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Shibao et al. Mini-invasive Surg 2019;3:16 I http://dx.doi.org/10.20517/2574-1225.2019.01 Page 5 of 8

of dissected lymph nodes, while the overall 5-year survival rates of the OE and MIE/HMIE groups did
not differ to a statistically significant extent. Mamidanna et al. investigated a population-based national
[35]
study evaluating the short-term outcomes following OE (n = 6347) vs. MIE (n = 1155) for cancer in England.
No differences were observed between the OE and MIE groups with regard to 30-day mortality and overall
medical morbidity. The reintervention rate of the MIE group was higher than that of the OE group. Zhou et al.
[36]
reported a meta-analysis of 48 studies involving 14,311 cases of resectable esophageal or EGJ cancer. In
comparison to patients undergoing OE (n = 9,973), those undergoing MIE/HMIE (n = 4,509) had a significantly
lower rate of in-hospital mortality. Patients undergoing MIE also had significantly lower rates of pulmonary
complications and arrhythmia. The limitation of this study was that almost all of the included studies were
non-randomized case-control studies (RCTs, n = 1; observational studies, n = 47), with a diversity of study
designs and surgical interventions. They concluded that MIE should be the first-choice surgery for esophageal
cancer patients. However, these findings must be interpreted cautiously due to the selection bias, as the patients
selected for MIE had early-stage cancer with better physical status.

Luketich et al. conducted a multi-center, phase II, prospective study that revealed that MIE (n = 95) is feasible
[14]
with low peri-operative morbidity (49.5%) and mortality (2.1%), and a 3-year overall survival rate of 58.4%
Biere et al. conducted a randomized trials of MIE vs. OE for patients with esophageal or EGJ cancer. In
[37]
this study, 59 patients were randomized to the MIE group and 56 patients were randomized to the OE group.
They revealed the advantages of MIE over OE, including a reduced incidence of postoperative pulmonary
infections, a shorter length of hospitalization and better quality of life scores, indicating improved patient
recovery. Mariette et al. conducted a multicenter, randomized controlled trial that included 207 patients
[38]
(MIRO trial). They investigated a HMIE using thoracotoic chest access with laparoscopy for abdominal
access. In comparison to Ivor-Lewis resection, HMIE reduced the rate of postoperative complications and
improved morbidity with an equivalent number of dissected lymph nodes, and no difference in resectability
and curability. In the OE group, 64.4% of the patients had major postoperative morbidity in comparison to
35.9% in the HMIE group (P < 0.01). The incidence of pulmonary complications was 30.1% in the OE group
and 17.7% in the HMIE group (P < 0.05). The 30-day mortality rate was 4.9% in both arms. They also reported
a one-year follow-up results of the quality of life with their RCT participants and demonstrated that the
MIE group had a better physical component, global health, and postoperative pain . A propensity score
[39]
matched analysis of 3,780 patients who underwent OE or MIE for esophageal cancer by both transhiatal and
Ivor-Lewis approaches demonstrated that OE and MIE had similar rates of morbidity and mortality. MIE
was associated with longer operation times, higher rates of reoperation, and empyema, but a shorter median
length of hospitalization. OE was associated with higher rates of wound infection, postoperative transfusion,
and ileus .
[40]

Yerokun et al. investigated the predictive factors associated with the use of minimally invasive approaches
[41]
(n = 1,308) for patients in the National Cancer Database who underwent resection of middle and distal
esophageal cancers (n = 4,266). In the MIE group, the number of lymph nodes examined was significantly
higher (15 vs. 13; P = 0.016) and the hospital stay was significantly shorter (10 days vs. 11 days; P = 0.046),
however the rates of resection margin positivity, readmission, postoperative mortality, and, 3-year survival
were comparable. With regard to oncological safety, no differences were found in OS or disease-free survival
after 1 and 3 years of follow-up, with a better quality of life of physical components at 1 and 3 years of
follow-up [33,39] . Thus, they concluded that MIE is considered to be a safe surgical approach and the majority
of patients with a resectable cancer of esophagus or EGJ should be treated with MIE.

Shanmugasundaram et al. reported a meta-analysis of 4 studies involving 573 cases of resectable
[42]
esophageal or EGJ cancer. In comparison to patients undergoing OE (n = 9,973), those undergoing
McKeown’s-MIE (n = 4,509) had a significantly lower rates of pulmonary complications, less blood loss, and
a shorter duration of hospital stay but a longer operating time.