Open Transhiatal Esophagectomy Research Articles

Depth Analysis of Open Transhiatal Esophagectomy Outcomes (Orringer Technique) in Patients with Esophageal Cancer from 1990 to 2015: A 25-Year Experience Single-center Study

Background: Esophageal cancer is an invasive tumor with rapid growth and a poor prognosis. The annual incidence of esophageal cancer in the United States is 6 per 100 000 men and 1.6 per 100 000 women. This is different in the case of Iran, and the number of patients in the country is higher than in other countries. In this evaluation, the researchers present the experience with open Transhiatal Esophagectomy (Orringer) technique outcomes. Objectives: This study aimed at evaluating the Orringer technique and its complications in patients with esophageal cancer for 25 years at the Cancer Research Center of Shahid Beheshti University of Medical Sciences. Methods: This is a descriptive study conducted from the beginning of 1988 to 2016. In this study, 114 patients with a mean age of 55 years and a gender classification of 60% male and 40% female were evaluated. Results: After resection, more than 98% of patients were in the T3 N1 - N3 stage. There were 4 mortalities: 2 were due to descending aorta tearing, 1 was due to tracheobronchial tearing, and 1 was pneumonia From 40 cases of pleural effusion, only 5 cases (12.5%) needed a thoracotomy tube. Only 2 patients needed intervention from 30 patients with dysphagia; 1 case was relieved by balloon dilatation and the other needed a free jejunal flap. Five-year survivals were 30% and 20% versus 48% and 23% in the neoadjuvant and non-neoadjuvant groups, respectively. conclusions: The present study and other experiences showed that non-radical surgery such as the Orringer technique is acceptable and compassable compared to radical surgery in 3 fields.

Contributing factors to lymph node recovery with esophagectomy by thoracic surgeons: an analysis of the Society of Thoracic Surgeons General Thoracic Surgery Database.

Given the association between lymphadenectomy and survival after esophagectomy, and the ongoing development of effective adjuvant protocols for identified residual disease, we determined factors contributing to lymph node yield and effects on postoperative morbidity following esophagectomy by thoracic surgeons. Using the Society of Thoracic Surgeons General Thoracic Surgery Database, all patients who underwent esophagectomy for primary esophageal cancer with gastric conduit reconstruction from 2012 to 2016 were identified. Patient demographics, technical factors, and tumor characteristics associated with lymph node yield were determined using a multivariable multilevel mixed-effects regression model. Associations between lymph node yield and perioperative morbidity and mortality were similarly assessed. A total of 8480 patients were included. The median number of nodes harvested was 16 [Interquartile Range 11-22]. Factors associated with fewer nodes included female gender (b=-0.53, P=0.032), body mass index <18.5 (b=-1.46, P=0.012), prior cardiothoracic surgery (b=-0.73, P=0.015), intraoperative blood transfusion (b=-1.43, P<0.001), squamous cell histology (b=-0.86, P=0.006), and neoadjuvant treatment (b=-1.41, P<0.001). Operative approach significantly affected lymph node yield, with minimally invasive approaches demonstrating higher lymph node counts, and open transhiatal esophagectomy recovering the fewest nodes. Findings were independent of clinical center. There was no association of higher lymph node yield with 30-day mortality, with only slightly increased risk for chyle leak (odds ratio [OR] 1.02, P=0.012). In conclusion, several patient and tumor factors affect lymph node recovery with esophagectomy, independent of hospital center. Technical aspects, specifically minimally invasive approach, play a significant role in quantified lymph node yield. Higher operative lymph node yield was associated with minimal increased morbidity.

Transhiatal robot-assisted minimally invasive esophagectomy: unclear benefits compared to traditional transhiatal esophagectomy.

