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Surgical outcomes after totally minimally invasive Ivor Lewis
esophagectomy. A systematic review and meta-analysis
*
María A. Casas , Cristian A. Angeramo , Camila Bras Harriott , Francisco Schlottmann
*
Department of Surgery, Hospital Alem
an of Buenos Aires, Argentina
article info
Article history:
Accepted 16 November 2021
Available online xxx
Keywords:
Transthoracic esophagectomy
Ivor Lewis esophagectomy
Minimally invasive esophagectomy
Anastomotic leak
Morbidity
Mortality
abstract
Background: A transthoracic esophagectomy is associated with high rates of morbidity. Minimally
invasive esophagectomy has emerged to decrease such morbidity. The aim of this study was to accurately
determine surgical outcomes after totally minimally invasive Ivor-Lewis Esophagectomy (TMIE).
Methods: A systematic literature search was performed to identify original articles analyzing patients
who underwent TMIE. Main outcomes included overall morbidity, major morbidity, pneumonia,
arrhythmia, anastomotic leak, chyle leak, and mortality. A meta-analysis was conducted to estimate the
overall weighted proportion and its 95% confidence interval (CI) for each analyzed outcome.
Results: A total of 5619 patients were included for analysis; 4781 (85.1%) underwent a laparoscopic/
thoracoscopic esophagectomy and 838 (14.9%) a robotic-assisted esophagectomy. Mean age of patients
was 63.5 (55e67) years and 75.8% were male. Overall morbidity and major morbidity rates were 39%
(95% CI, 33%e45%) and 20% (95% CI, 13%e28%), respectively. Postoperative pneumonia and arrhythmia
rates were 10% (95% CI, 8%e13%) and 12% (95% CI, 8%e17%), respectively. Anastomotic leak rate across
studies was 8% (95% CI, 6%e10%). Chyle leak rate was 3% (95% CI, 2%e5%). Mortality rate was 2% (95% CI,
2%e2%). Median ICU stay and length of hospital stay were 2 (1e4) and 11.2 (7e20) days, respectively.
Conclusions: Totally minimally invasive Ivor-Lewis esophagectomy is a challenging procedure with high
morbidity rates. Strategies to enhance postoperative outcomes after this operation are still needed.
©2021 Published by Elsevier Ltd.
1. Introduction
Esophageal cancer constitutes a major global health problem
with one of the highest financial burden among cancers [1]. Glob-
ally, it is the 7th most common cancer worldwide and the 6th most
common cause of cancer death [2]. Although squamous cell carci-
noma is the most frequent, the incidence of adenocarcinoma has
been rising over the past years due to the increasing prevalence of
obesity and gastroesophageal reflux disease in developed nations
[3,4].
The mainstay curative treatment of esophageal cancer is surgical
resection, which is usually combined with chemoradiotherapy or
chemotherapy for locally advanced tumors [5]. An esophagectomy
is associated with high rates of morbidity, which ultimately affects
patient's quality of life [6,7]. In an attempt to decrease post-
operative morbidity, minimally invasive esophagectomy (MIE) has
gained popularity in the last decade [8]. This approach has proven
to be associated with reduced postoperative pain, reduced
morbidity and mortality, faster recovery time and shorter hospital
stay, along with similar oncologic outcomes as compared to open
esophagectomy [9e12]. However, high technical complexity of MIE
along with the considerable learning curves, still makes chal-
lenging the broad embracement of this approach [13e15]. Unfor-
tunately, data regarding perioperative outcomes after MIE are
heterogenous and often include different type of operations (e.g.
Mc Keown and Ivor Lewis) and approaches (e.g. hybrid and totally
minimally invasive) [16,17].
The aim of this systematic review and meta-analysis was to
accurately determine surgical outcomes after totally minimally
invasive Ivor-Lewis Esophagectomy (TMIE).
