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Outcomes of minimally invasive esophagectomy (MIE) in high grade dysplasia of the esophagus
Abstract
The management of high-grade dysplasia (HGD) of the esophagus is controversial with some clinicians advocating non-operative ablation or surveillance. Minimally invasive esophagectomy (MIE) allows re-section of the esophagus and may minimize morbidity. This report summarizes our experience with MIE for HGD.
A retrospective review of 28 patients who underwent MIE for a pre-operative diagnosis of HGD. MIE initially involved a laparoscopic transhiatal approach (n=1), but subsequently evolved to laparoscopy with VATS mobilization (n=27) of the esophagus.
From August 1996 to March 2001, 28 patients underwent MIE. There were 23 males and five females; median age was 61 (40-78) years. Median hospital stay was 5 (3-20) days and ICU stay was 1 (1-20) day. One patient required conversion to laparotomy because of dense adhesions. There were ten other patients who had successful MIE despite prior laparotomy. Median operating time was 8 (5.8-13) h. One death occurred from sepsis, pneumonia and multi-system organ failure. Complications occurred in 15 patients. In addition to the patient who died, five re-operations were required for: small bowel perforation (n=1), jejunostomy leak (n=1), pyloric dilation for gastric outlet obstruction (n=1), cholecystectomy (n=1), incision and drainage of an abdominal abscess (n=1). Final pathologies were HGD (n=17), in situ cancer (n=6) and invasive cancer (n=5). At a median follow-up of 13 (2-41) months all hospital survivors are alive and free of disease.
This report confirms the risk of occult cancer in patients with HGD (39% in this series) supporting the recommendation for esophagectomy. MIE can be performed with acceptable results and may minimize morbidity compared to previous reports of open esophagectomy for HGD.
... Traditionally, esophagectomy has remained the mainstay of managing those patients with early mucosal neoplasia in BE. This is not only because of the significant risk of progression to OAC but also because up to 40% of patients with HGD may already harbor occult cancer in the Barrett's segment [11], although subsequent studies suggest this rate is much lower [12]. Even in specialist high-volume centers this operation carries a high mortality rate of 2-5% and subsequent morbidity of up to 40% [13,14]. ...
Aim:
The aim was to evaluate the cost-effectiveness of endoscopic eradication therapy (EET) with combined endoscopic mucosal resection and radiofrequency ablation for the treatment of high-grade dysplasia (HGD) arising in patients with Barrett's esophagus compared with endoscopic surveillance alone in the UK.
Materials & methods:
The cost-effectiveness model consisted of a decision tree and modified Markov model. A lifetime time horizon was adopted with the perspective of the UK healthcare system.
Results:
The base case analysis estimates that EET for the treatment of HGD is cost-effective at a GB£20,000 cost-effectiveness threshold compared with providing surveillance alone for HGD patients (incremental cost-effectiveness ratio: GB£1272).
Conclusion:
EET is likely to be a cost-effective treatment strategy compared with surveillance alone in patients with HGD arising in Barrett's esophagus in the UK.
... Indications for robotic esophagectomy parallel those of other MIE approaches: Barrett esophagus with highgrade dysplasia, end-stage achalasia, esophageal strictures, and esophageal cancer (4)(5)(6)(7)(8). While many T4 esophageal cancers are not amenable to surgical resection, selected patients have safely undergone en bloc resection of aorta or intrathoracic trachea or carina along with esophagectomy, but this would generally be a contraindication to robotic esophagectomy (9,10). ...
Robotic esophagectomy is an increasingly used modality. Patients who are candidates for traditional, open esophagectomy are typically also candidates for robotic esophagectomy. Knowledge of and training on the robotic platform is critical for success. Patient and port positioning is described. Either a hand-sewn or stapled intrathoracic anastomosis may be performed. Minimally invasive esophagectomy (MIE) appears to be associated with decreased respiratory complications versus open esophagectomy. Robotic esophagectomy may be performed with excellent perioperative outcomes, though long-term oncologic data regarding the operation are not yet available.
This comprehensive textbook, now fully revised, rewritten and updated in its fourth edition, provides an authoritative account of all aspects of perioperative care for surgical patients. All areas of medical disease are discussed with clear recommendations for work up and management in the perioperative period. Basic discussions of surgical procedures are included to help non-surgeons understand the procedures and their implications for patient care. This definitive account includes numerous contributions from leading experts at national centers of medical excellence. It will serve as a significant work of reference for internists, anesthesiologists and surgeons.
This comprehensive textbook, now fully revised, rewritten and updated in its fourth edition, provides an authoritative account of all aspects of perioperative care for surgical patients. All areas of medical disease are discussed with clear recommendations for work up and management in the perioperative period. Basic discussions of surgical procedures are included to help non-surgeons understand the procedures and their implications for patient care. This definitive account includes numerous contributions from leading experts at national centers of medical excellence. It will serve as a significant work of reference for internists, anesthesiologists and surgeons.
This comprehensive textbook, now fully revised, rewritten and updated in its fourth edition, provides an authoritative account of all aspects of perioperative care for surgical patients. All areas of medical disease are discussed with clear recommendations for work up and management in the perioperative period. Basic discussions of surgical procedures are included to help non-surgeons understand the procedures and their implications for patient care. This definitive account includes numerous contributions from leading experts at national centers of medical excellence. It will serve as a significant work of reference for internists, anesthesiologists and surgeons.
This comprehensive textbook, now fully revised, rewritten and updated in its fourth edition, provides an authoritative account of all aspects of perioperative care for surgical patients. All areas of medical disease are discussed with clear recommendations for work up and management in the perioperative period. Basic discussions of surgical procedures are included to help non-surgeons understand the procedures and their implications for patient care. This definitive account includes numerous contributions from leading experts at national centers of medical excellence. It will serve as a significant work of reference for internists, anesthesiologists and surgeons.
This comprehensive textbook, now fully revised, rewritten and updated in its fourth edition, provides an authoritative account of all aspects of perioperative care for surgical patients. All areas of medical disease are discussed with clear recommendations for work up and management in the perioperative period. Basic discussions of surgical procedures are included to help non-surgeons understand the procedures and their implications for patient care. This definitive account includes numerous contributions from leading experts at national centers of medical excellence. It will serve as a significant work of reference for internists, anesthesiologists and surgeons.
Gastric procedures performed with the patient under general anesthesia include those done for complications of peptic ulcer disease (parietal cell vagotomy (PCV), vagotomy and pyloroplasty (VP), vagotomy and antrectomy (VA), hemigastrectomy alone); for benign neoplasms (proximal or distal gastrectomy); and for malignant neoplasms (extended subtotal or total gastrectomy). In the laparoscopic surgery era, antireflux procedures involving the fundus of the stomach and antiobesity procedures including gastric bypass or banding are commonly performed.
While open or laparoscopic PCV or denervation of the fundus and body of the stomach (parietal cell area) is rarely performed currently, open or laparoscopic VP and VA are still occasionally necessary for patients with life-threatening complications of duodenal ulcers – hemorrhage, perforation, or obstruction. Such patients usually have untreated Helicobacter pylori infections or a virulent ulcer diathesis of unknown cause. VP and VA involve cutting the vagal nerve trunks at the esophageal hiatus and rearranging or resecting the pylorus. With antrectomy, all the gastrin-secreting cells are removed as well and reanastomosis to the duodenum (Billroth I) or jejunum (Billroth II) is necessary. Preoperative decompression of the stomach for 5 to 7 days and antibiotic irrigation the night before operation is indicated in patients with gastric dilation from pyloric obstruction. Hemigastrectomy (removal of the ulcer and the distal stomach) is 96% curative for patients with uncomplicated and complicated gastric ulcers and 100% curative for those with benign tumors (leiomyomas).
