Transhiatal Resection Research Articles

978 Laparoscopic Spleen Preserving Distal Pancreatectomy for Large Pancreatic Tumor

We present the case of a 71-year-old female with a five month history of dysphagia, weight loss and heartburn. Preoperative investigation with barium swallow and upper endoscopy demonstrated a large lower esophageal pulsion divertictulum. A laparoscopic transhiatal resection of the esophageal diverticulum was performed with Heller myotomy and crural repair. Intraoperative endoscopy helps to identify the diverticulum in the mediastinum, to ensure complete resection of the diverticulum, to ensure an adequate esophageal myotomy, and to perform an air leak test. A Heller myotomy is performed to treat the esophageal dysmotility. A fundoplication is not performed due to poor esophageal motility.

981 A Pilot Trial of Endoscopic Radiofrequency Ablation for the Eradication of Esophageal Squamous Intraepithelial Neoplasia and Early Squamous Cell Carcinoma Limited to the Mucosa

We present the case of a 71-year-old female with a five month history of dysphagia, weight loss and heartburn. Preoperative investigation with barium swallow and upper endoscopy demonstrated a large lower esophageal pulsion divertictulum. A laparoscopic transhiatal resection of the esophageal diverticulum was performed with Heller myotomy and crural repair. Intraoperative endoscopy helps to identify the diverticulum in the mediastinum, to ensure complete resection of the diverticulum, to ensure an adequate esophageal myotomy, and to perform an air leak test. A Heller myotomy is performed to treat the esophageal dysmotility. A fundoplication is not performed due to poor esophageal motility.

975 Laparoscopic Assisted Total Gastrectomy With D2 Dissection and Roux-en-Y J Pouch

We present the case of a 71-year-old female with a five month history of dysphagia, weight loss and heartburn. Preoperative investigation with barium swallow and upper endoscopy demonstrated a large lower esophageal pulsion divertictulum. A laparoscopic transhiatal resection of the esophageal diverticulum was performed with Heller myotomy and crural repair. Intraoperative endoscopy helps to identify the diverticulum in the mediastinum, to ensure complete resection of the diverticulum, to ensure an adequate esophageal myotomy, and to perform an air leak test. A Heller myotomy is performed to treat the esophageal dysmotility. A fundoplication is not performed due to poor esophageal motility.

976 Standard Distal Gastrectomy With D2 Nodal Dissection

We present the case of a 71-year-old female with a five month history of dysphagia, weight loss and heartburn. Preoperative investigation with barium swallow and upper endoscopy demonstrated a large lower esophageal pulsion divertictulum. A laparoscopic transhiatal resection of the esophageal diverticulum was performed with Heller myotomy and crural repair. Intraoperative endoscopy helps to identify the diverticulum in the mediastinum, to ensure complete resection of the diverticulum, to ensure an adequate esophageal myotomy, and to perform an air leak test. A Heller myotomy is performed to treat the esophageal dysmotility. A fundoplication is not performed due to poor esophageal motility.

982 Spontaneous Reflux During Videoesophagram: Its Clinical Significance and Correlation With pH Monitoring

We present the case of a 71-year-old female with a five month history of dysphagia, weight loss and heartburn. Preoperative investigation with barium swallow and upper endoscopy demonstrated a large lower esophageal pulsion divertictulum. A laparoscopic transhiatal resection of the esophageal diverticulum was performed with Heller myotomy and crural repair. Intraoperative endoscopy helps to identify the diverticulum in the mediastinum, to ensure complete resection of the diverticulum, to ensure an adequate esophageal myotomy, and to perform an air leak test. A Heller myotomy is performed to treat the esophageal dysmotility. A fundoplication is not performed due to poor esophageal motility.

