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Wang J, Wu Z, Freund JE, de Groot EM, Shan F, Ruurda JP, Li Z, van Hillegersberg R. Comparison between AJCC 8th edition gastric and esophageal ypTNM classification system in Siewert II esophagogastric junction adenocarcinomas: A retrospective study based on Eastern and Western Data. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108730. [PMID: 39357412 DOI: 10.1016/j.ejso.2024.108730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2024] [Revised: 09/20/2024] [Accepted: 09/27/2024] [Indexed: 10/04/2024]
Abstract
INTRODUCTION Multimodal therapy has become the standard treatment for curable upper gastrointestinal cancers. However, it remains unclear which 8th edition AJCC post-neoadjuvant therapy pathological classification system, esophageal (ypTNM-EC) or gastric (ypTNM-GC), can predict the overall survival (OS) of patients with Siewert II adenocarcinomas better. METHODS Patients diagnosed with Siewert II adenocarcinomas receiving neoadjuvant therapy plus curative resection at the University Medical Center Utrecht (UMC Utrecht) and the Peking University Cancer Hospital (PUCH) between the 2001 and 2022 were included in this study. The patients from two institutions were analyzed separately. Predictive univariable and multivariable Cox models based on ypTNM-EC and ypTNM-GC were constructed. The C-index and calibration curves were used to compare the predictive abilities of ypTNM-EC and ypTNM-GC Cox models. RESULTS A total of 125 patients from UMCU and 145 from PUCH were included. There was no significant difference in the C-index between the ypTNM-EC and the ypTNM-GC univariable and multivariable Cox models in the UMC Utrecht (p-value = 0.883; p-value=0.681) and PUCH (p-value = 0.808; p-value=0.548) cohorts, and no significant difference was observed between their calibration curves in the two cohorts. CONCLUSION The AJCC 8th edition ypTNM prognostic classification systems for esophageal and gastric cancer demonstrated no difference in predicting OS for patients with Siewert II adenocarcinomas both in the Western and Eastern data. The ypTNM-GC, with fewer stage groups, may offer greater convenience for clinical application.
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Affiliation(s)
- Jingpu Wang
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Zhouqiao Wu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery, Peking University Cancer Hospital and Institute, Beijing, China
| | - Jan Erik Freund
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Eline M de Groot
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Fei Shan
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery, Peking University Cancer Hospital and Institute, Beijing, China
| | - Jelle P Ruurda
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Ziyu Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery, Peking University Cancer Hospital and Institute, Beijing, China.
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Bjelovic M, Gunjic D, Babic T, Veselinovic M, Djukanovic M, Potkonjak D, Milosavljevic V. Safe Transition from Open to Total Minimally Invasive Esophagectomy for Cancer Utilizing Process Management Methodology. J Clin Med 2024; 13:4364. [PMID: 39124631 PMCID: PMC11312586 DOI: 10.3390/jcm13154364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Revised: 07/14/2024] [Accepted: 07/17/2024] [Indexed: 08/12/2024] Open
Abstract
Background: The global shift from open esophagectomy (OE) to minimally invasive esophagectomy (MIE) for treating esophageal cancer is well-established. Recent data indicate that transitioning from hybrid minimally invasive esophagectomy (hMIE) to total minimally invasive esophagectomy (tMIE) can be challenging due to concerns about higher leakage rates and lower lymph node counts, especially at the beginning of the learning curve. This study aimed to demonstrate that a safe transition from OE to tMIE for cancer is possible using process management methodology. Methods: A step-change approach was adopted in process management planning, with hMIE serving as an intermediate step between OE and tMIE. This single-center, case-control study included 150 patients who underwent the Ivor Lewis procedure with curative intent for esophageal cancer. Among these patients, 50 underwent OE, 50 hMIE (laparoscopic procedure followed by conventional right thoracotomy), and 50 tMIE (laparoscopic and thoracoscopic approach). A preceptored training scheme was implemented during execution, and treatment results were monitored and controlled to ensure a safe transition. Results: During the transition, the tMIE group was not worse than the hMIE and OE groups regarding operation duration (p = 0.135), overall postoperative complications (p = 0.020), anastomotic leakage rates (p = 0.773), 30-day mortality (p = 1.0), and oncological outcomes (based on R status (p = 0.628) and 2-year survival (p = 0.967)). Additionally, the tMIE group showed superior results in terms of major postoperative pulmonary complications (p = 0.004) and ICU stay duration (p < 0.001). Conclusions: Utilizing managerial methodology and practice in surgery, as a bridge between interdisciplinary and transdisciplinary approaches, demonstrated that transitioning from OE to tMIE, with hMIE as an intermediate step, is safe and feasible without compromising outcomes.
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Affiliation(s)
- Milos Bjelovic
- Euromedic General Hospital, Bulevar umetnosti 29, 11070 Belgrade, Serbia;
- School of Medicine Foca, University East Sarajevo, Studentska 5, 73300 Foca, Bosnia and Herzegovina
| | - Dragan Gunjic
- Euromedic General Hospital, Bulevar umetnosti 29, 11070 Belgrade, Serbia;
| | - Tamara Babic
- Department for Minimally Invasive Upper Digestive Surgery, Hospital for Digestive Surgery, Clinical Center of Serbia, Dr Koste Todorovica Street 6, 11000 Belgrade, Serbia; (T.B.); (M.V.); (D.P.)
| | - Milan Veselinovic
- Department for Minimally Invasive Upper Digestive Surgery, Hospital for Digestive Surgery, Clinical Center of Serbia, Dr Koste Todorovica Street 6, 11000 Belgrade, Serbia; (T.B.); (M.V.); (D.P.)
- School of Medicine, University of Belgrade, Dr Subotica Street 8, 11000 Belgrade, Serbia
| | - Marija Djukanovic
- Department of Anesthesiology and Resuscitation, Hospital for Digestive Surgery, Clinical Center of Serbia, Dr Koste Todorovica Street 6, 11000 Belgrade, Serbia;
| | - Dario Potkonjak
- Department for Minimally Invasive Upper Digestive Surgery, Hospital for Digestive Surgery, Clinical Center of Serbia, Dr Koste Todorovica Street 6, 11000 Belgrade, Serbia; (T.B.); (M.V.); (D.P.)
| | - Vladimir Milosavljevic
- University Hospital Medical Center Bezanijska Kosa, Dr Zorza Matea Street, 11000 Belgrade, Serbia;
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Ebert MP, Fischbach W, Hollerbach S, Höppner J, Lorenz D, Stahl M, Stuschke M, Pech O, Vanhoefer U, Porschen R. S3-Leitlinie Diagnostik und Therapie der Plattenepithelkarzinome und Adenokarzinome des Ösophagus. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:535-642. [PMID: 38599580 DOI: 10.1055/a-2239-9802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Affiliation(s)
- Matthias P Ebert
- II. Medizinische Klinik, Medizinische Fakultät Mannheim, Universitätsmedizin, Universität Heidelberg, Mannheim
- DKFZ-Hector Krebsinstitut an der Universitätsmedizin Mannheim, Mannheim
- Molecular Medicine Partnership Unit, EMBL, Heidelberg
| | - Wolfgang Fischbach
- Deutsche Gesellschaft zur Bekämpfung der Krankheiten von Magen, Darm und Leber sowie von Störungen des Stoffwechsels und der Ernährung (Gastro-Liga) e. V., Giessen
| | | | - Jens Höppner
- Klinik für Allgemeine Chirurgie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck
| | - Dietmar Lorenz
- Chirurgische Klinik I, Allgemein-, Viszeral- und Thoraxchirurgie, Klinikum Darmstadt, Darmstadt
| | - Michael Stahl
- Klinik für Internistische Onkologie und onkologische Palliativmedizin, Evang. Huyssensstiftung, Evang. Kliniken Essen-Mitte, Essen
| | - Martin Stuschke
- Klinik und Poliklinik für Strahlentherapie, Universitätsklinikum Essen, Essen
| | - Oliver Pech
- Klinik für Gastroenterologie und Interventionelle Endoskopie, Krankenhaus Barmherzige Brüder, Regensburg
| | - Udo Vanhoefer
- Klinik für Hämatologie und Onkologie, Katholisches Marienkrankenhaus, Hamburg
| | - Rainer Porschen
- Gastroenterologische Praxis am Kreiskrankenhaus Osterholz, Osterholz-Scharmbeck
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Ketel MHM, Klarenbeek BR, Eddahchouri Y, Cheong E, Cuesta MA, van Daele E, Ferri LE, Gisbertz SS, Gutschow CA, Hubka M, Hölscher AH, Law S, Luyer MDP, Merritt RE, Morse CR, Mueller CL, Nieuwenhuijzen GAP, Nilsson M, Pattyn P, Shen Y, van den Wildenberg FJH, Abma IL, Rosman C, van Workum F. A Video-Based Procedure-Specific Competency Assessment Tool for Minimally Invasive Esophagectomy. JAMA Surg 2024; 159:297-305. [PMID: 38150247 PMCID: PMC10753443 DOI: 10.1001/jamasurg.2023.6522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 09/11/2023] [Indexed: 12/28/2023]
Abstract
Importance Minimally invasive esophagectomy (MIE) is a complex procedure with substantial learning curves. In other complex minimally invasive procedures, suboptimal surgical performance has convincingly been associated with less favorable patient outcomes as assessed by peer review of the surgical procedure. Objective To develop and validate a procedure-specific competency assessment tool (CAT) for MIE. Design, Setting, and Participants In this international quality improvement study, a procedure-specific MIE-CAT was developed and validated. The MIE-CAT contains 8 procedural phases, and 4 quality components per phase are scored with a Likert scale ranging from 1 to 4. For evaluation of the MIE-CAT, intraoperative MIE videos performed by a single surgical team in the Esophageal Center East Netherlands were peer reviewed by 18 independent international MIE experts (with more than 120 MIEs performed). Each video was assessed by 2 or 3 blinded experts to evaluate feasibility, content validity, reliability, and construct validity. MIE-CAT version 2 was composed with refined content aimed at improving interrater reliability. A total of 32 full-length MIE videos from patients who underwent MIE between 2011 and 2020 were analyzed. Data were analyzed from January 2021 to January 2023. Exposure Performance assessment of transthoracic MIE with an intrathoracic anastomosis. Main Outcomes and Measures Feasibility, content validity, interrater and intrarater reliability, and construct validity, including correlations with both experience of the surgical team and clinical parameters, of the developed MIE-CAT. Results Experts found the MIE-CAT easy to understand and easy to use to grade surgical performance. The MIE-CAT demonstrated good intrarater reliability (range of intraclass correlation coefficients [ICCs], 0.807 [95% CI, 0.656 to 0.892] for quality component score to 0.898 [95% CI, 0.846 to 0.932] for phase score). Interrater reliability was moderate (range of ICCs, 0.536 [95% CI, -0.220 to 0.994] for total MIE-CAT score to 0.705 [95% CI, 0.473 to 0.846] for quality component score), and most discrepancies originated in the lymphadenectomy phases. Hypothesis testing for construct validity showed more than 75% of hypotheses correct: MIE-CAT performance scores correlated with experience of the surgical team (r = 0.288 to 0.622), blood loss (r = -0.034 to -0.545), operative time (r = -0.309 to -0.611), intraoperative complications (r = -0.052 to -0.319), and severe postoperative complications (r = -0.207 to -0.395). MIE-CAT version 2 increased usability. Interrater reliability improved but remained moderate (range of ICCs, 0.666 to 0.743), and most discrepancies between raters remained in the lymphadenectomy phases. Conclusions and Relevance The MIE-CAT was developed and its feasibility, content validity, reliability, and construct validity were demonstrated. By providing insight into surgical performance of MIE, the MIE-CAT might be used for clinical, training, and research purposes.
