Hybrid Minimally Invasive vs Open Esophagectomy for Esophageal Cancer: 5-Year Outcomes

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In long-term follow-up of the French phase III MIRO trial reported in JAMA Surgery, Nuytens et al found no significant difference in 5-year overall or disease-free survival with hybrid minimally invasive esophagectomy vs open esophagectomy in patients with esophageal cancer.

In the multicenter trial, 207 patients with resectable cancer of the middle or lower third of the esophagus were randomly assigned between October 2009 and April 2012 to receive hybrid minimally invasive esophagectomy consisting of laparoscopic gastric mobilization with open right thoracotomy (n = 103) or open esophagectomy (n = 104). The primary endpoints of the current analysis were 5-year overall survival and disease-free survival in the intention-to-treat population.

Key Findings

Median follow-up was 58.2 months (95% confidence interval [CI] = 56.5–63.8 months). Overall survival at 5 years was 59% (95% CI = 48%–68%) in the hybrid minimally invasive esophagectomy group vs 47% (95% CI = 37%–57%) in the open esophagectomy group (hazard ratio [HR] = 0.71, 95% CI = 0.48–1.06, P = .09).

Disease-free survival at 5 years was 52% (95% CI = 42%–61%) in the hybrid minimally invasive esophagectomy group vs 44% (95% CI = 34%–53%) in the open esophagectomy group (HR = 0.81, 95% CI = 0.55–1.17, P = .26). There were no significant differences between groups in recurrence rate (40% vs 44%) or locations (12 vs 12 patients with locoregional recurrence, 23 vs 24 with distant metastasis, and 6 vs 10 with mixed recurrence).

Complication rates were 36% vs 64% for major complications at 30 days, 18% vs 30% for major pulmonary complications at 30 days, 10% vs 11% for intraoperative complications, 31% vs 39% for surgical complications, and 49% vs 58% for medical complications. On multivariable analysis, major intraoperative and postoperative complications (HR = 2.21, P < .001) and major pulmonary complications (HR = 1.94, P = .005) were significantly associated with poorer overall survival. Overall intraoperative and postoperative complications (HR = 1.93, P = .002) and major pulmonary complications (HR = 1.85, P = .006) were significantly associated with poorer disease-free survival.

The investigators concluded, “This study found no difference in long-term survival between the hybrid minimally invasive esophagectomy and open esophagectomy groups. Major postoperative overall complications and pulmonary complications appeared to be independent risk factors in decreased overall survival and disease-free survival, providing additional evidence that hybrid minimally invasive esophagectomy may be associated with improved oncological results compared with open esophagectomy primarily because of a reduction in postoperative complications.”

Frederiek Nuytens, MD, of Hôpital Huriez, CHU de Lille, is the corresponding author for the JAMA Surgery article.

Disclosure: The MIRO trial was funded by the Programme Hospitalier de Recherche Clinique. The current follow-up study had no additional funding. For full disclosures of the study authors, visit

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