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Faucher M, Dahan S, Morel B, de Guibert JM, Chow-Chine L, Gonzalez F, Bisbal M, Servan L, Sannini A, Tezier M, Tourret M, Cambon S, Pouliquen C, Mallet D, Nguyen Duong L, Ettori F, Mokart D. The Effect of Postoperative Sepsis on 1-Year Mortality and Cancer Recurrence Following Transhiatal Esophagectomy for Esophageal-Gastric Junction Adenocarcinomas: A Retrospective Observational Study. Cancers (Basel) 2025; 17:109. [PMID: 39796735 PMCID: PMC11719752 DOI: 10.3390/cancers17010109] [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: 12/02/2024] [Revised: 12/26/2024] [Accepted: 12/30/2024] [Indexed: 01/13/2025] Open
Abstract
INTRODUCTION Transhiatal esophagectomy (THE) is used for specific gastroesophageal junction adenocarcinomas. THE is a high-risk surgical procedure. We aimed to assess the impact of postoperative sepsis (sepsis or septic shock) on the 1-year mortality after THE and to determine the risk factors associated with these outcomes. Secondly, we aimed to assess the impact of postoperative sepsis and other risk factors on 1-year cancer recurrence. METHOD A retrospective, observational study was undertaken at the Paoli-Calmettes Institute, Marseille, from January 2012 to March 2022. RESULTS Of 118 patients, 24.6% (n = 29) presented with postoperative sepsis. Their 1-year mortality was 11% (n = 13), and their 1-year cancer recurrence was 23.7% (n = 28). In the multivariate analysis, independent factors for 1-year mortality were the following: postoperative sepsis (OR: 7.22 (1.11-47); p = 0.038), number of lymph nodes removed (OR: 0. 78 (0.64-0.95); p = 0.011), recurrence at one year (OR: 9.22 (1.66-51.1); p = 0.011), mediastinitis (OR: 17.7 (1.43-220); p = 0.025) and intraoperative driving pressure (OR: 1.77 (1.17-2.68); p = 0.015). For postoperative sepsis, independent factors were low-dose vasopressors (OR: 0.26; 95% CI: 0.07-0.95; p = 0.049), a cervical abscess (OR: 5.33; 95% CI: 1.5-18.9; p = 0.01), bacterial pneumonia (OR: 11.1; 95% CI: 2.99-41.0; p < 0.001) and a high SOFA score on day 1 (OR: 2.65; 95% CI: 1.36-5.19; p = 0.04). For 1-year cancer recurrence, independent factors were the number of lymph nodes removed (sHR: 0.87; 95% CI: 0.79-0.96; p = 0.005), pTNM stages of III or IV (sHR: 8.29; 95% CI: 2.71-25.32; p < 0.001) and postoperative sepsis (sHR: 6.54; 95% CI: 1.70-25.13; p = 0.005). CONCLUSIONS Our study indicates that after THE, postoperative sepsis influences survival and cancer recurrence. We identified the associated risk factors, suggesting an early diagnosis might decrease mortality and recurrence.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Djamel Mokart
- Department of Anesthesiology and Critical Care, Paoli-Calmettes Institute, 13009 Marseille, France; (M.F.); (S.D.); (B.M.); (J.M.d.G.); (L.C.-C.); (F.G.); (M.B.); (L.S.); (A.S.); (M.T.); (M.T.); (S.C.); (C.P.); (D.M.); (L.N.D.); (F.E.)
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Chobarporn T, Qureshi A, Hunter JG, Wood SG. Minimally Invasive Transhiatal Esophagectomy Using Antegrade Inversion Technique in Esophageal Cancer: 10-Year Experience from a Tertiary Care Center. J Laparoendosc Adv Surg Tech A 2024; 34:1119-1127. [PMID: 39441536 DOI: 10.1089/lap.2024.0297] [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] [Indexed: 10/25/2024] Open
Abstract
Background: Esophageal cancer surgery aims for curative intent but carries high complication rates. Transthoracic esophagectomy is the dominant approach, however, transhiatal esophagectomy (THE) offers selective advantages in certain clinical scenarios. Minimally invasive THE (MI-THE) is an evolving technique with limited data. Methods: This retrospective study reviewed 38 patients with esophageal cancer who underwent MI-THE using "Antegrade Inversion Technique" between 2013 and 2023 at a tertiary care center. Perioperative outcomes were analyzed. Data were presented as mean with standard deviation, median with interquartile range, and percentages. Results: Most patients (86.8%) had early-stage cancer. Median operative time was 375 minutes, hospital stay was 8 days, and intensive care unit stay was 3 days. All patients achieved a negative resection margin. Pleural effusion (57.9%) was the most common complication, followed by pneumothorax (31.6%) and surgical site infection (15.8%). Anastomotic leak rate was 13.2%. There was no mortality. Conclusions: MI-THE appears safe and feasible with encouraging perioperative outcomes, particularly for early-stage disease and high-risk patients. While potentially offering advantages over open THE, further research is needed to definitively establish its role compared to traditional approaches.
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Affiliation(s)
- Thitiporn Chobarporn
- Department of Surgery, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Alia Qureshi
- Division of Gastrointestinal and General Surgery, Department of Surgery, Faculty of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - John G Hunter
- Division of Gastrointestinal and General Surgery, Department of Surgery, Faculty of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Stephanie G Wood
- Division of Gastrointestinal and General Surgery, Department of Surgery, Faculty of Medicine, Oregon Health & Science University, Portland, Oregon, USA
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Oberoi M, Noor MS, Abdelfatah E. The Multidisciplinary Approach and Surgical Management of GE Junction Adenocarcinoma. Cancers (Basel) 2024; 16:288. [PMID: 38254779 PMCID: PMC10813924 DOI: 10.3390/cancers16020288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 12/28/2023] [Accepted: 01/05/2024] [Indexed: 01/24/2024] Open
Abstract
Gastroesophageal (GE) junction adenocarcinoma is an aggressive malignancy of growing incidence and is associated with public health issues such as obesity and GERD. Management has evolved over the last two decades to incorporate a multidisciplinary approach, including endoscopic intervention, neoadjuvant chemotherapy/chemoradiation, and minimally invasive or more limited surgical approaches. Surgical approaches include esophagectomy, total gastrectomy, and, more recently, proximal gastrectomy. This review analyzes the evidence for and applicability of these varied approaches in management, as well as areas of continued controversy and investigation.
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Affiliation(s)
| | | | - Eihab Abdelfatah
- Department of Surgery, NYU Langone Health, 120 Mineola Blvd., Suite 320h, Mineola, Long Island, NY 11501, USA; (M.O.); (M.S.N.)
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Dyas AR, Stuart CM, Bronsert MR, Schulick RD, McCarter MD, Meguid RA. Minimally invasive surgery is associated with decreased postoperative complications after esophagectomy. J Thorac Cardiovasc Surg 2022:S0022-5223(22)01269-7. [PMID: 36577613 DOI: 10.1016/j.jtcvs.2022.11.026] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 11/06/2022] [Accepted: 11/28/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Although some studies have compared esophagectomy outcomes by technique or approach, there is opportunity to strengthen our knowledge surrounding these outcomes. We aimed to perform a comprehensive comparison of esophagectomy postoperative complications. METHODS We retrospectively reviewed the American College of Surgeons National Surgical Quality Improvement Program database (2007-2018). Esophagectomies were identified using Current Procedural Terminology codes and grouped by operative technique (Ivor Lewis, transhiatal, McKeown) and surgical approach (minimally invasive vs open esophagectomy). Twelve postoperative complications were compared. Significant complications underwent risk adjustment using multivariate logistic regression. RESULTS Analysis was performed on 13,457 esophagectomies: 11,202 (83.2%) open and 2255 (16.8%) minimally invasive. There were 7611 (56.6%) Ivor Lewis, 3348 (24.9%) transhiatal, and 2498 (18.6%) McKeown procedures. There were significant differences among the surgical techniques in 6 of 12 risk-adjusted complications. When comparing the outcomes of minimally invasive techniques, there were only significant differences in 2 of 12 complications: overall morbidity (minimally invasive Ivor Lewis 30.5%, minimally invasive transhiatal 43.4%, minimally invasive McKeown 40.3%, P = .0009) and infections (minimally invasive Ivor Lewis 15.4%, minimally invasive transhiatal 26.0%, minimally invasive McKeown 25.3%, P = .0003). Patients who underwent minimally invasive surgery were less likely to have overall morbidity (odds ratio, 0.68; 95% confidence interval, 0.62-0.75), respiratory complications (odds ratio, 0.77; 95% confidence interval, 0.68-0.87), urinary tract infection (odds ratio, 0.61; 95% confidence interval, 0.43-0.88), renal complications (odds ratio, 0.52; 95% confidence interval, 0.34-0.81), bleeding complications (odds ratio, 0.36; 95% confidence interval, 0.30-0.43), and nonhome discharge (odds ratio, 0.54; 95% confidence interval, 0.45-0.64), and had shorter length of stay (9.7 vs 13.2 days, P < .0001). CONCLUSIONS Patients undergoing minimally invasive esophagectomy have lower rates of postoperative complications regardless of esophagectomy techniques. The minimally invasive approach was associated with reduced complication variance among 3 common esophagectomy techniques.
