Postoperative outcomes after minimally invasive esophagectomy: an international cohort study from the Oesophagogastric Anastomosis Audit (OGAA)

Objective: To compare the postoperative pulmonary complications (PPC) after minimally invasive or open transthoracic esophagectomy for esophageal cancer in an international, multicenter cohort. Summary of background data: Ongoing debate exists around the optimal surgical approach for esophageal cancer, with limited data assessing the external validity of randomised trials on outcomes of MIE Methods: Patients undergoing open (OE, n = 744), hybrid (HE, n = 500), and totally minimally invasive esophagectomy (TMIE, n = 540) for esophageal cancer were identified from the international, prospective Oesophagogastric Anastomosis Audit (OGAA). Multivariable models were used to investigate PPC (primary outcome) as well as overall complications, major complications, anastomotic leak and 90-day mortality (secondary outcomes). Results: PPC rates were lower after TMIE compared to OE and HE (28% vs 37% vs 39%, p = 0.002), even on adjusted analyses compared to OE (odds ratio (OR): 0.60, CI_95%: 0.45—0.78). TMIE was also associated with significantly lower overall complications (OR: 0.68, CI_95%: 0.52—0.88) compared to OE, but not for major complications (OR: 0.90, CI_95%: 0.67—1.21), anastomotic leak (OR: 1.39, CI_95%: 0.96—2.01) and 90-day mortality (OR: 0.49, CI_95%: 0.22—1.04). Sensitivity analyses by underlying respiratory disease, neoadjuvant chemoradiotherapy or high-volume centers confirmed above findings. Conclusion: This study provides real-world data that TMIE was associated with lower 90-day PPC than OE and HE approaches, especially in patients with underlying respiratory disease or receiving neoadjuvant chemoradiotherapy. These warrant a further review into causes and mechanisms in selected patients, and that quality assurance in delivery of TMIE is probably of major importance. The ideal surgical approach remains unclear, and ongoing trials will provide more evidence within a few years that may clarify the optimum approach to locally advanced esophageal cancers.