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Niu L, Hu B, Zhang L, Kang M. Risk factors for postoperative recurrence of pT2-3N0M0 esophageal squamous cell carcinoma and patterns of its recurrence. Biosci Trends 2024; 17:475-483. [PMID: 38123336 DOI: 10.5582/bst.2023.01294] [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] [Indexed: 12/23/2023]
Abstract
This study aimed to explore the patterns of postoperative recurrence in patients with pT2-3N0M0 esophageal squamous cell carcinoma (ESCC) and to identify the risk factors for the recurrence. Patients with pT2-3N0M0 ESCC who were treated at our hospital from January 2010 to August 2019 were divided into three categories: those with anastomotic recurrence, those with lymph node recurrence, and those with hematogenous metastasis. The sites of initial recurrence and metastasis were counted and potential risk factors were analyzed using univariate and multivariate Cox proportional hazard regression. Four hundred and eighty-five patients with pT2-3N0M0 ESCC were ultimately included, 176 (36.29%) of whom experienced tumor recurrence or metastasis. Cox multivariate analysis revealed that the postoperative T-stage, procedure, tumor location, and degree of differentiation were independent risk factors for postoperative recurrence (P < 0.05). The median time of recurrence was 38 months, and the most common site of recurrence was the lymph nodes in 126 patients (71.59%), followed by hematogenous metastasis in 73 patients (41.47%), and anastomotic recurrence in 21 patients (11.93%). 119 patients (67.61%) experienced recurrence within 36 months, with a probability of recurrence of 84.09% within 5 years, and recurrence remained relatively unchanged after 5 years. The proportion of postoperative lymph node recurrence and hematogenous metastasis in patients with pT3N0M0 ESCC was significantly higher than that in patients with pT2N0M0 ESCC (P < 0.05). At higher tumor locations in the body, the proportion of lymph node recurrence increased (P < 0.05). In conclusion, postoperative T-stage, procedure, tumor location, and degree of differentiation were independent risk factors for postoperative recurrence in pT2-3N0M0 ESCC, with regional lymph node recurrence being the most common pattern, emphasizing the importance of regional lymph nodes in this context.
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Affiliation(s)
- Li Niu
- Department of Radiation Oncology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Bo Hu
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Li Zhang
- Department of Radiation Oncology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Mei Kang
- Department of Radiation Oncology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
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2
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Joosten JJ, Slooter MD, van den Elzen RM, Bloemen PR, Gisbertz SS, Eshuis WJ, Daams F, de Bruin DM, van Berge Henegouwen MI. Perfusion assessment by fluorescence time curves in esophagectomy with gastric conduit reconstruction: a prospective clinical study. Surg Endosc 2023:10.1007/s00464-023-10107-9. [PMID: 37208482 PMCID: PMC10338581 DOI: 10.1007/s00464-023-10107-9] [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: 01/18/2023] [Accepted: 04/30/2023] [Indexed: 05/21/2023]
Abstract
BACKGROUND Intraoperative perfusion assessment with indocyanine green fluorescence angiography (ICG-FA) may reduce postoperative anastomotic leakage rates after esophagectomy with gastric conduit reconstruction. This study evaluated quantitative parameters derived from fluorescence time curves to determine a threshold for adequate perfusion and predict postoperative anastomotic complications. METHODS This prospective cohort study included consecutive patients who underwent FA-guided esophagectomy with gastric conduit reconstruction between August 2020 and February 2022. After intravenous bolus injection of 0.05-mg/kg ICG, fluorescence intensity was registered over time by PINPOINT camera (Stryker, USA). Fluorescent angiograms were quantitatively analyzed at a region of interest of 1 cm diameter at the anastomotic site on the conduit using tailor-made software. Extracted fluorescence parameters were both inflow (T0, Tmax, Fmax, slope, Time-to-peak) as outflow parameters (T90% and T80%). Anastomotic complications including anastomotic leakage (AL) and strictures were documented. Fluorescence parameters in patients with AL were compared to those without AL. RESULTS One hundred and three patients (81 male, 65.7 ± 9.9 years) were included, the majority of whom (88%) underwent an Ivor Lewis procedure. AL occurred in 19% of patients (n = 20/103). Both time to peak as Tmax were significantly longer for the AL group in comparison to the non-AL group (39 s vs. 26 s, p = 0.04 and 65 vs. 51 s, p = 0.03, respectively). Slope was 1.0 (IQR 0.3-2.5) and 1.7 (IQR 1.0-3.0) for the AL and non-AL group (p = 0.11). Outflow was longer in the AL group, although not significantly, T90% 30 versus 15 s, respectively, p = 0.20). Univariate analysis indicated that Tmax might be predictive for AL, although not reaching significance (p = 0.10, area under the curve 0.71) and a cut-off value of 97 s was derived, with a specificity of 92%. CONCLUSION This study demonstrated quantitative parameters and identified a fluorescent threshold which could be used for intraoperative decision-making and to identify high-risk patients for anastomotic leakage during esophagectomy with gastric conduit reconstruction. A significant predictive value remains to be determined in future studies.
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Affiliation(s)
- J J Joosten
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
| | - M D Slooter
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
| | - R M van den Elzen
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
- Department of Biomedical Engineering, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - P R Bloemen
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
- Department of Biomedical Engineering, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - S S Gisbertz
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
| | - W J Eshuis
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
| | - F Daams
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - D M de Bruin
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
- Department of Biomedical Engineering, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - M I van Berge Henegouwen
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands.
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Feenstra ML, Alkemade L, van den Bergh JE, Gisbertz SS, Daams F, van Berge Henegouwen MI, Eshuis WJ. Contrast-Enhanced Radiologic Evaluation of Gastric Conduit Emptying After Esophagectomy. Ann Surg Oncol 2023; 30:563-570. [PMID: 36210402 PMCID: PMC9726779 DOI: 10.1245/s10434-022-12596-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 08/22/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Nasogastric tube (NGT) insertion is the standard of care in many hospitals after esophagectomy for gastric conduit decompression. An upper gastrointestinal contrast passage evaluation (UGI-CE) is a diagnostic test to evaluate passage through the gastric conduit. The authors hypothesized that introducing routine UGI-CE after esophagectomy results in earlier removal of the NGT and resumption of oral intake. METHODS This retrospective study evaluated two consecutive series of patients undergoing esophagectomy, one before (control group) and one after the introduction of a routine UGI-CE on postoperative day (POD) 3 or 4 (UGI-CE group). If contrast passage was found on the UGI-CE, the NGT was capped and removed. In the control group, the NGT was routinely capped and removed on day 5 after surgery. The primary outcome was the POD on which oral diet was initiated. The secondary outcomes were the day of NGT removal, NGT reinsertions, postoperative complications, and length of hospital stay. RESULTS Each cohort included 74 patients. In the UGI-CE group, the contrast test was performed on median POD 3.5 (IQR, 3-4). The median day of NGT removal, initiation of clear liquids, and full liquid and solid intake was 1 to 2 days earlier in the UGI-CE group than in the control group (i.e. POD 4, 4, 5, and 6 vs. POD 5, 5, 6.5, and 8; all p < 0.001). The study found no significant differences in NGT reinsertions, pneumonias, anastomotic leakages, or hospital stay. CONCLUSION The routine use of a UGI-CE after esophagectomy led to earlier removal of the NGT and earlier resumption of oral intake.
