401
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Na KJ, Park S, Park IK, Kim YT, Kang CH. Outcomes after total robotic esophagectomy for esophageal cancer: a propensity-matched comparison with hybrid robotic esophagectomy. J Thorac Dis 2019; 11:5310-5320. [PMID: 32030248 PMCID: PMC6988082 DOI: 10.21037/jtd.2019.11.58] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 11/12/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Robot-assisted minimally invasive esophagectomy (RAMIE) reduces postoperative respiratory complications and enables meticulous mediastinal lymphadenectomy. However, whether adding a robotic abdominal procedure to a robotic thoracic procedure can result in better outcomes is unclear. We examined outcomes after total-RAMIE (T-RAMIE) and compared them with the outcomes after hybrid-RAMIE (H-RAMIE). METHODS Total of 227 patients who underwent robotic esophagectomy for esophageal cancer were included. T-RAMIE was defined as esophagectomy performed robotically in both the thoracic and abdominal cavities. Laparotomy was used instead of the robotic procedure in H-RAMIE. T-RAMIE was performed in 144 patients (63.4%), and propensity score matching produced 49 matched pairs from each group. Early and long-term clinical outcomes between the two groups were compared. RESULTS T-RAMIE was mostly performed for upper or mid-thoracic squamous cell carcinoma (n=119, 82.6%) and cervical anastomosis, and three-field lymphadenectomy was performed in 113 (78.5%) and 54 (37.5%) patients, respectively. One laparotomy conversion was necessary because of severe obesity. The propensity-matched analysis demonstrated that T-RAMIE showed a comparable 90-day mortality rate with H-RAMIE (0% vs. 6.1%, P=0.083). The incidence rates of total (63.3% vs. 63.3%; P=1.000), abdominal (8.2% vs. 14.3%; P=0.366), and respiratory complications (10.2% vs. 10.2%; P=1.000) were not different between two groups. The number of harvested abdominal lymph nodes was similar (12.4±9.0 vs. 12.3±8.9; P=0.992). Median follow-up duration for T-RAMIE and H-RAMIE was 16.3 and 23.5 months, respectively. Two-year overall survival rate (86.2% in T-RAMIE vs. 77.6% in H-RAMIE; P=0.150) and recurrence-free survival (76.6% in T-RAMIE vs. 62.2% in H-RAMIE; P=0.280) were comparable between the two groups. CONCLUSIONS In this matched analysis, T-RAMIE and H-RAMIE showed comparable early outcomes and long-term survival. The low tendencies of early mortality and conversion rate of T-RAMIE suggest that it might be a safe alternative to open stomach mobilization and abdominal lymphadenectomy.
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Affiliation(s)
- Kwon Joong Na
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Samina Park
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - In Kyu Park
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Young Tae Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Chang Hyun Kang
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul, Republic of Korea
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402
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Long-term Survival in Esophageal Cancer After Minimally Invasive Compared to Open Esophagectomy. Ann Surg 2019; 270:1005-1017. [DOI: 10.1097/sla.0000000000003252] [Citation(s) in RCA: 87] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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403
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Kumble LD, Silver E, Oh A, Abrams JA, Sonett JR, Hur C. Treatment of early stage (T1) esophageal adenocarcinoma: Personalizing the best therapy choice. World J Meta-Anal 2019; 7:406-417. [DOI: 10.13105/wjma.v7.i9.406] [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: 08/09/2019] [Revised: 10/03/2019] [Accepted: 10/19/2019] [Indexed: 02/06/2023] Open
Abstract
Esophagectomy is considered the primary form of management for esophageal adenocarcinoma (EAC); however, the surgery is associated with high rates of morbidity and mortality. For patients with early-stage EAC, endoscopic resection (ER) presents a potential curative treatment option that is less invasive and carries fewer risks procedure related risks, but it is associated with higher rates of cancer recurrence following the procedure. For some patients, age and comorbidities may prevent them from having esophagectomy as a treatment option, while other patients may be operative candidates but do not wish to undergo esophagectomy for a variety of reasons related to their values and preferences. Furthermore, while anxiety of cancer recurrence following ER may significantly diminish a patient’s quality of life (QOL), so might the morbidity surrounding esophagectomy. In addition to considering health status, patient preferences, and impacts on QOL, physicians and patients must also consider what treatments would be both beneficial and available to the patient, considering esophagectomy methods-minimally invasive vs open-or the use of chemoradiotherapy in addition to ER. Our article reviews and summarizes available treatment options for patients with early EAC and their potential effects on the health and wellbeing of patients based on the current data. We conclude with a request for more research of available options for early EAC patients, the conditions that determine when each option should be employed, and their effects not only on patient health but also QOL.
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Affiliation(s)
| | - Elisabeth Silver
- General Medicine, Columbia University Medical Center, New York, NY 10032, United States
| | - Aaron Oh
- General Medicine, Columbia University Medical Center, New York, NY 10032, United States
| | - Julian A Abrams
- Department of Medicine, Columbia University Medical Center, New York, NY 10032, United States
| | - Joshua R Sonett
- Department of Medicine, Columbia University Medical Center, New York, NY 10032, United States
| | - Chin Hur
- Department of Medicine, Columbia University Medical Center, New York, NY 10032, United States
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404
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Chiu CH, Chao YK. Pushing the envelope of minimally invasive esophagectomy. J Thorac Dis 2019; 11:E171-E173. [PMID: 31737331 DOI: 10.21037/jtd.2019.09.42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Chien-Hung Chiu
- Division of Thoracic Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, Taoyuan
| | - Yin-Kai Chao
- Division of Thoracic Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, Taoyuan
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405
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Brierley RC, Gaunt D, Metcalfe C, Blazeby JM, Blencowe NS, Jepson M, Berrisford RG, Avery KNL, Hollingworth W, Rice CT, Moure-Fernandez A, Wong N, Nicklin J, Skilton A, Boddy A, Byrne JP, Underwood T, Vohra R, Catton JA, Pursnani K, Melhado R, Alkhaffaf B, Krysztopik R, Lamb P, Culliford L, Rogers C, Howes B, Chalmers K, Cousins S, Elliott J, Donovan J, Heys R, Wickens RA, Wilkerson P, Hollowood A, Streets C, Titcomb D, Humphreys ML, Wheatley T, Sanders G, Ariyarathenam A, Kelly J, Noble F, Couper G, Skipworth RJE, Deans C, Ubhi S, Williams R, Bowrey D, Exon D, Turner P, Daya Shetty V, Chaparala R, Akhtar K, Farooq N, Parsons SL, Welch NT, Houlihan RJ, Smith J, Schranz R, Rea N, Cooke J, Williams A, Hindmarsh C, Maitland S, Howie L, Barham CP. Laparoscopically assisted versus open oesophagectomy for patients with oesophageal cancer-the Randomised Oesophagectomy: Minimally Invasive or Open (ROMIO) study: protocol for a randomised controlled trial (RCT). BMJ Open 2019; 9:e030907. [PMID: 31748296 PMCID: PMC6887040 DOI: 10.1136/bmjopen-2019-030907] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 06/17/2019] [Accepted: 08/19/2019] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Surgery (oesophagectomy), with neoadjuvant chemo(radio)therapy, is the main curative treatment for patients with oesophageal cancer. Several surgical approaches can be used to remove an oesophageal tumour. The Ivor Lewis (two-phase procedure) is usually used in the UK. This can be performed as an open oesophagectomy (OO), a laparoscopically assisted oesophagectomy (LAO) or a totally minimally invasive oesophagectomy (TMIO). All three are performed in the National Health Service, with LAO and OO the most common. However, there is limited evidence about which surgical approach is best for patients in terms of survival and postoperative health-related quality of life. METHODS AND ANALYSIS We will undertake a UK multicentre randomised controlled trial to compare LAO with OO in adult patients with oesophageal cancer. The primary outcome is patient-reported physical function at 3 and 6 weeks postoperatively and 3 months after randomisation. Secondary outcomes include: postoperative complications, survival, disease recurrence, other measures of quality of life, spirometry, success of patient blinding and quality assurance measures. A cost-effectiveness analysis will be performed comparing LAO with OO. We will embed a randomised substudy to evaluate the safety and evolution of the TMIO procedure and a qualitative recruitment intervention to optimise patient recruitment. We will analyse the primary outcome using a multi-level regression model. Patients will be monitored for up to 3 years after their surgery. ETHICS AND DISSEMINATION This study received ethical approval from the South-West Franchay Research Ethics Committee. We will submit the results for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER ISRCTN10386621.
