Key-hole (laparoscopic) versus standard cut (open) abdominal surgery for people with food-pipe (oesophageal) cancer

Review question

How does key-hole (laparoscopic) abdominal surgery compare to standard (open) abdominal surgery for people with food-pipe (oesophageal) cancer?

Background

The oesophagus (food pipe) is located mainly in the chest; it enters the abdomen (tummy) through an opening in the diaphragm (muscle that separates the chest from the abdomen). Removing tumours by surgery (oesophagectomy) is one of the recommended treatments for cancers that are limited to the oesophagus. The tumour can be removed through an abdominal opening, a chest opening, or a combination. When the tumour is removed through an abdominal opening, it is called transhiatal oesophagectomy (as the oesophagus is separated from its surrounding structures through the opening in the diaphragm). The abdominal surgery can be performed through either a key-hole or a standard cut. Key-hole surgery to remove oesophageal cancer (laparoscopic transhiatal oesophagectomy) is a relatively new procedure compared to the well-established standard cut surgery (open transhiatal oesophagectomy). In operations on other parts of the body, laparoscopic surgery has been shown to reduce complications and length of hospital stays compared to open surgery.

However, concerns remain about the safety of laparoscopic surgery. How do complications after operation (post-operative complications) compare between the two procedures? Does laparoscopic surgery remove the same amount of cancer and healthy border tissue as open surgery? Do people recovery more quickly after laparoscopic or open surgery? We sought to resolve these issues by searching the medical literature for studies on this topic.

Study characteristics

Randomised controlled trials are the best types of studies to find out whether one treatment is better than another since it ensures that similar types of people receive the new and the old treatment. But we did not find randomised controlled trials; we identified six relevant non-randomised studies with a total of 334 patients, which compared laparoscopic and open surgeries. Since one of the studies did not provide usable results, five studies, with 326 patients, provided information for this review; laparoscopic surgery = 151 patients and open surgery = 175 patients. In four of these studies, historical information was collected from hospital records. In one study, new information was collected. In general, new information is considered to be more reliable than information from hospital records.

Key results

The differences between laparoscopic and open transhiatal oesophagectomy were imprecise for: deaths during the short-term and long-term, the percentage of people with major complications, narrowing of the new junction between the gut, created after removing the oesophagus, cancer returning during the short-term and long-term, and the proportion of people who required blood transfusion. The proportion of patients with any complications and the average lengths of hospital stay were less in the key-hole group than the open cut group. There was lack of clarity about the difference in the amount of blood transfused between the two groups. None of the studies reported difficulty in swallowing after surgery, health-related quality of life, the amount of time it took to return to normal activity (same mobility as before surgery), or work.

Quality of the evidence

The quality of the evidence was very low. This was mainly because it was not clear whether participants who received laparoscopic surgery were similar to those who had open surgery. This makes the findings unreliable. Well-designed randomised controlled trials are necessary to obtain high-quality evidence on the best method to perform oesophagectomy.

Authors' conclusions: 

There are currently no randomised controlled trials comparing laparoscopic with open transhiatal oesophagectomy for patients with oesophageal cancers. In observational studies, laparoscopic transhiatal oesophagectomy is associated with fewer overall complications and shorter hospital stays than open transhiatal oesophagectomy. However, this association is unlikely to be causal. There is currently no information to determine a causal association in the differences between the two surgical approaches. Randomised controlled trials comparing laparoscopic transhiatal oesophagectomy with other methods of oesophagectomy are required to determine the optimal method of oesophagectomy.

Read the full abstract...
Background: 

Surgery is the preferred treatment for resectable oesophageal cancers, and can be performed in different ways. Transhiatal oesophagectomy (oesophagectomy without thoracotomy, with a cervical anastomosis) is one way to resect oesophageal cancers. It can be performed laparoscopically or by open method. With other organs, laparoscopic surgery has been shown to reduce complications and length of hospital stay compared to open surgery. However, concerns remain about the safety of laparoscopic transhiatal oesophagectomy in terms of post-operative complications and oncological clearance compared with open transhiatal oesophagectomy.

