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Deboever N, Jones CM, Yamashita K, Ajani JA, Hofstetter WL. Advances in diagnosis and management of cancer of the esophagus. BMJ 2024; 385:e074962. [PMID: 38830686 DOI: 10.1136/bmj-2023-074962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
Esophageal cancer is the seventh most common malignancy worldwide, with over 470 000 new cases diagnosed each year. Two distinct histological subtypes predominate, and should be considered biologically separate disease entities.1 These subtypes are esophageal adenocarcinoma (EAC) and esophageal squamous cell carcinoma (ESCC). Outcomes remain poor regardless of subtype, with most patients presenting with late stage disease.2 Novel strategies to improve early detection of the respective precursor lesions, squamous dysplasia, and Barrett's esophagus offer the potential to improve outcomes. The introduction of a limited number of biologic agents, as well as immune checkpoint inhibitors, is resulting in improvements in the systemic treatment of locally advanced and metastatic esophageal cancer. These developments, coupled with improvements in minimally invasive surgical and endoscopic treatment approaches, as well as adaptive and precision radiotherapy technologies, offer the potential to improve outcomes still further. This review summarizes the latest advances in the diagnosis and management of esophageal cancer, and the developments in understanding of the biology of this disease.
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Affiliation(s)
- Nathaniel Deboever
- Department of Thoracic and Cardiovascular Surgery, MD Anderson Cancer Center, Houston, TX, USA
| | - Christopher M Jones
- Early Cancer Institute, Department of Oncology, University of Cambridge, Cambridge, UK
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Kohei Yamashita
- Department of Gastrointestinal Medical Oncology, MD Anderson Cancer Center, Houston, TX, USA
| | - Jaffer A Ajani
- Department of Gastrointestinal Medical Oncology, MD Anderson Cancer Center, Houston, TX, USA
| | - Wayne L Hofstetter
- Department of Thoracic and Cardiovascular Surgery, MD Anderson Cancer Center, Houston, TX, USA
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2
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Dugan MM, Ross SB, Sucandy I, Slavin M, Pattilachan TM, Christodoulou M, Rosemurgy A. Cost comparison between medicare and private insurance for robotic transhiatal esophagectomy. J Robot Surg 2024; 18:30. [PMID: 38231356 DOI: 10.1007/s11701-023-01762-0] [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: 11/01/2023] [Accepted: 12/01/2023] [Indexed: 01/18/2024]
Abstract
Esophageal cancer is a significant health concern, with the robotic platform being increasingly adopted for transhiatal esophagectomy (THE). While literature exists regarding the cost of robotic THE and its benefits, there is limited data analyzing cost and concurrent hospital reimbursement based on payor or provider. This study aimed to compare hospital reimbursement after robotic THE for patients with Medicare versus private insurance. With IRB approval, a prospective study of 85 patients from 2012 to 2022 who underwent robotic THE was conducted. Private insurance was defined as coverage excluding Medicare, Medicaid, or self-pay. Statistical analyses involved Student's t test, Chi-square test, and Fisher's exact test, with p ≤ 0.05 considered statistically significant. Data are presented as median (mean ± standard deviation). Among the 85 patients, 64 had Medicare, and 21 had private insurance. Medicare patients exhibited more frequent history of prior abdominal or thoracic surgeries (41% vs 10%, p < 0.01). Both groups showed no differences in factors like sex, body mass index, ASA classification, operative duration, estimated blood loss, conversions to 'open', tumor size, and major postoperative complications (Clavien-Dindo ≥ III). Similarly, metrics such as hospital stay duration, in-hospital mortality, 30-day readmission, and various financial components including total and variable costs, hospital reimbursement, and net margin were consistent across both. Despite Medicare patients being older and often having a broader operative history, hospital costs and reimbursements did not differ from patients with private insurance post-robotic THE. The robotic platform appears to mitigate potential disparities in hospitalization costs and hospital reimbursement for THE between Medicare and private insurance.
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Affiliation(s)
- Michelle M Dugan
- Florida Atlantic University Schmidt College of Medicine, Boca Raton, FL, USA
- Digestive Health Institute, AdventHealth Tampa, University of Central Florida (UCF), 3000 Medical Park Drive, Suite #500, Tampa, FL, 33613, USA
| | - Sharona B Ross
- Digestive Health Institute, AdventHealth Tampa, University of Central Florida (UCF), 3000 Medical Park Drive, Suite #500, Tampa, FL, 33613, USA.
| | - Iswanto Sucandy
- Digestive Health Institute, AdventHealth Tampa, University of Central Florida (UCF), 3000 Medical Park Drive, Suite #500, Tampa, FL, 33613, USA
| | - Moran Slavin
- Digestive Health Institute, AdventHealth Tampa, University of Central Florida (UCF), 3000 Medical Park Drive, Suite #500, Tampa, FL, 33613, USA
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tara M Pattilachan
- Digestive Health Institute, AdventHealth Tampa, University of Central Florida (UCF), 3000 Medical Park Drive, Suite #500, Tampa, FL, 33613, USA
| | - Maria Christodoulou
- Digestive Health Institute, AdventHealth Tampa, University of Central Florida (UCF), 3000 Medical Park Drive, Suite #500, Tampa, FL, 33613, USA
| | - Alexander Rosemurgy
- Digestive Health Institute, AdventHealth Tampa, University of Central Florida (UCF), 3000 Medical Park Drive, Suite #500, Tampa, FL, 33613, USA
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Pang T, Nie M, Yin K. The correlation between the margin of resection and prognosis in esophagogastric junction adenocarcinoma. World J Surg Oncol 2023; 21:316. [PMID: 37814242 PMCID: PMC10561513 DOI: 10.1186/s12957-023-03202-7] [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: 08/08/2023] [Accepted: 09/30/2023] [Indexed: 10/11/2023] Open
Abstract
Adenocarcinoma of the gastroesophageal junction (AEG) has become increasingly common in Western and Asian populations. Surgical resection is the mainstay of treatment for AEG; however, determining the distance from the upper edge of the tumor to the esophageal margin (PM) is essential for accurate prognosis. Despite the relevance of these studies, most have been retrospective and vary widely in their conclusions. The PM is now widely accepted to have an impact on patient outcomes but can be masked by TNM at later stages. Extended PM is associated with improved outcomes, but the optimal PM is uncertain. Academics continue to debate the surgical route, extent of lymphadenectomy, preoperative tumor size assessment, intraoperative cryosection, neoadjuvant therapy, and other aspects to further ensure a negative margin in patients with gastroesophageal adenocarcinoma. This review summarizes and evaluates the findings from these studies and suggests that the choice of approach for patients with adenocarcinoma of the esophagogastric junction should take into account the extent of esophagectomy and lymphadenectomy. Although several guidelines and reviews recommend the routine use of intraoperative cryosections to evaluate surgical margins, its generalizability is limited. Furthermore, neoadjuvant chemotherapy and radiotherapy are more likely to increase the R0 resection rate. In particular, intraoperative cryosections and neoadjuvant chemoradiotherapy were found to be more effective for achieving negative resection margins in signet ring cell carcinoma.
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Affiliation(s)
- Tao Pang
- Department of Gastrointestinal Tract Surgery, First Affiliated Hospital of Naval Military Medical University, Shanghai, China
| | - Mingming Nie
- Department of Gastrointestinal Tract Surgery, First Affiliated Hospital of Naval Military Medical University, Shanghai, China
| | - Kai Yin
- Department of Gastrointestinal Tract Surgery, First Affiliated Hospital of Naval Military Medical University, Shanghai, China.
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4
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Higuchi Y, Kawaguchi Y, Shoda K, Akaike H, Saito R, Maruyama S, Shiraishi K, Furuya S, Amemiya H, Kawaida H, Ichikawa D. Analysis of surgical outcomes and risk factors for anastomotic leakage following trans-hiatal resection of esophagogastric junction cancer. Langenbecks Arch Surg 2023; 408:304. [PMID: 37561220 DOI: 10.1007/s00423-023-03036-7] [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: 03/21/2023] [Accepted: 08/01/2023] [Indexed: 08/11/2023]
Abstract
BACKGROUND The trans-hiatal lower esophagectomy is considered less invasive than the trans-thoracic esophagectomy for resection of esophagogastric junction (EGJ) cancer. However, the optimal procedure remains controversial and should be determined while considering both oncological and safety aspects. METHODS This retrospective study comprised 124 patients that underwent curative resection for EGJ cancer. The study analysis included 93 patients with tumor centers located within 2 cm of the EGJ. Clinicopathological findings and surgical outcomes were compared between patients treated using trans-hiatal and trans-thoracic approaches. RESULTS Sixty-three patients underwent lower esophagectomy using the trans-hiatal approach (TH-G). The remaining 30 patients underwent esophagectomy using the trans-thoracic approach (TT-E). The TH-G group were older, had a lower prevalence of lymphatic spread, shorter length of esophageal invasion, and shorter operative duration compared to the TT-E group. Although no significant differences in the frequency of postoperative complications, a higher proportion of patients in the TH-G group developed anastomotic leakage (16% vs. 7%, p = 0.33). Univariate and multivariate analyses demonstrated that cardiac comorbidity was an independent risk factor for anastomotic leakage (odds ratio, 5.24; 95% CI, 1.06-25.9; P < 0.05) in TH-G group. Further examination revealed that preoperative cardiothoracic ratio (CTR) with 50% or greater could be surrogate marker as risk factor for anastomotic leakage in TH-G group (35% vs. 7.5%, p < 0.05). CONCLUSIONS The trans-hiatal approach can be used for resection of EGJ cancer. However, special attention should be paid to the prevention of anastomotic leakage in patients with cardiac comorbidities or a large preoperative CTR.
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Affiliation(s)
- Yudai Higuchi
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo, Yamanashi, 4093898, Japan
| | - Yoshihiko Kawaguchi
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo, Yamanashi, 4093898, Japan
| | - Katsutoshi Shoda
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo, Yamanashi, 4093898, Japan
| | - Hidenori Akaike
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo, Yamanashi, 4093898, Japan
| | - Ryo Saito
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo, Yamanashi, 4093898, Japan
| | - Suguru Maruyama
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo, Yamanashi, 4093898, Japan
| | - Kensuke Shiraishi
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo, Yamanashi, 4093898, Japan
| | - Shinji Furuya
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo, Yamanashi, 4093898, Japan
| | - Hidetake Amemiya
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo, Yamanashi, 4093898, Japan
| | - Hiromichi Kawaida
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo, Yamanashi, 4093898, Japan
| | - Daisuke Ichikawa
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo, Yamanashi, 4093898, Japan.
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5
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Walmsley J, Ariyarathenam A, Berrisford R, Humphreys L, Sanders G, Tham JC, Wheatley T, Chan DSY. Oesophagectomy or Total Gastrectomy for the Management of Siewert II Gastroesophageal Junction Cancer: a Systematic Review and Meta-analysis. J Gastrointest Surg 2023:10.1007/s11605-023-05661-5. [PMID: 37010694 DOI: 10.1007/s11605-023-05661-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 03/03/2023] [Indexed: 04/04/2023]
Abstract
BACKGROUND There is no consensus on the ideal surgical management of patients with Siewert type II gastroesophageal junctional (GEJ) cancers. Due to its anatomical location, total gastrectomy and oesophagectomy are widely used methods of resection. The aim of this study was to determine the optimal surgical treatment of these patients. METHOD A systematic search of PubMed, Medline and Cochrane libraries was conducted for literature published between 2000 and 2022. Studies directly comparing oesophagectomy to gastrectomy for Siewert type II tumours were included. Outcome measures included rates of anastomotic leak, 30-day mortality, R0 resection and 5-year survival. Statistical analysis was performed using Review Manager 5.4. RESULTS Eleven studies involving 18,585 patients undergoing either oesophagectomy (n = 8618) or total gastrectomy (n = 9967) for Siewert type II GEJ cancer were included. There were no significant differences between the rates of anastomotic leak (OR 0.91, CI 0.59-1.40, p = 0.66) and R0 resection (OR 1.51, CI 0.93-2.42, p = 0.09). Patients undergoing total gastrectomy had a lower 30-day mortality (OR 0.66, CI 0.45-0.95, p = 0.03) and a greater 5-year overall survival (OR 1.49, CI 1.34-1.67, p < 0.001) compared to patients undergoing oesophagectomy. These differences were not statistically significant after excluding two large studies, which accounted for the majority of the total population in the analysis. CONCLUSION These results suggest that total gastrectomy results in lower 30-day mortality and improved overall survival in patients with Siewert type II GEJ cancer. However, interpretation of these results may be biased by the effect of two large studies.
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Affiliation(s)
- James Walmsley
- Department of Surgery, University Hospitals of Plymouth, Derriford Road, Plymouth, PL6 8DH, UK.
| | - Arun Ariyarathenam
- Department of Surgery, University Hospitals of Plymouth, Derriford Road, Plymouth, PL6 8DH, UK
| | - Richard Berrisford
- Department of Surgery, University Hospitals of Plymouth, Derriford Road, Plymouth, PL6 8DH, UK
| | - Lee Humphreys
- Department of Surgery, University Hospitals of Plymouth, Derriford Road, Plymouth, PL6 8DH, UK
| | - Grant Sanders
- Department of Surgery, University Hospitals of Plymouth, Derriford Road, Plymouth, PL6 8DH, UK
| | - Ji Chung Tham
- Department of Surgery, University Hospitals of Plymouth, Derriford Road, Plymouth, PL6 8DH, UK
| | - Tim Wheatley
- Department of Surgery, University Hospitals of Plymouth, Derriford Road, Plymouth, PL6 8DH, UK
| | - David S Y Chan
- Department of Surgery, University Hospitals of Plymouth, Derriford Road, Plymouth, PL6 8DH, UK
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Siddiqi A, Johnston FM. The Perioperative and Operative Management of Esophageal and Gastric Cancer. Surg Oncol Clin N Am 2023; 32:65-81. [PMID: 36410922 DOI: 10.1016/j.soc.2022.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Optimal management of esophageal and gastric cancer during the perioperative period requires a coordinated multidisciplinary treatment effort. Accurate staging guides treatment strategy. Advances in minimally invasive surgery and endoscopy have reduced risks associated with resection while maintaining oncological standards. Although the standard perioperative chemo-and radiotherapy regimens have not yet been established, randomized control trials exploring this subject show promising results.
