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Klevebro F, Ash S, Mueller C, Garbarino GM, Gisbertz SS, van Berge Henegouwen MI, Mandeville Y, Ferri L, Davies A, Maynard N, Low DE. Contemporary outcomes of left thoraco-abdominal esophagectomy due to cancer in the esophagus or gastroesophageal junction, a multicenter cohort study. Dis Esophagus 2024:doae039. [PMID: 38678385 DOI: 10.1093/dote/doae039] [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: 10/17/2023] [Revised: 04/08/2024] [Accepted: 04/15/2024] [Indexed: 04/29/2024]
Abstract
Surgery for cancer of the esophagus or gastro-esophageal junction can be performed with a variety of minimally invasive and open approaches. The left thoracoabdominal esophagectomy (LTE) is an open technique that gives an opportunity to operate in the chest and abdomen with excellent exposure of the gastro-esophageal junction through a single incision, and there is currently no equivalent minimally invasive technique available. The aim of this multi-institutional review was to study a large contemporary international study cohort of patients treated with LTE. An international multicenter cohort study was performed including all patients treated with LTE at six high-volume centers for gastro-esophageal cancer surgery between 2012 and 2022. Patient data were prospectively collected in each participating centers' institutional database. Information about patient, tumor, and treatment details were collected. The study cohort included a total of 793 patients treated with LTE during the study period. The most frequently observed complications were pneumonia in 185/727 (25.5%) patients and atrial fibrillation in 91/727 (12.5%). Anastomotic leak occurred in 35/727 (4.8%) patients; no patient suffered from conduit necrosis. Thirty-day mortality occurred in 15/785 (1.9%) patients and 90-day mortality in 39/785 (5.0%) patients. Factors with statistically significant association with survival were American Society for Anesthesiologists-score, tumor location, tumor stage, and tumor free resection margins. Neoadjuvant therapy was not associated with increased survival compared to surgery alone but neoadjuvant chemoradiotherapy compared to neoadjuvant chemotherapy showed statistically significant improved survival with hazard ratio 0.60 (95% confidence intervals:0.44-0.80, P = 0.001) in a multivariable adjusted model. This study demonstrates that LTE can be applied in selected patients with results that are comparable to other large studies of open and minimally invasive surgery for esophageal or gastro-esophageal cancer at high-volume centers.
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Affiliation(s)
- F Klevebro
- Department for Thorqacic Surgery, Virginia Mason Medical Center, Seattle, WA, USA
- CLINTEC, Karolinska Institute, Stockholm, Sweden
| | - S Ash
- Oxford University Hospitals NHS, Ludwig Institute for Cancer Research, Nuffield Department of Medicine, University of Oxford Trust, Oxford, UK
| | - C Mueller
- Mc Gill University Health Center, Montreal, Canada
| | - G M Garbarino
- Department of Surgery, Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Department of Medical Surgical Science and Translational Medicine, Sapienza University of Rome, Sant' Andrea Hospital, Rome, Italy
| | - S S Gisbertz
- Department of Surgery, Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - M I van Berge Henegouwen
- Department of Surgery, Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | | | - L Ferri
- Mc Gill University Health Center, Montreal, Canada
| | - A Davies
- St Thomas', King's College London, London, UK
| | - N Maynard
- Oxford University Hospitals NHS, Ludwig Institute for Cancer Research, Nuffield Department of Medicine, University of Oxford Trust, Oxford, UK
| | - D E Low
- Department for Thorqacic Surgery, Virginia Mason Medical Center, Seattle, WA, USA
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2
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Masuda Y, Leong EKF, So JBY, Shabbir A, Lam Jia Wei T, Chia DKA, Kim G. A systematic review and meta-analysis of mediastinoscopy-assisted transhiatal esophagectomy (MATHE). Surg Oncol 2024; 53:102042. [PMID: 38330804 DOI: 10.1016/j.suronc.2024.102042] [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: 10/02/2023] [Revised: 01/23/2024] [Accepted: 01/31/2024] [Indexed: 02/10/2024]
Abstract
BACKGROUND Transhiatal esophagectomy (THE) avoids thoracotomy but sacrifices mediastinal lymphadenectomy. Mediastinoscopy-assisted transhiatal esophagectomy (MATHE) allows for visualisation and en-bloc dissection of mediastinal lymph nodes while retaining the benefits of THE. However, given its novel inception, there is a paucity of literature. This study aimed to conduct the first meta-analysis to explore the efficacy of MATHE and clarify its role in the future of esophagectomy. METHODS Four databases (PubMed, EMBASE, Scopus, and Cochrane Library) were searched from inception to May 1, 2023. Studies were included if they reported outcomes for patients with esophageal cancer who underwent MATHE. Meta-analyses of proportions and pooled means were performed for the outcomes of intraoperative blood loss, lymph node (LN) harvest, mean hospital length of stay (LOS), mean operative time, R0 resection, conversion rates, 30-day mortality rate, 5-year OS, and surgical complications (anastomotic leak, cardiovascular [CVS] and pulmonary complications, chyle leak and recurrent laryngeal nerve palsy [RLN]). Sensitivity analyses were performed for outcomes with substantial statistical heterogeneity. RESULTS The search yielded 223 articles; 28 studies and 1128 patients were included in our analysis. Meta-analyses of proportions yielded proportion rates: 30-day mortality (0 %, 95 %CI 0-0), 5-year OS (60.5 %, 95 %CI 47.6-72.7), R0 resection (100 %, 95 %CI 99.3-100), conversion rate (0.1 %, 95 %CI 0-1.2). Among surgical complications, RLN palsy (14.6 %, 95 %CI 9.5-20.4) were most observed, followed by pulmonary complications (11.3 %, 95 %CI 7-16.2), anastomotic leak (9.7 %, 95 %CI 6.8-12.8), CVS complications (2.3 %, 95 %CI 0.9-4.1) and chyle leak (0.02 %, 95 %CI 0-0.8). Meta-analysis of pooled means yielded means: LN harvest (18.6, 95 %CI 14.3-22.9), intraoperative blood loss (247.1 ml, 95 %CI 173.6-320.6), hospital LOS (18.1 days, 95 %CI 14.4-21.8), and operative time (301.5 min, 95 %CI 238.4-364.6). There was moderate-to-high statistical heterogeneity. Findings were robust to sensitivity analyses. CONCLUSION MATHE is associated with encouraging post-operative mortality and complication rates, while allowing for radical mediastinal lymphadenectomy with reasonable lymph node harvest.
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Affiliation(s)
- Yoshio Masuda
- Ministry of Health Holdings Singapore, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Jimmy Bok Yan So
- Upper Gastrointestinal Surgery, National University Hospital, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Asim Shabbir
- Upper Gastrointestinal Surgery, National University Hospital, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Daryl Kai Ann Chia
- Upper Gastrointestinal Surgery, National University Hospital, Singapore.
| | - Guowei Kim
- Upper Gastrointestinal Surgery, National University Hospital, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Oberoi M, Noor MS, Abdelfatah E. The Multidisciplinary Approach and Surgical Management of GE Junction Adenocarcinoma. Cancers (Basel) 2024; 16:288. [PMID: 38254779 PMCID: PMC10813924 DOI: 10.3390/cancers16020288] [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: 11/11/2023] [Revised: 12/28/2023] [Accepted: 01/05/2024] [Indexed: 01/24/2024] Open
Abstract
Gastroesophageal (GE) junction adenocarcinoma is an aggressive malignancy of growing incidence and is associated with public health issues such as obesity and GERD. Management has evolved over the last two decades to incorporate a multidisciplinary approach, including endoscopic intervention, neoadjuvant chemotherapy/chemoradiation, and minimally invasive or more limited surgical approaches. Surgical approaches include esophagectomy, total gastrectomy, and, more recently, proximal gastrectomy. This review analyzes the evidence for and applicability of these varied approaches in management, as well as areas of continued controversy and investigation.
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Affiliation(s)
| | | | - Eihab Abdelfatah
- Department of Surgery, NYU Langone Health, 120 Mineola Blvd., Suite 320h, Mineola, Long Island, NY 11501, USA; (M.O.); (M.S.N.)
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Yuan P, Hu W, Liu Z, Wu N, Lin H, Li S, Hu Y. Left-primary & right-auxiliary operation mode in mediastinoscope-assisted radical esophagectomy. Surg Endosc 2023; 37:7884-7892. [PMID: 37644153 DOI: 10.1007/s00464-023-10341-1] [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: 03/02/2023] [Accepted: 07/30/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND Mediastinoscope-assisted transhiatal esophagectomy (MATHE) is the most minimally invasive esophagectomy procedure. It is a more challenging procedure and more difficult to be popularized than thoracoscopic surgery. We developed a new MATHE operation mode that provides a clearer visual field and makes the procedures simpler. METHODS A total of 80 patients with esophageal cancer were divided into a control group (n = 29) and a study group (n = 51). The control group underwent classic MATHE, while the study group received modified MATHE. We compared the two groups on operation time; intraoperative blood loss; blood transfusion amount; incidence rate of lung infection, recurrent laryngeal nerves (RLNs) injury, chylothorax, and anastomotic leakage; and upper mediastinal lymph node dissection. RESULTS The study group was significantly better than the control group in operation time (271.78 min vs. 322.90 min, p < 0.05), intraoperative blood loss (48.63 mL vs. 68.97 mL, p < 0.05), and left paratracheal lymph node (No. 4L) dissection rate (88.24% vs. 24.14%, p < 0.01). No significant differences were identified in the incidence rate of anastomotic leakage, lung complications, or RLNs injury between the two groups. CONCLUSION The modified MATHE is easier to perform. Modified MATHE is significantly superior to classic MATHE in operation time, intraoperative blood loss, and upper mediastinal lymph node dissection rate.
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Affiliation(s)
- Peisong Yuan
- Department of Thoracic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, China
| | - Weipeng Hu
- Department of Thoracic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, China
| | - Zheng Liu
- Department of Thoracic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, China
| | - Na Wu
- Department of Thoracic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, China
| | - Haonan Lin
- Department of Thoracic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, China
| | - Shiyu Li
- Department of Surgical Division I, Traditional Chinese Medicine Hospital of Wusheng County, Guangan, 638400, China
| | - Yang Hu
- Department of Thoracic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, China.
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Hagens ERC, Cui N, van Dieren S, Eshuis WJ, Laméris W, van Berge Henegouwen MI, Gisbertz SS. Preoperative Risk Stratification in Esophageal Cancer Surgery: Comparing Risk Models with the Clinical Judgment of the Surgeon. Ann Surg Oncol 2023; 30:5159-5169. [PMID: 37120485 PMCID: PMC10319689 DOI: 10.1245/s10434-023-13473-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 03/21/2023] [Indexed: 05/01/2023]
Abstract
BACKGROUND Numerous prediction models estimating the risk of complications after esophagectomy exist but are rarely used in practice. The aim of this study was to compare the clinical judgment of surgeons using these prediction models. METHODS Patients with resectable esophageal cancer who underwent an esophagectomy were included in this prospective study. Prediction models for postoperative complications after esophagectomy were selected by a systematic literature search. Clinical judgment was given by three surgeons, indicating their estimated risk for postoperative complications in percentage categories. The best performing prediction model was compared with the judgment of the surgeons, using the net reclassification improvement (NRI), category-free NRI (cfNRI), and integrated discrimination improvement (IDI) indexes. RESULTS Overall, 159 patients were included between March 2019 and July 2021, of whom 88 patients (55%) developed a complication. The best performing prediction model showed an area under the receiver operating characteristic curve (AUC) of 0.56. The three surgeons had an AUC of 0.53, 0.55, and 0.59, respectively, and all surgeons showed negative percentages of cfNRIevents and IDIevents, and positive percentages of cfNRInonevents and IDIevents. This indicates that in the group of patients with postoperative complications, the prediction model performed better, whereas in the group of patients without postoperative complications, the surgeons performed better. NRIoverall was 18% for one surgeon, while the remainder of the NRIoverall, cfNRIoverall and IDIoverall scores showed small differences between surgeons and the prediction models. CONCLUSION Prediction models tend to overestimate the risk of any complication, whereas surgeons tend to underestimate this risk. Overall, surgeons' estimations differ between surgeons and vary between similar to slightly better than the prediction models.
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Affiliation(s)
- Eliza R C Hagens
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Cancer Center, Amsterdam, The Netherlands
| | - Nanke Cui
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Cancer Center, Amsterdam, The Netherlands
| | - Susan van Dieren
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Cancer Center, Amsterdam, The Netherlands
| | - Wietse J Eshuis
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Cancer Center, Amsterdam, The Netherlands
| | - Wytze Laméris
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Cancer Center, Amsterdam, The Netherlands
| | - Mark I van Berge Henegouwen
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Cancer Center, Amsterdam, The Netherlands
| | - Suzanne S Gisbertz
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Cancer Center, Amsterdam, The Netherlands.
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Yang Y, Xin X, Chen P, Shi X, Yang C, Fan J, Zhang Y, Jia X. Left compared with right thoracic approach thoracotomy in esophageal cancer: a retrospective cohort study. J Cancer Res Clin Oncol 2023:10.1007/s00432-023-04765-4. [PMID: 37071207 DOI: 10.1007/s00432-023-04765-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 04/08/2023] [Indexed: 04/19/2023]
Abstract
BACKGROUND Esophagectomy is regarded as one of the optimal treatments for resectable esophageal cancer. However, the impact of surgical approach on the long-term prognosis of esophageal cancer remains controversial. This study attempted to compare the long-term survival outcomes of patients receiving left and right thoracic esophagectomy for esophageal cancer. METHODS A total of 985 patients underwent esophagectomy (including 453 left and 532 right thoracic approach) for esophageal cancer in Henan Cancer Hospital from January 2015 to December 2016 were enrolled. Their 5 year overall survival (OS) and disease-free survival (DFS) were retrospectively collected. Cox regression was performed to compare OS and DFS in patients who underwent left and right thoracic esophagectomy. Propensity score matching (PSM) analysis was used to balance confounding factors. RESULTS The 5 year OS rates were 60.21% in the left and 51.60% in the right thoracic esophagectomy, respectively (P = 0.67). The 5 year DFS rates were 56.73% in the left and 47.93% and in the right thoracic esophagectomy, respectively (P = 0.36). Cox regression analysis showed there was no significant difference in long-term survival between patients with left and right surgical access (OS: HR = 0.95, 95% CI 0.77-1.18; DFS: HR = 0.91, 95% CI 0.74-1.12). In the cohort of patients obtained by PSM, Cox regression analysis yielded the similar results. CONCLUSION For patients with resectable esophageal cancer, the surgical treatment through left thoracic approach can achieve the same long-term survival outcomes as the right thoracic approach.
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Affiliation(s)
- Yongli Yang
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, 450001, Henan, China
| | - Xin Xin
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, 450001, Henan, China
| | - Peinan Chen
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, 450008, China
| | - Xuezhong Shi
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, 450001, Henan, China
| | - Chaojun Yang
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, 450001, Henan, China
| | - Jingwen Fan
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, 450001, Henan, China
| | - Yi Zhang
- Department of Medical Record, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, 450008, China
| | - Xiaocan Jia
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, 450001, Henan, China.
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7
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Kalff MC, van Berge Henegouwen MI, Baas PC, Bahadoer RR, Belt EJT, Brattinga B, Claassen L, Ćosović A, Crull D, Daams F, van Dalsen AD, Dekker JWT, van Det MJ, Drost M, van Duijvendijk P, Eshuis WJ, van Esser S, Gaspersz MP, Görgec B, Groenendijk RPR, Hartgrink HH, van der Harst E, Haveman JW, Heisterkamp J, van Hillegersberg R, Kelder W, Kingma BF, Koemans WJ, Kouwenhoven EA, Lagarde SM, Lecot F, van der Linden PP, Luyer MDP, Nieuwenhuijzen GAP, Olthof PB, van der Peet DL, Pierie JPEN, Pierik EGJMR, Plat VD, Polat F, Rosman C, Ruurda JP, van Sandick JW, Scheer R, Slootmans CAM, Sosef MN, Sosef OV, de Steur WO, Stockmann HBAC, Stoop FJ, Voeten DM, Vugts G, Vijgen GHEJ, Weeda VB, Wiezer MJ, van Oijen MGH, Gisbertz SS. Trends in Distal Esophageal and Gastroesophageal Junction Cancer Care: The Dutch Nationwide Ivory Study. Ann Surg 2023; 277:619-628. [PMID: 35129488 DOI: 10.1097/sla.0000000000005292] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE This study evaluated the nationwide trends in care and accompanied postoperative outcomes for patients with distal esophageal and gastro-esophageal junction cancer. SUMMARY OF BACKGROUND DATA The introduction of transthoracic esophagectomy, minimally invasive surgery, and neo-adjuvant chemo(radio)therapy changed care for patients with esophageal cancer. METHODS Patients after elective transthoracic and transhiatal esophagectomy for distal esophageal or gastroesophageal junction carcinoma in the Netherlands between 2007-2016 were included. The primary aim was to evaluate trends in both care and postoperative outcomes for the included patients. Additionally, postoperative outcomes after transthoracic and tran-shiatal esophagectomy were compared, stratified by time periods. RESULTS Among 4712 patients included, 74% had distal esophageal tumors and 87% had adenocarcinomas. Between 2007 and 2016, the proportion of transthoracic esophagectomy increased from 41% to 81%, and neo-adjuvant treatment and minimally invasive esophagectomy increased from 31% to 96%, and from 7% to 80%, respectively. Over this 10-year period, postoperative outcomes improved: postoperative morbidity decreased from 66.6% to 61.8% ( P = 0.001), R0 resection rate increased from 90.0% to 96.5% (P <0.001), median lymph node harvest increased from 15 to 19 ( P <0.001), and median survival increased from 35 to 41 months ( P = 0.027). CONCLUSION In this nationwide cohort, a transition towards more neo-adju-vant treatment, transthoracic esophagectomy and minimally invasive surgery was observed over a 10-year period, accompanied by decreased postoperative morbidity, improved surgical radicality and lymph node harvest, and improved survival.
