IMPLEMENTATION OF A TOTALLY MINIMALLY INVASIVE ESOPHAGECTOMY PROGRAM FOR CANCER IN A HIGH-VOLUME CENTER: COMPARISON OF INITIAL SERIES RESULTS WITH TRADITIONAL OPEN TECHNIQUE

The minimally invasive approach is becoming increasingly popular; in fact, it has demonstrated non-inferior surgical and oncologic outcomes compared with open esophagectomy, with better short-term outcomes. Advantages include shorter hospital and ICU stays, fewer pulmonary infections, and less intraoperative blood loss. However, minimally invasive esophagectomy requires highly developed minimally invasive surgical skills and is a technically difficult procedure. Even in a tertiary center, developing a minimally invasive program takes time and has a protracted learning curve before a plateau of ideal results is reached. The purpose of this study is to evaluate the safety and efficacy of implementing a totally minimally invasive esophagectomy program for cancer in a high-volume center. In addition, it aimed to evaluate the impact of the learning curve on perioperative and oncologic outcomes. Survival and disease-free survival were included as secondary endpoints. This study is a prospective non-randomized control study from a single center. From the start of the minimally invasive program in June 2018 to October 2022, data were gathered on all consecutive patients who underwent elective Ivor Lewis esophagectomy at the Upper G.I. Surgery Unit “General surgery I” of Padova University. Patients undergoing Minimally Invasive Ivor Lewis Esophagectomy were assigned to the MIE group, those undergoing Open Ivor Lewis Esophagectomy to the OE group. By comparing the perioperative and oncological outcomes of patients who underwent MIE to those of patients treated with OE during the same period, we evaluated the safety and efficacy of the minimally invasive approach in the treatment of esophageal cancer. Subsequently, the MIE group was divided into two groups: Early Experience and Late Experience group. By comparing the perioperative and oncological outcomes between the two groups we evaluated the presence and the impact of a learning curve. During the inclusion period, 61 patients underwent MIE and 138 underwent OE. The mean operative time was shorter for the OE than for the MIE group (295 vs 363 min). The average number of lymph nodes harvested was higher during MIE than during OE (27,4 vs 20,8 lymph nodes). The number of total blood transfusions was lower in the OE compared to the MIE group (0,1 vs 0,7 blood units). No differences were found regarding surgical radicality or postoperative complications type and severity. Hospital stay, ICU stay and 90-days mortality and readmission rates were similar between the two groups. Comparing the patients undergone MIE in the early experience period (31 patients) to the ones of the late experience period (30 patients) we observed a decrease in the mean number of metastatic lymph nodes extracted (2,7 vs 0,3 lymph nodes), in the infective and thromboembolic complications rates (respectively 54,8% vs 13,3%, and 16,1% vs 0%), and in the average ICU total stay (1,6 vs 0,6 days). The findings of this study support the safety and efficacy of implementing a totally minimally invasive esophagectomy program for cancer in a high-volume center. In comparison to open technique, surgical and oncological outcomes, postoperative complication rates, morbidity and mortality rates were not compromised by the learning curve effect and met current international standards. According to our observations, MIE results in higher rates of lymph node yield, both in the abdominal and thoracic fields. We therefore propose that the effect of laparoscopic magnification can aid in a more accurate and precise lymph node dissection. Comparing the outcomes of the early experience with those of the late experience, we discovered improving trends in postoperative complication and recovery rates. In our high-volume center's experience, improving these outcomes has required 25 to 30 cases.