Meta-analysis of randomised clinical trials comparing open and laparoscopic anti-reflux surgery

Objective: The aim was to conduct a meta-analysis of the randomised evidence to determine the relative merits of laparoscopic anti-reflux surgery (LARS) and open anti-reflux surgery (OARS) for proven gastro-oesophageal reflux disease. Methodology: A search of the Medline, Embase, Science Citation Index, Current Contents and PubMed databases identified all randomised clinical trials that compared LARS and OARS and were published in the English language between 1990 and 2007. The meta-analysis was prepared in accordance with the Quality of Reporting of Meta-analyses (QUOROM) statement. The six outcome variables analysed were operating time, hospital stay, return to normal activity, perioperative complications, treatment failure and requirement for further surgery. Random effects meta-analyses were performed using odds ratios and weighted mean differences. Results: Twelve trials were considered suitable for the meta-analysis. A total of 503 patients underwent OARS and 533 had LARS. For three of the six outcomes the summary point estimates favoured LARS over OARS. There was a significant reduction of 2.68 days in the duration of hospital stay for the LARS group compared with the OARS group (WMD -2.68, 95% confidence interval (CI) -3.54 to -1.81; P < 0.0001), a significant reduction of 7.75 days in return to normal activity for the LARS group compared with the OARS group (WMD -7.75, 95% CI -14.37 to -1.14; P = 0.0216) and lastly there was a statistically significant reduction of 65% in the relative odds of complication rates for the LARS group compared with the OARS group (OR 0.35, 95% CI 0.16 to 0.75; P = 0.0072). Duration of operating time was significantly longer (39.02 minutes) in the LARS group (WMD 39.02, 95% CI 17.99 to 60.05; P = 0.0003). Treatment failure rates were comparable between the two groups (OR 1.39, 95% CI 0.71 to 2.72; P = 0.3423). Despite this the requirement for further surgery was significantly higher in the LARS group (OR 1.79, 95% CI 1.00 to 3.22; P = 0.05). Conclusions: Based on this meta-analysis, the authors conclude that LARS is an effective and safe alternative to OARS for the treatment of proven gastro-oesophageal reflux disease. LARS enables a faster convalescence and return to productive activity, with a reduced risk of complications and a similar treatment outcome to that of an open approach. However, there is a significantly higher rate of re-operation (79%) in the LARS group

Laparoscopic Transhiatal Esophagectomy for Esophageal Cancer

The incidence of esophageal cancer has increased over the last several decades, and the incidence of adenocarcinoma now surpasses that of squamous cell carcinoma. Esophagectomy is the best curative option for the treatment of resectable esophageal cancer but is a complex operation with significant morbidity and mortality. While the overall morbidity and mortality in those who are surgically treated has declined, approaching 40–50 % and 8–11 %, respectively, it is still significant. Over the past decade, minimally invasive esophagectomy (MIE) has been gaining favor as an attractive alternative to open resection with the potential to reduce surgical trauma, decrease morbidity, and shorten the length of hospital stay. Laparoscopic techniques were first adapted into the field of esophageal disease in 1991 with laparoscopic fundoplication, performed by Dallemagne et al. With this, the shift toward minimally invasive esophageal surgery began. Traditional approaches via open transhiatal or transthoracic (Ivor Lewis) resections were first “hybridized” with minimally invasive techniques, where parts of the procedure were performed in a minimally invasive fashion and other parts via standard incisions. In 1993, Collard and colleagues published their initial experience with thoracoscopic mobilization of the esophagus. The first esophagectomy performed completely via laparoscopy through a transhiatal approach was in 1995 by DePaula et al. In 1999, Watson et al. first described a completely minimally invasive Ivor Lewis technique