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  Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 54  |  Issue : 1  |  Page : 115-119
 

The comparison of thoracoscopic-laparoscopic esophagectomy and open esophagectomy: A meta-analysis


1 Department of Thoracic Surgical Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
2 Thoracic Cancer Treatment Center, Armed Police Beijing Corps Hospital, Beijing, China

Date of Web Publication1-Dec-2017

Correspondence Address:
Dr. Y Gao
Department of Thoracic Surgical Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijc.IJC_192_17

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 » Abstract 

OBJECTIVE: The objective of this study was to perform a meta-analysis to evaluate the effects of thoracoscopic-laparoscopic esophagectomy (TLE) and open esophagectomy (OE) in the treatment of esophageal cancer. METHODS: A literature search was performed using PubMed, Embase, and Google Scholar databases for relevant keywords and the medical subject headings. After we had screened further, 13 clinical trials were included in the final meta-analysis. Specific odds ratios (ORs), standardized mean differences (SMDs), mean differences (MDs), and confidence intervals (CIs) were calculated. RESULTS: The outcomes of treatment effects included anastomotic leakage, blood loss, number of lymph nodes harvested, and operating time. Comparing OE for esophageal cancer patients, the pooled OR of anastomotic leakage was 0.89 (95% CI = [0.47, 1.68]), the pooled SMD of blood loss was − 0.56 (95% CI = [−0.77, −0.35]), the pooled MD of lymph nodes harvested was − 0.93 (95% CI = [−2.35, 0.50]), and the pooled SMD of operating time was 0.31 (95% CI = [0.02, 0.59]). CONCLUSION: TLE was found to significantly decrease patients' blood loss. There is no difference of anastomotic leakage and the number of lymph nodes harvested between TLE and OE.


Keywords: Esophageal cancer, meta-analysis, open esophagectomy, thoracoscopic-laparoscopic esophagectomy


How to cite this article:
Wang B, Zuo Z, Chen H, Qiu B, Du M, Gao Y. The comparison of thoracoscopic-laparoscopic esophagectomy and open esophagectomy: A meta-analysis. Indian J Cancer 2017;54:115-9

How to cite this URL:
Wang B, Zuo Z, Chen H, Qiu B, Du M, Gao Y. The comparison of thoracoscopic-laparoscopic esophagectomy and open esophagectomy: A meta-analysis. Indian J Cancer [serial online] 2017 [cited 2020 Apr 6];54:115-9. Available from: http://www.indianjcancer.com/text.asp?2017/54/1/115/219561



 » Introduction Top


Esophageal cancer is the eighth most commonly diagnosed cancer worldwide and ranks sixth among all cancers in mortality.[1] The global incidence of esophageal cancer has rapidly increased in recent years.[2] The comprehensive conformal treatment based on surgery is the best way for the treatment of esophageal cancer. However, the traditional open surgery has disadvantage of big trauma, significant blood loss, and high mortality rate.[3],[4] In recent years, with the development of minimally invasive surgical techniques, minimally invasive esophagectomy has been performed in many hospitals, especially thoracoscopic-laparoscopic esophagectomy (TLE).[5] The surgical resection of esophageal cancer is very complicated. Whether TLE can achieve the principles of cancer treatment and decrease perioperative complications is still controversial. This study aims to perform a meta-analysis to evaluate the clinical effects of TLE and OE and to provide proofs for choosing optimal treatment project.


 » Methods Top


Searching method

We searched for relevant studies in PubMed, Embase, and Google Scholar databases that were published between 2005 and 2017. We limited the search to studies published in English. The search terms and keywords used included “thoracoscopic-laparoscopic esophagectomy,” “TLE,” “open esophagectomy,” “OE,” and “esophageal cancer.” Duplicate articles and unpublished studies from international meetings were excluded from the review.

Inclusion criteria

Eligible references were selected carefully based on the following criteria: (1) studies comparing the effects of TLE with open esophagectomy (OE) in the treatment of esophageal cancer prospective and retrospective controlled studies; (2) patients with esophageal cancer and liver and kidney function, hematology, electrocardiogram with no obvious abnormalities; (3) information collected including anastomotic leakage, blood loss, the number of lymph nodes harvested, and operating time; (4) The TLE refers to the esophagus resected or dissociated by endoscope; (5) The OE indicates esophagectomy without using thoracoscope or laparoscope.

