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Nuytens F, Lenne X, Clément G, Bruandet A, Eveno C, Piessen G. Effect of Phased Implementation of Totally Minimally Invasive Ivor Lewis Esophagectomy for Esophageal Cancer after Previous Adoption of the Hybrid Minimally Invasive Technique: Results from a French Nationwide Population-Based Cohort Study. Ann Surg Oncol 2021; 29:2791-2801. [PMID: 34837133 DOI: 10.1245/s10434-021-11110-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 10/01/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Several randomized controlled trials (RCTs) have demonstrated improved short-term outcomes of totally minimally invasive esophagectomy (TMIE) compared with open esophagectomy (OE); however, to what extent these outcomes can be extrapolated to a national level remains debatable. OBJECTIVE The aim of this study was to evaluate, on a nationwide basis, the short-term outcomes of TMIE and to analyze these results within the context of previously implemented hybrid minimally invasive esophagectomy (HMIE). METHODS All consecutive patients who underwent a curative Ivor Lewis esophagectomy in France between 2017 and 2019 were included in this retrospective cohort study. The primary endpoint was to compare 90-day postoperative mortality (POM) between OE, HMIE, and TMIE, while secondary endpoints were defined as the rate of postoperative complications. A matched and multivariate analysis was adjusted for confounding factors. RESULTS Overall, 2675 patients were included (1003 OE vs. 1498 HMIE vs. 174 TMIE). In every center where TMIE was performed, HMIE had been previously adopted. The matched 90-day POM rate in the TMIE group was significantly lower compared with the OE group (2.3% vs. 6.3%, p = 0.046) but not compared with the HMIE group (2.3% vs. 4.9%, p = 0.156). There was no significant difference between TMIE and OE, or TMIE and HMIE, regarding the 30-day fistula rate (21.8% vs. 17%, p = 0.176; and 21.8% vs. 21.3%, p = 0.88, respectively). TMIE was associated with a reduced rate of pulmonary complications compared with OE (33.9% vs. 44%, p = 0.027) and HMIE (33.9% vs. 42.8%, p = 0.05). Low-volume centers were identified as a negative predictive factor for 90-day POM (odds ratio 1.89, 95% confidence interval 1.3-2.75, p = 0.001). CONCLUSION TMIE is associated with a lower 90-day POM rate compared with OE and offers reduced rates of pulmonary complications compared with OE and HMIE. After previous adoption of the HMIE technique, TMIE can be safely implemented in high-volume centers nationwide.
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Affiliation(s)
- Frederiek Nuytens
- Department of Digestive and Oncological Surgery, Claude Huriez University Hospital, University Lille, Lille, France. .,Department of Digestive and Hepatobiliary/Pancreatic Surgery, AZ Groeninge Hospital, Kortrijk, Belgium.
| | - Xavier Lenne
- Medical Information Department, Lille University Hospital, Lille, France.,ULR 2694 - METRICS: Evaluation des technologies de sante et des pratiques médicales, University Lille, CHU Lille, Lille, France
| | - Guillaume Clément
- Medical Information Department, Lille University Hospital, Lille, France
| | - Amelie Bruandet
- Medical Information Department, Lille University Hospital, Lille, France.,ULR 2694 - METRICS: Evaluation des technologies de sante et des pratiques médicales, University Lille, CHU Lille, Lille, France
| | - Clarisse Eveno
- Department of Digestive and Oncological Surgery, Claude Huriez University Hospital, University Lille, Lille, France.,UMR9020-U1277 - CANTHER - Cancer Heterogeneity, Plasticity and Resistance to Therapies, University Lille, CNRS, Inserm, CHU Lille, Lille, France
| | - Guillaume Piessen
- Department of Digestive and Oncological Surgery, Claude Huriez University Hospital, University Lille, Lille, France.,UMR9020-U1277 - CANTHER - Cancer Heterogeneity, Plasticity and Resistance to Therapies, University Lille, CNRS, Inserm, CHU Lille, Lille, France
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Nuytens F, Lenne X, Clément G, Bruandet A, Eveno C, Piessen G. ASO Author Reflections: The Hybrid Technique as a Guide in the Transition from Open to Totally Minimally Invasive Esophagectomy-Lessons from a Nationwide Population-Based Study. Ann Surg Oncol 2021; 29:2802-2803. [PMID: 34812984 DOI: 10.1245/s10434-021-11114-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 10/25/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Frederiek Nuytens
- University Lille, Department of Digestive and Oncological Surgery, Claude Huriez University Hospital, CHU de Lille, Lille, France. .,Department of Digestive and Hepatobiliary/Pancreatic Surgery, AZ Groeninge Hospital, Kortrijk, Belgium.
| | - Xavier Lenne
- Medical Information Department, Lille University Hospital, Lille, France.,Univ. Lille, CHU Lille, ULR 2694 - METRICS : Evaluation des technologies de sante et des pratiques médicales, Lille, France
| | - Guillaume Clément
- Medical Information Department, Lille University Hospital, Lille, France
| | - Amelie Bruandet
- Medical Information Department, Lille University Hospital, Lille, France.,Univ. Lille, CHU Lille, ULR 2694 - METRICS : Evaluation des technologies de sante et des pratiques médicales, Lille, France
| | - Clarisse Eveno
- University Lille, Department of Digestive and Oncological Surgery, Claude Huriez University Hospital, CHU de Lille, Lille, France.,University Lille, CNRS, Inserm, CHU Lille, UMR9020-U1277 - CANTHER - Cancer Heterogeneity, Plasticity and Resistance to Therapies, Lille, France
| | - Guillaume Piessen
- University Lille, Department of Digestive and Oncological Surgery, Claude Huriez University Hospital, CHU de Lille, Lille, France.,University Lille, CNRS, Inserm, CHU Lille, UMR9020-U1277 - CANTHER - Cancer Heterogeneity, Plasticity and Resistance to Therapies, Lille, France
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Schröder W, Gisbertz SS, Voeten DM, Gutschow CA, Fuchs HF, van Berge Henegouwen MI. Surgical Therapy of Esophageal Adenocarcinoma-Current Standards and Future Perspectives. Cancers (Basel) 2021; 13:5834. [PMID: 34830988 PMCID: PMC8616112 DOI: 10.3390/cancers13225834] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 11/15/2021] [Accepted: 11/18/2021] [Indexed: 12/18/2022] Open
Abstract
Transthoracic esophagectomy is currently the predominant curative treatment option for resectable esophageal adenocarcinoma. The majority of carcinomas present as locally advanced tumors requiring multimodal strategies with either neoadjuvant chemoradiotherapy or perioperative chemotherapy alone. Minimally invasive, including robotic, techniques are increasingly applied with a broad spectrum of technical variations existing for the oncological resection as well as gastric reconstruction. At the present, intrathoracic esophagogastrostomy is the preferred technique of reconstruction (Ivor Lewis esophagectomy). With standardized surgical procedures, a complete resection of the primary tumor can be achieved in almost 95% of patients. Even in expert centers, postoperative morbidity remains high, with an overall complication rate of 50-60%, whereas 30- and 90-day mortality are reported to be <2% and <6%, respectively. Due to the complexity of transthoracic esophagetomy and its associated morbidity, esophageal surgery is recommended to be performed in specialized centers with an appropriate caseload yet to be defined. In order to reduce postoperative morbidity, the selection of patients, preoperative rehabilitation and postoperative fast-track concepts are feasible strategies of perioperative management. Future directives aim to further centralize esophageal services, to individualize surgical treatment for high-risk patients and to implement intraoperative imaging modalities modifying the oncological extent of resection and facilitating surgical reconstruction.
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Affiliation(s)
- Wolfgang Schröder
- Department of General, Visceral, Cancer and Transplantation Surgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, 50937 Cologne, Germany;
| | - Suzanne S. Gisbertz
- Cancer Center Amsterdam, Department of Surgery, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (S.S.G.); (D.M.V.); (M.I.v.B.H.)
| | - Daan M. Voeten
- Cancer Center Amsterdam, Department of Surgery, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (S.S.G.); (D.M.V.); (M.I.v.B.H.)
| | - Christian A. Gutschow
- Department of General and Transplantation Surgery, University Hospital Zurich, 8091 Zurich, Switzerland;
| | - Hans F. Fuchs
- Department of General, Visceral, Cancer and Transplantation Surgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, 50937 Cologne, Germany;
| | - Mark I. van Berge Henegouwen
- Cancer Center Amsterdam, Department of Surgery, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (S.S.G.); (D.M.V.); (M.I.v.B.H.)
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204
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van der Sluis PC, Babic B, Uzun E, Tagkalos E, Berlth F, Hadzijusufovic E, Lang H, Gockel I, van Hillegersberg R, Grimminger PP. Robot-assisted and conventional minimally invasive esophagectomy are associated with better postoperative results compared to hybrid and open transthoracic esophagectomy. Eur J Surg Oncol 2021; 48:776-782. [PMID: 34838394 DOI: 10.1016/j.ejso.2021.11.121] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 11/16/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Currently 4 surgical techniques are performed for transthoracic esophagectomy (open esophagectomy (OE), hybrid esophagectomy (HE), conventional minimally invasive esophagectomy (MIE) and robot assisted minimally invasive esophagectomy (RAMIE). Aim of this study was to compare these 4 different esophagectomy approaches regarding postoperative complications and short term oncologic outcomes. METHODS Between 2008 and 2019, consecutive patients who underwent esophagectomy with gastric conduit reconstruction were included in this single center study. The primary outcome of this study was the incidence of postoperative complications. RESULTS Overall 422 patients (OE (n = 107), HE (n = 101), MIE (n = 91) and RAMIE (n = 123)) were evaluated. Uncomplicated postoperative course was observed in 27% (OE), 34% (HE), 53% (MIE), and 63% (RAMIE) of patients (p < 0.001). Pulmonary complications were observed in 57% (OE), 44% (HE), 28% (MIE), and 21% (RAMIE) of patients (p < 0.001). Cardiac complications were present in 25% (OE), 23% (HE), 9% (MIE), and 11% (RAMIE) of patients (p < 0.001). MIE and RAMIE were associated with fewer wound infections (p < 0.001). Median hospital stay after MIE (13 days) and RAMIE (12 days) was shorter compared to OE (20 days) and HE (17 days) (p < 0.001). A median number of 21 (OE), 23 (HE), 23 (MIE), and 31 (RAMIE) lymph nodes was harvested (p < 0.001). CONCLUSION Total minimally invasive esophagectomy (MIE, RAMIE) was associated with a lower overall, pulmonary, cardiac and wound complication rate as well as a shorter hospital stay compared to open or hybrid approach (OE, HE). RAMIE resulted in higher lymph node harvest than MIE.
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Affiliation(s)
- Pieter C van der Sluis
- Department of General-, Visceral- and Transplant Surgery, UNIVERSITY MEDICAL CENTER of the Johannes Gutenberg University, Mainz, Germany
| | - Bejamin Babic
- Department of General-, Visceral- and Transplant Surgery, UNIVERSITY MEDICAL CENTER of the Johannes Gutenberg University, Mainz, Germany
| | - Eren Uzun
- Department of General-, Visceral- and Transplant Surgery, UNIVERSITY MEDICAL CENTER of the Johannes Gutenberg University, Mainz, Germany
| | - E Tagkalos
- Department of General-, Visceral- and Transplant Surgery, UNIVERSITY MEDICAL CENTER of the Johannes Gutenberg University, Mainz, Germany
| | - Felix Berlth
- Department of General-, Visceral- and Transplant Surgery, UNIVERSITY MEDICAL CENTER of the Johannes Gutenberg University, Mainz, Germany
| | - Edin Hadzijusufovic
- Department of General-, Visceral- and Transplant Surgery, UNIVERSITY MEDICAL CENTER of the Johannes Gutenberg University, Mainz, Germany
| | - Hauke Lang
- Department of General-, Visceral- and Transplant Surgery, UNIVERSITY MEDICAL CENTER of the Johannes Gutenberg University, Mainz, Germany
| | - Ines Gockel
- Department of Visceral, Transplant-, Thoracic- and Vascular Surgery, Department of Operative Medicine (DOPM), University Hospital of Leipzig, Leipzig, Germany
| | | | - Peter P Grimminger
- Department of General-, Visceral- and Transplant Surgery, UNIVERSITY MEDICAL CENTER of the Johannes Gutenberg University, Mainz, Germany.
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205
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Yan MH, Liu F, Qu BL, Cai BN, Yu W, Dai XK. Induction chemotherapy with albumin-bound paclitaxel plus lobaplatin followed by concurrent radiochemotherapy for locally advanced esophageal cancer. World J Gastrointest Oncol 2021; 13:1781-1790. [PMID: 34853650 PMCID: PMC8603460 DOI: 10.4251/wjgo.v13.i11.1781] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 07/18/2021] [Accepted: 08/23/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Albumin-bound paclitaxel (ABP) has been used as second- and higher-line treatments for advanced esophageal cancer, and its efficacy and safety have been well demonstrated. Lobaplatin (LBP) is a third-generation platinum antitumor agent; compared with the first two generations of platinum agents, it has lower toxicity and has been approved for the treatment of breast cancer, small cell lung cancer, and chronic granulocytic leukemia. However, its role in the treatment of esophageal cancer warrants further investigations.
AIM To investigate the efficacy and safety of induction chemotherapy with ABP plus LBP followed by concurrent radiochemotherapy (RCT) for locally advanced esophageal cancer.
METHODS Patients with pathologically confirmed advanced esophageal squamous cell carcinoma (ESCC) at our hospital were enrolled in this study. All patients were treated with two cycles of induction chemotherapy with ABP plus LBP followed by concurrent RCT: ABP 250 mg/m2, ivgtt, 30 min, d1, every 3 wk; and LBP, 30 mg/m2, ivgtt, 2 h, d1, every 3 wk. A total of four cycles were scheduled. The dose of the concurrent radiotherapy was 56-60 Gy/28-30 fractions, 1.8-2.0 Gy/fraction, and 5 fractions/wk.
RESULTS A total of 29 patients were included, and 26 of them completed the treatment protocol. After the induction chemotherapy, the objective response rate (ORR) was 61.54%, the disease control rate (DCR) was 88.46%, and the progressive disease (PD) rate was 11.54%; after the concurrent RCT, the ORR was 76.92%, the DCR was 88.46%, and the PD rate was 11.54%. The median progression-free survival was 11.1 mo and the median overall survival was 15.83 mo. Cox multivariate analysis revealed that two cycles of induction chemotherapy followed by concurrent RCT significantly reduced the risk of PD compared with two cycles of chemotherapy alone (P = 0.0024). Non-hematologic toxicities were tolerable, and the only grade 3 non-hematologic toxicity was radiation-induced esophagitis (13.79%). The main hematologic toxicity was neutropenia, and no grade 4 adverse event occurred.
CONCLUSION Induction chemotherapy with ABP plus LBP followed by concurrent RCT is effective in patients with locally advanced ESCC, with mild adverse effects. Thus, this protocol is worthy of clinical promotion and application.
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Affiliation(s)
- Mao-Hui Yan
- Department of Radiotherapy, The First Medical Center of the Chinese People's Liberation Army (PLA) General Hospital, Beijing 100853, China
| | - Fang Liu
- Department of Radiotherapy, The First Medical Center of the Chinese People's Liberation Army (PLA) General Hospital, Beijing 100853, China
| | - Bao-Lin Qu
- Department of Radiotherapy, The First Medical Center of the Chinese People's Liberation Army (PLA) General Hospital, Beijing 100853, China
| | - Bo-Ning Cai
- Department of Radiotherapy, The First Medical Center of the Chinese People's Liberation Army (PLA) General Hospital, Beijing 100853, China
| | - Wei Yu
- Department of Radiotherapy, The First Medical Center of the Chinese People's Liberation Army (PLA) General Hospital, Beijing 100853, China
| | - Xiang-Kun Dai
- Department of Radiotherapy, The First Medical Center of the Chinese People's Liberation Army (PLA) General Hospital, Beijing 100853, China
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206
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Bartella I, Fransen LFC, Gutschow CA, Bruns CJ, van Berge Henegouwen ML, Chaudry MA, Cheong E, Cuesta MA, Van Daele E, Gisbertz SS, van Hillegersberg R, Hölscher A, Mercer S, Moorthy K, Nafteux P, Nilsson M, Pattyn P, Piessen G, Räsanen J, Rosman C, Ruurda JP, Schneider PM, Sgromo B, Nieuwenhuijzen GA, Luyer MDP, Schröder W. Technique of open and minimally invasive intrathoracic reconstruction following esophagectomy-an expert consensus based on a modified Delphi process. Dis Esophagus 2021; 34:6102597. [PMID: 33846718 DOI: 10.1093/dote/doaa127] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 10/11/2020] [Accepted: 11/21/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND In recent years, minimally invasive Ivor Lewis (IL) esophagectomy with high intrathoracic anastomosis has emerged as surgical standard of care for esophageal cancer in expert centers. Alongside this process, many divergent technical aspects of this procedure have been devised in different centers. This study aims at achieving international consensus on the surgical steps of IL reconstruction using Delphi methodology. METHODS The expert panel consisted of specialized esophageal surgeons from 8 European countries. During a two-round Delphi process, a detailed analysis and consensus on key steps of intrathoracic gastric tube reconstruction (IL esophagectomy) was performed. RESULTS Response rates in Delphi rounds 1 and 2 were 100% (22 of 22 experts) and 83.3% (20 of 24 experts), respectively. Three essential technical areas of intrathoracic gastric tube reconstruction were identified: first, vascularization of the gastric conduit, second, gastric mobilization, tube formation and pull-up, and third, anastomotic technique. In addition, 3 main techniques for minimally invasive intrathoracic anastomosis are currently practiced: (i) end-to-side circular stapled, (ii) end-to-side double stapling, and (iii) side-to-side linear stapled technique. The step-by-step procedural analysis unveiled common approaches but also different expert practice. CONCLUSION This precise technical description may serve as a clinical guideline for intrathoracic reconstruction after esophagectomy. In addition, the results may aid to harmonize the technical evolution of this complex surgical procedure and thereby facilitate surgical training.
