Clinical Study Of Minimally Invasive Ivor Lewis Esophagectomy

Objective:Minimally invasive Ivor Lewis esophagectomy(MIILE)has been increasingly performed.To guide the implementation of this technically demanding procedure,a comprehensive assessment of MIILE learning curves should include both the general competence to accomplish the procedure and the ability to generate oncological benefits.These objectives are believed to be associated with different phases of the learning curve.Methods:A retrospective review of the esophageal cancer patients treated in our center between Janury 1,2011 and September 30,2014 was conducted.109 patients who underwent MIILE were enrolled in this study.Relevant variables were collected and assessed by regression analysis to identify suitable indicators for patient stratification and learning curve assessment.Thereafter,the differential analysis was performed among groups to validate the learning curve model.Results:Two variables,intrathoracic gastroesophageal anastomosis time and bilateral recurrent laryngeal nerve(RLN)lymphadenectomy number,which plateaued,respectively,after the 26th and 88th cases,were selected as meaningful indicators to identify different competence levels.Therefore,109 patients were chronologically subcategorized into three groups(the first 26 MIILEs as the early group,the next 62 cases as the middle group,and 21 most recent cases as the late group).Perioperative data were compared between groups with positive results to indicate a three-phase model for a learning curve for MIILE.Conclusion:A MIILE learning curve should include three discrete phases that indicate,successively,unskilled operation(general competence to accomplish,less proficiency),surgical proficiency,and oncological efficacy.Intrathoracic anastomosis time and bilateral RLN lymphadenectomy were identified as suitable indicators delineate the different stages of an MIILE learning curve.About 26 cases are needed to reach general competence,and after around 88 cases,a surgeon can perform the MIILE procedure with increased oncological benefits.Objective:To investigate the long-term efficacy of the minimally invasive Ivor Lewis esophagectomy(MIILE)in esophageal squamous cell carcinoma(ESCC)patients,a retrospective comparison of the clinical outcomes,quality of life(QOL)and survival between patients who underwent MIILE and left transthoracic esophagectomy(Sweet approach)was conducted.Methods:A detailed database search identified 614 patients who underwent MIILE and 243 patients who underwent Sweet esophagectomy between January 1,2011 and December 30,2017.After propensity score matching,216 paired cases were selected for statistical analysis.Survival was evaluated with Kaplan-Meier curves or Cox models.Results:MIILE was associated with a longer duration,less blood loss and more lymph node dissected than Sweet esophagectomy.MIILE patients su:ffered from less pain,less frequently developed pneumonia,and had fewer postoperative complications.Additionally,MIILE patients began oral intake earlier and had a shorter postoperative hospital stay,and enhanced recovery of QOL.There was no significant difference between the approaches regarding the recurrence pattern,2-year and 5-year overall survival(OS)or disease-free survival(DFS),except that patients with tumor-node-metastasis(TNM)stage I in the MIILE group demonstrated superior OS and DFS.Pathological TNM stage and postoperative complications were determined to be independent prognostic factors based on the multivariate analysis.Conclusion:MIILE is a safe and feasible approach for treating ESCC patients.MIILE approach may provide more postoperative advantages,enhanced QOL improvement,and more favorable long-term survival in early stage patients than the Sweet procedure.