Outcomes After Esophagectomy in Patients With Prior Antireflux or Hiatal Hernia Surgery

Esophagectomy is indicated occasionally for the treatment of patients with refractory gastroesophageal reflux disease (GERD) or recurrent hiatus hernia. The purpose of this study was to evaluate the impact of previous gastroesophageal operations on outcomes after esophagectomy for recurrent GERD or hiatus hernia. Using a prospectively accumulated database, a retrospective review was performed to identify patients undergoing esophagectomy for complicated GERD or hiatus hernia. Mortality, perioperative and functional outcomes, and need for reoperation were evaluated, assessing esophagectomy patients who had undergone prior operations for GERD or hiatus hernia. Of 258 patients with GERD or hiatus hernia undergoing esophagectomy, 104 had undergone a previous operation, with a median interval to esophagectomy of 28 months. Transhiatal resection was accomplished in fewer patients undergoing reoperation (87 of 104 versus 151 of 154; p<0.005). A gastric conduit was used as an esophageal replacement in fewer patients with previous operation(s) (89 of 104 versus 150 of 154; p<0.005). Esophagectomy patients with a history of prior gastroesophageal surgery, as compared with those without, sustained more blood loss and were more likely to require reoperation, and fewer reported good to excellent swallowing function (p<0.05). There was no difference in the occurrence of anastomotic leak. Esophagectomy in patients who have undergone prior operations for either GERD or hiatus hernia can be accomplished without thoracotomy and with satisfactory intermediate-term quality of life. Such patients should be evaluated and prepared for the use of alternative conduits should the remobilized stomach prove to be an unsatisfactory esophageal substitute at the time of esophagectomy.

Feasibility of a High Intrathoracic Esophagogastric Anastomosis Without Thoracic Access After Laparoscopic-Assisted Transhiatal Esophagectomy: A Pilot Experimental Study

The aim of the present study was to evaluate the feasibility of a technique that uses solely the transhiatal approach to create a high intrathoracic esophagogastric anastomosis after laparoscopic transhiatal resection of the distal esophagus. Using a laparoscopic approach, the esophagi of 10 midsized pigs were dissected and transected as high as possible in the thorax, and the anvil of a circular stapler was introduced perorally into the esophageal stump. Through a midline short laparotomy, the circular stapler was inserted into the gastric tube and advanced through the hiatus to be connected with the anvil and create the anastomosis. Development of the technique was completed within the first 6 experiments. The last 4 operations were entirely successful, standardized, and easily reproducible. The technique is feasible in this experimental setting. Further studies are required to establish if there is a clinical role for this technique in esophageal surgery.

The prognostic importance of pathologically involved celiac node metastases in node-positive patients with carcinoma of the distal esophagus or gastroesophageal junction: a surgical series from the Mayo Clinic

The management of esophageal cancer with involvement of celiac lymph nodes is controversial. The purpose of this retrospective study was to evaluate the clinical importance of metastases to celiac lymph nodes in patients with carcinoma of the distal esophagus or gastroesophageal junction (GEJ) who undergo surgical treatment with curative intent. We reviewed the medical records of 310 patients who underwent definitive esophagectomy at the Mayo Clinic, Rochester, Minnesota, between 1976 and 1999 for carcinoma of the distal esophagus or GEJ. The disease location was distal esophagus in 163 and GEJ in 147. Fifty-two patients (17%) were found to have celiac node involvement. The survival of these patients was compared with that of 97 N0 patients and 161 N1 patients without celiac node involvement. Squamous cell carcinoma and adenocarcinomas were found in 24% and 76%, respectively. Ivor Lewis esophagectomy was the most common surgical procedure (76%), followed by transhiatal resection (14%) and modified Ivor Lewis procedure (5%). The median number of nodes resected was 15 (range, 2-45). The median survival of the entire group was 18.8 months. The median survival was 48 months (range, 1.6 months-22 years) for N0 patients and 15.9 months (range, 0.03 months-14.4 years) for N1 patients without celiac node disease (P < 0.001). The median survival was 11.7 months (range, 2.2 months-15.7 years) for celiac node-positive patients, and this difference was statistically significant when compared with survival in N0 patients (P= 0.001) but not when compared with that in N1 patients without celiac node disease (P= 0.57). Survival at 3 and 5 years was 61% and 45% for N0 patients, 21% and 9% for N1 patients without celiac node disease, and 18% and 11% for patients with celiac node disease, respectively. At 10 years, 7% of patients with celiac node involvement in their resected specimen were alive. By multivariate analysis, patients with 4 or more positive lymph nodes had the worst prognosis (risk ratio [RR], 2.63; 95% confidence interval [CI], 1.98-3.48), regardless of their location. We concluded that celiac node metastases were not an adverse prognostic indicator in patients with celiac node involvement compared with N1 patients without celiac node disease. Overall, the number of positive nodes, not their location, correlated best with survival. Although median survival was poor, a small number of patients with resected celiac node disease had long-term survival. Patients with undetected celiac node disease at the time of surgical resection who were subsequently found to have celiac node involvement appeared to have a prognosis similar to that of patients with stage III disease. Therefore, treatment with curative intent should be considered for fit patients with celiac node disease.