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Affiliation(s)
- Marianne C Kalff
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Mark I van Berge Henegouwen
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Peter C Baas
- Department of Surgery, Martini Ziekenhuis, Groningen, the Netherlands
| | - Renu R Bahadoer
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Eric J T Belt
- Department of Surgery, Albert Schweitzer Ziekenhuis, Dordrecht, the Netherlands
| | - Baukje Brattinga
- Department of Surgery, MC Leeuwarden, Leeuwarden, the Netherlands
| | - Linda Claassen
- Department of Surgery, Gelre Ziekenhuis, Apeldoorn, the Netherlands
| | - Admira Ćosović
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - David Crull
- Department of Surgery, Ziekenhuisgroep Twente, Almelo, the Netherlands
| | - Freek Daams
- Department of Surgery, VU University Medical Center, Amsterdam, the Netherlands
| | | | | | - Marc J van Det
- Department of Surgery, Ziekenhuisgroep Twente, Almelo, the Netherlands
| | - Manon Drost
- Department of Surgery, Albert Schweitzer Ziekenhuis, Dordrecht, the Netherlands
| | | | - Wietse J Eshuis
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Stijn van Esser
- Department of Surgery, Reinier de Graaf Groep, Delft, the Netherlands
| | | | - Burak Görgec
- Department of Surgery, Maasstad Ziekenhuis, Rotterdam, the Netherlands
| | | | - Henk H Hartgrink
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Jan Willem Haveman
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Joos Heisterkamp
- Department of Surgery, Elisabeth-TweeSteden Ziekenhuis, Tilburg, the Netherlands
| | | | - Wendy Kelder
- Department of Surgery, Martini Ziekenhuis, Groningen, the Netherlands
| | - B Feike Kingma
- Department of Surgery, UMC Utrecht, Utrecht, the Netherlands
| | - Willem J Koemans
- Department of Surgery, Antoni van Leeuwenhoek Ziekenhuis, Amsterdam, the Netherlands
| | | | | | - Frederik Lecot
- Department of Surgery, Zuyderland, Heerlen, the Netherlands
| | | | - Misha D P Luyer
- Department of Surgery, Catharina Ziekenhuis, Eindhoven, the Netherlands
| | | | - Pim B Olthof
- Department of Surgery, Reinier de Graaf Groep, Delft, the Netherlands
| | | | | | | | - Victor D Plat
- Department of Surgery, VU University Medical Center, Amsterdam, the Netherlands
| | - Fatih Polat
- Department of Surgery, Canisius Wilhelmina Ziekenhuis, Nijmegen, the Netherlands
| | - Camiel Rosman
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Jelle P Ruurda
- Department of Surgery, UMC Utrecht, Utrecht, the Netherlands
| | - Johanna W van Sandick
- Department of Surgery, Antoni van Leeuwenhoek Ziekenhuis, Amsterdam, the Netherlands
| | - Rene Scheer
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | | | | | - Odin V Sosef
- Department of Surgery, Zuyderland, Heerlen, the Netherlands
| | - Wobbe O de Steur
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Fanny J Stoop
- Department of Surgery, Canisius Wilhelmina Ziekenhuis, Nijmegen, the Netherlands
| | - Daan M Voeten
- Department of Surgery, Spaarne Gasthuis, Haarlem, the Netherlands
| | - Guusje Vugts
- Department of Surgery, Catharina Ziekenhuis, Eindhoven, the Netherlands
| | | | - Víola B Weeda
- Department of Surgery, Albert Schweitzer Ziekenhuis, Dordrecht, the Netherlands
| | - Marinus J Wiezer
- Department of Surgery, St Antonius Ziekenhuis, Nieuwegein, the Netherlands
| | - Martijn G H van Oijen
- Department of Medical Oncology, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Suzanne S Gisbertz
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
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8
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Clinical advantage of transmediastinal esophagectomy in terms of postoperative respiratory complications. Int J Clin Oncol 2023; 28:748-755. [PMID: 36928515 DOI: 10.1007/s10147-023-02328-8] [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: 07/05/2022] [Accepted: 03/08/2023] [Indexed: 03/18/2023]
Abstract
BACKGROUND Although the transmediastinal approach as a radical esophagectomy for esophageal carcinoma patients has attracted attention, its advantages over the transthoracic approach remain unclear. This study aimed to evaluate the efficacy of transmediastinal esophagectomy (TME) in terms of postoperative respiratory complications compared to that of open transthoracic esophagectomy (TTE). METHODS We reviewed patients with thoracic and abdominal esophageal carcinoma who underwent TME or TTE between February 2014 and November 2021. We compared postoperative respiratory complications as the primary outcome. The secondary outcomes included perioperative operation time, blood loss, postoperative complications, and the number of harvested mediastinal lymph nodes. RESULTS Overall, 60 and 54 patients underwent TME and TTE, respectively. The baseline characteristics were similar between the two groups, except for age and histological type. There were no intraoperative lethal complications in either group. The incidence of respiratory complications was significantly lower in the TME group than in the TTE group (6.7 vs. 22.2%, p = 0.03). The TME group had a shorter operation time (403 vs. 451 min, p < 0.01), less blood loss (107 vs. 253 mL, p < 0.01), and slightly higher anastomotic leakage (11.7 vs. 5.6%, p = 0.33). The number of harvested lymph nodes was similar in both groups (24 vs. 26, p = 0.10). Multivariate analysis revealed that TME is an independent factor in reducing respiratory complications (odds ratio = 0.27, p = 0.04). CONCLUSIONS TME for esophageal carcinoma was performed safely. TME was superior to TTE in terms of postoperative respiratory complications; however, the relatively higher frequency of anastomotic leakage should be considered and requires further evaluation.
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Papaconstantinou D, Frountzas M, Ruurda JP, Mantziari S, Tsilimigras DI, Koliakos N, Tsivgoulis G, Schizas D. Risk factors and consequences of post-esophagectomy delirium: a systematic review and meta-analysis. Dis Esophagus 2023:6991265. [PMID: 36655317 DOI: 10.1093/dote/doac103] [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: 07/29/2022] [Revised: 10/05/2022] [Accepted: 10/16/2022] [Indexed: 01/20/2023]
Abstract
Post-operative delirium (POD) is a state of mental and neurocognitive impairment characterized by disorientation and fluctuating levels of consciousness. POD in the context of esophageal surgery may herald serious and potentially life-threatening post-operative complications, or conversely be a symptom of severe underlying pathophysiologic disturbances. The aim of the present systematic review and meta-analysis is to explore risk factors associated with the development of POD and assess its impact on post-operative outcomes. A systematic literature search of the MedLine, Web of Science, Embase and Cochrane CENTRAL databases and the clinicaltrials.gov registry was undertaken. A random-effects model was used for data synthesis with pooled outcomes expressed as Odds Ratios (OR), or standardized mean differences (WMD) with corresponding 95% Confidence Intervals. Seven studies incorporating 2449 patients (556 with POD and 1893 without POD) were identified. Patients experiencing POD were older (WMD 0.29 ± 0.13 years, P < 0.001), with higher Charlson's Comorbidity Index (CCI; WMD 0.31 ± 0.23, P = 0.007) and were significantly more likely to be smokers (OR 1.38, 95% CI 1.07-1.77, P = 0.01). Additionally, POD was associated with blood transfusions (OR 2.08, 95% CI 1.56-2.77, P < 0.001), and a significantly increased likelihood to develop anastomotic leak (OR 2.03, 95% CI 1.25-3.29, P = 0.004). Finally, POD was associated with increased mortality (OR 2.71, 95% CI 1.24-5.93, P = 0.01) and longer hospital stay (WMD 0.4 ± 0.24, P = 0.001). These findings highlight the clinical relevance and possible economic impact of POD after esophagectomy for malignant disease and emphasize the need of developing effective preventive strategies.
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Affiliation(s)
- Dimitrios Papaconstantinou
- Third Department of Surgery, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - Maximos Frountzas
- First Propaedeutic Department of Surgery, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Jelle P Ruurda
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Stella Mantziari
- Department of Visceral Surgery, Faculty of Biology and Medicine UNIL, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Diamantis I Tsilimigras
- Department of Surgery, The Ohio State University Wexner Medical Center, James Comprehensive Cancer Center, Columbus, OH, USA
| | - Nikolaos Koliakos
- Third Department of Surgery, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - Georgios Tsivgoulis
- Second Department of Neurology, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - Dimitrios Schizas
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
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10
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Henckens SPG, Hagens ERC, van Berge Henegouwen MI, Meijer SL, Eshuis WJ, Gisbertz SS. Impact of increasing lymph node yield on staging, morbidity and survival after esophagectomy for esophageal adenocarcinoma. Eur J Surg Oncol 2023; 49:89-96. [PMID: 35933270 DOI: 10.1016/j.ejso.2022.07.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 06/27/2022] [Accepted: 07/11/2022] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Extended lymphadenectomy during esophagectomy for esophageal cancer may increase survival, but also increase morbidity. This study analyses the influence of lymph node yield after transthoracic esophagectomy for esophageal adenocarcinoma on the number of positive lymph nodes, pathological N-stage, complications and survival. MATERIALS AND METHODS Consecutive patients undergoing transthoracic esophagectomy for esophageal adenocarcinoma between 2010 and 2020 were prospectively recorded (follow-up until January 2022). Lymph node yield was analyzed as continuous and dichotomous variable (≤30 vs. ≥31 nodes). The effect of lymph node yield on number of positive lymph nodes, complications, disease-free (DFS) and overall survival (OS) was assessed in multivariable regression analyses. RESULTS 585 patients were included. Median lymph node yield increased from 25 (IQR 20-34) in 2010 to 39 (IQR 32-50) in 2020. Higher lymph node yield was associated with more positive lymph nodes (≥31 vs. ≤30 IRR 1.39, 95%CI 1.11-1.75). In 258 (y)pN + patients, the percentage of (y)pN3-stage increased with 14% between patients with ≤30 and ≥ 31 lymph nodes examined (p 0.014). Higher lymph node yield was not associated with more complications. Superior survival was seen in patients with ≥31 vs. ≤30 lymph nodes examined [DFS: HR 0.73, 95%CI 0.58-0.93, OS: HR 0.71, 95%CI 0.55-0.93)]. CONCLUSIONS A lymph node yield of 31 or higher was associated with upstaging and superior survival after esophagectomy for esophageal adenocarcinoma, without increasing morbidity. Extended lymphadenectomy may therefore be regarded as an important part of the multimodal treatment of esophageal cancer.
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Affiliation(s)
- Sofie P G Henckens
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Meibergdreef 9, Amsterdam, the Netherlands; Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands; Amsterdam UMC, Location University of Amsterdam, Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Meibergdreef 9, Amsterdam, the Netherlands.
| | - Eliza R C Hagens
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Meibergdreef 9, Amsterdam, the Netherlands; Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands; Amsterdam UMC, Location University of Amsterdam, Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Meibergdreef 9, Amsterdam, the Netherlands
| | - Mark I van Berge Henegouwen
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Meibergdreef 9, Amsterdam, the Netherlands; Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands; Amsterdam UMC, Location University of Amsterdam, Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Meibergdreef 9, Amsterdam, the Netherlands
| | - Sybren L Meijer
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands; Amsterdam UMC, Location University of Amsterdam, Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Meibergdreef 9, Amsterdam, the Netherlands; Amsterdam UMC, Location University of Amsterdam, Department of Pathology, Meibergdreef 9, Amsterdam, the Netherlands
| | - Wietse J Eshuis
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Meibergdreef 9, Amsterdam, the Netherlands; Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands; Amsterdam UMC, Location University of Amsterdam, Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Meibergdreef 9, Amsterdam, the Netherlands
| | - Suzanne S Gisbertz
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Meibergdreef 9, Amsterdam, the Netherlands; Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands; Amsterdam UMC, Location University of Amsterdam, Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Meibergdreef 9, Amsterdam, the Netherlands.
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11
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Klevebro F, Han S, Ash S, Mueller C, Cools-Lartigue J, Maynard N, Ferri L, Low D. Open left thoracoabdominal esophagectomy a viable option in the era of minimally invasive esophagectomy. Dis Esophagus 2022; 36:6576314. [PMID: 35511475 DOI: 10.1093/dote/doac024] [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: 01/17/2022] [Revised: 03/27/2022] [Indexed: 01/11/2023]
Abstract
Minimally invasive surgical technique has become standard at many institutions in esophageal cancer surgery. In some situations, however other surgical approaches are required. Left thoracoabdominal esophagectomy (LTE) facilitates complete resection of esophageal cancer particularly for bulky distal esophageal tumors, but there are concerns that this approach is associated with significant morbidity. Prospectively entered esophagectomy databases from three high-volume centers were reviewed for patients undergoing LTE or MIE 2009-2019. Patient demographics, tumor characteristics, operative outcomes, postoperative outcomes, and pathologic surrogates of oncologic efficacy (R0 resection rate, and number of resected lymph nodes) were compared. In total 915 patients were included in the study, LTE was applied in 684 (74.8%) patients, and MIE in 231 (25.2%) patients. LTE patients had more locally advanced tumor stage and received more neoadjuvant treatment. Patients treated with MIE had more comorbidities. The results showed no difference in overall postoperative complications (LTE = 61.7%, MIE = 65.7%, P = 0.289), severe complications (Clavien-Dindo ≥IIIa (LTE = 25.9%, MIE 26.8%, P = 0.806)), pneumonia (LTE = 29.0%, MIE = 24.7%, P = 0.211), anastomotic leak (LTE = 7.8%, MIE = 11.3%, P = 0.101), or in-hospital mortality (LTE = 2.6%, MIE = 3.5%, P = 0.511). Median number of resected lymph nodes was 24 for LTE and 25 for MIE (P = 0.491). LTE was used for more advanced tumors in patients that were more likely to have received neoadjuvant treatment compared with MIE, however postoperative morbidity, mortality, and oncologic outcomes were equivalent to that of MIE in this cohort. In conclusion open resection with left thoracoabdominal approach is a valid option in selected patients when performed at high-volume esophagectomy centers.