This comprehensive textbook, now fully revised, rewritten and updated in its fourth edition, provides an authoritative account of all aspects of perioperative care for surgical patients. All areas of medical disease are discussed with clear recommendations for work up and management in the perioperative period. Basic discussions of surgical procedures are included to help non-surgeons understand the procedures and their implications for patient care. This definitive account includes numerous contributions from leading experts at national centers of medical excellence. It will serve as a significant work of reference for internists, anesthesiologists and surgeons.
This comprehensive textbook, now fully revised, rewritten and updated in its fourth edition, provides an authoritative account of all aspects of perioperative care for surgical patients. All areas of medical disease are discussed with clear recommendations for work up and management in the perioperative period. Basic discussions of surgical procedures are included to help non-surgeons understand the procedures and their implications for patient care. This definitive account includes numerous contributions from leading experts at national centers of medical excellence. It will serve as a significant work of reference for internists, anesthesiologists and surgeons.
This comprehensive textbook, now fully revised, rewritten and updated in its fourth edition, provides an authoritative account of all aspects of perioperative care for surgical patients. All areas of medical disease are discussed with clear recommendations for work up and management in the perioperative period. Basic discussions of surgical procedures are included to help non-surgeons understand the procedures and their implications for patient care. This definitive account includes numerous contributions from leading experts at national centers of medical excellence. It will serve as a significant work of reference for internists, anesthesiologists and surgeons.
This comprehensive textbook, now fully revised, rewritten and updated in its fourth edition, provides an authoritative account of all aspects of perioperative care for surgical patients. All areas of medical disease are discussed with clear recommendations for work up and management in the perioperative period. Basic discussions of surgical procedures are included to help non-surgeons understand the procedures and their implications for patient care. This definitive account includes numerous contributions from leading experts at national centers of medical excellence. It will serve as a significant work of reference for internists, anesthesiologists and surgeons.
This comprehensive textbook, now fully revised, rewritten and updated in its fourth edition, provides an authoritative account of all aspects of perioperative care for surgical patients. All areas of medical disease are discussed with clear recommendations for work up and management in the perioperative period. Basic discussions of surgical procedures are included to help non-surgeons understand the procedures and their implications for patient care. This definitive account includes numerous contributions from leading experts at national centers of medical excellence. It will serve as a significant work of reference for internists, anesthesiologists and surgeons.
This comprehensive textbook, now fully revised, rewritten and updated in its fourth edition, provides an authoritative account of all aspects of perioperative care for surgical patients. All areas of medical disease are discussed with clear recommendations for work up and management in the perioperative period. Basic discussions of surgical procedures are included to help non-surgeons understand the procedures and their implications for patient care. This definitive account includes numerous contributions from leading experts at national centers of medical excellence. It will serve as a significant work of reference for internists, anesthesiologists and surgeons.
This comprehensive textbook, now fully revised, rewritten and updated in its fourth edition, provides an authoritative account of all aspects of perioperative care for surgical patients. All areas of medical disease are discussed with clear recommendations for work up and management in the perioperative period. Basic discussions of surgical procedures are included to help non-surgeons understand the procedures and their implications for patient care. This definitive account includes numerous contributions from leading experts at national centers of medical excellence. It will serve as a significant work of reference for internists, anesthesiologists and surgeons.
This comprehensive textbook, now fully revised, rewritten and updated in its fourth edition, provides an authoritative account of all aspects of perioperative care for surgical patients. All areas of medical disease are discussed with clear recommendations for work up and management in the perioperative period. Basic discussions of surgical procedures are included to help non-surgeons understand the procedures and their implications for patient care. This definitive account includes numerous contributions from leading experts at national centers of medical excellence. It will serve as a significant work of reference for internists, anesthesiologists and surgeons.
This comprehensive textbook, now fully revised, rewritten and updated in its fourth edition, provides an authoritative account of all aspects of perioperative care for surgical patients. All areas of medical disease are discussed with clear recommendations for work up and management in the perioperative period. Basic discussions of surgical procedures are included to help non-surgeons understand the procedures and their implications for patient care. This definitive account includes numerous contributions from leading experts at national centers of medical excellence. It will serve as a significant work of reference for internists, anesthesiologists and surgeons.
This comprehensive textbook, now fully revised, rewritten and updated in its fourth edition, provides an authoritative account of all aspects of perioperative care for surgical patients. All areas of medical disease are discussed with clear recommendations for work up and management in the perioperative period. Basic discussions of surgical procedures are included to help non-surgeons understand the procedures and their implications for patient care. This definitive account includes numerous contributions from leading experts at national centers of medical excellence. It will serve as a significant work of reference for internists, anesthesiologists and surgeons.
This comprehensive textbook, now fully revised, rewritten and updated in its fourth edition, provides an authoritative account of all aspects of perioperative care for surgical patients. All areas of medical disease are discussed with clear recommendations for work up and management in the perioperative period. Basic discussions of surgical procedures are included to help non-surgeons understand the procedures and their implications for patient care. This definitive account includes numerous contributions from leading experts at national centers of medical excellence. It will serve as a significant work of reference for internists, anesthesiologists and surgeons.
This comprehensive textbook, now fully revised, rewritten and updated in its fourth edition, provides an authoritative account of all aspects of perioperative care for surgical patients. All areas of medical disease are discussed with clear recommendations for work up and management in the perioperative period. Basic discussions of surgical procedures are included to help non-surgeons understand the procedures and their implications for patient care. This definitive account includes numerous contributions from leading experts at national centers of medical excellence. It will serve as a significant work of reference for internists, anesthesiologists and surgeons.
This comprehensive textbook, now fully revised, rewritten and updated in its fourth edition, provides an authoritative account of all aspects of perioperative care for surgical patients. All areas of medical disease are discussed with clear recommendations for work up and management in the perioperative period. Basic discussions of surgical procedures are included to help non-surgeons understand the procedures and their implications for patient care. This definitive account includes numerous contributions from leading experts at national centers of medical excellence. It will serve as a significant work of reference for internists, anesthesiologists and surgeons.
This comprehensive textbook, now fully revised, rewritten and updated in its fourth edition, provides an authoritative account of all aspects of perioperative care for surgical patients. All areas of medical disease are discussed with clear recommendations for work up and management in the perioperative period. Basic discussions of surgical procedures are included to help non-surgeons understand the procedures and their implications for patient care. This definitive account includes numerous contributions from leading experts at national centers of medical excellence. It will serve as a significant work of reference for internists, anesthesiologists and surgeons.
This comprehensive textbook, now fully revised, rewritten and updated in its fourth edition, provides an authoritative account of all aspects of perioperative care for surgical patients. All areas of medical disease are discussed with clear recommendations for work up and management in the perioperative period. Basic discussions of surgical procedures are included to help non-surgeons understand the procedures and their implications for patient care. This definitive account includes numerous contributions from leading experts at national centers of medical excellence. It will serve as a significant work of reference for internists, anesthesiologists and surgeons.
This comprehensive textbook, now fully revised, rewritten and updated in its fourth edition, provides an authoritative account of all aspects of perioperative care for surgical patients. All areas of medical disease are discussed with clear recommendations for work up and management in the perioperative period. Basic discussions of surgical procedures are included to help non-surgeons understand the procedures and their implications for patient care. This definitive account includes numerous contributions from leading experts at national centers of medical excellence. It will serve as a significant work of reference for internists, anesthesiologists and surgeons.
