A 15-year review of esophagectomy for carcinoma of the esophagus and cardia

Transhiatal robot-assisted minimally invasive esophagectomy: unclear benefits compared to traditional transhiatal esophagectomy

Esophagectomy is a high-risk operation, regardless of technique. Minimally invasive transthoracic esophagectomy could reduce length of stay and pulmonary complications compared to traditional open approaches, but the benefits of minimally invasive transhiatal esophagectomy are unclear. We performed a retrospective review of prospectively gathered data for open transhiatal esophagectomies (THEs) and transhiatal robot-assisted minimally invasive esophagectomies (TH-RAMIEs) performed at a high-volume academic center between 2013 and 2017. Multivariate logistic regression was used to calculate adjusted odds ratios (aORs) for outcomes. 465 patients met inclusion criteria (378 THE and 87 TH-RAMIE). THE patients more likely had an ASA score of 3 + (89.1% vs 77.0%, p = 0.012), whereas TH-RAMIE patients more likely had a pathologic staging of 3+ (43.7% vs. 31.2%, p = 0.026). TH-RAMIE patients were less likely to receive epidurals (aOR 0.06, 95% confidence interval [CI] 0.03-0.14, p < 0.001), but epidural use itself was not associated with differences in outcomes. TH-RAMIE patients experienced higher rates of pulmonary complications (adjusted odds ratio [OR] 1.82, 95% CI 1.03-3.22, p = 0.040), particularly pulmonary embolus (aOR 5.20, 95% CI 1.30-20.82, p = 0.020). There were no statistically significant differences in lymph node harvest, unexpected ICU admission, length of stay, in-hospital mortality, or 30-day readmission or mortality rates. The TH-RAMIE approach had higher rates of pulmonary complications. There were no statistically significant advantages to the TH-RAMIE approach. Further investigation is needed to understand the benefits of a minimally invasive approach to the open transhiatal esophagectomy.

Microvessel density as a prognostic factor in esophageal squamous cell cancer patients: A meta-analysis

BACKGROUND

To date, literature has emerged that shows contradictory results about the prognostic role of microvessel density (MVD) in esophageal squamous cell cancer (ESCC). The aim of the study set out to evaluate the correlation between MVD and the prognosis of ESCC.

METHODS

Identified publications from various databases were obtained and reviewed. A meta-analysis was performed to evaluate the prognostic role of MVD among ESCC patients.

RESULTS

A total of 11 eligible studies containing 891 ESCC cases were included in the meta-analysis. The pooled hazard ratio for overall survival was 2.39 (95% confidence interval 1.92-2.96, P < .001). Heterogeneity among the studies was not significant, and publication bias was not found. Subgroup analyses were also performed on different issues, such as districts, antibodies, and median age.

CONCLUSION

High MVD is a prognostic factor among ESCC that indicated worse prognosis in these patients. More studies are needed, and through abundant evidence, the topic could be re-evaluated by then.

Our Clinical Experience of Self-Expanding Metal Stent for Malignant Central Airway Obstruction

Background

We studied the safety, effectiveness, and limitations of airway stenting using self-expanding metal stent (SEMS) in patients with malignant central airway obstruction (CAO).

Methods

A retrospective review of records of patients undergoing SEMS placement for malignant CAO during year 2013 - 2014 was done.

Results

Sixteen patients (11 males and five females) underwent SEMS placement for malignant CAO. Median (range) age was 66 (54 - 78) years. No perioperative or immediate postoperative complications were seen except acute myocardial infarction (AMI) in one patient. Three patients were transferred to intensive care unit (ICU) for closer monitoring after the procedure and were discharged the next day. All four patients with lung atelectasis on presentation experienced complete re-expansion of the lung post-stenting. The dyspnea was substantially relieved in 14 (87.5%) patients. Two of the three patients who had been intubated were weaned off from the ventilator following stent insertion. Stent patency was maintained until death in all patients except one. Median survival from the date of diagnosis and the date of stent placement in lung cancer, esophageal cancer, and thyroid cancer were 140 (21 - 564) and 85 (15 - 361), 288 (80 - 419) and 61 (60 - 171), and 129 (71 - 187) and 67 (16 - 118) days, respectively. This survival was similar to reported expected survival associated with the underlying malignancy. During follow-up, granulation tissue (n = 1), mucostasis (n = 1), and tumor ingrowth (n = 2) were the most frequently encountered complications.

Conclusion

SEMSs are safe and effective in reversing respiratory failure caused by malignant CAO, averting premature death, allowing application of cancer targeted therapy, and restoring impending shortened survival to expected life expectancy associated with the underlying malignancy.

Lymphovascular invasion of tumor cells in lymph node metastases has a negative impact on survival in esophageal cancer

BACKGROUND

Lymph node metastases constitute a strong prognostic factor in esophageal cancer. Nevertheless, the mechanisms and relevance of further spread of tumor cells from these already established metastatic sites have not been studied in this disease. The aim of this study was to investigate lymphatic vessel invasion (LVI) of tumor cells and lymphatic microvessel density in lymph node metastases in a large cohort of patients with node-positive esophageal cancer.

METHODS

A total of 120 patients with node-positive esophageal cancer (67 adenocarcinomas, 53 squamous cell carcinomas) and radical esophagectomy were analyzed for LVI and lymphatic microvessel density in primary tumors and lymph node metastases using D2-40 immunostaining. In 18 patients, additional tissue from distant metastases was available.

RESULTS

LVI was present in 52.1% (62/119) of primary tumors, 52.5% (63/120) of lymph nodes, and 22.2% (4/18) of distant metastases. LVI in primary tumors strongly correlated with LVI in lymph node metastases (P < .05), regardless of histologic subtype. In univariate analysis, LVI in lymph node metastases was associated with shorter disease-free survival and overall survival in all tumors and in adenocarcinomas, and with shorter disease-free survival in squamous cell carcinomas (P < .05, log-rank test). Multivariable analysis revealed LVI in lymph node metastases as an independent prognostic factor for disease-free survival in the whole cohort and for disease-free and overall survival in patients with adenocarcinomas (P < .05, Cox regression).

CONCLUSION

LVI in lymph node metastasis is a significant prognostic factor in metastatic esophageal carcinoma and seems to play a relevant role in disease progression.

Increasing diagnostic accuracy to grade dysplasia in Barrett's esophagus using an immunohistochemical panel for CDX2, p120ctn, c-Myc and Jagged1

Background

Patients with non-dysplastic Barrett’s esophagus (ND-BE) and low-grade dysplasia (LGD) are typically monitored by periodic endoscopic surveillance, while those with high-grade dysplasia (HGD) and esophageal adenocarcinoma (EAC) are usually treated by more aggressive interventions like endoscopic mucosal resection, ablation or surgery. Therefore, the accurate grading of dysplasia in Barrett’s esophagus (BE) is essential for proper patient care. However, there is significant interobserver and intraobserver variability in the histologic grading of BE dysplasia. The objective of this study was to create an immunohistochemical (IHC) panel that facilitates the grading of BE dysplasia and can be used as an adjunct to histology in challenging cases.

Methods

100 BE biopsies were re-graded for dysplasia independently by 3 subspecialized gastrointestinal pathologists. IHC staining for CDX2, p120ctn, c-Myc and Jagged1 proteins was then performed and assessed by two separate methods of semi-quantitative scoring. Scores were integrated using a principal component analysis (PCA) and receiver operating characteristic (ROC) curve.

Results

Principal component analysis demonstrated the ability of this panel of proteins to segregate ND-BE/LGD and HGD/EAC, as the expression of the four proteins is significantly altered between the two subsets. Analysis of the receiver operating characteristic curve showed that this panel has the potential to aid in the grading of dysplasia in these two subcategories with both high sensitivity and specificity. While not able to discriminate between ND-BE and LGD, this panel of four proteins may be used as an adjunct to help discriminate subsets of ND-BE/LGD from HGD/EAC.

