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Herrera Kok JH, Marano L, van den Berg JW, Shetty P, Vashist Y, Lorenzon L, Rau B, van Hillegersberg R, de Manzoni G, Spallanzani A, Seo WJ, Nagata H, Eveno C, Mönig S, van der Sluis K, Solaini L, Wijnhoven BP, Puccetti F, Chevallay M, Lee E, D'Ugo D. Current trends in the management of Gastro-oEsophageal cancers: Updates to the ESSO core curriculum (ESSO-ETC-UGI-WG initiative). EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108387. [PMID: 38796969 DOI: 10.1016/j.ejso.2024.108387] [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: 03/04/2024] [Revised: 04/26/2024] [Accepted: 05/02/2024] [Indexed: 05/29/2024]
Abstract
Gastro-oEsophageal Cancers (GECs) are severe diseases whose management is rapidly evolving. The European Society of Surgical Oncology (ESSO) is committed to the generation and spread of knowledge, and promotes the multidisciplinary management of cancer patients through its core curriculum. The present work discusses the approach to GECs, including the management of oligometastatic oesophagogastric cancers (OMEC), the diagnosis and management of peritoneal metastases from gastric cancer (GC), the management of Siewert Type II tumors, the importance of mesogastric excision, the role of robotic surgery, textbook outcomes, organ preserving options, the use of molecular markers and immune check-point inhibitors in the management of patients with GECs, as well as the improvement of current clinical practice guidelines for the management of patients with GECs. The aim of the present review is to provide a concise overview of the state-of-the-art on the management of patients with GECs and, at the same time, to share the latest advancements in the field and to foster the debate between surgical oncologists treating GECs worldwide. We are sure that our work will, at the same time, give an update to the advanced surgical oncologists and help the training surgical oncologists to settle down the foundations for their future practice.
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Affiliation(s)
- Johnn Henry Herrera Kok
- European Society of Surgical Oncology (ESSO), Education and Training Committee (ETC), Upper Gastrointestinal (UGI), Working Group (WG), Belgium; ESSO-European Young Surgeons and Alumni Club (EYSAC), Research Academy (RA), Belgium; Department of General and Digestive Surgery, Upper GI Unit, University Hospital of León, León, Spain.
| | - Luigi Marano
- European Society of Surgical Oncology (ESSO), Education and Training Committee (ETC), Upper Gastrointestinal (UGI), Working Group (WG), Belgium; Department of Medicine, Academy of Applied Medical and Social Sciences (AMiSNS), Akademia Medycznych i Społecznych Nauk Stosowanych, Elbląg, Poland
| | - Jan Willem van den Berg
- European Society of Surgical Oncology (ESSO), Education and Training Committee (ETC), Upper Gastrointestinal (UGI), Working Group (WG), Belgium; Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Preethi Shetty
- European Society of Surgical Oncology (ESSO), Education and Training Committee (ETC), Upper Gastrointestinal (UGI), Working Group (WG), Belgium; Department of Surgical Oncology, Kasturba Medical College, MAHE Manipal, India
| | - Yogesh Vashist
- European Society of Surgical Oncology (ESSO), Education and Training Committee (ETC), Upper Gastrointestinal (UGI), Working Group (WG), Belgium; Organ Transplant Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Laura Lorenzon
- ESSO-European Young Surgeons and Alumni Club (EYSAC), Research Academy (RA), Belgium; Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Beate Rau
- Department of Surgery, Campus Virchow-Klinikum and Charité Campus Mitte, Charité-Universitätsmedizin Berlin, Germany
| | | | - Giovanni de Manzoni
- Department of General Surgery, Upper GI Unit, University Hospital of Verona, Verona, Italy
| | - Andrea Spallanzani
- Department of Oncology and Hematology, University of Modena and Reggio Emilia Hospital, Modena, Italy
| | - Won Jun Seo
- Department of Surgery, Korea University Guro Hospital, Seoul, Republic of Korea; PIPS-GC Study Group, Republic of Korea
| | - Hiromi Nagata
- Department of Gastric Surgery, National Cancer Center Hospital East, Chiba, Japan
| | - Clarisse Eveno
- Department of Surgery, Lille University Hospital, Lille, France
| | - Stefan Mönig
- Department of Surgery, University Hospitals of Geneva, Geneva, Switzerland
| | - Karen van der Sluis
- Department of Surgery, The Netherlands Cancer Institute Antoni van Leewenhoek, Amsterdam, the Netherlands
| | - Leonardo Solaini
- Department of General and Oncologic Surgery, Morgagni Pierantoni Hospital, Forli, Italy
| | - Bas Pl Wijnhoven
- Department of Surgery, Erasmus Medical Center Cancer Institute, Amsterdam, the Netherlands
| | - Francesco Puccetti
- Gastrointestinal Surgery Unit, Department of Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Mickael Chevallay
- Department of Surgery, University Hospitals of Geneva, Geneva, Switzerland
| | - Eunju Lee
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam-si, Republic of Korea; Department of Surgery, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong-si, Republic of Korea
| | - Domenico D'Ugo
- European Society of Surgical Oncology (ESSO), Education and Training Committee (ETC), Upper Gastrointestinal (UGI), Working Group (WG), Belgium; Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; ESSO Past-President, Republic of Korea
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Sasaki K, Tsuruda Y, Shimonosono M, Noda M, Uchikado Y, Omoto I, Setoyama T, Matsushita D, Arigami T, Baba K, Kurahara H, Ohtsuka T. Comparison of the subtotal and narrow gastric conduit for cervical esophagogastrostomy after esophagectomy in esophageal cancer patients: a propensity score-matched analysis. Esophagus 2024; 21:41-50. [PMID: 37828145 DOI: 10.1007/s10388-023-01027-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 09/28/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND Several reports have compared narrow gastric conduit (NGC) with subtotal gastric conduit (SGC) for cervical esophagogastrostomy after esophagectomy; however, whether which one is more beneficial in terms of postoperative complications remains unclear. To determine the optimal gastric conduit type, we retrospectively investigated and compared the postoperative complications between NGC and SGC used in cervical circular-tapered esophagogastrostomy after esophagectomy through a propensity score-matched analysis. METHODS Between 2008 and 2022, 577 consecutive esophageal cancer patients who underwent esophagectomy and cervical circular-stapled esophagogastrostomy were enrolled in this study. RESULTS Of the 577 patients, 77 were included each in the SGC and NGC groups, after propensity score matching. Clinical characteristics did not differ between the two groups. The anastomotic leakage rate was significantly lower in the SGC group than in the NGC group (5% vs. 22%, p < 0.01). The anastomotic stenosis rate was significantly higher in the SGC group (16% vs. 5%, p = 0.03). Multivariate logistic analysis showed that NGC, subcutaneous route, and age were significant independent factors associated with anastomotic leakage (odds ratios, 8.58, 6.49, and 5.21; p < 0.01, < 0.01 and 0.03, respectively) and that SGC was a significant independent factor associated with anastomotic stricture (odds ratios, 4.91; p = 0.04). CONCLUSIONS In cervical circular-stapled esophagogastrostomy after esophagectomy, SGC was superior to NGC in terms of reducing the risk of anastomotic leakage, although the risk of anastomotic stricture needs to be resolved.
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Affiliation(s)
- Ken Sasaki
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, Kagoshima, 890-8520, Japan.
| | - Yusuke Tsuruda
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, Kagoshima, 890-8520, Japan
| | - Masataka Shimonosono
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, Kagoshima, 890-8520, Japan
| | - Masahiro Noda
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, Kagoshima, 890-8520, Japan
| | - Yasuto Uchikado
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, Kagoshima, 890-8520, Japan
| | - Itaru Omoto
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, Kagoshima, 890-8520, Japan
| | - Tetsuro Setoyama
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, Kagoshima, 890-8520, Japan
| | - Daisuke Matsushita
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, Kagoshima, 890-8520, Japan
| | - Takaaki Arigami
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, Kagoshima, 890-8520, Japan
| | - Kenji Baba
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, Kagoshima, 890-8520, Japan
| | - Hiroshi Kurahara
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, Kagoshima, 890-8520, Japan
| | - Takao Ohtsuka
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, Kagoshima, 890-8520, Japan
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Garbarino GM, van Berge Henegouwen MI, Gisbertz SS, Eshuis WJ. Today's Mistakes and Tomorrow's Wisdom in the Surgical Treatment of Barrett's Adenocarcinoma. Visc Med 2022; 38:203-211. [PMID: 35814974 PMCID: PMC9210033 DOI: 10.1159/000524928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 05/02/2022] [Indexed: 09/17/2023] Open
Abstract
Background Barrett's esophagus is a premalignant condition caused by longstanding gastroesophageal reflux disease and may progress to low-grade dysplasia, high-grade dysplasia (HGD), and finally esophageal adenocarcinoma. Summary Barrett's adenocarcinoma can be treated either by endoscopic or surgical resection, depending on the clinical staging. Endoscopic resection is a safe and adequate treatment option for HGD, mucosal tumors, and low-risk submucosal tumors. Its role in the treatment of high-risk submucosal tumors and the role of organ-preserving sentinel node navigated surgery are still under investigation. Esophagectomy with neoadjuvant chemoradiation or perioperative chemotherapy is considered the standard of care for locally advanced Barrett's adenocarcinoma. Regarding operative technique, there is no proven superiority of one technique over another, although a minimally invasive transthoracic technique seems most commonly applied nowadays. In this review, state-of-the-art evidence and future expectations are presented regarding indications for resection, neoadjuvant or perioperative therapy, type of surgery, and postoperative follow-up for Barrett's adenocarcinoma. Key Messages In Barrett's adenocarcinoma, endoscopic resection is the standard treatment option for low-risk mucosal and submucosal tumors. For high-risk submucosal tumors, endoscopic submucosal dissection with close surveillance and sentinel node navigated surgery are currently being studied. For locally advanced cancer, a multimodal therapy including esophagectomy is the standard of care. Nowadays, in high-volume centers, a minimally invasive transthoracic esophagectomy with an intrathoracic anastomosis is the most common procedure for Barrett's adenocarcinoma.
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Affiliation(s)
- Giovanni Maria Garbarino
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Medical Surgical Science and Translational Medicine, Sapienza University of Rome, Sant'Andrea Hospital, Rome, Italy
| | - Mark Ivo van Berge Henegouwen
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Suzanne Sarah Gisbertz
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Wietse Jelle Eshuis
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
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Surgical Approaches to Oesophageal Carcinoma: Evolution and Evaluation. Indian J Surg 2021. [DOI: 10.1007/s12262-019-02057-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Giulini L, Nasser CA, Tank J, Papp M, Stein HJ, Dubecz A. Hybrid robotic versus hybrid laparoscopic Ivor Lewis oesophagectomy: a case-matched analysis. Eur J Cardiothorac Surg 2021; 59:1279-1285. [PMID: 33448299 DOI: 10.1093/ejcts/ezaa473] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 11/15/2020] [Accepted: 11/25/2020] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES Robotic-assisted oesophagectomy for cancer has been increasingly employed worldwide; however, the benefits of this technique compared to conventional minimally invasive oesophagectomy are unclear. Since 2016, hybrid robotic minimally invasive oesophagectomy (R-HMIE) has increasingly replaced hybrid laparoscopic minimally invasive oesophagectomy (HMIE) as the standard of care in our institution. The aim of this study was to compare these procedures. METHODS Over a 10-year period, 686 patients underwent oesophagectomy at our institution. Out of these patients, 128 patients with cancer were treated with a hybrid minimally invasive technique. Each patient who underwent R-HMIE was matched according to gender, age, comorbidity, American Society of Anesthesiologists classification, Union International Contre le Cancer stage, localization, histology and neoadjuvant treatment with a patient who underwent HMIE. Perioperative parameters were extracted from our database and compared between the 2 groups. RESULTS After the matching procedure, 88 patients were included in the study. Between HMIE and R-HMIE, no significant differences (P > 0.05) were found in operating time (median 281 vs 300 min), R0 resection rate (n = 42 vs 42), harvested lymph nodes (median 28 vs 24), hospital stay (median 19 vs 17 days) and intensive care unit stay (median 7 vs 6.5 days). Regarding surgical complications, no difference could be observed either (n = 42 vs 44). CONCLUSIONS Minimally invasive oesophagectomy remains a challenging operation with high morbidity even in a high-volume institution. According to our intra- and short-term results, we have found no difference between R-HMIE and HMIE.
