Systematic review of minimally invasive resection for gastro-oesophageal cancer

Thoracoscopic esophagectomy in the prone position

BACKGROUND

Minimally invasive esophageal surgery has arisen in an attempt to reduce the significant complications associated with esophagectomy. Despite proposed technical and physiological advantages, the prone position technique has not been widely adopted. This article reviews the current status of prone thoracoscopic esophagectomy.

METHODS

A systematic literature search was performed to identify all published clinical studies related to prone esophagectomy. Medline, EMBASE and Google Scholar were searched using the keywords "prone," "thoracoscopic," and "esophagectomy" to identify articles published between January 1994 and September 2010. A critical review of these studies is given, and where appropriate the technique is compared to the more traditional minimally invasive technique utilising the left lateral decubitus position.

RESULTS

Twelve articles reporting the outcomes following prone thoracoscopic oesophagectomy were tabulated. These studies were all non-randomised single-centre prospective or retrospective studies of which four compared the technique to traditional minimally invasive surgery. Although prone esophagectomy is demonstrated as being both feasible and safe, there is no convincing evidence that it is superior to other forms of esophageal surgery. Most authors comment that the prone position is associated with superior surgical ergonomics and theoretically offers a number of physiological benefits.

CONCLUSION

The ideal approach within minimally invasive esophageal surgery continues to be a subject of debate since no single method has produced outstanding results. Further clinical studies are required to see whether ergonomic advantages of the prone position can be translated into improved patient outcomes.

Does minimally invasive esophagectomy (MIE) provide for comparable oncologic outcomes to open techniques? A systematic review

PURPOSE

The aim of this study is to compare minimally invasive esophagectomy (MIE) and open techniques with respect to oncologic outcomes through analysis of the extent of lymph node clearance, number of lymph nodes retrieved, oncologic stage, and 5-year mortality.

METHODOLOGY

A systematic review of the literature review was conducted using MEDLINE, PubMed, EMBASE, and the Cochrane databases (1950-2011), and evaluated all comparative studies. Comparison between the open and MIE/hybrid MIE (HMIE) groups was possible with data being available for direct comparison.

RESULTS

After careful review, 17 case-control studies with 1,586 patients having an esophagectomy were included in this systematic review. The median (range) number of lymph nodes found in the MIE, open and HMIE groups were 16 (5.7-33.90), 10 (3-32.80) and 17 (17-17.15), of which there was significance between the MIE and open groups (p=0.03) but not significant between MIE versus HMIE (p=0.25). There was no statistical significance in pathologic stage between open, MIE and HMIE groups. Generally, there were good short-term (30 day) survival rates between all three groups. The open group had 5-year survival rates between 16% and 57% compared to the MIE group 12.5%-63% (p=0.33). Overall 5-year survival was found to be not significant between open group and MIE (p=0.93). MIE does not appear on statistical evidence to present any survival advantage.

CONCLUSION

The evidence of this study suggests that MIE is equivalent to standard open esophagectomy in achieving similar oncological outcomes. Further randomised controlled trials are required to provide for a higher level of evidence.

Diagnosis and treatment of non-metastatic esophagogastric junction adenocarcinoma: what are the current options?

While the prevalence of distal gastric cancer is decreasing in the western world, there has been an alarming rise in the incidence of esophagogastric junction adenocarcinoma (EGJA) during recent decades. Current reports show that the prognosis of EGJA remains poor. Therapy strategies are complex due to the anatomical location of the junction between the esophagus and stomach. Surgery, based on Siewert's classification and associated with regional lymphadenectomy, is the mainstay of treatment. Transthoracic esophagectomy is recommended for type I EGJA, while total gastrectomy is recommended for type III EGJA; both approaches can be considered for type II EGJA. Surgery alone can be indicated only for stage I and IIa tumors. Perioperative chemotherapy should be considered for stage IIb, III and non-metastatic stage IV tumors. Adjuvant chemoradiation can be proposed for tumors with high-risk of recurrence in the absence of neoadjuvant therapy. Neoadjuvant chemoradiation can be proposed for predominantly esophageal EGJA, and might well become a standard treatment for all EGJA tumors in the near future. A multidisciplinary approach is essential for optimal diagnosis and management.

Quality of life after esophagectomy for cancer

Esophageal cancer is an aggressive and physically and emotionally devastating disease. It has one of the poorest survival rates among all malignant tumors, mainly due to late symptom presentation and early metastatic dissemination. Cure is possible through extensive surgery, typically followed by a long recovery period, affecting general well-being, as well as basic aspects of life, such as eating, drinking and socializing. Health-related quality of life (HRQL) is a multidimensional concept assessing symptoms and functions related to a disease or its treatment from the patient's perspective. HRQL is a fundamental part of treatment in surgical oncology, particularly in esophageal cancer. This review assesses the scientific data regarding some HRQL aspects after esophageal cancer surgery, for example, postoperative recovery time, determinants of postoperative HRQL and long-term HRQL.