Esophagectomy is a high-risk operation, regardless of technique. Minimally invasive transthoracic esophagectomy could reduce length of stay and pulmonary complications compared to traditional open approaches, but the benefits of minimally invasive transhiatal esophagectomy are unclear. We performed a retrospective review of prospectively gathered data for open transhiatal esophagectomies (THEs) and transhiatal robot-assisted minimally invasive esophagectomies (TH-RAMIEs) performed at a high-volume academic center between 2013 and 2017. Multivariate logistic regression was used to calculate adjusted odds ratios (aORs) for outcomes. 465 patients met inclusion criteria (378 THE and 87 TH-RAMIE). THE patients more likely had an ASA score of 3 + (89.1% vs 77.0%, p = 0.012), whereas TH-RAMIE patients more likely had a pathologic staging of 3+ (43.7% vs. 31.2%, p = 0.026). TH-RAMIE patients were less likely to receive epidurals (aOR 0.06, 95% confidence interval [CI] 0.03-0.14, p < 0.001), but epidural use itself was not associated with differences in outcomes. TH-RAMIE patients experienced higher rates of pulmonary complications (adjusted odds ratio [OR] 1.82, 95% CI 1.03-3.22, p = 0.040), particularly pulmonary embolus (aOR 5.20, 95% CI 1.30-20.82, p = 0.020). There were no statistically significant differences in lymph node harvest, unexpected ICU admission, length of stay, in-hospital mortality, or 30-day readmission or mortality rates. The TH-RAMIE approach had higher rates of pulmonary complications. There were no statistically significant advantages to the TH-RAMIE approach. Further investigation is needed to understand the benefits of a minimally invasive approach to the open transhiatal esophagectomy.

Laparoscopic transhiatal esophagectomy in esophageal cancer patients with high-risk post-operative complications.

Surgical treatment of esophageal cancer is challenging, due to considerable morbidity, especially in high surgical risk patients. While transhiatal esophagectomy leads to good oncological outcomes and reduced postoperative complications, less invasive techniques might further improve outcomes. Our goal was to compare results of laparoscopic transhiatal esophagectomy (LTE) with open transhiatal esophagectomy (OTE) in esophageal cancer patients at high surgical risk. From 2014 to 2020, 128 patients were identified. Seventy received OTE while 51 received LTE. After propensity score matching (1:1), postoperative complications, analysis of overall and disease-free survival, and survival-related prognostic factors were assessed in two groups of 48 patients. Ninety-one (77%) patients were men with a mean age of 65 ± 10.3 years. Those who underwent OTE experienced more clinical and surgical complications. In LTE patients, the number of mean resected lymph nodes was 25.9, and in patients who had OTE, it was 17.4 (P < 0.001). Overall survival was 56.0% in the LTE group and 33.6% (P = 0.023) in the OTE group. In multivariable analysis of overall survival, open surgery and incomplete pathological response were seen as worse negative factors. In multivariable analysis, metastatic lymph nodes, incomplete pathologic response, surgical complications, and a Charlson's index > 2 (P = 0.014) were associated with poor prognosis. Both surgical methods are safe with similar morbidity and mortality; however, LTE was associated with fewer complications, a higher number of resected lymph nodes, better overall survival, and more prognostic factors related to global and disease-free overall survival in high-risk patients.

Similar Quality of Life After Conventional and Robotic Transhiatal Esophagectomy

BackgroundPatient-reported outcomes (PROs) for minimally invasive esophagectomy (MIE) have demonstrated benefits compared with open transthoracic or 3-hole esophagectomy. PROs, including quality of life (QoL) and fear of recurrence (FoR), comparing open transhiatal esophagectomy (THE) and transhiatal robotic-assisted MIE (Th-RAMIE) have been limited. MethodsAt a single, high-volume academic center, patients undergoing THE and Th-RAMIE with gastric conduit for clinical stage I to III esophageal cancer from 2013 to 2018 were evaluated. The European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ-C30), the EORTC Quality of Life Questionnaire in Esophageal Cancer (QLQ-OES18), and the FoR survey were administered preoperatively and at 1, 6, and 12 months postoperatively. Linear mixed-effects models were used for QoL and FoR score comparisons. Perioperative outcomes were also compared. ResultsA total of 309 patients (212 in the group and 97 in the Th-RAMIE group) were included. The Th-RAMIE cohort had a significantly higher number of lymph nodes harvested (14 ± 0.8 vs 11.2 ± 0.4; P = .01), a shorter length of stay (days, 10.0 ± 6.7 vs 12.1 ± 7.0; P = .03), lower rates of postoperative ileus (5% vs 15%; P = .02), and fewer opioids prescribed at discharge (71% vs 85%; P = .03). After adjustment, there were no significant differences in QLQ-C30, QLQ-OES18, and FoR scores between the groups out to 1 year postoperatively. ConclusionsThere were no clear patient-reported benefits of Th-RAMIE over THE for esophageal cancer. However, Th-RAMIE conferred several perioperative benefits.

