551
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Zhang R, Kang N, Xia W, Che Y, Wan J, Yu Z. Thoracoscopic purse string technique for minimally invasive Ivor Lewis esophagectomy. J Thorac Dis 2014; 6:148-51. [PMID: 24605229 DOI: 10.3978/j.issn.2072-1439.2013.12.27] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Accepted: 12/12/2013] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Thoracolaparoscopic esophagectomy with chest anastomosis (TLE-chest) is increasingly performed for middle and lower esophageal cancer; however, gastroesophageal anastomosis for this surgery remains both challenging and inefficient. To address this issue, we previously reported our MIE technique with Ivor-Lewis anastomosis. Here we present the video to introduce our TLE-chest operation procedures. METHODS TLE-chest with a combined thoracoscopic and laparoscopic technique was performed by one group of surgeons. From October 2011 to September 2013, 80 esophageal cancer patients were treated with TLE-chest using this improved anastomotic technique. RESULTS The surgery was successful for all patients, although the anastomosis in one patient required intraoperative manual repair. No patients required open conversion. In this video, dissociation of stomach, and dissection of lymph nodes, creation of gastric tube and staple line embedding, jejunostomy were carried out by laparoscopic surgery. Dissection of esophageal cancer and mediastinal lymph nodes were done through rib 3 or 4 by a 3-4 cm video-assisted right anterior minithoracotomy, then esophago-gastric anastomosis was performed in right thoracic cavity This video shows the R0 resection of T3N0M0 esophageal cancer. Totally, 36 lymph nodes were dissected, including 21 mediastinal lymph nodes and 15 abdominal lymph nodes. The patient recovered well and was discharged on day 8 after the surgery, with good short term outcomes. CONCLUSIONS A safe, cost effective purse string stapled anastomotic technique has been presented for TLE-chest in our video. It is consistent with the oncology principles.
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Affiliation(s)
- Renquan Zhang
- Department of Thoracic Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei 230022, China
| | - Ningning Kang
- Department of Thoracic Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei 230022, China
| | - Wanli Xia
- Department of Thoracic Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei 230022, China
| | - Yun Che
- Department of Thoracic Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei 230022, China
| | - Jun Wan
- Department of Thoracic Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei 230022, China
| | - Zaicheng Yu
- Department of Thoracic Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei 230022, China
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552
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Bencini L, Bernini M, Farsi M. Laparoscopic approach to gastrointestinal malignancies: Toward the future with caution. World J Gastroenterol 2014; 20:1777-1789. [PMID: 24587655 PMCID: PMC3930976 DOI: 10.3748/wjg.v20.i7.1777] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2013] [Revised: 11/07/2013] [Accepted: 11/30/2013] [Indexed: 02/06/2023] Open
Abstract
After the rapid acceptance of laparoscopy to manage multiple benign diseases arising from gastrointestinal districts, some surgeons started to treat malignancies by the same way. However, if the limits of laparoscopy for benign diseases are mainly represented by technical issues, oncologic outcomes remain the foundation of any procedures to cure malignancies. Cancerous patients represent an important group with peculiar aspects including reduced survival expectancy, worsened quality of life due to surgery itself and adjuvant therapies, and challenging psychological impact. All these issues could, potentially, receive a better management with a laparoscopic surgical approach. In order to confirm such aspects, similarly to testing the newest weapons (surgical or pharmacologic) against cancer, long-term follow-up is always recommendable to assess the real benefits in terms of overall survival, cancer-free survival and quality of life. Furthermore, it seems of crucial importance that surgeons will be correctly trained in specific oncologic principles of surgical oncology as well as in modern miniinvasive technologies. Therefore, laparoscopic treatment of gastrointestinal malignancies requires more caution and deep analysis of published evidences, as compared to those achieved for inflammatory bowel diseases, gastroesophageal reflux disease or diverticular disease. This review tries to examine the evidence available to date for the use of laparoscopy and robotics in malignancies arising from the gastrointestinal district.
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553
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Minimally invasive Ivor Lewis esophagectomy: description of a learning curve. J Am Coll Surg 2014; 218:1130-40. [PMID: 24698488 DOI: 10.1016/j.jamcollsurg.2014.02.014] [Citation(s) in RCA: 104] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Revised: 02/06/2014] [Accepted: 02/12/2014] [Indexed: 01/08/2023]
Abstract
BACKGROUND Minimally invasive Ivor Lewis esophagectomy (MIE) is gaining popularity for the treatment of esophageal cancer. However, as it is a technically demanding operation, a learning curve should be defined to guide training and allow implementation at institutions not currently using this technique. STUDY DESIGN Our study included a retrospective series of the first 80 consecutive patients undergoing MIE by a single surgeon with advanced training in minimally invasive esophageal surgery in independent practice at a high-volume tertiary center. Patients were stratified into 2 groups of 40 patients, with chronological order defining early and late experiences. Primary end points included conversion to open procedure, surgical time, blood loss, chest drainage duration, time to oral intake, hospital stay, postoperative morbidity, and mortality. The cumulative sum methodology was used and analyzed by visually inspecting the plots. RESULTS Conversion to open procedure occurred in 2 (5%) patients in the early group and none in the late group (p = 0.49). Comparing early vs late experience, mean surgical time was 364 vs 316 minutes (p < 0.01), estimated blood loss was 205 vs 176 mL (p = 0.14), median hospital stay was 7 vs 6 days (p < 0.01), and morbidity was observed in 16 (40%) and 14 (35%) patients (p = 0.82), respectively. There were no anastomotic leaks or 30-day mortality. Cumulative sum plots showed decreasing surgical time after patient 54 (plateau after patient 31), decreasing chest tube duration after patients 38 and 33, sooner oral intake after patient 35, and decreased hospital stay after patient 33. CONCLUSIONS Improved operative and perioperative parameters for MIE were observed in the last 40 patients when compared with the first 40 patients. A reasonable learning curve for MIE would require the operation and perioperative care of 35 to 40 patients.
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554
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Mallipeddi MK, Onaitis MW. The Contemporary Role of Minimally Invasive Esophagectomy in Esophageal Cancer. Curr Oncol Rep 2014; 16:374. [DOI: 10.1007/s11912-013-0374-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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555
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Xu M, Liu C, Guo M, Sun X, Sun X, Luo J, Tian J, Jiang X. Combined laparoscopic-thoracoscopic esophagectomy and intrathoracic esophagogastric anastomsis. J Thorac Dis 2014; 5:895-7. [PMID: 24416509 DOI: 10.3978/j.issn.2072-1439.2013.12.11] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Accepted: 12/09/2013] [Indexed: 11/14/2022]
Abstract
We retrospectively analyzed the clinical data of 112 patients who underwent esophagectomy for esophageal carcinoma and gastro-esophageal anastomosis in right thoracic cavity from October 2011 to June 2013. First, the gastric tube was created with the aid of linear stapling device by removing the stomach and dissecting lymph nodes under laparoscopy and making a 3-4 cm incision through the subxiphoid area in the upper abdomen. Second, the thoracic esophagus and lymph nodes were dissected during thoracoscopic procedure. Gastric tube was inserted into the chest cavity and placed in the posterior mediastinum. The thoracic gastro-esophageal anastomosis was stapled with a circular stapler. Combined laparoscopic-thoracoscopic esophagectomy and intrathoracic esophagogastric anastomosis is technically feasible and safe, with minimized trauma, less operative blood loss and quick recovery.
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Affiliation(s)
- Meiqing Xu
- Department of Thoracic Surgery, the Affiliated Provincial Hospital of Anhui Medical University, Hefei 230001, China
| | - Changqing Liu
- Department of Thoracic Surgery, the Affiliated Provincial Hospital of Anhui Medical University, Hefei 230001, China
| | - Mingfa Guo
- Department of Thoracic Surgery, the Affiliated Provincial Hospital of Anhui Medical University, Hefei 230001, China
| | - Xiangxiang Sun
- Department of Thoracic Surgery, the Affiliated Provincial Hospital of Anhui Medical University, Hefei 230001, China
| | - Xiaohui Sun
- Department of Thoracic Surgery, the Affiliated Provincial Hospital of Anhui Medical University, Hefei 230001, China
| | - Jing Luo
- Department of Thoracic Surgery, the Affiliated Provincial Hospital of Anhui Medical University, Hefei 230001, China
| | - Jieyong Tian
- Department of Thoracic Surgery, the Affiliated Provincial Hospital of Anhui Medical University, Hefei 230001, China
| | - Xianliang Jiang
- Department of Thoracic Surgery, the Affiliated Provincial Hospital of Anhui Medical University, Hefei 230001, China
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556
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Shen G, Pan SB, Wu M, Zhang S, Xu XF, Chen G. Use of efficient purse-string stapling technique for esophagogastric anastomosis in minimally invasive Ivor Lewis esophagectomy. J Thorac Dis 2014; 5:898-901. [PMID: 24416510 DOI: 10.3978/j.issn.2072-1439.2013.12.10] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Accepted: 12/05/2013] [Indexed: 12/21/2022]
Abstract
Minimally invasive esophagectomy (MIE) is increasingly accepted in the treatment of locoregional or advanced esophageal cancer. Laparoscopic-thoracoscopic Ivor-Lewis esophagectomy has been proved to be effective in treating middle and distal esophageal cancer, however, intrathoracic esophagogastric anastomosis is technically complex. When using circular stapler for making intrathoracic anastomosis in MIE, both transoral and transthoracic methods are frequently used for delivering the anvil into the esophageal stump. Herein, we report a new method to construct a thoracoscopic esophagogastric anastomosis by using a circular stapler: efficient purse-string stapling technique (EST). This technique is easy to handle and especially good to be used in patients with distal esophageal cancer or expanded esophageal cavity.
