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: misbah.52@gmail.com
Abstract
BACKGROUND: There has been an increasing
inclination towards minimally invasive esophagectomies
(MIEs) at our institute recently for resectable oesophageal
cancer. OBJECTIVES: The purpose of the present
study is to report peri-operative and long-term procedure
specific outcomes of the two groups and analyse their
changing pattern at our institute. METHODS: All adult
patients with a diagnosis of oesophageal cancer managed
at our institute from 2005 to 2015 were included in this
retrospective study. Patients’ demographic and clinical
characteristics were recorded through our hospital
information system. The cohort of esophagectomies
was allocated into two groups, conventional open
esophagectomy (OE) or total laparoscopic MIE; hybrid
esophagectomies were taken as a separate group. The
short-term outcome measures are an operative time
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
according to the Clavien-Dindo classification system.
Long-term outcomes are long-term procedure related
complications over a minimum follow-up of 1 year.
Trends were analysed by visually inspecting the graphic
plots for mean number of events in each group each
year. RESULTS: Our results showed no difference in
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DOI:
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mortality, length of hospital and ICU stays and incidence of
major complications between three groups on uni- and multi-
variate analysis (P > 0.05). The operative time was significantly
longer in MIE group (odds ratio [OR]: 1.66, confidence interval
[CI]: 2.4–11.5). The incidence of long-term complication was low
for MIE (OR: 1.0, CI: 133–1.017). However, all post-operative
surgical outcomes trended to improve in both groups over the
course of this study and stayed better for MIE group except for
the operative time. CONCLUSION: MIE has overall comparable
surgical outcomes to its conventional counterpart. Furthermore,
the peri-operative outcomes tend to improve in our centre with
the maturation of program and experience.
Key words: Minimally invasive esophagectomy, peri-operative
outcomes, resectable oesophageal cancer
INTRODUCTION
Esophagectomy the main treatment option for resectable
oesophageal cancer is a complex operation with significant
morbidity and mortality.[1-3] Minimally invasive esophagectomy
(MIE) was described in 1990s in an endeavour to reduce
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Cite this article as: Khan M, Ashraf MI, Syed AA, Khattak S, Urooj N,
Muzaffar A. Morbidity analysis in minimally invasive esophagectomy for
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
 Khan, et al.: Morbidity analysis of esophageal cancer laparoscopic vs. conventional surgery
operative morbidity.[4] Luketich et al. in 1998 demonstrated
the potential feasibility of the procedure by publishing
their results on 8 MIEs using either laparoscopic and/or
thoracoscopic techniques with no perioperative mortalities
and one anastomotic leak.[1,5] MIE since then is becoming
the routine procedure for resectable oesophageal cancer
with apparently similar peri-operative short and long-term
outcomes.[2,6] In the absence of strong evidence confirming
to the efficacy of the technique with a single published
randomised controlled trial and another in process,[7,8] most
of the evidence from literature comes from various large
retrospective case series and their meta-analysis.[9-12] Further
problems such as those inherent to the learning phase of MIE
have been less frequently addressed.[3,13-15]
Our institute being the largest cancer centre of the country
has also seen a shift from conventional to minimally invasive
techniques for resectable oesophageal cancer over the past
decade.[16] Moreover, during the same period our surgical
oncology program has evolved into a high volume centre
for the management of this disease. With the start of our
first minimally invasive hybrid esophagectomy in 2011, it
has grown into a standard treatment modality over recent
few years, limiting the conventional open approach mainly
for emergency esophagectomies.
The purpose of the present study is to analyse the peri-
operative and long-term procedure related outcomes of
the two groups at our institute and to report the results. In
addition, the idea is to assess the changes in the occurrence
of these outcomes in a time-dependant fashion.
METHODS
All adult patients with a histo-pathological diagnosis
of oesophageal cancer managed at our institute after a
multidisciplinary meeting decision for surgical resection
from September 2005 to September 2015 were included in
the study.
An exemption status was granted by the hospital Ethical
Review Committee for conduction of this study. All patients
demographic and baseline clinical and pathological
characteristics are recorded Table 1. Furthermore, radiologic,
endoscopic, operative and post-operative details were
documented. The co-morbid conditions for each patient
were graded according to Charlson et al. co-morbidity scoring
system.[17,18] The cases with more complex surgery including
en bloc resection of adjacent organs (splenectomy/gastrectomy)
and tumours of upper one-third of the oesophagus with
concomitant laryngectomy or pharngectomy were excluded
Journal of Minimal Access Surgery | Volume 13 | Issue 3 | July-September 2017
from the study. Similarly, pathological subtypes other than
adeno and squamous cell cancer of the oesophagus were
excluded.
