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A minimally invasive esophagectomy resulted in improved postoperative outcomes and just as many resection rates (R0) as open surgery – with the added bonus of a significantly greater harvest of lymph nodes.
Compared with those who had open surgery, patients who underwent the minimally invasive surgery had significantly less blood loss, shorter hospital stays, and fewer major complications, said Dr. Adam C. Berger, who presented the study results at the recent annual meeting of the Southern Surgical Association.
Although further studies are needed to confirm the benefits of such an approach, "Our current practice is to attempt minimally invasive esophagectomies in all patients," said Dr. Berger of the Kimmel Cancer Center at the Thomas Jefferson University Hospital in Philadelphia.
He and his colleagues presented a retrospective study comparing surgical and oncologic outcomes in two groups of patients with esophageal cancer. His database comprised 65 patients who underwent esophagectomy with a thoracoscopic component (11 thoracoscopy/laparotomy, 2 Ivor-Lewis thoracoscopy/laparoscopy, and 52 three-hole thoracoscopy/laparoscopy). These were compared with a control group of 53 patients who underwent open surgery (15 Ivor-Lewis and 38 three-hole esophagectomy) during the same time period.
The patients’ mean age was 61 years. Neoadjuvant therapy was administered in 28 (43%) of the minimally invasive esophagectomy (MIE) group and 43 (81%) of the open surgery group.
Adenocarcinoma was present in most of the patients (85% MIE and 74% open). Squamous cell carcinoma occurred in 6% of the MIE group and 26% of the open group; there were also five cases (8%) of high-grade dysplasia in the MIE group. One patient had MIE for esophageal melanoma.
Dr. Berger briefly described his MIE approach. During the thoracoscopy, he uses 10-mm ports in the anterior axillary line at the fourth and eighth intercostal spaces and at the posterior axillary line. "A 5-mm port is placed at the tip of the scapula, and a suction port can be placed between the ports in the anterior axillary line," he said. "Finally, a suture is placed in the tendinous portion of the diaphragm to maintain retraction."
He uses a Penrose drain to encircle and retract the esophagus. The azygous vein is divided, and the aortic branches are divided or clipped. "The subcarinal lymph node package is dissected under direct vision and removed, and paraesophageal lymph nodes and tissue dissected up with the specimen."
During the subsequent laparoscopy, Dr. Berger places a 5-mm port in the right lateral subcostal area to accommodate a liver retractor, a 12-mm port in the umbilicus for the camera, an additional 12-mm working port in the right subcostal region, and a 5-mm port in the left subcostal region. "Once the gastric mobilization is complete, we often enlarge the 12-mm right subcostal port to about 5 cm and place a Lap Disk."
After dissecting the neck, he isolates and divides the esophagus. The completed reconstruction involves sewing the tip of the gastric tube to the chest tube and pulling that tube back up into the neck for a side-to-side esophagectomy. Anastomosis is in the neck with the gastric tube in the posterior mediastinum.
Mortality was similar in both groups of patients (8%). While the overall rate of complications was not significantly different (48% MIE vs. 60% open), the rate of major complications was (20% vs. 41%). Respiratory failure or acute respiratory distress syndrome occurred in a significantly smaller percentage of MIE patients (8% vs. 21%). There were also fewer cases of pneumonia among the MIE patients, but this was not a significant difference (8% vs. 18%). "Interestingly, there was a significant increase in the number of patients with a deep venous thrombosis or pulmonary embolism in the open group (2% vs. 11%)," Dr. Berger said. "This may have something to do with earlier postoperative mobilization for patients with MIE."
MIE patients also fared significantly better in terms of blood loss (182 mL vs. 619 mL) and median length of stay (9 vs. 16 days).
Oncologic outcomes were as good as, or better than, those seen in open surgery "There was no difference in R0 resection rates," Dr. Berger pointed out (97% MIE vs. 94% open). "We also saw a more than doubling of the number of examined lymph nodes in the MIE group, which was highly significant (20 vs. 9; P less than .0001)."
Despite the positive outcomes, Dr. Berger pointed out a major limitation of the study. Because his group attempts the MIE approach in all patients, "It’s impossible to find a concurrent group of patients who had open surgery for comparison." Also, he noted, "Pathology standards have changed and, thus, the importance of lymph nodes has become more recognized. Higher node yields are shown to be an important prognostic factor for survival. Therefore, our pathologists are now more diligent in finding the lymph nodes in the specimen."
Dr. Berger said he had no financial declarations.
