Comparison of robotic-assisted minimally invasive esophagectomy versus minimally invasive esophagectomy: A propensity-matched study from a single high-volume institution

OBJECTIVE

Robotic-assisted minimally invasive esophagectomy accounts for a growing proportion of esophagectomies, potentially due to improved technical capabilities simplifying the challenging aspects of standard minimally invasive esophagectomy. However, there is limited evidence directly comparing both operations. The objective is to evaluate the short-term and long-term outcomes of robotic-assisted minimally invasive esophagectomy in comparison with the minimally invasive esophagectomy approach for patients with esophageal cancer over a 7-year period at a high-volume center. The primary end points of this study were overall survival and disease-free survival. Secondary end points included operation-specific morbidity, lymph node yield, readmission status, and in-hospital, 30-day, and 90-day mortality.

METHODS

Patients who underwent robotic-assisted minimally invasive esophagectomy or standard minimally invasive esophagectomy over a 7-year period were identified from a prospectively maintained database. Inclusion criteria were patients with stage I to III disease, operations performed past the learning curve, and no evidence of scleroderma or cirrhosis. A 1:3 propensity match (robotic-assisted minimally invasive esophagectomy:minimally invasive esophagectomy) for multiple clinical covariates was performed to identify the final study cohort. Perioperative outcomes were compared between the 2 operations.

RESULTS

A total of 734 patients undergoing minimally invasive esophagectomy (n = 630) or robotic-assisted minimally invasive esophagectomy (n = 104) for esophageal cancer were identified. After exclusions and matching, a total cohort of 246 patients undergoing robotic-assisted minimally invasive esophagectomy (n = 65) or minimally invasive esophagectomy (n = 181) were identified. There was no difference in overall survival (P = .69) or disease-free survival (P = .70). There were no significant differences in rates of major morbidity: pneumonia (17% vs 17%, P = .34), chylothorax (8% vs 9%, P = .95), recurrent laryngeal nerve injury (0% vs 1.5%, P = 1), anastomotic leak (5% vs 4%, P = .49), intraoperative complications (9% vs 8%, P = .73), or complete resection rates (99% vs 96%, P = .68). There was no difference in in-hospital (P = .89), 30-day (P = .66) or 90-day mortality (P = .73) between both cohorts. The robotic-assisted minimally invasive esophagectomy cohort yielded a higher median lymph node harvest in comparison with the minimally invasive esophagectomy cohort (32 vs 29, P = .02).

CONCLUSIONS

Robotic-assisted minimally invasive esophagectomy may improve lymphadenectomy in patients undergoing esophagectomy for cancer. Minimally invasive esophagectomy and robotic-assisted minimally invasive esophagectomy are otherwise associated with similar mortality, morbidity, and perioperative outcomes. Further prospective study is required to investigate whether improved lymph node resection may translate to improved oncologic outcomes.

Evaluation of electromagnetic navigational bronchoscopic biopsy of lung lesions performed by a thoracic surgical service

BACKGROUND

With the increasing use of computed tomography scans for lung cancer screening and surveillance of other cancers, thoracic surgeons are being referred patients with lung lesions for biopsies. Electromagnetic navigational bronchoscopy-guided lung biopsy is a relatively new technique for bronchoscopic biopsy. Our objective was to evaluate the diagnostic yields and safety of electromagnetic navigational bronchoscopy-guided lung biopsy.

METHODS

We conducted a retrospective review of patients who underwent an electromagnetic navigational bronchoscopy biopsy, performed by a thoracic surgical service, and evaluated its safety and diagnostic accuracy.

RESULTS

In total, 110 patients (men 46, women 64) underwent electromagnetic navigational bronchoscopy sampling of pulmonary lesions (n = 121; median size 27 mm; interquartile range 17-37 mm). There was no procedure-related mortality. Pneumothorax requiring pigtail drainage occurred in 4 patients (3.5%). Ninety-three (76.9%) of the lesions were malignant. Eighty-seven (71.9%) of the 121 lesions had an accurate diagnosis. Accuracy increased with increased lesion size (P = .0578) with a yield of 50% for lesions <2 cm, increasing to 81% for lesions ≥2 cm. The lesions that demonstrated a positive "bronchus sign" had a yield of 87% (45/52) compared with 61% (42/69) in lesions with a negative "bronchus sign" (P = .0359).

CONCLUSION

Thoracic surgeons can perform electromagnetic navigational bronchoscopy safely, with minimal morbidity and with good diagnostic yields. Accuracy increases with the presence of a bronchus sign and increasing lesion size. Patients with larger tumors and the bronchus sign may be candidates for this approach to biopsy. Further work is required to define the role of electromagnetic navigational bronchoscopy in the diagnosis of pulmonary lesions.

State of the Art in Lung Nodule Localization

Lung nodule and ground-glass opacity localization for diagnostic and therapeutic purposes is often a challenge for thoracic surgeons. While there are several adjuncts and techniques in the surgeon's armamentarium that can be helpful, accurate localization persists as a problem without a perfect solution. The last several decades have seen tremendous improvement in our ability to perform major operations with minimally invasive procedures and resulting lower morbidity. However, technological advances have not been as widely realized for lung nodule localization to complement minimally invasive surgery. This review describes the latest advances in lung nodule localization technology while also demonstrating that more efforts in this area are needed.