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Affiliation(s)
- Luca Giulini
- Department of Surgery, Paracelsus Medical University Nuremberg, Nuremberg, Germany
| | - Corinna A Nasser
- Department of Surgery, Paracelsus Medical University Nuremberg, Nuremberg, Germany
| | - Julian Tank
- Department of Surgery, Paracelsus Medical University Nuremberg, Nuremberg, Germany
| | - Marton Papp
- Centre for Bioinformatics, University of Veterinary Medicine Budapest, Budapest, Hungary
| | - Hubert J Stein
- Department of Surgery, Paracelsus Medical University Nuremberg, Nuremberg, Germany
| | - Attila Dubecz
- Department of Surgery, Paracelsus Medical University Nuremberg, Nuremberg, Germany
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Li B, Yang Y, Toker A, Yu B, Kang CH, Abbas G, Soukiasian HJ, Li H, Daiko H, Jiang H, Fu J, Yi J, Kernstine K, Migliore M, Bouvet M, Ricciardi S, Chao YK, Kim YH, Wang Y, Yu Z, Abbas AE, Sarkaria IS, Li Z. International consensus statement on robot-assisted minimally invasive esophagectomy (RAMIE). J Thorac Dis 2020; 12:7387-7401. [PMID: 33447428 PMCID: PMC7797844 DOI: 10.21037/jtd-20-1945] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Bin Li
- Department of Thoracic Surgery, Section of Esophageal Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yang Yang
- Department of Thoracic Surgery, Section of Esophageal Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Alper Toker
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, School of Medicine, Morgantown, WV, USA
| | - Bentong Yu
- Department of Thoracic Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Chang Hyun Kang
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Ghulam Abbas
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, School of Medicine, Morgantown, WV, USA
| | - Harmik J Soukiasian
- Division of Thoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Hecheng Li
- Department of Thoracic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hiroyuki Daiko
- Department of Esophageal Surgery, National Cancer Center Hospital East, Chiba, Japan
| | - Hongjing Jiang
- Department of Esophageal Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Jianhua Fu
- Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Jun Yi
- Department of Cardiothoracic Surgery, Jinling Hospital, Medical Scholl of Nanjing University, Nanjing, China
| | - Kemp Kernstine
- Department of Cardiothoracic Surgery, UT Southwestern, Dallas, TX, USA
| | - Marcello Migliore
- Section of Thoracic Surgery, Department of Surgery and Medical Specialties, Policlinico University Hospital, University of Catania, Catania, Italy
| | - Michael Bouvet
- Department of Surgery, University of California San Diego, San Diego, CA, USA
| | - Sara Ricciardi
- Division of Thoracic Surgery, Department of Surgical, Medical, Molecular, Pathology and Critical Care, University Hospital of Pisa, Pisa, Italy
| | - Yin-Kai Chao
- Division of Thoracic Surgery, Chang Gung Memorial Hospital-Linkou, Chang Gung University, Taoyuan
| | - Yong-Hee Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yun Wang
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Zhentao Yu
- Department of Esophageal Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Abbas E Abbas
- Division of Thoracic Surgery, Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Inderpal S Sarkaria
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Zhigang Li
- Department of Thoracic Surgery, Section of Esophageal Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
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Bruna M, Mingol F, Vaqué FJ. Results of a National Survey about Therapeutic Management in Esophageal Cancer. Cir Esp 2020; 99:329-338. [PMID: 32788047 DOI: 10.1016/j.ciresp.2020.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 06/02/2020] [Accepted: 06/26/2020] [Indexed: 10/23/2022]
Abstract
There are numerous controversial aspects in the perioperative and surgical management of patients with esophageal cancer. The aim of this study is to evaluate the differences between the hospitals of our country in the adjuvant and surgical treatment of these patients. We conducted a descriptive study of 56 surveys answered from February to April 2020, evaluating hospital characteristics, number of procedures, management of distal adenocarcinoma and squamous cell carcinoma of the middle third of the esophagus, type of anastomosis, use of nasogastric tube and drains, and clinical follow-up. The median number of annual esophagectomies per hospital was 10, and only 7.1% performed more than 20. In distal adenocarcinoma, 62.5% use preoperative chemoradiotherapy, an abdominal and transthoracic approach (57.1%), and an infracarinal lymphadenectomy (51.8%) or extended to right paratracheal lymph nodes (41.1%). In squamous cell carcinoma of the middle third of the esophagus, 89.3% use preoperative chemoradiotherapy, surgery in three fields (73.2%) and extended mediastinal lymphadenectomy (52%). Intrathoracic anastomosis is performed mechanically in 77.8% and cervical anastomosis preferably manually (71.4%). Pleural and abdominal drains are usually placed by 77.6% and 48.2%, respectively, while the nasogastric tube is normally used by 57.1%. A clinical pathway is followed by 57.1%, and 28.6% use a specific enhanced recovery after surgery protocol. Thus, in the management of esophageal cancer, there are some clear differences between hospitals in our country regarding adjuvant treatment, surgical approach, type of lymphadenectomy and anastomosis performed.
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Affiliation(s)
- Marcos Bruna
- Unidad de Cirugía Esofagogástrica y Carcinomatosis Peritoneal, Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario y Politécnico La Fe, Valencia, España.
| | - Fernando Mingol
- Unidad de Cirugía Esofagogástrica y Carcinomatosis Peritoneal, Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - Francisco Javier Vaqué
- Unidad de Cirugía Esofagogástrica y Carcinomatosis Peritoneal, Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario y Politécnico La Fe, Valencia, España
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- Unidad de Cirugía Esofagogástrica y Carcinomatosis Peritoneal, Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario y Politécnico La Fe, Valencia, España
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Zhu DS, Cao JW, Geng MF, Huang XY, Hu CM, Li J, Fu DH, Liu W. Wide Gastric Conduit Increases the Risk of Benign Anastomotic Stricture After Esophagectomy. Am Surg 2020; 86:621-627. [PMID: 32683957 DOI: 10.1177/0003134820923317] [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: 11/16/2022]
Abstract
BACKGROUND To identify the association between the width of the gastric conduit and the benign anastomotic stricture (BAS) after esophagectomy with end-to-side cervical anastomosis for esophageal cancer. METHODS Patients with esophageal cancer who underwent esophagectomy between July 2013 and July 2014 were included in this study. The gastric conduit was used for reconstruction in all patients and end-to-side cervical anastomosis were performed using a circular stapler. The patients were divided into a narrow group (3-5 cm) and a wide group (>5 cm) based on the gastric conduit width. Univariate and multivariate logistic regressions were used to analyze the possible factors (patients' age, gender, preoperative comorbidities, neoadjuvant chemotherapy, gastric conduit width, anastomotic leakage) that could affect the incidence of BAS. RESULTS Two-hundred and one patients were included in this study. The median follow-up period was 29 months (17-58 months). Seven cases (3.5%) showed anastomotic leakage in the postoperative period and 38 patients (18.9%) developed BAS; all within the first year of follow-up. In univariate analysis, the width of the gastric conduit was the only risk factor for the development of BAS (odds ratio [OR] = 3.36, P = .005). In multivariate logistic regression analysis, the wide group was an independent significant risk factor for the development of BAS developing compared with the narrow group (OR = 2.84, P = .02). CONCLUSIONS A wide gastric conduit width (>5 cm) is an independent risk factor for the development of BAS after esophagectomy and stapled cervical end-to-side anastomosis for esophageal cancer.
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Affiliation(s)
- Dong-Shan Zhu
- 12510 Department of Thoracic Surgery, The First Hospital of Jilin University, Changchun, China
| | - Jian-Wei Cao
- Department of Thoracic Surgery, Anyang Tumor Hospital, Anyang, China
| | - Ming-Fei Geng
- Department of Thoracic Surgery, Anyang Tumor Hospital, Anyang, China
| | - Xiao-Yu Huang
- Department of Thoracic Surgery, Anyang Tumor Hospital, Anyang, China
| | - Chong-Ming Hu
- Department of Thoracic Surgery, Anyang Tumor Hospital, Anyang, China
| | - Jian Li
- Department of Thoracic Surgery, Anyang Tumor Hospital, Anyang, China
| | - Dong-Hong Fu
- Department of Thoracic Surgery, Anyang Tumor Hospital, Anyang, China
| | - Wei Liu
- 12510 Department of Thoracic Surgery, The First Hospital of Jilin University, Changchun, China
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Udagawa H. Past, present, and future of three-field lymphadenectomy for thoracic esophageal cancer. Ann Gastroenterol Surg 2020; 4:324-330. [PMID: 32724875 PMCID: PMC7382429 DOI: 10.1002/ags3.12338] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 02/28/2020] [Accepted: 03/22/2020] [Indexed: 12/14/2022] Open
Abstract
In spite of repeated appeal of the effectiveness of three-field lymphadenectomy (3FL) by Japanese esophageal surgeons, it has not been accepted worldwide as a standard therapeutic measure for thoracic esophageal cancer. In this review, a concise summary of the history of 3FL, its present position, and its future perspective is discussed. Although a lack of randomized controlled trial (RCT) is one of the largest criticisms of 3FL, it seems difficult to make 3FL world-standard even if a RCT with a positive result was made. The essence of 3FL has revealed the fact that bilateral cervical paraesophageal nodes and nodes in the bilateral supraclavicular fossae are regional nodes of thoracic esophageal cancer. To let the world admit this essence should be the real endpoint of "3FL issue" without RCT. In the era of new modalities, Japanese surgeons should be free from the idea that 3FL is indispensable though the essence of 3FL should remain.
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Affiliation(s)
- Harushi Udagawa
- Toranomon Hospital KajigayaKawasaki CityJapan
- Okinaka Memorial Institute for Medical ResearchTokyoJapan
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10
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Wang J, Yao F, Yao J, Xu L, Qian JL, Shan LM. 21- versus 25-mm Circular Staplers for Cervical Anastomosis: A Propensity-Matched Study. J Surg Res 2019; 246:427-434. [PMID: 31699537 DOI: 10.1016/j.jss.2019.09.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 07/28/2019] [Accepted: 09/13/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND The use of a small circular stapler (CS) has been reported to increase the incidence of benign anastomotic stricture of the intrathoracic anastomosis after esophagectomy, but no study has evaluated the effects of the CS size on cervical esophagogastrostomy. Based on a propensity-matched comparison, the present study was designed to determine whether the perioperative outcomes differ between 21- and 25-mm CSs after minimally invasive esophagectomy with cervical anastomosis. METHODS From January 2015 to December 2017, 162 patients who received CS cervical esophagogastric anastomosis after minimally invasive esophagectomy for esophageal cancer were identified from our surgical database. A propensity-matched analysis was used to compare the outcomes between the 21- and 25-mm CS groups. Endpoints included anastomotic leak, dysphagia, reflux, stricture, and other major postoperative outcomes within 6 postoperative months. RESULTS There were 69 and 93 patients in the 21- and 25-mm CS groups, respectively. Propensity matching produced 57 patients in each group. The two groups were not remarkably different in benign anastomotic stricture rate (P = 0.528). All strictures were resolved by balloon dilatation. The 25-mm CS group had a significantly longer operative time in cervical anastomosis than the 21-mm group (P = 0.005). No statistically significant differences in anastomotic leak rates, dysphagia scores, reflux scores, or other postoperative complications were noted between the two groups. CONCLUSIONS The use of a 21-mm CS in minimally invasive esophagectomy with cervical esophagogastric anastomosis did not result in greater anastomotic stricture as compared with a 25-mm CS. The 21-mm CS was associated with a significantly shorter operative time.