This comprehensive textbook, now fully revised, rewritten and updated in its fourth edition, provides an authoritative account of all aspects of perioperative care for surgical patients. All areas of medical disease are discussed with clear recommendations for work up and management in the perioperative period. Basic discussions of surgical procedures are included to help non-surgeons understand the procedures and their implications for patient care. This definitive account includes numerous contributions from leading experts at national centers of medical excellence. It will serve as a significant work of reference for internists, anesthesiologists and surgeons.
This comprehensive textbook, now fully revised, rewritten and updated in its fourth edition, provides an authoritative account of all aspects of perioperative care for surgical patients. All areas of medical disease are discussed with clear recommendations for work up and management in the perioperative period. Basic discussions of surgical procedures are included to help non-surgeons understand the procedures and their implications for patient care. This definitive account includes numerous contributions from leading experts at national centers of medical excellence. It will serve as a significant work of reference for internists, anesthesiologists and surgeons.
This comprehensive textbook, now fully revised, rewritten and updated in its fourth edition, provides an authoritative account of all aspects of perioperative care for surgical patients. All areas of medical disease are discussed with clear recommendations for work up and management in the perioperative period. Basic discussions of surgical procedures are included to help non-surgeons understand the procedures and their implications for patient care. This definitive account includes numerous contributions from leading experts at national centers of medical excellence. It will serve as a significant work of reference for internists, anesthesiologists and surgeons.
This comprehensive textbook, now fully revised, rewritten and updated in its fourth edition, provides an authoritative account of all aspects of perioperative care for surgical patients. All areas of medical disease are discussed with clear recommendations for work up and management in the perioperative period. Basic discussions of surgical procedures are included to help non-surgeons understand the procedures and their implications for patient care. This definitive account includes numerous contributions from leading experts at national centers of medical excellence. It will serve as a significant work of reference for internists, anesthesiologists and surgeons.
This comprehensive textbook, now fully revised, rewritten and updated in its fourth edition, provides an authoritative account of all aspects of perioperative care for surgical patients. All areas of medical disease are discussed with clear recommendations for work up and management in the perioperative period. Basic discussions of surgical procedures are included to help non-surgeons understand the procedures and their implications for patient care. This definitive account includes numerous contributions from leading experts at national centers of medical excellence. It will serve as a significant work of reference for internists, anesthesiologists and surgeons.
This comprehensive textbook, now fully revised, rewritten and updated in its fourth edition, provides an authoritative account of all aspects of perioperative care for surgical patients. All areas of medical disease are discussed with clear recommendations for work up and management in the perioperative period. Basic discussions of surgical procedures are included to help non-surgeons understand the procedures and their implications for patient care. This definitive account includes numerous contributions from leading experts at national centers of medical excellence. It will serve as a significant work of reference for internists, anesthesiologists and surgeons.
This comprehensive textbook, now fully revised, rewritten and updated in its fourth edition, provides an authoritative account of all aspects of perioperative care for surgical patients. All areas of medical disease are discussed with clear recommendations for work up and management in the perioperative period. Basic discussions of surgical procedures are included to help non-surgeons understand the procedures and their implications for patient care. This definitive account includes numerous contributions from leading experts at national centers of medical excellence. It will serve as a significant work of reference for internists, anesthesiologists and surgeons.
This comprehensive textbook, now fully revised, rewritten and updated in its fourth edition, provides an authoritative account of all aspects of perioperative care for surgical patients. All areas of medical disease are discussed with clear recommendations for work up and management in the perioperative period. Basic discussions of surgical procedures are included to help non-surgeons understand the procedures and their implications for patient care. This definitive account includes numerous contributions from leading experts at national centers of medical excellence. It will serve as a significant work of reference for internists, anesthesiologists and surgeons.
This comprehensive textbook, now fully revised, rewritten and updated in its fourth edition, provides an authoritative account of all aspects of perioperative care for surgical patients. All areas of medical disease are discussed with clear recommendations for work up and management in the perioperative period. Basic discussions of surgical procedures are included to help non-surgeons understand the procedures and their implications for patient care. This definitive account includes numerous contributions from leading experts at national centers of medical excellence. It will serve as a significant work of reference for internists, anesthesiologists and surgeons.
This comprehensive textbook, now fully revised, rewritten and updated in its fourth edition, provides an authoritative account of all aspects of perioperative care for surgical patients. All areas of medical disease are discussed with clear recommendations for work up and management in the perioperative period. Basic discussions of surgical procedures are included to help non-surgeons understand the procedures and their implications for patient care. This definitive account includes numerous contributions from leading experts at national centers of medical excellence. It will serve as a significant work of reference for internists, anesthesiologists and surgeons.
This comprehensive textbook, now fully revised, rewritten and updated in its fourth edition, provides an authoritative account of all aspects of perioperative care for surgical patients. All areas of medical disease are discussed with clear recommendations for work up and management in the perioperative period. Basic discussions of surgical procedures are included to help non-surgeons understand the procedures and their implications for patient care. This definitive account includes numerous contributions from leading experts at national centers of medical excellence. It will serve as a significant work of reference for internists, anesthesiologists and surgeons.
This comprehensive textbook, now fully revised, rewritten and updated in its fourth edition, provides an authoritative account of all aspects of perioperative care for surgical patients. All areas of medical disease are discussed with clear recommendations for work up and management in the perioperative period. Basic discussions of surgical procedures are included to help non-surgeons understand the procedures and their implications for patient care. This definitive account includes numerous contributions from leading experts at national centers of medical excellence. It will serve as a significant work of reference for internists, anesthesiologists and surgeons.
This comprehensive textbook, now fully revised, rewritten and updated in its fourth edition, provides an authoritative account of all aspects of perioperative care for surgical patients. All areas of medical disease are discussed with clear recommendations for work up and management in the perioperative period. Basic discussions of surgical procedures are included to help non-surgeons understand the procedures and their implications for patient care. This definitive account includes numerous contributions from leading experts at national centers of medical excellence. It will serve as a significant work of reference for internists, anesthesiologists and surgeons.
This comprehensive textbook, now fully revised, rewritten and updated in its fourth edition, provides an authoritative account of all aspects of perioperative care for surgical patients. All areas of medical disease are discussed with clear recommendations for work up and management in the perioperative period. Basic discussions of surgical procedures are included to help non-surgeons understand the procedures and their implications for patient care. This definitive account includes numerous contributions from leading experts at national centers of medical excellence. It will serve as a significant work of reference for internists, anesthesiologists and surgeons.
This comprehensive textbook, now fully revised, rewritten and updated in its fourth edition, provides an authoritative account of all aspects of perioperative care for surgical patients. All areas of medical disease are discussed with clear recommendations for work up and management in the perioperative period. Basic discussions of surgical procedures are included to help non-surgeons understand the procedures and their implications for patient care. This definitive account includes numerous contributions from leading experts at national centers of medical excellence. It will serve as a significant work of reference for internists, anesthesiologists and surgeons.