The authors report that the
complete resection rates (R0) were similar between patients who underwent
minimally invasive esophagectomy (MIE) and those who underwent an open
transthoracic esophagectomy (more than 94%). However, the number of lymph nodes
resected was significantly higher in the MIE group, which had fewer serious
complications and a shorter length of hospital stay. In their conclusion, the
authors highlight similar R0 resection rates, improved lymphadenectomy, and improved
perioperative outcomes with a minimally invasive approach.
This is an interesting study, but it has some
important limitations. First, it is a retrospective comparison, not a
randomized study. The approaches were adopted in different time periods with
potential differences in practice patterns – such as pathologic evaluation of
specimens or policies regarding hospital discharge – that may have accounted
for some of the differences observed. Second, although the open and MIE groups
were matched for age and gender, there may be important differences between
them. Neoadjuvant chemoradiation was used nearly twice as often in the open
transthoracic group as in the MIE group, and this different rate might confound
the analysis because it may reflect a more advanced clinical stage and be
associated with an increase in perioperative complications.
The 8% mortality appears high, compared with other
recent series. For example, mortality was 2% in the multicenter MIE trial
conducted by the Eastern
Cooperative Oncology Group (ECOG 2202). Although the authors describe
oncologic efficacy in terms of completeness of resection, the lack of
longer-term outcome data on recurrence and survival is a major limitation.
Nonetheless the authors should be commended for their efforts.
Dr. James D. Luketich is Henry T.
Bahnson Professor and chairman, department of cardiothoracic surgery, University of Pittsburgh Medical
Center.
The authors report that the
complete resection rates (R0) were similar between patients who underwent
minimally invasive esophagectomy (MIE) and those who underwent an open
transthoracic esophagectomy (more than 94%). However, the number of lymph nodes
resected was significantly higher in the MIE group, which had fewer serious
complications and a shorter length of hospital stay. In their conclusion, the
authors highlight similar R0 resection rates, improved lymphadenectomy, and improved
perioperative outcomes with a minimally invasive approach.
This is an interesting study, but it has some
important limitations. First, it is a retrospective comparison, not a
randomized study. The approaches were adopted in different time periods with
potential differences in practice patterns – such as pathologic evaluation of
specimens or policies regarding hospital discharge – that may have accounted
for some of the differences observed. Second, although the open and MIE groups
were matched for age and gender, there may be important differences between
them. Neoadjuvant chemoradiation was used nearly twice as often in the open
transthoracic group as in the MIE group, and this different rate might confound
the analysis because it may reflect a more advanced clinical stage and be
associated with an increase in perioperative complications.
The 8% mortality appears high, compared with other
recent series. For example, mortality was 2% in the multicenter MIE trial
conducted by the Eastern
Cooperative Oncology Group (ECOG 2202). Although the authors describe
oncologic efficacy in terms of completeness of resection, the lack of
longer-term outcome data on recurrence and survival is a major limitation.
Nonetheless the authors should be commended for their efforts.
Dr. James D. Luketich is Henry T.
Bahnson Professor and chairman, department of cardiothoracic surgery, University of Pittsburgh Medical
Center.
The authors report that the
complete resection rates (R0) were similar between patients who underwent
minimally invasive esophagectomy (MIE) and those who underwent an open
transthoracic esophagectomy (more than 94%). However, the number of lymph nodes
resected was significantly higher in the MIE group, which had fewer serious
complications and a shorter length of hospital stay. In their conclusion, the
authors highlight similar R0 resection rates, improved lymphadenectomy, and improved
perioperative outcomes with a minimally invasive approach.
This is an interesting study, but it has some
important limitations. First, it is a retrospective comparison, not a
randomized study. The approaches were adopted in different time periods with
potential differences in practice patterns – such as pathologic evaluation of
specimens or policies regarding hospital discharge – that may have accounted
for some of the differences observed. Second, although the open and MIE groups
were matched for age and gender, there may be important differences between
them. Neoadjuvant chemoradiation was used nearly twice as often in the open
transthoracic group as in the MIE group, and this different rate might confound
the analysis because it may reflect a more advanced clinical stage and be
associated with an increase in perioperative complications.
The 8% mortality appears high, compared with other
recent series. For example, mortality was 2% in the multicenter MIE trial
conducted by the Eastern
Cooperative Oncology Group (ECOG 2202). Although the authors describe
oncologic efficacy in terms of completeness of resection, the lack of
longer-term outcome data on recurrence and survival is a major limitation.
Nonetheless the authors should be commended for their efforts.
Dr. James D. Luketich is Henry T.
