Effect of en bloc esophagectomy and total meso-esophagectomy on esophageal cancer patients: a systematic review and meta-analysis

Background: Esophagectomy offers the chance of cure for esophageal cancer, however, the optimal circumferential extent of surgery remains uncertain. En bloc esophagectomy (EBE) and total meso-esophagectomy (TME) have yielded inconsistent results. Therefore, the purpose of this study was to evaluate the surgical and oncological effects of EBE and TME on esophageal cancer patients. Methods: Four databases including PubMed, Cochrane Library, Web of Science, and Embase were searched through to March 1 st , 2022, and the references of eligible studies were further evaluated. Randomized controlled trials comparing the efficacy of EBE and TME were included, and the risk of biases for included studies was assessed with the Cochrane risk of bias tool by two reviewers independently. The outcomes were recorded as mean difference, risk ratio, odds ratio, and hazard ratio with its corresponding 95% confidence interval. Results: Overall, a total of 14 randomized controlled trials involving 3,106 subjects were included. Compared with standard resection, higher blood loss [mean difference =56.29 (14.80, 97.77), P=0.008], more dissected lymph nodes [mean difference =14.39 (9.79, 19.00), P<0.001], and superior long-term outcomes for early [overall survival: hazard ratio =0.31 (0.10, 0.96), P=0.04; disease-free survival: hazard ratio =0.71 (0.41, 1.21), P=0.21] and advanced-stage esophageal cancer patients [overall survival: hazard ratio =0.47 (0.33, 0.66), P<0.001; disease-free survival: hazard ratio =0.62 (0.38, 0.99), P=0.05] were observed in the EBE group, while TME showed less blood loss [mean difference =−74.03 (−96.69, −51.38), P<0.001], shorter operation time [mean difference =−32.37 (−65.12, 0.37), P=0.05], and better overall survival [hazard ratio =0.74 (0.55, 0.98), P=0.04]. Conclusions: EBE is highly technically demanding and is associated with comparable surgical trauma and better long-term outcomes comparted to the standard esophagectomy. TME has a better long-term prognosis without improving operative bleeding and operation time. Further prospective studies are required to verify the efficacy of EBE and TME.