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Affiliation(s)
- Jian Wang
- Division of Thoracic Surgery, The Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Fei Yao
- Division of Thoracic Surgery, The Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing, Jiangsu, China.
| | - Ju Yao
- Division of Thoracic Surgery, The Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Lei Xu
- Division of Thoracic Surgery, The Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Jun-Ling Qian
- Division of Thoracic Surgery, The Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Li-Mei Shan
- Division of Thoracic Surgery, The Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
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11
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Zhang M, Zhang C, Wu QC. Health-related quality of life and survival among 10-year survivors of esophageal cancer surgery: gastric tube reconstruction versus whole stomach reconstruction. J Thorac Dis 2019; 11:3284-3291. [PMID: 31559031 DOI: 10.21037/jtd.2019.08.56] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background To compare the health-related quality of life (HRQL) and long-term survival between patients after oncologic esophagectomy with narrow gastric tube (NGT) reconstruction and whole stomach (WS) reconstruction. Methods Between 2007 and 2008, a total of 104 patients undergoing esophagectomy were included in this research. Fifty-two patients were enrolled in NGT group and 52 in WS group. HRQL was assessed at 3 weeks, 6 months, 1 year, 2 years, 5 years and 10 years after surgery. The questionnaire was designed with reference to the European Organization for Research and Treatment of Cancer QLQ-C30 and QLQ-QES18. Results For patients' baseline characteristics, there was no significant difference between groups. Patients in NGT group had significantly less postoperative reflux than those in WS group. Dysphagia is the only symptom that was significantly worse in WS group than in NGT group at 10 years follow-up. The number of patients presenting good HRQL between groups did not reveal significant differences at 10 years follow-up. The 10-year survival was 33.3% for patients in NGT group and 11.5% for patients in WS group (P<0.05). Conclusions Because of a better long-term survival (P=0.027), gastric tube reconstruction may be a better choice for patients undergoing oncologic esophagectomy. HRQL recovers to a level comparable in most patients who survive 10 years after esophagectomy for cancer, although some digestive tract symptoms, like dysphagia, may last during the whole postoperative period and represent a poor prognosis.
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Affiliation(s)
- Min Zhang
- Department of Cardiothoracic Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Cheng Zhang
- Department of Cardiothoracic Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Qing-Chen Wu
- Department of Cardiothoracic Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
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12
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Chen J, Liu Q, Zhang X, Yang H, Tan Z, Lin Y, Fu J. Comparisons of short-term outcomes between robot-assisted and thoraco-laparoscopic esophagectomy with extended two-field lymph node dissection for resectable thoracic esophageal squamous cell carcinoma. J Thorac Dis 2019; 11:3874-3880. [PMID: 31656660 DOI: 10.21037/jtd.2019.09.05] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Video-assisted thoracoscopic surgery has been identified as priori choice compared with open approaches in esophageal cancer surgery. With the developments in the Da Vinci robotic system, the robot-assisted minimally invasive esophagectomy (RAMIE) has been increasingly popular. However, whether RAMIE could be a better choice over thoraco-laparoscopic minimally invasive esophagectomy (TLMIE) is unclear. Methods The clinicopathological characteristics of patients who received RAMIE or TLMIE with modern two-field lymph node dissection in Sun Yat-sen University Cancer Center between Jan 2016 to Jan 2018 were retrospectively retrieved. The 1:1 propensity score match analysis was performed to compare the short-term effectiveness and safety between the two groups. Results Two hundred and fifteen esophageal squamous cell carcinoma (ESCC) patients received RAMIE (101 patients) or TLMIE (114 patients) were included in the analysis. After a 1:1 propensity score matching, 108 patients (54 pairs) who received RAMIE or TLMIE displayed no significant variance in baseline clinicopathological characteristics. No significant difference in operative time, intraoperative blood loss, number of resected lymph nodes, and R0 resection rates were observed between the matched groups. However, the recurrent laryngeal nerve protection was better in RAMIE group (P=0.021). Nevertheless, both the incidences of common postoperative complications and length of ICU (hospital) stay were similar in two groups. The average total (P=0.009) and daily (P=0.028) expenses of RAMIE were higher. Conclusions In general, RAMIE could benefit patients by providing better recurrent laryngeal nerve protection. In order to promote the applications of RAMIE, more efforts should be made to reduce the costs by the social and medical insurance agencies.
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Affiliation(s)
- Junying Chen
- Sun Yat-sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, China.,Guangdong Esophageal Cancer Institute, Guangzhou 510060, China
| | - Qianwen Liu
- Sun Yat-sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, China.,Guangdong Esophageal Cancer Institute, Guangzhou 510060, China
| | - Xu Zhang
- Sun Yat-sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, China.,Guangdong Esophageal Cancer Institute, Guangzhou 510060, China
| | - Hong Yang
- Sun Yat-sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, China.,Guangdong Esophageal Cancer Institute, Guangzhou 510060, China
| | - Zihui Tan
- Sun Yat-sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, China.,Guangdong Esophageal Cancer Institute, Guangzhou 510060, China
| | - Yaobin Lin
- Sun Yat-sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, China.,Guangdong Esophageal Cancer Institute, Guangzhou 510060, China
| | - Jianhua Fu
- Sun Yat-sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, China.,Guangdong Esophageal Cancer Institute, Guangzhou 510060, China
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13
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Liu G, Han Y, Peng L, Wang K, Fan Y. Reliability and safety of minimally invasive esophagectomy after neoadjuvant chemoradiation: a retrospective study. J Cardiothorac Surg 2019; 14:97. [PMID: 31138245 PMCID: PMC6537410 DOI: 10.1186/s13019-019-0920-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 05/13/2019] [Indexed: 12/12/2022] Open
Abstract
Background Thoracic surgeons have recognized the advantages of minimally invasive esophagectomy (MIE). However, MIE for locally advanced esophageal cancer after neoadjuvant chemoradiotherapy (NCRT) is controversial. This study aimed to nvestigate and summarise the reliability and safety of MIE after NCRT. Methods We retrospectively analyzed the perioperative outcomes of patients with locally advanced esophageal cancer who underwent minimally invasive esophagectomy after neoadjuvant chemoradiotherapy from January 2016 to January 2018, and compared them with patients who underwent MIE alone during the same period. Results In total, 107 patients were eligible for the study. Forty-four patients underwent MIE after NCRT (CRM), and 63 patients underwent MIE alone (MA). The surgical duration (253.59 ± 47.51 vs. 222.86 ± 42.86 min), intraoperative blood loss (164.55 ± 109.09 vs. 146.19 ± 112.89 ml), number of lymph nodes resected (18.36 ± 8.01 vs. 22.10 ± 12.03), duration of the postoperative hospital stay (12.84 ± 6.57 vs. 14.60 ± 8.48 days), postoperative intubation time (5.68 ± 3.08 vs. 6.54 ± 4.97 days), total incidence of complications (34.10% vs. 31.7%), and R0 resection rate (95.45% vs. 96.83%) had no significant difference. The incidence of arrhythmia was higher in CRM (P < 0.02). No mortality occurred postoperatively within 30 days in either group. Conclusion Minimally invasive esophagectomy after neoadjuvant chemoradiotherapy is a feasible, safe, and beneficial for postoperative recovery of patients. Electronic supplementary material The online version of this article (10.1186/s13019-019-0920-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Guangyuan Liu
- Department of Thoracic Surgery, Sichuan Cancer Hospital and Institute, No.55, Section4, South Renmin Road, Chengdu, 610041, China.
| | - Yongtao Han
- Department of Thoracic Surgery, Sichuan Cancer Hospital and Institute, No.55, Section4, South Renmin Road, Chengdu, 610041, China
| | - Lin Peng
- Department of Thoracic Surgery, Sichuan Cancer Hospital and Institute, No.55, Section4, South Renmin Road, Chengdu, 610041, China
| | - Kangning Wang
- Department of Thoracic Surgery, Sichuan Cancer Hospital and Institute, No.55, Section4, South Renmin Road, Chengdu, 610041, China
| | - Yu Fan
- Department of Radiation Oncology, Sichuan Cancer Hospital and Institute, No.55, Section4, South Renmi Road, Chengdu, 610041, China
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14
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Zhang Y, Han Y, Gan Q, Xiang J, Jin R, Chen K, Che J, Hang J, Li H. Early Outcomes of Robot-Assisted Versus Thoracoscopic-Assisted Ivor Lewis Esophagectomy for Esophageal Cancer: A Propensity Score-Matched Study. Ann Surg Oncol 2019; 26:1284-1291. [PMID: 30843161 DOI: 10.1245/s10434-019-07273-3] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND Both robot-assisted Ivor Lewis esophagectomy (RAILE) and conventional thoracoscopic-assisted Ivor Lewis esophagectomy (TAILE) are minimally invasive surgical techniques for the treatment of middle and distal esophageal cancer. However, no research studies comparing early outcomes between RAILE and TAILE have been reported. METHODS A retrospective analysis was made of 184 patients, 76 in the RAILE group and 108 in the TAILE group, who underwent minimally invasive Ivor Lewis esophagectomy between December 2014 and June 2018. Propensity score-matched analysis was performed between the two groups based on demographics, comorbidities, American Society of Anesthesiologists score, tumor location, tumor size, and pathological stage. Perioperative outcomes were compared. RESULTS Two conversions to thoracotomy occurred in the RAILE group. There was no 30-day in either group. Sixty-six matched pairs were identified for each group. Within the propensity score-matched cohorts, the operative time in the RAILE group was significantly longer than that in the TAILE group (302.0 ± 62.9 vs. 274.7 ± 38.0 min, P = 0.004). There was no significant difference in the blood loss [200.0 ml (interquartile range [IQR], 100.0-262.5 ml) vs. 200.0 ml (150.0-245.0 ml), P = 0.100], rates of overall complications (28.8 vs. 24.2%, P = 0.554), length of stay [9.0 days (IQR 8.0-12.3 days) vs. 9.0 days (IQR 8.0-11.3 days), P = 0.517], the number of total dissected lymph nodes (19.2 ± 9.2 vs. 19.3 ± 9.5, P = 0.955), and detailed categories of lymph nodes. CONCLUSIONS RAILE demonstrated comparable early outcomes compared with TAILE and should be considered as an alternative minimally invasive option for treating esophageal cancer.
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Affiliation(s)
- Yajie Zhang
- Department of Thoracic Surgery, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yu Han
- Department of Thoracic Surgery, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Qinyi Gan
- Department of Thoracic Surgery, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jie Xiang
- Department of Thoracic Surgery, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Runsen Jin
- Department of Thoracic Surgery, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Kai Chen
- Department of Thoracic Surgery, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jiaming Che
- Department of Thoracic Surgery, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Junbiao Hang
- Department of Thoracic Surgery, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Hecheng Li
- Department of Thoracic Surgery, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China.
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15
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Schröder W, Bruns C. [Current trends in oncological esophageal surgery : A worldwide survey]. Chirurg 2019; 90:30. [PMID: 30758624 DOI: 10.1007/s00104-019-0823-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- W Schröder
- Klinik für Allgemein-, Viszeral- und Tumorchirurgie, Universitätsklinik Köln, Kerpener Str. 62, 50937, Köln, Deutschland.
| | - C Bruns
- Klinik für Allgemein-, Viszeral- und Tumorchirurgie, Universitätsklinik Köln, Kerpener Str. 62, 50937, Köln, Deutschland
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16
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Factors during training which predict future use of minimally invasive thoracic surgery. Ann Med Surg (Lond) 2018; 35:149-152. [PMID: 30302245 PMCID: PMC6174821 DOI: 10.1016/j.amsu.2018.09.039] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 09/22/2018] [Accepted: 09/26/2018] [Indexed: 11/23/2022] Open
Abstract
Background While minimally invasive thoracic surgery (MIS) has increased nationwide over the years, most patients undergoing lung and esophageal resections still undergo an open approach. We performed a national survey to analyze factors associated with a propensity to perform MIS after completing a cardiothoracic training program. Materials and methods Cardiothoracic surgery trainees in 2 or 3-year programs from 2010 to 2016 were sent an online survey regarding the numbers and types of cases performed during training and current practice patterns as attending surgeons. Comfort level with MIS was also assessed. Responses were recorded and analyzed using SPSS. Results One hundred thirty-six trainees responded, with a mean of 121 lobectomies (30-250) and 40 esophagectomies (8-110) performed during training. Mean minimally invasive lobectomy and esophagectomy rates during training were 53% and 30% respectively. A greater ratio of MIS procedures performed during training correlated with a higher rate performed as an attending (lobectomies, p = 0.04; esophagectomies, p = 0.01) and a greater comfort level with performing these procedures (lobectomies, p = 0.01 and esophagectomies, p < 0.01). Conclusions Based on these results, performing a greater ratio of minimally invasive lobectomies and esophagectomies during fellowship training increases the likelihood of performing them as an attending. Trainees who perform more minimally invasive procedures as trainees are more likely to do so as attendings. Trainees who perform many open lobectomies do not necessarily convert to minimally invasive approaches as attendings. Trainees who perform many esophagectomies are less likely to convert as attendings.
