification Grade II or higher) that occurred within 7 days after MIE. RESULTS: Out of 489 patients, there were 90 patients (18.4%) with PPC: 75 patients with pneumonia, 24 patients with atelectasis, 13 patients with respiratory failure, 6 patients with ARDS, and 2 patients with pulmonary embolism. Twenty-eight patients suffered from 2 or more components of PPC. PPC patients were older (66.6 vs. 63.6 year, P = 0.038) and had higher amount of crystalloid (4200 vs. 3550 mL, P < 0.0001), and longer duration of anesthesia (670 vs. 625 min, P = 0.0062) than non-PPC patients. PPC patients were more likely to have had chronic obstructive pulmonary disease (COPD) (26.7 vs. 7.8%, P < 0.001). Incidence of PPC was significantly higher in patients with one-lung ventilation than with two-lung ventilation (37.1 vs. 15.3%, P < 0.001). Multivariable logistic regression analysis showed that PPC was associated with age (per 10 years, odds ratio (OR) = 1.41), COPD (OR = 3.43), one-lung ventilation (OR = 1.94), and volume of crystalloid (per 500 mL, OR = 1.22). CONCLUSIONS: Two-lung rather than one-lung ventilation should be chosen and fluid overload should be avoided in patients undergoing MIE in the prone position.

Indocyanine green perfusion assessment of the gastric conduit in minimally invasive Ivor Lewis esophagectomy.

BACKGROUND: Anastomotic leak is a serious complication following esophagectomy. The aim of the study was to report our experience with indocyanine green fluorescence angiography (ICG-FA)-PINPOINT® assisted minimally invasive Ivor Lewis esophagectomy (MILE) and assess factors associated with anastomotic leak. METHODS: We reviewed consecutive patients undergoing MILE from 2013 to 2018. Intraoperative real-time assessment of gastric conduit was performed using ICG-FA with PINPOINT®. Perfusion was categorized as good perfusion (brisk ICG visualization to conduit tip) or non-perfusion (any demarcation along the conduit). RESULTS: 100 patients (81 males, median age 68 [60-72]) underwent MILE for malignancy in 96 patients and benign disease in 4 patients. There were six anastomotic leaks all managed with endoscopic stent placement. There was no intraoperative mortality and no 30-day mortality in leak patients. Patients with a leak were more likely to be overweight with BMI > 25 (100% versus 53%, p = 0.03), have pre-existing diabetes (50% versus 13%, p = 0.04), and have higher intraoperative estimated blood loss (260 mL [95-463] versus 75 mL [48-150], p = 0.03). Anastomotic leaks occurred more frequently in the non-perfusion (67%) versus the good perfusion category (33%, p = 0.03). By multivariable analysis, diabetes (odds ratio [OR] 6.42; p = 0.04) and non-perfusion (OR 6.60; p = 0.04) were independently associated with leak. CONCLUSION: Intraoperative use of ICG-FA may be a useful adjunct to assess perfusion of the gastric conduit with non-perfusion being independently associated with a leak. While perfusion plays an important role in anastomotic integrity, development of a leak is multifactorial, and ICG-FA should be used in conjunction with the optimization of patient and procedural components to minimize leak rates. Prospective, randomized studies are required to validate the interpretation, efficacy, and application of this novel technology in minimally invasive esophagectomies.

Near infrared perfusion assessment of gastric conduit during minimally invasive Ivor Lewis esophagectomy.

INTRODUCTION: Anastomotic leak and conduit necrosis are devastating complications following Ivor Lewis esophagectomy. Near infrared imaging (NIR) using IndoCyanine Green allows for real time tissue perfusion assessment which may reduce anastomotic leak during minimally invasive Ivor Lewis esophagectomy (MIE). METHODS: Forty consecutive MIE were performed by a single surgeon at a tertiary referral center. The first 20 were assessed for gastric conduit perfusion by clinical criteria (Group 1). The second 20 were also assessed using NIR laparoscopic system (Group 2). RESULTS: Comparing Group 1 to Group 2, no significant differences were found in overall complication rate, readmission or reoperation rate. NIR resulted in resection of the non perfused proximal portion of the conduit in 30% (6/20). Two patients in group 2 group developed anastomotic leak (2/20) compared to 0 in Group 1 (p = 0.49). Graft necrosis led to one mortality in Group 1, while there were 0 mortalities in Group 2. (p = 1.0). CONCLUSION: Although NIR plays a role in assessment of tissue perfusion, in our study its use did not result in reduction of anastomotic leak rate.

Intrathoracic versus Cervical ANastomosis after minimally invasive esophagectomy for esophageal cancer: study protocol of the ICAN randomized controlled trial.

BACKGROUND: Currently, a cervical esophagogastric anastomosis (CEA) is often performed after minimally invasive esophagectomy (MIE). However, the CEA is associated with a considerable incidence of anastomotic leakage requiring reintervention or reoperation and moderate functional results. An intrathoracic esophagogastric anastomosis (IEA) might reduce the incidence of anastomotic leakage, improve functional results and reduce costs. The objective of the ICAN trial is to compare anastomotic leakage and postoperative morbidity, mortality, quality of life and cost-effectiveness between CEA and IEA after MIE. METHODS/DESIGN: The ICAN trial is an open randomized controlled multicentre superiority trial, comparing CEA (control group) with IEA (intervention group) after MIE. All patients with esophageal cancer planning to undergo curative MIE are considered for inclusion. A total of 200 patients will be included in the study and randomized between the groups in a 1:1 ratio. The primary outcome is anastomotic leakage requiring reintervention or reoperation, and secondary outcomes are (amongst others) other postoperative complications, new onset of organ failure, length of stay, mortality, benign strictures requiring dilatation, quality of life and cost-effectiveness. DISCUSSION: We hypothesize that an IEA after MIE is associated with a lower incidence of anastomotic leakage requiring reintervention or reoperation than a CEA. The trial is also designed to give answers to additional research questions regarding a possible difference in functional outcome, quality of life and cost-effectiveness. TRIAL REGISTRATION: Netherlands Trial Register: NTR4333 . Registered on 23 December 2013.