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Affiliation(s)
- Mirte H. M. Ketel
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Yassin Eddahchouri
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Edward Cheong
- The PanAsia Surgery Group, Mount Elizabeth Hospital, Singapore
| | - Miguel A. Cuesta
- Department of Surgery, Amsterdam University Medical Centers, Location VUmc, Amsterdam, the Netherlands
| | - Elke van Daele
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
| | - Lorenzo E. Ferri
- Department of Surgery, McGill University Health Centre, Montreal General Hospital, Montreal, Quebec, Canada
| | - Suzanne S. Gisbertz
- Amsterdam UMC location University of Amsterdam, Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands
| | - Christian A. Gutschow
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Michal Hubka
- Department of Thoracic Surgery, Virginia Mason Medical Center, Seattle, Washington
| | - Arnulf H. Hölscher
- Department for General, Visceral and Trauma Surgery, Elisabeth-Krankenhaus-Essen GmbH, Essen, Germany
| | - Simon Law
- Department of Surgery, Queen Mary Hospital, School of Clinical Medicine, The University of Hong Kong, Hong Kong
| | - Misha D. P. Luyer
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - Robert E. Merritt
- Department of Surgery, Ohio State University Wexner Medical Center, Columbus
| | | | - Carmen L. Mueller
- Department of Surgery, McGill University Health Centre, Montreal General Hospital, Montreal, Quebec, Canada
| | | | - Magnus Nilsson
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Piet Pattyn
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
| | - Yaxing Shen
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | | | - Inger L. Abma
- IQ Healthcare, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Camiel Rosman
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Frans van Workum
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
- Department of Surgery, Canisius-Wilhelmina Hospital, Nijmegen, the Netherlands
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Maeda H, Endo H, Ichihara N, Miyata H, Hasegawa H, Kamiya K, Kakeji Y, Yoshida K, Seto Y, Yamaue H, Yamamoto M, Kitagawa Y, Uemura S, Hanazaki K. Days of the week and 90-day mortality after esophagectomy: analysis of 33,980 patients from the National Clinical Database. Langenbecks Arch Surg 2024; 409:36. [PMID: 38217701 DOI: 10.1007/s00423-023-03214-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 12/28/2023] [Indexed: 01/15/2024]
Abstract
PURPOSE The effect of the days of the week on the short-term outcomes after elective surgeries has been suggested; however, such data on esophagectomies remain limited. This study aimed to investigate the association between the day of the week and mortality rates after elective esophagectomy using a large-scale clinical database in Japan. METHODS The data of elective esophagectomies, registered in the National Clinical Database in Japan, for esophageal cancer treatment between 2012 and 2017 were analyzed. We hypothesized that the later days of the week could have higher odds ratios of death after elective esophagectomy. With 22 relevant clinical variables and days of surgery, 90-day mortality was evaluated using hierarchical logistic regression modeling. RESULTS Ninety-day mortality rates among 33,980 patients undergoing elective esophagectomy were 1.8% (range, 1.5-2.1%). Surgeries were largely concentrated on earlier days of the week, whereas esophagectomies performed on Fridays accounted for only 11.1% of all cases. Before risk adjustment, lower odds ratios of 90-day mortality were found on Tuesday and a tendency towards lower odds ratios on Thursday. In the hierarchical logistic regression model, 21 independent factors of 90-day mortality were identified. However, the adjusted odds ratios of 90-day mortality for Tuesday, Wednesday, Thursday, and Friday were 0.87, 1.09, 0.85, and 0.88, respectively, revealing no significant difference. CONCLUSION The results imply that the variation in 90-day mortality rates after esophagectomy on different days of the week may be attributed to differing preoperative risk factors of the patient group rather than the disparity in medical care provided.
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Affiliation(s)
- Hiromichi Maeda
- Department of Surgery, Kochi Medical School, Oko-cho, Nankoku, Kochi, 783-8505, Japan
| | - Hideki Endo
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Nao Ichihara
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Hiroaki Miyata
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Hiroshi Hasegawa
- Project Management Subcommittee, The Japanese Society of Gastroenterological Surgery, Tokyo, Japan
| | - Kinji Kamiya
- Project Management Subcommittee, The Japanese Society of Gastroenterological Surgery, Tokyo, Japan
| | - Yoshihiro Kakeji
- Database Committee, The Japanese Society of Gastroenterological Surgery, Tokyo, Japan
| | - Kazuhiro Yoshida
- Department of Gastroenterological and Pediatric Surgery, Graduate School of Medicine, Gifu University, Gifu, 501-1193, Japan
| | - Yasuyuki Seto
- Department of Gastrointestinal Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Hiroki Yamaue
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1 Kimiidera, Wakayama, Wakayama, 641-8510, Japan
| | | | - Yuko Kitagawa
- The Japanese Society of Gastroenterological Surgery, Tokyo, Japan
- Department of Surgery, Keio University School of Medicine, Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan
| | - Sunao Uemura
- Department of Surgery, Kochi Medical School, Oko-cho, Nankoku, Kochi, 783-8505, Japan
| | - Kazuhiro Hanazaki
- Department of Surgery, Kochi Medical School, Oko-cho, Nankoku, Kochi, 783-8505, Japan.
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Bîrlă R, Hoara P, Achim F, Dinca V, Ciuc D, Constantinoiu S, Constantin A. Minimally invasive surgery for gastro-oesophageal junction adenocarcinoma: Current evidence and future perspectives. World J Gastrointest Oncol 2023; 15:1675-1690. [PMID: 37969407 PMCID: PMC10631441 DOI: 10.4251/wjgo.v15.i10.1675] [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: 07/05/2023] [Revised: 09/04/2023] [Accepted: 09/22/2023] [Indexed: 10/10/2023] Open
Abstract
Minimally invasive surgery is increasingly indicated in the management of malignant disease. Although oesophagectomy is a difficult operation, with a long learning curve, there is actually a shift towards the laparoscopic/thoracoscopic/ robotic approach, due to the advantages of visualization, surgeon comfort (robotic surgery) and the possibility of the whole team to see the operation as well as and the operating surgeon. Although currently there are still many controversial topics, about the surgical treatment of patients with gastro-oesophageal junction (GOJ) adenocarcinoma, such as the type of open or minimally invasive surgical approach, the type of oesophago-gastric resection, the type of lymph node dissection and others, the minimally invasive approach has proven to be a way to reduce postoperative complications of resection, especially by decreasing pulmonary complications. The implementation of new technologies allowed the widening of the range of indications for this type of surgical approach. The short-term and long-term results, as well as the benefits for the patient - reduced surgical trauma, quick and easy recovery - offer this type of surgical treatment the premises for future development. This article reviews the updates and perspectives on the minimally invasive approach for GOJ adenocarcinoma.
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Affiliation(s)
- Rodica Bîrlă
- Department of General Surgery, Carol Davila University, Bucharest 011172, Romania
| | - Petre Hoara
- Department of General Surgery, Carol Davila University of Medicine and Pharmacy, Bucharest 020021, Romania
| | - Florin Achim
- Department of General Surgery, Carol Davila University, Bucharest 011172, Romania
| | - Valeriu Dinca
- Faculty of Medicine, “Titu Maiorescu” University, Bucharest 031593, Romania
| | - Diana Ciuc
- Faculty of Medicine, “Titu Maiorescu” University, Bucharest 031593, Romania
| | - Silviu Constantinoiu
- Department of General Surgery, Carol Davila University, Bucharest 011172, Romania
| | - Adrian Constantin
- Department of General Surgery, Carol Davila University, Bucharest 011172, Romania
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Ikoma N, Grotz T, Kawakubo H, Kim HI, Matsuda S, Hirata Y, Nakao A, Williams LA, Wang XS, Mendoza T, Wang X, Badgwell BD, Mansfield PF, Hyung WJ, Strong VE, Kitagawa Y. Trans-pacific multicenter collaborative study of minimally invasive proximal versus total gastrectomy for proximal gastric and gastroesophageal junction cancers. BMC Surg 2023; 23:262. [PMID: 37653380 PMCID: PMC10472658 DOI: 10.1186/s12893-023-02163-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 08/16/2023] [Indexed: 09/02/2023] Open
Abstract
BACKGROUND The current standard operation for proximal gastric and gastroesophageal junction (P/GEJ) cancers with limited esophageal extension is total gastrectomy (TG). TG is associated with impaired appetite and weight loss due to the loss of gastric functions such as production of ghrelin and with anemia due to intrinsic factor loss and vitamin B12 malabsorption. Theoretically, proximal gastrectomy (PG) can mitigate these problems by preserving gastric function. However, PG with direct esophagogastric reconstruction is associated with severe postoperative reflux, delayed gastric emptying, and poor quality of life (QoL). Minimally invasive PG (MIPG) with antireflux techniques has been increasingly performed by experts but is technically demanding owing to its complexity. Moreover, the actual advantages of MIPG over minimally invasive TG (MITG) with regards to postoperative QoL are unknown. Our overall objective of this study is to determine the short-term QoL benefits of MIPG. Our central hypotheses are that MIPG is safe and that patients have improved appetite after MIPG with effective antireflux techniques, which leads to an overall QoL improvement when compared with MITG. METHODS Enrollment of a total of 60 patients in this prospective survey-collection study is expected. Procedures (MITG versus MIPG, antireflux techniques for MIPG [double-tract reconstruction versus the double-flap technique]) will be chosen based on surgeon and/or patient preference. Randomization is not considered feasible because patients often have strong preferences regarding MITG and MIPG. The primary outcome is appetite level (reported on a 0-10 scale) at 3 months after surgery. With an expected 30 patients per cohort (MITG versus MIPG), this study will have 80% power to detect a one-point difference in appetite level. Patient-reported outcomes will be longitudinally collected (including questions about appetite and reflux), and specific QoL items, body weight, body mass index and ghrelin, albumin, and hemoglobin levels will be compared. DISCUSSION Surgeons from the US, Japan, and South Korea formed this collaboration with the agreement that the surgical approach to P/GEJ cancers is an internationally important but controversial topic that requires immediate action. At the completion of the proposed research, our expected outcome is the establishment of the benefit and safety of MIPG. TRIAL REGISTRATION This trial was registered with Clinical Trials Reporting Program Registration under the registration number NCI-2022-00267 on January 11, 2022, as well as with ClinicalTrials.gov under the registration number NCT05205343 on January 11, 2022.
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Affiliation(s)
- Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | | | - Hyoung-Il Kim
- Department of Surgery, Yonsei University College of Medicine, 50-1 Yonsei-Ro, Seodaemun-Gu, Seoul, 03722, Republic of Korea.
| | | | - Yuki Hirata
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Loretta A Williams
- Department of Symptom Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Xin Shelley Wang
- Department of Symptom Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Tito Mendoza
- Department of Symptom Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Xuemei Wang
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Brian D Badgwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Paul F Mansfield
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Woo-Jin Hyung
- Department of Surgery, Yonsei University College of Medicine, 50-1 Yonsei-Ro, Seodaemun-Gu, Seoul, 03722, Republic of Korea
| | - Vivian E Strong
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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8
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S3-Leitlinie Diagnostik und Therapie der Plattenepithelkarzinome und Adenokarzinome des Ösophagus. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:e209-e307. [PMID: 37285869 DOI: 10.1055/a-1771-6953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
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9
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Hölscher AH, Bollschweiler E, Fetzner UK, Babic B. Surgical approach to advanced Siewert II cancer: beyond the borders? The West Side. Updates Surg 2023; 75:329-333. [PMID: 36001282 DOI: 10.1007/s13304-022-01363-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 08/13/2022] [Indexed: 01/24/2023]
Abstract
The surgical approach to Siewert type II cancer should be individualized as there is no "one size fits all" option. Criteria for individualization are epidemiological, functional, oncologic and surgical items. However, our preferred procedure for advanced adenocarcinoma of the esophagogastric junction type II is esophagectomy, if this or transhiatal extended gastrectomy are both possible with R0 resection. Esophagectomy has the advantages of a longer esophageal safety margin, complete mediastinal lymphadenectomy, easier anastomosis, routine minimal invasive gastrolysis with abdominal lymphadenectomy and preservation of a gastric reservoir.
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Affiliation(s)
- Arnulf H Hölscher
- Center for Esophagogastric Cancer Surgery, St. Elisabethen Hospital Frankfurt, Ginnheimer Str. 3, 60487, Frankfurt, Germany.
| | | | - Ulrich K Fetzner
- Clinic for General Surgery, Visceral-, Thoracic-, Paediatric- and Endocrine Surgery, Johannes Wesling Clinic, University Clinic of the Ruhr University Bochum, Minden, Germany
| | - Benjamin Babic
- Center for Esophagogastric Cancer Surgery, St. Elisabethen Hospital Frankfurt, Ginnheimer Str. 3, 60487, Frankfurt, Germany
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10
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Froiio C, Uzun E, Hadzijusufovic E, Capovilla G, Berlth F, Lang H, Grimminger PP. Semiprone thoracoscopic approach during totally minimally invasive Ivor-Lewis esophagectomy seems to be beneficial. Dis Esophagus 2023; 36:6627608. [PMID: 35780319 DOI: 10.1093/dote/doac044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 05/24/2022] [Accepted: 06/13/2022] [Indexed: 02/01/2023]
Abstract
Minimally invasive Ivor-Lewis Esophagectomy (MIE) is widely accepted as a surgical treatment of resectable esophageal cancer. Aim of this paper is to describe the surgical details of our standardized MIE technique and its safety. We also evaluate the esophageal mobilization in semiprone compared to the left lateral position. A retrospective analysis of 141 consecutive patients who underwent Ivor-Lewis esophagectomy for cancer, from February 2016 to September 2021, was conducted. All the procedures were performed by totally thoraco-laparoscopic with an intrathoracic end-to-side circular stapled anastomosis. Thoracic phase was performed in left lateral position (LLP-group, n=47) followed by a semiprone position (SP-group, n=94). The intraoperative and postoperative outcomes were prospectively collected and analyzed. The procedure was completed without intraoperative complication in 94.68% of cases in SP-group and in 93.62% of cases in LLP-group (P=0.99). The total operative time and thoracic operative time were significantly shorter in SP-group (P=0.0096; P=0.009). No statistically significant differences were detected in postoperative outcomes between the groups, except for anastomotic strictures (higher in LLP-group, P=0.02) and intensive care unit stay (longer in LLP-group, P=00.1). No reoperation was needed in any cases. Surgical radicality was comparable; the median of harvested lymph nodes was significantly higher in SP-group (P<0.0001). The present semiprone technique of thoraco-laparoscopic Ivor-Lewis esophagectomy is safe and feasible but may also provide some advantages in terms of lymph nodes harvested and total operation time.