Health-related quality of life among 5-year survivors of esophageal cancer surgery: a prospective population-based study

PURPOSE

To clarify whether health-related quality of life (HRQL) can be restored in 5-year survivors of esophageal cancer surgery.

PATIENTS AND METHODS

The nationwide Swedish prospective and population-based cohort for this study consisted of patients with esophageal cancer who were treated surgically between 2001 and 2005 and were alive 5 years after surgery. The European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire C30 (EORTC QLQ-C30) and EORTC QLQ-OES18 (the disease site-specific module for esophageal cancer) were used to assess HRQL 6 months, 3 years, and 5 years postoperatively. Paired t tests were used to evaluate changes in HRQL over time. Patients' HRQL was classified as improved, stable, or deteriorated. Multivariable linear regression was used to calculate mean score difference in HRQL with 95% CIs between patients and a background population according to HRQL category.

RESULTS

Among 153 eligible patients alive after 5 years, 117 (76%) answered all HRQL assessments. Among a random sample of 6,969 Swedish adults representing the corresponding background population, 4,910 (70.5%) participated. For most patients, HRQL remained stable or improved over time, and their HRQL was comparable to that of the background population. Patients who deteriorated over time reported large and clinically significant mean score differences for all measures. For example, 5 years after surgery, physical function was stable or improved in 86% of patients and their mean score (87) was similar to that of the background population (88), but the 14% who deteriorated had a substantially lower mean score of 56.

CONCLUSION

HRQL recovers to a level comparable to that in the background population in most patients who survive 5 years after esophagectomy for cancer, although a subgroup of patients has substantially worse HRQL.

Open or minimally invasive resection for oesophageal cancer?

Oesophagectomy is one of the most challenging surgical operations. Potential for morbidity and mortality is high. Minimally invasive techniques have been introduced in an attempt to reduce postoperative complications and recovery times. Debate continues over whether these techniques decrease morbidity and whether the quality of the oncological resection is compromised. Globally, minimally invasive oesophagectomy (MIO) has been shown to be feasible and safe, with outcomes similar to open oesophagectomy. There are no controlled trials comparing the outcomes of MIO with open techniques, just a few comparative studies and many single institution series from which assessments of the current role of MIO have been made. The reported improvements of MIO include reduced blood loss, shortened time in high dependency care and decreased length of hospital stay. In comparative studies there is no clear reduction in respiratory complications, although larger series suggest that MIO may have a benefit. Although MIO approaches report less lymph node retrieval compared with open extended lymphadenectomy, MIO cancer outcomes are comparable. MIO will be a major component of the future oesophageal surgeons' armamentarium, but should continue to be carefully assessed. Randomized trials comparing MIO versus open resection in oesophageal cancer are urgently needed: two phase III trials are recruiting, the TIME and the MIRO trials.

Treatment strategies in gastric cancer

BACKGROUND

Gastric cancer has become less common but remains among the leading causes of death from cancer, with a 5-year survival rate of only 20% to 25%. Although diagnostic techniques have improved, most patients with gastric cancer in the Western world (unlike in some Asian countries) already have locally advanced disease when diagnosed and may thus need not only surgery, but also perioperative chemotherapy and/or radiotherapy.

METHOD

Articles published from 2000 to 2010 and containing the terms "gastric cancer," "surgery," and "chemotherapy" in combination with "review" or "randomized trial" were retrieved by a search in the Cochrane Library and Medline databases and selectively reviewed.

RESULTS

Complete (R0) resection of the tumor remains the standard treatment whenever possible. Complete endoscopic resection suffices only in special types of carcinoma that are confined to the gastric mucosa. Depending on the histological findings, either a subtotal distal gastrectomy or a total (perhaps extended total) gastrectomy can be performed. The long-term benefit of systematic D2 lymphadenectomy has now been shown in a randomized trial: the rates of tumor-related death and of local or regional recurrence were found to be significantly lower with D2 than with D1 lymphadenectomy. Multimodal treatment strategies including perioperative chemotherapy and/or radiotherapy can further improve local and regional tumor control and lessen the rate of systemic metastasis.

CONCLUSION

The standardization of surgical procedures lowered the operative risk in the treatment of gastric cancer. Patients with locally advanced disease can now derive additional benefit from perioperative chemotherapy with an increase of the 5-year survival rates of more than 10%.

Laparoscopic transhiatal esophagectomy at a low-volume center

Results of this study suggest that surgeon experience is more important than the absolute number of procedures performed each year as regards operative morbidity and mortality.

Background and Objectives:

Surgical treatment of esophageal cancer is associated with a high rate of morbidity, even in specialized centers. Minimally invasive esophageal resection has become increasingly feasible and is gaining popularity in some high-volume institutions. This study assesses the short-term outcomes of laparoscopic transhiatal esophagectomy performed by a single surgeon at a single low-volume institution over a 20-month period.