The most common two malignant tumors involving the esophagus and the esophagogastric junction are adenocarcinoma, which is more common in Western countries, and squamous cell carcinoma, which is more commonly seen in Asia. Diagnosis and identification of tumor cell type is done with endoscopic biopsies. Accurate staging of esophageal cancer is important as it impacts prognosis and facilitates staged directed treatment. Staging is done according to the TNM classification with the current staging version being published by the AJCC (UICC) 7th Edition. Staging is done on the basis of depth of penetration in the wall of the esophagus or stomach (T stage), the number of lymph nodes involved (N stage) and evidence for metastatic spread to other organs (M stage). Anatomic location of the cancer in the esophagus, R status (Resection margins) and G status (Tumor differentiation) can also play an important role in assigning tumor stage and deciding on treatment approach. Staging that is assigned following investigation is typified as “clinical stage”; staging following endoscopic or surgical resection is classified as “pathologic stage.”The most important investigations to provide direct information regarding accurate clinical stage include upper endoscopy, computed tomography scans, positron emission tomography scans, and endoscopic ultrasounds. In selected patients, endoscopic mucosal resections, endobronchial ultrasound, MRI scans, and thoracoscopic and laparoscopic procedures can also play a role. The results of tumor staging are best reviewed in a multidisciplinary tumor board where all the information can be assessed and appropriate treatment can be assigned in a multidisciplinary fashion.
Endoscopic mucosal resection (EMR) is a technique developed for the removal of sessile or flat neoplastic lesions confined to the superficial layers (mucosa and submucosa) of the gastrointestinal tract. Bleeding and perforation are well-known complications of EMR. Here we report the first case of paralytic ileus after EMR of a caecal polyp. A 66-year-old man was scheduled for elective EMR of a 3.5-cm caecal polyp under general anaesthesia after a screening colonoscopy. The procedure was performed by an expert endoscopist, and air was insufflated during the procedure because of the unavailability of CO2. The polyp was successfully removed; the procedure duration was 81 min. After the procedure, the patient complained of abdominal pain and dyspnoea. He developed tachypnoea and tachycardia as well as oxygen desaturation with SpO2 84%. He was administered oxygen therapy via a non-rebreather mask, following which his oxygenation improved. His abdominal X-ray findings were consistent with ileus. Therefore, a nasogastric tube was placed, and the patient was admitted to our hospital. He was managed conservatively and underwent serial abdominal X-rays that showed improvement of the ileus. On the fourth day of admission, he was started on an oral diet; on the sixth day of admission, he was discharged with resolving ileus. Computed tomography enterography performed 1 week after discharge showed complete resolution of the ileus. Factors that may have contributed to the occurrence of ileus in our patient include the use of air during the procedure, location of the polyp (caecal), duration of the procedure, effect of electrocautery, use of general anaesthesia and possibility of aspiration pneumonitis. This case report will make endoscopists aware of the abovementioned factors while performing EMR as this procedure can lead to the complication of paralytic ileus with significant patient morbidity. Conservative treatment should be attempted first before any other intervention.
Esophagogastrectomy is usually performed for high-grade dysplasia or carcinoma of the esophagus, particularly of the middle and lower thirds. Less common indications for this procedure are nondilatable stricture of the distal esophagus requiring resection and rupture of the esophagus that is irreparable. Two separate incisions are generally used: Abdominal and right thoracic. A left thoracotomy or left thoracoabdominal incision may be used for carcinoma of the distal esophagus and the gastroesophageal junction. A combined laparoscopic/thoracoscopic approach is currently undergoing clinical evaluation but is still considered experimental, while the open approach remains the gold standard. To mobilize the stomach, the short gastric, left gastroepiploic, and left gastric arteries are sacrificed, and the blood supply through the right gastroepiploic and right gastric arteries is preserved. The distal line of resection in the proximal stomach is securely closed and an esophagogastric anastomosis is performed on the anterior surface of the stomach below the line of resection. Feeding jejunostomy with pyloroplasty or pyloromyotomy may be done. Surgical stress is great and the procedure has relatively high morbidity and mortality rates. Anesthesia is endotracheal, using a double lumen tube to allow the lung on the side of the operation to remain collapsed. The procedure takes 4 to 6 hours and requires 2 to 4 units of blood. Usual postoperative course: Expected postoperative hospital stay: Seven to 10 days. Operative mortality: The operative mortality rate is approximately 4%-5%. © Cambridge University Press 2004 and Cambridge University Press, 2009.
This chapter will explore recent advances of minimally invasive treatment for dysplasia and early cancer arising in Barrett's esophagus (BE). These techniques can be broadly categorized into therapy that removes tissue for histological evaluation (endoscopic resection) and those that do not (ablative therapies). An overview of each technique is presented including a summary of clinical studies and adverse events. The use of endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), radiofrequency ablation (RFA), photodynamic therapy (PDT), argon plasma coagulation (APC), and cryoablation are discussed, with a video demonstrating both EMR and RFA. Finally there is a discussion on subsquamous intestinal metaplasia and the use of biomarkers to predict therapeutic response.
A surgeon may witness a radical shift in therapies a few times during a career. For example, the introduction and refinement of laparoscopic and thoracoscopic techniques have brought about a revolution in the management of a multitude of abdominal and thoracic disease processes over the past generation. Another more recent, yet equally significant, paradigm shift has been the popularization of endoscopic therapies for early esophageal neoplasia.
Minimally invasive surgical (MIS) procedures have become commonplace in modern surgical practice. The term minimally invasive surgery has been and continues to be interchangeably applied to describe laparoscopic, laparoscopic-assisted, thoracoscopic, and telesurgical (robotic) procedures. Minimally invasive surgical procedures for the treatment of benign and malignant disorders of the esophagus are being developed, refined, and clinically applied in parallel with the exponential availability of novel technologies and instrumentation. Herein, we review the progression from lapa-roscopic/thoracoscopic esophagectomy to telesurgical esophagectomy, presently termed minimally invasive esophagectomy, and describe the telesurgical procedure as well as early the clinical outcome experience.
The early development of innovative surgical procedures is usually reported as retrospective case series, wasting opportunities to provide useful information and introducing bias. We present a report of an innovative procedure in development, using the Prospective Development Study (PDS) format recommended by the IDEAL Collaboration.
We report the development of robotically assisted oesophagectomy by a two-surgeon team from the first robotic case onwards. Key outcomes (blood loss, robotic operating time, lymph node yield, length of stay and complications) are prospectively reported for each patient sequentially. Reasons for rejecting cases for robotic surgery are explained. All changes to technique or indication are highlighted, showing when they occurred and explaining why they were instituted.
The first robotic oesophagectomy was attempted in December 2009. Subsequently 55 oesophagectomies were undertaken, 34 using the robot and 21 without it. Seven deliberate changes in technique occurred during the series. Nodal yield increased markedly after adopting formal mediastinal node dissection and clipping of the thoracic duct. No obvious trends were noted in other outcomes. The robot facilitated Intra-thoracic anastomosis, but mediastinal node dissection showed no advantages due to loss of haptic sensation. Complication rates, R0 rates and nodal yield were considered acceptable.
Presenting the development experience in this way improved the clarity of transmission of the main learning points for other surgeons, eliminated bias from selective reporting and explained other types of selection bias. The IDEAL Prospective Development Study has clear advantages over standard case series format for presenting uncontrolled early study data from innovative procedures.
Copyright © 2015. Published by Elsevier Ltd.
Patients with gastroesophageal reflux disease and Barrett's esophagus can be a management challenge for the treating physician or surgeon. The goals of therapy include relief of reflux symptoms, induction of histologic regression, and prevention of progression of intestinal metaplasia to dysplasia or invasive carcinoma. Antireflux surgery is effective at achieving these end points, although ongoing follow-up and endoscopic surveillance are essential. In cases of dysplasia or early esophageal neoplasia associated with Barrett's esophagus, endoscopic resection and ablation have supplanted esophagectomy as the standard of care in most cases. Esophageal resection continues to have a role, however, in a minority of appropriately selected candidates.
