Thoracolaparoscopy Esophagectomy For Middle And Lower Thoracic Esophageal Cancer: A Comparison Of Clinical Outcomes Between Ivor-Lewis Approach And McKeown Approach

Objectives:To evaluate the feasibility,safety and short-term outcomes ofcombined laparoscopic and thoracoscopic esophagectomy and intrathoracicesophagogastric anastomosis(Ivor Lewis approach)for the treatment of middle andlower thoracic esophageal cancer.Methods：We retrospectively analyzed clinical data of116patients withesophageal cancer who underwent completely minimally invasive esophagectomy byone surgical team in Affiliated Union Hospital of Fujian Medical University fromDecember2010to January2013.All the116patients were divided into two groupsaccording to their different surgical approach,including40patients who underwentcombined laparoscopic and thoracoscopic esophagectomy and intrathoracicesophagogastric anastomosis using a transoral anvil (Orvil)(MIE-Ivor-Lewisgroup,2-incision)and76patients who underwent combined laparoscopic andthoracoscopic esophagectomy and cervical anastomosis (MIE-McKeown group,3-incision). Patients were stratified by surgical approach and perioperative outcomesanalyzed,lymph node dissection,short-term quality of life and survival werecompared between the two groups.Results：These demographic characteristics were similar between the twooperative approaches.The location of the esophageal cancer is the primary differencebetween the two approaches to MIE.67.5%patients of MIE-Ivor-Lewis group werelower thoracic esophageal cancer,75%patients of MIE-McKeown group were middlethoracic esophageal cancer. All the patients underwent the R0resection.There was nostatistical differences between two groups in intra-operative blood loss,bloodtransfusions,conversion to open,time to resume oral intake, postoperative hospital stay,the median number of lymph nodes resected and the lymph nodes metastasisrate.The operation time of MIE-Ivor-Lewis group was significantly less than that ofMIE-McKeown group(294.1±37.3min VS320.5±55.5min, P=0.017).The extubationtime，hospital cost of MIE-Ivor-Lewis group were significantly more than that ofMIE-McKeown group(5.7±2.5d VS4.8±3.2d，P=0.005，80191.5±24308.8yuan VS68038.6±21513.1yuan，P=0.007，respectively).There was no perioperative deathbetween two groups. The total post-operative complications was27.6%，and therewas no statistical differences between two groups in post-operativecomplications(20%VS31.6%, respectively),but anastomotic leak was significantlyless frequent in the MIE-Ivor-Lewis group (0VS13.2%,P=0.040).113patients werefollowed up from1～25months(median11.4±6.8months). There was no statisticaldifferences between two groups regard to short-term quality of life and survival.Conclusions: The MIE-Ivor-Lewis approach was associated with reducedoperation time and anastomotic leak for the treatment of middle and lower thoracicesophageal cancer，and resulted in acceptable lymph node resection，accurate staging.There was no statistical differences between two groups regard to short-term qualityof life and survival，but MIE-Ivor-Lewis approach costs more.Minimally invasiveIvor-Lewis esophagectomy can be performed safely,with good results in anexperienced center.