Original Article

Morbidity analysis in minimally invasive

esophagectomy for oesophageal cancer versus
conventional over the last 10 years, a single institution
experience
Misbah Khan, Muhammad Ijaz Ashraf, Aamir Ali Syed, Shahid Khattak, Namra Urooj, Anam Muzaffar
Department of Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre (SKMCH and RC), Lahore,
Pakistan

Address for Correspondence: Dr. Misbah Khan, 7-A Block R-3, Johar Town, Lahore 54000, Pakistan. E-mail: [email protected]

Abstract mortality, length of hospital and ICU stays and incidence of

major complications between three groups on uni- and multi-
BACKGROUND: There has been an increasing variate analysis (P > 0.05). The operative time was significantly
inclination towards minimally invasive esophagectomies longer in MIE group (odds ratio [OR]: 1.66, confidence interval
(MIEs) at our institute recently for resectable oesophageal [CI]: 2.4–11.5). The incidence of long-term complication was low
cancer. OBJECTIVES: The purpose of the present for MIE (OR: 1.0, CI: 133–1.017). However, all post-operative
study is to report peri-operative and long-term procedure surgical outcomes trended to improve in both groups over the
specific outcomes of the two groups and analyse their course of this study and stayed better for MIE group except for
changing pattern at our institute. METHODS: All adult the operative time. CONCLUSION: MIE has overall comparable
patients with a diagnosis of oesophageal cancer managed surgical outcomes to its conventional counterpart. Furthermore,
at our institute from 2005 to 2015 were included in this the peri-operative outcomes tend to improve in our centre with
retrospective study. Patients’ demographic and clinical the maturation of program and experience.
characteristics were recorded through our hospital
information system. The cohort of esophagectomies Key words: Minimally invasive esophagectomy, peri-operative
was allocated into two groups, conventional open outcomes, resectable oesophageal cancer
esophagectomy (OE) or total laparoscopic MIE; hybrid
esophagectomies were taken as a separate group. The
short-term outcome measures are an operative time
INTRODUCTION
in minutes, length of hospital and Intensive Care Unit
(ICU) stay in days, post-operative complications and
30 days in-hospital mortality. Complications are graded Esophagectomy the main treatment option for resectable
according to the Clavien-Dindo classification system. oesophageal cancer is a complex operation with significant
Long-term outcomes are long-term procedure related morbidity and mortality.[1-3] Minimally invasive esophagectomy
complications over a minimum follow-up of 1 year. (MIE) was described in 1990s in an endeavour to reduce
Trends were analysed by visually inspecting the graphic
plots for mean number of events in each group each
This is an open access article distributed under the terms of the
year. RESULTS: Our results showed no difference in
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Cite this article as: Khan M, Ashraf MI, Syed AA, Khattak S, Urooj N,
DOI: Muzaffar A. Morbidity analysis in minimally invasive esophagectomy for
10.4103/0972-9941.199606 oesophageal cancer versus conventional over the last 10 years, a single
institution experience. J Min Access Surg 2017;13:192-9.
Date of submission: 16/05/2016, Date of acceptance: 05/12/2016

192 © 2017 Journal of Minimal Access Surgery | Published by Wolters Kluwer - Medknow
 Khan, et al.: Morbidity analysis of esophageal cancer laparoscopic vs. conventional surgery