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Affiliation(s)
- Rachel C Brierley
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, University of Bristol, Bristol, UK
| | - Daisy Gaunt
- Bristol Randomised Trials Collaboration, Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Chris Metcalfe
- Bristol Randomised Trials Collaboration, Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Jane M Blazeby
- Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, Bristol, UK
- Division of Surgery, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Natalie S Blencowe
- Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, Bristol, UK
- Division of Surgery, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Marcus Jepson
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | | | - Kerry N L Avery
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - William Hollingworth
- Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK
| | - Caoimhe T Rice
- Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK
| | - Aida Moure-Fernandez
- Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK
| | - Newton Wong
- Department of Cellular Pathology, North Bristol NHS Trust, Southmead Hospital, Bristol, UK
| | - Joanna Nicklin
- Division of Surgery, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Anni Skilton
- Medical Illustration, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Alex Boddy
- Department of Surgery, Leicester Royal Infirmary, Leicester, Leicester, UK
| | - James P Byrne
- Division of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, Hampshire, UK
| | - Tim Underwood
- Division of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, Hampshire, UK
| | - Ravi Vohra
- Department of General Surgery, Nottingham City Hospital, Nottingham, UK
| | - James A Catton
- Department of General Surgery, Nottingham City Hospital, Nottingham, UK
| | - Kish Pursnani
- Department of Upper GI Surgery, Royal Preston Hospital, Preston, UK
| | - Rachel Melhado
- Department of Oesophago-Gastric Surgery, Salford Royal NHS Foundation Trust, Salford, UK
| | - Bilal Alkhaffaf
- Department of Oesophago-Gastric Surgery, Salford Royal NHS Foundation Trust, Salford, UK
| | - Richard Krysztopik
- Gastroenterology Department, Royal United Hospital Bath NHS Trust, Bath, UK
| | - Peter Lamb
- General Surgery Department, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Lucy Culliford
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, University of Bristol, Bristol, UK
| | - Chris Rogers
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, University of Bristol, Bristol, UK
| | - Benjamin Howes
- Division of Surgery, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Katy Chalmers
- Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK
| | - Sian Cousins
- Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK
| | | | - Jenny Donovan
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Rachael Heys
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, University of Bristol, Bristol, UK
| | - Robin A Wickens
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, University of Bristol, Bristol, UK
| | - Paul Wilkerson
- Division of Surgery, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Andrew Hollowood
- Division of Surgery, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Christopher Streets
- Division of Surgery, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Dan Titcomb
- Division of Surgery, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | | | - Tim Wheatley
- Upper GI Surgery, Derriford Hospital, Plymouth, UK
| | | | | | - Jamie Kelly
- Division of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, Hampshire, UK
| | - Fergus Noble
- Division of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, Hampshire, UK
| | - Graeme Couper
- General Surgery Department, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | - Chris Deans
- General Surgery Department, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Sukhbir Ubhi
- Department of Surgery, Leicester Royal Infirmary, Leicester, Leicester, UK
| | - Robert Williams
- Department of Surgery, Leicester Royal Infirmary, Leicester, Leicester, UK
| | - David Bowrey
- Department of Surgery, Leicester Royal Infirmary, Leicester, Leicester, UK
| | - David Exon
- Department of Surgery, Leicester Royal Infirmary, Leicester, Leicester, UK
| | - Paul Turner
- Department of Upper GI Surgery, Royal Preston Hospital, Preston, UK
| | | | - Ram Chaparala
- Department of Oesophago-Gastric Surgery, Salford Royal NHS Foundation Trust, Salford, UK
| | - Khurshid Akhtar
- Department of Oesophago-Gastric Surgery, Salford Royal NHS Foundation Trust, Salford, UK
| | - Naheed Farooq
- Department of Oesophago-Gastric Surgery, Salford Royal NHS Foundation Trust, Salford, UK
| | - Simon L Parsons
- Department of General Surgery, Nottingham City Hospital, Nottingham, UK
| | - Neil T Welch
- Department of General Surgery, Nottingham City Hospital, Nottingham, UK
| | - Rebecca J Houlihan
- Division of Surgery, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Joanne Smith
- Upper GI Surgery, Derriford Hospital, Plymouth, UK
| | - Rachel Schranz
- Division of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, Hampshire, UK
| | - Nicola Rea
- General Surgery Department, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Jill Cooke
- Department of Surgery, Leicester Royal Infirmary, Leicester, Leicester, UK
| | | | - Carolyn Hindmarsh
- Department of Oesophago-Gastric Surgery, Salford Royal NHS Foundation Trust, Salford, UK
| | - Sally Maitland
- Department of General Surgery, Nottingham City Hospital, Nottingham, UK
| | - Lucy Howie
- Gastroenterology Department, Royal United Hospital Bath NHS Trust, Bath, UK
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406
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Comment on "Can Minimally Invasive Esophagectomy Replace Open Esophagectomy for Esophageal Cancer? Latest Analysis of 24,233 Esophagectomies From the Japanese National Clinical Database". Ann Surg 2019; 270:e110. [PMID: 31726635 DOI: 10.1097/sla.0000000000003347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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407
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Yang J, Chen L, Ge K, Yang JL. Efficacy of hybrid minimally invasive esophagectomy vs open esophagectomy for esophageal cancer: A meta-analysis. World J Gastrointest Oncol 2019; 11:1081-1091. [PMID: 31798787 PMCID: PMC6883181 DOI: 10.4251/wjgo.v11.i11.1081] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Revised: 06/14/2019] [Accepted: 08/19/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The first line treatment regimen for esophageal cancer is still surgical resection and the choice of surgical scheme depends on surgeon. Now the efficacy comparison of hybrid minimally invasive esophagectomy (HMIE) and open esophagectomy (OE) is still controversial.
AIM To compare the perioperative and postoperative outcomes of HMIE and OE in patients with esophageal cancer.
METHODS PubMed, EMBASE, and Cochrane Library databases were searched for related articles. The odds ratio (OR) or standard mean difference (SMD) with a 95% confidence interval (CI) was used to evaluate the effectiveness of HMIE and OE.
