Susanne Warner, MD, Yu-Hui Chang, PhD, Harshita Paripati, MD, Helen Ross, MD, Jonathan Ashman, MD, PhD, Kristi Harold, MD, Ryan Day, MD, Chee-Chee Stucky, MD, William Rule, MD, and Dawn Jaroszewski, MD Divisions of Cardiothoracic Surgery, Health Sciences Research, Hematology and Oncology, Radiation Oncology, and Minimally Invasive Surgery, Mayo Clinic, Phoenix, Arizona
Background. Minimally invasive esophagectomy (MIE) is accepted for resection of early esophageal cancers. The optimal surgical approach for more advanced disease is unknown. An evaluation of MIE in patients with advanced tumors having undergone neoadjuvant chemoradiotherapy (nCRT) is presented. Methods. A retrospective review of patients with esophageal cancer who underwent MIE from November 2006 to November 2011 was performed Results. In total, 96 consecutive patients underwent MIE for malignancy. Median age was 65 years (range 26 to 88), and 86% were male. Adenocarcinoma represented 87% of patients. Eighty-three percent of patients were staged IIa or higher and 62 (65%) patients received neoadjuvant chemoradiotherapy. Four (6%) patients additionally received intraoperative electron beam radiotherapy. Twenty-six (27%) patients received postoperative adjuvant therapy with 22 (85%) of these having also received neoadjuvant chemoradiotherapy. All cases were completed thoraco-laparoscopically except
for 2 conversions to mini-laparotomy. Twelve (12%) cervical anastomoses and 84 (88%) thoracic anastomoses were performed. Median operative time was 326 minutes (range 193 to 567) and did not differ significantly between those with and without nCRT. Complete pathologic response was seen in 21 (34%) of the 62 patients receiving neoadjuvant treatment. Major and minor morbidities were experienced in 28% and 38.5% of patients. There were 2 (2%) in-hospital mortalities; 1 each having received or not received neoadjuvant therapy. At median follow-up 24 months (range 3 to 70 months), overall survival was 58% and 55 (57%) patients were alive without recurrence. Conclusions. Minimally invasive esophagectomy is an acceptable surgical therapy for advanced-stage esophageal malignancies after nCRT without evidence for increased morbidity or mortality.
A
2011. Benign esophageal disease was excluded. Patients developing metastasis, local progression during nCRT or became medically inoperable were excluded. The treatment and selection algorithms were identical whether surgery was planned as minimally invasive esophagectomy (MIE) versus open surgery. All patients presented as surgical candidates to cohort’s surgeon were planned for MIE. Patient demographics, treatments, and clinical outcomes were examined by review of electronic medical records. Tumor staging was determined using the American Joint Committee for Cancer Staging (AJCC) classification system 7th edition [21]. Staging included computed tomography and positron emission tomography (CT/PET) scanning in conjunction with endoscopic ultrasound [22]. All patients underwent placement of jejunostomy feeding tubes for perioperative nutritional support either preoperatively or at the time of esophagectomy. Feeding tubes were placed preoperatively in patients with limited oral intake or who experienced greater than 20% loss of body weight during nCRT.
lthough advanced esophageal carcinoma has a poor prognosis, recent reports have shown increased survival with trimodality therapy [1–7]. Minimally invasive surgical approaches are gaining popularity; however, many surgeons still prefer an open technique for advanced tumors [2, 8–20]. In particular, concern is raised as to whether there is increased operative complexity and postoperative complications after neoadjuvant chemoradiotherapy (nCRT). A review of our MIE experience was performed comparing patient cohorts having had trimodality treatment versus surgery alone.
Material and Methods A retrospective review was conducted of patients treated consecutively for esophageal carcinoma with MIE by a single surgeon November 2006-November Accepted for publication Sept 13, 2013. Address correspondence to Dr Jaroszewski, Division of Cardiothoracic Surgery, 5777 E Mayo Blvd, Phoenix, AZ 85054; e-mail: jaroszewski. [email protected].