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Affiliation(s)
- Gang Shen
- Department of Thoracic Surgery, Second Affiliated Hospital of Zhejiang University, Hangzhou 310009, China
| | - Sai-Bo Pan
- Department of Thoracic Surgery, Second Affiliated Hospital of Zhejiang University, Hangzhou 310009, China
| | - Ming Wu
- Department of Thoracic Surgery, Second Affiliated Hospital of Zhejiang University, Hangzhou 310009, China
| | - Sai Zhang
- Department of Thoracic Surgery, Second Affiliated Hospital of Zhejiang University, Hangzhou 310009, China
| | - Xiao-Fang Xu
- Department of Thoracic Surgery, Second Affiliated Hospital of Zhejiang University, Hangzhou 310009, China
| | - Gang Chen
- Department of Thoracic Surgery, Second Affiliated Hospital of Zhejiang University, Hangzhou 310009, China
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557
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Chen B, Zhang B, Zhu C, Ye Z, Wang C, Ma D, Ye M, Kong M, Jin J, Lin J, Wu C, Wang Z, Ye J, Zhang J, Hu Q. Modified McKeown minimally invasive esophagectomy for esophageal cancer: a 5-year retrospective study of 142 patients in a single institution. PLoS One 2013; 8:e82428. [PMID: 24376537 PMCID: PMC3869695 DOI: 10.1371/journal.pone.0082428] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2013] [Accepted: 10/22/2013] [Indexed: 11/28/2022] Open
Abstract
Background To achieve decreased invasiveness and lower morbidity, minimally invasive esophagectomy (MIE) was introduced in 1997 for localized esophageal cancer. The combined thoracoscopic-laparoscopic esophagectomy (left neck anastomosis, defined as the McKeown MIE procedure) has been performed since 2007 at our institution. From 2007 to 2011, our institution subsequently evolved as a high-volume MIE center in China. We aim to share our experience with MIE, and have evaluated the outcomes of 142 patients. Methods We retrospectively reviewed 142 consecutive patients who had presented with esophageal cancer undergoing McKeown MIE from July 2007 to December 2011. The procedure, surgical outcomes, disease-free and overall survival of these cases were assessed. Results The average total procedure time was 270.5±28.1 min. The median operation time for thoracoscopy was 81.5±14.6 min and for laparoscopy was 63.8±9.1 min. The average blood loss associated with thoracoscopy was 123.8±39.2 ml, and for laparoscopic procedures was 49.9±14.3 ml. The median number of lymph nodes retrieved was 22.8. The 30 day mortality rate was 0.7%. Major surgical complications occurred in 24.6% and major non-surgical complications occurred in 18.3% of these patients. The median DFS and OS were 36.0±2.6 months and 43.0±3.4 months respectively. Conclusions Surgical and oncological outcomes following McKeown MIE for esophageal cancer were acceptable and comparable with those of open-McKeown esophagectomy. The procedure was both feasible and safe – properties that can be consolidated by experience.
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Affiliation(s)
- Baofu Chen
- Department of Thoracic Surgery, Taizhou Hospital, Wenzhou Medical College, Linhai, Zhejiang, China
| | - Bo Zhang
- Department of Thoracic Surgery, Taizhou Hospital, Wenzhou Medical College, Linhai, Zhejiang, China
| | - Chengchu Zhu
- Department of Thoracic Surgery, Taizhou Hospital, Wenzhou Medical College, Linhai, Zhejiang, China
- * E-mail:
| | - Zhongrui Ye
- Department of Thoracic Surgery, Taizhou Hospital, Wenzhou Medical College, Linhai, Zhejiang, China
| | - Chunguo Wang
- Department of Thoracic Surgery, Taizhou Hospital, Wenzhou Medical College, Linhai, Zhejiang, China
| | - Dehua Ma
- Department of Thoracic Surgery, Taizhou Hospital, Wenzhou Medical College, Linhai, Zhejiang, China
| | - Minhua Ye
- Department of Thoracic Surgery, Taizhou Hospital, Wenzhou Medical College, Linhai, Zhejiang, China
| | - Min Kong
- Department of Thoracic Surgery, Taizhou Hospital, Wenzhou Medical College, Linhai, Zhejiang, China
| | - Jiang Jin
- Department of Thoracic Surgery, Taizhou Hospital, Wenzhou Medical College, Linhai, Zhejiang, China
| | - Jiang Lin
- Department of Thoracic Surgery, Taizhou Hospital, Wenzhou Medical College, Linhai, Zhejiang, China
| | - Chunlei Wu
- Department of Thoracic Surgery, Taizhou Hospital, Wenzhou Medical College, Linhai, Zhejiang, China
| | - Zheng Wang
- Department of Thoracic Surgery, Taizhou Hospital, Wenzhou Medical College, Linhai, Zhejiang, China
| | - Jiahong Ye
- Department of Thoracic Surgery, Taizhou Hospital, Wenzhou Medical College, Linhai, Zhejiang, China
| | - Jian Zhang
- Department of Thoracic Surgery, Taizhou Hospital, Wenzhou Medical College, Linhai, Zhejiang, China
| | - Quanteng Hu
- Department of Thoracic Surgery, Taizhou Hospital, Wenzhou Medical College, Linhai, Zhejiang, China
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558
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Gibson MK, Dhaliwal AS, Clemons NJ, Phillips WA, Dvorak K, Tong D, Law S, Pirchi ED, Räsänen J, Krasna MJ, Parikh K, Krishnadath KK, Chen Y, Griffiths L, Colleypriest BJ, Farrant JM, Tosh D, Das KM, Bajpai M. Barrett's esophagus: cancer and molecular biology. Ann N Y Acad Sci 2013; 1300:296-314. [PMID: 24117650 DOI: 10.1111/nyas.12252] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The following paper on the molecular biology of Barrett's esophagus (BE) includes commentaries on signaling pathways central to the development of BE including Hh, NF-κB, and IL-6/STAT3; surgical approaches for esophagectomy and classification of lesions by appropriate therapy; the debate over the merits of minimally invasive esophagectomy versus open surgery; outcomes for patients with pharyngolaryngoesophagectomy; the applications of neoadjuvant chemotherapy and chemoradiotherapy; animal models examining the surgical models of BE and esophageal adenocarcinoma; the roles of various morphogens and Cdx2 in BE; and the use of in vitro BE models for chemoprevention studies.