RESULTS Seventeen studies including a total of 2397 patients were selected. HMIE was significantly associated with less blood loss (SMD = -0.43, 95%CI: -0.66, -0.20; P = 0.0002) and lower incidence of pulmonary complications (OR = 0.72, 95%CI: 0.57, 0.90; P = 0.004). No significant differences were seen in the lymph node yield (SMD = 0.11, 95%CI: -0.08, 0.30; P = 0.26), operation time (SMD = 0.24, 95%CI: -0.14, 0.61; P = 0.22), total complications rate (OR = 0.68, 95%CI: 0.46, 0.99; P = 0.05), cardiac complication rate (OR = 0.91, 95%CI: 0.62, 1.34; P = 0.64), anastomotic leak rate (OR = 0.95, 95%CI: 0.67, 1.35; P = 0.78), duration of intensive care unit stay (SMD = -0.01, 95%CI: -0.21, 0.19; P = 0.93), duration of hospital stay (SMD = -0.13, 95%CI: -0.28, 0.01; P = 0.08), and total mortality rates (OR = 0.70, 95%CI: 0.47, 1.06; P = 0.09) between the two treatment groups.
CONCLUSION Compared with the OE, HMIE shows less blood loss and pulmonary complications. However, further studies are necessary to evaluate the long-term oncologic outcomes of HMIE.
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Affiliation(s)
- Jiao Yang
- Department of Infectious Diseases, Zhejiang Hospital, 12 Lingyin Road, Hangzhou 310013, Zhejiang Province, China
| | - Ling Chen
- Department of Infectious Diseases, Zhejiang Hospital, 12 Lingyin Road, Hangzhou 310013, Zhejiang Province, China
| | - Ke Ge
- Department of Infectious Diseases, Zhejiang Hospital, 12 Lingyin Road, Hangzhou 310013, Zhejiang Province, China
| | - Jian-Le Yang
- Department of Infectious Diseases, Zhejiang Hospital, 12 Lingyin Road, Hangzhou 310013, Zhejiang Province, China
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408
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Markar SR, Lagergren J. Surgical and Surgeon-Related Factors Related to Long-Term Survival in Esophageal Cancer: A Review. Ann Surg Oncol 2019; 27:718-723. [PMID: 31691111 PMCID: PMC7000496 DOI: 10.1245/s10434-019-07966-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Indexed: 01/01/2023]
Abstract
Esophagectomy is the mainstay of curative treatment for most patients with a diagnosis of esophageal cancer. This procedure needs to be optimized to secure the best possible chance of cure for these patients. Research comparing various surgical approaches of esophagectomy generally has failed to identify any major differences in long-term prognosis. Comparisons between minimally invasive and open esophagectomy, transthoracic and transhiatal approaches, radical and moderate lymphadenectomy, and high and moderate hospital volume generally have provided only moderate alterations in long-term survival rates after adjustment for established prognostic factors. In contrast, some direct surgeon-related factors, which remain independent of known prognostic factors, seem to influence the long-term survival more strongly in esophageal cancer. Annual surgeon volume is strongly prognostic, and recent studies have suggested the existence of long surgeon proficiency gain curves for achievement of stable 5-year survival rates and possibly also a prognostic influence of surgeon age and weekday of surgery. The available literature indicates a potentially more critical role of the individual surgeon’s skills than that of variations in surgical approach for optimizing the long-term survival after esophagectomy for esophageal cancer. This finding points to the value of paying more attention to how the skills of the individual esophageal cancer surgeon can best be achieved and maintained. Careful selection and evaluation of the most suitable candidates, appropriate and structured training programs, and regular peer-review assessments of experienced surgeons may be helpful in this respect.
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Affiliation(s)
- Sheraz R Markar
- Upper Gastrointestinal Surgery, NS 67, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Surgery and Cancer, Imperial College London, London, UK
| | - Jesper Lagergren
- Upper Gastrointestinal Surgery, NS 67, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden. .,School of Cancer and Pharmaceutical Sciences, King's College London, London, UK.
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409
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Hofstetter WL. Open versus hybrid minimally invasive esophagectomy: Join the crowd, but do not throw away your abdominal retractors just yet. J Thorac Cardiovasc Surg 2019; 158:1475-1478. [DOI: 10.1016/j.jtcvs.2019.05.090] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Revised: 05/18/2019] [Accepted: 05/22/2019] [Indexed: 11/16/2022]
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410
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Cools-Lartigue J, Ferri L. Hybrid esophagectomy: the best of both worlds. J Thorac Dis 2019; 11:S1951-S1953. [PMID: 31632795 DOI: 10.21037/jtd.2019.08.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Jonathan Cools-Lartigue
- Department of Surgery, Division of Thoracic Surgery, Montreal General Hospital, McGill University Health Centre, Montreal Quebec, Canada
| | - Lorenzo Ferri
- Department of Surgery, Division of Thoracic Surgery, Montreal General Hospital, McGill University Health Centre, Montreal Quebec, Canada
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411
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van der Sluis PC, Grimminger PP, van Hillegersberg R, Ruurda JPH. Hybrid minimally invasive esophagectomy for esophageal cancer: less is more. J Thorac Dis 2019; 11:S1935-S1937. [PMID: 31632791 DOI: 10.21037/jtd.2019.08.90] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Pieter Christiaan van der Sluis
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Peter Philipp Grimminger
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
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412
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Phillips AW, Hardy K, Navidi M, Kamarajah SK, Madhavan A, Immanuel A, Griffin SM. Impact of Lymphadenectomy on Survival After Unimodality Transthoracic Esophagectomy for Adenocarcinoma of Esophagus. Ann Surg Oncol 2019; 27:692-700. [DOI: 10.1245/s10434-019-07905-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Indexed: 01/04/2023]
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413
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Conversion to open surgery during minimally invasive esophagectomy portends worse short-term outcomes: an analysis of the National Cancer Database. Surg Endosc 2019; 34:3470-3478. [DOI: 10.1007/s00464-019-07124-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 09/17/2019] [Indexed: 12/14/2022]
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414
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Yanni F, Singh P, Tewari N, Parsons SL, Catton JA, Duffy J, Welch NT, Vohra RS. Comparison of Outcomes with Semi-mechanical and Circular Stapled Intrathoracic Esophagogastric Anastomosis following Esophagectomy. World J Surg 2019; 43:2483-2489. [PMID: 31222637 DOI: 10.1007/s00268-019-05057-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Several techniques have been described for esophagogastric anastomosis following esophagectomy. This study compared the outcomes of circular stapled anastomoses with semi-mechanical technique using a linear stapler. METHODS Perioperative data were extracted from a contemporaneously collected database of all consecutive esophagectomies for cancer with intrathoracic anastomoses performed in the Trent Oesophago-Gastric Unit between January 2015 and April 2018. Anastomotic techniques: circular stapled versus semi-mechanical, were evaluated and outcomes were compared. The primary outcome was anastomotic leak rate. Secondary outcomes included anastomotic stricture, overall complication rates, length of stay (LOS) and 30 day all-cause mortality. RESULTS One hundred and fifty-nine consecutive esophagectomies with intrathoracic anastomosis were performed during the study period. There were no significant differences between the two groups in terms of age, American Society of Anaesthesiologists score, Charlson comorbidity index and neoadjuvant therapies received. Circular stapled anastomoses were performed in 85 patients, while 74 patients received a semi-mechanical anastomosis. Clavien-Dindo complications II or more were higher in the circular stapled group (p = 0.02). There were 16 (10%) anastomotic leaks overall, three (4%) in semi-mechanical group versus 13 (15%) in the circular stapled group (p < 0.019). There was no statistically significant difference between the two groups in terms of LOS, 30-day mortality or the need for endoscopic dilatation of the anastomosis at 3 months follow-up. CONCLUSION The move from a circular stapled to a semi-mechanical intrathoracic anastomosis has been associated with a reduced postoperative anastomotic leak rate following esophagectomy for esophageal cancer.