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Affiliation(s)
- Minke L. Feenstra
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands ,Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands ,Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - Lily Alkemade
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Janneke E. van den Bergh
- Radiology and Nuclear Medicine, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Suzanne S. Gisbertz
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands ,Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands ,Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - Freek Daams
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands ,Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands ,Department of Surgery, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Mark I. van Berge Henegouwen
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands ,Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands ,Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - Wietse J. Eshuis
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands ,Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands ,Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
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Hardy NP, Joosten JJ, Dalli J, Hompes R, Cahill RA, van Berge Henegouwen MI. Evaluation of inter-user variability in indocyanine green fluorescence angiography to assess gastric conduit perfusion in esophageal cancer surgery. Dis Esophagus 2022; 35:6568917. [PMID: 35428892 DOI: 10.1093/dote/doac016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 02/21/2022] [Accepted: 02/14/2022] [Indexed: 02/07/2023]
Abstract
Indocyanine Green Fluorescence Angiography (ICGFA) has been deployed to tackle malperfusion-related anastomotic complications. This study assesses variations in operator interpretation of pre-anastomotic ICGFA inflow in the gastric conduit. Utilizing an innovative online interactive multimedia platform (Mindstamp), esophageal surgeons completed a baseline opinion-practice questionnaire and proceeded to interpret, and then digitally assign, a distal transection point on 8 ICGFA videos of esophageal resections (6 Ivor Lewis, 2 McKeown). Annotations regarding gastric conduit transection by ICGFA were compared between expert users versus non-expert participants using ImageJ to delineate longitudinal distances with Shapiro Wilk and t-tests to ascertain significance. Expert versus non-expert correlation was assessed via Intraclass Correlation Coefficients (ICC). Thirty participants (13 consultants, 6 ICGFA experts) completed the study in all aspects. Of these, a high majority (29 participants) stated ICGFA should be used routinely with most (21, including 5/6 experts) stating that 11-50 cases were needed for competency in interpretation. Among users, there were wide variations in dosing (0.05-3 mg/kg) and practice impact. Agreement regarding ICGFA video interpretation concerning transection level among experts was 'moderate' (ICC = 0.717) overall but 'good' (ICC = 0.871) among seven videos with Leave One Out (LOO) exclusion of the video with highest disagreement. Agreement among non-experts was moderate (ICC = 0.641) overall and in every subgroup including among consultants (ICC = 0.626). Experts choose levels that preserved more gastric conduit length versus non-experts in all but one video (P = 0.02). Considerable variability exists with ICGFA interpretation and indeed impact. Even adept users may be challenged in specific cases. Standardized training and/or computerized quantitative fluorescence may help better usage.
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Affiliation(s)
- Niall P Hardy
- UCD Centre for Precision Surgery, University College Dublin, Dublin, Ireland
| | - Johanna J Joosten
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Jeffrey Dalli
- UCD Centre for Precision Surgery, University College Dublin, Dublin, Ireland
| | - Roel Hompes
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Ronan A Cahill
- UCD Centre for Precision Surgery, University College Dublin, Dublin, Ireland.,Department of Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Mark I van Berge Henegouwen
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
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Slaman AE, Eshuis WJ, van Berge Henegouwen MI, Gisbertz SS. Improved anastomotic leakage rates after the "flap and wrap" reconstruction in Ivor Lewis esophagectomy for cancer. Dis Esophagus 2022; 36:6611911. [PMID: 35724430 PMCID: PMC9817821 DOI: 10.1093/dote/doac036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 04/29/2022] [Indexed: 01/11/2023]
Abstract
Anastomotic leakage after esophagectomy has serious consequences. In Ivor Lewis esophagectomy, a shorter and possibly better vascularized gastric conduit is created than in McKeown esophagectomy. Intrathoracic anastomoses can additionally be wrapped in omentum and concealed behind the pleura ("flap and wrap" reconstruction). Aims of this observational study were to assess the anastomotic leakage incidence after transhiatal esophagectomy (THE), McKeown esophagectomy (McKeown), Ivor Lewis esophagectomy (IL) without "flap and wrap" reconstruction, and IL with "flap and wrap" reconstruction. Consecutive patients undergoing esophagectomy at a tertiary referral center between January 2013 and April 2019 were included. Primary outcome was the anastomotic leakage rate. Secondary outcomes were postoperative outcomes, mortality, and 3-year overall survival. A total of 463 patients were included. The anastomotic leakage incidence after THE (n = 37), McKeown (n = 97), IL without "flap and wrap" reconstruction (n = 39), and IL with "flap and wrap" reconstruction (n = 290) were 24.3, 32.0, 28.2, and 7.2% (P < 0.001). THE and IL with "flap and wrap" reconstruction required fewer reoperations for anastomotic leakage (0 and 1.4%) than McKeown and IL without "flap and wrap" reconstruction (6.2 and 17.9%, P < 0.001). Fewer anastomotic leakages are observed after Ivor Lewis esophagectomy with "flap and wrap" reconstruction compared to transhiatal, McKeown and Ivor Lewis esophagectomy without "flap and wrap" reconstruction. The "flap and wrap" reconstruction seems a promising technique to further reduce anastomotic leakages and its severity in esophageal cancer patients who have an indication for Ivor Lewis esophagectomy.
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Affiliation(s)
- Annelijn E Slaman
- Department of Surgery, Amsterdam UMC location AMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Wietse J Eshuis
- Department of Surgery, Amsterdam UMC location AMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Mark I van Berge Henegouwen
- Department of Surgery, Amsterdam UMC location AMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Suzanne S Gisbertz
- Address correspondence to: Dr S.S. Gisbertz, Department of Surgery, Amsterdam UMC location AMC, University of Amsterdam, Cancer Center Amsterdam, Meibergdreef 9, Amsterdam, AZ 1105, the Netherlands.
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Xie J, Zhang L, Liu Z, Lu CL, Xu GH, Guo M, Lian X, Liu JQ, Zhang HW, Zheng SY. Advantages of McKeown minimally invasive oesophagectomy for the treatment of oesophageal cancer: propensity score matching analysis of 169 cases. World J Surg Oncol 2022; 20:52. [PMID: 35216598 PMCID: PMC8881864 DOI: 10.1186/s12957-022-02527-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 02/18/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Oesophagectomy, the gold standard for oesophageal cancer treatment, causes significantly high morbidity and mortality. McKeown minimally invasive oesophagectomy (MIE) is preferred for treating oesophageal malignancies; however, limited studies with large sample sizes focusing on the surgical and oncological outcomes of this procedure have been reported. We aimed to compare the clinical safety and efficacy of McKeown MIE with those of open oesophagectomy (OE). PATIENTS AND METHODS Overall, 338 oesophageal cancer patients matched by gender, age, location, size, and T and N stages (McKeown MIE: 169 vs OE: 169) were analysed. The clinicopathologic features, operational factors, postoperative complications, and prognoses were compared between the groups. RESULTS McKeown MIE resulted in less bleeding (200 mL vs 300 mL, p<0.01), longer operation time (335.0 h vs 240.0 h, p<0.01), and higher number of harvested lymph nodes (22 vs 9, p<0.01) than OE did. Although the rate of recurrent laryngeal nerve injury in the two groups was not significantly different, incidence of anastomotic leakage (8 vs 24, p=0.003) was significantly lower in the McKeown MIE group. In addition, patients who underwent McKeown MIE had higher 5-year overall survival than those who underwent OE (69.9% vs 40.4%, p<0.001). CONCLUSION McKeown MIE is proved to be feasible and safe to achieve better surgical and oncological outcomes for oesophageal cancer compared with OE.