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Affiliation(s)
- Amn Siddiqi
- Department of Surgery, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Baltimore, MD 21287, USA
| | - Fabian M Johnston
- Division of Gastrointestinal Surgical Oncology, Johns Hopkins University, 600 North Wolfe Street, Baltimore, MD 21287, USA.
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7
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Junttila A, Helminen O, Helmiö M, Huhta H, Kallio R, Koivukangas V, Kokkola A, Laine S, Lietzen E, Meriläinen S, Pohjanen VM, Rantanen T, Ristimäki A, Räsänen JV, Saarnio J, Sihvo E, Toikkanen V, Tyrväinen T, Valtola A, Kauppila JH. Long-Term Survival After Transhiatal Versus Transthoracic Esophagectomy: A Population-Based Nationwide Study in Finland. Ann Surg Oncol 2022; 29:8158-8167. [PMID: 36006492 DOI: 10.1245/s10434-022-12349-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 07/12/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND No population-based studies comparing long-term survival after transhiatal esophagectomy (THE) and transthoracic esophagectomy (TTE) exist. This study aimed to compare the 5-year survival of esophageal cancer patients undergoing THE or TTE in a population-based nationwide setting. METHODS This study included all curatively intended THE and TTE for esophageal cancer in Finland during 1987-2016, with follow-up evaluation until 31 December 2019. Cox proportional hazard models provided hazard ratios (HRs) with 95% confidence intervals (CIs) of 5-year and 90-day mortality. The results were adjusted for age, sex, year of operation, comorbidities, histology, neoadjuvant treatment, and pathologic stage. RESULTS A total of 1338 patients underwent THE (n = 323) or TTE (n = 1015). The observed 5-year survival rate was 39.3% after THE and 45.0% after TTE (p = 0.072). In adjusted model 1, THE was not associated with greater 5-year mortality (HR 0.99; 95% CI 0.82-1.20) than TTE. In adjusted model 2, including T stage instead of pathologic stage, the 5-year mortality hazard rates after THE (HR 0.87, 95% CI 0.72-1.05) and TTE were comparable. The 90-day mortality rate for THE was higher than for TTE (adjusted HR 0.72; 95% CI 0.45-1.14). In subgroup analyses, no differences between THE and TTE were observed in Siewert II gastroesophageal junction cancers, esophageal cancers, or pN0 tumors, nor in the comparison of THE and TTE with two-field lymphadenectomy. The sensitivity analysis, including patients with missing patient records, who underwent surgery during 1996-2016 mirrored the main analysis. CONCLUSIONS This Finnish population-based nationwide study suggests no difference in 5-year or 90-day mortality after THE and TTE for esophageal cancer.
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Affiliation(s)
- Anna Junttila
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.
| | - Olli Helminen
- Surgery Research Unit, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Mika Helmiö
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
| | - Heikki Huhta
- Surgery Research Unit, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Raija Kallio
- Department of Oncology and Radiotherapy, Oulu University Hospital, Oulu, Finland
| | - Vesa Koivukangas
- Surgery Research Unit, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Arto Kokkola
- Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Simo Laine
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
| | - Elina Lietzen
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
| | - Sanna Meriläinen
- Surgery Research Unit, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Vesa-Matti Pohjanen
- Cancer and Translational Medicine Research Unit, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Tuomo Rantanen
- Department of Surgery, University of Eastern Finland and Kuopio University Hospital, Kuopio, Finland
| | - Ari Ristimäki
- Department of Pathology, HUSLAB, HUS Diagnostic Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.,Applied Tumor Genomics Research Program, Research Programs Unit, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Jari V Räsänen
- Department of General Thoracic and Oesophageal Surgery, Heart and Lung Centre, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Juha Saarnio
- Surgery Research Unit, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Eero Sihvo
- Department of Surgery, Central Finland Central Hospital, Jyväskylä, Finland
| | - Vesa Toikkanen
- Department of Cardiothoracic Surgery, Heart Center, Tampere University Hospital and University of Tampere, Tampere, Finland
| | - Tuula Tyrväinen
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
| | - Antti Valtola
- Department of Surgery, University of Eastern Finland and Kuopio University Hospital, Kuopio, Finland
| | - Joonas H Kauppila
- Surgery Research Unit, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland.,Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Insitutet and Karolinska University Hospital, Stockholm, Sweden
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Plat VD, Stam WT, Bootsma BT, Straatman J, Klausch T, Heineman DJ, van der Peet DL, Daams F. Short-term outcome for high-risk patients after esophagectomy. Dis Esophagus 2022; 36:6611914. [PMID: 35724560 PMCID: PMC9817823 DOI: 10.1093/dote/doac028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 03/29/2022] [Accepted: 02/14/2022] [Indexed: 01/11/2023]
Abstract
Transthoracic esophagectomy (TTE) for esophageal cancer facilitates mediastinal dissection; however, it has a significant impact on cardiopulmonary status. High-risk patients may therefore be better candidates for transhiatal esophagectomy (THE) in order to prevent serious complications. This study addressed short-term outcome following TTE and THE in patients that are considered to have a higher risk of surgery-related morbidity. This population-based study included patients who underwent a curative esophagectomy between 2011 and 2018, registered in the Dutch Upper GI Cancer Audit. The Charlson comorbidity index was used to assign patients to a low-risk (score ≤ 1) and high-risk group (score ≥ 2). Propensity score matching was applied to produce comparable groups between high-risk patients receiving TTE and THE. Primary endpoint was mortality (in-hospital/30-day mortality), secondary endpoints included morbidity and oncological outcomes. Additionally, a matched subgroup analysis was performed, including only cervical reconstructions. Of 5,438 patients, 945 and 431 high-risk patients underwent TTE and THE, respectively. After propensity score matching, mortality (6.3 vs 3.3%, P = 0.050), overall morbidity, Clavien-Dindo ≥ 3 complications, pulmonary complications, cardiac complications and re-interventions were significantly more observed after TTE compared to THE. A significantly higher mortality after TTE with a cervical reconstruction was found compared to THE (7.0 vs. 2.2%, P = 0.020). Patients with a high Charlson comorbidity index predispose for a complicated postoperative course after esophagectomy, this was more outspoken after TTE compared to THE. In daily practice, these outcomes should be balanced with the lower lymph node yield, but comparable positive node count and radicality after THE.
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Affiliation(s)
- Victor D Plat
- Address correspondence to: V.D. Plat, MD, Amsterdam University Medical Centers, VU University Medical center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands.
| | - Wessel T Stam
- Department of Gastrointestinal Surgery, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
| | - Boukje T Bootsma
- Department of Gastrointestinal Surgery, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
| | - Jennifer Straatman
- Department of Gastrointestinal Surgery, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
| | - Thomas Klausch
- Department of Epidemiology and Biostatistics, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
| | - David J Heineman
- Department of Gastrointestinal Surgery, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands,Department of Cardiothoracic Surgery, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
| | - Donald L van der Peet
- Department of Gastrointestinal Surgery, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
| | - Freek Daams
- Department of Gastrointestinal Surgery, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
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9
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Soltani E, Mahmoodzadeh H, Jabbari Nooghabi A, Jabbari Nooghabi M, Ravankhah Moghaddam K, Hassanzadeh Haddad E. Transhiatal versus transthoracic esophagectomy for esophageal SCC: outcomes and complications. J Cardiothorac Surg 2022; 17:150. [PMID: 35681156 PMCID: PMC9185877 DOI: 10.1186/s13019-022-01912-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 06/02/2022] [Indexed: 11/10/2022] Open
Abstract
Background Transhiatal esophagectomy (THE) and transthoracic esophagectomy (TTE) are both accepted procedures for esophageal cancer but still the most effective surgical approach continues to be controversial. This study aimed to determine post-operative complications and outcomes of TTE compared with THE. Methods A retrospective analysis was performed on data of 243 adult patients with resectable esophageal cancer who underwent THE or TTE between December 2016 and October 2018. Demographic data, consisting of preoperative co-morbidities, disease stage, and perioperative morbidity and mortality were collected. Results Among the patients, 99 individuals (40.7%) had a transhiatal resection and 144 (59.3%) had a transthoracic resection. Most patients (83.1%) were above 50 years old with no significant difference between groups (p = 0.297). The frequency distribution of comorbidities was similar in both groups. The most common site of the tumor in TTE group was middle esophagus and in THE group was lower esophagus. The most common complication was recurrence of dysphagia which was more common in THE group without significant difference. The other complications including pulmonary and cardiac events, tracheal and recurrent laryngeal nerve injury, chylothorax and anastomosis stricture did not differ between the groups. The operative mortality within 30 days after the operation was 2.8% with significant difference favored the THE group (THE 0%, TTE 5.2%, p = 0.033). Conclusion Because of the controversies, the decision on the type of surgical technique in esophageal cancer treatment hinges on patient’s co-morbidities, cancer stage, tumor location and surgeon’s experience.
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Affiliation(s)
- Ehsan Soltani
- Surgical Oncology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
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10
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Yin Z, Yang RM, Jiang YQ, Chen Q, Cai HR. Perioperative Clinical Results of Transcervical and Transhiatal Esophagectomy versus Thoracoscopic Esophagectomy in Patients with Esophageal Carcinoma: A Prospective, Randomized, Controlled Study. Int J Gen Med 2022; 15:3393-3404. [PMID: 35378918 PMCID: PMC8976491 DOI: 10.2147/ijgm.s347230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 02/28/2022] [Indexed: 11/23/2022] Open
Abstract
Background This study assessed the efficacy of transcervical and transhiatal esophagectomy versus thoracoscopic esophagectomy in patients with esophageal carcinoma (EC). Methods A total of 80 patients with EC were enrolled in this study, including 40 cases in the observation group that received transcervical combine transhiatal esophagectomy and the rest 40 cases of the group that underwent thoracoscopic esophagectomy. The preoperative, intraoperative, and postoperative data were analyzed between the two surgeries, regarding perioperative bleeding, the total number of dissected mediastinal lymph nodes, operative time, number of lymph nodes in the left para-recurrent laryngeal nerve (para-RLN) or the right para-RLN, time in the intensive care unit (ICU), postoperative pain score, the length of postoperative stay (LOPS), PO2/fraction of inspired oxygen (PO2/FiO2), pulmonary infection, and lymphatic metastasis. Results The operations were successfully performed in all 80 patients. The results showed that patients who underwent transcervical and transhiatal esophagectomy had shorter operations than those with transthoracic esophagectomy (200 minutes vs 235 minutes, Kruskal–Wallis test [Z] = –3.700, P < 0.001). The number of dissected mediastinal lymph nodes in the left para-RLN in the observation group was higher than in the control group (25.0% vs 2.5%, Z = 2.568, P = 0.010). The postoperative pain score day 1 (0.0% vs 17.5%, Z = –4.292, P < 0.001), postoperative pain score day 3 (12.5% vs 37.5%, Z = –3.363, P < 0.001) and 48-h PO2/FiO2 (290 minutes vs 255 minutes, Z = 3.747, P < 0.001) were significant between the two groups. The LOPS of patients with EC in the observation group was shorter than the control group (7 vs 8, Z = –2.119, P = 0.034). The number of patients receiving transcervical and transhiatal esophagectomy that developed postoperative pulmonary infections was less than the controls (chi-square [χ2] = 4.114, P = 0.043). Moreover, the transcervical and transhiatal esophagectomy was an independent protect factor for postoperative pulmonary infection (odds ratio [OR] =7.801, P = 0.037). Conclusion The transcervical and transhiatal esophagectomy is a good operation for treating patients with EC, which may offer an opportunity to treat cases who cannot have thoracotomy.
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Affiliation(s)
- Zhe Yin
- Department of Thoracic Surgery, Chongqing University Cancer Hospital, Chongqing Cancer Hospital, Chongqing, 400030, People’s Republic of China
| | - Ren-Mei Yang
- Department of Thoracic Surgery, Chongqing University Cancer Hospital, Chongqing Cancer Hospital, Chongqing, 400030, People’s Republic of China
| | - Yue-Quan Jiang
- Department of Thoracic Surgery, Chongqing University Cancer Hospital, Chongqing Cancer Hospital, Chongqing, 400030, People’s Republic of China
| | - Qi Chen
- Department of Anesthesiology, Chongqing University Cancer Hospital, Chongqing Cancer Hospital, Chongqing, 400030, People’s Republic of China
| | - Hua-Rong Cai
- Department of Thoracic Surgery, Chongqing University Cancer Hospital, Chongqing Cancer Hospital, Chongqing, 400030, People’s Republic of China
- Correspondence: Hua-Rong Cai, Department of Thoracic Surgery, Chongqing University Cancer Hospital, Chongqing Cancer Hospital, No. 181 Hanyu Road, Shapingba District, Chongqing, 400030, People’s Republic of China, Tel +86 15523501699, Email
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11
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Surgical Therapy of Esophageal Adenocarcinoma-Current Standards and Future Perspectives. Cancers (Basel) 2021; 13:cancers13225834. [PMID: 34830988 PMCID: PMC8616112 DOI: 10.3390/cancers13225834] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 11/15/2021] [Accepted: 11/18/2021] [Indexed: 12/18/2022] Open
Abstract
Simple Summary Subtotal resection of the esophagus with resection of local lymph nodes is the oncological procedure of choice for advanced esophageal cancer. Reconstruction of the intestinal tract is predominantly performed with a gastric tube. Even in specialized centers, this surgical procedure is associated with a high complication but low mortality rate. Therefore, clinical research aims to develop peri- and intra-operative strategies to improve the patient related outcome. Abstract Transthoracic esophagectomy is currently the predominant curative treatment option for resectable esophageal adenocarcinoma. The majority of carcinomas present as locally advanced tumors requiring multimodal strategies with either neoadjuvant chemoradiotherapy or perioperative chemotherapy alone. Minimally invasive, including robotic, techniques are increasingly applied with a broad spectrum of technical variations existing for the oncological resection as well as gastric reconstruction. At the present, intrathoracic esophagogastrostomy is the preferred technique of reconstruction (Ivor Lewis esophagectomy). With standardized surgical procedures, a complete resection of the primary tumor can be achieved in almost 95% of patients. Even in expert centers, postoperative morbidity remains high, with an overall complication rate of 50–60%, whereas 30- and 90-day mortality are reported to be <2% and <6%, respectively. Due to the complexity of transthoracic esophagetomy and its associated morbidity, esophageal surgery is recommended to be performed in specialized centers with an appropriate caseload yet to be defined. In order to reduce postoperative morbidity, the selection of patients, preoperative rehabilitation and postoperative fast-track concepts are feasible strategies of perioperative management. Future directives aim to further centralize esophageal services, to individualize surgical treatment for high-risk patients and to implement intraoperative imaging modalities modifying the oncological extent of resection and facilitating surgical reconstruction.