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Affiliation(s)
- F Klevebro
- Department of Thoracic Surgery, Virginia Mason Medical Center, Seattle WA, USA.,Department of Surgery, CLINTEC Karolinska Institutet, Stockholm, Sweden
| | - S Han
- Department of Thoracic Surgery, Virginia Mason Medical Center, Seattle WA, USA
| | - S Ash
- Department of Medicine, Oxford University Hospitals NHS, Ludwig Institute for Cancer Research, Nuffield, University of Oxford Trust, Oxford, UK
| | - C Mueller
- Division of Thoracic and Upper Gastrointestinal Surgery, Mc Gill University Health Center, Montreal, Canada
| | - J Cools-Lartigue
- Division of Thoracic and Upper Gastrointestinal Surgery, Mc Gill University Health Center, Montreal, Canada
| | - N Maynard
- Department of Medicine, Oxford University Hospitals NHS, Ludwig Institute for Cancer Research, Nuffield, University of Oxford Trust, Oxford, UK
| | - L Ferri
- Division of Thoracic and Upper Gastrointestinal Surgery, Mc Gill University Health Center, Montreal, Canada
| | - D Low
- Department of Thoracic Surgery, Virginia Mason Medical Center, Seattle WA, USA
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12
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Junttila A, Helminen O, Kauppila JH. ASO Author Reflections: Similar Long-Term Survival After Transhiatal Compared to Transthoracic Esophagectomy. Ann Surg Oncol 2022; 29:8168-8169. [PMID: 36114440 PMCID: PMC9640448 DOI: 10.1245/s10434-022-12443-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 08/09/2022] [Indexed: 11/26/2022]
Affiliation(s)
- Anna Junttila
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.
| | - Olli Helminen
- Surgery Research Unit, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Joonas H Kauppila
- Surgery Research Unit, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Insitutet and Karolinska University Hospital, Stockholm, Sweden
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13
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Reichert M, Lang M, Pons-Kühnemann J, Sander M, Padberg W, Hecker A. Perioperative statin medication impairs pulmonary outcome after abdomino-thoracic esophagectomy. Perioper Med (Lond) 2022; 11:47. [PMID: 36104793 PMCID: PMC9472330 DOI: 10.1186/s13741-022-00280-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 08/28/2022] [Indexed: 11/30/2022] Open
Abstract
Background Although surgery is the curative option of choice for patients with locally advanced esophageal cancer, morbidity, especially the rate of pulmonary complications, and consequently mortality of patients undergoing abdomino-thoracic esophagectomy remain unacceptably high. Causes for developing post-esophagectomy pulmonary complications are trauma to the lung and thoracic cavity as well as systemic inflammatory response. Statins are known to influence inflammatory pathways, but whether perioperative statin medication impacts on inflammatory response and pulmonary complication development after esophagectomy had not been investigated, yet. Methods Retrospective analysis and propensity score matching of patients, who either received perioperative statin medication [statin( +)] or not [statin( −)], with regard to respiratory impairment (PaO2/FiO2 < 300 mmHg), pneumonia development, and inflammatory serum markers after abdomino-thoracic esophagectomy. Results Seventy-eight patients who underwent abdomino-thoracic esophagectomy for cancer were included into propensity score pair-matched analysis [statin( +): n = 26 and statin( −): n = 52]. Although no differences were seen in postoperative inflammatory serum markers, C-reactive protein values correlated significantly with the development of pneumonia beyond postoperative day 3 in statin( −) patients. This effect was attenuated under statin medication. No difference was seen in cumulative incidences of respiratory impairment; however, significantly higher rate (65.4% versus 38.5%, p = 0.0317, OR 3.022, 95% CI 1.165–7.892) and higher cumulative incidence (p = 0.0468) of postoperative pneumonia were seen in statin( +) patients, resulting in slightly longer postoperative stay on intensive care unit (p = 0.0612) as well as significantly prolonged postoperative in-hospital stay (p = 0.0185). Conclusions Development of pulmonary complications after abdomino-thoracic esophagectomy is multifactorial but frequent. The establishment of preventive measures into the perioperative clinical routine is mandatory for an improved patient outcome. Perioperative medication with statins might influence pneumonia development in the highly vulnerable lung after abdomino-thoracic esophagectomy. Perioperative interruption of statin medication might be beneficial in appropriate patients; however, further clinical trials and translational studies are needed to prove this hypothesis.
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14
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Junttila A, Helminen O, Helmiö M, Huhta H, Kallio R, Koivukangas V, Kokkola A, Laine S, Lietzen E, Meriläinen S, Pohjanen VM, Rantanen T, Ristimäki A, Räsänen JV, Saarnio J, Sihvo E, Toikkanen V, Tyrväinen T, Valtola A, Kauppila JH. Long-Term Survival After Transhiatal Versus Transthoracic Esophagectomy: A Population-Based Nationwide Study in Finland. Ann Surg Oncol 2022; 29:8158-8167. [PMID: 36006492 DOI: 10.1245/s10434-022-12349-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 07/12/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND No population-based studies comparing long-term survival after transhiatal esophagectomy (THE) and transthoracic esophagectomy (TTE) exist. This study aimed to compare the 5-year survival of esophageal cancer patients undergoing THE or TTE in a population-based nationwide setting. METHODS This study included all curatively intended THE and TTE for esophageal cancer in Finland during 1987-2016, with follow-up evaluation until 31 December 2019. Cox proportional hazard models provided hazard ratios (HRs) with 95% confidence intervals (CIs) of 5-year and 90-day mortality. The results were adjusted for age, sex, year of operation, comorbidities, histology, neoadjuvant treatment, and pathologic stage. RESULTS A total of 1338 patients underwent THE (n = 323) or TTE (n = 1015). The observed 5-year survival rate was 39.3% after THE and 45.0% after TTE (p = 0.072). In adjusted model 1, THE was not associated with greater 5-year mortality (HR 0.99; 95% CI 0.82-1.20) than TTE. In adjusted model 2, including T stage instead of pathologic stage, the 5-year mortality hazard rates after THE (HR 0.87, 95% CI 0.72-1.05) and TTE were comparable. The 90-day mortality rate for THE was higher than for TTE (adjusted HR 0.72; 95% CI 0.45-1.14). In subgroup analyses, no differences between THE and TTE were observed in Siewert II gastroesophageal junction cancers, esophageal cancers, or pN0 tumors, nor in the comparison of THE and TTE with two-field lymphadenectomy. The sensitivity analysis, including patients with missing patient records, who underwent surgery during 1996-2016 mirrored the main analysis. CONCLUSIONS This Finnish population-based nationwide study suggests no difference in 5-year or 90-day mortality after THE and TTE for esophageal cancer.
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Affiliation(s)
- Anna Junttila
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.
| | - Olli Helminen
- Surgery Research Unit, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Mika Helmiö
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
| | - Heikki Huhta
- Surgery Research Unit, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Raija Kallio
- Department of Oncology and Radiotherapy, Oulu University Hospital, Oulu, Finland
| | - Vesa Koivukangas
- Surgery Research Unit, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Arto Kokkola
- Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Simo Laine
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
| | - Elina Lietzen
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
| | - Sanna Meriläinen
- Surgery Research Unit, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Vesa-Matti Pohjanen
- Cancer and Translational Medicine Research Unit, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Tuomo Rantanen
- Department of Surgery, University of Eastern Finland and Kuopio University Hospital, Kuopio, Finland
| | - Ari Ristimäki
- Department of Pathology, HUSLAB, HUS Diagnostic Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.,Applied Tumor Genomics Research Program, Research Programs Unit, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Jari V Räsänen
- Department of General Thoracic and Oesophageal Surgery, Heart and Lung Centre, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Juha Saarnio
- Surgery Research Unit, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Eero Sihvo
- Department of Surgery, Central Finland Central Hospital, Jyväskylä, Finland
| | - Vesa Toikkanen
- Department of Cardiothoracic Surgery, Heart Center, Tampere University Hospital and University of Tampere, Tampere, Finland
| | - Tuula Tyrväinen
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
| | - Antti Valtola
- Department of Surgery, University of Eastern Finland and Kuopio University Hospital, Kuopio, Finland
| | - Joonas H Kauppila
- Surgery Research Unit, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland.,Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Insitutet and Karolinska University Hospital, Stockholm, Sweden
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15
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Szakó L, Németh D, Farkas N, Kiss S, Dömötör RZ, Engh MA, Hegyi P, Eross B, Papp A. Network meta-analysis of randomized controlled trials on esophagectomies in esophageal cancer: The superiority of minimally invasive surgery. World J Gastroenterol 2022; 28:4201-4210. [PMID: 36157121 PMCID: PMC9403425 DOI: 10.3748/wjg.v28.i30.4201] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 04/26/2022] [Accepted: 07/17/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Previous meta-analyses, with many limitations, have described the beneficial nature of minimal invasive procedures.
AIM To compare all modalities of esophagectomies to each other from the results of randomized controlled trials (RCTs) in a network meta-analysis (NMA).
METHODS We conducted a systematic search of the MEDLINE, EMBASE, Reference Citation Analysis (https://www.referencecitationanalysis.com/) and CENTRAL databases to identify RCTs according to the following population, intervention, control, outcome (commonly known as PICO): P: Patients with resectable esophageal cancer; I/C: Transthoracic, transhiatal, minimally invasive (thoracolaparoscopic), hybrid, and robot-assisted esophagectomy; O: Survival, total adverse events, adverse events in subgroups, length of hospital stay, and blood loss. We used the Bayesian approach and the random effects model. We presented the geometry of the network, results with probabilistic statements, estimated intervention effects and their 95% confidence interval (CI), and the surface under the cumulative ranking curve to rank the interventions.
RESULTS We included 11 studies in our analysis. We found a significant difference in postoperative pulmonary infection, which favored the minimally invasive intervention compared to transthoracic surgery (risk ratio 0.49; 95%CI: 0.23 to 0.99). The operation time was significantly shorter for the transhiatal approach compared to transthoracic surgery (mean difference -85 min; 95%CI: -150 to -29), hybrid intervention (mean difference -98 min; 95%CI: -190 to -9.4), minimally invasive technique (mean difference -130 min; 95%CI: -210 to -50), and robot-assisted esophagectomy (mean difference -150 min; 95%CI: -240 to -53). Other comparisons did not yield significant differences.
CONCLUSION Based on our results, the implication of minimally invasive esophagectomy should be favored.
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Affiliation(s)
- Lajos Szakó
- Institute of Translational Medicine, University of Pécs, Medical School, Pécs 7624, Hungary
- János Szentágothai Research Centre, University of Pécs, Medical School, Pécs 7624, Hungary
| | - Dávid Németh
- Institute for Translational Medicine, University of Pécs, Medical School, Pécs 7624, Hungary
- Institute of Bioanalysis, University of Pécs, Medical School, Pécs 7624, Hungary
| | - Nelli Farkas
- Institute of Translational Medicine, University of Pécs, Medical School, Pécs 7624, Hungary
- Institute of Bioanalysis, University of Pécs, Medical School, Pécs 7624, Hungary
| | - Szabolcs Kiss
- Insittute of Translational Medicine, University of Pécs, Medical School, Pécs 7624, Hungary
- Doctoral School of Clinical Medicine, University of Szeged, Medical School, Szeged 6720, Hungary
| | - Réka Zsuzsa Dömötör
- Institute for Translational Medicine, University of Pécs, Medical School, Pécs 7624, Hungary
| | - Marie Anne Engh
- Institute of Translational Medicine, University of Pécs, Medical School, Pécs 7624, Hungary
| | - Péter Hegyi
- Institute of Translational Medicine, University of Pécs, Medical School, Pécs 7624, Hungary
- First Department of Medicine, University of Szeged, Medical School, Szeged 6725, Hungary
| | - Balint Eross
- Institute of Translational Medicine, University of Pecs, Medical School, Pecs 7624, Hungary
| | - András Papp
- Department of Surgery, Clinical Center, University of Pécs, Medical School, Pécs 7624, Hungary
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16
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Plat VD, Stam WT, Bootsma BT, Straatman J, Klausch T, Heineman DJ, van der Peet DL, Daams F. Short-term outcome for high-risk patients after esophagectomy. Dis Esophagus 2022; 36:6611914. [PMID: 35724560 PMCID: PMC9817823 DOI: 10.1093/dote/doac028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 03/29/2022] [Accepted: 02/14/2022] [Indexed: 01/11/2023]
Abstract
Transthoracic esophagectomy (TTE) for esophageal cancer facilitates mediastinal dissection; however, it has a significant impact on cardiopulmonary status. High-risk patients may therefore be better candidates for transhiatal esophagectomy (THE) in order to prevent serious complications. This study addressed short-term outcome following TTE and THE in patients that are considered to have a higher risk of surgery-related morbidity. This population-based study included patients who underwent a curative esophagectomy between 2011 and 2018, registered in the Dutch Upper GI Cancer Audit. The Charlson comorbidity index was used to assign patients to a low-risk (score ≤ 1) and high-risk group (score ≥ 2). Propensity score matching was applied to produce comparable groups between high-risk patients receiving TTE and THE. Primary endpoint was mortality (in-hospital/30-day mortality), secondary endpoints included morbidity and oncological outcomes. Additionally, a matched subgroup analysis was performed, including only cervical reconstructions. Of 5,438 patients, 945 and 431 high-risk patients underwent TTE and THE, respectively. After propensity score matching, mortality (6.3 vs 3.3%, P = 0.050), overall morbidity, Clavien-Dindo ≥ 3 complications, pulmonary complications, cardiac complications and re-interventions were significantly more observed after TTE compared to THE. A significantly higher mortality after TTE with a cervical reconstruction was found compared to THE (7.0 vs. 2.2%, P = 0.020). Patients with a high Charlson comorbidity index predispose for a complicated postoperative course after esophagectomy, this was more outspoken after TTE compared to THE. In daily practice, these outcomes should be balanced with the lower lymph node yield, but comparable positive node count and radicality after THE.
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Affiliation(s)
- Victor D Plat
- Address correspondence to: V.D. Plat, MD, Amsterdam University Medical Centers, VU University Medical center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands.
| | - Wessel T Stam
- Department of Gastrointestinal Surgery, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
| | - Boukje T Bootsma
- Department of Gastrointestinal Surgery, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
| | - Jennifer Straatman
- Department of Gastrointestinal Surgery, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
| | - Thomas Klausch
- Department of Epidemiology and Biostatistics, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
| | - David J Heineman
- Department of Gastrointestinal Surgery, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands,Department of Cardiothoracic Surgery, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
| | - Donald L van der Peet
- Department of Gastrointestinal Surgery, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
| | - Freek Daams
- Department of Gastrointestinal Surgery, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
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17
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Soltani E, Mahmoodzadeh H, Jabbari Nooghabi A, Jabbari Nooghabi M, Ravankhah Moghaddam K, Hassanzadeh Haddad E. Transhiatal versus transthoracic esophagectomy for esophageal SCC: outcomes and complications. J Cardiothorac Surg 2022; 17:150. [PMID: 35681156 PMCID: PMC9185877 DOI: 10.1186/s13019-022-01912-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 06/02/2022] [Indexed: 11/10/2022] Open
Abstract
Background Transhiatal esophagectomy (THE) and transthoracic esophagectomy (TTE) are both accepted procedures for esophageal cancer but still the most effective surgical approach continues to be controversial. This study aimed to determine post-operative complications and outcomes of TTE compared with THE. Methods A retrospective analysis was performed on data of 243 adult patients with resectable esophageal cancer who underwent THE or TTE between December 2016 and October 2018. Demographic data, consisting of preoperative co-morbidities, disease stage, and perioperative morbidity and mortality were collected. Results Among the patients, 99 individuals (40.7%) had a transhiatal resection and 144 (59.3%) had a transthoracic resection. Most patients (83.1%) were above 50 years old with no significant difference between groups (p = 0.297). The frequency distribution of comorbidities was similar in both groups. The most common site of the tumor in TTE group was middle esophagus and in THE group was lower esophagus. The most common complication was recurrence of dysphagia which was more common in THE group without significant difference. The other complications including pulmonary and cardiac events, tracheal and recurrent laryngeal nerve injury, chylothorax and anastomosis stricture did not differ between the groups. The operative mortality within 30 days after the operation was 2.8% with significant difference favored the THE group (THE 0%, TTE 5.2%, p = 0.033). Conclusion Because of the controversies, the decision on the type of surgical technique in esophageal cancer treatment hinges on patient’s co-morbidities, cancer stage, tumor location and surgeon’s experience.
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Affiliation(s)
- Ehsan Soltani
- Surgical Oncology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
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Schizas D, Papaconstantinou D, Krompa A, Athanasiou A, Triantafyllou T, Tsekrekos A, Ruurda JP, Rouvelas I. Minimally invasive oesophagectomy in the prone versus lateral decubitus position: a systematic review and meta-analysis. Dis Esophagus 2022; 35:6310142. [PMID: 34175947 DOI: 10.1093/dote/doab042] [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: 04/11/2021] [Revised: 05/17/2021] [Accepted: 06/01/2021] [Indexed: 12/11/2022]
Abstract
The thoracic phase of minimally invasive esophagectomy was initially performed in the lateral decubitus position (LDP); however, many experts have gradually transitioned to a prone position (PP) approach. The aim of the present systematic review and meta-analysis is to quantitatively compare the two approaches. A systematic literature search of the MEDLINE, Embase, Google Scholar, Web of Knowledge, China National Knowledge Infrastructure and ClinicalTrials.gov databases was undertaken for studies comparing outcomes between patients undergoing minimally invasive esophageal surgery in the PP versus the LDP. In total, 15 studies with 1454 patients (PP; n = 710 vs. LDP; n = 744) were included. Minimally invasive esophagectomy in the PP provides statistically significant reduction in postoperative respiratory complications (Risk ratios 0.5, 95% confidence intervals [CI] 0.34-0.76, P < 0.001), blood loss (weighted mean differences [WMD] -108.97, 95% CI -166.35 to -51.59 mL, P < 0.001), ICU stay (WMD -0.96, 95% CI -1.7 to -0.21 days, P = 0.01) and total hospital stay (WMD -2.96, 95% CI -5.14 to -0.78 days, P = 0.008). In addition, prone positioning increases the overall yield of chest lymph node dissection (WMD 2.94, 95% CI 1.54-4.34 lymph nodes, P < 0.001). No statistically significant difference in regards to anastomotic leak rate, mortality and 5-year overall survival was encountered. Subgroup analysis revealed that the protective effect of prone positioning against pulmonary complications was more pronounced for patients undergoing single-lumen tracheal intubation. A head to head comparison of minimally invasive esophagectomy in the prone versus the LDP reveals superiority of the former method, with emphasis on the reduction of postoperative respiratory complications and reduced length of hospitalization. Long-term oncologic outcomes appear equivalent, although validation through prospective studies and randomized controlled trials is still necessary.
