Comparison of outcomes following transhiatal or Ivor Lewis esophagectomy for esophageal carcinoma

Perioperative Outcomes After Combined Esophagectomy and Lung Resection

INTRODUCTION

The impact of concomitant lung resection during esophagectomy on short-term outcomes is not well characterized. This study tests the hypothesis that lung resection at the time of esophagectomy is not associated with increased perioperative morbidity or mortality.

METHODS

Perioperative outcomes for esophageal cancer patients who underwent esophagectomy alone (EA) were compared to patients who had concurrent esophagectomy and lung resection (EL) using the NSQIP database between 2006-2017. Predictors of morbidity and mortality, including combined surgery, were evaluated using multivariable logistic regression.

RESULTS

Among the 6,225 study patients, 6,068 (97.5%) underwent EA and 157 (2.5%) underwent EL. There were no differences in baseline characteristics between the two groups. Operating time for EL was longer than EA (median 416 versus 371 minutes, P < 0.01). Median length of stay was 10 d for both groups. Perioperative mortality was not significantly different between EL and EA patients (5.1% versus 2.8%, P = 0.08). EL patients had higher rates of postoperative pneumonia (22.3% versus 16.2%, P = 0.04) and sepsis (11.5% versus 7.1%, P = 0.03), however major complication rates overall were similar (40.8% versus 35.3%, P = 0.16). Combining lung resection with esophagectomy was not independently associated with increased postoperative morbidity (AOR 1.21 [95% CI 0.87-1.69]) or mortality (AOR 1.63 [95% CI 0.74-3.58]).

CONCLUSIONS

Concurrent lung resection during esophagectomy is not associated with increased mortality or overall morbidity, but is associated with higher rates of pneumonia beyond esophagectomy alone. Surgeons considering combined lung resection with esophagectomy should carefully evaluate the patient's risk for pulmonary complications and pursue interventions preoperatively to optimize respiratory function.

Evolution of Esophagectomy for Cancer Over 30 Years: Changes in Presentation, Management and Outcomes

Background

Esophageal cancer has seen a considerable change in management and outcomes over the last 30 years. Historically, the overall prognosis has been regarded as poor; however, the use of multimodal treatment and the integration of enhanced recovery pathways have improved short- and long-term outcomes.

Objective

The aim of this study was to evaluate the changing trends in presentation, management, and outcomes for patients undergoing surgical treatment for esophageal cancer over 30 years from a single-center, high-volume unit in the UK.

Patients and Methods

Data from consecutive patients undergoing esophagectomy for cancer (adenocarcinoma or squamous cell carcinoma) between 1989 and 2018 from a single-center, high-volume unit were reviewed. Presentation method, management strategies, and outcomes were evaluated. Patients were grouped into successive 5-year cohorts for comparison and evaluation of changing trends.

Results

Between 1989 and 2018, 1486 patients underwent esophagectomy for cancer. Median age was 65 years (interquartile range [IQR] 59–71) and 1105 (75%) patients were male. Adenocarcinoma constituted 1105 (75%) patients, and overall median survival was 29 months (IQR 15–68). Patient presentation changed, with epigastric discomfort now the most common presentation (70%). An improvement in mortality from 5 to 2% (p < 0.001) was seen over the time period, and overall survival improved from 22 to 56 months (p < 0.001); however, morbidity increased from 54 to 68% (p = 0.004).

Conclusions

Long-term outcomes have significantly improved over the 30-year study period. In addition, mortality and length of stay have improved despite an increase in complications. The reasons for this are multifactorial and include the use of perioperative chemo(radio)therapy, the introduction of an enhanced recovery pathway, and improved patient selection.

Meta-analysis of Transhiatal Esophagectomy in carcinoma of esophagogastric junction, does it have an advantage?

PURPOSE

Compare the clinical outcome of Transhiatal Esophagectomy (THE) approach and open Thoracic Esophagectomy (TTE) approach in the carcinoma of esophagogastric junction (CEGJ).

METHODS

Relevant literature published until 2016 from PubMed, Cochrane Library, Ovid (Medline) and EMBASE were retrieved. Meta-analysis was achieved by using the Stata12 software.

RESULTS

A total of 18 studies and 2202 cases of patients were involved in this meta-analysis. THE showed to decrease the hospital stay, hospital mortality, surgical time, and blood loss in the operation. However, fewer lymph nodes would be yielded by this surgical option. A 5-year survival advantage of THE was only observed in North America subgroup.

CONCLUSIONS

Except the above operative related advantages, there was no clear evidence that THE has a further advantage in CEGJ.

Prevention of postoperative pulmonary complications through intensive preoperative respiratory rehabilitation in patients with esophageal cancer

Postoperative pulmonary complications (PPCs) after esophagectomy have been reported to occur in 15.9-30% of patients and lead to increased postoperative morbidity and mortality, prolonged duration of hospital stay, and additional medical costs. The purpose of this retrospective cohort study was to investigate the possible prevention of PPCs by intensive preoperative respiratory rehabilitation in esophageal cancer patients who underwent esophagectomy. The subjects included 100 patients (87 males and 13 females with mean age 66.5 ± 8.6 years) who underwent esophagectomy. They were divided into two groups: 63 patients (53 males and 10 females with mean age 67.4 ± 9.0 years) in the preoperative rehabilitation (PR) group and 37 patients (34 males and 3 females with mean age 65.0 ± 7.8 years) in the non-PR (NPR) group. The PR group received sufficient preoperative respiratory rehabilitation for >7 days, and the NPR group insufficiently received preoperative respiratory rehabilitation or none at all. The results of the logistic regression analysis and multivariate analysis to correct for all considerable confounding factors revealed the rates of PPCs of 6.4% and 24.3% in the PR group and NPR group, respectively. The PR group demonstrated a significantly less incidence rate of PPCs than the NPR group (odds ratio: 0.14, 95% confidential interval: 0.02~0.64). [Correction added after online publication 25 June 2012: confidence interval has been changed from -1.86~ -0.22] This study showed that the intensive preoperative respiratory rehabilitation reduced PPCs in esophageal cancer patients who underwent esophagectomy.

Prediction of major postoperative complications and survival for locally advanced esophageal carcinoma patients

BACKGROUND

Predicting the major complications after esophagectomy is important and may help in preselecting patients who are most likely to benefit from surgery, especially in locally advanced esophageal cancer patients who have poor prognosis.

OBJECTIVE

To identify the factors associated with the development of pneumonia and anastomotic leakage complications, and the survival characteristics in locally advanced esophageal cancer patients.

METHODS

A consecutive series of 232 locally advanced esophageal cancer patients (183 men and 49 women, median age 63 years) who underwent esophagectomy at Prince of Songkla University Hospital between 1998 and 2007 was analyzed.

RESULTS

There were nine (3.8%) 30-day mortalities. Pneumonia occurred in 53 patients (22.8%) and anastomotic leakage in 37 patients (15.9%). Multivariate analyses showed that low body mass index was related to leakage (p = 0.015), while soft-diet dysphagia (p = 0.009), forced expiratory volume in 1 second <75% (p = 0.0005), type of surgery (McKeown technique) (p = 0.019), and long operative time (p = 0.006) were related to pneumonia. The median survival rate was 13.0 months. Stage 2b patients had longer survival than stages 3 and 4a patients (p = 0.0001).