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17
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He H, Wu Q, Wang Z, Zhang Y, Chen N, Fu J, Zhang G. Short-term outcomes of robot-assisted minimally invasive esophagectomy for esophageal cancer: a propensity score matched analysis. J Cardiothorac Surg 2018; 13:52. [PMID: 29792203 PMCID: PMC5967100 DOI: 10.1186/s13019-018-0727-4] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 05/09/2018] [Indexed: 01/11/2023] Open
Abstract
Background Minimally invasive esophagectomy (MIE) was shown to be effective in reducing the morbidity and was adopted increasingly. The robot-assisted minimally invasive esophagectomy (RAMIE) remains in the initial stage of application. This study evaluated its safety and feasibility by comparing short-term outcomes of RAMIE and video-assisted minimally invasive esophagectomy (VAMIE). Methods Between March 2016 and December 2017, 115 consecutive patients underwent RAMIE or VAMIE at our institute. The baseline characteristics, pathological data and short-term outcomes of these two group patients were collected and compared. RAMIE patients were propensity score matched with VAMIE patients for a more accurate comparison. Results Matching based on propensity scores produced 27 patients in each group. After propensity score matching (PSM), the baseline characteristics between the two groups were comparable. The operation time in RAMIE group was significantly longer than that in VAMIE group (349 and 294 min, respectively; P < 0.001). The blood loss volume in RAMIE group was less than that in VAMIE group (119 and 158 ml, respectively), but with no statistically significant difference (P = 0.062). There was no significant difference between the two groups with respect to the mean number of dissected lymph nodes (20 and 19, respectively; P = 0.420), postoperative hospital stay (13.8 and 12.7 days, respectively; P = 0.548), the rate of overall complications (37.0 and 33.3%, respectively; P = 0.776) and the rates of detailed complications between the two groups. Conclusions The short-term outcomes of RAMIE is comparable to VAMIE, demonstrating safety and feasibility of RAMIE.
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Affiliation(s)
- Haiqi He
- Department of thoracic surgery, The First Affiliated Hospital of Xi'an Jiaotong University, 277 West Yanta Road, Xi'an, Shaanxi, 710061, China
| | - Qifei Wu
- Department of thoracic surgery, The First Affiliated Hospital of Xi'an Jiaotong University, 277 West Yanta Road, Xi'an, Shaanxi, 710061, China
| | - Zhe Wang
- Department of thoracic surgery, The First Affiliated Hospital of Xi'an Jiaotong University, 277 West Yanta Road, Xi'an, Shaanxi, 710061, China
| | - Yong Zhang
- Department of thoracic surgery, The First Affiliated Hospital of Xi'an Jiaotong University, 277 West Yanta Road, Xi'an, Shaanxi, 710061, China
| | - Nanzheng Chen
- Department of thoracic surgery, The First Affiliated Hospital of Xi'an Jiaotong University, 277 West Yanta Road, Xi'an, Shaanxi, 710061, China
| | - Junke Fu
- Department of thoracic surgery, The First Affiliated Hospital of Xi'an Jiaotong University, 277 West Yanta Road, Xi'an, Shaanxi, 710061, China
| | - Guangjian Zhang
- Department of thoracic surgery, The First Affiliated Hospital of Xi'an Jiaotong University, 277 West Yanta Road, Xi'an, Shaanxi, 710061, China.
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18
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Li X, Wang W, Zhou Y, Yang D, Wu J, Zhang B, Wu Z, Tang J. Efficacy comparison of transcervical video-assisted mediastinoscopic lymphadenectomy combined with left transthoracic esophagectomy versus right transthoracic esophagectomy for esophageal cancer treatment. World J Surg Oncol 2018; 16:25. [PMID: 29426329 PMCID: PMC5807757 DOI: 10.1186/s12957-017-1268-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2017] [Accepted: 11/07/2017] [Indexed: 02/07/2023] Open
Abstract
Background This study aimed to propose a new surgical strategy, i.e., the transcervical video-assisted mediastinoscopic lymphadenectomy (VAMLA) with esophagectomy via the left transthoracic approach for patients with esophageal cancer (EC), and to compare the outcomes with those of esophagectomy via the right thoracic approach. Methods From December 2014 to March 2016, 49 cases were enrolled in this non-randomized concurrent control study. Twenty-eight patients with EC who underwent transcervical VAMLA with esophagectomy via the left transthoracic approach were assigned into the study group, while 21 EC patients undergoing esophagectomy via the right transthoracic approach during the same period were enrolled into the control group. Operative outcomes including operative time, the numbers of removed lymph nodes, intraoperative blood loss, the length of hospital stay, and postoperative complications in both groups were evaluated and compared. Results There were no significant differences in the baseline profiles between the two groups, and all patients in the two groups successfully underwent the surgery. There was a significant difference between transcervical VAMLA with esophagectomy via the left thoracic approach and esophagectomy via the right thoracic approach with regard to the number of all dissected lymph nodes [(29.0 ± 8.7) vs. (17.8 ± 8.1), p < 0.05], dissected superior mediastinal lymph nodes [(11.2 ± 5.0) vs. (3.7 ± 2.9), p < 0.05], and dissected in the recurrent laryngeal nerve lymph nodes [(5.6 ± 3.5) vs. (2.3 ± 2.1), p < 0.05]. No significant differences were observed in the operative time, intraoperative blood loss, length of postoperative hospital stay, number of dissected abdominal lymph nodes, postoperative pulmonary complications (pneumonia and atelectasis), anastomotic fistula, chylothorax, and vocal cord paralysis (p > 0.05). Conclusion Transcervical VAMLA combined with esophagectomy via the left thoracic approach appears technically feasible and safe and shows advantages in the number of dissected superior mediastinal lymph nodes, suggesting that it may serve as a new treatment option for patients with esophageal carcinoma.
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Affiliation(s)
- Xu Li
- Department of Thoracic Surgery, The Second Xiangya Hospital of Central South University, Changsha, Hunan, 410011, China
| | - Wenxiang Wang
- The Second Department of Thoracic Surgery, Hunan Cancer Hospital and The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, No.283 Tongzipo Street, Yuelu District, Changsha, Hunan, 410013, China.
| | - Yong Zhou
- The Second Department of Thoracic Surgery, Hunan Cancer Hospital and The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, No.283 Tongzipo Street, Yuelu District, Changsha, Hunan, 410013, China
| | - Desong Yang
- The Second Department of Thoracic Surgery, Hunan Cancer Hospital and The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, No.283 Tongzipo Street, Yuelu District, Changsha, Hunan, 410013, China
| | - Jie Wu
- The Second Department of Thoracic Surgery, Hunan Cancer Hospital and The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, No.283 Tongzipo Street, Yuelu District, Changsha, Hunan, 410013, China
| | - Baihua Zhang
- The Second Department of Thoracic Surgery, Hunan Cancer Hospital and The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, No.283 Tongzipo Street, Yuelu District, Changsha, Hunan, 410013, China
| | - Zhining Wu
- The Second Department of Thoracic Surgery, Hunan Cancer Hospital and The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, No.283 Tongzipo Street, Yuelu District, Changsha, Hunan, 410013, China
| | - Jinming Tang
- The Second Department of Thoracic Surgery, Hunan Cancer Hospital and The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, No.283 Tongzipo Street, Yuelu District, Changsha, Hunan, 410013, China
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Jin R, Xiang J, Han D, Zhang Y, Li H. Robot-assisted Ivor-Lewis esophagectomy with intrathoracic robot-sewn anastomosis. J Thorac Dis 2017; 9:E990-E993. [PMID: 29268555 DOI: 10.21037/jtd.2017.09.96] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
This video clip demonstrated a performance of robot-assisted Ivor-Lewis esophagectomy with intrathoracic robot-sewn anastomosis. The patient had an esophageal mass located approximately 33 cm away from incisor, and robot-assisted Ivor-Lewis esophagectomy was applied for him. Importantly, a double-layer esophago-gastric anastomosis was made by robotic hand-sewn suture. Our early experience demonstrated that the robot-sewn intrathoracic anastomosis is feasible and safe with a lower complication rate and the absence of anastomotic leakage.
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Affiliation(s)
- Runsen Jin
- Department of Thoracic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Jie Xiang
- Department of Thoracic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Dingpei Han
- Department of Thoracic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Yajie Zhang
- Department of Thoracic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Hecheng Li
- Department of Thoracic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
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Liu Y, Li JJ, Zu P, Liu HX, Yu ZW, Ren Y. Two-step method for creating a gastric tube during laparoscopic-thoracoscopic Ivor-Lewis esophagectomy. World J Gastroenterol 2017; 23:8035-8043. [PMID: 29259379 PMCID: PMC5725298 DOI: 10.3748/wjg.v23.i45.8035] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 08/15/2017] [Accepted: 09/05/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To introduce a two-step method for creating a gastric tube during laparoscopic-thoracoscopic Ivor-Lewis esophagectomy and assess its clinical application.
METHODS One hundred and twenty-two patients with middle or lower esophageal cancer who underwent laparoscopic-thoracoscopic Ivor-Lewis esophagectomy at Liaoning Cancer Hospital and Institute from March 2014 to March 2016 were included in this study, and divided into two groups based on the procedure used for creating a gastric tube. One group used a two-step method for creating a gastric tube, and the other group used the conventional method. The two groups were compared regarding the operating time, surgical complications, and number of stapler cartridges used.
RESULTS The mean operating time was significantly shorter in the two-step method group than in the conventional method group [238 (179-293) min vs 272 (189-347) min, P < 0.01]. No postoperative death occurred in either group. There was no significant difference in the rate of complications [14 (21.9%) vs 13 (22.4%), P = 0.55] or mean number of stapler cartridges used [5 (4-6) vs 5.2 (5-6), P = 0.007] between the two groups.
CONCLUSION The two-step method for creating a gastric tube during laparoscopic-thoracoscopic Ivor-Lewis esophagectomy has the advantages of simple operation, minimal damage to the tubular stomach, and reduced use of stapler cartridges.
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Affiliation(s)
- Yu Liu
- Department of Thoracic Surgery, Cancer Hospital of China Medical University/Liaoning Cancer Hospital and Institute, Shenyang 110042, Liaoning Province, China
| | - Ji-Jia Li
- Department of Thoracic Surgery, Cancer Hospital of China Medical University/Liaoning Cancer Hospital and Institute, Shenyang 110042, Liaoning Province, China
| | - Peng Zu
- Department of Thoracic Surgery, Cancer Hospital of China Medical University/Liaoning Cancer Hospital and Institute, Shenyang 110042, Liaoning Province, China
| | - Hong-Xu Liu
- Department of Thoracic Surgery, Cancer Hospital of China Medical University/Liaoning Cancer Hospital and Institute, Shenyang 110042, Liaoning Province, China
| | - Zhan-Wu Yu
- Department of Thoracic Surgery, Cancer Hospital of China Medical University/Liaoning Cancer Hospital and Institute, Shenyang 110042, Liaoning Province, China
| | - Yi Ren
- Department of Thoracic Surgery, Cancer Hospital of China Medical University/Liaoning Cancer Hospital and Institute, Shenyang 110042, Liaoning Province, China
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Hayata K, Nakamori M, Nakamura M, Ojima T, Iwahashi M, Katsuda M, Tsuji T, Kato T, Kitadani J, Takeuchi A, Tabata H, Yamaue H. Circular stapling versus triangulating stapling for the cervical esophagogastric anastomosis after esophagectomy in patients with thoracic esophageal cancer: A prospective, randomized, controlled trial. Surgery 2017; 162:131-138. [PMID: 28318550 DOI: 10.1016/j.surg.2017.01.013] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Revised: 01/12/2017] [Accepted: 01/17/2017] [Indexed: 01/26/2023]
Abstract
BACKGROUND Several studies have reported that the triangulating stapling method decreases the incidence of anastomotic stricture after esophagectomy, but no randomized, controlled trial has confirmed the efficacy of the triangulating stapling method for cervical esophagogastrostomy. We compared triangulating stapling and circular stapling for cervical esophagogastric anastomosis regarding the decrease in anastomotic stricture after esophagectomy for thoracic esophageal cancer. METHODS Between August 2010 and April 2014, 100 patients enrolled in this randomized, controlled trial at the Wakayama Medical University Hospital were allocated randomly to either the circular stapling group (n = 49) or the triangulating stapling group (n = 51). The primary end point was the incidence of anastomotic stricture within 12 months postoperatively. This randomized, controlled trial was registered with the University Hospital Medical Information Network Clinical Trial Registry (UMIN000004848). RESULTS There were no differences between the circular stapling and triangulating stapling groups in terms of clinical data. The amount of time required for esophagogastric anastomosis was slightly greater for the triangulating stapling group (22 minutes) than for the circular stapling group (18 minutes) (P = .028). Anastomotic stricture occurred in 8 patients (17%) in the circular stapling group and 9 patients (19%) in the triangulating stapling group (P = .935). The rate of anastomotic leakage was 11% for the circular stapling group and 2% for the triangulating stapling group (P = .073). CONCLUSION The triangulating stapling method for cervical anastomosis for thoracic esophageal cancer does not decrease the incidence of anastomotic stricture compared with the circular stapling method within 12 postoperative months but may affect the rate of anastomotic leakage.
