A PROSPECTIVE STUDY COMPARING PERIOPERATIVE AND [Autosaved].pptx
1. A PROSPECTIVE STUDY COMPARING PERIOPERATIVE AND
POSTOPERATIVE OUTCOMES OF TRANSTHORACIC VERSUS
TRANSHIATAL ESOPHAGECTOMY IN ESOPHAGEAL CARCINOMA
DR LALTHLAMUANA
DNB RESIDENT,DEPARTMENT OF GENERAL SURGERY
CIVIL HOSPITAL, AIZAWL
PHONE : 7023112331
EMAIL : THLAMUANAKNOX@GMAIL.COM
2. INTRODUCTION
• Esophageal cancer is the eighth most common cancer in the world, particularly adenocarcinoma.
• Countries with a low HDI like India have a high incidence of esophageal cancer with higher proportion of squamous cancers.
• A very high incidence of esophageal cancers has been reported in North-East region of India.
• In men, Aizawl district in Mizoram state has the highest incidence of all cancers (270 per 100 000 people).
• In women, the highest incidence of cancer is in Papumpare district (249 per 100 000 people), followed by Aizawl district (207 per
100000).
• Since incidence of esophageal carcinoma in Mizoram is very high this study aimed to compare transthoracic and transhiatal
esophagectomy approaches to esophageal cancer in Civil hospital, Aizawl.
3. MATERIALS AND METHODS
• All patients who came to study centre and diagnosed with esophageal cancer who had undergone TTE or THE during November 2020 to May
2022.
• This prospective study have a sample size of 40, who are divided into two groups TTE and THE preferably based on location of tumor.
• The patients were divided into two groups:
1. Group 1, TTE (transthoracic esophagectomy)
2. Group 2, THE (transhiatal esophagectomy)
• According to the patient’s general condition, tumor location and surgeon preference.
• No randomization was done as surgery UNIT 1 performed THE procedure for all operable cases
• Surgery UNIT 2 performed TTE procedure for middle 1/3rd and THE procedure for lower 1/3rd lesion and GE junction.
4. MATERIALS AND METHODS
• All patients were informed about the surgical procedure and its complications, and written informed consent
was obtained.
Following parameters were recorded and were compared between groups
• Comorbid diseases, Neoadjuvant treatment status: chemotherapy/ radiotherapy Response to therapy,
• Tumour localizations (middle 1/3, lower 1/3, gastroesophageal junction),
• Pathological stage, Duration of surgery, Mean blood loss, Intraoperative complications,
• Postoperative complications, Chyle leakage, anastomotic leakage, Postoperative hospital stay, Hoarseness
of voice, 30 day mortality.
5. INCLUSION CRITERIA
• All patients who came to study centre and
diagnosed with esophageal cancer who had
undergone TTE or THE.
EXCLUSION CRITERIA
1. Patients with upper third esophageal carcinoma.
2. Patients who underwent palliative surgical treatment.
3. Patients not fit for surgery.
4. Patients who were not willing for surgery.
5. Patients who underwent Video-assisted thoracoscopic
surgery (VATS) and Thoracoabdominal esophagectomy.
8. Results and Observations
• Median blood loss was 700 mL (550-1200) in TTE Group and 500 mL (300-600) in THE
Group.
9. Results and Observations
• Histological type was most commonly Squamous cell
carcinoma in both TTE Group and THE Group (100% and 85%,
respectively).
• Adenocarcinoma was seen in 15% of patients in THE group
• R0 resection was performed in 14 (70%) patients in TTE Group
and in 13 patients (65%) in THE Group (p=0.778),
• R1 resection 20% in TTE and 30% in THE group,
• R2 resection 10% in TTE and 5% in THE group.
10. TTE GROUP THE GROUP
The median number of lymph nodes removed was calculated
as 36.50 (33-42) in TTE Group
and as 16 (12-18) in THE Group, respectively
The median number of metastatic lymph nodes was 5.50 (1-11)
in TTE Group and 3 (0-9) in
THE Group with no statistically significant difference between
the two groups (p = 0.052)
11. • The median number of metastatic lymph nodes was
5.50 (1-11) in TTE Group and 3 (0-9) in THE
Group with no statistically significant difference
between the two groups
12. TTE GROUP THE GROUP
• The median duration of hospitalization in the postoperative
intensive care unit (ICU) was 2 (2-5) days in TTE Group and
2 (1-4) days in THE Group.
13. • Statistically significant differences in the number of days
spent in the hospital in general ward (p=0.052)
14. • In terms of pT-category,45% of patients in TTE had T2 and T3 stage,10% had T4
• While in THE group 50% had T2, 20% had T3 and 5% had T1 & T4 each.
• The majority of esophagectomies were performed for T2 in THE group tumors.
• In the case of pN-category, where 50 % of patients in TTE Group were in N2
• 25 % of those in THE Group were found in N2 and N3.
15.
16. DISCUSSION
• The study was performed with the intent to compare transthoracic and transhiatal esophagectomy as regarding
early postoperative outcome, morbidity, mortality from 18 months study.
• The right transthoracic esophagectomy, (Mc Keown procedure), has for long been considered the Gold standard
of surgical treatment for thoracic esophageal carcinoma.
• With the aim to diminish the postoperative pulmonary morbidity after thoracotomy, Orringer popularized
transhiatal esophagectomy 35 years ago, describing comparable survival rates with transthoracic approach.
17. • The mean age of the patients with esophageal cancer in the study ranged from 33 to 76 years, the male sex
had significant dominance with male to female ratio of 7:3.
• In this, All patients in both the TTE and THE group (p=1.000) received neoadjuvant therapy except 2 patients
from THE group. Preoperative staging was performed by using CT scan.
• In this study, the tumor site was located in lower third in 60%, GE junction in 25% & middle third in 15% for
THE and in all cases of TTE tumor was located in middle third esophagus.
21. CONCLUSION
In this prospective comparative study over 18 months, there is no significant difference in mortality when comparing TTE
with THE. The mortality rate for procedures considered in the study was 10% in TTE group and 15% in THE group.
Overall complications were significantly more in TTE group 80% versus 50% in THE group (p=0.047). The most common
complications were of pulmonary origin more in TTE group which was statistically significant (p=0.004)
The study also observed that groups of patients undergoing THE have fewer pulmonary complications as compared to TTE
and less blood loss, decreased requirement of ICU and mechanical ventilation.
Time taken to perform TTE is significantly more than THE.
Average number of lymph node harvested is significantly more in TTE as compared to THE.
22. LIMITATIONS OF THE STUDY
1. The number of patients included in our study is relatively low and follow up was of 30 days only.
2. The study has been done in a single center.
3. The study was carried out in a tertiary care hospital, so hospital bias cannot be ruled out.
4. Since the study was conducted in a tertiary care teaching center where there are different consultants performing
esophagectomy there can be some variation in dissection technique and duration of surgery.
5. There was no provision of endoscopic ultrasound to look for more precise T Staging and no facility of PET Scans for locating
distant metastasis more precisely.
6. The discrepancy noted in the study could be due to high inter operator variability including anesthetists and intensivist while
in OT and ICU respectively