The cohort of esophagectomies was allocated into two
groups depending on the type of surgery conventional open
esophagectomy (OE) or MIEs. To maintain a clear segregation
of MIE and conventional groups, hybrid procedures with
only one of the abdominal or thoracic approaches being
done through laparoscope or thoracoscope are taken as a
separate group.
The short-term outcome measures are operative time in
minutes, length of hospital stay in days, length of post-
operative Intensive Care Unit (ICU) stay in days, post-
operative complications and 30 days in-hospital mortality.
Complications are graded according to the Clavien-Dindo
classification system.[19] Long-term outcomes are long-term
procedure related complications recorded over a minimum
follow up of 1 year.
All variables were obtained through our hospital information
system by three main investigators and were reviewed
independently by the main investigator (Khan M). The
frequency and nature of post-operative complications
were determined based on daily physician progress notes
supplemented by relevant investigation reports. The
hospital length of stay was determined by the surgery and
discharge date and operative times were determined based
on anaesthesia records. The long-term complication rate was
calculated for patients with a minimum follow-up of 1 year.
Furthermore, the changes in above mentioned morbidity
parameters from 2005 to 2015, in minimally invasive group
as compared to conventional were analysed. Results in the
two arms MIE versus OE are further evaluated for a subset
analysis according to the type of surgery performed (three-
stage, two-stage and trans hiatal) for assessment.
For the purpose of division, Conventional techniques
of esophagectomy included procedures without any
laparoscopic or thoracoscopic component including
transhiatal and three stage McKeown esophagectomy via
right thoracotomy approach. While MIE techniques included
total laparoscopic transhiatal or video-assisted thoracoscopic
three-stage procedures with a laparoscopic abdominal part.
Stomach was used for reconstruction in all of our cases with
a hand sewn gastro-oesophageal anastomosis except one.
All cases were jointly performed by one of the two surgical
oncologists and one thoracic surgeon over the period of
this study. The video-assisted thoracoscopic or thoracotomy
portion of the operation is performed in the left lateral
193
 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,
and the abdominal part of both open and laparoscopic
portion is done in a modified Lloyd-Davis position for better
assistant and instrument positioning. All patients are followed
up in surgical oncology clinic at 1 week post-surgery followed
by 1 month, 3 months, and then every 6 months.
Statistical analysis
This is a retrospective comparative cohort study. All analysis
was performed with IBM SPSS Statistical Software version
19.0. Armonk, NY, USA. We looked at frequencies and
proportions. Chi-square test for categorical and ANOVA test
for continuous variables were utilized. Continuous variables
were dichotomized according to the clinical importance
or median value of each variable. Uni- and multi-variate
logistic regression analysis was performed for the main
outcome measures controlling all other variables in the
study. Differences that achieved a two-tailed P < 0.05 were
considered statistically significant for the present study.
Trends were analysed by visually inspecting the graphic plots
for mean number of events in each group each year.
RESULTS
Out of 247 consecutive esophagectomies performed at our
institute from September 2005 to September 2015, 216
patients with diagnosed squamous or adeno-carcinoma
of oesophagus and Type I, II gastro-oesophageal junction
managed with a standard esophagectomy without a
laryngectomy, pharyngectomy were included in the study.
Among these, 90 were conventional open, 95 were minimally
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
three-stage procedures were treated as conventional open
esophagectomies due to retrospective nature of the study.
The patient and tumour characteristics were similar among
groups on the basis of gender distribution, body mass
index, co-morbidity index, initial tumour stage according
to the seventh edition of the American Joint Committee on
Cancer guidelines and tumour grade. However, due to the
inclusion of emergency oesophageal resections done mainly
via open approach (n = 7; 6 endoscopy related and 1radiation
necrosis), proportion of patients without neoadjuvant
treatment and less pathological treatment response was
high in OE group. The OE group also had a higher number
of transhiatal procedures done for GE junction adeno-
carcinomas reaching statistical significance.
The outcome variables distribution among various types of
esophageal resections is shown in Table 2. Median length
of follow-up for all patients was 12 months (range 0–90).