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Affiliation(s)
- Keiji Hayata
- Second Department of Surgery, Wakayama Medical University, School of Medicine, Wakayama, Japan
| | - Mikihito Nakamori
- Second Department of Surgery, Wakayama Medical University, School of Medicine, Wakayama, Japan
| | - Masaki Nakamura
- Second Department of Surgery, Wakayama Medical University, School of Medicine, Wakayama, Japan
| | - Toshiyasu Ojima
- Second Department of Surgery, Wakayama Medical University, School of Medicine, Wakayama, Japan
| | - Makoto Iwahashi
- Second Department of Surgery, Wakayama Medical University, School of Medicine, Wakayama, Japan
| | - Masahiro Katsuda
- Second Department of Surgery, Wakayama Medical University, School of Medicine, Wakayama, Japan
| | - Toshiaki Tsuji
- Second Department of Surgery, Wakayama Medical University, School of Medicine, Wakayama, Japan
| | - Tomoya Kato
- Second Department of Surgery, Wakayama Medical University, School of Medicine, Wakayama, Japan
| | - Jyunya Kitadani
- Second Department of Surgery, Wakayama Medical University, School of Medicine, Wakayama, Japan
| | - Akihiro Takeuchi
- Second Department of Surgery, Wakayama Medical University, School of Medicine, Wakayama, Japan
| | - Hirotaka Tabata
- Second Department of Surgery, Wakayama Medical University, School of Medicine, Wakayama, Japan
| | - Hiroki Yamaue
- Second Department of Surgery, Wakayama Medical University, School of Medicine, Wakayama, Japan.
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Mu JW, Gao SG, Xue Q, Mao YS, Wang DL, Zhao J, Gao YS, Huang JF, He J. Comparison of short-term outcomes and three yearsurvival between total minimally invasive McKeown and dual-incision esophagectomy. Thorac Cancer 2017; 8:80-87. [PMID: 28052566 PMCID: PMC5334296 DOI: 10.1111/1759-7714.12404] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Revised: 10/03/2016] [Accepted: 10/07/2016] [Indexed: 12/30/2022] Open
Abstract
Background The aim of this study was to compare the short‐term outcomes and three‐year survival between dual‐incision esophagectomy (DIE) and total minimally invasive McKeown esophagectomy (MIME) for esophageal cancer patients with negative upper mediastinal lymph nodes requiring esophagectomy and neck anastomosis. Methods One hundred and fifty patients underwent DIE, while 361 patients received total MIME. Perioperative outcomes and three‐year survival were compared in unmatched and propensity score matched data between two groups. Results Both unmatched and matched analysis demonstrated that there were no significant differences in the number of lymph nodes harvested, or major or minor complication rates between the DIE and MIME groups. Compared with patients who underwent DIE, patients who underwent total MIME had longer operation duration (310 minutes vs. 345 minutes; P = 0.002). However, there was significantly less intraoperative blood loss in the total MIME compared with the DIE group (191 mL vs. 287 mL, respectively; P < 0.001). Kaplan‐Meier analysis demonstrated a trend that patients who underwent MIME had longer overall (79.5% vs. 64.1%; P = 0.063) and disease‐free three‐year survival (65.3% vs. 82.8%; P = 0.058) compared with patients who underwent DIE. Conclusions Both total MIME and DIE are feasible for the surgical treatment of esophageal cancer patients with negative upper mediastinal lymph nodes requiring esophagectomy and neck anastomosis. However, MIME was associated with better overall and disease‐free three‐year survival compared with DIE.
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Affiliation(s)
- Ju-Wei Mu
- Department of Thoracic Surgical Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shu-Geng Gao
- Department of Thoracic Surgical Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qi Xue
- Department of Thoracic Surgical Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - You-Sheng Mao
- Department of Thoracic Surgical Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Da-Li Wang
- Department of Thoracic Surgical Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jun Zhao
- Department of Thoracic Surgical Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yu-Shun Gao
- Department of Thoracic Surgical Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jin-Feng Huang
- Department of Thoracic Surgical Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jie He
- Department of Thoracic Surgical Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Haverkamp L, Seesing MFJ, Ruurda JP, Boone J, V Hillegersberg R. Worldwide trends in surgical techniques in the treatment of esophageal and gastroesophageal junction cancer. Dis Esophagus 2017; 30:1-7. [PMID: 27001442 DOI: 10.1111/dote.12480] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The aim of this study was to evaluate the worldwide trends in surgical techniques for esophageal cancer surgery by comparing it to our survey from 2007. In addition, new questions were added for gastroesophageal junction (GEJ) cancer. An international survey on surgery of esophageal and GEJ cancer was performed among surgical members of the International Society for Diseases of the Esophagus, the World Organization for Specialized Studies on Disease of the Esophagus, the International Gastric Cancer Association. Also, surgeons from personal networks were contacted. The participants filled out a web based questionnaire about surgical strategies for esophageal and gastroesophageal cancer. The overall response rate was 478/1147 (42%). The respondents represented 49 different countries and 6 different continents. The annual cumulative number of esophageal and gastric resections per surgeon was low (≤11) in 11%, medium (11-21) in 17%, and high (≥21) in 72% of respondents. In a subgroup analysis of esophageal surgeons the number of high volume surgeons increased from 45 to 54% over the past 7 years. The preferred lymph node dissection was two-field in 86%. A gastric conduit was the preferred method of reconstruction in 95%. In 2014, the preferred approach to esophagectomy was minimally invasive transthoracic in 43%, compared with 14% in 2007. In minimally invasive transthoracic esophagectomy the cervical anastomosis was favored in 54% of respondents in 2014 compared with 87% in 2007. The preferred technique of construction of the cervical anastomosis was hand-sewn in 64% and stapled in 36%, whereas the thoracic anastomosis was stapled in 77% and hand-sewn in 23%. The preferred surgical approach for Siewert type 1 tumors (5-1 cm proximal of the GEJ) was esophagectomy in 93% of respondents, whereas 6% favored gastrectomy and 3% combined a distal esophagectomy with a proximal gastrectomy. For Siewert type 2 tumors (1-2 cm from the GEJ) an extended gastrectomy was favored by 66% of respondents, followed by esophagectomy in 27% and total gastrectomy in 7%. Siewert type 3 tumors (2-5 cm distal of the GEJ) were preferably treated with gastrectomy in 90% of respondents, esophagectomy in 6%, and extended gastrectomy in 4%. The preferred curative surgical treatment of esophageal cancer is minimally invasive transthoracic esophagectomy with a two-field lymph node dissection and gastric conduit reconstruction. A strong worldwide trend toward minimally invasive surgery is observed. The preferred surgical treatment of GEJ tumors is esophagectomy for Siewert type 1 tumors and gastrectomy for Siewert type 3 tumors. The majority of surgeons favor an extended gastrectomy for Siewert type 2 tumors.
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Affiliation(s)
- L Haverkamp
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M F J Seesing
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - J P Ruurda
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - J Boone
- Department of Radiology, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
| | - R V Hillegersberg
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
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Abstract
In esophageal cancer surgery, perfusion of the gastric conduit is a critical issue. Measurement of gastric intramucosal pH (pHi) is a method to identify anaerobic metabolism as a sign of impaired perfusion. In this study we aimed to monitor changes in the perfusion of the gastric conduit at key steps during and after esophagectomy. pHi was measured per- and postoperatively using intermittent gastric tonometry in 32 patients undergoing open, 65%, or video-assisted thoracoscopic esophagectomy for esophageal cancer. Measurements focused on the surgical steps when the vascular supply to the gastric conduit was altered. A tonometry catheter was successfully placed in all patients and a decrease in pHi (mean ± SD) was observed from baseline to after the division of the short gastric vessels (7.33 ± 0.07 to 7.29 ± 0.07, P = 0.005). A further reduction after the ligation of the left gastric artery (7.26 ± 0.08, P < 0.001) and after final linear stapling the gastric conduit (7.15 ± 0.13, P < 0.001) was observed. Two hours after surgery, pHi increased (7.24 ± 0.09, P = 0.002). In contrast to open surgery, a trend towards less reduction in pHi was seen in thoracoscopic surgery. Patients with anastomotic leaks had lower pHi on the first postoperative day (7.12 ± 0.05 vs. 7.27 ± 0.08, P = 0.040). It can be concluded that each surgical step altering the vascular supply to the gastric conduit resulted in detectable changes, however transient, in pHi. Patients with low pHi on the first postoperative day were more prone to have clinically relevant anastomotic leaks.
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Affiliation(s)
- Gustav Linder
- Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | - Jakob Hedberg
- Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | - Martin Björck
- Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | - Magnus Sundbom
- Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
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25
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Schröder W, Bruns C. [Current trends in oncological esophageal surgery : A worldwide survey]. Chirurg 2016; 88:74. [PMID: 27995296 DOI: 10.1007/s00104-016-0358-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- W Schröder
- Klinik für Allgemein-, Viszeral- und Tumorchirurgie, Universitätsklinik Köln, Kerpener Str. 62, 50937, Köln, Deutschland.
| | - C Bruns
- Klinik für Allgemein-, Viszeral- und Tumorchirurgie, Universitätsklinik Köln, Kerpener Str. 62, 50937, Köln, Deutschland
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26
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Mu JW, Gao SG, Xue Q, Mao YS, Wang DL, Zhao J, Gao YS, Huang JF, He J. The impact of operative approaches on outcomes of middle and lower third esophageal squamous cell carcinoma. J Thorac Dis 2016; 8:3588-3595. [PMID: 28149553 DOI: 10.21037/jtd.2016.12.42] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND The aim of this study was to investigate the perioperative outcomes and 3-year overall survival (OS) of 2 approaches including Sweet and open Ivor Lewis esophagectomy in the surgical treatment of middle and lower third esophageal squamous cell carcinoma. METHODS The medical records of 1,746 consecutive patients who underwent esophagectomy for middle and lower esophageal cancer between January 2009 and September 2015 at the First Department of Thoracic Oncologic Surgery of Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College were retrospectively reviewed. The clinical variables and 3-year survival were compared between Sweet (n=1,701) and open Ivor Lewis (n=45) approaches in unmatched and propensity score matching analysis. RESULTS Patients who received esophagectomy by Sweet approach had shorter duration of surgery (mean 212 vs. 390 min; P<0.001), more lymph nodes removed (mean 24 vs. 19; P=0.005), lower overall complications rate (24.4% vs. 11.7%; P=0.009), lower total hospital cost (¥77,200 vs. 106,000; P=0.045) compared with patients who received open Ivor Lewis approach. After propensity score matching analysis, Sweet approach was still associated with decreased duration of surgery (mean 210 vs. 390 min; P<0.001), more lymph nodes removed (mean 24 vs. 19; P=0.050), and lower total hospital cost (¥86,800 vs. 106,000; P=0.045) compared with Ivor Lewis approach. However, there were no significant differences in overall complication rates (24.4% vs. 24.4%; P=1.000) between two approaches. There was no significant difference in 3-year OS between Sweet and open Ivor Lewis approaches (59.9% vs. 61.4%; P=0.637) in unmatched analysis and in matched analysis (77.8% vs. 61.4%; P=0.264). CONCLUSIONS In this cohort, for middle and lower third esophageal squamous cell carcinoma patients, both Sweet and open Ivor Lewis approaches are feasible in terms of perioperative outcomes and 3-year OS.