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Affiliation(s)
- Caterina Froiio
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, Mainz, Germany.,Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, San Donato Milanese, Milano, Italy
| | - Eren Uzun
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, Mainz, Germany
| | - Edin Hadzijusufovic
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, Mainz, Germany
| | - Giovanni Capovilla
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, Mainz, Germany
| | - Felix Berlth
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, Mainz, Germany
| | - Hauke Lang
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, Mainz, Germany
| | - Peter P Grimminger
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, Mainz, Germany
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11
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Luijten JCHBM, Verstegen MHP, van Workum F, Nieuwenhuijzen GAP, van Berge Henegouwen MI, Gisbertz SS, Wijnhoven BPL, Verhoeven RHA, Rosman C. Survival after Ivor Lewis versus McKeown esophagectomy for cancer: propensity score matched analysis. Dis Esophagus 2023:6972913. [PMID: 36617230 DOI: 10.1093/dote/doac100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 11/08/2022] [Accepted: 11/28/2022] [Indexed: 01/09/2023]
Abstract
It is unknown whether Ivor Lewis (IL) or McKeown (McK) esophagectomy is preferred in patients with potentially curable esophageal or gastro-esophageal junction (GEJ) cancer. Patients with mid- and distal esophageal and GEJ cancer without distant metastases who underwent IL or McK esophagectomy in the Netherlands between 2015 and 2017, were selected from the Netherlands Cancer Registry. Patients were propensity score matched for sex, age, American Society of Anesthesiologist classification, comorbidity, tumor type, tumor location, clinical stage, neoadjuvant treatment and year of diagnosis. The primary outcome was a 3-year relative survival (RS). Secondary outcome parameters were number of lymph nodes examined, number of positive lymph nodes, radical resection rate, tumor regression grade, post-operative complications and mortality. A total of 1627 patients who underwent IL (n = 1094) or McK (n = 533) esophagectomy were included. Patient and tumor characteristics were balanced after propensity score matching, leaving 658 patients to be compared. The 3-year RS was 54% after IL and 50% after McK esophagectomy, P = 0.140. The median number of lymph nodes examined, median number of positive lymph nodes, radical resection rate and tumor regression grade were comparable between both groups. Recurrent laryngeal nerve palsy (2 vs. 5%, P = 0.006) occurred less frequently after IL esophagectomy. No differences were observed in post-operative anastomotic leakage rate, pulmonary complication rate and mortality rates. There was no statistically significant difference in the 3-year RS between IL and McK esophagectomy. Based on these results, both IL and McK esophagectomy can be performed in patients with mid to distal esophageal and GEJ cancer.
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Affiliation(s)
- J C H B M Luijten
- Department of Research, Netherlands Comprehensive Cancer Organization, Utrecht 3501, The Netherlands.,Department of Surgery, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen 6525, The Netherlands
| | - M H P Verstegen
- Department of Surgery, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen 6525, The Netherlands.,Imperial College London, London SW7 2AZ, UK
| | - F van Workum
- Department of Surgery, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen 6525, The Netherlands.,Imperial College London, London SW7 2AZ, UK
| | | | - M I van Berge Henegouwen
- Department of Surgery, Amsterdam UMC-Location AMC, University of Amsterdam, Cancer Centre Amsterdam, Amsterdam 1081, The Netherlands
| | - S S Gisbertz
- Department of Surgery, Amsterdam UMC-Location AMC, University of Amsterdam, Cancer Centre Amsterdam, Amsterdam 1081, The Netherlands
| | - B P L Wijnhoven
- Department of Surgery, Erasmus MC, Rotterdam 3015, The Netherlands
| | - R H A Verhoeven
- Department of Research, Netherlands Comprehensive Cancer Organization, Utrecht 3501, The Netherlands.,Department of Surgery, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen 6525, The Netherlands
| | - C Rosman
- Department of Surgery, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen 6525, The Netherlands
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12
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Muir D, Antonowicz S, Whiting J, Low D, Maynard N. Implementation of the Esophagectomy Complication Consensus Group definitions: the benefits of speaking the same language. Dis Esophagus 2022; 35:6603615. [PMID: 35673848 DOI: 10.1093/dote/doac022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 03/17/2022] [Indexed: 12/24/2022]
Abstract
In 2015 the Esophagectomy Complication Consensus Group (ECCG) reported consensus definitions for complications after esophagectomy. This aimed to reduce variation in complication reporting, attributed to heterogeneous definitions. This systematic review aimed to describe the implementation of this definition set, including the effect on complication frequency and variation. A systematic literature review was performed, identifying all observational and randomized studies reporting complication frequencies after esophagectomy since the ECCG publication. Recruitment periods before and subsequent to the index ECCG publication date were included. Coefficients of variance were calculated to assess outcome heterogeneity. Of 144 studies which met inclusion criteria, 70 (48.6%) used ECCG definitions. The median number of separately reported complication types was five per study; only one study reported all ECCG complications. The coefficients of variance of the reported frequencies of eight of the 10 most common complications were reduced in studies which used the ECCG definitions compared with those that did not (P = 0.036). Among ECCG studies, the frequencies of postoperative pneumothorax, reintubation, and pulmonary emboli were significantly reduced in 2020-2021, compared with 2015-2019 (P = 0.006, 0.034, and 0.037 respectively). The ECCG definition set has reduced variation in esophagectomy morbidity reporting. This adds greater confidence to the observed gradual improvement in outcomes with time, and its ongoing use and wider dissemination should be encouraged. However, only a handful of outcomes are widely reported, and only rarely is it used in its entirety.
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Affiliation(s)
- Duncan Muir
- Department of Upper GI Surgery, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Stefan Antonowicz
- Department of Upper GI Surgery, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Jack Whiting
- Department of Upper GI Surgery, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Donald Low
- Department of Thoracic Surgery and Thoracic Oncology, Virginia Mason Medical Center, Seattle, WA, USA
| | - Nick Maynard
- Department of Upper GI Surgery, Oxford University Hospitals NHS Trust, Oxford, UK
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13
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Capovilla G, Hadzijusufovic E, Tagkalos E, Froiio C, Berlth F, Mann C, Staubitz J, Uzun E, Lang H, Grimminger PP. End to side circular stapled anastomosis during robotic-assisted Ivor Lewis minimally invasive esophagectomy (RAMIE). Dis Esophagus 2022; 35:6492661. [PMID: 34979549 DOI: 10.1093/dote/doab088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 11/11/2021] [Indexed: 12/11/2022]
Abstract
Robotic-assisted minimally invasive esophagectomy (RAMIE) represents an established approach for the treatment of esophageal cancer. Aim of this study is to evaluate the feasibility and safety of our technique for performing the intrathoracic anastomosis during RAMIE.All the procedures were performed by the same surgeon using the same technique for performing the intrathoracic anastomosis. Intraoperative and postoperative outcomes were recorded. Postoperative complications were classified according to the Esophagectomy Complications Consensus Group (ECCG); the primary outcome was the evaluation of the feasibility and safety of our technique. From 2016 to 2021, 204 patients underwent Ivor Lewis RAMIE at our Center. Two patients (0.9%) were converted during the thoracic phase. The anastomosis was completed in all the other patients forming complete anastomotic rings. The median duration for the robotic-assisted thoracoscopic phase was 224 minutes. Twenty-two of the RAMIE-Ivor Lewis patients had an anastomotic leakage (10.3%). The overall 90-day postoperative mortality was 1.9%. The procedure resulted to be feasible and safe in our cohort of patients.
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Affiliation(s)
- Giovanni Capovilla
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Edin Hadzijusufovic
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Evangelos Tagkalos
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Caterina Froiio
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany.,Department of General Surgery, IRCCS Policlinico San Donato, University of Milan, Milano, Italy
| | - Felix Berlth
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Carolina Mann
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Julia Staubitz
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Eren Uzun
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Hauke Lang
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Peter P Grimminger
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
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14
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Schlottmann F, Angeramo CA, Bras Harriott C, Casas MA, Herbella FAM, Patti MG. Transthoracic Esophagectomy: Hand-sewn Versus Side-to-side Linear-stapled Versus Circular-stapled Anastomosis: A Systematic Review and Meta-analysis. Surg Laparosc Endosc Percutan Tech 2022; 32:380-392. [PMID: 35583556 DOI: 10.1097/sle.0000000000001050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 10/12/2021] [Indexed: 12/08/2022]
Abstract
BACKGROUND Three anastomotic techniques are mostly used to create an esophagogastric anastomosis in a transthoracic esophagectomy: hand-sewn (HS), side-to-side linear-stapled (SSLS), and circular-stapled (CS). The aim of this study was to compare surgical outcomes after HS, SSLS, and CS intrathoracic esophagogastric anastomosis. MATERIALS AND METHODS A systematic review using the MEDLINE database was performed to identify original articles analyzing outcomes after HS, SSLS, and CS esophagogastric anastomosis. The main outcome was an anastomotic leakage rate. Secondary outcomes included overall morbidity, major morbidity, and mortality. A meta-analysis of proportions and linear regression models were used to assess the effect of each anastomotic technique on the different outcomes. RESULTS A total of 101 studies comprising 12,595 patients were included; 8835 (70.1%) with CS, 2532 (20.1%) with HS, and 1228 (9.8%) with SSLS anastomosis. Anastomotic leak occurred in 10% [95% confidence interval (CI), 6%-15%], 9% (95% CI, 6%-13%), and 6% (95% CI, 5%-7%) of patients after HS, SSLS, and CS anastomosis, respectively. Risk of anastomotic leakage was significantly higher with HS anastomosis (odds ratio=1.73, 95% CI: 1.47-2.03, P<0.0001) and SSLS (odds ratio=1.68, 95% CI: 1.36-2.08, P<0.0001), as compared with CS. Overall morbidity (HS: 52% vs. SLSS: 39% vs. CS: 35%) and major morbidity (HS: 33% vs. CS: 19%) rates were significantly lower with CS anastomosis. Mortality rate was 4% (95% CI, 3%-6%), 2% (95% CI, 2%-3%), and 3% (95% CI, 3%-4%) after HS, SSLS, and CS anastomosis, respectively. CONCLUSION HS and SSLS intrathoracic esophagogastric anastomoses are associated with significantly higher rates of an anastomotic leak than CS anastomosis.
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Affiliation(s)
- Francisco Schlottmann
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
- Department of Surgery, University of Illinois at Chicago, Chicago, IL
| | - Cristian A Angeramo
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
| | | | - María A Casas
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
| | | | - Marco G Patti
- Department of Surgery, University of Virginia, Charlottesville, Virginia
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15
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Fabbi M, van Berge Henegouwen MI, Fumagalli Romario U, Gandini S, Feenstra M, De Pascale S, Gisbertz SS. End-to-side circular stapled versus side-to-side linear stapled intrathoracic esophagogastric anastomosis following minimally invasive Ivor-Lewis esophagectomy: comparison of short-term outcomes. Langenbecks Arch Surg 2022; 407:2681-2692. [PMID: 35639136 DOI: 10.1007/s00423-022-02567-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 05/21/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE The search for the optimal procedure for creation of a safe gastroesophageal intrathoracic anastomosis with a lower risk of leakage in totally minimally invasive Ivor-Lewis esophagectomy (TMIIL) is ongoing. In the present study, we compared the outcomes of end-to-side (with circular stapler [CS]) and side-to-side (with linear stapler [LS]) techniques for intrathoracic anastomosis during TMIIL performed in 2 European high-volume centers for upper gastrointestinal surgery. A propensity score method was used to compare the CS and LS groups. METHODS We retrospectively evaluated patients with lower esophageal cancer or Siewert type 1 or 2 esophagogastric junction carcinoma who underwent a planned TMIIL esophagectomy, performed from January 2017 to September 2020. The anastomosis was created by a semi-mechanical technique using a LS in one center and by a mechanical technique using a CS in the other center. General features, operative techniques, pathology data, and short-term outcomes were analyzed. Statistical evaluations were performed on the whole cohort, stratifying the analyses by risk strata factors identified with the propensity scores, and on a subgroup of patients matched by propensity score. The primary endpoint of the study was the rate of anastomotic leakage in the two groups. Secondary endpoints included rates of anastomotic stricture and overall postoperative complications. RESULTS Considering the whole population, 256 patients were included; of those, 220 received the anastomosis with a circular stapler (CS group), and 36 received the anastomosis with a linear stapler (LS group). No significant differences by group in terms of sex, age, American Society of Anesthesiologists physical status classification, and type of neoplasm were showed. The rate of anastomotic leakage did not differ in the two groups (9.6% CS vs. 5.6% LS, p = 0.438), as well as the rate of anastomotic stricture in the 3-month follow-up (0.9% CS vs. 2.8% LS, p = 0.367). The rate of chyle leakage and of pulmonary, cardiac, and infective complications was not significantly different in the groups. After propensity score matching, 72 patients were included in the analysis. The 2 obtained propensity score matched groups did not differ for any of the clinical and pathologic variables considered for the analysis, resulting in well-balanced cohorts. The results obtained on the whole population were confirmed in the matched groups. CONCLUSIONS The results of our study suggest that both techniques for esophagogastric anastomosis during TMIIL are feasible, safe, and effective, with comparable rates of postoperative anastomotic leakage and stricture.
