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van Boxel GI, Kingma BF, Voskens FJ, Ruurda JP, van Hillegersberg R. Robotic-assisted minimally invasive esophagectomy: past, present and future. J Thorac Dis 2020; 12:54-62. [PMID: 32190354 DOI: 10.21037/jtd.2019.06.75] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Esophagectomy for cancer of the esophagus is increasingly performed using minimally invasive techniques. After the introduction of minimally invasive esophagectomy (MIE) in the early 1990's, robotic-assisted techniques followed after the turn of the millennium. The advent of robotic platforms has allowed the development of robotic-assisted minimally invasive esophagectomy (RAMIE) over the past 15 years. Although recent trials have shown superior peri-operative morbidity and quality of life compared to open esophagectomy, no randomized trials have compared RAMIE to conventional MIE. This paper summarizes the current literature on RAMIE and provides an overview of expected future developments in robotic surgery.
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Affiliation(s)
- Gijsbert I van Boxel
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - B Feike Kingma
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Frank J Voskens
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Jelle P Ruurda
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
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52
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Hölscher AH, Law S. Esophagogastric junction adenocarcinomas: individualization of resection with special considerations for Siewert type II, and Nishi types EG, E=G and GE cancers. Gastric Cancer 2020; 23:3-9. [PMID: 31691875 DOI: 10.1007/s10120-019-01022-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 10/20/2019] [Indexed: 02/07/2023]
Abstract
For Siewert type II adenocarcinoma of the esophagogastric junction (AEG II), or similar tumors classified as Nishi EG, E=G, GE, the type of surgical resection and reconstruction should be individualized. Criteria for decision making mainly focus on the oral extent of esophageal infiltration, the cT and cN category and the functional status of the patient. For cT1/cT2 adenocarcinomas, which are non-poorly cohesive, intestinal type of Lauren Grading 1 or 2 without clinical signs of lymph node metastasis at the distal stomach, a limited transhiatal proximal gastrectomy with double tract reconstruction is recommended. For advanced adenocarcinomas, subtotal esophageal and proximal gastric resection with gastric pull-up or distal esophageal resection with total gastrectomy and esophagojejunostomy are competing procedures. Criteria for choosing the appropriate type of surgery are discussed.
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Affiliation(s)
- Arnulf H Hölscher
- Center for Esophageal and Gastric Cancer Surgery, AGAPLESION Markushospital Frankfurt, Wilhelm-Epstein-Strasse 4, 60431, Frankfurt am Main, Germany. .,Contilia Center for Esophageal Diseases, Elisabeth Hospital Essen, Essen, Germany.
| | - Simon Law
- Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong (SAR), China
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53
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Bundred JR, Kamarajah SK, Siaw‐Acheampong K, Nepogodiev D, Jefferies B, Singh P, Evans R, Griffiths EA, Alderson D, Gossage J, McKay S, Mohamed I, van Hillegersberg R, Vohra R, Wanigsooriya K, Whitehouse T, Bagajevas A, Bekele A, Blanco‐Colino R, Da Roit A, El Kafsi‐Mawley J, Gjata A, Gockel I, Castro RG, Harustiak T, Hsu P, Isik A, Kechagias A, Kennedy A, Kidane B, Mahendran HA, Mejia L, Moreno JI, Negoi I, Santiago AJ, Sayyed R, Schneider P, Soares AS, Sousa M, Takeda FR, Vanstraten S, Wallner B, Wijnhoven B, Achiam M, Agustin T, Akbar A, Al‐Bahrani A, Al‐Khyatt W, Albertsmeier M, Alghunaim E, Alkhaffaf B, Allum W, Am F, Andreollo N, Arndt A, Babor R, Barbosa J, Bardini R, Beardsmore D, Beban G, Bernardes A, Berrisford R, Bianchi A, Bjelovic M, Boddy A, Bolca C, Bonavina L, Bryce G, Byrom R, Casaca R, Chan D, Charalabopoulos A, Cheong E, Ciotola F, Colak E, Collins C, Constantinoiu S, Costa R, Dahlke M, Darling G, Dawas K, de Manzoni G, Denewer A, Devadas M, Dexter S, Dikinis S, Dimitrios T, Dolan J, Duong C, Egberts J, Elgharably Y, Elhadi M, Elmahi S, Farias FA, Fekaj E, Fernández J, Forshaw M, Freire J, French D, Gacevski G, Gaedcke J, Gananadha S, Gijon MM, Gokhale J, Gordon A, Grimminger P, Guevara R, Guner A, Gutknecht S, Mahmoodzadeh H, Halldestam I, Hedberg J, Heisterkamp J, Higgs S, Hii M, Hindmarsh A, Hoppner J, Isaza A, Izbicki J, Jacobs R, Jain P, Johansson J, Johnston B, Kafsi J, Kassa S, Kelty C, Khan I, Khoo D, Khyatt S, Kjaer D, Korkolis D, Kreuser N, Larsen M, Lau P, Leite J, Lewis W, Liakakos T, Loureiro C, Mahendran A, Maynard N, Mcgregor R, Mcnally S, Medina‐Franco H, Meguid R, Melhado R, Mercer S, Migliore M, Mingol F, Mogoanta S, Mohri Y, Mönig S, Moreno J, Motas N, Murphy T, Naqi S, Ni R, Niazi S, Oglesby S, Okonta K, Ortiz SR, Pal K, Palazzo F, Pascher A, Pascual M, Pata G, Pera M, Puig S, Ramirez J, Raptis D, Räsänen J, Reim D, Reynolds J, Robb W, Robertson K, Rosero G, Rosman C, Rossaak J, Saarnio J, Santiago A, Schiesser M, Scurtu R, Sekhniaidze D, Sevinç B, Skipworth R, So J, Trugeda MS, Syed A, Takahashi AML, Takeda F, Talbot M, Tareen M, Terashima M, Testini M, Tewari N, Tez M, Thomas M, Tirnaksiz M, Tonini V, Tu C, Turner P, Underwood T, Uzair A, Vallve‐Bernal M, Valmasoni M, Vicente C, Videira JF, Viswanath YKS, Weindelmayer J, White R, Wigle D, Wilkerson P, Wills V, Zacharakis E, Zuluaga M. International Variation in Surgical Practices in Units Performing Oesophagectomy for Oesophageal Cancer: A Unit Survey from the Oesophago-Gastric Anastomosis Audit (OGAA). World J Surg 2019; 43:2874-2884. [PMID: 31332491 DOI: 10.1007/s00268-019-05080-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Anastomotic leaks are associated with significant risk of morbidity, mortality and treatment costs after oesophagectomy. The aim of this study was to evaluate international variation in unit-level clinical practice and resource availability for the prevention and management of anastomotic leak following oesophagectomy. METHOD The Oesophago-Gastric Anastomosis Audit (OGAA) is an international research collaboration focussed on improving the care and outcomes of patients undergoing oesophagectomy. Any unit performing oesophagectomy worldwide can register to participate in OGAA studies. An online unit survey was developed and disseminated to lead surgeons at each unit registered to participate in OGAA. High-income country (HIC) and low/middle-income country (LMIC) were defined according to the World Bank whilst unit volume were defined as < 20 versus 20-59 versus ≥60 cases/year in the unit. RESULTS Responses were received from 141 units, a 77% (141/182) response rate. Median annual oesophagectomy caseload was reported to be 26 (inter-quartile range 12-50). Only 48% (68/141) and 22% (31/141) of units had an Enhanced Recovery After Surgery (ERAS) program and ERAS nurse, respectively. HIC units had significantly higher rates of stapled anastomosis compared to LMIC units (66 vs 31%, p = 0.005). Routine post-operative contrast-swallow anastomotic assessment was performed in 52% (73/141) units. Stent placement and interventional radiology drainage for anastomotic leak management were more commonly available in HICs than LMICs (99 vs 59%, p < 0.001 and 99 vs 83%, p < 0.001). CONCLUSIONS This international survey highlighted variation in surgical technique and management of anastomotic leak based on case volume and country income level. Further research is needed to understand the impact of this variation on patient outcomes.