Conclusions

We propose that the maximum utility of this IHC panel of CDX2, p120ctn, c-Myc, and Jagged1 proteins would be to distinguish between LGD and HGD in histologically challenging cases, given the aggressive interventions still used for HGD in many institutions, and hence may aid in the optimal patient management. The results of this initial study are promising, though further validation is needed before this panel can be used clinically, including future randomized prospective studies with larger patient cohorts from diverse locations.

Electronic supplementary material

The online version of this article (doi:10.1186/s13000-016-0473-7) contains supplementary material, which is available to authorized users.

Minimally invasive esophagectomy for benign disease

MIE can provide patients with reduced morbidity and a rapid recovery in the treatment of benign conditions. There is few data examining the long-term outcomes of MIE specifically in the context of benign disease. At present, MIE should be performed in centers with experience in advanced minimally invasive esophageal surgery, and it requires a team approach. Multicenter, prospective randomized controlled trials will be required to determine the superiority of MIE compared with open esophagectomy. Further investigation will be required to determine the effect of MIE on quality of life and long-term outcomes in the treatment of benign conditions.

Barrett's esophagus and cancer risk: how research advances can impact clinical practice

Barrett’s esophagus (BE) is the only known precursor to esophageal adenocarcinoma (EAC), whose incidence has increased sharply in the last 4 decades. The annual conversion rate of BE to cancer is significant, but small. The identification of patients at a higher risk of cancer therefore poses a clinical conundrum. Currently, endoscopic surveillance is recommended in BE patients, with the aim of diagnosing either dysplasia or cancer at early stages, both of which are curable with minimally invasive endoscopic techniques. There is a large variation in clinical practice for endoscopic surveillance, and dysplasia as a marker of increased risk is affected by sampling error and high interobserver variability. Screening programs have not yet been formally accepted, mainly due to the economic burden that would be generated by upper gastrointestinal endoscopy. Screening programs have not yet been formally accepted, mainly due to the economic burden that would be generated by widespread indication to upper gastrointestinal endoscopy. In fact, it is currently difficult to formulate an accurate algorithm to confidently target the population at risk, based on the known clinical risk factors for BE and EAC. This review will focus on the clinical and molecular factors that are involved in the development of BE and its conversion to cancer and on how increased knowledge in these areas can improve the clinical management of the disease.

Accuracy of endoscopic ultrasound in preoperative staging of early esophageal cancer: A Meta-analysis

AIM: To evaluate the accuracy of endoscopic ultrasound (EUS) in the preoperative staging of early esophageal cancer.

METHODS: We searched the Medline, PubMed, Web of Science, Embase, Cochrane Central Trials, Wanfang, CBM, CNKI and VIP databases for relevant studies published. Study selection, quality assessment and data extraction were performed by two reviewers independently. Meta-Disc (version1.4) software was used to perform the meta-analysis for sensitivity, specificity, positive likelihood ratio (LR), and negative LR. Pooling results were derived (by) using the fixed-effect model when significant heterogeneity was not present, and the random-effect model was applied otherwise. A summary receiver-operating characteristic (SROC) curve was constructed. Furthermore, to explore the potential sources of heterogeneity, we used meta-regression to estimate the effect of the characteristics of the studies on the diagnostic accuracy of EUS. In addition, the outliers were identified by the method described by Deville and a subgroup analysis was performed by excluding the outliers. We used Stata statistical software (version 10.0) to assess the publication bias using the Begg-Mazumdar indictor and Harbord-Egger indictor.

RESULTS: Twenty studies with a total of 1115 patients were included in this analysis. The pooled sensitivity, specificity, and positive and negative likelihood ratio of EUS for T1m staging were 0.85 (95%CI: 0.83-0.88), 0.86 (95%CI: 0.83-0.89), 5.34 (95%CI: 3.67-7.76), and 0.21 (95%CI: 0.15-0.29), respectively. For stage T1sm, these results were 0.87 (95%CI: 0.84-0.90), 0.85 (95%CI: 0.82-0.88), 4.64 (95%CI: 3.47-6.22), and 0.18 (95%CI: 0.13-0.25). For stage N, these results were 0.71 (95%CI: 0.61-0.80), 0.78 (95%CI: 0.71-0.84), 2.93 (95%CI: 1.49-5.79), and 0.46 (95%CI: 0.18-1.22). The percent of area under the curve was 92.1% for both stage T1m and stage T1sm, and 80% for stage N. No significant publication bias was found with either the Begg-Mazumdar indictor (P = 0.216) or the Harbord-Egger indictor (P = 0. 412).

CONCLUSION: EUS has excellent sensitivity and specificity in diagnosing the T1 stage of early esophageal cancer. However, the frequency of EUS probe and the experience of the endosonographers can affect the diagnostic accuracy of EUS. EUS plays an important role in clinical selection of surgical approaches and treatments.

Fluoroscopically guided balloon dilation or temporary stent placement for patients with gastric conduit strictures after esophagectomy with esophagogastrostomy

OBJECTIVE

The purpose of this study was to evaluate the clinical features of patients with gastric conduit strictures after esophagectomy and to report our initial experience in the management of these strictures with fluoroscopically guided balloon dilation, temporary stent placement, or both.

MATERIALS AND METHODS

From January 1996 to January 2012, 12 patients with gastric conduit stricture after esophagectomy underwent fluoroscopic balloon dilation, temporary stent placement, or both. Stent placement was indicated in patients who had gastro-respiratory fistulas or recurrent symptoms within 2 weeks of balloon dilation. Technical and clinical success, complications, and length of strictures were retrospectively evaluated.

RESULTS

The mean length of strictures in all patients was 49 mm (range, 21-76 mm). The strictures were accompanied by gastrorespiratory fistulas in four patients. Seven patients with gastric conduit strictures without fistulas underwent 23 balloon dilations. Five patients underwent stent placement owing to gastrorespiratory fistula formation (n = 4) and frequent recurrent symptoms after balloon dilation (n = 1). During a mean follow-up period of 8 months (range, 2-28 months), clinical success was achieved in 11 patients (91.6%) after a single balloon dilation (n = 1), multiple balloon dilations (n = 5), or stent placement (n = 5). Complications occurred in 3 of 10 patients (30%) after balloon dilation and in one of five patients (20%) after stent placement.

CONCLUSION

Gastric conduit strictures are characterized by their substantial length and tend to be accompanied by gastrorespiratory fistulas. Despite relatively high complication and recurrence rates, this study may offer a viable treatment of gastric conduit strictures by using fluoroscopically guided balloon dilation and stent placement.

Screening and risk stratification for Barrett's esophagus: how to limit the clinical impact of the increasing incidence of esophageal adenocarcinoma

Barrett's esophagus (BE) and gastroesophageal reflux disease are the strongest risk factors for esophageal adenocarcinoma. To reduce the clinical impact of this disease, endoscopic screening to detect BE has been proposed and nonendoscopic diagnostic techniques are under investigation. Because screening would result in new diagnoses of BE and additional costs related to endoscopic surveillance, novel tools for risk stratification are also warranted. Dysplasia is the gold standard for risk stratification. Molecular biomarkers may provide a more objective and reproducible estimation of the individual risk, and further prospective studies are required as a prelude to introducing biomarkers into routine clinical practice.

Thoracoscopic esophagectomy in the prone position

BACKGROUND

Minimally invasive esophageal surgery has arisen in an attempt to reduce the significant complications associated with esophagectomy. Despite proposed technical and physiological advantages, the prone position technique has not been widely adopted. This article reviews the current status of prone thoracoscopic esophagectomy.

METHODS

A systematic literature search was performed to identify all published clinical studies related to prone esophagectomy. Medline, EMBASE and Google Scholar were searched using the keywords "prone," "thoracoscopic," and "esophagectomy" to identify articles published between January 1994 and September 2010. A critical review of these studies is given, and where appropriate the technique is compared to the more traditional minimally invasive technique utilising the left lateral decubitus position.

