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Simple and reliable transhiatal reconstruction after laparoscopic proximal gastrectomy with lower esophagectomy for Siewert type II tumors: y-shaped overlap esophagogastric tube reconstruction. Langenbecks Arch Surg 2022; 407:1881-1890. [PMID: 35486151 DOI: 10.1007/s00423-022-02536-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 04/24/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE Despite the increasing incidence of adenocarcinoma of the esophagogastric junction, laparoscopic proximal gastrectomy with lower esophagectomy (PGLE) is not widely accepted owing to the lack of standardized reconstruction techniques. In this study, we developed a new reconstruction method named y-shaped overlap esophagogastric tube reconstruction, which reproduces an angle of His and a pseudo-fornix, to be used in laparoscopic transhiatal PGLE. This study aimed to determine the feasibility of this novel reconstruction method. METHODS This retrospective study included the analysis of short- and mid-term surgical outcomes of 30 consecutive patients with Siewert type II esophagogastric junction adenocarcinoma who underwent laparoscopic PGLE with y-shaped overlap esophagogastric tube reconstruction from April 2015 to August 2020. A novel method was used to form a 6-cm pseudo-fornix and an angle of His using the distal esophagus and a long gastric tube. RESULTS The median operation time was 369 min, and the median blood loss was 28 mL. The median follow-up period after surgery was 37 months. Although two patients experienced postoperative anastomotic leakage, none of the patients developed stenosis. One patient experienced moderate reflux symptoms, whereas four patients developed moderate reflux esophagitis based on the 1-year follow-up endoscopic examination; the condition of all patients could be efficiently controlled with medication. CONCLUSION The short- and mid-term surgical outcomes of y-shaped overlap esophagogastric tube reconstruction reflected the feasibility of this simple technique and suggested its potential utility as a reconstruction alternative for Siewert type II tumors.
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Fan Y, Liu M, Li S, Yu J, Qi X, Tan F, Xu K, Zhang N, Yao Z, Yang H, Zhang C, Xing J, Wang Z, Cui M, Su X. Surgical and oncological efficacy of laparoscopic-assisted total gastrectomy versus open total gastrectomy for gastric cancer by propensity score matching: a retrospective comparative study. J Cancer Res Clin Oncol 2021; 147:2153-2165. [PMID: 33415526 PMCID: PMC8164618 DOI: 10.1007/s00432-020-03503-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 12/12/2020] [Indexed: 12/23/2022]
Abstract
PURPOSE The application of laparoscopic-assisted total gastrectomy (LATG) for resectable gastric cancer (GC) remains controversial compared with open total gastrectomy (OTG), especially for advanced gastric cancer (AGC) patients according to the inconsistent results demonstrated in the previous studies. The aim of this study was to evaluate the short-term and long-term outcomes between LATG and OTG in a population with more than 80% AGC patients by applying propensity score matching (PSM) method. METHODS The data of 365 clinical stage I-III GC cases who underwent total gastrectomy with D2 lymphadenectomy were retrospectively collected from January 2011 to April 2018 in the Department of Gastrointestinal Surgery IV of Peking University Cancer Hospital. Propensity scores were generated through taking all covariates into consideration and 131 pairs of patients receiving either LATG or OTG were matched. Intraoperative, postoperative, and survival parameters were compared in the matched groups accordingly. Risk factors for postoperative complications and overall survival were further analyzed. RESULTS Patient characteristics in the LATG and OTG groups were well balanced after PSM. LATG showed advantages with respect to shorter time to ambulation, first flatus, and first whole liquid diet intake. No significant differences were found between the two groups with regard to postoperative complications as well as overall survival in terms of different pathological stage. Older age was found as an independent risk factor for postoperative complications, and pathological stage for overall survival as well. CONCLUSION LATG appears to have comparable surgical and oncological safety with OTG by experienced surgeons.
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Affiliation(s)
- Yingcong Fan
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Maoxing Liu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Shijie Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Endoscopy, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Jianhong Yu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Xinyu Qi
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Fei Tan
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Kai Xu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Nan Zhang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Zhendan Yao
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Hong Yang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Chenghai Zhang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Jiadi Xing
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital and Institute, Beijing, 100142, China
| | - Zaozao Wang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital and Institute, Beijing, 100142, China.
| | - Ming Cui
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital and Institute, Beijing, 100142, China.
| | - Xiangqian Su
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital and Institute, Beijing, 100142, China.