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Affiliation(s)
- Dimitrios Schizas
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Dimitrios Papaconstantinou
- Third Department of Surgery, National and Kapodistrian University of Athens, Attikon University Hopsital, Athens, Greece
| | - Anastasia Krompa
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | | | - Tania Triantafyllou
- First Propedeutic Department of Surgery, National and Kapodistrian University of Athens, Hippocration General Hospital, Athens, Greece
| | - Andrianos Tsekrekos
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden.,Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Jelle P Ruurda
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ioannis Rouvelas
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden.,Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
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19
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Lundberg E, Lagergren P, Mattsson F, Lagergren J. Life Expectancy in Survivors of Esophageal Cancer Compared with the Background Population. Ann Surg Oncol 2022; 29:2805-2811. [PMID: 35190948 PMCID: PMC8989824 DOI: 10.1245/s10434-022-11416-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 01/16/2022] [Indexed: 12/02/2022]
Abstract
It is unknown whether the survival of patients cured of esophageal cancer differs from that of the corresponding background population. This nationwide and population-based cohort study included all patients who survived for at least 5 years after surgery for esophageal cancer in Sweden between 1987 and 2015, with follow-up throughout 2020. Relative survival rates with 95% confidence intervals (95% CI) were calculated by dividing the observed with the expected survival. The expected survival was assessed from the entire Swedish population of the corresponding age, sex, and calendar year. Yearly relative survival rates were calculated between 6 and 10 years postoperatively. Among all 762 participants, the relative survival was initially similar to the background population (96.1%, 95% CI 94.3–97.9%), but decreased each following postoperative year to 83.5% (95% CI 79.5–87.6%) by year 10. The drop in relative survival between 6 and 10 years was more pronounced in participants with a history of squamous cell carcinoma [from 94.5% (95% CI 91.2–97.8%) to 70.8% (95% CI 64.0–77.6%)] than in those with adenocarcinoma [from 96.9% (95% CI 94.8–99.0%) to 91.5% (95% CI 86.6–96.3%)], and in men [from 96.0% (95% CI 93.8–98.1%) to 81.8% (95% CI 76.8–86.8%)] than in women [from 96.4% (95% CI 93.4–99.5%) to 88.1% (95% CI 81.5–94.8%)]. No major differences were found between age groups. In conclusion, esophageal cancer survivors had a decline in survival between 6 and 10 years after surgery compared with the corresponding general population, particularly those with a history of squamous cell carcinoma of the esophagus and male sex.
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Affiliation(s)
- Ellinor Lundberg
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Pernilla Lagergren
- Surgical Care Science, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden. .,Department of Surgery and Cancer, Imperial College London, London, UK.
| | - Fredrik Mattsson
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Jesper Lagergren
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.,School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
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20
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Effect of peri-operative chemotherapy regimen on survival in the treatment of locally advanced oesophago-gastric adenocarcinoma - A comparison of the FLOT and 'MAGIC' regimens. Eur J Cancer 2022; 163:180-188. [PMID: 35085931 DOI: 10.1016/j.ejca.2021.12.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 12/16/2021] [Accepted: 12/19/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Peri-operative chemotherapy improves survival in patients with locally advanced oesophago-gastric adenocarcinoma. Two regimens with proven survival benefits are epirubicin, cisplatin plus capecitabine or fluorouracil (Medical Research Council Adjuvant Gastric Infusional Chemotherapy, MAGIC) and fluorouracil plus leucovorin, oxaliplatin, and docetaxel (FLOT). This study aimed to compare the effect of these regimens on survival (primary aim) and pathological response, surgical complications, adverse events and chemotherapy completion rates. METHODS Cohort study including 946 patients treated with FLOT (n = 257) or MAGIC (n = 689) who underwent surgical resection for oesophageal (n = 743) or gastric (n = 203) adenocarcinoma between 2002 and 2021 at St Thomas' Hospital or The Royal Marsden Hospital, London, UK. Survival analysis was performed using multivariable Cox regression, providing hazard ratios (HRs) with 95% confidence intervals (CIs) adjusted for age, sex, clinical T-stage, clinical N-stage, tumour grade and presence of signet ring cells. RESULTS Patients treated with FLOT had better overall survival (HR = 0.69, 95% CI 0.50-0.94) and disease-free survival (HR = 0.75, 95% CI 0.58-0.98) than MAGIC. Patients treated with FLOT were more likely to have a complete pathological response (9.5% FLOT versus 5.5% MAGIC, p = 0.027) and were less likely to have a positive resection margin (19.1% FLOT versus 32.2% MAGIC, p < 0.001). The stratified analysis revealed similar results for oesophageal and gastric tumours. Rates of surgical complications, chemotherapy-associated adverse events and completion were similarly distributed between treatment groups. CONCLUSIONS Patients with oesophageal or gastric adenocarcinoma treated with peri-operative FLOT had better survival and pathological response than those treated with peri-operative MAGIC. Rates of surgical complications, adverse events and chemotherapy completion were comparable.
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21
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Harris A, Butterworth J, Boshier PR, MacKenzie H, Tokunaga M, Sunagawa H, Mavroveli S, Ni M, Mikhail S, Yeh CC, Blencowe NS, Avery KNL, Hardwick R, Hoelscher A, Pera M, Zaninotto G, Law S, Low DE, van Lanschot JJB, Berrisford R, Barham CP, Blazeby JM, Hanna GB. Development of a Reliable Surgical Quality Assurance System for 2-stage Esophagectomy in Randomized Controlled Trials. Ann Surg 2022; 275:121-130. [PMID: 32224728 DOI: 10.1097/sla.0000000000003850] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim was to develop a reliable surgical quality assurance system for 2-stage esophagectomy. This development was conducted during the pilot phase of the multicenter ROMIO trial, collaborating with international experts. SUMMARY OF BACKGROUND DATA There is evidence that the quality of surgical performance in randomized controlled trials influences clinical outcomes, quality of lymphadenectomy and loco-regional recurrence. METHODS Standardization of 2-stage esophagectomy was based on structured observations, semi-structured interviews, hierarchical task analysis, and a Delphi consensus process. This standardization provided the structure for the operation manual and video and photographic assessment tools. Reliability was examined using generalizability theory. RESULTS Hierarchical task analysis for 2-stage esophagectomy comprised fifty-four steps. Consensus (75%) agreement was reached on thirty-nine steps, whereas fifteen steps had a majority decision. An operation manual and record were created. A thirty five-item video assessment tool was developed that assessed the process (safety and efficiency) and quality of the end product (anatomy exposed and lymphadenectomy performed) of the operation. The quality of the end product section was used as a twenty seven-item photographic assessment tool. Thirty-one videos and fifty-three photographic series were submitted from the ROMIO pilot phase for assessment. The overall G-coefficient for the video assessment tool was 0.744, and for the photographic assessment tool was 0.700. CONCLUSIONS A reliable surgical quality assurance system for 2-stage esophagectomy has been developed for surgical oncology randomized controlled trials. ETHICAL APPROVAL 11/NW/0895 and confirmed locally as appropriate, 12/SW/0161, 16/SW/0098.Trial registration number: ISRCTN59036820, ISRCTN10386621.
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Affiliation(s)
- Alexander Harris
- Department of Surgery & Cancer, Imperial College London, United Kingdom
| | - James Butterworth
- Department of Surgery & Cancer, Imperial College London, United Kingdom
| | - Piers R Boshier
- Department of Surgery & Cancer, Imperial College London, United Kingdom
| | - Hugh MacKenzie
- Department of Surgery & Cancer, Imperial College London, United Kingdom
| | - Masanori Tokunaga
- Department of Gastrointestinal Surgery, Tokyo Medical and Dental University, Japan
| | - Hideki Sunagawa
- Department of Gastroenterological Surgery, New Tokyo Hospital, Japan
| | - Stella Mavroveli
- Department of Surgery & Cancer, Imperial College London, United Kingdom
| | - Melody Ni
- Department of Surgery & Cancer, Imperial College London, United Kingdom
| | - Sameh Mikhail
- Department of General Surgery, Faculty of Medicine University of Cairo, Egypt
| | - Chi-Chuan Yeh
- Department of Surgery, National Taiwan University Hospital, Taiwan
| | - Natalie S Blencowe
- Division of Surgery, University Hospitals Bristol NHS Foundation Trust, United Kingdom
- National Institute for Health Research Bristol Biomedical Research Centre, University of Bristol, United Kingdom
| | - Kerry N L Avery
- National Institute for Health Research Bristol Biomedical Research Centre, University of Bristol, United Kingdom
| | - Richard Hardwick
- Upper gastrointestinal Unit, Cambridge University Hospitals NHS Foundation Trust, United Kingdom
| | - Arnulf Hoelscher
- Center for Esophageal and Gastric Surgery, Agaplesion Markus Hospital, Germany
| | - Manuel Pera
- Department of Surgery, Hospital del Mar, Spain
| | | | - Simon Law
- Department of Esophageal and Upper Gastrointestinal Surgery, The University of Hong Kong Queen Mary Hospital, Hong Kong
| | - Donald E Low
- Department of Thoracic Surgery, Virginia Mason Medical Center, Seattle, WA
| | | | - Richard Berrisford
- Department of Surgery, University Hospitals Plymouth NHS Trust, United Kingdom
| | | | - Jane M Blazeby
- Division of Surgery, University Hospitals Bristol NHS Foundation Trust, United Kingdom
- National Institute for Health Research Bristol Biomedical Research Centre, University of Bristol, United Kingdom
| | - George B Hanna
- Department of Surgery & Cancer, Imperial College London, United Kingdom
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22
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Surgical Therapy of Esophageal Adenocarcinoma-Current Standards and Future Perspectives. Cancers (Basel) 2021; 13:cancers13225834. [PMID: 34830988 PMCID: PMC8616112 DOI: 10.3390/cancers13225834] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 11/15/2021] [Accepted: 11/18/2021] [Indexed: 12/18/2022] Open
Abstract
Simple Summary Subtotal resection of the esophagus with resection of local lymph nodes is the oncological procedure of choice for advanced esophageal cancer. Reconstruction of the intestinal tract is predominantly performed with a gastric tube. Even in specialized centers, this surgical procedure is associated with a high complication but low mortality rate. Therefore, clinical research aims to develop peri- and intra-operative strategies to improve the patient related outcome. Abstract Transthoracic esophagectomy is currently the predominant curative treatment option for resectable esophageal adenocarcinoma. The majority of carcinomas present as locally advanced tumors requiring multimodal strategies with either neoadjuvant chemoradiotherapy or perioperative chemotherapy alone. Minimally invasive, including robotic, techniques are increasingly applied with a broad spectrum of technical variations existing for the oncological resection as well as gastric reconstruction. At the present, intrathoracic esophagogastrostomy is the preferred technique of reconstruction (Ivor Lewis esophagectomy). With standardized surgical procedures, a complete resection of the primary tumor can be achieved in almost 95% of patients. Even in expert centers, postoperative morbidity remains high, with an overall complication rate of 50–60%, whereas 30- and 90-day mortality are reported to be <2% and <6%, respectively. Due to the complexity of transthoracic esophagetomy and its associated morbidity, esophageal surgery is recommended to be performed in specialized centers with an appropriate caseload yet to be defined. In order to reduce postoperative morbidity, the selection of patients, preoperative rehabilitation and postoperative fast-track concepts are feasible strategies of perioperative management. Future directives aim to further centralize esophageal services, to individualize surgical treatment for high-risk patients and to implement intraoperative imaging modalities modifying the oncological extent of resection and facilitating surgical reconstruction.
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Alfaifi S, Chu R, Hui X, Broderick S, Hooker C, Brock M, Bush E, Hales R, Anderson L, Hoff J, Friedes C, Han-Oh S, Mcnutt T, Ha J, Yang S, Battafarano R, Feliciano J, Voong KR. Trimodality therapy for esophageal cancer: The role of surgical and radiation treatment parameters in the development of anastomotic complications. Thorac Cancer 2021; 12:3121-3129. [PMID: 34651445 PMCID: PMC8636205 DOI: 10.1111/1759-7714.14130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/13/2021] [Accepted: 08/14/2021] [Indexed: 01/03/2023] Open
Abstract
Background Here, we investigated the relationship between clinical parameters, including the site of surgical anastomosis and radiation dose to the anastomotic region, and anastomotic complications in esophageal cancer patients treated with trimodality therapy. Methods Between 2007 and 2016, esophageal cancer patients treated with trimodality therapy at a tertiary academic cancer center were identified. Patient, treatment, and outcome parameters were collected. Radiation dose to the gastric regions were extracted. Anastomotic complication was defined as leak and/or stricture. We used Fisher's exact and Wilcoxon rank‐sum tests to compare the association between clinical parameters and anastomotic complications. Results Of 89 patients identified, the median age was 63 years, 82% (n = 73) were male, and 82% had distal (n = 47) or gastroesophageal junction (n = 26) tumors. Median follow‐up was 25.8 months. Esophagectomies were performed with cervical (65%, n = 58) or thoracic anastomoses (35%, n = 31). Anastomotic complications developed in 60% (n = 53). Cervical anastomosis was associated with anastomotic complications (83%, n = 44/53, p < 0.01). Radiation to any gastric substructure was not associated with anastomotic complications (p > 0.05). In the subset of patients with distal/gastroesophageal junction tumors undergoing esophagectomy with cervical anastomosis where radiation was delivered to the future neoesophagus, 80% (n = 35/44) developed anastomotic complications. In this high‐risk subgroup, radiation was not associated with anastomotic complications (p > 0.05). Conclusions Our analysis did not demonstrate an association between radiation dose to gastric substructures and anastomotic complications. However, it showed an association between esophagectomy with cervical anastomosis and anastomotic complications. Patients with distal/gastroesophageal junction tumors who undergo esophagectomy with cervical anastomosis have higher rates of anastomotic complications unrelated to radiation to gastric substructures.
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Affiliation(s)
- Salem Alfaifi
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Robert Chu
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Xuan Hui
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Stephen Broderick
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Craig Hooker
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Malcolm Brock
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Errol Bush
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Russell Hales
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Lori Anderson
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jeffrey Hoff
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Cole Friedes
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Sarah Han-Oh
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Todd Mcnutt
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jinny Ha
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Stephen Yang
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Richard Battafarano
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Joy Feliciano
- Departments of Medical Oncology, Johns Hopkins University, Baltimore, Maryland, USA
| | - K Ranh Voong
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland, USA
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Shi K, Qian R, Zhang X, Jin Z, Lin T, Lang B, Wang G, Cui D, Zhang B, Hua X. Video-assisted mediastinoscopic and laparoscopic transhiatal esophagectomy for esophageal cancer. Surg Endosc 2021; 36:4207-4214. [PMID: 34642798 DOI: 10.1007/s00464-021-08754-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 09/27/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Mediastinoscopy was originally applied for lymph node biopsy and mediastinal tumor resection. Improved video imaging with spreadable working channels enabled mediastinoscopy for inspection and tissue biopsy in the superior mediastinum but it is rarely used in minimally invasive esophageal cancer surgery. In this prospective trial, the practicability and security of spreadable video-assisted mediastinoscopic combined with laparoscopic transhiatal esophagectomy (VAME) with video-assisted thoracoscopic esophagectomy (VATE) were compared. METHODS A total of 200 eligible patients with esophageal squamous cell carcinoma were randomly divided into VAME or VATE groups. Early postoperative outcomes and lymph node dissection between the two groups were compared. RESULTS The operation time was significantly shorter (164.3 ± 47.0 min vs. 265.4 ± 47.2 min, P < 0.001), the number of dissected lymph nodes was less (15.8 ± 4.5 vs. 20.3 ± 6.5, P < 0.001), and the intraoperative blood loss was also significantly reduced (94.7 ± 56.7 mL vs. 184.4 ± 65.2 mL, P < 0.001) in the VAME compared to the VATE group, respectively. The incidence of pneumonia was lower (7% vs. 29%; P < 0.001) and the length of hospital stay was shorter in the VAME group compared to the VATE group (18.0 ± 7.6 days vs. 23.2 ± 7.2, P < 0.001, respectively). The chyle leak incidence appeared to be lower in the VAME group but statistical significance was not reached (1% vs. 4%; P = 0.369). There were no differences in the incidence of anastomotic leakages and recurrent laryngeal nerve paralysis between the groups. No 30-day mortality occurred in any of the cases. CONCLUSION VAME appears to be a practicable and secure method for esophagectomy but needs further proof of concept. Clinical registration number: Registered at Chinese Clinical Trial Registry, ChiCTR1900022797.