Copyright © 2015 Elsevier Inc. All rights reserved.
Barrett’s esophagus is associated with an increased occurrence of mucosal dysplasia and adenocarcinoma in the specialized glandular mucosa, with a 30- to 52-fold increase in the occurrence of esophageal cancer compared with the normal population. An alternative to esophagectomy as a treatment modality is needed because of the high morbidity and mortality associated with it. Photodynamic therapy offers an alternative nonsurgical therapy that eliminates dysplasia and superficial cancer, and reduces Barrett’s mucosa while reducing the risks and costs compared with those of esophagectomy. The use of photodynamic therapy in the ablation of Barrett’s mucosa is reviewed.
A number of case reports have described the application of minimally invasive surgical techniques to accomplish esophagectomy. However, most reports have employed thoracoscopic or laparoscopic techniques to perform esophagectomy in addition to an "access" incision which often approaches a standard laparotomy or thoracotomy.
This report describes a total laparoscopic transhiatal esophagectomy in a 55 year old female with Barrett's esophagus and high grade dysplasia.
The patient had an uneventful recovery and was discharged home on the fourth day after a total laparoscopic esophagectomy. This report demonstrates the technical feasibility of this complex procedure by a minimally invasive approach.
Surgical resection of the esophagus is frequently recommended for Barrett's high-grade dysplasia (HGD) without cancer.
During a 20-year period, patients were diagnosed and observed through an organized surveillance program at the Hines Veterans Affairs Hospital. The program was supported by Hines VA and organized and managed by 2 endoscopists using preestablished endoscopic criteria.
Barrett's esophagus was diagnosed in 1099 patients, and 36,251 esophageal mucosal specimens were reviewed. Seventy-nine of 1099 patients (7.2%) initially had HGD (34 prevalent) or subsequently developed HGD (45 incident) without evidence of cancer. Of the 75 HGD patients who remained without detectable cancer after the 1 year of intensive searching, 12 developed cancer (16%) during a mean 7.3-year surveillance period: 11 of the 12 who were compliant were considered cured with surgical or ablation therapy. Cancer did not develop in the remaining 63 HGD patients during the surveillance period.
HGD without cancer in Barrett's esophagus follows a relatively benign course in the majority of patients. In the patients who eventually progress to cancer during regular surveillance, surgical resection is curative. Surveillance endoscopies with biopsy is a valid and safe follow-up strategy for Barrett's patients who have HGD without cancer.
Hypothesis
Minimally invasive esophagectomy can be performed as safely as conventional esophagectomy and has distinct perioperative outcome advantages.Design
A retrospective comparison of 3 methods of esophagectomy: minimally invasive, transthoracic, and blunt transhiatal.Setting
University medical center.Patients
Eighteen consecutive patients underwent combined thoracoscopic and laparoscopic esophagectomy from October 9, 1998, through January 19, 2000. These patients were compared with 16 patients who underwent transthoracic esophagectomy and 20 patients who underwent blunt transhiatal esophagectomy from June 1, 1993, through August 5, 1998.Main Outcome Measures
Operative time, amount of blood loss, number of operative transfusions, length of intensive care and hospital stays, complications, and mortality.Results
Patients who had minimally invasive esophagectomy had shorter operative times, less blood loss, fewer transfusions, and shortened intensive care unit and hospital courses than patients who underwent transthoracic or blunt transhiatal esophagectomy. There was no significant difference in the incidence of anastomotic leak or respiratory complications among the 3 groups.Conclusion
Minimally invasive esophagectomy is safe and provides clinical advantages compared with transthoracic and blunt transhiatal esophagectomy.
Background:
Thoracic surgeons traditionally performed thoracotomy and myotomy for achalasia. Recently minimally invasive approaches have been reported with good success. This report summarizes our single-institution experience using video-assisted thoracoscopy (VATS) or laparoscopy (LAP) for the treatment of achalasia.
Methods:
A review of 62 patients undergoing minimally invasive myotomy for achalasia was performed. There were 27 male and 35 female patients. Mean age was 53 years (range 14 to 86). Thirty-seven (59.7%) had failed prior treatments (balloon dilation, botulinim toxin injection, or prior surgery). Outcomes studied were dysphagia score (1 = none, 5 = severe), Short-Form 36 quality of life (SF36 QOL) score, and heartburn-related QOL index (HRQOL).
Results:
Surgery included myotomy and partial fundoplication (5 VATS and 57 LAP). Mortality was zero, and complications occurred in 9 (14.5%) patients. There were 6 perforations (4 repaired by LAP and 2 open). Median length of stay was 2 days, time to oral intake was 1 day. At a mean of 19 months follow-up, 92.5% of patients were satisfied with outcome. Dysphagia scores improved from 3.6 to 1.5 (p < 0.01) but 3 patients ultimately required esophagectomy for recurrent dysphagia. HRQOL scores for heartburn and SF-36 QOL scores were comparable with control populations.
Conclusions:
Minimally invasive myotomy and partial fundoplication for achalasia improved dysphagia in 92.5% of patients with heartburn and QOL scores were comparable with normal values at 19-month follow-up. The laparoscopic approach offers excellent results and was the preferred approach by our thoracic group for treating achalasia. Thoracic residency training should strive to include laparoscopic esophageal experience.
Twelve patients presenting with symptomatic esophagitis associated with hiatal hernia and gastroesophageal reflux underwent operative management under laparoscopic guidance. The antireflux procedure employed was the Nissen fundoplication. The authors completed the operation laparoscopically in nine patients. Postoperatively, patients were evaluated with repeat fiberoptic endoscopy, esophageal manometry, and barium contrast studies. Postoperative results were considered excellent on the basis of these studies and complete control of symptoms. The mortality rate was 0%. The only major operative complication was a pneumonia that occurred in one patient. At 1 month follow-up, six patients were totally asymptomatic. The authors conclude that laparoscopic treatment of gastroesophageal reflux associated with a hiatal hernia is feasible by a procedure that has already proven its value during open surgery.
Twelve patients with benign and malignant esophageal diseases were treated by transhiatal esophagectomy, without thoracotomy, using abdominal-mediastinal dissection conducted by videolaparoscopy. A cervical approach was used to retrieve the esophagus and to perform the esophagogastric anastomosis. The procedure was indicated in patients with advanced achalasia of the esophagus, severe reflux stenosis, squamous cell carcinoma, and adenocarcinoma of the esophagus. Three pleural perforations occurred during surgery. Blood loss was minimal. One patient required conversion to open surgery, two patients were submitted to chest drainage, and three had transitory dysphonia. One patient had an anastomotic leak with subsequent stenosis requiring endoscopic dilatation. No mortality occurred in this small series.
Barrett's esophagus is a metaplastic change in the mucosal lining which represents a peculiar form of healing in response to the chronic injury due to gastroesophageal reflux. It has been recognized that this change is associated with an increased risk of developing esophageal adenocarcinoma. Several factors have been shown to identify the patients who are at particular risk for carcinoma, the most importance of which is the development of dysplasia. As a result, management of patients with Barrett's esophagus must include careful endoscopic surveillance with histological examination of the biopsies by two independent experienced pathologists. Patients with low-grade dysplasia require complete control of reflux and careful endoscopic surveillance. Because the majority of patients with high-grade dysplasia will have co-existent adenocarcinoma, and because of difficulties in differentiating high-grade dysplasia from invasive adenocarcinoma, esophagectomy is the treatment of choice for these individuals. This approach has been shown to result in a significant improvement in survival in patients with esophageal cancer identified under surveillance.
