Open Versus Hybrid and Total Minimally Invasive Transthoracic Ivor Lewis Esophagectomy Following Neoadjuvant FLOT Chemotherapy: An Australian and New Zealand Cohort Study

BACKGROUND: In Australian and Aotearoa New Zealand (ANZ), it is unclear whether minimally invasive transthoracic Ivor Lewis esophagectomy (MIO) is superior to open techniques with regards to perioperative and oncological outcomes. Most evidence on this topic have been derived from high-volume centers prior to the advent of perioperative FLOT chemotherapy. How these findings are applicable to the ANZ context, where oesophagectomies are typically performed in low-moderate volume centers, is unknown. This study compares perioperative outcomes and long-term survival between patients undergoing transthoracic open versus hybrid and total MIO following neoadjuvant FLOT chemotherapy across multiple ANZ centers. METHODS: Retrospective analysis of transthoracic oesophagectomies undertaken between 2017 and 2022 following neoadjuvant FLOT chemotherapy from 22 ANZ centers. The primary endpoint was the rate of major (Clavien-Dindo grade ≥ 3) postoperative complication. Secondary endpoints included nodal yield, surgery time, length-of-stay, and rates of perioperative complications, positive resection margins, ICU readmissions, in-hospital mortality, 30-day hospital readmissions, textbook outcome, adjuvant chemotherapy delivered, as well as disease free (DFS) and overall survival (OS). RESULTS: Open esophagectomy, hybrid MIO and total MIO was performed in 155 (62.5%), 61 (24.6%), and 32 (12.9%) patients, respectively. From open to total MIO, there was a stepwise decrease in the rate of major postoperative complications (Open: 38.7%, hybrid MIO: 29.5%, total MIO: 15.6%, p = 0.032). This was associated with reduced length-of-stay Median(IQR), Open: 14 (11-23), hybrid MIO: 13 (11-23), total MIO: 10 (8-12), p = 0.031, and lower rates of pulmonary (Open: 49.0%, hybrid MIO: 42.6%, total MIO: 28.1%, p = 0.031), cardiac (Open: 20.0%, hybrid MIO: 6.6%, total MIO: 3.1%, p = 0.006), sepsis (Open: 18.7%, hybrid MIO: 8.2%, total MIO: 3.1%, p = 0.022), and wound (Open: 12.3%, hybrid MIO: 3.3%, total MIO: 0.0%, p = 0.019) complications. No significant differences were observed in other perioperative endpoints. Moreover, institutional factors including enhanced recovery after surgery programs and hospital case volume interacted with surgical technique to influence postoperative complication rates. Importantly, adjusted DFS and OS were comparable between the three groups. CONCLUSIONS: In ANZ, MIO was associated with fewer complications and comparable survival compared to open transthoracic esophagectomy. These findings support the safety of MIO in lower-volume settings in the era of perioperative FLOT chemotherapy.