Methods:

Over the study period, 16 patients underwent laparoscopic transhiatal esophagectomy. All patients were men with an average age of 70 years (range, 50 to 81).

Results:

Two patients required intraoperative conversion to alternative surgical techniques, 1 to an Ivor-Lewis esophagectomy and 1 to an open transhiatal approach. Average operative time was 198 minutes (range, 147 to 303). Mean hospital stay was 16.7 days (range, 9 to 30). The average number of resected lymph nodes was 11.7, and 2 patients had benign pathology. No deaths occurred in the 30-day postoperative period.

Conclusion:

Laparoscopic transhiatal esophagectomy is an advanced laparoscopic procedure that can be performed with equivalent morbidity and mortality by a low-volume surgeon in a low-volume center with results comparable to those of high-volume centers. While several authors have demonstrated a correlation between lower mortality rates and high-volume esophagectomy hospitals, our results support surgeon experience as more important than the absolute number of procedures performed each year.

Video. Surgical optimisation of the gastric conduit for minimally invasive oesophagectomy

BACKGROUND

Total minimally invasive oesophagectomy (MIO) is a valid alternative to open surgery for the management of oesophagogastric cancer and may lead to a more rapid restoration of health-related quality of life post surgery. However, a high incidence of gastric conduit failure (GCF) has also been observed which could be detrimental to any potential benefits of this approach. Technical modifications have been introduced in an attempt to reduce conduit morbidity, and the aim of this study was to evaluate their efficacy.

METHODS

Minimally invasive oesophagectomy has been the procedure of choice in our unit since April 2004. Data on patient and surgical variables are entered onto a prospective database. Laparoscopic ischaemic conditioning (LIC) by ligation of the left gastric vessels 2 weeks prior to MIO was introduced in April 2006. Extracorporeal formation of the gastric conduit through a minilaparotomy was offered to patients since January 2008. Where present, GCF was characterised as one of three types: I, simple anastomotic leak; II, conduit tip necrosis; and III, whole conduit necrosis.

RESULTS

As of January 2010, 131 patients had undergone an MIO and GCF was observed in 21 patients (16.0%). Sixty-seven patients had LIC and 9 of them (13.4%) developed GCF (I, 10.4%; II, 0%; III, 3.0%) compared to 12 (18.8%) of 64 patients who did not have LIC (I, 6.3%; II, 7.8%; III, 4.7%). A total of 43 patients had an extracorporeally fashioned conduit and 6 (14.0%) developed GCF (I, 11.6%; II, 0%; III, 2.3%), whilst 88 had an intracorporeal conduit with 15 (17.0%) developing GCF (I, 6.8%; II, 5.7%; III, 4.5%). GCF can be reduced with the incorporation of LIC and an extracorporeally fashioned conduit, with possible elimination of type II conduit tip necrosis.

CONCLUSIONS

Surgical modification of a three-stage minimally invasive oesophagectomy technique, with the further incorporation of laparoscopic ischaemic conditioning and extracorporeal conduit formation, reduces gastric conduit morbidity, allowing the potential benefits of this approach to be realised.

Open versus laparoscopically-assisted oesophagectomy for cancer: a multicentre randomised controlled phase III trial - the MIRO trial

Background

Open transthoracic oesophagectomy is the standard treatment for infracarinal resectable oesophageal carcinomas, although it is associated with high mortality and morbidity rates of 2 to 10% and 30 to 50%, respectively, for both the abdominal and thoracic approaches. The worldwide popularity of laparoscopic techniques is based on promising results, including lower postoperative morbidity rates, which are related to the reduced postoperative trauma. We hypothesise that the laparoscopic abdominal approach (laparoscopic gastric mobilisation) in oesophageal cancer surgery will decrease the major postoperative complication rate due to the reduced surgical trauma.

Methods/Design

The MIRO trial is an open, controlled, prospective, randomised multicentre phase III trial. Patients in study arm A will receive laparoscopic-assisted oesophagectomy, i.e., a transthoracic oesophagectomy with two-field lymphadenectomy and laparoscopic gastric mobilisation. Patients in study arm B will receive the same procedure, but with the conventional open abdominal approach. The primary objective of the study is to evaluate the major postoperative 30-day morbidity. Secondary objectives are to assess the overall 30-day morbidity, 30-day mortality, 30-day pulmonary morbidity, disease-free survival, overall survival as well as quality of life and to perform medico-economic analysis. A total of 200 patients will be enrolled, and two safety analyses will be performed using 25 and 50 patients included in arm A.

Discussion

Postoperative morbidity remains high after oesophageal cancer surgery, especially due to major pulmonary complications, which are responsible for 50% of the postoperative deaths. This study represents the first randomised controlled phase III trial to evaluate the benefits of the minimally invasive approach with respect to the postoperative course and oncological outcomes in oesophageal cancer surgery.