CONCLUSION

Patient body mass index, dysphagia, spirometry, type of surgical technique, and operative time can help predict the likelihood of pulmonary or leak complications after esophagectomy. TNM (Tumor, Node, Metastasis) staging can help predict the overall survival after resection in locally advanced cases.

Transthoracic oesophagectomy with lymphadenectomy in 100 oesophageal cancer patients: multidisciplinary approach

OBJECTIVES Analysis of the results on the treatment of esophageal cancer by transthoracic esophagectomy by a multidisciplinary team of surgeons and oncologists. METHODS Between January 1990 and December 2009, 100 consecutive patients underwent transthoracic esophagectomy. Data were collected prospectively and clinical, pathological and histological features of the tumors were analyzed as well as the results of postoperative morbidity and mortality. RESULTS The average patient age was 55 years (range 31- 83 years). In 59 cases the tumor was located in the lower third and in 41 cases in the middle third. Forty-six patients had adenocarcinoma and 54 squamous cell carcinoma. In 54 cases radio-chemotherapy was planned preoperatively. Classifi cation according to pathological tumor stage was: stage 0 in 21 patients, stage I in 10 patients, stage IIa in 28, stage IIb in 9, stage III in 21 and stage IV in 11. The mean number of lymph nodes examined was 14 (range 0-28). Hospital mortality occurred in 4 cases and postoperative complications in 29 patients (33%). The most frequent postoperative complication was pulmonary complications in 17 cases. The average hospital stay was 15.2 days (range 10-40 days) CONCLUSIONS The results of esophageal cancer have been improved in recent years due to the formation of multidisciplinary teams in this pathology. In our study we have shown that the results obtained with the transthoracic technique for cancer of the esophagus are within the ranges reported in the literature for teams with high prevalence of the disease.

Transthoracic versus transhiatal esophagectomy for the treatment of esophagogastric cancer: a meta-analysis

OBJECTIVE

To study the differences in short and long-term outcomes of transthoracic and transhiatal esophagectomy for cancer.

BACKGROUND

Studies have compared transthoracic with transhiatal esophagectomy with varying results. Previous systematic reviews (1999, 2001) do not include the latest randomized controlled trials.

METHODS

Systematic review of English-language studies comparing transthoracic with transhiatal esophagectomy up to January 31, 2010. Meta-analysis was used to summate the study outcomes. Methodological and surgical quality of included studies was assessed.

RESULTS

Fifty-two studies, comprising 5905 patients (3389 transthoracic and 2516 transhiatal) were included in the analysis. No study met all minimum surgical quality standards. Transthoracic operations took longer and were associated with a significantly longer length of stay. There was no difference in blood loss. The transthoracic group had significantly more respiratory complications, wound infections, and early postoperative mortality, whereas anastomotic leak, anastomotic stricture, and recurrent laryngeal nerve palsy rate was significantly higher in the transhiatal group. Lymph node retrieval was reported in 4 studies and was significantly greater in the transthoracic group by on average 8 lymph nodes. Analysis of 5-year survival showed no significant difference between the groups and was subject to significant heterogeneity.

CONCLUSIONS

This meta-analysis of studies comparing transthoracic with transhiatal esophagectomy for cancer demonstrates no difference in 5-year survival, however lymphadenectomy and reported surgical quality was suboptimal in both groups and the transthoracic group had significantly more advanced cancer. The finding of equivalent survival should therefore be viewed with caution.

The impact of operative approach for oesophageal cancer on outcome: the transhiatal approach may influence circumferential margin involvement

AIM

Surgery for oesophageal cancer remains the only means of cure for invasive tumours. It is claimed that the surgical approach for these cancers impacts on morbidity and may influence the ability to achieve tumour clearance and therefore survival, however there is no conclusive evidence to support one approach over another. This study aims to determine the impact of operative approach on tumour margin involvement and survival.

METHODS

Data were extracted from the Scottish Audit of Gastric and Oesophageal Cancer (SAGOC), a prospective population-based audit of all oesophageal and gastric cancers in Scotland between 1997 and 1999 with a minimum of five-year follow up. Analysis focused on the three commonest approaches (Ivor Lewis n = 140, transhiatal n = 68, left thoraco-laparotomy n = 142) for oesophageal cancer.

RESULTS

Operative approach had no significant impact on post-operative morbidity, mortality, overall margin involvement and survival. Transhiatal approach resulted in significantly more circumferential margin involvement (p = 0.019), and the presence of circumferential margin involvement significantly reduced five-year survival (median survival 13 months) compared to no margin involvement (median survival 25 months, p = 0.001).

CONCLUSION

Surgical approach for oesophageal cancer had no significant effect on morbidity, post-operative mortality and five-year survival. Non-selective use of the transhiatal approach is associated with a significantly greater circumferential margin involvement, with positive circumferential margin impacting adversely on 5-year survival.

Lymphadenectomy along the left recurrent laryngeal nerve by a minimally invasive esophagectomy in the prone position for thoracic esophageal cancer

BACKGROUND

A thoracoabdominal esophagectomy for esophageal cancer is a severely invasive procedure. A thoracoscopic esophagectomy may minimize injury to the chest wall and reduce surgical invasiveness. Conventional thoracoscopic procedures are performed in the left lateral-decubitus position. Recently, procedures performed in the prone position have received more attention because of improvements in operative exposure or surgeon ergonomics. However, the efficacy of the prone position in an aggressive thoracoscopic esophagectomy with an extensive lymphadenectomy has not been fully documented.

METHODS

We successfully performed a thoracoscopic esophagectomy with a three-field extensive lymphadenectomy in 43 esophageal carcinoma patients in the prone position from December 2007 to December 2009. We describe our procedures with the patients in the prone position, focusing especially on a lymphadenectomy along the left recurrent laryngeal nerve where the nodes are frequently involved and precise dissection is technically challenging. To determine further the advantages of this position, we retrospectively compared surgical outcomes in 43 patients to those of 34 patients who underwent a thoracoscopic esophagectomy in the left lateral decubitus position as a historical control from January 2006 to November 2007.

RESULTS

It was easier to explore the operative field around the left recurrent laryngeal nerve during a thoracoscopic esophagectomy in the prone position. The mean duration of the aggressive thoracoscopic procedure in the prone position was 307 min, which was significantly longer than in the left lateral decubitus position, but the total estimated blood loss in the prone position was significantly lower. There was no difference in the incidence of postoperative complications between the two procedures.

CONCLUSIONS

A thoracoscopic esophagectomy in the prone position is technically safe and feasible and provides better surgeon ergonomics and better operative exposure around the left recurrent laryngeal nerve during an aggressive esophagectomy.

Open versus minimally invasive esophagectomy: a single-center case controlled study

BACKGROUND

Recent advances in laparoscopic and thoracoscopic surgery have made it possible to perform esophagectomy using minimally invasive techniques. Although technically complex, recent case studies showed that minimally invasive approaches to esophagectomy are feasible and have the potential to improve mortality, hospital stay, and functional outcome.