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Affiliation(s)
- Isabel Bartella
- Department of General, Visceral and Cancer Surgery, University Hospital Cologne, Cologne, Germany
| | - Laura F C Fransen
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - Christian A Gutschow
- Department of General and Transplantation Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Christiane J Bruns
- Department of General, Visceral and Cancer Surgery, University Hospital Cologne, Cologne, Germany
| | - Mark L van Berge Henegouwen
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - M Asif Chaudry
- Department of Surgery, The Royal Marsden Hospital, London, UK
| | - Edward Cheong
- Department of Upper GI Surgery, Norfolk and Norwich University Hospital, Norwich, UK
| | - Miguel A Cuesta
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Elke Van Daele
- Department of GI Surgery, University Hospital Ghent, Ghent, Belgium
| | - Suzanne S Gisbertz
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | | | - Arnulf Hölscher
- Center for Esophageal and Gastric Cancer Surgery, Markushospital Frankfurt, Frankfurt am Main, Germany
| | - Stuart Mercer
- Department of Upper GI Surgery, Queen Alexandra Hospital, Portsmouth, UK
| | - Krishna Moorthy
- Department of Surgery and Cancer, St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Philippe Nafteux
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Magnus Nilsson
- Department of Upper Abdominal Disease, Karolinska University Hospital, Stockholm, Sweden
| | - Piet Pattyn
- Department of GI Surgery, University Hospital Ghent, Ghent, Belgium
| | - Guillaume Piessen
- Department of Digestive and Oncological Surgery, Lille University Hospital, Lille, France
| | - Jari Räsanen
- Department of General Thoracic and Esophageal Surgery, Helsinki University Hospital, Helsinki, Finland
| | - Camiel Rosman
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Jelle P Ruurda
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Paul M Schneider
- Department of General and Transplantation Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Bruno Sgromo
- Department of Upper GI Surgery, Oxford University Hospitals, Oxford, UK
| | | | - Misha D P Luyer
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - Wolfgang Schröder
- Department of General, Visceral and Cancer Surgery, University Hospital Cologne, Cologne, Germany
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207
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Eyck BM, Klevebro F, van der Wilk BJ, Johar A, Wijnhoven BPL, van Lanschot JJB, Lagergren P, Markar SR, Lagarde SM. Lasting symptoms and long-term health-related quality of life after totally minimally invasive, hybrid and open Ivor Lewis esophagectomy. Eur J Surg Oncol 2021; 48:582-588. [PMID: 34763951 DOI: 10.1016/j.ejso.2021.10.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 10/12/2021] [Accepted: 10/24/2021] [Indexed: 11/28/2022] Open
Abstract
AIM Compared to open esophagectomy (OE), both totally minimally invasive (TMIE) and laparoscopy-assisted hybrid minimally invasive (HMIE) reduce postoperative morbidity and improve short-term health-related quality of life (HRQoL). We aimed to compare lasting symptoms and long-term HRQoL in an international population-based setting between patients who underwent Ivor Lewis TMIE, HMIE or OE. METHODS Patients who were relapse-free at least one year after TMIE, HMIE or OE for esophageal or junctional carcinoma between January 2010 and June 2016 were included. Patients completed the LASER questionnaire to assess lasting symptoms after esophagectomy and the EORTC QLQ-C30 and QLQ-OG25 questionnaires to assess HRQoL. Primary endpoint was chest pain and secondary endpoints were pain from chest scars or abdominal scars, abdominal pain, fatigue and physical functioning. Differences in lasting symptoms and HRQoL were assessed with multivariable logistic and ANCOVA regression, respectively. RESULTS A total of 362 patients were included (TMIE n = 91, HMIE n = 85, OE n = 186). Median follow-up was 3.9 years (IQR 2.8-5.4). Chest pain was reported less after TMIE compared with HMIE (adjusted OR 0.21, 95% CI 0.05-0.84), but was comparable between TMIE and OE (adjusted OR 0.41, 95% CI 0.12-1.41) and between HMIE and OE (adjusted OR 1.85, 95% CI 0.71-4.81). All secondary endpoints were comparable between TMIE, HMIE and OE. The impact of symptoms on taking medication, return to work, and performance status were comparable between groups. CONCLUSION Surgical technique seems to have little effect on lasting symptoms and long-term HRQoL after a median of four years after Ivor Lewis esophagectomy.
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Affiliation(s)
- Ben M Eyck
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands.
| | - Fredrik Klevebro
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Berend J van der Wilk
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Asif Johar
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Bas P L Wijnhoven
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - J Jan B van Lanschot
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Pernilla Lagergren
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Surgery and Cancer, Imperial College London, United Kingdom
| | - Sheraz R Markar
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Surgery and Cancer, Imperial College London, United Kingdom
| | - Sjoerd M Lagarde
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
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Mederos MA, de Virgilio MJ, Shenoy R, Ye L, Toste PA, Mak SS, Booth MS, Begashaw MM, Wilson M, Gunnar W, Shekelle PG, Maggard-Gibbons M, Girgis MD. Comparison of Clinical Outcomes of Robot-Assisted, Video-Assisted, and Open Esophagectomy for Esophageal Cancer: A Systematic Review and Meta-analysis. JAMA Netw Open 2021; 4:e2129228. [PMID: 34724556 PMCID: PMC8561331 DOI: 10.1001/jamanetworkopen.2021.29228] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
IMPORTANCE The utilization of robot-assisted minimally invasive esophagectomy (RAMIE) for esophageal cancer is increasing, despite limited data comparing RAMIE with other surgical approaches. OBJECTIVE To evaluate the literature for clinical outcomes of RAMIE compared with video-assisted minimally invasive esophagectomy (VAMIE) and open esophagectomy (OE). DATA SOURCES A systematic search of PubMed, Cochrane, Ovid Medline, and Embase databases from January 1, 2013, to May 6, 2020, was performed. STUDY SELECTION Studies that compared RAMIE with VAMIE and/or OE for cancer were included. DATA EXTRACTION AND SYNTHESIS Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline, data were extracted by independent reviewers. A random-effects meta-analysis of 9 propensity-matched studies was performed for the RAMIE vs VAMIE comparison only. A narrative synthesis of RAMIE vs VAMIE and OE was performed. MAIN OUTCOMES AND MEASURES The outcomes of interest were intraoperative outcomes (ie, estimated blood loss [EBL], operative time, lymph node [LN] harvest), short-term outcomes (anastomotic leak, recurrent laryngeal nerve [RLN] palsy, pulmonary and total complications, and 90-day mortality), and long-term oncologic outcomes. RESULTS Overall, 21 studies (2 randomized clinical trials, 11 propensity-matched studies, and 8 unmatched studies) with 9355 patients were included. A meta-analysis was performed with 9 propensity-matched studies comparing RAMIE with VAMIE. The random-effects pooled estimate found an adjusted risk difference (RD) of -0.06 (95% CI, -0.11 to -0.01) favoring fewer pulmonary complications with RAMIE. There was no evidence of differences between RAMIE and VAMIE in LN harvest (mean difference [MD], -1.1 LN; 95% CI, -2.45 to 0.25 LNs), anastomotic leak (RD, 0.0; 95% CI, -0.03 to 0.03), EBL (MD, -6.25 mL; 95% CI, -18.26 to 5.77 mL), RLN palsy (RD, 0.01; 95% CI, -0.08 to 0.10), total complications (RD, 0.05; 95% CI, -0.01 to 0.11), or 90-day mortality (RD, -0.01; 95% CI, -0.02 to 0.0). There was low certainty of evidence that RAMIE was associated with a longer disease-free survival compared with VAMIE. For OE comparisons (data not pooled), RAMIE was associated with a longer operative time, decreased EBL, and less pulmonary and total complications. CONCLUSIONS AND RELEVANCE In this study, RAMIE had similar outcomes as VAMIE but was associated with fewer pulmonary complications compared with VAMIE and OE. Studies on long-term functional and cancer outcomes are needed.
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Affiliation(s)
- Michael A. Mederos
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California
| | | | - Rivfka Shenoy
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California
- Veterans Health Administration, Greater Los Angeles Healthcare System, Los Angeles, California
- National Clinician Scholars Program, University of California, Los Angeles
| | - Linda Ye
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Paul A. Toste
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California
- Veterans Health Administration, Greater Los Angeles Healthcare System, Los Angeles, California
- Olive View–UCLA Medical Center, Sylmar, California
| | - Selene S. Mak
- Veterans Health Administration, Greater Los Angeles Healthcare System, Los Angeles, California
| | | | - Meron M. Begashaw
- Veterans Health Administration, Greater Los Angeles Healthcare System, Los Angeles, California
| | - Mark Wilson
- US Department of Veterans Affairs, Washington, DC
- Department of Surgery, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - William Gunnar
- VHA National Center for Patient Safety, Ann Arbor, Michigan
- University of Michigan, Ann Arbor
| | - Paul G. Shekelle
- Veterans Health Administration, Greater Los Angeles Healthcare System, Los Angeles, California
| | - Melinda Maggard-Gibbons
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California
- Veterans Health Administration, Greater Los Angeles Healthcare System, Los Angeles, California
- Olive View–UCLA Medical Center, Sylmar, California
| | - Mark D. Girgis
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California
- Veterans Health Administration, Greater Los Angeles Healthcare System, Los Angeles, California
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209
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Runkel M, Kuvendjiska J, Marjanovic G, Fichtner-Feigl S, Diener MK. Ligamentum teres augmentation (LTA) for hiatal hernia repair after minimally invasive esophageal resection: a new use for an old structure. Langenbecks Arch Surg 2021; 406:2521-2525. [PMID: 34611750 PMCID: PMC8578099 DOI: 10.1007/s00423-021-02284-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 07/18/2021] [Indexed: 01/07/2023]
Abstract
PURPOSE Hiatal hernias with intrathoracic migration of the intestines are serious complications after minimally invasive esophageal resection with gastric sleeve conduit. High recurrence rates have been reported for standard suture hiatoplasties. Additional mesh reinforcement is not generally recommended due to the serious risk of endangering the gastric sleeve. We propose a safe, simple, and effective method to close the hiatal defect with the ligamentum teres. METHODS After laparoscopic repositioning the migrated intestines, the ligamentum teres is dissected from the ligamentum falciforme and the anterior abdominal wall. It is then positioned behind the left lobe of the liver and swung toward the hiatal orifice. Across the anterior aspect of the hiatal defect it is semi-circularly fixated with non-absorbable sutures. Care should be taken not to endanger the blood supply of the gastric sleeve. RESULTS We have used this technique for a total of 6 patients with hiatal hernias after hybrid minimally invasive esophageal resection in the elective (n = 4) and emergency setting (n = 2). No intraoperative or postoperative complications have been observed. No recurrence has been reported for 3 patients after 3 months. CONCLUSION Primary suture hiatoplasties for hiatal hernias after minimally invasive esophageal resection can be technically challenging, and high postoperative recurrence rates are reported. An alternative, safe method is needed to close the hiatal defect. Our promising preliminary experience should stimulate further studies regarding the durability and efficacy of using the ligamentum teres hepatis to cover the hiatal defect.
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Affiliation(s)
- Mira Runkel
- Department of General and Visceral Surgery, Medical Center, University of Freiburg, Hugstetterstrasse 55, 79106, Freiburg, Germany
| | - Jasmina Kuvendjiska
- Department of General and Visceral Surgery, Medical Center, University of Freiburg, Hugstetterstrasse 55, 79106, Freiburg, Germany
| | - Goran Marjanovic
- Department of General and Visceral Surgery, Medical Center, University of Freiburg, Hugstetterstrasse 55, 79106, Freiburg, Germany
| | - Stefan Fichtner-Feigl
- Department of General and Visceral Surgery, Medical Center, University of Freiburg, Hugstetterstrasse 55, 79106, Freiburg, Germany
| | - Markus K Diener
- Department of General and Visceral Surgery, Medical Center, University of Freiburg, Hugstetterstrasse 55, 79106, Freiburg, Germany.
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210
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Urabe M, Ohkura Y, Haruta S, Ueno M, Udagawa H. Factors Affecting Blood Loss During Thoracoscopic Esophagectomy for Esophageal Carcinoma. J Chest Surg 2021; 54:466-472. [PMID: 34667136 PMCID: PMC8646075 DOI: 10.5090/jcs.21.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 07/17/2021] [Accepted: 08/05/2021] [Indexed: 11/23/2022] Open
Abstract
Background Major intraoperative hemorrhage reportedly predicts unfavorable survival outcomes following surgical resection for esophageal carcinoma (EC). However, the factors predicting the amount of blood lost during thoracoscopic esophagectomy have yet to be sufficiently studied. We sought to identify risk factors for excessive blood loss during video-assisted thoracoscopic surgery (VATS) for EC. Methods Using simple and multiple linear regression models, we performed retrospective analyses of the associations between clinicopathological/surgical factors and estimated hemorrhagic volume in 168 consecutive patients who underwent VATS-type esophagectomy for EC. Results The median blood loss amount was 225 mL (interquartile range, 126–380 mL). Abdominal laparotomy (p<0.001), thoracic duct resection (p=0.014), and division of the azygos arch (p<0.001) were significantly related to high volumes of blood loss. Body mass index and operative duration, as continuous variables, were also correlated positively with blood loss volume in simple linear regression. The multiple linear regression analysis identified prolonged operative duration (p<0.001), open laparotomy approach (p=0.003), azygos arch division (p=0.005), and high body mass index (p=0.014) as independent predictors of higher hemorrhage amounts during VATS esophagectomy. Conclusion As well as body mass index, operation-related factors such as operative duration, open laparotomy, and division of the azygos arch were independently predictive of estimated blood loss during VATS esophagectomy for EC. Laparoscopic abdominal procedures and azygos arch preservation might be minimally invasive options that would potentially reduce intraoperative hemorrhage, although oncological radicality remains an important consideration.
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Affiliation(s)
- Masayuki Urabe
- Department of Gastroenterological Surgery, Toranomon Hospital, Tokyo, Japan
| | - Yu Ohkura
- Department of Gastroenterological Surgery, Toranomon Hospital, Tokyo, Japan.,Okinaka Memorial Institute for Medical Research, Tokyo, Japan
| | - Shusuke Haruta
- Department of Gastroenterological Surgery, Toranomon Hospital, Tokyo, Japan
| | - Masaki Ueno
- Department of Gastroenterological Surgery, Toranomon Hospital, Tokyo, Japan.,Okinaka Memorial Institute for Medical Research, Tokyo, Japan
| | - Harushi Udagawa
- Department of Gastroenterological Surgery, Toranomon Hospital, Tokyo, Japan.,Okinaka Memorial Institute for Medical Research, Tokyo, Japan
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211
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Veziant J, Gaillard M, Barat M, Dohan A, Barret M, Manceau G, Karoui M, Bonnet S, Fuks D, Soyer P. Imaging of postoperative complications following Ivor-Lewis esophagectomy. Diagn Interv Imaging 2021; 103:67-78. [PMID: 34654670 DOI: 10.1016/j.diii.2021.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 09/21/2021] [Indexed: 02/08/2023]
Abstract
Postoperative imaging plays a key role in the identification of complications after Ivor-Lewis esophagectomy (ILE). Careful analysis of imaging examinations can help identify the cause of the presenting symptoms and the mechanism of the complication. The complex surgical procedure used in ILE results in anatomical changes that make imaging interpretation challenging for many radiologists. The purpose of this review was to make radiologists more familiar with the imaging findings of normal anatomical changes and those of complications following ILE to enable accurate evaluation of patients with an altered postoperative course. Anastomotic leak, gastric conduit necrosis and pleuropulmonary complications are the most serious complications after ILE. Computed tomography used in conjunction with oral administration of contrast material is the preferred diagnostic tool, although it conveys limited sensitivity for the diagnosis of anastomotic fistula. In combination with early endoscopic assessment, it can also help early recognition of complications and appropriate therapeutic management.