Trial Registration

NCT00937456 (ClinicalTrials.gov)

Demonstration of the IDEAL recommendations for evaluating and reporting surgical innovation in minimally invasive oesophagectomy

Background

The Idea, Development, Evaluation, Assessment and Long term study (IDEAL) framework makes recommendations for evaluating and reporting surgical innovation and adoption, but remains untested.

Methods

A prospective database was created for the introduction of minimally invasive techniques for oesophagectomy. IDEAL stages of development and evaluation were examined retrospectively in a series of patients undergoing laparoscopically assisted oesophagectomy (LAO), two- or three-phase minimally invasive oesophagectomy (MIO) and open oesophagectomy.

Results

A total of 192 patients were involved. In IDEAL stages 1 and 2a, LAO in 16 patients was uneventful, but two-phase MIO in six patients was abandoned following consecutive technical complications. Two-phase MIO was modified to a three-phase MIO procedure, and the results of LAO (67 patients), three-phase MIO (35) and open techniques (68) were studied in IDEAL stage 2b. Major complications (Clavien–Dindo grades III and IV) occurred in 12 (18 per cent), nine (26 per cent) and 14 (21 per cent) LAO, three-phase MIO and open procedures respectively. There were four in-hospital deaths (2 LAO and 2 open).

Conclusion

The IDEAL framework is a feasible method for documenting the development and implementation of a procedure. MIO should now be compared with open surgery in a randomized controlled trial (IDEAL stage 3).

Minimally-invasive subtotal oesophagectomy: three-stage thoracoscopic, laparoscopic subtotal oesophagectomy with cervical anastomosis

This contribution describes a minimally-invasive approach to subtotal oesophagectomy. Indications, pre-emptive ischaemic conditioning and feeding jejunostomy are discussed. In the lateral position, the oesophagus is mobilized thoracoscopically in a specific order, formally identifying 'at risk' structures. A radical en bloc dissection is performed with formal lymphadenectomy. Slings are placed around proximal and distal oesophagus and a paravertebral catheter is inserted for postoperative analgesia. In the supine position, the stomach is mobilized laparoscopically, preserving the gastroepiploic arcade and the right gastric artery. Kocher's manoeuvre is undertaken. Lymphadenectomy is performed around the coeliac axis, common hepatic, left gastric and splenic arteries. The proximal oesophagus is delivered through a cervical approach and transected, suturing the distal end to a delivery system to facilitate passage of the conduit through the mediastinum. The mobilized stomach is delivered through a 6-cm right paramedian minilaparotomy and a wide gastric conduit formed, preserving collateral supply and venous drainage from the distal lesser curve. The conduit is passed to the neck using a vacuum/camera sleeve technique and anastomosed to the transected cervical oesophagus with a semi-mechanical technique. The paramedian minilaparotomy is closed with a local anaesthetic catheter in the posterior sheath and the conduit brought back into an anatomical position laparoscopically. Postoperative care is described.

A UK-based cost-utility analysis of radiofrequency ablation or oesophagectomy for the management of high-grade dysplasia in Barrett's oesophagus

BACKGROUND

In the UK, oesophagectomy is the current recommendation for patients with persistent high-grade dysplasia in Barrett's oesophagus. Radiofrequency ablation is an alternative new technology with promising early trial results.

AIM

To undertake a cost-utility analysis comparing these two strategies.

METHODS

We constructed a Markov model to simulate the natural history of a cohort of patients with high-grade dysplasia in Barrett's oesophagus undergoing one of two treatment options: (i) oesophagectomy or (ii) radiofrequency ablation followed by endoscopic surveillance with oesophagectomy for high-grade dysplasia recurrence or persistence.

RESULTS

In the base case analysis, radiofrequency ablation dominated as it generated 0.4 extra quality of life years at a cost saving of £1902. For oesophagectomy to be the most cost-effective option, it required a radiofrequency ablation treatment failure rate (high-grade dysplasia persistence or progression to cancer) of >44%, or an annual risk of high-grade dysplasia recurrence or progression to cancer in the ablated oesophagus of >15% per annum. There was an 85% probability that radiofrequency ablation remained cost-effective at the NICE willingness to pay threshold range of £20 000-30 000.

CONCLUSION

Radiofrequency ablation is likely to be a cost-effective option for high-grade dysplasia in Barrett's oesophagus in the UK.

Oesophagogastric junction adenocarcinoma: which therapeutic approach?

Gastric and oesophageal cancers are among the leading causes of cancer-related death worldwide. By contrast with the decreasing prevalence of gastric cancer, incidence and prevalence of oesophagogastric junction adenocarcinoma (OGJA) are rising rapidly in developed countries. We provide an update about treatment strategies for resectable OGJA. Here we review findings from the latest randomised trials and meta-analyses, and propose guidelines regarding endoscopic, surgical, and perioperative treatments. Through a team approach, members from all diagnostic and therapeutic disciplines, such as gastroenterologists, surgeons, oncologists, radiologists, and radiotherapists, can effectively administer a range of treatment modalities.

