Oesophagectomy: The expanding role of minimally invasive surgery in oesophageal cancer

[Evidence for Minimal Invasive Oesophageal Resection]

In the course of the last 20 years, minimally invasive therapy has become much more important in all areas. In particular, surgical procedures have been established in oncological surgery, even without generating the necessary evidence to assure that the quality is equal to that achieved with open procedures. For this purpose, it has only been in recent years that appropriate randomised controlled studies followed by meta-analyses have been carried out. In this article, we summarise the evidence for minimally invasive resection of the oesophagus and review current literature for each procedure.

Mediastinal anatomical landmarks, their variants and tips for video-assisted thoracoscopic navigation during oesophageal extirpation

Purpose

There is no systematic description of primary anatomical landmarks that allow a surgeon to reliably and safely navigate the superior and posterior mediastinum’s fat tissue spaces near large vessels and nerves during video-assisted endothoracoscopic interventions in the prone position of a patient. Our aim was to develop an algorithm of sequential visual navigation during thoracoscopic extirpation of the esophagus and determine the most permanent topographic and anatomical landmarks allowing safe thoracoscopic dissection of the esophagus in the prone position.

Methods

The anatomical study of the mediastinal structural features was carried out on 30 human cadavers before and after opening the right pleural cavity.

Results

For thoracoscopic extirpation of the esophagus in the prone position, anatomical landmarks are defined, their variants are assessed, and an algorithm for their selection is developed, allowing their direct visualization before and after opening the mediastinal pleura.

Conclusion

The proposed algorithm for topographic and anatomical navigation based on the key anatomical landmarks in the posterior mediastinum provides safe performance of the video-assisted thoracoscopic extirpation of the esophagus in the prone position.

Surgical Outcomes After Neoadjuvant Chemoradiation Followed by Curative Surgery in Patients With Esophageal Cancer: An Intergroup Phase lll Trial of the Swiss Group for Clinical Cancer Research (SAKK 75/08)

OBJECTIVE

To assess the impact of surgical technique in regard to morbidity and mortality after neoadjuvant treatment for esophageal cancer.

BACKGROUND

The SAKK trial 75/08 was a multicenter phase III trial (NCT01107639) comparing induction chemotherapy followed by chemoradiation and surgery in patients with locally advanced esophageal cancer.

METHODS

Patients in the control arm received induction chemotherapy with cisplatin and docetaxel, followed by concomitant chemoradiation therapy with cisplatin, docetaxel, and 45Gy. In the experimental arm, the same regimen was used with addition of cetuximab. After completion of neoadjuvant treatment, patients underwent esophagectomy. The experimental arm received adjuvant cetuximab. Surgical outcomes and complications were prospectively recorded and analyzed.

RESULTS

Total of 259 patients underwent esophagectomy. Overall complication rate was 56% and reoperation rate was 15% with no difference in complication rates for transthoracic versus transhiatal resections (56% vs 54%, P = 0.77), nor for video assisted thoracic surgeries (VATS) versus open transthoracic resections (67% vs 55%, P = 0.32). There was a trend to higher overall complication rates in squamous cell carcinoma versus adenocarcinoma (65% vs 51%, P = 0.035), and a significant difference in ARDS in squamous cell carcinoma with 14% versus 2% in adenocarcinoma (P = 0.0002). For patients with involved lymph nodes, a lymph node ratio of ≥0.1 was an independent predictor of PFS (HR 2.5, P = 0.01) and OS (HR 2.2, P = 0.03).

CONCLUSIONS

This trial showed no difference in surgical complication rates between transthoracic and transhiatal resections. For patients with involved lymph nodes, lymph node ratio was an independent predictor of progression free survival and overall survival.

THE Big Deal: An Institution's Experience with Robotic Transhiatal Esophagectomy

As minimally invasive operations evolve, it is imperative to evaluate the advantages and risks involved. The aim of our study was to evaluate our institution's experience in incorporating a robotic platform for transhiatal esophagectomy (THE). Patients undergoing robotic THE were prospectively followed. Data are presented as median (mean ± SD). Forty-five patients were of 67 (67 ± 6.9) years and BMI 26 (27 ± 5.5) kg/m2. Nine per cent of operations were converted to “open,” but none in the last 25 operations. Operative duration of robotic THE was 334 (364 ± 108.8) minutes and estimated blood loss was 200 (217 ± 144.0) mL, which decreased with time ( P = 0.017). Length of stay was 8 (12 ± 11.1) days. Twenty per cent had respiratory failure requiring intubation that resolved, 4 per cent developed pneumonia, 11 per cent developed a surgical site infection, 2 per cent developed renal insufficiency, and 2 per cent developed a UTI. Two per cent (one patient) died within 30 days postoperatively, because of cardiac arrest. Our experience with robotic THE promotes robotic application because we endeavor to achieve high-level proficiency. With experience, we improved estimated blood loss and converted fewer transhiatal esophagectomies to “open.” Our length of hospital stay seems long but reflects the ill-health of patients, as does the variety of complications. Our data support the evolving future of THE, which will integrally include a robotic approach.