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Affiliation(s)
- Julie Veziant
- Department of Digestive, Hepatobiliary and Endocrine Surgery, Hôpital Cochin, APHP.Centre, 75014 Paris, France; Université de Paris, Faculté de Médecine, 75006 Paris, France
| | - Martin Gaillard
- Department of Digestive, Hepatobiliary and Endocrine Surgery, Hôpital Cochin, APHP.Centre, 75014 Paris, France; Université de Paris, Faculté de Médecine, 75006 Paris, France.
| | - Maxime Barat
- Université de Paris, Faculté de Médecine, 75006 Paris, France; Department of Radiology, Hôpital Cochin, APHP.Centre, 75014, Paris, France
| | - Anthony Dohan
- Université de Paris, Faculté de Médecine, 75006 Paris, France; Department of Radiology, Hôpital Cochin, APHP.Centre, 75014, Paris, France
| | - Maximilien Barret
- Université de Paris, Faculté de Médecine, 75006 Paris, France; Department of Gastroenterology and Digestive Oncology, Hôpital Cochin, APHP.Centre, 75014 Paris, France
| | - Gilles Manceau
- Université de Paris, Faculté de Médecine, 75006 Paris, France; Department of General and Digestive Surgery, Hôpital Européen Georges Pompidou, APHP.Centre, 75015 Paris, France
| | - Mehdi Karoui
- Université de Paris, Faculté de Médecine, 75006 Paris, France; Department of General and Digestive Surgery, Hôpital Européen Georges Pompidou, APHP.Centre, 75015 Paris, France
| | - Stéphane Bonnet
- Université de Paris, Faculté de Médecine, 75006 Paris, France; Department of Digestive, Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, 75014 Paris, France
| | - David Fuks
- Department of Digestive, Hepatobiliary and Endocrine Surgery, Hôpital Cochin, APHP.Centre, 75014 Paris, France; Université de Paris, Faculté de Médecine, 75006 Paris, France
| | - Philippe Soyer
- Université de Paris, Faculté de Médecine, 75006 Paris, France; Department of Radiology, Hôpital Cochin, APHP.Centre, 75014, Paris, France
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212
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Moons J, Depypere L, Lerut T, van Achterberg T, Coosemans W, Van Veer H, Mandeville Y, Nafteux P. Impact of the introduction of an enhanced recovery pathway in esophageal cancer surgery: a cohort study and propensity score matching analysis. Dis Esophagus 2021; 34:6141530. [PMID: 33598683 DOI: 10.1093/dote/doab007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 11/10/2020] [Accepted: 12/24/2020] [Indexed: 12/11/2022]
Abstract
Enhanced recovery pathways (ERP) have the potential to improve clinical outcomes. Aim of this study was to determine the impact of ERP on perioperative results as compared with traditional care (TC) after esophagectomy. In this study, two cohorts were compared. Cohort 1 represented 296 patients to whom TC was provided. Cohort 2 consisted of 200 unselected ERP patients. Primary endpoints were postoperative complications. Secondary endpoints were the length of stay and 30-day readmission rates. To confirm the possible impact of ERP, a propensity matched analysis (1:1) was conducted. A significant decrease in complications was found in ERP patients, especially for pneumonia and respiratory failure requiring reintubation (39% in TC and 14% in ERP; P<0.0001 and 17% vs. 12%; P<0.0001, respectively) and postoperative blood transfusion (26.7%-11%; P<0.0001). Furthermore, median length of stay was also significantly shorter: 13 days (interquartile range [IQR] 10-23) in TC compared with 10 days (IQR 8-14) in ERP patients (P<0.0001). The 30-day readmission rate (5.4% in TC and 9% in ERP; P=0.121) and in-hospital mortality rate (4.4% in TC and 2.5% in ERP; P=0.270) were not significantly affected. A propensity score matching confirmed a significant impact on pneumonia (P=0.0001), anastomotic leak (P=0.047), several infectious complications (P=0.01-0.034), blood transfusion (P=0.001), Comprehensive Complications Index (P=0.01), and length of stay (P=0.0001). We conclude that ERP for esophagectomy is associated with significantly fewer postoperative complications and blood transfusions, which results in a significant decrease of length of stay without affecting readmission and mortality rates.
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Affiliation(s)
- J Moons
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - L Depypere
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - T Lerut
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - T van Achterberg
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Leuven, Belgium
| | - W Coosemans
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - H Van Veer
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - Y Mandeville
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - P Nafteux
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
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213
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[Treatment recommendations for early esophageal cancer : Endoscopic and surgical options]. Chirurg 2021; 92:1077-1084. [PMID: 34622303 DOI: 10.1007/s00104-021-01513-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/09/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND Esophageal cancer represents a complex tumor entity with an increasing proportion of adenocarcinomas. Early esophageal cancer is staged as m1-m3 depending on the depth of infiltration into the mucosa and as sm1-sm3 depending on invasion into the submucosa. The risk of lymph node metastasis is strongly correlated with the depth of invasion and increases by leaps and bounds with submucosal infiltration. MATERIAL AND METHODS This review is based on publications retrieved by a selective database search (MEDLINE, PubMed, Cochrane Library, International Standard Randomised Controlled Trial Number, ISRCTN, registry) on the current management of early esophageal cancer. RESULTS The endoscopic diagnostics and evaluation of the dignity of superficial esophageal cancer by traditional staining techniques have been expanded by virtual chromoendoscopy. Endoscopic resection is the diagnostic and therapeutic procedure of choice for mucosal low risk adenocarcinomas (grade 1 or 2, no blood or lymph vessel invasion). Under certain prerequisites adenocarcinomas of the upper submucosa (sm1) can also be endoscopically removed. All other stages necessitate surgical treatment. In squamous cell carcinoma without risk factors a surgical oncological esophageal resection is indicated after infiltration of the third mucosal layer (m3). Endoscopic submucosal dissection (ESD) shows high rates of en bloc and R0 (curative) resections even with large lesions. CONCLUSION Borderline cases between endoscopic and surgical treatment of early esophageal cancer necessitate an interdisciplinary approach and individually adapted management, which in the locally advanced stage are always embedded in a multimodal concept.
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214
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Booka E, Kikuchi H, Hiramatsu Y, Takeuchi H. The Impact of Infectious Complications after Esophagectomy for Esophageal Cancer on Cancer Prognosis and Treatment Strategy. J Clin Med 2021; 10:jcm10194614. [PMID: 34640631 PMCID: PMC8509636 DOI: 10.3390/jcm10194614] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 10/02/2021] [Accepted: 10/04/2021] [Indexed: 01/09/2023] Open
Abstract
Despite advances in the perioperative management of esophagectomy, it is still a highly invasive procedure for esophageal cancer and is associated with severe postoperative complications. The two major postoperative infectious complications after esophagectomy are pulmonary complications and anastomotic leakage. We previously reported that postoperative infectious complications after esophagectomy adversely affect long-term survival significantly in a single institution and meta-analysis. Additionally, we reviewed the mechanisms of proinflammatory cytokines, such as C-X-C motif ligand 8 (CXCL8) and its cognate receptor, C-X-C chemokine receptor 2 (CXCR2), in contributing to tumorigenesis and tumor progression. Moreover, we previously reported that introducing minimally invasive esophagectomy, including robot assistance, laparoscopic gastric mobilization, and multidisciplinary team management, significantly reduced postoperative infectious complications after esophagectomy. Further, this review also suggests future treatment strategies for esophageal cancer, considering the adverse effect of postoperative infectious complications after esophagectomy.
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Affiliation(s)
- Eisuke Booka
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu 431-3192, Shizuoka, Japan; (E.B.); (H.K.); (Y.H.)
| | - Hirotoshi Kikuchi
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu 431-3192, Shizuoka, Japan; (E.B.); (H.K.); (Y.H.)
| | - Yoshihiro Hiramatsu
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu 431-3192, Shizuoka, Japan; (E.B.); (H.K.); (Y.H.)
- Department of Perioperative Functioning Care and Support, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu 431-3192, Shizuoka, Japan
| | - Hiroya Takeuchi
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu 431-3192, Shizuoka, Japan; (E.B.); (H.K.); (Y.H.)
- Correspondence: ; Tel.: +81-534-352-277
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215
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Hipp J, Thomaschewski M, Hummel R, Hoeppner J. [Complete response after neoadjuvant therapy for esophageal cancer : Implications for surgery]. Chirurg 2021; 93:132-137. [PMID: 34596707 DOI: 10.1007/s00104-021-01509-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2021] [Indexed: 10/20/2022]
Abstract
A relevant number of patients with locally advanced esophageal squamous cell carcinoma and adenocarcinoma show a locoregional complete response of the tumor in the resected material after neoadjuvant therapy with modern chemotherapy and chemoradiation protocols. Due to a high rate of perioperative morbidity and decreased long-term quality of life following esophagectomy, the current treatment algorithm with neoadjuvant therapy and post-neoadjuvant esophagectomy on principle is critically questioned. An individualized treatment algorithm with extended clinical evaluation of post-neoadjuvant remission status and esophagectomy as needed is discussed. Patients with complete remission after neoadjuvant therapy are identified in an extended restaging protocol. Cases of clinical complete remission are treated with an active surveillance concept with esophagectomy as needed, i.e. surgery only when a local tumor recurrence is detected. Retrospective cohort studies have suggested that the active surveillance concept with esophagectomy as needed does not lead to a deterioration of overall survival rates in the patient collective. European prospective randomized, controlled, noninferiority studies with an oncological endpoint are currently evaluating the possibilities of organ-preserving concepts for clinical complete remission of esophageal cancer.
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Affiliation(s)
- Julian Hipp
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum Freiburg, Freiburg, Deutschland
| | - Michael Thomaschewski
- Klinik für Chirurgie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Deutschland
| | - Richard Hummel
- Klinik für Chirurgie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Deutschland
| | - Jens Hoeppner
- Klinik für Chirurgie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Deutschland.
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216
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Sato H, Miyawaki Y, Lee S, Sugita H, Sakuramoto S, Tsubosa Y. Effectiveness and safety of a newly introduced multidisciplinary perioperative enhanced recovery after surgery protocol for thoracic esophageal cancer surgery. Gen Thorac Cardiovasc Surg 2021; 70:170-177. [PMID: 34596825 DOI: 10.1007/s11748-021-01717-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 09/27/2021] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Data are sparse regarding the multidisciplinary perioperative enhanced recovery after surgery protocol (E-P) for thoracic esophageal cancer surgery that was newly used at another institution. Therefore, this study aimed to retrospectively evaluate the effectiveness and safety of the protocol. METHODS We enrolled 101 patients who underwent transthoracic esophagectomy for E-P at the Shizuoka Cancer Center Hospital (SCC). The outcomes obtained at the SCC were compared with the outcomes of 140 patients treated with E-P at the Saitama Medical University International Medical Center (SMU). At the SMU, we compared the results before and after the introduction of E-P. RESULTS The rates of morbidity, pulmonary complications, and postoperative pneumonia were 44%, 31%, and 6.9% at the SCC and 44%, 27%, and 6.5% at the SMU (P = 0.91, 0.55, and 0.88, respectively). The mean time to walk was 1.1 and 1.5 days at the SCC and SMU, respectively (P < 0.001). The median length of hospital stay was longer at the SMU than at the SCC (24.0 versus 20.8 days; P = 0.004). In the comparative study before and after the introduction of E-P, the rate of postoperative pneumonia was 16% in the conventional management group and 6.5% in the E-P group (P = 0.02). CONCLUSION Postoperative pneumonia was reduced before and after introduction of E-P. As similar short-term postoperative outcomes were promising (except for the time to walk and postoperative hospital stay), the same E-P that was safely performed at the SMU can be implemented as a standard practice.
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Affiliation(s)
- Hiroshi Sato
- Division of Gastroenterological Surgery, Saitama Medical University International Medical Center, 1397 Yamane, Hidaka-shi, Saitama, 350-1298, Japan.
| | - Yutaka Miyawaki
- Division of Gastroenterological Surgery, Saitama Medical University International Medical Center, 1397 Yamane, Hidaka-shi, Saitama, 350-1298, Japan
| | - Seigi Lee
- Division of Gastroenterological Surgery, Saitama Medical University International Medical Center, 1397 Yamane, Hidaka-shi, Saitama, 350-1298, Japan
| | - Hirofumi Sugita
- Division of Gastroenterological Surgery, Saitama Medical University International Medical Center, 1397 Yamane, Hidaka-shi, Saitama, 350-1298, Japan
| | - Shinichi Sakuramoto
- Division of Gastroenterological Surgery, Saitama Medical University International Medical Center, 1397 Yamane, Hidaka-shi, Saitama, 350-1298, Japan
| | - Yasuhiro Tsubosa
- Division of Esophageal Surgery, Shizuoka Cancer Center Hospital, Nagaizumi, Japan
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217
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Higaki E, Abe T, Fujieda H, Hosoi T, Nagao T, Komori K, Ito S, Itoh N, Matsuo K, Shimizu Y. Significance of Antimicrobial Prophylaxis for the Prevention of Early-Onset Pneumonia After Radical Esophageal Cancer Resection: A Retrospective Analysis of 356 Patients Undergoing Thoracoscopic Esophagectomy. Ann Surg Oncol 2021; 29:1374-1387. [PMID: 34591223 DOI: 10.1245/s10434-021-10867-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 09/03/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Postoperative pneumonia is a common complication after esophagectomy and is associated with a high mortality rate. Although many randomized, controlled trials have been conducted on the prevention of postoperative pneumonia, little attention has been paid to the efficacy of antimicrobial prophylaxis. The purpose of this study was to investigate the impact of antimicrobial prophylaxis on the prevention of postoperative pneumonia. METHODS Data of patients with esophageal cancer who underwent thoracoscopic esophagectomy between 2016 and 2020 were collected. Early-period patients received cefazolin (CEZ) per protocol as antimicrobial prophylaxis (n = 250), and later-period patients received ampicillin/sulbactam (ABPC/SBT) (n = 106) because of the unavailability of CEZ in Japan. The incidence of pneumonia was compared between treatments in this quasi-experimental setting. Pneumonia detected by routine computed tomography (CT) on postoperative Days 5-6 was defined as early-onset pneumonia, and pneumonia that developed later was defined as late-onset pneumonia. RESULTS The incidence of early-onset pneumonia was significantly lower (3.8% vs. 13.6%, P = 0.006), and the median length of postoperative hospital stay was significantly shorter (17 vs. 20 days, P < 0.001) in the ABPC/SBT group than in the CEZ group. The incidence of late-onset pneumonia was similar between groups (9.4% vs. 10.0%, P = 0.870). The incidence of Clostridioides difficile infections and the incidence of multidrug-resistant organisms were similar between groups. Multivariate analyses consistently showed the superiority of ABPC/SBT to CEZ in preventing early-onset pneumonia (odds ratio: 0.20, P = 0.006). CONCLUSIONS ABPC/SBT after esophagectomy was better at preventing early-onset pneumonia compared with CEZ and was feasible regarding the development of antimicrobial resistance.
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Affiliation(s)
- Eiji Higaki
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Nagoya, Aichi, Japan.
| | - Tetsuya Abe
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Nagoya, Aichi, Japan
| | - Hironori Fujieda
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Nagoya, Aichi, Japan
| | - Takahiro Hosoi
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Nagoya, Aichi, Japan
| | - Takuya Nagao
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Nagoya, Aichi, Japan
| | - Koji Komori
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Nagoya, Aichi, Japan
| | - Seiji Ito
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Nagoya, Aichi, Japan
| | - Naoya Itoh
- Division of Infectious Diseases, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Keitaro Matsuo
- Division of Cancer Epidemiology and Prevention, Aichi Cancer Center Research Institute, Nagoya, Japan.,Division of Cancer Epidemiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yasuhiro Shimizu
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Nagoya, Aichi, Japan
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218
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Müller-Stich BP, Probst P, Nienhüser H, Fazeli S, Senft J, Kalkum E, Heger P, Warschkow R, Nickel F, Billeter AT, Grimminger PP, Gutschow C, Dabakuyo-Yonli TS, Piessen G, Paireder M, Schoppmann SF, van der Peet DL, Cuesta MA, van der Sluis P, van Hillegersberg R, Hölscher AH, Diener MK, Schmidt T. Meta-analysis of randomized controlled trials and individual patient data comparing minimally invasive with open oesophagectomy for cancer. Br J Surg 2021; 108:1026-1033. [PMID: 34491293 DOI: 10.1093/bjs/znab278] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 06/23/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Minimally invasive oesophagectomy (MIO) for oesophageal cancer may reduce surgical complications compared with open oesophagectomy. MIO is, however, technically challenging and may impair optimal oncological resection. The aim of the present study was to assess if MIO for cancer is beneficial. METHODS A systematic literature search in MEDLINE, Web of Science and CENTRAL was performed and randomized controlled trials (RCTs) comparing MIO with open oesophagectomy were included in a meta-analysis. Survival was analysed using individual patient data. Random-effects model was used for pooled estimates of perioperative effects. RESULTS Among 3219 articles, six RCTs were identified including 822 patients. Three-year overall survival (56 (95 per cent c.i. 49 to 62) per cent for MIO versus 52 (95 per cent c.i. 44 to 60) per cent for open; P = 0.54) and disease-free survival (54 (95 per cent c.i. 47 to 61) per cent versus 50 (95 per cent c.i. 42 to 58) per cent; P = 0.38) were comparable. Overall complication rate was lower for MIO (odds ratio 0.33 (95 per cent c.i. 0.20 to 0.53); P < 0.010) mainly due to fewer pulmonary complications (OR 0.44 (95 per cent c.i. 0.27 to 0.72); P < 0.010), including pneumonia (OR 0.41 (95 per cent c.i. 0.22 to 0.77); P < 0.010). CONCLUSION MIO for cancer is associated with a lower risk of postoperative complications compared with open resection. Overall and disease-free survival are comparable for the two techniques. LAY SUMMARY Oesophagectomy for cancer is associated with a high risk of complications. A minimally invasive approach might be less traumatic, leading to fewer complications and may also improve oncological outcome. A meta-analysis of randomized controlled trials comparing minimally invasive to open oesophagectomy was performed. The analysis showed that the minimally invasive approach led to fewer postoperative complications, in particular, fewer pulmonary complications. Survival after surgery was comparable for the two techniques.