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Laparoscopic Transhiatal Esophagectomy for Invasive Esophageal Adenocarcinoma. J Gastrointest Surg 2021; 25:9-15. [PMID: 32077047 DOI: 10.1007/s11605-019-04506-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 12/16/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Esophagectomy is a fundamental step to achieve long-term disease-free survival in esophageal cancer. While various approaches have been described, there is no consensus on the single best technique to optimize operative and oncologic outcomes. We aim to report the modern experience with laparoscopic transhiatal esophagectomy (LTHE) for invasive adenocarcinoma. METHODS We reviewed all patients who underwent LTHE with extended lymph node dissection for distal esophageal adenocarcinoma (EAC) at our institution between 2007 and 2016. Pre-operative characteristics, operative details, postoperative complications, and long-term outcomes were tracked by review of the electronic medical record and patient surveys. Survival rates were calculated with Kaplan-Meier curves. RESULTS Eighty-two EAC patients underwent LTHE during the study period (84% male, mean age 65, mean BMI 27.8, large). Most patients were clinical stage III (42.7%) and 68.3% had received neoadjuvant chemoradiation (nCRT). Laparoscopy was successful in 93.9%, with five cases requiring conversion to open (6.1%). The median lymph node harvest was 19. Overall complication rate (major and minor) was 45.5% and ninety-day mortality was 4%. Overall 5-year survival was 52% (77% for stage 1, 57% for stage 2, 37% for stage 3). CONCLUSIONS Laparoscopic transhiatal esophagectomy has an important role in current esophageal cancer treatment and can be performed with curative intent in patients with distal esophageal tumors. In addition to the well-known advantages of laparoscopy, the increased mediastinal visibility and a modern focus on oncologic principles seem to have a positive impact on cancer survival compared to the open transhiatal approach.
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Abstract
Laparoscopic and thoracoscopic or robotic-assisted minimally invasive esophagectomy offers benefits in decreased postoperative complications and faster recovery. The choice of operation depends on patient and surgeon factors. McKeown or 3-field esophagectomy requires dissection in the abdomen, chest, and neck, with a cervical anastomosis. Ivor Lewis esophagectomy is performed with abdominal and right chest dissection and intrathoracic anastomosis. Transhiatal or transmediastinal esophagectomy is performed with abdominal and cervical dissections and a cervical anastomosis and is preferential in patients with significant pulmonary risk factors. Preparation and operative conduct for laparoscopic and robotic approaches for these operations, and the expected postoperative recovery are detailed.
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Lee Y, Min SH, Park KB, Park YS, Ahn SH, Park DJ, Kim HH. Long-term Outcomes of Laparoscopic Versus Open Transhiatal Approach for the Treatment of Esophagogastric Junction Cancer. J Gastric Cancer 2019; 19:62-71. [PMID: 30944759 PMCID: PMC6441771 DOI: 10.5230/jgc.2019.19.e1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 01/08/2019] [Accepted: 01/10/2019] [Indexed: 12/16/2022] Open
Abstract
Purpose The laparoscopic transhiatal approach (LA) for adenocarcinoma of the esophagogastric junction (AEJ) is advantageous since it allows better visualization of the surgical field than the open approach (OA). We compared the surgical outcomes of the 2 approaches. Materials and Methods We analyzed 108 patients with AEJ who underwent transhiatal distal esophagectomy and gastrectomy with curative intent between 2003 and 2015. Surgical outcomes were reviewed using electronic medical records. Results The LA and OA were performed in 37 and 71 patients, respectively. Compared to the OA, the LA was associated with significantly shorter duration of postoperative hospital stay (9 vs. 11 days, P=0.001), shorter proximal resection margins (3 vs. 7 mm, P=0.004), and extended operative times (240 vs. 191 min, P=0.001). No significant difference was observed between the LA and OA for intraoperative blood loss (100 vs. 100 mL, P=0.392) or surgical morbidity rate (grade≥II) for complications (8.1% vs. 23.9%, P=0.080). Two cases of anastomotic leakage occurred in the OA group. The number of harvested lymph nodes was not significantly different between the LA and OA groups (54 vs. 51, P=0.889). The 5-year overall and 3-year relapse-free survival rates were 81.8% and 50.7% (P=0.024) and 77.3% and 46.4% (P=0.009) for the LA and OA groups, respectively. Multivariable analyses revealed no independent factors associated with overall survival. Conclusions The LA is feasible and safe with short- and long-term oncologic outcomes similar to those of the OA.
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Affiliation(s)
- Yoontaek Lee
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sa-Hong Min
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Ki Bum Park
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Young Suk Park
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sang-Hoon Ahn
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Do Joong Park
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hyung-Ho Kim
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
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Dunn DH, Johnson EM, Anderson CA, Krueger JL, DeFor TE, Morphew JA, Banerji N. Operative and survival outcomes in a series of 100 consecutive cases of robot-assisted transhiatal esophagectomies. Dis Esophagus 2017; 30:1-7. [PMID: 28859385 DOI: 10.1093/dote/dox045] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 04/04/2017] [Indexed: 12/11/2022]
Abstract
Robotic-assisted transhiatal esophagectomy (RATE) is a technically complex procedure with potential for improved postoperative outcomes. In this report, we describe our experience with RATE in a large case series. A retrospective review was conducted to collect clinical, outcomes, and survival data for 100 consecutive patients with esophageal cancer (n = 98) and benign (n = 2) conditions undergoing RATE between March 2007 and December 2014. Progression-free (PFS) and overall (OS) survival were estimated using the Kaplan-Meier curves with comparisons by log-rank tests. Median operative time and estimated blood loss were 264 minutes and 75 mL, respectively. Median intensive care unit stay was 1 day and median length of hospital stay was 8 days. Postoperative complications commonly observed were nonmalignant pleural effusion (38%) and recurrent laryngeal nerve injury (33%); 30 day mortality rate was 2%. Median number of lymph nodes removed during RATE was 17 and R0 resection was achieved in 97.8% patients. At the end of the median follow-up period of 27.7 months, median PFS was 41 months and median OS was 54 months. 1-year and 3-year PFS rates were 82% (95% CI, 75%-89%) and 53% (95% CI, 42%-62%), respectively, and OS rates were 95% (95% CI, 91%-99%) and 57% (95% CI, 46%-67%). In our experience, RATE is an effective and safe oncologic surgical procedure in a carefully selected group of patients with acceptable operative time, minimal blood loss, standard postoperative morbidity and adequate PFS and OS profiles.