Open versus minimally invasive esophagectomy: trends of utilization and associated outcomes in England

OBJECTIVE

To assess the trends in uptake of minimal invasive esophagectomy in England over the last 12 years (1996/1997-2007/2008) and to compare their clinical outcomes with those after open esophagectomy.

SUMMARY OF BACKGROUND DATA

Around 7400 people are affected each year in the United Kingdom. Prognosis following esophageal resection is, however, poor. Even after "curative" surgery, 5-year survival rates do not exceed 25%. The minimally invasive approach to esophagectomy has attracted attention as a potentially less invasive alternative to conventional surgery.

METHODS

Data on patients undergoing esophagectomy for esophageal cancer were extracted from a national administrative database. The outcomes of interest were in-hospital mortality, 30-day in-hospital mortality, 30-day total (ie, in and out of hospital) mortality, 365-day total mortality, 28-day emergency readmission rates, and length of hospital stay. Hierarchical logistic regression was used to identify the effect of minimal invasive esophagectomy (MIE) on the outcomes after adjustment for age, gender, socioeconomic deprivation, and comorbidity.

RESULTS

A total of 18,673 esophagectomies were performed over the 12-year study period. The use of minimal access surgery increased exponentially over time (from 0.6% in 1996/1997 to 16.0% in 2007/2008). There was a suggestion that patients undergoing MIE had better 1-year survival rates than patients receiving open esophagectomy (OR = 0.68, 95% CI = 0.46-1.01, P = 0.058).

CONCLUSION

The uptake of MIE in England is increasing exponentially. With the possible exception of 1-year survival, patients selected for MIE demonstrated similar mortality and length of stay outcomes when compared with those undergoing conventional surgery. These results need to be confirmed in large-scale randomized controlled trials.

Minimally invasive esophagectomy

Esophageal resection is associated with a high morbidity and mortality rate. Minimally invasive esophagectomy (MIE) might theoretically decrease this rate. We reviewed the current literature on MIE, with a focus on the available techniques, outcomes and comparison with open surgery. This review shows that the available literature on MIE is still crowded with heterogeneous studies with different techniques. There are no controlled and randomized trials, and the few retrospective comparative cohort studies are limited by small numbers of patients and biased by historical controls of open surgery. Based on the available literature, there is no evidence that MIE brings clear benefits compared to conventional esophagectomy. Increasing experience and the report of larger series might change this scenario.

Minimally invasive esophagectomy

Esophageal resection is associated with a high morbidity and mortality rate. Minimally invasive esophagectomy (MIE) might theoretically decrease this rate. We reviewed the current literature on MIE, with a focus on the available techniques, outcomes and comparison with open surgery. This review shows that the available literature on MIE is still crowded with heterogeneous studies with different techniques. There are no controlled and randomized trials, and the few retrospective comparative cohort studies are limited by small numbers of patients and biased by historical controls of open surgery. Based on the available literature, there is no evidence that MIE brings clear benefits compared to conventional esophagectomy. Increasing experience and the report of larger series might change this scenario.

Esophageal resection for high-grade dysplasia and intramucosal carcinoma: When and how?

High-grade dysplasia (HGD) and intramucosal carcinoma (IMC) in the setting of Barrett’s esophagus have traditionally been treated with esophagectomy. However, with the advent of endoscopic mucosal resection and endoscopic ablative therapies, endoscopic therapy at centers with expertise is now an established treatment of Barrett’s-esophagus-related neoplasia, including HGD and IMC. Esophagectomy is today reserved for more selected cases with submucosal invasion, evidence for lymph node metastasis, or unsuccessful endoscopic therapy.

Perioperative outcomes after transition from conventional to minimally invasive Ivor-Lewis esophagectomy in a specialized center

BACKGROUND

Minimally invasive techniques are now increasingly adopted for the treatment of esophageal cancers. Benefits such as earlier functional recovery and less need for transfusion and intensive care stay should be balanced by a determination to avoid compromise to the oncologic integrity of the procedure, especially in the early phase of transition from open to laparoscopic surgery. This study aimed to compare primary outcomes including oncologic clearance, complications, and functional recovery between open and laparoscopic esophagectomy in a single center.

METHODS

This prospective study recruited 75 consecutive patients undergoing Ivor-Lewis esophagectomy, all treated by a single surgeon. These patients were divided into three groups. The 24 patients in group A underwent open Ivor-Lewis esophagectomy. The remaining patients underwent laparoscopic Ivor-Lewis esophagectomy in two groups: 25 patients in an early cohort (group B) and 26 patients in a later cohort (group C). All the patients were treated according to the same protocol.