Pleural dye marking of lung nodules by electromagnetic navigation bronchoscopy

INTRODUCTION

Electromagnetic navigation bronchoscopy (ENB)-guided pleural dye marking is useful to localize small peripheral pulmonary nodules for sublobar resection.

OBJECTIVE

To report findings on the use of ENB-guided dye marking among participants in the NAVIGATE study.

METHODS

NAVIGATE is a prospective, multicentre, global and observational cohort study of ENB use in patients with lung lesions. The current subgroup report is a prespecified 1-month interim analysis of ENB-guided pleural dye marking in the NAVIGATE United States cohort.

RESULTS

The full United States cohort includes 1215 subjects from 29 sites (April 2015 to August 2016). Among those, 23 subjects (24 lesions) from seven sites underwent dye marking in preparation for surgical resection. ENB was conducted for dye marking alone in nine subjects while 14 underwent dye marking concurrent with lung lesion biopsy, lymph node biopsy and/or fiducial marker placement. The median nodule size was 10 mm (range 4-22) and 83.3% were <20 mm in diameter. Most lesions (95.5%) were located in the peripheral third of the lung, at a median of 3.0 mm from the pleura. The median ENB-specific procedure time was 11.5 minutes (range 4-38). The median time from dye marking to resection was 0.5 hours (range 0.3-24). Dye marking was adequate for surgical resection in 91.3%. Surgical biopsies were malignant in 75% (18/24).

CONCLUSION

In this study, ENB-guided dye marking to localize lung lesions for surgery was safe, accurate and versatile. More information is needed about surgical practice patterns and the utility of localization procedures.

Factors influencing recurrence following anatomic lung resection for clinical stage I non-small cell lung cancer

OBJECTIVES

Anatomic lung resection provides the best opportunity for long-term survival in the setting of early-stage non-small cell lung cancer (NSCLC). However, 20-30% of patients develop recurrent disease following complete (R0) resection for Stage I disease. In the current study, we analyze the impact of patient, surgical and pathologic variables upon recurrence patterns following anatomic lung resection for clinical stage I NSCLC.

PATIENTS AND METHODS

A total of 1132 patients (384 segmentectomies, 748 lobectomies) with clinical stage I NSCLC were evaluated. Predictors of recurrence were identified by proportional hazards regression. Differences in recurrence patterns between groups are illustrated by log rank tests applied to Kaplan-Maier estimates.

RESULTS

A total of 227 recurrences (20.0%) were recorded at a median follow-up of 36.8 months (65 locoregional, 155 distant). There was no significant difference in recurrence patterns when comparing segmentectomy and lobectomy. Multivariate analysis demonstrated that angiolymphatic invasion, tumor size, tumor grade and the presence of only mild-moderate tumor inflammation were independent predictors of recurrence risk.

CONCLUSIONS

Recurrence following anatomic lung resection is influenced predominantly by pathological variables (tumor size, tumor grade, angiolymphatic invasion, tumor inflammation). Optimization of surgical margin in relation to tumor size may improve outcomes. Extent of resection (segmentectomy vs. lobectomy) does not appear to have an impact on recurrence-free survival when adequate margins are obtained.

Mesh cruroplasty in laparoscopic repair of paraesophageal hernias is not associated with better long-term outcomes compared to primary repair

BACKGROUND

Equipoise still exists regarding routine mesh cruroplasty during laparoscopic paraesophageal hernia (PEH). We aimed to determine whether selective mesh cruroplasty is associated with differences in recurrence and patient-reported outcomes.

METHODS

We compared symptom outcomes (n = 688) and radiographic recurrences (n = 101; at least 10% [or 2 cm] of stomach above hiatus) for 795 non-emergent PEH repair with fundoplication (n = 106 with mesh).

RESULTS

Heartburn, regurgitation, epigastric pain, and anti-reflux medication use decreased significantly in both groups while postoperative dysphagia (mesh; p = 0.14), and bloating (non-mesh; p = 0.32), were unchanged. Radiographic recurrence rates were similar (15 mesh [22%] versus 86 non-mesh [17%]; p = 0.32; median 27 [IQR 14, 53] months), but was associated with surgical dissatisfaction (13% vs 4%; p = 0.007).

CONCLUSIONS

Selective mesh cruroplasty was not associated with differences in symptom outcomes or radiographic recurrence rates during laparoscopic PEH repair. Radiographic recurrence was associated with dissatisfaction, emphasizing the need for continued focus on reducing recurrences.

Minimally invasive staging of esophageal cancer

Esophageal cancer is one of the most common malignancies in the world today and the sixth-leading cause of cancer-related mortality. Accurate preoperative staging of esophageal cancer is imperative to the selection of appropriate treatments. Patients with esophageal carcinomas typically undergo a multimodality staging process including noninvasive imaging techniques, such as computed tomography (CT) and positron emission tomography (PET), as well as endoscopic ultrasound (EUS), which is slightly more invasive. Minimally invasive surgical staging, with laparoscopy, occasionally in combination with video-assisted thoracoscopy, is used in the staging process at select institutions and has been shown to be more accurate than noninvasive staging modalities. Two major advantages of minimally invasive surgical staging over conventional techniques are the improved assessment of locoregional disease and enhanced identification of distant metastases. These advantages decrease the likelihood that the patient will undergo a nontherapeutic laparotomy. Currently, no clear consensus exists regarding which patients with esophageal cancer would benefit most from the addition of minimally invasive surgical staging. We have, however, found that minimally invasive surgical staging with laparoscopy is particularly valuable in detection of occult distant metastases. In this article, we summarize the staging modalities for esophageal cancer including minimally invasive surgical staging.

