title: Hybrid minimally invasive esophagectomy vs. open esophagectomy: a matched case analysis in 120 patients.
abstract: OBJECTIVE
  In esophageal surgery, total minimally invasive techniques compete with hybrid and robot-assisted procedures. The benefit of the individual techniques for the patient remains vague. At our institution, the hybrid minimally invasive laparoscopic-thoracotomic esophagectomy (HMIE) has been routinely applied since 2013. We conducted this retrospective study to analyze the perioperative outcome.
  
  
  METHODS
  Since 2013, 60 patients were operated in HMIE technique for esophageal cancer. Each of these patients was paired according to the criteria of gender, BMI, age, tumor histology, pulmonary preexisting conditions, and a history of smoking with a patient treated by open esophagectomy (OE). Perioperative parameters were extracted from our prospectively maintained database and compared among the groups.
  
  
  RESULTS
  The HMIE and OE groups were homogeneous in terms of patient- and tumor-related data. There was no difference in lymph nodes harvested (22 vs. 20, p = 0.459) and R0-resection rate (95 vs. 93%, p = 0.500). The operation time for the HMIE was significantly shorter (329 vs. 407 min, p < 0.001). There was no difference between the groups with respect to surgical complications (37 vs. 37%, p = 0.575), but the patients undergoing hybrid technique showed more delayed gastric emptying (23 vs. 10%, p = 0.042). Pulmonary morbidity was significantly reduced after HMIE (20 vs. 42%, p = 0.009). This affected both the occurrence of pneumonia and pleural effusions. The difference in the overall complication rate was not significant (50 vs. 60%, p = 0.179), but life-threatening complications (Clavien/Dindo 4/5) were less frequent (2 vs. 12%, p = 0.031). Overall, there was significantly less need for transfusion after HMIE (18 vs. 50%, p < 0.001), and hospital (and IMC) stay was significantly shorter (14 (6) vs. 18 (7) days, p = 0.002 (0.003)). The multivariate analysis confirms the surgical procedure as an independent risk factor for the development of pulmonary complications (OR 3.2, p = 0.011). Furthermore, preexisting pulmonary conditions were identified as a risk factor (OR 3.6, p = 0.006).
  
  
  CONCLUSIONS
  Our retrospective analysis shows that reduction of postoperative pulmonary morbidity, perioperative blood loss, and shortening of hospital stay can be achieved by HMIE. The procedure is safe, and the rate of surgical complications and oncological radicality is comparable to the conventional procedure.
authors.affiliation: Department of General and Visceral Surgery and Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany. Torben.Glatz@uniklinik-freiburg.de.
authors.forename: Torben
authors.identifier: http://orcid.org/0000-0003-3404-2711
authors.initials: T
authors.lastname: Glatz
authors.affiliation: Department of General and Visceral Surgery and Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany.
authors.forename: Goran
authors.initials: G
authors.lastname: Marjanovic
authors.affiliation: Department of General and Visceral Surgery and Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany.
authors.forename: Birte
authors.initials: B
authors.lastname: Kulemann
authors.affiliation: Department of General and Visceral Surgery and Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany.
authors.forename: Olivia
authors.initials: O
authors.lastname: Sick
authors.affiliation: Department of General and Visceral Surgery and Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany.
authors.forename: Ulrich Theodor
authors.initials: UT
authors.lastname: Hopt
authors.affiliation: Department of General and Visceral Surgery and Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany.
authors.forename: Jens
authors.initials: J
authors.lastname: Hoeppner
mesh_terms: D000230:Adenocarcinoma / Q000601:surgery*; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002294:Carcinoma, Squamous Cell / Q000601:surgery*; D004938:Esophageal Neoplasms / Q000601:surgery*; D016629:Esophagectomy / Q000009:adverse effects* / Q000379:methods; D005260:Female; D006801:Humans; D010535:Laparoscopy / Q000009:adverse effects*; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D061646:Operative Time; D011183:Postoperative Complications / Q000453:epidemiology*; D012189:Retrospective Studies; D013908:Thoracotomy / Q000009:adverse effects
keywords: Esophageal cancer; Esophagectomy; Gastric pull-up; Minimally invasive surgery; Outcome; Postoperative morbidity