Oncological Outcomes After Radical Esophagectomy from a Tertiary Cancer Center.

Although esophageal cancers have poor survival outcomes, evidence suggests that preoperative chemoradiation followed by surgery have improved survival outcomes. Minimally invasive surgery has equivalent oncological outcomes with less complication compared with open surgery, but there is insufficient data available in South Indian population. Our aim was to analyze the perioperative outcome and survival between minimally invasive and open transhiatal esophagectomy group. Data from patients operated for esophageal cancer in our department from the year 2015 to 2018 were collected retrospectively using medical records. Among 55 carcinoma esophagus patients, squamous histology (67%) and lower third location (57%) being predominant. Twenty-six patients underwent video-assisted thoracoscopic surgery (VATS)-assisted esophagectomy and 18 patients underwent open transhiatal esophagectomy. Eleven patients were inoperable. Sixteen patients in VATS arm and three patients in transhiatal arm received preoperative chemoradiation. VATS arm has lesser intraoperative blood loss, early pulmonary recovery with early intercostal drain removal, and lesser hospital stay but longer mean operating time of 171 min versus 140 min (P < 0.01). It has higher mean nodal harvest of 15 versus 7 nodes (P 0.01) and higher overall median survival of 36 months (95% CI, 29.3 to 42.7) as against 23 months (95% CI, 17.8 to 29.2) for transhiatal arm (P < 0.01). VATS-assisted esophagectomy is less morbid procedure with early postoperative recovery, better oncological outcomes, and improved survival compared with transhiatal arm which is equivalent to apex centers in India.

Transhiatal robot assisted minimally invasive esophagectomy (Th-RAMIE)

We review the operative technique of the transhiatal robot assisted minimally invasive esophagectomy (Th-RAMIE) that has been developed to continue the legacy and account for the lessons learned from decades of performing the open transhiatal esophagectomy. We will review the management of intra- and postoperative complications associated with the procedure, and postoperative outcomes. Common complications that occur more frequently after Th-RAMIE include recurrent laryngeal nerve injury, anastomotic leak, and anastomotic stricture, and bilateral pleural effusions, all of which can be managed with good outcomes.

Analysis of Minimally Invasive Esophagectomy at a Single Veterans Affairs Medical Center.

To date, there are no published studies focusing on the benefits of minimally invasive esophagectomy (MIE) versus open esophagectomy at a Veterans Affairs Medical Center (VAMC). Our primary outcome was the incidence of esophageal malignancy in the veteran population and the postoperative morbidity following traditional and MIE for malignancy. Retrospective analysis of the incidence of esophageal malignancy at a Veteran Integrated Service Network (VISN) 5 VAMC reported to the VAMC Esophageal Tumor Registry between 2003 and 2016 and outcomes of the veterans who received esophagectomy for malignancy. Patients were followed for 5 years following diagnosis of esophageal malignancy. The Washington DC VAMC Tumor Registry recorded over 130 individuals with a new diagnosis of esophageal cancer between 2003 and 2016; 18 patients underwent an open transhiatal or Ivor Lewis esophagectomy and nine underwent an Ivor Lewis MIE. Surgical candidates had an average stage less than two (T1-3, N0-1, M0) and nonsurgical candidates had an average stage greater than three. Age, body mass index, smoking status, or renal function at time of surgery was similar between the two surgical groups. Patients who underwent an MIE had less blood loss (222 cc versus 822 cc, P < .001), fewer transfusions (11% versus 56%, P = .027), and more nodes harvested (10.33 versus 2.72, P < .001) with no change in leak rate (11% versus 17%, P = .703) or postoperative mortality (0% versus 6%, P = .490) compared to traditional esophagectomy. This report supports the migration toward MIE for malignancy and reemphasizes that veterans present with advanced disease.

Global Gene Expression Change Induced by Major Thoracoabdominal Surgery.