operative morbidity.[4] Luketich et al. in 1998 demonstrated from the study. Similarly, pathological subtypes other than
the potential feasibility of the procedure by publishing adeno and squamous cell cancer of the oesophagus were
their results on 8 MIEs using either laparoscopic and/or excluded.
thoracoscopic techniques with no perioperative mortalities
and one anastomotic leak.[1,5] MIE since then is becoming The cohort of esophagectomies was allocated into two
the routine procedure for resectable oesophageal cancer groups depending on the type of surgery conventional open
with apparently similar peri-operative short and long-term esophagectomy (OE) or MIEs. To maintain a clear segregation
outcomes.[2,6] In the absence of strong evidence confirming of MIE and conventional groups, hybrid procedures with
to the efficacy of the technique with a single published only one of the abdominal or thoracic approaches being
randomised controlled trial and another in process,[7,8] most done through laparoscope or thoracoscope are taken as a
of the evidence from literature comes from various large separate group.
retrospective case series and their meta-analysis.[9-12] Further
problems such as those inherent to the learning phase of MIE The short-term outcome measures are operative time in
have been less frequently addressed.[3,13-15] minutes, length of hospital stay in days, length of post-
operative Intensive Care Unit (ICU) stay in days, post-
Our institute being the largest cancer centre of the country operative complications and 30 days in-hospital mortality.
has also seen a shift from conventional to minimally invasive Complications are graded according to the Clavien-Dindo
techniques for resectable oesophageal cancer over the past classification system.[19] Long-term outcomes are long-term
decade.[16] Moreover, during the same period our surgical procedure related complications recorded over a minimum
oncology program has evolved into a high volume centre follow up of 1 year.
for the management of this disease. With the start of our
first minimally invasive hybrid esophagectomy in 2011, it All variables were obtained through our hospital information
has grown into a standard treatment modality over recent system by three main investigators and were reviewed
few years, limiting the conventional open approach mainly independently by the main investigator (Khan M). The
for emergency esophagectomies. frequency and nature of post-operative complications
were determined based on daily physician progress notes
The purpose of the present study is to analyse the peri- supplemented by relevant investigation reports. The
operative and long-term procedure related outcomes of hospital length of stay was determined by the surgery and
the two groups at our institute and to report the results. In discharge date and operative times were determined based
addition, the idea is to assess the changes in the occurrence on anaesthesia records. The long-term complication rate was
of these outcomes in a time-dependant fashion. calculated for patients with a minimum follow-up of 1 year.
Furthermore, the changes in above mentioned morbidity
METHODS parameters from 2005 to 2015, in minimally invasive group
as compared to conventional were analysed. Results in the
All adult patients with a histo-pathological diagnosis two arms MIE versus OE are further evaluated for a subset
of oesophageal cancer managed at our institute after a analysis according to the type of surgery performed (three-
multidisciplinary meeting decision for surgical resection stage, two-stage and trans hiatal) for assessment.
from September 2005 to September 2015 were included in
the study. For the purpose of division, Conventional techniques
of esophagectomy included procedures without any
An exemption status was granted by the hospital Ethical laparoscopic or thoracoscopic component including
Review Committee for conduction of this study. All patients transhiatal and three stage McKeown esophagectomy via
demographic and baseline clinical and pathological right thoracotomy approach. While MIE techniques included
characteristics are recorded Table 1. Furthermore, radiologic, total laparoscopic transhiatal or video-assisted thoracoscopic
endoscopic, operative and post-operative details were three-stage procedures with a laparoscopic abdominal part.
documented. The co-morbid conditions for each patient Stomach was used for reconstruction in all of our cases with
were graded according to Charlson et al. co-morbidity scoring a hand sewn gastro-oesophageal anastomosis except one.
system.[17,18] The cases with more complex surgery including All cases were jointly performed by one of the two surgical
en bloc resection of adjacent organs (splenectomy/gastrectomy) oncologists and one thoracic surgeon over the period of
and tumours of upper one-third of the oesophagus with this study. The video-assisted thoracoscopic or thoracotomy
concomitant laryngectomy or pharngectomy were excluded portion of the operation is performed in the left lateral

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 Khan, et al.: Morbidity analysis of esophageal cancer laparoscopic vs. conventional surgery

