Surgical Management Of Esophageal Cancer Research Articles

MS O09 - OGC Long-term oncological outcomes following totally minimally invasive, hybrid and open oesophagectomy for cancer

Abstract Background There has been a significant shift in the surgical management of oesophageal cancer, with increased popularity of minimally invasive oesophagectomy in comparison to open approaches. Data thus far has largely focused on the peri-operative and short-term benefits with limited study on long-term oncological outcomes. This study aims to explore patterns of oesophageal cancer recurrence and survival following minimally invasive and open oesophagectomy. Method This was a retrospective review of consecutive patients who underwent open (OO), hybrid (HO) and minimally invasive (MIO) oesophagectomy for cancer at a regional oesophago-gastric centre in the UK between 2014-2023. Follow-up data was obtained from the centre’s established surgical database, in addition to the regional radiology, MDT and electronic patient records to record survival, recurrence, and patterns of recurrence (locoregional, haematological, distal nodal, peritoneal and number of recurrence sites). Results 437 patients (170 OO; 132 HO; 135 MIO) were included. There was no difference in baseline data between the groups. Overall survival rates at 1-, 3-, and 5-year were 88%, 64% and 54%. Recurrence rates at 1-, 3-, and 5-year were 17%, 35% and 41%. Haematological and locoregional recurrence made up 37% and 33% of all recurrence types. 52% of patients had one type of recurrence at diagnosis. After adjusting for disease stage, there was no significant difference between operative approaches with respect to survival and recurrence rates (at 1,3 and 5 years), time to recurrence, or patterns of recurrence. Conclusion This study found no significant difference in long-term oncological outcomes when comparing different minimally invasive and open surgical approaches to oesophagectomy. MIO can continue to be offered to patients as a safe alternative to open surgery. Further multi-centre prospective research is required to validate these results.

Role of the Pectoralis Major Muscle Flap in the Multidisciplinary Treatment of Esophageal Cancer.

Management of esophageal cancer is complex. Esophagectomy is associated with risk of significant complications. In this case series, we share the experience of our multidisciplinary team of thoracic surgeons and otolaryngologists in managing complications arising in the surgical treatment of esophageal cancer with the assistance of regional tissue transfer in the form of the pectoralis major flap. We present a case series highlighting 3 patients who underwent esophagectomy who experienced significant anastomotic or conduit complications which were managed with a pectoralis muscle flap. Complications included tracheoesophageal fistula, refractory stenosis, and gastric conduit necrosis. Using a pectoralis major muscle flap with both myocutaneous and myofascial transfers was key to successful management. In the first patient, esophageal stent erosion after posterior tracheal wall dissection resulted in a tracheoesophageal fistula reconstructed through interposition of a myofascial flap. In the second patient, a tubed myocutaneous flap was interposed between the remnant gastric conduit and cervical esophagus to manage a posttreatment stenosis following resection of the stenosed segment. Finally, a myofascial flap was utilized to bolster a colonic interposition flap after initial necrosis of a gastric conduit that necessitated the creation of a temporary pharyngocutaneous fistula and subsequent colon interposition. Multidisciplinary care and collaboration are integral components for optimization of patient outcomes. In this case series, otolaryngology and thoracic surgery utilized multiple tools within their armamentarium to manage complications associated with the surgical management of esophageal cancer.

Trends in Surgical Management of Esophageal Cancer.

Management of esophageal cancer has changed to a combined modality approach over the past two decades due to poor outcome. Recently, multimodal treatment has become the standard practice. The aim of this study was to evaluate the changing trends in management and outcomes of esophagectomy over 15 years from a single center in Nepal. Patients with squamous cell carcinoma and adenocarcinoma of esophagus/ gastroesophageal junction who underwent surgery between 2001-2018 were analyzed. Patients were grouped into three successive 5-year periods. 547 patients underwent esophagectomy during 2001-2018. There was increased trend of neoadjuvant treatment from 9-13% to 52% (p<.001) and minimally invasive surgery (MIS) from 0% to 80% (p<.001). 30-day mortality decreased from 8% to 1% (p=.01). The 5-overall survival was 24% which increased from 17% to 27% (p=.003). Long term outcome has improved over last 15 years with decreasing mortality which appears to be due to incorporation of MIS and neoadjuvant treatment.

Strategies to decrease morbidity in surgical management of esophageal cancer: a single center experience.