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12
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Shen J, Zhu X, Du Y, Zhu Y, Yu P, Yang L, Xu Z, Huang L, Zhang Y, Zhang Y, Liu L, Cheng X. Adjuvant SOX chemotherapy versus concurrent chemoradiotherapy after D2 radical resection of locally advanced esophagogastric junction (EGJ) adenocarcinoma: study protocol for a randomized phase III trial (ARTEG). Trials 2021; 22:753. [PMID: 34717717 PMCID: PMC8556914 DOI: 10.1186/s13063-021-05617-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 09/13/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Survival benefit of adjuvant radiotherapy for locally advanced gastric cancer following gastrectomy plus D2 lymphadenectomy has always been controversial. Esophagogastric junction (EGJ) adenocarcinoma, which is usually classified as gastric cancer in East Asia, often has a higher locoregional recurrence rate after operation because of its special anatomical characteristics. The aim of this study is to determine whether adjuvant radiotherapy can improve survival of locally advanced EGJ adenocarcinoma after D2 radical resection. METHODS In this phase III, randomized, open label, controlled trial, we plan to recruit 378 patients with Siewert type II and III adenocarcinoma of EGJ, who had undergone transabdominal radical surgery and D2 lymphadenectomy, and were divided into pathological stage IIB to IIIC. All patients will be randomized 1:1 to receive either adjuvant chemotherapy alone (control group) or adjuvant chemotherapy plus chemoradiotherapy (experimental group). Patients allocated to control group will receive eight cycles of S-1 plus oxaliplatin (SOX), while the experimental group will receive two cycles of SOX followed by 45-Gy RT combined with S-1 and four additional cycles of SOX. The primary endpoint is 3-year disease-free survival rate (DFS). The secondary endpoints are 3-year overall survival rate (OS), 3-year locoregional recurrence-free survival rate (LRFS), 3-year distant metastasis-free survival rate (DMFS), and quality of life (QoL). DISCUSSION In the past, the adjuvant treatment of EGJ adenocarcinoma needs to draw on the experience of esophageal adenocarcinoma or gastric adenocarcinoma. In this study, EGJ adenocarcinoma is considered as an independent disease, and the conclusion will provide evidence for optimal adjuvant therapy of locally advanced EGJ adenocarcinoma after D2 radical resection. TRIAL REGISTRATION ClinicalTrials.gov NCT03973008 . Registered on 1 June 2019 (retrospectively registered), URL: https://clinicaltrials.gov/ct2/show/NCT03973008?term=NCT03973008&draw=2&rank=1.
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Affiliation(s)
- Jinwen Shen
- Department of Abdominal Radiotherapy, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), 1 East Banshan Road, Hangzhou, 310022, P.R. China.,Zhejiang Provincial Research Center for Cancer of Upper Gastrointestinal Tract, 1 East Banshan Road, Hangzhou, 310022, P.R. China
| | - Xiu Zhu
- Department of Pathology, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), 1 East Banshan Road, Hangzhou, 310022, P.R. China
| | - Yian Du
- Zhejiang Provincial Research Center for Cancer of Upper Gastrointestinal Tract, 1 East Banshan Road, Hangzhou, 310022, P.R. China.,Department of Abdominal Surgery, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), 1 East Banshan Road, Hangzhou, 310022, P.R. China
| | - Yuan Zhu
- Department of Abdominal Radiotherapy, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), 1 East Banshan Road, Hangzhou, 310022, P.R. China.,Zhejiang Provincial Research Center for Cancer of Upper Gastrointestinal Tract, 1 East Banshan Road, Hangzhou, 310022, P.R. China
| | - Pengfei Yu
- Zhejiang Provincial Research Center for Cancer of Upper Gastrointestinal Tract, 1 East Banshan Road, Hangzhou, 310022, P.R. China.,Department of Abdominal Surgery, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), 1 East Banshan Road, Hangzhou, 310022, P.R. China
| | - Litao Yang
- Zhejiang Provincial Research Center for Cancer of Upper Gastrointestinal Tract, 1 East Banshan Road, Hangzhou, 310022, P.R. China.,Department of Abdominal Surgery, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), 1 East Banshan Road, Hangzhou, 310022, P.R. China
| | - Zhiyuan Xu
- Zhejiang Provincial Research Center for Cancer of Upper Gastrointestinal Tract, 1 East Banshan Road, Hangzhou, 310022, P.R. China.,Department of Abdominal Surgery, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), 1 East Banshan Road, Hangzhou, 310022, P.R. China
| | - Ling Huang
- Zhejiang Provincial Research Center for Cancer of Upper Gastrointestinal Tract, 1 East Banshan Road, Hangzhou, 310022, P.R. China.,Department of Abdominal Surgery, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), 1 East Banshan Road, Hangzhou, 310022, P.R. China
| | - Yunli Zhang
- Zhejiang Provincial Research Center for Cancer of Upper Gastrointestinal Tract, 1 East Banshan Road, Hangzhou, 310022, P.R. China.,Department of Abdominal Surgery, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), 1 East Banshan Road, Hangzhou, 310022, P.R. China
| | - Yanqiang Zhang
- Zhejiang Provincial Research Center for Cancer of Upper Gastrointestinal Tract, 1 East Banshan Road, Hangzhou, 310022, P.R. China.,Department of Abdominal Surgery, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), 1 East Banshan Road, Hangzhou, 310022, P.R. China
| | - Luying Liu
- Department of Abdominal Radiotherapy, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), 1 East Banshan Road, Hangzhou, 310022, P.R. China. .,Zhejiang Provincial Research Center for Cancer of Upper Gastrointestinal Tract, 1 East Banshan Road, Hangzhou, 310022, P.R. China.
| | - Xiangdong Cheng
- Zhejiang Provincial Research Center for Cancer of Upper Gastrointestinal Tract, 1 East Banshan Road, Hangzhou, 310022, P.R. China. .,Department of Abdominal Surgery, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), 1 East Banshan Road, Hangzhou, 310022, P.R. China.
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13
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Alfaifi S, Chu R, Hui X, Broderick S, Hooker C, Brock M, Bush E, Hales R, Anderson L, Hoff J, Friedes C, Han-Oh S, Mcnutt T, Ha J, Yang S, Battafarano R, Feliciano J, Voong KR. Trimodality therapy for esophageal cancer: The role of surgical and radiation treatment parameters in the development of anastomotic complications. Thorac Cancer 2021; 12:3121-3129. [PMID: 34651445 PMCID: PMC8636205 DOI: 10.1111/1759-7714.14130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/13/2021] [Accepted: 08/14/2021] [Indexed: 01/03/2023] Open
Abstract
Background Here, we investigated the relationship between clinical parameters, including the site of surgical anastomosis and radiation dose to the anastomotic region, and anastomotic complications in esophageal cancer patients treated with trimodality therapy. Methods Between 2007 and 2016, esophageal cancer patients treated with trimodality therapy at a tertiary academic cancer center were identified. Patient, treatment, and outcome parameters were collected. Radiation dose to the gastric regions were extracted. Anastomotic complication was defined as leak and/or stricture. We used Fisher's exact and Wilcoxon rank‐sum tests to compare the association between clinical parameters and anastomotic complications. Results Of 89 patients identified, the median age was 63 years, 82% (n = 73) were male, and 82% had distal (n = 47) or gastroesophageal junction (n = 26) tumors. Median follow‐up was 25.8 months. Esophagectomies were performed with cervical (65%, n = 58) or thoracic anastomoses (35%, n = 31). Anastomotic complications developed in 60% (n = 53). Cervical anastomosis was associated with anastomotic complications (83%, n = 44/53, p < 0.01). Radiation to any gastric substructure was not associated with anastomotic complications (p > 0.05). In the subset of patients with distal/gastroesophageal junction tumors undergoing esophagectomy with cervical anastomosis where radiation was delivered to the future neoesophagus, 80% (n = 35/44) developed anastomotic complications. In this high‐risk subgroup, radiation was not associated with anastomotic complications (p > 0.05). Conclusions Our analysis did not demonstrate an association between radiation dose to gastric substructures and anastomotic complications. However, it showed an association between esophagectomy with cervical anastomosis and anastomotic complications. Patients with distal/gastroesophageal junction tumors who undergo esophagectomy with cervical anastomosis have higher rates of anastomotic complications unrelated to radiation to gastric substructures.
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Affiliation(s)
- Salem Alfaifi
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Robert Chu
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Xuan Hui
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Stephen Broderick
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Craig Hooker
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Malcolm Brock
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Errol Bush
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Russell Hales
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Lori Anderson
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jeffrey Hoff
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Cole Friedes
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Sarah Han-Oh
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Todd Mcnutt
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jinny Ha
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Stephen Yang
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Richard Battafarano
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Joy Feliciano
- Departments of Medical Oncology, Johns Hopkins University, Baltimore, Maryland, USA
| | - K Ranh Voong
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland, USA
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14
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Oh SE, Lee GH, An JY, Lee JH, Sohn TS, Bae JM, Kim S, Choi MG. Comparison of transabdominal and transthoracic surgical approaches in the treatment of Siewert type II esophagogastric junction cancers: A propensity score-matching analysis. Eur J Surg Oncol 2021; 48:370-376. [PMID: 34433514 DOI: 10.1016/j.ejso.2021.08.006] [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: 03/18/2021] [Revised: 07/09/2021] [Accepted: 08/06/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The appropriate surgical approach for Siewert type II esophagogastric junction (EGJ) cancer remains under discussion. We compared surgical outcomes between transabdominal (TA) and transthoracic (TT) approaches for treating type II EGJ cancers. MATERIALS AND METHODS This retrospective study reviewed 397 type II EGJ cancer patients who underwent surgery from January 2001 to May 2019. We used a 1:3 propensity score-matching method for the analysis. The matching factors were age, sex, American Society of Anesthesiologists score, period of operation, and pathologic stage. Matching was performed using the MatchIt package of R 4.0.2. RESULTS A total of 46 patients in the TT group was matched to 126 patients in the TA group. R0 resection was achieved in both groups and was not statistically different between groups (p = 0.455). In the TA group, the operation time and in-hospital stay length were significantly shorter (p < 0.001) and the intraoperative estimated blood loss (EBL) was significantly lower than in the TT group (p = 0.011). The postoperative complication rate between the two groups was significantly different (p = 0.003). There was marginal difference in the five-year OS rate (p = 0.049) and significant difference in the five-year DFS (p = 0.039). However, surgical approach was not a significant prognostic factor in multivariate analysis of OS or DFS. CONCLUSIONS There was no clear survival benefit of one approach over the other. However, less intraoperative bleeding, lower postoperative complication rate, shorter operation time, and reduced in-hospital stay length were correlated with the TA approach.
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Affiliation(s)
- Sung Eun Oh
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
| | - Geun Hee Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
| | - Ji Yeong An
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
| | - Jun Ho Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
| | - Tae Sung Sohn
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
| | - Jae Moon Bae
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
| | - Sung Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea; Department of Surgery, Samsung Changwon Medical Center, Sungkyunkwan University School of Medicine, Changwon-si, Gyeongsangnam-do, South Korea.
| | - Min-Gew Choi
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
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15
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Minimally invasive total adventitial resection of the cardia for tumours of the oesophagogastric junction. Langenbecks Arch Surg 2021; 406:2273-2285. [PMID: 33904977 DOI: 10.1007/s00423-021-02174-0] [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: 10/13/2020] [Accepted: 04/11/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE A cohort study analysing phases and outcomes of the learning curve required to master minimally invasive total adventitial resection of the cardia. METHODS Data from 198 consecutive oesophagectomies performed by a single surgeon was collected prospectively. Patients' stratification reflected chronologically and technically the four main phases of the learning curve: open surgery (open total adventitial resection of the cardia (TARC), n = 45), hybrid Ivor Lewis oesophagectomy (HILO, n = 50), laparoscopic-thoracoscopic assisted (LTA, n = 56) and totally minimally invasive TARC (TMI TARC, n = 47). Operating time, hospital stay, specimen lymph nodes and resection margins were analysed. Five-year survival was the main long-term outcome measured. RESULTS Overall 5-year survival was 45%. Perioperative mortality was 1.5% (n = 3). Hospital stay was 22 ± 23 days. Specimen lymph node median was 20 (range: 15-26). Resection margins were negative (R = 0, American College of Pathologists) in 193 cases (97.4%). Five-year survival in the four phases was 37.8%, 44.9%, 42.9% and 55.3%, showing a positive trend towards the end of the learning curve (p = 0.024). Median specimen lymph nodes was 20 (range: 15-22) for open TARC, 18.5 (13-25) for HILO, 19.5 (15-25) for LTA and 23 (18-30) for TMI TARC (p = 0.006). TMI TARC, adenocarcinoma, R >0, T >2, N >0 and LyRa (ratio positive/total specimen nodes) were associated with survival on univariate analysis. T >2 and LyRa independently predicted worse survival on multivariate analysis. CUSUM analysis showed surgical proficiency gain since laparoscopy was introduced. CONCLUSION Mastering minimally invasive TARC requires a long learning curve. TMI TARC is safe and oncologically appropriate and may benefit long-term survival: it should be validated by randomised trials as a standardised anatomical resection for tumours of the oesophagogastric junction.