Table 1: Basic demographic, clinical and histo‑pathological variables stratified by the type of surgery
Conventional Minimally invasive Hybrid Total P
n=90 (41.6%) n=95 (44%) n=31 (14.4%) n=216 (100%)
Age (years)
Mean (SD) 56.5 (10.7) 53.2 (9.9) 48.7 (13.1) 53.9 (11.0) 0.002
Range 18-81 22-75 23-73 18-81
BMI
Mean (SD) 21.6 (4.0) 21.7 (4.3) 22.3 (3.9) 21.7 (4.1) 0.671
Range 15-35 11.6-33 15-30.8 11.6-35
Female, n (%) 38 (42.2) 47 (49.5) 14 (45.2) 99 (45.8) 0.611
Charlson score, n (%)
0 71 (78.9) 84 (88.4) 28 (90.3) 183 (84.7) 0.310
1-2 16 (17.8) 10 (10.5) 3 (9.7) 29 (13.4)
3 or more 3 (3.3) 1 (1.1) 0 4 (1.9)
Tumour type, n (%)
Squamous 65 (72.2) 77 (81.1) 28 (90.3) 170 (78.7) 0.079
Adeno 25 (27.8) 18 (18.9) 3 (9.7) 46 (21.3)
Tumour grade, n (%)
Well 12 (13.8) 13 (14.9) 3 (9.7) 28 (13.7) 0.494
Moderately 61 (70.1) 53 (60.9) 19 (61.3) 133 (64.9)
Poorly 14 (16.1) 21 (24.1) 9 (29.0) 44 (21.5)
Tumour ‘Ti’ stage, n (%)
T1, T2 5 (5.7) 4 (4.2) 1 (3.2) 10 (4.7) 0.266
T3 60 (68.2) 64 (67.4) 27 (87.1) 151 (70.6)
T4 23 (26.1) 27 (28.4) 3 (9.7) 53 (24.8)
Endoscopic tumour location, n (%)
Oesophagus 40 (44.9) 68 (71.6) 25 (80.6) 133 (61.9) 0.000
GE junction Siewart Type 1 34 (38.2) 23 (24.2) 6 (19.4) 63 (29.3)
GE junction Siewart Type 2 15 (16.9) 4 (4.2) 0 19 (8.8)
Surgery type, n (%)
Transhiatal 77 (85.6) 24 (25.3) 0 101 (46.8) 0.000
Three‑stage 13 (14.4) 71 (74.7) 24 (77.4) 108 (50.0)
Two‑stage 0 (0) 0 (0) 7 (22.6) 7 (3.2)
Neo‑adjuvant chemo, n (%) 83 (92.2) 94 (98.9) 31 (100) 208 (96.3) 0.027
Neo‑adjuvant radiation, n (%) 70 (77.8) 88 (92.6) 29 (93.5) 187 (86.6) 0.006
Pathological ‘pT’ stage, n (%)
Complete response T0 35 (38.9) 53 (55.8) 21 (67.7) 109 (50.5) 0.031
T1-T3 52 (57.8) 41 (43.2) 10 (32.3) 103 (47.7)
T4 3 (3.3) 1 (1.1) 0 4 (1.9)
Adjuvant, n (%) 11 (12.2) 7 (7.4) 1 (3.2) 19 (8.8) 0.252
Type of conduit, n (%)
Stomach 89 (98.9) 95 (100) 31 (100) 215 (99.5) 0.495
Other, colon 1 (1.1)
BMI: Body mass index, Ti: Tumour ‘T’ initial stage on diagnosis, GE: Gastro‑oesophageal, SD: Standard deviation

decubitus position for optimal thoracic lymphadenectomy, outcome measures controlling all other variables in the
and the abdominal part of both open and laparoscopic study. Differences that achieved a two-tailed P < 0.05 were
portion is done in a modified Lloyd-Davis position for better considered statistically significant for the present study.
assistant and instrument positioning. All patients are followed Trends were analysed by visually inspecting the graphic plots
up in surgical oncology clinic at 1 week post-surgery followed for mean number of events in each group each year.
by 1 month, 3 months, and then every 6 months.
RESULTS
Statistical analysis
This is a retrospective comparative cohort study. All analysis Out of 247 consecutive esophagectomies performed at our
was performed with IBM SPSS Statistical Software version institute from September 2005 to September 2015, 216
19.0. Armonk, NY, USA. We looked at frequencies and patients with diagnosed squamous or adeno-carcinoma
proportions. Chi-square test for categorical and ANOVA test of oesophagus and Type I, II gastro-oesophageal junction
for continuous variables were utilized. Continuous variables managed with a standard esophagectomy without a
were dichotomized according to the clinical importance laryngectomy, pharyngectomy were included in the study.
or median value of each variable. Uni- and multi-variate Among these, 90 were conventional open, 95 were minimally
logistic regression analysis was performed for the main invasive and 31 hybrid esophagectomies. 7 minimally invasive

