Laparoscopic trans hiatal esophagectomy for early cancer-final

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Laparoscopic trans hiatal esophagectomy for early cancer-final

  1. 1. Laparoscopic Trans-Hiatal Esophagectomy for Early Cancer Abeezar I. Sarela Department of Upper GI & Minimally Invasive Surgery Leeds, UK
  2. 2. SAGES Presenter Disclosure Slide Abeezar I. Sarela Nothing To Disclose
  3. 3. Agenda Early Esophageal Carcinoma <ul><li>Pathology </li></ul><ul><li>Diagnosis and Staging </li></ul><ul><li>Role of Endoscopic Therapy </li></ul><ul><li>Indications for surgery </li></ul><ul><li>Type of surgery </li></ul><ul><ul><li>Transhiatal vs. Transthoracic esophagectomy </li></ul></ul><ul><ul><li>Conventional laparoscopic trans-hiatal esophagectomy </li></ul></ul><ul><ul><li>Vagus-sparing esophagectomy </li></ul></ul><ul><ul><li>Merindino operation </li></ul></ul>
  4. 4. What is Early Esophageal Cancer? Superficial Esophageal Carcinoma Japanese Esophageal Society Esophagus 2009;6:1-25 T1a + T1b AJCC/TNM 7 th Edition Early Esophageal Carcinoma Japanese Esophageal Society Esophagus 2009;6:1-25 T1a AJCC/TNM 7th Edition
  5. 5. pT1 Esophageal Carcinoma Depth of primary tumor and lymph node metastasis <ul><li>Adenocarcinoma </li></ul><ul><li>157 patients </li></ul><ul><li>T1a: 45%, N+ 0% </li></ul><ul><li>T1b: 55%, N+ 21% </li></ul><ul><li>Distant N+ < 2% </li></ul><ul><li>5 year survival: 83% </li></ul><ul><li>Squamous Carcinoma </li></ul><ul><li>133 patients </li></ul><ul><li>T1a: 20%, N+8% </li></ul><ul><li>T1b: 80%, N+36% </li></ul><ul><li>Distant N+: 4-11% </li></ul><ul><li>5 year survival: 63% </li></ul>Stein et al. Ann Surg 2005;242:566-573
  6. 6. Subclassification of Depth of Invasion by Superficial Carcinoma of the Esophagus in Surgically Resected Specimens Endoscopic Resection Specimens sm1 carcinoma: invades less than 200 microns into the submucosa Japanese Esophageal Society. Japanese Classification of Esophageal Cancer. !0 th Ed. Esophagus 2009;6:1-25
  7. 7. Relationship between Depth of Invasion and Lymph Node Metastasis in Superficial Squamous Carcinoma Takubo et al. Histopathology 2007;51:733-742
  8. 8. Relationship between Depth of Invasion and Lymph Node Metastasis in Superficial Adenocarcinoma <ul><li>Transhiatal Esophagectomy: 120 patients </li></ul><ul><li>m1-sm1 : 79 patients, N+ 1 patient (1%) </li></ul><ul><li>sm2-sm3: 41 patients, N+ 18 patients (44%) </li></ul><ul><li>5 yr survival </li></ul><ul><ul><li>N0: 97% </li></ul></ul><ul><ul><li>N+: 57% </li></ul></ul>Westerterp et al. Virchows Arch 2005;446:497-504
  9. 9. Oncological Outcomes Esophagectomy for pT1 Adenocarcinoma Saha et al. Surg Endosc 2009;23:119-124 40 patients - T1b 11 patients - N1 20% of T1b - Poor differentiation 4 patients Liver 22 N0 Poor T1a Trans-thoracic Liver 8 N1 Poor T1b Trans-thoracic Nodes 6 N0 Poor T1b Trans-Hiatal Site of recurrence Time to recurrence Node status Differentiation Tumor Depth Operation
  10. 10. Diagnosis and Staging of Early (T1a) and Superficial (T1a+T1b) Esophageal Carcinoma
  11. 11. Endoscopic Diagnosis of Early Esophageal Carcinoma Fujinon “FICE” Olympus “Tri-Modality”
  12. 12. Can we predict the risk of lymph node metastasis? 27% 50% 20% 10% 10% Incidence of nodal metastasis Takubo et al. Histopathology 2007;51:733-742
  13. 13. High Risk Factors for Lymph Node Metastasis <ul><li>Depth of invasion – T1b </li></ul><ul><li>Morphology – types 0-I and 0-III </li></ul><ul><li>Lymphatic permeation </li></ul><ul><li>Poor histological differentiation </li></ul><ul><li>Tumor size </li></ul><ul><li>Infiltrative growth pattern </li></ul>Takubo et al. Histopathology 2007;51:733-742
  14. 14. Endoscopic Ultrasound (EUS) <ul><li>Conventional EUS </li></ul><ul><ul><li>5 layers </li></ul></ul><ul><ul><li>Poor distinction: T1a vs. T1b </li></ul></ul><ul><li>High Frequency Ultrasound Probe Sonography (HFUPS) </li></ul><ul><ul><li>9 layers </li></ul></ul><ul><li>Ultrasound-guided FNA of peri-esophageal nodes? </li></ul>
