Abstract: Objective:To investigate the clinical efficacy of minimally invasive esophagectomy and open triple-incision esophagectomy for esophageal cancer (EC).
Methods:The retrospective cohort study was conducted. The clinicopathological data of 454 EC patients who were admitted to the Tianjin Medical University Cancer Institute and Hospital from January 2012 to September 2016 were collected. Of 454 patients, 229 undergoing thoracoscopic esophagectomy (194) or combined thoracoscopic + laparoscopic esophagectomy (35) were allocated into the minimally invasive group, and 225 undergoing open triple-incision esophagectomy in the left cervical, right chest and epigastric regions were allocated into the open group. Observation indicators: (1) intraoperative situations; (2) postoperative recovery situations; (3) stratified analysis; (4) follow-up and survival situations. follow-up using outpatient examination and telephone interview was performed to detect the postoperative survival up to October 2017. Measurement data with normal distribution were represented as ±s, and t test was used for comparison between groups. Measurement data with skewed distribution were described as M (range), nonparametric test was used for comparison between groups. Count data were expressed as percentage, and the chisquare test or fisher exact probability method were used to test comparison between groups. KaplanMeier method was used to calculate survival rate and draw survival curve. Logrank test was used for survival analysis.
Results:(1) Intraoperative situations: operation time, numbers of upper mediastina lymph node dissected and right laryngeal nerve lymph node dissected in stage 0-Ⅱ of TNM staging and numbers of neck lymph nodes dissected in stage Ⅲ of TNM staging were respectively (307±70)minutes, 4 (range, 0-18), 2 (range, 0-10), 0 (range, 0-24) in the minimally invasive group and (267±49)minutes, 3 (range, 0-15), 1 (range, 0-7), 0 (range, 0-46) in the open group, with statistically significant differences between groups (t=7.071, Z=-2.207,-2.717,-1.969, P<0.05). (2) Postoperative recovery situations: thoracic drainagetube removal time and volume of drainage fluid were respectively 5 days (range, 2-88 days), 280 mL (range, 0-7 792 mL) in the minimally invasive group and 8 days (range, 1-72 days), 1 650 mL (range, 225-7 970 mL), with statistically significant differences between groups (Z=-9.618,-15.443, P<0.05). The cases with total postoperative complications, arrhythmia and recurrent laryngeal nerve paralysis were 72, 20, 35 in the minimally invasive group and 100, 36, 56 in the open group, with statistically significant differences between groups (x²=8.155, 5.542, 6.533, P<0.05). Patients may be combined with multiple complications. Two patients died within 30 days postoperatively, including 1 with respiratory failure and 1 with pulmonary embolism. Patients with other complications were improved after symptomatic and supportive treatments. (3) Stratified analysis: of 229 patients in the minimally invasive group, 93 underwent surgery within the physician′s learning curve and 136 underwent surgery after physician′s learning curve. Operation time, volume of intraoperative blood loss, dissected numbers of upper mediastina lymph node, right laryngeal nerve lymph node, left laryngeal nerve lymph node, middle mediastinal lymph node and lower mediastinal lymph node, cases with pneumonia, recurrent laryngeal nerve paralysis, chylothorax, anastomotic stenosis, anastomotic fistula, respiratory failure and pulmonary embolism in 93 patients were respectively (306±68)minutes, (217±178)mL, 3 (range, 0-20), 2 (range, 0-8), 0 (range, 0-10), 6(range, 0-17), 1 (range, 0-6), 5, 16, 1, 5, 3, 2, 2 in the minimally invasive group and (308±72)minutes, (200±112)mL, 4 (range, 0-37), 2 (range, 0-10), 0 (range, 0-8), 7 (range, 0-20), 1 (range, 0-10), 4, 19, 3, 3, 4, 4, 0 in the open group, with a statistically significant difference in number of upper mediastina lymph node dissected between groups (Z=-2.472, P<0.05) and no statistically significant difference in other indicators between groups (t=-0.160, 0.917, Z=-0.113,-1.698,-0.950,-0.510, x²=0.342, 0.446, P>0.05). (4) follow-up and survival situations: of 454 patients, 415 were followed up for 1- 62 months, with a median time of 28 months. Among the 415 patients, operation time ≥ 3 years was detected in 162 patients, (77 in the minimally invasive group and 85 in the open group), and 3year cumulative survival rates of the minimally invasive and open groups were 68.1% and 53.8%, showing no statistically significant difference between groups (x²=3.293, P>0.05). Further subgroup analysis showed that postoperative 3year cumulative survival rates of patients with the stage Ⅰ-Ⅱ and Ⅲ of TNM staging were respectively 82.1%, 53.7% in the minimally invasive group and 62.6%, 48.6% in the open group, showing no statistically significant difference between groups (x²=2.664, 0.382, P>0.05).
Conclusion:Minimally invasive esophagectomy has some characteristics of less surgical trauma postoperative complications, and its resection effect is comparable to open esophagectomy.