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Affiliation(s)
- Manrica Fabbi
- Department of Digestive Surgery, European Institute of Oncology (IRCCS), Milan, Italy.
| | - Mark I van Berge Henegouwen
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | | | - Sara Gandini
- Department of Experimental Oncology, European Institute of Oncology (IRCCS), Milan, Italy
| | - Minke Feenstra
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Stefano De Pascale
- Department of Digestive Surgery, European Institute of Oncology (IRCCS), Milan, Italy
| | - Suzanne S Gisbertz
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
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16
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Jiang X, Xu X, Ding L, Zhu H, Lu J, Zhao K, Zhu S, Xu Q. Predictive value of preoperative handgrip strength on postoperative outcomes in patients with gastrointestinal tumors: a systematic review and meta-analysis. Support Care Cancer 2022; 30:6451-6462. [PMID: 35316404 DOI: 10.1007/s00520-022-06983-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 03/11/2022] [Indexed: 12/29/2022]
Abstract
PURPOSE This systematic review and meta-analysis aimed to explore the predictive value of preoperative handgrip strength on postoperative outcomes in patients with gastrointestinal tumors. METHODS Databases including Cochrane Library, Pubmed, Embase, Web of Science, and CINAHL Complete were searched for articles published from the establishment of database until August 7, 2021. Two researchers independently screened the literature, extracted the data, and evaluated the quality. RESULTS Eight studies were included, involving five prospective and three retrospective cohort studies with 2291 participants. The prevalence of preoperative low handgrip strength ranged from 11.8 to 62.7%. Preoperative low handgrip strength was associated with an increased risk of total complications (OR = 2.23, 95%CI = 1.43-3.50), pneumonia (OR = 5.16, 95%CI = 3.17-8.38), ileus (OR = 2.48, 95%CI = 1.09-5.65), and short-term mortality (OR = 7.28, 95%CI = 1.90-27.92). CONCLUSION This systematic review and meta-analysis indicated that preoperative HGS had important value to predict certain adverse postoperative outcomes among patients with GI tumors. Low handgrip strength criteria, definition of total complications, and country are the potential sources of heterogeneity, and more research are required to test and update these results.
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Affiliation(s)
- Xiaoman Jiang
- School of Nursing, Nanjing Medical University, Nanjing, 211166, China
| | - Xinyi Xu
- Faculty of Health, Queensland University of Technology, Brisbane, 4702, Australia
| | - Lingyu Ding
- School of Nursing, Nanjing Medical University, Nanjing, 211166, China
| | - Hanfei Zhu
- School of Nursing, Nanjing Medical University, Nanjing, 211166, China
| | - Jinling Lu
- Department of Surgery, the First Affiliated Hospital of Nanjing Medical University, Nanjing, 211166, China
| | - Kang Zhao
- School of Nursing, Nanjing Medical University, Nanjing, 211166, China
| | - Shuqin Zhu
- School of Nursing, Nanjing Medical University, Nanjing, 211166, China
| | - Qin Xu
- School of Nursing, Nanjing Medical University, Nanjing, 211166, China.
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17
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Casas MA, Angeramo CA, Bras Harriott C, Schlottmann F. Surgical outcomes after totally minimally invasive Ivor Lewis esophagectomy. A systematic review and meta-analysis. Eur J Surg Oncol 2021; 48:473-481. [PMID: 34955315 DOI: 10.1016/j.ejso.2021.11.119] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 09/20/2021] [Accepted: 11/16/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND A transthoracic esophagectomy is associated with high rates of morbidity. Minimally invasive esophagectomy has emerged to decrease such morbidity. The aim of this study was to accurately determine surgical outcomes after totally minimally invasive Ivor-Lewis Esophagectomy (TMIE). METHODS A systematic literature search was performed to identify original articles analyzing patients who underwent TMIE. Main outcomes included overall morbidity, major morbidity, pneumonia, arrhythmia, anastomotic leak, chyle leak, and mortality. A meta-analysis was conducted to estimate the overall weighted proportion and its 95% confidence interval (CI) for each analyzed outcome. RESULTS A total of 5619 patients were included for analysis; 4781 (85.1%) underwent a laparoscopic/thoracoscopic esophagectomy and 838 (14.9%) a robotic-assisted esophagectomy. Mean age of patients was 63.5 (55-67) years and 75.8% were male. Overall morbidity and major morbidity rates were 39% (95% CI, 33%-45%) and 20% (95% CI, 13%-28%), respectively. Postoperative pneumonia and arrhythmia rates were 10% (95% CI, 8%-13%) and 12% (95% CI, 8%-17%), respectively. Anastomotic leak rate across studies was 8% (95% CI, 6%-10%). Chyle leak rate was 3% (95% CI, 2%-5%). Mortality rate was 2% (95% CI, 2%-2%). Median ICU stay and length of hospital stay were 2 (1-4) and 11.2 (7-20) days, respectively. CONCLUSIONS Totally minimally invasive Ivor-Lewis esophagectomy is a challenging procedure with high morbidity rates. Strategies to enhance postoperative outcomes after this operation are still needed.
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Affiliation(s)
- María A Casas
- Department of Surgery, Hospital Alemán of Buenos Aires, Argentina
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18
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Luo S, Xu J, Xiong W, Li J, Luo L, Zheng Y, Zeng H, Liu Y, Yang L, Wu Z, Yang X, Wang W. Feasibility and efficacy of transthoracic single-port assisted laparoscopic esophagogastrectomy for Siewert type II adenocarcinoma of the esophagogastric junction. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1540. [PMID: 34790746 PMCID: PMC8576657 DOI: 10.21037/atm-21-4574] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 10/02/2021] [Indexed: 01/13/2023]
Abstract
Background The surgical treatment of Siewert type II adenocarcinoma of the esophagogastric junction (AEG) is controversial, and no systematic technology has been established. The aim of this retrospective study is to introduce the technology of transthoracic single-port assisted laparoscopic esophagogastrectomy. Methods Data from patients with Siewert type II AEG who underwent transthoracic single-port assisted laparoscopic esophagogastrectomy in Guangdong Provincial Hospital of Chinese Medicine from May 2017 to December 2020 were analyzed. Results A total of 35 patients, including 30 males and 5 females, were enrolled in this study. Eight patients underwent proximal gastrectomy while the other 27 patients underwent total gastrectomy. The median operative times were 247.5 (195.0–275.0) min and 290.0 (173.0–530.0) min for proximal and total gastrectomy, respectively. The median lower mediastinal lymph node dissection (LMLD) time was 41.5 (20.0–57.0) min and the median estimated blood loss was 100.0 (20.0–200.0) mL. The median number of harvested mediastinal lymph nodes was 5 [2–13]. Lower mediastinal lymph node metastasis occurred in 9 patients (25.7%). The lower mediastinal lymph node metastasis rate was significantly higher in patients with esophageal involvement exceeding 2 cm [>2 vs. ≤2 cm: 55.6% (5/9) vs. 15.4% (4/26), P=0.03]. The median postoperative hospital stay was 10 [6–73] days. Overall morbidity was 11.8% (4 patients), including 2 cases of pleural effusion, 1 case of pancreatic fistula, and 1 case of anastomotic leakage. Conclusions Transthoracic single-port assisted laparoscopic esophagogastrectomy is safe and feasible. It has the advantages of reducing the difficulty of LMLD and digestive tract reconstruction.
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Affiliation(s)
- Sijing Luo
- General Surgery 1, Guangdong Provincial Hospital of Chinese Medicine, Zhuhai, China
| | - Jiamin Xu
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Wenjun Xiong
- Gastrointestinal Surgery, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
| | - Jin Li
- Gastrointestinal Surgery, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
| | - Lijie Luo
- Gastrointestinal Surgery, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
| | - Yansheng Zheng
- Gastrointestinal Surgery, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
| | - Haiping Zeng
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yangwen Liu
- General Surgery 1, Zhaotong Hospital of Chinese Medicine, Zhaotong, China
| | - Licong Yang
- General Surgery 1, Zhaotong Hospital of Chinese Medicine, Zhaotong, China
| | - Zhengqian Wu
- General Surgery 1, Zhaotong Hospital of Chinese Medicine, Zhaotong, China
| | - Xiaobo Yang
- State Key Laboratory of Dampness Syndrome of Chinese Medicine, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
| | - Wei Wang
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, China.,Gastrointestinal Surgery, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
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19
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Comment On 'Learning Curves of Ivor Lewis Totally Minimally Invasive Esophagectomy by Hospital and Surgeon Characteristics A Retrospective Multi-National Cohort Study'. Ann Surg 2021; 274:e929-e930. [PMID: 34380965 DOI: 10.1097/sla.0000000000005145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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20
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A long-term follow-up study of minimally invasive Ivor Lewis esophagectomy with linear stapled anastomosis. Surg Endosc 2021; 36:1979-1988. [PMID: 33837477 DOI: 10.1007/s00464-021-08482-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Accepted: 03/28/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND Minimally invasive esophagectomy (MIE) is increasingly performed to expect lower complication rate compared to open esophagectomy. Studies of minimally invasive Ivor Lewis esophagectomy (MIILE) with circular staplers have reported better outcomes compared to MIE with cervical anastomosis, but frequent anastomotic complications have also been reported. MIILE with linear staplers is a promising alternative, but the long-term functional and oncological outcomes are uncertain. METHODS To evaluate the functional and oncological outcomes of MIILE with linear stapled anastomosis, a retrospective cohort study was performed in 104 patients who underwent MIILE with linear stapled anastomosis for esophageal malignant tumors. The primary endpoints were the overall complication and anastomotic leak rates. The secondary endpoints were late complications, overall and disease-free survival, and nutritional status at 6 and 12 months after MIILE. RESULTS Anastomotic leak occurred in 4 patients (3.8%). The short-term complication rate of grade IIIb or higher was 6.7%. During a median 57-month follow-up period, anastomotic stricture occurred in one patient, 7 required hiatal hernia repair, and 2 underwent conduit revision surgery. The 5-year overall survival and disease-free survival rates were 69.3% and 59.5%, respectively. Status of reflux esophagitis at the time of most recent evaluation was grade N/A/B/C/D in 52/10/10/13/8 among 93 patients who had follow-up endoscopy. The mean body weight loss at 6 and 12 months after MIILE was 11.3 and 11.8% with maintenance of the serum albumin level. CONCLUSIONS MIILE with linear stapled anastomosis is a safe procedure with a low anastomotic complication rate and favorable long-term functional and survival outcomes.
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Pather K, Deladisma AM, Guerrier C, Kriley IR, Awad ZT. Indocyanine green perfusion assessment of the gastric conduit in minimally invasive Ivor Lewis esophagectomy. Surg Endosc 2021; 36:896-903. [PMID: 33580319 DOI: 10.1007/s00464-021-08346-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Accepted: 01/27/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Anastomotic leak is a serious complication following esophagectomy. The aim of the study was to report our experience with indocyanine green fluorescence angiography (ICG-FA)-PINPOINT® assisted minimally invasive Ivor Lewis esophagectomy (MILE) and assess factors associated with anastomotic leak. METHODS We reviewed consecutive patients undergoing MILE from 2013 to 2018. Intraoperative real-time assessment of gastric conduit was performed using ICG-FA with PINPOINT®. Perfusion was categorized as good perfusion (brisk ICG visualization to conduit tip) or non-perfusion (any demarcation along the conduit). RESULTS 100 patients (81 males, median age 68 [60-72]) underwent MILE for malignancy in 96 patients and benign disease in 4 patients. There were six anastomotic leaks all managed with endoscopic stent placement. There was no intraoperative mortality and no 30-day mortality in leak patients. Patients with a leak were more likely to be overweight with BMI > 25 (100% versus 53%, p = 0.03), have pre-existing diabetes (50% versus 13%, p = 0.04), and have higher intraoperative estimated blood loss (260 mL [95-463] versus 75 mL [48-150], p = 0.03). Anastomotic leaks occurred more frequently in the non-perfusion (67%) versus the good perfusion category (33%, p = 0.03). By multivariable analysis, diabetes (odds ratio [OR] 6.42; p = 0.04) and non-perfusion (OR 6.60; p = 0.04) were independently associated with leak. CONCLUSION Intraoperative use of ICG-FA may be a useful adjunct to assess perfusion of the gastric conduit with non-perfusion being independently associated with a leak. While perfusion plays an important role in anastomotic integrity, development of a leak is multifactorial, and ICG-FA should be used in conjunction with the optimization of patient and procedural components to minimize leak rates. Prospective, randomized studies are required to validate the interpretation, efficacy, and application of this novel technology in minimally invasive esophagectomies.