*
María A. Casas, Cristian A. Angeramo, Camila Bras Harriott, and Francisco
Schlottmann have no conflict of interest, financial ties or funding/support to
disclose.
*Corresponding author. Department of Surgery, Division of Esophageal and
Gastric Surgery, Hospital Alem
an of Buenos Aires, 1640 Pueyrredon Ave, Buenos
Aires, Argentina.
E-mail address: fschlottmann@hospitalaleman.com (F. Schlottmann).
Contents lists available at ScienceDirect
European Journal of Surgical Oncology
journal homepage: www.ejso.com
https://doi.org/10.1016/j.ejso.2021.11.119
0748-7983/©2021 Published by Elsevier Ltd.
European Journal of Surgical Oncology xxx (xxxx) xxx
Please cite this article as: M.A. Casas, C.A. Angeramo, C. Bras Harriott et al., Surgical outcomes after totally minimally invasive Ivor Lewis
esophagectomy. A systematic review and meta-analysis, European Journal of Surgical Oncology, https://doi.org/10.1016/j.ejso.2021.11.119
2. Methods
2.1. Data sources
A systematic literature review of articles on minimally invasive
esophagectomy was performed according to the PRISMA (Preferred
Reporting Items for Systematic Reviews and Meta-Analyses) guide-
lines [18]. To avoid missing articles, the search strategy was
completed with manual screening of references of identified arti-
cles and relevant reviews. The electronic search was conducted in
the Medline database using the Pubmed search engine and
Cochrane Central Register of Controlled Trials. The following key
terms were entered to identify relevant studies: “Transthoracic
esophagectomy”,“Minimally invasive esophagectomy”,“Minimally
invasive esophageal surgery”,“Minimally invasive Ivor-Lewis
Esophagectomy”,“Robotic assisted minimally invasive esoph-
agectomy”, and “Totally minimally invasive esophagectomy”. The
keywords were used in all possible combinations to obtain the
maximal number of articles.
2.2. Study selection and data extraction
Eligible studies for the present meta-analysis included those
analyzing patients undergoing TMIE. Only patients with an
intrathoracic anastomosis were included. TMIE was defined as an
esophagectomy in which neither thoracotomy nor laparotomy
was performed. The search strategy was restricted to studies on
human subjects, reported in English, and published between
2000 and 2020. Only original articles with more than 50 patients
were included. For studies including different types of approach
(e.g. hybrid esophagectomy, open esophagectomy, and/or TMIE)
only the subgroup of patients who underwent TMIE were
included in the analysis. Experimental studies in animal models,
abstracts, case reports, reviews, editorials, and comments were
excluded. When different articles were reported on the same
cohort, only the study with the largest study population was
selected for the analysis.
A total of 1725 articles were initially screened. After removing
duplicates and publications that did not meet the inclusion criteria,
431 articles were evaluated by two independent authors (AC and
CBH) based on the methodological quality of the publications, with
discrepancies reconciled by the senior author (FS). Finally, 38 arti-
cles were included for the meta-analysis [19e56]. A summary of
the selection process is shown in Fig. 1.
The following data were extracted from the articles: publica-
tion year, study design, number of patients, demographic vari-
ables, surgical approach, operative variables, overall morbidity,
major morbidity, pneumonia, arrhythmia, anastomotic leak rate,
Fig. 1. Selection process in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses).
M.A. Casas, C.A. Angeramo, C. Bras Harriott et al. European Journal of Surgical Oncology xxx (xxxx) xxx
2
Table 1
Characteristics of studies included in the meta-analysis.