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Affiliation(s)
- Michael K Gibson
- Department of Medicine and Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Arashinder S Dhaliwal
- Department of Medicine and Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Nicholas J Clemons
- Surgical Oncology Research Laboratory, Peter MacCallum Cancer Centre, East Melbourne, VIC, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia.,Department of Surgery, St. Vincent's Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - Wayne A Phillips
- Surgical Oncology Research Laboratory, Peter MacCallum Cancer Centre, East Melbourne, VIC, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia.,Department of Surgery, St. Vincent's Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - Katerina Dvorak
- Department of Cellular and Molecular Medicine, Arizona Cancer Center, University of Arizona Cancer Center, Tucson, Arizona
| | - Daniel Tong
- Division of Esophageal and Upper Gastrointestinal Surgery, Department of Surgery, The University of Hong Kong, Hong Kong
| | - Simon Law
- Division of Esophageal and Upper Gastrointestinal Surgery, Department of Surgery, The University of Hong Kong, Hong Kong
| | - E Daniel Pirchi
- Servicio de Cirugía, Hospital Britanico de Buenos Aires, Buenos Aires, Argentina
| | - Jari Räsänen
- Division of General Thoracic and Esophageal Surgery, Helsinki University Central Hospital, Helsinki, Finland
| | - Mark J Krasna
- Jersey Shore University Medical Center, Neptune, New Jersey
| | - Kaushal Parikh
- Department of Gastroenterology & Hepatology, and Centre for Experimental & Molecular Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Kausilia K Krishnadath
- Department of Gastroenterology & Hepatology, and Centre for Experimental & Molecular Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Yu Chen
- Department of Biology & Biochemistry, University of Bath, Bath, UK
| | | | | | - J Mark Farrant
- Department of Biology & Biochemistry, University of Bath, Bath, UK
| | - David Tosh
- Department of Biology & Biochemistry, University of Bath, Bath, UK
| | - Kiron M Das
- Department of Medicine, UMDNJ-RWJMS, New Brunswick, New Jersey
| | - Manisha Bajpai
- Department of Medicine, UMDNJ-RWJMS, New Brunswick, New Jersey
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559
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Gertler R, Feith M. Minimalinvasive Chirurgie bei Malignomen des Gastrointestinaltrakts: Ösophagus - Kontra-Position. Visc Med 2013. [DOI: 10.1159/000357580] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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560
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Hoeppner J, Zirlik K, Brunner T, Bronsert P, Kulemann B, Sick O, Marjanovic G, Hopt UT, Makowiec F. Multimodal treatment of locally advanced esophageal adenocarcinoma: Which regimen should we choose? Outcome analysis of perioperative chemotherapy versus neoadjuvant chemoradiation in 105 patients. J Surg Oncol 2013; 109:287-93. [DOI: 10.1002/jso.23498] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2013] [Accepted: 10/23/2013] [Indexed: 11/07/2022]
Affiliation(s)
- Jens Hoeppner
- Department of Surgery; University of Freiburg; Freiburg Germany
| | - Katja Zirlik
- Department of Medicine; University of Freiburg; Freiburg Germany
| | - Thomas Brunner
- Department of Radiation Oncology; University of Freiburg; Freiburg Germany
| | - Peter Bronsert
- Department of Pathology; University of Freiburg; Freiburg Germany
| | - Birte Kulemann
- Department of Surgery; University of Freiburg; Freiburg Germany
| | - Olivia Sick
- Department of Surgery; University of Freiburg; Freiburg Germany
| | | | | | - Frank Makowiec
- Department of Surgery; University of Freiburg; Freiburg Germany
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561
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Markar SR, Karthikesalingam A, Penna M, Low DE. Assessment of short-term clinical outcomes following salvage esophagectomy for the treatment of esophageal malignancy: systematic review and pooled analysis. Ann Surg Oncol 2013; 21:922-31. [PMID: 24212722 DOI: 10.1245/s10434-013-3364-0] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Indexed: 11/18/2022]
Abstract
BACKGROUND Combined chemoradiotherapy is increasingly being used as definitive treatment for locoregional esophageal malignancy. Patients with residual or recurrent localized cancer are often selectively considered for salvage esophagectomy (SALV). The aim of this pooled analysis was to compare short-term clinical outcomes from SALV following definitive chemoradiotherapy with those from planned esophagectomy following neoadjuvant chemoradiotherapy (NCRS). METHODS MEDLINE, EMBASE, Cochrane, trial registries, conference proceedings and reference lists were searched for relevant comparative studies. Primary outcome measures were in-hospital mortality, anastomotic leak and pulmonary complications. Secondary outcomes were length of hospital stay, negative (R0) resection margin, and estimated blood loss. RESULTS Eight studies comprising 954 patients; 242 (SALV) and 712 (NCRS) were included. SALV was associated with a significantly increased incidence of post-operative mortality (9.50 vs. 4.07 %; pooled odds ratio [POR] = 3.02; p < 0.001), anastomotic leak (23.97 vs. 14.47 %; POR = 1.99; p = 0.005), pulmonary complications (29.75 vs. 16.99 %; POR = 2.12; p < 0.001), and an increased length of hospital stay (weighted mean difference = 8.29 days; 95 % CI 7.08-9.5; p < 0.001). There were no significant differences between the groups in the incidence of negative resection margins or estimated blood loss. CONCLUSIONS SALV has poorer short-term outcomes when compared with planned esophagectomy following neoadjuvant chemoradiotherapy. Patients and multidisciplinary tumor boards should be made aware of these differences in outcomes and SALV should be reserved for practice in high-volume institutions.
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Affiliation(s)
- Sheraz R Markar
- Department of Thoracic Surgery, Virginia Mason Medical Center, Seattle, WA, USA
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562
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Louie BE. Invited commentary. Ann Thorac Surg 2013; 96:1832. [PMID: 24182468 DOI: 10.1016/j.athoracsur.2013.07.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Revised: 07/10/2013] [Accepted: 07/18/2013] [Indexed: 10/26/2022]
Affiliation(s)
- Brian E Louie
- Division of Thoracic Surgery, Swedish Cancer Institute and Medical Center, Ste 850, 1101 Madison St, Seattle, WA98104.
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563
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Hybrid trans-thoracic esophagectomy with side-to-side stapled intra-thoracic esophagogastric anastomosis for esophageal cancer. J Gastrointest Surg 2013; 17:1972-9. [PMID: 23835733 DOI: 10.1007/s11605-013-2281-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2013] [Accepted: 06/26/2013] [Indexed: 01/31/2023]
Abstract
Esophagectomy is the primary treatment modality for non-metastatic esophageal cancer. A trans-thoracic approach is used in most centers in the United States. Anastomotic complications, such as leakage and stricture, are associated with worse short-term and long-term outcomes. Recent data suggest that a side-to-side mechanical intra-thoracic esophagogastric anastomosis is associated with a reduced rate of anastomotic leaks and strictures. This article describes the technique of trans-thoracic hybrid esophagectomy with side-to-side intra-thoracic esophagogastric anastomosis for esophageal cancer.
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564
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Davison JM, Ellis ST, Foxwell TJ, Luketich JD, Gibson MK, Kuan SF, Nason KS. MUC2 expression is an adverse prognostic factor in superficial gastroesophageal adenocarcinomas. Hum Pathol 2013; 45:540-8. [PMID: 24290360 DOI: 10.1016/j.humpath.2013.10.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Revised: 10/15/2013] [Accepted: 10/16/2013] [Indexed: 02/07/2023]
Abstract
Mucin core proteins (MUCs) are expressed in tissue-specific patterns in the gastrointestinal tract and expression is deregulated in Barrett's metaplasia. Based on differential expression, MUCs have been used to classify adenocarcinomas into distinct phenotypes (eg, intestinal, gastric, pancreaticobiliary, etc). Because MUC expression patterns carry prognostic significance in other tumors, we evaluated MUC expression in superficial adenocarcinomas of the gastroesophageal junction and esophagus (EAC) to determine whether there are differences in outcome associated with MUC subtype in this potentially curable subset of EAC. We classified 142 resected, superficial (T1) EAC based on their pattern of expression of MUC2, MUC5AC, MUC6 and MUC1. The association between survival and MUC expression pattern was determined in univariate and multivariate analyses. The MUC2 positive "intestinal" phenotype was associated with significantly worse prognosis in submucosal EAC (hazard ratio 2.2, 95% confidence interval 1.2-4.2), independent of node stage and other prognostic factors. MUC2 expression in submucosal EAC also showed significantly accelerated time to recurrence (hazard ratio 2.8, 95% confidence interval 1.2-6.8) after adjusting for node stage. The classification of superficial EAC by MUC protein expression has prognostic significance. MUC2 expression is an adverse prognostic indicator in submucosal EAC, independent of node stage and other prognostic factors.
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Affiliation(s)
- Jon M Davison
- Department of Pathology, University of Pittsburgh School of Medicine, Presbyterian University Hospital A610, Pittsburgh, PA 15213.
| | - Shane T Ellis
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213
| | - Tyler J Foxwell
- Department of Pathology, University of Pittsburgh School of Medicine, Presbyterian University Hospital A610, Pittsburgh, PA 15213
| | - James D Luketich
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213
| | - Michael K Gibson
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213
| | - Shih-Fan Kuan
- Department of Pathology, University of Pittsburgh School of Medicine, Presbyterian University Hospital A610, Pittsburgh, PA 15213
| | - Katie S Nason
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213
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565
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Yamamoto M, Weber JM, Karl RC, Meredith KL. Minimally invasive surgery for esophageal cancer: review of the literature and institutional experience. Cancer Control 2013; 20:130-7. [PMID: 23571703 DOI: 10.1177/107327481302000206] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Esophageal cancer represents a major public health problem in the world. Several minimally invasive esophagectomy (MIE) techniques have been described and represent a safe alternative for the surgical management of esophageal cancer in selected centers with high volume and surgeons experienced in minimally invasive procedures. METHODS The authors reviewed the most recent and largest studies published in the medical literature that reported the outcomes for MIE techniques. RESULTS In larger series, MIE has proven to be equivalent in postoperative morbidity and mortality to the open esophagectomy. However, MIE has been associated with less blood loss, reduced postoperative pain, decreased time in the intensive care unit, and shortened length of hospital stay compared with the conventional open approaches. Despite limited data, no significant difference in survival stage for stage has been observed between open esophagectomy and MIE. CONCLUSIONS The myriad of MIE techniques complicates the debate for defining the optimal surgical approach for the treatment of esophageal cancer. Randomized controlled trials comparing MIE with conventional open esophagectomy are needed to clarify the ideal procedure with the lowest postoperative morbidity, best quality of life after surgery, and long-term survival.