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Lin Z, Chen W, Chen Y, Peng X, Yan S, He F, Fu R, Jiang Y, Hu Z. Achieving adequate lymph node dissection in treating esophageal squamous cell carcinomas by radical lymphadenectomy: Beyond the scope of numbers of harvested lymph nodes. Oncol Lett 2019; 18:1617-1630. [PMID: 31423229 PMCID: PMC6607061 DOI: 10.3892/ol.2019.10465] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Accepted: 04/15/2019] [Indexed: 12/26/2022] Open
Abstract
Previous studies have recommended harvesting a large number of lymph nodes (LNs) to improve the survival of patients with esophageal squamous cell carcinoma (ESCC). These studies or clinical guidelines focus on the total harvested LNs during lymphadenectomy; however, the extent of LN dissection (LND) required in patients with ESCCs remains controversial. The present study proposed a novel individualized adequate LND (ALND) strategy to compliment current guidelines to improve individualized therapeutic efficacy. For N0 cases, ALND was defined as an LN harvest of >55% of the LNs from nodal zones adjacent to the tumor location; and for N+ cases, ALND was defined as 8, 8, 8, 8 or 16 LNs dissected from the involved cervical, upper, middle, lower and celiac zones, respectively. Retrospective analysis of the ESCC cohort revealed that the ALND was associated with improved patient survival [hazard ratio (HR)=0.45 and 95% CI=0.30–0.66)]. Stratified analyses revealed that the protective role of ALND was prominent, with the exception of higher pN+ staged (pN2-3) cases (HR=0.52, 95% CI=0.23–1.18). Furthermore, ALND was associated with improved survival in local diseases (T1-3/N0-1; HR=0.50, 95% CI=0.30–0.84) and locally advanced diseases (T4/Nany or T1-3/N2-3; HR=0.32, 95% CI=0.15–0.68). These findings suggested that the proposed ALND strategy may effectively improve the survival of patients with ESCC.
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Affiliation(s)
- Zheng Lin
- Department of Epidemiology and Health Statistics, Fujian Provincial Key Laboratory of Environment Factors and Cancer, School of Public Health, Fujian Medical University, Fuzhou, Fujian 350108, P.R. China.,Key Laboratory of Ministry of Education for Gastrointestinal Cancer, Fujian Medical University, Fuzhou, Fujian 350108, P.R. China
| | - Weilin Chen
- Department of Radiation Oncology, Affiliated Zhangzhou Hospital of Fujian Medical University, Zhangzhou, Fujian 363000, P.R. China
| | - Yuanmei Chen
- Department of Thoracic Surgery, Fujian Provincial Cancer Hospital, Fuzhou, Fujian 350014, P.R. China
| | - Xiane Peng
- Department of Epidemiology and Health Statistics, Fujian Provincial Key Laboratory of Environment Factors and Cancer, School of Public Health, Fujian Medical University, Fuzhou, Fujian 350108, P.R. China.,Key Laboratory of Ministry of Education for Gastrointestinal Cancer, Fujian Medical University, Fuzhou, Fujian 350108, P.R. China
| | - Siyou Yan
- Department of Epidemiology and Health Statistics, Fujian Provincial Key Laboratory of Environment Factors and Cancer, School of Public Health, Fujian Medical University, Fuzhou, Fujian 350108, P.R. China
| | - Fei He
- Department of Epidemiology and Health Statistics, Fujian Provincial Key Laboratory of Environment Factors and Cancer, School of Public Health, Fujian Medical University, Fuzhou, Fujian 350108, P.R. China.,Key Laboratory of Ministry of Education for Gastrointestinal Cancer, Fujian Medical University, Fuzhou, Fujian 350108, P.R. China
| | - Rong Fu
- Department of Epidemiology and Health Statistics, Fujian Provincial Key Laboratory of Environment Factors and Cancer, School of Public Health, Fujian Medical University, Fuzhou, Fujian 350108, P.R. China
| | - Yixian Jiang
- Department of Epidemiology and Health Statistics, Fujian Provincial Key Laboratory of Environment Factors and Cancer, School of Public Health, Fujian Medical University, Fuzhou, Fujian 350108, P.R. China
| | - Zhijian Hu
- Department of Epidemiology and Health Statistics, Fujian Provincial Key Laboratory of Environment Factors and Cancer, School of Public Health, Fujian Medical University, Fuzhou, Fujian 350108, P.R. China.,Key Laboratory of Ministry of Education for Gastrointestinal Cancer, Fujian Medical University, Fuzhou, Fujian 350108, P.R. China
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55
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Wong CL, Law S. Extent of lymphadenectomy for Barrett's cancer. Transl Gastroenterol Hepatol 2019; 4:36. [PMID: 31231703 DOI: 10.21037/tgh.2019.05.07] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 04/16/2019] [Indexed: 01/27/2023] Open
Abstract
Adenocarcinoma of the esophagus and esophagogastric junction (EGJ) has become the predominant histological cell type in western countries due to the prevalence of obesity, gastroesophageal reflux disease and Barrett's esophagus. There is some evidence that this is increasing in the East as well. Surgery aims at achieving an R0 resection with clear margins, together with adequate and appropriate lymphadenectomy. Siewert type I and II cancers are more likely to be associated with Barrett's esophagus (especially in western countries), while type III cancers are mostly proximal gastric cancers that have grown upwards to involve the EGJ. For type I cancers, most surgeons would perform an esophagectomy, with at least an infra-carinal lymphadenectomy. It is more controversial for type II tumors, with some surgeons preferring an esophagectomy, while others may opt for a proximal or total radical gastrectomy via an abdominal approach. All procedures can be performed using open or minimally invasive methods. In addition to oncologic reasons, the chosen surgical approach also depends on expertise available, safety issues, and postoperative quality-of-life considerations. More data are needed in this area. How to integrate knowledge and also multimodality treatment strategies is an active area of research.
