Decreasing Complications After Ivor-Lewis Esophagectomy: Is a Totally Minimally Invasive Approach the Solution?

Background: Despite improvements over time, Ivor Lewis Esophagectomy (ILE), a potentially curative surgical option for patients with invasive esophageal cancer, carries high morbidity and mortality. We analyzed postoperative outcomes in patients undergoing ILE at our institution, comparing open (OE), hybrid (HE), and totally minimally invasive (TMIE) approaches.

Methods: We reviewed the records of patients who underwent elective ILE for benign or malignant pathology at our institution (2018-2022). Patients who underwent transhiatal or McKeown esophagectomy, as well as those undergoing emergent procedures, were excluded. Factors associated with major postoperative complications (Clavien-Dindo Grade ≥ 3) were assessed using multivariable analysis (MVA).

Results: Of 260 patients, 135 met the inclusion criteria: 40 (29.6%) underwent OE, 50 (37.0%) underwent HE, and 45 (33.3%) underwent TMIE. Median length of stay was shorter for patients undergoing TMIE compared to OE and HE (9 vs. 12 and 13 days, p < 0.001). A higher major postoperative complication rate was noted in patients undergoing OE and HE compared to TMIE (32.5% and 36% vs. 13.3%) (p = 0.03). This result persisted on MVA (OE: aOR 3.4, p = 0.04; HE: aOR 5.5, p = 0.002; reference:TMIE).

Conclusion: A totally minimally invasive approach to Ivor-Lewis Esophagectomy is associated with lower major postoperative complications and shortened length of stay at our institution. Prospective evaluations in the United States population are warranted to optimize and standardize surgical approaches.