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Affiliation(s)
- Maki Yamamoto
- Gastrointestinal Tumor Program, H Lee Moffitt Cancer Center, Tampa, FL 33612, USA
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566
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Nieponice A, Badaloni AE, Jobe BA, Hoppo T, Pellegrini C, Velanovich V, Falk GW, Reavis K, Swanstrom L, Sharma VK, Nachman F, Ciotola FF, Caro LE, Cerisoli C, Cavadas D, Figueroa LD, Pirchi D, Gibson M, Elizalde S, Cohen H. Management of early-stage esophageal neoplasia (MESEN) consensus. World J Surg 2013; 38:96-105. [PMID: 24101017 DOI: 10.1007/s00268-013-2235-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Treatment of esophageal adenocarcinoma often involves surgical resection. Newer technologies in interventional endoscopy have led to a substantial paradigm shift in the management of early-stage neoplasia in Barrett's esophagus comprising high-grade dysplasia (HGD), intramucosal carcinoma, and, in some cases, submucosal carcinoma. However, there has been no consensus regarding the indications for esophageal preservation in these cases. In this work, consensus guidelines were established for the management of early-stage esophageal neoplasia considering clinically relevant aspects (age, comorbidities, and social environment) in each scenario. METHODS Seventeen experts were invited to participate based on their background and clinical expertise at high-volume centers. A questionnaire was created that included four clinical scenarios covering a wide range of situations within HGD and/or early esophageal neoplasia, particularly where controversies are likely to exist. Each of the clinical scenarios was open to discussion subdivided by patient age (20, 50, and 80 s). For each clinical scenario an expert was chosen to defend that position. Each defense triggered a subsequent discussion during a consensus meeting. Conclusions of that discussion together with an accompanying literature analysis allowed experts to confirm or change their original choices and served as the basis for the recommendations stated in this article. RESULTS There was 100 % consensus supporting esophageal preservation in patients with HGD, independent of patient age or Barrett's length. In patients with T1a adenocarcinoma, consensus for preservation was not reached (65 %) for young and middle-aged individuals but was supported for elderly patients (100 %). For T1b adenocarcinoma, consensus was reached for surgical resection (90 %), leaving organ preservation for patients with very low risk of nodal invasion or poor surgical candidates. CONCLUSION Advances in endoscopic imaging and therapy allow for organ preservation in most settings of early-stage neoplasia of the esophagus, provided that the patient understands the implications of this decision.
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Affiliation(s)
- Alejandro Nieponice
- Department of Surgery, University of Favaloro, Av. Belgrano 1746, C1093AAS, Buenos Aires, Argentina,
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567
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Cash JC, Zehetner J, Hedayati B, Bildzukewicz NA, Katkhouda N, Mason RJ, Lipham JC. Outcomes following laparoscopic transhiatal esophagectomy for esophageal cancer. Surg Endosc 2013; 28:492-9. [PMID: 24100862 DOI: 10.1007/s00464-013-3230-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2013] [Accepted: 09/17/2013] [Indexed: 12/19/2022]
Abstract
BACKGROUND Most published minimally invasive esophagectomy techniques involve a multiple field approach, including laparoscopic and thoracoscopic esophageal mobilization. Laparoscopic transhiatal esophagectomy (LTE) should potentially reduce the complications associated with thoracotomy. This study aims to compare outcomes of LTE with open transhiatal esophagectomy (OTE) and en-bloc esophagectomy (EBE). METHODS Retrospective chart review was performed on all patients who had an LTE for cancer between July 2008 and July 2012 at our institution. Data was compared with an historic cohort of patients who underwent OTE and EBE at the same institution from July 2002 to July 2008. RESULTS There were 33 patients with LTE, compared with 60 patients with OTE and 139 with EBE. The presence of minor operative complications was similar (p = 0.36), but major complications were significantly less common in the LTE group (12, 23 and 33 %, respectively; p = 0.04). The median number of blood transfusions during hospitalization was significantly lower in the LTE group (0, 2.5 and 3, respectively; p = 0.005). Median tumor size was significantly smaller (1.5, 2.2, and 3 cm, respectively; p = 0.03), but the LTE group had a significantly higher percentage of patients with neoadjuvant treatment (39, 14 and 29 %, respectively; p = 0.008). Median lymph node yield for LTE was lower (24, 36 and 48, respectively; p < 0.0001), but the percentage of patients with positive nodes was similar (33, 33 and 39 %, respectively; p = 0.69). Mortality was equivalent among the groups (0, 2 and 4 %, respectively; p = 0.38). The median LOS for the LTE group was significantly lower (10, 13 and 15 days, respectively; p < 0.0001). Overall survival was not different between the three groups (p = 0.65), with median survival at 24 months of 70, 65 and 65 %, respectively. CONCLUSION LTE can be performed safely with less major complications and shorter hospital stay than open esophagectomy. The reduced lymph-node harvest did not impact overall survival.
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Affiliation(s)
- J Christian Cash
- Department of Surgery, Keck School of Medicine, University of Southern California, 1510 San Pablo St, Suite 514, Los Angeles, CA, 90033, USA
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568
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Ninomiya I, Okamoto K, Fujimura T, Fushida S, Osugi H, Ohta T. Oncologic Outcomes of Thoracoscopic Esophagectomy with Extended Lymph Node Dissection: 10-year Experience from a Single Center. World J Surg 2013; 38:120-30. [DOI: 10.1007/s00268-013-2238-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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569
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Gockel I, Paschold M, Lang H, Heid F. Minimalinvasive abdominothorakale Ösophagusresektion mit transoraler Ösophagogastrostomie. Anaesthesist 2013; 62:836-44. [DOI: 10.1007/s00101-013-2223-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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570
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A Decade Analysis of Trends and Outcomes of Partial Versus Total Esophagectomy in the United States. Ann Surg 2013; 258:450-8. [DOI: 10.1097/sla.0b013e3182a1b11d] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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571
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Puntambekar S, Kenawadekar R, Pandit A, Nadkarni A, Joshi S, Agarwal G, Bhat NA, Malik J, Reddy S. Minimally invasive esophagectomy in the elderly. Indian J Surg Oncol 2013; 4:326-31. [PMID: 24426751 DOI: 10.1007/s13193-013-0263-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2013] [Accepted: 08/14/2013] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE A retrospective analysis of a prospectively maintained database to evaluate our experience in elderly patients (>70 years) undergoing Thoracolaparoscopic esophagectomy for cancer oesophagus. To ascertain whether age, is a limiting factor for patients undergoing minimally invasive esophagectomy. METHODS All Patients above 70 years of age, referred to the Gastro-esophageal clinic were included in the study. Tumours were staged as per AJCC 6th ed. 2002. Patients diagnosed with T1/2/3, N0/1 lesion of the mid/lower oesophagus (Infra Azygous) and type I and II Gastro esophageal junction tumours were included in the study. Patients with ASA grade IV were excluded. All patients who underwent Thoracolaparoscopic esophagectomy from January 2009 till January 2012 were evaluated for their perioperative outcomes. RESULTS Sixty eight patients underwent Minimal Invasive esophagectomy from January 2009 to January 2012. There were 45 males and 23 females. The average age in elderly group was 75.76 ± 5.96 years (range 70 to 91). Mean operative time was 178.84 ± 65.26 min, mean blood loss 143.84 ml(range 32-450 ml), mean ICU stay 3.84 days(range 2-11 days) and mean hospital stay was 12.76 days(range 8-21 days). Pneumonia and Cardiac related complications occurred in 10.30 % and 1.47 % patients respectively. None of the procedures required conversion to open thoracotomy. CONCLUSIONS Thoracolaparoscopic esophagectomy is feasible and surgically safe in elderly patients with low morbidity and mortality. Thus age of a patient should not be considered a limiting factor. ULTRAMINI ABSTRACT This is an original article about our experience of thoracolaparoscopic esophagectomy for cancer esophagus in elderly patients. After analyzing the data we feel that age of the patient cannot be a truly limiting factor for patient diagnosed of esophageal cancer to undergo minimally invasive esophagectomy.