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Affiliation(s)
- D H Dunn
- VPCI Esophageal and Gastric Cancer Program
| | | | | | | | - T E DeFor
- Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - N Banerji
- JNNI Research, Abbott Northwestern Hospital
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Parry K, Ruurda JP, van der Sluis PC, van Hillegersberg R. Current status of laparoscopic transhiatal esophagectomy for esophageal cancer patients: a systematic review of the literature. Dis Esophagus 2017; 30:1-7. [PMID: 26919257 DOI: 10.1111/dote.12477] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Minimally invasive techniques in transhiatal esophagectomy (THE) were introduced to reduce morbidity and enhance postoperative recovery. Aim of this study was to systematically review the current status and possible beneficial effects of the minimally invasive approach in THE. A systematic search was performed in PubMed, the Cochrane Library, and Embase to identify English articles published on laparoscopic THE. Comparative cohort studies were included for critical appraisal. Data describing perioperative and oncological outcomes were analyzed. A total of four comparative cohort studies that compared laparoscopic THE (n = 122) with open THE (n = 144) and four noncomparative cohort studies reporting on laparoscopic THE (n = 212) were included in this review. Median blood loss was significantly lower in the laparoscopic group in all studies (100-500 vs. 526-900 mL). Length of hospital stay was also significantly shorter for the laparoscopic approach in all studies (9-13 vs. 12-16 days). One study reported less major postoperative complications after laparoscopic THE (12 vs. 23%), in the other studies no differences were found. Also no differences were found with regard to operating time, postoperative morbidity, radicality, and lymph node retrieval. Based on these pioneer studies, laparoscopic THE was demonstrated to be safe and feasible with evidence of reduced blood loss and shorter hospital stays. However, level 1 evidence is lacking and further research is warranted to confirm these findings and also to evaluate long-term oncologic outcomes.
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Affiliation(s)
- K Parry
- Department of Surgery, University Medical Center Utrecht, The Netherlands
| | - J P Ruurda
- Department of Surgery, University Medical Center Utrecht, The Netherlands
| | - P C van der Sluis
- Department of Surgery, University Medical Center Utrecht, The Netherlands
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Laparoscopic-assisted versus open total gastrectomy for Siewert type II and III esophagogastric junction carcinoma: a propensity score-matched case-control study. Surg Endosc 2016; 31:3495-3503. [DOI: 10.1007/s00464-016-5375-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 11/25/2016] [Indexed: 01/07/2023]
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DeLong JC, Kelly KJ, Jacobsen GR, Sandler BJ, Horgan S, Bouvet M. The benefits and limitations of robotic assisted transhiatal esophagectomy for esophageal cancer. J Vis Surg 2016; 2:156. [PMID: 29078542 DOI: 10.21037/jovs.2016.09.01] [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] [Received: 08/05/2016] [Accepted: 08/31/2016] [Indexed: 11/06/2022]
Abstract
Robotic-assisted transhiatal esophagectomy (RATE) is a minimally invasive approach to total esophagectomy with less morbidity but equivalent efficacy when compared with the traditional open approach. The robotic platform offers numerous technical advantages that assist with the esophageal dissection, which allows the procedure to be completed without entry into the thoracic cavity. The major criticism of the transhiatal approach is that it forfeits the ability of the surgeon to perform a formal lymphadenectomy, but this does not appear to affect long-term survival.