RESULTS

The three groups were adequately matched. The findings showed trends toward a reduction in median operative time, with group A requiring 260 min, group B requiring 249 min, and group C requiring 223 min (p = 0.06), and a significant reduction in the requirement for perioperative blood transfusion between groups A (65%) and C (27%) (p = 0.02). The median lymph node yield was significantly less in group B (n = 13) than in group A (n = 24) or group C (n = 22) (p = 0.003). There was no significant difference between the three groups in the length of hospital stay (median stay, 14-16 days) or the requirement for critical care beds (median stay, 3-4 days). The in-hospital mortality rate was zero, and the morbidity rate did not differ between the three groups.

CONCLUSIONS

This study shows that laparoscopic Ivor-Lewis esophagectomy is associated with a reduced need for blood transfusion, a shorter operative time, and an adequate lymph node harvest. Oncologic principles are not compromised during the transition phase from open to laparoscopic esophagectomy.

Initial Institutional Experience with Thoracoscopic Assisted Esophagectomy

We report our initial experience with thoracoscopic assisted esophagectomy (TAE) in patients with esophageal carcinoma. Clinical outcome measures are reported for 14 consecutive patients who underwent thoracoscopically assisted esophagectomy at our institution between January 2007 and June 2009. These outcomes were compared with 18 patients who underwent open esophagectomy (OE) during this time. All 14 patients were male, with a median age of 63. All had distal esophageal adenocarcinoma: stage I (7), II A (2), II B (3), and III (2). Surgical approaches included laparotomy combined with thoracoscopy and cervical (n = 12), or intrathoracic anastomosis (n = 2). Compared with an open approach, the thoracoscopic assisted esophagectomies were longer (median time 460 vs 386 minutes), and they were associated with less blood loss (250 mL vs 500 mL) and less respiratory complications (14.3% vs 27.8%). In our TAE group more lymph nodes were removed (median number 12 in TAE vs 10 in OE). The overall morbidity was similar in both groups (42.8% in TAE vs 50% in OE group), but the in-hospital mortality was reduced with TAE (7.1% with TAE vs 16.7% with OE). TAE is feasible with a low conversion rate, acceptable morbidity, and low mortality.

Advances in the surgical treatment of esophageal cancer

Surgical resection remains the predominant modality in the management of esophageal cancer. Transthoracic and transhiatal esophagectomy are the procedures that are most frequently performed. Minimally invasive esophagectomy is feasible but will require further evaluation with well-designed trials and long-term follow-up before it can be widely adopted. Technical improvements have lowered the rate of cervical anastomotic leak and improved the management of thoracic anastomotic leak. Outcome studies demonstrated that the optimal mortality, morbidity, and survival outcomes are obtained when esophageal resections are performed by experienced surgeons in high-volume institutions.

Respiratory complications after oesophageal surgery

PURPOSE OF REVIEW

The most frequent complications of oesophageal surgery are respiratory and these are associated with increased critical care stay, hospital stay and mortality. This review focuses on the risk factors associated with the development of respiratory complications after oesophageal surgery.

RECENT FINDINGS

An acceptable operative mortality, increased and improved quality of life can be gained in appropriately selected patients. When induction therapy is scheduled, smoking cessation is advised. The preoperative treatment of airway pathogens can reduce postoperative complications and this may be particularly relevant in patients who have received induction chemoradiotherapy. Nonrandomized studies suggest that thoracic epidural analgesia improves outcome. Minimally invasive surgery is increasingly used and appears safe but direct comparisons to open surgery in terms of respiratory complications are awaited. Few randomized studies are available to guide anaesthetic management but anaesthetists should aim to avoid hypoxaemia, hypotension, aspiration and limit blood and fluid administration. Postoperative aspiration is common and steps to reduce it are recommended.

SUMMARY

The multifactorial nature of respiratory complications after oesophageal surgery may mean that a number of interventions are needed to have a detectable influence on outcome, much like a care bundle strategy.

Managing complex patients on a medical psychiatric unit: an observational study of university hospital costs associated with medical service use, length of stay, and psychiatric intervention

OBJECTIVE

Although there is a suggestion that the medical psychiatric unit (MPU) may reduce length of hospital stay (LOS), little is known about costs in terms of medical service use and psychiatric interventions in MPU care.

METHOD

A record linkage study was conducted, linking cost data of hospital medical service use, LOS, and hospital psychiatric interventions to patients admitted to the MPU of the Maastricht University Medical Centre (MUMC) between 1998 and 2004. The data set was analyzed to enable comparison between cost changes of the same complex patient population following either MPU index admission or index admissions to reference MUMC medical wards.