Overall 30-day mortality rate, rate of major complications
requiring re-intervention or re-exploration and length
of hospital and post-operative ICU stay were statistically
insignificant between the groups. The results for these
outcomes stayed insignificant on multivariate analysis
performed by controlling all other variables including age,
tumour location, tumour grade and morphology, radiological
and pathological stage, neo-adjuvant or adjuvant treatment
and type of esophagectomy, that is, transhiatal, two-stage
or three-stage [Table 3]. In our series, rate of long term
complications remained low for MIE and the mean operative
time longer for MIE and hybrid groups with statistically
significant difference on multivariate analysis.
The Class I and II minor complication group included minor
respiratory and wound complications, fluid electrolyte
disturbances or any other complications including atrial
fibrillations, diarrhoea, urinary tract infection, surgical
emphysema, recurrent laryngeal nerve injury etc., managed
either conservatively or with medications. The major
complications group included major Class III and IV
respiratory complications requiring additional radiological
or surgical intervention, in addition to re-explorations for
thoracic duct or tracheo-bronchial tree injury, conduit failure,
haemorrhage or anastomotic leak.
Long-term complications were 22.2%, 11.6% of them were
anastomotic strictures requiring multiple dilations and stent
placement in 25 cases. Rest were 8.7% long term reflux and
aspiration related symptoms and 1.9% incisional hernias
including one diaphragmatic hernia.
However, when the results were analysed in a time dependent
fashion we found out that the overall rate of all peri-operative
morbidity parameters utilised in our study stayed better for
minimally invasive group and showed a uniform improvement
for both the groups. It was only the mean operative time
which stayed consistently longer for the MIE group [Figure 1].
DISCUSSION
Minimally invasive technique is being utilized for resectable
oesophageal cancers since 2011 at our centre and has
resulted in a constant decrease in the number of conventional
esophagectomies with only two conventional transhiatal
esophagectomy procedures done during year 2015 for
emergency oesophageal perforation.
Recent systematic reviews and meta-analysis comparing MIE
to conventional esophagectomies including Watanabe et al.,
Dantoc et al., and Kim et al.[1,6,20-23] have shown no statistically
significant difference between groups in terms of 30-day
mortality, similar to our data with an overall mortality lower
in MIE group (2.1% vs. 8.9% conventional and 3.2% hybrid)
without any statistically significant difference on multi-variate
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
(mean 1 day) was lower for minimally invasive group in our
series, but values did not reach a statistical significance.
The median length of hospital stay (median 9 days) is
comparable or less than most of the series but without
significant difference between groups.[9,12,16,22] Larger series
by Schoppmann et al. (MIE 12 vs. OE 24) and Kauppi et al.
(MIE 13 vs. OE 14,) have reported their results with a length
of hospital stay significantly shorter for MIE group with no
significant difference for operative time, whereas the median
ICU stay was better for MIE in series by Schoppmann et al.
and stayed similar for groups in Kauppi et al.[9,12]
The operative time in our series was significantly longer
for minimally invasive group (MIE median 330 min vs. 240
OE) similar to what was shown in the meta-analysis by
Watanabe et al. and a recently published Society of Thoracic
Surgeons National Database analysis of USA (443 vs. 312 min;
P < 0.001).[1,20,22,24] Their results also showed a shorter median
hospital stay (9 vs. 10 days) and higher re-operation rate
(9.9% vs. 4.4%) in MIE group than conventional open. The
complication rates were described quite heterogeneously
by all of the above series with peri-operative morbidity
advantage of the two groups staying still arguable.[22]
The frequency of individual procedure specific complications
in our series in different groups is shown in Table 4. The
overall rate of minor pulmonary complications managed with
chest physiotherapy and incentive spirometry and Class III
complications requiring bronchoscopy, radiological drainage
or chest tube insertion for a pleural effusion, pneumothorax
or lung collapse was higher for MIE and hybrid techniques
in our series accounting for a higher number of thoracic
procedures in these groups as compared to conventional.
However, rate of Class IV pulmonary complications involving
prolonged ventilation and re-explorations were similar
between the groups. Overall rate of pulmonary complications
by many series have reported a low incidence of pulmonary
complications with MIE group,[9,12] also the randomised
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

Journal of Minimal Access Surgery | Volume 13 | Issue 3 | July-September 2017 197

 Khan, et al.: Morbidity analysis of esophageal cancer laparoscopic vs. conventional surgery
pulmonary infection rate,[7] these series however did not
include minor class I complications such as basal atelectasis,
pleural effusion or minor pneumothorax in their analysis.
Furthermore, the true rate of respiratory infections in our
series was MIE 28.4% versus OE 21.1% and hybrid 29%. While it
was 21.8 for transhiatal and 28% for 3-stage esophagectomies.