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
(Ann Thorac Surg 2014;97:439–45) Ó 2014 by The Society of Thoracic Surgeons
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.09.042
GENERAL THORACIC
Outcomes of Minimally Invasive Esophagectomy in Esophageal Cancer After Neoadjuvant Chemoradiotherapy
GENERAL THORACIC
440
WARNER ET AL MIE IN ESOPHAGEAL CANCER AFTER NCRT
Length of surgery was determined by nursing records indicating time of incision and time of procedure completion. Time for placement of feeding tube in patients who received feeding tubes during MIE was not able to be separated out with existing operative records and adjustment for placement of jejunostomy tube by analysis of covariance was used. A subgroup analysis excluding patients with intraoperative radiation therapy (IORT) was performed to compare operating time. Postoperative complications were collected from electronic records and were recorded based on The Society of Thoracic Surgeons National Database initiative [23]. Major complications and morbidities included those requiring return to the operating room (defined as return to the operation during hospitalization or within 30 days of surgery for procedure-related complication), anastomotic or conduit leak of any degree (including clinically asymptomatic), prolonged intubation 48 hours or greater, acute respiratory distress syndrome requiring reintubation and respiratory support, and myocardial infarction (diagnosed by either electrocardiogram changes or troponin levels). Anastomotic leak was defined as evidence of contrast extravasation at esophagogastric anastomosis or conduit or as evidenced by clinical evaluation. Pneumonia was defined as consolidation seen on chest roentgenogram (the presence of defined infiltrate or significant atelectasis with or without leukocytosis, positive sputum culture, or fever) being treated with antibiotic therapy. Operative mortality was defined as death during initial hospitalization. Dysphagia complaints in postoperative follow-up were investigated through endoscopy or esophagram. The diagnosis of stricture was the presence of postoperative radiographic or endoscopic evidence of narrowing (1.8 or renal failure on dialysis History of PE History of stroke Peripheral vascular disease EUS performed, n (%) CT/PET done, n (%) Histology, n (%) Metastatic breast Adenocarcinoma Squamous cell carcinoma Dysplasia Death, n (%) a
Wilcoxon rank sum test.
b
63.0 53 27.0 13.0
(41.0–88.0) (85.5%) (21.0–48.3) (0.0–50.0)
Surgery Only (n ¼ 34) 68.5 30 28.7 0.0
(26.0–84.0) (88.2%) (19.6–47.4) (0.0–30.0)
p Value 0.0798a 0.7063b 0.2669a
Background. Minimally invasive esophagectomy (MIE) is accepted for resection of early esophageal cancers. The optimal surgical approach for more advanced disease is unknown. An evaluation of MIE in patients with advanced tumors having undergone neoadjuvant chemoradiotherapy (nCRT) is presented. Methods. A retrospective review of patients with esophageal cancer who underwent MIE from November 2006 to November 2011 was performed Results. In total, 96 consecutive patients underwent MIE for malignancy. Median age was 65 years (range 26 to 88), and 86% were male. Adenocarcinoma represented 87% of patients. Eighty-three percent of patients were staged IIa or higher and 62 (65%) patients received neoadjuvant chemoradiotherapy. Four (6%) patients additionally received intraoperative electron beam radiotherapy. Twenty-six (27%) patients received postoperative adjuvant therapy with 22 (85%) of these having also received neoadjuvant chemoradiotherapy. All cases were completed thoraco-laparoscopically except
for 2 conversions to mini-laparotomy. Twelve (12%) cervical anastomoses and 84 (88%) thoracic anastomoses were performed. Median operative time was 326 minutes (range 193 to 567) and did not differ significantly between those with and without nCRT. Complete pathologic response was seen in 21 (34%) of the 62 patients receiving neoadjuvant treatment. Major and minor morbidities were experienced in 28% and 38.5% of patients. There were 2 (2%) in-hospital mortalities; 1 each having received or not received neoadjuvant therapy. At median follow-up 24 months (range 3 to 70 months), overall survival was 58% and 55 (57%) patients were alive without recurrence. Conclusions. Minimally invasive esophagectomy is an acceptable surgical therapy for advanced-stage esophageal malignancies after nCRT without evidence for increased morbidity or mortality.