Excluding standard

Those reserches which are not clinical controlled trials of esophageal cancer patient and are about other surgical treatment will be excluded; data description is not clear. The transhiatal esophageal resection was excluded.

Data extraction

Two researchers selected independently the relevant literature and then download and extracted all the data using standardized data-abstraction forms. The study design of the literature according to the above inclusion criteria was included in the evaluation of the patients, the intervention measures, and the observation results. The data were extracted from the first author, year of publication, anastomotic leakage, blood loss, the number of lymph nodes harvested, operating time.

Statistical analysis

The summary odds ratios (ORs), standardized mean differences (SMDs), mean differences (MDs) with 95% confidence intervals (CIs) were calculated using RevMan (version 5.3). A random effect (RE) model was adopted. We defined significant heterogeneity as being that of the Chi-square test P < 0.1 or an I2 measure >50%, based on a statement from the Cochrane Handbook.


 » Results Top


Literature searches and study characteristics

[Figure 1] shows the study selection process. After a preliminary screening of the retrieved literature and further screening, we obtained 13 studies. The basic information for the 13 eligible studies is summarized in [Table 1].
Figure 1: The study selection process

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Table 1: Baseline characteristics of included studies

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Quality assessment

We assessed the quality of included studies using Newcastle–Ottawa Scale (NOS).[18] Each study was evaluated respectively by two independent investigators. NOS contains three characters: how to select the involved groups, the similarity between the groups, and how to assess follow-up and outcomes. The number of total scores was recorded to evaluate the quality of included studies in our study. Full marks of NOS are nine scores.

Meta-analysis of the anastomotic leakage of thoracoscopic-laparoscopic esophagectomy and open esophagectomy

The anastomotic leakage was reported in 13 studies [Figure 2]. The pooled OR from these 13 studies was 1.16 (95% CI, 0.51–2.65). The I2 estimate of the variance between the studies is 68% and P = 0.0002, which showed high heterogeneity. Due to significant heterogeneity of the data, we performed a sensitivity analysis for included studies where we sequentially excluded each study from our meta-analysis. Using this approach, we found that heterogeneity was mainly caused by the study of Braghetto 2013. Subsequently, the literature was excluded and the heterogeneity of the data was low (P = 0.08) while the I2 estimate of the variance between the studies was 39%. The pooled OR from these 12 studies was 0.89 (95% CI, 0.47–1.68). According to our analysis, the difference between TLE and OE was not significant (P = 0.72).
Figure 2: The comparison of the anastomotic leakage between thoracoscopic-laparoscopic esophagectomy and open esophagectomy group

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Meta-analysis of the blood loss of thoracoscopic-laparoscopic esophagectomy and open esophagectomy

The blood loss was reported in eight studies [Figure 3]. The pooled SMD from these eight studies was −0.56 (95% CI [−0.77, −0.35]). We performed a sensitivity analysis for included studies where we sequentially excluded each study from our meta-analysis. Using this approach, we found that heterogeneity was mainly caused by the studies of Gao, 2011 and Sihag, 2012. Subsequently, the I2 estimate of the variance between the studies is 25% and P = 0.25, which showed low heterogeneity. According to our analysis, the blood loss of between TLE and OE was significant (P< 0.01) and the blood loss of TLE was much less than OE.
Figure 3: The comparison of the blood loss between thoracoscopic-laparoscopic esophagectomy and open esophagectomy group

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Meta-analysis of the number of lymph nodes harvested of thoracoscopic-laparoscopic esophagectomy and open esophagectomy

The number of lymph nodes harvested was reported in nine studies [Figure 4]. The pooled MD from these nine studies was − 0.93 (95% CI, [−2.35, 0.50]). We performed a sensitivity analysis and excluded the study of Pham, 2010. The I2 estimate of the variance between the studies is 50% and P = 0.20, which showed low heterogeneity. According to our analysis, the number of lymph nodes between TLE and OE was not significant (P = 0.20).
Figure 4: The comparison of the number of lymph nodes harvested between thoracoscopic-laparoscopic esophagectomy and open esophagectomy group