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Affiliation(s)
- Fady Yanni
- Trent Oesophago-Gastric Unit, Nottingham University Hospitals NHS Trust, Nottingham City Hospital, Hucknall Road, Nottingham, NG5 1PB, UK.
| | - Pritam Singh
- Trent Oesophago-Gastric Unit, Nottingham University Hospitals NHS Trust, Nottingham City Hospital, Hucknall Road, Nottingham, NG5 1PB, UK
| | - Nilanjana Tewari
- Trent Oesophago-Gastric Unit, Nottingham University Hospitals NHS Trust, Nottingham City Hospital, Hucknall Road, Nottingham, NG5 1PB, UK
| | - Simon L Parsons
- Trent Oesophago-Gastric Unit, Nottingham University Hospitals NHS Trust, Nottingham City Hospital, Hucknall Road, Nottingham, NG5 1PB, UK
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham , Nottingham, UK
| | - James A Catton
- Trent Oesophago-Gastric Unit, Nottingham University Hospitals NHS Trust, Nottingham City Hospital, Hucknall Road, Nottingham, NG5 1PB, UK
| | - John Duffy
- Trent Oesophago-Gastric Unit, Nottingham University Hospitals NHS Trust, Nottingham City Hospital, Hucknall Road, Nottingham, NG5 1PB, UK
| | - Neil T Welch
- Trent Oesophago-Gastric Unit, Nottingham University Hospitals NHS Trust, Nottingham City Hospital, Hucknall Road, Nottingham, NG5 1PB, UK
| | - Ravinder S Vohra
- Trent Oesophago-Gastric Unit, Nottingham University Hospitals NHS Trust, Nottingham City Hospital, Hucknall Road, Nottingham, NG5 1PB, UK
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham , Nottingham, UK
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415
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Wang WJ, Li R, Guo CA, Li HT, Yu JP, Wang J, Xu ZP, Chen WK, Ren ZJ, Tao PX, Zhang YN, Wang C, Liu HB. Systematic assessment of complications after robotic-assisted total versus distal gastrectomy for advanced gastric cancer: A retrospective propensity score-matched study using Clavien-Dindo classification. Int J Surg 2019; 71:140-148. [PMID: 31568844 DOI: 10.1016/j.ijsu.2019.09.029] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 07/11/2019] [Accepted: 09/24/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Despite increasing evidence demonstrated robot-assisted distal gastrectomy (RADG) is safe and feasible for the treatment of advanced gastric cancer (AGC), robot-assisted total gastrectomy (RATG) remains a challenging procedure due to its technical difficulties and possible postoperative complications (POCs). This study aimed to systematically evaluate POCs following RATG. METHODS Between January 2017 and January 2019, 319 AGC patients with pathological stage T2-4aN0-3M0 who underwent RADG or RATG were enrolled. POCs were stratified using the Clavien-Dindo classification. One-to-one propensity score matching was performed to reduce confounding differences. RESULTS After matching, 266 patients met the criteria for further analysis. Ultimately, 64 patients (24.1%) who developed POCs had 126 clinical manifestation events. Overall the POCs rate was significantly greater after RATG in comparison with RADG (29.3% vs. 18.8%; P = 0.045), and more major POCs (Clavien-Dindo grade ≥ IIIa) were observed in the RATG group (14.3% vs. 5.3%; P = 0.013). The POCs were then classified into local and systemic POCs. The rates of local POCs (35.3% vs. 19.5%; P = 0.004) and systemic POCs (24.8% vs. 15.0%; P = 0.046) were significantly higher in the RATG group than the RADG group. Subgroup analysis showed that the anastomotic leakage rate was higher after RATG (5.3% vs. 0.8%; P = 0.031), whereas the remaining POCs were similar between the two groups. Patients with higher POCs significantly had longer postoperative length of stay (R = 0.895, P = 0.003). Multivariate analysis confirmed age, extent of resection, and TNM stage were risk factors for all POCs. CONCLUSIONS These findings demonstrated that RATG is technically feasible and safe for treatment of AGC with acceptable morbidity and mortality rates. The POCs rate of RATG was higher than RADG, especially for anastomotic leakage. More effective anastomotic techniques are needed in RATG to prevent leakage.
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Affiliation(s)
- Wen-Jie Wang
- Second Clinical Medical College, Lanzhou University, Lanzhou, 730030, Gansu, PR China; Department of General Surgery, Lanzhou University Second Hospital, Lanzhou, 730030, Gansu, PR China; Key Laboratory of Stem Cells and Gene Drugs of Gansu Province, Lanzhou, 730050, PR China
| | - Rui Li
- Second Clinical Medical College, Lanzhou University, Lanzhou, 730030, Gansu, PR China; Department of General Surgery, Lanzhou University Second Hospital, Lanzhou, 730030, Gansu, PR China
| | - Chang-An Guo
- Second Clinical Medical College, Lanzhou University, Lanzhou, 730030, Gansu, PR China; Key Laboratory of Stem Cells and Gene Drugs of Gansu Province, Lanzhou, 730050, PR China; Department of Emergency, Lanzhou University Second Hospital, Lanzhou, 730030, Gansu, PR China
| | - Hong-Tao Li
- Department of General Surgery, The 940th Hospital of Joint Logistics Support Force of Chinese People's Liberation Army, Lanzhou, 730050, Gansu, PR China
| | - Jian-Ping Yu
- Department of General Surgery, The 940th Hospital of Joint Logistics Support Force of Chinese People's Liberation Army, Lanzhou, 730050, Gansu, PR China
| | - Jing Wang
- Department of General Surgery, The 940th Hospital of Joint Logistics Support Force of Chinese People's Liberation Army, Lanzhou, 730050, Gansu, PR China; Clinical Medical College, Gansu University of Traditional Chinese Medicine, Lanzhou, 730000, Gansu, PR China
| | - Zi-Peng Xu
- Second Clinical Medical College, Lanzhou University, Lanzhou, 730030, Gansu, PR China; Department of General Surgery, The 940th Hospital of Joint Logistics Support Force of Chinese People's Liberation Army, Lanzhou, 730050, Gansu, PR China
| | - Wei-Kai Chen
- Department of General Surgery, The 940th Hospital of Joint Logistics Support Force of Chinese People's Liberation Army, Lanzhou, 730050, Gansu, PR China; Clinical Medical College, Gansu University of Traditional Chinese Medicine, Lanzhou, 730000, Gansu, PR China
| | - Zhi-Jian Ren
- Second Clinical Medical College, Lanzhou University, Lanzhou, 730030, Gansu, PR China; Department of General Surgery, Lanzhou University Second Hospital, Lanzhou, 730030, Gansu, PR China
| | - Peng-Xian Tao
- Second Clinical Medical College, Lanzhou University, Lanzhou, 730030, Gansu, PR China; Department of General Surgery, Lanzhou University Second Hospital, Lanzhou, 730030, Gansu, PR China
| | - Ya-Nan Zhang
- Second Clinical Medical College, Lanzhou University, Lanzhou, 730030, Gansu, PR China; Department of General Surgery, Lanzhou University Second Hospital, Lanzhou, 730030, Gansu, PR China
| | - Chen Wang
- Second Clinical Medical College, Lanzhou University, Lanzhou, 730030, Gansu, PR China; Department of General Surgery, Lanzhou University Second Hospital, Lanzhou, 730030, Gansu, PR China.
| | - Hong-Bin Liu
- Second Clinical Medical College, Lanzhou University, Lanzhou, 730030, Gansu, PR China; Department of General Surgery, The 940th Hospital of Joint Logistics Support Force of Chinese People's Liberation Army, Lanzhou, 730050, Gansu, PR China.