In this study we described our experience in decreasing morbidity by performing a few changes during and after the Ivor Lewis esophagectomy. This is a retrospective single center experience comparing a control period (group A) and a study period (group B) in patients who underwent esophagectomy for esophageal cancer (control group: 23; study group: 17). Control group had postero-lateral thoracotomy and a gastric tube without aspiration during postoperative period. Study group had limited lateral muscle sparing thoracotomy and postoperatively the gastric tube was routinely left for 1 week with intermittent aspiration (10 times every two hours for 1 week). Average operation time was 312±56 minutes in control period, in study period 189±36 min. Average ICU stay was 10 (7-32) days in the control group, in study group 4 (1-8) days. Anastomotic leak rate was significantly higher in control vs. study group (53.3% vs. 16.6%; P<0.05). Respiratory complications were significantly lower in the study group (47.8% vs. 17.6%). The combination of a limited lateral thoracotomy and postoperative intermittent aspiration seem to reduce the rate of respiratory and anastomotic complication after Ivor-Lewis' procedure.

Does Circular Stapler Size in Surgical Management of Esophageal Cancer Affect Anastomotic Leak Rate? 4-Year Experience of a European High-Volume Center.

Simple SummaryOne of the most severe postoperative complications after a transthoracic esophagectomy for esophageal cancer is a leakage of the anastomosis created between the remnant esophagus and the stomach. There is substantial debate on which surgical technique and which stapler are the best. The aim of this study was to retrospectively analyze whether the stapler diameter had an impact on postoperative anastomotic leak rates during a 4-year time frame from 2016 to 2020. A total of 632 patients (open, hybrid, and totally minimally invasive esophagectomy) met the inclusion criteria. A total of 214 patients underwent an anastomosis with a 25 mm stapler vs. 418 patients with a 28 mm stapler. Anastomotic leak rates were 15.4% vs. 10.8%, respectively. Stapler size should be chosen according to the individual anatomical situation of the patient and may be of higher relevance in patients undergoing totally minimally invasive reconstruction.Anastomotic leak is one of the most severe postoperative complications and is therefore considered a benchmark for the quality of surgery for esophageal cancer. There is substantial debate on which anastomotic technique is the best for patients undergoing Ivor Lewis esophagectomy. Our standardized technique is a circular stapled anastomosis with either a 25 or 28 mm anvil. The aim of this study was to retrospectively analyze whether the stapler diameter had an impact on postoperative anastomotic leak rates during a 4-year time frame from 2016 to 2020. A total of 632 patients (open, hybrid, and totally minimally invasive esophagectomy) met the inclusion criteria. A total of 214 patients underwent an anastomosis with a 25 mm stapler vs. 418 patients with a 28 mm stapler. Anastomotic leak rates were 15.4% vs. 10.8%, respectively (p = 0.0925). Stapler size should be chosen according to the individual anatomical situation of the patient. Stapler size may be of higher relevance in patients undergoing totally minimally invasive reconstruction.

Esophagectomy for cancer in the obese patient

: Obesity is a prevalent cause of morbidity and mortality worldwide. It is a demonstrated risk factor for the development of many types of cancers, esophageal adenocarcinoma included. Esophagectomy in obese patients is a safe and feasible procedure which leads to good oncological and clinical outcomes. However, the surgical management of esophageal cancer in patients with BMIs in the range of obesity presents specific challenges involving pre-operative testing, anesthesia management, technical precautions and post-operative concerns. These aspects are here reviewed and discussed.

Surgical Approaches to Oesophageal Carcinoma: Evolution and Evaluation

Oesophageal cancer is a virulent malignancy and continues to represent a formidable challenge for both patients and clinicians. Surgical resection remains the most definitive form of treatment whether performed alone or in combination with chemotherapy and radiation therapy as part of a multimodality treatment strategy. There are several controversies in the surgical management of oesophageal cancer including the surgical approach, extent of resection, optimal fields of lymph node dissection, and the ideal location of anastomosis. Multiple approaches have been described for esophagectomy, which can be thematically grouped under two major categories: either transthoracic or transhiatal. The main controversy rests on whether a more extended resection through thoracotomy provides superior oncological outcomes as opposed to resection with relatively limited morbidity and mortality through a transhiatal approach. After numerous trials that have addressed these issues, neither approach has consistently proven to be superior to the other one, and both can provide excellent short-term results in the hands of experienced surgeons. At present, the trend is towards minimally invasive surgery in search of a better outcome as well as quality of life.

P216 WHAT IS THE TIME BURDEN AND RESPONSE RATE ASSOCIATED WITH WRITTEN OR ONLINE COMPLETION OF HEALTH-RELATED QUALITY OF LIFE QUESTIONNAIRES AFTER CANCER TREATMENT?