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Affiliation(s)
- Keouna Pather
- Department of Surgery, UF Health, 653 West 8th Street, Jacksonville, FL, 32209, USA.
| | - Adeline M Deladisma
- Department of Surgery, UF Health, 653 West 8th Street, Jacksonville, FL, 32209, USA
| | | | - Isaac R Kriley
- Department of Surgery, UF Health, 653 West 8th Street, Jacksonville, FL, 32209, USA
| | - Ziad T Awad
- Department of Surgery, UF Health, 653 West 8th Street, Jacksonville, FL, 32209, USA.,University of Florida, Jacksonville, FL, USA
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Learning Curves of Ivor Lewis Totally Minimally Invasive Esophagectomy by Hospital and Surgeon Characteristics: A Retrospective Multi-National Cohort Study. Ann Surg 2021; 275:911-918. [PMID: 33605581 DOI: 10.1097/sla.0000000000004801] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To describe the pooled learning curves of Ivor Lewis TMIE in hospitals stratified by predefined hospital and surgeon related factors. SUMMARY BACKGROUND DATA Ivor Lewis totally minimally invasive esophagectomy (TMIE) is known to have a long learning curve which is associated with considerable learning associated morbidity. It is unknown whether hospital and surgeon characteristics are associated with more efficient learning. METHODS A retrospective analysis of prospectively collected data of consecutive Ivor Lewis TMIE patients in 14 European hospitals was performed. Outcome parameters used as proxy for efficient learning were learning curve length, learning associated morbidity and the plateau level regarding anastomotic leakage and textbook outcome. Pooled incidences were plotted for the factor-based subgroups using generalized additive models and two-phase models. Casemix predicted outcomes were plotted and compared with observed outcomes. The investigated factors included annual volume, (TMIE) experience, clinic visits, courses and fellowships followed, and proctor supervision. RESULTS This study included 2121 patients. The length of the learning curve was shorter for centers with an annual volume ≥50 compared to centers with an annual volume < 50. Analysis with an annual volume cut-off of 30 cases showed similar but less pronounced results. No outcomes suggesting more efficient learning were found for longer experience as consultant, visiting an expert clinic, completing a MIE fellowship or implementation under proctor supervision. CONCLUSIONS More efficient learning was observed in centers with higher annual volume. Visiting an expert clinic, completing a fellowship, or implementation under a proctor's supervision were not associated with more efficient learning.
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Pang W, Liu G, Zhang Y, Huang Y, Yuan X, Zhao Z, Zhang C. Total laparoscopic transabdominal-transdiaphragmatic approach for treating Siewert II tumors: a prospective analysis of a case series. World J Surg Oncol 2021; 19:26. [PMID: 33485350 PMCID: PMC7827998 DOI: 10.1186/s12957-021-02136-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 01/14/2021] [Indexed: 01/19/2023] Open
Abstract
Background Although the morbidity of gastric cancer has decreased, the incidence of adenocarcinoma of the esophagogastric junction (AEG) is increasing. Furthermore, no consensus exists on which surgical approach should be applied for Siewert type II AEG. The purpose of our study was to evaluate the technical safety and feasibility of a new surgical approach. Methods Sixty patients with Siewert type II AEG underwent laparoscopic total gastrectomy with the total laparoscopic transabdominal-transdiaphragmatic (TLTT) approach, which needs an incision in the diaphragm. Results The median operative time, reconstruction time, and estimated blood loss were 214.8 ± 41.6 min, 29.40 ± 7.1 min, and 209.0 ± 110.3 ml, respectively. All of the patients had negative surgical margins. Conclusion There were no intraoperative complications or conversions to open surgery. Our surgical procedure provides a unique option for the safe application of laparoscopic lower mediastinal lymph node dissection and gastrointestinal reconstruction. Trial registration Chinese Clinical Trial Registry, ChiCTR1800014336. Registered on 31 December 2017 - Prospectively registered, http://www.chictr.org.cn/edit.aspx?pid=23111&htm=4. Supplementary Information The online version contains supplementary material available at 10.1186/s12957-021-02136-2.
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Affiliation(s)
- Wei Pang
- Department of General Surgery, The Sixth Medical Center of PLA General Hospital, Beijing, 100048, China.,Department of General Surgery, Xinan Hospital, The Third Military Medical University, Chongqing, 400037, China
| | - Gang Liu
- Department of General Surgery, The Sixth Medical Center of PLA General Hospital, Beijing, 100048, China
| | - Yan Zhang
- Department of General Surgery, The Sixth Medical Center of PLA General Hospital, Beijing, 100048, China
| | - Yun Huang
- Department of General Surgery, The Sixth Medical Center of PLA General Hospital, Beijing, 100048, China
| | - Xinpu Yuan
- Department of General Surgery, The Sixth Medical Center of PLA General Hospital, Beijing, 100048, China
| | - Zhanwei Zhao
- Department of General Surgery, The Sixth Medical Center of PLA General Hospital, Beijing, 100048, China.
| | - Chaojun Zhang
- Department of General Surgery, The Sixth Medical Center of PLA General Hospital, Beijing, 100048, China.
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Giacopuzzi S, Weindelmayer J, de Manzoni G. RAMIE: tradition drives innovation-feasibility of a robotic-assisted intra-thoracic anastomosis. Updates Surg 2020; 73:847-852. [PMID: 33247384 PMCID: PMC7694887 DOI: 10.1007/s13304-020-00932-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Accepted: 11/11/2020] [Indexed: 01/06/2023]
Abstract
Due to the difficulties in the intra-thoracic esophagogastric anastomosis creation, totally minimally invasive Ivor Lewis esophagectomy (MIE) did not encountered a large diffusion, preferring hybrid techniques or cervical anastomosis. Robot-assisted minimally invasive esophagectomy (RAMIE) has gained popularity due to an easy reproducibility of the open anastomotic technique. In this feasibility study, we described the RAMIE technique introduced in our Center, providing innovative details for a mechanical end-to-end anastomosis. With patient in prone position, esophagectomy is conducted through the meso-esophagus plan. Robotic hand-sewn purse-string is realized above Azygos vein. A 4-cm thoracotomy in the fifth intercostal space is performed by enlarging the trocar incision. The tubulization is performed to create an access pouch for the introduction of the circular stapler. After the creation of the end-to-end anastomosis, the access pouch is resected and a robotic over-sewn is realized. From January 2020 until July 2020, ten patients were enrolled. No restriction in term of age, BMI, ASA grade or previous surgery were applied. Median operative time was 700 min. R0 resection was achieved in all cases with a good lymph node harvesting. No anastomotic leak or stricture were observed. One chyle leak was treated conservatively. Median length of stay was 8 days and 90 days mortality was 0%. This study evidenced how robotic surgery allowed us to perform the same anastomosis of our open technique with good oncological results and morbidity and length of stay comparable with our previous results. Of note, longer operative time has been recorded. Further studies after the completion of the learning curve are necessary to address more definite conclusions.
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Affiliation(s)
- Simone Giacopuzzi
- General and Upper GI Surgery Division, Azienda Ospedaliera Universitaria Integrata Verona, Piazzale Aristide Stefani 1, 37126, Verona, Italy
| | - Jacopo Weindelmayer
- General and Upper GI Surgery Division, Azienda Ospedaliera Universitaria Integrata Verona, Piazzale Aristide Stefani 1, 37126, Verona, Italy.
| | - Giovanni de Manzoni
- General and Upper GI Surgery Division, Azienda Ospedaliera Universitaria Integrata Verona, Piazzale Aristide Stefani 1, 37126, Verona, Italy
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Hagens ER, Feenstra ML, van Egmond MA, van Laarhoven HW, Hulshof MC, Boshier PR, Low DE, van Berge Henegouwen MI, Gisbertz SS. Influence of body composition and muscle strength on outcomes after multimodal oesophageal cancer treatment. J Cachexia Sarcopenia Muscle 2020; 11:756-767. [PMID: 32096923 PMCID: PMC7296271 DOI: 10.1002/jcsm.12540] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Revised: 11/30/2019] [Accepted: 01/07/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Influence of sarcopenia in combination with other body composition parameters and muscle strength on outcomes after oesophageal surgery for oesophageal cancer remains unclear. The objectives were (i) to describe the incidence of sarcopenia in relation to adipose tissue quantity and distribution and muscle strength; (ii) to evaluate if neoadjuvant chemoradiation (nCRTx) influences body composition and muscle strength; and (iii) to evaluate the influence of body composition and muscle strength on post-operative morbidity and long-term survival. METHODS This retrospective study included patients with oesophageal cancer who received nCRTx followed by surgery between January 2011 and 2016. Skeletal muscle, visceral, and subcutaneous adipose tissue cross-sectional areas were calculated based on computed tomography scans, and muscle strength was measured using hand grip tests, 30 seconds chair stand tests, and maximal inspiratory and expiratory pressure tests prior to nCRTx and after nCRTx. RESULTS A total of 322 patients were included in this study. Sarcopenia was present in 55.6% of the patients prior to nCRTx and in 58.2% after nCRTx (P = 0.082). Patients with sarcopenia had a significantly lower muscle strength and higher fat percentage. The muscle strength and incidence of sarcopenia increased while the mean body mass index and fat percentage decreased during nCRTx. A body mass index above 25 kg/m2 was associated with anastomotic leakage (P = 0.032). Other body composition parameters were not associated with post-operative morbidity. A lower handgrip strength prior to nCRTx was associated with pulmonary and cardiac complications (P = 0.023 and P = 0.009, respectively). In multivariable analysis, a lower number of stands during the 30 seconds chair stand test prior to nCRTx (hazard ratio 0.93, 95% confidence interval 0.87-0.99, P = 0.017) and visceral adipose tissue of >128 cm2 after nCRTx (hazard ratio 1.81, 95% confidence interval 1.30-2.53, P = 0.001) were associated with worse overall survival. CONCLUSIONS Sarcopenia occurs frequently in patients with oesophageal cancer and is associated with less muscle strength and a higher fat percentage. Body composition changes during nCRTx did not influence survival. Impaired muscle strength and a high amount of visceral adipose tissue are associated with worse survival. Therefore, patients with poor fitness might benefit from preoperative nutritional and muscle strengthening guidance, aiming to increase muscle strength and decrease visceral adipose tissue. However, this should be confirmed in a large prospective study.
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Affiliation(s)
- Eliza R.C. Hagens
- Department of SurgeryAmsterdam University Medical Centers, University of Amsterdam, Cancer Center AmsterdamAmsterdamThe Netherlands
| | - Minke L. Feenstra
- Department of SurgeryAmsterdam University Medical Centers, University of Amsterdam, Cancer Center AmsterdamAmsterdamThe Netherlands
| | - Maarten A. van Egmond
- Department of RehabilitationAmsterdam University Medical Centers, University of Amsterdam, Cancer Center AmsterdamAmsterdamThe Netherlands
| | - Hanneke W.M. van Laarhoven
- Department of Medical OncologyAmsterdam University Medical Centers, University of Amsterdam, Cancer Center AmsterdamAmsterdamThe Netherlands
| | - Maarten C.C.M. Hulshof
- Department of RadiotherapyAmsterdam University Medical Centers, University of Amsterdam, Cancer Center AmsterdamAmsterdamThe Netherlands
| | - Piers R. Boshier
- Department of Thoracic Surgery and Thoracic OncologyVirginia Mason Medical CenterSeattleWAUSA
- Department of Surgery and CancerImperial College LondonLondonUK
| | - Donald E. Low
- Department of Thoracic Surgery and Thoracic OncologyVirginia Mason Medical CenterSeattleWAUSA
| | - Mark I. van Berge Henegouwen
- Department of SurgeryAmsterdam University Medical Centers, University of Amsterdam, Cancer Center AmsterdamAmsterdamThe Netherlands
| | - Suzanne S. Gisbertz
- Department of SurgeryAmsterdam University Medical Centers, University of Amsterdam, Cancer Center AmsterdamAmsterdamThe Netherlands
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Propensity score-matched comparison between open and minimal invasive hybrid esophagectomy for esophageal adenocarcinoma. Langenbecks Arch Surg 2020; 405:521-532. [PMID: 32388717 DOI: 10.1007/s00423-020-01882-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Accepted: 04/15/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND This study compared the outcome between patients who had an open and those who had a hybrid esophagectomy for T1 or T3 esophageal adenocarcinoma (eAC). No clear data are available concerning this question based on T-category. METHODS Two groups of patients with esophagectomy and high intrathoracic esophagogastrostomy for eAC were analyzed: hybrid (laparoscopy + right thoracotomy) (n = 835) and open (laparotomy + right thoracotomy) (n = 188). Outcome criteria were 30- and 90-day mortality, R0-resection rate (R0), number of resected lymph nodes (rLNs), and 5-year survival rate (5y-SR). For each type of surgery, three patient groups were analyzed: pT1-carcinoma (group-1), cT3Nx and neoadjuvant chemoradiation (group-2), and pT3N0-3 without neoadjuvant therapy (group-3). The comparison was based on a propensity score matching in relation of 1:2 for open versus hybrid. RESULTS In group-1 (38 open vs 76 hybrid) R0-resection (100%), 30-day mortality (0%), 90-day mortality (2.6% vs 0%), and rLNs (median 29.5 vs 28.5) were not significantly different. The pN0-rate was 76% in the open and 92% in the hybrid group (p = 0.036). Accordingly, the 5y-SR was 69% and 87% (p = 0.016), but the prognosis of the subgroups pT1pN0 or pT1pN+ was not significantly different between open or hybrid. In group-2 (68 open vs 135 hybrid) R0-resection (97%), 30-day (0% vs 0.7%) and 90-day (4%) mortality, rLNs (28.5 vs 26), and 5y-SR (36% vs 41%) were not significantly different. In group-3 (37 open vs 75 hybrid) R0, postoperative mortality, rLNs, and 5y-SR were not significantly different. CONCLUSION In a propensity score-matched comparison of patients with an open or hybrid esophagectomy for esophageal adenocarcinoma the quality of oncologic resection, postoperative mortality and prognosis are not different.