RESULTS

Twelve articles reporting the outcomes following prone thoracoscopic oesophagectomy were tabulated. These studies were all non-randomised single-centre prospective or retrospective studies of which four compared the technique to traditional minimally invasive surgery. Although prone esophagectomy is demonstrated as being both feasible and safe, there is no convincing evidence that it is superior to other forms of esophageal surgery. Most authors comment that the prone position is associated with superior surgical ergonomics and theoretically offers a number of physiological benefits.

CONCLUSION

The ideal approach within minimally invasive esophageal surgery continues to be a subject of debate since no single method has produced outstanding results. Further clinical studies are required to see whether ergonomic advantages of the prone position can be translated into improved patient outcomes.

Diagnostic accuracy of EUS in differentiating mucosal versus submucosal invasion of superficial esophageal cancers: a systematic review and meta-analysis

BACKGROUND

The prognosis of esophageal cancer (EC) depends on the depth of tumor invasion and lymph node metastasis. EC limited to the mucosa (T1a) can be treated effectively with minimally invasive endoscopic therapy, whereas submucosal (T1b) EC carries relatively high risk of lymph node metastasis and requires surgical resection.

OBJECTIVE

To determine the diagnostic accuracy of EUS in differentiating T1a EC from T1b EC.

DESIGN

We performed a comprehensive search of MEDLINE, SCOPUS, Cochrane, and CINAHL Plus databases to identify studies in which results of EUS-based staging of EC were compared with the results of histopathology of EMR or surgically resected esophageal lesions. DerSimonian-Laird random-effects model was used to estimate the pooled sensitivity, specificity, and likelihood ratio, and a summary receiver operating characteristic (SROC) curve was created.

SETTING

Meta-analysis of 19 international studies.

PATIENTS

Total of 1019 patients with superficial EC (SEC).

INTERVENTIONS

EUS and EMR or surgical resection of SEC.

MAIN OUTCOME MEASUREMENTS

Sensitivity and specificity of EUS in accurately staging SEC.

RESULTS

The pooled sensitivity, specificity, and positive and negative likelihood ratio of EUS for T1a staging were 0.85 (95% CI, 0.82-0.88), 0.87 (95% CI, 0.84-0.90), 6.62 (95% CI, 3.61-12.12), and 0.20 (95% CI, 0.14-0.30), respectively. For T1b staging, these results were 0.86 (95% CI, 0.82-0.89), 0.86 (95% CI, 0.83-0.89), 5.13 (95% CI, 3.36-7.82), and 0.17 (95% CI, 0.09-0.30), respectively. The area under the curve was at least 0.93 for both mucosal and submucosal lesions.

LIMITATIONS

Heterogeneity was present among the studies.

CONCLUSION

Overall EUS has good accuracy (area under the curve ≥0.93) in staging SECs. Heterogeneity among the included studies suggests that multiple factors including the location and type of lesion, method and frequency of EUS probe, and the experience of the endosonographer can affect the diagnostic accuracy of EUS.

Transthoracic versus transhiatal esophagectomy for the treatment of esophagogastric cancer: a meta-analysis

OBJECTIVE

To study the differences in short and long-term outcomes of transthoracic and transhiatal esophagectomy for cancer.

BACKGROUND

Studies have compared transthoracic with transhiatal esophagectomy with varying results. Previous systematic reviews (1999, 2001) do not include the latest randomized controlled trials.

METHODS

Systematic review of English-language studies comparing transthoracic with transhiatal esophagectomy up to January 31, 2010. Meta-analysis was used to summate the study outcomes. Methodological and surgical quality of included studies was assessed.

RESULTS

Fifty-two studies, comprising 5905 patients (3389 transthoracic and 2516 transhiatal) were included in the analysis. No study met all minimum surgical quality standards. Transthoracic operations took longer and were associated with a significantly longer length of stay. There was no difference in blood loss. The transthoracic group had significantly more respiratory complications, wound infections, and early postoperative mortality, whereas anastomotic leak, anastomotic stricture, and recurrent laryngeal nerve palsy rate was significantly higher in the transhiatal group. Lymph node retrieval was reported in 4 studies and was significantly greater in the transthoracic group by on average 8 lymph nodes. Analysis of 5-year survival showed no significant difference between the groups and was subject to significant heterogeneity.

CONCLUSIONS

This meta-analysis of studies comparing transthoracic with transhiatal esophagectomy for cancer demonstrates no difference in 5-year survival, however lymphadenectomy and reported surgical quality was suboptimal in both groups and the transthoracic group had significantly more advanced cancer. The finding of equivalent survival should therefore be viewed with caution.

Minimally invasive esophagectomy: the evolution and technique of minimally invasive surgery for esophageal cancer

Beginning with the widespread introduction of laparoscopic cholecystectomy in late 1989, minimally invasive surgical technique has been refined in conjunction with the development of advanced instrumentation and have subsequently been applied to increasingly complicated disease processes. Esophageal surgeons have increasingly incorporated minimally invasive surgery into their practice since the first laparoscopic fundoplication was described by Dallemagne et al. in 1991. Esophagectomy is associated with significant morbidity and mortality even in highly experienced centers. Many esophageal surgeons have had a great deal of interest in minimally invasive esophagectomy (MIE), which has the potential advantages of being a less traumatic procedure with a resultant improvement in postoperative convalescence and fewer wound and cardiopulmonary complications compared to the open approaches. Throughout the 1990s, as confidence with laparoscopic surgery of the esophagogastric junction grew, MIE was initially attempted with hybrid operations combining traditional open surgery with minimally invasive approaches. Subsequently, a totally laparoscopic transhiatal approach was described; however, this approach was perceived to be very challenging and has not gained widespread acceptance. Approaches used at present depend on cancer stage, cancer location, body habitus, and pulmonary function. For localized cancer (T1N0) or HGD, we prefer laparoscopic inversion esophagectomy (retrograde or antigrade). This approach may also be used for patients at high risk for thoracotomy. For locally advanced cancer in the middle third of the esophagus or for proximal third esophageal cancer, we prefer 3-field MIE (abdomen, and chest with neck anastomosis). For locally advanced cancer in the distal esophagus, especially in patients with a short thick neck, we prefer thoracoscopic-laparoscopic (2-field) esophagectomy (TLE).

Pulmonary Complications due to Esophagectomy

INTRODUCTION

Esophageal carcinoma is the scourge of human beings. Pulmonary complications in patients who have undergone operation are common (20-30% of cases) and there are no suitable tools and ways to predict these complications.

METHODS

During a period of 10 years, from March 1998 to February 2007, 200 patients (150 male and 50 female) underwent Esophagectomy due to esophageal carcinoma in thoracic surgery ward retrospectively. Complications include the length of hospitalization, mechanical ventilation, morbidity and mortality. Patients' risk factors include age, preoperative chemo-radiotherapy, stage of the disease and preoperative spirometry condition.

RESULTS

WE GROUPED OUR PATIENTS INTO THREE CATEGORIES: Normal (FEV1 ≥ 80% predicted), mildly impaired (FEV1 65% to 79% predicted), more severely impaired (FEV1 < 65% predicted).Although almost all patients had radiographic pulmonary abnormalities, significant pulmonary complications occurred in 40 patients (20%) which underwent Esophagectomy. Pleural effusion and atelectasia in 160 patients (80%). 24 patients needed chest-tube insertion. 20 patients (10%) developed ARDS. 14 patients (7%) developed chylothorax. 20 patients (10%) of patients died during their postoperative hospital stay. 30 patients (15%) required mechanical ventilation for greater than 48 hours.

CONCLUSION

We reviewed a number of preoperative clinical variables to determine whether they contributed to postoperative pulmonary complications as well as other outcomes. In general, age, impaired pulmonary function especially in those patients with FEV1 less than 65% predicted was associated with prolonged hospital length of stay (LOS). In fact pulmonary complications rate after Esophagectomy are high and there was associated mortality and morbidity.

