The objectives were to determine factors associated with conversion to open surgery in patients with esophageal cancer who underwent minimally invasive esophagectomy (MIE, including laparo-thoracoscopic and robotic) and the impact of conversion to open surgery on patient outcomes.
We included patients from the National Cancer Database with esophageal and gastroesophageal junction cancer who underwent MIE from 2010 to 2015. Patient-, tumor-, and facility-related characteristics as well as short-term and oncologic outcomes were compared between patients who were converted to open surgery and those who underwent successful MIE without conversion to open surgery. Multivariable logistic regression models were used to analyze risk factors for conversion to open surgery from attempted MIE.
7306 patients underwent attempted MIE. Of these patients, 82 of 1487 (5.2%) robotic-assisted esophagectomies were converted to open, compared to 691 of 5737 (12.0%) laparo-thoracoscopic esophagectomies (p < 0.001). Conversion rates decreased significantly over the study period (ptrend = 0.010). Patient age, tumor size, and nodal involvement were independently associated with conversion. Facility minimally invasive cumulative volume and robotic approach were associated with decreased conversion rates. Patients whose MIEs were converted had increased 90-day mortality [Odds Ratio (OR) 1.49; 95% Confidence Interval (CI) 1.10, 2.02], prolonged hospital stay (OR 1.39; 95% CI 1.17, 1.66), and higher rates of unplanned readmission (OR 1.67; 95% CI 1.27, 2.20). No significant differences were found in surgical margins or number of lymph nodes harvested.
Patients undergoing attempted MIE requiring conversion to open surgery had significantly worse short-term outcomes including postoperative mortality. Patient factors and hospital experience contribute to conversion rates. These findings should inform surgeons and patients considering esophagectomy for cancer.
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Minimally invasive esophagectomy
Robotic-assisted minimally invasive esophagectomy
Video-assisted minimally invasive esophagectomy
National Cancer Database
Randomized controlled trial
Minimally invasive surgical
Length of stay
Torre LA, Siegel RL, Ward EM, Jemal A (2016) Global cancer incidence and mortality rates and trends: an update. Cancer Epidemiol Biomark Prev 25:16–27
Torre LA, Bray F, Siegel RL et al (2015) Global cancer statistics, 2012. CA Cancer J Clin 65:87–108
National Comprehensive Cancer Network Esophageal and Esophagogastric Junction Cancers (2018)
Bhagat R, Bronsert MR, Juarez-Colunga E et al (2018) Postoperative complications drive unplanned readmissions after esophagectomy for cancer. Ann Thorac Surg 105:1476–1482
Thirunavukarasu P, Gabriel E, Attwood K et al (2016) Nationwide analysis of short-term surgical outcomes of minimally invasive esophagectomy for malignancy. Int J Surg 25:69–75
Sihag S, Kosinski AS, Gaissert HA et al (2016) Minimally invasive versus open esophagectomy for esophageal cancer: A comparison of early surgical outcomes from the Society of Thoracic Surgeons National Database. Ann Thorac Surg 101:1281–1288 (Discussion 1288–1289)
Seesing MFJ, Gisbertz SS, Goense L et al (2017) A propensity score matched analysis of open versus minimally invasive transthoracic esophagectomy in the Netherlands. Ann Surg 266:839–846
Luketich JD, Pennathur A, Awais O et al (2012) Outcomes after minimally invasive esophagectomy: review of over 1000 patients. Ann Surg 256:95–103
Mu JW, Gao SG, Xue Q et al (2015) Updated experiences with minimally invasive McKeown esophagectomy for esophageal cancer. World J Gastroenterol 21:12873–12881
Luketich JD, Pennathur A, Franchetti Y et al (2015) Minimally invasive esophagectomy: results of a prospective phase II multicenter trial-the eastern cooperative oncology group (E2202) study. Ann Surg 261:702–707
