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Esophageal adenocarcinoma p t1 sages


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Esophageal adenocarcinoma p t1 sages

  1. 1. Oncological Outcomes After Laparoscopic Trans-Hiatal Resection for pT1 Esophageal Adenocarcinoma Arin Saha, Simon Dexter & Abeezar Sarela Department of Upper GI & Minimally Invasive Surgery, Leeds, UK
  2. 2. Early Esophageal Adenocarcinoma <ul><li>Resection is optimum treatment </li></ul><ul><li>Limited lymphadenectomy is adequate </li></ul><ul><li>Stein et al. Ann Surg 2000;232:733-42 </li></ul><ul><li>Transhiatal vs. Transthoracic resection </li></ul><ul><ul><li>similar long-term survival </li></ul></ul><ul><ul><li>lower peri-operative mortality </li></ul></ul><ul><ul><li>Chang et al. Ann Surg 2008;85:424-429 </li></ul></ul><ul><li>Laparoscopic trans-hiatal esophagectomy is safe and feasible </li></ul><ul><li>Sarela et al. SAGES 2007 </li></ul>
  3. 3. Endoscopic Mucosal Resection <ul><li>Definitive treatment for esophageal adenocarcinoma limited to mucosa (T1a) or submucosa (T1b)? </li></ul><ul><li>Limitations </li></ul><ul><ul><li>Lymph node metastasis </li></ul></ul><ul><ul><li>Multi-focal cancer </li></ul></ul><ul><ul><li>Lymphovascular invasion </li></ul></ul>
  4. 4. Aims <ul><li>To describe pathological characteristics and clinical outcomes of laparoscopic transhiatal esophagectomy or open esophagectomy for pT1 adenocarcinoma </li></ul><ul><li>To identify patients who might be appropriate candidates for EMR </li></ul>
  5. 5. Patients & Operations Post-operative follow-up: median 44 months (range, 12-93) Jan 2000-Dec 2006 Esophagectomies for Adenocarcinoma 172 patients Pathological stage: T1 No neo-adjuvant therapy 44 patients (26%) Laparoscopic Transhiatal Esophagectomy 16 patients (36%) Open Ivor Lewis Esophagectomy 24 patients (55%) Open Transhiatal Esophagectomy 4 patients (9%)
  6. 6. Laparoscopic vs. Open Resection 16 (3-28) 19 (10-51) 15 (4-41) Lymph node retrieval 0 2 0 Post-operative Mortality Open Transhiatal 4 patients Open Ivor Lewis 24 patients Laparoscopic Transhiatal 16 patients
  7. 7. Pathological Characteristics Esophagectomy for pT1 adenocarcinoma 14 (32%) Tumor length > 1cm 31 (70%) Long segment Barrett’s (> 3cm) 4 (9%) Poor differentiation 11 (25%) Submucosal invasion (pT1b) No. of patients (%) Total: 44 patients Feature
  8. 8. Pathological Characteristics Esophagectomy for pT1 adenocarcinoma Aggregate number of patients who may have been inadequately treated by EMR: 29 (66%) 2 (5%) Lymphovascular invasion 27 (61%) Multifocal carcinoma or HGD 2 (5%) Lymph node metastasis No. of patients (%) Total : 44 patients Impediments to EMR
  9. 9. Oncological Outcome Esophagectomy for pT1 Adenocarcinoma Liver 22 N0 Poor T1a Open Ivor Lewis Liver 8 N1 Poor T1b Open Ivor Lewis Nodes 6 N0 Poor T1b Lap. Trans-Hiatal Site of recurrence Time to recurrence Node status Differentiation Tumor Depth Operation
  10. 10. Conclusions <ul><li>Similar lymph node retrieval with laparoscopic trans-hiatal esophagectomy or open esophagectomy </li></ul><ul><li>Small but definite risk (7%) of recurrent disease after esophagectomy for T1 adenocarcinoma </li></ul><ul><li>No evidence of oncological detriment by laparoscopic resection </li></ul>
  11. 11. Conclusions <ul><li>66% of early esophageal adenocarcinoma may have been inadequately treated by EMR </li></ul><ul><li>EMR should be reserved for highly selected patients </li></ul>