Bahnson Professor and chairman, department of cardiothoracic surgery, University of Pittsburgh Medical
Center.
A minimally invasive esophagectomy resulted in improved postoperative outcomes and just as many resection rates (R0) as open surgery – with the added bonus of a significantly greater harvest of lymph nodes.
Compared with those who had open surgery, patients who underwent the minimally invasive surgery had significantly less blood loss, shorter hospital stays, and fewer major complications, said Dr. Adam C. Berger, who presented the study results at the recent annual meeting of the Southern Surgical Association.
Although further studies are needed to confirm the benefits of such an approach, "Our current practice is to attempt minimally invasive esophagectomies in all patients," said Dr. Berger of the Kimmel Cancer Center at the Thomas Jefferson University Hospital in Philadelphia.
He and his colleagues presented a retrospective study comparing surgical and oncologic outcomes in two groups of patients with esophageal cancer. His database comprised 65 patients who underwent esophagectomy with a thoracoscopic component (11 thoracoscopy/laparotomy, 2 Ivor-Lewis thoracoscopy/laparoscopy, and 52 three-hole thoracoscopy/laparoscopy). These were compared with a control group of 53 patients who underwent open surgery (15 Ivor-Lewis and 38 three-hole esophagectomy) during the same time period.
The patients’ mean age was 61 years. Neoadjuvant therapy was administered in 28 (43%) of the minimally invasive esophagectomy (MIE) group and 43 (81%) of the open surgery group.
Adenocarcinoma was present in most of the patients (85% MIE and 74% open). Squamous cell carcinoma occurred in 6% of the MIE group and 26% of the open group; there were also five cases (8%) of high-grade dysplasia in the MIE group. One patient had MIE for esophageal melanoma.
Dr. Berger briefly described his MIE approach. During the thoracoscopy, he uses 10-mm ports in the anterior axillary line at the fourth and eighth intercostal spaces and at the posterior axillary line. "A 5-mm port is placed at the tip of the scapula, and a suction port can be placed between the ports in the anterior axillary line," he said. "Finally, a suture is placed in the tendinous portion of the diaphragm to maintain retraction."
He uses a Penrose drain to encircle and retract the esophagus. The azygous vein is divided, and the aortic branches are divided or clipped. "The subcarinal lymph node package is dissected under direct vision and removed, and paraesophageal lymph nodes and tissue dissected up with the specimen."
During the subsequent laparoscopy, Dr. Berger places a 5-mm port in the right lateral subcostal area to accommodate a liver retractor, a 12-mm port in the umbilicus for the camera, an additional 12-mm working port in the right subcostal region, and a 5-mm port in the left subcostal region. "Once the gastric mobilization is complete, we often enlarge the 12-mm right subcostal port to about 5 cm and place a Lap Disk."
After dissecting the neck, he isolates and divides the esophagus. The completed reconstruction involves sewing the tip of the gastric tube to the chest tube and pulling that tube back up into the neck for a side-to-side esophagectomy. Anastomosis is in the neck with the gastric tube in the posterior mediastinum.
Mortality was similar in both groups of patients (8%). While the overall rate of complications was not significantly different (48% MIE vs. 60% open), the rate of major complications was (20% vs. 41%). Respiratory failure or acute respiratory distress syndrome occurred in a significantly smaller percentage of MIE patients (8% vs. 21%). There were also fewer cases of pneumonia among the MIE patients, but this was not a significant difference (8% vs. 18%). "Interestingly, there was a significant increase in the number of patients with a deep venous thrombosis or pulmonary embolism in the open group (2% vs. 11%)," Dr. Berger said. "This may have something to do with earlier postoperative mobilization for patients with MIE."
MIE patients also fared significantly better in terms of blood loss (182 mL vs. 619 mL) and median length of stay (9 vs. 16 days).
Oncologic outcomes were as good as, or better than, those seen in open surgery "There was no difference in R0 resection rates," Dr. Berger pointed out (97% MIE vs. 94% open). "We also saw a more than doubling of the number of examined lymph nodes in the MIE group, which was highly significant (20 vs. 9; P less than .0001)."
Despite the positive outcomes, Dr. Berger pointed out a major limitation of the study. Because his group attempts the MIE approach in all patients, "It’s impossible to find a concurrent group of patients who had open surgery for comparison." Also, he noted, "Pathology standards have changed and, thus, the importance of lymph nodes has become more recognized. Higher node yields are shown to be an important prognostic factor for survival. Therefore, our pathologists are now more diligent in finding the lymph nodes in the specimen."
Dr. Berger said he had no financial declarations.