METHODS

We have performed a case controlled pair-matched study comparing 62 patients who had undergone either minimally invasive (MIE) or open esophagectomy (OE) between 2004 and 2007. Patients were matched by tumor stage and localization, sex, age, and preoperative ASA score. Pathologic stage, operative time, blood loss, transfusion requirements, hospital length of stay, postoperative morbidity, and mortality were recorded.

RESULTS

Statistically significant differences were seen in the overall number of patients with surgical morbidity (MIE: 25% vs. OE: 74%, p = 0.014), the transfusion rate (MIE: 12.9% vs. OE: 41.9%, p = 0.001), and the rate of postoperative respiratory complications (MIE: 9.7% vs. OE: 38.7%, p = 0.008). There was no difference with respect to the duration of surgery. The number of resected lymph nodes and rate of pathologic complete resection were comparable. ICU stay [MIE: 3 days (range = 0-15) vs. OE: 6 days (range = 1-40), p = 0.03] and hospital stay [MIE: 12 days (range = 8-46) vs. OE: 24 days (range = 10-79), p = 0.001] were significantly shorter in the MIE group.

CONCLUSION

The results of this case-controlled study provide further evidence for the feasibility and possible improvements in the postoperative morbidity of minimally invasive esophagectomy. Our data are comparable to those from other centers and lead us to initiate the first prospectively randomized study comparing the morbidity of total minimally invasive esophagectomy with the open technique.

Esophagectomy for the treatment of esophageal cancer

Esophageal cancer is an aggressive disease with an overall poor prognosis. Esophagectomy remains a key therapeutic option in treating patients who have this disease. Tailoring the surgical approach to the patient and the nature of his or her malignancy is essential. Over time, advances in staging, preoperative assessment, operative techniques, and postoperative care have resulted in decreased operative mortality and better long-term outcomes.

Impact of obesity on perioperative outcomes of minimally invasive esophagectomy

BACKGROUND

Abnormal body mass index has been targeted as a predictor of complications after major surgery. The aim of this study was to review the impact of obesity on perioperative outcomes after minimally invasive esophagectomy.

METHODS

This study was a single-institution retrospective review of patients undergoing minimally invasive esophagectomy for high-grade dysplasia or cancer of the esophagus between 1999 and 2004. A body mass index of 30 or greater was considered obese. Patients with a body mass index less than 18.5 were excluded because of the potentially adverse effects of malnutrition on outcomes.

RESULTS

A total of 282 eligible patients were identified. There were 84 obese and 198 nonobese patients (mean body mass index = 34.5 versus 25.5; p < 0.0001). Preoperative demographics, comorbidities, and cancer status were similar, except for a higher prevalence of diabetes (p = 0.002), lower prevalence of peripheral vascular disease (p = 0.045), and lower prevalence of stage III disease in the obese group (p = 0.044). Operative time was significantly longer in obese patients (375 versus 301 minutes; p = 0.0001), and estimated blood loss was similar (433 versus 377 mL, obese versus nonobese, respectively). There were 5 (1.8%) overall 30-day perioperative mortalities, with no differences between the groups. Overall major (obese, 23 [27.5%] versus nonobese, 68 [34.3%]) and minor (obese, 23 [27.5%] versus nonobese, 65 [32.8%]) complication rates were also similar. Furthermore, there were no significant differences in any individual complications. There was no difference in median intensive care unit stay (obese, 1 day versus nonobese, 2 days) or overall hospital stay (obese, 7 days versus nonobese, 8 days).

CONCLUSIONS

Obesity was associated with longer operative times. Our review suggests that obesity is not a risk factor for mortality, postoperative complications, or length of hospitalization after minimally invasive esophagectomy.

Minimally invasive esophagectomy: lessons learned from 104 operations

OBJECTIVES

To review the outcomes of 104 consecutive minimally invasive esophagectomy (MIE) procedures for the treatment of benign and malignant esophageal disease.

SUMMARY BACKGROUND DATA

Although minimally invasive surgical approaches to esophagectomy have been reported since 1992, MIE is still considered investigational at most institutions.

METHODS

This prospective study evaluates 104 MIE procedures performed between August 1998 and September 2007. Main outcome measures include operative techniques, operative times, blood loss, length of stay, conversion rates, morbidities, and mortalities.

RESULTS

Indications for surgery were esophageal cancer (n = 80), Barrett esophagus with high-grade dysplasia (n = 6), recalcitrant stricture (n = 8), gastrointestinal stromal tumor (n = 3), and gastric cardia cancer (n = 7). Surgical approaches included thoracoscopic/laparoscopic esophagectomy with a cervical anastomosis (n = 47), minimally invasive Ivor Lewis esophagectomy (n = 51), laparoscopic hand-assisted blunt transhiatal esophagectomy (n = 5), and laparoscopic proximal gastrectomy (n = 1). There were 77 males. The mean age was 65 years. Three patients (2.9%) required conversion to a laparotomy. The median ICU and hospital stays were 2 and 8 days, respectively. Major complications occurred in 12.5% of patients and minor complications in 15.4% of patients. The incidence of leak was 9.6% and of anastomotic stricture was 26%. The 30-day mortality was 1.9% with an in-hospital mortality of 2.9%. The mean number of lymph nodes retrieved was 13.8.

CONCLUSIONS

Minimally invasive esophagectomy is feasible with a low conversion rate, acceptable morbidity, and low mortality. Our preferred operative approach is the laparoscopic\thoracoscopic Ivor Lewis resection, which provides a tension-free intrathoracic anastomosis.

Pharmacotherapy for oesophagogastric cancer

Gastric cancer is the seventh and oesophageal cancer the ninth most common cancer in the UK, and >50% of patients present with locally advanced or metastatic disease. The incidence of oesophageal and oesophagogastric junctional tumours is increasing, making these important disease entities to understand and research. Despite improvements in surgical and peri-operative supportive care, 3-year overall survival with surgery alone for resectable disease is still poor. Outcomes in localised oesophageal cancer are improved with pre-operative chemotherapy, and in gastric cancer with peri-operative treatment or post-operative chemoradiotherapy. Oesophageal squamous cell carcinoma can be treated with definitive chemoradiotherapy as an alternative to surgery. While survival in patients presenting with metastatic disease is improved with the addition of systemic chemotherapy, median survival remains <1 year. Patients who are otherwise fit can be offered chemotherapy and this is superior to best supportive care. Regimens including a platinum and an anthracycline agent are favoured by the results of randomised trials. No standard second-line therapy has emerged. New research into taxanes has shown promising anti-cancer activity, and novel areas of investigation include incorporation of agents targeting vascular endothelial growth factor or epidermal growth factor receptor into standard regimens. This review focuses on the clinical trial evidence that dictates the optimal management of localised and advanced oesophagogastric cancer, focusing on pharmacotherapy. We examine areas of current research and highlight future therapeutic directions.

Comparing outcomes after transthoracic and transhiatal esophagectomy: a 5-year prospective cohort of 17,395 patients

BACKGROUND

Debate continues over whether transhiatal esophagectomy (THE) offers decreased morbidity and mortality compared with transthoracic esophagectomy (TTE). To definitively answer this question, we used the Nationwide Inpatient Sample database to compare morbidity and mortality after THE and TTE.

STUDY DESIGN

Using ICD-9 procedure codes, we queried the Nationwide Inpatient Sample database for patients undergoing THE and TTE. Multivariate statistical analysis was completed to compare morbidity, mortality, length of stay, and hospital volume analysis between the groups.