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16
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Takahashi C, Shridhar R, Huston J, Blinn P, Maramara T, Meredith K. Comparative outcomes of transthoracic versus transhiatal esophagectomy. Surgery 2021; 170:263-270. [PMID: 33894983 DOI: 10.1016/j.surg.2021.02.036] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 02/09/2021] [Accepted: 02/11/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Surgical resection has become a mainstay of therapy for locally advanced esophageal cancer and can increase survival significantly. With the advancement of minimally invasive surgery, there is still debate on the best approach for esophagectomy. We report a modern analysis of outcomes with transthoracic versus transhiatal esophagectomy. METHODS A prospectively managed esophagectomy database was queried for patients undergoing transthoracic or transhiatal esophagectomy between 1996 and 2016. Continuous variables were compared using the Kruskal-Wallis or the analysis of variance tests as appropriate. Pearson χ2 test was used to compare categorical variables. All statistical tests were 2-sided and an α (type I) error < .05 was considered statistically significant. RESULTS A total of 846 patients underwent esophagectomy with a median age of 66 (28-86) years. There was no difference in estimated blood loss for transthoracic and transhiatal, but mean operating room times were longer for transthoracic versus transhiatal (P < .001), and the number of retrieved lymph nodes was higher for transthoracic versus transhiatal (P < .002). Postoperative complications occurred in 207 (29%) transthoracic patients vs 59 (44.7%) transhiatal patients, (P < .001). The most common complications in transthoracic versus transhiatal techniques, respectively, were anastomotic leaks: 4.3% vs 9.8%; (P = .01), anastomotic stricture 7% vs 26.5%; (P < .001), and pneumonia 12.6% vs 22.7%; (P < .002). Median survival significantly improved in patients undergoing transthoracic (62 months) vs transhiatal (39 months) P = .03. CONCLUSION We found that a transthoracic approach was associated with lower pneumonias, anastomotic leaks, wound infections, and strictures, with an improvement in nodal harvest. Survival was also significantly improved in patients who underwent transthoracic esophagectomy.
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Affiliation(s)
| | | | - Jamie Huston
- Sarasota Memorial Institute for Cancer Care, Sarasota, FL
| | - Paige Blinn
- Sarasota Memorial Institute for Cancer Care, Florida State University College of Medicine, Sarasota, FL
| | - Taylor Maramara
- Sarasota Memorial Institute for Cancer Care, Florida State University College of Medicine, Sarasota, FL
| | - Kenneth Meredith
- Sarasota Memorial Institute for Cancer Care, Florida State University College of Medicine, Sarasota, FL.
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Ma J, Wang W, Zhang B, Li X, Wu J, Wu Z. Minimally invasive esophagectomy via Sweet approach in combination with cervical mediastinoscopy is a valuable approach for surgical treatment of esophageal cancer. ZHONG NAN DA XUE XUE BAO. YI XUE BAN = JOURNAL OF CENTRAL SOUTH UNIVERSITY. MEDICAL SCIENCES 2021; 46:60-68. [PMID: 33678638 PMCID: PMC10878293 DOI: 10.11817/j.issn.1672-7347.2021.190568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Indexed: 11/03/2022]
Abstract
OBJECTIVES To compare the short-, mid-, and long-term outcomes in patients with esophageal cancer between minimally invasive esophagectomy via Sweet approach in combination with cervical mediastinoscopy (MIE-SM) and minimally invasive esophagectomy via McKeown approach (MIE-MC), and to evaluate the value of MIE-SM in the surgical treatment of esophageal cancer. METHODS A prospective, nonrandomized study was adopted. A total of 65 esophageal cancer patients after MIE-SM and MIE-MC from June 2014 to May 2016 were included. Among them, 33 patients underwent MIE-SM and 32 patients underwent MIE-MC. Short-term outcomes (including the duration of surgery, intraoperative blood loss volume, ICU stay time, postoperative complications, postoperative hospital stay, reoperation, open surgery, number of dissected lymph nodes, and 30-day mortality), mid-term outcomes, [including Quality of Life Core Questionnaire (QLQ-C30) and the esophageal site-specific module (QLQ-OES18)], long-term outcomes [including overall survival and disease-free survival] were compared between the 2 groups. RESULTS Radical resection (R0) were achieved in all patients. There were no significant differences in the duration of surgery, intraoperative blood loss volume, ICU stay time, postoperative complications, and postoperative hospital stay between the 2 groups (all P>0.05). More lymph nodes were dissected in the MIE-SM group (24.1±7.3) than those in the MIE-MC group (17.8±5.0, P<0.001). The emotional function, global health status scale scores in QLQ-C30 scale in the MIE-SM group were significantly higher than those in the MIE-MC group (P=0.025, P<0.001, respectively), and the pain score in the MIE-SM group was significantly lower than that in the MIE-MC group (P=0.013). QLQ-OES18 results showed that the pain score in the MIE-SM group was significantly lower than that in the MIE-MC group (P=0.021). Survival analysis showed that the overall survival and disease-free survival were similar between the 2 groups. CONCLUSIONS MIE-SM appears to be a safe surgical approach, which may get better quality of life, suffer less pain, and can achieve the same therapeutic effect as MIE-MC. Therefore, MIE-SM should be considered as a valuable approach for the treatment of middle and lower esophageal cancer.
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Affiliation(s)
- Junliang Ma
- Second Department of Thoracic Surgery, Hunan Cancer Hospital & Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha 410013.
- Department of Thoracic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi Guizhou 563003, China.
| | - Wenxiang Wang
- Second Department of Thoracic Surgery, Hunan Cancer Hospital & Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha 410013.
| | - Baihua Zhang
- Second Department of Thoracic Surgery, Hunan Cancer Hospital & Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha 410013
| | - Xu Li
- Second Department of Thoracic Surgery, Hunan Cancer Hospital & Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha 410013
| | - Jie Wu
- Second Department of Thoracic Surgery, Hunan Cancer Hospital & Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha 410013
| | - Zhining Wu
- Second Department of Thoracic Surgery, Hunan Cancer Hospital & Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha 410013
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Pang W, Liu G, Zhang Y, Huang Y, Yuan X, Zhao Z, Zhang C. Total laparoscopic transabdominal-transdiaphragmatic approach for treating Siewert II tumors: a prospective analysis of a case series. World J Surg Oncol 2021; 19:26. [PMID: 33485350 PMCID: PMC7827998 DOI: 10.1186/s12957-021-02136-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 01/14/2021] [Indexed: 01/19/2023] Open
Abstract
Background Although the morbidity of gastric cancer has decreased, the incidence of adenocarcinoma of the esophagogastric junction (AEG) is increasing. Furthermore, no consensus exists on which surgical approach should be applied for Siewert type II AEG. The purpose of our study was to evaluate the technical safety and feasibility of a new surgical approach. Methods Sixty patients with Siewert type II AEG underwent laparoscopic total gastrectomy with the total laparoscopic transabdominal-transdiaphragmatic (TLTT) approach, which needs an incision in the diaphragm. Results The median operative time, reconstruction time, and estimated blood loss were 214.8 ± 41.6 min, 29.40 ± 7.1 min, and 209.0 ± 110.3 ml, respectively. All of the patients had negative surgical margins. Conclusion There were no intraoperative complications or conversions to open surgery. Our surgical procedure provides a unique option for the safe application of laparoscopic lower mediastinal lymph node dissection and gastrointestinal reconstruction. Trial registration Chinese Clinical Trial Registry, ChiCTR1800014336. Registered on 31 December 2017 - Prospectively registered, http://www.chictr.org.cn/edit.aspx?pid=23111&htm=4. Supplementary Information The online version contains supplementary material available at 10.1186/s12957-021-02136-2.
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Affiliation(s)
- Wei Pang
- Department of General Surgery, The Sixth Medical Center of PLA General Hospital, Beijing, 100048, China.,Department of General Surgery, Xinan Hospital, The Third Military Medical University, Chongqing, 400037, China
| | - Gang Liu
- Department of General Surgery, The Sixth Medical Center of PLA General Hospital, Beijing, 100048, China
| | - Yan Zhang
- Department of General Surgery, The Sixth Medical Center of PLA General Hospital, Beijing, 100048, China
| | - Yun Huang
- Department of General Surgery, The Sixth Medical Center of PLA General Hospital, Beijing, 100048, China
| | - Xinpu Yuan
- Department of General Surgery, The Sixth Medical Center of PLA General Hospital, Beijing, 100048, China
| | - Zhanwei Zhao
- Department of General Surgery, The Sixth Medical Center of PLA General Hospital, Beijing, 100048, China.
| | - Chaojun Zhang
- Department of General Surgery, The Sixth Medical Center of PLA General Hospital, Beijing, 100048, China.
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19
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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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20
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A 10-year ACS-NSQIP Analysis of Trends in Esophagectomy Practices. J Surg Res 2020; 256:103-111. [DOI: 10.1016/j.jss.2020.06.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 05/29/2020] [Accepted: 06/16/2020] [Indexed: 02/06/2023]
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21
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Broderick RC, Horgan S, Fuchs HF. Robotic transhiatal esophagectomy. Dis Esophagus 2020; 33:5836482. [PMID: 32399553 DOI: 10.1093/dote/doaa037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 04/11/2020] [Accepted: 04/17/2020] [Indexed: 12/11/2022]
Abstract
Horgan et al. described the first robotic-assisted transhiatal esophagectomy in 2003. Although there is debate regarding the oncologic appropriateness of transhiatal versus thoracic approach to esophagectomy in malignancy, comparative data are still lacking. This paper with video describes step by step how and when to perform a transhiatal robotic-assisted resection in patients with esophageal cancer.
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Affiliation(s)
- Ryan C Broderick
- Department of Surgery, Division of Minimally Invasive Surgery, University of California San Diego, San Diego, CA, USA
| | - Santiago Horgan
- Department of Surgery, Division of Minimally Invasive Surgery, University of California San Diego, San Diego, CA, USA
| | - Hans F Fuchs
- Department of Surgery, University of Cologne, Köln, Germany
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22
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Adenocarcinoma of the Gastroesophageal Junction with Synchronous Renal Cell Carcinoma: A Case Report and Literature Review. ACTA MEDICA BULGARICA 2020. [DOI: 10.2478/amb-2020-0028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Abstract
Gastroesophageal junction adenocarcinoma is a rare type of cancer of the esophagus. It is usually diagnosed in advanced stages and much less frequently in the earlier stage, where surgical treatment is essential. Surgical treatment is also essential in kidney cancer. The occurrence of synchronous malignancies with an esophageal malignancy is a well-described phenomenon with an incidence ranging from 3.6 to 27.1%. To the best of our knowledge, only 11 cases of synchronous esophageal and renal cell carcinoma (RCC) have been previously described. We present a patient operated simultaneously for cancer of the gastroesophageal junction with synchronous renal cell carcinoma. The finding in the kidney was accidentally discovered by the routine CT scan on the occasion of the relatively early carcinoma of the gastroesophageal junction detected by upper endoscopy. The patient was admitted to the Thoracic Surgery Department, where Ivor-Lewis gastroesophagoplasty and right nephrectomy simultaneously were performed. The patient was followed for 5 years without evidence of disease progression.
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23
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It's not always too late: a case for minimally invasive salvage esophagectomy. Surg Endosc 2020; 35:4700-4711. [PMID: 32940794 DOI: 10.1007/s00464-020-07937-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 08/25/2020] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Standard of care for locally advanced esophageal carcinoma is neoadjuvant chemoradiation (nCRT) and surgical resection 4-8 weeks after completion of nCRT. It is recommended that the CRT to surgery interval not exceed 90 days. Many patients do not undergo surgery within this timeframe due to patient/physician preference, complete clinical response, or poor performance status. Select patients are offered salvage esophagectomy (SE), defined in two ways: resection for recurrent/persistent disease after complete response to definitive CRT (dCRT) or esophagectomy performed > 90 days after completion of nCRT. Salvage esophagectomy reportedly has higher postoperative morbidity and poor survival outcomes. In this study, we assessed outcomes, overall, and disease-free survival of patients undergoing salvage esophagectomy by both definitions (recurrent/persistent disease after dCRT and/or > 90 days), compared to planned (resection after nCRT/within 90 days) esophagectomy (PE). MATERIALS AND METHODS Retrospective review of a prospectively maintained database identified patients who underwent minimally invasive esophagectomy at a single institution from 2009 to 2019. Esophagectomy for benign disease and patients who did not receive nCRT were excluded. Outcomes included postoperative complications, length of stay (LOS), disease-free survival, and overall survival. RESULTS 97 patients underwent minimally invasive esophageal resection for esophageal carcinoma. 89.7% of patients were male. Mean age was 64.9 years (range 36-85 years). 94.8% of patients had adenocarcinoma, with 16 transthoracic and 81 transhiatal approaches. On comparing planned esophagectomy (n = 87) to esophagectomy after dCRT failure (n = 10), no significant differences were identified in overall survival (p = 0.73), disease-free survival (p = 0.32), 30-day or major complication rate, anastomotic leak, or LOS. Similarly, when comparing esophagectomy < 90 days after CRT (n = 62) to > 90 days after CRT completion (n = 35), no significant differences were identified in overall survival (p = 0.39), disease-free survival (p = 0.71), 30-day or major complication rate, LOS, or anastomotic leak rate between groups. In this comparison, local recurrence was noted to be elevated with SE as compared to PE (64.3% vs. 25.0%, p = 0.04). CONCLUSION Overall survival and disease-free survival were equivalent between SE and PE. Local recurrence was noted to be increased with SE, though this did not appear to affect survival. Although planned esophagectomy remains the standard of care, salvage esophagectomy has comparable outcomes and is appropriate for selected patients.