Author Year Design N
patients
Median
Age
Gender
Male (%)
EAC
(%)
Approach Mean Operative
Time (minutes)
Anastomotic
Leak (%)
Chyle
Leak (%)
Overall
Morbidity
(%)
Major
Morbidity
(%)
Pneumonia
(%)
Arrhythmia
(%)
Mortality
(%)
ICU Stay
(days)
Median
LOS (days)
Nguyen [19] 2008 Prospective 51 64 64.7 NA LAP/THO 249 7.8 NA NA 11.8 NA NA 1.9 2.9 9.7
Jaroszewski [20] 2011 Retrospective 51 65 84.3 86.3 LAP/THO 338 9.8 2 49 NA 15.7 31.4 NA NA 11
Luketich [21] 2012 Retrospective 530 64 78.3 77.5 LAP/THO NA 4.3 NA NA 17.7 NA NA 1.7 2 7
Noble [22] 2012 Retrospective 53 66 81.1 NA LAP/THO 300 9.4 1.9 69.8 22.6 NA 11.3 0 1 12
De La Fuente [23] 2013 Retrospective 50 66 78 30 Robotic 445 2 4 28 NA 2.5 10 0 2 10.9
Hernandez [24] 2013 Prospective 52 65 78.9 88.5 Robotic 442 1.9 3.8 26.9 NA 2.6 9.6 0 NA NA
Mu [25] 2014 Retrospective 52 59 59.6 NA LAP/THO 420 7.7 NA 21.2 NA NA NA 1.9 NA 17
Tapias [26] 2014 Retrospective 80 61.5 83.8 85 LAP/THO 339 0 0 37.5 NA 6.3 2.5 0 1 7
Xie [27] 2014 Retrospective 106 63.2 70.8 6.6 LAP/THO 249 4.7 3.8 26.4 14.1 2.8 2.8 1.9 2.2 11.8
Mei [28] 2015 Retrospective 131 63 76.3 6.9 LAP/THO 252 3.1 4.6 32.1 12.2 17.6 3.8 2.3 NA 10.9
Mungo [29] 2015 Retrospective 52 66 76.9 88.5 LAP/THO NA 13.5 NA NA NA 5.8 17.3 3.8 NA 9
Cerfolio [30] 2016 Retrospective 85 63 87.1 NA Robotic 360 4.7 5.9 36.5 NA 5.1 7.1 3.5 NA 8
Goense [31] 2016 Retrospective 167 63.5 83.2 NA LAP/THO NA 24 NA NA NA NA NA NA NA NA
Jeon [32] 2016 Retrospective 58 64.3 93.1 NA LAP/THO 371 5.2 NA 39.7 NA 1.7 NA 1.7 3.5 13.6
Salem [33] 2016 Retrospective 129 67 79.8 88.4 Robotic 407 3.9 NA NA 22.5 7.7 NA 1.6 3.3 11.3
Straatman [34] 2016 Retrospective 282 62.8 77.3 81.3 LAP/THO 333 15.2 NA 43.6 NA NA 4.3 2.1 2 12
Ahmadi [35] 2017 Retrospective 73 64 86.3 79.5 LAP/THO 517 13.7 NA 74 56.2 NA 31.5 4.1 NA 10
Berkelmans [36] 2017 Retrospective 114 66 86 93 LAP/THO NA 21.1 10.5 72.8 43.8 6.1 NA 0.9 NA 14
Egberts [37] 2017 Retrospective 75 66 68 96 Robotic 392 16 NA 69.3 NA NA NA 4 NA 16
Liu [38] 2017 Retrospective 122 61.9 78.7 NA LAP/THO 285 1.6 NA 22.1 NA 11.5 3.3 0 NA NA
Zhang Z [39] 2017 Retrospective 90 62.9 75.6 NA LAP/THO 267 4.4 3.3 25.6 12.2 NA 3.3 1.1 NA 11.5
Kang [40] 2018 Retrospective 215 62.8 83.3 2.3 LAP/THO 297 2.8 2.3 27.9 12.1 NA NA 0.5 NA 20
Stenstra [41] 2018 Retrospective 164 64 79.9 77.4 LAP/THO 270 14.6 NA 40.2 NA NA 24.4 3.7 3 11
Van Workum [42] 2018 Retrospective 561 65 84.1 88.8 LAP/THO 268 14.4 8.7 61.5 33.3 27.8 17.1 2.3 1 11