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Affiliation(s)
- Jun Xie
- Department of Thoracic Surgery, The First Affiliated Hospital of Soochow University, Shizi Street No. 188, Suzhou, 215006, Jiangsu, China
| | - Lei Zhang
- The Key Laboratory of Biomedical Information Engineering of Ministry of Education, School of Life Science and Technology, Xi'an Jiaotong University, Xi'an, Shanxi Province, China
| | - Zhen Liu
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China
| | - Chun-Lei Lu
- Digestive Diseases Center of Wuxi Mingci Hospital, No. 599 Zhongnan Road, Jinxing Street, Wuxi City, 214000, Jiangsu Province, China
| | - Guang-Hui Xu
- Department of General Surgery, Xijing Hospital of Digestive Diseases, The Fourth Military Medical University, Xi'an, 710033, Shan Xi Province, China
| | - Man Guo
- Department of General Surgery, Xijing Hospital of Digestive Diseases, The Fourth Military Medical University, Xi'an, 710033, Shan Xi Province, China
| | - Xiao Lian
- Department of General Surgery, Xijing Hospital of Digestive Diseases, The Fourth Military Medical University, Xi'an, 710033, Shan Xi Province, China
| | - Jin-Qiang Liu
- Department of General Surgery, Xijing Hospital of Digestive Diseases, The Fourth Military Medical University, Xi'an, 710033, Shan Xi Province, China
| | - Hong-Wei Zhang
- Digestive Diseases Center of Wuxi Mingci Hospital, No. 599 Zhongnan Road, Jinxing Street, Wuxi City, 214000, Jiangsu Province, China.
| | - Shi-Ying Zheng
- Department of Thoracic Surgery, The First Affiliated Hospital of Soochow University, Shizi Street No. 188, Suzhou, 215006, Jiangsu, China.
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7
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Feenstra ML, Ten Hoope W, Hermanides J, Gisbertz SS, Hollmann MW, van Berge Henegouwen MI, Eshuis WJ. Optimal Perioperative Pain Management in Esophageal Surgery: An Evaluation of Paravertebral Analgesia. Ann Surg Oncol 2021; 28:6321-6328. [PMID: 34050429 PMCID: PMC8460583 DOI: 10.1245/s10434-021-10172-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 04/01/2021] [Indexed: 11/18/2022]
Abstract
Background For esophagectomy, thoracic epidural analgesia (TEA) is the standard of care for perioperative pain management. Although effective, TEA is associated with moderate to serious adverse events such as hypotension and neurologic complications. Paravertebral analgesia (PVA) may be a safe alternative. The authors hypothesized that TEA and PVA are similar in efficacy for pain treatment in thoracolaparoscopic Ivor Lewis esophagectomy. Methods This retrospective cohort study compared TEA with PVA in two consecutive series of 25 thoracolaparoscopic Ivor Lewis esophagectomies. In this study, TEA consisted of continuous epidural bupivacaine and sufentanil infusion with a patient-controlled bolus function. In PVA, the catheter was inserted by the surgeon under thoracoscopic vision during surgery. Administration of PVA consisted of continuous paravertebral bupivacaine infusion after a bolus combined with patient-controlled analgesia using intravenous morphine. The primary outcome was the median highest recorded Numeric Pain Rating Scale (NRS) during the 3 days after surgery. The secondary outcomes were vasopressor consumption, fluid administration, and length of hospital stay. Results In both groups, the median highest recorded NRS was 4 or lower during the first three postoperative days. The patients with PVA had a higher overall NRS (mean difference, 0.75; 95% confidence interval 0.49–1.44). No differences were observed in any of the other secondary outcomes. Conclusion For the patients undergoing thoracolaparoscopic Ivor Lewis esophagectomy, TEA was superior to PVA, as measured by NRS during the first three postoperative days. However, both modes provided adequate analgesia, with a median highest recorded NRS of 4 or lower. These results could form the basis for a randomized controlled trial. Supplementary Information The online version contains supplementary material available at 10.1245/s10434-021-10172-1.
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Affiliation(s)
- Minke L Feenstra
- Department of Surgery, Amsterdam University Medical Centers, Location AMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands.,Department of Anesthesiology, Amsterdam University Medical Centers, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Werner Ten Hoope
- Department of Anesthesiology, Amsterdam University Medical Centers, Location AMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Anesthesiology, Rijnstate Hospital, Arnhem, The Netherlands
| | - Jeroen Hermanides
- Department of Anesthesiology, Amsterdam University Medical Centers, Location AMC, University of Amsterdam, Amsterdam, The Netherlands.
| | - Suzanne S Gisbertz
- Department of Surgery, Amsterdam University Medical Centers, Location AMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Markus W Hollmann
- Department of Anesthesiology, Amsterdam University Medical Centers, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Mark I van Berge Henegouwen
- Department of Surgery, Amsterdam University Medical Centers, Location AMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Wietse J Eshuis
- Department of Surgery, Amsterdam University Medical Centers, Location AMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
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8
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Slooter MD, de Bruin DM, Eshuis WJ, Veelo DP, van Dieren S, Gisbertz SS, van Berge Henegouwen MI. Quantitative fluorescence-guided perfusion assessment of the gastric conduit to predict anastomotic complications after esophagectomy. Dis Esophagus 2020; 34:5917378. [PMID: 33016305 PMCID: PMC8141822 DOI: 10.1093/dote/doaa100] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Fluorescence angiography (FA) assesses anastomotic perfusion during esophagectomy with gastric conduit reconstruction, but its interpretation is subjective. This study evaluated time to fluorescent enhancement in the gastric conduit, with the aim to determine a threshold to predict postoperative anastomotic complications. METHODS In a prospective cohort study, all consecutive patients undergoing esophagectomy with gastric conduit reconstruction from July 2018 to October 2019 were included. FA was performed before anastomotic reconstruction following injection of indocyanine green (ICG). During FA, the following time points were recorded: ICG injection, first fluorescent enhancement in the lung, at the base of the gastric conduit, at the planned anastomotic site, and at ICG watershed or in the tip of the gastric conduit. Anastomotic complications including anastomotic leakage and clinically relevant strictures were documented. RESULTS Eighty-four patients were included, the majority (67 out of 84, 80%) of which underwent an Ivor Lewis procedure. After a median follow-up of 297 days, anastomotic leakage was observed in 12 out of 84 (14.3%) and anastomotic stricture in 12 out of 82 (14.6%). Time between ICG injection and enhancement in the tip was predictive for anastomotic leakage (P = 0.174, area under the curve = 0.731), and a cut-off value of 98 seconds was derived (specificity: 98%). All times to enhancement at the planned anastomotic site and ICG watershed were significantly predictive for the occurrence of a stricture, however area under the curves were <0.7. CONCLUSIONS The identified fluorescent threshold can be used for intraoperative decision making or to identify potentially high-risk patients for anastomotic leakage after esophagectomy with gastric conduit reconstruction.