RESULTS

Between 1999 and 2003, 17,395 patients included in the Nationwide Inpatient Sample underwent esophagectomy. Mean patient age was similar in those undergoing THE and TTE (61.9 versus 62.0 years, respectively). Overall morbidity and mortality after esophagectomy were 50.7% and 8.8%, respectively. In-hospital mortality after THE was 8.91% compared with 8.47% after TTE (p=0.642). Multivariate regression analysis showed no difference in the incidence of mediastinitis, wound, infectious, pulmonary, gastrointestinal, cardiovascular, systemic, procedure-related, or overall complications or hospital length of stay between the two groups. Controlling additionally for hospital volume showed high-volume centers (more than 10 esophagectomies per year) had significantly lower mortality rates than low-volume centers (10 or fewer esophagectomies per year, p=0.024). Additionally, low-volume centers have a higher incidence of gastrointestinal and systemic complications in the TTE group (p=0.048 and p=0.038, respectively).

CONCLUSIONS

This large-volume, multicenter study constitutes the largest cohort in the literature to compare outcomes after THE and TTE. These findings indicate the outcomes after THE and TTE for esophageal disease are equivalent, although higher-volume centers will have lower morbidity and mortality.

The impact of operative approach on outcome of surgery for gastro-oesophageal tumours

BACKGROUND

The choice of operation for tumours at or around the gastro-oesophageal junction remains controversial with little evidence to support one technique over another. This study examines the prevalence of margin involvement and nodal disease and their impact on outcome following three surgical approaches (Ivor Lewis, transhiatal and left thoraco-laparotomy) for these tumours.

METHODS

A retrospective analysis was conducted of patients undergoing surgery for distal oesophageal and gastro-oesophageal junction tumours by a single surgeon over ten years. Comparisons were undertaken in terms of tumour clearance, nodal yield, postoperative morbidity, mortality, and median survival. All patients were followed up until death or the end of the data collection (mean follow up 33.2 months).

RESULTS

A total of 104 patients were operated on of which 102 underwent resection (98%). Median age was 64.1 yrs (range 32.1-79.4) with 77 males and 25 females. Procedures included 29 Ivor Lewis, 31 transhiatal and 42 left-thoraco-laparotomies. Postoperative mortality was 2.9% and median survival 23 months. Margin involvement was 24.1% (two distal, one proximal and 17 circumferential margins). Operative approach had no significant effect on nodal clearance, margin involvement, postoperative mortality or morbidity and survival. Lymph node positive disease had a significantly worse median survival of 15.8 months compared to 39.7 months for node negative (p = 0.007), irrespective of approach.

CONCLUSION

Surgical approach had no effect on postoperative mortality, circumferential tumour, nodal clearance or survival. This suggests that the choice of operative approach for tumours at the gastro-oesophageal junction may be based on the individual patient and tumour location rather than surgical dogma.

Use of pedicled omentum in esophagogastric anastomosis for prevention of anastomotic leak

BACKGROUND

Esophagogastrectomy for carcinoma of the esophagus is the standard surgical treatment for cure or palliation. Esophagogastric anastomotic leakage is a life-threatening postoperative complication, more so if the leakage occurs in the chest.

METHODS

A prospective, randomized study was conducted on 238 patients treated for carcinoma of the esophagus between January 2000 and January 2006. The study excluded 44 patients (18.49%) who were inoperable. The patients were assigned to two treatment groups of 97 each (A and B) according to a restricted permuted block randomization plan. Group A patients underwent esophagogastrectomy with wrapping of the pedicled omentum around the esophagogastric anastomosis. Group B patients underwent esophagogastrectomy without using the omental graft. An Ivor-Lewis type esophagogastrectomy (TTE) was done in 122 patients (62.89%) and a transhiatal esophagogastrectomy (THE) was done in 72 (37.11%).

RESULTS

Anastomotic leaks occurred in 3 group A patients (3.09%) and in 14 (14.43%) group B patients. In group A, 54 patients underwent THE and 43 had TTE, with anastomotic leakage in 2 (3.70%) and 1 (2.33%) patients, respectively. In group B, 48 patients had THE and 49 had TTE, with anastomotic leakage in 8 (16.26%) and 6 (12.24%), respectively. The difference in the incidence of leakage was statistically significant (p = 0.005). There was no complication related to the omental graft technique nor was there a significant difference in the mortality between the two groups.

CONCLUSIONS

The pedicled omental transposition for reinforcing the anastomotic suture line significantly reduces the incidence of leakage after esophagogastrectomy for carcinoma of the esophagus, thus decreasing the morbidity and mortality of the procedure.

Minimally Invasive Esophagectomy: Early Experience and Outcomes

Minimally invasive esophageal surgery has the potential to improve mortality, hospital stay, and functional outcomes when compared with open methods. Although technically complex, combined laparoscopic and thoracoscopic esophageal resection is feasible. A case series of 20 patients who underwent minimally invasive total esophagectomy is presented. This study was a review of a prospective database. The purpose was to evaluate early results with laparoscopic total esophagectomy for benign and malignant disease. Between January 2003 and November 2005, 20 patients underwent minimally invasive esophageal surgery. All operations were performed by the same two surgeons. Age, gender, indications for surgery, pathologic stage, operative time, blood loss, transfusion requirements, intensive care unit length of stay, hospital length of stay, postoperative complications, and mortality were recorded. Diet progression, dysphagia, and need for stricture management were also recorded. Of the 20 minimally invasive total esophagectomies performed, 18 (90%) were completed successfully. The average age of the patients was 53 years. Indications for surgery were malignancy (n = 13), carcinoma in situ in the setting of Barrett's esophagus (n = 2), and benign stricture (n = 3). The average operating time was 467 minutes (range 346–580 min). Median blood loss was 350 mL (range 150–500 mL). The median intensive care unit stay was 2 days, and the median hospital length of stay was 12 days. Pathology revealed that 7 per cent of patients had stage I disease, 27 per cent of patients had stage II disease, and 53 per cent of patients had stage III disease. There was a single mortality (5%), a cervical leak in two patients (10%), a gastric tip necrosis in one patient (5%), and tracheoesophageal fistula in one patient (5%). Major complications occurred in eight patients (40%) and minor complications in nine (50%). Thirteen (72%) patients were discharged on enteral tube feeds to supplement caloric intake. The application of minimally invasive techniques in the arena of esophageal surgery continues to evolve. This approach has the potential to improve mortality, hospital stay, and other outcomes when compared with open methods. Although technically complex, laparoscopic total esophagectomy is feasible.

Pulmonary complications in patients with chronic obstructive pulmonary disease following transthoracic esophagectomy

AIM: To investigate the incidence of various types of postoperative pulmonary complications (POPCs) and to evaluate the significance of perioperative arterial blood gases in patients with esophageal cancer accompanied with chronic obstructive pulmonary disease (COPD) after esophagectomy.

MEHTODS: Three hundred and fifty-eight patients were divided into POPC group and COPD group. We performed a retrospective review of the 358 consecutive patients after esophagectomy for esophageal cancer with or without COPD to assess the possible influence of COPD on postoperative pulmonary complications. We classified COPD into four grades according to percent-predicted forced expiratory volume in 1 s (FEV1) and analyzed the incidence rate of complications among the four grades. Perioperative arterial blood gases were tested in patients with or without pulmonary complications in COPD group and compared with POPC group.

