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Long-term Survival in Esophageal Cancer After Minimally Invasive Compared to Open Esophagectomy

A Systematic Review and Meta-analysis

Gottlieb-Vedi, Eivind MD*; Kauppila, Joonas H. PhD*,†; Malietzis, George PhD; Nilsson, Magnus PhD§; Markar, Sheraz R. PhD*,‡; Lagergren, Jesper PhD*,¶

doi: 10.1097/SLA.0000000000003252

Objective: 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 comparing long-term survival after MIE and OE. Additionally, an extensive hand-search was conducted. The I2 test and χ2 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 χ2 = 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.

*Upper Gastrointestinal Surgery, Department of Molecular medicine and Surgery, Karolinska Institutet, and Karolinska University Hospital, Stockholm, Sweden

Cancer and Translational Medicine Research Unit, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland

Department of Surgery & Cancer, Imperial College London, London, UK

§Department of Clinical Science, Intervention and Technology, Karolinska Institutet and Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden

School of Cancer and Pharmaceutical Sciences, King's College London, and Guy's and St Thomas’ NHS Foundation Trust, London, UK.

Reprints: Eivind Gottlieb-Vedi, MD, Upper Gastrointestinal Surgery, NS 67, Department of Molecular medicine and Surgery, Karolinska Institutet, 171 76 Stockholm, Sweden. E-mail:

Funding: The study was funded by the Swedish Research Council and Swedish Cancer Society.

The authors declare no conflicts of interest.

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