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Perioperative Outcomes in Minimally Invasive vs. Open Esophagectomy: an ACS-NSQIP Analysis
Grace L Laidlaw, *Leah M Backhus, *Joseph B Shrager, *Mark F Berry
Stanford University School of Medicine, Stanford, CA

Background: Minimally invasive esophagectomy (MIE) has been shown to be feasible for esophageal cancer, yet advantages over open esophagectomy (OE) and adoption in clinical practice outside of highly specialized centers have not been well characterized. The purpose of this study was to quantify the use of MIE in a national multi-center patient cohort, and to test the hypothesis that MIE has less short-term morbidity compared to OE using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database.
Methods: All patients ≥ 18 years of age who underwent an esophagectomy for esophageal cancer in the 2005-2013 ACS-NSQIP database were identified, with MIE patients distinguished from OE patients by use of any minimally invasive current procedural terminology (CPT) codes for the procedure. Multivariable linear and logistic regressions were used to compare postoperative length of stay, morbidity, and mortality between MIE and OE in an overall NSQIP cohort; analyses were repeated using a propensity-matched cohort to account for confounding by indication.
Results: Of 3,901 patients who met inclusion criteria, 638 (16.4%) were MIE and 3,263 (83.6%) were OE. The use of MIE increased from 6.5% in 2005 to 22.3% in 2013, and was most common in three-field approaches (26.6% [193/725]). Patients undergoing MIE were slightly older than those undergoing OE and were less likely to have been given pre-operative chemotherapy or radiation, but no other significant differences in demographics or comorbidities were observed (table). MIE patients had a lower rate of major morbidity in univariate analysis, but there were no statistically significant differences in length of stay, readmission, re-operation, and mortality between the two groups (table). MIE continued to be associated with a lower risk of major morbidity relative to OE (OR 0.80, p=0.02) in multivariable analysis, an effect confirmed using a propensity-matched cohort (OR 0.83, p=0.049). In multivariable subgroup analyses stratified by specific technique, MIE use was associated with less major morbidity in both Ivor-Lewis (OR 0.70, p=0.01) and three-field (OR 0.70, p=0.049) approaches, with results confirmed in propensity-matched cohorts.
Conclusions: In an early period where MIE was used in a minority of patients undergoing resection of esophageal cancer, an MIE approach was associated with lower rates of major morbidity but otherwise similar outcomes to open procedures. These results suggest it is safe for surgeons to introduce MIE into their practice, though further evaluation will be needed to evaluate the benefits of MIE over OE as experience with MIE techniques increase across a variety of practice environments.

Overall Cohort
MIE (n=638)Open (n=3263)p-value
Baseline Characteristics
Mean Age (years)64.563.70.04
Male Gender (n, %)530 (83.1%)2737 (83.9%)0.61
White Race (n, %)564 (88.4%)2748 (84.2%)0.12
Mean BMI28.027.90.61
Diabetes (n, %)114 (17.9%)576 (17.7%)0.55
Recent Smoker (n, %)175 (27.4%)869 (26.6%)0.86
Any Dyspnea on Exertion (n, %)73 (11.4%)351 (10.8%)0.88
H/o COPD (n, %)50 (7.8%)144 (7.5%)0.8
H/o CHF (n, %)1 (0.2%)4 (0.1%)0.59
H/o HTN requiring medication (n, %)343 (53.8%)1705 (52.3%)0.49
Independent Functional Status (n, %)633 (99.2%)3213 (98.5%)0.43
Metastatic cancer (n, %)14 (2.2%)101 (3.1%)0.22
>10% weight loss in 6m PTS (n, %)138 (21.6%)649 (19.9%)0.32
Chemotherapy in 30d PTS (n, %)44 (6.9%)312 (9.6%)<0.001
Radiation in 90d PTS (n, %)77 (12.1%)589 (18.1%)<0.001
Outcomes
Mean Length of Stay (days, 95% CI)14.7 (13.6 15.8)15.4 (14.3 - 16.5)0.19
Readmission (n, %)55 (11.2%)222 (12.0%)0.62
Reoperation (n, %)73 (14.7%)257 (13.7%)0.57
Composite Major Morbidity (n, %)230 (36.1%)408 (40.5%)0.03
Mortality (n, %)14 (2.2%)106 (3.3%)0.16

MIE = Minimally invasive esophagectomy
BMI = Body mass index
COPD = Chronic obstructive pulmonary disease
CHF = Congestive heart failure
HNT = Hypertension
PTS = Prior to surgery


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