Abstract Background Patient reported outcomes are increasingly important assessments to be applied in the follow-up of patients after cancer treatment. The primary aim of this study was to clarify the patient related time burden associated with completing these questionnaires. Secondary aims was to assess completion rates, and to investigate how symptomatic outcome differs according to the response time. Method Patients who had undergone surgical management of esophageal cancer (1991-2018) and were disease-free at the time of assessment were asked to complete a total of six questionnaires: SF36, EORTC-QLQ-C30, EORTC-QLQ-OG25, EuroQol 5D, Digestive Symptom Questionnaire, and Dumping Syndrome Rating Scale. Patients were offered either paper or online questionnaires that were completed consecutively allowing for accurate quantification of the time taken to complete each online questionnaire. Results In total, 117 of 147 eligible patients (79.6%) responded to the questionnaires. In the online group 60 (90.9%) responded compared to 57 (70.4%) in the paper group (P=0.002). The median age was 74.5 years in the online group compared to 70.9 years in the paper group (P=0.022). In the patients completing their questionnaires online, the six questionnaires took on average 26.4 (range 10-55) minutes to complete. The fastest quartile of patients completed the six questionnaires in 17 minutes or less (N=14). There was no significant association between time to complete the questionnaires and age, gender, time from surgery or health-related quality of life scores. Conclusions The results of the study demonstrates that online questionnaires in some ways might be superior to paper questionnaires, and that patients are willing and able to complete online questionnaires irrespective of age. Time to complete questionnaires was not associated with level of health-related quality of life.

Using Benchmarking Standards to Evaluate Transition to Minimally Invasive Esophagectomy

Minimally invasive esophagectomy (MIE) is performed in nearly 50% of patients worldwide. The effectiveness of the technique arises from a single randomized control trial and multiple single series cohorts. Consistent reporting of complications is varied. We describe our experience of transitioning to MIE compared with open esophagectomy (OE) with the use of Esophageal Complications Consensus Group (ECCG) standardized complication benchmark definitions. Between 2007 and 2017, all patients undergoing esophagectomy were identified with the use of a prospectively curated database. Complications were defined by the ECCG and graded with the Clavien-Dindo (most severe complication) and comprehensive complication index (complexity of complications during hospital stay). Of 383 patients, 299 (76%) were men with a median age of 64.5 years (range, 56-72 years). MIE was performed in 49.6%. No differences were found in age, histologic finding (P= .222), pT stage (P= .136), or nodal positivity (P= .918). Stage 3 cancers accounted for 42.0% of OEs and 47.9% of MIEs. A thoracic anastomosis was more frequent in MIEs (156 of 190; 82.1%) than in OEs (113 of 193; 58.5%; P= .001). Frequency, severity (Clavien-Dindo), and complexity (comprehensive complication index) of complications were better in the MIE group, without compromising operative outcomes. No differences were identified in individual complication groupings or grade in MIEs compared with OEs (pneumonia: 19.5% versus 26.9% ([P= .09]; intensive care unit readmission: 7.4% versus 9.3% [P= .519]; atrial fibrillation: 11.1% versus 6.7% [P= .082], or grade of leak [P= .99]). These results compare favorably to those reported by ECCG. MIE can be the standard approach for surgical management of esophageal cancer. Introduction of the approach in each surgeon's practice should be benchmarked to international standards.

Guidelines for Perioperative Care in Esophagectomy: Enhanced Recovery After Surgery (ERAS®) Society Recommendations.

Enhanced recovery after surgery (ERAS) programs provide a format for multidisciplinary care and has been shown to predictably improve short term outcomes associated with surgical procedures. Esophagectomy has historically been associated with significant levels of morbidity and mortality and as a result routine application and audit of ERAS guidelines specifically designed for esophageal resection has significant potential to improve outcomes associated with this complex procedure. A team of international experts in the surgical management of esophageal cancer was assembled and the existing literature was identified and reviewed prior to the production of the guidelines. Well established procedure specific components of ERAS were reviewed and updated with changes relevant to esophagectomy. Procedure specific, operative and technical sections were produced utilizing the best current level of evidence. All sections were rated regarding the level of evidence and overall recommendation according to the evaluation (GRADE) system. Thirty-nine sections were ultimately produced and assessed for quality of evidence and recommendations. Some sections were completely new to ERAS programs due to the fact that esophagectomy is the first guideline with a thoracic component to the procedure. The current ERAS society guidelines should be reviewed and applied in all centers looking to improve outcomes and quality associated with esophageal resection.