Wu [43] 2018 Retrospective 67 62 82.1 9 LAP/THO NA 1.5 1.5 65.7 NA 26.9 NA 1.5 3 15
Zhan [44] 2018 Retrospective 257 65.4 74.3 NA LAP/THO 307 6.6 3.1 30.4 NA 16.3 3.1 0.4 1.7 13.7
Kukar [45] 2019 Retrospective 121 66 56.2 94.2 LAP/THO 463 5 1.7 52.9 NA 9.9 12.4 0.8 NA 8
Meredith [46] 2019 Retrospective 95 62 85.3 NA LAP/THO 299 4.2 NA 29.5 NA 13.7 46.3 NA NA 9
Meredith [46] 2019 Retrospective 144 66 78.5 NA Robotic 409 2.8 NA 23.6 NA 14.4 30.6 NA NA 9
Souche [47] 2019 Retrospective 58 62 65.5 77.6 LAP/THO 380 31 NA NA 34.5 10.3 17.2 0 NA 19
Tagkalos [48] 2019 Retrospective 50 62 NA NA Robotic 383 12 NA 24 NA 3 NA 0 1 12
Tagkalos [48] 2019 Retrospective 50 64 NA NA LAP/THO 321 18 NA 40 NA 18 NA 2 2.5 19
Wang Qi [49] 2019 Retrospective 216 61 83.8 NA LAP/THO 265.5 5 3.7 50.9 6 37 25.9 2.3 4 13
Zhang H [50] 2019 Retrospective 77 61.6 88.3 18.2 Robotic 349.4 6.5 1.3 39 NA 5.4 1.3 0 1 12.2
Zhang Y [51] 2019 Retrospective 76 61.8 77.6 NA Robotic 303 9.2 1.3 31.6 NA 3.8 6.6 0 NA 9
Awad [52] 2020 Retrospective 100 65.1 80 75 LAP/THO 384 6 0 40 NA 4 20 2 NA 10.3
Berlth [53] 2020 Retrospective 100 66 84 NA Robotic NA 5 NA NA 18 7 NA 1 1 11
Merritt [54] 2020 Retrospective 173 62.1 80.3 90.2 LAP/THO NA 4 0 40.5 NA 5.8 16.8 2 NA 8
Shen [55] 2020 Retrospective 102 55 70.6 0 LAP/THO 323 5.9 NA NA NA NA NA NA NA 11.5
Zhang T [56] 2020 Retrospective 590 61.1 83,9 0 LAP/THO NA NA NA 17.6 NA 9.5 NA 1.4 NA NA
Abbreviations: EAC: Esophageal Adenocarcinoma; LAP/THO: Laparoscopy/Thoracoscopy; ICU: Intensive care unit; LOS: Length of stay; NA: Not available.
M.A. Casas, C.A. Angeramo, C. Bras Harriott et al. European Journal of Surgical Oncology xxx (xxxx) xxx
3
chyle leak, blood loss, blood transfusion, reoperation rate, inten-
sive care unit (ICU) stay, length of hospital stay (LOS), and
mortality.
2.3. Main outcomes and measures
Main outcomes included overall morbidity, major morbidity,
pneumonia, arrhythmia, anastomotic leak, chyle leak, and
Fig. 2. Proportion forest plot of overall morbidity after totally minimally invasive Ivor Lewis esophagectomy.
Fig. 3. Proportion forest plot of major morbidity after totally minimally invasive Ivor Lewis esophagectomy.
M.A. Casas, C.A. Angeramo, C. Bras Harriott et al. European Journal of Surgical Oncology xxx (xxxx) xxx
4
mortality. If a study did not describe some of the outcomes
mentioned above, the variable was noted as not available.