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416
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Carroll PA, Jacob N, Yeung JC, Darling GE. Using Benchmarking Standards to Evaluate Transition to Minimally Invasive Esophagectomy. Ann Thorac Surg 2019; 109:383-388. [PMID: 31541632 DOI: 10.1016/j.athoracsur.2019.08.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 06/26/2019] [Accepted: 08/08/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Minimally invasive esophagectomy (MIE) is performed in nearly 50% of patients worldwide. The effectiveness of the technique arises from a single randomized control trial and multiple single series cohorts. Consistent reporting of complications is varied. We describe our experience of transitioning to MIE compared with open esophagectomy (OE) with the use of Esophageal Complications Consensus Group (ECCG) standardized complication benchmark definitions. METHODS Between 2007 and 2017, all patients undergoing esophagectomy were identified with the use of a prospectively curated database. Complications were defined by the ECCG and graded with the Clavien-Dindo (most severe complication) and comprehensive complication index (complexity of complications during hospital stay). RESULTS Of 383 patients, 299 (76%) were men with a median age of 64.5 years (range, 56-72 years). MIE was performed in 49.6%. No differences were found in age, histologic finding (P = .222), pT stage (P = .136), or nodal positivity (P = .918). Stage 3 cancers accounted for 42.0% of OEs and 47.9% of MIEs. A thoracic anastomosis was more frequent in MIEs (156 of 190; 82.1%) than in OEs (113 of 193; 58.5%; P = .001). Frequency, severity (Clavien-Dindo), and complexity (comprehensive complication index) of complications were better in the MIE group, without compromising operative outcomes. No differences were identified in individual complication groupings or grade in MIEs compared with OEs (pneumonia: 19.5% versus 26.9% ([P = .09]; intensive care unit readmission: 7.4% versus 9.3% [P = .519]; atrial fibrillation: 11.1% versus 6.7% [P = .082], or grade of leak [P = .99]). CONCLUSIONS These results compare favorably to those reported by ECCG. MIE can be the standard approach for surgical management of esophageal cancer. Introduction of the approach in each surgeon's practice should be benchmarked to international standards.
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Affiliation(s)
- Paul A Carroll
- Division of Thoracic Surgery, Toronto General Hospital, University Hospital Network, Toronto, Ontario, Canada.
| | - Nithin Jacob
- Division of Thoracic Surgery, Toronto General Hospital, University Hospital Network, Toronto, Ontario, Canada
| | - Jonathan C Yeung
- Division of Thoracic Surgery, Toronto General Hospital, University Hospital Network, Toronto, Ontario, Canada
| | - Gail E Darling
- Division of Thoracic Surgery, Toronto General Hospital, University Hospital Network, Toronto, Ontario, Canada
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417
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Duprée A, von Kroge PH, Izbicki JR, Wipper SH, Mann O. [Fluorescence angiography for esophageal anastomoses : Perfusion evaluation of the gastric conduit with indocyanine green]. Chirurg 2019; 90:875-879. [PMID: 31471660 DOI: 10.1007/s00104-019-01021-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The incidence of esophageal cancer continues to increase. Despite increasing experience in esophageal surgery and perioperative management, anastomotic leakage remains a frequent and severe complication. OBJECTIVE The aim of this article is to demonstrate the current role of fluorescence angiography (FA) with indocyanine green (ICG) in the assessment of esophageal anastomoses. The main focus is on the evaluation of the perfusion situation. MATERIAL AND METHODS A systematic search was carried out in PubMed and Medline on FA and ICG, especially with respect to current subjective and objective interpretation approaches of FA against the background of own research. RESULTS The rate of anastomotic leakage remains high despite modern surgical procedures. Assessment of neoesophageal perfusion with FA can significantly reduce the rate of anastomotic leakage. At present, FA is mostly subjectively applied in small case studies. The study situation is heterogeneous. Randomized studies do not so far exist. CONCLUSION The use of FA with ICG is suitable for evaluation of perfusion of the gastric tube. The implementation is simple and can be standardized. Prospective, randomized trials and objective quantification are needed in the future in order to clarify the potential of the technique.
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Affiliation(s)
- A Duprée
- Klinik und Poliklinik für Allgemein‑, Viszeral- und Thoraxchirurgie, Universitätsklinikum Hamburg Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland.
| | - P H von Kroge
- Klinik und Poliklinik für Allgemein‑, Viszeral- und Thoraxchirurgie, Universitätsklinikum Hamburg Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland
| | - J R Izbicki
- Klinik und Poliklinik für Allgemein‑, Viszeral- und Thoraxchirurgie, Universitätsklinikum Hamburg Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland
| | - S H Wipper
- Klinik und Poliklinik für Gefäßmedizin, Universitäres Herz- und Gefäßzentrum, Universitätsklinikum Hamburg Eppendorf, Hamburg, Deutschland
| | - O Mann
- Klinik und Poliklinik für Allgemein‑, Viszeral- und Thoraxchirurgie, Universitätsklinikum Hamburg Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland
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418
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Klevebro F, Elliott JA, Slaman A, Vermeulen BD, Kamiya S, Rosman C, Gisbertz SS, Boshier PR, Reynolds JV, Rouvelas I, Hanna GB, van Berge Henegouwen MI, Markar SR. Cardiorespiratory Comorbidity and Postoperative Complications following Esophagectomy: a European Multicenter Cohort Study. Ann Surg Oncol 2019; 26:2864-2873. [PMID: 31183640 PMCID: PMC6682565 DOI: 10.1245/s10434-019-07478-6] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND The impact of cardiorespiratory comorbidity on operative outcomes after esophagectomy remains controversial. This study investigated the effect of cardiorespiratory comorbidity on postoperative complications for patients treated for esophageal or gastroesophageal junction cancer. PATIENTS AND METHODS A European multicenter cohort study from five high-volume esophageal cancer centers including patients treated between 2010 and 2017 was conducted. The effect of cardiorespiratory comorbidity and respiratory function upon postoperative outcomes was assessed. RESULTS In total 1590 patients from five centers were included; 274 (17.2%) had respiratory comorbidity, and 468 (29.4%) had cardiac comorbidity. Respiratory comorbidity was associated with increased risk of overall postoperative complications, anastomotic leak, pulmonary complications, pneumonia, increased Clavien-Dindo score, and critical care and hospital length of stay. After neoadjuvant chemoradiotherapy, respiratory comorbidity was associated with increased risk of anastomotic leak [odds ratio (OR) 1.83, 95% confidence interval (CI) 1.11-3.04], pneumonia (OR 1.65, 95% CI 1.10-2.47), and any pulmonary complication (OR 1.52, 95% CI 1.04-2.22), an effect which was not observed following neoadjuvant chemotherapy or surgery alone. Cardiac comorbidity was associated with increased risk of cardiovascular and pulmonary complications, respiratory failure, and Clavien-Dindo score ≥ IIIa. Among all patients, forced expiratory volume in 1 s (FEV1)/forced vital capacity (FVC) ratio > 70% was associated with reduced risk of overall postoperative complications, cardiovascular complications, atrial fibrillation, pulmonary complications, and pneumonia. CONCLUSIONS The results of this study suggest that cardiorespiratory comorbidity and impaired pulmonary function are associated with increased risk of postoperative complications after esophagectomy performed in high-volume European centers. Given the observed interaction with neoadjuvant approach, these data indicate a potentially modifiable index of perioperative risk.
