594. totally minimally invasive 2-stage esophagectomy versus hybrid 2-stage esophagectomy. a single center experience

Abstract Totally minimally invasive 2-stage esophagectomy (TMIE) eliminates the thoracotomy associated with hybrid 2-stage minimally invasive esophagectomy (hybrid-MIE). This has an important role in minimizing post-operative respiratory complications. There is ongoing growing evidence in published literature of improved clinical and oncological outcomes in totally MIE comparing to hybrid MIE, due to enhanced optics and extend of lymphadenectomy as well as to shorter length of hospital stay and surgical trauma associated to thoracoscopy. This is a retrospective analysis of consecutive patients that underwent 2-stage minimally invasive esophagectomy for esophageal and gastro-esophageal junction Siewert type I-II cancers. TMIE combines a laparoscopic and thoracoscopic approach while hybrid-MIE includes laparoscopic open thoracotomic phase. Study included adult patients with no upper age limit (>18 years). All esophagectomies for benign disease, as well as emergency operations were excluded from the study. Primary endpoints were 30- and 90-day mortality rate, anastomotic leak, anastomotic stricture, pulmonary complications, and length of hospital stay. Secondary endpoints were overall survival and progression-free survival rates respectively. During an 8-year-period, 150 patients underwent hybrid-MIE, while 200 underwent TMIE. Operative-time was shorter in the hybrid-MIE group (320 vs 280 min). Anastomotic leak was significantly reduced in the TMIE group comparing to the hybrid-MIE group (2.5% vs 9.5%). Respiratory complications were reduced in the TMIE group (10 vs 25%). Median LOS was similar (7 vs 7.5 days). Median number of resected-lymph nodes was increased in the TMIE group (28 vs 35 lymph nodes). OS survival rate was 60 versus 51 months and PFS was 52 vs 43 months in the TMIE and hybrid-MIE groups respectively. In general, TMIE was associated with moderately lower morbidity compared to hybrid-MIE, but randomized controlled evidence is lacking. The higher anastomotic leakage rate, higher rate of pulmonary complications and lower lymph node count that was found after hybrid-MIE in comparative analysis, indicate that TMIE can significantly improve clinical outcomes of patients undergoing esophagectomy. The findings of this study should be considered carefully by surgeons when moving from hybrid-MIE to TMIE.