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Affiliation(s)
- Jonathan C DeLong
- Department of Surgery, University of California San Diego, San Diego, CA, USA
| | - Kaitlyn J Kelly
- Department of Surgery, University of California San Diego, San Diego, CA, USA
| | - Garth R Jacobsen
- Department of Surgery, University of California San Diego, San Diego, CA, USA
| | - Bryan J Sandler
- Department of Surgery, University of California San Diego, San Diego, CA, USA
| | - Santiago Horgan
- Department of Surgery, University of California San Diego, San Diego, CA, USA
| | - Michael Bouvet
- Department of Surgery, University of California San Diego, San Diego, CA, USA
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Crespin OM, Farjah F, Cuevas C, Armstrong A, Kim BT, Martin AV, Pellegrini CA, Oelschlager BK. Hiatal Herniation After Transhiatal Esophagectomy: an Underreported Complication. J Gastrointest Surg 2016; 20:231-6. [PMID: 26589526 DOI: 10.1007/s11605-015-3033-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 11/13/2015] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The incidence and presentation of hiatal hernias after esophagectomy (HHAE) are not well characterized, and may be changing with increased survival from esophageal cancer. The aims of this study were to define the incidence and presentation of HHAE in our population of patients undergoing transhiatal esophagectomy (THE), as it may have implications for management. METHODS A retrospective cohort study (2004-2013) was performed of esophageal cancer patients who underwent THE. To determine the presence or absence of HHAE independent of the original radiology report, a radiologist sub-specializing in body imaging independently reviewed post-operative computed tomography images. A time-to-event competing risk analysis was performed to estimate the cumulative incidence of HHAE. RESULTS Among 192 patients, the two-year cumulative incidence of HHAE was 14 % (95 % confidence interval 7.5-21 %). Of the 22 patients determined to have HHAE by independent expert radiologist review, only 11 (50 %) were identified by the original interpreting radiologist. Seven patients were symptomatic, and each underwent hiatal hernia repair (4 via laparotomy, 3 via laparoscopy). CONCLUSION HHAE is not rare and is often unrecognized. As more patients with esophageal cancer survive, the number of patients becoming symptomatic and requiring repair may also rise. Therefore, it is important to consider this diagnosis when following patients long-term after esophagectomy.
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Affiliation(s)
- Oscar M Crespin
- Department of Surgery, University of Washington, Seattle, WA, USA.
| | - Farhood Farjah
- Department of Surgery, University of Washington, Seattle, WA, USA.,Surgical Outcomes Research Center, University of Washington, Seattle, WA, USA
| | - Carlos Cuevas
- Department of Radiology Seattle, University of Washington, Seattle, WA, USA
| | | | - Bryan T Kim
- Department of Surgery, University of Washington, Seattle, WA, USA
| | - Ana V Martin
- Department of Surgery, University of Washington, Seattle, WA, USA
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Ecker BL, Savulionyte GE, Datta J, Dumon KR, Kucharczuk J, Williams NN, Dempsey DT. Laparoscopic transhiatal esophagectomy improves hospital outcomes and reduces cost: a single-institution analysis of laparoscopic-assisted and open techniques. Surg Endosc 2015; 30:2535-42. [PMID: 26416370 DOI: 10.1007/s00464-015-4519-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Accepted: 08/06/2015] [Indexed: 01/26/2023]
Abstract
BACKGROUND Several case series have demonstrated that laparoscopic transhiatal esophagectomy (LTHE) is associated with favorable perioperative outcomes compared to historical data for open transhiatal esophagectomy (OTHE). Contemporaneous evaluation of open and laparoscopic THE is rare, limiting meaningful comparison of techniques. METHODS All patients who underwent OTHE (n = 32) and LTHE (n = 41) during the introduction of the latter procedure at our institution (1/2012-4/2014) were identified, and patient charts were retrospectively reviewed. RESULTS Indications for operation included 69 patients with esophageal malignancy (adenocarcinoma: 64; squamous cell carcinoma: 4; melanoma: 1) and 4 patients with benign disease. There were no significant differences in clinicopathologic variables between OTHE and LTHE cohorts, except for an increased rate of cardiovascular disease in the LTHE cohort (p = 0.04). There was no significant difference in median operative time or operative complications, yet LTHE was associated with a lower incidence of intraoperative blood transfusion (p < 0.01). There were no 30-day mortalities. LTHE was associated with a reduced time to reach 24-h tube feeding goals (p = 0.02), shorter length of hospital stay (p = 0.01), and 6 % reduced median direct cost (p = 0.04). There were no significant differences in rates of major perioperative morbidities. Patients were followed for a median of 11.0 months during which there were no significant differences between cohorts in disease-free survival or overall survival. CONCLUSION When compared to OTHE, LTHE improves surgical outcomes and decreases hospital costs; short-term oncologic outcomes are similar. LTHE is preferable to OTHE in patients requiring transhiatal esophagectomy.
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Affiliation(s)
- Brett L Ecker
- Department of Surgery, University of Pennsylvania, 3400 Spruce St., Philadelphia, PA, 19104, USA
| | - Goda E Savulionyte
- Department of Surgery, University of Pennsylvania, 3400 Spruce St., Philadelphia, PA, 19104, USA
| | - Jashodeep Datta
- Department of Surgery, University of Pennsylvania, 3400 Spruce St., Philadelphia, PA, 19104, USA
| | - Kristoffel R Dumon
- Department of Surgery, University of Pennsylvania, 3400 Spruce St., Philadelphia, PA, 19104, USA
| | - John Kucharczuk
- Department of Surgery, University of Pennsylvania, 3400 Spruce St., Philadelphia, PA, 19104, USA
| | - Noel N Williams
- Department of Surgery, University of Pennsylvania, 3400 Spruce St., Philadelphia, PA, 19104, USA
| | - Daniel T Dempsey
- Department of Surgery, University of Pennsylvania, 3400 Spruce St., Philadelphia, PA, 19104, USA.