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Awad ZT, Abbas S, Puri R, Dalton B, Chesire DJ. Minimally Invasive Ivor Lewis Esophagectomy (MILE): technique and outcomes of 100 consecutive cases. Surg Endosc 2020; 34:3243-3255. [DOI: 10.1007/s00464-020-07529-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 03/26/2020] [Indexed: 02/06/2023]
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[Hybrid esophagectomy with intraoperative hyperspectral imaging : Video article]. Chirurg 2020; 91:1-12. [PMID: 32067066 DOI: 10.1007/s00104-020-01139-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The technique of hybrid esophagectomy with systematic 2‑field lymphadenectomy for esophageal cancer showed a significant reduction in postoperative morbidity in a recently published prospective randomized study. This video publication presents the abdominothoracic hybrid procedure with (i) laparoscopic gastrolysis and ischemic conditioning of the stomach and (ii) 2-stage transthoracic esophagectomy with gastric pull-up, intrathoracic gastric tube formation and anastomosis. Intraoperative hyperspectral imaging (HSI) during the thoracic part of the operation is used for identification of the ideally perfused anastomotic region.
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Learning Curve and Associated Morbidity of Minimally Invasive Esophagectomy: A Retrospective Multicenter Study. Ann Surg 2019; 269:88-94. [PMID: 28857809 DOI: 10.1097/sla.0000000000002469] [Citation(s) in RCA: 191] [Impact Index Per Article: 38.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To investigate the morbidity that is associated with the learning curve of minimally invasive esophagectomy. BACKGROUND Although learning curves have been described, it is currently unknown how much extra morbidity is associated with the learning curve of technically challenging surgical procedures. METHODS Prospectively collected data were retrospectively analyzed of all consecutive patients undergoing minimally invasive Ivor Lewis esophagectomy in 4 European expert centers. The primary outcome parameter was anastomotic leakage. Secondary outcome parameters were operative time and textbook outcome ("optimal outcome"). Learning curves were plotted using weighted moving average and CUSUM analysis was used to determine after how many cases the plateau was reached. Learning associated morbidity was calculated with area under the curve analysis. RESULTS This study included 646 patients. Three of the 4 hospitals reached the plateau of 8% anastomotic leakage. The length of the learning curve was 119 cases. The mean incidence of anastomotic leakage decreased from 18.8% during the learning phase to 4.5% after the plateau had been reached (P < 0.001). Thirty-six extra patients (10.1% of all patients operated on during the learning curve) experienced learning associated anastomotic leakage, that could have been avoided if patients were operated by surgeons who had completed the learning curve. The incidence of textbook outcome increased from 28% to 53% and the mean operative time decreased from 344 minutes to 270 minutes. CONCLUSIONS A considerable number of 36 extra patients (10.1%) experienced learning associated anastomotic leakage. More research is urgently needed to investigate how learning associated morbidity can be reduced to increase patient safety during learning curves.
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Comment on: A Propensity Score Matched Analysis of Open Versus Minimally Invasive Transthoracic Esophagectomy in the Netherlands. Ann Surg 2019; 268:e74-e75. [PMID: 29334558 DOI: 10.1097/sla.0000000000002642] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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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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Plum PS, Herbold T, Berlth F, Christ H, Alakus H, Bludau M, Chang DH, Bruns CJ, Hölscher AH, Chon SH. Outcome of Self-Expanding Metal Stents in the Treatment of Anastomotic Leaks After Ivor Lewis Esophagectomy. World J Surg 2019; 43:862-869. [PMID: 30377723 DOI: 10.1007/s00268-018-4832-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Esophageal anastomotic leakages after Ivor Lewis esophagectomy are severe and life-threatening complications. We analyzed the outcome of using self-expanding metal stents (SEMS) in the treatment of postoperative leakage after esophagogastrostomy. METHODS Seventy patients with esophageal anastomotic leakage after Ivor Lewis esophagectomy for esophageal cancer who had received SEMS treatment between January 2006 and December 2015 at our clinic were identified in this retrospective study. The patients were analyzed according to demographic characteristics, risk factors, leakage characteristics, stent characteristics, stent-related complications, sealing success rate and mortality. RESULTS Over a 10-year period, 70 patients received SEMS as treatment for postoperative anastomotic leakage after esophagectomy. Technical success of esophageal stenting in anastomotic leakage was achieved in 50 out of 70 cases (71.4%). Sealing success rate was 70% (n = 49) with a median treatment of 28 days (range 7-87). In 20 patients (28.6%), stent-related complications, such as stenosis, dislocation, leakage persistence, perforation or esophagotracheal fistula occurred after the SEMS treatment. Sixty-one patients (87.1%) survived SEMS treatment of esophagogastric anastomotic leakage. Mean follow-up for all patients was 38 months (IQR 10-76), and no significant difference was found in a comparison of the long-term survival rate between patients with successful and unsuccessful SEMS treatment. CONCLUSIONS The management of esophageal anastomotic leaks after Ivor Lewis esophagectomy with SEMS is effective, safe and technically feasible. Aggressive non-surgical management should be considered when developing a treatment plan for stenting.
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Affiliation(s)
- Patrick Sven Plum
- Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Till Herbold
- Department of General, Visceral and Transplantation Surgery, RWTH Aachen, Aachen, Germany
| | - Felix Berlth
- Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Hildegard Christ
- Institute of Medical Statistics and Bioinformatics, University of Cologne, Cologne, Germany
| | - Hakan Alakus
- Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Marc Bludau
- Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - De-Hua Chang
- Institute of Radiology, University Hospital of Cologne, Cologne, Germany
| | - Christiane Josephine Bruns
- Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | | | - Seung-Hun Chon
- Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany.
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Souche R, Nayeri M, Chati R, Huet E, Donici I, Tuech JJ, Borie F, Prudhomme M, Jaber S, Fabre JM. Thoracoscopy in prone position with two-lung ventilation compared to conventional thoracotomy during Ivor Lewis procedure: a multicenter case-control study. Surg Endosc 2019; 34:142-152. [PMID: 30868323 DOI: 10.1007/s00464-019-06742-w] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Accepted: 03/06/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Intraoperative management based on thoracoscopy, prone position and two-lung ventilation could decrease the rate of postoperative pulmonary complications after esophagectomy. The aim of this study was to compare this multifaceted approach (MIE-PP) and conventional thoracotomy for Ivor Lewis procedure after a systematic laparoscopic dissection. METHODS Data from 137 consecutive patients undergoing Ivor Lewis procedures between 2010 and 2017 at two tertiary centers was analyzed retrospectively. The outcomes of patients who underwent MIE-PP (n = 58; surgeons group 1) were compared with those of patients undergoing conventional approach (n = 79; surgeons group 2). Our primary outcome was major postoperative pulmonary complications. Our main secondary outcomes were anastomotic leak, quality of resection and mortality. RESULTS Female patients were more prevalent in the MIE-PP group (p = 0.002). Other patient characteristics, cTNM staging and neoadjuvant treatment rate were not different between groups. Major postoperative pulmonary complications were significantly lower in the MIE-PP group compared to Conventional group (24 vs. 44%; p = 0.014). Anastomotic leak occurred in 31 versus 18% in MIE-PP group and Conventional groups, respectively (p = 0.103). Complete resection rate (98 vs. 95%; p = 0.303) and mean number of harvested lymph nodes (16 (4-40) vs. 18 (3-37); p = 0.072) were similar between the two groups. Postoperative mortality rates were 0 versus 2% at day 30 (p = 0.508) and 0 versus 7.6% at day 90 (p = 0.038). CONCLUSION Short-term outcomes of minimally invasive Ivor Lewis using thoracoscopy, prone position and two-lung ventilation are at least equivalent to the hybrid approach. Anastomotic leak after MIE-PP remains a major concern.
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Affiliation(s)
- R Souche
- Digestive and Minimally Invasive Surgery Unit, Department of Digestive Surgery and Transplantation, Saint Eloi Hospital, University of Montpellier - Nîmes, 80 Avenue Augustin Fliche, 34295, Montpellier, France.
| | - M Nayeri
- Digestive Surgery Department, Carémeau Hospital, University of Montpellier - Nîmes, Place du professeur Debré, 30900, Nîmes, France
| | - R Chati
- Digestive Surgery Department, Charles Nicolle Hospital, University of Rouen, 1 rue de Germont, 76031, Rouen, France
| | - E Huet
- Digestive Surgery Department, Charles Nicolle Hospital, University of Rouen, 1 rue de Germont, 76031, Rouen, France
| | - I Donici
- Digestive Surgery Department, Carémeau Hospital, University of Montpellier - Nîmes, Place du professeur Debré, 30900, Nîmes, France
| | - J J Tuech
- Digestive Surgery Department, Charles Nicolle Hospital, University of Rouen, 1 rue de Germont, 76031, Rouen, France
| | - F Borie
- Digestive Surgery Department, Carémeau Hospital, University of Montpellier - Nîmes, Place du professeur Debré, 30900, Nîmes, France
| | - M Prudhomme
- Digestive Surgery Department, Carémeau Hospital, University of Montpellier - Nîmes, Place du professeur Debré, 30900, Nîmes, France
| | - S Jaber
- Department of Reanimation and Anesthesiology, Saint Eloi Hospital, University of Montpellier - Nîmes, 80 Avenue Augustin Fliche, 34295, Montpellier, France
| | - J M Fabre
- Digestive and Minimally Invasive Surgery Unit, Department of Digestive Surgery and Transplantation, Saint Eloi Hospital, University of Montpellier - Nîmes, 80 Avenue Augustin Fliche, 34295, Montpellier, France
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Stenstra MHBC, van Workum F, van den Wildenberg FJH, Polat F, Rosman C. Evolution of the surgical technique of minimally invasive Ivor-Lewis esophagectomy: description according to the IDEAL framework. Dis Esophagus 2019; 32:5105841. [PMID: 30247660 DOI: 10.1093/dote/doy079] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Totally minimally invasive Ivor-Lewis esophagectomy (Ivor Lewis TMIE) is a technically challenging procedure and is associated with a learning curve. Refinement of surgical technique is an important part of this learning curve. However, detailed descriptions of these refinements according to the idea, development, exploration, assessment, and long-term follow-up (IDEAL) framework are lacking and this study was undertaken to fill this knowledge gap. From 2010 until 2016, all consecutive patients (n = 164) were included from the first patient undergoing Ivor Lewis TMIE. Surgical reports were analyzed and surgeons were interviewed to determine surgical refinements. These data were used to describe the transition of the surgical technique from IDEAL stage IIB to stage III. The main findings were that four refinements were made to the surgical procedure in IDEAL stage IIB: (1) At case 9, the use of the 25 mm OrVil was abandoned, exchanged for a 28 mm EEA stapler and a large omental wrap around the anastomosis was introduced; (2) at case 27, the omental wrap was reduced in volume; (3) at case 60, the omental wrap was refined to cover the full 360° of the anastomosis and (4) at case 77, the fixation of the anvil with the Endostitch was replaced by fixation with two Endoloops®. During the transition from IDEAL stage IIB to stage III, the incidence of anastomotic leakage decreased from 26.0% to 4.6% (P < 0.001) and the incidence of textbook outcome increased from 31.2% to 47.1% (P = 0.039). In conclusion, this study describes the surgical refinements that were made during the progression of Ivor Lewis TMIE from IDEAL stage IIB to IDEAL stage III. During IDEAL stage IIB, postoperative outcome improved as surgical proficiency was gained and the technique was refined.