RESULTS: Patients with COPD (29/86, 33.7%) had more pulmonary complications than those without COPD (36/272, 13.2%) (P < 0.001). Pneumonia (15/29, 51.7%), atelectasis (13/29, 44.8%), prolonged O₂ supplement (10/29, 34.5%), and prolonged mechanical ventilation (8/29, 27.6%) were the major complications in COPD group. Moreover, patients with severe COPD (gradeIIB, FEV1 < 50% of predicted) had more POPCs than those with moderate(gradeIIA, 50%-80% of predicted) and mild (gradeI≥ 80% of predicted) COPD (P < 0.05). PaO₂ was decreased and PaCO₂ was increased in patients with pulmonary complications in COPD group in the first postoperative week.

CONCLUSION: The criteria of COPD are the critical predictor for pulmonary complications in esophageal cancer patients undergoing esophagectomy. Severity of COPD affects the incidence rate of the pulmonary complication, and percent-predicted FEV1 is a good predictive variable for pulmonary complication in patients with COPD. Arterial blood gases are helpful in directing perioperative management.

Minimally invasive esophagectomy: short- and long-term outcomes

BACKGROUND

We aimed to assess the outcomes including the effect on quality of life (QoL) of a group of patients having a minimally invasive esophagectomy (MIE).

METHODS

Patients with esophageal cancer were offered MIE over a 22-month period. Data on outcomes were collected prospectively, including formal quality-of-assessments.

RESULTS

There were 25 patients offered MIE. Two patients were converted to a laparotomy to improve the lymphadenectomy. There were no deaths. Respiratory problems (pneumonia, 28%) were the most common in the 64% of patients who had a complication. The median blood loss was 300 ml, time of surgery 330 min, and time to discharge 11 days. There was a decrease in the measured QoL both in general and specifically for the esophageal patients, taking 18-24 months to return to baseline.

CONCLUSIONS

MIE was performed with morbidity similar to other approaches. There were no clear benefits shown in this group of patients with respect to postoperative recovery or short- to medium-term QoL.

Hand-assisted laparoscopic and thoracoscopic surgery (HALTS) in radical esophagectomy with three-field lymphadenectomy for thoracic esophageal cancer

AIM

To prove the feasibility of hand-assisted laparoscopic and thoracoscopic surgery (HALTS) for radical esophagectomy with three-field lymphadenectomy to thoracic esophageal cancer.

METHODS

Esophagectomy with three-field lymphadenectomy was performed using HALTS in 19 patients with thoracic esophageal cancer without distant metastasis. Five patients had chemo-radiotherapy prior to surgery.

RESULTS

All operations were completed successfully without the need for open surgery. Mean surgical time was 476+/-58 min, and mean blood loss during surgery was 343+/-184 mL. All patients started tube feeding and were moved from the intensive care unit to the general surgery ward the day after surgery. Discharge occurred a median of 10 days after surgery. Fifteen patients could return to full time jobs from 8 to 62 days after surgery (median 22 days) and from 1 to 35 days after discharge (median 9 days). Other three could return to daily activities at home soon as well. No major complications occurred, except one anastomotic leak. In terms of lung function, %FEV(1) was not changed whereas %VC was reduced significantly 1 month after surgery. All but two recurrences have been healthy without a relapse for a mean of 289 days.

CONCLUSIONS

These results suggest that HALTS may be a useful surgical technique to reduce the invasiveness of conventional radical esophagectomy with three-field lymphadenectomy for thoracic esophageal cancer.

Transhiatal Esophagectomy

Controversy still remains regarding the appropriateness of THE asa cancer operation. Critics argue that without an en bloc mediastinal lymphadenectomy, THE does not provide accurate staging or the potential for a curative procedure; however, operative margins are similar after transthoracic and transhiatal esophagectomy, and van Sandick and co-workers reported that 73% of margins were microscopically negative. In many cases, esophageal carcinoma appears to be a systemic disease at the time of diagnosis. According to Orringer and colleagues, 46% of patients have Stage III or IV disease at the time of operation, and Altorki and co-authors found that 35% of patients thought to be potentially curable were found to have occult cervical lymph node disease after three-field lymph node dissection. In addition, survival after THE is similar to that reported after transthoracic esophagectomy as well as radical esophagectomy with mediastinal lymphadenectomy. The most important determinants of survival appear to be the biologic behavior of the tumor and the stage at the time of resection rather than the operative approach, and esophageal carcinoma will likely require systemic therapy for a cure. Transhiatal esophagectomy has been used increasingly in the resection of benign and malignant disease, and has several potential advantages over transthoracic esophagectomy, including significantly decreased respiratory complications and mediastinitis due to the avoidance of thoracotomy and intrathoracic anastomosis. In a meta-analysis of fifty studies comparing transthoracic and transhiatal resection, Hulscher et al found significantly higher early morbidity and mortality rates after transthoracic resections, which was confirmed in a later randomized study of 220 patients(Table 2). Survival after THE is also equivalent to or better than that seen after transthoracic esophagectomy, and transhiatal esophagectomy should be considered in all patients requiring esophagectomy for benign or malignant disease.

Transthoracic or transhiatal resection for middle- and lower-third esophageal carcinoma?

Transthoracic esophagectomy (TTE) and transhiatal esophagectomy (THE) are two common methods of resection for esophageal cancer. Although many studies have been performed in Western countries, there are still controversies over which method is the better procedure. In this study, postoperative improvement in dysphagia and the degree of postoperative pain were compared. The cases of 50 patients undergoing TTE and 23 undergoing THE for esophageal cancer between March 1997 and October 2002 were retrospectively reviewed. The location of the lesion, clinical stage (TNM), operative time, operative blood loss, hospital stay, complications, number of lymph nodes dissected, and survival duration were recorded. Pre- and postoperative dysphagia scores and postoperative pain perception (using a visual analog scale) were analyzed. Preoperative clinical stage and lesion site were not significantly different in the TTE and THE groups. The operative time was longer and the number of lymph nodes removed was larger in the TTE group. However, there were no differences in operative blood loss, hospital stay, complications, survival duration, and improvement in dysphagia. Pain perception in the THE group was significantly better than that in the TTE group. THE is a safe and rapid procedure, with recovery and survival periods similar to those for TTE. Both patient groups enjoyed the same ability to eat. Therefore, THE is an acceptable alternative to TTE for patients with middle- and lower-third esophageal cancer. Moreover, THE caused much less postoperative pain than TTE, which made patients more comfortable.

Cirugía laparoscópica en el cáncer de esófago

INTRODUCTION

For the last year we have substituted laparotomy with laparoscopy for the abdominal stage of esophageal cancer surgery. We report our experience of the introduction of video-assisted surgery in the treatment of esophageal cancer.

PATIENTS AND METHOD

We report our experience of nine patients diagnosed with esophageal cancer. In seven patients laparoscopy was preceded by right thoracotomy and esophageal dissection. Then, a left anterolateral cervicotomy was performed to remove the specimen and to construct the esophagogastroanastomosis. In two patients the laparoscopic technique was performed first and the Ivor Lewis procedure was completed by right thoracotomy.