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Mei X, Xu M, Guo M, Xie M, Liu C, Wang Z. Minimally invasive Ivor-Lewis oesophagectomy is a feasible and safe approach for patients with oesophageal cancer. ANZ J Surg 2015; 86:274-9. [PMID: 25962993 DOI: 10.1111/ans.13161] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2015] [Indexed: 12/17/2022]
Affiliation(s)
- Xinyu Mei
- Department of Thoracic Surgery; Shandong Provincial Hospital affiliated to Shandong University; Jinan China
- Department of Thoracic Surgery; Anhui Provincial Hospital; Hefei China
| | - Meiqing Xu
- Department of Thoracic Surgery; Anhui Provincial Hospital; Hefei China
| | - Mingfa Guo
- Department of Thoracic Surgery; Anhui Provincial Hospital; Hefei China
| | - Mingran Xie
- Department of Thoracic Surgery; Anhui Provincial Hospital; Hefei China
| | - Changqing Liu
- Department of Thoracic Surgery; Anhui Provincial Hospital; Hefei China
| | - Zhou Wang
- Department of Thoracic Surgery; Shandong Provincial Hospital affiliated to Shandong University; Jinan China
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Fujiwara H, Shiozaki A, Konishi H, Komatsu S, Kubota T, Ichikawa D, Okamoto K, Morimura R, Murayama Y, Kuriu Y, Ikoma H, Nakanishi M, Sakakura C, Otsuji E. Hand-assisted laparoscopic transhiatal esophagectomy with a systematic procedure for en bloc infracarinal lymph node dissection. Dis Esophagus 2014; 29:131-8. [PMID: 25487303 DOI: 10.1111/dote.12303] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Laparoscopic transhiatal esophagectomy is a minimally invasive approach for esophageal cancer. However, a transhiatal procedure has not yet been established for en bloc mediastinal dissection. The purpose of this study was to present our novel procedure, hand-assisted laparoscopic transhiatal esophagectomy, with a systematic procedure for en bloc mediastinal dissection. The perioperative outcomes of patients who underwent this procedure were retrospectively analyzed. Transhiatal subtotal mobilization of the thoracic esophagus with en bloc lymph node dissection distally from the carina was performed according to a standardized procedure using a hand-assisted laparoscopic technique, in which the operator used a long sealing device under appropriate expansion of the operative field by hand assistance and long retractors. The thoracoscopic procedure was performed for upper mediastinal dissection following esophageal resection and retrosternal stomach roll reconstruction, and was avoided based on the nodal status and operative risk. A total of 57 patients underwent surgery between January 2012 and June 2013, and the transthoracic procedure was performed on 34 of these patients. In groups with and without the transthoracic procedure, total operation times were 370 and 216 minutes, blood losses were 238 and 139 mL, and the numbers of retrieved nodes were 39 and 24, respectively. R0 resection rates were similar between the groups. The incidence of recurrent laryngeal nerve palsy was significantly higher in the group with the transthoracic procedure, whereas no significant differences were observed in that of pneumonia between these groups. The hand-assisted laparoscopic transhiatal method, which is characterized by a systematic procedure for en bloc mediastinal dissection supported by hand and long device use, was safe and feasible for minimally invasive esophagectomy.
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Affiliation(s)
- H Fujiwara
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - A Shiozaki
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - H Konishi
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - S Komatsu
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - T Kubota
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - D Ichikawa
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - K Okamoto
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - R Morimura
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Y Murayama
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Y Kuriu
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - H Ikoma
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - M Nakanishi
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - C Sakakura
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - E Otsuji
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
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Hong L, Guo XD, Lv J, Wang YS, Li YD. Effects of transthoracic vs transabdominal hiatal approaches for treatment of esophago-gastric junction adenocarcinoma. Shijie Huaren Xiaohua Zazhi 2014; 22:3963-3967. [DOI: 10.11569/wcjd.v22.i26.3963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare the effects of transthoracic and transabdominal hiatal approaches for the treatment of Siewert types Ⅱ and Ⅲ adenocarcinoma of the esophago-gastric junction.
METHODS: A total of 350 patients who were pathologically diagnosed with Siewert type Ⅱ or type Ⅲ adenocarcinoma of the esophago-gastric junction and underwent surgical treatment at our hospital were included, of whom 148 received surgery via the transthoracic approach (transthoracic group) and 202 received surgery via transabdominal hiatal approach (transabdominal hiatal group). Intraoperative parameters, postoperative recovery and complications were compared between the two groups of patients.