Technique of Open Ivor Lewis Esophagectomy

Technique of Open Ivor Lewis Esophagectomy

Diagnostic criteria and surgical procedure for megaesophagus - a personal experience

Megaesophagus is the end-stage of achalasia cardiae. It is the result of peristaltic disorders and slow decompensation of the muscular layer of the esophagus. The aim of this article is to detail the diagnostic criteria and surgical management of megaesophagus. Criteria were acute bending of esophagus axis; lack of esophagus peristalsis, and no response to stimulation in the manometric test; and Los Angeles C/D esophagitis in the endoscopic examination. Between 1991 and 2004 seven patients (5 females, 2 males; age, 51-67 years; average age, 59 +/- 8 years) were treated. A bypass made from the pedunculated part of the jejunum connecting the part of esophagus above the narrowing with the praepyloric part of the stomach was made. Access was by an abdominal approach. A jejunum bypass was made in six patients with megaesophagus. A transhiatal esophageal resection was carried out, and in the second stage a supplementary esophagus was made from the right half of the colon on the ileocolic vessels in one patient who had experienced two earlier unsuccessful operations. Symptoms of dysphagia, recurrent inflammation of the respiratory tract, and pain subsided in all patients. Complications were not reported in the postoperative period. All patients survived. Subsequent radiographic and endoscopic examination showed very good outcome. The jejunum bypass gave very good results in the surgical treatment of megaesophagus.

Minimally invasive esophagectomy for cancer☆

Since 1992, various combinations of thoracoscopy (VATS), laparoscopy or hand-assisted thoracolaparoscopy have been used for 'minimally invasive' cancer esophagectomy (MIE). Despite widespread current use, indications and potential benefits of the many technical approaches remain controversial. A systematic literature search was conducted until June 2007. Out of 128 publications, 46 original series (1932 patients) met the inclusion criteria and were analyzed for surgical and oncological outcome. No prospective controlled study has compared any MIE technique to another or to open surgery. Most publications are retrospective series of highly selected patients, mostly excluding high-risk patients and locally advanced (T3) tumors. Altogether, the overall conversion rate was 5.9%, mortality 2.9% and morbidity 46%, many papers reporting only major complications. Overall, rates for pulmonary complications were 22%, leakage 8.8% and vocal cord palsy 7.1%. Fifteen tracheo-bronchial injuries or fistulas (1% of all VATS cases) were reported. Laparoscopy and VATS were combined in 11 series (609 patients, 4.7% conversions, 2.4% mortality). VATS combined with (mini)-laparotomy was reported in 14 papers (743 patients, 6.3% conversions, 2.4% mortality). Laparoscopy combined with right thoracotomy was reported in four papers (147 patients, 5.4% conversions, 2% mortality). Laparoscopic transhiatal resections were reported in 17 papers (433 patients, 7% conversions, 4.6% mortality). Overall morbidity rates for these four approaches were 43%, 47.6%, 51.6% and 46%, respectively. Data on oncological outcome are scarce. Lymph node retrieval (median of all series: 14 nodes, range 5-62) was mostly inferior to open surgery standards and follow-up too short to draw definitive conclusions regarding long-term survival. Based on the available literature, the morbidity and mortality of MIE is substantial and not inferior to radical open esophagectomy in experienced centers. Many different operative techniques for MIE have been reported without obvious superiority for any of them. The term 'minimally invasive' is not supported by hitherto reported results. Selection bias and huge variability in extent of resection and lymphadenectomy impair comparisons of different MIE techniques. Oncological outcome of MIE remains largely unknown by lack of good quality data and selection bias. MIE remains an investigational and still evolving treatment for invasive cancer.