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Affiliation(s)
| | - F van Workum
- Department of Surgery, Radboud University Medical Centre
| | | | - F Polat
- Department of surgery, Canisius-Wilhelmina Hospital, Nijmegen, the Netherlands
| | - C Rosman
- Department of Surgery, Radboud University Medical Centre
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Asti E, Bernardi D, Sozzi M, Bonavina L. Minimally invasive esophagectomy for Barrett's adenocarcinoma. Transl Gastroenterol Hepatol 2018; 3:77. [PMID: 30505964 DOI: 10.21037/tgh.2018.09.16] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 09/28/2018] [Indexed: 12/15/2022] Open
Abstract
Minimally invasive esophagectomy has become the preferred approach for invasive Barrett's adenocarcinoma because it can speed recovery and enhance patient's quality of life. Multiple minimally invasive surgical techniques have been described during the last two decades. Preoperative staging, anatomy and physiological patient's status, comorbidity, and experience of the surgical team should drive the choice of the surgical approach. The trans-thoracic Ivor Lewis esophagectomy, either hybrid or totally minimal invasive, remains the preferred approach in these patients. Lymph node yield and short-term clinical outcomes have proven similar to open surgery, while quality of life appears improved. To establish a minimally invasive esophagectomy program, a steep learning curve and a multidisciplinary approach are required in order to provide optimal staging, personalized therapy, and adequate perioperative care. The role of minimally invasive surgery in the treatment of invasive Barrett's adenocarcinoma will continue to expand in synergy with enhanced recovery after surgery pathways.
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Affiliation(s)
- Emanuele Asti
- Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Italy
| | - Daniele Bernardi
- Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Italy
| | - Marco Sozzi
- Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Italy
| | - Luigi Bonavina
- Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Italy
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Deng J, Su Q, Ren Z, Wen J, Xue Z, Zhang L, Chu X. Comparison of short-term outcomes between minimally invasive McKeown and Ivor Lewis esophagectomy for esophageal or junctional cancer: a systematic review and meta-analysis. Onco Targets Ther 2018; 11:6057-6069. [PMID: 30275710 PMCID: PMC6157998 DOI: 10.2147/ott.s169488] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Purpose Minimally invasive esophagectomy is increasingly performed for esophageal or gastroesophageal junctional cancer, with advantages of improved perioperative outcomes in comparison with open esophagectomy. McKeown and Ivor Lewis are widely used procedures of minimally invasive esophagectomy, and there have been controversies on which one is preferred for patients with resectable esophageal or junctional cancer. Patients and methods This review was registered at the International Prospective Register of Systematic Reviews (number CRD42017075989). Studies in PubMed, Embase, Web of Science, the Cochrane Library, and ClinicalTrials.gov were thoroughly investigated. Eligible studies included prospective and retrospective studies evaluating short-term outcomes of minimally invasive McKeown esophagectomy (MIME) vs minimally invasive Ivor Lewis esophagectomy (MILE) in patients with resectable esophageal or junctional tumors. Main parameters included anastomotic leak and 30-day/in-hospital mortality. Overall incidence rates (ORs)/weighted mean difference (WMD) with 95% confidence intervals (CIs) were calculated by employing random-effects models. Results Fourteen studies containing 3,468 cases were included in this meta-analysis. Age, male sex, and American Joint Committee on Cancer (AJCC) stage between the 2 groups were not statistically different. MIME led to more blood loss, longer operating time, and longer hospital stay than MILE. MIME was associated with higher incidence of pulmonary complications (OR =1.96, 95% CI =1.28–3.00) as well as total anastomotic leak (OR =2.55, 95% CI =1.40–4.63), stricture (OR =2.07, 95% CI =1.05–4.07), and vocal cord injury/palsy (OR =5.62, 95% CI =3.46–9.14). In addition, the differences of R0 resection rate, number of lymph modes retrieved, blood transfusion rate, length of intensive care unit stay, incidence of cardiac arrhythmia, and Chyle leak between MIME and MILE were not statistically significant. Notably, incidence of severe anastomotic leak (OR =1.28, 95% CI =0.73–2.24) and 30-day/in-hospital mortality (OR =1.76, 95% CI =0.92–3.36) as well as 90-day mortality (OR =2.22, 95% CI =0.71–6.98) between the 2 procedures were also not significantly different. Conclusion This study suggests that MIME and MILE are comparable with respect to clinical safety. MILE may be a better option when oncologically and clinically suitable. MIME is still a safe alternative procedure when clinically indicated. However, this evidence is at risk for bias; randomized controlled trials are needed to validate or correct our results.
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Affiliation(s)
- Jianqing Deng
- Department of Thoracic Surgery, Chinese PLA General Hospital, Beijing, People's Republic of China,
| | - Qingqing Su
- Department of Nursing Department, Chinese PLA General Hospital, Beijing, People's Republic of China
| | - Zhipeng Ren
- Department of Thoracic Surgery, Chinese PLA General Hospital, Beijing, People's Republic of China,
| | - Jiaxin Wen
- Department of Thoracic Surgery, Chinese PLA General Hospital, Beijing, People's Republic of China,
| | - Zhiqiang Xue
- Department of Thoracic Surgery, Chinese PLA General Hospital, Beijing, People's Republic of China,
| | - Lianbin Zhang
- Department of Thoracic Surgery, Chinese PLA General Hospital, Beijing, People's Republic of China,
| | - Xiangyang Chu
- Department of Thoracic Surgery, Chinese PLA General Hospital, Beijing, People's Republic of China,
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Gisbertz SS, Hagens ERC, Ruurda JP, Schneider PM, Tan LJ, Domrachev SA, Hoeppner J, van Berge Henegouwen MI. The evolution of surgical approach for esophageal cancer. Ann N Y Acad Sci 2018; 1434:149-155. [PMID: 30191569 DOI: 10.1111/nyas.13957] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 06/18/2018] [Accepted: 08/02/2018] [Indexed: 12/14/2022]
Abstract
Esophageal surgery for esophageal cancer has been performed for over a century now. Minimally invasive esophagectomy (MIE) was first described in 1992, and it is now a standard approach in many countries. However, MIE is technically difficult and requires a long learning curve. It takes >100 cases to train for MIE with gastric tube reconstruction with an intrathoracic anastomosis. A possible option to overcome several challenges of MIE might be the use of a robotic system. A robot-assisted MIE was first described in 2005, and long-term results have shown its feasibility and safety. Over the years, different approaches for esophagectomy have been established. Our review discusses these developments and recent literature on open, minimally invasive and robotic esophageal surgery.
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Affiliation(s)
- Suzanne S Gisbertz
- Department of Surgery, the Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Eliza R C Hagens
- Department of Surgery, the Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Jelle P Ruurda
- Department of Surgical Oncology, the University Medical Center Utrecht, Utrecht, the Netherlands
| | - Paul M Schneider
- The Center for Visceral, Thoracic and Specialized Tumor Surgery, Hirslanden Medical Center, Zurich, Switzerland
| | - Li Jie Tan
- Division of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | | | - Jens Hoeppner
- Faculty of Medicine, University of Freiburg Medical Center, Freiburg, Germany
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Qi W, Zixiang W, Tianwei Z, Shuai F, Sai Z, Gang S, Ming W. Long-term outcomes of 530 esophageal squamous cell carcinoma patients with minimally invasive Ivor Lewis esophagectomy. J Surg Oncol 2018; 117:957-969. [PMID: 29878389 DOI: 10.1002/jso.24997] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 01/02/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND OBJECTIVES The short-term benefits of minimally invasive esophagectomy (MIE) Ivor Lewis were proved, but 6-year outcomes in esophageal squamous cell carcinoma (ESCC) patients remain unclear. We sought to investigate perioperative outcomes, quality of life (QOL), survival and impact of adjuvant therapy in ESCC patients who underwent MIE Ivor Lewis. METHODS We conducted a retrospective review of 530 ESCC patients treated with MIE Ivor Lewis from 2011 to 2016. Relevant variables were collected and assessed. Overall survival (OS) and disease-free survival (DFS) was analyzed by Kaplan-Meier or Cox proportional hazards modeling. RESULTS Median operation duration was 266 min. The median number of lymph nodes was 28. The 30-day postoperative mortality was 1.7%. At a median follow-up of 41 months, the 6-year OS and DFS were 44.7% and 46.1%. Adjuvant chemoradiotherapy offered survival advantages in advanced stage patients. Pathological tumor-node-metastasis stage, postoperative complications, and recurrent laryngeal nerve lymphadenectomy were independent prognostic factors based on multivariate analysis. Generalized estimating equation analysis showed a rapid postoperative QOL improvement. CONCLUSIONS MIE Ivor Lewis is a safe and feasible procedure in ESCC patients. It offers satisfactory perioperative outcomes, rapid QOL improvement, and acceptable long-term oncologic survival. Adjuvant chemoradiotherapy may improve OS and DFS in advanced stage patients.
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Affiliation(s)
- Wang Qi
- Department of Thoracic Surgery, 2nd Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Wu Zixiang
- Department of Thoracic Surgery, 2nd Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Zhan Tianwei
- Department of Thoracic Surgery, 2nd Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Fang Shuai
- Department of Thoracic Surgery, 2nd Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Zhang Sai
- Department of Thoracic Surgery, 2nd Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Shen Gang
- Department of Thoracic Surgery, 2nd Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Wu Ming
- Department of Thoracic Surgery, 2nd Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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Hagens ERC, Anderegg MCJ, van Berge Henegouwen MI, Gisbertz SS. International Survey on the Management of Anastomotic Leakage After Esophageal Resection. Ann Thorac Surg 2018; 106:1702-1708. [PMID: 29883644 DOI: 10.1016/j.athoracsur.2018.05.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2017] [Revised: 05/04/2018] [Accepted: 05/09/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Anastomotic leakage is one of the most severe complications following esophageal surgery, leading to significant morbidity, prolonged hospital stay, considerable costs, decreased quality of life, and increased mortality. Management of anastomotic leakage is complicated and has currently not been standardized. The objective of this research is to gain insight into the different opinions on anastomotic leakage management among upper gastrointestinal surgeons and verify the need for diagnostic and treatment guidelines. METHODS Surgeons with interest in esophageal surgery were invited to participate in an international online questionnaire. The survey consisted of questions pertaining to the surgeons' experience, operation techniques, management routine, and opinion on future international guidelines on the treatment of anastomotic leakage. RESULTS Of the 331 invited surgeons, 40% participated in the survey. Among the 129 responders, 90.7% use laboratory diagnostics and 62.8% use imaging or endoscopy postoperatively on a routine basis to detect anastomotic leakage. In case of suspected anastomotic leakage, the most chosen diagnostic imaging modalities were computed tomography scan (35.7%) or dynamic swallow investigation (33.3%). Independent from the clinical manifestations, participants of this survey treat patients very differently. More than 70% of the responders agreed that there is a need for diagnostic and therapeutic international guidelines on anastomotic leakage management. CONCLUSIONS This survey shows that there is no standardized guideline for diagnostic workup or management of anastomotic leakage and that there is a need for an international guideline regarding the optimal management of anastomotic leakage.
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Affiliation(s)
- Eliza R C Hagens
- Department of Surgery, Academic Medical Center and Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Maarten C J Anderegg
- Department of Surgery, Academic Medical Center and Cancer Center Amsterdam, Amsterdam, The Netherlands
| | | | - Suzanne S Gisbertz
- Department of Surgery, Academic Medical Center and Cancer Center Amsterdam, Amsterdam, The Netherlands.
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Cuesta MA, van der Peet DL, Gisbertz SS, Straatman J. Mediastinal lymphadenectomy for esophageal cancer: Differences between two countries, Japan and the Netherlands. Ann Gastroenterol Surg 2018; 2:176-181. [PMID: 29863178 PMCID: PMC5980465 DOI: 10.1002/ags3.12172] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Accepted: 04/05/2018] [Indexed: 12/18/2022] Open
Abstract
Extent of mediastinal lymphadenectomy during esophagectomy is clearly different between two representative countries of the Eastern and Western world, such as Japan and the Netherlands. In Japan, a clear policy is the standard complete two- or three-field type of lymphadenectomy whereas, in the Netherlands, a limited form is usually carried out. Reasons for these differences can be found in the different types of tumor, 80% of adenocarcinomas in the West and almost 95% of squamous cell cancer in Japan. Moreover, location of the tumors, distally located in the Netherlands whereas, in Japan, the majority are located in the middle and proximal thoracic esophagus. Also, type of neoadjuvant therapy, namely chemoradiotherapy in the Netherlands, and chemotherapy in Japan, are different. Arguments for more extended mediastinal lymphadenectomy are currently challenged in the West, first by the systematic use of chemoradiotherapy as neoadjuvant therapy and, second, the retrospective analysis of large data. According to two studies, the importance of extended lymphadenectomy is shown to be relative and less clear, especially in esophageal adenocarcinomas after neoadjuvant therapy. International efforts such as the TIGER study will help to standardize and find a relationship between the type and location of esophageal cancer, use of neoadjuvant therapy, extent of lymphadenectomy and survival.