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Affiliation(s)
- M D Slooter
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - D M de Bruin
- Amsterdam UMC, University of Amsterdam, Department of Biomedical Engineering and Physics, Amsterdam, the Netherlands
| | - W J Eshuis
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - D P Veelo
- Amsterdam UMC, University of Amsterdam, Department of Anesthesiology, Amsterdam, the Netherlands
| | - S van Dieren
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - S S Gisbertz
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - M I van Berge Henegouwen
- Address correspondence to: Professor Dr M.I. van Berge Henegouwen, MD, PhD, surgeon, Department of Surgery, Amsterdam University Medical Centres (UMC), location Academic Medical Centre (AMC), Postbox 22660, 1100 DD Amsterdam, the Netherlands.
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9
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van Rijswijk AS, Hagens ERC, van der Peet DL, van Berge Henegouwen MI, Gisbertz SS. Differences in Esophageal Cancer Surgery in Terms of Surgical Approach and Extent of Lymphadenectomy: Findings of an International Survey. Ann Surg Oncol 2019; 26:2063-2072. [PMID: 30903323 PMCID: PMC6545175 DOI: 10.1245/s10434-019-07316-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Esophagectomy and lymphadenectomy are essential parts of the multimodal treatment of esophageal carcinoma with curative intent. Treatment regimens vary globally and are subject to debate. A global survey was designed to gain insight into current practice. METHODS Fifty-seven international expert upper gastrointestinal surgeons received a personal invitation to participate in the survey, which focused on demographics and experience; extent of lymphadenectomy in adeno and squamous cell carcinoma; use of classification systems; neoadjuvant therapy; surgical approach; and specimen handling. RESULTS The response rate was 88% (50/57 surgeons), with a mean age of 51.6 years and a median number of 15 years of experience in esophageal surgery. The variety in the extent of lymphadenectomy in proximal, middle and distal squamous cell carcinoma, and Siewert I, II and III adenocarcinoma, was considerable. The number of different combinations of lymph node (LN) stations that were resected in the same tumor was high, while the number of surgeons who removed the exact same combination of LN stations was low. Illustrative is Siewert I adenocarcinoma, in which 27 unique combinations of LN stations were resected, with a maximum of two surgeons performing the exact same dissection. Use of neoadjuvant therapy, surgical approach, and specimen handling also show great variety among participants. CONCLUSION There is no uniform, worldwide strategy for surgical treatment of esophageal cancer. The extent of lymphadenectomy shows great variation for both histologic types. An international observational study is needed to provide evidence on the distribution pattern of lymph node metastases in esophageal cancer and the necessary extent of lymphadenectomy.
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Affiliation(s)
- A S van Rijswijk
- Amsterdam UMC, Department of Surgery, Cancer Center Amsterdam, University of Amsterdam, Amsterdam, The Netherlands
| | - E R C Hagens
- Amsterdam UMC, Department of Surgery, Cancer Center Amsterdam, University of Amsterdam, Amsterdam, The Netherlands
| | - D L van der Peet
- Amsterdam UMC, Department of Surgery, Cancer Center Amsterdam, VU University Amsterdam, Amsterdam, The Netherlands
| | - M I van Berge Henegouwen
- Amsterdam UMC, Department of Surgery, Cancer Center Amsterdam, University of Amsterdam, Amsterdam, The Netherlands
| | - S S Gisbertz
- Amsterdam UMC, Department of Surgery, Cancer Center Amsterdam, University of Amsterdam, Amsterdam, The Netherlands.
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10
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Deng HY, Huang WX, Li G, Li SX, Luo J, Alai G, Wang Y, Liu LX, Lin YD. Comparison of short-term outcomes between robot-assisted minimally invasive esophagectomy and video-assisted minimally invasive esophagectomy in treating middle thoracic esophageal cancer. Dis Esophagus 2018. [PMID: 29538633 DOI: 10.1093/dote/doy012] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Whether the robot-assisted minimally invasive esophagectomy (RAMIE) has any advantages over the video-assisted minimally invasive esophagectomy (VAMIE) remains controversial. In this study, we tried to compare the short-term outcomes of RAMIE with that of VAMIE in treating middle thoracic esophageal cancer from a single medical center. Consecutive patients undergoing RAMIE or VAMIE for middle thoracic esophageal cancer from April 2016 to April 2017 were prospectively included for analysis. Baseline data and pathological findings as well as short-term outcomes of these two group (RAMIE group and VAMIE group) patients were collected and compared. A total of 84 patients (RAMIE group: 42 patients; VAMIE group: 42 patients) were included for analysis. The baseline characteristics between the two groups were comparable. RAMIE yielded significantly larger numbers of total dissected lymph nodes (21.9 and 17.8, respectively; P = 0.042) and the right recurrent laryngeal nerve (RLN) lymph nodes (2.1 and 1.2, respectively; P = 0.033) as well as abdominal lymph nodes (10.8 and 7.7, respectively; P = 0.041) than VAMIE. Even though RAMIE may consume more overall operation time, it could significantly decrease total blood loss compared to VAMIE (97 and 161 mL, respectively; P = 0.015). Postoperatively, no difference of the risk of major complications or hospital stay was observed between the two groups. In conclusion, RAMIE had significant advantage of lymphadenectomy especially for dissecting RLN lymph nodes over VAMIE with a comparable rate of postoperative complications. Further randomized controlled trials are badly needed to confirm and update our conclusions.
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Affiliation(s)
- H-Y Deng
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, China.,Lung Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - W-X Huang
- Department of Healthcare, West China Hospital, Sichuan University, Chengdu, China
| | - G Li
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - S-X Li
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - J Luo
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - G Alai
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Y Wang
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - L-X Liu
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Y-D Lin
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, China
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11
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Zhou X, Lu Z, Wang T, Huang Z, Zhu W, Miao Y. Plasma miRNAs in diagnosis and prognosis of pancreatic cancer: A miRNA expression analysis. Gene 2018; 673:181-193. [PMID: 29913239 DOI: 10.1016/j.gene.2018.06.037] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 06/12/2018] [Indexed: 02/06/2023]
Abstract
The differential expression of microRNAs (miRNAs) in plasma of pancreatic cancer (PC) patients may act as a diagnostic biomarker. A four-stage study was performed to identify plasma miRNAs with potential in detecting PC. Exiqon panels (20 PC vs. 10 normal controls (NCs)) were applied in the screening phase to obtain miRNA profiling. The identified miRNAs were further assessed in the training (40 PC vs. 40 NCs) and testing stages (112 PC vs. 116 NCs) with qRT-PCR assays. A six-miRNA signature including up-regulated miR-122-5p, miR-125b-5p, miR-192-5p, miR-193b-3p, miR-221-3p and miR-27b-3p was identified. The signature could accurately discriminate PC patients from NCs with areas under the receiver operating characteristic curve of 0.848, 0.833 and 0.937 for the training, testing and the external validation stage (41 PC vs. 50 NCs), respectively. The multivariate Cox regression analyses showed that down-regulated plasma miR-125b-5p could predict worse OS independent from late tumor stage and high CA19-9. All the six miRNAs except miR-122-5p showed high expression levels in PC tissues than those in matched normal tissues. MiR-122-5p and miR-193b-3p were up-regulated, while miR-221-3p was down-regulated in plasma exosomes from PC patients. Bioinformatics analysis demonstrated that the miRNAs might involve in several molecular pathways closely related with PC such as p53 signaling pathway, pancreatic cancer, TGF-beta signaling pathway and so on. In conclusion, we identified a six-miRNA signature in plasma which could act as a non-invasive biomarker in diagnosis and prognosis of PC. Plasma miR-125b-5p might act as an independent biomarker in predicting OS of PC patients.