Non-Elective Paraesophageal Hernia Repair Portends Worse Outcomes in Comparable Patients: a Propensity-Adjusted Analysis

INTRODUCTION

Patients undergoing non-elective paraesophageal hernia repair (PEHR) have worse perioperative outcomes. Because they are usually older and sicker, however, these patients may be more prone to adverse events, independent of surgical urgency. Our study aimed to determine whether non-elective PEHR is associated with differential postoperative outcome compared to elective repair, using propensity-score weighting.

METHODS

We abstracted data for patients undergoing PEHR (n = 924; non-elective n = 171 (19 %); 1997-2010). Using boosted regression, we generated a propensity-weighted dataset. Odds of 30-day/in-hospital mortality and major complications after non-elective surgery were determined.

RESULTS

Patients undergoing non-elective repair were significantly older, had more adverse prognostic factors, and significantly more major complications (38 versus 18 %; p < 0.001) and death (8 versus 1 %; p < 0.001). After propensity weighting, median absolute percentage bias across 28 propensity-score variables improved from 19 % (significant imbalance) to 5.6 % (well-balanced). After adjusting propensity-weighted data for age and comorbidity score, odds of major complications were still nearly two times greater (OR 1.67, CI 1.07-2.61) and mortality nearly three times greater (OR 2.74, CI 0.93-8.1) than for elective repair.

CONCLUSIONS

Even after balancing significant differences in baseline characteristics, non-elective PEHR was associated with worse outcomes than elective repair. Symptomatic patients should be referred for elective repair by experienced surgeons.

Electromagnetic Navigation Bronchoscopy-Guided Dye Marking for Thoracoscopic Resection of Pulmonary Nodules

BACKGROUND

Computed tomography scans are increasingly used not only for lung cancer screening but also for staging and evaluation of other cancers. As a result, more patients with pulmonary nodules, many with subcentimeter lesions, are being referred to thoracic surgeons, some with concern for primary lung neoplasm and others with possible metastatic lung lesions. Obtaining a definitive diagnosis of these lesions is difficult. Electromagnetic navigational bronchoscopy (ENB)-guided pleural dye marking followed by thoracoscopic resection is a novel alternative technique for definitive diagnosis. The main objective of this study was to evaluate the feasibility and our initial experience with ENB-guided dye localization and minimally invasive resection for diagnosis of lung lesions.

METHODS

Selected patients with lung lesions underwent ENB-guided dye marking and minimally invasive resection. The primary end points were the rate of nodule localization and definitive diagnosis of the nodule.

RESULTS

We performed ENB-guided localization and minimally invasive resection in 29 patients. The median lesion size was 10 mm, with a median distance from pleural surface of 13 mm. The operative mortality was 0%. The median hospital stay was 3 days. The nodule was localized and resected, and a definitive diagnosis was obtained in all patients (29 of 29; 100%). The nodule was neoplastic in 19 patients. All malignant lesions were completely resected with negative microscopic margins.

CONCLUSIONS

Our initial experience with ENB-guided dye localization and minimally invasive resection found that the technique was feasible, safe, and successful in the diagnosis of small lung lesions. Thoracic surgeons should further investigate this method and incorporate it into their armamentarium.

A propensity-matched analysis comparing survival after primary minimally invasive esophagectomy followed by adjuvant therapy to neoadjuvant therapy for esophagogastric adenocarcinoma

OBJECTIVES

Prognosis for patients with locally advanced esophagogastric adenocarcinoma (EAC) is poor with surgery alone, and adjuvant therapy after open esophagectomy is frequently not tolerated. After minimally invasive esophagectomy (MIE); however, earlier return to normal function may render patients better able to receive adjuvant therapy. We examined whether primary MIE followed by adjuvant chemotherapy influenced survival compared with propensity-matched patients treated with neoadjuvant therapy.

METHODS

Patients with stage II or higher EAC treated with MIE (N = 375) were identified. Using 30 pretreatment covariates, propensity for assignment to either neoadjuvant followed by MIE (n = 183; 54%) or MIE as primary therapy (n = 156; 46%) was calculated, generating 97 closely matched pairs. Hazard ratios were adjusted for age, sex, body mass index, smoking, comorbidity, and final pathologic stage.

RESULTS

In propensity-matched pairs, adjusted hazard ratio for death did not differ significantly for primary MIE compared with neoadjuvant (hazard ratio, 0.83; 95% confidence interval, 0.60-1.16). Recurrence patterns were similar between groups and 65% of patients with IIb or greater pathologic stage received adjuvant therapy. Clinical staging was inaccurate in 37 out of 105 patients (35%) who underwent primary MIE (n = 18 upstaged and n = 19 downstaged).