A
2011. Benign esophageal disease was excluded. Patients developing metastasis, local progression during nCRT or became medically inoperable were excluded. The treatment and selection algorithms were identical whether surgery was planned as minimally invasive esophagectomy (MIE) versus open surgery. All patients presented as surgical candidates to cohort’s surgeon were planned for MIE. Patient demographics, treatments, and clinical outcomes were examined by review of electronic medical records. Tumor staging was determined using the American Joint Committee for Cancer Staging (AJCC) classification system 7th edition [21]. Staging included computed tomography and positron emission tomography (CT/PET) scanning in conjunction with endoscopic ultrasound [22]. All patients underwent placement of jejunostomy feeding tubes for perioperative nutritional support either preoperatively or at the time of esophagectomy. Feeding tubes were placed preoperatively in patients with limited oral intake or who experienced greater than 20% loss of body weight during nCRT.
lthough advanced esophageal carcinoma has a poor prognosis, recent reports have shown increased survival with trimodality therapy [1–7]. Minimally invasive surgical approaches are gaining popularity; however, many surgeons still prefer an open technique for advanced tumors [2, 8–20]. In particular, concern is raised as to whether there is increased operative complexity and postoperative complications after neoadjuvant chemoradiotherapy (nCRT). A review of our MIE experience was performed comparing patient cohorts having had trimodality treatment versus surgery alone.
Material and Methods A retrospective review was conducted of patients treated consecutively for esophageal carcinoma with MIE by a single surgeon November 2006-November Accepted for publication Sept 13, 2013. Address correspondence to Dr Jaroszewski, Division of Cardiothoracic Surgery, 5777 E Mayo Blvd, Phoenix, AZ 85054; e-mail: jaroszewski. [email protected].
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
(Ann Thorac Surg 2014;97:439–45) Ó 2014 by The Society of Thoracic Surgeons
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.09.042
GENERAL THORACIC
Outcomes of Minimally Invasive Esophagectomy in Esophageal Cancer After Neoadjuvant Chemoradiotherapy
GENERAL THORACIC
440
WARNER ET AL MIE IN ESOPHAGEAL CANCER AFTER NCRT
Length of surgery was determined by nursing records indicating time of incision and time of procedure completion. Time for placement of feeding tube in patients who received feeding tubes during MIE was not able to be separated out with existing operative records and adjustment for placement of jejunostomy tube by analysis of covariance was used. A subgroup analysis excluding patients with intraoperative radiation therapy (IORT) was performed to compare operating time. Postoperative complications were collected from electronic records and were recorded based on The Society of Thoracic Surgeons National Database initiative [23]. Major complications and morbidities included those requiring return to the operating room (defined as return to the operation during hospitalization or within 30 days of surgery for procedure-related complication), anastomotic or conduit leak of any degree (including clinically asymptomatic), prolonged intubation 48 hours or greater, acute respiratory distress syndrome requiring reintubation and respiratory support, and myocardial infarction (diagnosed by either electrocardiogram changes or troponin levels). Anastomotic leak was defined as evidence of contrast extravasation at esophagogastric anastomosis or conduit or as evidenced by clinical evaluation. Pneumonia was defined as consolidation seen on chest roentgenogram (the presence of defined infiltrate or significant atelectasis with or without leukocytosis, positive sputum culture, or fever) being treated with antibiotic therapy. Operative mortality was defined as death during initial hospitalization. Dysphagia complaints in postoperative follow-up were investigated through endoscopy or esophagram. The diagnosis of stricture was the presence of postoperative radiographic or endoscopic evidence of narrowing (1.8 or renal failure on dialysis History of PE History of stroke Peripheral vascular disease EUS performed, n (%) CT/PET done, n (%) Histology, n (%) Metastatic breast Adenocarcinoma Squamous cell carcinoma Dysplasia Death, n (%) a
Wilcoxon rank sum test.
b
63.0 53 27.0 13.0
(41.0–88.0) (85.5%) (21.0–48.3) (0.0–50.0)
Surgery Only (n ¼ 34) 68.5 30 28.7 0.0
(26.0–84.0) (88.2%) (19.6–47.4) (0.0–30.0)
p Value 0.0798a 0.7063b 0.2669a