Multimodale Therapie des Ösophaguskarzinoms

Surgery is still the treatment of choice in patients with resectable oesophageal cancer. However, recent randomised controlled trials suggest beneficial effects of adjuvant or neoadjuvant treatment modalities on progression-free and overall survival compared to surgery alone. Neoadjuvant chemoradiotherapy in combination with surgery is most effective in squamous cell carcinomas. Increased perioperative morbidity and mortality should be minimised by surgery in a high-volume centre. In adenocarcinomas of the gastro-oesophageal junction neoadjuvant chemotherapy shows beneficial effects compared to surgery alone. A transhiatal resection should be preferred in distal oesophageal cancer compared to a transthoracic oesophageal resection if the patient is in poor condition. In all other cases a transthoracic resection remains the procedure of choice. Chemoradiotherapy alone is an alternative to surgery in high-risk patients with squamous cell carcinomas of the oesophagus. Therefore the treatment of patients with oesophageal cancer should always include an individualised, multimodal approach including surgery, chemotherapy, and radiotherapy.

Nyelőcsőtumor miatt végzett laparoscopos transhiatalis nyelőcső-exstirpatior

Minimally invasive oesophageal resection is a real alternative to the conventional open operative techniques in the surgical treatment of oesophageal tumours. The authors present a case of a 51 year-old female patient who initially underwent an upper GI endoscopy for vague stomach symptoms. The examination revealed an oesophageal tumour of approximately 2 cm in length, located at 32 cm from the incisors. Abdominal ultrasound and CT scans were carried out, which showed that the tumour had breached the submucosa, but regional lymph node metastasis was not detected. Since an intraluminal flexible endoscopic ablation of the tumour could not have been carried out, a laparoscopic transhiatal oesophagus excision was done. The oesophagus was replaced by an intracorporal tubulated stomach in the posterior mediastinum. In the postoperative period a gastro-pleural fistula developed in the middle third of the stomach, which was treated conservatively (thoracic drainage, Salem probe). A phlegmone developed next to the feeding jejunostomy - at the site of one of the trocars - required exploration, the re-suturing of the jejunostomy due to persisting leakage of the small intestine. 3 months after the operation the patient was asymptomatic and gained 2 kg weight. Laparoscopic transhiatal oesophagus resection has all the benefits of the minimally invasive techniques; in addition, it makes possible to do a more radical surgery than with the traditional transhiatal operation. The authors review the relevant literature and present other minimal invasive techniques, discussing the results on lymph node dissection, pyloroplasty, as well as replacement.

Perfusional evaluation of postesophagectomy gastroplasty with a radioisotopic study

Anastomotic fistula represents one of the frequent causes of postoperative morbidity and mortality following transhiatal esophageal resections. The main etiological factor is the ischemia of the gastric tube created for digestive transit reconstruction. Evidence suggests that per operative hypoperfusion can be maintained or even impaired after the surgery. Several methods have been employed in an attempt to assess the blood perfusion of the gastric flap, but they all pose limitations. However, there is a chronological relationship between perfusion assessments, which are almost exclusively performed per operatively, and the occurrence of a leak, which commonly appears several days after the surgery. The authors have developed a method of gastric perfusion evaluation by single photon emission computed tomography scintigraphy, which corrects that temporal matter, allowing the estimation of postoperative gastric perfusion. It is noninvasive, low cost, and may be applied by the time frame when most fistulas occur. High correlation between the event fistula and the low radiotracer uptake in the group of studied patients could be demonstrated. A role in the research of perfusion evaluation of different types of esophageal reconstruction is suggested.

Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the distal esophagus

There is much controversy about the surgical approach to esophageal carcinoma: should an extensive resection be done to optimize long term survival or should the extent of the operation be limited to obtain lower perioperative morbidity and mortality rates? Thirty-one patients with carcinoma of the lower third of the esophagus who were clinically fit for either transhiatal resection (THR) or transthoracic resection (TTR) were prospectively randomized to THR (16 patients) and TTR (15 patients). Patients of the two groups were comparable in age, sex, preoperative tumor staging, and pulmonary and cardiac risks for surgery. There was no significant difference in the operative complications among both groups. However, the amount of blood loss was significantly more in the TTR group (P 0.05). There was no 30-day mortality in the THR group but there were 2 mortalities in the TTR group from mediastinitis (1 patients) and pulmonary embolism (1 patient). The median survival rates were 19 and 16.5 months, respectively, for the THR and TTR groups (P>0.05). In conclusion, although there was no demonstrable statistical difference in results between THR and TTR approaches, the THR approach is preferred as early survival rate are better and should be considered for all cases with adenocarcinoma of the lower end of the oesophagus.

Chirurgische Therapie des Ösophaguskarzinoms: Eine prospektive 20-Jahres-Analyse

The aim of our study was the analysis of long-term developments in the surgical therapy for esophageal carcinoma at our hospital over a period of 20 years with a differentiated view on the two predominant histological tumour types. Between September 1985 and September 2005, esophageal resections were performed in 470 patients at our clinic on account of a malignant tumour of the esophagus. The abdomino-thoracic resection with abdominal and extended mediastinal lymph node dissection as well as intrathoracic anastomosis was the standard treatment in the case of squamous cell carcinoma, whereas in adenocarcinoma a transhiatal resection with abdominal and dorsal mediastinal lymphadenectomy and cervical esophagogastrostomy was carried out. For analysis of the development, the study period of 20 years was divided into two intervals: interval 1 from 9 / 1985 to 9 / 1995, and interval 2 from 10 / 1995 to 9 / 2005. Both tumour entities displayed in the last interval (10 / 1995 to 9 / 2005) significantly earlier tumour stages. A proportionally identical amount of transhiatal resections for squamous cell carcinoma was found in both intervals, whereas the transhiatal procedures for adenocarcinoma increased in the last decade (3.6 % in the period between 9 / 1985 and 9 / 1995, as compared with 23.6 % between 10 / 1995 and 9 / 2005) (p < 0.05). While the overall prognosis for squamous cell carcinoma did not significantly differ in the two decades (p = 0.2040), patients with adenocarcinoma were found to have a significantly improved long-term survival (log-rank test: p = 0.0365) in the second decade. The prognosis for adenocarcinoma, therefore, could be improved in the course of time with a 3-year survival rate of finally 40 % (as compared with 17.5 % in the first decade), and a 5-year survival rate of 25 % (as compared with 15 %). Surgical therapy for esophageal carcinoma has undergone distinct changes over the past 20 years. These are mainly due to epidemiological and diagnostic aspects, an improved selection of patients, whereby the operative procedure is adapted to the tumour stage and the operative risk for the patient. Especially with adenocarcinoma of the esophagus, these changes have led to a significantly more favourable long-term prognosis.

En bloc esophagectomy reduces local recurrence and improves survival compared with transhiatal resection after neoadjuvant therapy for esophageal adenocarcinoma

Neoadjuvant therapy is commonly used for esophageal adenocarcinoma. We have reported reduced local recurrence rates and improved survival after an en bloc esophagectomy compared with a transhiatal resection as primary therapy for adenocarcinoma of the esophagus. The aim of this study was to determine whether the benefits of an en bloc resection would extend to patients after neoadjuvant therapy. The charts of all patients with esophageal adenocarcinoma that had neoadjuvant therapy and en bloc or transhiatal esophagectomy from 1992-2005 were reviewed. Patients found to have systemic metastatic disease at the time of the operation or who had an incomplete resection were excluded. There were 58 patients: 40 had an en bloc resection and 18 had a transhiatal esophagectomy. A complete pathologic response occurred in 17 (29.3%) of 58 patients. Median follow-up was 34.1 months after en bloc resection and 18.3 months after transhiatal resection (P = .18). Overall survival at 5 years and survival in patients with residual disease after neoadjuvant therapy was significantly better with an en bloc resection (overall survival: 51% for en bloc resection and 22% for transhiatal resection [P = .04]; survival with residual disease: 48% for en bloc resection and 9% for transhiatal resection [P = .02]). Survival in patients with complete pathologic response tended to be better after an en bloc resection (en bloc, 70%; transhiatal, 43%; P = .3). An en bloc resection provides a survival advantage to patients after neoadjuvant therapy compared with a transhiatal resection, particularly for those with residual disease. Similar to patients treated with primary resection, an en bloc esophagectomy is the procedure of choice after neoadjuvant therapy.