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Affiliation(s)
- Adam R Dyas
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colo; Surgical Outcomes and Applied Research, University of Colorado School of Medicine, Aurora, Colo.
| | - Christina M Stuart
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colo; Surgical Outcomes and Applied Research, University of Colorado School of Medicine, Aurora, Colo
| | - Michael R Bronsert
- Surgical Outcomes and Applied Research, University of Colorado School of Medicine, Aurora, Colo; Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, Colo
| | - Richard D Schulick
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colo; Surgical Outcomes and Applied Research, University of Colorado School of Medicine, Aurora, Colo
| | - Martin D McCarter
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colo; Surgical Outcomes and Applied Research, University of Colorado School of Medicine, Aurora, Colo
| | - Robert A Meguid
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colo; Surgical Outcomes and Applied Research, University of Colorado School of Medicine, Aurora, Colo; Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, Colo
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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 PMCID: PMC9640399 DOI: 10.1245/s10434-022-12349-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [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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Szakó L, Németh D, Farkas N, Kiss S, Dömötör RZ, Engh MA, Hegyi P, Eross B, Papp A. Network meta-analysis of randomized controlled trials on esophagectomies in esophageal cancer: The superiority of minimally invasive surgery. World J Gastroenterol 2022; 28:4201-4210. [PMID: 36157121 PMCID: PMC9403425 DOI: 10.3748/wjg.v28.i30.4201] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 04/26/2022] [Accepted: 07/16/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Previous meta-analyses, with many limitations, have described the beneficial nature of minimal invasive procedures. AIM To compare all modalities of esophagectomies to each other from the results of randomized controlled trials (RCTs) in a network meta-analysis (NMA). METHODS We conducted a systematic search of the MEDLINE, EMBASE, Reference Citation Analysis (https://www.referencecitationanalysis.com/) and CENTRAL databases to identify RCTs according to the following population, intervention, control, outcome (commonly known as PICO): P: Patients with resectable esophageal cancer; I/C: Transthoracic, transhiatal, minimally invasive (thoracolaparoscopic), hybrid, and robot-assisted esophagectomy; O: Survival, total adverse events, adverse events in subgroups, length of hospital stay, and blood loss. We used the Bayesian approach and the random effects model. We presented the geometry of the network, results with probabilistic statements, estimated intervention effects and their 95% confidence interval (CI), and the surface under the cumulative ranking curve to rank the interventions. RESULTS We included 11 studies in our analysis. We found a significant difference in postoperative pulmonary infection, which favored the minimally invasive intervention compared to transthoracic surgery (risk ratio 0.49; 95%CI: 0.23 to 0.99). The operation time was significantly shorter for the transhiatal approach compared to transthoracic surgery (mean difference -85 min; 95%CI: -150 to -29), hybrid intervention (mean difference -98 min; 95%CI: -190 to -9.4), minimally invasive technique (mean difference -130 min; 95%CI: -210 to -50), and robot-assisted esophagectomy (mean difference -150 min; 95%CI: -240 to -53). Other comparisons did not yield significant differences. CONCLUSION Based on our results, the implication of minimally invasive esophagectomy should be favored.
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Affiliation(s)
- Lajos Szakó
- Institute of Translational Medicine, University of Pécs, Medical School, Pécs 7624, Hungary
- János Szentágothai Research Centre, University of Pécs, Medical School, Pécs 7624, Hungary
| | - Dávid Németh
- Institute for Translational Medicine, University of Pécs, Medical School, Pécs 7624, Hungary
- Institute of Bioanalysis, University of Pécs, Medical School, Pécs 7624, Hungary
| | - Nelli Farkas
- Institute of Translational Medicine, University of Pécs, Medical School, Pécs 7624, Hungary
- Institute of Bioanalysis, University of Pécs, Medical School, Pécs 7624, Hungary
| | - Szabolcs Kiss
- Insittute of Translational Medicine, University of Pécs, Medical School, Pécs 7624, Hungary
- Doctoral School of Clinical Medicine, University of Szeged, Medical School, Szeged 6720, Hungary
| | - Réka Zsuzsa Dömötör
- Institute for Translational Medicine, University of Pécs, Medical School, Pécs 7624, Hungary
| | - Marie Anne Engh
- Institute of Translational Medicine, University of Pécs, Medical School, Pécs 7624, Hungary
| | - Péter Hegyi
- Institute of Translational Medicine, University of Pécs, Medical School, Pécs 7624, Hungary
- First Department of Medicine, University of Szeged, Medical School, Szeged 6725, Hungary
| | - Balint Eross
- Institute of Translational Medicine, University of Pecs, Medical School, Pecs 7624, Hungary
| | - András Papp
- Department of Surgery, Clinical Center, University of Pécs, Medical School, Pécs 7624, Hungary
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Ahmadinejad M, Hashemi M, Tabatabai A. A Comparative Study between the Postoperative Complications of Stripping Esophagectomy and Classic (Orringer's Technique) Esophagectomy. Surg J (N Y) 2022; 8:e34-e40. [PMID: 35128051 PMCID: PMC8807099 DOI: 10.1055/s-0041-1736666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 08/19/2021] [Indexed: 10/25/2022] Open
Abstract
Recent studies have suggested that morbidity and mortality rate of transhiatal esophagectomy is comparable to that of thoracotomy, calling the need for the modifications in the surgical procedures. Our methodology includes stripping of esophagus by nasogastric tube to reduce the manipulation of thoracic cavity and associated complications. We also present the comparison between the stripping and classic (Orringer's technique) esophagectomy. Patients presenting esophageal carcinoma from 2015 to 2017 were the target of this study. Patients undergoing esophagectomy were randomized to have classic or stripping esophagectomy. Operating time, manipulation time, blood losses during the surgery, duration of hospitalization, volume intake, hypotension time, arrhythmia, and transfusion were the recorded parameters. Complications, such as anastomotic leak, cardiac effects, and morbidity, were also studied. Seventy patients were referred for transhiatal esophagectomy for esophageal carcinoma at the Al Zahra Hospital. Mean ages of patients in the stripping and Orringer group were 64.00 ± 10.57 and 57.42 ± 12.20 years, respectively. Manipulation time, operating time, blood loss during the surgery, and transfusion were statistically significant variables between the two groups. Although volume intake and duration of hospitalization were not significantly different parameters, however, betterment in the outcomes was evident. Substantial decrease in overall complications via stripping method was obtained, hence can be suggested as an effective alternative, to remove the need of thoracotomy, for transhiatal esophagectomy.
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Affiliation(s)
- Mojtaba Ahmadinejad
- Department of General Surgery, Faculty of Medicine, Úlborz University of Medical Sciences, Karaj, Iran
| | - Mozaffar Hashemi
- Department of General Surgery, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Abbas Tabatabai
- Department of General Surgery, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
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Surgical Approaches to Oesophageal Carcinoma: Evolution and Evaluation. Indian J Surg 2021. [DOI: 10.1007/s12262-019-02057-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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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: 3.3] [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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10
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Holakouie-Naieni K, Mansournia MA, Doosti-Irani A, Rahimi-Foroushani A, Haddad P. Treatment-related complications in patients with esophageal cancer: A systematic review and network meta-analysis. Surgeon 2021; 19:37-48. [PMID: 32209308 DOI: 10.1016/j.surge.2020.01.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Accepted: 01/22/2020] [Indexed: 01/30/2023]
Abstract
BACKGROUND The aim of this review was to compare the available treatments of esophageal cancer, in terms of pulmonary, cardiovascular complications, anastomotic leakage, and esophagitis after treatment in patients with esophageal squamous cell carcinoma (SCC). METHODS Medline, Web of Science, Scopus, the Cochrane Library and Embase were searched. The randomized controlled trials (RCT) that had compared the treatment -related complications of treatments for esophageal SCC were included. We included 39 randomized control trials in a network meta-analysis. The Chi2-test was used to assess of heterogeneity. The loop-specific and design-by-treatment interaction methods were used for assessment of consistency assumption. The risk ratio with 95% confidence interval (CI) was used to report the effect-sizes in the network meta-analysis. RESULTS The pulmonary complication, cardiac complication, anastomotic leakage, and esophagitis were reported in 31, 11, 17, and 15 RCTs respectively. Video-assisted thoracoscopy + laparoscopy (VATS) was rank as the first and second treatment in terms of lower risk for pulmonary complication and anastomotic leakage. There was no statistically significant difference between treatments in terms of lower risk of cardiovascular complications. However, Surgery + Cisplatin + Fluorouracil (SCF) was ranked as better treatment. 3-dimensional conformal radiotherapy + Docetaxel + Cisplatin (3DCRTDC) was the best treatment in terms of lower risk for esophagitis. CONCLUSION According to the results of this study, it seems the risk of pulmonary, cardiovascular, anastomotic leakage and esophagitis complications for VATS, SCF, surgery + radiotherapy (SRT), and 3DCRTDC was lower than other treatments respectively in the networks.
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Affiliation(s)
- Kourosh Holakouie-Naieni
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Ali Mansournia
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Amin Doosti-Irani
- Department of Epidemiology, School of Public Health, Hamadan University of Medical Sciences, Hamadan, Iran; Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.
| | - Abbas Rahimi-Foroushani
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Peiman Haddad
- Radiation Oncology Research Center, Cancer Institute, Tehran University of Medical Sciences, Tehran, Iran
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11
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Nusrath S, Saxena AR, Raju KVVN, Patnaik S, Subramanyeshwar Rao T, Bollineni N. The Value of Lymphadenectomy Post-Neoadjuvant Therapy in Carcinoma Esophagus: a Review. Indian J Surg Oncol 2020; 11:538-548. [PMID: 33013140 DOI: 10.1007/s13193-020-01156-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 06/30/2020] [Indexed: 10/23/2022] Open
Abstract
Lymph nodal metastasis is one of the most important prognostic factors determining survival in patients with carcinoma esophagus. Radical esophagectomy, with the resection of surrounding lymph nodes, is considered the prime treatment of carcinoma esophagus. An extensive lymphadenectomy improves the accuracy of staging and betters locoregional control, but its effect on survival is still not apparent and carries the disadvantage of increased morbidity. The extent of lymphadenectomy during esophagectomy also remains debatable, with many studies revealing contradictory results, especially in the era of neoadjuvant therapy. The pattern of distribution and the number of nodal metastasis are modified by neoadjuvant therapy. The paper reviews the existing evidence to determine whether increased lymph node yield improves oncological outcomes in patients undergoing esophagectomy with particular attention to those patients receiving neoadjuvant therapy.