To evaluate early results with laparoscopic total esophagectomy for benign and malignant disease of the esophagus.
Case series involving 9 patients with mean follow-up of 13 months.
An advanced endoscopic surgery unit at a tertiary referral teaching hospital.
Between December 12, 1993, and December 1, 1996, 9 patients with a mean age of 61 years underwent laparoscopic esophagectomy. Indications were adenocarcinoma in 5, squamous cell carcinoma in 1, dysplastic Barrett esophagus in 2, and refractory stricture with severe shortening in 1.
Gastroduodenal mobilization, transhiatal wide esophageal dissection, gastric tube formation (8 cases), pyloromyotomy (2 cases), cervical anastomosis (8 cases), and laparoscopic jejunal feeding tube placement (8 cases).
Operative time, amount of blood loss, operative complications, length of hospital stay, postoperative complications, dysphagia rates, and survival.
All procedures were completed endoscopically. Operative time was 6.5 hours (range, 4 3/4 to 9 1/4). Average blood loss was 290 mL. One patient required a right thoracoscopy for an intrathoracic anastomosis because of questionable viability of the gastric tube. Mean hospital stay was 6.4 days (range, 4-9 days). Hospital complications included subclavian vein thrombosis (1 patient), dysphonia (6 patients), and atelectasis (5 patients). There were no anastomotic leaks. Three patients subsequently died: 2 of distant metastatic cancer (at 13 months and 33 months) and 1 of cardiac failure at 10 months. The 6 surviving patients were cancer free at a mean follow-up of 13 months. One patient had left vocal cord paralysis. All patients were doing well and had Visick scores of I or II.
Laparoscopic esophagectomy is a technically feasible but difficult procedure. Despite the long operative times, patients do well and benefit from a shorter hospital stay and more rapid recovery compared with open esophagectomy. Its role as a curative cancer procedure remains unknown, but it may have a place on the basis of its palliative superiority.
Endoscopic ultrasonography is frequently used to locally stage esophageal cancer, but few studies exist to validate its accuracy for lymph node metastases. Our objective was to compare endoscopic ultrasonography with video-assisted thoracoscopic and laparoscopic staging in evaluating lymph node metastases in esophageal cancer.
Twenty-six patients with potentially resectable esophageal cancer were identified by conventional imaging. Endoscopic ultrasonography was performed followed by laparoscopic and thoracoscopic staging, and locoregional staging was compared.
In eight patients endoscopic ultrasonography indicated N0 disease, but laparoscopy and thoracoscopy documented N1 disease in six. In five of 26 (19%) obstruction prevented endoscopic ultrasonography; three had N1 by laparoscopy and thoracoscopy. Thirteen patients had N1 disease according to endoscopic ultrasonography, and 12 of 13 (92%) had N1 disease by laparoscopy and thoracoscopy. The sensitivity and specificity of endoscopic ultrasonography for nodal evaluation were 65% and 66%, respectively. Sensitivity decreased to 44% for lymph node metastases less than 1 cm. No instances of T4 disease were found by surgical staging when endoscopic ultrasonography indicated T3 disease. Endoscopic ultrasonography revealed no distant metastases in any patient, but in four of 26 (15%) laparoscopy identified liver metastases.
The accuracy of endoscopic ultrasonography in the diagnosis of lymph node metastases in esophageal cancer was 65% and only 44% for lymph node metastases less than 1 cm diameter. Laparoscopy and thoracoscopy improved the accuracy of staging lymph node metastases in esophageal cancer and had the advantage of evaluating the thoracic and abdominal cavities for metastases.
Intestinal metaplastic mucosa in Barrett's oesophagus can be replaced by squamous epithelium after mucosal thermal ablation associated with acid suppression therapy.
To assess whether restoration of squamous epithelium can be obtained after ablation of Barrett's oesophagus using argon plasma coagulation (APC) associated with proton pump inhibitor (PPI) therapy.
Thirty one patients with Barrett's oesophagus received APC. Omeprazole (40 mg/day) was given from the first APC application to one month after completion of the treatment, then given symptomatically. Twenty four hour pH-metry was performed during endotherapy.
Complete re-epithelialisation was visualised at endoscopy in 25/31 patients (81%) after a mean number of 2.4 APC sessions (range 1-4). Only partial squamous re-epithelialisation was observed in three patients and three others had no eradication. At histological assessment, eradication of Barrett's oesophagus was only confirmed in 19/31 patients (61%) due to the presence of a few residual Barrett's glands under the new squamous epithelium. Complete eradication was related to a Barrett's oesophagus segment length of less than 4 cm and the absence of circumferential extension but not to the normalisation of oesophageal acid exposure under PPI therapy. Seventeen patients with apparently complete endoscopic and histological eradication of Barrett's oesophagus were re-evaluated at one year; eight (47%) disclosed relapsing islands of Barrett metaplasia despite continuous omeprazole therapy (10-40 mg/day).
APC combined with 40 mg omeprazole daily can eradicate Barrett's mucosa with apparent squamous re-epithelialisation in the majority of patients even in the absence of normalisation of oesophageal acid exposure. However, one year after endotherapy for Barrett's oesophagus, relapse is frequent but limited in extent.
The rising incidence of esophageal adenocarcinoma in western countries requires a new strategy in the management of dysplasia in Barrett's esophagus. Esophagectomy, which has high morbidity and mortality rates, has been recommended to treat patients with severe dysplasia. Strictly superficial laser coagulation with tissue ablation therefore is a desirable option for the management of dysplasia in Barrett's esophagus because the tissue to be ablated is only about 2 mm thick. Potassium-titanyl-phosphate (KTP) laser light with a wavelength of 532 nm is preferentially absorbed by hemoglobin and therefore combines excellent coagulation with limited tissue penetration. We report first clinical results with KTP laser superficial vaporization of dysplasia and early cancer in Barrett's esophagus.
Eight men and 2 women 43 to 84 years of age with short segments of Barrett's esophagus or traditional Barrett's esophagus and histologically proved low-grade (n = 4) and high-grade (n = 4) dysplasia or early adenocarcinoma (n = 2) were selected for this pilot study. For all patients thermal endoscopic destruction was conducted with a frequency-doubled neodymium:yttrium-aluminum-garnet (Nd:YAG) KTP laser system. Laser therapy was performed by means of the free-beam method with coaxial insufflation of gas. An average of 2.4 sessions per patient were required for ablation of the Barrett's mucosa.
Two to three days after laser treatment the response of the ablated mucosa was assessed with endoscopy and biopsy. Samples taken showed fibrinoid necrosis of the mucosal layer. A complete response was obtained for all 10 patients. Replacement by normal squamous cell epithelium was induced in combination with acid suppression therapy of up to 80 mg omeprazole daily. No complications occurred. In two patients biopsy showed specialized mucosa beneath the restored squamous cell epithelial layer. Follow-up times were as long as 15 months (mean value 10.6 months).
KTP laser destruction of Barrett's esophagus induced mucosal regeneration with normal squamous cell epithelium in combination with acid suppression. Limitation of the depth of thermal destruction in Barrett's esophagus minimizes risk for perforation or stricture formation. KTP laser ablation of Barrett's esophagus seems to be feasible and safe in short segments of Barrett's esophagus with dysplasia or early cancer.