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 Khan, et al.: Morbidity analysis of esophageal cancer laparoscopic vs. conventional surgery

surgeries converted to open transhiatal and 4 MIE into open emphysema, recurrent laryngeal nerve injury etc., managed
three-stage procedures were treated as conventional open either conservatively or with medications. The major
esophagectomies due to retrospective nature of the study. complications group included major Class III and IV
respiratory complications requiring additional radiological
The patient and tumour characteristics were similar among or surgical intervention, in addition to re-explorations for
groups on the basis of gender distribution, body mass thoracic duct or tracheo-bronchial tree injury, conduit failure,
index, co-morbidity index, initial tumour stage according haemorrhage or anastomotic leak.
to the seventh edition of the American Joint Committee on
Cancer guidelines and tumour grade. However, due to the Long-term complications were 22.2%, 11.6% of them were
inclusion of emergency oesophageal resections done mainly anastomotic strictures requiring multiple dilations and stent
via open approach (n = 7; 6 endoscopy related and 1radiation placement in 25 cases. Rest were 8.7% long term reflux and
necrosis), proportion of patients without neoadjuvant aspiration related symptoms and 1.9% incisional hernias
treatment and less pathological treatment response was including one diaphragmatic hernia.
high in OE group. The OE group also had a higher number
of transhiatal procedures done for GE junction adeno- However, when the results were analysed in a time dependent
carcinomas reaching statistical significance. fashion we found out that the overall rate of all peri-operative
morbidity parameters utilised in our study stayed better for
The outcome variables distribution among various types of minimally invasive group and showed a uniform improvement
esophageal resections is shown in Table 2. Median length for both the groups. It was only the mean operative time
of follow-up for all patients was 12 months (range 0–90). which stayed consistently longer for the MIE group [Figure 1].
Overall 30-day mortality rate, rate of major complications
requiring re-intervention or re-exploration and length DISCUSSION
of hospital and post-operative ICU stay were statistically
insignificant between the groups. The results for these Minimally invasive technique is being utilized for resectable
outcomes stayed insignificant on multivariate analysis oesophageal cancers since 2011 at our centre and has
performed by controlling all other variables including age, resulted in a constant decrease in the number of conventional
tumour location, tumour grade and morphology, radiological esophagectomies with only two conventional transhiatal
and pathological stage, neo-adjuvant or adjuvant treatment esophagectomy procedures done during year 2015 for
and type of esophagectomy, that is, transhiatal, two-stage emergency oesophageal perforation.
or three-stage [Table 3]. In our series, rate of long term
complications remained low for MIE and the mean operative Recent systematic reviews and meta-analysis comparing MIE
time longer for MIE and hybrid groups with statistically to conventional esophagectomies including Watanabe et al.,
significant difference on multivariate analysis. Dantoc et al., and Kim et al.[1,6,20-23] have shown no statistically
significant difference between groups in terms of 30-day
The Class I and II minor complication group included minor mortality, similar to our data with an overall mortality lower
respiratory and wound complications, fluid electrolyte in MIE group (2.1% vs. 8.9% conventional and 3.2% hybrid)
disturbances or any other complications including atrial without any statistically significant difference on multi-variate
fibrillations, diarrhoea, urinary tract infection, surgical analysis.