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Affiliation(s)
- F Klevebro
- Department of Upper Abdominal Surgery, Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden.
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden.
| | - J A Elliott
- Department of Surgery, Trinity College Dublin, Dublin, Ireland
- The National Esophageal and Gastric Center, St. James's Hospital, Dublin, Ireland
| | - A Slaman
- Department of Surgery, Amsterdam University Medical Centers, Cancer Center Amsterdam, University of Amsterdam, Amsterdam, The Netherlands
| | - B D Vermeulen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - S Kamiya
- Department of Upper Abdominal Surgery, Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - C Rosman
- Radboud University, Nijmegen, The Netherlands
| | - S S Gisbertz
- Department of Surgery, Amsterdam University Medical Centers, Cancer Center Amsterdam, University of Amsterdam, Amsterdam, The Netherlands
| | - P R Boshier
- Department Surgery and Cancer, Imperial College London, London, UK
| | - J V Reynolds
- Department of Surgery, Trinity College Dublin, Dublin, Ireland
- The National Esophageal and Gastric Center, St. James's Hospital, Dublin, Ireland
| | - I Rouvelas
- Department of Upper Abdominal Surgery, Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - G B Hanna
- Department Surgery and Cancer, Imperial College London, London, UK
| | - M I van Berge Henegouwen
- Department of Surgery, Amsterdam University Medical Centers, Cancer Center Amsterdam, University of Amsterdam, Amsterdam, The Netherlands
| | - S R Markar
- Department Surgery and Cancer, Imperial College London, London, UK
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419
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Inflammatory response and recurrence after minimally invasive esophagectomy. Langenbecks Arch Surg 2019; 404:761-769. [DOI: 10.1007/s00423-019-01818-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 08/19/2019] [Indexed: 02/07/2023]
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420
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Reichert M, Schistek M, Uhle F, Koch C, Bodner J, Hecker M, Hörbelt R, Grau V, Padberg W, Weigand MA, Hecker A. Ivor Lewis esophagectomy patients are particularly vulnerable to respiratory impairment - a comparison to major lung resection. Sci Rep 2019; 9:11856. [PMID: 31413282 PMCID: PMC6694108 DOI: 10.1038/s41598-019-48234-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 07/29/2019] [Indexed: 12/15/2022] Open
Abstract
Pulmonary complications and a poor clinical outcome are common in response to transthoracic esophagectomy, but their etiology is not well understood. Clinical observation suggests that patients undergoing pulmonary resection, a surgical intervention with similarities to the thoracic part of esophagectomy, fare much better, but this has not been investigated in detail. A retrospective single-center analysis of 181 consecutive patients after right-sided thoracotomy for either Ivor Lewis esophagectomy (n = 83) or major pulmonary resection (n = 98) was performed. An oxygenation index <300 mm Hg was used to indicate respiratory impairment. When starting surgery, respiratory impairment was seen more frequently in patients undergoing major pulmonary resection compared to esophagectomy patients (p = 0.009). On postoperative days one to ten, however, esophagectomy caused higher rates of respiratory impairment (p < 0.05) resulting in a higher cumulative incidence of postoperative respiratory impairment for patients after esophagectomy (p < 0.001). Accordingly, esophagectomy patients were characterized by longer ventilation times (p < 0.0001), intensive care unit and total postoperative hospital stays (both p < 0.0001). In conclusion, the postoperative clinical course including respiratory impairment after Ivor Lewis esophagectomy is significantly worse than that after major pulmonary resection. A detailed investigation of the underlying causes is required to improve the outcome of esophagectomy.
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Affiliation(s)
- Martin Reichert
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital of Giessen, Rudolf-Buchheim Strasse 7, D-35392, Giessen, Germany.
| | - Magdalena Schistek
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital of Giessen, Rudolf-Buchheim Strasse 7, D-35392, Giessen, Germany
| | - Florian Uhle
- Department of Anesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 110, D-69120, Heidelberg, Germany
| | - Christian Koch
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital of Giessen, Rudolf-Buchheim Strasse 7, D-35392, Giessen, Germany
| | - Johannes Bodner
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital of Giessen, Rudolf-Buchheim Strasse 7, D-35392, Giessen, Germany.,Department of Thoracic Surgery, München Klinik Bogenhausen, Englschalkinger Strasse 77, D-81925, Munich, Germany
| | - Matthias Hecker
- Department of Pulmonary and Critical Care Medicine, University of Giessen and Marburg Lung Center (UGMLC), University Hospital of Giessen, Klinikstrasse 33, D-35392, Giessen, Germany
| | - Rüdiger Hörbelt
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital of Giessen, Rudolf-Buchheim Strasse 7, D-35392, Giessen, Germany
| | - Veronika Grau
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital of Giessen, Rudolf-Buchheim Strasse 7, D-35392, Giessen, Germany.,Laboratory of Experimental Surgery, German Centre for Lung Research (DZL), Justus-Liebig-University Giessen, Feulgenstrasse 10-12, D-35392, Giessen, Germany
| | - Winfried Padberg
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital of Giessen, Rudolf-Buchheim Strasse 7, D-35392, Giessen, Germany
| | - Markus A Weigand
- Department of Anesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 110, D-69120, Heidelberg, Germany
| | - Andreas Hecker
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital of Giessen, Rudolf-Buchheim Strasse 7, D-35392, Giessen, Germany
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421
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Abstract
The updated German S3 guidelines recommend transthoracic subtotal esophagectomy with 2‑field lymphadenectomy for surgical treatment of esophageal cancer in patients with squamous cell carcinoma and adenocarcinoma of the esophagogastric (AEG type I) junction of the middle and lower third. For AEG type III transhiatal extended total gastrectomy with distal esophageal resection is favored. Patients with AEG type II can be treated by both procedures under the prerequisite that an R0 resection can be achieved. A limited resection of the distal esophagus and the proximal stomach can only be considered in cT1 N0 M0 possibly cT2 AEG junction without an oncological risk constellation, i.e. grade G1/G2, intestinal type and no poorly cohesive carcinoma, because the rate of lymph node metastasis at the distal stomach is less than 2%. Minimally invasive procedures provide advantages compared to open esophagectomy due to the lower rate of postoperative total and especially pulmonary complications. This is true for hybrid esophagectomy (laparoscopy and thoracotomy) versus open access in cases of intrathoracic anastomoses and for total minimally invasive esophagectomy including robotic techniques versus open access in cervical esophagogastrostomy.
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422
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Weksler B. Commentary: "Sometimes the hardest thing in life is to know which bridge to cross and which to burn"-A word for the reluctant minimally invasive esophageal surgeon. J Thorac Cardiovasc Surg 2019; 158:1479-1480. [PMID: 31395369 DOI: 10.1016/j.jtcvs.2019.07.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 07/01/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Benny Weksler
- Division of Thoracic and Esophageal Surgery, Department of Thoracic and Cardiovascular Surgery, Allegheny General Hospital, Pittsburgh, Pa.