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Affiliation(s)
- Xin Zhou
- Department of Oncology, First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing 210029, Jiangsu Province, PR China.
| | - Zipeng Lu
- Pancreas Center, First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing 210029, Jiangsu Province, PR China; Pancreas Institute, Nanjing Medical University, Nanjing 210029, Jiangsu Province, PR China
| | - Tongshan Wang
- Department of Oncology, First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing 210029, Jiangsu Province, PR China
| | - Zebo Huang
- Department of Oncology, The Affiliated Hospital of Jiangnan University, 200 Huihe Road, Wuxi 214062, Jiangsu Province, PR China
| | - Wei Zhu
- Department of Oncology, First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing 210029, Jiangsu Province, PR China.
| | - Yi Miao
- Pancreas Center, First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing 210029, Jiangsu Province, PR China; Pancreas Institute, Nanjing Medical University, Nanjing 210029, Jiangsu Province, PR China.
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12
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A six-microRNA signature in plasma was identified as a potential biomarker in diagnosis of esophageal squamous cell carcinoma. Oncotarget 2018; 8:34468-34480. [PMID: 28380431 PMCID: PMC5470983 DOI: 10.18632/oncotarget.16519] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 03/15/2017] [Indexed: 12/22/2022] Open
Abstract
The differential expression of microRNAs (miRNAs) in plasma of esophageal squamous cell carcinoma (ESCC) patients may serve as a diagnostic biomarker. A four-stage study was conducted to identify plasma miRNAs with potential in detecting ESCC. Exiqon panels (2 ESCC pools vs. 1 normal control (NC) pool) were applied in the screening phase to obtain miRNA profiles. The identified miRNAs were further evaluated through training (36 ESCC VS. 42 NCs) and testing stages (101 ESCC VS. 113 NCs) with qRT-PCR assays. A six-miRNA signature including up-regulated miR-106a, miR-18a, miR-20b, miR-486-5p, miR-584 and down-regulated miR-223-3p in ESCC was identified. The signature could accurately discriminate ESCC patients from NCs with areas under the receiver operating characteristic curve of 0.935, 0.959 and 0.966 for the training, testing and the additional validation stage (41 ESCC VS. 50 NCs), respectively. MiR-106a and miR-584 were significantly up-regulated in tumor tissues with qRT-PCR assays. And miR-584 was also up-regulated in ESCC tissues from TCGA database. In addition, exosomal miR-223-3p and miR-584 were consistently dysregulated with those in plasma and could also act as biomarkers in diagnosis of ESCC. In conclusion, we identified a six-miRNA signature in plasma which could act as a non-invasive biomarker in detection of ESCC.
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13
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Lagarde SM, Anderegg MCJ, Gisbertz SS, Meijer SL, Hulshof MCCM, Bergman JJGHM, van Laarhoven HWM, van Berge Henegouwen MI. Lymph node metastases near the celiac trunk should be considered separately from other nodal metastases in patients with cancer of the esophagus or gastroesophageal junction after neoadjuvant treatment and surgery. J Thorac Dis 2018; 10:1511-1521. [PMID: 29707301 DOI: 10.21037/jtd.2018.02.81] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background The aim of the present study is to identify the incidence and prognostic significance of lymph node metastases near the celiac trunk in patients who underwent neoadjuvant chemo(radio)therapy followed by esophagectomy. Methods Between March 1994 and September 2013 a total of 462 consecutive patients with cancer of the esophagus or gastroesophageal junction (GEJ) who underwent potentially curative esophageal resection after neoadjuvant chemotherapy (N=88; 19.0%) or neoadjuvant chemoradiotherapy (CRT) (N=374; 81.0%) were included. Results Seventy one (15.4%) patients had truncal node metastases in the resection specimen. Metastases to these nodes occurred more frequently in male patients with adenocarcinoma and in tumors at the gastro-esophageal junction. A lower response to neoadjuvant treatment, higher ypT and ypN stages and a poorer grade of differentiation were significantly related with truncal node metastases. Patients with tumor positive truncal nodes had a worse median overall survival (17 vs. 55 months). In multivariate analysis, truncal node metastases were independently associated with a worse survival. Only 22 (31.0%) of the 71 patients with tumor positive truncal nodes were identified preoperatively with EUS or CT. In contrast, 37 patients had suspicious truncal nodes on EUS or CT, but metastases in the pathology specimen were absent. Conclusions In the present study, it is demonstrated that positive truncal nodes in the resection specimen after neoadjuvant therapy, are associated with advanced tumor stages and are an independent factor for inferior survival.
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Affiliation(s)
- Sjoerd M Lagarde
- Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands
| | | | - Suzanne S Gisbertz
- Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands
| | - Sybren L Meijer
- Department of Pathology, Academic Medical Center, Amsterdam, the Netherlands
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Giacopuzzi S, Weindelmayer J, Treppiedi E, Bencivenga M, Ceola M, Priolo S, Carlini M, de Manzoni G. Enhanced recovery after surgery protocol in patients undergoing esophagectomy for cancer: a single center experience. Dis Esophagus 2017; 30:1-6. [PMID: 28375472 DOI: 10.1093/dote/dow024] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 11/16/2016] [Indexed: 12/11/2022]
Abstract
This article is about an emerging issue in esophageal surgery: enhanced recovery after surgery (ERAS) Few data are published in literature and its safety and feasibility is still debated. The focus of our paper is on the feasibility of an ERAS protocol for esophagectomy (including both the Ivor-Lewis and McKeown procedure) in a high volume center comparing to a standard perioperative protocol. We introduced a novelty item on this type of surgery: resume of oral feeding in the first postoperative day. We analyzed the dropout rate for each item and the postoperative morbidity. We studied 39 patients operated in the Upper GI division of Verona University Hospital between January 2013 and August 2014; 22 patients (ERAS group) were studied in a perspective way while 17 patients (standard group) were studied retrospectively. The enhanced recovery protocol included intraoperative fluid management, time of extubation after surgery, intensive care unit discharge, drains and nasogastric tube management, mobilization of the patient, oral food intake. We compared the results between the two groups in term of hospital stay, postoperative morbidity and mortality. We also calculated the percentage completion of the protocol, evaluating patient drop-out rates for each of the items. Patients showed an improvement in the ERAS group in terms of earlier extubation, earlier intensive care unit discharge (p < 0.01), earlier thoracic drain, urinary catheter (p < 0.01) and nasogastric tube removal (p = 0.02), earlier mobilization (p < 0.01), and resume of oral feeding (p < 0.01). Median length of hospital stays in the ERAS group was 9 days while in the standard group was 10 days (p = 0.23). Postoperative morbidity and mortality were comparable between the two groups. This study shows the feasibility and safety of an ERAS protocol for esophageal surgery in a high-volume center. These data strengthen the literature results on this argument calling for larger sample size studies.