To test the hypothesis that major thoracoabdominal surgery induces gene expression changes associated with adverse outcomes. Widely different traumatic injuries evoke surprisingly similar gene expression profiles, but there is limited information on whether the iatrogenic injury caused by major surgery is associated with similar patterns. With informed consent, blood samples were obtained from 50 patients before and after open transhiatal esophagectomy or pancreaticoduodenectomy. Twelve cases with complicated recoveries (death, infection, venous thromboembolism) were matched with 12 cases with uneventful recoveries. Global gene expression was assayed using human microarray chips. A 2-fold change with a corrected P < 0.05 was considered differentially expressed. In these 24 patients, 522 genes were differentially expressed after surgery; 248 (48%) were upregulated (innate immunity and inflammation) and 274 (52%) were downregulated [adaptive immunity (antigen presentation, T-cell function)]. Hierarchical clustering of the profile reliably predicted pre- and postoperative status. The within-patient change was 3.08 ± 0.91-fold. There was no measurable association with age, malignancy, procedure, surgery length, operative blood loss, or transfusion requirements, but was positively associated with postoperative infection (3.81 ± 0.97 vs 2.79 ± 0.73; P = 0.009) and hospital length of stay (r = 0.583, P = 0.003). Venous thromboembolism and mortality each occurred in one patient, thus no associations were possible. Major surgery induces a quantifiable pattern of gene expression change that is associated with adverse outcome. This could reflect early impaired adaptive immunity and suggests potential therapeutic targets to improve postoperative recovery.

Laparoscopic transhiatal esophagectomy improves hospital outcomes and reduces cost: a single-institution analysis of laparoscopic-assisted and open techniques.

Several case series have demonstrated that laparoscopic transhiatal esophagectomy (LTHE) is associated with favorable perioperative outcomes compared to historical data for open transhiatal esophagectomy (OTHE). Contemporaneous evaluation of open and laparoscopic THE is rare, limiting meaningful comparison of techniques. All patients who underwent OTHE (n=32) and LTHE (n=41) during the introduction of the latter procedure at our institution (1/2012-4/2014) were identified, and patient charts were retrospectively reviewed. Indications for operation included 69 patients with esophageal malignancy (adenocarcinoma: 64; squamous cell carcinoma: 4; melanoma: 1) and 4 patients with benign disease. There were no significant differences in clinicopathologic variables between OTHE and LTHE cohorts, except for an increased rate of cardiovascular disease in the LTHE cohort (p=0.04). There was no significant difference in median operative time or operative complications, yet LTHE was associated with a lower incidence of intraoperative blood transfusion (p<0.01). There were no 30-day mortalities. LTHE was associated with a reduced time to reach 24-h tube feeding goals (p=0.02), shorter length of hospital stay (p=0.01), and 6% reduced median direct cost (p=0.04). There were no significant differences in rates of major perioperative morbidities. Patients were followed for a median of 11.0months during which there were no significant differences between cohorts in disease-free survival or overall survival. When compared to OTHE, LTHE improves surgical outcomes and decreases hospital costs; short-term oncologic outcomes are similar. LTHE is preferable to OTHE in patients requiring transhiatal esophagectomy.

Gastrotracheal Fistula as a Result of Transhiatal Esophagectomy for Esophageal Cancer: An Unusual Complication.

Gastrotracheal fistula following open transhiatal esophagectomy (Orringer's technique) for esophageal cancer is an unusual but lethal complication. Surgical intervention with resection of the fistula tract and primary interrupted suturing of gastric and tracheal orifices using a muscle flap interposition has proved to be a successful method. We report the case of a 73-year-old male with an adenocarcinoma of the distal part of the esophagus, who underwent open transhiatal esophagectomy (Orringer's technique) with gastric tube reconstruction and cervical anastomosis. The patient did not receive induction chemoradiotherapy before the esophagectomy. Two attempts of surgical repair of fistula failed and the patient died. Being aware of warning signs such as dyspnea and respiratory distress accompanied by bilious content in the tracheal tube is helpful in the early detection and treatment of this type of fistula.