RESULTS

Due to the reduced number of operated patients, the results are of little significance. Morbidity was 38.3%. The mean duration of the surgical procedure in laparoscopic patients was 4 h 50 min. However, perioperative blood loss, postoperative complications, analgesic requirements and mean length of hospital stay were reduced.

CONCLUSIONS

Video-assisted esophagectomy can be performed as safely as conventional esophagectomy and has considerable perioperative advantages. The introduction of the laparoscopic procedure is the first step in using video-assisted surgery at all stages of esophageal cancer surgery.

Fast tracking after Ivor Lewis esophagogastrectomy

OBJECTIVES

We streamlined our care using an algorithm for the postoperative care of patients who undergo Ivor Lewis esophagogastrectomy to try to reduce hospital stay to 7 days and maintain safety and patient satisfaction.

METHODS

A consecutive series of 90 patients who underwent elective esophageal resection by one general thoracic surgeon were studied. An algorithm to guide postoperative care was used, featuring avoidance of the ICU, early ambulation, jejunal tube feeds starting on postoperative day (POD) 1, removal of nasogastric tube and epidural on POD 3, a gastrograffin swallow on PODs 4 or 5, and discharge on POD 7.

RESULTS

There were 90 patients (70 men). Fifty-two patients (58%) underwent preoperative radiation and chemotherapy. Esophagectomies were done for cancer or high-grade dysplasia. Forty-two of the last 55 patients (77%) went directly to the floor. Sixteen patients (17.7%) had major complications, which included pneumonia in 5 patients and aspiration pneumonia in 4 patients. There were no anastomotic leaks, and there were four operative deaths (4.4%). There was a greater incidence of failure to fast track, and to have a major complication in patients who underwent neoadjuvant treatment (p = 0.025 and p = 0.048, respectively). Median hospital stay was 7 days (range, 6 to 74 days). Complications or mortality could not be definitively attributed to fast tracking. Ninety-seven percent reported excellent satisfaction with their hospital stay, and four patients were readmitted within 1 month of discharge.

CONCLUSIONS

Fast tracking patients using an algorithm after esophageal resection is safe and delivers minimal morbidity and mortality, and a high patient satisfaction rate. A median hospital stay of 7 days is possible, and the ICU can be avoided in most patients.

Successful treatment of esophageal cancer with transhiatal esophagectomy after heart transplantation

A 55-year-old heart transplant recipient with reflux esophagitis presented for routine endoscopic surveillance of an area of Barrett's metaplasia initially seen 3 years previously. Esophagogastroduodenoscopy revealed adenocarcinoma at 33 cm from the incisors. The preoperative clinical stage was T1N0M0 by endoscopic ultrasound. Transhiatal esophagectomy was performed with R0 resection of the cancer, and the patient recovered uneventfully. Pathologic examination confirmed esophageal adenocarcinoma (T1N0M0) in Barrett's mucosa. The patient is doing well, and has no evidence of disease after 18 months.

Thoracoscopic and laparoscopic esophagectomy for benign and malignant disease: lessons learned from 46 consecutive procedures

BACKGROUND

Transhiatal and transthoracic esophagectomy are common approaches for esophageal resection. The literature is limited regarding the combined thoracoscopic and laparoscopic approach to esophagectomy. The aim of this study was to evaluate the outcomes of combined thoracoscopic and laparoscopic esophagectomy for the treatment of benign and malignant esophageal disease.

STUDY DESIGN

We performed a retrospective chart review of 46 consecutive minimally invasive esophagectomies performed between August 1998 and September 2002. Indications for esophagectomy were carcinoma (n = 38), Barrett's esophagus with high-grade dysplasia (n = 3), and recalcitrant stricture (n = 5). Of 38 patients with carcinoma 23 (61%) had neoadjuvant therapy. The main outcome measures were operative time, blood loss, length of intensive care unit and hospital stay, conversion rate, morbidity, mortality, pathology, disease recurrence, and survival.

RESULTS

Approaches to esophagectomy were thoracoscopic and laparoscopic esophagectomy (n = 41), thoracoscopic and laparoscopic Ivor Lewis resection (n = 3), abdominal only laparoscopic esophagogastrectomy (n = 1), and hand-assisted laparoscopic transhiatal esophagectomy (n = 1). Minimally invasive esophagectomy was successfully completed in 45 (97.8%) of 46 patients. The mean operative time was 350 +/- 75 minutes and the mean blood loss was 279 +/- 184 mL. The median length of intensive care unit stay was 2 days and median length of stay was 8 days. Major complications occurred in 17.4% of patients and minor complications occurred in 10.8%. Late complications were seen in 26.1% of patients. The overall mortality was 4.3%. Among the 38 patients who underwent esophagectomy for cancer the 3-year survival was 57%. In a mean followup of 26 months there was no trocar site or neck wound recurrences.

CONCLUSIONS

A thoracoscopic and laparoscopic approach to esophagectomy is technically feasible and safe for the treatment of benign and malignant esophageal disease. With a mean followup of 26 months thoracoscopic and laparoscopic esophagectomy appears to be an oncologically acceptable surgical approach for the treatment of esophageal cancer.

Analysis of pulmonary complications after three-field lymph node dissection for esophageal cancer

BACKGROUND

Pulmonary complications are a major component of morbidity and mortality after esophagectomy, and have not been well studied after extended lymphadenectomy.

METHODS

Four hundred forty-one patients underwent three-field lymph node dissection and were retrospectively reviewed. Pulmonary complications developed in 32 patients (7.3%) and resulted in 11 deaths (34.4% of pulmonary complications were fatal, and 62.4% of all mortality was caused by pulmonary complications). Pulmonary complications were divided into primary (group A) and secondary pulmonary morbidities (group B), and analyzed separately. Perioperative arterial blood gases on room air were compared with a matched control group (group C).

RESULTS

All primary complications occurred in the first postoperative week, whereas secondary complications were distributed evenly after operation. The incidence of serious infection (60% versus 23.5%, p = 0.041) and respiratory failure (70.6% versus 31.6%, p = 0.045) was significantly higher in group B as compared with group A and was associated with a higher death rate (47.1% versus 15.8%, p = 0.047). Changes in arterial blood gases were similar in groups A and C, both PaO(2) and pH were reduced in group B, and PaCO(2) was increased. Independent risk factors for primary pulmonary complications were history of major operation, abnormal spirometry, and chronic renal dysfunction. Predictive factors for secondary pulmonary complications were old age, concomitant total gastrectomy, major anastomotic leakage, and bilateral vocal cord palsy.

CONCLUSIONS

Pulmonary complications can be kept at a low level, but they still account for most of the mortality after three-field lymph node dissection. Primary and secondary pulmonary complications are two distinct entities that should be managed differently. Arterial blood gases on room air are helpful in the management of pulmonary complications.

Preoperative prediction of the risk of pulmonary complications after esophagectomy for cancer

OBJECTIVES

Pulmonary complication is a frequent morbid event after esophagectomy for cancer. Its prediction may help select patients for preoperative rehabilitation.

METHODS

We performed a retrospective review of 292 patients (231 men and 61 women; mean age, 60.1 years) who underwent esophagectomy for cancer between 1980 and 2000. Data were analyzed to identify factors associated with the development of pulmonary complications (reintubation for isolated respiratory failure and pneumonia). A scoring system was developed, and its ability to predict complications was assessed.

