The Study: In the Western world, the majority of esophageal cancers occur in the distal esophagus. Surgically, that means combined thoracic and abdominal approaches to tumor resection are often necessary. In other words, surgery for esophageal cancer is a big deal. The major draw to minimally-invasive approaches is to reduce surgical complications and morbidity, but these benefits must be carefully weighed with cancer outcomes. In this trial, patients with stage I-III squamous cell carcinoma or adenocarcinoma of the middle or distal third of the esophagus were randomized to a completely open versus hybrid minimally-invasive approach. The hybrid approach consisted of an open thoracotomy and en bloc esophagectomy with laparoscopic gastric mobilization. Of just over 200 patients randomized, over half had a major intraoperative or postoperative complication. But that rate was almost half with the hybrid approach (36%) than with the open approach (64%). In particular, the hybrid approach reduced pulmonary complications from 30 → 18%. While not a primary endpoint, rate of overall survival at 3 years was notably 67% among the hybrid arm versus 55% in the open arm.
Bottom Line: A minimally-invasive approach during distal esophagectomy reduces the risk of major complications, perhaps translating to the hefty numeric difference in overall survival. | Mariette, N Engl J Med 2019