RESULTS: The number of patients receiving multi-visceral resection was more in the transabdominal hiatal group than in the transthoracic group (χ2 = 12.744, P = 0.002), but the operative time, intraoperative blood loss, length of esophageal resection and number of patients receiving transfusion were lower in the transabdominal hiatal group (P = 0.039, 0.011, 0.009, 0.000). Postoperative pain score and antibiotic use duration in the transthoracic group were significantly higher than those in the transabdominal hiatal group (t = 5.879, 9.388, P = 0.005, 0.000), and the length of hospital stay, postoperative hospitalization cost, reoperation, and readmission rate showed the same trend (P = 0.027, 0.021, 0.048, 0.025). Although the rates of abdominal cavity infection and anastomotic stenosis showed no statistical differences between the two groups (χ2 = 1.524, 0.149, P = 0.217, 0.700), the rates of lung infection, postoperative bleeding and anastomotic leakage were significantly higher in the transthoracic group than in the transabdominal hiatal group (χ2 = 9.031, 9.031, 4.215, P = 0.003, 0.040, 0.024).
CONCLUSION: Patients with type Ⅱ or Ⅲ adenocarcinoma of the esophago-gastric junction treated via the transabdominal hiatal approach suffered from less intraoperative trauma and had quicker recovery and lower incidence of complications.
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Shiozaki A, Fujiwara H, Murayama Y, Komatsu S, Kuriu Y, Ikoma H, Nakanishi M, Ichikawa D, Okamoto K, Ochiai T, Kokuba Y, Otsuji E. Perioperative outcomes of esophagectomy preceded by the laparoscopic transhiatal approach for esophageal cancer. Dis Esophagus 2014; 27:470-8. [PMID: 23088181 DOI: 10.1111/j.1442-2050.2012.01439.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
This study was designed to determine the efficacy of esophagectomy preceded by the laparoscopic transhiatal approach (LTHA) with regard to the perioperative outcomes of esophageal cancer. The esophageal hiatus was opened by hand-assisted laparoscopic surgery, and carbon dioxide was introduced into the mediastinum. Dissection of the distal esophagus was performed up to the level of the tracheal bifurcation. En bloc dissection of the posterior mediastinal lymph nodes was performed using LTHA. Next, cervical lymphadenectomy, reconstruction via a retrosternal route with a gastric tube and anastomosis from a cervical approach were performed. Finally, a small thoracotomy (around 10 cm in size) was made to extract the thoracic esophagus and allow upper mediastinal lymphadenectomy to be performed. The treatment outcomes of 27 esophageal cancer patients who underwent LTHA-preceding esophagectomy were compared with those of 33 patients who underwent the transthoracic approach preceding esophagectomy without LTHA (thoracotomy; around 20 cm in size). The intrathoracic operative time and operative bleeding were significantly decreased by LTHA. The total operative time did not differ between the two groups, suggesting that the abdominal procedure was longer in the LTHA group. The number of resected lymph nodes did not differ between the two groups. Postoperative respiratory complications occurred in 18.5% of patients treated with LTHA and 30.3% of those treated without it. The increase in the number of peripheral white blood cells and the duration of thoracic drainage were significantly decreased by this method. Our surgical procedure provides a good surgical view of the posterior mediastinum, markedly shortens the intrathoracic operative time, and decreases the operative bleeding without increasing major postoperative complications.
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Affiliation(s)
- A Shiozaki
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
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Esophagogastric tube reconstruction with stapled pseudo-fornix in laparoscopic proximal gastrectomy: a novel technique proposed for Siewert type II tumors. Langenbecks Arch Surg 2014; 399:517-23. [PMID: 24424495 DOI: 10.1007/s00423-014-1163-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Accepted: 01/03/2014] [Indexed: 12/29/2022]
Abstract
PURPOSE The incidence of adenocarcinoma of the esophagogastric junction is increasing, but laparoscopic proximal gastrectomy is not widely accepted due to the absence of a standardized technique of reconstruction. This report describes a novel technique of esophagogastric tube reconstruction in laparoscopic proximal gastrectomy for Siewert type II tumors. METHODS Laparoscopic proximal gastrectomy, sometimes with transhiatal distal esophagectomy, was performed. After a perigastric, suprapancreatic, and lower thoracic paraesophageal lymphadenectomy, a gastric tube of 35-mm width was prepared. An esophagogastric tube anastomosis with pseudo-fornix was made with a no-knife linear stapler to prevent postoperative reflux esophagitis. RESULTS Fifteen patients with Siewert type II tumors underwent this operation. They included six patients with early-stage cancer, six at high risk for transhiatal total gastrectomy due to several comorbidities, and three who needed palliative tumor resection. The mean operation time was 315 min. One postoperative anastomotic leak was treated conservatively, and three anastomotic stenoses were resolved with endoscopic balloon dilatation. Postoperative 1-year follow-up endoscopy revealed four cases of reflux esophagitis that were well controlled by medication. CONCLUSIONS This new technique of reconstruction was feasible. With the advantage of a gastric tube, a tension-free anastomosis was possible even for bulky tumors that needed lower esophagectomy. Although long-term follow-up and a larger number of patients are required to evaluate long-term functional outcomes and oncological adequacy, our procedure has the potential of becoming a treatment of choice for early-stage Siewert type II tumors and/or for some selected high-risk patients who need tumor resection.