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Affiliation(s)
- Claudia Ly Wong
- Division of Esophageal and Upper Gastrointestinal Surgery, Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China
| | - Simon Law
- Division of Esophageal and Upper Gastrointestinal Surgery, Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China
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56
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Kingma BF, Marges OM, Van Hillegersberg R, Ruurda JP. Routine chest X-rays after the removal of chest tubes are not necessary following esophagectomy. J Thorac Dis 2019; 11:S799-S804. [PMID: 31080661 DOI: 10.21037/jtd.2018.12.74] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Chest X-rays (CXRs) are commonly performed after removing chest tubes following surgery. However, the value of this practice is unclear for patients who underwent esophagectomy. Therefore, the aim of this study was to investigate the clinical relevance of routinely performing a CXR after chest tube removal during the postoperative course of esophagectomy. Methods A single-center prospective database was used to select all patients who underwent esophagectomy with gastric conduit reconstruction between 2015 and 2017. Patients who received a CXR within 4 hours after removal of at least one chest tube were included. The radiological reports of these CXRs were evaluated for intrapleural air and fluid. Cases requiring re-insertion of a chest tube on the day of CXR or the day afterwards were identified and the clinical situation of these patients was reviewed. Results Some 117 patients were included and a total of 231 chest tube removals were followed by a CXR within 4 hours. Re-insertion of a chest tube was performed in a total of 6 cases (3%) on the day or the day after this CXR. All these 6 patients had clinical signs or symptoms indicating respiratory problems. In total, new intrapleural air was found on the ipsilateral side of previous chest tube removal in 33 cases (14%) and new intrapleural fluid occurred on the ipsilateral side of previous chest tube removal in 24 cases (10%). Conclusions In conclusion, a CXR after chest tube removal may safely be reserved for patients who develop clinical signs or symptoms that indicate respiratory problems.
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Affiliation(s)
- B Feike Kingma
- Department of Surgery, University Medical Center Utrecht, The Netherlands
| | - Onno M Marges
- Department of Surgery, University Medical Center Utrecht, The Netherlands
| | | | - Jelle P Ruurda
- Department of Surgery, University Medical Center Utrecht, The Netherlands
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57
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Kingma BF, de Maat MFG, van der Horst S, van der Sluis PC, Ruurda JP, van Hillegersberg R. Robot-assisted minimally invasive esophagectomy (RAMIE) improves perioperative outcomes: a review. J Thorac Dis 2019; 11:S735-S742. [PMID: 31080652 DOI: 10.21037/jtd.2018.11.104] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Robotic assisted minimal invasive esophagectomy (RAMIE) is increasingly applied as a clinically and oncologically safe technique in the surgical treatment of esophageal cancer. This review focuses on the advantages and potential opportunities of RAMIE to improve the perioperative and oncological outcomes based on the evidence from current literature. In addition, critical notes on aspects such as procedure duration and costs are addressed in this paper.
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Affiliation(s)
- B Feike Kingma
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Michiel F G de Maat
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Sylvia van der Horst
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Pieter C van der Sluis
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Jelle P Ruurda
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Richard van Hillegersberg
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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58
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Seesing MFJ, Kingma BF, Weijs TJ, Ruurda JP, van Hillegersberg R. Reducing pulmonary complications after esophagectomy for cancer. J Thorac Dis 2019; 11:S794-S798. [PMID: 31080660 DOI: 10.21037/jtd.2018.11.75] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The cornerstone of curative care for esophageal cancer is neoadjuvant chemoradiotherapy followed by esophagectomy with a radical lymphadenectomy. An esophagectomy is a major and complex surgical procedure and is often followed by postoperative morbidity, especially pulmonary complications. These complications may lead to an increase in hospital stay, intensive care unit admission rate and mortality. Therefore, perioperative strategies to reduce these complications have been investigated and implemented in clinical practice. In this review we highlight the influence of minimally invasive surgery, postoperative pain management, early identification of complications and the usage of uniform definitions on (pulmonary) complications after esophagectomy. Finally, we will discuss some future perspectives.
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Affiliation(s)
- Maarten F J Seesing
- Department of Surgical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - B Feike Kingma
- Department of Surgical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Teus J Weijs
- Department of Surgical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jelle P Ruurda
- Department of Surgical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
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59
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Mir MR, Lashkari M, Ghalehtaki R, Mir A, Latif AH. Transhiatal versus Left Transthoracic Esophagectomy for Gastroesophageal Junction Cancer; The Impact of Surgical Approach on Postoperative Complications. Middle East J Dig Dis 2019; 11:104-109. [PMID: 31380007 PMCID: PMC6663288 DOI: 10.15171/mejdd.2018.135] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 03/11/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Esophagectomy is the mainstay of treatment for esophageal cancer. Although different surgical approaches have been described, choosing the most appropriate technique is still on debate. We compared the complications of transhiatal esophagectomy (THE) versus left transthoracic esophagectomy (LTE) among a group of Iranian patients with gastroesophageal junction cancer. METHODS This was a retrospective study between 2011 and 2013 on 40 patients with gastroesophageal cancer. 23 patients underwent THE and the others underwent LTE. 30-day postoperative mortality, complications, duration of hospital stay, and number of dissected lymph nodes were studied. RESULTS 37.5% of the patients had squamous cell carcinoma. No mortality was seen. Totally, 10 patients suffered from complications. Cardiac and pulmonary complications occurred in eight and six patients, respectively. No patients suffered from vocal cord injuries and anastomotic leakage. The mean duration of postoperative hospital stay was 11.82 ± 3.8 days, and the mean number of dissected lymph nodes was 8.2 ± 3.9. No significant difference was seen between the two groups (p > 0.05). CONCLUSION Choosing between the approaches for resection of gastroesophageal cancer may not impact the complications and mortality rates. We propose that LTE approach could be used safely in comparison with THE, and that selecting between THE and LTE may be based on the surgeon's preference and experience.
