Meta-Analysis
Copyright ©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Aug 14, 2022; 28(30): 4201-4210
Published online Aug 14, 2022. doi: 10.3748/wjg.v28.i30.4201
Network meta-analysis of randomized controlled trials on esophagectomies in esophageal cancer: The superiority of minimally invasive surgery
Lajos Szakó, Dávid Németh, Nelli Farkas, Szabolcs Kiss, Réka Zsuzsa Dömötör, Marie Anne Engh, Péter Hegyi, Balint Eross, András Papp
Lajos Szakó, Nelli Farkas, Marie Anne Engh, Péter Hegyi, Institute of Translational Medicine, University of Pécs, Medical School, Pécs 7624, Hungary
Lajos Szakó, János Szentágothai Research Centre, University of Pécs, Medical School, Pécs 7624, Hungary
Dávid Németh, Réka Zsuzsa Dömötör, Institute for Translational Medicine, University of Pécs, Medical School, Pécs 7624, Hungary
Dávid Németh, Nelli Farkas, Institute of Bioanalysis, University of Pécs, Medical School, Pécs 7624, Hungary
Szabolcs Kiss, Insittute of Translational Medicine, University of Pécs, Medical School, Pécs 7624, Hungary
Szabolcs Kiss, Doctoral School of Clinical Medicine, University of Szeged, Medical School, Szeged 6720, Hungary
Péter Hegyi, First Department of Medicine, University of Szeged, Medical School, Szeged 6725, Hungary
Balint Eross, Institute of Translational Medicine, University of Pecs, Medical School, Pecs 7624, Hungary
András Papp, Department of Surgery, Clinical Center, University of Pécs, Medical School, Pécs 7624, Hungary
Author contributions: Szakó L conceptualized the work, contributed to establishment of the search key, selection strategy, data extraction, interpretation of the results, and writing of the manuscript; Németh D and Farkas N performed the bio-statistical analyses, and contributed to the interpretation of the results and writing of the manuscript; Kiss S helped was involved in the conceptualization, coordination of the work, and writing the manuscript; Dömötör RZ conceptualized, wrote, and critically appraised the manuscript; Engh MA was involved in the conceptualization, data extraction, risk of bias assessment, writing of the manuscript, and language revision of the manuscript; Hegyi P contributed to the conceptualization, interpretation of the results, critical appraisal, and writing of the manuscript; Erőss BM conceptualized the work, interpreted the results, critically appraised and wrote the manuscript; Papp A provided supervision, and was involved in the conceptualization, interpretation of the results, critical appraisal, and writing of the manuscript.
Conflict-of-interest statement: All authors have no conflicts of interest to declare.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: András Papp, PhD, Associate Professor, Department of Surgery, Clinical Center, University of Pécs, Medical School, 13 Ifjúság útja, Pécs 7624, Hungary. papp.andras@pte.hu
Received: January 16, 2022
Peer-review started: January 16, 2022
First decision: April 12, 2022
Revised: April 26, 2022
Accepted: July 16, 2022
Article in press: July 16, 2022
Published online: August 14, 2022
Abstract
BACKGROUND

Previous meta-analyses, with many limitations, have described the beneficial nature of minimal invasive procedures.

AIM

To compare all modalities of esophagectomies to each other from the results of randomized controlled trials (RCTs) in a network meta-analysis (NMA).

METHODS

We conducted a systematic search of the MEDLINE, EMBASE, Reference Citation Analysis (https://www.referencecitationanalysis.com/) and CENTRAL databases to identify RCTs according to the following population, intervention, control, outcome (commonly known as PICO): P: Patients with resectable esophageal cancer; I/C: Transthoracic, transhiatal, minimally invasive (thoracolaparoscopic), hybrid, and robot-assisted esophagectomy; O: Survival, total adverse events, adverse events in subgroups, length of hospital stay, and blood loss. We used the Bayesian approach and the random effects model. We presented the geometry of the network, results with probabilistic statements, estimated intervention effects and their 95% confidence interval (CI), and the surface under the cumulative ranking curve to rank the interventions.

RESULTS

We included 11 studies in our analysis. We found a significant difference in postoperative pulmonary infection, which favored the minimally invasive intervention compared to transthoracic surgery (risk ratio 0.49; 95%CI: 0.23 to 0.99). The operation time was significantly shorter for the transhiatal approach compared to transthoracic surgery (mean difference -85 min; 95%CI: -150 to -29), hybrid intervention (mean difference -98 min; 95%CI: -190 to -9.4), minimally invasive technique (mean difference -130 min; 95%CI: -210 to -50), and robot-assisted esophagectomy (mean difference -150 min; 95%CI: -240 to -53). Other comparisons did not yield significant differences.

CONCLUSION

Based on our results, the implication of minimally invasive esophagectomy should be favored.

Keywords: Surgery, Esophageal cancer, Esophagectomy, Network meta-analysis, Minimally invasive, Laparoscopy

Core Tip: Minimally invasive laparoscopic techniques should be the preferred approach for the treatment of esophageal cancer, due to the lower incidence of postoperative pulmonary complications.