Barrett's esophagus is associated with an increased occurrence of mucosal dysplasia and adenocarcinoma in the specialized glandular mucosa, with a 30- to 52-fold increase in the occurrence of esophageal cancer compared with the normal population. An alternative to esophagectomy as a treatment modality is needed because of the high morbidity and mortality associated with it. Photodynamic therapy offers an alternative nonsurgical therapy that eliminates dysplasia and superficial cancer, and reduces Barrett's mucosa while reducing the risks and costs compared with those of esophagectomy. The use of photodynamic therapy in the ablation of Barrett's mucosa is reviewed.
To review the authors' clinical experience with transhiatal esophagectomy (THE) and the refinements in this procedure that have evolved.
Increased use of THE during the past two decades has generated controversy about the merits and safety of this approach compared with transthoracic esophageal resection. The authors' large THE experience provides a valuable basis for benchmarking data regarding the procedure.
The results of THE were analyzed retrospectively using the authors' prospectively established esophageal resection database and follow-up information on these patients.
From 1976 to 1998, THE was performed in 1085 patients, 26% with benign disease and 74% with cancer. The procedure was possible in 98.6% of cases. Stomach was the esophageal substitute in 96%. The hospital mortality rate was 4%. Blood loss averaged 689 cc. Major complications were anastomotic leak (13%), atelectasis/pneumonia (2%), intrathoracic hemorrhage, recurrent laryngeal nerve paralysis, chylothorax, and tracheal laceration (<1% each). Actuarial survival of patients with carcinoma equaled or exceeded that reported after transthoracic esophagectomy. Late functional results were good or excellent in 70%. With preoperative pulmonary and physical conditioning, a side-to-side stapled cervical esophagogastric anastomosis (<3% incidence of leak), and postoperative epidural anesthesia, the need for an intensive care unit stay has been eliminated and the length of stay reduced to 7 days.
THE is possible in most patients requiring esophageal resection and can be performed with greater safety and fewer complications than the traditional transthoracic approaches.
Barrett's esophagus with high-grade dysplasia (BE/HGD) is associated with invasive carcinoma in 30% to 70% of cases. Esophagectomy is the treatment of choice for patients with BE/HGD but esophagectomy can be associated with high morbidity and mortality. The aim of our study was to report our preliminary experience in applying minimally invasive surgical techniques to esophagectomy for BE/HGD.
From August 1996 to February 1999, 12 consecutive patients underwent minimally invasive esophagectomy for biopsy-proven BE/HGD. Our consort consisted of 7 men and 5 women; average age was 64 years (range, 40-78 years). All patients underwent a complete laparoscopic or combined laparoscopic and thoracoscopic resection of the esophagus with cervical anastomosis.
Mean operative time was 7.8 +/- 2.1 hours, mean intensive care unit stay was 2.6 +/- 2.2 days, and mean length of hospital stay was 8.3 +/- 4.7 days. Five patients (42%) had carcinoma in situ or carcinoma identified on pathologic specimen. Analyses of all resected lymph nodes in the 12 patients were negative for metastatic disease. There were 6 major complications in 5 patients: 1 patient had a small bowel perforation requiring operative repair, 2 patients needed prolonged ventilatory support for respiratory insufficiency, and 3 patients had delayed gastric emptying requiring revision of the pyloromyotomy. The single minor complication in this series was a jejunostomy tube-site infection. There were no conversions to laparotomy or thoracotomy. All patients were alive and free of metastatic disease at a mean follow-up of 12.6 months.
Minimally invasive esophagectomy is a feasible and safe alternative to conventional open esophagectomy for patients with BE/HGD.
We sought to evaluate the effect of operative volume, hospital size, and cancer specialization on morbidity, mortality, and hospital use after esophagectomy for cancer.
Data derived from the Health Care Utilization Project was used to evaluate all Medicare-reimbursed esophagectomies for treatment of cancer from 1994 to 1996 in 13 national cancer institutions and 88 community hospitals. The complications of care, length of stay, hospital charges, and mortality were assessed according to hospital size (>/=600 beds vs <600 beds), cancer specialization (national cancer institution vs community hospital), and operative volume (esophageal [>/=5 Medicare esophagectomies per year vs <5 Medicare esophagectomies per year] and nonesophageal operations [>/=3333 cases per year vs <3333 cases per year]).
Mortality was lower in national cancer institution hospitals (4.2% [confidence interval, 2.0%-6.4%] vs 13.3% [confidence interval, 4.2%-26.2%], P =. 05) and in hospitals performing a large number of esophagectomies (3. 0% [confidence interval, 0.09%-5.1%] vs 12.2% [confidence interval, 4.5%-19.8%], P <.05). Multivariate analysis revealed that the independent risk factor for operative mortality was the volume of esophagectomies performed (odds ratio, 3.97; P =.03) and not the number of nonesophageal operations, hospital size, or cancer specialization. Hospitals performing a large number of esophagectomies also showed a tendency toward decreased complications (55% vs 68%, P =.06), decreased length of stay (14.7 days vs 17.7 days, P =.006), and decreased charges ($39,867 vs $62, 094, P <.005).
These results demonstrate improved outcomes and decreased hospital use in hospitals that perform a large number of esophagectomies and support the concept of tertiary referral centers for such complex oncologic procedures as esophagectomies.
Minimally invasive esophagectomy can be performed as safely as conventional esophagectomy and has distinct perioperative outcome advantages.
A retrospective comparison of 3 methods of esophagectomy: minimally invasive, transthoracic, and blunt transhiatal.
University medical center.
Eighteen consecutive patients underwent combined thoracoscopic and laparoscopic esophagectomy from October 9, 1998, through January 19, 2000. These patients were compared with 16 patients who underwent transthoracic esophagectomy and 20 patients who underwent blunt transhiatal esophagectomy from June 1, 1993, through August 5, 1998.
Operative time, amount of blood loss, number of operative transfusions, length of intensive care and hospital stays, complications, and mortality.
Patients who had minimally invasive esophagectomy had shorter operative times, less blood loss, fewer transfusions, and shortened intensive care unit and hospital courses than patients who underwent transthoracic or blunt transhiatal esophagectomy. There was no significant difference in the incidence of anastomotic leak or respiratory complications among the 3 groups.
Minimally invasive esophagectomy is safe and provides clinical advantages compared with transthoracic and blunt transhiatal esophagectomy.
The aims of this study were to evaluate the prevalence of invasive cancer in patients with high-grade dysplasia in Barrett's oesophagus and to verify whether a second endoscopy with multiple biopsies could improve the accuracy of preoperative diagnosis. In addition, the mortality, morbidity and survival rates in patients with high-grade dysplasia having oesophageal resection were recorded.
Fifteen patients were observed from 1982 to 1998; the first seven patients were offered primary oesophageal resection after diagnosis. The other eight patients underwent a second endoscopy with a median of 12 biopsies examined. All later underwent oesophageal resection.
Invasive adenocarcinoma was found in five patients, with a minimal difference between the first and second periods (two of seven versus three of eight). There were no perioperative deaths. Early morbidity was observed in eight patients and late morbidity in four. The actuarial survival rate was 79 per cent at 5 years. The Karnofsky status was unchanged from preoperative values in 13 of 15 patients after a median follow-up of 46 months.
These patients with high-grade dysplasia had a 33 per cent probability of harbouring invasive oesophageal carcinoma but even a second endoscopy failed to identify patients with invasive tumour. Oesophagectomy was performed with no deaths and remains a rational treatment in patients fit for surgery.