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Affiliation(s)
- B P Müller-Stich
- Department of General, Visceral and Transplant Surgery, Ruprecht Karl University of Heidelberg, Heidelberg, Germany
| | - P Probst
- Department of General, Visceral and Transplant Surgery, Ruprecht Karl University of Heidelberg, Heidelberg, Germany.,The Study Center of the German Surgical Society (SDGC), Ruprecht Karl University of Heidelberg, Heidelberg, Germany
| | - H Nienhüser
- Department of General, Visceral and Transplant Surgery, Ruprecht Karl University of Heidelberg, Heidelberg, Germany
| | - S Fazeli
- Department of General, Visceral and Transplant Surgery, Ruprecht Karl University of Heidelberg, Heidelberg, Germany
| | - J Senft
- Department of General, Visceral and Transplant Surgery, Ruprecht Karl University of Heidelberg, Heidelberg, Germany
| | - E Kalkum
- The Study Center of the German Surgical Society (SDGC), Ruprecht Karl University of Heidelberg, Heidelberg, Germany
| | - P Heger
- Department of General, Visceral and Transplant Surgery, Ruprecht Karl University of Heidelberg, Heidelberg, Germany.,The Study Center of the German Surgical Society (SDGC), Ruprecht Karl University of Heidelberg, Heidelberg, Germany
| | - R Warschkow
- Department of Surgery, Kantonsspital, St. Gallen, Switzerland
| | - F Nickel
- Department of General, Visceral and Transplant Surgery, Ruprecht Karl University of Heidelberg, Heidelberg, Germany
| | - A T Billeter
- Department of General, Visceral and Transplant Surgery, Ruprecht Karl University of Heidelberg, Heidelberg, Germany
| | - P P Grimminger
- Department of General, Visceral and Transplant Surgery, Johannes Gutenberg University, Mainz, Germany
| | - C Gutschow
- Department of Visceral and Transplant Surgery, University Hospital Zurich, Zurich, Switzerland
| | - T S Dabakuyo-Yonli
- Epidemiology and Quality of Life Unit, INSERM 1231, Centre Georges François Leclerc, Dijon, France
| | - G Piessen
- Department of Digestive and Oncological Surgery, Claude Huriez University Hospital, Lille, France
| | - M Paireder
- Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - S F Schoppmann
- Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - D L van der Peet
- Gastrointestinal and Minimally Invasive Surgery, Vrije University Medical Centre, Amsterdam, the Netherlands
| | - M A Cuesta
- Gastrointestinal and Minimally Invasive Surgery, Vrije University Medical Centre, Amsterdam, the Netherlands
| | - P van der Sluis
- Department of Surgical Oncology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - R van Hillegersberg
- Department of Surgical Oncology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - A H Hölscher
- Contilia Centre for Oesophageal Diseases, Elisabeth Hospital, Essen, Germany
| | - M K Diener
- Department of General, Visceral and Transplant Surgery, Ruprecht Karl University of Heidelberg, Heidelberg, Germany
| | - T Schmidt
- Department of General, Visceral and Transplant Surgery, Ruprecht Karl University of Heidelberg, Heidelberg, Germany
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219
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Tagkalos E, van der Sluis PC, Berlth F, Poplawski A, Hadzijusufovic E, Lang H, van Berge Henegouwen MI, Gisbertz SS, Müller-Stich BP, Ruurda JP, Schiesser M, Schneider PM, van Hillegersberg R, Grimminger PP. Robot-assisted minimally invasive thoraco-laparoscopic esophagectomy versus minimally invasive esophagectomy for resectable esophageal adenocarcinoma, a randomized controlled trial (ROBOT-2 trial). BMC Cancer 2021; 21:1060. [PMID: 34565343 PMCID: PMC8474742 DOI: 10.1186/s12885-021-08780-x] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 09/13/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND For patients with esophageal adenocarcinoma or cancer of the gastroesophageal junction, radical esophagectomy with 2-field lymphadenectomy is the cornerstone of the multimodality treatment with curative intent. Both conventional minimally invasive esophagectomy (MIE) and robot assisted minimally invasive esophagectomy (RAMIE) were shown to be superior compared to open transthoracic esophagectomy considering postoperative complications. However, no randomized comparison exists between MIE and RAMIE in the Western World for patients with esophageal adenocarcinoma. METHODS This is an investigator-initiated and investigator-driven multicenter randomized controlled parallel-group superiority trial. All adult patients (age ≥ 18 and ≤ 90 years) with histologically proven, surgically resectable (cT1-4a, N0-3, M0) esophageal adenocarcinoma of the intrathoracic esophagus or adenocarcinoma of the gastroesophageal junction and with European Clinical Oncology Group performance status 0, 1 or 2 will be assessed for eligibility and included after obtaining informed consent. Patients (n = 218) with resectable esophageal adenocarcinoma of the intrathoracic esophagus or adenocarcinoma of the gastroesophageal junction are randomized to either RAMIE (n = 109) or MIE (n = 109). The primary outcome of this study is the total number of resected abdominal and mediastinal lymph nodes specified per lymph node station. CONCLUSION This is the first randomized controlled trial designed to compare RAMIE to MIE as surgical treatment for resectable esophageal adenocarcinoma or adenocarcinoma of the gastroesophageal junction in the Western World. The hypothesis of the proposed study is that RAMIE will result in a higher abdominal and mediastinal lymph node yield specified per station compared to conventional MIE. Short-term results and the primary endpoint (total number of resected abdominal and mediastinal lymph nodes per lymph node station) will be analyzed and published after discharge of the last randomized patient within this trial. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04306458 . Registered 13th March 2020, https://clinicaltrials.gov/ct2/show/NCT04306458; Date of first enrolment 18.01.2021; Target sample size 218; Recruitment status: Recruiting; Protocol version 2; Issue date 10.03.2020; Rev. 02.02.2021; Authors ET, PCvdS, PPG.
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Affiliation(s)
- E Tagkalos
- Department of General-, Visceral- and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, D-55131, Mainz, Germany
| | - P C van der Sluis
- Department of General-, Visceral- and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, D-55131, Mainz, Germany
| | - F Berlth
- Department of General-, Visceral- and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, D-55131, Mainz, Germany
| | - A Poplawski
- Institute for Medical Biometry, Epidemiology and Informatics (IMBEI), University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - E Hadzijusufovic
- Department of General-, Visceral- and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, D-55131, Mainz, Germany
| | - H Lang
- Department of General-, Visceral- and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, D-55131, Mainz, Germany
| | - M I van Berge Henegouwen
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - S S Gisbertz
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - B P Müller-Stich
- Department of General, Visceral, and Trauma Surgery, University of Heidelberg, Heidelberg, Germany
| | - J P Ruurda
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M Schiesser
- Chirurgisches Zentrum Zürich, Klinik Hirslanden, Zürich, Switzerland
| | - P M Schneider
- Chirurgisches Zentrum Zürich, Klinik Hirslanden, Zürich, Switzerland
| | - R van Hillegersberg
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - P P Grimminger
- Department of General-, Visceral- and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, D-55131, Mainz, Germany.
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220
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Na KJ, Kang CH, Park S, Park IK, Kim YT. Robotic esophagectomy versus open esophagectomy in esophageal squamous cell carcinoma: a propensity-score matched analysis. J Robot Surg 2021; 16:841-848. [PMID: 34542834 DOI: 10.1007/s11701-021-01298-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 08/19/2021] [Indexed: 12/21/2022]
Abstract
We aimed to compare the short- and long-term outcomes between robotic esophagectomy (RE) and open esophagectomy (OE) in patients with esophageal squamous cell carcinoma (ESCC). Among the patients who underwent esophagectomy for ESCC from 2008 to 2017, 402 patients (n = 178 in RE and n = 224 in OE) were enrolled and, after propensity-score matching, 136 patients in each group were selected. The total rate of complications was comparable, whereas the rate of major complications was higher in OE (p < 0.01). Hospital stay was longer in OE (15 days in OE vs. 13 days in RE; p = 0.03) with a comparable early mortality rate. Complete resection was equally achieved in both groups (96.3% in RE vs. 97.0% in OE; p = 0.74). The numbers of retrieved lymph nodes (LN) were significantly higher in RE (42.8 in RE vs 35.3 in OE; p < 0.01), especially for LNs in the left lower cervical paratracheal, both recurrent laryngeal nerves, and paraesophageal area. The 5-year overall survival rate was higher in RE (75.1% in RE vs. 57.9% in OE; p = 0.02), whereas, the freedom from recurrence was comparable between the two groups (68.8% in RE vs. 54.7% in OE; p = 0.15). Notably, RE achieved a significantly higher rate of 5-year freedom from regional nodal recurrence than OE (81.4% in RE vs. 62.7% in OE, p = 0.03). RE contributed to a lower rate of major complications and shorter hospital stays. Furthermore, RE showed increased long-term overall survival and freedom from regional LN recurrence rates, with a higher yield of LN dissection compared to OE.
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Affiliation(s)
- Kwon Joong Na
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Chang Hyun Kang
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.
| | - Samina Park
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - In Kyu Park
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Young Tae Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
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221
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Saviaro H, Rintala J, Kauppila JH, Yannopoulos F, Meriläinen S, Koivukangas V, Huhta H, Helminen O, Saarnio J. Thirty years of esophageal cancer surgery in Oulu University Hospital. J Thorac Dis 2021; 13:4638-4649. [PMID: 34527305 PMCID: PMC8411167 DOI: 10.21037/jtd-21-520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 06/11/2021] [Indexed: 12/05/2022]
Abstract
Background Esophagectomy is the mainstay of surgical treatment of esophageal cancer, but involves high operative risk. The aim of this study was to review the evolution surgical treatment of esophageal cancer in Northern Finland, with introduction of minimally invasive techniques. Methods All elective esophagectomies performed in Oulu University Hospital between years 1987 and 2020 were included. Treatment strategies were compared to current guidelines including staging and use of neoadjuvant therapy, and benchmark values including postoperative morbidity, hospital stay, readmissions and 90-day mortality. Long-term survival was compared to previous national studies. Results Between years 1987 and 2020 a total of 341 underwent an esophagectomy. Transhiatal resection was performed to 167 (49.3%), Ivor Lewis to 129 (38.1%) and McKeown to 42 (12.4%) patients. MIE was performed to 49 (14.5%) patients. During the past four years 83.7% of locally advanced diseases received neoadjuvant treatment. Since 1987, gradual improvements have occurred especially in incidence of pleural effusion requiring additional drainage procedure (highest in 2011–2013 and in last four years 14.0%), recurrent nerve injuries (highest in 2008–2010 29.4% and lowest in 2017–2020 1.8%) and in 1-year survival rate (1987–1998 68.4% vs. 2017–2020 82.1%). No major changes in comorbidity, complication rate, anastomosis leaks, hospital stay or postoperative mortality were seen. Conclusions Esophageal cancer surgery has gone through major changes over three decades. Current guideline-based treatment has resulted with progressive improvement in mid- and long-term survival. However, despite modern protocol, no major improvement has occurred for example in major complications, anastomosis leak rates or hospital stay.
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Affiliation(s)
- Henna Saviaro
- Surgery Research Unit, Cancer and Translational Medicine Research Unit, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Jukka Rintala
- Surgery Research Unit, Cancer and Translational Medicine Research Unit, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Joonas H Kauppila
- Surgery Research Unit, Cancer and Translational Medicine Research Unit, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland.,Upper Gastrointestinal Surgery, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Fredrik Yannopoulos
- Surgery Research Unit, Cancer and Translational Medicine Research Unit, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Sanna Meriläinen
- Surgery Research Unit, Cancer and Translational Medicine Research Unit, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Vesa Koivukangas
- Surgery Research Unit, Cancer and Translational Medicine Research Unit, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Heikki Huhta
- Surgery Research Unit, Cancer and Translational Medicine Research Unit, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Olli Helminen
- Surgery Research Unit, Cancer and Translational Medicine Research Unit, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Juha Saarnio
- Surgery Research Unit, Cancer and Translational Medicine Research Unit, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
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Mayanagi S, Ishikawa A, Matsui K, Matsuda S, Irino T, Nakamura R, Fukuda K, Wada N, Kawakubo H, Hijikata N, Ando M, Tsuji T, Kitagawa Y. Association of preoperative sarcopenia with postoperative dysphagia in patients with thoracic esophageal cancer. Dis Esophagus 2021; 34:6031240. [PMID: 33306782 DOI: 10.1093/dote/doaa121] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 08/27/2020] [Accepted: 10/23/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND The purpose of the current study was to clarify the relationship between clinical features of dysphagia after esophagectomy and preoperative sarcopenia. METHODS A total of 187 cases were included in the current study. The psoas cross-sectional area on pre-treatment computed tomography was measured in thoracic esophageal cancer patients who underwent curative resection. The psoas muscle index (PMI) cut-off levels for sarcopenia were 6.36 cm2/m2 for men and 3.92 cm2/m2 for women. Swallowing function was evaluated using videofluoroscopic swallowing study (VFSS) and fiberoptic endoscopic evaluation of swallowing (FEES) at postoperative days 7-15, and classified according to the food intake level scale (FILS). Perioperative swallowing rehabilitation was performed in all cases. RESULTS In the 187 included patients, the median PMI was 5.42 cm2/m2 for men and 3.43 cm2/m2 for women, and 133 cases (71%) met the sarcopenia criteria. The FILS <4 (no oral intake) was 15% in the non-sarcopenia group, and 38% in the sarcopenia group (P = 0.003). There was no significant difference in the incidence of postoperative complications, including pneumonia and re-admission due to pneumonia, between the two groups. Preoperative sarcopenia and recurrent laryngeal nerve palsy were be independent risk factors for postoperative dysphagia. CONCLUSIONS Sarcopenic patients with esophageal cancer develop postoperative dysphagia more often than non-sarcopenic patients. Prehabilitation and nutritional support for patients with preoperative sarcopenia could play an important role to mitigate postoperative dysphagia.
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Affiliation(s)
- Shuhei Mayanagi
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Aiko Ishikawa
- Department of Rehabilitation Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Kazuaki Matsui
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Satoru Matsuda
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Tomoyuki Irino
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Rieko Nakamura
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Kazumasa Fukuda
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Norihito Wada
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Hirofumi Kawakubo
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Nanako Hijikata
- Department of Rehabilitation Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Makiko Ando
- Department of Rehabilitation Medicine, Keio University Hospital, Tokyo, Japan
| | - Tetsuya Tsuji
- Department of Rehabilitation Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
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223
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Vimolratana M, Sarkaria IS, Goldman DA, Rizk NP, Tan KS, Bains MS, Adusumilli PS, Sihag S, Isbell JM, Huang J, Park BJ, Molena D, Rusch VW, Jones DR, Bott MJ. Two-Year Quality of Life Outcomes After Robotic-Assisted Minimally Invasive and Open Esophagectomy. Ann Thorac Surg 2021; 112:880-889. [DOI: 10.1016/j.athoracsur.2020.09.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 08/03/2020] [Accepted: 09/28/2020] [Indexed: 11/30/2022]
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224
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D'Journo XB, Boulate D, Fourdrain A, Loundou A, van Berge Henegouwen MI, Gisbertz SS, O'Neill JR, Hoelscher A, Piessen G, van Lanschot J, Wijnhoven B, Jobe B, Davies A, Schneider PM, Pera M, Nilsson M, Nafteux P, Kitagawa Y, Morse CR, Hofstetter W, Molena D, So JBY, Immanuel A, Parsons SL, Larsen MH, Dolan JP, Wood SG, Maynard N, Smithers M, Puig S, Law S, Wong I, Kennedy A, KangNing W, Reynolds JV, Pramesh CS, Ferguson M, Darling G, Schröder W, Bludau M, Underwood T, van Hillegersberg R, Chang A, Cecconello I, Ribeiro U, de Manzoni G, Rosati R, Kuppusamy M, Thomas PA, Low DE. Risk Prediction Model of 90-Day Mortality After Esophagectomy for Cancer. JAMA Surg 2021; 156:836-845. [PMID: 34160587 PMCID: PMC8223144 DOI: 10.1001/jamasurg.2021.2376] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 03/13/2021] [Indexed: 02/06/2023]
Abstract
Importance Ninety-day mortality rates after esophagectomy are an indicator of the quality of surgical oncologic management. Accurate risk prediction based on large data sets may aid patients and surgeons in making informed decisions. Objective To develop and validate a risk prediction model of death within 90 days after esophagectomy for cancer using the International Esodata Study Group (IESG) database, the largest existing prospective, multicenter cohort reporting standardized postoperative outcomes. Design, Setting, and Participants In this diagnostic/prognostic study, we performed a retrospective analysis of patients from 39 institutions in 19 countries between January 1, 2015, and December 31, 2019. Patients with esophageal cancer were randomly assigned to development and validation cohorts. A scoring system that predicted death within 90 days based on logistic regression β coefficients was conducted. A final prognostic score was determined and categorized into homogeneous risk groups that predicted death within 90 days. Calibration and discrimination tests were assessed between cohorts. Exposures Esophageal resection for cancer of the esophagus and gastroesophageal junction. Main Outcomes and Measures All-cause postoperative 90-day mortality. Results A total of 8403 patients (mean [SD] age, 63.6 [9.0] years; 6641 [79.0%] male) were included. The 30-day mortality rate was 2.0% (n = 164), and the 90-day mortality rate was 4.2% (n = 353). Development (n = 4172) and validation (n = 4231) cohorts were randomly assigned. The multiple logistic regression model identified 10 weighted point variables factored into the prognostic score: age, sex, body mass index, performance status, myocardial infarction, connective tissue disease, peripheral vascular disease, liver disease, neoadjuvant treatment, and hospital volume. The prognostic scores were categorized into 5 risk groups: very low risk (score, ≥1; 90-day mortality, 1.8%), low risk (score, 0; 90-day mortality, 3.0%), medium risk (score, -1 to -2; 90-day mortality, 5.8%), high risk (score, -3 to -4: 90-day mortality, 8.9%), and very high risk (score, ≤-5; 90-day mortality, 18.2%). The model was supported by nonsignificance in the Hosmer-Lemeshow test. The discrimination (area under the receiver operating characteristic curve) was 0.68 (95% CI, 0.64-0.72) in the development cohort and 0.64 (95% CI, 0.60-0.69) in the validation cohort. Conclusions and Relevance In this study, on the basis of preoperative variables, the IESG risk prediction model allowed stratification of an individual patient's risk of death within 90 days after esophagectomy. These data suggest that this model can help in the decision-making process when esophageal cancer surgery is being considered and in informed consent.