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15
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Cai L, Li Y, Sun L, Yang XW, Wang WB, Feng F, Xu GH, Guo M, Lian X, Zhang HW. Better perioperative outcomes in thoracoscopic-esophagectomy with two-lung ventilation in semi-prone position. J Thorac Dis 2017; 9:117-122. [PMID: 28203413 DOI: 10.21037/jtd.2017.01.27] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND One-lung ventilation (OLV) anesthesia intubation route is often used in patients undergoing thoracoscopic-esophagectomy in semi-prone position. Recently, the two-lung ventilation (TLV) approach becomes popular. However, limited studies have compared the two ventilation approaches in parallel. Here, we report a single-center, retrospective study of comparing TLV and OLV approach in patients undergoing thoracoscopic-esophagectomy in semi-prone position. METHODS From January 2013 to November 2014, 147 patients were enrolled into the current study and were given thoracoscopic-esophagectomy in semi-prone position either by OLV or TLV. Intraoperative respiratory functional data and perioperative surgical parameters of the two approaches were collected and analyzed. RESULTS Of the 147 patients, 64 patients received OLV and 83 patients received TLV, and all of them were successfully under gone thoracoscopic procedures without conversion to open thoracotomy. There was no incidence of major intraoperative complications or perioperative death. There were no statistically different in postoperative respiratory complications, either. However, TLV approach resulted in better intraoperative respiratory function (PaCO2, PaO2, SaO2), shorter preparation time for anesthesia induction, less blood loss, shorter thoracoscopic operating time and less postoperative hospital stay (P<0.05). The incidence of postoperative respiratory complications and quantity of the resected thoracic lymph node showed no difference between the two ventilation approach (P>0.05). CONCLUSION This study demonstrated that TLV intubation approach is superior to OLV approach during the thoracoscopic-esophagectomy in semi-prone position. According to this, TLV approach is a technically feasible, convenient and safe anesthesia induction approach for esophageal cancer surgery.
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Affiliation(s)
- Lei Cai
- Division of Digestive Surgery, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Yan Li
- Department of Anesthesiology, Northwest Women's and Children's Hospital, Xi'an 710061, China
| | - Li Sun
- Division of Digestive Surgery, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Xue-Wen Yang
- Division of Digestive Surgery, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Wen-Bin Wang
- Division of Digestive Surgery, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Fan Feng
- Division of Digestive Surgery, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Guang-Hui Xu
- Division of Digestive Surgery, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Man Guo
- Division of Digestive Surgery, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Xiao Lian
- Division of Digestive Surgery, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Hong-Wei Zhang
- Division of Digestive Surgery, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
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16
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Complications, Not Minimally Invasive Surgical Technique, Are Associated with Increased Cost after Esophagectomy. Minim Invasive Surg 2016; 2016:7690632. [PMID: 28053785 PMCID: PMC5178372 DOI: 10.1155/2016/7690632] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Accepted: 11/14/2016] [Indexed: 12/02/2022] Open
Abstract
Background. Minimally invasive esophagectomy (MIE) techniques offer similar oncological and surgical outcomes to open methods. The effects of MIE on hospital costs are not well documented. Methods. We reviewed the electronic records of patients who underwent esophagectomy at a single academic institution between January 2012 and December 2014. Esophagectomy techniques were grouped into open, hybrid, MIE, and transhiatal (THE) esophagectomy. Univariate and multivariate analyses were performed to assess the impact of surgery on total hospital cost after esophagectomy. Results. 80 patients were identified: 11 THE, 11 open, 41 hybrid, and 17 MIE. Median total cost of the hospitalization was $31,375 and was similar between surgical technique groups. MIE was associated with higher intraoperative costs, but not total hospital cost. Multivariable analysis revealed that the presence of a complication, increased age, American Society of Anesthesiologists class IV (ASA4), and preoperative coronary artery disease (CAD) were associated with significantly increased cost. Conclusions. Despite the association of MIE with higher operation costs, the total hospital cost was not different between surgical technique groups. Postoperative complications and severe preoperative comorbidities are significant drivers of hospital cost associated with esophagectomy. Surgeons should choose technique based on clinical factors, rather than cost implications.
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17
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Zhang BY, Geng Q. Thoracoscopic-laparoscopic esophagectomy and enhanced recovery after surgery. Shijie Huaren Xiaohua Zazhi 2016; 24:4423-4429. [DOI: 10.11569/wcjd.v24.i33.4423] [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] [Indexed: 02/06/2023] Open
Abstract
Thoracoscopic-laparoscopic esophagectomy has already become a common procedure of minimally invasive esophagectomy. Enhanced recovery after surgery (ERAS) is a series of ways that use multidisciplinary care methods to minimize surgical stress and hasten recovery. ERAS has obvious advantages in decreasing postoperative complications, shortening postoperative hospital stay, reducing medical costs, and increasing the satisfaction of patients. Under the guidance of ERAS, thoracoscopic-laparoscopic esophagectomy combined with optimized measures taken in perioperative period will be the future development direction of esophagectomy.
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Flanagan JC, Batz R, Saboo SS, Nordeck SM, Abbara S, Kernstine K, Vasan V. Esophagectomy and Gastric Pull-through Procedures: Surgical Techniques, Imaging Features, and Potential Complications. Radiographics 2016; 36:107-21. [PMID: 26761533 DOI: 10.1148/rg.2016150126] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Esophagectomy takes the center stage in the curative treatment of local and local-regional esophageal cancer. It is a complex procedure with a high postoperative complication rate. When interpreting imaging studies, radiologists must understand the surgical techniques used and their potential complications. The most common surgical techniques are transthoracic esophagectomies, such as the Ivor Lewis and McKeown techniques, and transhiatal esophagectomy. Variations of these techniques include different choices of conduit (ie, stomach, colon, or jejunum) to serve in lieu of the resected esophagus. Postoperative imaging and accurate interpretation is vital in the aftercare of these patients. Chest radiographs, esophagrams, and computed tomographic images play an essential role in early identification of complications. Pulmonary complications and anastomotic leaks are the leading causes of postoperative morbidity and mortality secondary to esophagectomy. Other complications include technical and functional problems and delayed complications such as anastomotic strictures and disease recurrence. An esophagographic technique is described that is performed by using hand injection of contrast material into an indwelling nasogastric tube. Familiarity with the various types of esophagectomy and an understanding of possible complications are of utmost importance for radiologists and allow them to be key participants in the treatment of patients undergoing these complicated procedures.