Outcomes following laparoscopic transhiatal esophagectomy for esophageal cancer

Most published minimally invasive esophagectomy techniques involve a multiple field approach, including laparoscopic and thoracoscopic esophageal mobilization. Laparoscopic transhiatal esophagectomy (LTE) should potentially reduce the complications associated with thoracotomy. This study aims to compare outcomes of LTE with open transhiatal esophagectomy (OTE) and en-bloc esophagectomy (EBE). Retrospective chart review was performed on all patients who had an LTE for cancer between July 2008 and July 2012 at our institution. Data was compared with an historic cohort of patients who underwent OTE and EBE at the same institution from July 2002 to July 2008. There were 33 patients with LTE, compared with 60 patients with OTE and 139 with EBE. The presence of minor operative complications was similar (p=0.36), but major complications were significantly less common in the LTE group (12, 23 and 33%, respectively; p=0.04). The median number of blood transfusions during hospitalization was significantly lower in the LTE group (0, 2.5 and 3, respectively; p=0.005). Median tumor size was significantly smaller (1.5, 2.2, and 3cm, respectively; p=0.03), but the LTE group had a significantly higher percentage of patients with neoadjuvant treatment (39, 14 and 29%, respectively; p=0.008). Median lymph node yield for LTE was lower (24, 36 and 48, respectively; p<0.0001), but the percentage of patients with positive nodes was similar (33, 33 and 39%, respectively; p=0.69). Mortality was equivalent among the groups (0, 2 and 4%, respectively; p=0.38). The median LOS for the LTE group was significantly lower (10, 13 and 15 days, respectively; p<0.0001). Overall survival was not different between the three groups (p=0.65), with median survival at 24 months of 70, 65 and 65%, respectively. LTE can be performed safely with less major complications and shorter hospital stay than open esophagectomy. The reduced lymph-node harvest did not impact overall survival.

Perioperative outcomes of laparoscopic transhiatal esophagectomy with antegrade esophageal inversion for high-grade dysplasia and invasive esophageal cancer

We examined the safety and effectiveness of antegrade laparoscopic inversion esophagectomy (LIE) for patients with multifocal high-grade dysplasia and distal esophageal cancer. We reviewed our experience with antegrade LIE, using an institutional research board-approved prospective database. Thirty-six patients with an average age of 64 years underwent LIE. Indications included multifocal high-grade dysplasia (n = 4), adenocarcinoma (n = 30), and squamous cell carcinoma (n=2); 11 patients had undergone neoadjuvant chemoradiation. LIE was completed successfully in 34 (94%) patients, whereas 2 required a conversion to open transhiatal esophagectomy. LIE required 221 minutes to perform, with a median blood loss of 100 mL. R0 resection was achieved in 97% of cases with a median lymph node harvest 15. Median hospital stay was 8 days, and 61% of patients were discharged to their home. Postoperative complications included anastomotic leak (n = 11) and stricture (n = 18), atrial arrhythmia (n = 5), pneumonia (n = 4), and tracheoesophageal fistula (n = 2). Operative outcomes after neoadjuvant therapy did not differ from those for primary operative resection. Antegrade LIE is a safe treatment approach for patients with high-grade dysplasia and distal esophageal cancer. Complete resection with an adequate lymph node harvest can be achieved consistently for primary operative resection or after neoadjuvant chemoradiation.

Laparoscopic versus open transhiatal esophagectomy for distal and junction cancer

the only curative treatment for esophageal cancer is surgical resection. This treatment is associated with a high morbidity rate and long in-hospital recovery period. Both transthoracic and transhiatal esophagectomies are performed worldwide. The transhiatal approach may reduce the respiratory infection rate in compromised patients with distal esophageal and gastro-esophageal (GE) cancers. Minimally invasive esophagectomy could further improve post-operative outcome. Two cohorts of laparoscopic and open transhiatal esophagectomy for cancer were compared for short- and long-term outcome. from January 2001 through December 2004, 50 patients who underwent laparoscopic transhiatal esophagectomy were compared to a historical group of 50 patients who had undergone open transhiatal esophagectomy between January 1998 and December 2000. Post-operative management was identical in both groups. no significant differences were seen between the two groups with regard to baseline characteristics and oncological parameters including resection margin (R0 82 vs. 74%, p = 0.334) and 5-year survival. Operation time did not differ significantly between the groups. (300 vs. 280 min, p = 0.110). Median hospital stay and intensive care unit stay were significantly shorter in the laparoscopic group (13 vs. 16 days, p = 0.001 and 1 vs. 3 days, p = 0.000 respectively). minimally invasive transhiatal esophagectomy is feasible and has the same oncological outcome as open transhiatal esophagectomy. Faster recovery without a significant longer operation time could be the major benefit of the laparoscopic transhiatal approach. To our knowledge, this is the largest comparative study in literature comparing laparoscopic transhiatal with open transhiatal esophagectomy for cancers of distal and GE junction. Randomized trials are needed to further clarify the role of laparoscopic transhiatal approach for esophageal cancer.