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Affiliation(s)
- Mohammad Reza Mir
- Department of Surgical Oncology, Cancer Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Marzieh Lashkari
- Radiation Oncology Research Center, Cancer Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Ghalehtaki
- Radiation Oncology Research Center, Cancer Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Mir
- Department of General Surgery, Dr. Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Hossein Latif
- Department of General Surgery, Dr. Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
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van der Horst S, de Maat MFG, van der Sluis PC, Ruurda JP, van Hillegersberg R. Extended thoracic lymph node dissection in robotic-assisted minimal invasive esophagectomy (RAMIE) for patients with superior mediastinal lymph node metastasis. Ann Cardiothorac Surg 2019; 8:218-225. [PMID: 31032205 DOI: 10.21037/acs.2019.01.04] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Background Robot-assisted surgery may have a role in improving oncological outcomes in esophagectomy. Especially in the anatomical areas in the chest that are more difficult to reach in open surgery (including the superior mediastinum). The dexterity of the robotic instruments aid in performing a more extensive nodal dissection and the precision and detailed vision of the robotic system potentially improves staging, oncological outcomes and reduces complications (i.e., recurrent nerve palsy). In this article, we describe our experience and clinical outcomes in patients treated by robot assisted minimal invasive esophagectomy (RAMIE) in cN+ esophageal cancer patients with positive nodes localized in the superior mediastinum. Methods From May 2007-2018, all patients who had involved nodes by either fluor-18-deoxyglucose positron-emission-tomography-computed tomography (FDG-PET-CT) or endoscopic ultrasound (EUS) + fine needle aspiration (FNA) localized in the superior mediastinum (above level Th4/sternal angle) were identified. Patient characteristics, perioperative data, postoperative clinical outcomes/complications and overall survival were prospectively recorded and retrospectively evaluated. Results Forty patients (48% adenocarcinoma) met our inclusion criteria. All patients underwent a three-stage procedure with cervical anastomosis and 90% of the patients underwent neoadjuvant chemoradiotherapy. Mortality occurred in three patients (7.5%), of which two were caused by severe acute respiratory distress syndrome (ARDS). The most frequent complications were pneumonia (25%), chylothorax (20%), anastomotic leakage (17.5%) and vocal cord paralysis (17.5%) which was grade 1 in 72% of the patients. Radicality rate (R0 resection) was 98% and the average lymph node yield was 24 (range, 9-57). Median overall and disease-free survival was 26 and 17 months, respectively. Conclusions RAMIE for esophageal cancer patients with node positive disease in the superior mediastinum is associated with increased mortality/morbidity. Oncological outcome showed excellent lymph node yield, R0 rate and survival was equal compared to patients with lower mediastinal node positive disease.
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Affiliation(s)
- Sylvia van der Horst
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Michiel F G de Maat
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Jelle P Ruurda
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
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Neoadjuvant chemoradiotherapy or chemotherapy for gastroesophageal junction adenocarcinoma: A systematic review and meta-analysis. Gastric Cancer 2019; 22:245-254. [PMID: 30483986 DOI: 10.1007/s10120-018-0901-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Accepted: 11/20/2018] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The preferred neoadjuvant treatment for gastroesophageal junction (GEJ) adenocarcinoma is still matter of debate. We conducted a meta-analysis to assess the different impact of neoadjuvant combined chemotherapy and radiotherapy (CTRT) versus chemotherapy (CT) alone. METHODS A comprehensive search was performed in EMBASE, PubMed, and Cochrane Library databases from inception to 30th June 2018. Studies comparing survival of patients who underwent CTRT or CT alone before surgery for GEJ adenocarcinoma were included. Hazard ratio (HR) for overall survival (OS) was extracted, and a random-effects model was used for pooled analysis. Median OS, 5-year OS, complete pathologic response (pCR), locoregional and distant failure rates were also calculated. RESULTS 22 studies including 18,260 patients were considered for the final analysis. The pooled results demonstrated that combined CTRT do not significantly reduce the risk of death (HR 0.95, 95% CI 0.84-1.07; P = 0.41) but has a positive impact on the risk of relapse (HR 0.85, 95% CI 0.75-0.97; P = 0.01) compared to CT alone. Addition of RT to CT alone significantly increased the odds of pCR by 2.8 (95% CI 2.27-3.47; P < 0.001) and reduced the risk of locoregional failure (OR 0.6, 95% CI 0.39-0.91; P = 0.01) but not the risk of distant metastases (OR 0.81, 95% CI 0.59-1.11; P = 0.19). CONCLUSIONS In this systematic review and meta-analysis comparing neoadjuvant CTRT with CT for adenocarcinoma of GEJ, we found no difference in terms of median OS, despite a higher pCR rate and a reduced risk of locoregional recurrences for the combined approach. Further studies, preferably large randomized clinical trials, are needed to confirm these results.
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Asti E, Bernardi D, Sozzi M, Bonavina L. Minimally invasive esophagectomy for Barrett's adenocarcinoma. Transl Gastroenterol Hepatol 2018; 3:77. [PMID: 30505964 DOI: 10.21037/tgh.2018.09.16] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 09/28/2018] [Indexed: 12/15/2022] Open
Abstract
Minimally invasive esophagectomy has become the preferred approach for invasive Barrett's adenocarcinoma because it can speed recovery and enhance patient's quality of life. Multiple minimally invasive surgical techniques have been described during the last two decades. Preoperative staging, anatomy and physiological patient's status, comorbidity, and experience of the surgical team should drive the choice of the surgical approach. The trans-thoracic Ivor Lewis esophagectomy, either hybrid or totally minimal invasive, remains the preferred approach in these patients. Lymph node yield and short-term clinical outcomes have proven similar to open surgery, while quality of life appears improved. To establish a minimally invasive esophagectomy program, a steep learning curve and a multidisciplinary approach are required in order to provide optimal staging, personalized therapy, and adequate perioperative care. The role of minimally invasive surgery in the treatment of invasive Barrett's adenocarcinoma will continue to expand in synergy with enhanced recovery after surgery pathways.
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Affiliation(s)
- Emanuele Asti
- Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Italy
| | - Daniele Bernardi
- Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Italy
| | - Marco Sozzi
- Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Italy
| | - Luigi Bonavina
- Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Italy
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63
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Abstract
Esophagolymphadenectomy is the cornerstone of multimodality treatment for resectable esophageal cancer. The preferred surgical approach is transthoracic, with a two-field lymph node dissection and gastric conduit reconstruction. A minimally invasive approach has been shown to reduce postoperative complications and increase quality of life. Robot-assisted minimally invasive esophagectomy (RAMIE) was developed to facilitate this complex thoracoscopic procedure. RAMIE has been shown to be safe with good oncologic results and reduced morbidity. The use of RAMIE opens new indications for curative surgery in patients with T4b tumors, high mediastinal tumors, and lymph node metastases after neoadjuvant treatment.