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Affiliation(s)
- Shailesh Puntambekar
- Department of Minimal Access Surgery, Galaxy Care Laparoscopic Institute, Karve Road, Pune, India
| | - Rahul Kenawadekar
- Department of Minimal Access Surgery, Galaxy Care Laparoscopic Institute, Karve Road, Pune, India
| | - Archit Pandit
- Department of Minimal Access Surgery, Galaxy Care Laparoscopic Institute, Karve Road, Pune, India
| | - Akshay Nadkarni
- Department of Minimal Access Surgery, Galaxy Care Laparoscopic Institute, Karve Road, Pune, India
| | - Saurabh Joshi
- Department of Minimal Access Surgery, Galaxy Care Laparoscopic Institute, Karve Road, Pune, India
| | - Geetanjali Agarwal
- Department of Minimal Access Surgery, Galaxy Care Laparoscopic Institute, Karve Road, Pune, India
| | - Nasir Ahmad Bhat
- Department of Minimal Access Surgery, Galaxy Care Laparoscopic Institute, Karve Road, Pune, India
| | - Jainul Malik
- Department of Minimal Access Surgery, Galaxy Care Laparoscopic Institute, Karve Road, Pune, India
| | - Sunil Reddy
- Department of Minimal Access Surgery, Galaxy Care Laparoscopic Institute, Karve Road, Pune, India
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572
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Markar SR, Arya S, Karthikesalingam A, Hanna GB. Technical factors that affect anastomotic integrity following esophagectomy: systematic review and meta-analysis. Ann Surg Oncol 2013; 20:4274-81. [PMID: 23943033 DOI: 10.1245/s10434-013-3189-x] [Citation(s) in RCA: 146] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Due to the significant contribution of anastomotic leak, with its disastrous consequences to patient morbidity and mortality, multiple parameters have been proposed and individually meta-analyzed for the formation of the ideal esophagogastric anastomosis following cancer resection. The purpose of this pooled analysis was to examine the main technical parameters that impact on anastomotic integrity. METHODS Medline, Embase, trial registries, and conference proceedings were searched. Technical factors evaluated included hand-sewn versus stapled esophagogastric anastomosis (EGA), cervical versus thoracic EGA, minimally invasive versus open esophagectomy, anterior versus posterior route of reconstruction and ischemic conditioning of the gastric conduit. The outcome of interest was the incidence of anastomotic leak, for which pooled odds ratios were calculated for each technical factor. RESULTS No significant difference in the incidence of anastomotic leak was demonstrated for the following technical factors: hand-sewn versus stapled EGA, minimally invasive versus open esophagectomy, anterior versus posterior route of reconstruction and ischemic conditioning of the gastric conduit. Four randomized, controlled trials comprising 298 patients were included that compared cervical and thoracic EGA. Anastomotic leak was seen more commonly in the cervical group (13.64 %) than in the thoracic group (2.96 %). Pooled analysis demonstrated a significantly increased incidence of anastomotic leak in the cervical group (pooled odds ratio = 4.73; 95 % CI 1.61-13.9; P = 0.005). CONCLUSIONS A tailored surgical approach to the patient's physiology and esophageal cancer stage is the most important factor that influences anastomotic integrity after esophagectomy.
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Affiliation(s)
- Sheraz R Markar
- Division of Surgery, Department of Surgery and Cancer, St Mary's Hospital, Imperial College London, London, UK,
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573
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Hernandez JM, Dimou F, Weber J, Almhanna K, Hoffe S, Shridhar R, Karl R, Meredith K. Defining the learning curve for robotic-assisted esophagogastrectomy. J Gastrointest Surg 2013; 17:1346-51. [PMID: 23690208 DOI: 10.1007/s11605-013-2225-2] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2012] [Accepted: 04/29/2013] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The expansion of robotic-assisted surgery is occurring quickly, though little is generally known about the "learning curve" for the technology with utilization for complex esophageal procedures. The purpose of this study is to define the learning curve for robotic-assisted esophagogastrectomy with respect to operative time, conversion rates, and patient safety. METHODS We have prospectively followed all patients undergoing robotic-assisted esophagogastrectomy and compared operations performed at our institutions by a single surgeon in successive cohorts of 10 patients. Our measures of proficiency included: operative times, conversion rates, and complications. Statistical analyses were undertaken utilizing Spearman regression analysis and Mann-Whitney U test. Significance was accepted with 95 % confidence. RESULTS Fifty-two patients (41 male: 11 female) of mean age 66.2 ± 8.8 years underwent robotic-assisted esophagogastrectomies for malignant esophageal disease. Neoadjuvant chemoradiation was administered to 30 (61 %) patients. A significant reduction in operative times (p <0.005) following completion of 20 procedures was identified (514 ± 106 vs. 397 ± 71.9). No conversions to open thoracotomy were required. Complication rates were low and not significantly different between any 10-patient cohort; however, no complications occurred in the final 10-patient cohort. There were no in-hospital mortalities. CONCLUSIONS For surgeons proficient in performing minimally-invasive esophagogastrectomies, the learning curve for a robotic-assisted procedure appears to begin near proficiency after 20 cases. Operative complications and conversions were infrequent and unchanged across successive 10-patient cohorts.
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574
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Lin J, Kang M, Chen C, Lin R. Thoracoscopic oesophageal mobilization during thoracolaparoscopy three-stage oesophagectomy: a comparison of lateral decubitus versus semiprone positions. Interact Cardiovasc Thorac Surg 2013; 17:829-34. [PMID: 23842760 DOI: 10.1093/icvts/ivt306] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The aim of this study is to compare thoracoscopic mobilization of the oesophagus in the lateral decubitus position and the semiprone position and to identify potential differences between the two techniques. METHODS A retrospective review of a prospectively maintained oesophagectomy database identified 150 patients undergoing combined thoracoscopic and laparoscopic oesophagectomy (TLO). Of these, 90 cases underwent thoracoscopic oesophageal mobilization in the left lateral decubitus position. The remaining 60 cases underwent thoracoscopic oesophageal mobilization in the semiprone position. RESULTS There were no differences in the clinicopathological factors and tumour characteristics between the two groups. There was no significant difference in the blood loss, operation time, the incidence of conversion, length of hospital stay or in the number of retrieved mediastinal and abdominal nodes between the two groups. There was no significant difference with regard to the incidence of respiratory complications, anastomotic leaks, vocal cord palsy, chylothorax, delayed gastric emptying, arrhythmia and intestinal obstruction between the two groups. CONCLUSIONS The semiprone and lateral decubitus positions each have their inherent advantages and disadvantages. Our initial experience confirmed that while the semiprone position is associated with superior surgical ergonomics and better exposure of the posterior mediastinum, there is no convincing evidence that semiprone thoracoscopic oesophagectomy is superior to the left lateral decubitus positioning with respect to the major surgical outcomes and oncological clearance.
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Affiliation(s)
- Jiangbo Lin
- Department of Thoracic Surgery, Affiliated Union Hospital of Fujian Medical University, Fuzhou, China
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575
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Cuesta MA, Biere SSAY, van Berge Henegouwen MI, van der Peet DL. Randomised trial, Minimally Invasive Oesophagectomy versus open oesophagectomy for patients with resectable oesophageal cancer. J Thorac Dis 2013; 4:462-4. [PMID: 23050108 DOI: 10.3978/j.issn.2072-1439.2012.08.12] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2012] [Accepted: 08/21/2012] [Indexed: 11/14/2022]
Affiliation(s)
- Miguel A Cuesta
- Department of Surgery, VU University medical centre, Amsterdam, the Netherlands
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576
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Abstract
Esophageal resection remains the primary treatment for local regional esophageal cancer, although its role in superficial (T1A) cancers and squamous cell cancer is in evolution. Mortality associated with esophagectomy has historically been high but is improving with the current expectation of in-hospital mortality rates of 2-4% in high-volume centers. Most patients with regional cancers (T2-4 N0-3) are recommended for neoadjuvant therapy, which most commonly involves radiochemotherapy. Some centers have proposed treating with definitive chemoradiation and reserving surgery for patients who have persistent or recurrent disease. 'Salvage resections' are possible but are associated with higher levels of perioperative morbidity and mortality, and treatment decisions should routinely be based on multidisciplinary discussion in the tumor board. Although open surgical resection (both transthoracic and transhiatal operations) remain the most common approach, minimally invasive or hybrid operations are being done in up to 30% of procedures internationally. There are some indications that minimally invasive esophagectomy may decrease the incidence of respiratory complications and decrease length of stay. At this point, oncologic outcomes appear equivalent between open and minimally invasive procedures. Recent reviews from high-volume esophagectomy centers demonstrate that elderly patients can selectively undergo esophagectomy with the expectation of increased complications but similar mortality and survival to younger patients. Multiple studies confirm that quality of life following esophagectomy can be equivalent to the general population when surgery is done in experienced centers. Patients requiring surgical treatment of esophageal cancer should be referred to high-volume centers, especially those with established care pathways or enhanced recovery programs to improve outcomes including morbidity, mortality, survival, and quality of life.
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Affiliation(s)
- Donald E Low
- Department of Thoracic Surgery and Thoracic Oncology, Virginia Mason Medical Center, Seattle, WA 98111, USA.
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577
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Hanna GB, Arya S, Markar SR. Variation in the standard of minimally invasive esophagectomy for cancer--systematic review. Semin Thorac Cardiovasc Surg 2013. [PMID: 23200072 DOI: 10.1053/j.semtcvs.2012.10.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Minimally invasive esophagectomy (MIE) has been increasingly performed to treat esophageal cancer. Studies published between 1990 and 2012 that described the use of MIE for cancer in at least 50 patients were included for systematic review. The literature search retrieved 34 publications comprising 18 case series, 15 comparative studies, and 1 randomized control trial. Results revealed a wide variability in surgical techniques and perioperative outcomes with a lack of standardized definitions of postoperative complications. In most studies, radical formal lymphadenectomy was not performed and the lymph node harvest fell below the minimum number recommended to achieve survival benefits. There is a need to reach a consensus regarding surgical approaches in MIE, the definition of postoperative complications and the extent of lymphadenectomy before embarking on further randomized controlled trials comparing MIE vs. open approach.