Overall morbidity was defined as any deviation from the normal
postoperative course. Major morbidity included Clavien-Dindo
grade III/IV complications. Mortality was defined as death before
discharge from hospital or within the first 30 postoperative days.
Anastomotic leak was defined based on at least one of the
following: radiographic findings, clinical symptoms, endoscopy or
operative finding [20,22,31,33e35,41e43,47,48,50]. Only 3 studies
[41,42,48] reported AL according to the International Consensus of
Esophagectomy Complications Consensus Group (ECCG) [57], and
26 studies did not report how anastomotic leak was defined or
diagnosed [19,21,23e30,32,36e40,44e46,49,51e56].
2.4. Statistical analysis
We conducted a meta-analysis of proportions to determine
overall morbidity, major morbidity, pneumonia, arrhythmia, anas-
tomotic leak, chyle leak, blood transfusion, reoperation rate, and
mortality. The Cochran Q and the I2 tests were used to assess and
describe the heterogeneity of each study. A Cochrane Q probability
of <0.10 was used to define the heterogeneity of the study and I2
values of 25%, 50% and 75% were considered as indicators of low,
moderate and high heterogeneity, respectively. Due to differences
between the included studies and non-controllable variables, a
random-effects model was used to perform the pooled analysis of
proportion with 95% confidence interval (CI). To assess the possi-
bility of publication bias, funnel plots were created and evaluated
for asymmetry.
The summary statistics were treated as independent observa-
tions. The minimum, maximum, and median value was calculated
for age, blood loss, operative time, ICU stay, and LOS.
All statistical analyses were performed using R software version
4.0.4.
3. Results
A total of 38 studies comprising 5619 patients were included for
analysis; 4781 (85.1%) patients underwent a laparoscopic/thoraco-
scopic esophagectomy and 838 (14.9%) a robotic-assisted esoph-
agectomy. The mean age of patients was 63.5 years (55e67) and
75.8% were male. Mean operative time was 352 (249e517) minutes.
Median blood loss was 186.65 ml (35e350) and 4% (95% CI, 2%e7%)
of the patients required blood transfusion (heterogeneity was 0.19
(p <0.11) with an inconsistency (I [2]) statistic of 38%). Table 1 de-
scribes main characteristics of the studies included in the analysis.
Overall morbidity rate was 39% (95% CI, 33%e45%) (Fig. 2). The
heterogeneity chi-squared of the weighted pooled proportion was
0.49% (p <0.01) with an I [2] statistic of 93%. Major morbidity rate
was 20% (95% CI, 13%e28%) (Fig. 3). The heterogeneity chi-squared
of the weighted pooled proportion was 0.46 (p <0.01) with an I [2]
statistic of 92%.
Postoperative pneumonia rate was 10% (95% CI, 8%e13%) (Fig. 4).
The heterogeneity chi-squared of the weighted pooled proportion
was 0.58% (p <0.01) with an I [2] statistic of 89%. Arrhythmia rate
among studies was 12% (95% CI, 8%e17%). The heterogeneity chi-
squared of the weighted pooled proportion was 0.63 (p <0.01)
with an inconsistency (I [2]) statistic of 90%.
Fig. 4. Proportion forest plot of pneumonia after totally minimally invasive Ivor Lewis esophagectomy.
M.A. Casas, C.A. Angeramo, C. Bras Harriott et al. European Journal of Surgical Oncology xxx (xxxx) xxx
5
Anastomotic leak rate across studies was 8% (95% CI, 6%e10%)
(Fig. 5). The heterogeneity chi-squared of the weighted pooled
proportion was 0.47(p <0.01) with an inconsistency (I [2]) statistic
of 82%. Chyle leak rate was 3% (95% CI, 2%e5%). The heterogeneity
chi-squared of the weighted pooled proportion was 0.34 (p <0.01)
with an inconsistency (I [2]) statistic of 60%.