CONCLUSIONS

Primary MIE followed by adjuvant chemotherapy guided by pathologic findings did not negatively influence survival and allowed for accurate staging compared with clinical staging. Our data suggest that primary MIE in patients with resectable EAC may be a reasonable approach, improving stage-based prognostication and potentially minimizing overtreatment in patients with early stage disease through accurate stage assignments. A randomized controlled trial testing this hypothesis is needed.

Recurrence and survival outcomes after anatomic segmentectomy versus lobectomy for clinical stage I non-small-cell lung cancer: a propensity-matched analysis

PURPOSE

Although anatomic segmentectomy has been considered a compromised procedure by many surgeons, recent retrospective, single-institution series have demonstrated tumor recurrence and patient survival rates that approximate those achieved by lobectomy. The primary objective of this study was to use propensity score matching to compare outcomes after these anatomic resection approaches for stage I non-small-cell lung cancer.

PATIENTS AND METHODS

A retrospective data set including 392 segmentectomy patients and 800 lobectomy patients was used to identify matched segmentectomy and lobectomy cohorts (n = 312 patients per group) using a propensity score matching algorithm that accounted for confounding effects of preoperative patient variables. Primary outcome variables included freedom from recurrence and overall survival. Factors affecting survival were assessed by Cox regression analysis and Kaplan-Meier estimates.

RESULTS

Perioperative mortality was 1.2% in the segmentectomy group and 2.5% in the lobectomy group (P = .38). At a mean follow-up of 5.4 years, comparing segmentectomy with lobectomy, no differences were noted in locoregional (5.5% v 5.1%, respectively; P = 1.00), distant (14.8% v 11.6%, respectively; P = .29), or overall recurrence rates (20.2% v 16.7%, respectively; P = .30). Furthermore, when comparing segmentectomy with lobectomy, no significant differences were noted in 5-year freedom from recurrence (70% v 71%, respectively; P = .467) or 5-year survival (54% v 60%, respectively; P = .258). Segmentectomy was not found to be an independent predictor of recurrence (hazard ratio, 1.11; 95% CI, 0.87 to 1.40) or overall survival (hazard ratio, 1.17; 95% CI, 0.89 to 1.52).

CONCLUSION

In this large propensity-matched comparison, lobectomy was associated with modestly increased freedom from recurrence and overall survival, but the differences were not statistically significant. These results will need further validation by prospective, randomized trials (eg, Cancer and Leukemia Group B 140503 trial).

Has the paradigm changed away from lobectomy for stage I non-small cell lung cancer (NSCLC)? Anatomic segmentectomy: Surgery’s answer to image-guided ablation/radiation therapy for the small peripheral lung lesion

7577

Background: Lobectomy has been the “gold standard” for stage I NSCLC management. Image guided ablation/radiation therapy approaches are now being touted as alternatives to surgery despite concerns regarding diagnosis, pathologic staging, local control, and delayed toxicities. We evaluated the diagnostic utility and oncologic efficacy of lung sparing, anatomic segmentectomy for indeterminate pulmonary nodules and clinical stage I NSCLC. Methods: Retrospective review of 1,005 anatomic segmentectomies from 2002-2012 for indeterminate pulmonary nodules and clinical stage I NSCLC. Outcome variables included perioperative data, morbidity and mortality. Survival was assessed with the Kaplan-Maier method. Results: Mean age was 66.7 years. Median lesion size was 1.9 cm. VATS was employed in 62.8% of cases. Median operative time and blood loss was 112 minutes and 80 ml, respectively. Median hospital stay was 5 days. Major complications occurred in 12.7%. Thirty-day mortality was 1.0%. Of these, NSCLC was identified in 71.6%, metastases in 8.7%, and other benign conditions in 19.7%. Among patients with clinical stage I NSCLC, clinical: pathological upstaging was seen in 34.5%. Local recurrence rate was 5.2% and five-year freedom from any recurrence was 69%, equivalent to lobectomy in our experience. Conclusions: Anatomic segmentectomy is a valuable primary surgical approach today. In this era of competing image-guided ablation modalities, anatomic segmentectomy provides safety, diagnostic accuracy and adherence to oncologic surgical principles including completeness of resection with adequate surgical margins, systematic nodal staging improving pathologic accuracy, and tissue for pharmacogenomic assessment to guide individualized adjuvant therapy.

A clinical prediction rule for perioperative mortality and major morbidity after laparoscopic giant paraesophageal hernia repair

OBJECTIVE

In the current era, giant paraesophageal hernia repair by experienced minimally invasive surgeons has excellent perioperative outcomes when performed electively. However, nonelective repair is associated with significantly greater morbidity and mortality, even when performed laparoscopically. We hypothesized that clinical prediction tools using pretreatment variables could be developed that would predict patient-specific risk of postoperative morbidity and mortality.

METHODS

We assessed 980 patients who underwent giant paraesophageal hernia repair (1997-2010; 80% elective and 97% laparoscopic). We assessed the association between clinical predictor covariates, including demographics, comorbidity, and urgency of operation, and risk for in-hospital or 30-day mortality and major morbidity. By using forward stepwise logistic regression, clinical prediction models for mortality and major morbidity were developed.