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Affiliation(s)
- George B Hanna
- Division of Surgery, Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, London, United Kingdom.
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578
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Levy RM, Pennathur A, Luketich JD. Randomized trial comparing minimally invasive esophagectomy and open esophagectomy: early perioperative outcomes appear improved with a minimally invasive approach. Semin Thorac Cardiovasc Surg 2013. [PMID: 23200069 DOI: 10.1053/j.semtcvs.2012.10.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Esophagectomy is an important curative treatment modality for esophageal cancer, but is a complex operation with associated risks. A minimally invasive approach to esophagectomy may decrease the risks associated with resection. Recently, an important study was published in the Lancet by Biere and colleagues that reported the results of a randomized study, with the primary endpoint of postoperative pulmonary infection, comparing minimally invasive esophagectomy versus open esophagectomy for esophageal cancer. The findings from this trial confirm the data from previous, non-randomized studies and highlight the substantial early postoperative benefits of minimally invasive esophagectomy.
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Affiliation(s)
- Ryan M Levy
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center Pittsburgh, Pennsylvania 15213, USA
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579
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Kleinberg L. Therapy for locally advanced adenocarcinoma of the gastroesophageal junction: optimizing outcome. Semin Radiat Oncol 2013. [PMID: 23207046 DOI: 10.1016/j.semradonc.2012.10.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Adenocarcinoma of the distal esophagus and gastroesophageal junction has been rapidly increasing in incidence in Western nations over the past several decades. Although in the past, a similar management strategy has been used for adenocarcinoma and squamous cell carcinoma, without distinguishing by location or pathology, there is now greater motivation to optimize therapeutic strategies for adenocarcinoma in general and by specific location within the esophagus, with the goal of improving outcome. Siewert recognized the need to classify tumors based on anatomic location and proposed a classification scheme for distal esophageal and gastroesophageal junction neoplasms to guide therapy and allow more meaningful study. Although the available randomized data relevant to adenocarcinoma patients often include a mix of the 2 histologies and the various anatomical locations bundled together, these data suggest that a variety of surgical approaches are appropriate and that neoadjuvant therapy improves survival for patients with locally advanced disease. Although definitive evidence is lacking, neoadjuvant chemoradiation appears superior to neoadjuvant chemotherapy alone for improving resectability, maintaining locoregional control, and maximizing survival. There is a need to identify more effective approaches to identifying optimal systemic regimens for individual patients that may be combined with local therapy to further improve outcome.
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Affiliation(s)
- Lawrence Kleinberg
- Department of Radiation Oncology and Molecular Radiation Sciences, The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD 21231, USA.
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580
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Peyre CG, Peters JH. Minimally invasive surgery for esophageal cancer. Surg Oncol Clin N Am 2013; 22:15-25, v. [PMID: 23158082 DOI: 10.1016/j.soc.2012.08.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Minimally invasive surgery has revolutionized the surgical management of benign foregut disease, as well as pulmonary and other gastrointestinal malignancies. With the potential to reduce operative morbidity and increase patient satisfaction, minimally invasive esophagectomy for the management of esophageal cancer is gaining in popularity. It is unclear, however, whether the minimally invasive approach to esophageal cancer resection has comparable long-term oncologic results. This article discusses the rationale for minimally invasive esophagectomy, describes the surgical technique, and reviews the published results.
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Affiliation(s)
- Christian G Peyre
- Department of Surgery, University of Rochester School of Medicine & Dentistry, 601 Elmwood Avenue, BOX SURG, Rochester, NY 14642, USA
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581
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Lateral position could provide more excellent hemodynamic parameters during video-assisted thoracoscopic esophagectomy for cancer. Surg Endosc 2013; 27:3720-5. [DOI: 10.1007/s00464-013-2953-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Accepted: 03/22/2013] [Indexed: 12/15/2022]
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582
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583
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de la Fuente SG, Weber J, Hoffe SE, Shridhar R, Karl R, Meredith KL. Initial experience from a large referral center with robotic-assisted Ivor Lewis esophagogastrectomy for oncologic purposes. Surg Endosc 2013; 27:3339-47. [PMID: 23549761 DOI: 10.1007/s00464-013-2915-6] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2012] [Accepted: 03/03/2013] [Indexed: 01/10/2023]
Abstract
BACKGROUND We report our initial experience of patients undergoing robotic-assisted Ivor Lewis esophagogastrectomy (RAIL) for oncologic purposes at a large-referral center. METHODS A retrospective review of all consecutive patients undergoing RAIL from 2010-2011 was performed. Basic demographics were recorded. Oncologic variables recorded included: tumor type, location, postoperative tumor margins, and nodal harvest. Immediate 30-day postoperative complications also were analyzed. RESULTS Fifty patients underwent RAIL with median age of 66 (range 42-82) years. The mean body mass index was 28.6 ± 0.7 kg/m(2); 54% and the majority had an American Society of Anesthesiologists classification of 3. The mean and median number of lymph nodes retrieved during surgery was 20 ± 1.4 and 18.5 respectively. R0 resections were achieved in all patients. Postoperative complications occurred in 14 (28%) patients, including atrial fibrillation in 5 (10%), pneumonia in 5 (10%), anastomotic leak in 1 (2%), conduit staple line leak in 1 (2%), and chyle leak in 2 (4%). The median ICU stay and length of hospitalization (LOH) were 2 and 9 days respectively. Total mean operating time calculated from time of skin incision to wound closure was 445 ± 85 minutes; however, operative times decreased over time. Similarly, there was a trend toward lower complications after the first 29 cases but this did not reach statistical significance. There were no in-hospital mortalities. CONCLUSIONS We demonstrated that RAIL for esophageal cancer can be performed safely and may be associated with fewer complications after a learning curve, shorter ICU stay, and LOH.
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Affiliation(s)
- Sebastian G de la Fuente
- Division of Surgical Oncology, Florida Hospital Orlando, University of Central Florida, 2415 N. Orange Ave, Suite 400, Orlando, FL 32804, USA.
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584
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Ninomiya I, Osugi H, Fujimura T, Fushida S, Okamoto K, Maruzen S, Oyama K, Kinoshita J, Tsukada T, Kitagawa H, Takamura H, Nakagawara H, Tajima H, Hayashi H, Makino I, Ohta T. Thoracoscopic esophagectomy with extended lymph node dissection in the left lateral position: technical feasibility and oncologic outcomes. Dis Esophagus 2013; 27:159-67. [PMID: 23551804 DOI: 10.1111/dote.12071] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The aim of this study was to estimate the technical and oncologic feasibility of video-assisted thoracoscopic radical esophagectomy (VATS) in the left lateral position. From January 2003 to December 2011, 132 patients with esophageal cancer underwent VATS. The mean duration of the thoracic procedure and the entire procedure was 294 ± 88 and 623 ± 123 minutes, respectively. Mean blood loss during the thoracic procedure and the entire procedure was 313 ± 577 and 657 ± 719 g, respectively. The mean number of dissected thoracic lymph nodes was 32.6 ± 12.9. There were four in-hospital deaths (3.0%); two patients (1.5%) died of acute respiratory distress syndrome and two patients (1.5%) died of tumor progression. Postoperative unilateral or bilateral recurrent laryngeal nerve (RLN) palsy, or pneumonia was found in 33 (25.0%), 21 (15.9%), and 27(20.5%) patients, respectively. The patients were divided into the first 66 patients who underwent VATS (Group 1) and the subsequent 66 patients (Group 2). The numbers of cases who underwent neoadjuvant or induction chemotherapy for T4 tumor and intrathoracic anastomosis were higher in Group 2 than in Group 1. The duration of the procedure, amount of blood loss, and the number of dissected thoracic lymph nodes were not different between the two groups. The total number of dissected lymph nodes was higher in Group 2 than in Group 1 (72.6 ± 27.8 vs. 62.6 ± 21.6, P = 0.023). The rate of bilateral RLN palsy was less in Group 2 than in Group 1 (7.6% vs. 24.2%, P = 0.042). The mean follow-up period was 38.7 months. Primary recurrence consisted of hematogenous, lymphatic, peritoneal dissemination, pleural dissemination, and locoregional in 15 (11.3%), 20 (15.1%), 3 (2.3%), 4 (3.0%), and 5 patients (3.8%), respectively. The rate of regional lymph node recurrence within the dissection field was only 4.5%. The prognosis of patients with lymph node metastasis was significantly poorer than that of patients without lymph node metastasis. However, the prognosis of the 11 cases that had metastasis only around RLNs was similar to that of node-negative cases. Thirteen patients with pathological remnant tumor (R1 or R2) did not survive longer than 5 years at present. The overall 5-year survival rate of stage I, II, and III disease after curative VATS was 82.2%, 77.0%, and 52.3%, respectively. Expansion of VATS criteria for patients after induction chemotherapy for T4 tumor or thoracoscopic anastomosis did not adversely affect the surgical results by experience. Although the VATS procedure is accompanied by a certain degree of morbidity including RLN palsy and pulmonary complications, VATS has an excellent locoregional control effect. In addition, the favorable survival after VATS shows that the procedure is oncologically feasible.