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Ashok A, Niyogi D, Ranganathan P, Tandon S, Bhaskar M, Karimundackal G, Jiwnani S, Shetmahajan M, Pramesh CS. The enhanced recovery after surgery (ERAS) protocol to promote recovery following esophageal cancer resection. Surg Today 2020; 50:323-334. [PMID: 32048046 PMCID: PMC7098920 DOI: 10.1007/s00595-020-01956-1] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 11/29/2019] [Indexed: 02/07/2023]
Abstract
Esophageal cancer surgery, comprising esophagectomy with radical lymphadenectomy, is a complex procedure associated with considerable morbidity and
mortality. The enhanced recovery after surgery (ERAS) protocol which aims to improve perioperative care, minimize complications, and accelerate recovery is showing promise for achieving better perioperative outcomes. ERAS is a multimodal approach that has been reported to shorten the length of hospital stay, reduce surgical stress response, decrease morbidity, and expedite recovery. While ERAS components straddle preoperative, intraoperative, and postoperative periods, they need to be seen in continuum and not as isolated elements. In this review, we elaborate on the components of an ERAS protocol after esophagectomy including preoperative nutrition, prehabilitation, counselling, smoking and alcohol cessation, cardiopulmonary evaluation, surgical technique, anaesthetic management, intra- and postoperative fluid management and pain relief, mobilization and physiotherapy, enteral and oral feeding, removal of drains, and several other components. We also share our own institutional protocol for ERAS following esophageal resections.
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Affiliation(s)
- Apurva Ashok
- Division of Thoracic Surgery, Department of Surgical Oncology, Tata Memorial Centre, Tata Memorial Hospital, Homi Bhabha National Institute, Parel, Mumbai, 400012, India
| | - Devayani Niyogi
- Division of Thoracic Surgery, Department of Surgical Oncology, Tata Memorial Centre, Tata Memorial Hospital, Homi Bhabha National Institute, Parel, Mumbai, 400012, India
| | - Priya Ranganathan
- Division of Thoracic Surgery, Department of Anesthesiology, Critical Care and Pain, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Sandeep Tandon
- Division of Thoracic Surgery, Department of Pulmonary Medicine, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Maheema Bhaskar
- Division of Thoracic Surgery, Department of Pulmonary Medicine, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - George Karimundackal
- Division of Thoracic Surgery, Department of Surgical Oncology, Tata Memorial Centre, Tata Memorial Hospital, Homi Bhabha National Institute, Parel, Mumbai, 400012, India
| | - Sabita Jiwnani
- Division of Thoracic Surgery, Department of Surgical Oncology, Tata Memorial Centre, Tata Memorial Hospital, Homi Bhabha National Institute, Parel, Mumbai, 400012, India
| | - Madhavi Shetmahajan
- Division of Thoracic Surgery, Department of Anesthesiology, Critical Care and Pain, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - C S Pramesh
- Division of Thoracic Surgery, Department of Surgical Oncology, Tata Memorial Centre, Tata Memorial Hospital, Homi Bhabha National Institute, Parel, Mumbai, 400012, India.
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Reichert M, Schistek M, Uhle F, Koch C, Bodner J, Hecker M, Hörbelt R, Grau V, Padberg W, Weigand MA, Hecker A. Ivor Lewis esophagectomy patients are particularly vulnerable to respiratory impairment - a comparison to major lung resection. Sci Rep 2019; 9:11856. [PMID: 31413282 PMCID: PMC6694108 DOI: 10.1038/s41598-019-48234-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 07/29/2019] [Indexed: 12/15/2022] Open
Abstract
Pulmonary complications and a poor clinical outcome are common in response to transthoracic esophagectomy, but their etiology is not well understood. Clinical observation suggests that patients undergoing pulmonary resection, a surgical intervention with similarities to the thoracic part of esophagectomy, fare much better, but this has not been investigated in detail. A retrospective single-center analysis of 181 consecutive patients after right-sided thoracotomy for either Ivor Lewis esophagectomy (n = 83) or major pulmonary resection (n = 98) was performed. An oxygenation index <300 mm Hg was used to indicate respiratory impairment. When starting surgery, respiratory impairment was seen more frequently in patients undergoing major pulmonary resection compared to esophagectomy patients (p = 0.009). On postoperative days one to ten, however, esophagectomy caused higher rates of respiratory impairment (p < 0.05) resulting in a higher cumulative incidence of postoperative respiratory impairment for patients after esophagectomy (p < 0.001). Accordingly, esophagectomy patients were characterized by longer ventilation times (p < 0.0001), intensive care unit and total postoperative hospital stays (both p < 0.0001). In conclusion, the postoperative clinical course including respiratory impairment after Ivor Lewis esophagectomy is significantly worse than that after major pulmonary resection. A detailed investigation of the underlying causes is required to improve the outcome of esophagectomy.
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Affiliation(s)
- Martin Reichert
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital of Giessen, Rudolf-Buchheim Strasse 7, D-35392, Giessen, Germany.
| | - Magdalena Schistek
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital of Giessen, Rudolf-Buchheim Strasse 7, D-35392, Giessen, Germany
| | - Florian Uhle
- Department of Anesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 110, D-69120, Heidelberg, Germany
| | - Christian Koch
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital of Giessen, Rudolf-Buchheim Strasse 7, D-35392, Giessen, Germany
| | - Johannes Bodner
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital of Giessen, Rudolf-Buchheim Strasse 7, D-35392, Giessen, Germany.,Department of Thoracic Surgery, München Klinik Bogenhausen, Englschalkinger Strasse 77, D-81925, Munich, Germany
| | - Matthias Hecker
- Department of Pulmonary and Critical Care Medicine, University of Giessen and Marburg Lung Center (UGMLC), University Hospital of Giessen, Klinikstrasse 33, D-35392, Giessen, Germany
| | - Rüdiger Hörbelt
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital of Giessen, Rudolf-Buchheim Strasse 7, D-35392, Giessen, Germany
| | - Veronika Grau
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital of Giessen, Rudolf-Buchheim Strasse 7, D-35392, Giessen, Germany.,Laboratory of Experimental Surgery, German Centre for Lung Research (DZL), Justus-Liebig-University Giessen, Feulgenstrasse 10-12, D-35392, Giessen, Germany
| | - Winfried Padberg
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital of Giessen, Rudolf-Buchheim Strasse 7, D-35392, Giessen, Germany
| | - Markus A Weigand
- Department of Anesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 110, D-69120, Heidelberg, Germany
| | - Andreas Hecker
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital of Giessen, Rudolf-Buchheim Strasse 7, D-35392, Giessen, Germany
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26
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Clemente-Gutiérrez U, Medina-Franco H, Santes O, Morales-Maza J, Alfaro-Goldaracena A, Heslin MJ. Open surgical treatment for esophageal cancer: transhiatal vs. transthoracic, does it really matter? J Gastrointest Oncol 2019; 10:783-788. [PMID: 31392059 DOI: 10.21037/jgo.2019.03.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Uriel Clemente-Gutiérrez
- Department of Surgery, National Institute of Medical Sciences and Nutrition Salvador Zubiran, Mexico City, México
| | - Heriberto Medina-Franco
- Department of Surgery, National Institute of Medical Sciences and Nutrition Salvador Zubiran, Mexico City, México
| | - Oscar Santes
- Department of Surgery, National Institute of Medical Sciences and Nutrition Salvador Zubiran, Mexico City, México
| | - Jesús Morales-Maza
- Department of Surgery, National Institute of Medical Sciences and Nutrition Salvador Zubiran, Mexico City, México
| | - Alejandro Alfaro-Goldaracena
- Department of Surgery, National Institute of Medical Sciences and Nutrition Salvador Zubiran, Mexico City, México
| | - Martin J Heslin
- Department of Surgery, Division of Surgical Oncology, The University of Alabama at Birmingham, Birmingham, AL, USA
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27
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Bruna Esteban M, Ortíz Escandell MÁ, Parilla Paricio P. Cancer of the esophagogastric junction: A border in continuous movement. Cir Esp 2019; 97:425-426. [PMID: 31164216 DOI: 10.1016/j.ciresp.2019.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 03/03/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Marcos Bruna Esteban
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario y Politécnico La Fe, Valencia, España.
| | | | - Pascual Parilla Paricio
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario Virgen de la Arrixaca, Murcia, España
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28
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Reddavid R, Strignano P, Sofia S, Evangelista A, Deiro G, Cannata G, Chiaro P, Maiello F, Mineccia M, Ferrero A, Leli R, Gentilli S, Polastri R, Borghi F, Camandona M, Romagnoli R, Morino M, Degiuli M. Transhiatal distal esophagectomy for Siewert type II cardia cancer can be a treatment option in selected patients. Eur J Surg Oncol 2019; 45:1943-1949. [PMID: 31005469 DOI: 10.1016/j.ejso.2019.04.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 12/28/2018] [Accepted: 04/01/2019] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND While surgical treatment of Siewert I and III (S1,S3) Esophagogastric Junction (EGJ) cancer is codified, the efficay of transhiatal procedure with anastomosis in the lower mediastinum for Siewert II (S2) still remains a dibated topic. METHODS This is a large multicenter retrospective study. The results of 598 consecutive patients submitted to resection with curative intent from January 2000 to January 2017 were reported. Clinical and oncological outcomes of different procedures performed in S2 tumor were analyzed to investigate the efficacy of transhiatal approach. RESULTS The 5-year overall survival rate (OS) was poor (32%) for all Siewert types. The most performed operations in S2 cancer were proximal gastrectomy + transthoracic esophagectomy (TTE or Ivor-Lewis procedure, 60%), total gastrectomy + transhiatal distal esophagectomy with anastomosis in the chest (THE, 24%) and total gastrectomy + transthoracic esophagectomy (TGTTE, 15%). Cardiovascular and pulmonary complications were higher after TTE. On the contrary, surgical complications were significantly higher after THE. Postoperative mortality was similar. The distribution of TNM stages was different in the 3 types of procedures: patients submitted to THE had an earlier stage disease. With this bias, OS after THE was higher than after TTE but the difference was not significant (49.85% vs 28.42%, p = 0.0587). CONCLUSIONS Despite a higher rate of postoperative surgical complications, OS after total gastrectomy and transhiatal distal esophagectomy was at least comparable to that of transthoracic approach in less advanced S2 tumors. Therefore, THE with anastomosis in the chest could be a treatmen option in earlier S2 tumors.
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Affiliation(s)
- Rossella Reddavid
- University of Turin. Department of Oncology, Surgical Oncology and Digestive Surgery Unit, San Luigi University Hospital (S.L.U.H.), Regione Gonzole 10, 10049, Orbassano, Turin, Italy
| | - Paolo Strignano
- University of Turin, Department os Surgical Sciences, Unit of General Surgery 2U, Ospedale Molinette, AOU Città della Salute e della Scienza di Torino, Corso Bramante 88, 10126, Turin, Italy
| | - Silvia Sofia
- University of Turin. Department of Oncology, Surgical Oncology and Digestive Surgery Unit, San Luigi University Hospital (S.L.U.H.), Regione Gonzole 10, 10049, Orbassano, Turin, Italy
| | - Andrea Evangelista
- Unit of Clinical Epidemiology, AOU Città della Salute e della Scienza di Torino and Centro di Riferimento per l'Epidemiologia e la Prevenzione Oncologica in Piemonte (CPO), Corso Bramante 88, 10126, Turin, Italy
| | - Giacomo Deiro
- University of Eastern Piedmont, Department of Health Sciences, General Surgery Unit Ospedale Maggiore della Carita, Corso Mazzini 18, 28100, Novara, Italy
| | - Gaspare Cannata
- Unit of General and Oncological Surgery, Department of Surgery, ASO SS Croce e Carle, V Coppino 26, 12100, Cuneo, Italy
| | - Paolo Chiaro
- Unit of General Surgery, Ospedale S Giovanni Bosco, Piazza del Donatore di Sangue 3, 10154, Turin, Italy
| | - Fabio Maiello
- Department of General Surgery, Ospedale degli Infermi di Biella, Via dei Ponderanesi 2, 13900, Ponderano, Biella, Italy
| | - Michela Mineccia
- Department of General and Oncological Surgery, Ospedale Umberto I di Torino (Mauriziano), Corso Turati 62, 10128, Turin, Italy
| | - Alessandro Ferrero
- Department of General and Oncological Surgery, Ospedale Umberto I di Torino (Mauriziano), Corso Turati 62, 10128, Turin, Italy
| | - Renzo Leli
- Unit of General Surgery, Ospedale S Giovanni Bosco, Piazza del Donatore di Sangue 3, 10154, Turin, Italy
| | - Sergio Gentilli
- University of Eastern Piedmont, Department of Health Sciences, General Surgery Unit Ospedale Maggiore della Carita, Corso Mazzini 18, 28100, Novara, Italy
| | - Roberto Polastri
- Department of General Surgery, Ospedale degli Infermi di Biella, Via dei Ponderanesi 2, 13900, Ponderano, Biella, Italy
| | - Felice Borghi
- Unit of General and Oncological Surgery, Department of Surgery, ASO SS Croce e Carle, V Coppino 26, 12100, Cuneo, Italy
| | - Michele Camandona
- University of Turin, Department os Surgical Sciences, Unit of Digestive and Oncological Surgery 1U, Ospedale Molinette, AOU Città della Salute e della Scienza di Torino, Corso Bramante 88, 10126, Turin, Italy
| | - Renato Romagnoli
- University of Turin, Department os Surgical Sciences, Unit of General Surgery 2U, Ospedale Molinette, AOU Città della Salute e della Scienza di Torino, Corso Bramante 88, 10126, Turin, Italy
| | - Mario Morino
- University of Turin, Department os Surgical Sciences, Unit of Digestive and Oncological Surgery 1U, Ospedale Molinette, AOU Città della Salute e della Scienza di Torino, Corso Bramante 88, 10126, Turin, Italy
| | - Maurizio Degiuli
- University of Turin. Department of Oncology, Surgical Oncology and Digestive Surgery Unit, San Luigi University Hospital (S.L.U.H.), Regione Gonzole 10, 10049, Orbassano, Turin, Italy.