Photodynamic therapy (PDT) is an alternative treatment option for the palliation of obstructive esophageal cancer. We report our experience with PDT for patients presenting with inoperable, obstructing, or bleeding esophageal cancer.
Seventy-seven patients with inoperable, obstructing esophageal cancer were treated with PDT from November 1996 to July 1998. Photofrin (1.5-2.0 mg/kg) was administered, followed by endoscopic light treatment (630 nm red dye laser) at 48 h. Dysphagia score (1 for no dysphagia to 5 for complete obstruction), dysphagia-free interval, and patient survival were assessed.
Seventy-seven patients underwent 125 PDT courses. The mean dysphagia score at 4 weeks after PDT in 90.8% of the patients improved from 3.2 +/- 0.7 to 1.9 +/- 0.8 (p < 0.05). PDT adequately controlled bleeding in all six patients who had bleeding. The most common complications after the 125 PDT courses were esophageal stricture (4.8%), Candida esophagitis (3.2%), symptomatic pleural effusion (3.2%), and sunburn (10.0%). Twenty-nine patients (38%) required more than one PDT course, and seven patients required placement of an expandable metal stent for recurrent dysphagia. The mean dysphagia-free interval was 80.3 +/- 58.2 days. The median survival was 5.9 months.
Photodynamic therapy is a safe and effective treatment for the palliation of obstructing and bleeding esophagus cancer.
To summarize the authors' laparoscopic experience for paraesophageal hernia (PEH).
Laparoscopic antireflux surgery and repair of small hiatal hernias are now routinely performed. Repair of a giant PEH is more complex and requires conventional surgery in most centers. Giant PEH accounts for approximately 5% of all hiatal hernias. Medical management may be associated with a 50% progression of symptoms and a significant death rate. Conventional open surgery has a low death rate, but complications are significant and return to routine activities is delayed in this frequently elderly population. Recently, short-term outcome studies have reported that minimally invasive approaches to PEH may be associated with a lower complication rate, a shorter hospital stay, and faster recovery.
From July 1995 to February 2000, 100 patients (median age 68) underwent laparoscopic repair of a giant PEH. Follow-up included heartburn scores and quality of life measurements using the SF-12 physical component and mental component summary scores.
There were 8 type II hernias, 85 type III, and 7 type IV. Sac removal, crural repair, and antireflux procedures were performed (72 Nissen, 27 Collis-Nissen). The 30-day death rate was zero; there was one surgery-related death at 5 months from a perioperative stroke. Intraoperative complications included pneumothorax, esophageal perforation, and gastric perforation. There were three conversions to open surgery. Major postoperative complications included stroke, myocardial infarction, pulmonary emboli, adult respiratory distress syndrome, and repeat operations (two for abscess and one each for hematoma, repair leak, and recurrent hernia). Median length of stay was 2 days. Median follow-up at 12 months revealed resumption of proton pump inhibitors in 10 patients and one repeat operation for recurrence. The mean heartburn score was 2.3 (0, best; 45, worst); the satisfaction score was 91%; physical and mental component summary scores were 49 and 54, respectively (normal, 50).
This report represents the largest series to date of laparoscopic repair of giant PEH. In the authors' center with extensive experience in minimally invasive surgery, laparoscopic repair of giant PEH was successfully performed in 97% of patients, with a minimal complication rate, a 2-day length of stay, and good intermediate results.
Open esophagectomy can be associated with significant morbidity and delay return to routine activities. Minimally invasive surgery may lower the morbidity of esophagectomy but only a few small series have been published.
From August 1996 to September 1999, 77 patients underwent minimally invasive esophagectomy. Initially, esophagectomy was approached totally laparoscopically or with mini-thoracotomy; thoracoscopy subsequently replaced thoracotomy.
Indications included esophageal carcinoma (n = 54), Barrett's high-grade dysplasia or carcinoma in situ (n = 17), and benign miscellaneous (n = 6). There were 50 men and 27 women with an average age of 66 years (range 30 to 94 years). Median operative time was 7.5 hours (4.5 hours with > 20 case experience). Median intensive care unit stay was 1 day (range 0 to 60 days); median length of stay was 7 days (range 4 to 73 days) with no operative or hospital mortalities. There were four nonemergent conversions to open esophagectomy; major and minor complication rates were 27% and 55%, respectively.
Minimally invasive esophagectomy is technically feasible and safe in our center, which has extensive minimally invasive and open esophageal experience. Open surgery should remain the standard until future studies conclusively demonstrate advantages of minimally invasive approaches.
Accurate pretreatment staging for patients with esophageal cancer (EC) is becoming increasingly important in the evaluation and comparison of different treatment modalities. Noninvasive staging methods are imperfect in detecting lymph node metastasis in patients with EC. Surgical staging with the thoracoscopic/laparoscopic (Ts/Ls) technique may provide accurate staging information that is useful for evaluating and comparing the results of clinical trials of preoperative chemotherapy and radiotherapy. It can be used to confirm or exclude suspicious distant metastasis found by other staging methods. Pretreatment (lymph node) biopsies obtained by Ts/Ls staging allow further molecular biologic analysis to detect occult lymph node metastasis for more accurate lymph node staging. Since 1992, we have used Ts/Ls staging for EC in 111 patients. We found that Ts/Ls is a promising method for staging lymph nodes in EC patients. A recent study showed that pretreatment surgical lymph node staging can predict response and survival for EC patients receiving trimodality treatment (ie, radiation, chemotherapy, and surgery). The information obtained with surgical staging now offers us the opportunity to optimize therapy to specific patient groups based on the extent of disease at the time of initial presentation. Nevertheless, unlike the practice of mediastinoscopy in lung cancer patients, Ts/Ls staging in EC patients remains an academic interest rather than a clinical practice. The concept of accurate pretreatment staging of EC remains to be realized and accepted in the clinical community.
Gastroesophageal reflux disease (GERD) is a common clinical problem. Circumstantial evidence continues to suggest that infection with Helicobacter pylori may protect some patients from developing GERD and its complications. An empirical trial of a proton-pump inhibitor may now be a reasonable alternative to endoscopy or 24-hour pH testing for the diagnosis of GERD. Long-term follow-up data covering more than over a decade indicate that proton-pump inhibitors are effective and safe agents for the treatment of GERD. Furthermore, a strategy of proton-pump inhibitors first may be the most cost-effective approach to GERD. It remains unclear why some patients with GERD develop Barrett's esophagus, whereas others do not. Recent studies demonstrate the importance of pulses of acid or bile in increasing cell proliferation and cyclooxygenase-2 expression in Barrett's epithelium cell cultures. Short-segment Barrett's esophagus is now clearly associated with an increased risk of dysplasia or cancer compared to intestinal metaplasia of the cardia, and the cancer risk in this condition is similar to that with long-segment Barrett's esophagus. However, the overall cancer risk in patients with Barrett's esophagus is lower than previously estimated, at approximately 0.5% annually. Ablation techniques continue to show promise, but are not yet ready for routine clinical use. Endoscopic mucosal resection is a new treatment option for selected patients with high-grade dysplasia or superficial esophageal adenocarcinoma.
Transhiatalesophagectomy: clinical experience and refinements
- Orringermb
- Marshallb
OrringerMB,MarshallB,IannettoniMD.Transhiatalesophagectomy: clinical experience and refinements. Ann Surg 1999;230:392–403.