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Affiliation(s)
- Syed Nusrath
- Department of Surgical Oncology, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, India
| | - Ajesh Raj Saxena
- Department of Surgical Oncology, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, India
| | - K V V N Raju
- Department of Surgical Oncology, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, India
| | - Sujith Patnaik
- Department of Surgical Oncology, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, India
| | - T Subramanyeshwar Rao
- Department of Surgical Oncology, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, India
| | - Naren Bollineni
- Department of Surgical Oncology, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, India
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12
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Comparative Perioperative Outcomes by Esophagectomy Surgical Technique. J Gastrointest Surg 2020; 24:1261-1268. [PMID: 31197697 DOI: 10.1007/s11605-019-04269-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 05/10/2019] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Surgical resection is vital in the curative management of patients with esophageal cancer. However, a myriad of surgical procedures exists based on surgeon preference and training. We report on the perioperative outcomes based on esophagectomy surgical technique. METHODS A prospectively managed esophagectomy database was queried for patients undergoing esophagectomy from 1996 and 2016. Basic demographics, tumor characteristics, operative details, and post-operative outcomes were recorded and analyzed by comparison of transhiatal vs Ivor-lewis and minimally invasive (MIE) vs open procedures. RESULTS We identified 856 patients who underwent esophagectomy. Neoadjuvant therapy was administered in 543 patients (63.4%). There were 504 (58.8%) open esophagectomies and 302 (35.2%) MIE. There were 13 (1.5%) mortalities and this did not differ among techniques (p = 0.6). While there was no difference in overall complications between MIE and open, complications occurred less frequently in patients undergoing RAIL and MIE IVL compared to other techniques (p = 0.003). Pulmonary complications also occurred less frequently in RAIL and MIE IVL (p < 0.001). Anastomotic leaks were less common in patients who underwent IVL compared to trans-hiatal approaches (p = 0.03). MIE patients were more likely to receive neoadjuvant therapy (p = 0.001), have lower blood loss (p < 0.001), have longer operations (p < 0.001), and higher lymph node harvests (p < 0.001) compared to open patients. CONCLUSION Minimally invasive and robotic Ivor Lewis techniques demonstrated substantial benefits in post-operative complications. Oncologic outcomes similarly favor MIE IVL and RAIL.
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13
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Tseng J, Posner MC. For Gastroesophageal Junction Cancers, Does an "Esophageal" or "Gastric" Surgical Approach Offer Better Perioperative and Oncologic Outcomes? Ann Surg Oncol 2019; 27:511-517. [PMID: 31571057 DOI: 10.1245/s10434-019-07732-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND The optimal surgical approach to the resection of gastoesophageal junction cancer is unknown. A comprehensive literature search was conducted to further compare the esophageal and gastric approaches to gastroesophageal junction cancer. METHODS A systematic review of the literature from January 1990 to May 2018 was performed to determine whether an esophageal or gastric surgical approach offers better perioperative and oncologic outcomes. RESULTS A total of 179 abstracts were identified and after excluding publications for non-English language, primary focus on neoadjuvant and/or adjuvant treatment, lack of comparison of surgical approaches or not addressing morbidity, mortality, or survival-related outcomes, a total of 14 nonrandomized, comparative studies were reviewed in detail. CONCLUSIONS The proximal and distant extent of the tumor based on Siewert type classification greatly influences choice of operation. Overall survival rates and surgical outcomes are comparable, and surgical approach should be dictated by patient factors.
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14
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Lin Z, Chen W, Chen Y, Peng X, Yan S, He F, Fu R, Jiang Y, Hu Z. Achieving adequate lymph node dissection in treating esophageal squamous cell carcinomas by radical lymphadenectomy: Beyond the scope of numbers of harvested lymph nodes. Oncol Lett 2019; 18:1617-1630. [PMID: 31423229 PMCID: PMC6607061 DOI: 10.3892/ol.2019.10465] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Accepted: 04/15/2019] [Indexed: 12/26/2022] Open
Abstract
Previous studies have recommended harvesting a large number of lymph nodes (LNs) to improve the survival of patients with esophageal squamous cell carcinoma (ESCC). These studies or clinical guidelines focus on the total harvested LNs during lymphadenectomy; however, the extent of LN dissection (LND) required in patients with ESCCs remains controversial. The present study proposed a novel individualized adequate LND (ALND) strategy to compliment current guidelines to improve individualized therapeutic efficacy. For N0 cases, ALND was defined as an LN harvest of >55% of the LNs from nodal zones adjacent to the tumor location; and for N+ cases, ALND was defined as 8, 8, 8, 8 or 16 LNs dissected from the involved cervical, upper, middle, lower and celiac zones, respectively. Retrospective analysis of the ESCC cohort revealed that the ALND was associated with improved patient survival [hazard ratio (HR)=0.45 and 95% CI=0.30–0.66)]. Stratified analyses revealed that the protective role of ALND was prominent, with the exception of higher pN+ staged (pN2-3) cases (HR=0.52, 95% CI=0.23–1.18). Furthermore, ALND was associated with improved survival in local diseases (T1-3/N0-1; HR=0.50, 95% CI=0.30–0.84) and locally advanced diseases (T4/Nany or T1-3/N2-3; HR=0.32, 95% CI=0.15–0.68). These findings suggested that the proposed ALND strategy may effectively improve the survival of patients with ESCC.
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Affiliation(s)
- Zheng Lin
- Department of Epidemiology and Health Statistics, Fujian Provincial Key Laboratory of Environment Factors and Cancer, School of Public Health, Fujian Medical University, Fuzhou, Fujian 350108, P.R. China.,Key Laboratory of Ministry of Education for Gastrointestinal Cancer, Fujian Medical University, Fuzhou, Fujian 350108, P.R. China
| | - Weilin Chen
- Department of Radiation Oncology, Affiliated Zhangzhou Hospital of Fujian Medical University, Zhangzhou, Fujian 363000, P.R. China
| | - Yuanmei Chen
- Department of Thoracic Surgery, Fujian Provincial Cancer Hospital, Fuzhou, Fujian 350014, P.R. China
| | - Xiane Peng
- Department of Epidemiology and Health Statistics, Fujian Provincial Key Laboratory of Environment Factors and Cancer, School of Public Health, Fujian Medical University, Fuzhou, Fujian 350108, P.R. China.,Key Laboratory of Ministry of Education for Gastrointestinal Cancer, Fujian Medical University, Fuzhou, Fujian 350108, P.R. China
| | - Siyou Yan
- Department of Epidemiology and Health Statistics, Fujian Provincial Key Laboratory of Environment Factors and Cancer, School of Public Health, Fujian Medical University, Fuzhou, Fujian 350108, P.R. China
| | - Fei He
- Department of Epidemiology and Health Statistics, Fujian Provincial Key Laboratory of Environment Factors and Cancer, School of Public Health, Fujian Medical University, Fuzhou, Fujian 350108, P.R. China.,Key Laboratory of Ministry of Education for Gastrointestinal Cancer, Fujian Medical University, Fuzhou, Fujian 350108, P.R. China
| | - Rong Fu
- Department of Epidemiology and Health Statistics, Fujian Provincial Key Laboratory of Environment Factors and Cancer, School of Public Health, Fujian Medical University, Fuzhou, Fujian 350108, P.R. China
| | - Yixian Jiang
- Department of Epidemiology and Health Statistics, Fujian Provincial Key Laboratory of Environment Factors and Cancer, School of Public Health, Fujian Medical University, Fuzhou, Fujian 350108, P.R. China
| | - Zhijian Hu
- Department of Epidemiology and Health Statistics, Fujian Provincial Key Laboratory of Environment Factors and Cancer, School of Public Health, Fujian Medical University, Fuzhou, Fujian 350108, P.R. China.,Key Laboratory of Ministry of Education for Gastrointestinal Cancer, Fujian Medical University, Fuzhou, Fujian 350108, P.R. China
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15
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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: 1] [Impact Index Per Article: 0.2] [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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16
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Azari FS, Roses RE. Management of Early Stage Gastric and Gastroesophageal Junction Malignancies. Surg Clin North Am 2019; 99:439-456. [PMID: 31047034 DOI: 10.1016/j.suc.2019.02.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Esophageal and gastric carcinomas are prevalent malignancies worldwide. In contrast to the poor prognosis associated with advanced stages of disease, early stage disease has a favorable prognosis. Early stage gastric cancer (ESGC) is defined as cancer in which the depth of invasion is limited to the submucosal layer of the stomach on histologic examination, regardless of lymph node status. ESGC that meets standard or expanded criteria can be treated via endoscopic mucosal resection and endoscopic submucosal dissection. Similar indications for endoscopic interventions exist for gastroesophageal junction and esophageal malignancies."
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Affiliation(s)
- Feredun S Azari
- Department of Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, 4 Silverstein Pavilion, Philadelphia, PA 19104, USA
| | - Robert E Roses
- Department of Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, 4 Silverstein Pavilion, Philadelphia, PA 19104, USA.
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17
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Moaven O, Wang TN. Combined Modality Therapy for Management of Esophageal Cancer: Current Approach Based on Experiences from East and West. Surg Clin North Am 2019; 99:479-499. [PMID: 31047037 DOI: 10.1016/j.suc.2019.02.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Human evolutionary genetic divergence and distinctive environmental exposures have contributed to the development of clinicopathologic variations of esophageal cancer in Eastern and Western countries. Different treatment strategies have derived from the disparate regional experiences. Treatment strategy is more standardized in the West. Trimodality treatment with neoadjuvant chemoradiation followed by surgery is widely accepted as the standard treatment of locally advanced esophageal adenocarcinoma and esophageal squamous cell carcinoma. Trimodality treatment has not been adopted in many Eastern countries, and standard treatment is neoadjuvant chemotherapy. Several randomized trials are ongoing that may alter the standard management of esophageal cancer worldwide.
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Affiliation(s)
- Omeed Moaven
- Division of Surgical Oncology, Department of Surgery, Wake Forest University, Medical Center Boulevard, Winston-Salem, NC 27157, USA
| | - Thomas N Wang
- Division of Surgical Oncology, Department of Surgery, University of Alabama at Birmingham, BDB 609, 1808 7th Avenue South, Birmingham, AL 35294-3411, USA.
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18
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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: 0.3] [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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19
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Feltracco P, Bortolato A, Barbieri S, Michieletto E, Serra E, Ruol A, Merigliano S, Ori C. Perioperative benefit and outcome of thoracic epidural in esophageal surgery: a clinical review. Dis Esophagus 2018; 31:4683666. [PMID: 29211841 DOI: 10.1093/dote/dox135] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 10/26/2017] [Indexed: 12/11/2022]
Abstract
Surgery for esophageal cancer is a highly stressful and painful procedure, and a significant amount of analgesics may be required to eliminate perioperative pain and blunt the stress response to surgery. Proper management of postoperative pain has invariably been shown to reduce the incidence of postoperative complications and accelerate recovery. Neuraxial analgesic techniques after major thoracic and upper abdominal surgery have long been established to reduce respiratory, cardiovascular, metabolic, inflammatory, and neurohormonal complications.The aim of this review is to evaluate and discuss the relevant clinical benefits and outcome, as well as the possibilities and limits of thoracic epidural anesthesia/analgesia (TEA) in the setting of esophageal resections. A comprehensive search of original articles was conducted investigating relevant literature on MEDLINE, Cochrane reviews, Google Scholar, PubMed, and EMBASE from 1985 to July2017. The relationship between TEA and important endpoints such as the quality of postoperative pain control, postoperative respiratory complications, surgical stress-induced immunosuppression, the overall postoperative morbidity, length of hospital stay, and major outcomes has been explored and reported. TEA has proven to enable patients to mobilize faster, cooperate comfortably with respiratory physiotherapists and achieve satisfactory postoperative lung functions more rapidly. The superior analgesia provided by thoracic epidurals compared to that from parenteral opioids may decrease the incidence of ineffective cough, atelectasis and pulmonary infections, while the associated sympathetic block has been shown to enhance bowel blood flow, prevent reductions in gastric conduit perfusion, and reduce the duration of ileus. Epidural anesthesia/analgesia is still commonly used for major 'open' esophageal surgery, and the recognized advantages in this setting are soundly established, in particular as regards the early recovery from anesthesia, the quality of postoperative pain control, and the significantly shorter duration of postoperative mechanical ventilation. However, this technique requires specific technical skills for an optimal conduction and is not devoid of risks, complications, and failures.