Table 2: Outcome distribution among various groups

n (%) Median (range)
Mortality Class I and II Class III and IV LT complicationsa Operative time min LOS days ICU stay days
complications complications
Total n = 216 11 (5.1) 115 (53.2) 48 (22.2) 39 (22.2) 310 (140-870) 9 (6-55) 1 (0-27)
(100%)
P 0.114 0.03 0.723 0.007 0.001 0.733 0.167
Minimally invasive 2 (2.1) 61 (64.2) 18 (18.9) 11 (16.2) 330 (195-750) 9 (7-47) 1 (1-13)
Transhiatal 0 15 (62.5) 4 (16.7) 7 (33.3) 297 (200-550) 9.5 (7-21) 1 (1-9)
3‑stage 2 (2.8) 46 (64.8) 14 (19.7) 4 (8.5) 345 (195-750) 9 (7-47) 1 (1-13)
Conventional 8 (8.9) 39 (43.3) 21 (23.3) 22 (27.8) 240 (140-810) 9 (6-55) 1.5 (0-27)
Transhiatal 8 (10.4) 31 (40.3) 17 (22.1) 15 (22.7) 222 (140-390) 9 (6-55) 1 (0-27)
3‑stage 0 8 (61.5) 4 (30.8) 7 (53.8) 345 (240-810) 10 (8-14) 2 (1-4)
Hybrid 1 (3.2) 15 (48.4) 9 (29.0) 6 (20.7) 425 (140-870) 11 (7-33) 1 (1-23)
Out of 176 patients with a complete 1 year follow‑up. LOS: Length of stay, ICU: Intensive Care Unit, LT: Long‑term
a

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 Khan, et al.: Morbidity analysis of esophageal cancer laparoscopic vs. conventional surgery

Table 3: Results of uni‑ and multi‑variate analysis for risk of occurrence of outcome measures in minimally invasive and hybrid
group as compared to conventional
Uni‑variate analysis Multi‑variate analysis
OR 95% CI P Adjusted OR 95% CI P
Mortality
Conventional
Minimally invasive −1.512 0.05-1.07 0.060 −0.851 0.04-4.40 0.475
Hybrid −1.074 0.04-2.85 0.321 −0.237 0.02-25.72 0.894
Class I and II
Conventional
Minimally invasive −0.853 0.24-0.77 0.005 0.798 1.02-4.86 0.045
Hybrid −0.204 0.36-1.85 0.626 −0.024 0.29-3.24 0.968
Class III and IV
Conventional
Minimally invasive −0.264 0.38-1.56 0.465 −0.435 0.26-1.64 0.360
Hybrid 0.296 0.54-3.36 0.527 0.057 0.27-4.16 0.935
Long‑term complications
(minimum follow up of 1 year)
Conventional
Minimally invasive −0.693 0.22-1.13 0.094 −1.002 0.133- 0.054
1.017
Hybrid −0.392 0.24-1.88 0.454 −0.925 0.09-1.79 0.229
Operative time >240 min
Conventional
Minimally invasive 1.525 2.41-8.77 0 1.655 2.39-11.48 0
Hybrid 3.604 4.79- 0.001 3.937 6.09- 0
281.4 431.07
Length of hospital stay
2 weeks or more
Conventional
Minimally invasive −0.361 0.29-1.68 0.421 −0.086 0.29-2.85 0.882
Hybrid 0.547 0.62-4.82 0.297 0.861 0.45-12.36 0.307
Length of ICU stay >48 h
Conventional
Minimally invasive −0.843 0.19-0.95 0.038 −0.388 0.22-2.09 0.501
Hybrid −0.459 0.22-1.85 0.402 0.252 0.24-6.89 0.768
OR: Odds ratio, CI: Confidence interval, ICU: Intensive Care Unit

The major complication rate (22%) and length of ICU stay (9.9% vs. 4.4%) in MIE group than conventional open. The
(mean 1 day) was lower for minimally invasive group in our complication rates were described quite heterogeneously
series, but values did not reach a statistical significance. by all of the above series with peri-operative morbidity
The median length of hospital stay (median 9 days) is advantage of the two groups staying still arguable.[22]
comparable or less than most of the series but without
significant difference between groups.[9,12,16,22] Larger series The frequency of individual procedure specific complications
by Schoppmann et al. (MIE 12 vs. OE 24) and Kauppi et al. in our series in different groups is shown in Table 4. The
(MIE 13 vs. OE 14,) have reported their results with a length overall rate of minor pulmonary complications managed with
of hospital stay significantly shorter for MIE group with no chest physiotherapy and incentive spirometry and Class III
significant difference for operative time, whereas the median complications requiring bronchoscopy, radiological drainage
ICU stay was better for MIE in series by Schoppmann et al. or chest tube insertion for a pleural effusion, pneumothorax
and stayed similar for groups in Kauppi et al.[9,12] or lung collapse was higher for MIE and hybrid techniques
in our series accounting for a higher number of thoracic
The operative time in our series was significantly longer procedures in these groups as compared to conventional.
for minimally invasive group (MIE median 330 min vs. 240 However, rate of Class IV pulmonary complications involving
OE) similar to what was shown in the meta-analysis by prolonged ventilation and re-explorations were similar
Watanabe et al. and a recently published Society of Thoracic between the groups. Overall rate of pulmonary complications
Surgeons National Database analysis of USA (443 vs. 312 min; by many series have reported a low incidence of pulmonary
P < 0.001).[1,20,22,24] Their results also showed a shorter median complications with MIE group,[9,12] also the randomised
hospital stay (9 vs. 10 days) and higher re-operation rate control trial by Biere et al. published a very low over all