Objectives: 

To assess the benefits and harms of laparoscopic versus open oesophagectomy for people with oesophageal cancer undergoing transhiatal oesophagectomy.

Search strategy: 

We electronically searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, Science Citation Index Expanded, and trials registers until August 2015. We also searched the references of included trials to identify further trials.

Selection criteria: 

We considered randomised controlled trials and non-randomised studies comparing laparoscopic with open transhiatal oesophagectomy in patients with resectable oesophageal cancer, regardless of language, blinding, or publication status for the review.

Data collection and analysis: 

Three review authors independently identified trials, assessed risk of bias and extracted data. We calculated the risk ratio (RR) or hazard ratio (HR) with 95% confidence intervals (CI), using both fixed-effect and random-effects models, with RevMan 5, based on intention-to-treat analyses.

Main results: 

We found no randomised controlled trials on this topic. We included six non-randomised studies (five retrospective) that compared laparoscopic versus open transhiatal oesophagectomy (334 patients: laparoscopic = 154 patients; open = 180 patients); five studies (326 patients: laparoscopic = 151 patients; open = 175 patients) provided information for one or more outcomes. Most studies included a mixture of adenocarcinoma and squamous cell carcinoma and different stages of oesophageal cancer, without metastases. All the studies were at unclear or high risk of bias; the overall quality of evidence was very low for all the outcomes.

The differences between laparoscopic and open transhiatal oesophagectomy were imprecise for short-term mortality (laparoscopic = 0/151 (adjusted proportion based on meta-analysis estimate: 0.5%) versus open = 2/175 (1.1%); RR 0.44; 95% CI 0.05 to 4.09; participants = 326; studies = 5; I² = 0%); long-term mortality (HR 0.97; 95% CI 0.81 to 1.16; participants = 193; studies = 2; I² = 0%); anastomotic stenosis (laparoscopic = 4/36 (11.1%) versus open = 3/37 (8.1%); RR 1.37; 95% CI 0.33 to 5.70; participants = 73; studies = 1); short-term recurrence (laparoscopic = 1/16 (6.3%) versus open = 0/4 (0%); RR 0.88; 95% CI 0.04 to 18.47; participants = 20; studies = 1); long-term recurrence (HR 1.00; 95% CI 0.84 to 1.18; participants = 173; studies = 2); proportion of people who required blood transfusion (laparoscopic = 0/36 (0%) versus open = 6/37 (16.2%); RR 0.08; 95% CI 0.00 to 1.35; participants = 73; studies = 1); proportion of people with positive resection margins (laparoscopic = 15/102 (15.8%) versus open = 27/111 (24.3%); RR 0.65; 95% CI 0.37 to 1.12; participants = 213; studies = 3; I² = 0%); and the number of lymph nodes harvested during surgery (median difference between the groups varied from 12 less to 3 more lymph nodes in the laparoscopic compared to the open group; participants = 326; studies = 5).

The proportion of patients with serious adverse events was lower in the laparoscopic group (10/99, (10.3%) compared to the open group = 24/114 (21.1%); RR 0.49; 95% CI 0.24 to 0.99; participants = 213; studies = 3; I² = 0%); as it was for adverse events in the laparoscopic group = 37/99 (39.9%) versus the open group = 71/114 (62.3%); RR 0.64; 95% CI 0.48 to 0.86; participants = 213; studies = 3; I² = 0%); and the median lengths of hospital stay were significantly less in the laparoscopic group than the open group (three days less in all three studies that reported this outcome; number of participants = 266). There was lack of clarity as to whether the median difference in the quantity of blood transfused was statistically significant favouring laparoscopic oesophagectomy in the only study that reported this information. None of the studies reported post-operative dysphagia, health-related quality of life, time-to-return to normal activity (return to pre-operative mobility without caregiver support), or time-to-return to work.

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