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423
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424
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Elliott JA, O'Byrne L, Foley G, Murphy CF, Doyle SL, King S, Guinan EM, Ravi N, Reynolds JV. Effect of neoadjuvant chemoradiation on preoperative pulmonary physiology, postoperative respiratory complications and quality of life in patients with oesophageal cancer. Br J Surg 2019; 106:1341-1351. [PMID: 31282584 DOI: 10.1002/bjs.11218] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 03/16/2019] [Accepted: 03/26/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND It remains controversial whether neoadjuvant chemoradiation (nCRT) for oesophageal cancer influences operative morbidity, in particular pulmonary, and quality of life. This study combined clinical outcome data with systematic evaluation of pulmonary physiology to determine the impact of nCRT on pulmonary physiology and clinical outcomes in locally advanced oesophageal cancer. METHODS Consecutive patients treated between 2010 and 2016 were included. Three-dimensional conformal radiation was standard, with a lung dose-volume histogram of V20 less than 25 per cent, and total radiation between 40 and 41·4 Gy. Forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC) and diffusion capacity for carbon monoxide (DLCO) were assessed at baseline and 1 month after nCRT. Radiation-induced lung injury (grade 2 or greater), comprehensive complications index (CCI) and pulmonary complications were monitored prospectively. Health-related quality of life was assessed among disease-free patients in survivorship. RESULTS Some 228 patients were studied. Comparing pulmonary physiology values before with those after nCRT, FEV1 decreased from mean(s.d.) 96·8(17·7) to 91·5(20·4) per cent (-3·6(10·6) per cent; P < 0·001), FVC from 104·9(15·6) to 98·1(19·8) per cent (-3·2(11·9) per cent; P = 0·005) and DLCO from 97·6(20·7) to 82·2(20·4) per cent (-14·8(14·0) per cent; P < 0·001). Five patients (2·2 per cent) developed radiation-induced lung injury precluding surgical resection. Smoking (P = 0·005) and increased age (P < 0·001) independently predicted percentage change in DLCO. Carboplatin and paclitaxel with 41·4 Gy resulted in a greater DLCO decline than cisplatin and 5-fluorouracil with 40 Gy (P = 0·001). On multivariable analysis, post-treatment DLCO predicted CCI (P = 0·006), respiratory failure (P = 0·020) and reduced physical function in survivorship (P = 0·047). CONCLUSION These data indicate that modern nCRT alters pulmonary physiology, in particular diffusion capacity, which is linked to short- and longer-term clinical consequences, highlighting a potentially modifiable index of risk.
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Affiliation(s)
- J A Elliott
- Department of Surgery, Trinity Centre for Health Sciences, Trinity College Dublin, and St James's Hospital, Dublin, Ireland
| | - L O'Byrne
- Department of Surgery, Trinity Centre for Health Sciences, Trinity College Dublin, and St James's Hospital, Dublin, Ireland
| | - G Foley
- School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - C F Murphy
- Department of Surgery, Trinity Centre for Health Sciences, Trinity College Dublin, and St James's Hospital, Dublin, Ireland
| | - S L Doyle
- Department of Surgery, Trinity Centre for Health Sciences, Trinity College Dublin, and St James's Hospital, Dublin, Ireland.,School of Biological Sciences, Dublin Institute of Technology, Dublin, Ireland
| | - S King
- Department of Surgery, Trinity Centre for Health Sciences, Trinity College Dublin, and St James's Hospital, Dublin, Ireland
| | - E M Guinan
- School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - N Ravi
- Department of Surgery, Trinity Centre for Health Sciences, Trinity College Dublin, and St James's Hospital, Dublin, Ireland
| | - J V Reynolds
- Department of Surgery, Trinity Centre for Health Sciences, Trinity College Dublin, and St James's Hospital, Dublin, Ireland
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425
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Hybrid Minimally Invasive Esophagectomy-Surgical Technique and Results. J Clin Med 2019; 8:jcm8070978. [PMID: 31284370 PMCID: PMC6678699 DOI: 10.3390/jcm8070978] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 07/04/2019] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Hybrid minimally invasive esophagectomy (HMIE) has been proven to be superior when compared with open esophagectomy, with a significant reduction of postoperative morbidity. In HMIE, the laparotomy is replaced by a minimally invasive laparoscopic approach. The radical mediastinal resection plus reconstruction is performed by a thoracic approach through a muscle-sparing thoracotomy. In this instructional article, we describe the surgical technique of HMIE in detail in order to facilitate possible adoption of the procedure by other surgeons. In addition, we give the monocentric results of our own practice. METHODS Between 2013 and 2018, HMIE was performed in 157 patients. The morbidity and mortality data of the procedure is shown in a retrospective monocentric analysis. RESULTS Overall, 54% of patients had at least one perioperative complication. Anastomotic leak was evident in 1.9%, and a single patient had focal conduit necrosis of the gastric pull-up. Postoperative pulmonary morbidity was 31%. Pneumonia was found in 17%. The 90 day mortality was 2.5%. Wound infection rate was 3%, and delayed gastric emptying occurred in 17% of patients. In follow up, 12.7% presented with diaphragmatic herniation of the bowel, requiring laparoscopic hernia reduction and hiatal reconstruction and colopexy several months after surgery. CONCLUSION HMIE is a highly reliable technique, not only for the resection part but especially in terms of safety in reconstruction and anastomosis. For esophageal surgeons with experience in minimally invasive anti-reflux procedures and obesity surgery, HMIE is easy and fast to learn and adopt.
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426
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Helminen O, Sihvo E, Gunn J, Sipilä JOT, Rautava P, Kytö V. Trends and results of oesophageal cancer surgery in Finland between 2004 and 2014. Eur J Cardiothorac Surg 2019; 57:107-113. [DOI: 10.1093/ejcts/ezz189] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Revised: 05/22/2019] [Accepted: 05/26/2019] [Indexed: 12/11/2022] Open
Abstract
Abstract
OBJECTIVES
Few population-based studies reporting trends in oesophageal cancer surgery exist. The aim of this study was to assess the incidence of oesophageal cancer, changes in resection rates, patient demographics and short- and long-term outcomes of oesophagectomy at the population level in Finland.
METHODS
All Finnish patients diagnosed with cancer of the oesophagus or gastrooesophageal junction between 1 January 2004 and 31 December 2014 identified from the nationwide registries were included. The follow-up ended on 31 December 2016. For evaluation of changes in demographics and treatment, data were divided into 2 periods: 2004–2009 and 2010–2014. For comparison of short-and long-term outcomes, adjustments for age, sex, comorbidity, tumour stage and histology were used.
RESULTS
The number of diagnosed oesophageal cancers was 4266. Of these, 740 underwent oesophagectomy. Resection rate increased from 15.2% in 2004–2009 to 19.6% in 2010–2014. The median number of oesophagectomies in Finnish hospitals increased from 1.9 to 3.7 per hospital per year. At the same time, minimally invasive surgery became more common (6.3% vs 35.1%, P < 0.0001) and a trend for increase in neoadjuvant treatment was observed (46.8% vs 53.8%, P = 0.0582). The rate of type III anastomosis leaks and conduit necroses was 5.1% without differences in time periods. Three-year [52.4% vs 61.6%, adjusted hazard ratio (HR) 0.75, 95% confidence interval (CI) 0.59–0.95] and 5-year survival (42.1% vs 56.5%, adjusted HR 0.70, 95% CI 0.57–0.87) improved.