RESULTS

Urgency of operation was a significant predictor of mortality (elective 1.1% [9/778] vs nonelective 8% [16/199]; P < .001) and major morbidity (elective 18% [143/781] vs nonelective 41% [81/199]; P < .001). The most common adverse outcomes were pulmonary complications (n = 199; 20%). A 4-covariate prediction model consisting of age 80 years or more, urgency of operation, and 2 Charlson comorbidity index variables (congestive heart failure and pulmonary disease) provided discriminatory accuracy for postoperative mortality of 88%. A 5-covariate model (sex, age by decade, urgency of operation, congestive heart failure, and pulmonary disease) for major postoperative morbidity was 68% predictive.

CONCLUSIONS

Predictive models using pretreatment patient characteristics can accurately predict mortality and major morbidity after giant paraesophageal hernia repair. After prospective validation, these models could provide patient-specific risk prediction, tailored for individual patient characteristics, and contribute to decision-making regarding surgical intervention.

Outcomes after minimally invasive esophagectomy: review of over 1000 patients

BACKGROUND

Esophagectomy is a complex operation and is associated with significant morbidity and mortality. In an attempt to lower morbidity, we have adopted a minimally invasive approach to esophagectomy.

OBJECTIVES

Our primary objective was to evaluate the outcomes of minimally invasive esophagectomy (MIE) in a large group of patients. Our secondary objective was to compare the modified McKeown minimally invasive approach (videothoracoscopic surgery, laparoscopy, neck anastomosis [MIE-neck]) with our current approach, a modified Ivor Lewis approach (laparoscopy, videothoracoscopic surgery, chest anastomosis [MIE-chest]).

METHODS

We reviewed 1033 consecutive patients undergoing MIE. Elective operation was performed on 1011 patients; 22 patients with nonelective operations were excluded. Patients were stratified by surgical approach and perioperative outcomes analyzed. The primary endpoint studied was 30-day mortality.

RESULTS

The MIE-neck was performed in 481 (48%) and MIE-Ivor Lewis in 530 (52%). Patients undergoing MIE-Ivor Lewis were operated in the current era. The median number of lymph nodes resected was 21. The operative mortality was 1.68%. Median length of stay (8 days) and ICU stay (2 days) were similar between the 2 approaches. Mortality rate was 0.9%, and recurrent nerve injury was less frequent in the Ivor Lewis MIE group (P < 0.001).

CONCLUSIONS

MIE in our center resulted in acceptable lymph node resection, postoperative outcomes, and low mortality using either an MIE-neck or an MIE-chest approach. The MIE Ivor Lewis approach was associated with reduced recurrent laryngeal nerve injury and mortality of 0.9% and is now our preferred approach. Minimally invasive esophagectomy can be performed safely, with good results in an experienced center.

Factors influencing recurrence following anatomic lung resection for non-small cell lung cancer

7074

Background: Anatomic lung resection provides the patient with the best chance for cure in the setting of early-stage non-small cell lung cancer (NSCLC). Despite complete (R0) resection, up to 20-30% of patients will develop recurrent disease. In the current study, we analyze the impact of surgical and pathologic variables upon recurrence patterns following anatomic lung resection for clinical stage I NSCLC. Methods: A total of 1,192 patients (394 segmentectomies, 805 lobectomies) with clinical stage I NSCLC were evaluated. The primary outcome variable was recurrence. Multivariate analysis was performed based upon clinical (age, gender, comorbidities), surgical (operation, approach, surgical margin) and pathological (pleural invasion, tumor size and histology) variables. Predictors of recurrence were identified by proportional hazards regression. Differences in recurrence patterns between groups are illustrated by log rank tests applied to Kaplan-Maier estimates. Results: A total of 243 recurrences (20.3%) were recorded at a mean follow-up of 35.6 months (71 locoregional, 172 distant). There was no significant difference in recurrence patterns when comparing segmentectomy and lobectomy. Multivariate analysis demonstrated that a margin:tumor ratio < 1, angiolymphatic invasion and the presence of only mild-moderate tumor inflammation were predictors of recurrence risk. Conclusions: Recurrence following anatomic lung resection is influenced predominantly by pathological variables (tumor size, angiolymphatic invasion, tumor inflammation). Optimization of surgical margin in relation to tumor size may improve outcomes. Extent of resection (segmentectomy vs. lobectomy) does not appear to have an impact on recurrence-free survival when adequate margins are obtained. These data have implications regarding the potential use of adjuvant therapy in selected Stage I patients at high risk for recurrence. [Table: see text]

Influence of age and IB status after resection of node-negative non-small cell lung cancer

BACKGROUND

Anatomic segmentectomy has been proposed as a reasonable alternative to lobectomy in the management of small early-stage non-small cell lung cancers. We reviewed our outcomes with anatomic segmentectomy versus lobectomy for stages IA and IB non-small cell lung cancer stratified by age and stage.

METHODS

We conducted a retrospective review of prospectively-collected data analyzing outcomes after anatomic segmentectomy (n=305) for stage IA (n=187) or IB (n=118) NSCLC from 1999 to 2010. Lobectomy was performed in 594 patients for stage IA (n=290) and IB (n=304) disease during the same period. Surgical approach was stratified by stage and by the following age groups: less than 70, 70 to 79, and 80 or greater. Primary outcome variables included complications, mortality, recurrence patterns, and survival. Mean follow-up was 37 months.