The Merendino procedure following preoperative imatinib mesylate for locally advanced gastrointestinal stromal tumor of the esophagogastric junction

BackgroundGastrointestinal stromal tumors (GIST) of the esophagogastric junction might pose a major problem to surgical resection. If locally advanced, extended or multivisceral resection with relevant procedural-specific morbidity and mortality is often necessary.Case presentationWe report a case of a patient with a locally advanced GIST of the esophagogastric junction who was treated by transhiatal resection of the lower esophagus and gastric cardia with reconstruction by interposition of segment of the jejunum (Merendino procedure). Prior to resection, downsizing of the tumor had successfully been achieved by treatment with imatinib mesylate for six months. Histological proof of GIST by immunohistochemical expression of c-KIT and/or PDGF alpha Receptor is crucial to allow embarking on this treatment strategy.ConclusionA multimodal approach for an advanced GIST of the esophagogastric junction with preoperative administration of imatinib mesylate could avoid extended resection. The Merendino procedure might be considered as the reconstruction method of choice after resection of GIST at this location.

Laparoscopic transhiatal resection for malignancies of the distal esophagus: Outcome of the first 50 resected patients

Although different neoadjuvant therapies are being developed, surgical treatment remains the only curative therapy for esophageal cancer. For years, the procedure of choice for esophageal cancer was the Ivor-Lewis1 operation, later modified, as three-stage esophagectomy by McKeown.2 With this modified procedure, the esophagus is resected by means of a right-sided thoracotomy combined with a laparotomy using cervical esophagogastric anastomosis. The other frequently used procedure is the transhiatal esophageal resection according to Orringer and Sloan,3 in which a thoracotomy is avoided.

Extended Transthoracic Resection Compared With Limited Transhiatal Resection for Adenocarcinoma of the Mid/Distal Esophagus

To determine whether extended transthoracic esophagectomy for adenocarcinoma of the mid/distal esophagus improves long-term survival. A randomized trial was performed to compare surgical techniques. Complete 5-year survival data are now available. A total of 220 patients with adenocarcinoma of the distal esophagus (type I) or gastric cardia involving the distal esophagus (type II) were randomly assigned to limited transhiatal esophagectomy or to extended transthoracic esophagectomy with en bloc lymphadenectomy. Patients with peroperatively irresectable/incurable cancer were excluded from this analysis (n = 15). A total of 95 patients underwent transhiatal esophagectomy and 110 patients underwent transthoracic esophagectomy. After transhiatal and transthoracic resection, 5-year survival was 34% and 36%, respectively (P = 0.71, per protocol analysis). In a subgroup analysis, based on the location of the primary tumor according to the resection specimen, no overall survival benefit for either surgical approach was seen in 115 patients with a type II tumor (P = 0.81). In 90 patients with a type I tumor, a survival benefit of 14% was seen with the transthoracic approach (51% vs. 37%, P = 0.33). There was evidence that the treatment effect differed depending on the number of positive lymph nodes in the resection specimen (test for interaction P = 0.06). In patients (n = 55) without positive nodes locoregional disease-free survival after transhiatal esophagectomy was comparable to that after transthoracic esophagectomy (86% and 89%, respectively). The same was true for patients (n = 46) with more than 8 positive nodes (0% in both groups). Patients (n = 104) with 1 to 8 positive lymph nodes in the resection specimen showed a 5-year locoregional disease-free survival advantage if operated via the transthoracic route (23% vs. 64%, P = 0.02). There is no significant overall survival benefit for either approach. However, compared with limited transhiatal resection extended transthoracic esophagectomy for type I esophageal adenocarcinoma shows an ongoing trend towards better 5-year survival. Moreover, patients with a limited number of positive lymph nodes in the resection specimen seem to benefit from an extended transthoracic esophagectomy.