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Affiliation(s)
- Kefeng Shi
- Department of Thoracic Surgery, Henan Provincial Chest Hospital, No. 1 Weiwu Road, Zhengzhou, 450000, China
| | - Rulin Qian
- Department of Thoracic Surgery, Henan Provincial Chest Hospital, No. 1 Weiwu Road, Zhengzhou, 450000, China.
| | - Xiao Zhang
- Department of Thoracic Surgery, Luoyang Central Hospital Affiliated To Zhengzhou University, No. 288 Zhongzhou Middle Road, Luoyang, 471099, China.
| | - Zhe Jin
- Department of Thoracic Surgery, Nanyang Central Hospital, Nanyang, 473003, China
| | - Tao Lin
- Department of Thoracic Surgery, Nanyang Central Hospital, Nanyang, 473003, China
| | - Baoping Lang
- Department of Thoracic Surgery, Luoyang Central Hospital Affiliated To Zhengzhou University, No. 288 Zhongzhou Middle Road, Luoyang, 471099, China
| | - Guolei Wang
- Department of Thoracic Surgery, Henan Provincial Chest Hospital, No. 1 Weiwu Road, Zhengzhou, 450000, China
| | - Dong Cui
- Department of Thoracic Surgery, Henan Provincial Chest Hospital, No. 1 Weiwu Road, Zhengzhou, 450000, China
| | - Binbin Zhang
- Department of Thoracic Surgery, Henan Provincial Chest Hospital, No. 1 Weiwu Road, Zhengzhou, 450000, China
| | - Xionghuai Hua
- Department of Thoracic Surgery, Henan Provincial Chest Hospital, No. 1 Weiwu Road, Zhengzhou, 450000, China
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Deng XM, Zhu TY, Wang GJ, Gao BL, Wang JT, Li RX, Zhang YF, Ding HX. Lymph node metastasis pattern and significance of left gastric artery lymph node dissection in esophagectomy for esophageal cancers. World J Surg Oncol 2021; 19:296. [PMID: 34635107 PMCID: PMC8504036 DOI: 10.1186/s12957-021-02405-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 09/19/2021] [Indexed: 12/02/2022] Open
Abstract
Purpose To investigate the lymph node metastasis pattern and significance of dissection of the left gastric artery lymph nodes in radical en bloc esophagectomy for esophageal squamous carcinomas based on the lymphatic drainage pathway revealed by carbon nanoparticle labeling. Materials and methods Patients who underwent en bloc esophagectomy endoscopically were retrospectively enrolled. Carbon nanoparticles were injected in the submucosa of upper thoracic esophagus to label the relevant draining lymph nodes. The clinical data, lymph nodes dissected, surgical technique, and complications were analyzed. Results En bloc esophagectomy was successful in all 179 patients. Metastases to the left gastric artery lymph nodes were positive in 42 patients (23.5%) but negative in 137 (76.5%). The left gastric lymph nodes were labeled, whereas no celiac lymph nodes were labeled by carbon nanoparticles. A total of 4652 lymph nodes were resected, with 26 lymph nodes per patient. Seventy-three patients had lymph node metastasis (73/179). Seventeen patients had metastasis to the recurrent laryngeal nerve lymph nodes (9.5%). The metastasis rate of the lower thoracic esophageal cancer to the left gastric artery lymph nodes was 37.0%, significantly greater than that at the middle (15.4%) or upper (6.7%) thoracic segment. The lymph node metastasis rate was significantly (P < 0.05) increased with the length of the cancerous lesion, infiltration depth, and poor differentiation. Univariate analysis revealed that the metastasis rate to the left gastric artery lymph nodes was significantly (P < 0.05) associated with paraesophageal lymph node metastasis, para-cardial lymph metastasis, and TNM classification. Multivariate analysis indicated that cancer location (odds ratio 8.32, 95% confidence interval 2.12–32.24) was significantly (P < 0.05) associated with metastasis to the left gastric artery lymph nodes, with the cancer at the middle and lower thoracic segments significantly more than in the upper thoracic segment. Conclusion Certain patterns exist in lymph node metastasis of esophageal cancer, and in radical esophagectomy of esophageal cancers, dissection of the left gastric artery lymph nodes is necessary to prevent possible residual or metastasis of esophageal squamous carcinomas based on the lymphatic drainage pathway of esophageal carcinomas demonstrated by carbon nanoparticle labeling.
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Affiliation(s)
- Xiu-Mei Deng
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Zhengzhou University, 1 Jianshe Road, Zhengzhou, 450052, China
| | - Tian-Yu Zhu
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Zhengzhou University, 1 Jianshe Road, Zhengzhou, 450052, China
| | - Guo-Jun Wang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Zhengzhou University, 1 Jianshe Road, Zhengzhou, 450052, China.
| | - Bu-Lang Gao
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Zhengzhou University, 1 Jianshe Road, Zhengzhou, 450052, China
| | - Jing-Tao Wang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Zhengzhou University, 1 Jianshe Road, Zhengzhou, 450052, China
| | - Rui-Xin Li
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Zhengzhou University, 1 Jianshe Road, Zhengzhou, 450052, China
| | - Yun-Fei Zhang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Zhengzhou University, 1 Jianshe Road, Zhengzhou, 450052, China
| | - Heng-Xuan Ding
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Zhengzhou University, 1 Jianshe Road, Zhengzhou, 450052, China
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Ye H, Wang X, Li X, Gan X, Zhong H, Wu X, Cao Q. Effect of single-port inflatable mediastinoscopy simultaneous laparoscopic-assisted radical esophagectomy on respiration and circulation. J Cardiothorac Surg 2021; 16:288. [PMID: 34627298 PMCID: PMC8502305 DOI: 10.1186/s13019-021-01671-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 09/25/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND AND PURPOSE We previously developed a new surgical method, namely, single-port inflatable mediastinoscopy simultaneous laparoscopic-assisted radical esophagectomy. The purpose of this study was to evaluate the effect of carbon dioxide inflation on respiration and circulation using this approach. METHODS From April 2018 to October 2020, 105 patients underwent this novel surgical approach. The changes in respiratory and circulatory functions were reported when the mediastinal pressure and pneumoperitoneum pressure were 10 and 12 mmHg, respectively. Data on blood loss, operative time, and postoperative complications were also collected. RESULTS 104 patients completed the operation successfully, except for 1 patient who was converted to thoracotomy because of intraoperative injury. During the operation, respectively, the heart rate, mean arterial pressure, central venous pressure, peak airway pressure, end-expiratory partial pressure of carbon dioxide and partial pressure of carbon dioxide increased in an admissibility range. The pH and oxygenation index decreased 1 h after inflation, but these values were all within a safe and acceptable range and restored to the baseline level after CO2 elimination. Postoperative complications included anastomotic fistula (8.6%), pleural effusion that needed to be treated (8.6%), chylothorax (0.9%), pneumonia (7.6%), arrhythmia (3.8%) and postoperative hoarseness (18.2%). There were no cases of perioperative death. CONCLUSIONS When the inflation pressure in the mediastinum and abdomen was 10 mmHg and 12 mmHg, respectively, the inflation of carbon dioxide from single-port inflatable mediastinoscopy simultaneous laparoscopic-assisted radical esophagectomy did not cause serious changes in respiratory and circulatory function or increase perioperative complications.
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Affiliation(s)
- Haibo Ye
- Department of Thoracic Surgery, The Fifth Affiliated Hospital of Sun Yat-Sen University, 52 East Meihua Road, Xiangzhou District, Zhuhai, 519000, Guangdong, China
- Department of Anesthesia, The Fifth Affiliated Hospital of Sun Yat-Sen University, 52 East Meihua Road, Xiangzhou District, Zhuhai, 519000, Guangdong, China
| | - Xiaojin Wang
- Department of Thoracic Surgery, The Fifth Affiliated Hospital of Sun Yat-Sen University, 52 East Meihua Road, Xiangzhou District, Zhuhai, 519000, Guangdong, China
| | - Xiaojian Li
- Department of Thoracic Surgery, The Fifth Affiliated Hospital of Sun Yat-Sen University, 52 East Meihua Road, Xiangzhou District, Zhuhai, 519000, Guangdong, China
| | - Xiangfeng Gan
- Department of Thoracic Surgery, The Fifth Affiliated Hospital of Sun Yat-Sen University, 52 East Meihua Road, Xiangzhou District, Zhuhai, 519000, Guangdong, China
| | - Hongcheng Zhong
- Department of Thoracic Surgery, The Fifth Affiliated Hospital of Sun Yat-Sen University, 52 East Meihua Road, Xiangzhou District, Zhuhai, 519000, Guangdong, China
| | - Xiangwen Wu
- Department of Thoracic Surgery, The Fifth Affiliated Hospital of Sun Yat-Sen University, 52 East Meihua Road, Xiangzhou District, Zhuhai, 519000, Guangdong, China.
| | - Qingdong Cao
- Department of Thoracic Surgery, The Fifth Affiliated Hospital of Sun Yat-Sen University, 52 East Meihua Road, Xiangzhou District, Zhuhai, 519000, Guangdong, China.
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Takahashi C, Shridhar R, Huston J, Blinn P, Maramara T, Meredith K. Comparative outcomes of transthoracic versus transhiatal esophagectomy. Surgery 2021; 170:263-270. [PMID: 33894983 DOI: 10.1016/j.surg.2021.02.036] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 02/09/2021] [Accepted: 02/11/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Surgical resection has become a mainstay of therapy for locally advanced esophageal cancer and can increase survival significantly. With the advancement of minimally invasive surgery, there is still debate on the best approach for esophagectomy. We report a modern analysis of outcomes with transthoracic versus transhiatal esophagectomy. METHODS A prospectively managed esophagectomy database was queried for patients undergoing transthoracic or transhiatal esophagectomy between 1996 and 2016. Continuous variables were compared using the Kruskal-Wallis or the analysis of variance tests as appropriate. Pearson χ2 test was used to compare categorical variables. All statistical tests were 2-sided and an α (type I) error < .05 was considered statistically significant. RESULTS A total of 846 patients underwent esophagectomy with a median age of 66 (28-86) years. There was no difference in estimated blood loss for transthoracic and transhiatal, but mean operating room times were longer for transthoracic versus transhiatal (P < .001), and the number of retrieved lymph nodes was higher for transthoracic versus transhiatal (P < .002). Postoperative complications occurred in 207 (29%) transthoracic patients vs 59 (44.7%) transhiatal patients, (P < .001). The most common complications in transthoracic versus transhiatal techniques, respectively, were anastomotic leaks: 4.3% vs 9.8%; (P = .01), anastomotic stricture 7% vs 26.5%; (P < .001), and pneumonia 12.6% vs 22.7%; (P < .002). Median survival significantly improved in patients undergoing transthoracic (62 months) vs transhiatal (39 months) P = .03. CONCLUSION We found that a transthoracic approach was associated with lower pneumonias, anastomotic leaks, wound infections, and strictures, with an improvement in nodal harvest. Survival was also significantly improved in patients who underwent transthoracic esophagectomy.
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Affiliation(s)
| | | | - Jamie Huston
- Sarasota Memorial Institute for Cancer Care, Sarasota, FL
| | - Paige Blinn
- Sarasota Memorial Institute for Cancer Care, Florida State University College of Medicine, Sarasota, FL
| | - Taylor Maramara
- Sarasota Memorial Institute for Cancer Care, Florida State University College of Medicine, Sarasota, FL
| | - Kenneth Meredith
- Sarasota Memorial Institute for Cancer Care, Florida State University College of Medicine, Sarasota, FL.
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Vieira FM, Chedid MF, Gurski RR, Schirmer CC, Cavazzola LT, Schramm RV, Rosa ARP, Kruel CDP. TRANSHIATAL ESOPHAGECTOMY IN SQUAMOUS CELL CARCINOMA OF THE ESOPHAGUS: WHAT ARE THE BEST INDICATIONS? ACTA ACUST UNITED AC 2021; 33:e1567. [PMID: 33759957 PMCID: PMC7983525 DOI: 10.1590/0102-672020200004e1567] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 11/04/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Overall survival in patients who underwent transhiatal esophagectomy submitted or not to neoadjuvant therapy. Southern Brazil has one of the highest incidences of esophageal squamous cell carcinoma in the world. Transthoracic esophagectomy allows more complete abdominal and thoracic lymphadenectomy than transhiatal. However, this one is associated with less morbidity. AIM To analyze the outcomes and prognostic factors of squamous esophageal cancer treated with transhiatal procedure. METHODS All patients selected for transhiatal approach were included as a potentially curative treatment and overall survival, operative time, lymph node analysis and use of neoadjuvant therapy were analyzed. RESULTS A total of 96 patients were evaluated. The overall 5-year survival was 41.2%. Multivariate analysis showed that operative time and presence of positive lymph nodes were both associated with a worse outcome, while neoadjuvant therapy was associated with better outcome. The negative lymph-node group had a 5-year survival rate of 50.2%. CONCLUSION Transhiatal esophagectomy can be safely used in patients with malnutrition degree that allows the procedure, in those with associated respiratory disorders and in the elderly. It provides considerable long-term survival, especially in the absence of metastases to local lymph nodes. The wider use of neoadjuvant therapy has the potential to further increase long-term survival.
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Affiliation(s)
- Felipe Monge Vieira
- Postgraduate Program in Surgical Sciences, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Marcio Fernandes Chedid
- Postgraduate Program in Surgical Sciences, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil.,Department of Digestive Surgery, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Richard Ricachenevsky Gurski
- Postgraduate Program in Surgical Sciences, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil.,Department of Digestive Surgery, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Carlos Cauduro Schirmer
- Department of Digestive Surgery, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Leandro Totti Cavazzola
- Postgraduate Program in Surgical Sciences, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil.,Department of General Surgery, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Ricardo Vitiello Schramm
- Postgraduate Program in Surgical Sciences, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
| | | | - Cleber Dario Pinto Kruel
- Postgraduate Program in Surgical Sciences, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil.,Department of Digestive Surgery, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
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Minimally Invasive Esophagectomy the Standard of Care: Experience from a Tertiary Care Cancer Center from India. Indian J Surg Oncol 2021; 12:335-349. [PMID: 34295078 DOI: 10.1007/s13193-021-01291-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Accepted: 02/24/2021] [Indexed: 10/21/2022] Open
Abstract
For localized esophageal cancer, esophageal resection remains the prime form of treatment but is a highly invasive procedure associated with prohibitive morbidity. Minimally invasive esophagectomy (MIE) by laparoscopic or thoracoscopic approach was therefore introduced to reduce surgical trauma and its associated morbidity. We thereby review our minimally invasive esophagectomy results with short- and long-term outcomes. From January 2010 through December 2016, 459 patients with carcinoma esophagus and gastro-esophageal junction undergoing minimally invasive esophagectomy were retrospectively reviewed. The morbidity, mortality data with short- and long-term results of the procedure were studied. Patients were stratified into two arms based on the approach into minimally invasive transhiatal esophagectomy (MI-THE) and minimal invasive transthoracic esophagectomy TTE (MI-THE). Thirty days mortality in the whole cohort was 3.5% (2.5% in MI-THE vs. 5% in MI-TTE arm). Anastomotic leak rates (5 vs. 4.9%), median intensive care unit (ICU) stay (4 days), hospital stay (9 days), were similar between both the approaches. Major pulmonary complications were significantly higher in MI-TTE arm (18.9% vs 12.5%) (p 0.047). Cardiac, renal, conduit-related complication rates, vocal cord palsy, chyle leak, re-exploration, and late stricture rates were similar between the groups. The median number of nodes resected was higher in the MI-TTE arm (14 vs. 12) (p 0.002). R0 resection rate in the entire cohort was 89% (87.4% in MI-THE, 92% in MI-TTE arm p 0.12). The median overall survival and disease-free survival were also not different between MI-THE and MI-TTE arms (34 vs. 38 months, p 0.64) (24 vs. 36 months, p 0.67). Minimally invasive esophagectomy either by transhiatal or transthoracic approach is feasible and can be safely accomplished with a low morbidity and mortality and with satisfactory R0 resection rates, good nodal harvest, and acceptable long-term oncological outcomes.