Survival and quality of life after minimally invasive esophagectomy: a single-surgeon experience

Reports on quality of life (QOL) after minimally invasive esophagectomy (MIE) have been limited. This report compares perioperative outcomes, survival, and QOL after MIEs with open transthoracic esophagectomy (TTE) and open transhiatal esophagectomy (THE). After institutional review board approval, retrospective review of a prospectively maintained database identified patients who underwent esophageal resection for esophageal cancer at Creighton University between August 2003 and August 2010. Patients with preoperative stage 4 disease, emergent procedures, laparoscopic transhiatal esophagectomies, or esophagojeujunostomies were excluded from the study. The study patients were categorized as having undergone open TTE, open THE, or MIE. Overall survival (OS) was the interval between diagnosis and death or follow-up assessment. Disease-free survival (DFS) was the interval between surgery and recurrence, death, or follow-up assessment. For the patients who survived at least 1year after surgery, QOL was assessed using European Organization for Research and Treatment of Cancer (EORTC-QLQ, version 3.0) and esophageal module (EORTC-QLQ OES 18) questionnaires. The study criteria were satisfied by 104 patients. Lymph node harvest with MIE (median = 20) was similar to that with open TTEs (median = 19) and significantly higher (P<0.001) than that with open THEs (median = 12). The percentage of patients requiring intraoperative blood transfusion in the MIE group (23.4%) was significantly lower (P<0.001) than in the open TTE (73.1%) and THE (67.7%) groups. The volume of intraoperative blood product transfusion was significantly lower for the MIE patients (median = 0ml) than for the open TTE (median = 700ml) and THE (median = 700ml) patients. The incidence of respiratory complications with MIEs (10.64%) was significantly lower than with open TTEs (34.61%) and THEs (32.26%). The groups did not differ significantly in terms of R0 resection rates, OS, DFS, or QOL. MIEs offer a safe and viable alternative to open esophagectomies because they reduce the need and volume of intraoperative blood product transfusion and postoperative respiratory complications without compromising oncological clearance, survival, and QOL.

Esophegeal replacement in children with AIDS

We report 2 human immunodeficiency virus–positive patients with refractory esophageal strictures secondary to candidiasis. They presented with progressive dysphagia and had suffered from oropharyngeal and/or esophageal candidiasis within the preceding 3 months. Both failed conservative management of these strictures, including systemic antifungal therapy, administration of proton pump inhibitors, and numerous attempts at stricture dilation, ultimately progressing to open transhiatal esophagectomy. Although challenging in the immunocompromised host, successful treatment of these strictures by gastric interposition is achievable with minimal morbidity.

Comparison of Laparoscopic Inversion Esophagectomy and Open Transhiatal Esophagectomy for High-Grade Dysplasia and Stage I Esophageal Adenocarcinoma

The perioperative outcomes of laparoscopic inversion esophagectomy (LIE) are comparable to those of open transhiatal esophagectomy (THE), with potential benefits related to the use of minimally invasive techniques. Case-control study. Tertiary care university hospital. From July 1, 2003, through March 31, 2008, 21 consecutive patients underwent LIE for high-grade dysplasia or clinical stage I esophageal cancer. We compared these patients with 21 stage-matched control patients treated with THE from August 1, 1995, through August 31, 2003. Operative time, blood loss, length of hospital stay, perioperative complications, and disease-free survival. Mean (SD) operative times for LIE (399 [86] minutes) and THE (407 [127] minutes) were not significantly different (P = .80). Patients undergoing LIE had significantly lower intraoperative blood loss (168 mL; P < .001) and overall length of hospital stay (10 days; P = .03) compared with those in the THE group (526 mL and 14 days, respectively). Complication rates were not significantly different between the groups. With a median follow-up of 29 months, there has been 1 systemic recurrence in the LIE group. Laparoscopic inversion esophagectomy is a safe and effective approach to the treatment of high-grade dysplasia and early esophageal adenocarcinoma. Compared with THE, LIE decreases operative blood loss and length of hospital stay without increasing the operative time, morbidity, or mortality related to esophagectomy.