RESULTS

Segmentectomy was associated with reduced complications (43.6% vs 58.7%) and mortality (0% vs 7.8%) in patients greater than 80 years old, without a difference in recurrence rates. There was no difference in complications or mortality in the younger age groups. Freedom from recurrence was similar between segmentectomy and lobectomy for stage IA tumors across all age groups. A reduced recurrence-free survival was seen with segmentectomy for stage IB tumors, especially with visceral pleural invasion (median 22.7 vs 29.6 months), p=0.048).

CONCLUSIONS

Segmentectomy appears to be a reasonable approach for early-stage NSCLC in patients 80 years of age or greater due to reduced morbidity and mortality with equivalent freedom from recurrence. Although equivalent survival was seen in all age groups for stage IA, these data further support the use of lobectomy for resection of stage IB tumors.

Gastroesophageal reflux disease symptom severity, proton pump inhibitor use, and esophageal carcinogenesis

HYPOTHESIS

Screening for esophageal adenocarcinoma has focused on identifying Barrett esophagus (BE) in patients with severe, long-standing symptoms of gastroesophageal reflux disease (GERD). Unfortunately, 95% of patients who develop esophageal adenocarcinoma are unaware of the presence of BE before their cancer diagnosis, which means they never had been selected for screening. One possible explanation is that no correlation exists between the severity of GERD symptoms and cancer risk. We hypothesize that severe GERD symptoms are not associated with an increase in the prevalence of BE, dysplasia, or cancer in patients undergoing primary endoscopic screening.

DESIGN

Cross-sectional study.

SETTING

University hospital.

PATIENTS

A total of 769 patients with GERD.

INTERVENTIONS

Primary screening endoscopy performed from November 1, 2004, through June 7, 2007.

MAIN OUTCOMES MEASURES

Symptom severity, proton pump inhibitor therapy, and esophageal adenocarcinogenesis (ie, BE, dysplasia, or cancer).

RESULTS

Endoscopy revealed adenocarcinogenesis in 122 patients. An increasing number of severe GERD symptoms correlated positively with endoscopic findings of esophagitis (odds ratio, 1.05; 95% confidence interval, 1.01-1.09). Conversely, an increasing number of severe GERD symptoms were associated with decreased odds of adenocarcinogenesis (odds ratio, 0.94; 95% confidence interval, 0.89-0.98). Patients taking proton pump inhibitors were 61.3% and 81.5% more likely to have adenocarcinogenesis if they reported no severe typical or atypical GERD symptoms, respectively, compared with patients taking proton pump inhibitors, who reported that all symptoms were severe.

CONCLUSIONS

Medically treated patients with mild or absent GERD symptoms have significantly higher odds of adenocarcinogenesis compared with medically treated patients with severe GERD symptoms. This finding may explain the failure of the current screening paradigm in which the threshold for primary endoscopic examination is based on symptom severity.

Quality of life after collis gastroplasty for short esophagus in patients with paraesophageal hernia

BACKGROUND

Collis gastroplasty is an important component of laparoscopic giant paraesophageal hernia (GPEH) repair in patients with persistent shortened esophagus after aggressive laparoscopic mobilization. Concerns remain, however, regarding symptomatic outcomes compared with fundoplication alone. This study assessed the impact of Collis gastroplasty on quality of life after laparoscopic GPEH repair.

METHODS

We performed 795 nonemergent laparoscopic GPEH repairs with fundoplication (with Collis, n = 454; fundoplication alone, n = 341). Radiographic follow-up and symptom assessment were obtained a median 22 months and 20 months, respectively, after fundoplication alone and 36 and 33 months, respectively, after Collis (p < 0.001). Radiographic recurrence, reoperation for recurrent hernia or intolerable symptoms, overall symptom improvement, and quality of life were examined.

RESULTS

Compared with fundoplication alone, Collis patients had significantly larger GPEH (p = 0.027) and fewer comorbidities (p = 0.002). Radiographic recurrences were similar (p = 0.353). Symptom improvement was significant for both (p < 0.001), although Collis was associated with better pain resolution (p < 0.001) and less gas bloat (p = 0.003). Quality of life was good to excellent in 88% (90% Collis versus 86% fundoplication alone, p = 0.17).

CONCLUSIONS

Symptomatic outcomes after laparoscopic fundoplication with Collis gastroplasty are excellent and comparable with those of fundoplication alone. These results confirm that utilization of Collis gastroplasty, based on intraoperative assessment for shortened esophagus, is not detrimental to the overall outcome or quality of life associated with the laparoscopic approach to GPEH. Collis gastroplasty is recommended as an important procedure in the surgeon's armamentarium for laparoscopic repair of GPEH.

Impact of anastomotic leak on outcomes after transhiatal esophagectomy

BACKGROUND

The development of anastomotic leaks and/or strictures can be associated with considerable morbidity and impairment of quality of life. In the current study, we evaluated the outcomes of patients who developed anastomotic complications after esophagectomy to elucidate the impact of these events on morbidity, mortality, and subsequent need for dilation.

METHODS

We analyzed retrospectively the clinical course of 235 patients who underwent transhiatal esophagectomy for cancer from 2001 to 2009. Patients with confirmed anastomotic leaks were identified and classified with the following scale: class 1: Radiographic leak only, no intervention; class 2: leak requiring opening of the wound, cervical and/or percutaneous drainage; class 3: disruption of anastomosis (10-50% circumference) with perianastomotic abscess requiring video-assisted thoracoscopic surgery or thoracotomy; and class 4: gastric tip necrosis with anastomotic separation (>50% circumference).

