ArticlesMinimally invasive versus open oesophagectomy for patients with oesophageal cancer: a multicentre, open-label, randomised controlled trial
Introduction
The global incidence of oesophageal cancer has increased by 50% in the past two decades, from 316 000 people diagnosed in 1990 to 482 300 new cases recorded in 2008.1, 2 Surgical resection with radical lymphadenectomy, usually after neoadjuvant chemotherapy or chemoradiotherapy, is regarded as the only curative option for resectable oesophageal cancer.3, 4, 5
Mortality rates in oesophageal resection are less than 5%.6 However, at least half the patients who have open oesophagectomy, performed through a right thoracotomy and laparotomy, are at risk for developing pulmonary complications that need protracted stay in intensive-care units and hospitals, with subsequent consequences for quality of life during convalescence.6 Minimally invasive oesophagectomy, avoiding thoracotomy and laparotomy, can reduce the rate of pulmonary infections, thus reducing stay in hospital.7, 8 Because of these potential advantages, minimally invasive oesophagectomy is being increasingly implemented; however, no randomised trials have investigated the benefits of this technique.9, 10 We compared open with minimally invasive oesophagectomy in patients with oesophageal cancer to assess the rate of pulmonary infections and quality of life associated with the minimally invasive procedure.
Section snippets
Study design and participants
We undertook a multicentre, open-label, randomised trial between June 1, 2009, and March 31, 2011 at five centres: two in Amsterdam (Netherlands), and one in Nijmegen (Netherlands), Girona (Spain), and Milan (Italy). Eligible participants had resectable oesophageal cancer (cT1–3, N0–1, M0), histologically proven adenocarcinoma, squamous cell carcinoma, or undifferentiated carcinoma of the intrathoracic oesophagus and gastro-oesophageal junction. Patients were aged 18–75 years and had a WHO
Results
The figure shows the trial profile. We randomly assigned 115 of 144 eligible patients to receive either open oesophagectomy or minimally invasive oesophagectomy. Four crossovers occurred: two patients assigned to the open oesophagectomy group underwent minimally invasive oesophagectomy, and two assigned to minimally invasive oesophagectomy developed a WHO-ECOG score of 3 during neoadjuvant treatment and thus had transhiatal oesophagectomy (appendix). Eight patients did not undergo a resection (
Discussion
In this trial, minimally invasive oesophagectomy resulted in a lower incidence of pulmonary infections 2 weeks after surgery and during stay in hospital, a shorter hospital stay, and better short-term quality of life than did open oesophagectomy, with no compromise in the quality of the resected specimen. The reduced frequency of pulmonary infections in the minimally invasive group could be explained by several factors, all of which might reduce the development of atelectasis.
Use of the prone
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