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Deo KB, Singh H, Gupta V, Das A, Verma GR, Gupta R. Thoracoscopy-Assisted Esophagectomy vs Transhiatal Esophagectomy for Carcinoma Esophagus: a Prospective Comparison of Short-Term Outcomes. J Gastrointest Cancer 2021; 53:333-340. [PMID: 33629171 DOI: 10.1007/s12029-021-00607-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2021] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Transhiatal esophagectomy (THE) was popularized to reduce the morbidity of esophagectomy. Thoracoscopy-assisted esophagectomy (TAE) offers esophageal dissection under magnified vision. This study compares the short-term morbidity and oncological outcome following TAE and THE for esophageal carcinoma. METHODOLOGY This is a prospective comparative (January 2017-May 2018) study between TAE and THE for >cT1bN1 esophageal carcinoma. After neoadjuvant chemoradiotherapy (NACRT), responders and patients with stable diseases were subjected to surgery. Thoracoscopy in esophagectomy was performed in prone position. Follow-up duration was at least 4 weeks post-discharge. RESULTS Thirty-three patients of esophageal carcinoma undergoing TAE (n = 18) or THE (n = 15) were included. Common locations of tumor were lower third of esophagus (72.7%) and esophagogastric junction (18.2%). Majority (73.3%) had squamous cell carcinoma. Median interval between NACRT and surgery was 13 weeks. The mean operating time was significantly more with TAE than THE (292.5 vs 207.33 min, p = 0.005). R0 resection rate in TAE was 83.3% compared with 66.7% in THE. There was no difference in the lymph node yield. There was non-significant trend towards lower incidence of major pulmonary complication (66.7% vs 80.0%), cardiac complications (27.8% vs 46.7%), anastomotic leak (27.8% vs 46.7%), recurrent laryngeal nerve palsy (16.7% vs 20.0%), and overall major morbidity (Clavien-Dindo ≥ III) (44.4% vs 66.7%) in TAE than THE. The chyle leak was observed more in TAE (16.7%) than THE (6.7%). CONCLUSIONS TAE achieved higher R0 resection rate and better short-term morbidity than THE. Enrollment of small number of cases in the study precluded statistical significance. TRIAL REGISTRATION This study was registered in Clinical Trial Registry-India (CTRI registration no: CTRI/2018/05/013880) in 14-05-2018.
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Affiliation(s)
- Kunal Bikram Deo
- Department of Surgical Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
- Department of Surgery, B P Koirala Institute of Health Sciences, Dharan, Nepal
| | - Harjeet Singh
- Department of Surgical Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Vikas Gupta
- Department of Surgical Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ashim Das
- Department of Histopathology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ganga Ram Verma
- Department of Surgical Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Rajesh Gupta
- Department of Surgical Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.
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Wang T, Wu Y, Zhou H, Wu C, Zhang X, Chen Y, Zhao D. Development and validation of a novel competing risk model for predicting survival of esophagogastric junction adenocarcinoma: a SEER population-based study and external validation. BMC Gastroenterol 2021; 21:38. [PMID: 33499821 PMCID: PMC7836166 DOI: 10.1186/s12876-021-01618-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 01/17/2021] [Indexed: 12/16/2022] Open
Abstract
Background Adenocarcinoma in Esophagogastric Junction (AEG) is a severe gastrointestinal malignancy with a unique clinicopathological feature. Hence, we aimed to develop a competing risk nomogram for predicting survival for AEG patients and compared it with new 8th traditional tumor-node-metastasis (TNM) staging system. Methods Based on data from the Surveillance, Epidemiology, and End Results (SEER) database of AEG patients between 2004 and 2010, we used univariate and multivariate analysis to filter clinical factors and then built a competing risk nomogram to predict AEG cause-specific survival. We then measured the clinical accuracy by comparing them to the 8th TNM stage with a Receiver Operating Characteristic (ROC) curve, Brier score, and Decision Curve Analysis (DCA). External validation was performed in 273 patients from China National Cancer Center. Results A total of 1755 patients were included in this study. The nomogram was based on five variables: Number of examined lymph nodes, grade, invasion, metastatic LNs, and age. The results of the nomogram was greater than traditional TNM staging with ROC curve (1-year AUC: 0.747 vs. 0.641, 3-year AUC: 0.761 vs. 0.679, 5-year AUC: 0.759 vs. 0.682, 7-year AUC: 0.749 vs. 0.673, P < 0.001), Brier score (3-year: 0.198 vs. 0.217, P = 0.012; 5-year: 0.198 vs. 0.216, P = 0.008; 7-year: 0.199 vs. 0.215, P = 0.014) and DCA. In external validation, the nomogram also showed better diagnostic value than traditional TNM staging and great prediction accuracy. Conclusion We developed and validated a novel nomogram and risk stratification system integrating clinicopathological characteristics for AEG patients. The model showed superior prediction ability for AEG patients than traditional TNM classification.
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Affiliation(s)
- Tongbo Wang
- Department of Pancreatic and Gastric Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 17 PanjiayuanNanli, Chaoyang District, Beijing, 100021, China
| | - Yan Wu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Pathology, Peking University Cancer Hospital & Institute, Beijing, 100142, China
| | - Hong Zhou
- Department of Pancreatic and Gastric Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 17 PanjiayuanNanli, Chaoyang District, Beijing, 100021, China
| | - Chaorui Wu
- Department of Pancreatic and Gastric Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 17 PanjiayuanNanli, Chaoyang District, Beijing, 100021, China
| | - Xiaojie Zhang
- Department of Pancreatic and Gastric Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 17 PanjiayuanNanli, Chaoyang District, Beijing, 100021, China
| | - Yingtai Chen
- Department of Pancreatic and Gastric Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 17 PanjiayuanNanli, Chaoyang District, Beijing, 100021, China.
| | - Dongbing Zhao
- Department of Pancreatic and Gastric Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 17 PanjiayuanNanli, Chaoyang District, Beijing, 100021, China.
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Narayan RR, Poultsides GA. Advances in the surgical management of gastric and gastroesophageal junction cancer. Transl Gastroenterol Hepatol 2021; 6:16. [PMID: 33409410 DOI: 10.21037/tgh.2020.02.06] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 01/15/2020] [Indexed: 12/21/2022] Open
Abstract
Since Theodore Billroth and Cesar Roux perfected the methods of post-gastrectomy reconstruction in the late 19th century, surgical management of gastric and gastroesophageal cancer has made incremental progress. The majority of patients with localized disease are treated with perioperative combination chemotherapy or neoadjuvant chemoradiation. Staging laparoscopy before initiation of treatment or before surgical resection has improved staging accuracy and can drastically inform treatment decisions. The longstanding and contentious debate on the optimal extent of lymph node dissection for gastric cancer appears to have settled in favor of D2 dissection with the recently published 15-year follow-up of the Dutch randomized trial. Minimally invasive gastric and gastroesophageal resections are performed routinely in most centers affording faster recovery and equivalent oncologic outcomes. Pylorus-preserving distal (central) gastrectomy has emerged as a less invasive, function-preserving option for T1N0 middle-third gastric cancers, while randomized data on its oncologic adequacy are pending. Multi-visceral resections and cytoreductive surgery with hyperthermic intraperitoneal chemotherapy has been utilized selectively for patients with locally advanced tumors who have demonstrated disease control on preoperative chemotherapy. This review summarizes the current standard of surgical care for gastroesophageal junction and gastric cancer as well as highlights recent and upcoming advances to the field.
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Affiliation(s)
- Raja R Narayan
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - George A Poultsides
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
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Pratap A, McCarter MD, Watson TJ. Surgical Management of Barrett's-Related Neoplasia. Gastrointest Endosc Clin N Am 2021; 31:205-218. [PMID: 33213796 DOI: 10.1016/j.giec.2020.09.003] [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: 02/04/2023]
Abstract
The management of Barrett's-related neoplasia has benefited from advances in endoscopic assessment, resection, and ablation, along with improved pathologic and radiographic staging. The development of specialized, high-volume esophageal multidisciplinary teams, with improvements in patient selection, preparation, perioperative care, minimally invasive operative approaches, and enhanced recovery after surgery programs, has contributed to improved outcomes for patients undergoing esophagectomy for Barrett's-related neoplasia.
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Affiliation(s)
- Akshay Pratap
- Department of Surgery, University of Colorado, Aurora, CO, USA
| | - Martin D McCarter
- Department of Surgery, Division of Surgical Oncology, University of Colorado Denver, Academic Office One, L15-6106, 12631 East 17th Avenue, MS C325, Aurora, CO 80045, USA.
| | - Thomas J Watson
- Department of Surgery, MedStar Georgetown University Hospital, Georgetown University School of Medicine, 3900 Reservoir Road Northwest, Washington, DC 20007, USA
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Evaluation of subcarinal lymph node dissection and metastasis in transmediastinal radical esophagectomy. Esophagus 2021; 18:461-467. [PMID: 33599862 PMCID: PMC8172491 DOI: 10.1007/s10388-021-00824-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 02/05/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND The aim of the present study was to evaluate subcarinal lymph node dissection in transmediastinal radical esophagectomy and subcarinal lymph node metastasis in patients with esophageal cancer. METHODS Three hundred and twenty-three patients with primary esophageal cancer who underwent transmediastinal or transthoracic esophagectomy with radical two- or three-field lymph node dissection were retrospectively investigated. The clinicopathological characteristics of patients with subcarinal lymph node metastasis were analyzed in detail. RESULTS The median of dissected subcarinal lymph nodes in transmediastinal and transthoracic esophagectomy groups was 6 and 7, respectively, and there was no significant difference between the two groups (p = 0.12). Of all patients, 26 (8.0%) were pathologically diagnosed as positive for subcarinal lymph node metastasis, whereas only 7 (26.9%) of those with metastasis were preoperatively diagnosed as positive. In addition, all patients with subcarinal lymph node metastasis had other non-subcarinal lymph node metastasis. By univariate analysis, subcarinal lymph node metastasis was found in larger (≥ 30 mm) and deeper (T3/T4a) primary lesions (p = 0.02 and 0.02, respectively), but it was not found in 49 patients with the primary lesion located in the upper thoracic esophagus. CONCLUSIONS Subcarinal lymph nodes can be dissected in transmediastinal esophagectomy, almost equivalent to transthoracic esophagectomy. The tumor size, depth, and location may be predictive factors for subcarinal lymph node metastasis.
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A 10-year ACS-NSQIP Analysis of Trends in Esophagectomy Practices. J Surg Res 2020; 256:103-111. [DOI: 10.1016/j.jss.2020.06.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 05/29/2020] [Accepted: 06/16/2020] [Indexed: 02/06/2023]
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Baram A, Sherzad H. Trans-thoracic versus trans-hiatal resection for oesophageal carcinoma: a retrospective comparative study of a single-centre case series. THE CARDIOTHORACIC SURGEON 2020; 28:25. [PMID: 38624644 PMCID: PMC7686938 DOI: 10.1186/s43057-020-00035-y] [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: 07/20/2020] [Accepted: 11/10/2020] [Indexed: 12/24/2022] Open
Abstract
Background Oesophageal carcinoma (EC) is the eighth most common cancer. Surgery is the cornerstone of management for resectable EC. Trans-thoracic oesophagectomy (TTE) and trans-hiatal oesophagectomy (THE) are the two most widely practised procedures. Most of the related controversies are centred on both early and late post-operative complications and mortality (in terms of overall survival and cancer-free survival).This was a single-centre, retrospective, comparative study analysing the outcomes of two EC resection methods. All 87 patients underwent surgery by the same surgical team over 13 years. Consequently, 87 oesophagectomies with curative intent were performed and divided into the TTE group (group A = 47) and the THE group (group B = 40). Results The mean patient age was 65.60 ± 6.30 years in the TTE group and 63.48 ± 9.34 years in the THE group. No significant difference was found in operative time, blood loss or duration of stay in the intensive care unit. The duration of hospital stay was significantly different between the THE and TTE groups (17.25 ± 5.92 vs. 12.93 ± 3.44, respectively; P ≤ 0.001). In-hospital mortality was higher in the TTE group (9/47, 19.14%) than in the THE group (5/40, 12.5%) (P = 0.400). The mean survival rate from our series showed the superiority of group A (TTE) (65.56 months) over group B (THE) (45.01 months), with P = 0.146. Conclusion No high level of evidence suggests the superiority of one surgical procedure over another. The THE procedure is less time-consuming concerning care and follow-up, and most patients were more satisfied and experienced less pain than with the TTE procedure. Both THE and TTE have comparable post-operative anastomotic complications, and they have no significant long-term survival differences.
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Affiliation(s)
- Aram Baram
- Department of Surgery, School of Medicine, Faculty of Medical Sciences, University of Sulaimani, François Mitterrand Street, Sulaymaniyah, 46001 Iraq
- Department of Thoracic and Cardiovascular Surgery, Sulaimani Teaching Hospital, Al Sulaymaniyah, Kurdistan Region 46001 Iraq
| | - Hiwa Sherzad
- Kurdistan Board for Medical Specialization/Cardiothoracic and Vascular Surgery, Sulaimani DOH, Al Sulaymaniyah, Kurdistan Region Iraq
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The Association of Textbook Outcome and Long-Term Survival After Esophagectomy for Esophageal Cancer. Ann Thorac Surg 2020; 112:1134-1141. [PMID: 33221197 DOI: 10.1016/j.athoracsur.2020.09.035] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 09/11/2020] [Accepted: 09/16/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Esophagectomy is the key component of curative esophageal cancer treatment. Textbook outcome is a composite measure describing an optimal perioperative course, including variables related to radical resection, including at least 15 lymph nodes, and an uncomplicated postoperative course without hospital readmission. This study assessed clinicopathologic predictors of textbook outcome and the association of textbook outcome with survival in 2 tertiary referral centers. METHODS All patients with esophageal cancer who underwent esophagectomy with gastric tube reconstruction and curative intent between 2007 and 2016 were included. Patients with carcinoma in situ and patients undergoing a salvage or nonelective procedure were excluded. The primary end point was the association of textbook outcome of esophageal cancer surgery with long-term survival. Secondary end points were clinicopathologic predictors of textbook outcome. RESULTS In total, 1065 patients were included, of whom 327 achieved textbook outcome (30.7%). Squamous cell carcinoma (odds ratio [OR], 0.56; 95% confidence interval [CI], 0.39 to 0.80), hybrid approach (OR, 0.30; 95% CI, 0.10 to 0.89), and American Society of Anesthesiologists (ASA) class II or higher predicted worse textbook rates (ASA class II: OR, 0.33, 95% CI, 0.22 to 0.49; ASA class III or IV: OR, 0.68; 95% CI, 0.48 to 0.96), whereas neoadjuvant therapy predicted a better textbook rate (OR, 1.58; 95% CI, 1.08 to 2.31). Superior overall (hazard ratio, 0.77; 95% CI, 0.64 to 0.93) and disease-free survival (hazard ratio, 0.80; 95% CI, 0.67 to 0.96) were observed in the textbook outcome group. CONCLUSIONS Achieved textbook outcome was associated with better overall and disease-free survival, thus illustrating the association of improved short-term outcomes and long-term survival and the importance of pursuing textbook outcome.
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Kamarajah SK, Marson EJ, Zhou D, Wyn-Griffiths F, Lin A, Evans RPT, Bundred JR, Singh P, Griffiths EA. Meta-analysis of prognostic factors of overall survival in patients undergoing oesophagectomy for oesophageal cancer. Dis Esophagus 2020; 33:5843554. [PMID: 32448903 DOI: 10.1093/dote/doaa038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 03/25/2020] [Accepted: 04/17/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Currently, the American Joint Commission on Cancer (AJCC) staging system is used for prognostication for oesophageal cancer. However, several prognostically important factors have been reported but not incorporated. This meta-analysis aimed to characterize the impact of preoperative, operative, and oncological factors on the prognosis of patients undergoing curative resection for oesophageal cancer. METHODS This systematic review was performed according to PRISMA guidelines and eligible studies were identified through a search of PubMed, Scopus, and Cochrane CENTRAL databases up to 31 December 2018. A meta-analysis was conducted with the use of random-effects modeling to determine pooled univariable hazard ratios (HRs). The study was prospectively registered with the PROSPERO database (Registration: CRD42018157966). RESULTS One-hundred and seventy-one articles including 73,629 patients were assessed quantitatively. Of the 122 factors associated with survival, 39 were significant on pooled analysis. Of these. the strongly associated prognostic factors were 'pathological' T stage (HR: 2.07, CI95%: 1.77-2.43, P < 0.001), 'pathological' N stage (HR: 2.24, CI95%: 1.95-2.59, P < 0.001), perineural invasion (HR: 1.54, CI95%: 1.36-1.74, P < 0.001), circumferential resection margin (HR: 2.17, CI95%: 1.82-2.59, P < 0.001), poor tumor grade (HR: 1.53, CI95%: 1.34-1.74, P < 0.001), and high neutrophil:lymphocyte ratio (HR: 1.47, CI95%: 1.30-1.66, P < 0.001). CONCLUSION Several tumor biological variables not included in the AJCC 8th edition classification can impact on overall survival. Incorporation and validation of these factors into prognostic models and next edition of the AJCC system will enable personalized approach to prognostication and treatment.
