Minimally Invasive Techniques and Hybrid Operations for Esophageal Cancer

Risk Factors for Tumor Positive Resection Margins After Neoadjuvant Chemoradiotherapy for Esophageal Cancer: Results From the Dutch Upper GI Cancer Audit: A Nationwide Population-Based Study

OBJECTIVE

To identify risk factors for tumor positive resection margins after neoadjuvant chemoradiotherapy (nCRT) followed by esophagectomy for esophageal cancer.

SUMMARY BACKGROUND DATA

Esophagectomy after nCRT is associated with tumor positive resection margins in 4% to 9% of patients. This study evaluates potential risk factors for positive resection margins after nCRT followed by esophagectomy.

METHODS

All patients who underwent an elective esophagectomy following nCRT in 2011 to 2017 in the Netherlands were included. A multivariable logistic regression was performed to assess the association between potential risk factors and tumor positive resection margins.

RESULTS

In total, 3900 patients were included. Tumor positive resection margins were observed in 150 (4%) patients. Risk factors for tumor positive resection margins included tumor length (in centimeters, OR: 1.1, 95% CI: 1.0-1.1), cT4-stage (OR: 3.0, 95% CI: 1.2-6.7), and an Ivor Lewis esophagectomy (OR: 1.6, 95% CI: 1.0-2.6). Predictors associated with a lower risk of tumor positive resection margins were squamous cell carcinoma (OR: 0.4, 95% CI: 0.2-0.7), distal tumors (OR: 0.5, 95% CI: 0.3-1.0), minimally invasive surgery (OR: 0.6, 95% CI: 0.4-0.9), and a hospital volume of >60 esophagectomies per year (OR: 0.6, 95% CI: 0.4-1.0).

CONCLUSIONS

In this nationwide cohort study, tumor and surgical related factors (tumor length, histology, cT-stage, tumor location, surgical procedure, surgical approach, hospital volume) were identified as risk factors for tumor positive resection margins after nCRT for esophageal cancer. These results can be used to improve the radical resection rate by careful selection of patients and surgical approach and are a plea for centralization of esophageal cancer care.

Operative Outcomes of Minimally Invasive Esophagectomy versus Open Esophagectomy for Resectable Esophageal Cancer

Background There is a recent rise in the incidence of esophageal carcinoma in India. Surgical resection with or without neoadjuvant chemoradiation is the current treatment modality of choice. Postoperative complications, especially pulmonary complications, affect many patients who undergo open esophagectomy for esophageal cancer. Minimally invasive esophagectomy (MIE) could reduce the pulmonary complications and reduce the postoperative stay.

Methodology We performed a retrospective analysis of prospectively collected data of 114 patients with esophageal cancer in the department of surgical oncology at a tertiary cancer center in South India between January 2019 and March 2020. We included patients with resectable cancer of middle or lower third of the esophagus, and gastroesophageal junction tumors (Siewert I). MIE was performed in 27 patients and 78 patients underwent open esophagectomy (OE). The primary outcome measured was postoperative complications of Clavien–Dindo grade II or higher within 30 days. Other outcomes measured include overall mortality within 30 days, intraoperative complications, operative duration and the length of hospital stay.

Results A postoperative complication rate of 18.5% was noted in the MIE group, compared with 41% in the OE group ( p = 0.034). Pulmonary complications were noted in 7.4% in the MIE group compared to 25.6% in the OE group ( p = 0.044). Postoperative mortality rates, intraoperative complications, and other nonpulmonary postoperative complications were almost similar with MIE as with open esophagectomy. Although the median operative time was more in the MIE group (260 minutes vs. 180 minutes; p < 0.0001), the median length of hospital stay was shorter in patients undergoing MIE (9 days vs. 12 days; p = 0.0001).

Conclusions We found that MIE resulted in lower incidence of postoperative complications, especially pulmonary complications. Although, MIE was associated with prolonged operative duration, it resulted in shorter hospital stay.

Minimal Invasive Esophagectomy-a New Dawn of EsophagealSurgery

Surgery is the mainstay of esophageal cancer. However, esophagectomy is a major surgical trauma on a patient with high morbidity and mortality. The intent of minimally invasive esophagectomy (MIE) is to decrease the degree of surgical trauma and perioperative morbidity associated with open surgery, and provide faster recovery and shorter hospital stay with the equivalent oncological outcome. It also allows for lesser pulmonary morbidity, less blood loss, less pain, and a better quality of life. MIE is safe and effective but has a steep learning curve with high technical expertise. Recently, it is increasingly accepted and adopted all over the globe. In this article, we discuss the safety, efficacy, short-term, and oncological outcomes of thoracoscopic- and laparoscopic-assisted minimally invasive esophagectomy and robotic surgery compared with open esophagectomy with a special focus on the Indian perspective.

Clinical outcomes of video-assisted thoracoscopic surgery esophagectomy for esophageal cancer: a propensity score-matched analysis

Background

Minimally invasive esophagectomy theoretically offers advantages compared with open esophagectomy (OE). The aim of this study was to compare the early- and mid-term outcomes between video-assisted thoracoscopic surgery (VATS) esophagectomy (VE) and OE in patients with esophageal cancer.

Methods

Between November 2011 and July 2015, a total of 172 patients were divided into two groups depending on the method of esophagectomy: the VE group (n=42) and the OE group (n=130). A propensity analysis that incorporated perioperative variables, such as age, sex, preoperative pulmonary function, Charlson comorbidity index, tumor location, histologic grade of the tumor, pathologic stage and operative procedure (Ivor Lewis or McKeown) was performed, and postoperative outcomes were compared.

Results

Matching based on propensity scores produced 42 patients in each group for the analysis. After propensity matching, there were only two operative mortalities in the OE group, and both died of postoperative pneumonia. The overall incidence of postoperative complications was 38.1% (16 of 42) and 57.1% (24 of 42) in the VE group and in the OE group, respectively (P=0.088). The incidence of pulmonary complications was lower in the VE group than in the OE group (9.5% vs. 40.5%, P=0.004). The 2-year overall survival and disease-free survival were not different between the two groups (74.4% and 69.5% in the VE group, 69.5% and 69.8% in the OE group, P=0.865 and P=0.513, respectively).

Conclusions

In select patients, superior short-term surgical results and equal oncological outcomes were achieved with VE compared with OE.

[Oncologic esophageal resection and reconstruction : Open, hybrid, minimally invasive or robotic?]

Minimally invasive resections are increasingly employed in oncologic surgery for esophageal carcinoma. The new German S3 guideline states that esophagectomy, as well as reconstruction of the esophagus, can be performed minimally invasively or in combination with open techniques (hybrid). However, the current value of different techniques - ranging from complete minimally invasive esophagectomy over hybrid to robotic surgery - remains unregarded.This review provides a critical comparison of these techniques based on current evidence. Minimally invasive procedures of oncologic esophageal resection are safe in experienced hands and show numerous advantages with regard to postoperative reconvalescence. Laparoscopic gastrolysis with intra-abdominal lymphadenectomy and muscle sparing as well as anterolateral mini-thoracotomy (also via VATS as single-port technique) as a hybrid method also result in a relevant reduction of postoperative mortality and offer the possibility of extended mediastinal lymphadenectomy, which requires a high level of expertise when performed thoracoscopically. At present, robotic esophagectomy is applied in only a few clinics in Germany. A lack of evidence based on studies for esophageal surgery, as well as high acquisition and operating costs of the robotic system, have to be taken into account.