Short-term outcomes of Ivor Lewis vs. McKeown esophagectomy: A meta-analysis

Abstract

ObjectiveThe objective of this article is to assess the rate of anastomotic leak and other perioperative outcomes in patients undergoing esophagectomy with either thoracic or cervical anastomosis.MethodsThis meta-analysis was conducted by searching relevant literature studies in Web of Science, Cochrane Library, PubMed, and Embase databases. Articles that included patients undergoing esophagectomy and compared perioperative outcomes of McKeown with Ivor Lewis procedures were included. The primary outcome parameter was anastomotic leak, and secondary outcome parameters were grade ≥2 anastomotic leak, chylothorax, recurrent laryngeal nerve injury, hospital length of stay, intensive care unit (ICU) length of stay, postoperative mortality rate, operative time, blood loss, R0 resection rate, and lymph nodes examined.ResultsA total of eight studies, with 3,291 patients (1,857 Ivor Lewis procedure and 1,434 McKeown procedure) were eligible for analysis. Meta-analysis showed that Ivor Lewis procedure was associated with lower rate of anastomosis leak of all grades [risk ratio (RR), 0.67; 95% confidence interval (CI), 0.55–0.82; P = 0.0001], lower rate of recurrent laryngeal nerve injury (RR, 0.14; 95% CI, 0.08–0.25), and shorter length of hospital stay (weighted mean difference, 0.13; 95% CI, 0.04–0.22). Grade ≥2 anastomotic leak, chylothorax, ICU length of stay, postoperative mortality rate, operative time, blood loss, R0 resection rate, and lymph nodes examined were similar between the two groups.ConclusionsAlthough all grades of anastomotic leak and recurrent laryngeal nerve injury are higher in the McKeown procedure, this meta-analysis supports similar short-term outcomes and oncological efficacy between Ivor Lewis and McKeown esophagectomy.

What is the best reconstruction procedure after esophagectomy? A meta‐analysis comparing posterior mediastinal and retrosternal approaches

“…21 The McKeown procedure has the advantages of cervical lymph node dissection and more proximal resection margins in terms of oncologic efficacy; however, no difference was observed in the total lymph nodes retrieved during surgery and R0 resection rates between the two procedures in the meta-analysis. 43 These results…”

“…46 Further, the meta-analysis reported that the McKeown procedure was associated with significantly higher grades of anastomotic leakage and recurrent laryngeal nerve palsy than the Ivor Lewis procedure. 43 Therefore, the anastomotic leakage rate was higher in the McKeown procedure; however, the RCT reported that the anastomotic leakage rate in the McKeown procedure was 34.1%, 43 which was considerably higher than that reported in NCD data in Japan. 21 The McKeown procedure has the advantages of cervical lymph node dissection and more proximal resection margins in terms of oncologic efficacy; however, no difference was observed in the total lymph nodes retrieved during surgery and R0 resection rates between the two procedures in the meta-analysis.…”

“…44 However, most recent esophagectomies are minimally invasive, and reports of the Ivor Lewis procedure via MIE are increasing. 43 Two important reports were recently published, and the superior approach (Ivor Lewis vs. McKeown) remains controversial. 43,46 One is an RCT conducted in the Netherlands, which was limited to MIE, 46 and the other is a meta-analysis focusing on cases reported in the past decades.…”

“…43 Two important reports were recently published, and the superior approach (Ivor Lewis vs. McKeown) remains controversial. 43,46 One is an RCT conducted in the Netherlands, which was limited to MIE, 46 and the other is a meta-analysis focusing on cases reported in the past decades. 43 The RCT revealed that the Ivor Lewis procedure was associated with a significantly lower anastomotic leak rate than the McKeown procedure (12.3% vs. 34.1%; p < 0.001).…”

“…indicate that all studies included in the meta-analysis enrolled patients with middle to distal thoracic esophageal or gastroesophageal junction cancer, in whom cervical lymph node dissection is not required; thus, both procedures are oncologically feasible. 43 Therefore, Ivor Lewis esophagectomy offers perioperative and oncological safety for tumors located under the carina. Recently, a propensity score-matched analysis using data from the Netherlands Cancer Registry and a Population-based Nationwide Study in Finland both reported no statistically significant difference in long-term survival between the Ivor Lewis and McKeown procedures.…”