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Kang N, Zhang R, Ge W, Si P, Jiang M, Huang Y, Fang Y, Yao L, Wu K. Major complications of minimally invasive Ivor Lewis oesophagectomy using the purse string-stapled anastomotic technique in 215 patients with oesophageal carcinoma. Interact Cardiovasc Thorac Surg 2018; 27:708-713. [PMID: 29718251 DOI: 10.1093/icvts/ivy124] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 03/21/2018] [Indexed: 01/07/2023] Open
Affiliation(s)
- Ningning Kang
- Department of Thoracic Surgery, 1st Affiliated Hospital of Anhui Medical University, Hefei City, China
| | - Renquan Zhang
- Department of Thoracic Surgery, 1st Affiliated Hospital of Anhui Medical University, Hefei City, China
| | - Wei Ge
- Department of Thoracic Surgery, 1st Affiliated Hospital of Anhui Medical University, Hefei City, China
| | - Panpan Si
- Department of Thoracic Surgery, 1st Affiliated Hospital of Anhui Medical University, Hefei City, China
| | - Menglong Jiang
- Department of Thoracic Surgery, 1st Affiliated Hospital of Anhui Medical University, Hefei City, China
| | - Yunlong Huang
- Department of Thoracic Surgery, 1st Affiliated Hospital of Anhui Medical University, Hefei City, China
| | - Yanxin Fang
- Department of Thoracic Surgery, 1st Affiliated Hospital of Anhui Medical University, Hefei City, China
| | - Long Yao
- Department of Thoracic Surgery, 1st Affiliated Hospital of Anhui Medical University, Hefei City, China
| | - Kaiming Wu
- Department of Thoracic Surgery, 1st Affiliated Hospital of Anhui Medical University, Hefei City, China
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Guerra F, Vegni A, Gia E, Amore Bonapasta S, Di Marino M, Annecchiarico M, Coratti A. Early experience with totally robotic esophagectomy for malignancy. Surgical and oncological outcomes. Int J Med Robot 2018; 14:e1902. [PMID: 29508541 DOI: 10.1002/rcs.1902] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2017] [Revised: 12/22/2017] [Accepted: 01/18/2018] [Indexed: 12/18/2022]
Affiliation(s)
- Francesco Guerra
- Division of Oncological and Robotic General Surgery; Careggi University Hospital; Florence Italy
| | - Alessandra Vegni
- Division of Oncological and Robotic General Surgery; Careggi University Hospital; Florence Italy
| | - Elena Gia
- Division of Oncological and Robotic General Surgery; Careggi University Hospital; Florence Italy
| | - Stefano Amore Bonapasta
- Division of Oncological and Robotic General Surgery; Careggi University Hospital; Florence Italy
| | - Michele Di Marino
- Division of Oncological and Robotic General Surgery; Careggi University Hospital; Florence Italy
| | - Mario Annecchiarico
- Division of Oncological and Robotic General Surgery; Careggi University Hospital; Florence Italy
| | - Andrea Coratti
- Division of Oncological and Robotic General Surgery; Careggi University Hospital; Florence Italy
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Chang T, Hsiao PN, Tsai MY, Huang PM, Cheng YJ. Perioperative management and outcomes of minimally invasive esophagectomy: case study of a high-volume tertiary center in Taiwan. J Thorac Dis 2018; 10:1670-1676. [PMID: 29707319 DOI: 10.21037/jtd.2018.01.147] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Mortality and complication rates for surgical esophagectomy remain high despite progress in surgical techniques and perioperative care. Minimally invasive surgery and intraoperative goal-directed fluid management are gaining popularity in Taiwan; however, perioperative complications and short-term outcomes have been rarely reported. In this retrospective study, we analyzed the surgical procedures performed as well as the perioperative outcomes and treatments after esophagectomy in a high-volume medical center in Taiwan. The goals of this study are to compare the complications and the following treatment between different surgical procedures and to analyze if any preoperative coexisting disease and anesthesia conduct might be associated with postoperative complications and hospitalization course. Methods We retrospectively reviewed the data of all patients who had undergone esophagectomy and reconstruction in 2015. Patient characteristics, type of surgery performed, method of anesthesia, postoperative hospitalization course, and additional surgical interventions were reviewed and analyzed. Results In total, 64 patients were included. Among them, 58 patients (90.6%) were reported squamous cell carcinoma, 33 patients (51.6%) received McKeown minimally invasive esophagectomy (MIE), and 20 (31.3%) received Ivor-Lewis MIE. The most common postoperative complications were pulmonary complications (18.7%), such as empyema and pleural effusion, dysrhythmias (14.1%), anastomosis leakage (14.1%), vocal cord paralysis (9.4%), gastric tube stenosis (4.7%), chyle leakage (4.7%), and acute kidney injury (AKI, 4.7%). Twenty-five percent of patients received secondary operative interventions for the aforementioned complications. Postoperative arrhythmia (P=0.042), pulmonary complications (P=0.009), and AKI (P=0.015) were significantly associated with prolonged intensive care unit (ICU) stays. Thirty-day and 90-day mortality rates were 3.1% and 4.7% respectively. Patients with preoperative arrhythmias have a higher risk of developing post-operative dysrhythmia (P=0.013) and lung complications (P=0.036). Patients with an underlying heart disease are at higher risk of post-op AKI (P=0.002) and second surgical intervention (P=0.013). Chronic kidney diseases are associated with post-op dysrhythmia (P=0.013), lung complications (P=0.036) and post-op AKI (P≤0.01). Although McKeown MIE bore a significantly longer surgical time and higher intraoperatively-infused crystalloid than did Ivor Lewis MIE, there were no significant differences regarding postoperative cardiothoracic complications and patient outcomes. Conclusions Postoperative outcomes of McKeown MIE and Ivor-Lewis MIE were comparable in our center and short term outcomes were similar to those in previous reports. However, despite neoadjuvant concurrent chemoradiation therapy (CCRT), the use of minimally invasive techniques, and well-controlled anesthesia, the incidence of perioperative complications remains high. Our results suggest that patients with preoperative comorbidity of arrhythmia, heart diseases, and CKD are associated with more common post-operative complications. Furthermore, postoperative dysrhythmias, pulmonary complications, and AKI warrant special anesthetic and surgical care to prevent prolonged ICU stay.
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Affiliation(s)
- Tzu Chang
- Department of Anesthesiology, National Taiwan University Hospital, Taipei
| | - Po-Ni Hsiao
- Department of Anesthesiology, National Taiwan University Hospital, Taipei
| | - Man-Yin Tsai
- Department of Anesthesiology, National Taiwan University Hospital, Taipei
| | - Pei-Ming Huang
- Department of Surgery, National Taiwan University Hospital, Taipei
| | - Ya-Jung Cheng
- Department of Anesthesiology, National Taiwan University Hospital, Taipei
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Jezerskyte E, van Berge Henegouwen MI, Cuesta MA, Gisbertz SS. Gastro-esophageal junction cancers: what is the best minimally invasive approach? J Thorac Dis 2017; 9:S751-S760. [PMID: 28815071 DOI: 10.21037/jtd.2017.06.56] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The short-term advantages of minimally invasive esophagectomy (MIE) in terms of less morbidity and better quality of life (QoL) in comparison with open esophagectomy (OE) became visible in the last few years. There are two main MIE approaches: a transthoracic esophagectomy (TTE) (either accompanied by an intrathoracic or cervical anastomosis) or a transhiatal esophagectomy (THE) (accompanied by a cervical anastomosis). Additionally, minimally invasive gastrectomy is increasingly gaining popularity over open gastrectomy. Controversy still exists about what approach is the best for esophagogastric junction tumors (EGJ) and the choice of the approach is currently based on the surgeons' discretion. In this study, we describe the definition, staging and classification, indications for each minimally invasive approach for EGJ tumors, the surgical technique, current developments and problems regarding surgical treatment for patients with cancer of the EGJ.
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Affiliation(s)
- Egle Jezerskyte
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | | | - Miguel A Cuesta
- Department of Surgery, VU University Medical Center, Amsterdam, The Netherlands
| | - Suzanne S Gisbertz
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
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Bonavina L, Asti E, Sironi A, Bernardi D, Aiolfi A. Hybrid and total minimally invasive esophagectomy: how I do it. J Thorac Dis 2017; 9:S761-S772. [PMID: 28815072 DOI: 10.21037/jtd.2017.06.55] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Esophagectomy is a major surgical procedure associated with a significant risk of morbidity and mortality. Minimally invasive esophagectomy is becoming the preferred approach because of the potential to limit surgical trauma, reduce respiratory complications, and promote earlier functional recovery. Various hybrid and total minimally invasive surgical techniques have been introduced in clinical practice over the past 20 years, and minimally invasive esophagectomy has been shown equivalent to open surgery concerning the short-term outcomes. Implementation of a minimally invasive esophagectomy program is technically demanding and requires a significant learning curve and the infrastructure of a dedicated multidisciplinary center where optimal staging, individualized therapy, and perioperative care can be provided to the patient. Both hybrid and total minimally invasive techniques of esophagectomy have proven safe and effective in expert centers. The choice of the surgical approach should be driven by preoperative staging, tumor site and histology, comorbidity, patient's anatomy and physiological status, and surgeon's experience.
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Affiliation(s)
- Luigi Bonavina
- Division of General Surgery, Department of Biomedical Sciences for Health, University of Milan, IRCCS Policlinico San Donato, Milan, Italy
| | - Emanuele Asti
- Division of General Surgery, Department of Biomedical Sciences for Health, University of Milan, IRCCS Policlinico San Donato, Milan, Italy
| | - Andrea Sironi
- Division of General Surgery, Department of Biomedical Sciences for Health, University of Milan, IRCCS Policlinico San Donato, Milan, Italy
| | - Daniele Bernardi
- Division of General Surgery, Department of Biomedical Sciences for Health, University of Milan, IRCCS Policlinico San Donato, Milan, Italy
| | - Alberto Aiolfi
- Division of General Surgery, Department of Biomedical Sciences for Health, University of Milan, IRCCS Policlinico San Donato, Milan, Italy
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Brown AM, Pucci MJ, Berger AC, Tatarian T, Evans NR, Rosato EL, Palazzo F. A standardized comparison of peri-operative complications after minimally invasive esophagectomy: Ivor Lewis versus McKeown. Surg Endosc 2017. [PMID: 28643075 DOI: 10.1007/s00464-017-5660-4] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND While our institutional approach to esophageal resection for cancer has traditionally favored a minimally invasive (MI) 3-hole, McKeown esophagectomy (MIE 3-hole) during the last five years several factors has determined a shift in our practice with an increasing number of minimally invasive Ivor Lewis (MIE IL) resections being performed. We compared peri-operative outcomes of the two procedures, hypothesizing that MIE IL would be less morbid in the peri-operative setting compared to MIE 3-hole. METHODS Our institution's IRB-approved esophageal database was queried to identify all patients who underwent totally MI esophagectomy (MIE IL vs. MIE 3-hole) from June 2011 to May 2016. Patient demographics, preoperative and peri-operative data, as well as post-operative complications were compared between the two groups. Post-operative complications were analyzed using the Clavien-Dindo classification system. RESULTS There were 110 patients who underwent totally MI esophagectomy (MIE IL n = 49 [45%], MIE 3-hole n = 61 [55%]). The majority of patients were men (n = 91, 83%) with a median age of 62.5 (range 31-83). Preoperative risk stratifiers such as ECOG score, ASA, and Charlson Comorbidity Index were not significantly different between groups. Anastomotic leak rate was 2.0% in the MIE IL group compared to 6.6% in the MIE 3-hole group (p = 0.379). The rate of serious (Clavien-Dindo 3, 4, or 5) post-operative complications was significantly less in the MIE IL group (34.7 vs. 59.0%, p = 0.013). Serious pulmonary complications were not significantly different (16.3 vs. 26.2%, p = 0.251) between the two groups. CONCLUSIONS In this cohort, totally MIE IL showed significantly less severe peri-operative morbidity than MIE 3-hole, but similar rates of serious pulmonary complications and anastomotic leaks. These findings confirm the safety of minimally invasive Ivor Lewis esophagectomies for esophageal cancer when oncologically and clinically appropriate. Minimally invasive McKeown esophagectomy remains a satisfactory and appropriate option when clinically indicated.
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Affiliation(s)
- Andrew M Brown
- Department of Surgery, Thomas Jefferson University Hospital, 1100 Walnut St. 5th Floor, Philadelphia, PA, 19107, USA
| | - Michael J Pucci
- Department of Surgery, Thomas Jefferson University Hospital, 1100 Walnut St. 5th Floor, Philadelphia, PA, 19107, USA
| | - Adam C Berger
- Department of Surgery, Thomas Jefferson University Hospital, 1100 Walnut St. 5th Floor, Philadelphia, PA, 19107, USA
| | - Talar Tatarian
- Department of Surgery, Thomas Jefferson University Hospital, 1100 Walnut St. 5th Floor, Philadelphia, PA, 19107, USA
| | - Nathaniel R Evans
- Department of Surgery, Thomas Jefferson University Hospital, 1100 Walnut St. 5th Floor, Philadelphia, PA, 19107, USA
| | - Ernest L Rosato
- Department of Surgery, Thomas Jefferson University Hospital, 1100 Walnut St. 5th Floor, Philadelphia, PA, 19107, USA
| | - Francesco Palazzo
- Department of Surgery, Thomas Jefferson University Hospital, 1100 Walnut St. 5th Floor, Philadelphia, PA, 19107, USA.
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