Oesophagectomy at a New Zealand regional centre: where to now?

This study aims to define contemporary trends in characteristics, costs and management of patients diagnosed with oesophageal adenocarcinoma in New Zealand. Clinical, pathological and management data of the 135 patients presenting with histologically proven adenocarcinoma to our institution over a 5-year period (January 2010 to December 2014) was collected. Primary analysis reviewed patient demographics, co-morbidities, treatment strategy and survival. Secondary analysis defined operative outcomes including complications, mortality rates and overall survival to December 2016. Thirty-eight patients underwent oesophago-gastrectomy (resection rate 28%) with curative intent following neoadjuvant chemotherapy with Clavien-Dindo ≥3 complications in 17 patients (46%). Actuarial survivals from surgery at 1, 3 and 5 years were (79, 55 and 50%), with 19 patients (54%) alive and disease free at a median follow-up of 26.5 months (range 1-82 months). Overall, this represented one sixth of the national volume of oesophagectomy. Ninety-seven patients were managed non-surgically due to metastatic or advanced local disease (n = 64), co-morbid status (n = 27), patients choice (n = 2) and unknown (n = 4). Median survival from diagnosis in non-resected patients was 9 months (range 1-40 months). Oesophagectomy remains a challenging procedure for any institution, although good results can be achieved. Foci for referral are emerging in New Zealand for the surgical management of oesophageal cancer.

Surgical management of esophageal cancer.

Esophageal cancer (EC) is an aggressive malignancy associated with an overall poor prognosis. The specific risk factors for EC vary by histologic type as well as geographic distribution but there is no widely applicable screening strategy to date. Patients can present with vague symptoms which can prove to be a diagnostic challenge. Furthermore, cases tend to present at a late stage, making therapeutic approach difficult. Despite ongoing changes in management strategy, surgery remains the only viable option for cure in early stage malignancy. Advances in operative and peri-operative management have led to a relatively safe and efficacious procedure that provides durable therapy. Additionally, careful consideration of procedure specific factors can help maximize patient benefit. This review focuses on the surgical approaches to the management of EC and highlights select current trends and recent advances.

Patients' Preferences for Surgical Management of Esophageal Cancer: A Discrete Choice Experiment.

Background Obtaining insight into patients’ preferences is important to optimize cancer care. We investigated patients’ preferences for surgical management of esophageal cancer.MethodsWe conducted a discrete choice experiment among adult patients who had undergone esophagectomy for adenocarcinoma or squamous cell cancer of the esophagus. Patients’ preferences were quantified with regression analysis using scenarios based on five aspects: risk of in-hospital mortality, risk of persistent symptoms, chance of 5-year survival, risk of surgical and non-surgical complications, and hospital volume of esophageal cancer surgery.ResultsThe response rate was 68 % (104/142). All aspects proved to influence patients’ preferences (p < 0.05). Persisting gastrointestinal symptoms and 5-year survival were the most important attributes, but preferences varied between patients. On average, patients were willing to trade-off 9.5 % (CI 2.4–16.6 %) 5-year survival chance to obtain a surgical treatment with 30 % lower risk of gastrointestinal symptoms, or 8.1 % (CI 4.0–12.2 %) 5-year survival chance for being treated in a high instead of a low-volume hospital.ConclusionsPatients are willing to trade-off some 5-year survival chance to achieve an improvement in early outcomes. Given the preference heterogeneity among participants, the present study underlines the importance of a patient-tailored approach when discussing prognosis and treatment.

A personal perspective on controversies in the surgical management of oesophageal cancer.

Significant disagreement and debate persist regarding several aspects of the optimal surgical management of oesophageal cancer. We address some of these issues based on our consecutive series of 165 patients undergoing oesophageal resection (reported in full elsewhere) and the available literature. The areas considered are controversial but we argue in favour of a 'traditional' two-stage open approach (Ivor-Lewis), leaving the pylorus alone, making no attempt to perform a radical lymphadenectomy and fashioning a hand sewn anastomosis.

Surgical controversies in esophageal cancer

Several controversies concerning the optimal surgical management of esophageal cancer exist. The extent of resection, the surgical approach, the optimal lymph node dissection, and the volume–outcome relationship potentially influence the overall outcome of patients undergoing a surgical treatment for esophageal cancer. Especially in the context of perioperative, randomized studies in esophageal cancer, it appears indispensable to understand the broad range of quality indicators of esophageal cancer surgery.