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Meta-analysis of the operating time of thoracoscopic-laparoscopic esophagectomy and open esophagectomy

The operating time was reported in nine studies [Figure 5]. The pooled SMD from these nine studies was 0.31 (95% CI, [0.02, 0.59]). We performed a sensitivity analysis and excluded the studies of Pham, 2010; Gao, 2011; Nguyen, 2000; and Parameswaran, 2009. The I2 estimate of the variance between the studies was 58% and P = 0.04, which showed mediate heterogeneity, so we used the RE model. According to our analysis, the surgical time of TLE was longer than OE (P = 0.04).
Figure 5: The comparison of the operating time between thoracoscopic-laparoscopic esophagectomy and open esophagectomy group

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 » Discussion Top


The three most common techniques for esophagectomy are the transhiatal approach, the Ivor Lewis esophagectomy (right thoracotomy and laparotomy), and the McKeown technique (right thoracotomy followed by laparotomy and neck incision with cervical anastomosis).[19] There are some shortages for OE, such as high incidence perioperative complications. With the rapid development of minimally invasive surgery, a lot of surgeons have realized that we need to pay more and more attention to surgery itself besides clinical results of surgery.[20] To meet the patient's physical and psychological needs, reducing surgical trauma has become a concept and trend of modern surgery.[21] At present, TLE has been carried out in many medical centers and become gradually the focus of attention. Our study found that the blood loss of the TLE group showed a clear advantage compared with OE group, however, anastomotic leakage and the number of lymph nodes harvested did not show difference. In addition, TLE group needs more operating time than OE group. The magnification of endoscope can fully show the anatomical structure so that reduce or even avoid intraoperative adjacent organs damage. Meanwhile, TLE has an advantage of smaller incision compared with OE. This will reduce the bleeding of the wound and incidence of postoperative complications. The efficacy of esophageal cancer surgery is largely related to the number of lymph node dissection. With the progress of surgical technique, laparoscopic surgery can achieve the same effect of open surgery.[22] This study found that there was no difference in lymph node dissection between the two groups. Minimally invasive operation has less effect on function of heart and lung and avoids diaphragmatic incision.[23] TLE maintains integrity of the thorax and abdomen so that release of various inflammatory factors was reduced.[24] Our study found that the operation time of TLE group was still longer than that of OE group, which may be due to difference of surgeons' skill. Because TLE is a new technique, the surgeons need to more time to study it. With the continuous development of minimally invasive technology, clinicians will improve the level of surgical operation and operation time will be greatly reduced.

However, our study has some disadvantages. First, the included samples are small, which may affect our results. Second, to confirm our results, we need more randomized clinical trials with high quality. Other restrictions of our study include: some TLE studies did not have control groups, so they were excluded from this study. This decreased the amount of included studies; some reports showed high heterogeneity in our study. This may lead to existence of bias in the final results.


 » Conclusion Top


Our study showed that TLE is safe and effective. TLE leads to lower blood loss compared with OE. We believe that the TLE will benefit an increasing number of patients with the development of endoscopic techniques.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
 » References Top

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Mao WM, Zheng WH, Ling ZQ. Epidemiologic risk factors for esophageal cancer development. Asian Pac J Cancer Prev 2011;12:2461-6.  Back to cited text no. 1
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Sihag S, Kosinski AS, Gaissert HA, Wright CD, Schipper PH. Minimally invasive versus open esophagectomy for esophageal cancer: A comparison of early surgical outcomes from the society of thoracic surgeons national database. Ann Thorac Surg 2016;101:1281-8.  Back to cited text no. 3
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Birkmeyer JD, Siewers AE, Finlayson EV, Stukel TA, Lucas FL, Batista I, et al. Hospital volume and surgical mortality in the United States. N Engl J Med 2002;346:1128-37.  Back to cited text no. 4
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Parameswaran R, Veeramootoo D, Krishnadas R, Cooper M, Berrisford R, Wajed S. Comparative experience of open and minimally invasive esophagogastric resection. World J Surg 2009;33:1868-75.  Back to cited text no. 13
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
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