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Paetau mie 090211
Paetau mie 090211
Paetau mie 090211
Paetau mie 090211
Paetau mie 090211
Paetau mie 090211
Paetau mie 090211
Paetau mie 090211
Paetau mie 090211
Paetau mie 090211
Paetau mie 090211
Paetau mie 090211
Paetau mie 090211
Paetau mie 090211
Paetau mie 090211
Paetau mie 090211
Paetau mie 090211
Paetau mie 090211
Paetau mie 090211
Paetau mie 090211
Paetau mie 090211
Paetau mie 090211
Paetau mie 090211
Paetau mie 090211
Paetau mie 090211
Paetau mie 090211
Paetau mie 090211
Paetau mie 090211
Paetau mie 090211
Paetau mie 090211
Paetau mie 090211
Paetau mie 090211
Paetau mie 090211
Paetau mie 090211
Paetau mie 090211
Paetau mie 090211
Paetau mie 090211
Paetau mie 090211
Paetau mie 090211
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Paetau mie 090211

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  • SCC and adeno ca represent 2 different diseases w/ different pathogenesis, epidemiology and tumor biology
  • 1 st described in the 1936, became popular in the 1970’s
  • 1 st described in 194 Limited proximal resection margin
  • A modification of the procedure 1 st described by McKeown in 1976 Higher resection margin
  • Poor long-term survival of surgery alone
  • POET: German mulitcenter trial
  • Retrospecive review of 97 charts: Jan 2007- August 2010
  • Independent of access, significant differences in morbidity were found: If the pleural cavity violated regardless of the approach, pulmonary complications are more likely. When one avoids the pleural cavity, there is and increased incidence of recurrent laryngeal nerve injury probably due to inadvertent traction placed on the nerve during mediastinal dissection. An increased risk of wound complications was also noted in the extrathoracic group. ? Increased retraction/trauma
  • Transcript

    • 1. Surgical Approaches to Esophageal Cancer Alyssa Paetau PGY-5 GI/Surg Conference 9/2/2011
    • 2. Esophageal Cancer∗ 16,640 diagnoses; 14,500 deaths yearly ∗ 3:1 male predominance∗ 5-year survival (SEER data base): ∗ 1975-1977: 5% ∗ 1996-2004: 17%∗ 30-40% will have potentially resectable disease on presentation
    • 3. Adenocarcinoma∗ A consequence of persistent GERD∗ Distal esophagus undergoes intestinal metaplasia ∗ Hyperproliferation ∗ Acquire DNA damage, become morphologically dyplasic and then frankly malignant∗ 94% occur below the tracheal bifurcation∗ Commonly recur w/ distant dissemination
    • 4. Squamous Cell Carcinoma∗ Incidence decreasing∗ Tobacco/EtOH abuse∗ Epithelial dysplasia, CIS, invasive carcinoma∗ 65% are located above the tracheal bifurcation∗ Recur locoregionally first∗ Tumor location incorporated into the 2010 TNM staging system for SCC only ∗ Higher stage for middle and upper 1/3
    • 5. Esophagectomy∗ Various approaches∗ Open∗ Minimally invasive ∗ Introduced in 1994 ∗ Aim to reduce morbidity but have comparable oncologic outcomes∗ Choice depends on: ∗ Surgeon preference ∗ Tumor location
    • 6. Transhiatal esophagectomy∗ Upper midline laparotomy or laparoscopy to mobilize the stomach∗ Blind mediastinal dissection through the hiatus∗ Neoesophagus is transposed through the posterior mediastinum∗ Anastamosis is performed at the level of the clavicles∗ Pros: proximal margin is well away from the tumor site, extra-thoracic/extra-pleural anastatomosis, decreased cardiopulmonary complications∗ Cons: vocal cord palsy, increased bleeding, arrhythmias, inability to perform a full thoracic lymphadenectomy
    • 7. Ivor-Lewis Esophagectomy∗ R-thoracotomy and laparotomy∗ Pros: direct exposure of the intrathoracic esophagus, equal long-term survival∗ Cons: morbidity of a thoracotomy incision, anastomosis is performed in the chest ∗ Leak rate is <5% but difficult to manage ∗ Complete drainage is not possible ∗ Empyema ∗ Negative intrathoracic P causes higher rates of dysphagia, reflux ∗ Dilation of conduit over time?