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Affiliation(s)
- P Feltracco
- Departments of Medicine, UO Anesthesia and Intensive Care
| | - A Bortolato
- Departments of Medicine, UO Anesthesia and Intensive Care
| | - S Barbieri
- Departments of Medicine, UO Anesthesia and Intensive Care
| | - E Michieletto
- Departments of Medicine, UO Anesthesia and Intensive Care
| | - E Serra
- Departments of Medicine, UO Anesthesia and Intensive Care
| | - A Ruol
- Surgical, Oncological and Gastroenterological Sciences, School of Medicine, Clinica Chirurgica, University of Padova, Padova, Italy
| | - S Merigliano
- Surgical, Oncological and Gastroenterological Sciences, School of Medicine, Clinica Chirurgica, University of Padova, Padova, Italy
| | - C Ori
- Departments of Medicine, UO Anesthesia and Intensive Care
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20
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Markar SR, Noordman BJ, Mackenzie H, Findlay JM, Boshier PR, Ni M, Steyerberg EW, van der Gaast A, Hulshof MCCM, Maynard N, van Berge Henegouwen MI, Wijnhoven BPL, Reynolds JV, Van Lanschot JJB, Hanna GB. Multimodality treatment for esophageal adenocarcinoma: multi-center propensity-score matched study. Ann Oncol 2017; 28:519-527. [PMID: 28039180 PMCID: PMC5391716 DOI: 10.1093/annonc/mdw560] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background The primary aim of this study was to compare survival from neoadjuvant chemoradiotherapy plus surgery (NCRS) versus neoadjuvant chemotherapy plus surgery (NCS) for the treatment of esophageal or junctional adenocarcinoma. The secondary aims were to compare pathological effects, short-term mortality and morbidity, and to evaluate the effect of lymph node harvest upon survival in both treatment groups. Methods Data were collected from 10 European centers from 2001 to 2012. Six hundred and eight patients with stage II or III oesophageal or oesophago-gastric junctional adenocarcinoma were included; 301 in the NCRS group and 307 in the NCS group. Propensity score matching and Cox regression analyses were used to compensate for differences in baseline characteristics. Results NCRS resulted in significant pathological benefits with more ypT0 (26.7% versus 5%; P < 0.001), more ypN0 (63.3% versus 32.1%; P < 0.001), and reduced R1/2 resection margins (7.7% versus 21.8%; P < 0.001). Analysis of short-term outcomes showed no statistically significant differences in 30-day or 90-day mortality, but increased incidence of anastomotic leak (23.1% versus 6.8%; P < 0.001) in NCRS patients. There were no statistically significant differences between the groups in 3-year overall survival (57.9% versus 53.4%; Hazard Ratio (HR)= 0.89, 95%C.I. 0.67-1.17, P = 0.391) nor disease-free survival (52.9% versus 48.9%; HR = 0.90, 95%C.I. 0.69-1.18, P = 0.443). The pattern of recurrence was also similar (P = 0.660). There was a higher lymph node harvest in the NCS group (27 versus 14; P < 0.001), which was significantly associated with a lower recurrence rate and improved disease free survival within the NCS group. Conclusion The survival differences between NCRS and NCS maybe modest, if present at all, for the treatment of locally advanced esophageal or junctional adenocarcinoma. Future large-scale randomized trials must control and monitor indicators of the quality of surgery, as the extent of lymphadenectomy appears to influence prognosis in patients treated with NCS, from this large multi-center European study.
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Affiliation(s)
- S R Markar
- Department of Surgery & Cancer, Imperial College London, London, UK
| | - B J Noordman
- Department of Surgery, Erasmus MC-University Medical Centre, Rotterdam, Netherlands
| | - H Mackenzie
- Department of Surgery & Cancer, Imperial College London, London, UK
| | - J M Findlay
- Oxford Oesophagogastric Centre, Oxford University Hospitals, Oxford, UK
| | - P R Boshier
- Department of Surgery & Cancer, Imperial College London, London, UK
| | - M Ni
- Department of Surgery & Cancer, Imperial College London, London, UK
| | - E W Steyerberg
- Centre for Medical Decision Sciences, Department of Public Health
| | - A van der Gaast
- Department of Medical Oncology, Erasmus MC-University Medical Centre, Rotterdam
| | - M C C M Hulshof
- Department of Radiation Oncology, Academic Medical Centre, Amsterdam
| | - N Maynard
- Oxford Oesophagogastric Centre, Oxford University Hospitals, Oxford, UK
| | | | - B P L Wijnhoven
- Department of Surgery, Erasmus MC-University Medical Centre, Rotterdam, Netherlands
| | - J V Reynolds
- Department of Surgery, Trinity College Dublin and St James's Hospital, Dublin, Ireland
| | - J J B Van Lanschot
- Department of Surgery, Erasmus MC-University Medical Centre, Rotterdam, Netherlands
| | - G B Hanna
- Department of Surgery & Cancer, Imperial College London, London, UK
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21
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Are Thoracotomy and/or Intrathoracic Anastomosis Still Predictors of Postoperative Mortality After Esophageal Cancer Surgery?: A Nationwide Study. Ann Surg 2017; 266:854-862. [PMID: 28742697 DOI: 10.1097/sla.0000000000002401] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Intrathoracic (vs cervical) anastomosis and a thoracotomy (vs absence) have previously been associated with increasing postoperative mortality (POM). Recent improvements in surgical practices and perioperative management may have changed these dogmas. OBJECTIVES The aim of this study was to evaluate the impact of performing intrathoracic anastomosis and/or thoracotomy on POM after esophageal cancer surgery in recent years. METHODS All consecutive patients who underwent esophageal cancer surgery with reconstruction between 2010 and 2012 in France were included (n = 3286). Patients with a thoracoscopic approach were excluded (n = 4). We compared 30-day POM between patients having received intrathoracic (vs cervical) anastomosis and between those having received a thoracotomy or not. Multivariate analyses and propensity score matching were used to adjust for confounding factors. RESULTS Patients had either cervical (n = 548) or intrathoracic (n = 2738) anastomosis. Thirty-day POM was higher after cervical anastomosis (8.8% vs 4.9%, P < 0.001). Having received a thoracotomy (n = 3061) was associated with a decreased risk of 30-day POM (5.3% vs 9.3%, P = 0.011). After adjustment for confounding factors, cervical anastomosis was associated with 30-day POM [odds ratio (OR) 1.71; 95% confidence interval (CI) 1.05-2.77); P = 0.032], whereas performing a thoracotomy was not associated with 30-day POM (OR 0.97; 95% CI 0.51-1.84; P = 0.926). CONCLUSIONS Nowadays, intrathoracic anastomosis provides a lower 30-day POM rate compared to cervical anastomosis, and performing a thoracotomy is not associated with POM. Systematic anastomosis neck placement or thoracotomy avoidance is not a relevant argument anymore to decrease POM.
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22
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An Update on Randomized Clinical Trials in Gastric Cancer. Surg Oncol Clin N Am 2017; 26:621-645. [PMID: 28923222 DOI: 10.1016/j.soc.2017.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The optimal treatment of esophageal cancer is still being defined. The timing of surgical management and the application of chemotherapy and radiation in the neoadjuvant and adjuvant settings have been studied in several prospective, randomized, controlled trials. This article outlines some of the historical as well as updated research that has been published regarding the management of esophageal cancer.
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23
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Yan R, Dang C. Meta-analysis of Transhiatal Esophagectomy in carcinoma of esophagogastric junction, does it have an advantage? Int J Surg 2017; 42:183-190. [PMID: 28343029 DOI: 10.1016/j.ijsu.2017.03.052] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 02/25/2017] [Accepted: 03/17/2017] [Indexed: 01/11/2023]
Abstract
PURPOSE Compare the clinical outcome of Transhiatal Esophagectomy (THE) approach and open Thoracic Esophagectomy (TTE) approach in the carcinoma of esophagogastric junction (CEGJ). METHODS Relevant literature published until 2016 from PubMed, Cochrane Library, Ovid (Medline) and EMBASE were retrieved. Meta-analysis was achieved by using the Stata12 software. RESULTS A total of 18 studies and 2202 cases of patients were involved in this meta-analysis. THE showed to decrease the hospital stay, hospital mortality, surgical time, and blood loss in the operation. However, fewer lymph nodes would be yielded by this surgical option. A 5-year survival advantage of THE was only observed in North America subgroup. CONCLUSIONS Except the above operative related advantages, there was no clear evidence that THE has a further advantage in CEGJ.
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Affiliation(s)
- Rong Yan
- Department of Surgical Oncology, First Affiliated Hospital of Xi'an JiaoTong University, Xi'an, China
| | - Chengxue Dang
- Department of Surgical Oncology, First Affiliated Hospital of Xi'an JiaoTong University, Xi'an, China.