RESULTS

Resection was performed for squamous cancer (n = 100), adenocarcinoma (n = 186), and other histologic types (n = 6) in patients with stages 0 or I (n = 53), II (n = 94), III (n = 114), and IV (n = 23) disease. Pulmonary complications, which developed in 78 (27%) patients, were associated with a 4.5-fold increase in operative mortality (7%-32%). Multivariable analysis identified independent predictors of pulmonary complications to be patient age (odds ratio [OR], 1.31; 95% confidence interval [CI], 0.99-1.74; P =.059), percentage forced expiratory volume in 1 second (OR, 1.21; 95% CI, 1.07-1.38; P =.003), and possibly performance status (OR, 1.48; 95% CI, 0.88-2.50; P =.14). A scoring system using these 3 covariates was developed, which predicted incremental risk of pulmonary complications (P =.013). The incremental risks of cardiovascular and overall cardiopulmonary complications were also predicted with this scoring system (P <.01 for each).

CONCLUSIONS

A scoring system using patient age, spirometry, and performance status helps predict the likelihood of pulmonary and cardiovascular complications after esophagectomy and can help select patients who may benefit from preoperative cardiopulmonary rehabilitation.

Prognostic Factors Associated with Resectable Carcinoma of the Esophagus

A retrospective review of esophagectomy for esophageal carcinoma between 1982 and 1999 was performed. Two hundred twenty-two patients (mean age 61.7 years) underwent esophagectomy: 128 transhiatal, 74 Ivor Lewis, and 20 abdominal. Most tumors were adenocarcinoma (65%); the majority were in the lower third or cardia (78%). Excluding operative mortality the one-, 3–, and 5-year survival rates were 67, 39, and 31 per cent (median survival, 16.3 months) respectively. The hospital mortality rate was 6.8 per cent. Through univariate analysis race other than white, history of weight loss, poor or moderate differentiation ( P = 0.05), full-thickness invasion ( P = 0.02), positive lymph nodes ( P < 0.01), Ivor Lewis esophagectomy ( P = 0.02), intraoperative blood transfusion ( P = 0. 01), and tumor location in the upper or middle third in node-positive patients ( P = 0.02) were associated with a poorer survival. Adjuvant therapy improved survival for patients with positive lymph nodes ( P < 0.01). In multivariate analysis positive lymph nodes, tumor location, intraoperative blood transfusion, and adjuvant therapy were independent predictors of survival. To optimize survival esophagectomy for esophageal carcinoma should be performed without blood transfusion, and node-positive patients should receive multimodal therapy.

Transhiatal esophagectomy for treatment of benign and malignant esophageal disease

Since our initial 1978 report, we have performed transhiatal esophagectomy (THE) in 1085 patients with intrathoracic esophageal disease: 285 (26%) benign lesions and 800 (74%) malignant lesions (4.5% upper, 22% middle, and 73.5% lower third/cardia). THE was possible in 97% of patients in whom it was attempted; reconstruction was performed at the same operation in all but six patients. The esophageal substitute was positioned in the original esophageal bed in 98%, stomach being used in 782 patients (96%) and colon in those with a prior gastric resection. Hospital mortality was 4%, with three deaths due to uncontrollable intraoperative hemorrhage. Major complications included anastomotic leak (13%), atelectasis/pneumonia prolonging hospitalization (2%), recurrent laryngeal nerve paralysis, chylothorax, and tracheal laceration (< 1% each). There were five reoperations for mediastinal bleeding within 24 hours of THE. Intraoperative blood loss averaged 689 ml. Altogether, 78% of the patients had no postoperative complications. Actuarial survival of the cancer patients mirrors that reported after transthoracic esophagectomy. Late functional results are good or excellent in 80%. Approximately 50% have required one or more anastomotic dilatations. With intensive preadmission pulmonary and physical conditioning, use of a side-to-side staple technique (which has reduced the cervical esophagogastric anastomotic leak rate to less than 3%), and postoperative epidural anesthesia, the need for an intensive care unit stay has been eliminated and the length of hospital stay was reduced to 7 days. We concluded that THE can be achieved in most patients requiring esophageal resection for benign and malignant disease and with greater safety and less morbidity than the traditional transthoracic approaches.

Transthoracic versus transhiatal resection for carcinoma of the esophagus: a meta-analysis

There is much controversy about the surgical approach to esophageal carcinoma: should an extensive resection be done to optimize long-term survival or should the extent of the operation be limited to obtain lower perioperative morbidity and mortality rates? We systematically reviewed the English-language literature published during the past decade, with emphasis on the differences between transthoracic and transhiatal resections regarding early morbidity, in-hospital mortality rates, and 3- and 5-year survival. Although transthoracic resections had significantly higher early (pulmonary) morbidity and mortality rates, 5-year survival was approximately 20% after both transthoracic and transhiatal resections.

Ivor Lewis esophagogastrectomy for esophageal cancer

BACKGROUND

To examine the efficacy of the Ivor Lewis esophagogastrectomy for esophageal carcinoma prior to the widespread use of preoperative chemotherapy and irradiation, we reviewed our experience.

METHODS

We reexamined the cases of 220 consecutive patients who underwent an Ivor Lewis esophagogastrectomy for esophageal cancer from January 1992 through December 1995.

RESULTS

There were 196 men (89.1%) and 24 women. Median age was 65 years (range, 29 to 85 years). The results of pathological study showed adenocarcinoma in 188 patients (85.5%), squamous cell carcinoma in 31 (14.1%), and leiomyosarcoma in 1 patient (0.5%). Postsurgical staging was as follows: stage 0 in 10 patients, stage I in 19, stage IIa in 38, stage IIb in 28, stage III in 111, and stage IV in 14. The operative mortality rate was 1.4% (3 patients), and complications occurred in 83 patients (37.7%). Follow-up was 98.6% complete. Median survival for operative survivors was 1.9 years (range, 32 days to 8.7 years). The overall 5-year survival rate was 25.2%; it was 80% for patients in stage 0, 94.4% for those in stage I, 36.0% for those in stage IIa, 14.3% for patients in stage IIb, 10% for those in stage III and 0% for patients in stage IV.

CONCLUSIONS

Ivor Lewis esophagogastrectomy for esophageal cancer is a safe operation. Long-term survival is stage dependent. The low survival associated with advanced cancers should stimulate the search for effective neoadjuvant therapy.

Biologic and clinical significance of lymphadenectomy

Interest in the lymphatic system and its relationship to metastases has developed owing to renewed interest in sentinel node biopsy. This article summarizes the anatomy, physiology, and biology of the lymphatic system and lymph node metastases, and reviews studies of lymph node metastases and surgical resection of cancers in different anatomic sites. On the basis of these studies, the authors conclude that lymph node metastasis functions as an indicator of prognosis, not the controlling or determining factor of prognosis. Thus, varying degrees of treatment of regional lymph nodes and metastases do not seem to be controlling factors in the outcome of cancer.