RESULTS

Anastomotic leaks were encountered in 30 patients (13%). Anastomotic leaks were associated with greater morbidity (70% vs 47%; P = .02) and stricture formation (57% vs 19%; P = .0001). Mortality was not different. Increasing leak class was associated with an increased need for postoperative anastomotic dilations (P = .016).

CONCLUSION

Anastomotic integrity after esophagectomy has a substantial impact on perioperative course and long-term swallowing. A more formal radiographic and endoscopic leak classification system seems justified.

Management of giant paraesophageal hernia

Management of giant paraesophageal hernia remains one of the most difficult challenges faced by surgeons treating complex benign esophageal disorders. These large hernias are acquired disorders; therefore, they invariably present in elderly patients. The dilemma that surgeons faced in the open surgical era was the risk of open surgery in this elderly, sick patient population versus the life threatening catastrophic complications, nearly 30% in some series, observed with medical management. During the 1990s, it was clearly recognized that laparoscopic surgery led to decreased morbidity with a quicker recovery. This has lead to a 6-fold increase in the surgical management of giant paraesophageal hernias over the last decade compared to a period of five decades of open surgery; however, this has not necessarily translated into better outcomes. One of the major issues with giant paraesophageal hernias is recognizing short esophagus and performing a lengthening procedure, if needed. Open series which report liberal use of Collis gastroplasty leading to a tension-free intraabdominal fundoplication have shown the best anatomic and clinical outcomes. As we duplicate the open experience laparoscopically, the principle of identifying a shortened esophagus and constructing a neo-esophagus must be honored for the success of the operation. The benefits of laparoscopy are obvious but should not come at the cost of a lesser operation. This review will illustrate that laparoscopic repair of giant paraesophageal hernia at experienced centers can be performed safely with similar outcomes to open series when the fundamental principles of the operation are maintained.

Surgical management of epiphrenic diverticula in the minimally invasive era

BACKGROUND

Epiphrenic diverticula are rare outpouchings of the distal esophagus that infrequently require surgical intervention for the treatment of symptoms. In cases where surgical therapy is indicated, the traditional approach is through a thoracotomy. Advances in minimally invasive techniques have led to thoracoscopic and more recently laparoscopic management of epiphrenic diverticula. The purpose of this article is to review the literature on minimally invasive surgery for epiphrenic diverticula with particular attention to the operative approach and technique, surgical mortality and morbidity, and symptomatic outcomes.

METHODS

A review of the literature limited to studies in the English language and performed on humans was conducted on PubMed using the following key words: "esophageal diverticula" and "epiphrenic". Articles retrieved by the PubMed search were reviewed.

CONCLUSIONS

A minimally invasive approach to epiphrenic diverticula offers reduced operative mortality, decreased length of stay, and similar symptom relief compared with open surgery in the hands of experienced laparoscopic surgeons.

Roux-en-Y near esophagojejunostomy for intractable gastroesophageal reflux after antireflux surgery

BACKGROUND

Intractable gastroesophageal reflux disease (GERD) after prior antireflux operation presents a difficult challenge. Our objective was to investigate the role of Roux-en-Y near esophagojejunostomy (RNYNEJ) in the management of intractable reflux symptoms after prior antireflux surgery.

METHODS

Between June 2000 and October 2005, 25 patients with GERD after antireflux surgery underwent RNYNEJ. The endpoints evaluated were improvement in GERD symptoms using the GERD-Health Related Quality of Life (HRQL) scale, overall patient satisfaction, overall patient weight loss, and improvement of comorbid conditions.

RESULTS

There were 4 men and 21 women (mean age 51 years; range, 35 to 74). Seventy two percent had a body mass index (BMI) greater than 30. Forty-four percent had more than one antireflux surgery and 40% had a previous Collis gastroplasty. The perioperative mortality was 0%. Six patients (24%) developed major postoperative complications, including anastomotic leak (n = 2) and Roux-limb obstruction (n = 1). The median length of stay was 6 days. Eighty percent of the patients reported satisfaction at mean follow-up time of 16.5 months. Their BMI reduced from 35.8 to 27.7 (p < 0.001). Seventy three percent of comorbid conditions were improved and the GERD HRQL score improved from 29.9 to 7.3 (p < 0.001).

CONCLUSIONS

The RNYNEJ for persistent GERD after prior antireflux surgery is technically challenging with significant morbidity. However, the majority of the patients reported satisfaction with significant improvement in symptoms. Many patients had associated benefits of weight loss and improvement in comorbid conditions. Roux-en-Y near esophagojejunostomy should be considered as an important option for the treatment of intractable GERD after prior antireflux surgery, particularly in the obese.

Comparison of surgical approaches to recalcitrant gastroesophageal reflux disease in the patient with scleroderma

BACKGROUND

Scleroderma is associated with severe esophageal dysmotility and gastroesophageal reflux disease (GERD). Results after antireflux surgery have been suboptimal due to the profound esophageal dysmotility seen in this disease. We hypothesized that laparoscopic Roux-en-Y gastric bypass (RYGBP) would lead to less dysphagia and better control of GERD symptoms. This report summarizes our initial results of RYGBP compared with other surgical approaches.