    • 8. 3-Field Esophagectomy∗ R-thoracotomy, laparotomy, cervical incision∗ Pros: exposure, anastomosis in the neck, extended lymphadenectomy Fujita H, Kakegawa T, Yamana H et al. Mortality and morbidity rates, postoperative course, quality of life, and prognosis after extended radical lymphadenectomy for esophageal cancer. Ann Surg 1995; 222: 654-662∗ Cons: morbidity of 3 large incisions, higher incidence of recurrent laryngeal N. injury
    • 9. 3-field vs. 2-field Minimally Invasive Esophagectomy3-Field MIE 2-field MIE∗ VATS via a prone ∗ Transcervical videoscope approach esophageal dissection∗ Requires single lung (TVED) ventilation that increases ∗ Decreased operative time cardiopulmonary ∗ Improved visualization morbidity ∗ Avoids single-lung∗ Conduit is intra-pleural ventilation ∗ Conduit is extra-pleural
    • 10. MIE vs. Open∗ No oncologic difference noted in recent retrospective comparison of 64 patients w/ stage 2 or 3 disease (33MIE and 31 Ivor-Lewis) ∗ Survival at 2 years: 55% vs. 32% ∗ Did not reach statistical significance but concluded that outcomes were comparable Sing RK, et al. Minimally invasive esophagectomy provides equivalent oncologic outcomes to open esophagectomy for locally advanced esophageal carcinoma. Arch Surg 2011 Jun; 146(6):711-4
    • 11. MW 47032693∗ 75yo M c/o odynophagia and epigastic pain ∗ Long h/o dysphagia and occasional regurgitation managed w/ dietary and behavior modifications∗ PMH: HTN, gout, h/o tobacco use∗ PSH: L5 diskectomy∗ EGD (OH): suspicious esophageal nodule at 42cm ∗ Path: Moderately differentiated SCC∗ EUS (OH): T1B or possible T2 lesion∗ CT/PET-CT (OH): negative for metastatic disease
    • 12. MW∗ EUS: ∗ 3cm mass at the GEJ involving half the luminal circumference ∗ Invading the muscularis propria ∗ T2N0 ∗ Path: Moderately differentiated SCC∗ Referral to Oncology/Radiation Oncology
    • 13. Neoadjuvant Therapy for Regionally Advanced Disease ∗ Purpose of XRT: ∗ reduce tumor size ∗ decrease risk of spread during surgical manipulation ∗ Purpose of chemo: ∗ eliminate micromets ∗ downstage the tumor ∗ improve resectability
    • 14. Neoadjuvant Therapy for Regionally Advanced Disease∗ Multiple RCTs that have evaluated chemo followed by surgery vs. surgery alone∗ Meta-analysis that included 8 RCTs and 1724 patients demonstrated a statistically significant survival benefit Urschel JD et al. A meta analysis of randomized controlled trials that compared neoadjuvant chemotherapy and surgery to surgery alone for resectable esophageal cancer. Am J of Surg 2003; 185:538. ∗Absolute 2-year survival benefit of 7 % ∗20-25% of patients will have a pathologic complete response
    • 15. Neoadjuvant Therapy for Regionally Advanced Disease∗ Preoperative Chemotherapy or Radiochemotherapy in Esophagogastric Adenocarcinoma Trial (POET) ∗ R0 resection in 70 and 72% ∗ 3-year survival was better in the chemo/XRT group (47 vs. 28%, p=0.07) ∗ Closed because of poor accrual (126 of 394 patients) Stahl M et al. Phase III comparison of preoperative chemotherapy compared with chemoradiotherapy in patients with locally advanced adenocarcinoma of the EG junction. J of Clin Onc. 2009; 27:851∗ National Comprehensive Cancer Network recommends preoperative chemoradiation for T2-3N0 stage 1 to stage 3 SCC and adenocarcinoma