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Cash JC, Zehetner J, Hedayati B, Bildzukewicz NA, Katkhouda N, Mason RJ, Lipham JC. Outcomes following laparoscopic transhiatal esophagectomy for esophageal cancer. Surg Endosc 2013; 28:492-9. [PMID: 24100862 DOI: 10.1007/s00464-013-3230-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2013] [Accepted: 09/17/2013] [Indexed: 12/19/2022]
Abstract
BACKGROUND Most published minimally invasive esophagectomy techniques involve a multiple field approach, including laparoscopic and thoracoscopic esophageal mobilization. Laparoscopic transhiatal esophagectomy (LTE) should potentially reduce the complications associated with thoracotomy. This study aims to compare outcomes of LTE with open transhiatal esophagectomy (OTE) and en-bloc esophagectomy (EBE). METHODS Retrospective chart review was performed on all patients who had an LTE for cancer between July 2008 and July 2012 at our institution. Data was compared with an historic cohort of patients who underwent OTE and EBE at the same institution from July 2002 to July 2008. RESULTS There were 33 patients with LTE, compared with 60 patients with OTE and 139 with EBE. The presence of minor operative complications was similar (p = 0.36), but major complications were significantly less common in the LTE group (12, 23 and 33 %, respectively; p = 0.04). The median number of blood transfusions during hospitalization was significantly lower in the LTE group (0, 2.5 and 3, respectively; p = 0.005). Median tumor size was significantly smaller (1.5, 2.2, and 3 cm, respectively; p = 0.03), but the LTE group had a significantly higher percentage of patients with neoadjuvant treatment (39, 14 and 29 %, respectively; p = 0.008). Median lymph node yield for LTE was lower (24, 36 and 48, respectively; p < 0.0001), but the percentage of patients with positive nodes was similar (33, 33 and 39 %, respectively; p = 0.69). Mortality was equivalent among the groups (0, 2 and 4 %, respectively; p = 0.38). The median LOS for the LTE group was significantly lower (10, 13 and 15 days, respectively; p < 0.0001). Overall survival was not different between the three groups (p = 0.65), with median survival at 24 months of 70, 65 and 65 %, respectively. CONCLUSION LTE can be performed safely with less major complications and shorter hospital stay than open esophagectomy. The reduced lymph-node harvest did not impact overall survival.
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Affiliation(s)
- J Christian Cash
- Department of Surgery, Keck School of Medicine, University of Southern California, 1510 San Pablo St, Suite 514, Los Angeles, CA, 90033, USA
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Hanna GB, Arya S, Markar SR. Variation in the standard of minimally invasive esophagectomy for cancer--systematic review. Semin Thorac Cardiovasc Surg 2013. [PMID: 23200072 DOI: 10.1053/j.semtcvs.2012.10.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Minimally invasive esophagectomy (MIE) has been increasingly performed to treat esophageal cancer. Studies published between 1990 and 2012 that described the use of MIE for cancer in at least 50 patients were included for systematic review. The literature search retrieved 34 publications comprising 18 case series, 15 comparative studies, and 1 randomized control trial. Results revealed a wide variability in surgical techniques and perioperative outcomes with a lack of standardized definitions of postoperative complications. In most studies, radical formal lymphadenectomy was not performed and the lymph node harvest fell below the minimum number recommended to achieve survival benefits. There is a need to reach a consensus regarding surgical approaches in MIE, the definition of postoperative complications and the extent of lymphadenectomy before embarking on further randomized controlled trials comparing MIE vs. open approach.
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Affiliation(s)
- George B Hanna
- Division of Surgery, Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, London, United Kingdom.
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Bhayani NH, Gupta A, Dunst CM, Kurian AA, Halpin VJ, Swanström LL. Does Morbid Obesity Worsen Outcomes After Esophagectomy? Ann Thorac Surg 2013; 95:1756-61. [DOI: 10.1016/j.athoracsur.2013.01.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Revised: 12/19/2012] [Accepted: 01/08/2013] [Indexed: 11/30/2022]
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Noble F, Kelly JJ, Bailey IS, Byrne JP, Underwood TJ. A prospective comparison of totally minimally invasive versus open Ivor Lewis esophagectomy. Dis Esophagus 2013; 26:263-71. [PMID: 23551569 DOI: 10.1111/j.1442-2050.2012.01356.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The majority of esophagectomies in Western parts of the world are performed by a transthoracic approach reflecting the prevalence of adenocarcinoma of the lower esophagus or esophagogastric junction. Minimally invasive esophagectomy (MIE) has been reported in a variety of formats, but there are no series that directly compare totally minimally invasive thoracolaparoscopic 2 stage esophagectomy (MIE-2) with open Ivor Lewis (IVL). A prospective single-center cohort study of patients undergoing elective MIE-2 or IVL between January 2005 and November 2010 was performed. Short-term clinicopathologic outcomes were recorded using validated systems. One hundred and six patients (median age 66, range 36-85, 88 M : 18 F) underwent two-stage esophagectomy (53 MIE-2 and 53 IVL). Patient demographics (age, sex, body mass index, American Society of Anesthesiologists grade, tumor characteristics, neoadjuvant chemotherapy, and TNM stage) were comparable between the two groups. Outcomes for MIE-2 and IVL were comparable for anastomotic leak rates (5 [9%] vs. 2 [4%], P= 0.241), resection margin clearance (R0) (43 [81%] vs. 38 [72%], P= 0.253), median lymph node yield (19 vs. 18, P= 0.584), and median length of stay (12 [range 7-91] vs. 12 [range 7-101] days), respectively. Blood loss was significantly less for MIE-2 compared with IVL (median 300 [range 0-1250] mL vs. 400 [range 0-3000] mL, respectively, P= 0.021). MIE-2 in this series of selected patients supports its efficacy, when performed by an experienced minimally invasive surgical team. A well-designed multicenter trial addressing clinical effectiveness is now required.