Reoperation rate was 11% (95% CI, 8%e15%). The heterogeneity
chi-squared of the weighted pooled proportion was 0.18 (p <0.01)
with an inconsistency (I [2]) statistic of 71%.
The 30-day mortality rate was 2% (95% CI, 2%e2%) (Fig. 6). The
heterogeneity chi-squared of the weighted pooled proportion was
0(p¼0.95) with an I [2] statistic of 0%. Median ICU stay was 2 (1e4)
days and median LOS was 11.2 (7e20) days.
The shape of the funnel plots (Supplementary data) did not
indicate any apparent asymmetry, suggesting that there was no
publication bias likely affecting the results.
4. Discussion
In the last decade, esophagectomy is increasingly being
performed by a minimally invasive approach. Due to the rising
prevalence of esophagogastric junction tumors, a transthoracic
approach with intrathoracic anastomosis is often chosen. In this
systematic review and meta-analysis, we aimed to determine
perioperative outcomes of a large series of patients undergoing
totally minimally invasive Ivor-Lewis Esophagectomy. We were
able to estimate rates of morbidity and mortality that might help
defining global benchmarks of this complex procedure.
Minimally invasive surgery is increasingly becoming a standard
of care for multiple procedures [58e61]. Reduced intraoperative
blood loss, less postoperative pain, higher patient satisfaction,
faster resumption of bowel function and oral diet, and quicker re-
turn to daily activities are some of the advantages associated with
this approach [9e12]. The first MIE was described in 1990, and
since then many studies have been able to show better surgical
outcomes as compared to the conventional approach [9e12].
Luketich et al. [62] presented one of the initial largest series of MIE
with remarkable low rates of pneumonia and 30-day mortality
(7.7% and 1.4%, respectively). The TIME trial was the first random-
ized trial comparing patients undergoing MIE or open
Fig. 5. Proportion forest plot of anastomotic leak after totally minimally invasive Ivor Lewis esophagectomy.
M.A. Casas, C.A. Angeramo, C. Bras Harriott et al. European Journal of Surgical Oncology xxx (xxxx) xxx
6
esophagectomy and demonstrated that postoperative pulmonary
infection rates significantly decrease after MIE. Shorter LOS and
better quality of life were also seen in the MIE group. In addition,
oncologic outcomes were not affected by the minimally invasive
approach, with similar survival in both groups [10].
Postoperative morbidity after an esophagectomy remains high
and varies between 40 and 80% among the literature [63,64]. Un-
fortunately, heterogeneous esophageal cancer populations with
different operations and approaches are often combined together
in the studies. As totally minimally invasive Ivor-Lewis esoph-
agectomy is one of the most commonly operations performed for
the treatment of esophagogastric junction tumors in Western
countries, we intended to determine the surgical outcomes spe-
cifically after this procedure. We found that postoperative
morbidity after TMIE is indeed high with overall and major
morbidity rates of 39% and 22%, respectively. In addition, post-
operative pneumonia occurred in 10% of patients, which demon-
strates that pulmonary complications are also a concern even with
the use of a thoracoscopic approach. Arrhythmias, mainly atrial
fibrillation (AF), are common after major non-cardiac thoracic
surgery (incidence range of 10e40%) [65e67]. AF tends to occur in
the immediate postoperative period, and it has been associated
with increased hospitalization and burden costs. Day et al. reported
an AF incidence of 31.4% in patients undergoing TMIE, which was
associated with an increased LOS. However, AF was not associated
with other postoperative complications such as anastomotic leak,
pneumonia, and/or 60-day mortality [68]. We found that arrhyth-
mias occurred in approximately 12% of the patients after TMIE.
Undoubtedly, TMIE is a challenging procedure with an associ-
ated long learning curve. Therefore, institutional effective imple-
mentation programs might be necessary to increase patient safety
and shorten learning curves of the operation [69]. Anastomotic
leakage is one of the most feared complications after esoph-
agectomy, as it not only significantly increases perioperative mor-
tality rates but also detrimentally affects long-term survival in
esophageal cancer patients [13,70e72]. In our meta-analysis, the
weighted pooled proportion of anastomotic leak was 8%. A recent
multicenter analysis of TMIE reported significant higher leak rates
(14.9%) in patients with intrathoracic esophagogastrostomy [73].