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Affiliation(s)
- Xavier Benoit D'Journo
- Department of Thoracic Surgery, Aix-Marseille University, North Hospital, Marseille, France
| | - David Boulate
- Department of Thoracic Surgery, Aix-Marseille University, North Hospital, Marseille, France
| | - Alex Fourdrain
- Department of Thoracic Surgery, Aix-Marseille University, North Hospital, Marseille, France
| | - Anderson Loundou
- Department of Thoracic Surgery, Aix-Marseille University, North Hospital, Marseille, France
| | - Mark I van Berge Henegouwen
- Department of Gastrointestinal Surgery, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Suzanne S Gisbertz
- Department of Gastrointestinal Surgery, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - J Robert O'Neill
- Department of Oesophago-Gastric Cancer Surgery, Cambridge Oesophago-Gastric Centre, Addenbrookes Hospital, Cambridge, United Kingdom
| | - Arnulf Hoelscher
- Center for Esophageal Diseases, Elisabeth Hospital Essen, University Medicine Essen, Essen, Germany
| | - Guillaume Piessen
- Department of Digestive and Oncological Surgery, Claude Huriez University Hospital, Lille, France
| | - Jan van Lanschot
- Department of Digestive Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Bas Wijnhoven
- Department of Digestive Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Blair Jobe
- Esophageal and Lung Institute, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Andrew Davies
- Department of Digestive Surgery, Guy's & St Thomas' National Health Service Foundation Trust, London, United Kingdom
| | - Paul M Schneider
- Department of Digestive and Oncological Surgery, Hirslanden Medical Center, Zurich, Switzerland
| | - Manuel Pera
- Department of Digestive Surgery, Hospital Universitario del Mar, Barcelona, Spain
| | - Magnus Nilsson
- Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Philippe Nafteux
- Department of Digestive Surgery, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Yuko Kitagawa
- Department of Thoracic Surgery, Keio University, Tokyo, Japan
| | | | - Wayne Hofstetter
- Department of Thoracic Surgery, MD Anderson Cancer Center, Houston, Texas
| | - Daniela Molena
- Department of Thoracic and Cardiovascular Surgery, Memorial Sloan Kettering Cancer Center, New York City, New York
| | - Jimmy Bok-Yan So
- Department of Thoracic Surgery, National University Hospital, Singapore, Singapore
| | - Arul Immanuel
- Department of Surgery, Northern Oesophagogastric Cancer Unit, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
| | - Simon L Parsons
- Department of Upper Gastrointestinal Surgery, Nottingham University Hospitals National Health Service Trust, Nottingham, United Kingdom
| | | | - James P Dolan
- Digestive Health Center, Oregon Health and Science University, Portland
| | - Stephanie G Wood
- Digestive Health Center, Oregon Health and Science University, Portland
| | - Nick Maynard
- Oesophagogastric Cancer Multidisciplinary Team, Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom
| | - Mark Smithers
- Department of Surgery, Princess Alexandra Hospital, University of Queensland, Brisbane, Australia
| | - Sonia Puig
- Department of Gastrointestinal Surgery, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham Foundation Trust, Birmingham, United Kingdom
| | - Simon Law
- Department of Gastrointestinal Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Ian Wong
- Department of Gastrointestinal Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Andrew Kennedy
- Department of Gastrointestinal Surgery, Royal Victoria Hospital, Belfast, Northern Ireland
| | - Wang KangNing
- Department of Thoracic Surgery, Sichuan Cancer Hospital & Institute, Chengdu, China
| | - John V Reynolds
- Department of Surgery, St James's Hospital Trinity College, Dublin, Ireland
| | - C S Pramesh
- Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India
| | - Mark Ferguson
- Department of Thoracic Surgery, The University of Chicago Medicine, Chicago, Illinois
| | - Gail Darling
- Department of Thoracic Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Wolfgang Schröder
- Department of Digestive Surgery, University Hospital of Cologne, Cologne, Germany
| | - Marc Bludau
- Department of Digestive Surgery, University Hospital of Cologne, Cologne, Germany
| | - Tim Underwood
- Department of Gastrointestinal Surgery, University Hospital Southampton National Health Service Foundation Trust, Southampton, United Kingdom
| | | | - Andrew Chang
- Department of Thoracic Surgery, University of Michigan Health System, Ann Arbor
| | - Ivan Cecconello
- Department of Digestive Surgery, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Ulysses Ribeiro
- Department of Digestive Surgery, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Giovanni de Manzoni
- Department of Upper Gastrointestinal Surgery, University of Verona, Verona, Italy
| | - Riccardo Rosati
- Department of Upper Gastrointestinal Surgery, Vita-Salute San Raffaele University, Milan, Italy
| | | | | | - Donald E Low
- Department of Thoracic Surgery, Virginia Mason Medical Center, Seattle, Washington
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225
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Postoperative hiatal herniation after open vs. minimally invasive esophagectomy; a systematic review and meta-analysis. Int J Surg 2021; 93:106046. [PMID: 34411750 DOI: 10.1016/j.ijsu.2021.106046] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 04/29/2021] [Accepted: 08/03/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND Post-esophagectomy hiatal hernia (PEHH) is a known, but relatively uncommon, complication after esophagectomies. The incidence of PEHH seems to be increasing since the introduction of minimally invasive esophagectomy. This systematic review and meta-analysis aimed to determine the pooled incidence of PEHH after esophagectomy, and to evaluate if minimally invasive technique is associated with increased risk for PEHH compared to open esophagectomy. METHODS A systematic search of PubMed, Medline via Ovid and Web of Science was performed. Retrospective and prospective studies in English language describing the incidence or risk factors for PEHH were included. Weighted incidence of PEHH after all types of esophagectomy, and after open or minimally invasive technique was calculated. RESULTS A total of 7943 esophagectomy patients were included in the analysis. In total, 310 patients (3.9%) were diagnosed with PEHH. The estimated weighted incidence rate for PEHH after open esophagectomy was 0.024 (95% confidence interval: 0.012-0.045) compared to 0.065 (95% confidence interval: 0.040-0.106) after minimally invasive esophagectomy. Odds ratio for PEHH after minimally invasive esophagectomy compared to open esophagectomy was 2.76 (95% confidence interval: 1.49-5.11). CONCLUSION The risk for post-esophagectomy hiatal hernia was significantly higher after minimally invasive esophagectomy compared to open technique. Heterogeneity and retrospective designs of the included studies were important limitations of the analysis. Future studies should investigate preventive measures to reduce PEHH after minimally invasive esophagectomy.
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226
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Mazzola M, Giani A, Crippa J, Morini L, Zironda A, Bertoglio CL, De Martini P, Magistro C, Ferrari G. Totally Laparoscopic Pancreaticoduodenectomy: Comparison Between Early and Late Phase of an Initial Single-Center Learning Curve. Indian J Surg Oncol 2021; 12:688-698. [DOI: 10.1007/s13193-021-01422-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 08/09/2021] [Indexed: 12/25/2022] Open
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227
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Paireder M, Asari R, Radlspöck W, Fabbri A, Tschoner A, Függer R, Zacherl J, Schoppmann SF. Esophageal resection in Austria—preparing a national registry. Eur Surg 2021. [DOI: 10.1007/s10353-021-00734-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Summary
Background
Esophageal resection is a technically challenging procedure. Despite improvements in perioperative management and outcome, it is still associated with considerably high morbidity and mortality rates even if performed in high-volume centers. This study aimed to shed light on the results of routine patient care in three representative referral centers concerning caseload and surgical and oncological outcomes.
Methods
This study is a retrospective, multicenter, national-wide analysis of a newly established database including perioperative and long-term outcome data from three referral centers in Austria.
Results
In a 6-year study period (2013–2018), 411 patients were eligible for analysis. The indication for esophageal resection was esophageal adenocarcinoma in 299 (72.7%) patients and esophageal squamous cell carcinoma in 90 (21.9%) patients. The abdominothoracic approach (70.1%) was the most common operation, followed by transhiatal extended gastrectomy (14.8%) and a thoracic-abdominal-cervical approach (8.5%). Most patients (77.9%) underwent neoadjuvant therapy (chemotherapy 45.3%, radiochemotherapy in 32.6%). A minimally invasive approach was chosen in 25.3%. Major complications and mortality were seen in 21.7% and 2.9%, respectively. The 1‑year survival rate was 84%, 3‑year survival 60%, and 5‑year survival was 52%. The pooled overall median survival was 110 months (95% CI 33.97–186.03).
Conclusion
This first publication of the Austrian Society of Esophageal Surgery shows that the outcome of esophageal surgery for cancer in Austria compares well with that of renowned international centers. However, a more comprehensive approach including as many national centers as possible will improve outcome research, offer quality management, and improve patient safety. The study group invites all Austrian institutions performing esophagectomy to participate in the initiative.
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228
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Chao YK, Wen YW. Cost-effectiveness analysis of thoracoscopic versus open esophagectomy for esophageal cancer: a population-based study. Dis Esophagus 2021; 34:6009335. [PMID: 33249485 DOI: 10.1093/dote/doaa116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 09/17/2020] [Accepted: 10/06/2020] [Indexed: 12/11/2022]
Abstract
The question as to whether the clinical benefits of video-assisted thoracoscopic esophagectomy (VATE) do outweigh its increased costs remains unanswered. Here, we analyzed the cost-effectiveness of VATE versus open esophagectomy (OE) in a real-world setting. Using 2008-2015 Taiwanese Health Insurance claim data, we identified 3271 patients with esophageal cancer who underwent transthoracic esophagectomy. By taking into account nine confounding variables, we constructed a 1:1 propensity score-matched sample of patients who underwent VATE or OE (n = 629 each). Direct costs incurred within three years after surgery and survival were analyzed. There were no significant intergroup differences in terms of R0 resection rates, length of stay, as well as 30- and 90-day mortality and unplanned readmission rates. However, the number of dissected nodes was higher in the VATE group (median: 24 vs. 18, P < 0.001). While VATE had higher index hospitalization costs (median, 12331 USD vs. 10730 USD, P < 0.001), cost differences were reduced over time. The average accumulated cost person-month of VATE declined below that of OE at 14 months after hospital discharge. Overall survival (OS) figures were more favorable for patients treated with VATE (3-year OS: 47% vs. 41%; life expectancy: 4.04 life-years [LY] vs. 3.30 LY). The cost-effectiveness plane showed that only 0.3% of all VATE procedures were more costly and less effective than OE. The probabilities for VATE to be cost-effective at the willingness-to-pay (WTP) thresholds of 10000 and 50000 USD/LY were 63.5% and 92.4%, respectively. Using commonly accepted WTP thresholds, VATE was more cost-effective than OE for patients with esophageal cancer.
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Affiliation(s)
- Yin-Kai Chao
- Division of Thoracic Surgery, Chang Gung Memorial Hospital-Linkou, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yu-Wen Wen
- Clinical Informatics and Medical Statistics Research Center, Chang Gung University, Taoyuan, Taiwan
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229
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Verstegen MHP, Slaman AE, Klarenbeek BR, van Berge Henegouwen MI, Gisbertz SS, Rosman C, van Workum F. Outcomes of Patients with Anastomotic Leakage After Transhiatal, McKeown or Ivor Lewis Esophagectomy: A Nationwide Cohort Study. World J Surg 2021; 45:3341-3349. [PMID: 34373937 PMCID: PMC8476360 DOI: 10.1007/s00268-021-06250-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2021] [Indexed: 12/24/2022]
Abstract
Background Anastomotic leakage has a great impact on clinical outcomes after esophagectomy. It has never been studied whether anastomotic leakage is of equal severity between different types of esophagectomy (i.e., transhiatal, McKeown and Ivor Lewis) in terms of postoperative mortality and morbidity. Methods All esophageal cancer patients with anastomotic leakage after transhiatal, McKeown or Ivor Lewis esophagectomy between 2011 and 2019 were selected from the Dutch Upper Gastrointestinal Cancer Audit (DUCA) registry. The primary outcome was 30-day/in-hospital mortality. Secondary outcomes included postoperative complications, re-operation and ICU readmission rate. Results Data from 1030 patients with anastomotic leakage after transhiatal (n=287), McKeown (n=397) and Ivor Lewis esophagectomy (n=346) were evaluated. The 30-day/in-hospital mortality rate was 4.5% in patients with leakage after transhiatal esophagectomy, 8.1% after McKeown and 8.1% after Ivor Lewis esophagectomy (P=0.139). After correction for confounders, leakage after transhiatal resection was associated with lower mortality (OR 0.152–0.699, P=0.004), but mortality after McKeown and Ivor Lewis esophagectomy was similar. Re-operation rate was 24.0% after transhiatal, 40.6% after McKeown and 41.3% after Ivor Lewis esophagectomy (P<0.001). ICU readmission rate was 24.0% after transhiatal, 37.8% after McKeown and 43.4% after Ivor Lewis esophagectomy (P<0.001). Conclusion This study in patients with anastomotic leakage confirms a strong association between severity of clinical consequences and different types of esophagectomy. It supports the hypothesis that cervical leakage is generally less severe than intrathoracic leakage. The clinical impact of anastomotic leakage should be taken into account, in addition to its incidence, when different types of esophagectomy are compared by clinicians or researchers.
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Affiliation(s)
- Moniek H P Verstegen
- Department of Surgery and Radboud Institute of Health Sciences, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Annelijn E Slaman
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Bastiaan R Klarenbeek
- Department of Surgery and Radboud Institute of Health Sciences, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Mark I van Berge Henegouwen
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Suzanne S Gisbertz
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Camiel Rosman
- Department of Surgery and Radboud Institute of Health Sciences, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Frans van Workum
- Department of Surgery and Radboud Institute of Health Sciences, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
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230
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Abstract
Totally robotic esophagectomy is performed using a robotic technique without additional thoracoscopy or laparoscopy. However, most robotic esophagectomies are currently performed in a hybrid form combining robotic and other endoscopic techniques. Laparoscopic stomach mobilization and thoracoscopic esophagogastric anastomosis are commonly used methods in robotic esophagectomy. In this paper, totally robotic esophagectomy without thoracoscopic or laparoscopic assistance is presented.
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Affiliation(s)
- Chang Hyun Kang
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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231
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Laparoscopic versus laparotomic gastric pull-up following thoracoscopic esophagectomy: A propensity score-matched analysis. Asian J Surg 2021; 45:468-472. [PMID: 34364763 DOI: 10.1016/j.asjsur.2021.07.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 05/11/2021] [Accepted: 07/26/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Because of its capacity to reduce surgical trauma to the chest wall, thoracoscopic esophagectomy is considered paramount for decreasing the risk of pulmonary complications in the context of minimally invasive esophagectomy. Whether laparoscopy (LS) following thoracoscopic esophagectomy can further improve outcomes compared with open laparotomy (OL) is unknown. MATERIALS AND METHODS We retrospectively reviewed the clinical and imaging records of 428 patients who received McKeown esophagectomy with a thoracoscopic approach for cancer. Using propensity score matching based on eight parameters (age, sex, body mass index, Charlson comorbidity index, tumor location, type of preoperative therapy, reconstruction route, and occurrence/severity of postoperative vocal cord palsy), 60 pairs were identified and compared with regard to perioperative complications and overall survival (OS). RESULT Compared with OL, LS resulted in lower blood loss (mean: 171.21 versus 107.58 mL, respectively, p = 0.023) and a reduced incidence of pneumonia (13.3% versus 3.3%, respectively, p = 0.048), albeit at the expense of a longer operating time (mean: 399.37 versus 443.93 min, respectively, p = 0.003). Notably, lymph node yields and OS of patients who were treated with LS were similar to those observed in those who underwent OL. CONCLUSIONS Patients who receive LS after thoracoscopic esophagectomy experience lower blood loss and have a reduced risk of pneumonia than those treated with OL.