Comparisons between minimally invasive and open esophagectomy for esophageal cancer with cervical anastomosis: a retrospective study

BACKGROUND

As an extensive surgery, minimally invasive esophagectomy (MIE) has advantages in reducing morbidity and improving quality of life for patients suffering from esophageal cancer. This study aims to investigate differences between MIE and open esophagectomy (OE) for considerations of the safety of procedures, rate of tumor resection, postoperative complications, and quality of life. This paper also tends to provide some references for MIE on esophageal cancer therapy.

METHODS

A retrospective data analysis was undertaken on 140 patients who either underwent MIE or OE for esophageal cancer with cervical anastomosis from March 2013 to May 2014 by our surgical team. Preoperative characteristics were analyzed for both groups. Differences in perioperative and oncologic outcomes were compared in operation time, intraoperative blood loss, lymph nodes retrieved, and R0-resection rate. Accordingly, a comparative analysis was conducted on complications namely anastomotic leakage, pulmonary infection, in-hospital mortality, and short-term (3 months) postoperative EORTC C30 Global health as well.

RESULTS

A total of 140 patients (87 with MIE and 53 with OE) were enrolled and the two groups were homogeneous in terms of patient- and tumor-related data. There was no difference on postoperative ICU stay (21.15 ± 1.54 h vs 21.75 ± 1.68 h, p = 0.07) and R0-resection rate (100% vs 100%, p = 1.00). The operation time for MIE was significantly shorter (146.08 ± 17.35 min vs 200.34 ± 14.51 min, p <  0.0001), the intraoperative blood loss was remarkably saved (MIE vs OE, 83.91 ± 24.72 ml vs 174.53 ± 35.32 ml, P <  0.0001) and more lymph nodes were retrieved (MIE vs OE, 38.89 ± 4.31 vs 18.42 ± 3.66, P <  0.0001). There was no difference between the groups to postoperative complications and mortality. However, pulmonary infection in MIE was higher than in OE and the difference was not statistically significant (MIE vs OE, 20.75% vs 31.03%, P = 0.24). Complications such as in-hospital mortality and short-term (3 months) postoperative EORTC C30 Global health displayed no difference between both groups as well.

CONCLUSIONS

The number of lymph nodes and intraoperative blood loss were significantly ameliorated in MIE. A 4-5 cm longitudinal incision below the xiphoid process was made to create the gastric conduit under direct vision assisting in shortening the total operation time significantly.

Oncogenicity of lncRNA FOXD2-AS1 and its molecular mechanisms in human cancers

OBJECTIVES

Long non-coding RNAs (lncRNAs) are a group of noncoding RNAs with length larger than 200 nucleotides. LncRNAs have limited or no protein-coding capacity because of lack of obvious open reading frame. An increasing number of researches have shown that lncRNAs participate in the complex regulation network of cancer and play an important role in tumourigenesis and progression such as proliferation, migration and invasion. LncRNA FOXD2 adjacent opposite strand RNA 1 (FOXD2-AS1), located on chromosome 1p33 and with a transcript length of 2527 nucleotides, is a novel cancer-related lncRNA. FOXD2-AS1 was recently found to exhibit aberrant expression in various malignancies, including gastric, lung, bladder, colorectal, nasopharyngeal, esophageal, hepatocellular, thyroid and skin cancer, and its deregulation might be related to survival and prognosis of cancer patients. Pertinent to clinical practice, FOXD2-AS1 might act as a feasible biomarker or therapeutic target in human cancers. In this paper, we made a summary on the current findings concerning the biological functions and molecular mechanisms of FOXD2-AS1 in tumor progression.

MATERIALS AND METHODS

In this paper, we summarized and figured out recent studies about the expression and molecular biological mechanisms of FOXD2-AS1 in tumor progression. Existing relevant studies were obtained through a systematic search from PubMed, Embase, BioMedNet, GEO database and Cochrane Library.

RESULTS

FOXD2-AS1 was a valuable tumor-associated lncRNA. Its expression level was up-regulation in various malignancies, including gastric, lung, bladder, colorectal, nasopharyngeal, esophageal, hepatocellular, thyroid and skin cancer. In addition, the aberrant expressions of FOXD2-AS1 have shown to contribute to proliferation, migration and invasion of cancer cells, and its deregulation is related to carcinogensis, overall survival, disease free survival, prognosis and tumor progression.

CONCLUSIONS

LncRNA FOXD2-AS1 is an oncogene and probably represents a feasible biomarker or therapeutic target in human cancers.