CONCLUSIONS
This nationwide population-based study demonstrates an increase in resection rate, use of neoadjuvant treatment and minimally invasive surgery together with an improvement in long-term outcome after oesophageal cancer surgery.
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Affiliation(s)
- Olli Helminen
- Department of Surgery, Central Finland Central Hospital, Jyväskylä, Finland
| | - Eero Sihvo
- Department of Surgery, Central Finland Central Hospital, Jyväskylä, Finland
| | - Jarmo Gunn
- Heart Center, Turku University Hospital, University of Turku, Turku, Finland
| | - Jussi O T Sipilä
- Department of Neurology, North Karelia Central Hospital, Joensuu, Finland
- Division of Clinical Neurosciences, University of Turku, Turku, Finland
| | - Päivi Rautava
- Clinical Research Center, Turku University Hospital, Turku, Finland
- Department of Public Health, University of Turku, Turku, Finland
| | - Ville Kytö
- Heart Center, Turku University Hospital, University of Turku, Turku, Finland
- Research Center of Applied and Preventive Cardiovascular Medicine, University of Turku, Turku, Finland
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427
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Affiliation(s)
- June S Peng
- Department of Surgical Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Steven N Hochwald
- Department of Surgical Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
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428
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Pimiento JM, Fontaine JP. Minimally invasive transthoracic esophagectomy: pushing the boundaries to improve surgical outcomes. J Thorac Dis 2019; 11:S1336-S1338. [PMID: 31245126 DOI: 10.21037/jtd.2019.04.12] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Jose M Pimiento
- Department of Gastrointestinal Oncology, Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Jacques P Fontaine
- Department of Thoracic Oncology, Moffitt Cancer Center and Research Institute, Tampa, FL, USA
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429
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[Hybrid minimally invasive esophagectomy for esophageal cancer-MIRO trial]. Chirurg 2019; 90:677. [PMID: 31127335 DOI: 10.1007/s00104-019-0983-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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430
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Wong CL, Law S. Extent of lymphadenectomy for Barrett's cancer. Transl Gastroenterol Hepatol 2019; 4:36. [PMID: 31231703 DOI: 10.21037/tgh.2019.05.07] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 04/16/2019] [Indexed: 01/27/2023] Open
Abstract
Adenocarcinoma of the esophagus and esophagogastric junction (EGJ) has become the predominant histological cell type in western countries due to the prevalence of obesity, gastroesophageal reflux disease and Barrett's esophagus. There is some evidence that this is increasing in the East as well. Surgery aims at achieving an R0 resection with clear margins, together with adequate and appropriate lymphadenectomy. Siewert type I and II cancers are more likely to be associated with Barrett's esophagus (especially in western countries), while type III cancers are mostly proximal gastric cancers that have grown upwards to involve the EGJ. For type I cancers, most surgeons would perform an esophagectomy, with at least an infra-carinal lymphadenectomy. It is more controversial for type II tumors, with some surgeons preferring an esophagectomy, while others may opt for a proximal or total radical gastrectomy via an abdominal approach. All procedures can be performed using open or minimally invasive methods. In addition to oncologic reasons, the chosen surgical approach also depends on expertise available, safety issues, and postoperative quality-of-life considerations. More data are needed in this area. How to integrate knowledge and also multimodality treatment strategies is an active area of research.
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Affiliation(s)
- Claudia Ly Wong
- Division of Esophageal and Upper Gastrointestinal Surgery, Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China
| | - Simon Law
- Division of Esophageal and Upper Gastrointestinal Surgery, Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China
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431
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Chati R, Huet E, Tuech JJ. Oesogastric anastomosis technique by thoracoscopy in prone position during Ivor Lewis procedure (with video). J Visc Surg 2019; 156:356-357. [PMID: 31109913 DOI: 10.1016/j.jviscsurg.2019.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- R Chati
- Department of digestive surgery, Rouen university hospital, 1, rue Germont, 76031 Rouen cedex, France
| | - E Huet
- Department of digestive surgery, Rouen university hospital, 1, rue Germont, 76031 Rouen cedex, France
| | - J-J Tuech
- Department of digestive surgery, Rouen university hospital, 1, rue Germont, 76031 Rouen cedex, France.
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432
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Affiliation(s)
- Maziar Navidi
- Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
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433
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Yanala UR, Are C, Dhir M. The Best Approach to Esophagectomy: Do We Know Yet? Ann Surg Oncol 2019; 26:1976-1978. [PMID: 30989497 DOI: 10.1245/s10434-019-07355-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Indexed: 12/24/2022]
Affiliation(s)
- Ujwal R Yanala
- Department of Surgery, Division of Surgical Oncology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Chandrakanth Are
- Department of Surgery, Division of Surgical Oncology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Mashaal Dhir
- Division of Surgical Oncology, Department of Surgery, SUNY Upstate Medical Center, SUNY Upstate Medical University, 750 East Adams Street, Syracuse, NY, 13210, USA.
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434
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van den Berg JW, Tabrett K, Cheong E. Paravertebral catheter analgesia for minimally invasive Ivor Lewis oesophagectomy. J Thorac Dis 2019; 11:S786-S793. [PMID: 31080659 DOI: 10.21037/jtd.2019.03.47] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Background Oesophagectomy is a major complex operation associated with significant morbidity and mortality. Epidural analgesia has long been the gold standard postoperative analgesia but is associated with side-effects like hypotension, epidural haematoma and infection. In an attempt to lower morbidity and enhance recovery postoperatively, we have adopted the use of paravertebral catheter analgesia (PVCA) for patients undergoing totally minimal invasive oesophagectomy (TMIO). Methods Our objective was to review the current literature about the use of both PVCA and epidural analgesia. In addition, we evaluated the effect of PVCA in a large group of patients undergoing TMIO for cancer. We reviewed the records of 100 consecutive patients who had a TMIO with PVCA, spinal morphine, and PCA. Prospective independent scoring of postoperative pain, length of stay, high-dependency unit (HDU) stay, PVCA failure, the use of patient-controlled analgesia (PCA), and the use of vasoconstrictor medication postoperatively was analysed. Results One hundred consecutive patients received PVCA with PCA after the TMIO. Catheter related failures occurred in 4 cases. The median pain score over each of the 5 days were 0. The average pain score was highest in the first 24 hours and decreased over the next 4 days postoperatively. The use of PCA was highest in the first 2 days and reduced daily over the subsequent 3 days. Seven patients required rescue analgesia in the form of intercostal nerve (ICN) block. Spinal morphine was successful in 94% of cases. Vasoconstrictors were required in 19% on day 1 and 3% on day 2, postoperatively. Conclusions Intraoperative placement of PVCA results in good postoperative pain control after a TMIO. This technique is simple, safe, reproducible and with very low failure rates. Therefore, it should be used instead of epidural catheter analgesia.
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Affiliation(s)
- Jan Willem van den Berg
- Norfolk and Norwich Oesophago-gastric Cancer Centre, Norfolk and Norwich University Hospital, Colney Lane, Norwich, UK
| | - Kate Tabrett
- Norfolk and Norwich Oesophago-gastric Cancer Centre, Norfolk and Norwich University Hospital, Colney Lane, Norwich, UK
| | - Edward Cheong
- Norfolk and Norwich Oesophago-gastric Cancer Centre, Norfolk and Norwich University Hospital, Colney Lane, Norwich, UK
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435
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Scientific surgery. Br J Surg 2019. [DOI: 10.1002/bjs.11137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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