Esophagectomy without mortality: what can surgeons do?

Endoscopic methods in the treatment of early-stage esophageal cancer

Most patients with early esophageal cancer restricted to the mucosa may be offered endoscopic therapy, which is similarly effective, less invasive and less expensive than esophagectomy. Selection of appropriate relevant treatment and therapy methods should be performed at a specialized center with adequate facilities. The selection of an endoscopic treatment method for high-grade dysplasia and early-stage esophageal adenocarcinoma requires that tumor infiltration is restricted to the mucosa and that there is no neighboring lymph node metastasis. In squamous cell carcinoma, this treatment method is accepted in cases of tumors invading only up to the lamina propria of mucosa (m2). Tumors treated with the endoscopic method should be well or moderately differentiated and should not invade lymphatic or blood vessels. When selecting endoscopic treatments for these lesions, a combination of endoscopic resection and endoscopic ablation methods should be considered.

Seamless vascularized large-diameter tubular collagen scaffolds reinforced with polymer knittings for esophageal regenerative medicine

A clinical demand exists for alternatives to repair the esophagus in case of congenital defects, cancer, or trauma. A seamless biocompatible off-the-shelf large-diameter tubular scaffold, which is accessible for vascularization, could set the stage for regenerative medicine of the esophagus. The use of seamless scaffolds eliminates the error-prone tubularization step, which is necessary when emanating from flat scaffolds. In this study, we developed and characterized three different types of seamless tubular scaffolds, and evaluated in vivo tissue compatibility, including vascularization by omental wrapping. Scaffolds (luminal Ø ∼ 1.5 cm) were constructed using freezing, lyophilizing, and cross-linking techniques and included (1) single-layered porous collagen scaffold, (2) dual-layered (porous+dense) collagen scaffold, and (3) hybrid scaffold (collagen+incorporated polycaprolacton knitting). The latter had an ultimate tensile strength comparable to a porcine esophagus. To induce rapid vascularization, scaffolds were implanted in the omentum of sheep using a wrapping technique. After 6 weeks of biocompatibility, vascularization, calcification, and hypoxia were evaluated using immunohistochemistry. Scaffolds were biocompatible, and cellular influx and ingrowth of blood vessels were observed throughout the whole scaffold. No calcification was observed, and slight hypoxic conditions were detected only in the direct vicinity of the polymer knitting. It is concluded that seamless large-diameter tubular collagen-based scaffolds can be constructed and vascularized in vivo. Such scaffolds provide novel tools for esophageal reconstruction.

Optimal management of Barrett's esophagus: pharmacologic, endoscopic, and surgical interventions

Esophageal adenocarcinoma and its precursor, Barrett’s esophagus, are rapidly rising in incidence. This review serves to highlight the role of pharmacologic, endoscopic, and surgical intervention in the management of Barrett’s esophagus, which requires acid suppression and endoscopic assessment. Treatment with a proton pump inhibitor may decrease acid exposure and delay the progression to dysplasia. Patients who require aspirin for cardioprotection or other indications may also benefit in terms of a protective effect against the development of esophageal cancer. However, without other indications, aspirin is not indicated solely to prevent cancer. A careful endoscopic examination should include assessment of any visible lesions in a Barrett’s segment. An expert gastrointestinal pathologist should confirm neoplasia in the setting of Barrett’s esophagus. For those patients with high-grade dysplasia or intramucosal carcinoma, careful consideration of endoscopic therapy or surgical therapy must be given. All visible lesions in the setting of dysplasia should be targeted with focal endoscopic mucosal resection for both accurate histopathologic diagnosis and treatment. The remainder of the Barrett’s epithelium should be eradicated to address all synchronous and metachronous lesions. This may be done by tissue acquiring or nontissue acquiring means. Radiofrequency ablation has a positive benefit-risk profile for flat Barrett’s esophagus. At this time, endoscopic therapy is not indicated for nondysplastic Barrett’s esophagus. Esophagectomy is still reserved for selected cases with evidence of lymph node metastasis, unsuccessful endoscopic therapy, or with high-risk features of high-grade dysplasia or intramucosal carcinoma.

Adenocarcinoma of the esophagogastric junction: neoadjuvant radiochemotherapy and radical surgery : early results and toxicity

PURPOSE

To retrospectively evaluate treatment results and toxicity following a combined approach consisting of neoadjuvant radiochemotherapy and radical surgery in advanced adenocarcinoma of the esophagus and gastroesophageal junction.