  15. 15. Endoscopic Mucosal Resection <ul><li>Definitive treatment for early (T1a) esophageal adenocarcinoma </li></ul><ul><li>Intermediate staging strategy </li></ul>
  16. 16. Emerging Treatment Paradigm EMR of all resectable dysplastic lesions Favourable histology? Multifocality? Ablation of the remaining Barrett‘s - ?RFA Endoscopic Surveillance
  17. 17. Indications for Esophagectomy <ul><li>Complete EMR not feasible/not achieved </li></ul><ul><li>T1b: ≥20% incidence of nodal metastasis (? T1a-MM) </li></ul><ul><li>Unfavorable histological characteristics </li></ul><ul><ul><li>Poor differentiation </li></ul></ul><ul><ul><li>Lymphovascular invasion </li></ul></ul><ul><li>Multi-focal cancer </li></ul><ul><li>Peri-esophageal lymphadenopathy at EUS </li></ul>
  18. 18. Transhiatal vs. Transthoracic? <ul><li>Randomised clinical trial </li></ul><ul><li>Adenocarcinoma: Siewert types 1 or 2 </li></ul><ul><li>Final analysis on 205 patients </li></ul><ul><li>No difference in post-operative mortality </li></ul><ul><li>5 year actual survival benefit for transthoracic operation </li></ul><ul><ul><li>Limited to patients with 1-8 positive nodes </li></ul></ul><ul><ul><li>Overall survival: 14% benefit </li></ul></ul><ul><ul><li>Recurrence-free survival: 41% benefit </li></ul></ul>Hulscher et al. N Eng J Med 2002;347:1662-9; Omloo et al. Ann Surg 2007;246:992-1000
  19. 19. Laparoscopic Transhiatal Esophagectomy <ul><li>17 series </li></ul><ul><li>433 patients [median 20 (10-68)] </li></ul><ul><li>Exclusively trans-abdominal: mediastinal anastomosis after segmental resection </li></ul><ul><li>Laparoscopic dissection, mini-laparotomy and neck anastomosis </li></ul><ul><li>Entirely laparoscopic: specimen retrieval via the neck </li></ul>Decker et al. European Journal of Cardio-Thoracic Surgery. 2009;35:13-21
  20. 20. Laparoscopic Esophagectomy Transhiatal vs. Transthoracic Decker et al. European Journal of Cardio-Thoracic Surgery. 2009;35:13-21 17 (7-62) 10 (5-15) Lymph node count 2.4% 4.6% Mortality 6.8% 3% Re-operation 22% 22% Respiratory complic. 7.6% 13% Leakage 6.4% 10% Vocal cord palsy Transthoracic 1499 patients Transhiatal 433 patients
  21. 21. What is the Aim of Esophagectomy? <ul><li>T1a/Low-risk for lymph node metastasis – to eradicate the primary tumor </li></ul><ul><ul><li>Conventional laparoscopic transhiatal operation </li></ul></ul><ul><ul><li>Vagus-preserving esophagectomy </li></ul></ul><ul><ul><li>Merindino operation </li></ul></ul><ul><li>T1b/High-risk for lymph node metastasis – to achieve radical lymphadenectomy </li></ul><ul><ul><li>Trans-thoracic esophagectomy </li></ul></ul>
  22. 22. Laparoscopic Vagus-Sparing Esophagectomy <ul><li>Less extensive operation </li></ul><ul><li>Enhanced perfusion of gastric conduit </li></ul><ul><li>No need for pyloroplasty </li></ul><ul><li>Dumping & diarrhoea in less than 10% </li></ul><ul><li>Less weight loss </li></ul><ul><li>Less infectious complications </li></ul><ul><li>? cardioprotective </li></ul>Peyre et al. Ann Surg 2007;246:665-671 DeMeester S. Personal communication, 2010
  23. 23. Segmental Resection of the Gastroesophageal Junction and Reconstruction with a Pedicled Flap of Jejunum (Merindino Operation) <ul><li>94 patients </li></ul><ul><li>T1a or T1b adenocarcinoma </li></ul><ul><li>Transhiatal (11) vs. Transthoracic (60) vs. Merindino (24) </li></ul><ul><li>Similar lymph node retrieval </li></ul><ul><li>Merindino operation: </li></ul><ul><ul><li>Less complications </li></ul></ul><ul><ul><li>No mortality </li></ul></ul>Stein et al. Ann Surg 2000;232:733-742
  24. 25. Conclusions <ul><li>Early esophageal carcinoma – mucosal disease (T1a) </li></ul><ul><li>Very low risk of lymph node metastasis (limited to T1a-MM) </li></ul><ul><li>EMR: staging and treatment strategy </li></ul><ul><li>Laparoscopic trans-hiatal esophagectomy for incomplete definitive ensocopic therapy </li></ul><ul><li>Minimize morbidity </li></ul><ul><ul><li>Vagus-sparing esophagectomy </li></ul></ul><ul><ul><li>Merindino operation </li></ul></ul>

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