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29
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Takeuchi Y, Ebihara Y, Nakanishi Y, Asano T, Noji T, Kurashima Y, Murakami S, Nakamura T, Tsuchikawa T, Okamura K, Shichinohe T, Hirano S. Minimally invasive abdominal and left thoracic approach for esophagogastric junction adenocarcinoma with esophageal diverticulum: A case report. Asian J Endosc Surg 2019; 12:167-170. [PMID: 29888543 DOI: 10.1111/ases.12604] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 04/20/2018] [Accepted: 04/26/2018] [Indexed: 12/27/2022]
Abstract
Controversy remains regarding the optimal resection approach for Siewert type II adenocarcinoma of the esophagogastric junction (EGJ). Furthermore, an esophageal diverticulum, although rare, can complicate surgical procedures. Herein, we report a case of EGJ adenocarcinoma with an esophageal diverticulum that was treated using the minimally invasive abdominal and left thoracic approach (MALTA). A 72-year-old man, with EGJ adenocarcinoma and an epiphrenic diverticulum on esophagogastroduodenoscopy underwent endoscopic submucosal dissection. The pathological diagnosis of the specimen revealed invasion to the lymphatic vessels. Therefore, laparoscopic proximal gastrectomy and thoracoscopic lower esophagectomy with D1 lymph node dissection and double-tract reconstruction of the esophageal diverticulum were performed via MALTA. The patient was discharged without any postoperative morbidity. MALTA provides good visualization for the transection of the lower esophagus in cases of esophageal diverticulum. Moreover, MALTA for adenocarcinoma of the EGJ is technically feasible, even with the presence of a lower esophageal diverticulum.
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Affiliation(s)
- Yuta Takeuchi
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Yuma Ebihara
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Yoshitsugu Nakanishi
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Toshimichi Asano
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Takehiro Noji
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Yo Kurashima
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Soichi Murakami
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Toru Nakamura
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Takahiro Tsuchikawa
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Keisuke Okamura
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Toshiaki Shichinohe
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Satoshi Hirano
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Sapporo, Japan
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Mazer LM, Poultsides GA. What Is the Best Operation for Proximal Gastric Cancer and Distal Esophageal Cancer? Surg Clin North Am 2019; 99:457-469. [PMID: 31047035 DOI: 10.1016/j.suc.2019.02.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Cancer of the gastroesophageal junction (GEJ) is increasing in incidence, likely as a result of rising obesity and gastroesophageal reflux disease rates. The tumors that arise here share features of esophageal and gastric cancer, and are classified based on their location in relationship to the GEJ. The definition of the GEJ itself, as well as optimal resection strategy, extent of lymph node dissection, resection margin length, and reconstruction methods are still very much a subject of debate. This article summarizes the available evidence on this topic, and highlights specific areas for further research.
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Affiliation(s)
- Laura M Mazer
- Division of Minimally Invasive Surgery, Cedars-Sinai Medical Center, 8635 W. Third Street, West Medical Office Tower, Suite 795, Los Angeles, CA 90048, USA
| | - George A Poultsides
- Section of Surgical Oncology, Stanford University School of Medicine, Stanford University Hospital, 300 pasteur drive, H3680, Stanford, CA 94305, USA.
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Mir MR, Lashkari M, Ghalehtaki R, Mir A, Latif AH. Transhiatal versus Left Transthoracic Esophagectomy for Gastroesophageal Junction Cancer; The Impact of Surgical Approach on Postoperative Complications. Middle East J Dig Dis 2019; 11:104-109. [PMID: 31380007 PMCID: PMC6663288 DOI: 10.15171/mejdd.2018.135] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 03/11/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Esophagectomy is the mainstay of treatment for esophageal cancer. Although different surgical approaches have been described, choosing the most appropriate technique is still on debate. We compared the complications of transhiatal esophagectomy (THE) versus left transthoracic esophagectomy (LTE) among a group of Iranian patients with gastroesophageal junction cancer. METHODS This was a retrospective study between 2011 and 2013 on 40 patients with gastroesophageal cancer. 23 patients underwent THE and the others underwent LTE. 30-day postoperative mortality, complications, duration of hospital stay, and number of dissected lymph nodes were studied. RESULTS 37.5% of the patients had squamous cell carcinoma. No mortality was seen. Totally, 10 patients suffered from complications. Cardiac and pulmonary complications occurred in eight and six patients, respectively. No patients suffered from vocal cord injuries and anastomotic leakage. The mean duration of postoperative hospital stay was 11.82 ± 3.8 days, and the mean number of dissected lymph nodes was 8.2 ± 3.9. No significant difference was seen between the two groups (p > 0.05). CONCLUSION Choosing between the approaches for resection of gastroesophageal cancer may not impact the complications and mortality rates. We propose that LTE approach could be used safely in comparison with THE, and that selecting between THE and LTE may be based on the surgeon's preference and experience.
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Affiliation(s)
- Mohammad Reza Mir
- Department of Surgical Oncology, Cancer Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Marzieh Lashkari
- Radiation Oncology Research Center, Cancer Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Ghalehtaki
- Radiation Oncology Research Center, Cancer Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Mir
- Department of General Surgery, Dr. Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Hossein Latif
- Department of General Surgery, Dr. Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Yang ZF, Wu DQ, Wang JJ, Feng XY, Zheng JB, Hu WX, Li Y. Surgical approach for Siewert type II adenocarcinoma of the esophagogastric junction: transthoracic or transabdominal? -a single-center retrospective study. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:450. [PMID: 30603638 DOI: 10.21037/atm.2018.10.66] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background The surgical approach (transthoracic or transabdominal) for patients with Siewert type II adenocarcinoma of the esophagogastric junction (AEG) still remains controversial. Methods Data of patients with Siewert type II AEG were collected in the Guangdong General Hospital from 2004 to 2014 and we compared their clinicopathological outcome and prognosis in regard to the transthoracic (TT) and transabdominal (TA) approach. Results A total of 158 patients with Siewert type II AEG were analyzed and our results demonstrated that their overall medium survival was 52 months. Also, their 5-year overall survival rate was 39.1%, which was comparable between the TT and TA group (35.1% vs. 43.2%, P>0.05), while more lymph nodes were dissected in TA group (23.7±0.2 vs. 18.1±0.3, P<0.05), with less postoperative complications (14.3% vs. 28.4%, P<0.05) and shorten hospital stay (12±4 vs. 15±7 d, P<0.05). Conclusions For patients with Siewert type II AEG, the TA approach is more suitable to achieve an optimal extent of lymph node dissection, reduction in the incidence of complication, shorten hospital stay, and to promote the recovery.
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Affiliation(s)
- Zi-Feng Yang
- General Surgery Department, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - De-Qing Wu
- General Surgery Department, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Jun-Jiang Wang
- General Surgery Department, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Xing-Yu Feng
- General Surgery Department, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Jia-Bin Zheng
- General Surgery Department, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Wei-Xian Hu
- General Surgery Department, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Yong Li
- General Surgery Department, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
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Yura M, Takeuchi H, Fukuda K, Nakamura R, Suda K, Wada N, Kawakubo H, Kitagawa Y. High-risk group of upper and middle mediastinal lymph node metastasis in patients with esophagogastric junction carcinoma. Ann Gastroenterol Surg 2018; 2:419-427. [PMID: 30460345 PMCID: PMC6236104 DOI: 10.1002/ags3.12215] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 08/11/2018] [Accepted: 08/18/2018] [Indexed: 12/20/2022] Open
Abstract
AIM The aim of the present study was to clarify esophagogastric junction (EGJ) carcinoma patients who are at high risk of upper and middle mediastinal lymph node (MLN) metastasis. METHODS This was a retrospective study and included 110 consecutive patients with EGJ carcinoma who underwent R0/R1 resection at Keio University Hospital between January 2000 and December 2013. RESULTS Of the 110 patients, 18 (16.3%) had MLN metastasis, and the number increased to 23 (20.9%) when recurrence cases were added (adenocarcinoma, N = 11; squamous cell carcinoma, N = 12). Patients whose tumor epicenter was located above the EGJ had a significantly higher incidence of MLN metastasis/recurrence (18/51 [35.3%]) than those whose tumor epicenter was located below the EGJ (5/59 [8.5%]). The MLN metastasis/recurrence rate was particularly high when the distance from the EGJ to the proximal edge of the primary tumor was >3 cm for the upper and middle mediastinum (18.8%). Patients in a selected group (≥T2 and tumor epicenter located above the EGJ or below the EGJ with ≥3 cm esophageal invasion) showed 17.9% and 15.4% upper and middle MLN metastasis/recurrence rates, respectively. Therapeutic value of MLN dissection was relatively high (#105 + 106: 8.9, #110: 12.2). CONCLUSIONS Therapeutic value of MLN dissection to treat EGJ carcinomas was relatively high in patients with MLN metastasis. Our algorithm could select patients at high risk for MLN metastasis.
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Affiliation(s)
- Masahiro Yura
- Department of SurgeryKeio University School of MedicineTokyoJapan
| | - Hiroya Takeuchi
- Department of SurgeryHamamatsu University School of MedicineHamamatsu‐shiJapan
| | - Kazumasa Fukuda
- Department of SurgeryKeio University School of MedicineTokyoJapan
| | - Rieko Nakamura
- Department of SurgeryKeio University School of MedicineTokyoJapan
| | - Koichi Suda
- Department of SurgeryKeio University School of MedicineTokyoJapan
| | - Norihito Wada
- Department of SurgeryKeio University School of MedicineTokyoJapan
| | | | - Yuko Kitagawa
- Department of SurgeryKeio University School of MedicineTokyoJapan
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Potrc S, Ivanecz A, Krebs B, Marolt U, Iljevec B, Jagric T. Outcomes of the Surgical Treatment for Adenocarcinoma of the Cardia - Single Institution Experience. Radiol Oncol 2018. [PMID: 29520207 PMCID: PMC5839083 DOI: 10.1515/raon-2017-0039] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background Adenocarcinomas at the cardia are biologically aggressive tumors with poor long-term survival following curative resection. For resectable adenocarcinoma of the cardia, mostly esophagus extended total gastrectomy or esophagus extended proximal gastric resection is performed; however, the surgical approach, transhiatal or transthoracic, is still under discussion. Postoperative morbidity, mortality and long-term survival were analyzed to evaluate the potential differences in clinically relevant outcomes. Patients and methods Of altogether 844 gastrectomies performed between January 2000 and December 2016, 166 were done for the adenocarcinoma of the gastric cardia, which we analyzed with using the Cox proportional hazards model. Results 136 were esophagus extended total gastrectomy and 125 esophagus extended proximal gastric resection. A D2 lymphadenectomy was performed in 88.2%, splenectomy in 47.2%, and multivisceral resections in 12.4% of patients. R0 resection rate was 95.7%. The mean proximal resection margin on the esophagus was 42.45 mm. It was less than 21 mm in 9 patients. Overall morbidity regarding Clavien-Dindo classification (> 1) was altogether 28.6%. 15.5% were noted as surgical and 21.1% as medical complications. The 30-day mortality was 2.2%. The 5-year survival for R0 resections was 33.4%. Multivisceral resection, depth of tumor infiltration, nodal stage, and curability of the resection were identified as independent prognostic factors. Conclusions Transhiatal approach for resection of adenocarcinoma of the cardia is a safe procedure for patients with Siewert II and III regarding the postoperative morbidity and mortality; moreover, long-term survival is comparable to transthoracic approach. The complications associated with thoracoabdominal approach can therefore be avoided with no impact on the rate of local recurrence.
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Affiliation(s)
- Stojan Potrc
- Department of Abdominal Surgery, Surgical Clinic, University Medical Centre Maribor, Maribor, Slovenia
| | - Arpad Ivanecz
- Department of Abdominal Surgery, Surgical Clinic, University Medical Centre Maribor, Maribor, Slovenia
| | - Bojan Krebs
- Department of Abdominal Surgery, Surgical Clinic, University Medical Centre Maribor, Maribor, Slovenia
| | - Urska Marolt
- Department of Abdominal Surgery, Surgical Clinic, University Medical Centre Maribor, Maribor, Slovenia
| | - Bojan Iljevec
- Department of Abdominal Surgery, Surgical Clinic, University Medical Centre Maribor, Maribor, Slovenia
| | - Tomaz Jagric
- Department of Abdominal Surgery, Surgical Clinic, University Medical Centre Maribor, Maribor, Slovenia
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Kauppila JH, Johar A, Gossage JA, Davies AR, Zylstra J, Lagergren J, Lagergren P. Health-related quality of life after open transhiatal and transthoracic oesophagectomy for cancer. Br J Surg 2018; 105:230-236. [DOI: 10.1002/bjs.10745] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 09/11/2017] [Accepted: 10/02/2017] [Indexed: 01/07/2023]
Abstract
Abstract
Background
Transhiatal and transthoracic oesophagectomy in patients with oesophageal cancer have similar survival rates. Whether these approaches differ in health-related quality of life (HRQoL) is uncertain and was examined in this study.