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Affiliation(s)
- Sivesh K Kamarajah
- Northern Oesophagogastric Cancer Unit, Newcastle University NHS Foundation Trust Hospitals, Newcastle upon Tyne, UK.,Institute of Cellular Medicine, University of Newcastle, Newcastle upon Tyne, UK
| | - Ella J Marson
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Dengyi Zhou
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | | | - Aaron Lin
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Richard P T Evans
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Institute of Immunology and Immunotherapy, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - James R Bundred
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Pritam Singh
- Department of Upper Gastrointestinal Surgery, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Ewen A Griffiths
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
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Liu W, Guo X, Zhao H, Yu X, Wang C, Du L, Wang F, Mu J. Mediastinoscopy-assisted transhiatal esophagectomy versus thoraco-laparoscopic esophagectomy for esophageal cancer: a single-center initial experience. J Thorac Dis 2020; 12:4908-4914. [PMID: 33145064 PMCID: PMC7578494 DOI: 10.21037/jtd-20-1328] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Background We aimed to compare mediastinoscopy-assisted transhiatal esophagectomy (MATHE) with thoraco-laparoscopic esophagectomy (TLE) for patients with esophageal cancer in terms of the clinical effectiveness and perioperative complications. Methods In total, 98 patients who underwent esophagectomy consecutively for esophageal squamous cell carcinoma in our center from Jan. 2018 to Dec. 2019 were included in this study. Thirty patients underwent mediastinoscopy-assisted and laparoscopic transhiatal esophagectomy with cervical anastomosis (the MATHE group). The other sixty-eight patients received TLE (the TLE group). Each patient's general conditions and perioperative complications were recorded. Results Patients in the MATHE group were observed to have a higher incidence of postoperative hoarseness than those in the TLE group. There were no significant differences between the MATHE group and the TLE group in regards to the operation time, intraoperative blood loss, number of lymph nodes dissected or postoperative hospital stay. Similarly, no statistically significant differences were observed in the incidence of anastomotic fistula, respiratory complications, or chylothorax or in the conversion rate or in-hospital mortality rate between the two groups. Conclusions The short-term efficacy in the MATHE group was similar to that in the TLE group, although patients in the MATHE group may have had a higher incidence of postoperative hoarseness. Therefore, MATHE may be a feasible and safe surgical procedure for appropriate patients with esophageal cancer.
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Affiliation(s)
- Wenyi Liu
- Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China
| | - Xiaotong Guo
- Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China
| | - Hongbo Zhao
- Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China
| | - Xin Yu
- Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China
| | - Chunguang Wang
- Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China
| | - Longde Du
- Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China
| | - Feng Wang
- Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China
| | - Juwei Mu
- Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China.,Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Wu H, Shang L, Du F, Fu M, Liu J, Fang Z, Li L. Transhiatal versus transthoracic surgical approach for Siewert type Ⅱ adenocarcinoma of the esophagogastric junction: a meta-analysis. Expert Rev Gastroenterol Hepatol 2020; 14:1107-1117. [PMID: 32757864 DOI: 10.1080/17474124.2020.1806710] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND With the increasing prevalence of Siewert type Ⅱ adenocarcinoma of the esophagogastric junction (EGJ), the optimal surgical treatment is not universally agreed. This meta-analysis compares the safety and efficacy between the transhiahtal (TH) approach and the transthoracic (TT) approach. METHODS A systematic and electronic search of several databases was performed up to June 2020. The Newcastle-Ottawa scale was used to evaluate article quality and funnel plots were created to identify potential publication bias. The random-effects model was used when significant heterogeneity was identified. RESULTS In total, nine retrospective studies and two randomized controlled trials (RCTs) involving 2331 patients were included. Decreased intraoperative blood loss, shorter hospital stay, lower incidence of pulmonary complications, and longer 3-year overall survival were observed in the TH group. There were no significant differences concerning duration of surgery, R0 resection rate, number of dissected lymph nodes, perioperative mortality and morbidity rate, abdominal complication rate, or anastomotic leak rate. With regard to 5-year overall survival, a potential benefit may be achieved with the TH approach, which requires further confirmation. CONCLUSION In terms of surgery-related and long-term outcomes, the TH approach may be more appropriate for Siewert type Ⅱ adenocarcinoma of EGJ, especially for esophagus invasion ≤4 cm.
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Affiliation(s)
- Hao Wu
- Department of Gastroenterological Surgery, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University , Jinan, Shandong, China
| | - Liang Shang
- Department of Gastroenterological Surgery, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University , Jinan, Shandong, China.,Department of Gastroenterological Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University , Jinan, Shandong, China.,Key Laboratory of Engineering of Shandong Province, Shandong Provincial Hospital , Jinan, Shandong, China
| | - Fengying Du
- Department of Gastroenterological Surgery, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University , Jinan, Shandong, China
| | - Mengdi Fu
- Department of Clinical Medicine, Cheeloo College of Medicine, Shandong University , Jinan, Shandong, China
| | - Jin Liu
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University , Jinan, Shandong, China
| | - Zhen Fang
- Department of Gastroenterological Surgery, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University , Jinan, Shandong, China
| | - Leping Li
- Department of Gastroenterological Surgery, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University , Jinan, Shandong, China.,Department of Gastroenterological Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University , Jinan, Shandong, China.,Key Laboratory of Engineering of Shandong Province, Shandong Provincial Hospital , Jinan, Shandong, China
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Neary C, McAnena P, McAnena O, Kerin M, Collins C. C-Reactive Protein-Lymphocyte Ratio Identifies Patients at Low Risk for Major Morbidity after Oesophagogastric Resection for Cancer. Dig Surg 2020; 37:515-523. [PMID: 33105139 DOI: 10.1159/000510963] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 08/17/2020] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Complications following oesophagogastric surgery have significant implications for patient recovery. OBJECTIVE identify cost-effective biomarkers which can predict morbidity. METHODS Analysis of all upper gastrointestinal resections in Galway University Hospital from 2014 to 2018 was performed. The ability of C-reactive protein (CRP), neutrophil-lymphocyte ratio (NLR), and CRP-lymphocyte ratio (CLR) to predict morbidity, including anastomotic leak (AL), was assessed and compared. RESULTS Seventy-one oesophagectomies and 77 gastrectomies were performed. There were 2 (1%) 30-day mortalities and 83 (56%) morbidities of which 30 (20%) were of Clavien-Dindo grade 3 or higher. The rate of major morbidity within the oesophagectomy cohort was 27% and was 14% in the gastrectomy cohort. There were 11 (7%) ALs, 7 in the oesophagectomy cohort, and 4 in the gastrectomy cohort. From post-operative day (POD) 2 onwards, CRP could predict AL (POD2 AUC = 0.705, p = 0.025; POD3 AUC = 0.757, p = 0.005, POD4 AUC = 0.811, p = 0.001; and POD5 AUC = 0.824, p = 0.001). CLR predicted AL on POD2 onwards (POD2 AUC = 0.722, p = 0.005; POD3 AUC = 0.736, p = 0.01; POD4 AUC = 0.775, p = 0.003; and POD5 AUC = 0.817, p = 0.001). CRP level of 218 mg/dL and CLR level of 301 at POD 2 generated negative predictive values of 97 and 98%, respectively, for AL. Post-operative NLR did not display sufficient discriminatory ability for the outcomes. CONCLUSION CRP and CLR are reliable negative predictors of major morbidity, including AL, after oesophagogastric resection. Their use can inform patient intervention and recovery.
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Affiliation(s)
- Colm Neary
- Discipline of Surgery, Lambe Institute for Translational Research, National University of Ireland Galway, Galway, Ireland,
| | - Peter McAnena
- Discipline of Surgery, Lambe Institute for Translational Research, National University of Ireland Galway, Galway, Ireland
| | - Oliver McAnena
- Discipline of Surgery, Lambe Institute for Translational Research, National University of Ireland Galway, Galway, Ireland.,Department of Upper Gastrointestinal Surgery, Galway University Hospital, Galway, Ireland
| | - Michael Kerin
- Discipline of Surgery, Lambe Institute for Translational Research, National University of Ireland Galway, Galway, Ireland
| | - Chris Collins
- Discipline of Surgery, Lambe Institute for Translational Research, National University of Ireland Galway, Galway, Ireland.,Department of Upper Gastrointestinal Surgery, Galway University Hospital, Galway, Ireland
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Length of hospital stay after uncomplicated esophagectomy. Hospital variation shows room for nationwide improvement. Surg Endosc 2020; 35:6344-6357. [PMID: 33104919 PMCID: PMC8523439 DOI: 10.1007/s00464-020-08103-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 10/16/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND Within the scope of value-based health care, this study aimed to analyze Dutch hospital performance in terms of length of hospital stay after esophageal cancer surgery and its association with 30-day readmission rates. Since both parameters are influenced by the occurrence of complications, this study only included patients with an uneventful recovery after esophagectomy. METHODS All patients registered in the Dutch Upper Gastrointestinal Cancer Audit (DUCA) who underwent a potentially curative esophagectomy between 2015 and 2018 were considered for inclusion. Patients were excluded in case of an intraoperative/post-operative complication, readmission to the intensive care unit, or any re-intervention. Length of hospital stay was dichotomized around the national median into 'short admissions' and 'long admissions'. Hospital variation was evaluated using a case-mix-corrected funnel plot based on multivariable logistic regression analyses. Association of length of hospital stay with 30-day readmission rates was investigated using the χ2-statistic. RESULTS A total of 1007 patients was included. National median length of hospital stay was 9 days, ranging from 6.5 to 12.5 days among 17 hospitals. The percentage of 'short admissions' per hospital ranged from 7.7 to 93.5%. After correction for case-mix variables, 3 hospitals had significantly higher 'short admission' rates and 4 hospitals had significantly lower 'short admission' rates. Overall, 6.2% [hospital variation (0.0-13.2%)] of patients were readmitted. Hospital 30-day readmission rates were not significantly different between patients with a short length of hospital stay and those with a long length of hospital stay (5.5% versus 7.6%; p = 0.19). CONCLUSIONS Based on these nationwide audit data, median length of hospital stay after an uncomplicated esophagectomy was 9 days ranging from 6.5 to 12.5 days among Dutch hospitals. There was no association between length of hospital stay and readmission rates. Nationwide improvement might lead to a substantial reduction of hospital costs.
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Nusrath S, Saxena AR, Raju KVVN, Patnaik S, Subramanyeshwar Rao T, Bollineni N. The Value of Lymphadenectomy Post-Neoadjuvant Therapy in Carcinoma Esophagus: a Review. Indian J Surg Oncol 2020; 11:538-548. [PMID: 33013140 DOI: 10.1007/s13193-020-01156-w] [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: 02/19/2020] [Accepted: 06/30/2020] [Indexed: 10/23/2022] Open
Abstract
Lymph nodal metastasis is one of the most important prognostic factors determining survival in patients with carcinoma esophagus. Radical esophagectomy, with the resection of surrounding lymph nodes, is considered the prime treatment of carcinoma esophagus. An extensive lymphadenectomy improves the accuracy of staging and betters locoregional control, but its effect on survival is still not apparent and carries the disadvantage of increased morbidity. The extent of lymphadenectomy during esophagectomy also remains debatable, with many studies revealing contradictory results, especially in the era of neoadjuvant therapy. The pattern of distribution and the number of nodal metastasis are modified by neoadjuvant therapy. The paper reviews the existing evidence to determine whether increased lymph node yield improves oncological outcomes in patients undergoing esophagectomy with particular attention to those patients receiving neoadjuvant therapy.
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Affiliation(s)
- Syed Nusrath
- Department of Surgical Oncology, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, India
| | - Ajesh Raj Saxena
- Department of Surgical Oncology, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, India
| | - K V V N Raju
- Department of Surgical Oncology, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, India
| | - Sujith Patnaik
- Department of Surgical Oncology, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, India
| | - T Subramanyeshwar Rao
- Department of Surgical Oncology, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, India
| | - Naren Bollineni
- Department of Surgical Oncology, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, India
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Novel universally applicable technique for performing bilateral transcervical mediastinoscopic-assisted transhiatal laparoscopic esophagectomy: a truly minimally invasive procedure. Surg Endosc 2020; 35:5186-5192. [PMID: 32989533 DOI: 10.1007/s00464-020-08012-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 09/16/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND The procedure of mediastinoscopic-assisted transhiatal esophagectomy (MATE) is only performed in a few institutions, despite this being the ultimate form of minimally invasive surgery for performing esophagectomy for esophageal and esophagogastric cancer in that it entails no chest wall trauma. We have developed a novel, universally applicable, surgical procedure for performing bilateral transcervical mediastinoscopic-assisted transhiatal laparoscopic esophagectomy (BTC-MATLE) that is an improvement on standard MATE surgery for esophageal and esophagogastric cancer. METHODS The patient is placed in a supine position under general anesthesia with bilateral lung ventilation. BTC-MATLE combined with mediastinoscopic and transhiatal laparoscopic esophagectomy with total mediastinal lymph node dissection are performed synchronously. After lymph node dissection along both recurrent laryngeal nerves through bilateral cervical skin incisions, bilateral transcervical mediastinoscopic esophagectomy is performed to avoid collision outside the cervical region and ensure operability even in patients with narrow mediastimun. Laparoscopic gastric mobilization and subsequent lower esophageal mobilization meet the bilateral transcervical mediastinoscopic esophagectomy at the border of the middle and lower third of the esophagus. The gastric tube is pulled up into the cervical region via a posterior mediastinal route and anastomosed in the neck. RESULTS BTC-MATLE was performed on 16 high-risk patients (Charlson Comorbidity Index ≥ 3 in 14 patients and two octogenarians with complex comorbidities). Median operation time and postoperative hospital stay were 231 min and 15 days, respectively. R0 resection was achieved in 15 patients (94%), and there were no in-hospital deaths. CONCLUSIONS BTC-MATLE, a procedure for performing minimally invasive esophagectomy, is likely to become the applicable form of MATE surgery for esophageal and esophagogastric cancer, even in high-risk patients because it is truly minimally invasive and has excellent short-term outcomes.
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Yamagata Y, Saito K, Hirano K, Oya M. Long-term outcomes and safety of radical transmediastinal esophagectomy with preoperative docetaxel, cisplatin, and 5-fluorouracil combination chemotherapy for locally advanced squamous cell carcinoma of the thoracic esophagus. World J Surg Oncol 2020; 18:252. [PMID: 32962718 PMCID: PMC7510302 DOI: 10.1186/s12957-020-02023-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 09/09/2020] [Indexed: 12/14/2022] Open
Abstract
Background It is unknown whether transmediastinal esophagectomy (TME) is an acceptable surgical procedure for locally advanced esophageal squamous cell carcinoma (ESCC). Therefore, we investigated the feasibility of long-term survival after TME with neoadjuvant docetaxel, cisplatin, and 5-fluorouracil combination chemotherapy (DCF therapy). Methods This retrospective, observational study included locally advanced resectable ESCC. All patients received two cycles of preoperative DCF therapy (60 mg/m2 of docetaxel and cisplatin on day 1 and 700 mg/m2/day of 5-FU on days 1–5 in each cycle) followed by radical TME. The main outcomes were survival and the rate of adverse events of chemotherapy and surgery. Results Sixteen patients were included in this study. All patients received two cycles of DCF therapy, followed by surgery. The median follow-up duration of the 16 patients was 35.4 months. The 2-year overall survival (OS) was 93.3% (95% confidence interval [CI], 61.3–99.0), and the 3-year OS was 78.8% (95% CI, 47.3–92.7). The 2-year and 3-year relapse-free survivals were both 73.3% (95% CI, 43.6–89.1). Leukopenia and neutropenia occurred in most patients; however, they were controllable. Fifteen patients completed TME, and one was converted to open transthoracic esophagectomy because of tracheal injury. Three-field dissection was performed for 12 of 16 patients (75%), and R0 resection was achieved in 15 of 16 patients (93.8%). Three cases of grade IIIb chylothorax were observed. There was no mortality in this study. Conclusion Combined neoadjuvant DCF and TME for locally advanced ESCC was safe and less invasive than traditional therapies and had a satisfactory long-term prognosis.