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 Khan, et al.: Morbidity analysis of esophageal cancer laparoscopic vs. conventional surgery

Figure 1: Changes observed in outcome parameters over time among the comparison groups. OE: Open esophagectomy, MIE: Minimally invasive
esophagectomy

Table 4: Frequency of occurrence of various major complications in each group

Pulmonary Thoracic Wound Aspiration, Leak, Surgical Re‑ Stricture, Others,
complications, n (%) duct injury, complications, n (%) n (%) emphysema, exploration, n (%)a n (%)
I, II III IV n (%) n (%) n (%) n (%)

Minimally 31 (32.6) 11 (11.6) 2 (2.1) 3 (3.2) 13 (13.7) 3 (3.2) 4 (4.2) 5 (5.3) 6 (6.3) 9 (13.2) 25 (26.3)
invasive
Transhiatal 7 (29.2) 3 (12.5) 1 (4.2) 0 1 (4.2) 1 (4.2) 2 (8.4) 1 (4.2) 2 (8.4) 6 (28.6) 9 (37.5)
3‑stage 24 (33.8) 8 (11.3) 1 (1.4) 3 (4.2) 12 (16.9) 2 (2.8) 2 (2.8) 4 (5.6) 4 (5.6) 3 (6.4) 16 (22.5)
Conventional 23 (25.6) 8 (8.8) 2 (2.2) 2 (2.2) 8 (8.9) 10 (11.1) 8 (8.9) 4 (4.4) 7 (7.8) 14 (17.7) 25 (27.8)
Transhiatal 17 (22.1) 6 (7.8) 2 (2.6) 1 (1.3) 7 (9.1) 7 (9.1) 8* (10.4) 3 (3.9) 4 (5.2) 10 (15.2) 22 (28.6)
3‑stage 6 (46.2) 2 (15.4) 0 1 (7.7) 1 (7.7) 3 (23.1) 0 (0) 1 (7.7) 3 (23.1) 4 (30.8) 3 (23.1)
Hybrid 11 (35.5) 0 0 5 (16.1) 1 (3.2) 2* (6.4) 1 (3.2) 4 (12.9) 2 (6.9) 5 (16.1)
Total 65 (30.1) 16 (7.4) 4 (1.9) 5 (2.3) 26 (12) 14 (6.5) 14 (6.5) 10 (4.6) 17 (7.9) 25 (14.2) 55 (25.5)
*Include 2 gastric perforation in minimally invasive transhiatal and 1 gastric conduit necrosis in hybrid, aOut of 176 patients with complete 1 year follow‑up

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 Khan, et al.: Morbidity analysis of esophageal cancer laparoscopic vs. conventional surgery