Methods
Patients undergoing transhiatal or transthoracic surgery for lower-third oesophageal or gastro-oesophageal junctional cancer between 2011 and 2015 were selected from an institutional database. HRQoL outcomes were measured at 6 and 12 months after surgery using validated written questionnaires (European Organisation for Research and Treatment of Cancer QLQ-C30 and QLQ-OG25). Linear mixed models provided mean score differences (MSDs) with 95 per cent confidence intervals, adjusted for preoperative HRQoL, age, physical status (ASA fitness grade), tumour location, tumour stage, neoadjuvant therapy, adjuvant therapy and postoperative complications. MSD values of 10 or more were regarded as clinically relevant.
Results
Some 146 patients underwent transhiatal (86, 58·9 per cent) or transthoracic (60, 41·1 per cent) oesophagectomy. The HRQoL questionnaires were returned by 111 patients at 6 months and 74 at 12 months. At 6 months, transthoracic oesophagectomy was associated with worse role function (MSD –12, 95 per cent c.i. –23 to 0; P = 0·046). At 12 months, patients in the transthoracic group had more nausea and vomiting (MSD 11, 0 to 22; P = 0·045), dyspnoea (MSD 13, 1 to 25; P = 0·029) and constipation (MSD 20, 7 to 33; P = 0·003) than those in the transhiatal group.
Conclusion
Transhiatal oesophagectomy seems to offer better HRQoL than transthoracic oesophagectomy 6 and 12 months after surgery.
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Affiliation(s)
- J H Kauppila
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
- Cancer and Translational Medicine Research Unit, Medical Research Centre, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - A Johar
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - J A Gossage
- Division of Cancer Studies, King's College London, London, UK
- Department of Surgery, Guy's and St Thomas' Oesophago-Gastric Centre, London, UK
| | - A R Davies
- Division of Cancer Studies, King's College London, London, UK
- Department of Surgery, Guy's and St Thomas' Oesophago-Gastric Centre, London, UK
| | - J Zylstra
- Division of Cancer Studies, King's College London, London, UK
- Department of Surgery, Guy's and St Thomas' Oesophago-Gastric Centre, London, UK
| | - J Lagergren
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
- Division of Cancer Studies, King's College London, London, UK
- Department of Surgery, Guy's and St Thomas' Oesophago-Gastric Centre, London, UK
| | - P Lagergren
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
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Kauppila JH, Ringborg C, Johar A, Lagergren J, Lagergren P. Health-related quality of life after gastrectomy, esophagectomy, and combined esophagogastrectomy for gastroesophageal junction adenocarcinoma. Gastric Cancer 2018; 21:533-541. [PMID: 28852939 PMCID: PMC5906505 DOI: 10.1007/s10120-017-0761-2] [Citation(s) in RCA: 15] [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: 05/24/2017] [Accepted: 08/16/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND The postoperative health-related quality of life (HRQOL) outcomes in patients with gastroesophageal junction (GEJ) adenocarcinoma after gastrectomy and esophagectomy are unclear. The aim was to evaluate HRQOL outcomes 6 months after extended total gastrectomy, subtotal esophagectomy, and combined esophagogastrectomy. METHODS Patients who underwent surgery for GEJ adenocarcinoma of Siewert type 2 or 3 in 2001-2005 were identified from a nationwide Swedish prospective and population-based cohort. Three surgical strategies, i.e., gastrectomy, esophagectomy, or esophagogastrectomy, were analyzed in relationship to HRQOL measured at 6 months after surgery (main outcome). HRQOL was assessed using well-validated questionnaires for general (EORTC QLQ-C30) and esophageal cancer-specific (EORTC QLQ-OES18) symptoms. Mean score differences (MSD) and 95% confidence intervals (CI) were analyzed using ANCOVA and adjusted for age, sex, tumor stage, comorbidity, education level, hospital volume, and postoperative complications. MSDs > 10 were regarded as clinically relevant. RESULTS Among 176 patients with complete information on HRQOL and covariates, none of the MSDs for HRQOL among the three surgery groups were clinically and statistically significant. MSDs comparing esophagectomy and gastrectomy showed no major differences in global quality of life (MSD, +8, 95% CI, 0 to +16), physical function (MSD, +2, 95% CI, -5 to +9), pain (MSD, -3, 95% CI, -12 to +7), or reflux (MSD, +5, 95% CI, -4 to +14). Also, complication rates and 5-year survival rates were similar comparing esophagectomy and gastrectomy. CONCLUSIONS Extended total gastrectomy, subtotal esophagectomy, and combined esophagogastrectomy seemed to yield similar 6-month postoperative HRQOL outcomes for patients with GEJ adenocarcinoma.
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Affiliation(s)
- Joonas H. Kauppila
- 0000 0000 9241 5705grid.24381.3cUpper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, 17176 Stockholm, Sweden ,Cancer and Translational Medicine Research Unit, Medical Research Center Oulu, University of Oulu, Oulu University Hospital, Oulu, Finland
| | - Cecilia Ringborg
- 0000 0000 9241 5705grid.24381.3cSurgical Care Sciences, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, 17176 Stockholm, Sweden
| | - Asif Johar
- 0000 0000 9241 5705grid.24381.3cSurgical Care Sciences, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, 17176 Stockholm, Sweden
| | - Jesper Lagergren
- 0000 0000 9241 5705grid.24381.3cUpper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, 17176 Stockholm, Sweden ,grid.420545.2Division of Cancer Studies, King’s College London and Guy’s and St. Thomas’ NHS Foundation Trust, London, England, UK
| | - Pernilla Lagergren
- 0000 0000 9241 5705grid.24381.3cSurgical Care Sciences, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, 17176 Stockholm, Sweden
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Ilson DH, van Hillegersberg R. Management of Patients With Adenocarcinoma or Squamous Cancer of the Esophagus. Gastroenterology 2018; 154:437-451. [PMID: 29037469 DOI: 10.1053/j.gastro.2017.09.048] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 09/09/2017] [Accepted: 09/12/2017] [Indexed: 02/07/2023]
Abstract
Esophageal cancer is characterized by early and frequent metastasis. Surgery is the primary treatment for early-stage disease, whereas patients with patients with locally advanced disease receive perioperative chemotherapy or chemoradiotherapy. Squamous cancers can be treated with primary chemoradiotherapy without surgery, depending on their response to therapy and patient tolerance for subsequent surgery. Chemotherapy with a fluorinated pyrimidine and a platinum agent, followed by later treatment with taxanes and irinotecan, provides some benefit. Agents that inhibit the erb-b2 receptor tyrosine kinase 2 (ERBB2 or HER2), or vascular endothelial growth factor, including trastuzumab, ramucirumab, and apatinib, increase response and survival times. Esophageal adenocarcinomas have mutations in tumor protein p53 and mutations that activate receptor-associated tyrosine kinase, vascular endothelial growth factor, and cell cycle pathways, whereas esophageal squamous tumors have a distinct set of mutations. Esophageal cancers develop systems to evade anti-tumor immune responses, but studies are needed to determine how immune checkpoint modification contributes to esophageal tumor development.
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Affiliation(s)
- David H Ilson
- Memorial Sloan Kettering Cancer Center, New York, New York.
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Kauppila JH, Wahlin K, Lagergren J. Gastrectomy compared to oesophagectomy for Siewert II and III gastro-oesophageal junctional cancer in relation to resection margins, lymphadenectomy and survival. Sci Rep 2017; 7:17783. [PMID: 29259274 PMCID: PMC5736658 DOI: 10.1038/s41598-017-18005-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 12/05/2017] [Indexed: 02/06/2023] Open
Abstract
It is unclear whether gastrectomy or oesophagectomy offer better outcomes for gastro-oesophageal junction (GOJ) cancer. A total of 240 patients undergoing total gastrectomy (n = 85) or oesophagectomy (n = 155) for Siewert II-III GOJ adenocarcinoma were identified from a Swedish prospective population-based nationwide cohort. The surgical approaches were compared in relation to non-radical resection margins (main outcome) using multivariable logistic regression, providing odds ratios (ORs) and 95% confidence intervals (CIs), mean number of removed lymph nodes with standard deviation (SD) using ANCOVA, assessing mean differences and 95% CIs, and 5-year mortality using Cox regression estimating hazard ratios (HRs) and 95% CIs. The models were adjusted for age, sex, comorbidity, tumour stage, and surgeon volume. The non-radical resection rate was 15% for gastrectomy and 14% for oesophagectomy, and the adjusted OR was 1.61 (95% CI 0.68-3.83). The mean number of lymph nodes removed was 14.2 (SD ± 9.6) for gastrectomy and 14.2 (SD ± 10.4) for oesophagectomy, with adjusted mean difference of 2.4 (95% CI-0.2-5.0). The 5-year mortality was 76% following gastrectomy and 75% following oesophagectomy, with adjusted HR = 1.07 (95% CI 0.78-1.47). Gastrectomy and oesophagectomy for Siewert II or III GOJ cancer seem comparable regarding tumour-free resection margins, lymph nodes removal, and 5-year survival.
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Affiliation(s)
- Joonas H Kauppila
- Upper Gastrointestinal Surgery, Department of Molecular medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, 17176, Stockholm, Sweden. .,Cancer and Translational Medicine Research Unit, Medical Research Center Oulu, University of Oulu, Oulu University Hospital, Oulu, Finland.
| | - Karl Wahlin
- Upper Gastrointestinal Surgery, Department of Molecular medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, 17176, Stockholm, Sweden
| | - Jesper Lagergren
- Upper Gastrointestinal Surgery, Department of Molecular medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, 17176, Stockholm, Sweden.,Division of Cancer Studies, King's College London and Guy's and St Thomas' NHS Foundation Trust, London, England
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Minimally invasive esophagectomy via Sweet approach in combination with cervical mediastinoscopy for esophageal squamous cell carcinoma: a case series. INTERNATIONAL JOURNAL OF SURGERY-ONCOLOGY 2017; 2:e45. [PMID: 29302639 PMCID: PMC5732631 DOI: 10.1097/ij9.0000000000000045] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/19/2017] [Accepted: 09/01/2017] [Indexed: 02/06/2023]
Abstract
Objective: Minimally invasive esophagectomy (MIE) is increasingly used for the treatment of esophageal cancer. However, MIE via the Sweet approach has seldom been reported owing to the challenging procedure for a mediastinal lymph node. Thus, the approach of MIE via left-sided thoracoscopy coupled with video-assisted cervical mediastinoscopy (MIE-SM) was explored for eradicating the mediastinal lymph nodes and recurrent laryngeal nerve; the incidence of perioperative complications, mortality, and surgical radicality were analyzed. Materials and Methods: Thirty patients with esophageal carcinoma underwent MIE-SM between June 2014 and February 2016. The primary outcome was postoperative morbidity within 2 weeks postsurgery. The secondary outcome was surgical radicality, including the circumferential margins, and the number of lymph nodes dissected. Results: The MIE-SM was completed in all patients within 367.6±68.7 minutes. The incidences of postoperative morbidities including pulmonary complications, anastomotic leakage, chylothorax, or recurrent nerve injury were 43.3%. Conclusion: The MIE-SM was utilized for the first time to reduce the disadvantage of purely Sweet and McKeown approach, with favorable efficacy in the mediastinal and laryngeal recurrent nerve lymph node eradication. Thus, MIE-SM might be a promising alternative approach in treating esophageal cancer in selected patients.
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Transhiatal vs. Transthoracic Esophagectomy: A NSQIP Analysis of Postoperative Outcomes and Risk Factors for Morbidity. J Gastrointest Surg 2017; 21:1757-1763. [PMID: 28900830 DOI: 10.1007/s11605-017-3572-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 08/29/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Both transhiatal esophagectomy (THE) and transthoracic esophagectomy (TTE) are accepted procedures for esophageal resection. We aimed to compare postoperative outcomes between these procedures and identify risk factors for morbidity. METHODS A retrospective analysis was performed using the American College of Surgeons National Surgical Quality Improvement Program database. Adult patients who underwent THE or TTE between 2005 and 2014 were included. Postoperative morbidity, length of stay, and 30-day mortality were compared. Multivariable logistic regression was used to determine risk factors for complications, and likelihood ratio tests were used to assess whether the effect of each risk factor was different across THE and TTE. RESULTS A total of 4053 patients were included, 2362 (58.3%) underwent TTE and 1691 (41.7%) underwent THE. TTE was associated with higher incidences of postoperative pneumonia and bleeding requiring transfusion. THE had higher incidences of superficial wound infection, deep wound infection, urinary tract infection, and sepsis. There were no significant differences in occurrence of anastomotic leak (THE 7.6% vs. TTE 9.4%, p = 0.35) or 30-day mortality (THE 2.3% vs. TTE 2.5%, p = 0.63). Female gender, black race, hypertension, diabetes, chronic obstructive pulmonary disease, partially or fully dependent functional status, and an ASA score ≥ 3 were independently associated with postoperative complications. The impact of the risk factors on morbidity was similar across both procedures. CONCLUSIONS THE and TTE have similar incidence of anastomotic leak and 30-day mortality. The impact of gender, race, and patients' comorbidities on postoperative complications is similar across both types of esophagectomy.