Minimally Invasive Surgery for Esophageal Cancer: Review of the Literature and Institutional Experience

Esophageal cancer represents a major public health problem in the world. Several minimally invasive esophagectomy (MIE) techniques have been described and represent a safe alternative for the surgical management of esophageal cancer in selected centers with high volume and surgeons experienced in minimally invasive procedures. The authors reviewed the most recent and largest studies published in the medical literature that reported the outcomes for MIE techniques. In larger series, MIE has proven to be equivalent in postoperative morbidity and mortality to the open esophagectomy. However, MIE has been associated with less blood loss, reduced postoperative pain, decreased time in the intensive care unit, and shortened length of hospital stay compared with the conventional open approaches. Despite limited data, no significant difference in survival stage for stage has been observed between open esophagectomy and MIE. The myriad of MIE techniques complicates the debate for defining the optimal surgical approach for the treatment of esophageal cancer. Randomized controlled trials comparing MIE with conventional open esophagectomy are needed to clarify the ideal procedure with the lowest postoperative morbidity, best quality of life after surgery, and long-term survival.

Invited Commentary

Invited Commentary

Outcomes Assessment of the Surgical Management of Esophageal Cancer in Younger and Older Patients

The aim of this study was to assess the influence of age on disease presentation, clinical and pathologic staging, postoperative outcomes, costs, and long-term survival after esophagectomy for esophageal malignancy. All patients undergoing esophagectomy for cancer between 1991 and 2011 were prospectively enrolled in an Institutional Review Board approved database. A total of 493 patients underwent surgical resection during the study period; 58 (11.76%) of these patients were 50 years or less (44 ± 4.7) and 435 patients were greater than 50 years (67 ± 8.44). There was no difference in clinical stage; however, patients 50 years or less were more likely to have adenocarcinoma and reduced Charlson comorbidity index and younger patients tended to have a more delayed presentation as manifested by an increased period of dysphagia and a greater degree of weight loss. In the 50 or less age group there was a significantly greater use of neoadjuvant therapy in stage II patients and the use of neoadjuvant chemotherapy significantly decreased with increasing age. Surgery in the 50 or less age group was associated with significantly reduced intensive care unit stay, incidence of postoperative complications, and overall costs. Multivariate analysis also confirmed associations between increasing age and increased incidence of postoperative complications and cost. There were no significant differences in pathologic stage, positive resection margins, incidence of complete response to neoadjuvant therapy, or in overall survival. This study demonstrates younger patients have fewer complications and lower overall treatment costs after esophagectomy. In spite of having a more delayed presentation, younger patients presented with a similar stage and demonstrated similar overall survival.

Number of metastasis-positive lymph node stations is a simple and reliable prognostic factor following surgery in patients with esophageal cancer.

The aim of this study was to evaluate the utility of lymph node metastasis classification based on the number of positive stations in patients undergoing surgical management of esophageal cancer. Of 257 patients who underwent curative esophagectomy, 126 patients with lymph node involvement underwent assessment of nodal metastasis mode according to the 7th edition of the TNM classification (UICC), and the Japanese Guidelines for the Clinical and Pathological Studies on Carcinoma of the Esophagus. Lymph node metastasis mode was divided into single station (S) and multi-station (M) groups. The S group was subclassified into single-node-single-station (SS) or multi-node-single-station (MS), and the M group was subclassified into multi-station in pN1 (2 metastasis positive nodes; MM-pN1) or multi-station in pN2 or 3 (MM-pN2,3) by TNM classification, multi-station-single-area (MMS) or multi-station-multi-areas (MMM). The correlation between prognosis and lymph node metastasis mode was assessed. A total of 47 patients were classified as S (MS, n=11; SS, n=36), and 79 patients were classified as M (MM-pN1, n=12; MM-pN2,3, n=67; MMM, n=55; MMS, n=24). Prognosis was poorer among the M- than in the S-classified patients (p=0.0035), whereas prognosis was not significantly different between the subgroups. In conclusion, lymph node metastasis classification based on the number of metastasis-positive stations is a useful predictor of prognosis in patients undergoing surgical management of esophageal cancer. This system relies on a simple classification method that combines the Japanese classification based on lymphatic spread and the TNM classification based on the number of positive lymph nodes.

PWE-033 Comprehensive assessment of outcomes including costs and survival in younger vs older patients undergoing surgical management of oesophageal cancer

IntroductionThe aim of this study was to compare disease presentation, clinical and pathological staging, peri-operative outcome, costs and long-term survival of patients 50 years and under (≤50), and those over...