A minimally invasive esophagectomy resulted in improved postoperative outcomes and just as many resection rates (R0) as open surgery – with the added bonus of a significantly greater harvest of lymph nodes.
Compared with those who had open surgery, patients who underwent the minimally invasive surgery had significantly less blood loss, shorter hospital stays, and fewer major complications, said Dr. Adam C. Berger, who presented the study results at the recent annual meeting of the Southern Surgical Association.
Although further studies are needed to confirm the benefits of such an approach, "Our current practice is to attempt minimally invasive esophagectomies in all patients," said Dr. Berger of the Kimmel Cancer Center at the Thomas Jefferson University Hospital in Philadelphia.
He and his colleagues presented a retrospective study comparing surgical and oncologic outcomes in two groups of patients with esophageal cancer. His database comprised 65 patients who underwent esophagectomy with a thoracoscopic component (11 thoracoscopy/laparotomy, 2 Ivor-Lewis thoracoscopy/laparoscopy, and 52 three-hole thoracoscopy/laparoscopy). These were compared with a control group of 53 patients who underwent open surgery (15 Ivor-Lewis and 38 three-hole esophagectomy) during the same time period.
The patients’ mean age was 61 years. Neoadjuvant therapy was administered in 28 (43%) of the minimally invasive esophagectomy (MIE) group and 43 (81%) of the open surgery group.
Adenocarcinoma was present in most of the patients (85% MIE and 74% open). Squamous cell carcinoma occurred in 6% of the MIE group and 26% of the open group; there were also five cases (8%) of high-grade dysplasia in the MIE group. One patient had MIE for esophageal melanoma.
Dr. Berger briefly described his MIE approach. During the thoracoscopy, he uses 10-mm ports in the anterior axillary line at the fourth and eighth intercostal spaces and at the posterior axillary line. "A 5-mm port is placed at the tip of the scapula, and a suction port can be placed between the ports in the anterior axillary line," he said. "Finally, a suture is placed in the tendinous portion of the diaphragm to maintain retraction."
He uses a Penrose drain to encircle and retract the esophagus. The azygous vein is divided, and the aortic branches are divided or clipped. "The subcarinal lymph node package is dissected under direct vision and removed, and paraesophageal lymph nodes and tissue dissected up with the specimen."
During the subsequent laparoscopy, Dr. Berger places a 5-mm port in the right lateral subcostal area to accommodate a liver retractor, a 12-mm port in the umbilicus for the camera, an additional 12-mm working port in the right subcostal region, and a 5-mm port in the left subcostal region. "Once the gastric mobilization is complete, we often enlarge the 12-mm right subcostal port to about 5 cm and place a Lap Disk."
After dissecting the neck, he isolates and divides the esophagus. The completed reconstruction involves sewing the tip of the gastric tube to the chest tube and pulling that tube back up into the neck for a side-to-side esophagectomy. Anastomosis is in the neck with the gastric tube in the posterior mediastinum.
Mortality was similar in both groups of patients (8%). While the overall rate of complications was not significantly different (48% MIE vs. 60% open), the rate of major complications was (20% vs. 41%). Respiratory failure or acute respiratory distress syndrome occurred in a significantly smaller percentage of MIE patients (8% vs. 21%). There were also fewer cases of pneumonia among the MIE patients, but this was not a significant difference (8% vs. 18%). "Interestingly, there was a significant increase in the number of patients with a deep venous thrombosis or pulmonary embolism in the open group (2% vs. 11%)," Dr. Berger said. "This may have something to do with earlier postoperative mobilization for patients with MIE."
MIE patients also fared significantly better in terms of blood loss (182 mL vs. 619 mL) and median length of stay (9 vs. 16 days).
Oncologic outcomes were as good as, or better than, those seen in open surgery "There was no difference in R0 resection rates," Dr. Berger pointed out (97% MIE vs. 94% open). "We also saw a more than doubling of the number of examined lymph nodes in the MIE group, which was highly significant (20 vs. 9; P less than .0001)."
Despite the positive outcomes, Dr. Berger pointed out a major limitation of the study. Because his group attempts the MIE approach in all patients, "It’s impossible to find a concurrent group of patients who had open surgery for comparison." Also, he noted, "Pathology standards have changed and, thus, the importance of lymph nodes has become more recognized. Higher node yields are shown to be an important prognostic factor for survival. Therefore, our pathologists are now more diligent in finding the lymph nodes in the specimen."
Dr. Berger said he had no financial declarations.
FROM THE ANNUAL MEETING OF THE SOUTHERN SURGICAL ASSOCIATION