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Affiliation(s)
- R van Hillegersberg
- Department of Surgical Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA, Utrecht, The Netherlands.
| | - M F J Seesing
- Department of Surgical Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA, Utrecht, The Netherlands
| | - H J F Brenkman
- Department of Surgical Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA, Utrecht, The Netherlands
| | - J P Ruurda
- Department of Surgical Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA, Utrecht, The Netherlands
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64
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Abstract
Esophagolymphadenectomy is the cornerstone of multimodality treatment for resectable esophageal cancer. The preferred surgical approach is transthoracic, with a two-field lymph node dissection and gastric conduit reconstruction. A minimally invasive approach has been shown to reduce postoperative complications and increase quality of life. Robot-assisted minimally invasive esophagectomy (RAMIE) was developed to facilitate this complex thoracoscopic procedure. RAMIE has been shown to be safe with good oncologic results and reduced morbidity. The use of RAMIE opens new indications for curative surgery in patients with T4b tumors, high mediastinal tumors, and lymph node metastases after neoadjuvant treatment.
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65
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钟 海, 李 想, 梁 洪, 刘 南, 刘 煜, 张 军, 吴 旭. [Tubular gastric elongation surgery for high esophageal-gastric anastomosis after resection of esophageal cancer: analysis of 5 cases]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2018; 38:123-124. [PMID: 33177022 PMCID: PMC6765623 DOI: 10.3969/j.issn.1673-4254.2018.01.20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To summarize our experience with tubular gastric elongation surgery for management of insufficient gastric length for high esophageal-gastric anastomosis following esophageal carcinoma resection. METHODS From September, 2015 to October 2016, 5 patients with esophageal cancer were treated in our department, including two with cervical esophageal cancer and 3 with thoracic esophageal cancer. The patients with cervical esophageal cancer underwent pharyngeal resection, total laryngectomy, esophageal varus extubation and gastric oropharyngeal anastomosis, and the patients with thoracic esophageal cancer underwent esophageal cancer resection with incisions on the left neck, the right chest and the median abdomen. During the surgery, the length of the stomach was found insufficient to allow routine oropharyngeal anastomosis, and tubular gastric elongation was conducted to extend the tubular stomach to enable successful completion of the surgery. RESULTS All the patients recovered smoothly after the surgery and were discharged after 2-3 weeks. CONCLUSIONS Tubular gastric elongation surgery can be a good choice for high esophageal-gastric anastomosis after resection of esophageal cancer in cases of insufficient tubular stomach length or high tension at the anastomosis.
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Affiliation(s)
- 海 钟
- />南方医科大学附属南方医院惠侨医疗中心胸外科,广东 广州 510515Department of Thoracic Surgery, Southern Hospital, Southern Medical University, Guangzhou 510515, China
| | - 想 李
- />南方医科大学附属南方医院惠侨医疗中心胸外科,广东 广州 510515Department of Thoracic Surgery, Southern Hospital, Southern Medical University, Guangzhou 510515, China
| | - 洪森 梁
- />南方医科大学附属南方医院惠侨医疗中心胸外科,广东 广州 510515Department of Thoracic Surgery, Southern Hospital, Southern Medical University, Guangzhou 510515, China
| | - 南波 刘
- />南方医科大学附属南方医院惠侨医疗中心胸外科,广东 广州 510515Department of Thoracic Surgery, Southern Hospital, Southern Medical University, Guangzhou 510515, China
| | - 煜凡 刘
- />南方医科大学附属南方医院惠侨医疗中心胸外科,广东 广州 510515Department of Thoracic Surgery, Southern Hospital, Southern Medical University, Guangzhou 510515, China
| | - 军花 张
- />南方医科大学附属南方医院惠侨医疗中心胸外科,广东 广州 510515Department of Thoracic Surgery, Southern Hospital, Southern Medical University, Guangzhou 510515, China
| | - 旭 吴
- />南方医科大学附属南方医院惠侨医疗中心胸外科,广东 广州 510515Department of Thoracic Surgery, Southern Hospital, Southern Medical University, Guangzhou 510515, China
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66
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Seesing MFJ, Goense L, Ruurda JP, Luyer MDP, Nieuwenhuijzen GAP, van Hillegersberg R. Minimally invasive esophagectomy: a propensity score-matched analysis of semiprone versus prone position. Surg Endosc 2017; 32:2758-2765. [PMID: 29209832 PMCID: PMC5956092 DOI: 10.1007/s00464-017-5975-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 11/03/2017] [Indexed: 12/11/2022]
Abstract
Background The preferred surgical approach for esophageal cancer is a minimally invasive transthoracic esophagectomy with a two-field lymph node dissection. The thoracoscopic phase may be performed either in prone- or in left lateral decubitus (LLD) position. Prone positioning has been associated with better pulmonary outcomes compared to LLD positioning; however, conversion to a classic thoracotomy is more difficult. The semiprone position has been proposed as an alternative approach. Methods A retrospective review of a prospectively maintained database (2008–2014) was performed to compare postoperative complications, surgical radicality, and lymph node yield between patients who underwent three-stage minimally invasive transthoracic esophagectomy in either the prone or semiprone position. Comparative analyses were conducted before and after propensity score matching. Results One hundred and twenty-one patients were included. In total, 82 patients underwent minimally invasive esophagectomy (MIE) in semiprone position and 39 patients in prone position. After propensity score matching, both groups consisted of 39 patients. The operative time in the semiprone group was longer (368 vs. 225 min, P < 0.001) and in this group the lymph node yield was significantly higher (16 (range 6–80) vs. 13 (range 3–33), P = 0.019). There were no statistically significant differences regarding radical resections, postoperative complications, and hospital stay. Conclusion The use of semiprone positioning in MIE is safe, feasible, and at least comparable to MIE in prone position in terms of oncological clearance and postoperative complications.