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Abstract
Oesophageal cancer is the sixth most common cause of cancer-related death worldwide and is therefore a major global health challenge. The two major subtypes of oesophageal cancer are oesophageal squamous cell carcinoma (OSCC) and oesophageal adenocarcinoma (OAC), which are epidemiologically and biologically distinct. OSCC accounts for 90% of all cases of oesophageal cancer globally and is highly prevalent in the East, East Africa and South America. OAC is more common in developed countries than in developing countries. Preneoplastic lesions are identifiable for both OSCC and OAC; these are frequently amenable to endoscopic ablative therapies. Most patients with oesophageal cancer require extensive treatment, including chemotherapy, chemoradiotherapy and/or surgical resection. Patients with advanced or metastatic oesophageal cancer are treated with palliative chemotherapy; those who are human epidermal growth factor receptor 2 (HER2)-positive may also benefit from trastuzumab treatment. Immuno-oncology therapies have also shown promising early results in OSCC and OAC. In this Primer, we review state-of-the-art knowledge on the biology and treatment of oesophageal cancer, including screening, endoscopic ablative therapies and emerging molecular targets, and we discuss best practices in chemotherapy, chemoradiotherapy, surgery and the maintenance of patient quality of life.
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Affiliation(s)
- Elizabeth C. Smyth
- Department of Gastrointestinal Oncology, Royal Marsden Hospital, London & Sutton. United Kingdom
| | - Jesper Lagergren
- Division of Cancer Studies, King's College London, United Kingdom
- Upper Gastrointestinal Surgery, Department of Molecular medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, 17176 Stockholm, Sweden
| | | | - Florian Lordick
- University Cancer Center Leipzig, University Medicine Leipzig, Leipzig, Germany
| | - Manish A. Shah
- Sandra and Edward Meyer Cancer Center at Weill Cornell Medicine, New York-Presbyterian Hospital, New York. United States
| | - Pernilla Lagergren
- Surgical care science, Department of Molecular medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, 171 76 Stockholm, Sweden
| | - David Cunningham
- Department of Gastrointestinal Oncology, Royal Marsden Hospital, London & Sutton. United Kingdom
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Kauppila JH, Lagergren J. The surgical management of esophago-gastric junctional cancer. Surg Oncol 2016; 25:394-400. [PMID: 27916171 DOI: 10.1016/j.suronc.2016.09.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 09/04/2016] [Accepted: 09/13/2016] [Indexed: 12/14/2022]
Abstract
The best available surgical strategy in the treatment of resectable esophago-gastric junctional (EGJ) cancer is a controversial topic. In this review we evaluate the current literature and scientific evidence examining the surgical treatment of locally advanced EGJ cancer by comparing esophagectomy with gastrectomy, transhiatal with transthoracic esophagectomy, minimally invasive with open esophagectomy, and less extensive with more extensive lymphadenectomy. We also assess endoscopic procedures increasingly used for early EGJ cancer. The current evidence does not favor any of the techniques over the others in terms of oncological outcomes. Health-related quality of life may be better following gastrectomy compared to esophagectomy. Minimally invasive procedures might be less prone to surgical complications. Endoscopic techniques are safe and effective alternatives for early-stage EGJ cancer in the short term, but surgical treatment is the mainstay in fit patients due to the risk of lymph node metastasis. Any benefit of lymphadenectomy extending beyond local or regional nodes is uncertain. This review demonstrates the great need for well-designed clinical studies to improve the knowledge in how to optimize and standardize the surgical treatment of EGJ cancer.
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Affiliation(s)
- Joonas H Kauppila
- Department of Surgery and Medical Research Center Oulu, University of Oulu, P.O. Box 5000, 90014 Oulu, Finland; Oulu University Hospital, P.O. Box 21, 90029 Oulu, Finland; Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, 17176 Stockholm, Sweden.
| | - Jesper Lagergren
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, 17176 Stockholm, Sweden; Division of Cancer Studies, King's College London and Guy's and St Thomas' NHS Foundation Trust, London, England, UK
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Allaix ME, Long JM, Patti MG. Hybrid Ivor Lewis Esophagectomy for Esophageal Cancer. J Laparoendosc Adv Surg Tech A 2016; 26:763-767. [PMID: 27541591 DOI: 10.1089/lap.2016.29011.mea] [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: 12/21/2022] Open
Abstract
The last 25 years have witnessed a steady increase in the use of minimally invasive esophagectomy for the treatment of esophageal cancer. However, it is unclear which the optimal minimally invasive approach is: totally minimally invasive or hybrid (laparoscopic assisted or thoracoscopic assisted)? The current evidence from nonrandomized control trials suggests that hybrid laparoscopic-assisted esophagectomy couples the benefits of laparoscopy and the advantages of thoracotomy, leading to reduced surgical trauma without jeopardizing survival compared with open esophagectomy. Compromised blood supply and tension on the anastomosis are two of the main factors that lead to anastomotic leakage. Recent studies have shown that a side-to-side mechanical intrathoracic esophagogastric anastomosis is associated with low anastomotic complications. This article discusses surgical aspects and outcomes of hybrid laparoscopic-assisted esophagectomy for esophageal cancer.
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Affiliation(s)
- Marco E Allaix
- Department of Surgery, Center for Esophageal Diseases and Swallowing, University of North Carolina , Chapel Hill, North Carolina
| | - Jason M Long
- Department of Surgery, Center for Esophageal Diseases and Swallowing, University of North Carolina , Chapel Hill, North Carolina
| | - Marco G Patti
- Department of Surgery, Center for Esophageal Diseases and Swallowing, University of North Carolina , Chapel Hill, North Carolina
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Ryan CE, Paniccia A, Meguid RA, McCarter MD. Transthoracic Anastomotic Leak After Esophagectomy: Current Trends. Ann Surg Oncol 2016; 24:281-290. [PMID: 27406098 DOI: 10.1245/s10434-016-5417-7] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2016] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Leaks from intrathoracic esophagogastric anastomosis are thought to be associated with higher rates of morbidity and mortality than leaks from cervical anastomosis. We challenge this assumption and hypothesize that there is no significant difference in mortality based on the location of the esophagogastric anastomosis. METHODS A systematic literature search was conducted using PubMed and Embase databases on all studies published from January 2000 to June 2015, comparing transthoracic (TTE) and transhiatal (THE) esophagectomies. Studies using jejunal or colonic interposition were excluded. Outcomes analyzed were leak rate, leak-associated mortality, overall 30-day mortality, and overall morbidity. Meta-analyses were performed using Mantel-Haenszel statistical analyses on studies reporting leak rates of both approaches. Nominal data are presented as frequency and interquartile range (IQR); measures of the association between treatments and outcomes are presented as odds ratio (OR) with 95 % confidence interval. RESULTS Twenty-one studies (3 randomized controlled trials) were analyzed comprising of 7167 patients (54 % TTE). TTE approach yields a lower anastomotic leak rate (9.8 %; IQR 6.0-12.2 %) than THE (12 %; IQR 11.6-22.1 %; OR 0.56 [0.34-0.92]), without any significant difference in leak associated mortality (7.1 % TTE vs. 4.6 % THE: OR 1.83 [0.39-8.52]). There was no difference in overall 30-day mortality (3.9 % TTE vs. 4.3 % THE; OR 0.86 [0.66-1.13]) and morbidity (59.0 % TTE vs. 66.6 % THE; OR 0.76 [0.37-1.59]). DISCUSSION Based on meta-analysis, TTE is associated with a lower leak rate and does not result in higher morbidity or mortality than THE. The previously assumed higher rate of transthoracic anastomotic leak-associated mortality is overstated, thus supporting surgeon discretion and other factors to influence the choice of thoracic versus cervical anastomosis.
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Affiliation(s)
- Carrie E Ryan
- University of South Florida Morsani College of Medicine, Tampa, FL, USA.
| | - Alessandro Paniccia
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Aurora, CO, USA
| | - Robert A Meguid
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado, Aurora, CO, USA
| | - Martin D McCarter
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Aurora, CO, USA
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Transthoracically or transabdominally: how to approach adenocarcinoma of the distal esophagus and cardia. A meta-analysis. TUMORI JOURNAL 2016; 102:352-60. [PMID: 27230277 DOI: 10.5301/tj.5000517] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2016] [Indexed: 01/16/2023]
Abstract
Esophageal carcinoma is the eighth most frequent cancer worldwide and the sixth cancer-related cause of death. Here we propose a new meta-analysis to identify the most appropriate approach for resectable adenocarcinoma of the distal esophagus and cardia (Siewert 1-2). A systematic literature search was performed independently by 2 of the manuscript's authors using PubMed, EMBASE, Scopus and the Cochrane Library Central. The following criteria were set for inclusion in this meta-analysis: 1) studies comparing transthoracic esophagectomy and transhiatal esophagectomy for adenocarcinoma of the esophagus; 2) studies reporting at least 1 perioperative outcome; and 3) if more than 1 study was reported by the same institute, only the most recent or the highest quality study was included. A total of 6 articles dated between 1996 and 2012 fulfilled the selection criteria and were therefore included in this meta-analysis; this pool of articles consisted of 2 prospective and 4 retrospective studies. A statistically significant difference favoring the transthoracic procedure was noted regarding the number of retrieved lymph nodes, 5-year disease-free survival rate and 5-year overall survival rate (p = 0.001, p = 0.05 and p = 0.03, respectively). In conclusion, transthoracic esophagectomy for adenocarcinoma of the distal esophagus and esophagogastric junction (Siewert 1-2) appears to be superior to the transhiatal approach in terms of oncological outcomes.
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Feng F, Tian Y, Xu G, Liu S, Liu Z, Zheng G, Guo M, Lian X, Fan D, Zhang H. The length of proximal margin does not influence the prognosis of Siewert type II/III adenocarcinoma of esophagogastric junction after transhiatal curative gastrectomy. SPRINGERPLUS 2016; 5:588. [PMID: 27247885 PMCID: PMC4864759 DOI: 10.1186/s40064-016-2240-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Accepted: 04/27/2016] [Indexed: 12/13/2022]
Abstract
Background The optimal length of proximal margin for Siewert type II/III adenocarcinoma of the esophagogastric junction (AEJ) is still need to be clarified. The aim of the present study was to investigate the appropriate length of proximal margin for Siewert type II/III AEJ through transhiatal approach. Methods From September 2009 to December 2014, a total of 693 consecutive patients with Siewert type II/III AEJ were retrospectively analyzed. All patients received transhiatal R0 resection. The proximal margin length was measured immediately after resection. The prognostic value of proximal margin length on Siewert type II/III AEJ with transhiatal approach was analyzed. Results There were 404 cases of Siewert type II AEJ (58.3 %) and 289 cases of Siewert type III AEJ (41.7 %). Total gastrectomy was performed in 526 patients (75.9 %), and proximal gastrectomy was performed in 167 patients (24.1 %). The median length of the gross proximal margin was 2.4 (range 0.1–5.0) cm. Lymph node metastasis was the only independent prognostic predictor for Siewert type II AEJ. Tumor size and lymph node metastasis were independent prognostic predictors for Siewert type III AEJ. Conclusions For Siewert type II/III AEJ with esophageal invasion of 3 cm or less, proximal margin length does not influence the prognosis of patients after transhiatal curative gastrectomy.
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Affiliation(s)
- Fan Feng
- Department of Digestive Surgery, Xijing Hospital, Fourth Military Medical University, 127 West Changle Road, Xi'an, 710032 Shaanxi China
| | - Yangzi Tian
- Department of Dermatology, Xijing Hospital, Fourth Military Medical University, 127 West Changle Road, Xi'an, 710032 Shaanxi China
| | - Guanghui Xu
- Department of Digestive Surgery, Xijing Hospital, Fourth Military Medical University, 127 West Changle Road, Xi'an, 710032 Shaanxi China
| | - Shushang Liu
- Department of Digestive Surgery, Xijing Hospital, Fourth Military Medical University, 127 West Changle Road, Xi'an, 710032 Shaanxi China
| | - Zhen Liu
- Department of Digestive Surgery, Xijing Hospital, Fourth Military Medical University, 127 West Changle Road, Xi'an, 710032 Shaanxi China
| | - Gaozan Zheng
- Department of Digestive Surgery, Xijing Hospital, Fourth Military Medical University, 127 West Changle Road, Xi'an, 710032 Shaanxi China
| | - Man Guo
- Department of Digestive Surgery, Xijing Hospital, Fourth Military Medical University, 127 West Changle Road, Xi'an, 710032 Shaanxi China
| | - Xiao Lian
- Department of Digestive Surgery, Xijing Hospital, Fourth Military Medical University, 127 West Changle Road, Xi'an, 710032 Shaanxi China
| | - Daiming Fan
- Department of Digestive Surgery, Xijing Hospital, Fourth Military Medical University, 127 West Changle Road, Xi'an, 710032 Shaanxi China
| | - Hongwei Zhang
- Department of Digestive Surgery, Xijing Hospital, Fourth Military Medical University, 127 West Changle Road, Xi'an, 710032 Shaanxi China
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Optimal Extent of Lymph Node Dissection for Siewert Type II Esophagogastric Junction Adenocarcinoma. Ann Thorac Surg 2015; 100:263-9. [DOI: 10.1016/j.athoracsur.2015.02.075] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Revised: 02/19/2015] [Accepted: 02/26/2015] [Indexed: 12/13/2022]
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Orditura M, Galizia G, Lieto E, De Vita F, Ciardiello F. Treatment of esophagogastric junction carcinoma: An unsolved debate. World J Gastroenterol 2015; 21:4427-4431. [PMID: 25914451 PMCID: PMC4402289 DOI: 10.3748/wjg.v21.i15.4427] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Revised: 01/02/2015] [Accepted: 03/19/2015] [Indexed: 02/06/2023] Open
Abstract
The incidence of esophagogastric junction adenocarcinoma (AEG) is increasing worldwide. Barrett’s esophagus (BE) associated with dysplasia is the main risk factor for the development of cancer. Currently, screening programs to individuate and eradicate BE represent the best way to reduce AEG cancer. Several endoscopic approaches are here discussed. Surgical strategies for different types of AEG cancer are now fairly standardized, and multidisciplinary strategies using chemotherapy or chemoradiotherapy may improve the outcome of these patients. Here we briefly discuss the keypoints, main topics, and critical issues, according to accumulating evidence and taking into account our own experience.
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