Minimally invasive techniques for transthoracic oesophagectomy for oesophageal cancer: systematic review and network meta-analysis

Background Oesophagectomy is a demanding operation that can be performed by different approaches including open surgery or a combination of minimal access techniques. This systematic review and network meta-analysis aimed to evaluate the clinical outcomes of open, minimally invasive and robotic oesophagectomy techniques for oesophageal cancer. Methods A systematic literature search was conducted for studies reporting open oesophagectomy, laparoscopically assisted oesophagectomy (LAO), thoracoscopically assisted oesophagectomy (TAO), totally minimally invasive oesophagectomy (MIO) or robotic MIO (RAMIO) for oesophagectomy. A network meta-analysis of intraoperative (operating time, blood loss), postoperative (overall complications, anastomotic leaks, chyle leak, duration of hospital stay) and oncological (R0 resection, lymphadenectomy) outcomes, and survival was performed. Results Ninety-eight studies involving 32 315 patients were included in the network meta-analysis (open 17 824, 55.2 per cent; LAO 1576, 4.9 per cent; TAO 2421 7.5 per cent; MIO 9558, 29.6 per cent; RAMIO 917, 2.8 per cent). Compared with open oesophagectomy, both MIO and RAMIO were associated with less blood loss, significantly lower rates of pulmonary complications, shorter duration of stay and higher lymph node yield. There were no significant differences between surgical techniques in surgical-site infections, chyle leak, and 30- and 90-day mortality. MIO and RAMIO had better 1- and 5-year survival rates respectively compared with open surgery. Conclusion Minimally invasive and robotic techniques for oesophagectomy are associated with reduced perioperative morbidity and duration of hospital stay, with no compromise of oncological outcomes but no improvement in perioperative mortality.