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Affiliation(s)
- Jennifer C Flanagan
- From the Departments of Radiology (J.C.F., R.B., S.S.S., S.M.N., S.A., V.V.) and Surgery (K.K.), University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390; and University of Texas Southwestern Medical College, Dallas, Tex (S.M.N.)
| | - Richard Batz
- From the Departments of Radiology (J.C.F., R.B., S.S.S., S.M.N., S.A., V.V.) and Surgery (K.K.), University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390; and University of Texas Southwestern Medical College, Dallas, Tex (S.M.N.)
| | - Sachin S Saboo
- From the Departments of Radiology (J.C.F., R.B., S.S.S., S.M.N., S.A., V.V.) and Surgery (K.K.), University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390; and University of Texas Southwestern Medical College, Dallas, Tex (S.M.N.)
| | - Shaun M Nordeck
- From the Departments of Radiology (J.C.F., R.B., S.S.S., S.M.N., S.A., V.V.) and Surgery (K.K.), University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390; and University of Texas Southwestern Medical College, Dallas, Tex (S.M.N.)
| | - Suhny Abbara
- From the Departments of Radiology (J.C.F., R.B., S.S.S., S.M.N., S.A., V.V.) and Surgery (K.K.), University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390; and University of Texas Southwestern Medical College, Dallas, Tex (S.M.N.)
| | - Kemp Kernstine
- From the Departments of Radiology (J.C.F., R.B., S.S.S., S.M.N., S.A., V.V.) and Surgery (K.K.), University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390; and University of Texas Southwestern Medical College, Dallas, Tex (S.M.N.)
| | - Vasantha Vasan
- From the Departments of Radiology (J.C.F., R.B., S.S.S., S.M.N., S.A., V.V.) and Surgery (K.K.), University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390; and University of Texas Southwestern Medical College, Dallas, Tex (S.M.N.)
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Giugliano DN, Berger AC, Rosato EL, Palazzo F. Total minimally invasive esophagectomy for esophageal cancer: approaches and outcomes. Langenbecks Arch Surg 2016; 401:747-56. [PMID: 27401326 DOI: 10.1007/s00423-016-1469-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Accepted: 06/16/2016] [Indexed: 12/23/2022]
Abstract
Since the introduction of minimally invasive esophagectomy 25 years ago, its use has been reported in several high volume centers. With only one published randomized control trial and five meta-analyses comparing its outcomes to open esophagectomy, available level I evidence is very limited. Available technical approaches include total minimally invasive transthoracic (Ivor Lewis or McKeown) or transhiatal esophagectomy; several hybrid options are available with one portion of the procedure completed via an open approach. A review of available level I evidence with focus on total minimally invasive esophagectomy is presented. The old debate regarding the superiority of a transthoracic versus transhiatal approach to esophagectomy may have been settled by minimally invasive esophagectomy as only few centers are reporting on the latter being utilized. The studies with the highest level of evidence available currently show that minimally invasive techniques via a transthoracic approach are associated with less overall morbidity, fewer pulmonary complications, and shorter hospital stays than open esophagectomy. There appears to be no detrimental effect on oncologic outcomes and possibly an added benefit derived by improved lymph node retrieval. Quality of life improvements may also translate into improved survival, but no conclusive evidence exists to support this claim. Robotic and hybrid techniques have also been implemented, but there currently is no evidence showing that these are superior to other minimally invasive techniques.
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Affiliation(s)
- Danica N Giugliano
- Department of Surgery, Thomas Jefferson University Hospital, 1100 Walnut Street, Suite 500, Philadelphia, PA, 19107, USA
| | - Adam C Berger
- Department of Surgery, Thomas Jefferson University Hospital, 1100 Walnut Street, Suite 500, Philadelphia, PA, 19107, USA
| | - Ernest L Rosato
- Department of Surgery, Thomas Jefferson University Hospital, 1100 Walnut Street, Suite 500, Philadelphia, PA, 19107, USA
| | - Francesco Palazzo
- Department of Surgery, Thomas Jefferson University Hospital, 1100 Walnut Street, Suite 500, Philadelphia, PA, 19107, USA.
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20
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Do alterations in plasma albumin and prealbumin after minimally invasive esophagectomy for squamous cell carcinoma influence the incidence of cervical anastomotic leak? Surg Endosc 2015; 30:3943-9. [DOI: 10.1007/s00464-015-4705-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Accepted: 11/24/2015] [Indexed: 12/16/2022]
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Yang J, Xu C, Lian D, Ye S, Zeng Z, Liu D, Zhuang C. Esophageal reconstruction: posterior mediastinal or retrosternal route. J Surg Res 2015; 201:364-9. [PMID: 27020820 DOI: 10.1016/j.jss.2015.11.030] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Revised: 11/18/2015] [Accepted: 11/20/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND Although posterior mediastinal (PM) route and retrosternal (RS) route have been used for reconstruction after minimally invasive esophagectomy (MIE), the optimal route remains controversial. This study reviewed our experiences with McKeown MIEs for esophageal cancer and aimed to investigate which route was better for esophageal reconstruction. MATERIALS AND METHODS From December 2011 to December 2013, 103 patients who underwent McKeown MIE and esophageal reconstruction by PM or RS routes were reviewed. The decision regarding which approach was appropriated mainly depended on the first surgeon's preference and experience. Baseline demographics, operative, and postoperative data of the patients were analyzed. RESULTS Fifty-six and forty-seven patients receiving PM and RS route reconstruction were reviewed, respectively. Shorter operation time (P = 0.001), less blood loss (P = 0.029), and longer route length (P < 0.001) were observed in PM route compared with RS route. No difference was observed in the resection type, harvested lymph node, intensive care unit and hospital stay, postoperative complications, and in-hospital mortality between the two routes (all P > 0.05). CONCLUSIONS Both RS route and PM route were safe and effective. PM route was associated with shorter operation time, less blood loss, but longer route length compared with RS route.
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Affiliation(s)
- Jingrong Yang
- Department of Cardiothoracic Surgery, Fuzhou General Hospital of Nanjing Military Command, Fuzhou, Fujian, People's Republic of China
| | - Chi Xu
- Department of Cardiothoracic Surgery, Fuzhou General Hospital of Nanjing Military Command, Fuzhou, Fujian, People's Republic of China
| | - Duohuang Lian
- Department of Cardiothoracic Surgery, Fuzhou General Hospital of Nanjing Military Command, Fuzhou, Fujian, People's Republic of China
| | - Shixin Ye
- Department of Cardiothoracic Surgery, Fuzhou General Hospital of Nanjing Military Command, Fuzhou, Fujian, People's Republic of China
| | - Zhiyong Zeng
- Department of Cardiothoracic Surgery, Fuzhou General Hospital of Nanjing Military Command, Fuzhou, Fujian, People's Republic of China.