Decreasing morbidity and mortality in 100 consecutive minimally invasive esophagectomies

INTRODUCTION

Esophagectomy is a complex invasive procedure that requires exploration of multiple body cavities for removal and subsequent restoration of gastrointestinal continuity. In many institutions, esophagectomy morbidity and mortality rates remain high despite improvement of intensive care treatment. We reviewed our minimally invasive esophagectomy (MIE) experience of a consecutive series of 100 patients to analyze trends in morbidity and mortality as we transitioned from open to MIE.

METHODS

A total of 105 consecutive patients who underwent operative exploration for esophagectomy from August 2007 to January 2011 were reviewed. The preoperative evaluation, operative technique, and postoperative care of these cases were evaluated and analyzed for 100 patients who have had a MIE and compared with 32 open esophagectomies 2 years prior.

RESULTS

During the time frame of the study, 105 patients underwent an exploration for attempted esophagectomy. Resection was completed in 100 patients and was done for malignant disease in 95 patients and benign disease in 5 patients. There was one in hospital mortality due to a pulmonary embolism. There was no significant difference in postoperative complications consisting of transient left recurrent nerve injury (7 vs. 12.5%) or pneumonia (9 vs. 15.6%) in those who underwent MIE compared with open resection. However, wound infections were significantly less in patients who underwent MIE compared with open esophagectomy (1 vs. 12.5%, respectively, p = 0.01). Anastomotic leak (4 vs. 12.5%, p = 0.05) also was lower in those who underwent MIE. Median length of stay (LOS) was significantly less in patients who underwent MIE compared with open esophagectomy (7.5 vs. 14 days, p < 0.05). Finally, there was a trend toward improvement in median LOS in the 30 patients who underwent MIE during the most recent time period compared with the initial 17 patients who underwent MIE (7.5 vs. 10 days, p = 0.05)

CONCLUSIONS

Our results support the continued safe use of esophagectomy for selected esophageal diseases, including malignancy. Morbidity, especially wound infection, anastomotic leak, and length of stay is decreasing with the incorporation of minimally invasive techniques.

Minimally invasive surgery and cancer: controversies part 1

Perhaps there is no more important issue in the care of surgical patients than the appropriate use of minimally invasive surgery (MIS) for patients with cancer. Important advances in surgical technique have an impact on early perioperative morbidity, length of hospital stay, pain management, and quality of life issues, as clearly proved with MIS. However, for oncology patients, historically, the most important clinical questions have been answered in the context of prospective randomized trials. Important considerations for MIS and cancer have been addressed, such as what are the important immunologic consequences of MIS versus open surgery and what is the role of laparoscopy in the staging of gastrointestinal cancers? This review article discusses many of the key controversies in the minimally invasive treatment of cancer using the pro-con debate format.

The Effects of Prostaglandin E1 on Interleukin-6, Pulmonary Function and Postoperative Recovery in Oesophageetomised Patients

The inflammatory reactions and tissue response after oesophagectomy are leading causes of postoperative morbidity and mortality. We evaluated the effects of intraoperative infusion of prostaglandin E1 (PGE1) on interleukin-6 (IL-6) levels, (A-a) DO2, pulmonary function and complications. This randomised double-blind clinical trial study was performed on patients undergoing transthoracic oesophagectomy due to cancer. Thirty patients were randomly allocated to two groups: the PGE1 group (infusion of PGE1, 20 ng.kg−1.min−1) and a placebo group (infusion of normal saline 0.9%). The infusion was started before induction of anaesthesia and continued until the end of the operation. The groups were comparable in basic characteristics and preoperative pulmonary function. Patients in the PGE1 group were discharged significantly earlier from the intensive care unit (72±9 vs 83±17 hours) and hospital (13±4 vs 18±8 days) (P=0.04 and 0.03, respectively). The (A-a) DO2 was significantly less in the PGE1 group at 12 and 24 hours after the operation (P=0.001, P=0.003, respectively). Postoperatively, IL-6 levels were significantly higher in the placebo group than in the PGE1 group. There were no differences in the forced expiratory volume in the first second or forced vital capacity. The findings indicate that infusion of PGE1 attenuates the increase in serum levels of IL-6 in patients undergoing esophagectomy and improves the (A-a) DO2. Stays in the intensive care unit and hospital were shorter in the PGE1 group. However, there were no differences in pulmonary complications.

Esophageal cancer: pneumo-64-MDCT

BACKGROUND

Pre-surgical characterization and staging of esophageal cancer with only one imaging method could be useful since gastric invasion determines the scope of resection and the kind of surgery to be performed. Our aim is to demonstrate the usefulness of Pneumo-64-MDCT (PnCT64) in the presurgical characterization of esophageal neoplasms in correlation with surgical findings.

MATERIALS AND METHODS

A total of 50 patients with diagnosis of esophageal neoplasm were prospectively studied. A 14 French Foley catheter was used transorally in all patients. Air was instilled through the catheter to achieve esophageal distension. A 64-row MDCT scan was performed and the tumor was characterized according to scope, shape and anatomic location by using multiplanar 3D reconstructions and virtual endoscopy. Wall infiltration and presence of adenopathies were analyzed.

RESULTS

Adequate gastroesophageal distension was achieved in all patients. In 44/50 patients, wall thickening was observed, and in 34/50 regional adenopathies were found. In 29/50 patients the lesion was found in the lower third and in the gastroesophageal junction. The surgical correlation for wall infiltration was 85.7%.

CONCLUSIONS

PnCT64 proved to be useful and safe for identification of esophageal wall thickening and presurgical characterization. Optimal distension allowed definition of both upper and lower borders of the tumors located in the gastroesophageal junction, of utmost importance to determine the surgical approach.

Minimally invasive esophagectomy: lessons learned from 104 operations

OBJECTIVES

To review the outcomes of 104 consecutive minimally invasive esophagectomy (MIE) procedures for the treatment of benign and malignant esophageal disease.

SUMMARY BACKGROUND DATA

Although minimally invasive surgical approaches to esophagectomy have been reported since 1992, MIE is still considered investigational at most institutions.

METHODS

This prospective study evaluates 104 MIE procedures performed between August 1998 and September 2007. Main outcome measures include operative techniques, operative times, blood loss, length of stay, conversion rates, morbidities, and mortalities.

RESULTS

Indications for surgery were esophageal cancer (n = 80), Barrett esophagus with high-grade dysplasia (n = 6), recalcitrant stricture (n = 8), gastrointestinal stromal tumor (n = 3), and gastric cardia cancer (n = 7). Surgical approaches included thoracoscopic/laparoscopic esophagectomy with a cervical anastomosis (n = 47), minimally invasive Ivor Lewis esophagectomy (n = 51), laparoscopic hand-assisted blunt transhiatal esophagectomy (n = 5), and laparoscopic proximal gastrectomy (n = 1). There were 77 males. The mean age was 65 years. Three patients (2.9%) required conversion to a laparotomy. The median ICU and hospital stays were 2 and 8 days, respectively. Major complications occurred in 12.5% of patients and minor complications in 15.4% of patients. The incidence of leak was 9.6% and of anastomotic stricture was 26%. The 30-day mortality was 1.9% with an in-hospital mortality of 2.9%. The mean number of lymph nodes retrieved was 13.8.

CONCLUSIONS

Minimally invasive esophagectomy is feasible with a low conversion rate, acceptable morbidity, and low mortality. Our preferred operative approach is the laparoscopic\thoracoscopic Ivor Lewis resection, which provides a tension-free intrathoracic anastomosis.

Lymphatic vessel density as prognostic marker in esophageal adenocarcinoma

We studied tumor lymphatic vascular density (LVD) as a predictive marker for the risk of lymph node (LN) metastasis and its relationship to other prognostic parameters and survival in 75 patients with esophageal adenocarcinoma. Samples were immunostained for D2-40, CD31, and vascular endothelial growth factor (VEGF). Microvessels were counted in densely vascular/lymphatic foci (hot spots) at x400 field (0.17 mm2). Intensity of staining for VEGF was scored on a 2-tiered scale. CD31 microvessel counts showed significant correlation with tumor stage and patient survival (P < .01). D2-40 LVD demonstrated a significant correlation with LN metastases, lymphovascular invasion, and tumor stage (r = 0.45, r = 0.47, and r = 0.37, respectively) and with shorter disease-free survival. D2-40 detected lymphovascular invasion in 29 of 75 cases, more than with CD31 (23/75) and H&E (18/75). VEGF was expressed in 48 (64%) of 75 cases and was significantly correlated with lymphovascular invasion, LN metastases, and overall survival. Our study showed that angiogenesis and lymphangiogenesis have important roles in the progression of esophageal adenocarcinoma.