This discrepancy might be partially explained by the inclusion of
minor and clinically unapparent leakages in that multicenter study.
Unfortunately, only few studies included in our analysis precisely
defined anastomotic leak [20,22,31,33e35,41e43,47,48,50]. A
standardized complication reporting system should therefore be
advocated for future research to better define and compare peri-
operative complications [57].
Fig. 6. Proportion forest plot of mortality after totally minimally invasive Ivor Lewis esophagectomy.
M.A. Casas, C.A. Angeramo, C. Bras Harriott et al. European Journal of Surgical Oncology xxx (xxxx) xxx
7
Chyle leaks can be caused by thoracic duct injury during surgical
dissection and might occur in 1e4% of the patients [73e76]. In fact,
our weighted pooled proportion of chyle leak was 3%. Chylothorax
is associated with increased postoperative morbidity rates and
potentially life-threatening complications such as respiratory fail-
ure caused by lung compression, systemic hypovolemia, and
malnutrition among others [77,78]. Therefore, prompt recognition
and management are critical. Although most thoracic duct leaks
resolve with conservative management, patients with high output
(>1 L daily) or persistent leaks (>2 weeks) often require an
intervention.
Efforts to further improve postoperative outcomes after TMIE
are still needed. The use of indocyanine green fluorescence imaging
for the evaluation of the anastomosis has been growing in the last
years and might help reducing anastomotic leak rates [79e81].
Benefits of the robotic platform should also be explored. Three-
dimensional and magnified view, articulated instruments, tremor
filter and better ergonomics are some of the well-known advan-
tages of robotic surgery [82]. Although some studies have already
shown better outcomes after robotic esophagectomy [12,83],
robust evidence is still needed to strongly recommend this
approach. Finally, embracement of perioperative standardized in-
terventions such as enhanced recovery after surgery (ERAS) pro-
tocols might also help decreasing morbidity after esophagectomy
[57,84].
There are some limitations to our study. Mainly, standardization
was lacking in the reporting of postoperative outcomes. For
instance, several studies failed to define anastomotic leak. In
addition, considerable variability for most analyzed outcomes was
found among the studies. Despite these limitations, to our knowl-
edge this is the first meta-analysis defining postoperative outcomes
after totally minimally invasive esophagectomy with intrathoracic
anastomosis.
5. Conclusions
Totally minimally invasive Ivor-Lewis esophagectomy is a chal-
lenging procedure with high morbidity rates. Although growing
experience in minimally invasive esophagectomy will likely
improve our postoperative benchmarks, strategies to enhance
perioperative outcomes after this operation are still needed. Our
outcome analysis might serve as a reference to compare and eval-
uate performance after this complex procedure.
CRediT authorship contribution statement
María A. Casas: Conceptualization, Methodology, Formal anal-
ysis, Investigation, Resources, Data curation, Writing eoriginal
draft, Writing ereview &editing, Visualization, Project adminis-
tration. Cristian A. Angeramo: Conceptualization, Methodology,
Formal analysis, Investigation, Resources, Data curation, Writing e
original draft, Writing ereview &editing, Visualization, Project
administration. Camila Bras Harriott: Conceptualization, Meth-
odology, Formal analysis, Investigation, Resources, Data curation,
Writing eoriginal draft, Writing ereview &editing, Visualization,
Project administration. Francisco Schlottmann: Conceptualiza-
tion, Methodology, Formal analysis, Investigation, Resources, Data
curation, Writing eoriginal draft, Writing ereview &editing,
Visualization, Supervision, Project administration.
Appendix A. Supplementary data
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.ejso.2021.11.119.
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