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24
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Noordman BJ, Wijnhoven BPL, van Lanschot JJB. Optimal surgical approach for esophageal cancer in the era of minimally invasive esophagectomy and neoadjuvant therapy. Dis Esophagus 2016; 29:773-779. [PMID: 26382935 DOI: 10.1111/dote.12407] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The optimal surgical technique for the potentially curative treatment of patients with esophageal cancer is still under debate. The transhiatal esophagectomy (THE) with limited lymphadenectomy mainly focuses on a decrease of postoperative morbidity and mortality by preventing a formal thoracotomy. The transthoracic esophagectomy (TTE) with extended two-field lymphadenectomy attempts to improve the radicality of the resection and thus to increase locoregional tumor control, but is associated with increased postoperative morbidity. The recent introduction of different minimally invasive techniques probably decreases postoperative morbidity following TTE, with reduction of especially pulmonary complications, but high-quality evidence is still limited. It is widely agreed that extended lymphadenectomy as performed during TTE provides the benefit of more accurate staging, but its effect on improvement of survival is still debated. The literature on this topic is contradictory and the choice of surgical approach is primarily driven by personal opinions and institutional preferences. Moreover, the available evidence is mainly based on patients who underwent surgery alone without neoadjuvant therapy. Results of recent studies suggest that neoadjuvant chemoradiotherapy abolishes any possibly positive effect of extended lymphadenectomy as performed during TTE on survival, but this effect should be confirmed in future research. This review gives an overview and reflects the authors' personal view on the role of TTE and THE in the treatment of potentially curative treatment of patients with locally advanced esophageal cancer in the era of minimally invasive esophagectomy and neoadjuvant treatment and outlines future research perspectives.
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Affiliation(s)
- B J Noordman
- Department of Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.
| | - B P L Wijnhoven
- Department of Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - J J B van Lanschot
- Department of Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
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25
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Abstract
Survival for esophageal cancer has improved over the past four decades, probably as a result of a combination of more accurate staging, improved surgical outcomes, advances in adjuvant and neoadjuvant therapies, and the increasing implementation of multimodality treatment. Surgical resection still remains the mainstay in the treatment of localized esophageal adenocarcinoma. Multiple techniques have been described for esophagectomy, which are based on either a transthoracic or transhiatal approach. Despite proponents of each technique touting potential advantages such as superior oncologic resection with more extensive transthoracic lymphadenectomy compared to the relatively limited morbidity and mortality with a transhiatal resection, the superiority of one technique over another is not clear and may be relegated to a topic of historical significance in the era of minimally invasive surgery. With the increased acceptance of neoadjuvant multimodality therapy, both approaches have been shown to have acceptable outcomes. And in the hands of experienced surgeons, both techniques can provide excellent short-term results. Moreover, surgeon and hospital volume have shown to be strongly associated with improved operative morbidity and oncologic outcomes, which may supersede the type of approach selected for an individual patient.
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Affiliation(s)
- Jukes P Namm
- 1 Department of Surgery, Loma Linda University Health , Loma Linda, California
| | - Mitchell C Posner
- 2 Department of Surgery, University of Chicago Medicine , Chicago, Illinois
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26
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B G V, Nag HH, Varshney V. Laparoscopic-Assisted Transhiatal Esophagectomy (LATE) for Carcinoma of the Esophagus. Indian J Surg 2016; 80:5-8. [PMID: 29581677 DOI: 10.1007/s12262-016-1537-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Accepted: 07/19/2016] [Indexed: 11/29/2022] Open
Abstract
Total laparoscopic approach for the management of carcinoma of the esophagus has not gained much popularity due to its complexity. The aim of this study was to evaluate safety, feasibility, and outcome of laparoscopic-assisted transhiatal esophagectomy (LATE) for patients with carcinoma of the esophagus. This retrospective study involves a total of 26 patients with carcinoma of the esophagus who were considered for LATE by a single surgical team from January 2010 to September 2014. The median (range) age was 55 years (35-72), and male to female ratio was 20:6. The median (range) operative time, blood loss, and hospital stay were 300 min (180-660), 300 ml (100-500), and 11.5 days (8-25), respectively. Pulmonary complications and cervical anastomotic leak (including one patient with conduit necrosis) occurred in eight (30.7 %) and three (11.5 %) patients, respectively. AJCC stage (7th ed.) was IIA in 12 (46.15 %), IIB in 10 (38.46 %), IIIA in 3 (11.53 %), and IIIB in 1 (3.84 %) patient. Surgical resection margin was negative in all but one patient (3.8 %). The median (range) number of lymph nodes (LN) retrieved was 13 (8-28). During a median follow-up 19 months (8-39), five patients (19.23 %) developed recurrence and three (11.5 %) of them died. LATE is a safe and feasible for the management of selected patients with carcinoma of the lower thoracic esophagus.
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Affiliation(s)
- Vageesh B G
- Department of G I Surgery, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research (GIPMER), Room No. 220, Academic Block, GIPMER, New Delhi, 110002 India
| | - Hirdaya H Nag
- Department of G I Surgery, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research (GIPMER), Room No. 220, Academic Block, GIPMER, New Delhi, 110002 India
| | - Vaibhav Varshney
- Department of G I Surgery, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research (GIPMER), Room No. 220, Academic Block, GIPMER, New Delhi, 110002 India
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27
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Lindner K, Fritz M, Haane C, Senninger N, Palmes D, Hummel R. Postoperative complications do not affect long-term outcome in esophageal cancer patients. World J Surg 2015; 38:2652-61. [PMID: 24867467 DOI: 10.1007/s00268-014-2590-3] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND As esophagectomy is associated with a considerable complication rate, the aim of this study was to assess the impact of postoperative complications and neoadjuvant treatment on long-term outcome of adenocarcinoma (EAC) and squamous cell carcinoma (SCC) patients. METHODS Altogether, 134 patients undergoing transthoracic esophagectomy between 2005 and 2010 with intrathoracic stapler anastomosis were included in the study. Postoperative complications were allocated into three main categories: overall complications, acute anastomotic insufficiency, and pulmonary complications. Data were collected prospectively and reviewed retrospectively for the purpose of this study. RESULTS SCC patients suffered significantly more often from overall and pulmonary complications (SCC vs. EAC: overall complications 67 vs. 45 %, p = 0.044; pulmonary complications 56 vs. 34 %, p = 0.049). The anastomotic insufficiency rates did not differ significantly (SCC 11%, EAC 15%, p = 0.69). Long-term survival of EAC and SCC patients was not affected by perioperative (overall/pulmonary) complications or by the occurrence of anastomotic insufficiency. Also, neoadjuvant treatment did not influence the incidence of complications or long-term survival. CONCLUSIONS This is the first time the patient population of a center experienced with esophageal cancer surgery was assessed for the occurrence of general and esophageal cancer surgery-specific perioperative complications. Our results indicated that these complications did not affect long-term survival of EAC and SCC patients. Our data support the hypothesis that neoadjuvant treatment might not affect the incidence of perioperative complications or long-term survival after treatment of these tumor subtypes.
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Affiliation(s)
- Kirsten Lindner
- Department of General and Visceral Surgery, Muenster University Hospital, Waldeyerstr. 1, 48149, Münster, Germany,
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28
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Abstract
Lymphadenectomy as an essential part of the surgical treatment has been one of the most controversial aspects in the management of esophageal cancers. The purpose of this article was to review the evolution, the current role, and the optimal extent of lymphadenectomy for the treatment of esophageal cancers. Studies discussing the outcome of esophagectomy with lymph nodes dissection and comparing among different extent of lymphadenectomy were used in the analysis. Several studies including recently published articles reveal that additional radical lymphadenectomy may be beneficial in some patients with non-extreme esophageal cancer undergoing esophagectomy, whereas two-field lymph node dissection is suitable for distal esophageal cancers regardless of the histology of the tumor. Minimally invasive surgery and neoadjuvant therapy combined with radical surgery seem to show more benefit in selected cases, but further studies should be required to clearly demonstrate their efficacy and safety. The expertise and experience of the surgeons should also be taken into account in determining the success of these radical procedures.
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Affiliation(s)
- P Hiranyatheb
- Department of Gastroenterological Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
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29
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Manson JM, Beasley WD. A personal perspective on controversies in the surgical management of oesophageal cancer. Ann R Coll Surg Engl 2014; 96:575-8. [PMID: 25350177 PMCID: PMC4474096 DOI: 10.1308/003588414x13946184901605] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2013] [Indexed: 11/22/2022] Open
Abstract
Significant disagreement and debate persist regarding several aspects of the optimal surgical management of oesophageal cancer. We address some of these issues based on our consecutive series of 165 patients undergoing oesophageal resection (reported in full elsewhere) and the available literature. The areas considered are controversial but we argue in favour of a 'traditional' two-stage open approach (Ivor-Lewis), leaving the pylorus alone, making no attempt to perform a radical lymphadenectomy and fashioning a hand sewn anastomosis.
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Affiliation(s)
- J McK Manson
- Abertawe Bro Morgannwg University Health Board, UK
| | - WD Beasley
- Abertawe Bro Morgannwg University Health Board, UK
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30
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Transthoracic approach is associated with increased incidence of atrial fibrillation after esophageal resection. Surg Endosc 2014; 29:2039-45. [DOI: 10.1007/s00464-014-3908-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Accepted: 09/07/2014] [Indexed: 12/14/2022]
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Markar SR, Schmidt H, Kunz S, Bodnar A, Hubka M, Low DE. Evolution of standardized clinical pathways: refining multidisciplinary care and process to improve outcomes of the surgical treatment of esophageal cancer. J Gastrointest Surg 2014; 18:1238-46. [PMID: 24777435 DOI: 10.1007/s11605-014-2520-6] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Accepted: 03/31/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND The aim of this study is to determine the effect of the implementation and evolution of a multidisciplinary esophagectomy care pathway on postoperative outcomes over a 20-year experience. STUDY DESIGN All patients undergoing esophagectomy for cancer between 1991 and 2012 were included. Patients were divided into four groups (Gp1 1991-1996, Gp2 1997-2002, Gp3 2003-2007, and Gp4 2008-2012). RESULTS Five hundred and ninety-five patients were included (Gp1 92, Gp2 159, Gp3 161, and Gp4 183). Age remained consistent over time; however, a progressive significant increase was observed in BMI and Charlson comorbidity index. Increases were also noted in patients with clinical stage III cancers, in the use of neoadjuvant chemoradiotherapy, in salvage esophagectomy and in the utilization of pretreatment jejunostomy. We observed a significant reduction in estimated blood loss (EBL) and operative room IV fluid administration (ORFA) during the study period. Median ICU stay and length of hospital stay (LOS) (10 (5-50) to 8 (5-115) days) decreased over time. In-hospital mortality (0.3 %) and postoperative complications remained consistent over time. cumulative sum (CUSUM) analysis showed that EBL, ORFA, and LOS all declined during the study period, reaching mean values at case 120, 310, and 175, respectively. CONCLUSIONS The results of this study show that process improvement within the pathway is likely more significant than the level of comorbidities, application of neoadjuvant chemoradiation, or technical approach in patients undergoing esophagectomy.