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Affiliation(s)
- I Ninomiya
- Gastroenterologic Surgery, Department of Oncology, Division of Cancer Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa
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585
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Abstract
Oesophageal carcinoma is one of the most virulent malignant diseases and a major cause of cancer-related deaths worldwide. Diagnosis and accuracy of pretreatment staging have substantially improved throughout the past three decades. Therapy is challenging and the optimal approach is still debated. Oesophagectomy is considered to be the procedure of choice in patients with operable oesophageal cancer. Endoscopic measures and limited surgical procedures provide an alternative in patients with early carcinomas confined to the oesophageal mucosa. Chemotherapy and radiotherapy or concurrent chemoradiotherapy are also frequently applied, either as definitive treatment or as neoadjuvant therapy within multimodal approaches. The question of whether multimodal treatment offers improved results has been the focus of many studies since the 1990s. Although results are discordant and even some meta-analyses remain inconclusive, it is now widely accepted that multimodal therapy leads to a modest survival benefit. The role of minimally invasive oesophagectomy is not yet defined. Endoscopic stent insertion, radiotherapy and other palliative measures provide relief of tumour-related symptoms in advanced, unresectable tumour stages.
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586
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[Modern diagnostics and stage-oriented surgery: therapy of adenocarcinoma of the esophagogastric junction]. Chirurg 2013; 83:702-8, 710-1. [PMID: 22878576 DOI: 10.1007/s00104-011-2264-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The basis for decision-making about an individualized surgical treatment of adenocarcinoma of the esophagogastric junction is tumor staging and exact evaluation of the topography of the tumor in the small junctional area. The diagnostics mainly comprise endoscopy, biopsy, endosonography, computed tomography and partially diagnostic laparoscopy. This results in a clinical TNM staging and an evaluation according to the AEG classification from oral to aboral in type I (esophagus), type II (cardia) and type III (subcardia). Endoscopic resection is only appropriate for the infrequent mucosal carcinomas whereas the majority of the junctional carcinomas are treated by surgical resection. This is combined with neoadjuvant treatment in case of T3 or resectable T4 carcinomas. A type I carcinoma is removed by radical transthoracic en bloc esophagectomy with high intrathoracic esophagogastrostomy after gastric pull-up. In case of type II or III carcinomas, a transhiatal extended gastrectomy including distal esophageal resection is performed with reconstruction by Roux en Y esophagojejunostomy in the lower mediastinum. However, some advanced type II carcinomas which cannot be resected R0 at the esophagus need esophagectomy and gastric pull-up. This surgical strategy is justified by the topography of the lesion and the corresponding lymphatic drainage. Very rare indications are seen for a limited resection with interposition of small bowel in some mucosal carcinomas or total esophagogastrectomy with colon interposition in very advanced tumors. The neoadjuvant treatment comprises especially chemoradiation for type I and chemotherapy for type II and III carcinomas and leads to a significant survival benefit compared to surgery alone.
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587
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Abstract
Oesophageal carcinoma affects more than 450,000 people worldwide and the incidence is rapidly increasing. Squamous-cell carcinoma is the predominant form of oesophageal carcinoma worldwide, but a shift in epidemiology has been seen in Australia, the UK, the USA, and some western European countries (eg, Finland, France, and the Netherlands), where the incidence of adenocarcinoma now exceeds that of squamous-cell types. The overall 5-year survival of patients with oesophageal carcinoma ranges from 15% to 25%. Diagnoses made at earlier stages are associated with better outcomes than those made at later stages. In this Seminar we discuss the epidemiology, pathophysiology, diagnosis and staging, management, prevention, and advances in the treatment of oesophageal carcinoma.
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Affiliation(s)
- Arjun Pennathur
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
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588
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Intrathoracic esophagogastric anastomosis using a linear stapler following minimally invasive esophagectomy in the prone position. J Gastrointest Surg 2013; 17:397-402. [PMID: 22911126 DOI: 10.1007/s11605-012-2009-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2012] [Accepted: 08/14/2012] [Indexed: 01/31/2023]
Abstract
BACKGROUND Minimally invasive esophagectomy (MIE) in the prone position typically includes thoracoscopic mediastinal dissection and laparoscopic gastric tube construction, followed by esophagogastric anastomosis in the neck. We introduced an intrathoracic esophagogastric anastomosis using linear staplers. TECHNIQUE The lower mediastinal dissection and the gastric tube construction are done in the laparoscopic part of the operation. The esophagus is transected at the cranial level of the aortic arch after the completion of the upper mediastinal lymph node dissection in the prone position. The excess length of the gastric tube is sacrificed before making the anastomosis. Side-to-side esophagogastric anastomosis is performed using a 35-mm endoscopic linear stapler. The entry hole is closed with hand suturing using the posterior and the axillary port. RESULTS Twenty-six patients with middle or lower esophageal tumor underwent MIE with an intrathoracic anastomosis. The mean thoracoscopic procedure time was 302 min. One patient had an anastomotic leakage, which was successfully managed with drainage. There has been no anastomotic stenosis. Pneumonia was observed in two patients. There was no mortality. CONCLUSIONS MIE with an intrathoracic linear-stapled anastomosis with the patient in the prone position is safe and feasible.
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589
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Uzunoglu FG, Reeh M, Kutup A, Izbicki JR. Surgery of esophageal cancer. Langenbecks Arch Surg 2013; 398:189-93. [PMID: 23354360 DOI: 10.1007/s00423-013-1052-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2013] [Accepted: 01/14/2013] [Indexed: 12/26/2022]
Abstract
BACKGROUND Surgery is the only option for curative treatment in patients with esophageal carcinoma. Despite the debates related to the peri-operative therapy regime, a generally accepted consensus on surgical approach is not reached yet. The debate focuses mainly on pros and cons between radical transthoracic resection and the (limited) transhiatal resection in the last decade. METHODS The PubMed database was searched for randomized trials, meta-analyses, and retrospective single-center studies. The search terms were "esophageal carcinoma," "esophageal junction carcinomas," "transhiatal," "transthoracic," "morbidity," "mortality," and "surgery." RESULTS The radical transthoracic approach should be the standard of care for esophageal carcinoma since it does not go along with an increased risk of postoperative morbidity or mortality but reveals an improved survival. Patient-related co-morbidities are the most influencing factors for the postoperative outcome. For type II esophageal junction carcinoma, treatment options from transhiatal extended gastrectomy to esophagectomy with hemigastrectomy or esophagogastrectomy with colonic interposition are existing. In type III esophagogastric junction carcinomas, the transhiatal extended gastrectomy is the standard of care, and the minimally invasive approach should be performed in specialized centers. CONCLUSION Based on current available study results, this expert review provides a decision support for the best surgical strategy depending on tumor localization and patients' characteristics.
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Affiliation(s)
- F G Uzunoglu
- Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Martinistrasse 52, Hamburg, Germany
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590
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Coit D. Surgical approaches to invasive adenocarcinoma of the gastroesophageal junction. Am Soc Clin Oncol Educ Book 2013:0011300144. [PMID: 23714483 DOI: 10.14694/edbook_am.2013.33.e144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Despite a plethora of data, the optimal surgical approach to invasive adenocarcinoma of the gastroesophageal (GE) junction remains controversial. To quote Dr. Valerie Rusch, "Strong individual preferences and some degree of surgical mystique often govern the selection of operation for resection of GE junction adenocarcinomas."1 The fırst of these controversies is whether the optimal open surgical approach should be via the transabdominal, transthoracic (two-incision Ivor Lewis or three-incision McKeown), or transhiatal route. Proponents of the transthoracic or transhiatal routes have voiced strong opinions on the potential advantages and disadvantages of each approach (Table 1). It is clear from most large retrospective series that, in experienced hands, excellent results can be achieved by either approach. The principal advantage of the transthoracic route is the ability to perform a radical mediastinal lymphadenectomy en bloc with the primary tumor, the theory being that a more aggressive lymph node dissection would be associated with an improved long-term outcome. To date, however, this association of a more aggressive lymphadenectomy with improved outcome has remained elusive in most gastrointestinal malignancies, including esophageal cancer. Proponents of the transhiatal approach cite similar lymph node retrieval rates, the potential for lower short-term morbidity, and the potential for similar long-term outcomes.2 With the advent of newer technology, the controversy regarding the optimal surgical approach to adenocarcinoma of the GE junction has evolved in yet another direction, with proponents of a minimally invasive approach, citing even lower perioperative morbidity and mortality, again with comparable or even superior long-term oncologic results.