| | - Daoming Liu
- Department of Cardiothoracic Surgery, Fuzhou General Hospital of Nanjing Military Command, Fuzhou, Fujian, People's Republic of China
| | - Congwen Zhuang
- Department of Cardiothoracic Surgery, Fuzhou General Hospital of Nanjing Military Command, Fuzhou, Fujian, People's Republic of China
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Superiority of Minimally Invasive Oesophagectomy in Reducing In-Hospital Mortality of Patients with Resectable Oesophageal Cancer: A Meta-Analysis. PLoS One 2015. [PMID: 26196135 PMCID: PMC4509855 DOI: 10.1371/journal.pone.0132889] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background Compared with open oesophagectomy (OE), minimally invasive oesophagectomy (MIO) proves to have benefits in reducing the risk of pulmonary complications for patients with resectable oesophageal cancer. However, it is unknown whether MIO has superiority in reducing the occurrence of in-hospital mortality (IHM). Objective The objective of this meta-analysis was to explore the effect of MIO vs. OE on the occurrence of in-hospital mortality (IHM). Data Sources Sources such as Medline (through December 31, 2014), Embase (through December 31, 2014), Wiley Online Library (through December 31, 2014), and the Cochrane Library (through December 31, 2014) were searched. Study Selection Data of randomized and non-randomized clinical trials related to MIO versus OE were included. Interventions Eligible studies were those that reported patients who underwent MIO procedure. The control group included patients undergoing conventional OE. Study Appraisal and Synthesis Methods Fixed or random -effects models were used to calculate summary odds ratios (ORs) or relative risks (RRs) for quantification of associations. Heterogeneity among studies was evaluated by using Cochran’s Q and I2 statistics. Results A total of 48 studies involving 14,311 cases of resectable oesophageal cancer were included in the meta-analysis. Compared to patients undergoing OE, patients undergoing MIO had statistically reduced occurrence of IHM (OR=0.69, 95%CI =0.55 -0.86). Patients undergoing MIO also had significantly reduced incidence of pulmonary complications (PCs) (RR=0.73, 95%CI = 0.63-0.86), pulmonary embolism (PE) (OR=0.71, 95%CI= 0.51-0.99) and arrhythmia (OR=0.79, 95%CI = 0.68-0.92). Non-significant reductions were observed among the included studies in the occurrence of anastomotic leak (AL) (OR=0.93, 95%CI =0.78-1.11), or Gastric Tip Necrosis (GTN) (OR=0.89, 95%CI =0.54-1.49). Limitation Most of the included studies were non-randomized case-control studies, with a diversity of study designs, demographics of participants and surgical intervention. Conclusions Minimally invasive oesophagectomy (MIO) has superiority over open oesophagectomy (OE) in terms of the occurrence of in-hospital mortality (IHM) and should be the first-choice surgical procedure in esophageal surgery.
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Kauppi J, Räsänen J, Sihvo E, Huuhtanen R, Nelskylä K, Salo J. Open versus minimally invasive esophagectomy: clinical outcomes for locally advanced esophageal adenocarcinoma. Surg Endosc 2014; 29:2614-9. [PMID: 25480610 DOI: 10.1007/s00464-014-3978-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Accepted: 10/30/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND We compared oncologic and surgical outcome between minimally invasive esophagectomy (MIE) and the Ivor Lewis-type open approach (OE) in the treatment of locally advanced esophageal adenocarcinoma (EAC). MATERIALS AND METHODS Of 284 patients undergoing surgery for EAC between 2003 and 2013, the 153 selected with locally advanced EAC were 74 MIEs and 79 OEs [median age, 66 for MIE, 63 for OE (p = 0.009)]. Neoadjuvant therapy was given to 82% of MIEs and 78% of OEs. In the OE group, 86% was male, and in the MIE group, 78%. Data assessed were oncologic, intraoperative, and postoperative. RESULTS Mortality at 30 days was 3% for MIE and 1% for OE; and 90-day mortality was 4% for MIE and 5% for OE. The complication rate for MIE was 50%, and 60% for OE (p = 0.181). The pneumonia rate was 18% for MIE and 19% for OE; leak rate was 7% for MIE and 6% for OE; conduit necrosis was 0 for MIE and 3% for OE; and rate of airway-conduit fistula was 3% for MIE and 1 % for OE. Median blood loss (MIE 300 vs. OE 800, p < 0.0001), overall stay (MIE 13 vs. OE 14, p = 0.040), and harvested lymph nodes (MIE 20 vs. OE 22, p = 0.021) all were in favor of MIE. Median ICU stay and operative time did not differ. Neither did overall (OS) nor recurrence-free (RFS) 3-year survival differs significantly (MIE 64% vs. OS OE 49%, MIE 57% vs. RFS OE 53%). CONCLUSIONS In our institution, MIE appears to produce oncologic and survival results similar to those of OE. Shorter length of stay and less operative blood loss may reduce costs for MIE.
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Affiliation(s)
- Juha Kauppi
- Department of General Thoracic and Esophageal Surgery, Heart and Lung Center, Helsinki University Central Hospital, HUS, Haartmaninkatu 4, P. O. Box 340, Helsinki, 00029, Finland
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Huntington JT, Walker JP, Meara MP, Hazey JW, Melvin WS, Perry KA. Endoscopic mucosal resection for staging and treatment of early esophageal carcinoma: a single institution experience. Surg Endosc 2014; 29:2121-5. [PMID: 25472745 DOI: 10.1007/s00464-014-3962-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Accepted: 10/25/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND Endoscopic mucosal resection (EMR) has emerged for evaluation and treatment of esophageal nodules. We report our initial experience with EMR for T staging and management of early esophageal cancer. METHODS We reviewed patients undergoing EMR for esophageal adenocarcinoma between 2008 and 2013. The primary outcome measure was needed for esophagectomy. Secondary outcomes included complete eradication of adenocarcinoma, recurrence or persistence of cancer, nodal status for those undergoing esophagectomy, and complications of endoscopic treatment. RESULTS During the study period, 24 patients underwent EMR demonstrating carcinoma, and a grossly margin negative endoscopic resection was achieved in all cases. Ten patients (42 %) had evidence of submucosal invasion and were referred for esophagectomy. Patients with margin negative EMR (n = 10, 42 %) or positive radial margins (n = 4, 16 %) underwent endoscopic surveillance and treatment with radiofrequency ablation or repeat EMR as needed. Thirteen patients (93 %) with intramucosal cancer (IMC) have been successfully managed with ongoing endoscopic surveillance and treatment with a median follow-up of 15.5 months. One patient underwent esophagectomy due to recurrent IMC in the setting of long-segment multifocal high-grade dysplasia. There were no esophageal perforations, one patient developed a self-limited gastrointestinal hemorrhage following EMR, and one had an esophageal stricture following endoscopic management. CONCLUSIONS IMC can be successfully managed endoscopically and thus esophagectomy is avoided in a significant proportion of patients. Endoscopic management may be utilized in the setting of complete resection or radial margin involvement without evidence of submucosal invasion. Close endoscopic follow-up is of paramount importance even in those with negative margins, because recurrent disease may occur following EMR in these patients.
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Affiliation(s)
- Justin T Huntington
- Division of General and Gastrointestinal Surgery, The Ohio State University, Columbus, OH, 43210, USA,
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