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Abstract
OBJECTIVE To evaluate the incidence and risk factors of diaphragmatic herniation following esophagectomy for cancer (DHEC), and assess the results of surgical repair. SUMMARY BACKGROUND DATA The current incidence of DHEC is discussed with conflicting data regarding its treatment and natural course. METHODS Monocentric retrospective cohort study(2009-2018). From 902 patients, 719 patients with a complete follow-up of CT-scans after transthoracic esophagectomy for cancer were reexamined to identify the occurrence of a DHEC. The incidence of DHEC was estimated using Kalbfleisch and Prentice method and risk factors of DHEC were studied using the Fine and Gray competitive risk regression model by treating death as a competing event. Survival was analyzed. RESULTS 5-year DHEC incidence was 10.3% [95%CI, 7.8%-13.2%](n = 59), asymptomatic in 54.2% of cases. In the multivariable analysis, the risk factors for DHEC were: presence of hiatal hernia on preoperative CT scan (HR = 1.72[1.01-2.94], p = 0.046), previous hiatus surgery (HR = 3.68[1.61-8.45], p = 0.002), gastroesophageal junction tumor location (HR = 3.51[1.91-6.45], p < 0.001), neoadjuvant chemoradiotherapy (HR = 4.27[1.70-10.76], p < 0.001), and minimally invasive abdominal phase (HR = 2.98[1.60-5.55], p < 0.001). A cure for DHEC was achieved in 55.9%. The postoperative mortality rate was nil, the overall morbidity rate was 12.1%, and the DHEC recurrence rate was 30.3%. Occurrence of DHEC was significantly associated with a lower hazard rate of death in a time-varying Cox's regression analysis (HR = 0.43[0.23-0.81], p = 0.010). CONCLUSIONS The 5-year incidence of DHEC is 10.3% and is associated with a favorable prognosis. Surgical repair of symptomatic or progressive DHEC is associated with an acceptable morbidity. However, the optimal surgical repair technique remains to be determined in view of the large number of recurrences.
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233
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Van Dessel E, Moons J, Nafteux P, Van Veer H, Depypere L, Coosemans W, Lerut T, Coppens S, Neyrinck A. Perioperative fluid management in esophagectomy for cancer and its relation to postoperative respiratory complications. Dis Esophagus 2021; 34:5992355. [PMID: 33212482 DOI: 10.1093/dote/doaa111] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 07/17/2020] [Accepted: 09/01/2020] [Indexed: 12/11/2022]
Abstract
The optimal perioperative fluid management during esophagectomy is still not clear. Liberal regimens have been associated with higher morbidity and respiratory complications. Restrictive regimens might raise concerns for kidney function and increase the need to associate vasopressors. The aim of this study was to investigate retrospectively the perioperative fluid administration during esophagectomy and to correlate this with postoperative respiratory outcome. All patients who underwent esophagectomy between January and December 2016 were retrospectively analyzed. Patient characteristics, type of surgery and postoperative course were reviewed. Fluid administration and vasopressor use were calculated intraoperatively and during the postoperative stay at the recovery unit. Fluid overload was defined as a positive fluid balance of more than 125 mL/m2/h during the first 24 hours. Patients were divided in 3 groups: GRP0 (no fluid overload/no vasopressors); GRP1 (no fluid overload/need for vasopressors); GRP2 (fluid overload with/without vasopressors). Postoperative complications were prospectively recorded according to Esophagectomy Complications Consensus Group criteria. A total of 103 patients were analyzed: 35 (34%) GRP0, 50 (49%) GRP1 and 18 (17%) GRP2. No significant differences were found for age, treatment (neoadjuvant vs. primary), type of surgery (open/minimally invasive), histology nor comorbidities. There were significant (P ≤ 0.001) differences in fluid balance/m2/h (75 ± 21 mL; 86 ± 22 mL and 144 ± 20 mL) across GRP0, GRP1 and GRP2, respectively. We found differences in respiratory complications (GRP0 (20%) versus GRP1 (42%; P = 0.034) and GRP0 (20%) versus GRP2 (61%; P = 0.002)) and "Comprehensive Complications Index" (GRP0 (20.5) versus GRP1 (34.6; P = 0.015) and GRP0 (20.5) versus GRP2 (35.1; P = 0.009)). Multivariable analysis (binary logistic regression) for "any respiratory complication" was performed. Patients who received fluid overload (GRP2) had a 10.24 times higher risk to develop postoperative respiratory complications. When patients received vasopressors alone (GRP1), the chances of developing these complications were 3.57 times higher compared to GRP0. Among patients undergoing esophagectomy, there is a wide variety in the administration of fluid during the first 24 hours. There was a higher incidence of respiratory complications when patients received higher amounts of fluid or when vasopressors were used. We believe that a personalized and protocolized fluid administration algorithm should be implemented and that individual risk factors should be identified.
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Affiliation(s)
- Eleni Van Dessel
- Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium
| | - Johnny Moons
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - Philippe Nafteux
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - Hans Van Veer
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - Lieven Depypere
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - Willy Coosemans
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - Toni Lerut
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - Steve Coppens
- Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium.,Anesthesia and Algology Unit, Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Arne Neyrinck
- Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium.,Anesthesia and Algology Unit, Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
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234
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Sayed AI, Goel S, Aggarwal A, Singh S. Robot assisted minimally invasive esophagectomy: safety, perioperative morbidity and short-term oncological outcome-a single institution experience. J Robot Surg 2021; 16:517-525. [PMID: 34228249 DOI: 10.1007/s11701-021-01274-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Accepted: 06/26/2021] [Indexed: 11/30/2022]
Abstract
Robot assisted minimally invasive esophagectomy (RAMIE) has evolved over the past decade to become procedure of choice at many centers all over the world. The objective of this study is to present our experience of robot assisted minimally invasive esophagectomy with respect to perioperative morbidity and short-term oncological outcomes and a comparison of the same to a cohort of our patients who underwent open Mckeown's esophagectomy. This is a retrospective analysis of prospectively collected data of patients from October 2011 to October 2019. A total of 56 patients in open group and 58 patients in robotic group were enrolled. Upper and middle third was the most common site for open esophagectomy while middle and lower third was more common site for robotic esophagectomy (p < 0.0001). Median operative time was 340 min for open and 360 min for robotic esophagectomy (p = 0.004). A median of 16 lymph nodes were retrieved in either group. R0 resection was achieved in 86% in open and 97% in robotic group (p = 0.04). Median intensive care unit (ICU) stay (2 days versus 5 days) and median hospital stay (10.5 days versus 14.5 days) were both favoring for robotic group (p < 0.0001). Cardiac arrhythmias and pulmonary complications requiring ICU readmission occurred less frequently in patients undergoing robotic esophagectomy (p = 0.02). Two-year overall survival (p = 0.09) and 2-year disease-free survival (p = 0.32) was similar between the groups. RAMIE significantly reduced ICU as well as hospital stay and had oncological outcome similar to open Mckeown's esophagectomy.
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Affiliation(s)
- Assif Iqbal Sayed
- Department of GI and HPB Oncosurgery, Rajiv Gandhi Cancer Institute and Research Centre, Sector-5, Rohini, Delhi, 110085, India
| | - Shaifali Goel
- Department of GI and HPB Oncosurgery, Rajiv Gandhi Cancer Institute and Research Centre, Sector-5, Rohini, Delhi, 110085, India
| | - Abhishek Aggarwal
- Department of GI and HPB Oncosurgery, Rajiv Gandhi Cancer Institute and Research Centre, Sector-5, Rohini, Delhi, 110085, India
| | - Shivendra Singh
- Department of GI and HPB Oncosurgery, Rajiv Gandhi Cancer Institute and Research Centre, Sector-5, Rohini, Delhi, 110085, India. .,Department of GI and HPB Oncosurgery, Rajiv Gandhi Cancer Institute and Research Centre, Room no 3054, Ground floor, Sector -5, Rohini, Delhi, 110085, India.
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235
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Giulini L, Nasser CA, Tank J, Papp M, Stein HJ, Dubecz A. Hybrid robotic versus hybrid laparoscopic Ivor Lewis oesophagectomy: a case-matched analysis. Eur J Cardiothorac Surg 2021; 59:1279-1285. [PMID: 33448299 DOI: 10.1093/ejcts/ezaa473] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 11/15/2020] [Accepted: 11/25/2020] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES Robotic-assisted oesophagectomy for cancer has been increasingly employed worldwide; however, the benefits of this technique compared to conventional minimally invasive oesophagectomy are unclear. Since 2016, hybrid robotic minimally invasive oesophagectomy (R-HMIE) has increasingly replaced hybrid laparoscopic minimally invasive oesophagectomy (HMIE) as the standard of care in our institution. The aim of this study was to compare these procedures. METHODS Over a 10-year period, 686 patients underwent oesophagectomy at our institution. Out of these patients, 128 patients with cancer were treated with a hybrid minimally invasive technique. Each patient who underwent R-HMIE was matched according to gender, age, comorbidity, American Society of Anesthesiologists classification, Union International Contre le Cancer stage, localization, histology and neoadjuvant treatment with a patient who underwent HMIE. Perioperative parameters were extracted from our database and compared between the 2 groups. RESULTS After the matching procedure, 88 patients were included in the study. Between HMIE and R-HMIE, no significant differences (P > 0.05) were found in operating time (median 281 vs 300 min), R0 resection rate (n = 42 vs 42), harvested lymph nodes (median 28 vs 24), hospital stay (median 19 vs 17 days) and intensive care unit stay (median 7 vs 6.5 days). Regarding surgical complications, no difference could be observed either (n = 42 vs 44). CONCLUSIONS Minimally invasive oesophagectomy remains a challenging operation with high morbidity even in a high-volume institution. According to our intra- and short-term results, we have found no difference between R-HMIE and HMIE.
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Affiliation(s)
- Luca Giulini
- Department of Surgery, Paracelsus Medical University Nuremberg, Nuremberg, Germany
| | - Corinna A Nasser
- Department of Surgery, Paracelsus Medical University Nuremberg, Nuremberg, Germany
| | - Julian Tank
- Department of Surgery, Paracelsus Medical University Nuremberg, Nuremberg, Germany
| | - Marton Papp
- Centre for Bioinformatics, University of Veterinary Medicine Budapest, Budapest, Hungary
| | - Hubert J Stein
- Department of Surgery, Paracelsus Medical University Nuremberg, Nuremberg, Germany
| | - Attila Dubecz
- Department of Surgery, Paracelsus Medical University Nuremberg, Nuremberg, Germany
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Laparoscopic radical hysterectomy for cervical cancer by pulling the round ligament without a uterine manipulator. Eur J Obstet Gynecol Reprod Biol 2021; 264:31-35. [PMID: 34271363 DOI: 10.1016/j.ejogrb.2021.06.045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 06/03/2021] [Accepted: 06/27/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To demonstrate the experience of laparoscopic radical hysterectomy for cervical cancer without the use of a uterine manipulator and investigate the feasibility and treatment effectiveness of this surgical approach. MATERIALS AND METHODS The laparoscopic radical hysterectomy for cervical cancer by pulling the round ligament without a uterine manipulator prevented the oppression of the uterine manipulator on the tumour. Vaginal ligation was performed below the lesion of cervical cancer, and the vagina was cut off below the ligation line. Consequently, the exposure of cancer tissues in the abdominal cavity was prevented, enabling a tumour-free operation. We reviewed the medical records of the 22 patients with stage IB1-IIA2 cervical squamous cell carcinoma who were treated at our hospital between May 2019 and February 2020. All the patients underwent the laparoscopic radical hysterectomy for cervical cancer by pulling the round ligament. All the patients were informed about the different therapeutic schemes and surgical approaches as well as their advantages and disadvantages. Information about operative time, intraoperative blood loss, hospitalisation duration, postoperative complications, postoperative adjuvant therapy, prognosis and other data were recorded. RESULTS All the surgical procedures were successfully completed without perioperative complications, such as vascular injury, pelvic injury and abdominal organ injury. The mean operative duration was 204 min, and the mean operative blood loss was 102 mL. The mean duration of postoperative hospital stay was 13 days. Nineteen patients received postoperative chemotherapy once before hospital discharge. Urinary retention was the major postoperative complication. All the patients were followed up for 14-23 months. The median follow-up time was 18 months. 21 of the 22 patients survived. No recurrence was detected in the patients during follow-up. One patient who had a pelvic lymph node metastasis but refused complete chemoradiotherapy died before the last follow-up. CONCLUSIONS This surgical approach appears to be safe and feasible for patients with cervical cancer. A larger sample size and longer follow-up period are required to confirm whether this surgical approach can actually and effectively improve the prognosis.
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237
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van Workum F, Verstegen MHP, Klarenbeek BR, Bouwense SAW, van Berge Henegouwen MI, Daams F, Gisbertz SS, Hannink G, Haveman JW, Heisterkamp J, Jansen W, Kouwenhoven EA, van Lanschot JJB, Nieuwenhuijzen GAP, van der Peet DL, Polat F, Ubels S, Wijnhoven BPL, Rovers MM, Rosman C. Intrathoracic vs Cervical Anastomosis After Totally or Hybrid Minimally Invasive Esophagectomy for Esophageal Cancer: A Randomized Clinical Trial. JAMA Surg 2021; 156:601-610. [PMID: 33978698 DOI: 10.1001/jamasurg.2021.1555] [Citation(s) in RCA: 64] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Background Transthoracic minimally invasive esophagectomy (MIE) is increasingly performed as part of curative multimodality treatment. There appears to be no robust evidence on the preferred location of the anastomosis after transthoracic MIE. Objective To compare an intrathoracic with a cervical anastomosis in a randomized clinical trial. Design, Setting, and Participants This open, multicenter randomized clinical superiority trial was performed at 9 Dutch high-volume hospitals. Patients with midesophageal to distal esophageal or gastroesophageal junction cancer planned for curative resection were included. Data collection occurred from April 2016 through February 2020. Intervention Patients were randomly assigned (1:1) to transthoracic MIE with intrathoracic or cervical anastomosis. Main Outcomes and Measures The primary end point was anastomotic leakage requiring endoscopic, radiologic, or surgical intervention. Secondary outcomes were overall anastomotic leak rate, other postoperative complications, length of stay, mortality, and quality of life. Results Two hundred sixty-two patients were randomized, and 245 were eligible for analysis. Anastomotic leakage necessitating reintervention occurred in 15 of 122 patients with intrathoracic anastomosis (12.3%) and in 39 of 123 patients with cervical anastomosis (31.7%; risk difference, -19.4% [95% CI, -29.5% to -9.3%]). Overall anastomotic leak rate was 12.3% in the intrathoracic anastomosis group and 34.1% in the cervical anastomosis group (risk difference, -21.9% [95% CI, -32.1% to -11.6%]). Intensive care unit length of stay, mortality rates, and overall quality of life were comparable between groups, but intrathoracic anastomosis was associated with fewer severe complications (risk difference, -11.3% [-20.4% to -2.2%]), lower incidence of recurrent laryngeal nerve palsy (risk difference, -7.3% [95% CI, -12.1% to -2.5%]), and better quality of life in 3 subdomains (mean differences: dysphagia, -12.2 [95% CI, -19.6 to -4.7]; problems of choking when swallowing, -10.3 [95% CI, -16.4 to 4.2]; trouble with talking, -15.3 [95% CI, -22.9 to -7.7]). Conclusions and Relevance In this randomized clinical trial, intrathoracic anastomosis resulted in better outcome for patients treated with transthoracic MIE for midesophageal to distal esophageal or gastroesophageal junction cancer. Trial Registration Trialregister.nl Identifier: NL4183 (NTR4333).
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Affiliation(s)
- Frans van Workum
- Department of Surgery, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Moniek H P Verstegen
- Department of Surgery, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Bastiaan R Klarenbeek
- Department of Surgery, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Stefan A W Bouwense
- Department of Surgery, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands.,Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Mark I van Berge Henegouwen
- Department of Surgery, Amsterdam UMC, location AMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Freek Daams
- Department of Surgery, Amsterdam UMC, location VUmc, Amsterdam, the Netherlands
| | - Suzanne S Gisbertz
- Department of Surgery, Amsterdam UMC, location AMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Gerjon Hannink
- Department of Operating Rooms, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Jan Willem Haveman
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Joos Heisterkamp
- Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands
| | - Walther Jansen
- Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands
| | - Ewout A Kouwenhoven
- Department of Surgery, Ziekenhuisgroep (Hospital Group) Twente, Almelo, the Netherlands
| | - Jan J B van Lanschot
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | | | - Fatih Polat
- Department of Surgery, Canisius-Wilhelmina Hospital, Nijmegen, the Netherlands
| | - Sander Ubels
- Department of Surgery, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Bas P L Wijnhoven
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Maroeska M Rovers
- Department of Operating Rooms, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Camiel Rosman
- Department of Surgery, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
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Merritt RE, Abdel-Rasoul M, Fitzgerald M, D'Souza DM, Kneuertz PJ. The Academic Facility Is Associated with Higher Utilization of Esophagectomy and Improved Overall Survival for Esophageal Carcinoma. J Gastrointest Surg 2021; 25:1677-1689. [PMID: 33025288 DOI: 10.1007/s11605-020-04817-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 09/30/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Operable esophageal carcinoma is potentially curable with surgical resection. The short-term outcomes and overall survival rate for operable esophageal carcinoma may be impacted by the healthcare facility type where patients receive care. METHODS A total of 37, 271 cases with the American Joint Committee on Cancer clinical stage I, II, and III esophageal carcinoma that were reported to the National Cancer Data Base at over 12,721 facilities were analyzed. Healthcare facilities were dichotomized into the community and academic facility types. Marginal multivariable Cox proportional hazard models were used to evaluate differences in overall survival between facility types, which accounted for facility esophageal cancer volume. Propensity score methodology with inverse probability of treatment weighting was used to adjust for patient related baseline differences between facility types. RESULTS Patients with clinical stage I-III esophageal carcinoma who underwent esophagectomy at academic healthcare facilities had a significantly better overall survival compared with patients who underwent esophagectomy at community healthcare facilities [HR = 0.89: CI [0.84-0.95] (p = 0.0005)]. The rate of esophagectomy was significantly higher at the academic facilities (49.0% versus 26.5%; p < 0.0001). The 30-day and 90-day mortality rates for esophagectomy were significantly better for patients who underwent esophagectomy for esophageal cancer at the academic facility types. CONCLUSION Patients with clinical stage I-III esophageal carcinoma who received care at academic facility types had significantly better overall survival compared with community facility types. The utilization of esophagectomy was significantly higher and the short-term surgical outcomes were better for patients treated at academic facility types.
