Comparative Perioperative Outcomes by Esophagectomy Surgical Technique



Surgical resection is vital in the curative management of patients with esophageal cancer. However, a myriad of surgical procedures exists based on surgeon preference and training. We report on the perioperative outcomes based on esophagectomy surgical technique.


A prospectively managed esophagectomy database was queried for patients undergoing esophagectomy from 1996 and 2016. Basic demographics, tumor characteristics, operative details, and post-operative outcomes were recorded and analyzed by comparison of transhiatal vs Ivor-lewis and minimally invasive (MIE) vs open procedures.


We identified 856 patients who underwent esophagectomy. Neoadjuvant therapy was administered in 543 patients (63.4%). There were 504 (58.8%) open esophagectomies and 302 (35.2%) MIE. There were 13 (1.5%) mortalities and this did not differ among techniques (p = 0.6). While there was no difference in overall complications between MIE and open, complications occurred less frequently in patients undergoing RAIL and MIE IVL compared to other techniques (p = 0.003). Pulmonary complications also occurred less frequently in RAIL and MIE IVL (p < 0.001). Anastomotic leaks were less common in patients who underwent IVL compared to trans-hiatal approaches (p = 0.03). MIE patients were more likely to receive neoadjuvant therapy (p = 0.001), have lower blood loss (p < 0.001), have longer operations (p < 0.001), and higher lymph node harvests (p < 0.001) compared to open patients.


Minimally invasive and robotic Ivor Lewis techniques demonstrated substantial benefits in post-operative complications. Oncologic outcomes similarly favor MIE IVL and RAIL.

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  1. 1.

    Yamamoto S, Kawahara K, Maekawa T, Shiraishi T, Shirakusa T. Minimally invasive esophagectomy for stage I and II esophageal cancer. Ann Thorac Surg. 2005;80(6):2070–2075.

    PubMed  Google Scholar 

  2. 2.

    Siegel RL, Miller KD, Jemal A. Cancer Statistics, 2017. CA: a cancer journal for clinicians. 2018;67(1):7–30.

    Google Scholar 

  3. 3.

    Drahos J, Wu M, Anderson WF, et al. Regional variations in esophageal cancer rates by census region in the United States, 1999-2008. PloS one. 2013;8(7):e67913.

    CAS  PubMed  PubMed Central  Google Scholar 

  4. 4.

    Rustgi AK, El-Serag HB. Esophageal Carcinoma. New England Journal of Medicine. 2014;371(26):2499–2509.

    PubMed  Google Scholar 

  5. 5.

    Hur C, Miller M, Kong CY, et al. Trends in esophageal adenocarcinoma incidence and mortality. Cancer. 2013;119(6):1149–1158.

    PubMed  Google Scholar 

  6. 6.

    Wouters MW, Gooiker GA, van Sandick JW, Tollenaar RA. The volume-outcome relation in the surgical treatment of esophageal cancer: a systematic review and meta-analysis. Cancer. 2012;118(7):1754–1763.

    PubMed  Google Scholar 

  7. 7.

    Surveillance, Epidemiology, and End Results Program. SEER Statistical Fact Sheets: Esophageal Cancer. 2016.

  8. 8.

    NCCN Clinical Practice Guidelines in Oncology: Esophageal and Esophagogastric Junction Cancers. 2013.

  9. 9.

    Orringer MB, Marshall B, Iannettoni MD. Transhiatal esophagectomy for treatment of benign and malignant esophageal disease. World journal of surgery. 2001;25(2):196–203.

    CAS  PubMed  Google Scholar 

  10. 10.

    Mathisen DJ, Grillo HC, Wilkins EW, Jr., Moncure AC, Hilgenberg AD. Transthoracic esophagectomy: a safe approach to carcinoma of the esophagus. Ann Thorac Surg. 1988;45(2):137–143.

    CAS  PubMed  Google Scholar 

  11. 11.

    Willer BL, Mittal SK, Worrell SG, Mumtaz S, Lee TH. Applicability and feasibility of incorporating minimally invasive esophagectomy at a high volume center. Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract. 2010;14(8):1201–1206.

    Google Scholar 

  12. 12.

    Nagpal K, Ahmed K, Vats A, et al. Is minimally invasive surgery beneficial in the management of esophageal cancer? A meta-analysis. Surgical endoscopy. 2010;24(7):1621–1629.

    PubMed  Google Scholar 

  13. 13.

    Safranek P, Cubitt J, Booth M, Dehn T. Review of open and minimal access approaches to oesophagectomy for cancer. . Br J Surg 2010;Dec: 97(12):1845–1853.

    CAS  PubMed  Google Scholar 

  14. 14.

    Verhage RJ, Hazebroek EJ, Boone J, Van Hillegersberg R. Minimally invasive surgery compared to open procedures in esophagectomy for cancer: a systematic review of the literature. Minerva chirurgica. 2009;64(2):135–146.

    CAS  PubMed  Google Scholar 

  15. 15.