Is minimally invasive esophagectomy indicated for cancer?

Esophagectomy is an important component in the comprehensive treatment of esophageal cancer. The 5-year survival in patients who are treated with esophagectomy is approximately 35% compared with approximately 16% for all patients. However, esophagectomy is a complex operation with high (40-60%) morbidity and 5-20% mortality rates reported by many centers. Minimally invasive approaches to esophagectomy have been developed over the past decade; potential advantages of minimally invasive esophagectomy (MIE) include a reduced risk of perioperative morbidity and mortality with equivalent oncologic outcomes, including extent of lymphadectomy and survival. However, significant debate still exists regarding the role of MIE in the treatment of esophageal cancer, particularly given the limitations in the widespread implementation of this technically challenging operation. This review summarizes the current status of the use of minimally invasive surgery in treating esophageal cancer and seeks to answer the question of whether MIE is indicated in the treatment of esophageal cancer.

[Open and laparoscopic transhiatal oesophagectomy for cancer of the oesophagus: analysis of resection margins and lymph nodes]

INTRODUCTION

Surgical treatment of cancer of the oesophagus is associated with a high morbidity and mortality. Minimally invasive surgery has been proposed as an alternative to try to reduce these complications; however, at this time there are not many studies that evaluate the oncological validity of this method. The objective of this work is to give a preliminary audit of the results of our experience in both surgical techniques, with special emphasis on the oncopathological aspects (resection margins and lymph nodes).

MATERIAL AND METHOD

Between April 2003 and February 2007, 40 patients diagnosed with distal oesophageal cancer were surgically intervened at Charing Cross Hospital, London, 24 open and 16 by laparoscopy in accordance with the surgeon responsible. Of these, 50% received neoadjuvant chemotherapy. Both groups were homogeneous for age, sex, ASA, tumour stage and tumour location. In all cases, the pathological tumour stage (TNM), the tumour distal margin, tumour proximal margin, tumour circumference and number of resected lymph nodes, were collected in a data base.

RESULTS

The number of resected lymph nodes was similar in both groups; (19 for open and 18 for laparoscopy). The mean distal tumour margin for the group treated by open surgery was 4.9 cm compared to 4.3 in the group treated by laparoscopy (p = 0.578). The mean proximal tumour margin for the group treated by open surgery was 8.4 cm compared to 4.6 cm in the laparoscopy group (p = 0.004) and tumour circumference margin was positive in 11 patients (45%) belonging to the open group compared to 5 patients (33%) in the laparoscopy group (p = 0.519).

CONCLUSIONS

In our experience, laparoscopic surgery for cancer of the oesophagus appears to show similar initial results to those of open surgery as regards the number of resected lymph nodes and resection margins.

A phase II trial of paclitaxel and cisplatin in patients with advanced squamous-cell carcinoma of the esophagus

OBJECTIVE

To evaluate the response rate, survival, and toxicities of paclitaxel plus cisplatin combination in patients with advanced or metastatic squamous-cell carcinoma of the esophagus.

METHODS

Thirty-nine patients with definite measurable indices and no prior chemotherapy were enrolled. Patients were treated with paclitaxel 175 mg/m(2) and cisplatin 75 mg/m(2) by 2-hour infusion on day 1. Treatment was repeated every 21 days.

RESULTS

Thirty-nine patients were enrolled of which 35 patients were eligible to be evaluated to have had a response. The overall response rate was 48.6% [95% confidence interval (CI), 0.31-0.65] with complete and partial response rates of 2.8% and 45.7%, respectively. The median time to progression was 7 months, and median survival time of all patients was 13 months. There was a significant difference in the median overall survival between the patients who had showed response versus those who had not (P = 0.006). Median survival was 17 (95% CI, 11.9-22.0) and 10 months (95% CI, 7.6-12.4), respectively. The 1-year survival probability was 39%. Relief of dysphagia and pain were observed in 86.2% of all the patients. The most common toxicities were neutropenia and alopecia. No grade 4 toxicities and treatment-related deaths were recorded in all patients.

CONCLUSION

Paclitaxel and cisplatin is a promising treatment for patients with squamous-cell carcinoma of the esophagus. The toxicity of this regimen is within acceptable range.

Acute lung injury following an esophagectomy for esophageal cancer, with special reference to the clinical factors and cytokine levels of peripheral blood and pleural drainage fluid

Acute lung injury (ALI) is one of most serious complications to occur after an esophagectomy for esophageal cancer. However, the pathogenesis of ALI is still unclear. The cytokine levels of pleural drainage fluid as well as peripheral blood were measured in 27 patients who had undergone an extended radical esophagectomy. Both the clinical factors and cytokine levels were compared between 11 patients with (group I) and 16 without ALI (group II). ALI occurred more frequently in patients who underwent colon interposition than in those who received a gastric tube reconstruction (86%vs 25%, P = 0.009). The operation time of group I was significantly longer than that of group II. A logistic regression analysis revealed colon interposition to be an independent factor associated with the ALI (P < 0.05). Postoperative anastomotic leakage and systemic inflammatory response syndrome (SIRS) occurred more frequently in group I than in group II (P < 0.01). Both the serum interleukin-6 (IL-6) and IL-8 levels of group I were significantly higher than those of group II. IL-1beta and tumor necrosis factor-alpha were undetectable in the peripheral blood, whereas they were detectable in the pleural effusion. The IL-1beta of pleural effusion was higher in group I than group II. In conclusion, greater surgical stress, such as a longer operative time, is thus considered to be associated with the first attack of ALI. The adverse events developing in the extra-thoracic site, such as necrosis and local infection around anastomosis may therefore be the second attack. Furthermore, ALI may cause not only SIRS but also other complications such as anastomotic leakage.

Feasibility and outcomes of an early extubation policy after esophagectomy

BACKGROUND

Although early extubation of esophagectomy patients has been found to be feasible, safe, and associated with low morbidity, there is no uniform standard of care among high volume centers. Our objective is to examine a contemporary series of esophagectomies and identify the feasibility and outcome of an early extubation policy.

METHODS

This study is a retrospective review of all patients who underwent esophagectomy between January 2003 and December 2004 at the Massachusetts General Hospital. One hundred and two patients were analyzed from 129 consecutive patients who underwent esophagectomy and subsequently divided in two groups: The early extubation group was extubated in the operating room and the late extubation group was extubated in the intensive care unit (ICU).

RESULTS

Ninety percent were extubated early. Although most patients underwent a transthoracic or thoracoabdominal esophagectomy, the operative approach did not influence failure to extubate. Neoadjuvant therapy was not predictive of extubation failure. Most patients age 70 or greater (86%) were extubated early. There were three nonelective reintubations in the early extubation group secondary to acute respiratory distress syndrome. The median length of stay was 11 days and median ICU stay was one day. The 30-day mortality was 1.9% and the median survival was 28 months.

CONCLUSIONS

Attention to restricted intraoperative fluid balance, limited blood loss, anesthetic technique, and epidural use permit most patients undergoing esophageal resection to be safely extubated immediately postresection in the operating room.

Risk analysis in resection of thoracic esophageal cancer in the era of endoscopic surgery

BACKGROUND

Surgical outcomes after thoracoscopic esophagectomy were compared with those after open esophagectomy, and the prognostic values of factors potentially related to mortality and morbidity were evaluated.