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Affiliation(s)
- Ju-Wei Mu
- Department of Thoracic Surgical Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Shu-Geng Gao
- Department of Thoracic Surgical Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Qi Xue
- Department of Thoracic Surgical Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - You-Sheng Mao
- Department of Thoracic Surgical Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Da-Li Wang
- Department of Thoracic Surgical Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Jun Zhao
- Department of Thoracic Surgical Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Yu-Shun Gao
- Department of Thoracic Surgical Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Jin-Feng Huang
- Department of Thoracic Surgical Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Jie He
- Department of Thoracic Surgical Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
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27
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Minimally Invasive Esophagectomy in the Lateral-prone Position: Experience of 226 Cases. Surg Laparosc Endosc Percutan Tech 2016; 26:60-5. [PMID: 26679683 DOI: 10.1097/sle.0000000000000225] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND An open esophagectomy for esophageal cancer is a severely invasive procedure. Minimally invasive esophagectomy (MIE) has emerged as an effective alternative to open techniques. Conventionally, a thoracoscopic procedure is performed either in the left lateral decubitus position or in the prone position. Both positions have their disadvantage during the mobilization of the esophagus. In this study, we applied a novel position: the left lateral-prone position in the throacoscopic phase of MIE; we also describe the details of the technique and its feasibility, and present the initial results of this large-volume series. METHOD We performed 226 cases of MIEs for esophageal cancer successfully from February 2008 to September 2014. All patients received thoracoscopic mobilization of the esophagus, followed by larparoscopic mobilization of the stomach and cervical anastomosis (McKeown or 3-field lymphadenectomy dissection esophagectomy). The throacoscopic part was performed in the left lateral-prone position. Perioperative data and the surgical outcome were studied retrospectively. RESULT Of the 226 patients, 131 were men (57.9%) and 95 (42.1%) were women, with a median age of 64.5 years. All procedures were completed by thoracoscopy and laparoscopy, except 3 cases of conversion to open thoracotomy and 2 conversions to open laparotomy. Two-field lymphadenectomy was performed in 89 patients. Three-field lymphadenectomy was performed in 137 patients. Only 6 (2.7%) patients required blood transfusion. Postoperative morbidity was encountered in 78 (34.5%) patients, and anastomotic leak occurred in 9 cases (4.0%). Vocal cord paralysis was found in 11 cases (4.9%). The mean number of lymph nodes harvested was 21. The 30-day postoperative mortality rate was 1.3% (n=3). The mean length of hospital stay was 12.7 days. CONCLUSIONS MIE in the lateral-prone position is technically less demanding and provides better technical safety, with good oncological effectiveness. This positioning is a feasible and appropriate alternative for minimally invasive surgery of esophageal carcinoma.
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van der Sluis PC, Ruurda JP, Verhage RJJ, van der Horst S, Haverkamp L, Siersema PD, Borel Rinkes IHM, Ten Kate FJW, van Hillegersberg R. Oncologic Long-Term Results of Robot-Assisted Minimally Invasive Thoraco-Laparoscopic Esophagectomy with Two-Field Lymphadenectomy for Esophageal Cancer. Ann Surg Oncol 2015; 22 Suppl 3:S1350-6. [PMID: 26023036 PMCID: PMC4686562 DOI: 10.1245/s10434-015-4544-x] [Citation(s) in RCA: 110] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Indexed: 01/12/2023]
Abstract
BACKGROUND Open transthoracic esophagectomy is the worldwide gold standard in the treatment of resectable esophageal cancer. Robot-assisted minimally invasive thoraco-laparoscopic esophagectomy (RAMIE) for esophageal cancer may be associated with reduced blood loss, shorter intensive care unit (ICU) stay, and less cardiopulmonary morbidity; however, long-term oncologic results have not been reported to date. METHODS Between June 2007 and September 2011, a total of 108 patients with potentially resectable esophageal cancer underwent RAMIE at the University Medical Centre Utrecht, with curative intent. All data were recorded prospectively. RESULTS Median duration of the surgical procedure was 381 min (range 264-636). Pulmonary complications were most common and were observed in 36 patients (33 %). Median ICU stay was 1 day, and median overall postoperative hospital stay was 16 days. In-hospital mortality was 5 %. The majority of patients (78 %) presented with T3 and T4 disease, and 68 % of patients had nodal-positive disease (cN1-3). In 65 % of patients, neoadjuvant treatment (chemotherapy 57 %, chemoradiotherapy 7 %, radiotherapy 1 %) was administered, and in 103 (95 %) patients, a radical resection (R0) was achieved. The median number of lymph nodes was 26, median follow-up was 58 months, 5-year overall survival was 42 %, median disease-free survival was 21 months, and median overall survival was 29 months. Tumor recurrence occurred in 51 patients and was locoregional only in 6 (6 %) patients, systemic only in 31 (30 %) patients, and combined in 14 (14 %) patients. CONCLUSION RAMIE was shown to be oncologically effective, with a high percentage of R0 radical resections and adequate lymphadenectomy. RAMIE provided good local control with a low percentage of local recurrence at long-term follow up.
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Affiliation(s)
- P C van der Sluis
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands. .,Department of Surgery, G04.228, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - J P Ruurda
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - R J J Verhage
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - S van der Horst
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - L Haverkamp
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - P D Siersema
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - I H M Borel Rinkes
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - F J W Ten Kate
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - R van Hillegersberg
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands. .,Department of Surgery, G04.228, University Medical Center Utrecht, Utrecht, The Netherlands.
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Allum WH, Bonavina L, Cassivi SD, Cuesta MA, Dong ZM, Felix VN, Figueredo E, Gatenby PAC, Haverkamp L, Ibraev MA, Krasna MJ, Lambert R, Langer R, Lewis MPN, Nason KS, Parry K, Preston SR, Ruurda JP, Schaheen LW, Tatum RP, Turkin IN, van der Horst S, van der Peet DL, van der Sluis PC, van Hillegersberg R, Wormald JCR, Wu PC, Zonderhuis BM. Surgical treatments for esophageal cancers. Ann N Y Acad Sci 2015; 1325:242-68. [PMID: 25266029 DOI: 10.1111/nyas.12533] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The following, from the 12th OESO World Conference: Cancers of the Esophagus, includes commentaries on the role of the nurse in preparation of esophageal resection (ER); the management of patients who develop high-grade dysplasia after having undergone Nissen fundoplication; the trajectory of care for the patient with esophageal cancer; the influence of the site of tumor in the choice of treatment; the best location for esophagogastrostomy; management of chylous leak after esophagectomy; the optimal approach to manage thoracic esophageal leak after esophagectomy; the choice for operational approach in surgery of cardioesophageal crossing; the advantages of robot esophagectomy; the place of open esophagectomy; the advantages of esophagectomy compared to definitive chemoradiotherapy; the pathologist report in the resected specimen; the best way to manage patients with unsuspected positive microscopic margin after ER; enhanced recovery after surgery for ER: expedited care protocols; and long-term quality of life in patients following esophagectomy.
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Affiliation(s)
- William H Allum
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
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30
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Methods of reconstruction after esophagectomy on long-term health-related quality of life: a prospective, randomized study of 5-year follow-up. Med Oncol 2015; 32:122. [DOI: 10.1007/s12032-015-0568-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2015] [Accepted: 03/11/2015] [Indexed: 01/12/2023]
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Nakajima M, Satomura H, Takahashi M, Muroi H, Kuwano H, Kato H. Effectiveness of sternocleidomastoid flap repair for cervical anastomotic leakage after esophageal reconstruction. Dig Surg 2014; 31:306-11. [PMID: 25376597 DOI: 10.1159/000368090] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2014] [Accepted: 09/02/2014] [Indexed: 01/04/2023]
Abstract
BACKGROUND/AIMS The purpose of this study was to investigate the effectiveness of sternocleidomastoid (SCM) flap repair for anastomotic leakage after esophagectomy. METHODS A refractory cutaneous fistula from the gastric stump developed in 8 patients with esophageal cancer who underwent esophagogastric anastomosis after esophagectomy. All patients underwent SCM flap repair. The cutaneous fistula was removed and resutured. The sternal head of the left SCM was dissected from the manubrium of the sternum and sutured onto the repaired gastric stump. RESULTS The operative duration was 80-220 min (median, 120 min). The amount of intraoperative bleeding ranged from 5 to 182 g (median, 15 g). The absence of recurrent anastomotic leakage was confirmed after the SCM flap repair in every patient. Oral intake was initiated 7-15 days (median, 10 days) after the repair operation without discomfort. CONCLUSIONS SCM flap repair is an effective and minimally invasive treatment method for cervical anastomotic leakage after esophageal reconstruction. This method may be considered in patients with refractory leakage of the gastric stump after staple anastomosis.
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32
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D'Journo XB, Thomas PA. Current management of esophageal cancer. J Thorac Dis 2014; 6 Suppl 2:S253-64. [PMID: 24868443 DOI: 10.3978/j.issn.2072-1439.2014.04.16] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Accepted: 04/15/2014] [Indexed: 12/15/2022]
Abstract
Management of esophageal cancer has evolved since the two last decades. Esophagectomy remains the primary treatment for early stage esophageal cancer although its specific role in superficial cancers is still under debate since the development of endoscopic mucosal treatment. To date, there is strong evidence to consider that locally advanced cancers should be recommended for a multimodal treatment with a neoadjuvant chemotherapy or a combined chemoradiotherapy (CRT) followed by surgery. For locally advanced squamous cell carcinoma or for a part of adenocarcinoma, some centers have proposed treating with definitive CRT to avoid related-mortality of surgery. In case of persistent or recurrent disease, a salvage esophagectomy remains a possible option but this procedure is associated with higher levels of perioperative morbidity and mortality. Despite the debate over what constitutes the best surgical approach (transthoracic versus transhiatal), the current question is if a minimally procedure could reduce the periopertive morbidity and mortality without jeopardizing the oncological results of surgery. Since the last decade, minimally invasive esophagectomy (MIE) or hybrid operations are being done in up to 30% of procedures internationally. There are some consistent data that MIE could decrease the incidence of the respiratory complications and decrease the length of hospital-stay. Nowadays, oncologic outcomes appear equivalent between open and minimally invasive procedures but numerous phase III trials are ongoing.
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Affiliation(s)
- Xavier Benoit D'Journo
- Department of Thoracic Surgery and Diseases of the Esophagus, Aix-Marseille University Marseille, France
| | - Pascal Alexandre Thomas
- Department of Thoracic Surgery and Diseases of the Esophagus, Aix-Marseille University Marseille, France
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33
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Stahl M, Mariette C, Haustermans K, Cervantes A, Arnold D. Oesophageal cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2014; 24 Suppl 6:vi51-6. [PMID: 24078662 DOI: 10.1093/annonc/mdt342] [Citation(s) in RCA: 168] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- M Stahl
- Department of Medical Oncology and Hematology, Kliniken Essen-Mitte, Henricistr 92, Essen 45136, Germany
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Trugeda S, Fernández-Díaz MJ, Rodríguez-Sanjuán JC, Palazuelos CM, Fernández-Escalante C, Gómez-Fleitas M. Initial results of robot-assisted Ivor-Lewis oesophagectomy with intrathoracic hand-sewn anastomosis in the prone position. Int J Med Robot 2014; 10:397-403. [PMID: 24782293 DOI: 10.1002/rcs.1587] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Revised: 01/27/2014] [Accepted: 02/24/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND There is scanty experience concerning robot-assisted Ivor-Lewis oesophagectomy, so every new experience is helpful. METHODS We describe the techniques and short-term results of Ivor-Lewis oesophagectomy using a laparoscopic approach and robot-assisted thoracoscopy, and an observational study of prospective surveillance of the first 14 patients treated for oesophageal cancer. A gastric tube was created laparoscopically. Oesophagectomy was performed through a robot-assisted thoracoscopy followed by hand-sewn intrathoracic anastomosis. RESULTS There were no conversion cases. Mortality was zero. Six patients had a major complication. There were no cases of respiratory complication or recurrent laryngeal nerve palsy. Three patients had a radiological fistula (21.4%), successfully treated by endoscopic stenting, and one (7.1%) had an anastomosis leak needing reoperation. There were two cases of chylothorax (14.3%). CONCLUSIONS Our initial results suggest that the reported technique is safe and satisfies the oncological principles. It provides the advantages of minimally invasive surgery by overcoming some limitations of conventional thoracoscopy.