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Affiliation(s)
- Maarten F. J. Seesing
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Lucas Goense
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Jelle P. Ruurda
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Misha D. P. Luyer
- Department of Surgery, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | | | - Richard van Hillegersberg
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA Utrecht, The Netherlands
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67
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Schröder W, Lambertz R, van Hillegesberger R, Bruns C. [Differentiated surgical approach for adenocarcinoma of the gastroesophageal junction]. Chirurg 2017; 88:1010-1016. [PMID: 29098306 DOI: 10.1007/s00104-017-0544-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
For adenocarcinoma of the gastroesophageal junction (GEJ) the classification of Siewert with its three subtypes is well established as a practical approach to surgical treatment. Transthoracic esophagectomy with gastric tube formation is generally accepted as the surgical standard for adenocarcinoma of the distal esophagus (GEJ type I). Intrathoracic esophagogastrostomy has become the most frequently used anastomotic technique (Ivor Lewis esophagectomy). Both the abdominal and thoracic part can be safely performed with a minimally invasive access. For subcardiac gastric cancer (GEJ type III) transhiatal extended gastrectomy is the resection of choice. For true cardiac carcinomas (GEJ type II) it has not yet been decided which of the abovementioned surgical procedures offers the best long-term survival. If technically possible in terms of a complete resection, transhiatal extended gastrectomy should be preferred because of a better postoperative quality of life. For GEJ type II tumors a minimally invasive approach is not recommended if the extent of resection cannot be safely determined preoperatively.
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Affiliation(s)
- W Schröder
- Klinik und Poliklinik für Allgemein‑, Viszeral- und Tumorchirurgie, Universitätsklinik Köln, Kerpener Str. 62, 90933, Köln, Deutschland.
| | - R Lambertz
- Klinik und Poliklinik für Allgemein‑, Viszeral- und Tumorchirurgie, Universitätsklinik Köln, Kerpener Str. 62, 90933, Köln, Deutschland
| | | | - C Bruns
- Klinik und Poliklinik für Allgemein‑, Viszeral- und Tumorchirurgie, Universitätsklinik Köln, Kerpener Str. 62, 90933, Köln, Deutschland
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68
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Taurchini M, Cuttitta A. Minimally invasive and robotic esophagectomy: state of the art. J Vis Surg 2017; 3:125. [PMID: 29078685 PMCID: PMC5639027 DOI: 10.21037/jovs.2017.08.23] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 08/28/2017] [Indexed: 12/12/2022]
Abstract
Esophageal cancer is the eight most common cancer in the world and surgical resection remains the gold standard not only in providing the optimal chance for cure but also the best palliation for dysphagia. Esophagectomy is a complex operation and is associated with significant morbidity and mortality that are reported as 23-50% and 2-8% in western country. At the moment no gold standard techniques exist for esophagectomy. The choice of the technique depends on several factors; location of tumor and surgeon's experience are probably the most relevant. Minimally invasive esophagectomy (MIE), performed in high volume centers, has shown to reduce the rate of complications with the same oncological outcome as open esophagectomy. The addition of robotic technique to MIE is relatively new and is gaining widespread acceptance. Robotic assisted minimally invasive esophagectomy (RAMIE) is safe and feasible, and its short-term results are comparable to conventional MIE. Randomized studies are needed to assess if there is any real benefit associated to the use of the robotic approach.
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Affiliation(s)
- Marco Taurchini
- Unit of Thoracic Surgery, Casa Sollievo della Sofferenza Hospital, IRCCS, San Giovanni Rotondo, Italy
| | - Antonello Cuttitta
- Unit of Thoracic Surgery, Casa Sollievo della Sofferenza Hospital, IRCCS, San Giovanni Rotondo, Italy
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69
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Jezerskyte E, van Berge Henegouwen MI, Cuesta MA, Gisbertz SS. Gastro-esophageal junction cancers: what is the best minimally invasive approach? J Thorac Dis 2017; 9:S751-S760. [PMID: 28815071 DOI: 10.21037/jtd.2017.06.56] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The short-term advantages of minimally invasive esophagectomy (MIE) in terms of less morbidity and better quality of life (QoL) in comparison with open esophagectomy (OE) became visible in the last few years. There are two main MIE approaches: a transthoracic esophagectomy (TTE) (either accompanied by an intrathoracic or cervical anastomosis) or a transhiatal esophagectomy (THE) (accompanied by a cervical anastomosis). Additionally, minimally invasive gastrectomy is increasingly gaining popularity over open gastrectomy. Controversy still exists about what approach is the best for esophagogastric junction tumors (EGJ) and the choice of the approach is currently based on the surgeons' discretion. In this study, we describe the definition, staging and classification, indications for each minimally invasive approach for EGJ tumors, the surgical technique, current developments and problems regarding surgical treatment for patients with cancer of the EGJ.
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Affiliation(s)
- Egle Jezerskyte
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | | | - Miguel A Cuesta
- Department of Surgery, VU University Medical Center, Amsterdam, The Netherlands
| | - Suzanne S Gisbertz
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
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70
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Surgical approaches to adenocarcinoma of the gastroesophageal junction: the Siewert II conundrum. Langenbecks Arch Surg 2017; 402:1153-1158. [PMID: 28803334 DOI: 10.1007/s00423-017-1610-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 07/19/2017] [Indexed: 01/23/2023]
Abstract
BACKGROUND The Siewert classification system for gastroesophageal junction adenocarcinoma has provided morphological and topographical information to help guide surgical decision-making. Evidence has shown that Siewert I and III tumors are distinct entities with differing epidemiologic and histologic characteristics and distinct patterns of disease progression, requiring different treatment. Siewert II tumors share some of the characteristics of type I and III lesions, and the surgical approach is not universally agreed upon. Appropriate surgical options include transthoracic esophagogastrectomy, transhiatal esophagectomy, and transabdominal extended total gastrectomy. PURPOSE A review of the available evidence of the surgical management of Siewert II tumors is presented. CONCLUSIONS Careful review of the data appear to support the fact that a satisfactory oncologic resection can be achieved via a transabdominal extended total gastrectomy with a slight advantage in terms of perioperative complications, and overall postoperative quality of life. Overall and disease-free survival compares favorably to the transthoracic approach. These results can be achieved with careful selection of patients balancing more than just the Siewert type in the decision-making but considering also preoperative T and N stages, histological type (diffuse type requiring longer margins that are not always achievable via gastrectomy), and the presence of Barrett's esophagus.