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Affiliation(s)
- Sheraz R Markar
- Department of Thoracic Surgery, Virginia Mason Medical Center, 1100 Ninth Ave, Seattle, WA, 98111, USA
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32
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Baba Y, Watanabe M, Yoshida N, Baba H. Neoadjuvant treatment for esophageal squamous cell carcinoma. World J Gastrointest Oncol 2014; 6:121-8. [PMID: 24834142 PMCID: PMC4021328 DOI: 10.4251/wjgo.v6.i5.121] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Revised: 02/25/2014] [Accepted: 04/17/2014] [Indexed: 02/05/2023] Open
Abstract
Squamous cell carcinoma and adenocarcinoma are types of esophageal cancer, one of the most aggressive malignant diseases. Since both histological types present entirely different diseases with different epidemiology, pathogenesis and tumor biology, separate therapeutic strategies should be developed against each type. While surgical resection remains the dominant therapeutic intervention for patients with operable esophageal squamous cell carcinoma (ESCC), alternative strategies are actively sought to reduce the frequency of post-operative local or distant disease recurrence. Such strategies are particularly sought in the preoperative setting. Currently, the optimal management of resectable ESCC differs widely between Western and Asian countries (such as Japan). While Western countries focus on neoadjuvant or definitive chemoradiotherapy, neoadjuvant chemotherapy followed by surgery is the standard treatment in Japan. Importantly, each country and region has established its own therapeutic strategy from the results of local randomized control trials. This review discusses the current knowledge, available data and information regarding neoadjuvant treatment for operable ESCC.
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33
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Ganesamoni S, Krishnamurthy A. Three-field transthoracic versus transhiatal esophagectomy in the management of carcinoma esophagus-a single--center experience with a review of literature. J Gastrointest Cancer 2014; 45:66-73. [PMID: 24272910 DOI: 10.1007/s12029-013-9562-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND The management of esophageal cancer continues to be riddled with controversies, even as more and more clinical trials are being conducted amid a remarkable change in histology and epidemiology. Significant variations exist in the surgical treatment of esophageal cancer, and there is no consensus on the best surgical approach or the extent of lymphadenectomy. Interestingly, extended esophagectomy (three-field lymphadenectomy) has not been compared with transhiatal esophagectomy in a head-to-head fashion. METHODS We did a retrospective comparison of 111 consecutive patients who underwent curative resection for carcinoma of the esophagus, via either a transthoracic esophagectomy with three-field dissection (3F TTE) or transhiatal esophagectomy ("THE") at a regional cancer center in South India over a period of 5 years from 2002 to 2006. The primary outcome measure was 5-year disease-free (DFS) and the overall survival (OS). An exhaustive analysis of the short-term outcomes was also made. RESULTS The 5-year overall survival and disease-free survival were 52 and 49% in the 3F TTE group and 37 and 37%, respectively, in the "THE" group, which were not statistically significant. The short and the long-term outcomes in both the groups compared favorably with the other published series. CONCLUSIONS Our study possibly for the first time compares 3F TTE and "THE" in the management of resectable carcinoma of the esophagus. Although the survival outcomes of both the groups were not statistically different, 3F TTE did show a trend towards improved DFS and OS when compared to "THE" group. However, this being a retrospective study, the results of this analysis need to be verified in an adequately sized prospective randomized study.
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Affiliation(s)
- Sivaram Ganesamoni
- Surgical Oncology Cancer Institute (WIA), 38, Sardar Patel Rd, Adyar, Chennai, 600020, India,
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34
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Davies AR, Sandhu H, Pillai A, Sinha P, Mattsson F, Forshaw MJ, Gossage JA, Lagergren J, Allum WH, Mason RC. Surgical resection strategy and the influence of radicality on outcomes in oesophageal cancer. Br J Surg 2014; 101:511-7. [PMID: 24615656 DOI: 10.1002/bjs.9456] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/14/2014] [Indexed: 01/08/2023]
Abstract
BACKGROUND The optimal surgical approach to tumours of the oesophagus and oesophagogastric junction remains controversial. The principal randomized trial comparing transhiatal (THO) and transthoracic (TTO) oesophagectomy showed no survival difference, but suggested that some subgroups of patients may benefit from the more extended lymphadenectomy typically conducted with TTO. METHODS This was a cohort study based on two prospectively created databases. Short- and long-term outcomes for patients undergoing THO and TTO were compared. The primary outcome measure was overall survival, with secondary outcomes including time to recurrence and patterns of disease relapse. A Cox proportional hazards model provided hazard ratios (HRs) and 95 per cent confidence intervals (c.i.), with adjustments for age, tumour stage, tumour grade, response to chemotherapy and lymphovascular invasion. RESULTS Of 664 included patients (263 THO, 401 TTO), the distributions of age, sex and histological subtype were similar between the groups. In-hospital mortality (1·1 versus 3·2 per cent for THO and TTO respectively; P = 0·110) and in-hospital stay (14 versus 17 days respectively; P < 0·001) favoured THO. In the adjusted model, there was no difference in overall survival (HR 1·07, 95 per cent c.i. 0·84 to 1·36) or time to tumour recurrence (HR 0·99, 0·76 to 1·29) between the two operations. Local tumour recurrence patterns were similar (22·8 versus 24·4 per cent for THO and TTO respectively). No subgroup could be identified of patients who had benefited from more radical surgery on the basis of tumour location or stage. CONCLUSION There was no difference in survival or tumour recurrence for TTO and THO.
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Affiliation(s)
- A R Davies
- Department of Surgery, St Thomas' Hospital, King's College London, London, UK; Department of Surgery, Royal Marsden Hospital, King's College London, London, UK; Gastrointestinal Cancer, Division of Cancer Studies, King's College London, London, UK; Unit of Upper Gastrointestinal Research, Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
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35
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Shah SV, Chheda YP, Pillai SK, Shah SV. Total oesophagectomy for squamous cell carcinoma with or without standard two field node dissection - a prospective study. Indian J Surg Oncol 2014; 4:336-40. [PMID: 24426753 DOI: 10.1007/s13193-013-0264-5] [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: 12/29/2012] [Accepted: 08/16/2013] [Indexed: 11/29/2022] Open
Abstract
Cancer of the esophagus and gastroesophageal junction (GEJ) is notorious for its advanced stage at the time of diagnosis with transmural invasion and early lymphatic spread in the majority of the patients. R0 resection is the aim of surgery with curative intent. Regarding the role of lymphadenectomy, as in any other solid organ cancer, there are opposing views. Some surgeons argue that the presence of lymph node involvement equals systemic disease and that survival remains unchanged despite removal of these lymph nodes. For others the presence of lymph node involvement, even at a distance from the primary tumor, justifies an aggressive approach with radical esophagectomy combined with lymphadenectomy. The purpose of this article is to compare standard two field lymph node dissection versus non formal lymph node dissection in carcinoma esophagus. The conclusions are based on the experience with 60 cases of carcinoma esophagus over 2 years. In our opinion total esophagectomy with 2-field lymphadenectomy is the standard surgery for resectable squamous cell carcinoma of esophagus. It improves the lymphnode yield thereby ensuring adequate staging of the disease. It can be performed with acceptable morbidity and mortality as the nonformal lymphadenectomy procedure. Locoregional recurrence following 2 field lymphadenectomy is significantly low as compared to nonformal lymphadenectomy procedure though the distant recurrence rate is same. 2 year disease free survival in this study shows advantage of 2 field lymphadenectomy compared to non formal lymphadenectomy procedure.
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Affiliation(s)
- Shishir V Shah
- Department of Surgical Oncology, Gujarat Cancer and Research Institute, Ahmedabad, India
| | | | | | - Shakuntala Viren Shah
- Department of Surgical Oncology, Gujarat Cancer and Research Institute, Ahmedabad, India
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36
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Update on clinical impact, documentation, and management of complications associated with esophagectomy. Thorac Surg Clin 2013; 23:535-50. [PMID: 24199703 DOI: 10.1016/j.thorsurg.2013.07.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The assessment and monitoring of complications associated with esophageal resection suffers from the absence of an internationally recognized system for documenting the incidence and severity of complications. The impact of complications is significant, with direct effects being identified on mortality, length of stay, postoperative quality of life, and long-term survival. Newer systems of assessing surgical complication severity and the resources required to treat complications include the Accordion and Clavien grading systems. New endoscopic and interventional approaches to treating anastomotic leak and stricture and chyle leak can selectively decrease length of stay and costs of managing complications.
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37
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Gibson MK, Dhaliwal AS, Clemons NJ, Phillips WA, Dvorak K, Tong D, Law S, Pirchi ED, Räsänen J, Krasna MJ, Parikh K, Krishnadath KK, Chen Y, Griffiths L, Colleypriest BJ, Farrant JM, Tosh D, Das KM, Bajpai M. Barrett's esophagus: cancer and molecular biology. Ann N Y Acad Sci 2013; 1300:296-314. [PMID: 24117650 DOI: 10.1111/nyas.12252] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The following paper on the molecular biology of Barrett's esophagus (BE) includes commentaries on signaling pathways central to the development of BE including Hh, NF-κB, and IL-6/STAT3; surgical approaches for esophagectomy and classification of lesions by appropriate therapy; the debate over the merits of minimally invasive esophagectomy versus open surgery; outcomes for patients with pharyngolaryngoesophagectomy; the applications of neoadjuvant chemotherapy and chemoradiotherapy; animal models examining the surgical models of BE and esophageal adenocarcinoma; the roles of various morphogens and Cdx2 in BE; and the use of in vitro BE models for chemoprevention studies.
