Outcomes of videothoracoscopic esophagectomy with or without neoadjuvant chemoradiation for squamous cell carcinoma of esophagus: A 20-year single-center experience

Abstract

Introduction: Minimally invasive esophagectomy and neoadjuvant chemoradiation has gained popularity in the past two decades. The safety and postoperative outcome of videothoracoscopic (VATS) esophagectomy after neoadjuvant chemoradiation (CRT) remains controversial. Methods: From 1994 to 2013, patients with squamous cell cancer of the esophagus who underwent VATS esophagectomy in a single tertiary referral center in Hong Kong were studied. Patients were divided into two groups: (1) VATS esophagectomy and (2) CRT followed by VATS esophagectomy. Patients’ demographics, clinical-pathological data, postoperative outcome and long- term prognosis were compared. Results: A total of 189 patients were studied; 84 in the VATS and 105 in the CRT + VATS group. Patients’ demographics did not differ. CRT +VATS group had longer operating duration (460 vs. 383 mins) as well as thoracoscopy time (180 vs. 156 mins). Postoperatively, VATS group had higher incidence of pneumonia (25% vs. 9.5%, p=0.005), and tracheostomy rate (19% vs. 7.6%, p=0.027). However when only when patients from 2006 onwards were included, pneumonia rates were 20.4% vs. 9.2% (p=0.07) and tracheostomy rates were 7.4% vs. 6.1% (p=0.7). Other complications did not differ. Hospital mortality rate were both at 6%. CRT + VATS group sampled more lymph nodes (median 33.8 (range 1-78) vs. 26 (range 2-72), p=0.006. However again when patients from 2006 were included, the respective numbers were (median 34 (4-78) vs. 29 (2-72), p=0.371). CRT resulted in a 32.4% pCR rate, with consequent lower stage distribution compared to VATS group. Multivariate analysis identified pT-stage, number of involved nodes, and R-category as independent prognostic factors. In the VATS group, only the number of involved nodes and R-category were prognostic. Conclusions: VATS esophagectomy appeared safe after CRT. pT-stage, number of involved lymph nodes and R-category were determinant of long-term prognosis.