Esophageal cancer

Papers published in the English literature on esophageal cancer in 1999 were retrieved by a MEDLINE search. Selective publications were reviewed in light of current knowledge. Many studies were performed to refine staging methods of esophageal cancer, especially in the use of endoscopic ultrasound. Although better designs have overcome the problem of nontraversable tumors, its use in staging after neoadjuvant therapies remains suboptimal. Important studies on various surgical techniques were reported, including randomized trials on different routes of reconstruction after esophageal extirpation, and the updated results of transhiatal resections. In contrast to the minimalist approach of transhiatal resection, investigators from both East and West have also described the pathologic basis of lymphatic spread of esophageal cancer and its implications, favoring more radical lymphadenectomy. Another avenue that was explored is the use of neoadjuvant therapies to improve outcome. Different regimens were studied, and many papers focused on the molecular prediction of favorable response to such therapies. Overenthusiastic adoption of multimodality treatments is cautioned, however, in that they have not been validated. Further work is much needed in this area of research.

Risk factor analysis of post-operative mortality in oesophagectomy

Oesophagectomy for cancer is associated with a significant incidence of post-operative complications and death, and so this study sought to determine objective criteria which could better predict operative risk. Clinical risk factors for oesophagectomy and the results of objective investigations were assessed prospectively by independent surgical and intensive care specialists and a multivariate analysis was used to develop a scoring system for predicting operative risk. From September 1994 to June 1997, 32 patients from an overall experience of 70 oesophagectomy procedures for cancer at the Royal Adelaide Hospital were entered into this study. Hypertension, a history of previous cigarette smoking and FEV1/FVC were identified as independent predictors of the post-operative outcome. Age and FEV1/FVC were also significantly associated with the occurrence of cardiovascular and pulmonary complications respectively. The average risk score was 4.8 +/- 4.5 (mean +/- SD) for patients who died, 2.9 +/- 2.9 for patients who developed post-operative complications and 2.6 +/- 2.1 for patients who had an uncomplicated recovery. The likelihood of post-operative mortality and morbidity was highest in patients with a score of 5 or more. Mortality rates of different patient groups undergoing oesophagectomy by the same surgeons during the same time period were also compared, showing greatly different mortality rates. Important risk factors can be identified preoperatively, and a scoring system can be used to provide objective criteria which can be used to identify patients at an increased risk of post-operative complications and death. A prospective study of this scoring system is now needed to determine whether it proves useful in rejecting patients for surgery who would otherwise have undergone oesophagectomy.

Factors affecting morbidity, mortality, and survival in patients undergoing Ivor Lewis esophagogastrectomy

OBJECTIVES

To examine the safety of transthoracic esophagogastrectomy (TTE) in a multidisciplinary cancer center and to determine which clinical parameters influenced survival and the rates of death and complications.

SUMMARY BACKGROUND DATA

Although the incidence of cancer at the gastroesophageal junction has been rising rapidly in the United States, controversy still exists about the safety of surgical procedures designed to remove the distal esophagus and proximal stomach. Alternatives to TTE have been proposed because of the reportedly high rates of death and complications associated with the procedure.

METHODS

Data from 143 patients treated by TTE by one author (1989-1999) were entered into a computerized database. Preoperative clinical parameters were tested for effect on death, complications, and survival.

RESULTS

The patient population consisted of 127 men and 16 women. One hundred twenty-one patients had a history of tobacco abuse, and 118 reported the regular ingestion of alcohol. One hundred fifteen patients had adenocarcinoma, 16 had squamous cell cancer, 6 had another form of esophageal tumor, and 6 had high-grade dysplasia associated with Barrett epithelia. Fifty-six patients had adenocarcinomas arising in Barrett epithelium. Twenty-eight patients were treated with neoadjuvant chemoradiation before surgery. Three patients died within 30 days of surgery (mortality rate 2.1%). Five patients (3.5%) had a documented anastomotic leak; three died). Overall, 42 patients had complications (29%). Twenty-six had pulmonary complications (19%). The mean length of stay in the intensive care unit was 3.35 days; the mean hospital length of stay was 13.54 days. The overall 3-year survival rate was 29.6%.

CONCLUSIONS

A high ASA score and the development of complications predicted an increased length of stay. The presence of diabetes predicted the development of complication and an increased length of stay. None of the other parameters tested predicted perioperative death or complications. Only disease stage, diabetes, and blood transfusion affected overall survival. From these results with a large series of patients with gastroesophageal junction cancers, TTE can be performed with a low death rate (2.1%), a low leak rate (3. 5%), and an acceptable complication rate (29%).

Vocal cord paralysis after subtotal oesophagectomy

BACKGROUND

Although vocal cord paralysis is a well known complication of subtotal oesophagectomy, precise data concerning origin, incidence and associated morbidity are lacking.

METHODS

A retrospective study was performed of 241 patients who underwent transhiatal oesophagectomy for carcinoma of the mid/distal oesophagus between 1994 and 1998. Preoperative and postoperative laryngoscopy results were available for 140 patients.

RESULTS

There were 109 men and 31 women, of mean age 63 years. Thirty-one patients (22 per cent) with recurrent laryngeal nerve paralysis were identified, three with bilateral and 28 with unilateral dysfunction. Paralysis occurred ipsilateral to the side of the cervical incision in 22 of 28 patients. It was permanent in six patients. The associated morbidity was substantial: pulmonary complications were more common in patients with vocal cord paralysis (12 of 31 versus 26 (24 per cent) of 109), leading to significantly more reintubations, and a significantly prolonged ventilation time and stay in the intensive care unit.

CONCLUSION

Although mostly transient, vocal cord paralysis is a frequent complication with significant associated morbidity. In an extended transthoracic resection (including a lymphadenectomy in the aortopulmonary window where the left recurrent laryngeal nerve is at risk) the cervical anastomosis should be made on the left side, to minimize the risk of bilateral vocal cord paralysis.

Transhiatal esophagectomy: clinical experience and refinements

OBJECTIVE

To review the authors' clinical experience with transhiatal esophagectomy (THE) and the refinements in this procedure that have evolved.

BACKGROUND

Increased use of THE during the past two decades has generated controversy about the merits and safety of this approach compared with transthoracic esophageal resection. The authors' large THE experience provides a valuable basis for benchmarking data regarding the procedure.

METHODS

The results of THE were analyzed retrospectively using the authors' prospectively established esophageal resection database and follow-up information on these patients.

RESULTS

From 1976 to 1998, THE was performed in 1085 patients, 26% with benign disease and 74% with cancer. The procedure was possible in 98.6% of cases. Stomach was the esophageal substitute in 96%. The hospital mortality rate was 4%. Blood loss averaged 689 cc. Major complications were anastomotic leak (13%), atelectasis/pneumonia (2%), intrathoracic hemorrhage, recurrent laryngeal nerve paralysis, chylothorax, and tracheal laceration (<1% each). Actuarial survival of patients with carcinoma equaled or exceeded that reported after transthoracic esophagectomy. Late functional results were good or excellent in 70%. With preoperative pulmonary and physical conditioning, a side-to-side stapled cervical esophagogastric anastomosis (<3% incidence of leak), and postoperative epidural anesthesia, the need for an intensive care unit stay has been eliminated and the length of stay reduced to 7 days.

CONCLUSION

THE is possible in most patients requiring esophageal resection and can be performed with greater safety and fewer complications than the traditional transthoracic approaches.