The long term complication rate for anastomotic stricture
(MIE 9.5% vs. 15.6% in conventional group) is superior to
recently published data by Maas et al. showing high rates of
44% MIE and 39% OE on the 1 year follow-up of their multi-
centric randomised controlled trial patients.[7,25] In their
previously published review of 12 studies, describing various
intra-thoracic anastomotic techniques for minimally invasive
Ivor-Lewis esophagectomy anastomotic stricture rates ranged
from 0% to 27.5%.[26]
Out of thoracic duct injuries only two required thoracotomy
and duct ligation rest were managed conservatively with total
parenteral nutrition (TPN) and fat free diet. Also in case of
anastomotic leak on contrast study, 50% of the leaks were
successfully managed conservatively with TPN followed by
a prolonged naso-jejunal (NJ) tube feed, with remaining
7 cases requiring a re-exploration (3 conduit failures,
3 tracheo-esophageal fistulas and 1 anastomotic site leak).
Other major complications requiring re-exploration were
2 azygous vein rebleeds, 2 gastric outlet obstructions at
hiatus, 2 tracheo-bronchial tree injuries, 1 neck haemorrhage
and 1 large hiatus diaphragmatic hernia in the long term.
Other complications in Table 4 included post-operative medical
problems like fluid and electrolyte disturbances, cardiac issues
such as arrhythmias, uncontrolled hypertension, thrombo-
embolic phenomenon and urinary tract infections. Aspiration
was taken as a separate complication because of its multifactorial
relationship to anastomotic narrowing or recurrent laryngeal
nerve injury (RLNI), and its wide spectrum consequences of
minor cough and aspiration pneumonia to cases requiring
prolonged NJ or a feeding jejunostomy for repeated aspirations.
In terms of oncologic efficacy of the specimen as published
recently, the mean number of lymphnode harvest in our series
was 13.7 ± 5.6 and the rate of R0 resection in patients with
post neo-adjuvant residual disease (50% of study population)
was 53.4% with statistically insignificant difference among
the groups (P > 0.05).[27]
In-general, all post-operative surgical outcomes tended to
improve over the course of this study. With the maturation
of our program, we recognised a gradually decreasing
frequency of complications and lengths of ICU and
198
hospital stay. Very few studies have attempted to show the
evolution of minimally invasive techniques in comparison
to conventional and hybrid groups. [3,14,15,28] Tapias and
Morse in their study described the learning curve for MIE
of a single surgeon and observed improved operative time,
blood loss, median hospital stay and morbidity in their last
forty patients compared with the first 40.[14] Similar results
with improved operative and peri-operative outcomes were
shown by Arlow et al. in their series of 200 open transhiatal
esophagectomies performed over 13 years by same set of
surgeons.[15] In another recent series on 180 consecutive
minimally invasive McKeown esophagectomy by Mu et al.
no significant differences in post-operative morbidity were
found between their first sixty patients group as compared
to second and third sixty; however, there was significantly
longer duration of surgery in first group as compared to
other two.[3]
Limitations
Although we separated hybrid esophagectomies in our
study design for data comparison of outcome variables, yet
there were more number of transhiatal esophagectomies
in conventional group with a higher percentage of gastro-
oesophageal junction tumours in the same group and more
three-stage in MI group with an equally higher percentage
of oesophageal tumours, that can lead to a potential source
of bias for overall results. This was statistically minimised by
controlling these variables in multivariate analysis.
Hence, a retrospective study design and heterogeneity of
the cases with regards to the type of MIE (more three stage)
and conventional open (more transhiatal) resulting in a lack
of true match to match comparison of MIE and conventional
groups are main limitations for our study.
CONCLUSION
The data suggest that MIE has overall comparable surgical
outcomes to its conventional counterpart with a longer
operative time and low long-term complication rate. Also,
the peri-operative outcome tended to improve in our centre
with the maturation of program and experience.
Acknowledgements
Dr. Waleed Zafar, Dr. Farhana Badar Clinical Research
Scientists Section of Cancer Registry and Clinical Data
Management, Shuakat Khanum Memorial Cancer Hospital
and Research Centre.
Financial support and sponsorship
Nil.
Journal of Minimal Access Surgery | Volume 13 | Issue 3 | July-September 2017
 Khan, et al.: Morbidity analysis of esophageal cancer laparoscopic vs. conventional surgery
Conflicts of interest
There are no conflicts of interest.
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