He H, Wu Q, Wang Z et al (2018) Short-term outcomes of robot-assisted minimally invasive esophagectomy for esophageal cancer: a propensity score matched analysis. J Cardiothorac Surg 13:52
Yerokun BA, Sun Z, Yang CJ et al (2016) Minimally invasive versus open esophagectomy for esophageal cancer: a population-based analysis. Ann Thorac Surg 102:416–423
Biere SS, van Berge Henegouwen MI, Maas KW et al (2012) Minimally invasive versus open oesophagectomy for patients with oesophageal cancer: a multicentre, open-label, randomised controlled trial. Lancet 379:1887–1892
Mariette C, Markar SR, Dabakuyo-Yonli TS et al (2019) Hybrid minimally invasive esophagectomy for esophageal cancer. N Engl J Med 380:152–162
Straatman J, van der Wielen N, Cuesta MA et al (2017) Minimally invasive versus open esophageal resection: three-year follow-up of the previously reported randomized controlled trial: the TIME trial. Ann Surg 266:232–236
Weksler B, Sharma P, Moudgill N et al (2012) Robot-assisted minimally invasive esophagectomy is equivalent to thoracoscopic minimally invasive esophagectomy. Dis Esophagus 25:403–409
Park SY, Kim DJ, Yu WS, Jung HS (2016) Robot-assisted thoracoscopic esophagectomy with extensive mediastinal lymphadenectomy: experience with 114 consecutive patients with intrathoracic esophageal cancer. Dis Esophagus 29:326–332
Dunn DH, Johnson EM, Anderson CA et al (2017) Operative and survival outcomes in a series of 100 consecutive cases of robot-assisted transhiatal esophagectomies. Dis Esophagus 30:1–7
Biebl M, Andreou A, Chopra S et al (2018) Upper gastrointestinal surgery: robotic surgery versus laparoscopic procedures for esophageal malignancy. Visc Med 34:10–15
Coker AM, Barajas-Gamboa JS, Cheverie J et al (2014) Outcomes of robotic-assisted transhiatal esophagectomy for esophageal cancer after neoadjuvant chemoradiation. J Laparoendosc Adv Surg Tech A 24:89–94
Tapias LF, Morse CR (2014) Minimally invasive Ivor Lewis esophagectomy: description of a learning curve. J Am Coll Surg 218:1130–1140
Hernandez JM, Dimou F, Weber J et al (2013) Defining the learning curve for robotic-assisted esophagogastrectomy. J Gastrointest Surg 17:1346–1351
National Cancer Database (2017) National Cancer Database
Deyo RA, Cherkin DC, Ciol MA (1992) Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol 45:613–619
World Health Organization, Interim Commission of the World Health Organization, High-Level Working Group on the H et al (1976) International classification of diseases for oncology. World Health Organization, Geneva
Birkmeyer JD, Dimick JB (2004) Potential benefits of the new Leapfrog standards: effect of process and outcomes measures. Surgery 135:569–575
Chandra V, Nehra D, Parent R et al (2010) A comparison of laparoscopic and robotic assisted suturing performance by experts and novices. Surgery 147:830–839
Claassen L, van Workum F, Rosman C (2018) Learning curve and postoperative outcomes of minimally invasive esophagectomy. J Thor Dis 11:S777–S785
Dr. John D. Mitchell MD is a consultant on the Advisory Board for Medtronic, Dr. Alison L. Halpern MD, Ms. Chloe Friedman MPH, Dr. Robert J. Torphy MD, Dr. Mohammed H. Al-Musawi, MD MSc, Dr. Christopher D. Scott MD, Dr. Robert A. Meguid MD MPH, Dr. Martin D. McCarter MD, Dr. Michael J. Weyant MD, and Ana L. Gleisner MD PhD have no conflicts of interest or financial ties to disclose.
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Halpern, A.L., Friedman, C., Torphy, R.J. et al. Conversion to open surgery during minimally invasive esophagectomy portends worse short-term outcomes: an analysis of the National Cancer Database. Surg Endosc 34, 3470–3478 (2020). https://doi.org/10.1007/s00464-019-07124-y
- Minimally invasive esophagectomy
- Esophageal cancer