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71
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van Workum F, Berkelmans GH, Klarenbeek BR, Nieuwenhuijzen GAP, Luyer MDP, Rosman C. McKeown or Ivor Lewis totally minimally invasive esophagectomy for cancer of the esophagus and gastroesophageal junction: systematic review and meta-analysis. J Thorac Dis 2017; 9:S826-S833. [PMID: 28815080 DOI: 10.21037/jtd.2017.03.173] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Minimally invasive esophagectomy (MIE) has consistently been associated with improved perioperative outcome and similar oncological safety compared to open esophagectomy. However, it is currently unclear what type of MIE is preferred for patients with resectable esophageal cancer. METHODS Literature was searched in Medline, Embase and the Cochrane library combining relevant search terms. Articles that included patients undergoing totally minimally invasive esophagectomy (TMIE) or hybrid minimally invasive esophagectomy (HMIE) and compared McKeown with Ivor Lewis procedures were included. Studies were excluded if they included >10% of patients undergoing a procedure other than MIE McKeown or MIE Ivor Lewis (i.e., transhiatal resections). The primary outcome parameter was anastomotic leakage. Secondary outcome parameters were: other complications, reinterventions, reoperations, hospital length of stay, ICU length of stay, postoperative mortality, operative time, blood loss, R0 resection rate, lymph nodes examined, quality of life and costs. RESULTS Five studies with a total of 1,681 patients undergoing TMIE were included. There were no studies comparing HMIE McKeown versus HMIE Ivor Lewis. There were no randomized controlled trials and all included studies were cohort studies with a moderate risk of bias. No meta-analysis could be performed for R0 resection rate, survival, quality of life and costs because there was insufficient data available for these parameters. The incidence of anastomotic leakage did not differ between the groups [relative risk (RR) =1.39, 95% confidence interval (CI) =0.90-10.38, P=0.14]. TMIE Ivor Lewis was associated with a lower incidence of recurrent laryngeal nerve (RLN) trauma (RR =6.70, 95% CI =3.09-14.55, P<0.001), a shorter hospital length of stay [standardized mean difference (SMD) =0.17, 95% CI =0.06-0.28, P=0.002] and less blood loss (SMD =0.69, 95% CI =0.25-1.12, P=0.002). CONCLUSIONS TMIE Ivor Lewis is associated with improved outcome regarding RLN trauma, hospital length of stay and blood loss as compared to TMIE-McKeown, but the incidence of anastomotic leakage is not different. The evidence is limited, of low quality and at risk for bias. A randomized controlled trial is currently being performed in order to demonstrate whether a McKeown or Ivor Lewis procedure should be preferred in patients undergoing MIE.
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Affiliation(s)
| | - Gijs H Berkelmans
- Department of surgery, Catharina hospital, Eindhoven, the Netherlands
| | | | | | - Misha D P Luyer
- Department of surgery, Catharina hospital, Eindhoven, the Netherlands
| | - Camiel Rosman
- Department of surgery, Radboudumc, Nijmegen, the Netherlands
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72
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Bonavina L, Asti E, Sironi A, Bernardi D, Aiolfi A. Hybrid and total minimally invasive esophagectomy: how I do it. J Thorac Dis 2017; 9:S761-S772. [PMID: 28815072 DOI: 10.21037/jtd.2017.06.55] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Esophagectomy is a major surgical procedure associated with a significant risk of morbidity and mortality. Minimally invasive esophagectomy is becoming the preferred approach because of the potential to limit surgical trauma, reduce respiratory complications, and promote earlier functional recovery. Various hybrid and total minimally invasive surgical techniques have been introduced in clinical practice over the past 20 years, and minimally invasive esophagectomy has been shown equivalent to open surgery concerning the short-term outcomes. Implementation of a minimally invasive esophagectomy program is technically demanding and requires a significant learning curve and the infrastructure of a dedicated multidisciplinary center where optimal staging, individualized therapy, and perioperative care can be provided to the patient. Both hybrid and total minimally invasive techniques of esophagectomy have proven safe and effective in expert centers. The choice of the surgical approach should be driven by preoperative staging, tumor site and histology, comorbidity, patient's anatomy and physiological status, and surgeon's experience.
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Affiliation(s)
- Luigi Bonavina
- Division of General Surgery, Department of Biomedical Sciences for Health, University of Milan, IRCCS Policlinico San Donato, Milan, Italy
| | - Emanuele Asti
- Division of General Surgery, Department of Biomedical Sciences for Health, University of Milan, IRCCS Policlinico San Donato, Milan, Italy
| | - Andrea Sironi
- Division of General Surgery, Department of Biomedical Sciences for Health, University of Milan, IRCCS Policlinico San Donato, Milan, Italy
| | - Daniele Bernardi
- Division of General Surgery, Department of Biomedical Sciences for Health, University of Milan, IRCCS Policlinico San Donato, Milan, Italy
| | - Alberto Aiolfi
- Division of General Surgery, Department of Biomedical Sciences for Health, University of Milan, IRCCS Policlinico San Donato, Milan, Italy
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73
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Charalabopoulos A, Lorenzi B, Kordzadeh A, Tang CB, Kadirkamanathan S, Jayanthi NV. Role of 3D in minimally invasive esophagectomy. Langenbecks Arch Surg 2017; 402:555-561. [DOI: 10.1007/s00423-017-1570-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 02/13/2017] [Indexed: 01/19/2023]
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74
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Hybrid minimally invasive esophagectomy vs. open esophagectomy: a matched case analysis in 120 patients. Langenbecks Arch Surg 2017; 402:323-331. [PMID: 28083680 DOI: 10.1007/s00423-017-1550-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 01/01/2017] [Indexed: 02/06/2023]
Abstract
PURPOSE In esophageal surgery, total minimally invasive techniques compete with hybrid and robot-assisted procedures. The benefit of the individual techniques for the patient remains vague. At our institution, the hybrid minimally invasive laparoscopic-thoracotomic esophagectomy (HMIE) has been routinely applied since 2013. We conducted this retrospective study to analyze the perioperative outcome. METHODS Since 2013, 60 patients were operated in HMIE technique for esophageal cancer. Each of these patients was paired according to the criteria of gender, BMI, age, tumor histology, pulmonary preexisting conditions, and a history of smoking with a patient treated by open esophagectomy (OE). Perioperative parameters were extracted from our prospectively maintained database and compared among the groups. RESULTS The HMIE and OE groups were homogeneous in terms of patient- and tumor-related data. There was no difference in lymph nodes harvested (22 vs. 20, p = 0.459) and R0-resection rate (95 vs. 93%, p = 0.500). The operation time for the HMIE was significantly shorter (329 vs. 407 min, p < 0.001). There was no difference between the groups with respect to surgical complications (37 vs. 37%, p = 0.575), but the patients undergoing hybrid technique showed more delayed gastric emptying (23 vs. 10%, p = 0.042). Pulmonary morbidity was significantly reduced after HMIE (20 vs. 42%, p = 0.009). This affected both the occurrence of pneumonia and pleural effusions. The difference in the overall complication rate was not significant (50 vs. 60%, p = 0.179), but life-threatening complications (Clavien/Dindo 4/5) were less frequent (2 vs. 12%, p = 0.031). Overall, there was significantly less need for transfusion after HMIE (18 vs. 50%, p < 0.001), and hospital (and IMC) stay was significantly shorter (14 (6) vs. 18 (7) days, p = 0.002 (0.003)). The multivariate analysis confirms the surgical procedure as an independent risk factor for the development of pulmonary complications (OR 3.2, p = 0.011). Furthermore, preexisting pulmonary conditions were identified as a risk factor (OR 3.6, p = 0.006). CONCLUSION Our retrospective analysis shows that reduction of postoperative pulmonary morbidity, perioperative blood loss, and shortening of hospital stay can be achieved by HMIE. The procedure is safe, and the rate of surgical complications and oncological radicality is comparable to the conventional procedure.