    Bizekis C, Kent MS, Luketich JD, et al. Initial experience with minimally invasive Ivor Lewis esophagectomy. Ann Thorac Surg. 2006;82(2):402–406; discussion 406-407.

    PubMed  Google Scholar 

  16. 16.

    Santillan AA, Farma JM, Meredith KL, Shah NR, Kelley ST. Minimally invasive surgery for esophageal cancer. Journal of the National Comprehensive Cancer Network. 2008;6(9):879–884.

    PubMed  Google Scholar 

  17. 17.

    Luketich JD, Alvelo-Rivera M, Buenaventura PO, et al. Minimally invasive esophagectomy: outcomes in 222 patients. Ann Surg. 2003;238(4):486–494; discussion 494-485.

    PubMed  PubMed Central  Google Scholar 

  18. 18.

    Rinieri P, Ouattara M, Brioude G, et al. Long-term outcome of open versus hybrid minimally invasive Ivor Lewis oesophagectomy: a propensity score matched study. European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery. 2016.

  19. 19.

    Rentz J, Bull D, Harpole D, et al. Transthoracic versus transhiatal esophagectomy: a prospective study of 945 patients. The Journal of thoracic and cardiovascular surgery. 2003;125(5):1114–1120.

    PubMed  Google Scholar 

  20. 20.

    Goldminc M, Maddern G, Le Prise E, Meunier B, Campion JP, Launois B. Oesophagectomy by a transhiatal approach or thoracotomy: a prospective randomized trial. The British journal of surgery. 1993;80(3):367–370.

    CAS  PubMed  Google Scholar 

  21. 21.

    Chu KM, Law SY, Fok M, Wong J. A prospective randomized comparison of transhiatal and transthoracic resection for lower-third esophageal carcinoma. American journal of surgery. 1997;174(3):320–324.

    CAS  PubMed  Google Scholar 

  22. 22.

    de Boer AG, van Lanschot JJ, van Sandick JW, et al. Quality of life after transhiatal compared with extended transthoracic resection for adenocarcinoma of the esophagus. Journal of Clinical Oncology. 2004;22(20):4202–4208.

    PubMed  Google Scholar 

  23. 23.

    Nguyen N, Hinojosa M, Smith B, Chang K, Gray J, Hoyt D. Minimally invasive esophagectomy: lessons learned from 104 operations. Ann Surg. 2008;Dec;248(6):1081–1091.

  24. 24.

    Smithers BM, Gotley DC, Martin I, Thomas JM. Comparison of the outcomes between open and minimally invasive esophagectomy. Ann Surg. 2007;245(2):232–240.

    PubMed  PubMed Central  Google Scholar 

  25. 25.

    Luketich JP, Pennathur A; Awais, O; Levy, RM; Keeley, S; Shende, M; Weksler, B; Landreneau, RJ; Abbas, G; Schuchert, MJ; Nason, KS. Outcomes after minimally invasive esophagectomy: review of over 1000 patients. Ann Surg. 2012;256(1):95–103.

    PubMed  PubMed Central  Google Scholar 

  26. 26.

    Verhage R, Hazebroek E, Boone J, Van Hillegersberg R. Minimally invasive surgery for esophageal cancer. Minerva Chir. 2009;April;64(2):135–146.

  27. 27.

    Singh R, Pham T, Diggs B, Perkins S, Hunter J. Minimally invasive esophagectomy provides equivalent oncologic outcomes to open esophagectomy for locally advanced (stage II or III) esophageal carcinoma. Archives of surgery (Chicago, Ill : 1960). 2011;Jun;146(6):711–714.

  28. 28.

    Hulscher JB, van Sandick JW, de Boer AG, et al. Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the esophagus. The New England journal of medicine. 2002;347(21):1662–1669.

    PubMed  Google Scholar 

  29. 29.

    Biere S, Van Berge Henegouwen M, Maas K, et al. Minimally invasive versus open oesophagectomy for patients with oesophageal cancer: a multicentre, open-label, randomised controlled trial. Lancet 2012;May:379(9829):1887–1892.

  30. 30.

    Chang AC, Ji H, Birkmeyer NJ, Orringer MB, Birkmeyer JD. Outcomes after transhiatal and transthoracic esophagectomy for cancer. Ann Thorac Surg. 2008;85(2):424–429.

    PubMed  Google Scholar 

  31. 31.

    Chang AC, Birkmeyer JD. The volume-performance relationship in esophagectomy. Thoracic surgery clinics. 2006;16(1):87–94.

    PubMed  Google Scholar 

  32. 32.

    Dimick JB, Cowan JA, Jr., Ailawadi G, Wainess RM, Upchurch GR, Jr. National variation in operative mortality rates for esophageal resection and the need for quality improvement. Archives of surgery (Chicago, Ill : 1960). 2003;138(12):1305–1309.

    Google Scholar 

  33. 33.

    Sahni NR, Dalton M, Cutler DM, Birkmeyer JD, Chandra A. Surgeon specialization and operative mortality in United States: retrospective analysis. BMJ (Clinical research ed). 2016;354:i3571.

    Google Scholar 

  34. 34.