pulmonary infection rate,[7] these series however did not hospital stay. Very few studies have attempted to show the
include minor class I complications such as basal atelectasis, evolution of minimally invasive techniques in comparison
pleural effusion or minor pneumothorax in their analysis. to conventional and hybrid groups. [3,14,15,28] Tapias and
Furthermore, the true rate of respiratory infections in our Morse in their study described the learning curve for MIE
series was MIE 28.4% versus OE 21.1% and hybrid 29%. While it of a single surgeon and observed improved operative time,
was 21.8 for transhiatal and 28% for 3-stage esophagectomies. blood loss, median hospital stay and morbidity in their last
forty patients compared with the first 40.[14] Similar results
The long term complication rate for anastomotic stricture with improved operative and peri-operative outcomes were
(MIE 9.5% vs. 15.6% in conventional group) is superior to shown by Arlow et al. in their series of 200 open transhiatal
recently published data by Maas et al. showing high rates of esophagectomies performed over 13 years by same set of
44% MIE and 39% OE on the 1 year follow-up of their multi- surgeons.[15] In another recent series on 180 consecutive
centric randomised controlled trial patients.[7,25] In their minimally invasive McKeown esophagectomy by Mu et al.
previously published review of 12 studies, describing various no significant differences in post-operative morbidity were
intra-thoracic anastomotic techniques for minimally invasive found between their first sixty patients group as compared
Ivor-Lewis esophagectomy anastomotic stricture rates ranged to second and third sixty; however, there was significantly
from 0% to 27.5%.[26] longer duration of surgery in first group as compared to
other two.[3]
Out of thoracic duct injuries only two required thoracotomy
and duct ligation rest were managed conservatively with total Limitations
parenteral nutrition (TPN) and fat free diet. Also in case of Although we separated hybrid esophagectomies in our
anastomotic leak on contrast study, 50% of the leaks were study design for data comparison of outcome variables, yet
successfully managed conservatively with TPN followed by there were more number of transhiatal esophagectomies
a prolonged naso-jejunal (NJ) tube feed, with remaining in conventional group with a higher percentage of gastro-
7 cases requiring a re-exploration (3 conduit failures, oesophageal junction tumours in the same group and more
3 tracheo-esophageal fistulas and 1 anastomotic site leak). three-stage in MI group with an equally higher percentage
Other major complications requiring re-exploration were of oesophageal tumours, that can lead to a potential source
2 azygous vein rebleeds, 2 gastric outlet obstructions at of bias for overall results. This was statistically minimised by
hiatus, 2 tracheo-bronchial tree injuries, 1 neck haemorrhage controlling these variables in multivariate analysis.
and 1 large hiatus diaphragmatic hernia in the long term.
Hence, a retrospective study design and heterogeneity of
Other complications in Table 4 included post-operative medical the cases with regards to the type of MIE (more three stage)
problems like fluid and electrolyte disturbances, cardiac issues and conventional open (more transhiatal) resulting in a lack
such as arrhythmias, uncontrolled hypertension, thrombo- of true match to match comparison of MIE and conventional
embolic phenomenon and urinary tract infections. Aspiration groups are main limitations for our study.
was taken as a separate complication because of its multifactorial
relationship to anastomotic narrowing or recurrent laryngeal CONCLUSION
nerve injury (RLNI), and its wide spectrum consequences of
minor cough and aspiration pneumonia to cases requiring The data suggest that MIE has overall comparable surgical
prolonged NJ or a feeding jejunostomy for repeated aspirations. outcomes to its conventional counterpart with a longer
operative time and low long-term complication rate. Also,
In terms of oncologic efficacy of the specimen as published the peri-operative outcome tended to improve in our centre
recently, the mean number of lymphnode harvest in our series with the maturation of program and experience.
was 13.7 ± 5.6 and the rate of R0 resection in patients with
post neo-adjuvant residual disease (50% of study population) Acknowledgements
was 53.4% with statistically insignificant difference among Dr. Waleed Zafar, Dr. Farhana Badar Clinical Research
the groups (P > 0.05).[27] Scientists Section of Cancer Registry and Clinical Data
Management, Shuakat Khanum Memorial Cancer Hospital
In-general, all post-operative surgical outcomes tended to and Research Centre.
improve over the course of this study. With the maturation
of our program, we recognised a gradually decreasing Financial support and sponsorship
frequency of complications and lengths of ICU and Nil.

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 Khan, et al.: Morbidity analysis of esophageal cancer laparoscopic vs. conventional surgery

Conflicts of interest Description of a learning curve. J Am Coll Surg 2014;218:1130-40.

15. Arlow RL, Moore DF, Chen C, Langenfeld J, August DA. Outcome-volume
There are no conflicts of interest. relationships and transhiatal esophagectomy: Minimizing “failure to
rescue”. Ann Surg Innov Res 2014;8:9.
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