RESULTS

Comparisons revealed lower costs of medical service use in favor of the MPU (-euro104; 95% CI -euro174 to -euro35; P<.01). However, cost of psychiatric intervention and cost of LOS were higher after MPU admission (respectively, +euro165; 95% CI +euro25 to +euro305; P<.05; and +euro202; 95% CI +euro170 to +euro235; P<.001). Total costs were higher after MPU admission compared to medical ward admission (+euro263; 95% CI +euro68 to +euro458; P<.05). These differences were not moderated by somatic diagnosis or previous pattern of admissions.

CONCLUSION

The findings suggest that patients at the interface of psychiatric and somatic morbidity are diagnosed and treated adequately at the MPU, leading to a decrease in medical service use and an appropriate increase in exposure to psychiatric interventions. These results are specifically generalizable to MPUs with a focus on psychosomatic conditions, for instance, somatoform disorders or affective disorders with comorbid somatic diseases. However, failure to show cost savings in terms of LOS compared to medical wards outweighs cost-benefit derived from lower medical service use, suggesting that MPU activities may gain in cost-effectiveness if shifted more to outpatient psychosomatic care solutions.

Minimally invasive esophagectomy: an overview

Minimally invasive approaches to esophageal resection have been shown to be feasible and safe, with outcomes similar to open esophagectomy. There are no controlled trials comparing the outcomes of minimally invasive esophagectomy (MIE) with open techniques, just a few comparative studies and many single institution series from which assessment of MIE and its present role have been made. The reported improvements from MIE approaches include reduced blood loss, time in intensive care and time in hospital. In comparative studies there is no clear reduction in respiratory complications, although larger series suggest there may be a benefit from MIE. Although MIE approaches report less lymph node retrieval compared with open extended lymphadenectomy, MIE cancer outcomes are comparable with open surgery. MIE will be a major component of the future esophageal surgeons' armamentarium, but should continue to be carefully assessed. There is a role for multicentered studies to prospectively audit outcomes. Large numbers of patients would be required to perform randomized trials of MIE versus open resection.

Preemptive surgery for premalignant foregut lesions

INTRODUCTION

Preemptive surgery is the prophylactic removal of an organ at high risk for malignant transformation or the resection of a precancerous or "early" malignant neoplasm in an individual with a hereditary predisposition to cancer. Recent advances in molecular diagnostic techniques have improved our understanding of the biologic behavior of these conditions. Predictive testing is an emerging field that attempts to assess the potential risk of cancer development in predisposed individuals. Despite substantial improvement in these forms of testing, all results are imperfect. This information often becomes an important tool that is used by healthcare providers to evaluate the risk-benefit ratio of various risk modifying strategies (i.e., intensive surveillance or preemptive surgery).

METHODS

A systematic literature review was performed using Medline and the bibliographies of all referenced publications to identify articles relating to preemptive surgery for premalignant foregut lesions.

RESULTS AND DISCUSSION

In this review, we outline the controversies surrounding predictive risk assessment, surveillance strategies, and preemptive surgery in the management of high-grade dysplasia (HGD) in Barrett's esophagus (BE), hereditary diffuse gastric cancer (HDGC), bile duct cysts, primary sclerosing cholangitis (PSC), and pancreatic cystic neoplasms. Resection of BE is supported by the progressive nature of the disease, the risk of occult carcinoma, and the lethality of esophageal cancer. Prophylactic total gastrectomy for HDGC appears reasonable in the absence of accurate screening tests but must be balanced by the impact of surgical complications and altered quality of life. Surgical resection of biliary cysts theoretically eliminates the exposed epithelium to decrease the lifetime risk of cholangiocarcinoma. Liver transplantation for PSC remains controversial given the scarcity of donor organs and inability to accurately identify high-risk individuals. Given the uncertain natural history of pancreatic cystic neoplasms, the merits of selective versus obligatory resection will continue to be debated.

CONCLUSIONS

Preemptive operations require optimal judgment and surgical precision to maximize function and enhance survival. Ultimately, balancing the risk of surgical intervention with less invasive interventions or observation must be individualized on a case-by-case basis.

Robot-assisted thoracoscopic oesophagectomy for cancer

BACKGROUND

Thoracoscopic oesophagectomy was introduced to reduce the morbidity of transthoracic oesophagectomy. The aim was to assess the short- and mid-term results of robot-assisted thoracoscopic oesophagectomy for oesophageal cancer.

METHODS

Between October 2003 and May 2007, 47 patients with resectable oesophageal cancer underwent robot-assisted thoracoscopic oesophagectomy. Clinical data were collected prospectively.

RESULTS

Conversion to thoracotomy was necessary in seven patients. Median operating time was 450 min and median blood loss 625 ml. Median postoperative ventilation time was 1 day, intensive care stay 3 days and hospital stay 18 days. Twenty-one of 47 patients had pulmonary complications. Three patients died in hospital. A median of 29 (range 8-68) lymph nodes was dissected and R0 resection was achieved in 36 patients. Twenty-three patients had stage IVa disease. After a median follow-up of 35 months, median disease-free survival was 15 (95 per cent confidence interval 12 to 18) months.

