Outcome Comparison Of Different Surgical Approaches For Patients With Esophageal Cancer

PART ONE Outcomes of Endoscopic Resection vs Esophagectomy for patients with esophageal cancerObjectives:Endoscopic resection(ER)has been rapidly adopted in the treatment of early-stage esophageal cancer.We aimed to compare the outcomes of ER with esophagectomy for patients with small-sized(≤cm)stage T1a and T1b esophageal cancer in a population-based cohort.Methods:We queried the Surveillance,Epidemiology,and End Results database for patients with T1N0M0 esophageal cancer who underwent ER or esophagectomy and generated a balanced cohort with 217 matched pairs using propensity score matching(PSM).Kaplan-Meier method and multivariable Cox regression analysis were employed to investigate the matched cohort.Subgroup analyses of T stage were also performed.Results:We identified 702 patients;309(44.0%)underwent ER,and 393(56.0%)underwent esophagectomy.In the unmatched cohort,patients who underwent ER were older,more likely to have a T1a stage,and less likely to receive lymph node sampling.In the entire matched cohort,multivariate analysis found esophagectomy were associated with better overall survival(OS)(HR:0.62,95%CI:0.40-0.96,p=0.032)than ER,but no significant difference in esophageal cancer-specific survival(ECSS)(HR:1.37,95%CI:0.64-2.96,p=0.420)between the two procedures.The results were similar for subgroup analyses of stage T1b patients.However,ER and esophagectomy were associated with similar OS(HR:0.74,95%CI:0.41-1.36;p=0.334)and ECSS(HR:3.69,95%CI:0.95-14.39;p=0.060)in patients with stage T1a disease.Conclusions:In patients with stage T1 esophageal cancer,ER was similar to esophagectomy in terms of oncologic outcomes.More prospective studies should be implemented to determine the optimal treatment for T1b esophageal cancer patients with risk factors.PART TWO Short-term outcomes of MIE vs OE for patients with esophageal cancerObjectives:We performed a systematic review and meta-analysis to synthesize the available evidence regarding short-term outcomes between minimally invasive esophagectomy(MIE)and open esophagectomy(OE).Methods:Studies were identified by searching databases including PubMed,EMBASE,Web of Science and Cochrane Library up to March 2019 without language restrictions.Results of these searches were frltered according to a set of eligibility criteria and analyzed in line with PRISMA guidelines.Results:There were 33 studies included with a total of 13,269 patients in our review,out of which 4948 cases were of MIE and 8321 cases were of OE.The pooled results suggested that MIE had a better outcome regarding all-cause respiratory complications(RCs)(OR=0.56,95%CI=0.41-0.78,P=<0.001),in-hospital duration(SMD=-0.51;95%CI=-0.78-0.24;P=<0.001),and blood loss(SMD=-1.44;95%CI=-1.95-0.93;P=<0.001).OE was associated with shorter duration of operation time,while no statistically significant differences were observed regarding other outcomes.Additionally,subgroup analyses were performed for a number of different postoperative events.Conclusions:Our study indicated that MIE had more favorable outcomes than OE from the perspective of short-term outcomes.Further large-scale,multi-center randomized control trials are needed to explore the long-term survival outcomes after MIE versus OE.PART THREE Long-term outcomes of MIE vs OE for patients withesophageal cancerObjective:Evaluate the existing literature comparing long-term survival after minimally invasive esophagectomy(MIE)and open esophagectomy(OE),and conduct a meta-analysis based on relevant studies.Background:It is unknown whether the choice between MIE and OE influences the long-term survival in esophageal cancer.Methods:A systematic electronic search for articles was performed in Medline,Embase,Web of Science,and Cochrane Library for studies com-paring long-term survival after MIE and OE.Additionally,an extensive hand-search was conducted.The I2 test and x2 test were used to test for statistical heterogeneity.Publication bias and small-study effects were assessed using Egger test.A random-effects meta-analysis was performed for all-cause 5-year(main outcome)and 3-year mortality,and disease-specific 5-year and 3-year mortality.Meta-regression was performed for the 5-year mortality outcomes with adjustment for the covariates age,physical status,tumor stage,and neoadjuvant or adjuvant therapy.The results were presented as hazard ratios(HRs)with 95%confidence intervals(CIs).Results:The review identified 55 relevant studies.Among all 14,592 patients,7358(50.4%)underwent MIE and 7234(49.6%)underwent OE.The statistical heterogeneity was limited[I2=12%,95%confidence interval(CI)0%-41%,and x2=0.26]and the funnel plot was symmetrical both according to visual and statistical testing(Egger test=0.32).Pooled analysis revealed 18%lower 5-year all-cause mortality after MIE compared with OE(HR 0.82,95%CI 0.76-0.88).The meta-regression indicated no confounding.Conclusions:The long-term survival after MIE compares well with OE and may even be better.Thus,MIE can be recommended as a standard surgical approach for esophageal cancer.