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Affiliation(s)
- Yukinori Yamagata
- Department of Surgery, Dokkyo Medical University Saitama Medical Center, 2-1-50, Minami-Koshigaya, Koshigaya City, Saitama, Japan. .,Department of Gastric Surgery, National Cancer Center Hospital, 5-1-1, Tsukiji, Cyuo-ku, Tokyo, Japan.
| | - Kazuyuki Saito
- Department of Surgery, Dokkyo Medical University Saitama Medical Center, 2-1-50, Minami-Koshigaya, Koshigaya City, Saitama, Japan
| | - Kosuke Hirano
- Department of Surgery, Dokkyo Medical University Saitama Medical Center, 2-1-50, Minami-Koshigaya, Koshigaya City, Saitama, Japan
| | - Masatoshi Oya
- Department of Surgery, Dokkyo Medical University Saitama Medical Center, 2-1-50, Minami-Koshigaya, Koshigaya City, Saitama, Japan
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It's not always too late: a case for minimally invasive salvage esophagectomy. Surg Endosc 2020; 35:4700-4711. [PMID: 32940794 DOI: 10.1007/s00464-020-07937-2] [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: 04/05/2020] [Accepted: 08/25/2020] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Standard of care for locally advanced esophageal carcinoma is neoadjuvant chemoradiation (nCRT) and surgical resection 4-8 weeks after completion of nCRT. It is recommended that the CRT to surgery interval not exceed 90 days. Many patients do not undergo surgery within this timeframe due to patient/physician preference, complete clinical response, or poor performance status. Select patients are offered salvage esophagectomy (SE), defined in two ways: resection for recurrent/persistent disease after complete response to definitive CRT (dCRT) or esophagectomy performed > 90 days after completion of nCRT. Salvage esophagectomy reportedly has higher postoperative morbidity and poor survival outcomes. In this study, we assessed outcomes, overall, and disease-free survival of patients undergoing salvage esophagectomy by both definitions (recurrent/persistent disease after dCRT and/or > 90 days), compared to planned (resection after nCRT/within 90 days) esophagectomy (PE). MATERIALS AND METHODS Retrospective review of a prospectively maintained database identified patients who underwent minimally invasive esophagectomy at a single institution from 2009 to 2019. Esophagectomy for benign disease and patients who did not receive nCRT were excluded. Outcomes included postoperative complications, length of stay (LOS), disease-free survival, and overall survival. RESULTS 97 patients underwent minimally invasive esophageal resection for esophageal carcinoma. 89.7% of patients were male. Mean age was 64.9 years (range 36-85 years). 94.8% of patients had adenocarcinoma, with 16 transthoracic and 81 transhiatal approaches. On comparing planned esophagectomy (n = 87) to esophagectomy after dCRT failure (n = 10), no significant differences were identified in overall survival (p = 0.73), disease-free survival (p = 0.32), 30-day or major complication rate, anastomotic leak, or LOS. Similarly, when comparing esophagectomy < 90 days after CRT (n = 62) to > 90 days after CRT completion (n = 35), no significant differences were identified in overall survival (p = 0.39), disease-free survival (p = 0.71), 30-day or major complication rate, LOS, or anastomotic leak rate between groups. In this comparison, local recurrence was noted to be elevated with SE as compared to PE (64.3% vs. 25.0%, p = 0.04). CONCLUSION Overall survival and disease-free survival were equivalent between SE and PE. Local recurrence was noted to be increased with SE, though this did not appear to affect survival. Although planned esophagectomy remains the standard of care, salvage esophagectomy has comparable outcomes and is appropriate for selected patients.
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Kröll D, Borbély YM, Dislich B, Haltmeier T, Malinka T, Biebl M, Langer R, Candinas D, Seiler C. Favourable long-term survival of patients with esophageal cancer treated with extended transhiatal esophagectomy combined with en bloc lymphadenectomy: results from a retrospective observational cohort study. BMC Surg 2020; 20:197. [PMID: 32917177 PMCID: PMC7488573 DOI: 10.1186/s12893-020-00855-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 08/26/2020] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Although considered complex and challenging, esophagectomy remains the best potentially curable treatment option for resectable esophageal and esophagogastric junction (AEG) carcinomas. The optimal surgical approach and technique as well as the extent of lymphadenectomy, particularly regarding quality of life and short- and long-term outcomes, are still a matter of debate. To lower perioperative morbidity, we combined the advantages of a one-cavity approach with extended lymph node dissection (usually achieved by only a two-cavity approach) and developed a modified single-cavity transhiatal approach for esophagectomy. METHODS The aim of this study was to evaluate the outcome of an extended transhiatal esophageal resection with radical bilateral mediastinal en bloc lymphadenectomy (eTHE). A prospective database of 166 patients with resectable cancers of the esophagus (including adenocarcinomas of the AEG types I and II) were analyzed. Patients were treated between 2001 and 2017 with eTHE at a tertiary care university center. Relevant patient characteristics and outcome parameters were collected and analyzed. The primary endpoint was 5-year overall survival. Secondary outcomes included short-term morbidity, mortality, radicalness of en bloc resection and oncologic efficacy. RESULTS The overall survival rates at 1, 3 and 5 years were 84, 70, and 61.0%, respectively. The in-hospital mortality rate after eTHE was 1.2%. Complications with a Clavien-Dindo score of III/IV occurred in 31 cases (18.6%). A total of 25 patients (15.1%) had a major pulmonary complication. The median hospital stay was 17 days (interquartile range (IQR) 12). Most patients (n = 144; 86.7%) received neoadjuvant treatment. The median number of lymph nodes resected was 25 (IQR 17). The R0 resection rate was 97%. CONCLUSION In patients with esophageal cancer, eTHE without thoracotomy resulted in excellent long-term survival, an above average number of resected lymph nodes and an acceptable postoperative morbidity and mortality.
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Affiliation(s)
- Dino Kröll
- Department of Surgery, Campus Charité Mitte and Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany. .,Department of Visceral Surgery and Medicine, Inselspital Bern, Bern University Hospital and University of Bern, 3010, Bern, Switzerland.
| | - Yves Michael Borbély
- Department of Visceral Surgery and Medicine, Inselspital Bern, Bern University Hospital and University of Bern, 3010, Bern, Switzerland
| | - Bastian Dislich
- Institute of Pathology, Department of Clinical Pathology, Inselspital Bern, Bern University Hospital and University of Bern, 3010, Bern, Switzerland
| | - Tobias Haltmeier
- Department of Visceral Surgery and Medicine, Inselspital Bern, Bern University Hospital and University of Bern, 3010, Bern, Switzerland
| | - Thomas Malinka
- Department of Surgery, Campus Charité Mitte and Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Matthias Biebl
- Department of Surgery, Campus Charité Mitte and Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Rupert Langer
- Institute of Pathology, Department of Clinical Pathology, Inselspital Bern, Bern University Hospital and University of Bern, 3010, Bern, Switzerland
| | - Daniel Candinas
- Department of Visceral Surgery and Medicine, Inselspital Bern, Bern University Hospital and University of Bern, 3010, Bern, Switzerland
| | - Christian Seiler
- Department of Visceral Surgery and Medicine, Inselspital Bern, Bern University Hospital and University of Bern, 3010, Bern, Switzerland
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Mertens AC, Kalff MC, Eshuis WJ, Van Gulik TM, Van Berge Henegouwen MI, Gisbertz SS. Transthoracic Versus Transhiatal Esophagectomy for Esophageal Cancer: A Nationwide Propensity Score-Matched Cohort Analysis. Ann Surg Oncol 2020; 28:175-183. [PMID: 32607607 PMCID: PMC7752871 DOI: 10.1245/s10434-020-08760-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Indexed: 01/05/2023]
Abstract
Background Chemoradiation followed by resection has been the standard therapy for resectable (cT1-4aN0-3M0) esophageal carcinoma in the Netherlands since 2010. The optimal surgical approach remains a matter of debate. Therefore, the purpose of this study was to compare the transhiatal and the transthoracic approach concerning morbidity, mortality and oncological quality. Methods Data was acquired from the Dutch Upper GI Cancer Audit. Patients who underwent esophagectomy with curative intent and gastric tube reconstruction for mid/distal esophageal or esophagogastric junction carcinoma (cT1-4aN0-3M0) from 2011 to 2016 were included. Patients who underwent a transthoracic and transhiatal esophagectomy were compared after propensity score matching. Results After propensity score matching, 1532 of 4143 patients were included for analysis. The transthoracic approach yielded more lymph nodes (transthoracic median 19, transhiatal median 14; p < 0.001). There was no difference in the number of positive lymph nodes, however, the median (y)pN-stage was higher in the transthoracic group (p = 0.044). The transthoracic group experienced more chyle leakage (9.7% vs. 2.7%, p < 0.001), more pulmonary complications (35.5% vs. 26.1%, p < 0.001), and more cardiac complications (15.4% vs. 10.3%, p = 0.003). The transthoracic group required a longer hospital stay (median 14 vs. 11 days, p < 0.001), ICU stay (median 3 vs. 1 day, p < 0.001), and had a higher 30-day/in-hospital mortality rate (4.0% vs. 1.7%, p = 0.009). Conclusions In a propensity score-matched cohort, the transthoracic esophagectomy provided a more extensive lymph node dissection, which resulted in a higher lymph node yield, at the cost of increased morbidity and short-term mortality.
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Affiliation(s)
- Alexander C Mertens
- Amsterdam UMC, Department of Surgery, Cancer Center Amsterdam, University of Amsterdam, Amsterdam, The Netherlands.,Robotics and Mechatronics, University of Twente, Enschede, The Netherlands
| | - Marianne C Kalff
- Amsterdam UMC, Department of Surgery, Cancer Center Amsterdam, University of Amsterdam, Amsterdam, The Netherlands
| | - Wietse J Eshuis
- Amsterdam UMC, Department of Surgery, Cancer Center Amsterdam, University of Amsterdam, Amsterdam, The Netherlands
| | - Thomas M Van Gulik
- Amsterdam UMC, Department of Surgery, Cancer Center Amsterdam, University of Amsterdam, Amsterdam, The Netherlands
| | - Mark I Van Berge Henegouwen
- Amsterdam UMC, Department of Surgery, Cancer Center Amsterdam, University of Amsterdam, Amsterdam, The Netherlands
| | - Suzanne S Gisbertz
- Amsterdam UMC, Department of Surgery, Cancer Center Amsterdam, University of Amsterdam, Amsterdam, The Netherlands.
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49
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Early Respiratory Impairment and Pneumonia after Hybrid Laparoscopically Assisted Esophagectomy-A Comparison with the Open Approach. J Clin Med 2020; 9:jcm9061896. [PMID: 32560416 PMCID: PMC7355913 DOI: 10.3390/jcm9061896] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 06/03/2020] [Accepted: 06/08/2020] [Indexed: 12/23/2022] Open
Abstract
Patients undergoing esophageal cancer surgery are at high risk of developing severe pulmonary complications. Beneficial effects of minimally invasive esophagectomy had been discussed recently, but the incidence of perioperative respiratory impairment remains unclear. This is a retrospective single-center cohort study of patients, who underwent open (OE) or laparoscopically assisted, hybrid minimally invasive abdomino-thoracic esophagectomy (LAE) for cancer regarding respiratory impairment (PaO2/FiO2 ratio (P/FR) < 300 mmHg) and pneumonia. No differences were observed in the cumulative incidence of reduced P/FR between OE and LAE patients. Of note, until postoperative day (POD) 2, P/FR did not differ among both groups. Thereafter, the rate of patients with respiratory impairment was higher after OE on POD 3, 5, and 10 (p ≤ 0.05) and tended being higher on POD 7 and 9 (p ≤ 0.1). Although the duration of LAE procedure was slightly longer (total: p = 0.07, thoracic part: p = 0.004), the duration of surgery (Spearman's rank correlation coefficient (rsp) = -0.267, p = 0.006), especially of laparotomy (rsp = -0.242, p = 0.01) correlated inversely with respiratory impairment on POD 3 after OE. Pneumonia occurred on POD 5 (1-25) and 8.5 (3-14) after OE and LAE, respectively, with the highest incidence after OE (p = 0.01). In conclusion, respiratory impairment and pulmonary complications occur frequently after esophagectomy. Although early respiratory impairment is independent of the surgical approach, postoperative pneumonia rate is reduced after LAE.
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50
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Yin Q, Liu H, Song Y, Zhou S, Yang G, Wang W, Qie P, Xun X, Liu L. Clinical application and observation of single-port inflatable mediastinoscopy combined with laparoscopy for radical esophagectomy in esophageal squamous cell carcinoma. J Cardiothorac Surg 2020; 15:125. [PMID: 32503651 PMCID: PMC7275589 DOI: 10.1186/s13019-020-01168-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Accepted: 05/24/2020] [Indexed: 11/19/2022] Open
Abstract
Background Transthoracic esophagectomy is a crucial independent risk factor for the incidence of postoperative cardiopulmonary complications in elderly or comorbid patients. To reduce postoperative cardiopulmonary complications and promote postoperative recovery. We made an attempt to adopt the single-port inflatable mediastinoscopy combined with laparoscopy for radical esophagectomy in esophageal cancer to observe the clinical application and effect. Method Data of patients with esophageal carcinoma were collected in the Hebei General Hospital from May 2018 to November 2019. The operation time, surgical blood loss, the number of dissected lymph nodes, duration of drainage tube, duration of time on the ventilator, the length of stay in ICU, postoperative complications, the length of postoperative hospital stay were collected to assess the safety and feasibility of the single-port inflatable mediastinoscopy combined with laparoscopy for radical esophagectomy in esophageal cancer. Results A total of 22 patients with esophageal cancer were analyzed in our research. There were no cases of conversion to thoracotomy、perioperative death or postoperative cardiopulmonary complications. The average operation time of all enrolled patients was 4.26 ± 0.52 h、The surgical blood loss was 142 ± 36.50 ml、The amount of dissected lymph nodes were 21.6 ± 4.2、The duration of drainage tube was 5.8 ± 2.5 days、The duration of time on the ventilator was 6.5 ± 3.4 h、The length of stay in ICU was 1.2 ± 0.4 days、The postoperative hospital stay was 12.6 ± 2.5 days. Among all the enrolled patients, one patient (4.5%) developed anastomotic fistula on the third day after surgery. Anastomotic stricture was found in 5 patients (22.7%). Pleural effusion was found in 4 cases (18.2%). Recurrent laryngeal nerve injury caused hoarseness or cough after drinking water in 3 cases (13.6%).There was one patient (4.5%) of conversion to laparotomy as the patient had serious peritoneal adhesion. All of the patients were discharged successfully. Conclusion:Our results showed that this surgery of single-port inflatable mediastinoscopy combined with laparoscopy for radical esophagectomy in esophageal squamous cell carcinoma is safe and feasible. The feasibility and safety could be further and better investigated with a RCT to achieve more conclusive results.
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Affiliation(s)
- Qifan Yin
- Department of Thoracic Surgery, Hebei General Hospital, 348,West He-Ping Road, Shijiazhuang, 050051, Hebei Province, People's Republic of China
| | - Huining Liu
- Department of Thoracic Surgery, Hebei General Hospital, 348,West He-Ping Road, Shijiazhuang, 050051, Hebei Province, People's Republic of China
| | - Yongbin Song
- Department of Thoracic Surgery, Hebei General Hospital, 348,West He-Ping Road, Shijiazhuang, 050051, Hebei Province, People's Republic of China
| | - Shaohui Zhou
- Department of Thoracic Surgery, Hebei General Hospital, 348,West He-Ping Road, Shijiazhuang, 050051, Hebei Province, People's Republic of China
| | - Guang Yang
- Department of Thoracic Surgery, Hebei General Hospital, 348,West He-Ping Road, Shijiazhuang, 050051, Hebei Province, People's Republic of China
| | - Wenhao Wang
- Department of Thoracic Surgery, Hebei General Hospital, 348,West He-Ping Road, Shijiazhuang, 050051, Hebei Province, People's Republic of China
| | - Peng Qie
- Department of Thoracic Surgery, Hebei General Hospital, 348,West He-Ping Road, Shijiazhuang, 050051, Hebei Province, People's Republic of China
| | - Xuejiao Xun
- Department of Thoracic Surgery, Hebei General Hospital, 348,West He-Ping Road, Shijiazhuang, 050051, Hebei Province, People's Republic of China
| | - Lijun Liu
- Department of Thoracic Surgery, Hebei General Hospital, 348,West He-Ping Road, Shijiazhuang, 050051, Hebei Province, People's Republic of China.
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