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75
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van Workum F, Bouwense SAW, Luyer MDP, Nieuwenhuijzen GAP, van der Peet DL, Daams F, Kouwenhoven EA, van Det MJ, van den Wildenberg FJH, Polat F, Gisbertz SS, Henegouwen MIVB, Heisterkamp J, Langenhoff BS, Martijnse IS, Grutters JP, Klarenbeek BR, Rovers MM, Rosman C. Intrathoracic versus Cervical ANastomosis after minimally invasive esophagectomy for esophageal cancer: study protocol of the ICAN randomized controlled trial. Trials 2016; 17:505. [PMID: 27756419 PMCID: PMC5069944 DOI: 10.1186/s13063-016-1636-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Accepted: 10/03/2016] [Indexed: 12/29/2022] Open
Abstract
Background Currently, a cervical esophagogastric anastomosis (CEA) is often performed after minimally invasive esophagectomy (MIE). However, the CEA is associated with a considerable incidence of anastomotic leakage requiring reintervention or reoperation and moderate functional results. An intrathoracic esophagogastric anastomosis (IEA) might reduce the incidence of anastomotic leakage, improve functional results and reduce costs. The objective of the ICAN trial is to compare anastomotic leakage and postoperative morbidity, mortality, quality of life and cost-effectiveness between CEA and IEA after MIE. Methods/design The ICAN trial is an open randomized controlled multicentre superiority trial, comparing CEA (control group) with IEA (intervention group) after MIE. All patients with esophageal cancer planning to undergo curative MIE are considered for inclusion. A total of 200 patients will be included in the study and randomized between the groups in a 1:1 ratio. The primary outcome is anastomotic leakage requiring reintervention or reoperation, and secondary outcomes are (amongst others) other postoperative complications, new onset of organ failure, length of stay, mortality, benign strictures requiring dilatation, quality of life and cost-effectiveness. Discussion We hypothesize that an IEA after MIE is associated with a lower incidence of anastomotic leakage requiring reintervention or reoperation than a CEA. The trial is also designed to give answers to additional research questions regarding a possible difference in functional outcome, quality of life and cost-effectiveness. Trial registration Netherlands Trial Register: NTR4333. Registered on 23 December 2013.
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Affiliation(s)
- Frans van Workum
- Department of Surgery, Radboudumc, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Stefan A W Bouwense
- Department of Surgery, Radboudumc, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Misha D P Luyer
- Department of Surgery, Catharina Hospital, PO Box 1350, 5602 ZA, Eindhoven, The Netherlands
| | | | - Donald L van der Peet
- Department of Surgery, VU University Medical Centre, PO Box 7057, 1007 MB, Amsterdam, The Netherlands
| | - Freek Daams
- Department of Surgery, VU University Medical Centre, PO Box 7057, 1007 MB, Amsterdam, The Netherlands
| | - Ewout A Kouwenhoven
- Department of Surgery, Ziekenhuisgroep Twente, PO Box 7600, 7600 SZ, Almelo, The Netherlands
| | - Marc J van Det
- Department of Surgery, Ziekenhuisgroep Twente, PO Box 7600, 7600 SZ, Almelo, The Netherlands
| | | | - Fatih Polat
- Department of Surgery, Canisius-Wilhelmina Hospital, PO Box 9015, 6500 GS, Nijmegen, The Netherlands
| | - Suzanne S Gisbertz
- Department of Surgery, Academic Medical Centre, PO Box 22660, 1100 DD, Amsterdam, The Netherlands
| | | | - Joos Heisterkamp
- Department of Surgery, Elisabeth-Tweesteden Hospital, PO Box 90151, 5000 LC, Tilburg, The Netherlands
| | - Barbara S Langenhoff
- Department of Surgery, Elisabeth-Tweesteden Hospital, PO Box 90151, 5000 LC, Tilburg, The Netherlands
| | - Ingrid S Martijnse
- Department of Surgery, Elisabeth-Tweesteden Hospital, PO Box 90151, 5000 LC, Tilburg, The Netherlands
| | - Janneke P Grutters
- Department of Health Evidence, Radboudumc, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| | | | - Maroeska M Rovers
- Department of Health Evidence, Radboudumc, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Camiel Rosman
- Department of Surgery, Radboudumc, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
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76
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Goense L, van Rossum PSN, Kandioler D, Ruurda JP, Goh KL, Luyer MD, Krasna MJ, van Hillegersberg R. Stage-directed individualized therapy in esophageal cancer. Ann N Y Acad Sci 2016; 1381:50-65. [PMID: 27384385 DOI: 10.1111/nyas.13113] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 05/05/2016] [Indexed: 12/16/2022]
Abstract
Esophageal cancer is the eighth most common cancer worldwide, and the incidence of esophageal carcinoma is rapidly increasing. With the advent of new staging and treatment techniques, esophageal cancer can now be managed through various strategies. A good understanding of the advances and limitations of new staging techniques and how these can guide in individualizing treatment is important to improve outcomes for esophageal cancer patients. This paper outlines the recent progress in staging and treatment of esophageal cancer, with particularly attention to endoscopic techniques for early-stage esophageal cancer, multimodality treatment for locally advanced esophageal cancer, assessment of response to neoadjuvant treatment, and the role of cervical lymph node dissection. Furthermore, advances in robot-assisted surgical techniques and postoperative recovery protocols that may further improve outcomes after esophagectomy are discussed.
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Affiliation(s)
- Lucas Goense
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands.,Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Peter S N van Rossum
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands.,Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Daniela Kandioler
- Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Jelle P Ruurda
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Khean-Lee Goh
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Misha D Luyer
- Department of Surgery, Catharina Hospital Eindhoven, Eindhoven, the Netherlands
| | - Mark J Krasna
- Meridian Cancer Care, Jersey Shore University Medical Center, Neptune, New Jersey
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