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Affiliation(s)
- Michael K Gibson
- Department of Medicine and Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Arashinder S Dhaliwal
- Department of Medicine and Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Nicholas J Clemons
- Surgical Oncology Research Laboratory, Peter MacCallum Cancer Centre, East Melbourne, VIC, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia.,Department of Surgery, St. Vincent's Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - Wayne A Phillips
- Surgical Oncology Research Laboratory, Peter MacCallum Cancer Centre, East Melbourne, VIC, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia.,Department of Surgery, St. Vincent's Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - Katerina Dvorak
- Department of Cellular and Molecular Medicine, Arizona Cancer Center, University of Arizona Cancer Center, Tucson, Arizona
| | - Daniel Tong
- Division of Esophageal and Upper Gastrointestinal Surgery, Department of Surgery, The University of Hong Kong, Hong Kong
| | - Simon Law
- Division of Esophageal and Upper Gastrointestinal Surgery, Department of Surgery, The University of Hong Kong, Hong Kong
| | - E Daniel Pirchi
- Servicio de Cirugía, Hospital Britanico de Buenos Aires, Buenos Aires, Argentina
| | - Jari Räsänen
- Division of General Thoracic and Esophageal Surgery, Helsinki University Central Hospital, Helsinki, Finland
| | - Mark J Krasna
- Jersey Shore University Medical Center, Neptune, New Jersey
| | - Kaushal Parikh
- Department of Gastroenterology & Hepatology, and Centre for Experimental & Molecular Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Kausilia K Krishnadath
- Department of Gastroenterology & Hepatology, and Centre for Experimental & Molecular Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Yu Chen
- Department of Biology & Biochemistry, University of Bath, Bath, UK
| | | | | | - J Mark Farrant
- Department of Biology & Biochemistry, University of Bath, Bath, UK
| | - David Tosh
- Department of Biology & Biochemistry, University of Bath, Bath, UK
| | - Kiron M Das
- Department of Medicine, UMDNJ-RWJMS, New Brunswick, New Jersey
| | - Manisha Bajpai
- Department of Medicine, UMDNJ-RWJMS, New Brunswick, New Jersey
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38
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Shah DR, Martinez SR, Canter RJ, Yang AD, Bold RJ, Khatri VP. Comparative morbidity and mortality from cervical or thoracic esophageal anastomoses. J Surg Oncol 2013; 108:472-6. [DOI: 10.1002/jso.23423] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Accepted: 08/06/2013] [Indexed: 11/11/2022]
Affiliation(s)
- Dhruvil R. Shah
- Department of Surgery; Division of Surgical Oncology; Davis School of Medicine; University of California; Sacramento California
| | - Steve R. Martinez
- Department of Surgery; Division of Surgical Oncology; Davis School of Medicine; University of California; Sacramento California
| | - Robert J. Canter
- Department of Surgery; Division of Surgical Oncology; Davis School of Medicine; University of California; Sacramento California
| | - Anthony D. Yang
- Department of Surgery; Division of Surgical Oncology; Davis School of Medicine; University of California; Sacramento California
| | - Richard J. Bold
- Department of Surgery; Division of Surgical Oncology; Davis School of Medicine; University of California; Sacramento California
| | - Vijay P. Khatri
- Department of Surgery; Division of Surgical Oncology; Davis School of Medicine; University of California; Sacramento California
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39
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Perry KA, Funk LM, Muscarella P, Melvin WS. Perioperative outcomes of laparoscopic transhiatal esophagectomy with antegrade esophageal inversion for high-grade dysplasia and invasive esophageal cancer. Surgery 2013; 154:901-7; discussion 907-8. [PMID: 24008087 DOI: 10.1016/j.surg.2013.05.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2013] [Accepted: 05/10/2013] [Indexed: 12/25/2022]
Abstract
BACKGROUND We examined the safety and effectiveness of antegrade laparoscopic inversion esophagectomy (LIE) for patients with multifocal high-grade dysplasia and distal esophageal cancer. METHODS We reviewed our experience with antegrade LIE, using an institutional research board-approved prospective database. RESULTS Thirty-six patients with an average age of 64 years underwent LIE. Indications included multifocal high-grade dysplasia (n = 4), adenocarcinoma (n = 30), and squamous cell carcinoma (n = 2); 11 patients had undergone neoadjuvant chemoradiation. LIE was completed successfully in 34 (94%) patients, whereas 2 required a conversion to open transhiatal esophagectomy. LIE required 221 minutes to perform, with a median blood loss of 100 mL. R0 resection was achieved in 97% of cases with a median lymph node harvest 15. Median hospital stay was 8 days, and 61% of patients were discharged to their home. Postoperative complications included anastomotic leak (n = 11) and stricture (n = 18), atrial arrhythmia (n = 5), pneumonia (n = 4), and tracheoesophageal fistula (n = 2). Operative outcomes after neoadjuvant therapy did not differ from those for primary operative resection. CONCLUSION Antegrade LIE is a safe treatment approach for patients with high-grade dysplasia and distal esophageal cancer. Complete resection with an adequate lymph node harvest can be achieved consistently for primary operative resection or after neoadjuvant chemoradiation.
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Affiliation(s)
- Kyle A Perry
- Division of General and Gastrointestinal Surgery, The Ohio State University, Columbus, OH.
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40
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Fujiwara Y, Yoshikawa R, Kamikonya N, Nakayama T, Kitani K, Tsujie M, Yukawa M, Hara J, Yamamura T, Inoue M. Neoadjuvant chemoradiotherapy followed by esophagectomy vs. surgery alone in the treatment of resectable esophageal squamous cell carcinoma. Mol Clin Oncol 2013; 1:773-779. [PMID: 24649245 PMCID: PMC3915344 DOI: 10.3892/mco.2013.128] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2012] [Accepted: 04/29/2013] [Indexed: 01/23/2023] Open
Abstract
In order to improve the survival of esophageal cancer patients, a trimodality therapy consisting of esophagectomy in combination with neoadjuvant chemoradiotherapy (CRT) has been developed. In this study, we evaluated whether neoadjuvant CRT improved the outcomes of patients with resectable esophageal squamous cell carcinoma (ESCC) compared to surgery alone. Eighty-eight patients with resectable ESCC were treated with either neoadjuvant CRT followed by surgical resection (Group A, n=52), or surgery alone (Group B, n=36). CRT consisted of 5-fluorouracil (5-FU, 500 mg/m2 on days 1–5) and cisplatin (CDDP, 10–20 mg/kg body weight on days 1–5), repeated after 3 weeks. Survival analysis was performed using the log-rank test with the Kaplan-Meier method. The clinical response of the primary tumor and metastatic nodes was 80.8%. The postoperative complications profile was similar between the two groups, except for anastomotic leakage. The median survival time (MST) was not reached in Group A and was 27.4 months in Group B. The estimated 5-year overall survival (OS) rate was 50.3% in Group A and 39.9% in Group B (P=0.134). As regards stage II/III disease, Group A exhibited a better disease-free survival (DFS) compared to Group B (5-year DFS: 57.2% in Group A vs. 31.4% in Group B; P=0.025). Simultaneous locoregional and distant recurrences were more common in the surgery alone group (Group B, P=0.047). Neoadjuvant CRT with 5-FU and CDDP did not contribute to a better prognosis in patients with resectable ESCC. However, it may be beneficial for patients with stage II/III disease.
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Affiliation(s)
- Yoshinori Fujiwara
- Department of Digestive Surgery, Nara Hospital, Kinki University School of Medicine, Ikoma, Nara 630-0293
| | | | | | - Tsuyoshi Nakayama
- Department of Digestive Surgery, Nara Hospital, Kinki University School of Medicine, Ikoma, Nara 630-0293
| | - Kotaro Kitani
- Department of Digestive Surgery, Nara Hospital, Kinki University School of Medicine, Ikoma, Nara 630-0293
| | - Masanori Tsujie
- Department of Digestive Surgery, Nara Hospital, Kinki University School of Medicine, Ikoma, Nara 630-0293
| | - Masao Yukawa
- Department of Digestive Surgery, Nara Hospital, Kinki University School of Medicine, Ikoma, Nara 630-0293
| | - Johji Hara
- Department of Digestive Surgery, Nara Hospital, Kinki University School of Medicine, Ikoma, Nara 630-0293
| | - Takehira Yamamura
- Surgery, Hyogo College of Medicine, Nishinomiya, Hyogo 663-8501, Japan
| | - Masatoshi Inoue
- Department of Digestive Surgery, Nara Hospital, Kinki University School of Medicine, Ikoma, Nara 630-0293
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Kato H, Nakajima M. Treatments for esophageal cancer: a review. Gen Thorac Cardiovasc Surg 2013; 61:330-5. [PMID: 23568356 DOI: 10.1007/s11748-013-0246-0] [Citation(s) in RCA: 157] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2012] [Indexed: 01/15/2023]
Abstract
Esophageal cancer is the eighth most common form of cancer worldwide. The treatments for esophageal cancer depend on its etiology. For mucosal cancer, endoscopic mucosal resection and endoscopic submucosal dissection are standard, while for locally advanced cancer, esophagectomy remains the mainstay. The three most common techniques for thoracic esophagectomy are the transhiatal approach, the Ivor Lewis esophagectomy (right thoracotomy and laparotomy), and the McKeown technique (right thoracotomy followed by laparotomy and neck incision with cervical anastomosis). Surgery for carcinoma of the cervical esophagus requires an extensive procedure with laryngectomy in many cases. When the tumor is more advanced, neoadjuvant chemotherapy or neoadjuvant chemoradiotherapy is added. The theoretical advantages of adding chemotherapy to the treatment of esophageal cancer are potential tumor down-staging prior to surgery, as well as targeting micrometastases and, thus, decreasing the risk of distant metastasis. Cisplatin- and 5-fluorouracil-based regimes are used worldwide. Chemoradiotherapy is the standard for unresectable esophageal cancer and could also be considered as an option for resectable tumors. For patients who are medically or technically inoperable, concurrent chemoradiotherapy should be the standard of care. Although neoadjuvant chemoradiotherapy followed by surgery or salvage surgery after definitive chemoradiotherapy is a practical treatment; judicious patient selection is crucial. It is important to have a thorough understanding of these therapeutic modalities to assist in this endeavor.
