Curative surgery increases the 5-year survival of patients with oesophageal cancer from 10–15% overall to 40%, but postoperative morbidities affect more than half of all patients who undergo open oesophagectomy. Minimally invasive oesophagectomy (MIE) approaches have been developed to reduce postoperative pulmonary morbidity. Now, the efficacy of hybrid MIE surgery and open surgery have been compared in the MIRO phase III trial with promising results.

Credit: Simon Bradbrook/Springer Nature Limited

Hybrid MIE combines laparoscopic abdominal gastric mobilization with open thoracotomy. In 2012, the results of the TIME trial showed that total MIE (laparoscopic abdominal phase and thoracoscopic phase) was associated with a lower incidence of complications than open surgery. “However, total MIE is technically demanding and some studies suggest a higher risk of intrathoracic anastomotic leakage,” explains lead investigator Guillaume Piessen. Whether the maximal benefit of a MIE approach is mostly associated with the abdominal or thoracic phase needs to be determined in order to optimize the outcomes of oesophagectomy.

In the MIRO trial, patients with resectable squamous cell carcinoma or adenocarcinoma of the middle or lower third of the oesophagus were randomly allocated to undergo hybrid MIE (n = 103) or open oesophagectomy (n = 104). The incidence of major intraoperative and/or postoperative complications at 30 days was significantly lower with hybrid MIE than with open surgery (36% versus 64%; P < 0.001). The incidence of major pulmonary complications within 30 days of surgery was also lower in the hybrid MIE group (18% versus 30%). No differences between groups were observed in postoperative mortality at 30 days (1% versus 2%) or at 90 days (4% versus 6%).

At a median follow-up duration of 48.8 months, median overall survival durations were 52.2 months and 47.6 months with hybrid MIE and open surgery, respectively, although this difference was not statistically significant. Disease-free survival was similar between both groups: 57% and 48%, respectively, at 3 years and 53% versus 43% at 5 years. The pathological analysis revealed similar patterns of tumour histology, stage and nodal involvement between both groups.

“In our study, hybrid MIE was associated with a similar magnitude of benefit in terms of morbidity as that observed with total MIE in other studies, suggesting that the laparoscopic phase is the most critical to decrease morbidity compared with open surgery,” comments Piessen. “Our results will not change practice for the small proportion of expert surgeons performing total MIE (20–40% in Europe and North America), but will surely convince the vast majority of surgeons who still perform open oesophagectomy (~52% or probably more),” he concludes.