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Affiliation(s)
- S Trugeda
- Department of General Surgery, University Hospital 'Marqués de Valdecilla', University of Cantabria, Santander, Spain
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Li B, Zhang JH, Wang C, Song TN, Wang ZQ, Gou YJ, Yang JB, Wei XP. Delayed gastric emptying after esophagectomy for malignancy. J Laparoendosc Adv Surg Tech A 2014; 24:306-11. [PMID: 24742329 DOI: 10.1089/lap.2013.0416] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Controversy still exists about the need for pyloric drainage procedures after esophagectomy with gastric conduit reconstruction. Although pyloric drainage may prevent postoperative delayed gastric emptying (DGE), it may also promote dumping syndrome and bile reflux. The aims of this study were to audit the incidence and management of DGE in patients without routine pyloric drainage after esophagectomy in a university medical center. PATIENTS AND METHODS From July 2006 to June 2012, data from 356 consecutive patients who underwent esophagectomy with a gastric conduit without pyloric drainage for esophageal or gastric cardia carcinoma were reviewed. Major observation parameters were the incidence, management, and outcomes of DGE. RESULTS Overall incidence of DGE was 15.7% (56 of 356). Early DGE developed in 26 patients, and late DGE developed in 30 patients. There were no differences in demographic and intraoperative data between the two groups with or without DGE. More DGE was documented in patients with an intra-right thoracic gastric conduit (P=.031). A higher incidence of postoperative pneumonia was observed in patients exhibiting early DGE, but without significance (P=.254). There were also no significant impacts on respiratory failure (P=.848) and anastomotic leakage (P=.257). There was an increased postoperative hospital stay with DGE, but without significance (P=.089). Endoscopic balloon dilatation of the pylorus was used to manage 33.9% of patients with DGE, yielding a 78.9% (15 of 19) success rate without complications. In 3 patients endoscopy showed the pylorus was open, and their symptoms improved over time. One patient with tumor-related DGE was treated by pyloric stent. The remaining patients were adequately treated with conservative management. CONCLUSIONS Omitting the operative drainage procedure does not lead to an increased frequency of DGE after esophagectomy with a gastric conduit. Many patients responded to conservative management, and endoscopic balloon pyloric dilatation can be effective in managing the DGE postoperatively.
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Affiliation(s)
- Bin Li
- Department of Thoracic Surgery, Lanzhou University Second Hospital , Lanzhou University Second Clinical Medical College, Lanzhou, People's Republic of China
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Ma J, Zhan C, Wang L, Jiang W, Zhang Y, Shi Y, Wang Q. The sweet approach is still worthwhile in modern esophagectomy. Ann Thorac Surg 2014; 97:1728-33. [PMID: 24650587 DOI: 10.1016/j.athoracsur.2014.01.034] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Revised: 01/14/2014] [Accepted: 01/17/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND The Ivor Lewis and Sweet approaches are the two most widely used open transthoracic esophagectomy techniques. We evaluated and compared the therapeutic efficacy of these two approaches to determine the appropriate method to treat middle or lower third esophageal carcinomas. METHODS We retrospectively reviewed patients who underwent esophagectomy with the Sweet (n=748) and Ivor Lewis (n=167) approaches at Zhongshan Hospital, Fudan University between January 2007 and December 2010. Patients with preoperatively identified superior mediastinal lymph node metastases, high-level lesions (above the carina), and benign tumors were excluded. Perioperative-related indicators and 5-year survival rates were compared between groups. RESULTS Compared with the Ivor Lewis approach, the Sweet approach has a shorter operative time (181±71 minutes versus 208±63 minutes; p<0.001), less blood loss (167±71 mL versus 179±87 mL; p=0.043), and a lower incidence of transfusion (8.7% versus 13.8%; p=0.044) and postoperative complications (12.3% versus 20.4%; p=0.002). The Ivor Lewis approach was more likely to result in wound infection (3.2% versus 7.8%; p=0.010) and delayed gastric emptying (1.7% versus 4.7%; p=0.046). There was no significant difference between groups with regard to the number of lymph nodes harvested or total number of patients with lymph node metastases. There was no significant difference in locoregional recurrence, distant recurrence, or 5-year survival between approaches. CONCLUSIONS The Sweet approach has many advantages for the treatment of middle or lower third esophageal carcinomas. It is a safe, effective, and worthwhile approach in modern thoracic surgery.
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Affiliation(s)
- Jun Ma
- Department of Thoracic Surgery, ZhongShan Hospital, Fudan University, Shanghai, China
| | - Cheng Zhan
- Department of Thoracic Surgery, ZhongShan Hospital, Fudan University, Shanghai, China
| | - Lin Wang
- Department of Thoracic Surgery, ZhongShan Hospital, Fudan University, Shanghai, China
| | - Wei Jiang
- Department of Thoracic Surgery, ZhongShan Hospital, Fudan University, Shanghai, China
| | - Yongxing Zhang
- Department of Thoracic Surgery, ZhongShan Hospital, Fudan University, Shanghai, China
| | - Yu Shi
- Department of Thoracic Surgery, ZhongShan Hospital, Fudan University, Shanghai, China
| | - Qun Wang
- Department of Thoracic Surgery, ZhongShan Hospital, Fudan University, Shanghai, China.
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Update on clinical impact, documentation, and management of complications associated with esophagectomy. Thorac Surg Clin 2013; 23:535-50. [PMID: 24199703 DOI: 10.1016/j.thorsurg.2013.07.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The assessment and monitoring of complications associated with esophageal resection suffers from the absence of an internationally recognized system for documenting the incidence and severity of complications. The impact of complications is significant, with direct effects being identified on mortality, length of stay, postoperative quality of life, and long-term survival. Newer systems of assessing surgical complication severity and the resources required to treat complications include the Accordion and Clavien grading systems. New endoscopic and interventional approaches to treating anastomotic leak and stricture and chyle leak can selectively decrease length of stay and costs of managing complications.
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Clinical application of mucosal valve technique for anastomosis during esophagogastrostomy. J Gastrointest Surg 2013; 17:2051-8. [PMID: 24135987 DOI: 10.1007/s11605-013-2382-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2013] [Accepted: 10/01/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND The study aims to compare the efficacy in prevention of anastomotic complications using layer-to-layer mucosal valve technique versus circular stapled technique for esophagogastric intrathoracic anastomosis after resection for esophageal and gastric cardiac carcinoma. METHODS From January 2005 to December 2010, 136 patients received layer-to-layer mucosal valve technique (LM group), 219 received circular stapled anastomosis (CS group) after curative intent resection for esophageal and gastric cardiac carcinoma. The technique details were reported and the clinical results were analyzed. RESULTS The two groups were comparable on clinical baseline characteristics. The average duration of operation was longer with LM technique by 16 min, but without statistical significance (P = 0.073). There was no anastomotic leakage in the LM group, while in the CS group, leakage occurred in seven patients (3.2 %, P = 0.047). Both the incidence and grade of postoperative dysphagia were significantly lower in the LM group (P < 0.05). Significantly fewer patients experienced stricture after LM technique (3.8 %) compared with CS anastomosis (18.2 %, P < 0.001). CS anastomosis was associated with a significantly higher incidence of persistent stricture requiring more dilatation (P < 0.001). Symptoms of reflux were better controlled by LM technique; 82.7 % of patients were asymptomatic with respect to reflux compared to 58.9 % in the CS group, P < 0.001. And there was a significant reduction in the incidence of esophagitis in remnant esophagus in the LM group (P = 0.001). CONCLUSIONS The layered mucosal valve anastomosis could significantly diminish the incidence of anastomotic complications and could be used as an alternative for esophagogastric anastomosis after resection of esophageal and gastric cardiac carcinoma.
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Abstract
Esophageal resection remains the primary treatment for local regional esophageal cancer, although its role in superficial (T1A) cancers and squamous cell cancer is in evolution. Mortality associated with esophagectomy has historically been high but is improving with the current expectation of in-hospital mortality rates of 2-4% in high-volume centers. Most patients with regional cancers (T2-4 N0-3) are recommended for neoadjuvant therapy, which most commonly involves radiochemotherapy. Some centers have proposed treating with definitive chemoradiation and reserving surgery for patients who have persistent or recurrent disease. 'Salvage resections' are possible but are associated with higher levels of perioperative morbidity and mortality, and treatment decisions should routinely be based on multidisciplinary discussion in the tumor board. Although open surgical resection (both transthoracic and transhiatal operations) remain the most common approach, minimally invasive or hybrid operations are being done in up to 30% of procedures internationally. There are some indications that minimally invasive esophagectomy may decrease the incidence of respiratory complications and decrease length of stay. At this point, oncologic outcomes appear equivalent between open and minimally invasive procedures. Recent reviews from high-volume esophagectomy centers demonstrate that elderly patients can selectively undergo esophagectomy with the expectation of increased complications but similar mortality and survival to younger patients. Multiple studies confirm that quality of life following esophagectomy can be equivalent to the general population when surgery is done in experienced centers. Patients requiring surgical treatment of esophageal cancer should be referred to high-volume centers, especially those with established care pathways or enhanced recovery programs to improve outcomes including morbidity, mortality, survival, and quality of life.
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Affiliation(s)
- Donald E Low
- Department of Thoracic Surgery and Thoracic Oncology, Virginia Mason Medical Center, Seattle, WA 98111, USA.
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Wu S, Chen M, Wei L, Chen Z. Embedded cervical esophagogastrostomy: a simple and convenient method using a circular stapler after esophagectomy for esophageal carcinomas. Ann Surg Oncol 2013; 20:2984-90. [PMID: 23645482 PMCID: PMC3732760 DOI: 10.1245/s10434-013-2991-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2012] [Indexed: 01/13/2023]
Abstract
Background Cervical esophagogastrostomy is currently the most common method for esophageal reconstruction after esophagectomy. The advantages and disadvantages of hand-sewn, linear-stapled, or circular-stapled anastomoses have been subject to debate in recent years. We explored a new method of end-to-side anastomosis using a circular stapler that embeds the anastomosis and the remaining esophageal tissue into the gastric cavity to reduce the occurrence of anastomotic leakage and to prevent gastroesophageal reflux. Methods In 127 patients with esophageal carcinomas, end-to-side anastomoses with esophageal embedding were performed by connecting the anvil and body of the circular stapler inside the stomach before firing and embedding the anastomosis and remaining esophagus into the stomach after esophagectomy. Retrospective investigations on postoperative complications such as leakage, stricture, and gastroesophageal reflux were conducted. Results A total of 123 patients (96.9 %) had successful surgery, and 4 patients (3.3 %) developed anastomotic leakage, with the total morbidity of 20 of 123 (16.3 %) and in-hospital mortality of 1 of 123 (0.8 %). The incidence of stricture (<1 cm) affected 14 of 123 patients (11.4 %). Eight patients underwent dilatation treatment as a result of severe dysphagia (6.5 %). Half of the patients [62 of 123 (50.4 %)] experienced postoperative heartburn, 11 of 123 patients (8.9 %) experienced acid regurgitation, and 16 of 123 patients (13.0 %) experienced nocturnal cough. Conclusions Embedded cervical esophagogastrostomy with circular stapler is a simple and convenient method, with low incidence of anastomotic leakage and a good antireflux effect.
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Affiliation(s)
- Sen Wu
- Center of Thoracic Tumor, Henan Provincial People's Hospital, Zhengzhou, China.