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Affiliation(s)
- Hiroyuki Kato
- Department of Surgery I, Dokkyo Medical University, 880 Kitakobayashi, Mibu, Shimotsuga-gun, Tochigi, 321-0293, Japan
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De Giacomo T, Trentino P, Venuta F, Tsagkaropoulos S, Berloco PB, Diso D, Francioni F. Surgical treatment of esophageal carcinoma with curative intent: analysis of a single center experience. J Cardiothorac Surg 2013; 8:52. [PMID: 23509872 PMCID: PMC3618300 DOI: 10.1186/1749-8090-8-52] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2012] [Accepted: 02/15/2013] [Indexed: 11/21/2022] Open
Abstract
Background We retrospectively reviewed our series of 76 patients who underwent esophagectomy, with curative intent, for esophageal carcinoma over the last 10 years. Method The mean age was 60 years ranging between 46 to 76 years. Fifty-seven patients had a squamous cell carcinoma and 19 patients had an adenocarcinoma. In 15 cases induction therapy was accomplished prior to surgery. A narrow gastric tube was used to restore continuity in 74 patients (97.3%). Medical records were reviewed and data analysis was performed. Results Peri-operative mortality was 2.6%. Overall survival at 1, 3 and 5 years was 85,5%, 67,7% and 52,7%, respectively, with no significant difference between the squamous cell disease group and the adenocarcinoma group. Although T factor and stage at the time of surgery influenced overall survival, the presence of nodal metastasis had the major impact on survival as confirmed by univariate and multivariate analysis with a 5 year survival rate of 32% regardless of the use or not of adjuvant chemo-radiotherapy and the pathologic stage. Conclusions Esophagectomy still represents a valid treatment for esophageal carcinoma in well selected patients. Both pT stage and N stage appear to be the most important factors determining survival for patients with completely resected esophageal carcinoma.
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Affiliation(s)
- Tiziano De Giacomo
- Department of Surgery and Transplantation P, Stefanini, University of Rome Sapienza Policlinico Umberto I, Rome, Italy.
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Abstract
Oesophageal carcinoma affects more than 450,000 people worldwide and the incidence is rapidly increasing. Squamous-cell carcinoma is the predominant form of oesophageal carcinoma worldwide, but a shift in epidemiology has been seen in Australia, the UK, the USA, and some western European countries (eg, Finland, France, and the Netherlands), where the incidence of adenocarcinoma now exceeds that of squamous-cell types. The overall 5-year survival of patients with oesophageal carcinoma ranges from 15% to 25%. Diagnoses made at earlier stages are associated with better outcomes than those made at later stages. In this Seminar we discuss the epidemiology, pathophysiology, diagnosis and staging, management, prevention, and advances in the treatment of oesophageal carcinoma.
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Affiliation(s)
- Arjun Pennathur
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
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Coit D. Surgical approaches to invasive adenocarcinoma of the gastroesophageal junction. Am Soc Clin Oncol Educ Book 2013:0011300144. [PMID: 23714483 DOI: 10.14694/edbook_am.2013.33.e144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Despite a plethora of data, the optimal surgical approach to invasive adenocarcinoma of the gastroesophageal (GE) junction remains controversial. To quote Dr. Valerie Rusch, "Strong individual preferences and some degree of surgical mystique often govern the selection of operation for resection of GE junction adenocarcinomas."1 The fırst of these controversies is whether the optimal open surgical approach should be via the transabdominal, transthoracic (two-incision Ivor Lewis or three-incision McKeown), or transhiatal route. Proponents of the transthoracic or transhiatal routes have voiced strong opinions on the potential advantages and disadvantages of each approach (Table 1). It is clear from most large retrospective series that, in experienced hands, excellent results can be achieved by either approach. The principal advantage of the transthoracic route is the ability to perform a radical mediastinal lymphadenectomy en bloc with the primary tumor, the theory being that a more aggressive lymph node dissection would be associated with an improved long-term outcome. To date, however, this association of a more aggressive lymphadenectomy with improved outcome has remained elusive in most gastrointestinal malignancies, including esophageal cancer. Proponents of the transhiatal approach cite similar lymph node retrieval rates, the potential for lower short-term morbidity, and the potential for similar long-term outcomes.2 With the advent of newer technology, the controversy regarding the optimal surgical approach to adenocarcinoma of the GE junction has evolved in yet another direction, with proponents of a minimally invasive approach, citing even lower perioperative morbidity and mortality, again with comparable or even superior long-term oncologic results.
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Affiliation(s)
- Daniel Coit
- From the Memorial Sloan-Kettering Cancer Center, New York, NY
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Abstract
Tumors of the gastroesophageal junction have historically been treated as either gastric or esophageal cancer depending on institutional preferences. The Siewert classification system was designed to provide a more precise means of characterizing these tumors. In general, surgical treatment of Siewert 1 tumors is via esophagectomy. Siewert 2 and 3 tumors may be treated with either esophagectomy with proximal gastrectomy or extended total gastrectomy provided negative margins are obtained. All but the earliest stage tumors should be considered for neoadjuvant chemoradiotherapy.
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Abstract
The incidence of esophageal cancer is increasing in the developed world, with a relative increase in adenocarcinoma compared with squamous cell carcinoma. The distensible nature of the esophagus results in delayed development of symptoms associated with esophageal cancer; hence many patients have locally advanced or metastatic cancer at the time of initial presentation. Although resection remains the treatment of choice for early-stage esophageal cancer, the best treatment strategy for locally advanced esophageal cancer is debatable and, consequently, varies at different centers. This article discusses the published literature on various available therapeutic options for the treatment of locally advanced esophageal cancer.
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Affiliation(s)
- Ankit Bharat
- Division of Cardiothoracic Surgery, Washington University School of Medicine, Saint Louis, St Louis, MO 63110-1013, USA
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Klink CD, Binnebösel M, Otto J, Boehm G, von Trotha KT, Hilgers RD, Conze J, Neumann UP, Jansen M. Intrathoracic versus cervical anastomosis after resection of esophageal cancer: a matched pair analysis of 72 patients in a single center study. World J Surg Oncol 2012; 10:159. [PMID: 22866813 PMCID: PMC3489570 DOI: 10.1186/1477-7819-10-159] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2012] [Accepted: 07/15/2012] [Indexed: 12/05/2022] Open
Abstract
Background The aim of this study was to analyze the early postoperative outcome of esophageal cancer treated by subtotal esophageal resection, gastric interposition and either intrathoracic or cervical anastomosis in a single center study. Methods 72 patients who received either a cervical or intrathoracic anastomosis after esophageal resection for esophageal cancer were matched by age and tumor stage. Collected data from these patients were analyzed retrospectively regarding morbidity and mortality rates. Results Anastomotic leakage rate was significantly lower in the intrathoracic anastomosis group than in the cervical anastomosis group (4 of 36 patients (11%) vs. 11 of 36 patients (31%); p = 0.040). The hospital stay was significantly shorter in the intrathoracic anastomosis group compared to the cervical anastomosis group (14 (range 10–110) vs. 26 days (range 12 – 105); p = 0.012). Wound infection and temporary paresis of the recurrent laryngeal nerve occurred significantly more often in the cervical anastomosis group compared to the intrathoracic anastomosis group (28% vs. 0%; p = 0.002 and 11% vs. 0%; p = 0.046). The overall In-hospital mortality rate was 6% (4 of 72 patients) without any differences between the study groups. Conclusions The present data support the assumption that the transthoracic approach with an intrathoracic anastomosis compared to a cervical esophagogastrostomy is the safer and more beneficial procedure in patients with carcinoma of the lower and middle third of the esophagus due to a significant reduction of anastomotic leakage, wound infection, paresis of the recurrent laryngeal nerve and shorter hospital stay.
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Affiliation(s)
- Christian D Klink
- Department of General, Visceral and Transplantation Surgery, Aachen, Germany.
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Yang K, Chen HN, Chen XZ, Lu QC, Pan L, Liu J, Dai B, Zhang B, Chen ZX, Chen JP, Hu JK. Transthoracic resection versus non-transthoracic resection for gastroesophageal junction cancer: a meta-analysis. PLoS One 2012; 7:e37698. [PMID: 22675487 PMCID: PMC3366974 DOI: 10.1371/journal.pone.0037698] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2011] [Accepted: 04/25/2012] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The aim of this meta-analysis is to evaluate the impact of transthoracic resection on long-term survival of patients with GEJ cancer and to compare the postoperative morbidity and mortality of patients undergoing transthoracic resection with those of patients who were not undergoing transthoracic resection. METHOD Searches of electronic databases identifying studies from Medline, Cochrane Library trials register, and WHO Trial Registration etc were performed. Outcome measures were survival, postoperative morbidity and mortality, and operation related events. RESULTS Twelve studies (including 5 RCTs and 7 non-RCTs) comprising 1105 patients were included in this meta-analysis, with 591 patients assigned treatment with transthoracic resection. Transthoracic resection did not increase the 5-y overall survival rate for RCTs and non-RCTs (HR = 1.01, 95% CI 0.80- 1.29 and HR = 0.89, 95% CI 0.70- 1.14, respectively). Stratified by the Siewert classification, our result showed no obvious differences were observed between the group with transthoracic resection and group without transthoracic resection (P>0.05). The postoperative morbidity (RR = 0.69, 95% CI 0.48- 1.00 and OR = 0.55, 95% CI 0.25- 1.22) and mortality (RD = -0.03, 95% CI -0.06- 0.00 and RD = 0.00, 95% CI -0.05- 0.05) of RCTs and non-RCTs did not suggest any significant differences between the two groups. Hospital stay was long with thransthoracic resection (WMD = -5.80, 95% CI -10.38- -1.23) but did not seem to differ in number of harvested lymph nodes, operation time, blood loss, numbers of patients needing transfusion, and reoperation rate. The results of sensitivity analyses were similar to the primary analyses. CONCLUSIONS There were no significant differences of survival rate and postoperative morbidity and mortality between transthoracic resection group and non-transthoracic resection group. Both surgical approaches are acceptable, and that one offers no clear advantage over the other. However, the results should be interpreted cautiously since the qualities of included studies were suboptimal.
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Affiliation(s)
- Kun Yang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People’s Republic of China
| | - Hai-Ning Chen
- West China School of Medicine, Sichuan University, Chengdu, Sichuan Province, People’s Republic of China
| | - Xin-Zu Chen
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People’s Republic of China
| | - Qing-Chun Lu
- West China School of Medicine, Sichuan University, Chengdu, Sichuan Province, People’s Republic of China
| | - Lin Pan
- West China School of Medicine, Sichuan University, Chengdu, Sichuan Province, People’s Republic of China
| | - Jie Liu
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People’s Republic of China
| | - Bin Dai
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People’s Republic of China
| | - Bo Zhang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People’s Republic of China
| | - Zhi-Xin Chen
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People’s Republic of China
| | - Jia-Ping Chen
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People’s Republic of China
| | - Jian-Kun Hu
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People’s Republic of China
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