CONCLUSION

Robot-assisted thoracoscopic oesophagectomy was oncologically acceptable. Operating time, blood loss and pulmonary complications might decrease with further experience.

International survey on esophageal cancer: part I surgical techniques

In patients with esophageal cancer, radical surgical resection of the esophagus and surrounding lymph nodes is the only curative treatment option. Nevertheless, no standard surgical procedure exists. The aims of the present study were to gain insight into the frequencies of the various surgical techniques in esophageal cancer surgery as applied by surgeons throughout the world and to identify intercontinental differences regarding surgical techniques. Surgeons with particular interest in esophageal surgery, including members of the International Society for Diseases of the Esophagus, the European Society of Esophagology Group d'Etude Européen des Maladies de l'Oesophage and the OESO, were invited to participate in an online questionnaire. Questions were asked regarding approach to esophagectomy, extent of lymphadenectomy (LND), type of reconstruction, and anastomotic techniques. Subanalyses were performed for the surgeons' case volume per year, years of experience in esophageal cancer surgery, and continent. Of 567 invited surgeons, 269 participated, resulting in an overall response rate of 47%. The responders currently performing esophagectomies (n= 250; 44%), represented 41 countries across the six continents. Fifty-two percent of responders favor open transthoracic esophagectomy (TTE) over transhiatal esophagectomy (THE) or minimally invasive esophagectomy (MIE). THE is preferred by 26%, whereas MIE is favored by 14%. Eight percent have no preference for one approach to esophagectomy over the other. The extent of LND is most frequently the 2-field, routinely performed by 73% of surgeons. The continuity of the digestive tract is most frequently restored with a gastric conduit (85%). In open TTE, the anastomosis is routinely created in the neck by 56% of responders and in the chest by 40%. Cervical anastomoses are routinely fashioned by means of a handsewn technique by 65% of responders, while 35% favor the stapled technique. The cervical incision is predominantly performed vertically on the left side of the neck (routinely by 66%). A horizontal neck incision is routinely carried out by 19% of responders and a vertical right-sided incision by 11%. Significant differences in surgical techniques could be detected between low- and high-volume surgeons, between surgeons with <or=10 versus >or=21 years of experience, and between surgeons from different continents. In conclusion, currently the most commonly applied surgical procedure is the open right-sided transthoracic approach with a two-field lymphadenectomy, using a gastric tube anastomosed at the left side of the neck by means of a handsewn, end-to-side technique. The results of this survey provide baseline data for future research and for the development of international guidelines.

Is minimally invasive esophagectomy indicated for cancer?

Esophagectomy is an important component in the comprehensive treatment of esophageal cancer. The 5-year survival in patients who are treated with esophagectomy is approximately 35% compared with approximately 16% for all patients. However, esophagectomy is a complex operation with high (40-60%) morbidity and 5-20% mortality rates reported by many centers. Minimally invasive approaches to esophagectomy have been developed over the past decade; potential advantages of minimally invasive esophagectomy (MIE) include a reduced risk of perioperative morbidity and mortality with equivalent oncologic outcomes, including extent of lymphadectomy and survival. However, significant debate still exists regarding the role of MIE in the treatment of esophageal cancer, particularly given the limitations in the widespread implementation of this technically challenging operation. This review summarizes the current status of the use of minimally invasive surgery in treating esophageal cancer and seeks to answer the question of whether MIE is indicated in the treatment of esophageal cancer.

Minimally invasive esophagectomy for malignant and premalignant diseases of the esophagus

Minimally invasive approaches increasingly are used to treat esophageal cancer and Barrett's esophagitis with high-grade dysplasia. The goals of a minimally invasive esophageal resection are to provide sound oncologic therapy while minimizing morbidity. This article describes the technique the authors use for laparoscopic-thoracoscopic esophagectomy. Comparison data are presented for alternative endoscopic therapy primarily used in candidates not suitable for surgery.

Modern surgery for esophageal cancer

Primary treatment of carcinoma of the esophagus and cardia rests on surgical resection. Although recent advances have shown the suitability of endoscopic treatment in selected patients with very early cancers, and preliminary studies have suggested that responders to primary chemoradiation may be equivalent to resection in selected patients with squamous cell carcinoma, surgical resection remains the mainstay of therapy, as it has for the past 50 years. Various changes support highly individualized treatment decisions, in which each patient receives the treatment with the best chance of eliminating all disease.

Barrett's esophagus

Barrett's esophagus is an important step in the pathway to esophageal adenocarcinoma. Since most patients with Barrett's esophagus are undiagnosed and patients present with advanced adenocarcinoma de novo, prognosis for this disease remains poor. To identify those people with Barrett's esophagus who are at particular risk many new technologies are being developed. In association with these advances in risk stratification, progress is being made in the endoscopic treatment of Barrett's. Chemoprevention is also an area of interest and trials are underway.