    • 16. MW∗ Elected to undergo neoadjuvant tx ∗ Cisplatin/ 5-FU ∗ 50Gy∗ Re-staged: ∗ CT/PET-CT ∗ EUS: mucosal irregularity w/ the application of Lugol’s but no gross dx
    • 17. MW∗ To OR 8/4/11 for a 3-field MIE: ∗ Thoracoscopic esophageal mobilization ∗ Lap pyloroplasty ∗ Lap gastric mobilization and creation of a gastric conduit ∗ Cervical esophageal mobilization and esophagogastrostomy ∗ EGD w/ NGT placement
    • 18. MW∗ Extubated but re-intubated secondary to over-sedation and hypoxemia/hypoventilation on PACU∗ Extubated in ICU on POD #1∗ Transferred to the floor POD #2∗ A-fib w/ RVR on POD #3 ∗ Rate controlled w/ diltiazem ∗ Spontaneously converted to NSR in 24h∗ Esophagram on POD #4 showed no leak/delay∗ Discharged home POD #8
    • 19. MW∗ Path: ∗ Ulcer and associated acute and chronic inflammation at the GEJ ∗ No evidence of residual carcinoma ∗ 0/28 LNs
    • 20. RH 75360693∗ 78 yo M c/o dysphagia∗ PMH: HTN, OA∗ PSH: Open appy∗ EGD: Intrathoracic stomach; Barrett’s w/ HGD and a focus of adenocarcinoma∗ EUS: 1.5cm nodular area at the GEJ; extension into submocosa; no lympadenopathy
    • 21. RH∗ EMR: Moderately differentiated adenocarcinoma involving the muscularis mucosa; at least high-grade dysplasia at the lateral margin∗ EMR repeated: ∗ Lateral margin positive for HGD ∗ Cardia: adenocarcinoma involving the submucosa; lateral and deep margins are focally positive∗ PET/CT ∗ Intrathoracic stomach w/ organoaxial rotation∗ Referred to Surgery
    • 22. RH∗ To OR on 7/25 for a 2 field MIE: ∗ Transcervical videoscopic antegrade esophageal dissection ∗ Lap gastric mobilization and creation of a neoesophagus ∗ Lap pyloroplasty ∗ Transcervical esophagogastrostomy ∗ EGD w/ NGT placement
    • 23. RH∗ Extubated immediately post-op∗ Transferred out of ICU POD #1∗ POD #3: Esophagram ∗ Contrast delayed through pyloroplasty
    • 24. RH∗ POD #5: Esophagram repeated ∗ Minimal delay ∗ Blenderized diet started∗ Discharged home POD #8
    • 25. RH∗ Final Path: ∗ Focal residual moderately differentiated adenocarcinoma (0.5cm) involving the muscularis mucosa ∗ Negative margins ∗ 0/26 LNs ∗ T1aN0
    • 26. Our 3-field MIE Experience 1/07-8/10Goldberg RF, Bowers SP, et al. Technical and Perioperative Outcomes of Minimally Invasive Esophagectomy in the Prone Position. ∗ 42 patients ∗ Average age 68 years (37-87y) ∗ Diagnoses: ∗ 35 adenocarcinoma ∗ 4 Barrett’s w/ HGD ∗ 2 achalasia ∗ 1 SCC ∗ 38% underwent neo-adjuvant chemo ∗ Classified as low, medium, or high risk via the Modified Charlson Comorbidity Index
    • 27. Our 3-field MIE Experience 1/07-8/10∗ Median LOS: 8 days (6-51d)∗ Median ICU stay: 2 days (1-26)∗ Mean Operative Time (includes positioning): 402min (261-650min) ∗ Mean positioning time: 90min (46-148min) ∗ Mean prone surgical time: 108min (67-198min) ∗ Mean supine surgical time: 224min (120-364min)∗ Mean EBL: 180mL∗ 88% were extubated POD #0∗ Chest drainage needed for a median of 6 days (3-30d)
    • 28. Our 3-field MIE Experience 1/07-8/10∗ Predominant complications: ∗ 14 arrhythmias ∗ 7 pneumonias ∗ 5 anastomotic leaks ∗ 2 post-op 30-day mortalities∗ Higher risk patients had a higher risk of major complications∗ Higher BMI did not correlate to longer operative times∗ Of the 15 patients who had major complications, 12 were former smokers and 1 was still smoking at the time of surgery