METHODS

We performed a retrospective chart review of 153 patients who underwent esophagectomy for thoracic esophageal cancer. The thoracic surgical procedures were categorized into the following three groups: esophagectomy under standard thoracotomy (n = 37), assisted thoracoscopic esophagectomy with utility minithoracotomy (n = 38), and complete thoracoscopic esophagectomy (n = 78). Mortality and morbidity were compared among the three groups. Then, in a separate multivariate analysis, data on 14 potentially prognostic variables were extracted, and the relation to postoperative outcomes was examined.

RESULTS

Respiratory complications were the most frequent complications in all three groups, and their rate of occurrence was not significantly among the three groups. The 30-day and in-hospital mortality rates were significantly higher in the open group than in the other groups. Multivariate analysis demonstrated that patient age, sex, induction chemoradiation, and forced expiratory volume were independently significant contributing factors for respiratory complications, while the serum total protein concentration and open esophagectomy were significant factors for in-hospital mortality.

CONCLUSIONS

Our results demonstrated that respiratory complications are still the main cause of operative morbidity when using the thoracoscopic esophagectomy protocol and that use of the thoracoscopic procedure does not decrease the risk of respiratory complications. The use of the thoracoscopic procedure improved postoperative in-hospital mortality. The advantages of thoracoscopic esophagectomy should be investigated further. At this point in time, however, thoracoscopic esophagectomy can be considered a feasible, safe, and advantageous surgical option.

Minimally Invasive Esophagectomy: Early Experience and Outcomes

Minimally invasive esophageal surgery has the potential to improve mortality, hospital stay, and functional outcomes when compared with open methods. Although technically complex, combined laparoscopic and thoracoscopic esophageal resection is feasible. A case series of 20 patients who underwent minimally invasive total esophagectomy is presented. This study was a review of a prospective database. The purpose was to evaluate early results with laparoscopic total esophagectomy for benign and malignant disease. Between January 2003 and November 2005, 20 patients underwent minimally invasive esophageal surgery. All operations were performed by the same two surgeons. Age, gender, indications for surgery, pathologic stage, operative time, blood loss, transfusion requirements, intensive care unit length of stay, hospital length of stay, postoperative complications, and mortality were recorded. Diet progression, dysphagia, and need for stricture management were also recorded. Of the 20 minimally invasive total esophagectomies performed, 18 (90%) were completed successfully. The average age of the patients was 53 years. Indications for surgery were malignancy (n = 13), carcinoma in situ in the setting of Barrett's esophagus (n = 2), and benign stricture (n = 3). The average operating time was 467 minutes (range 346–580 min). Median blood loss was 350 mL (range 150–500 mL). The median intensive care unit stay was 2 days, and the median hospital length of stay was 12 days. Pathology revealed that 7 per cent of patients had stage I disease, 27 per cent of patients had stage II disease, and 53 per cent of patients had stage III disease. There was a single mortality (5%), a cervical leak in two patients (10%), a gastric tip necrosis in one patient (5%), and tracheoesophageal fistula in one patient (5%). Major complications occurred in eight patients (40%) and minor complications in nine (50%). Thirteen (72%) patients were discharged on enteral tube feeds to supplement caloric intake. The application of minimally invasive techniques in the arena of esophageal surgery continues to evolve. This approach has the potential to improve mortality, hospital stay, and other outcomes when compared with open methods. Although technically complex, laparoscopic total esophagectomy is feasible.

Cancer of the esophagus: the value of preoperative patient assessment

In the past few years, major improvements and new technologies have been proposed and applied in esophageal surgery. Its evolution depended not only on a thorough knowledge of surgical anatomy and technique, but also on important developments in pre- and postoperative care. Esophageal resection for cancer is still associated with high morbidity and mortality. Postoperative complications may be either patient or surgeon related. Patient-related factors include age, malnutrition, immunodepression and associated diseases. The surgeon-related factors are surgical experience, hospital volume and multidisciplinary approach. Preoperative evaluation is defined as the process of clinical assessment that precedes the delivery of anesthesia. The principle is to gain information concerning patients that leads to modification of their management, and improves the outcome from surgery.

Clinicopathologic comparison of Siewert type II and III adenocarcinomas of the gastroesophageal junction

BACKGROUND

Since Misumi et al. and Siewert proposed a new classification for carcinoma of the gastroesophageal junction (GEJ), few surgical studies using these criteria have been reported from Eastern countries. Siewert type II adenocarcinomas are managed using general rules for either gastric or esophageal cancer. We set out to determine whether type II adenocarcinoma is a distinct clinical entity requiring a more specific treatment plan.

METHODS

Among 125 Japanese patients who underwent resection of adenocarcinoma of the GEJ (type I, 2; type II, 44; type III, 79), 101 who underwent R0 resections (type II, 40; type III, 61) were analyzed to evaluate surgical results and compare clinicopathologic factors.

RESULTS

Barrett's epithelium was recognized in two patients with type II adenocarcinoma. Type II differed significantly from type III in higher prevalence of Borrmann macroscopic type 2, more frequent lymph node metastasis (58% vs. 34%), higher metastatic rate to lower mediastinal lymph nodes (13%), increased risk of hepatic recurrence, and lower 5-year survival after R0 resection (67.4% vs. 87.1%).

CONCLUSIONS

Clinicopathologic differences were evident between type II and III adenocarcinomas. Siewert type II adenocarcinoma differs sufficiently to be considered a clinical entity distinct and independent from type III.

Robotic-assisted transhiatal esophagectomy

BACKGROUND

Despite its reduced aggressiveness and excellent results obtained in certain diseases, minimally invasive surgery did not manage to significantly lower the risks of esophageal resections. Further advances in technology led to the creation of robotic systems with their unique maneuverability of the instruments and exceptional view on the operative field, thus setting the prerequisites for performance in complex surgical procedures and offering new possibilities to a disease notorious for its dismal prognosis.

MATERIALS AND METHODS

The robotic-assisted transhiatal esophagectomy technique was used in a patient with squamous cell carcinoma of the lower esophagus that had high medical risk for surgical therapy.

RESULTS

Esophageal resection and reconstruction were possible through a robotic-assisted minimally invasive transhiatal approach. There were no intraoperative incidents, blood loss was minimal, and lymph node dissection and removal was possible during the procedure. Early ambulation and conservative treatment of the mild complications that occurred offered a favorable postoperative outcome.

CONCLUSION

The robotic-assisted transhiatal esophagectomy technique is feasible and safe. Complex procedures become less technically demanding with the help of the robotic system and, thus, the minimally invasive approach can be offered for the benefit of selected patients. Further studies are required to confirm these observations and to establish the role of this procedure in the future.

The Influence of Technical Complications on Postoperative Outcome and Survival After Esophagectomy

BACKGROUND

The dismal survival associated with esophagectomy for cancer has led to the search for potentially correctable factors responsible for this poor prognosis. Although it is intuitive that technical complications could increase postoperative mortality, the effect on long-term survival is controversial.

METHODS

From 1990 to 2002, 434 patients underwent resection for squamous cell carcinoma of the intrathoracic esophagus. Prospectively collected data were reviewed for the presence of technical complications. Patient, tumor, and operative variables, postoperative outcome, and survival were compared between patients with technical complications and those without. Prognostic factors were assessed by multivariate analysis.

RESULTS

Technical complications occurred in 98 (22.6%) patients. Patients with technical complications had a higher prevalence of cardiac disease, more proximal tumors, and more cervical anastomoses. Technical complications were associated with an increased rate of pulmonary complications (37.8% vs. 10.7%; P<.001) and increased hospital mortality (9.2% vs. 3.3%; P=.025), but no difference in 30-day mortality (2% vs. 1.2%; P=.6). Poor-prognostic factors for survival included male sex, stage III/IV disease, cirrhosis, proximal tumors, and R1/R2 resection, but not technical complications.

CONCLUSIONS

Although immediate postoperative outcome and hospital mortality rates were increased, no effect on long-term survival was seen in patients with complications related to errors in surgical technique.