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Affiliation(s)
- Robert E Merritt
- Thoracic Surgery Division, The Ohio State University Wexner Medical Center, Doan Hall N847, 410 West 10th Avenue, Columbus, OH, 43210, USA.
| | - Mahmoud Abdel-Rasoul
- Center for Biostatistics, Department of Biomedical Informatics, College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Morgan Fitzgerald
- Thoracic Surgery Division, The Ohio State University Wexner Medical Center, Doan Hall N847, 410 West 10th Avenue, Columbus, OH, 43210, USA
| | - Desmond M D'Souza
- Thoracic Surgery Division, The Ohio State University Wexner Medical Center, Doan Hall N847, 410 West 10th Avenue, Columbus, OH, 43210, USA
| | - Peter J Kneuertz
- Thoracic Surgery Division, The Ohio State University Wexner Medical Center, Doan Hall N847, 410 West 10th Avenue, Columbus, OH, 43210, USA
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239
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Quaas A, Schloesser H, Fuchs H, Zander T, Arolt C, Scheel AH, Rueschoff J, Bruns C, Buettner R, Schroeder W. Improved Tissue Processing in Esophageal Adenocarcinoma After Ivor Lewis Esophagectomy Allows Histological Analysis of All Surgically Removed Lymph Nodes with Significant Effects on Nodal UICC Stages. Ann Surg Oncol 2021; 28:3975-3982. [PMID: 33305335 PMCID: PMC8184552 DOI: 10.1245/s10434-020-09450-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 11/16/2020] [Indexed: 01/02/2023]
Abstract
BACKGROUND In esophageal carcinoma, the numbers of metastatic and total removed lymph nodes (LN) are well-established variables of long-term prognosis. The overall rate of retrieved LN depends on neoadjuvant treatment, the extent of surgical lymphadenectomy, and the modality of the pathological workup. The question in this study is whether technically extended histopathological preparation can increase the number of detected (metastatic) LN with an impact on nodal UICC staging. PATIENTS AND METHODS A cohort of 77 patients with esophageal adenocarcinoma was treated with Ivor Lewis esophagectomy including standardized two-field lymphadenectomy. The specimens were grossed, and all manually detectable LN were retrieved. The remaining tissue was completely embedded by the advanced "acetone compression" retrieval technique. The primary outcome parameter was the total number of detected lymph nodes before and after acetone workup. RESULTS A mean number of 23,1 LN was diagnosed after standard manual LN preparation. With complete embedding of the fatty tissue using acetone compression, the number increased to 40.5 lymph nodes (p < 0.0001). The mean number of metastatic LN increased from 3.2 to 4.2 nodal metastases following acetone compression (p < 0.0001). Additional LN metastases which caused a change in the primary (y)pN stage were found in ten patients (13.0%). CONCLUSIONS Advanced lymph node retrieval by acetone compression allows a reliable statement on the real number of removed LN. Results demonstrate an impact on the nodal UICC stage. A future multicenter study will examine the prognostic impact of improved lymph node retrieval on long-term oncologic outcome.
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Affiliation(s)
- A Quaas
- Institute of Pathology, Gastrointestinal Cancer Group Cologne (GCGC), University Hospital Cologne, Cologne, Germany.
| | - H Schloesser
- Department of General, Visceral, Cancer and Transplantation Surgery, University Hospital Cologne, Cologne, Germany
| | - H Fuchs
- Department of General, Visceral, Cancer and Transplantation Surgery, University Hospital Cologne, Cologne, Germany
| | - T Zander
- Department of Internal Medicine I, University Hospital Cologne, Cologne, Germany
| | - C Arolt
- Institute of Pathology, Gastrointestinal Cancer Group Cologne (GCGC), University Hospital Cologne, Cologne, Germany
| | - A H Scheel
- Institute of Pathology, Gastrointestinal Cancer Group Cologne (GCGC), University Hospital Cologne, Cologne, Germany
| | - J Rueschoff
- Institute of Pathology, Nordhessen and Targos Molecular Pathology GmbH, Kassel, Germany
| | - C Bruns
- Department of General, Visceral, Cancer and Transplantation Surgery, University Hospital Cologne, Cologne, Germany
| | - R Buettner
- Institute of Pathology, Gastrointestinal Cancer Group Cologne (GCGC), University Hospital Cologne, Cologne, Germany
| | - W Schroeder
- Department of General, Visceral, Cancer and Transplantation Surgery, University Hospital Cologne, Cologne, Germany
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Klevebro F, Kauppila JH, Markar S, Johar A, Lagergren P. Health-related quality of life following total minimally invasive, hybrid minimally invasive or open oesophagectomy: a population-based cohort study. Br J Surg 2021; 108:702-708. [PMID: 34157084 PMCID: PMC10364862 DOI: 10.1002/bjs.11998] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 07/11/2020] [Accepted: 07/23/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND Minimally invasive oesophagectomy has been shown to reduce the risk of pulmonary complications compared with open oesophagectomy, but the effects on health-related quality of life (HRQoL) and oesophageal cancer survivorship remain unclear. The aim of this study was to assess the longitudinal effects of minimally invasive compared with open oesophagectomy for cancer on HRQoL. METHODS All patients who had surgery for oesophageal cancer in Sweden from January 2013 to April 2018 were identified. The exposure was total or hybrid minimally invasive oesophagectomy, compared with open surgery. The study outcome was HRQoL, evaluated by means of the European Organisation for Research and Treatment of Cancer questionnaires QLQ-C30 and QLQ-OG25 at 1 and 2 years after surgery. Mean differences and 95 per cent confidence intervals were adjusted for confounders. RESULTS Of the 246 patients recruited, 153 underwent minimally invasive oesophagectomy, of which 75 were hybrid minimally invasive and 78 were total minimally invasive procedures. After adjustment for age, sex, Charlson Co-morbidity Index score, pathological tumour stage and neoadjuvant therapy, there were no clinically and statistically significant differences in overall or disease-specific HRQoL after oesophagectomy between hybrid minimally invasive and total minimally invasive surgical technique versus open surgery. CONCLUSION In this population-based nationwide Swedish study, longitudinal HRQoL after minimally invasive oesophagectomy was similar to that of the open surgical approach.
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Affiliation(s)
- F Klevebro
- Surgical Care Science, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - J H Kauppila
- Surgical Care Science, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
- Research Unit of Surgery, Anaesthesia and Intensive Care, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - S Markar
- Surgical Care Science, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - A Johar
- Surgical Care Science, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - P Lagergren
- Surgical Care Science, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
- Department of Surgery and Cancer, Imperial College London, London, UK
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241
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Schroeder W, Mallmann C, Babic B, Bruns C, Fuchs HF. [Fast-track Rehabilitation after Oesophagectomy]. Zentralbl Chir 2021; 146:306-314. [PMID: 34154009 DOI: 10.1055/a-1487-7086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The multimodal and interprofessional concept of fast-track rehabilitation ("enhanced recovery after surgery", ERAS) is generally applicable to transthoracic oesophagectomy, but is associated with two special features as compared to other oncological procedures. Due to the high comorbidity of oesophageal cancer patients, fast-track pathways have to be considered as one component of perioperative management and cannot be separated from prehabilitation with preoperative conditioning of single organ dysfunctions. Since gastric reconstruction causes a high prevalence of delayed gastric conduit emptying (DGCE), early and sufficient postoperative oral feeding is not easily feasible. There is currently no generally accepted algorithm for the postoperative nutritional management as well as for the prophylaxis/treatment of DGCE. Fast-track prehabilitation does not influence the mortality rate in specialised centres. At present, it is not clear whether a fast-track pathway helps to reduce postoperative morbidity. After modified fast-track rehabilitation, hospital discharge is possible from the 8th postoperative day.
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Affiliation(s)
- Wolfgang Schroeder
- Klinik für Allgemein-, Viszeral- und Tumorchirurgie, Universitätsklinikum Köln, Deutschland
| | - Christoph Mallmann
- Klinik für Allgemein-, Viszeral- und Tumorchirurgie, Universitätsklinikum Köln, Deutschland
| | - Benjamin Babic
- Klinik für Allgemein-, Viszeral- und Tumorchirurgie, Universitätsklinikum Köln, Deutschland
| | - Christiane Bruns
- Klinik für Allgemein-, Viszeral- und Tumorchirurgie, Universitätsklinikum Köln, Deutschland
| | - Hans Friedrich Fuchs
- Klinik für Allgemein-, Viszeral- und Tumorchirurgie, Universitätsklinikum Köln, Deutschland
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242
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New Trends in Esophageal Cancer Management. Cancers (Basel) 2021; 13:cancers13123030. [PMID: 34204314 PMCID: PMC8235022 DOI: 10.3390/cancers13123030] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 06/10/2021] [Accepted: 06/13/2021] [Indexed: 12/08/2022] Open
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243
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Migliore M. Which is the best approach for minimally invasive oesophagectomy? Eur J Cardiothorac Surg 2021; 59:1285-1286. [PMID: 33582758 DOI: 10.1093/ejcts/ezab041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Affiliation(s)
- Marcello Migliore
- Thoracic Surgery, Cardio-Thoracic Department, University Hospital of Wales, Cardiff, UK.,Section of Thoracic Surgery, Department of Surgery and Medical Specialties, University of Catania, Catania, Italy
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244
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Coelho FDS, Barros DE, Santos FA, Meireles FC, Maia FC, Trovisco RA, Machado TM, Barbosa JA. Minimally invasive esophagectomy versus open esophagectomy: A systematic review and meta-analysis. Eur J Surg Oncol 2021; 47:2742-2748. [PMID: 34148823 DOI: 10.1016/j.ejso.2021.06.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 06/05/2021] [Indexed: 02/04/2023] Open
Abstract
The paradigm of the treatment of esophageal cancer has been changing with the increasing use of minimally invasive esophagectomy (MIE) in detriment of open esophagectomy (OE). We aimed to perform a meta-analysis to evaluate and compare these two techniques in terms of mortality and associated complications. The literature search was conducted in MEDLINE and U.S. National Library of Medicine Clinical Trials, considering eligible articles since 2015 to 2020. Clinical trials and observational studies were included. We presented results as mean differences with 95% confidence intervals and calculation of heterogeneity associated to the included studies. Thirty-one articles were included with a total of 34,465 participants diagnosed with esophageal adenocarcinoma or squamous cell carcinoma. MIE had tendency towards a decrease in 30- and 90- day mortality after surgery, but no statistically significative results were found. Major cardiovascular and respiratory complications were less frequent in the MIE group, despite high heterogeneity. Also, MIE might contribute to a decrease of minor post-operative complications, to an increase need of a second surgical intervention, to a greater risk for vocal cord lesions; but these results were not statistically significant. Additionally, no differences were found concerning risk of wound infection and for local and systemic recurrence. MIE may be more beneficial than OE, but these findings should be considered carefully.
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Affiliation(s)
- Francisca Dos S Coelho
- Faculdade de Medicina da Universidade do Porto, Alameda Professor Hernâni Monteiro, 4200-319, Porto, Portugal.
| | - Diana E Barros
- Faculdade de Medicina da Universidade do Porto, Alameda Professor Hernâni Monteiro, 4200-319, Porto, Portugal
| | - Filipa A Santos
- Faculdade de Medicina da Universidade do Porto, Alameda Professor Hernâni Monteiro, 4200-319, Porto, Portugal
| | - Flávia C Meireles
- Faculdade de Medicina da Universidade do Porto, Alameda Professor Hernâni Monteiro, 4200-319, Porto, Portugal
| | - Francisca C Maia
- Faculdade de Medicina da Universidade do Porto, Alameda Professor Hernâni Monteiro, 4200-319, Porto, Portugal
| | - Rita A Trovisco
- Faculdade de Medicina da Universidade do Porto, Alameda Professor Hernâni Monteiro, 4200-319, Porto, Portugal
| | - Teresa M Machado
- Faculdade de Medicina da Universidade do Porto, Alameda Professor Hernâni Monteiro, 4200-319, Porto, Portugal
| | - José A Barbosa
- Faculdade de Medicina da Universidade do Porto, Alameda Professor Hernâni Monteiro, 4200-319, Porto, Portugal; Serviço de Cirurgia, Centro Hospitalar Universitário de São João, E.P.E, Alameda Professor Hernâni Monteiro, 4200-319, Porto, Portugal
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245
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Fehrenbach U, Wuensch T, Gabriel P, Segger L, Yamaguchi T, Auer TA, Beetz NL, Denecke C, Kröll D, Raakow J, Knitter S, Chopra S, Thuss-Patience P, Pratschke J, Hamm B, Biebl M, Geisel D. CT Body Composition of Sarcopenia and Sarcopenic Obesity: Predictors of Postoperative Complications and Survival in Patients with Locally Advanced Esophageal Adenocarcinoma. Cancers (Basel) 2021; 13:cancers13122921. [PMID: 34208070 PMCID: PMC8230687 DOI: 10.3390/cancers13122921] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 06/06/2021] [Accepted: 06/08/2021] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND To assess the impact of body composition imaging biomarkers in computed tomography (CT) on the perioperative morbidity and survival after surgery of patients with esophageal cancer (EC). METHODS Eighty-five patients who underwent esophagectomy for locally advanced EC after neoadjuvant therapy between 2014 and 2019 were retrospectively enrolled. Pre- and postoperative CT scans were used to assess the body composition imaging biomarkers (visceral (VAT) and subcutaneous adipose tissue (SAT) areas, psoas muscle area (PMA) and volume (PMV), total abdominal muscle area (TAMA)). Sarcopenia was defined as lumbar skeletal muscle index (LSMI) ≤38.5 cm2/m2 in women and ≤52.4 cm2/m2 in men. Patients with a body mass index (BMI) of ≥30 were considered obese. These imaging biomarkers were correlated with major complications, anastomotic leakage, postoperative pneumonia, duration of postoperative hospitalization, disease-free survival (DFS), and overall survival (OS). RESULTS Preoperatively, sarcopenia was identified in 58 patients (68.2%), and sarcopenic obesity was present in 7 patients (8.2%). Sarcopenic patients were found to have an elevated risk for the occurrence of major complications (OR: 2.587, p = 0.048) and prolonged hospitalization (32 d vs. 19 d, p = 0.040). Patients with sarcopenic obesity had a significantly higher risk for postoperative pneumonia (OR: 6.364 p = 0.018) and a longer postoperative hospital stay (71 d vs. 24 d, p = 0.021). Neither sarcopenia nor sarcopenic obesity was an independent risk factor for the occurrence of anastomotic leakage (p > 0.05). Low preoperative muscle biomarkers (PMA and PMV) and their decrease (ΔPMV and ΔTAMA) during the follow-up period significantly correlated with shorter DFS and OS (p = 0.005 to 0.048). CONCLUSION CT body composition imaging biomarkers can identify high-risk patients with locally advanced esophageal cancer undergoing surgery. Sarcopenic patients have a higher risk of major complications, and patients with sarcopenic obesity are more prone to postoperative pneumonia. Sarcopenia and sarcopenic obesity are both subsequently associated with a prolonged hospitalization. Low preoperative muscle mass and its decrease during the postoperative follow-up are associated with lower DFS and OS.
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Affiliation(s)
- Uli Fehrenbach
- Department of Radiology, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (P.G.); (L.S.); (T.A.A.); (N.L.B.); (B.H.); (D.G.)
- Correspondence: ; Tel.: +49-(0)30-450-557-001; Fax: +49-(0)30-450-755-7901
| | - Tilo Wuensch
- Department of Surgery, Campus Charité Mitte and Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (T.W.); (C.D.); (D.K.); (J.R.); (S.K.); (S.C.); (J.P.); (M.B.)
| | - Pia Gabriel
- Department of Radiology, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (P.G.); (L.S.); (T.A.A.); (N.L.B.); (B.H.); (D.G.)
| | - Laura Segger
- Department of Radiology, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (P.G.); (L.S.); (T.A.A.); (N.L.B.); (B.H.); (D.G.)
| | - Takeru Yamaguchi
- Department of Radiology, Kobe University Graduate School of Medicine, Kobe 6500017, Japan;
| | - Timo Alexander Auer
- Department of Radiology, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (P.G.); (L.S.); (T.A.A.); (N.L.B.); (B.H.); (D.G.)