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Haverkamp L, van der Sluis PC, Verhage RJJ, Siersema PD, Ruurda JP, van Hillegersberg R. End-to-end cervical esophagogastric anastomoses are associated with a higher number of strictures compared with end-to-side anastomoses. J Gastrointest Surg 2013; 17:872-6. [PMID: 23400509 DOI: 10.1007/s11605-013-2159-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Accepted: 01/28/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND Leakage and benign strictures occur frequently after esophagectomy. The objective of this study was to analyze the outcome of hand-sewn end-to-end versus end-to-side cervical esophagogastric anastomoses. METHODS A series of 390 consecutive patients who underwent esophagectomy with gastric conduit reconstruction was analyzed. RESULTS The end-to-end technique was performed in 112 (29 %) patients and the end-to-side in 278 (71 %) patients. Anastomotic leakage occurred in 20 (18 %) patients with an end-to-end anastomosis versus 58 (21 %) patients with an end-to-side anastomosis (p = 0.50). A higher incidence in anastomotic strictures was seen in end-to-end anastomoses (48 (43 %)) compared with end-to-side anastomoses (89 (32 %); p = 0.04). Moreover, a median of 11 (7-17) dilations was necessary in patients with a benign anastomotic stricture in the end-to-end group compared with four (2-8) dilations in patients with a benign anastomotic stricture in the end-to-end group (p < 0.036). After multivariate analysis, the difference in anastomotic leakage rates remained nonsignificant (p = 0.74), whereas anastomotic stricture rate and number of dilations were higher in the end-to-end group (p = 0.03 and p = 0.01, respectively). CONCLUSION The technique of anastomosis is not significantly related to anastomotic leakage rate. However, patients with end-to-end anastomoses develop postoperative strictures more frequently, requiring a higher number of dilations compared to end-to-side anastomoses.
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Affiliation(s)
- Leonie Haverkamp
- Department of Surgery, University Medical Centre Utrecht, 3508 GA, Utrecht, The Netherlands
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Abstract
Oesophageal carcinoma is one of the most virulent malignant diseases and a major cause of cancer-related deaths worldwide. Diagnosis and accuracy of pretreatment staging have substantially improved throughout the past three decades. Therapy is challenging and the optimal approach is still debated. Oesophagectomy is considered to be the procedure of choice in patients with operable oesophageal cancer. Endoscopic measures and limited surgical procedures provide an alternative in patients with early carcinomas confined to the oesophageal mucosa. Chemotherapy and radiotherapy or concurrent chemoradiotherapy are also frequently applied, either as definitive treatment or as neoadjuvant therapy within multimodal approaches. The question of whether multimodal treatment offers improved results has been the focus of many studies since the 1990s. Although results are discordant and even some meta-analyses remain inconclusive, it is now widely accepted that multimodal therapy leads to a modest survival benefit. The role of minimally invasive oesophagectomy is not yet defined. Endoscopic stent insertion, radiotherapy and other palliative measures provide relief of tumour-related symptoms in advanced, unresectable tumour stages.
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Abstract
The advent of minimally invasive esophagectomy (MIE) attempts to decrease postoperative complications and mortality for this high-risk procedure. This review examines techniques in MIE, associated outcomes, and offers a critical appraisal of the literature surrounding this procedure. A Pubmed search was conducted for "minimally invasive esophagectomy" and associated synonyms. In addition, we analyze the outcomes at our institution through a prospectively maintained database. With varied techniques and utilization of different endpoints it is difficult to draw concrete conclusions from the current literature. Overall, however, there is no strong trend toward deceased mortality or decreased pulmonary complications from MIE, but there is a trend toward decreased intraoperative blood loss and shorter intensive care unit and ward stays. Until future studies are completed, MIE remains a useful tool in the armamentarium of the esophageal surgeon, and should be used not in exclusion of other approaches should patient or tumor factors dictate otherwise.
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van der Sluis PC, Ruurda JP, van der Horst S, Verhage RJJ, Besselink MGH, Prins MJD, Haverkamp L, Schippers C, Rinkes IHMB, Joore HCA, ten Kate FJW, Koffijberg H, Kroese CC, van Leeuwen MS, Lolkema MPJK, Reerink O, Schipper MEI, Steenhagen E, Vleggaar FP, Voest EE, Siersema PD, van Hillegersberg R. Robot-assisted minimally invasive thoraco-laparoscopic esophagectomy versus open transthoracic esophagectomy for resectable esophageal cancer, a randomized controlled trial (ROBOT trial). Trials 2012; 13:230. [PMID: 23199187 PMCID: PMC3564860 DOI: 10.1186/1745-6215-13-230] [Citation(s) in RCA: 117] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2012] [Accepted: 10/26/2012] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND For esophageal cancer patients, radical esophagolymphadenectomy is the cornerstone of multimodality treatment with curative intent. Transthoracic esophagectomy is the preferred surgical approach worldwide allowing for en-bloc resection of the tumor with the surrounding lymph nodes. However, the percentage of cardiopulmonary complications associated with the transthoracic approach is high (50 to 70%).Recent studies have shown that robot-assisted minimally invasive thoraco-laparoscopic esophagectomy (RATE) is at least equivalent to the open transthoracic approach for esophageal cancer in terms of short-term oncological outcomes. RATE was accompanied with reduced blood loss, shorter ICU stay and improved lymph node retrieval compared with open esophagectomy, and the pulmonary complication rate, hospital stay and perioperative mortality were comparable. The objective is to evaluate the efficacy, risks, quality of life and cost-effectiveness of RATE as an alternative to open transthoracic esophagectomy for treatment of esophageal cancer. METHODS/DESIGN This is an investigator-initiated and investigator-driven monocenter randomized controlled parallel-group, superiority trial. All adult patients (age ≥ 18 and ≤ 80 years) with histologically proven, surgically resectable (cT1-4a, N0-3, M0) esophageal carcinoma of the intrathoracic esophagus and with European Clinical Oncology Group performance status 0, 1 or 2 will be assessed for eligibility and included after obtaining informed consent. Patients (n = 112) with resectable esophageal cancer are randomized in the outpatient department to either RATE (n = 56) or open three-stage transthoracic esophageal resection (n = 56). The primary outcome of this study is the percentage of overall complications (grade 2 and higher) as stated by the modified Clavien-Dindo classification of surgical complications. DISCUSSION This is the first randomized controlled trial designed to compare RATE with open transthoracic esophagectomy as surgical treatment for resectable esophageal cancer. If our hypothesis is proven correct, RATE will result in a lower percentage of postoperative complications, lower blood loss, and shorter hospital stay, but with at least similar oncologic outcomes and better postoperative quality of life compared with open transthoracic esophagectomy. The study started in January 2012. Follow-up will be 5 years. Short-term results will be analyzed and published after discharge of the last randomized patient. TRIAL REGISTRATION Dutch trial register: NTR3291 ClinicalTrial.gov: NCT01544790.
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Affiliation(s)
- Pieter C van der Sluis
- Department of Surgery, G04.228, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
| | - Jelle P Ruurda
- Department of Surgery, G04.228, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
| | - Sylvia van der Horst
- Department of Surgery, G04.228, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
| | - Roy JJ Verhage
- Department of Surgery, G04.228, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
| | - Marc GH Besselink
- Department of Surgery, G04.228, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
| | - Margriet JD Prins
- Department of Surgery, G04.228, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
| | - Leonie Haverkamp
- Department of Surgery, G04.228, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
| | - Carlo Schippers
- Department of Surgery, G04.228, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
| | - Inne HM Borel Rinkes
- Department of Surgery, G04.228, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
| | - Hans CA Joore
- Department of Intensive Care Medicine, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
| | - Fiebo JW ten Kate
- Department of Pathology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
| | - Hendrik Koffijberg
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
| | - Christiaan C Kroese
- Department of Anesthesiology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
| | - Maarten S van Leeuwen
- Department of Radiology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
| | - Martijn PJK Lolkema
- Department of Medical Oncology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
| | - Onne Reerink
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
| | - Marguerite EI Schipper
- Department of Pathology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
| | - Elles Steenhagen
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
| | - Frank P Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
| | - Emile E Voest
- Department of Medical Oncology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
| | - Richard van Hillegersberg
- Department of Surgery, G04.228, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
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Dantoc MM, Cox MR, Eslick GD. The first randomised controlled trial on minimally invasive esophagectomy (MIE) and the ongoing quest for greater evidence. J Thorac Dis 2012; 4:459-61. [PMID: 23050107 DOI: 10.3978/j.issn.2072-1439.2012.08.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2012] [Accepted: 08/14/2012] [Indexed: 11/14/2022]
Affiliation(s)
- Marc M Dantoc
- The Whiteley-Martin Research Centre, Discipline of Surgery, The University of Sydney, Nepean Hospital, Penrith, New South Wales, Australia
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Uttley L, Campbell F, Rhodes M, Cantrell A, Stegenga H, Lloyd-Jones M. Minimally invasive oesophagectomy versus open surgery: is there an advantage? Surg Endosc 2012; 27:724-31. [PMID: 23052523 DOI: 10.1007/s00464-012-2546-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2012] [Accepted: 08/09/2012] [Indexed: 01/10/2023]
Abstract
BACKGROUND Oesophageal resection is the main method of curative treatment for cancer of the oesophagus. Despite advances in surgical technology and postoperative care, the survival rate and prognosis of people undergoing oesophagectomy is still poor. The use of minimally invasive techniques in oesophageal surgery offers hope of reduced recovery time due to a reduction in surgical trauma. Although the first reports of thoracoscopy- and laparoscopy-assisted oesophagectomy emerged some 20 years ago, there is still no consensus that the outcomes are clearly superior to outcomes following conventional open surgery. Increasingly, some surgeons promote the use of minimally invasive techniques for oesophagectomy but questions remain over its safety and efficacy compared with open surgery. METHODS We conducted a systematic review of the literature to compare minimally invasive techniques for oesophagectomy to open surgery. The outcomes of interest for efficacy and safety included mortality, operative complications, recurrence, and quality of life. RESULTS There were 28 included comparative studies. No randomised controlled studies (RCTs) were available and therefore the data need to be interpreted with caution. CONCLUSION Recommendations for future research are discussed. We argue that it is difficult to conduct an RCT for this procedure due to ethical considerations and suggest ways that future nonrandomised studies could be improved.
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Affiliation(s)
- Lesley Uttley
- School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield S1 4DA, UK.
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Verhage RJ, Ruiz A, Verheem A, Goldschmeding R, Borel Rinkes IH, van Hillegersberg R. Fibrin-thrombin coated sealant increases strength of esophagogastric anastomoses in a rat model. J Surg Res 2012; 176:e57-63. [DOI: 10.1016/j.jss.2011.12.028] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2011] [Revised: 12/08/2011] [Accepted: 12/13/2011] [Indexed: 12/11/2022]
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Jarral OA, Purkayastha S, Athanasiou T, Darzi A, Hanna GB, Zacharakis E. Thoracoscopic esophagectomy in the prone position. Surg Endosc 2012; 26:2095-103. [PMID: 22395952 DOI: 10.1007/s00464-012-2172-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2011] [Accepted: 01/13/2012] [Indexed: 12/11/2022]
Abstract
BACKGROUND Minimally invasive esophageal surgery has arisen in an attempt to reduce the significant complications associated with esophagectomy. Despite proposed technical and physiological advantages, the prone position technique has not been widely adopted. This article reviews the current status of prone thoracoscopic esophagectomy. METHODS A systematic literature search was performed to identify all published clinical studies related to prone esophagectomy. Medline, EMBASE and Google Scholar were searched using the keywords "prone," "thoracoscopic," and "esophagectomy" to identify articles published between January 1994 and September 2010. A critical review of these studies is given, and where appropriate the technique is compared to the more traditional minimally invasive technique utilising the left lateral decubitus position. RESULTS Twelve articles reporting the outcomes following prone thoracoscopic oesophagectomy were tabulated. These studies were all non-randomised single-centre prospective or retrospective studies of which four compared the technique to traditional minimally invasive surgery. Although prone esophagectomy is demonstrated as being both feasible and safe, there is no convincing evidence that it is superior to other forms of esophageal surgery. Most authors comment that the prone position is associated with superior surgical ergonomics and theoretically offers a number of physiological benefits. CONCLUSION The ideal approach within minimally invasive esophageal surgery continues to be a subject of debate since no single method has produced outstanding results. Further clinical studies are required to see whether ergonomic advantages of the prone position can be translated into improved patient outcomes.
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Affiliation(s)
- Omar A Jarral
- Department of Biosurgery and Surgical Technology, St. Mary's Hospital, Imperial College London, Praed Street, London, W2 1NY, UK
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Anatomical basis of the risk of injury to the right laryngeal recurrent nerve during thoracic surgery. Surg Radiol Anat 2012; 34:509-12. [DOI: 10.1007/s00276-012-0946-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2011] [Accepted: 02/14/2012] [Indexed: 11/25/2022]
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