Surgery and clinicopathological features of gastric adenocarcinoma involving the esophago-gastric junction

To clarify the optimal operative procedure for gastric adenocarcinoma involving the esophago-gastric junction (EGJ), we investigated 49 cases with an upper gastric cancer invading the esophagus who underwent surgical treatment in our department during the period from 1991 to 2000. According to Siewert's classification, there were 21 cases with a type II tumor, and 28 cases with a type III tumor. Twenty-five cases underwent surgery through an abdominal approach only. The remaining 24 cases were operated on via a left thoraco-abdominal approach. Eight (33%) of 24 cases who underwent extended lymphadenectomy through a left thoraco-abdominal approach had lower mediastinal lymph node metastasis. Metastasis was observed in cases with cancer invasion more than 2 cm from the EGJ. There were 6 cases with a T1 tumor, 6 with a T2 tumor, 27 with a T3 tumor, and 10 with a T4 tumor. Incidences of lymph node metastasis were 0% for T1, 67% for T2, 81% for T3, and 80% for T4. Proximal gastrectomy was performed in 6 cases at the early stage and in 10 cases at the advanced stage with distant metastasis (M1). Total gastrectomy was done in 33 cases at the advanced stage, and 3 of these 33 cases had metastasis to the parapyloric lymph nodes. We performed combined resection of the body and tail of the pancreas and the spleen in 7 cases. One of these 7 cases had direct invasion to the pancreas and 6 cases had remarkable metastasis to the lymph nodes along the splenic artery. Splenectomy preserving the pancreas was done in 24 cases. The incidences of metastasis of the lymph nodes along the splenic artery and the splenic hilum were 25% and 17%, respectively. We performed partial resection of the diaphragm surrounding the esophageal hiatus in 15 cases through a left thoraco-abdominal approach. Six cases had metastasis to the diaphragm and nine cases had direct invasion to the diaphragm. Tumors were stage I in 8 cases, II in 5 cases, III in 13 cases and IV in 23 cases, and the curability was categorized as A in 8 cases, B in 20 and C in 21. The overall 5-year-survival rate was 25%, and the rates according to cancer stage were 86% for stage I, 40% for stage II , 21% for stage III and 0% for stage IV. The 5-year survival rates of cases at stage II and III were 33% for cases using the left thoraco-abdominal approach and 28% for cases with the abdominal approach. Based on these results, we recommend distal esophagectomy with total gastrectomy, and occasional combined resection of the spleen and the diaphragm through a left thoraco-abdominal approach for advanced gastric adenocarcinoma involving the EGJ.

Epidemiology of esophageal adenocarcinoma

The incidence of esophageal adenocarcinoma has risen rapidly over the past 25 years in the United States as well as in several Western European countries. This increase had been most dramatic among white males. The majority of these cancers arise from a background of premalignant Barrett esophagus. However, less than 10% of the patients with esophageal adenocarcinoma were known to have Barrett esophagus previously. It is uncertain which risk factors contribute to the increasing incidence of esophageal adenocarcinoma, although gastroesophageal reflux disease, cigarette smoking, and obesity have been implicated. Whereas infection with Helicobacter pylori and use of non-steroidal anti-inflammatory drugs are associated with reduced risk, low intakes of fruit, vegetables, and cereal fibers seem to increase the risk of esophageal adenocarcinoma. Presently there is no evidence that strongly supports any specific strategy to screen a subgroup of the population at risk for Barrett esophagus and adenocarcinoma of the esophagus.

Low-dose steroid therapy at an early phase of postoperative acute respiratory distress syndrome

BACKGROUND

The acute respiratory distress syndrome (ARDS) that develops after thoracic surgery is usually lethal. The use of corticosteroids to treat ARDS has been the subject of great controversy.

METHODS

Therefore we compared conventional therapy with early low-dose steroid therapy in the treatment of postoperative ARDS. Methylprednisolone was given daily as an intravenous push every 6 hours and was changed to a single oral dose or discontinued, with a loading dose of 2 mg/kg followed by 2 mg/kg per day.

RESULTS

Over 2.5 years, 523 major thoracic operations were performed with postoperative ARDS developing in 20 patients (3.8%), of which 8 were treated with conventional therapy and 12 with early low-dose steroid therapy. Early low-dose steroid therapy significantly reduced postoperative mortality, with 7 patients (58.3%) recovering without mechanical ventilation.

CONCLUSIONS

We believe this is the first clinical study of low-dose methylprednisolone at an early phase of postoperative ARDS. The beneficial effects of the use of early low-dose steroids in ARDS are consistent with the hypothesis that fibroproliferation is an early response to lung injury, which is inhibited by early low-dose steroid therapy without disturbing operative wound healing.

Mortality and morbidity after resection for adenocarcinoma of the gastroesophageal junction: predictive factors

BACKGROUND

Resection for adenocarcinoma of the gastroesophageal junction (AGEJ) is associated with severe mortality and morbidity. This retrospective study aimed to evaluate mortality and morbidity after resection for AGEJ and to determine their predictive factors.

STUDY DESIGN

Data from 1,192 patients (mean age 65 +/- 11 years) who underwent resection for AGEJ by members of French Association of Surgery from 1985 to 2000 were collected. A stepwise logistic regression model was built to identify by multivariate analysis the variables independently associated with mortality, morbidity, anastomotic leakage, and major pulmonary complications.

RESULTS

Distribution of Siewert's type was: I = 480 (40%), II = 500 (42%), and III = 212 (18%). Most type I and II tumors were treated by esophagectomy and proximal gastrectomy (93% and 58%, respectively), using an approach including a thoracotomy (82% and 64%, respectively); type III tumors were treated mainly by total gastrectomy and distal esophagectomy (83%), through an exclusive transabdominal approach (69%). Seventy-six (6%) patients died postoperatively. Only American Society of Anesthesiologists (ASA) scores III and IV (p < 0.001) and period of study (p = 0.025) were predictive of mortality. Predictive factors of overall morbidity (overall rate = 35%) were high ASA score (p < 0.001), age more than 60 years (p = 0.020), male gender (p = 0.039), and cervical anastomosis (p = 0.001). Factors predictive of anastomotic leakage (overall rate = 9%) were high ASA score (p = 0.006) and manual anastomosis (p = 0.010). Factors predictive of major pulmonary complications (overall rate = 23%) were high ASA score (p = 0.015), age more than 60 years (p < 0.001), anastomotic leakage (p < 0.001), and abdominal complications (p = 0.003).

CONCLUSIONS

ASA score is a reliable predictive factor of operative mortality and morbidity after resection of AGEJ.

Minimally invasive esophagectomy

Minimally invasive esophagectomy can be safely performed in selected cases in centers specializing in minimally invasive esophageal surgery.Potential benefits include lessened physiologic insult, with decreased hospital stay and a more rapid recovery to full activity. Drawbacks include the cost of the disposable instrumentation and the steep learning curve. As thoracic surgeons continue to acquire expertise with this procedure, improved results may be expected. Prospective trials with longer follow-up will be required to confirm any advantages of MIE over conventional approaches. Open surgical approaches should remain the standard operation for esophagectomy in most institutions.

Bi-weekly chemotherapy of paclitaxel and cisplatin in patients with metastatic or recurrent esophageal cancer

Although various combinations of chemotherapy regimens have been tried for patients with esophageal cancer, their duration of survival is extremely poor. In this study, we investigated the safety and clinical efficacy of paclitaxel and cisplatin chemotherapy in metastatic or recurrent esophageal cancer. 32 patients enrolled in this study and the median age was 60 yr. Of all the 32, 28 patients (88%) had been treated previously, 22 of them with chemotherapy or radiation therapy. All patients in the study received biweekly paclitaxel (90 mg/m(2)) followed by cisplatin (50 mg/m(2)). One patient (3%) responded completely, and 12 patients (38%) showed a partial response; in 9 patients (28%) the disease remained stable, and in 10 patients (31%) it progressed. The objective response rate was 41%. The median duration of response was 4.8 months, and the median overall survival in all patients was 7 months. The 1-yr and 2-yr survival rates were 28.1% and 7.1%, respectively. Grade 3 or 4 of neutropenia and anemia were observed in 6 (19%) and 5 (16%) patients, respectively. The major non-hematologic toxicity was fatigue, but most of them could manageable. In conclusion, biweekly paclitaxel and cisplatin is effective in patients with metastatic or recurrent esophageal cancer.