Influence of circumferential resection margin on prognosis in distal esophageal and gastroesophageal cancer approached through the transhiatal route

We studied the influence of circumferential resection margin (CRM) involvement on survival in patients with malignancies of the distal esophagus and gastroesophageal junction. One hundred ten consecutive patients undergoing a laparoscopic or open transhiatal esophagectomy for malignancy of the distal 5 cm of the esophagus, or a Siewert I gastroesophageal junction tumor were analyzed, retrospectively. Only patients with potentially resectable tumors were included. CRM status was defined as clear or involved (microscopic tumor within 1 mm of the resection margin). Statistical analysis was done by means of univariate and multivariate analysis using the Kaplan-Meier method and Cox proportional hazard model. One hundred ten patients were analyzed. Sixty patients underwent open transhiatal esophagectomy, and 50 patients underwent laparoscopic transhiatal esophagectomy. There were 6 (5%) T(1), 18 (16%) T(2), and 86 (89%) T(3) tumors. CRM was clear in 68 (62%) patients and involved in 42 (38%) patients. Median survival in these groups was 50 vs. 20 months (P = 0.000). Since CRM involvement was only seen in T(3) tumors, this group was analyzed in detail. Median survival in the T(3)CRM(-) and T(3)CRM(+) group was 33 vs. 19 months (P = 0.004). For T(3)N(0) tumors, median survival in CRM(-) and CRM(+) was 40 and 22 months, respectively (P = 0.036). Median survival for T(3)N(1) tumors in CRM(-) and CRM(+) was 22 and 13 months, respectively (P = 0.049). Involvement of the circumferential resection margin was found to be an independent prognostic factor on survival in our study. It predicts a poor prognosis in patients with potentially resectable malignancies of the distal 5 cm of the esophagus and Siewert I adenocarcinomas of the gastro esophageal junction.

Immunological Consequences of Laparoscopic versus Open Transhiatal Resection for Malignancies of the Distal Esophagus and Gastroesophageal Junction

Background/Aim: Surgery remains the only curative therapy for esophageal cancer. The objective of the current study was to evaluate the impact of laparoscopic transhiatal esophagectomy versus open transhiatal esophagectomy on both inflammatory and immunological responses. Methods: Seventeen patients undergoing laparoscopic or open surgery were included in the study. The postoperative inflammatory response was assessed by measuring WBC count and CRP, IL-6, IL-8, soluble TNF I and II receptor, and elastase levels. The postoperative immune function was assessed by measuring the monocyte HLA-DR expression. LPS-binding protein (LBP) and bactericidal/permeability-increasing protein (BPI) were measured to evaluate bacterial translocation. Results: The IL-6 level increased significantly more in the patients who received open surgery as compared with the laparoscopic group. Both LBP and BPI increased predominantly in the laparoscopic group as compared with the group who received open surgery. No difference was found in HLA-DR expression between the two groups. Conclusion: Although both laparoscopic and conventional esophageal resections result in an activation of the inflammatory response, this study suggests that this response could be less pronounced after the laparoscopic approach. However, in the laparoscopic group higher LBP and BPI levels were seen, suggesting an increased endotoxemia. We postulate that the persistently elevated abdominal pressure results in a loss of mucosal barrier function, resulting in bacterial translocation. The cellular acidification of the cells of the peritoneum induced by CO₂ insufflation, however, blunts the expected inflammatory response.

Laparoscopic hand-assisted versus open transhiatal esophagectomy: a case-control study

This case-control study evaluated and compared the outcomes of laparoscopically assisted (LTE) and open transhiatal esophagectomy (OTE). In this study, 17 patients who underwent LTE during this period August 1999 through June 2003 were compared with 14 matched control patients who underwent OTE during this period December 1989 through September 2001. The groups had stage I esophageal cancer or lesser disease at the preoperative evaluation. Patients with prior upper abdominal or thoracic surgery were excluded. There was no significant difference between the groups with respect to age, body mass index, American Society of Anesthesiology (ASA) classification, or operating time. The estimated blood loss was 331 (+/- 220) ml for LTE and 542 (+/- 212) ml for OTE (p = 0.01). The hospital stay was 9.1 (+/- 3.2) days for LTE and 11.6 (+/- 2.9) days for OTE (p = 0.04). Comparing only the last six LTE with the OTE, the operating time was 311 (+/- 31) min for LTE and 388 (+/- 14) min for OTE (p = 0.02). The findings showed shorter operative time, less blood loss, and a shorter hospital stay with LTE than with OTE.