- Berlin Institute of Health (BIH), 10178 Berlin, Germany
| | - Nick Lasse Beetz
- Department of Radiology, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (P.G.); (L.S.); (T.A.A.); (N.L.B.); (B.H.); (D.G.)
| | - Christian Denecke
- Department of Surgery, Campus Charité Mitte and Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (T.W.); (C.D.); (D.K.); (J.R.); (S.K.); (S.C.); (J.P.); (M.B.)
| | - Dino Kröll
- Department of Surgery, Campus Charité Mitte and Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (T.W.); (C.D.); (D.K.); (J.R.); (S.K.); (S.C.); (J.P.); (M.B.)
| | - Jonas Raakow
- Department of Surgery, Campus Charité Mitte and Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (T.W.); (C.D.); (D.K.); (J.R.); (S.K.); (S.C.); (J.P.); (M.B.)
| | - Sebastian Knitter
- Department of Surgery, Campus Charité Mitte and Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (T.W.); (C.D.); (D.K.); (J.R.); (S.K.); (S.C.); (J.P.); (M.B.)
| | - Sascha Chopra
- Department of Surgery, Campus Charité Mitte and Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (T.W.); (C.D.); (D.K.); (J.R.); (S.K.); (S.C.); (J.P.); (M.B.)
| | - Peter Thuss-Patience
- Department of Hematology, Oncology and Cancer Immunology, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany;
| | - Johann Pratschke
- Department of Surgery, Campus Charité Mitte and Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (T.W.); (C.D.); (D.K.); (J.R.); (S.K.); (S.C.); (J.P.); (M.B.)
| | - Bernd Hamm
- Department of Radiology, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (P.G.); (L.S.); (T.A.A.); (N.L.B.); (B.H.); (D.G.)
| | - Matthias Biebl
- Department of Surgery, Campus Charité Mitte and Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (T.W.); (C.D.); (D.K.); (J.R.); (S.K.); (S.C.); (J.P.); (M.B.)
| | - Dominik Geisel
- Department of Radiology, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (P.G.); (L.S.); (T.A.A.); (N.L.B.); (B.H.); (D.G.)
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Flemming S, Lock JF, Hankir M, Reimer S, Petritsch B, Germer CT, Seyfried F. Successful management of therapy-refractory pseudoachalasia after Ivor Lewis esophagectomy by bypassing colonic pull-up: A case report. World J Clin Cases 2021; 9:3971-3978. [PMID: 34141755 PMCID: PMC8180226 DOI: 10.12998/wjcc.v9.i16.3971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 02/26/2021] [Accepted: 03/24/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Gastric pull-up after esophagectomy is still a demanding surgical procedure and associated with considerable morbidity such as anastomotic leaks, fistulas or stenoses. These complications are usually managed by endoscopy, but in extreme cases multidisciplinary management including reoperations may be necessary. Here, we report managing therapy-refractory pseudoachalasia after Ivor Lewis esophagectomy by bypassing colonic pull-up.
CASE SUMMARY A 70-year-old male with dysphagia and regurgitation after esophagectomy with gastric pull-up reconstruction was transferred to our tertiary hospital. Since endoscopic approaches including balloon dilatation and stenting failed, retrosternal colonic pull-up with Roux-en-Y reconstruction was performed with no subsequent adverse events.
CONCLUSION Secondary colonic pull-up is a demanding but successful surgical procedure in patients suffering from therapy-refractory complaints after esophagectomy with gastric pull-up reconstruction.
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Affiliation(s)
- Sven Flemming
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital of Wuerzburg, Würzburg 97080, Germany
| | - Johan F Lock
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital of Wuerzburg, Würzburg 97080, Germany
| | - Mohammed Hankir
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital of Wuerzburg, Würzburg 97080, Germany
| | - Stanislaus Reimer
- Department of Internal Medicine II, Section of Gastroenterology, University Hospital of Wuerzburg, Würzburg 97080, Germany
| | - Bernhard Petritsch
- Department of Diagnostic and Interventional Radiology, University Hospital of Wuerzburg, Würzburg 97080, Germany
| | - Christoph-Thomas Germer
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital of Wuerzburg, Würzburg 97080, Germany
| | - Florian Seyfried
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital of Wuerzburg, Würzburg 97080, Germany
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Challine A, Voron T, Dousset B, Creavin B, Katsahian S, Parc Y, Lazzati A, Lefèvre JH. Postoperative outcomes after laparoscopic or open gastrectomy. A national cohort study of 10,343 patients. Eur J Surg Oncol 2021; 47:1985-1995. [PMID: 34078568 DOI: 10.1016/j.ejso.2021.05.034] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 03/15/2021] [Accepted: 05/17/2021] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Laparoscopy for gastric cancer has not been as popular compared with other digestive surgeries, with conflicting reports on outcomes. The aim of this study focuses on the surgical techniques comparing open and laparoscopy by assessing the morbi-mortality and long-term complications after gastrectomy. METHODS A retrospective study (2013-2018) was performed on a prospective national cohort (PMSI). All patients undergoing resection for gastric cancer with a partial gastrectomy (PG) or total gastrectomy (TG) were included. Overall morbidity at 90 post-operative days and long-term results were the main outcomes. The groups (open and laparoscopy) were compared using a propensity score and volume activity matching after stratification on resection type (TG or PG). RESULTS A total of 10,343 patients were included. The overall 90-day mortality and morbidity were 7% and 45%, with reintervention required in 9.1%. High centre volume was associated with improved outcomes. There was no difference in population characteristics between groups after matching. An overall benefit for a laparoscopic approach after PG was found for morbidity (Open = 39.4% vs. Laparoscopy = 32.6%, p = 0.01), length of stay (Open = 14[10-21] vs. Laparoscopy = 11[8-17] days, p<0.0001). For TG, increased reintervention rate (Open = 10.8% vs. Laparoscopy = 14.5%, p = 0.04) and increased oesophageal stricture rate (HR = 2.54[1.67-3.85], p<0.001) were encountered after a laparoscopic approach. No benefit on mortality was found for laparoscopic approach in both type of resections after adjusted analysis. CONCLUSIONS Laparoscopy is feasible for PG with a substantial benefit on morbidity and length of stay, however, laparoscopic TG should be performed with caution, with of higher rates of reintervention and oesophageal stricture.
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Affiliation(s)
- Alexandre Challine
- Department of Digestive Surgery, APHP, Hôpital Cochin, Paris, France; Université de Paris, France; INSERM UMR 1138 Team 22, Centre de Recherche des Cordeliers, France
| | - Thibault Voron
- Department of Digestive Surgery, AP-HP, Hôpital, Saint Antoine, F-75012, Paris, France; Sorbonne Université, France
| | - Bertrand Dousset
- Department of Digestive Surgery, APHP, Hôpital Cochin, Paris, France; Université de Paris, France
| | - Ben Creavin
- Department of Surgery, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Sandrine Katsahian
- Université de Paris, France; INSERM UMR 1138 Team 22, Centre de Recherche des Cordeliers, France; Department of Biostatics, Hôpital Européen Georges Pompidou, APHP, Paris, France
| | - Yann Parc
- Department of Digestive Surgery, AP-HP, Hôpital, Saint Antoine, F-75012, Paris, France; Sorbonne Université, France
| | - Andrea Lazzati
- Université de Paris, France; INSERM UMR 1138 Team 22, Centre de Recherche des Cordeliers, France; Department of Digestive Surgery, Centre Hospitalier Intercommunal de Créteil, Creteil, France
| | - Jérémie H Lefèvre
- Department of Digestive Surgery, AP-HP, Hôpital, Saint Antoine, F-75012, Paris, France; Sorbonne Université, France.
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Nasrollahzadeh D, Roshandel G, Delhomme TM, Avogbe PH, Foll M, Saidi F, Poustchi H, Sotoudeh M, Malekzadeh R, Brennan P, Mckay J, Hainaut P, Abedi-Ardekani B. TP53 Targeted Deep Sequencing of Cell-Free DNA in Esophageal Squamous Cell Carcinoma Using Low-Quality Serum: Concordance with Tumor Mutation. Int J Mol Sci 2021; 22:5627. [PMID: 34073316 PMCID: PMC8197963 DOI: 10.3390/ijms22115627] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 04/28/2021] [Accepted: 05/17/2021] [Indexed: 12/30/2022] Open
Abstract
Circulating cell-free DNA (cfDNA) is emerging as a potential tumor biomarker. CfDNA-based biomarkers may be applicable in tumors without an available non-invasive screening method among at-risk populations. Esophageal squamous cell carcinoma (ESCC) and residents of the Asian cancer belt are examples of those malignancies and populations. Previous epidemiological studies using cfDNA have pointed to the need for high volumes of good quality plasma (i.e., >1 mL plasma with 0 or 1 cycles of freeze-thaw) rather than archival serum, which is often the main available source of cfDNA in retrospective studies. Here, we have investigated the concordance of TP53 mutations in tumor tissue and cfDNA extracted from archival serum left-over from 42 cases and 39 matched controls (age, gender, residence) in a high-risk area of Northern Iran (Golestan). Deep sequencing of TP53 coding regions was complemented with a specialized variant caller (Needlestack). Overall, 23% to 31% of mutations were concordantly detected in tumor and serum cfDNA (based on two false discovery rate thresholds). Concordance was positively correlated with high cfDNA concentration, smoking history (p-value = 0.02) and mutations with a high potential of neoantigen formation (OR; 95%CI = 1.9 (1.11-3.29)), suggesting that tumor DNA release in the bloodstream might reflect the effects of immune and inflammatory context on tumor cell turnover. We identified TP53 mutations in five controls, one of whom was subsequently diagnosed with ESCC. Overall, the results showed that cfDNA mutations can be reliably identified by deep sequencing of archival serum, with a rate of success comparable to plasma. Nonetheless, 70% non-identifiable mutations among cancer patients and 12% mutation detection in controls are the main challenges in applying cfDNA to detect tumor-related variants when blindly targeting whole coding regions of the TP53 gene in ESCC.
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Affiliation(s)
- Dariush Nasrollahzadeh
- Digestive Oncology Research Center, Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran 14117-13135, Iran; (D.N.); (F.S.); (H.P.); (M.S.); (R.M.)
- Genomic Epidemiology Branch, International Agency for Research on Cancer/World Health Organization (IARC/WHO), 69000 Lyon, France; (T.M.D.); (P.H.A.); (M.F.); (P.B.); (J.M.)
| | - Gholamreza Roshandel
- Golestan Research Center of Gastroenterology and Hepatology, Golestan University of Medical Sciences, Gorgan 49177-44563, Iran;
| | - Tiffany Myriam Delhomme
- Genomic Epidemiology Branch, International Agency for Research on Cancer/World Health Organization (IARC/WHO), 69000 Lyon, France; (T.M.D.); (P.H.A.); (M.F.); (P.B.); (J.M.)
- Institute for Research in Biomedicine (IRB Barcelona), Barcelona Institute of Science and Technology, 08036 Barcelona, Spain
| | - Patrice Hodonou Avogbe
- Genomic Epidemiology Branch, International Agency for Research on Cancer/World Health Organization (IARC/WHO), 69000 Lyon, France; (T.M.D.); (P.H.A.); (M.F.); (P.B.); (J.M.)
| | - Matthieu Foll
- Genomic Epidemiology Branch, International Agency for Research on Cancer/World Health Organization (IARC/WHO), 69000 Lyon, France; (T.M.D.); (P.H.A.); (M.F.); (P.B.); (J.M.)
| | - Farrokh Saidi
- Digestive Oncology Research Center, Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran 14117-13135, Iran; (D.N.); (F.S.); (H.P.); (M.S.); (R.M.)
| | - Hossein Poustchi
- Digestive Oncology Research Center, Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran 14117-13135, Iran; (D.N.); (F.S.); (H.P.); (M.S.); (R.M.)
| | - Masoud Sotoudeh
- Digestive Oncology Research Center, Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran 14117-13135, Iran; (D.N.); (F.S.); (H.P.); (M.S.); (R.M.)
| | - Reza Malekzadeh
- Digestive Oncology Research Center, Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran 14117-13135, Iran; (D.N.); (F.S.); (H.P.); (M.S.); (R.M.)
| | - Paul Brennan
- Genomic Epidemiology Branch, International Agency for Research on Cancer/World Health Organization (IARC/WHO), 69000 Lyon, France; (T.M.D.); (P.H.A.); (M.F.); (P.B.); (J.M.)
| | - James Mckay
- Genomic Epidemiology Branch, International Agency for Research on Cancer/World Health Organization (IARC/WHO), 69000 Lyon, France; (T.M.D.); (P.H.A.); (M.F.); (P.B.); (J.M.)
| | - Pierre Hainaut
- Institute for Advanced Biosciences, Inserm 1209 CNRS 5309 UGA, 38700 Grenoble, France;
| | - Behnoush Abedi-Ardekani
- Genomic Epidemiology Branch, International Agency for Research on Cancer/World Health Organization (IARC/WHO), 69000 Lyon, France; (T.M.D.); (P.H.A.); (M.F.); (P.B.); (J.M.)
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Chouliaras K, Hochwald S, Kukar M. Robotic-assisted Ivor Lewis esophagectomy, a review of the technique. Updates Surg 2021; 73:831-838. [PMID: 34014498 DOI: 10.1007/s13304-021-01000-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 02/09/2021] [Indexed: 11/29/2022]
Abstract
Esophageal resection is a key component of the multidisciplinary management of esophageal cancer. Robotic-assisted minimally invasive esophagectomy is gaining widespread approval amongst few centers with promising early data. There is significant variability in the operative approach utilized by different centers and this review describes, step-by-step, the operative technique at a high-volume tertiary center. The cornerstone of management is individualized surgical approach, based on patient, tumor and technical factors. Although our approach is based on aforementioned factors, our preferred approach is an Ivor Lewis esophagectomy and this review focuses on that. The procedure is broken down into three key parts, starting with an abdominal exploration and creation of the gastric conduit, placement of jejunostomy tube, moving to thoracic mobilization and creation of the side-side 6 cm stapled esophagogastric anastomosis with a final abdominal portion to assure proper positioning of the conduit and reducing redundancy. This approach is fully robotic and a side to side anastomosis facilitates the creation of a widely patent anastomosis therefore minimizing the risk of anastomotic leaks and strictures. Our experience with minimally invasive esophagectomy, as has been previously published, is associated with a 5.1% of anastomotic leak and 7.6% of anastomotic stricture. The robotic platform further optimizes this technique and helps us safely accomplish a side to side stapled anastomosis. Superior instrument dexterity in a restricted thoracic space is facilitated by intracorporeal suturing and robotic stapling. Thus, it obviates the need for a larger thoracotomy incision, which is typically needed for an EEA anastomosis, and that is traditionally associated with higher stricture rate.
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Affiliation(s)
- Konstantinos Chouliaras
- Department of Surgical Oncology, Roswell Park Comprehensive Cancer Center, 665 Elm Street, Buffalo, NY, 14203, USA
| | - Steven Hochwald
- Department of Surgical Oncology, Roswell Park Comprehensive Cancer Center, 665 Elm Street, Buffalo, NY, 14203, USA
| | - Moshim Kukar
- Department of Surgical Oncology, Roswell Park Comprehensive Cancer Center, 665 Elm Street, Buffalo, NY, 14203, USA.
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250
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Zheng Y, Li Y, Liu X, Sun H, Shen S, Ba Y, Wang Z, Liu S, Xing W. Minimally Invasive Versus Open McKeown for Patients with Esophageal Cancer: A Retrospective Study. Ann Surg Oncol 2021; 28:6329-6336. [PMID: 33987755 DOI: 10.1245/s10434-021-10105-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 03/17/2021] [Indexed: 12/07/2022]
Abstract
INTRODUCTION McKeown minimally invasive esophagectomy (McKeown-MIE) offers advantages in short-term outcomes compared with McKeown open esophagectomy (McKeown-OE); however, debate as to whether MIE is equivalent or better than OE regarding survival outcomes is ongoing. OBJECTIVE The aim of this study was to compare long-term survival between McKeown-MIE and McKeown-OE in a large cohort of esophageal cancer (EC) patients. METHODS We used a prospective database (independently managed by LinkDoc company) of the Thoracic Surgery Department at Henan Cancer Hospital and included patients who underwent McKeown-MIE and McKeown-OE for EC from 1 January 2015 to 6 January 2018. The perioperative data and overall survival (OS) rate in the two groups were retrospectively compared. RESULTS We included 502 patients who underwent McKeown-MIE (n = 306) or McKeown-OE (n = 196) for EC. The median age in the total patient population was 63 years. All baseline characteristics were well-balanced between the two groups. There was a significantly shorter mean operative time (269.76 min vs. 321.14 min, p < 0.001) in the OE group. The 30-day and in-hospital mortality rates were 0, and there was no difference in 90-day mortality (p = 0.053) between the groups. The postoperative stay was shorter in the MIE group and was 14 days and 18 days in the MIE and OE groups, respectively (p < 0.001). The OS at 60 months was 58.8% and 41.6% in the MIE and OE groups, respectively (p < 0.001) [hazard ratio 1.783, 95% confidence interval 1.347-2.359]. CONCLUSIONS These results showed that McKeown-MIE was associated with better long-term survival than McKeown-OE for patients with resectable EC.
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Affiliation(s)
- Yan Zheng
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, Henan, People's Republic of China
| | - Yin Li
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, Henan, People's Republic of China.,Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xianben Liu
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, Henan, People's Republic of China
| | - Haibo Sun
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, Henan, People's Republic of China
| | - Sining Shen
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, Henan, People's Republic of China
| | - Yufeng Ba
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, Henan, People's Republic of China
| | - Zongfei Wang
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, Henan, People's Republic of China
| | - Shilei Liu
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, Henan, People's Republic of China
| | - Wenqun Xing
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, Henan, People's Republic of China.
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