Transthoracic or transhiatal resection for middle- and lower-third esophageal carcinoma?

Transthoracic esophagectomy (TTE) and transhiatal esophagectomy (THE) are two common methods of resection for esophageal cancer. Although many studies have been performed in Western countries, there are still controversies over which method is the better procedure. In this study, postoperative improvement in dysphagia and the degree of postoperative pain were compared. The cases of 50 patients undergoing TTE and 23 undergoing THE for esophageal cancer between March 1997 and October 2002 were retrospectively reviewed. The location of the lesion, clinical stage (TNM), operative time, operative blood loss, hospital stay, complications, number of lymph nodes dissected, and survival duration were recorded. Pre- and postoperative dysphagia scores and postoperative pain perception (using a visual analog scale) were analyzed. Preoperative clinical stage and lesion site were not significantly different in the TTE and THE groups. The operative time was longer and the number of lymph nodes removed was larger in the TTE group. However, there were no differences in operative blood loss, hospital stay, complications, survival duration, and improvement in dysphagia. Pain perception in the THE group was significantly better than that in the TTE group. THE is a safe and rapid procedure, with recovery and survival periods similar to those for TTE. Both patient groups enjoyed the same ability to eat. Therefore, THE is an acceptable alternative to TTE for patients with middle- and lower-third esophageal cancer. Moreover, THE caused much less postoperative pain than TTE, which made patients more comfortable.

Outcome of surgical treatment for early adenocarcinoma of the esophagus or gastro-esophageal junction

Adenocarcinoma of the esophagus, or GEJ, has a poor prognosis. Early lesions [i.e. high grade dysplasia (HGD) or T1-carcinoma] are potentially curable. Local endoscopic therapies are promising treatment options for superficial lesions; however, for deeper lesions, surgical resection is considered to be the treatment of choice. To contribute to therapeutic decision-making, we retrospectively analysed the outcome of transhiatal esophagectomy in 120 patients with pathologically proven HGD (n=13) or T1-adenocarcinoma (n=107) of the distal esophagus or gastro-esophageal junction (GEJ). Tumors were subdivided into six different depths of invasion ('T1-mucosal' m1-m3, 'T1-submucosal' sm1-sm3), and the frequency of lymphatic dissemination and time to locoregional and/or distant recurrence were analysed. Only one of the 79 T1m1-3/sm1 tumors (1%) showed lymph node metastases as compared with 18 out of 41 T1sm2-3 tumors (44%). There was a significant difference in recurrence-free period between T1m1-m3/sm1 versus T1sm2-sm3 tumor patients (P log rank <0.0001), with 5-year recurrence-free percentages of 97% and 57%, respectively. In multivariate analysis including age, gender, tumor differentiation grade, N-stage and depth of invasion, only N-stage was an independent prognostic factor for recurrence-free period (hazard rate=5.9, 95% CI 1.7-20.7). However, if N-stage was excluded from analysis, only depth of invasion (T1sm2-3 versus T1m1-m3/sm1) was an independent prognostic factor for recurrence-free period (hazard rate=7.5, 95% CI 2.0-27.7). These data indicate that T1m1-m3/sm1 adenocarcinomas of esophagus or GEJ show a very low risk of lymphatic dissemination and are therefore eligible for local endoscopic therapy. After transhiatal surgical resection, almost half of the patients with T1sm2-sm3 lesions develop recurrent disease within 5 years, and therefore need additional therapy to improve survival.

Systemic treatment for oesophageal cancer

Oesophageal cancer, in particular adenocarcinomas, has shown a rapid and largely unexplained increase in incidence in the Western world. Despite advances in diagnostic and surgical techniques and improved pre- and postoperative care, the prognosis of most patients is poor. This Review will focus on the use of chemotherapy as part of multimodal treatment and for patients with metastatic disease. Randomised phase III trials have, for the most part, failed to demonstrate a survival advantage with the use of chemotherapy. It must be emphasised that many of these phase III trial were underpowered and do not meet today's standards. Recent phase II trials have suggested some progress when chemotherapy is incorporated into the management of patients with oesophageal cancer. However, confirmatory and adequately powered and designed phase III studies are urgently needed to improve patient outcomes and for better palliation of symptoms.

Effect of prostaglandin E1 on inflammatory responses and gas exchange in patients undergoing surgery for oesophageal cancer

BACKGROUND

Oesophageal surgery causes morbidity and mortality from respiratory complications. We tested the possibility that prostaglandin E1 (PGE1) could reduce inflammatory cytokine responses and improve gas exchange after oesophagectomy.

METHODS

We randomized 14 patients into two groups. One group received PGE1 20 ng kg(-1) min(-1) i.v. during anaesthesia (PGE1 group) and the other group did not (control group). Anaesthesia was maintained with sevoflurane and epidural anaesthesia. During oesophagectomy, ventilation of one lung was carried out with a double-lumen bronchial tube. The patients were extubated on or after the first postoperative day. Blood samples were taken at induction of anaesthesia, at the end of thoracotomy, at the end of the operation, 2 h after surgery and on the first day after surgery.

RESULTS

The groups were similar for ASA physical status, age, FEV1%, operation time, duration of thoracotomy, intraoperative fluid volume and blood loss. The arterial blood gas and arterial pressure during surgery were also similar in the PGE1 and control groups. However, the PaO2/FiO2 ratio on the first day after surgery was significantly greater in the PGE1 group compared with the control group. Serum concentrations of IL-6 and IL-8 increased after surgery in both groups. IL-6 was significantly less in the PGE1 group at the end of the operation and 2 h after the operation.

CONCLUSIONS

Intraoperative PGE1 reduced IL-6 production in patients undergoing oesophagectomy and oxygenation was better in the postoperative period.

Improved survival for patients with upper and/or middle mediastinal lymph node metastasis of squamous cell carcinoma of the lower thoracic esophagus treated with 3-field dissection

OBJECTIVE

To evaluate the outcomes with 2 and 3 lymph node dissection for patients with squamous cell carcinoma of the lower thoracic esophagus at a single institution.

BACKGROUND

Extensive lymph node dissection, including the upper mediastinum, for carcinoma of the lower thoracic esophagus is advocated as a standard surgical procedure with curative intent in Japan. However, its efficacy remains controversial.

METHODS

From January 1988 to December 1997, 532 patients with carcinomas of the thoracic esophagus underwent transthoracic esophagectomy and extensive lymph node dissection with curative intent at the National Cancer Center Hospital, Tokyo. Of these, 495 (93%) had squamous cell carcinomas. A total of 156 (29%) with tumors of the lower thoracic esophagus were retrospectively analyzed.

RESULTS

Of the 156 patients, 55 (35%) underwent 2-field and 101 (65%) underwent 3-field lymph node dissection. The operative morbidity and 30-day and in-hospital mortality rates were 68.0%, 1.3%, and 2.6%, respectively. The overall 5-year survival rate for the entire series was 49.3%. One hundred and seven (69%) had lymph node metastases. Upper and/or middle mediastinal lymph node metastases occurred in 42% of the series. The 5-year survival rate for patients with lymph node metastases in the upper and/or middle mediastinum was 23.3%. Among them, the values after 2- and 3-field lymph node dissection were 5.6% and 30.0%, respectively (P = 0.005). Thirteen (27%) of 48 patients with upper and/or middle mediastinal lymph node metastases treated with 3-field dissection had simultaneous cervical lymph node metastases and their 5-year survival rate was 23.1%.

CONCLUSION

The 3-field approach for extensive lymph node dissection provides better survival benefit for patients with squamous cell carcinoma of the lower thoracic esophagus compared to 2-field lymph node dissection when lymph node metastases are present in the upper and/or middle mediastinum.