    Hernandez J, Dimou F, Weber J, al e. Defining the learning curve for robotic-assisted esophagogastrectomy. Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract. 2013;Aug;17(8):1346–1351.

  35. 35.

    Nygaard K, Hagen S, Hansen HS, et al. Pre-operative radiotherapy prolongs survival in operable esophageal carcinoma: a randomized, multicenter study of pre-operative radiotherapy and chemotherapy. The second Scandinavian trial in esophageal cancer. World journal of surgery. 1992;16(6):1104–1109; discussion 1110.

    CAS  PubMed  Google Scholar 

  36. 36.

    Lv J, Cao XF, Zhu B, Ji L, Tao L, Wang DD. Long-term efficacy of perioperative chemoradiotherapy on esophageal squamous cell carcinoma. World journal of gastroenterology. 2010;16(13):1649–1654.

    CAS  PubMed  PubMed Central  Google Scholar 

  37. 37.

    Le Prise E, Etienne PL, Meunier B, et al. A randomized study of chemotherapy, radiation therapy, and surgery versus surgery for localized squamous cell carcinoma of the esophagus. Cancer. 1994;73(7):1779–1784.

    PubMed  Google Scholar 

  38. 38.

    Apinop C, Puttisak P, Preecha N. A prospective study of combined therapy in esophageal cancer. Hepato-gastroenterology. 1994;41(4):391–393.

    CAS  PubMed  Google Scholar 

  39. 39.

    Bosset JF, Gignoux M, Triboulet JP, et al. Chemoradiotherapy followed by surgery compared with surgery alone in squamous-cell cancer of the esophagus. The New England journal of medicine. 1997;337(3):161–167.

    CAS  PubMed  Google Scholar 

  40. 40.

    Walsh TN, Grennell M, Mansoor S, et al. Neoadjuvant treatment of advanced stage esophageal adenocarcinoma increases survival. Diseases of the Esophagus. 2002;15(2):121–124.

    CAS  PubMed  Google Scholar 

  41. 41.

    Urba SG, Orringer MB, Turrisi A, Iannettoni M, Forastiere A, Strawderman M. Randomized trial of preoperative chemoradiation versus surgery alone in patients with locoregional esophageal carcinoma. Journal of clinical oncology : official journal of the American Society of Clinical Oncology. 2001;19(2):305–313.

    CAS  Google Scholar 

  42. 42.

    Lee JL, Park SI, Kim SB, et al. A single institutional phase III trial of preoperative chemotherapy with hyperfractionation radiotherapy plus surgery versus surgery alone for resectable esophageal squamous cell carcinoma. Annals of oncology : official journal of the European Society for Medical Oncology. 2004;15(6):947–954.

    CAS  Google Scholar 

  43. 43.

    Burmeister BH, Smithers BM, Gebski V, et al. Surgery alone versus chemoradiotherapy followed by surgery for resectable cancer of the oesophagus: a randomised controlled phase III trial. The Lancet Oncology. 2005;6(9):659–668.

    PubMed  Google Scholar 

  44. 44.

    van Hagen P, Hulshof MC, van Lanschot JJ, et al. Preoperative chemoradiotherapy for esophageal or junctional cancer. The New England journal of medicine. 2012;366(22):2074–2084.

    PubMed  Google Scholar 

  45. 45.

    Kim DJ, Hyung WJ, Lee CY, et al. Thoracoscopic esophagectomy for esophageal cancer: feasibility and safety of robotic assistance in the prone position. The Journal of thoracic and cardiovascular surgery. 2010;139(1):53–59.e51.

    PubMed  Google Scholar 

  46. 46.

    Puntambekar S, Rayate N, Joshi S, Agarwal G. Robotic transthoracic esophagectomy in the prone position: experience with 32 patients with esophageal cancer. The Journal of thoracic and cardiovascular surgery. 2011;Nov;142(5):1283–1284.

  47. 47.

    Dantoc M, Cox MR, Eslick GD. Evidence to support the use of minimally invasive esophagectomy for esophageal cancer: a meta-analysis. Archives of surgery (Chicago, Ill : 1960). 2012;147(8):768–776.

    Google Scholar 

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Author information




1. Kenneth Meredith: Concept and design, data analysis and interpretation, manuscript writing and final approval.

2. Taylor Maramara: manuscript writing, and final approval.

3. Paige Blinn: manuscript writing, and final approval.

4. Daniel Lee: concept and design, data analysis, manuscript writing, and final approval.

5. Jamie Huston: Collection and assembly of data and final approval.

6. Ravi Shridhar: Concept and design, data analysis and interpretation, manuscript writing, and final approval.

Corresponding author

Correspondence to Kenneth L. Meredith.

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Meredith, K.L., Maramara, T., Blinn, P. et al. Comparative Perioperative Outcomes by Esophagectomy Surgical Technique. J Gastrointest Surg 24, 1261–1268 (2020).

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  • Esophagectomy
  • Robotic esophagectomy
  • Transhiatal
  • Ivor Lewis
  • Mckeown (three-field)