PATIENTS AND METHODS

Between 2005 and 2009, a total of 41 consecutive patients with newly diagnosed nonmetastatic adeno-carcinoma of the esophagus and the esophagogastric junction were evaluated, of whom 23 received neoadjuvant radiochemo-therapy (RCT). A total dose of 50.4 Gy with 2 cycles of simultaneous cisplatin/5-fluorouracil (FU) or Taxol/FU-chemotherapy were applied. A radical transthoracic subtotal esophageal and proximal gastric resection through a right thoracoabdominal laparotomy with intrathoracic anastomosis was performed 6-8 weeks following RCT. This was combined with a two-field lymphadenectomy of mediastinal and abdominal lymph nodes. Standard histopathological evaluation included the application of regression grading according to Werner and Höfler. Toxicity was recorded on the basis of CTC criteria; survival curves were calculated according to Kaplan-Meier. V10, V15, and V20 data were correlated with pulmonary toxicity.

RESULTS

Overall survival for all 23 patients was 61% at 3 years. Of the original 23 patients, 18 (78%) patients proceeded to radical surgery. Reasons for no surgery included advanced age of 79, 82, and 86 years (n = 3), severe comorbidity (n = 1), and progression during radiochemotherapy (n = 1). Surgical morbidity (grade 3-4) and mortality rates were 35% and 6%, respectively. Resurgery was necessary in 3 cases (18%). Clear resection margins were achieved in 17 of 18 patients (94%). Twelve of 18 (67%) patients initially diagnosed with T3 tumors and 3 of 3 patients with T4 tumors experienced downstaging. The ypN0 rate was 12 of 18 patients (67%). Out of a total of 18 patients, regression grading revealed < 10% viable cells in 8 (44%) including 3 cases (17%) with complete regression, 10-50% viable cells in 9 (50%) and > 50% viable cells in 1 patient. During the postoperative course or thereafter, 8 of 23 (35%) patients experienced pulmonary complications including pneumonia and/or pneumonitis. V10 > 20% (p = 0.019), V15 > 13% (p = 0.008), and V20 > 10% (p = 0.008) were associated with a significant increase in the rate of pulmonary toxic effects.

CONCLUSION

Neoadjuvant radiochemotherapy in patients with advanced adenocarcinoma of the esophagogastric junction followed by thoracoabdominal surgery is a feasible concept. Significant tumor regression in 44% of the patients and an ypN0 rate in 67% of the patients may favor this approach due to its high efficacy. However, to avoid toxic pulmonary effects constraints for low-dose radiation volume parameters need specific attention.

Esophageal resection for high-grade dysplasia and intramucosal carcinoma: When and how?

High-grade dysplasia (HGD) and intramucosal carcinoma (IMC) in the setting of Barrett’s esophagus have traditionally been treated with esophagectomy. However, with the advent of endoscopic mucosal resection and endoscopic ablative therapies, endoscopic therapy at centers with expertise is now an established treatment of Barrett’s-esophagus-related neoplasia, including HGD and IMC. Esophagectomy is today reserved for more selected cases with submucosal invasion, evidence for lymph node metastasis, or unsuccessful endoscopic therapy.

Effect of preoperative single-dose corticosteroid administration on postoperative morbidity following esophagectomy

BACKGROUND

Eight clinical trials involving the administration of preoperative i.v. methylprednisolone have been undertaken in order to decrease the considerable inflammatory response to esophageal resection, in an effort to decrease the supposedly associated morbidity and mortality

METHOD

A meta-analysis was performed for eight clinical end-points. Due to quality problems in seven of the eight included studies, a Bayesian meta-analysis using a skeptical prior derived from the results of the classical analysis was also performed.

RESULTS

The end-points including any organ dysfunction (OR = 0.30), respiratory complication (OR = 0.41), sepsis (OR = 0.37), liver dysfunction (OR = 18), cardiovascular dysfunction (OR = 0.28), and surgical anastomotic leak (OR = 0.42) were significantly decreased by methylprednisolone pretreatment. Following the Bayesian analysis, despite the use of skeptical priors, there is a 95% probability to obtain a relative risk reduction of at least 23% to 54%, depending of the end-point, by methylprednisolone pretreatment.

CONCLUSION

We are in the presence of a potential benefit that cannot be accepted at face value due to the quality problems of the included studies. But in the presence of a remaining potential benefit after a Bayesian analysis starting from a skeptical prior, the best option would be the planning of a large multicenter prospective randomized study.