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Affiliation(s)
- F Noble
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, Hampshire, UK
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Laparoscopic transhiatal resection for Siewert type II adenocarcinoma of the esophagogastric junction: operative technique and initial results. Surg Laparosc Endosc Percutan Tech 2012; 22:e199-203. [PMID: 22874699 DOI: 10.1097/sle.0b013e31825a72e2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Laparoscopic distal gastrectomy has gained wide acceptance, and laparoscopic total gastrectomy (LTG) and laparoscopic proximal gastrectomy (LPG) are now also performed for gastric cancer. We extended these techniques to treat Siewert type II adenocarcinoma of the esophagogastric junction (AEG). Ten patients with clinical T1 AEG type II underwent laparoscopic transhiatal (LTH) resection combined with LTG reconstructed by Roux-en-Y (LTH+LTG: n=2) or LPG reconstructed by jejunal interposition (LTH+LPG: n=8). Intracorporeal esophagojejunostomy was performed using a circular stapler, of which the anvil head was introduced transabdominally or transorally. The median operation time was 243 minutes, and blood loss was 25.5 g. There were no intraoperative complications or conversion to open surgery. No anastomotic leak was observed, but 1 diaphragmatic herniation to the left thoracic cavity occurred postoperatively. The median length of the proximal margin was 14.5 mm. This operation is technically feasible and can be safely performed after adequate experience of LTG or LPG, though esophagojejunostomy in the mediastinum is technically demanding.
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Dunn DH, Johnson EM, Morphew JA, Dilworth HP, Krueger JL, Banerji N. Robot-assisted transhiatal esophagectomy: a 3-year single-center experience. Dis Esophagus 2012; 26:159-66. [PMID: 22394116 DOI: 10.1111/j.1442-2050.2012.01325.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Minimally invasive esophagectomy has emerged as an important procedure for disease management in esophageal cancer (EC) with clear margin status, less morbidity, and shorter hospital stays compared with open procedures. The experience with transhiatal approach robotic esophagectomy (RE) for dissection of thoracic esophagus and associated morbidity is described here. Between March 2007 and November 2010, 40 patients with resectable esophageal indications underwent transhiatal RE at the institute. Clinical data for all patients were collected prospectively. Of 40 patients undergoing RE, one patient had an extensive benign stricture, one had high-grade dysplasia, and 38 had EC. Five patients were converted from robotic to open. Median operative time and estimated blood loss were 311 minutes and 97.2 mL, respectively. Median intensive care unit stay was 1 day (range, 0-16), and median length of hospital stay was 9 days (range, 6-36). Postoperative complications frequently observed were anastomotic stricture (n= 27), recurrent laryngeal nerve paresis (n= 14), anastomotic leak (n= 10), pneumonia (n= 8), and pleural effusion (n= 18). Incidence rates of laryngeal nerve paresis (35%) and leak rate (25%) were somewhat higher in comparison with that reported in literature. However, all vocal cord injuries were temporary, and all leaks healed following opening of the cervical incision and drainage. None of the patients died in the hospital, and 30-day mortality was 2.5% (1/40). Median number of lymph nodes removed was 20 (range, 3-38). In 33 patients with known lymph node locations, median of four (range, 0-12) nodes was obtained from the mediastinum, and median of 15 (range, 1-26) was obtained from the abdomen. R0 resection was achieved in 94.7% of patients. At the end of the follow-up period, 25 patients were alive, 13 were deceased, and 2 patients were lost to follow-up. For patients with EC, median disease-free survival was 20 months (range, 3-45). Transhiatal RE, by experience, is a feasible albeit evolving oncologic operation with low hospital mortality. The benefits include minimally invasive mediastinal dissection without thoracotomy or thoracoscopy. A reasonable operative time with minimal blood loss and postoperative morbidity can be achieved, in spite of the technically demanding nature of the procedure. Broader use of this technology in a setting of high-volume comprehensive surgical programs will almost certainly reduce the complication rates. Robotic tanshiatal esophagectomy with the elimination of a thoracic approach should be considered an option for the appropriate patient population in a comprehensive esophageal program.
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Affiliation(s)
- D H Dunn
- Esophageal and Gastric Cancer Program, Virginia Piper Cancer Institute, Abbott Northwestern Hospital, Allina Hospitals & Clinics, Minneapolis, Minnesota 55407, USA.
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