    • 29. Our Experience at MCJ: TVEDParker M, Bowers SP, Goldberg RF, et al. Transcervical videoscopic esophageal dissection during two-field minimally invasive esophagectomy: early patient experience. J Surg Endoscopy. ePub 24 June 2011.∗ Retrospective cohort study of 8 patients over a 10-month period∗ Mean age: 63 +/- 12 yrs∗ Mean BMI 30.2 +/- 5.1 kg/m2∗ 2 w/ HGD, 6 w/ adenocarcinoma, 1 s/p chemo/XRT∗ Results: ∗ Mean operative time: 292min (174-375min) (402 minutes) ∗ Mean blood loss: 119mL (180mL) ∗ Median ICU stay: 1 day (1-5days) (2 days) ∗ Median hospital stay: 7 days (5-16days) (8days) ∗ None required a chest tube ∗ 2 cervical anastomotic leaks ∗ 1 patient with leak, MI, and pneumonia ∗ 2 patients with vocal cord dysfunction
    • 30. Trans-thoracic Approaches to Esophagectomy Associated With Higher MorbidityRoss F Goldberg MD, Steven P Bowers MD, Michael Parker MD, John A Stauffer MD, MichaelHeckman MS, Colleen Thomas MS, Horacio J Asbun MD, John A Odell MD, C Daniel Smith MD ∗ Retrospective cohort study of 97 patients undergoing esophagectomy between 1/07-8/10 ∗ 3-field MIE: 48 ∗ 2-field MIE: 8 ∗ Transhiatal Open: 12 ∗ Ivor-Lewis: 10 ∗ Thoracoabdominal approach w/ cervical incision: 11 ∗ 3-field: 8
    • 31. MIE Open Difference [Open-MIE]Outcome P-value (N=56) (N=41) (95% CI)Cardiac complications 18 (32%) 17 (41%) 9% (-10%, 29%) 0.40Pulmonary complications 19 (34%) 18 (44%) 10% (-10%, 30%) 0.40Pulmonary intervention 17 (30%) 14 (34%) 4% (-15%, 23%) 0.83Pulmonary embolism or deep vein thrombosis 4 (7%) 1 (2%) -5% (-13%, 4%) 0.39Leak 6 (11%) 4 (10%) -1% (-13%, 11%) 1.00Leak intervention 3 (5%) 0 (0%) -5% (-11%, 1%) 0.26Renal complications 2 (4%) 2 (5%) 1% (-7%, 9%) 1.00Wound infection 3 (5%) 4 (10%) 4% (-6%, 15%) 0.45Pharmacologic interventions* 22 (39%) 21 (51%) 12% (-8%, 32%) 0.30Delayed gastric emptying 1 (2%) 1 (2%) 1% (-5%, 7%) 1.00Voice hoarseness/laryngeal injury 5 (9%) 3 (7%) -2% (-13%, 9%) 1.00In-hospital mortality 2 (4%) 2 (5%) 1% (-7%, 9%) 1.00Discharged on total parental nutrition 2 (4%) 1 (2%) -1% (-8%, 6%) 1.00Discharged on tube feeding 2 (4%) 10 (24%) 21% (7%, 35%) 0.004Clavien classification (Grade III or higher) 19 (34%) 17 (41%) 8% (-12%, 27%) 0.5330-day mortality** 2 (4%) 3 (7%) 4% (-6%, 13%) 0.6590-day follow-upDilatations for stricture 5 (9%) 5 (12%) 3% (-9%, 16%) 0.74- P-values result from Fisher’s exact test. *Pharmacologic intervention includes total parental nutrition, tube feeding, and blood transfusion.**30-day mortality includes those patients who died in the hospital.
    • 32. Intrathoracic vs. Extrathoracic
    • 33. Aftercare∗ Endoscopic Surveillance: at least annually ∗ After EMR: every 3 months for 1 year, then annually∗ Early strictures (<1 yr) are common (48/177 patients over a 3-year period) and usually benign ∗ Pyloric and anastomotic ∗ Can be a consequence of leak but not always ∗ >90% respond to dilation Sutliffe RP, et al. Anastamotic strictures and delayed gastric emptying after esophagectomy. Dis of the Esophagus (2008) 21, 712-717.∗ Self expanding plastic stents for anastamotic leak ∗ Earlier PO intake, shorter hospital course, decreased mortality Hunerbien M, et. Al. Treatment of Thoracic Anastomotic Leaks After Esophagectomy With Self-expanding Plastic Stents. Ann Surg. 2004 November; 240(5): 801–807

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