METHODS

A retrospective review identified scleroderma patients who underwent surgical management of GERD from 1995 to 2006. Complications and reinterventions were recorded. Symptom control was assessed by validated questionnaires that measured dysphagia (0 to 5; 0 = no dysphagia), GERD-heartburn-related quality of life index (0 to 45; 0 = best, 45 = worst), and overall quality of life with the Medical Outcomes Study 36-Item Short Form Health Survey.

RESULTS

Twenty-three scleroderma patients underwent surgical treatment for GERD (fundoplication, n = 10; RYGBP, n = 8; esophagectomy, n = 5). One patient died after esophagectomy and major morbidity occurred in 3 of the remaining 4 patients. No major complications occurred in any patient undergoing either fundoplication or RYGBP. Eighteen patients underwent evaluation by questionnaire at a median of 21 months postoperatively. Decreased dysphagia (0.42 versus 1.86, p = 0.05) and improved control of reflux (GERD-heartburn-related quality of life index score 4 versus 15.6, p = 0.05) were observed in the RYGBP patients compared with those undergoing fundoplication.

CONCLUSIONS

A high complication rate was seen among patients undergoing esophagectomy. Both reflux control and dysphagia rates were improved in the RYGBP group compared with fundoplication. This finding suggests that RYGBP may be an option for the primary management of scleroderma-associated gastroesophageal reflux.

Minimally invasive management of Boerhaave's syndrome

We report the case of a 42-year-old man with Boerhaave's syndrome. His medical history was significant only for a long-standing history of dysphagia. The patient presented to the emergency department with vomiting, followed by severe retrosternal and epigastric pain of sudden onset. An esophagogram showed evidence of free extravasation of contrast from the left posterolateral aspect of the distal esophagus just above the level of the hiatus. A minimally invasive technique was used to repair this injury.

Acute, complete proximal small bowel obstruction after laparoscopic gastric bypass due to intraluminal blood clot formation

BACKGROUND

To report the presentation and management of early complete proximal small bowel obstruction from intraluminal clot after laparoscopic Roux-en-Y gastric bypass.

METHODS

We performed a retrospective chart review of 5 female patients who developed small bowel obstruction at the jejunojejunostomy (JJ) secondary to intraluminal clot from January 2001 to January 2003. We analyzed the signs and symptoms, etiology of bowel obstruction, and operative treatment.

RESULTS

From January 2001 to January 2003, 5 patients who had undergone successful laparoscopic Roux-en-Y gastric bypass developed proximal small bowel obstruction from a solid intraluminal clot secondary to staple line bleeding. All patients were women, with an average age and body mass index of 37 years and 43.41 kg/m(2), respectively. All patients underwent an upper gastrointestinal series on postoperative day 1, which revealed no leak, and all became symptomatic on postoperative day 2. Tachycardia and a "sense of impending doom" were both observed in 80% of the patients with this clinical syndrome. The intraoperative findings consistently revealed intraluminal clot obstructing the JJ. After reexploration and anastomotic revision, all patients had an uneventful recovery, with an average hospital length of stay of 9.8 days (range 8-11).

CONCLUSION

Staple line bleeding potentially exacerbated by perioperative subcutaneous heparin use can cause proximal small bowel obstruction at the JJ after laparoscopic Roux-en-Y gastric bypass. It presents on postoperative day 2 most commonly as tachycardia and a "sense of impending doom." Prompt recognition and immediate reexploration will lead to an uneventful recovery. The need for complete anastomotic JJ revision is discussed.

Laparoscopic gastric bypass after antireflux surgery for the treatment of gastroesophageal reflux in morbidly obese patients: initial experience

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (LRYGBP) has been proven effective against gastroesophageal reflux disease (GERD) in morbidly obese patients. We present our experience with revision of antireflux procedures to LRYGBP in obese patients with recurrent GERD, weight gain or a combination of both and discuss the indications and technical considerations involved.

METHODS

Between June 2000 and December 2003, 7 morbidly obese patients with a mean BMI of 37.5 kg/m(2) underwent revision of an antireflux procedure to LRYGBP by our group. Important steps of the revision include dissection of the diaphragmatic crura and gastroesophageal fat pad, reduction and repair of hiatal hernia, and complete take-down of the wrap to avoid stapling over the fundoplication which can create an obstructed, septated pouch.

RESULTS

Mean operative time was 6 hr 12 min and length of stay was 4.8 days. There were 3 major complications postoperatively and no deaths. During follow-up, 5 patients developed anastomotic strictures and 2 patients were re-explored for gastric remnant herniation and intestinal obstruction. At a mean follow-up of 24 (3-44) months, mean excess weight loss was 70.7% and 14/20 (70%) co-morbid conditions were improved or resolved. GERD evaluation with the GERD-HRQL scale showed a significant reduction of GERD scores postoperatively (P =0.006).

CONCLUSIONS

Although LRYGBP after antireflux surgery is a technically more difficult procedure with a higher morbidity, it is feasible and effective for the treatment of recurrent GERD and worsening obesity with the additional advantage of weight loss and improvement of co-morbidities.