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Affiliation(s)
- Daniel Coit
- From the Memorial Sloan-Kettering Cancer Center, New York, NY
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591
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Wolter S, Mann O, Izbicki JR. Minimalinvasive Chirurgie bei Malignomen des Gastrointestinaltrakts: Ösophagus - Pro-Position. Visc Med 2013; 29:344-348. [DOI: 10.1159/000357486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023] Open
Abstract
<b><i>Hintergrund: </i></b>Die offene onkologische Resektion ist derzeit der Goldstandard in der Behandlung des Plattenepithel- und Adenokarzinoms des Ösophagus. Die mit den Therapieverfahren assoziierte Morbidität und Mortalität konnte in den letzten Jahren durch die Verbesserung des chirurgischen und perioperativen Managements deutlich gesenkt werden, bleibt aber im Vergleich zu anderen Eingriffen am Gastrointestinaltrakt weiterhin hoch. <b><i>Methoden: </i></b>Diese Übersicht basiert auf einer strukturierten Analyse der aktuellen, in MEDLINE, PubMed, EMBASE und den Cochrane Databases gelisteten Studien. <b><i>Ergebnisse: </i></b>In den letzten 20 Jahren sind zunehmend Arbeiten erschienen, die seit der Erstbeschreibung der minimalinvasiven Ösophagusresektion zeigen, dass in entsprechend erfahrenen Zentren die hohe Morbidität und Mortalität, insbesondere für pulmonale Komplikationen durch minimalinvasive Ösophagusresektionen, drastisch gesenkt werden konnte - ohne Verzicht auf onkologische Radikalität und ohne Verschlechterung des onkologischen Outcomes. Die postoperative Lebensqualität war ebenfalls nicht schlechter für minimalinvasiv operierte Patienten. Allerdings sind die minimalinvasiven Techniken im Bereich der Ösophaguschirurgie mit einer signifikanten Lernkurve verbunden - ein weiteres Argument für eine Zentralisierung der Ösophaguschirurgie. <b><i>Schlussfolgerungen: </i></b>Die bisher erhobenen Daten zur minimalinvasiven Ösophagusresektion sind zwar sehr vielversprechend, jedoch sind weitere kontrollierte randomisierte Studien erforderlich, um die bisher erhobenen Daten zu erhärten.
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592
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Abstract
Minimally invasive esophagectomy (MIE) has become an established approach for the treatment of esophageal carcinoma. In comparison with open esophagectomy MIE reduces blood loss, respiratory complications, and length of hospital stay. At the University of Pittsburgh, the authors now predominantly perform a laparoscopic-thoracoscopic Ivor Lewis esophagectomy. This article details this technique, discusses the recently published series of more than 1000 esophagectomies performed by the authors during the last 15 years, and reviews the current literature on MIE.
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593
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van der Sluis PC, Ruurda JP, van der Horst S, Verhage RJJ, Besselink MGH, Prins MJD, Haverkamp L, Schippers C, Rinkes IHMB, Joore HCA, ten Kate FJW, Koffijberg H, Kroese CC, van Leeuwen MS, Lolkema MPJK, Reerink O, Schipper MEI, Steenhagen E, Vleggaar FP, Voest EE, Siersema PD, van Hillegersberg R. Robot-assisted minimally invasive thoraco-laparoscopic esophagectomy versus open transthoracic esophagectomy for resectable esophageal cancer, a randomized controlled trial (ROBOT trial). Trials 2012; 13:230. [PMID: 23199187 PMCID: PMC3564860 DOI: 10.1186/1745-6215-13-230] [Citation(s) in RCA: 117] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2012] [Accepted: 10/26/2012] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND For esophageal cancer patients, radical esophagolymphadenectomy is the cornerstone of multimodality treatment with curative intent. Transthoracic esophagectomy is the preferred surgical approach worldwide allowing for en-bloc resection of the tumor with the surrounding lymph nodes. However, the percentage of cardiopulmonary complications associated with the transthoracic approach is high (50 to 70%).Recent studies have shown that robot-assisted minimally invasive thoraco-laparoscopic esophagectomy (RATE) is at least equivalent to the open transthoracic approach for esophageal cancer in terms of short-term oncological outcomes. RATE was accompanied with reduced blood loss, shorter ICU stay and improved lymph node retrieval compared with open esophagectomy, and the pulmonary complication rate, hospital stay and perioperative mortality were comparable. The objective is to evaluate the efficacy, risks, quality of life and cost-effectiveness of RATE as an alternative to open transthoracic esophagectomy for treatment of esophageal cancer. METHODS/DESIGN This is an investigator-initiated and investigator-driven monocenter randomized controlled parallel-group, superiority trial. All adult patients (age ≥ 18 and ≤ 80 years) with histologically proven, surgically resectable (cT1-4a, N0-3, M0) esophageal carcinoma of the intrathoracic esophagus and with European Clinical Oncology Group performance status 0, 1 or 2 will be assessed for eligibility and included after obtaining informed consent. Patients (n = 112) with resectable esophageal cancer are randomized in the outpatient department to either RATE (n = 56) or open three-stage transthoracic esophageal resection (n = 56). The primary outcome of this study is the percentage of overall complications (grade 2 and higher) as stated by the modified Clavien-Dindo classification of surgical complications. DISCUSSION This is the first randomized controlled trial designed to compare RATE with open transthoracic esophagectomy as surgical treatment for resectable esophageal cancer. If our hypothesis is proven correct, RATE will result in a lower percentage of postoperative complications, lower blood loss, and shorter hospital stay, but with at least similar oncologic outcomes and better postoperative quality of life compared with open transthoracic esophagectomy. The study started in January 2012. Follow-up will be 5 years. Short-term results will be analyzed and published after discharge of the last randomized patient. TRIAL REGISTRATION Dutch trial register: NTR3291 ClinicalTrial.gov: NCT01544790.
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Affiliation(s)
- Pieter C van der Sluis
- Department of Surgery, G04.228, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
| | - Jelle P Ruurda
- Department of Surgery, G04.228, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
| | - Sylvia van der Horst
- Department of Surgery, G04.228, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
| | - Roy JJ Verhage
- Department of Surgery, G04.228, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
| | - Marc GH Besselink
- Department of Surgery, G04.228, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
| | - Margriet JD Prins
- Department of Surgery, G04.228, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
| | - Leonie Haverkamp
- Department of Surgery, G04.228, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
| | - Carlo Schippers
- Department of Surgery, G04.228, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
| | - Inne HM Borel Rinkes
- Department of Surgery, G04.228, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
| | - Hans CA Joore
- Department of Intensive Care Medicine, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
| | - Fiebo JW ten Kate
- Department of Pathology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
| | - Hendrik Koffijberg
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
| | - Christiaan C Kroese
- Department of Anesthesiology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
| | - Maarten S van Leeuwen
- Department of Radiology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
| | - Martijn PJK Lolkema
- Department of Medical Oncology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
| | - Onne Reerink
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
| | - Marguerite EI Schipper
- Department of Pathology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
| | - Elles Steenhagen
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
| | - Frank P Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
| | - Emile E Voest
- Department of Medical Oncology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
| | - Richard van Hillegersberg
- Department of Surgery, G04.228, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
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594
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Zhang J, Wang R, Liu S, Luketich JD, Chen S, Chen H, Schuchert MJ. Refinement of minimally invasive esophagectomy techniques after 15 years of experience. J Gastrointest Surg 2012; 16:1768-74. [PMID: 22777054 DOI: 10.1007/s11605-012-1950-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2012] [Accepted: 06/24/2012] [Indexed: 01/31/2023]
Abstract
INTRODUCTION [corrected] In an effort to reduce the morbidity and mortality associated with open esophagectomy, a minimally invasive approach to esophagectomy was introduced at the University of Pittsburgh Medical Center (UPMC) in 1996. The objective of this article is to discuss the optimization and refinement of minimally invasive esophagectomy (MIE) techniques over the 15-year experience at UPMC. We also reviewed the literature on technical improvements in MIE. METHOD Literature highlights for MIE and related meta-analyses comparing open esophagectomy and MIE were reviewed. The rationale and outcomes of techniques refinements were discussed in detail. RESULTS Most meta-analyses and systematic reviews confirm the feasibility and safety of MIE and suggest similar oncologic outcomes as compared with open esophagectomy. Since 1996, over 1,000 minimally invasive esophagectomies have been performed at UPMC. We have made several refinements to the MIE procedure that we believe significantly improved our surgical outcomes. It included adjustment of width of the gastric conduit, application of omental flap, and conversion from minimally invasive, three-hole esophagectomy to minimally invasive Ivor Lewis esophagectomy. CONCLUSION MIE became a mainstay in the surgical treatment of esophageal cancer at UPMC. The technical improvements detailed above make the UPMC approach to MIE a feasible, safe, and efficient procedure.
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Affiliation(s)
- Jie Zhang
- Department of Oncology, Shanghai Medical College, Cancer Hospital of Fudan University, 270 Dong'an Road, Shanghai, China
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