Hiran C. Fernando

Minimally invasive esophagectomy: outcomes in 222 patients.

Objective: To assess our outcomes after minimally invasive esophagectomy (MIE). Summary Background Data: Esophagectomy has traditionally been performed by open methods. Results from most series include mortality rates in excess of 5% and hospital stays frequently greater than 10 days. MIE has the potential to improve these results, but only a few small series have been reported. This report summarizes our experience of 222 cases. Methods: From 1996 to 2002, MIE was performed in 222 patients. Indications for operation included high-grade dysplasia (n = 47) and cancer (n = 175). Neoadjuvant chemotherapy was used in 78 (35.1%) and radiation in 36 (16.2%). Initially, a laparoscopic transhiatal approach was used (n = 8), but subsequently our approach evolved to include thoracoscopic mobilization (n = 214). Results: There were 186 men and 36 women. Median age was 66.5 years (range, 39–89). Nonemergent conversion to open procedure was required in 16 patients (7.2%). MIE was successfully completed in 206 (92.8%) patients. The median intensive care unit stay was 1 day (range, 1–30); hospital stay was 7 days (range, 3–75). Operative mortality was 1.4% (n = 3). Anastomotic leak rate was 11.7% (n = 26). At a mean follow-up of 19 months (range, 1–68), quality of life scores were similar to preoperative values and population norms. Stage specific survival was similar to open series Conclusions: MIE offers results as good as or better than open operation in our center with extensive minimally invasive and open experience. In this single institution experience, we observed a lower mortality rate (1.4%) and shorter hospital stay (7 days) than most open series. Given these results, we are now developing an intergroup trial (ECOG 2202) to assess MIE in a multicenter setting.

Minimally invasive esophagectomy.

BACKGROUND Open esophagectomy can be associated with significant morbidity and delay return to routine activities. Minimally invasive surgery may lower the morbidity of esophagectomy but only a few small series have been published. METHODS From August 1996 to September 1999, 77 patients underwent minimally invasive esophagectomy. Initially, esophagectomy was approached totally laparoscopically or with mini-thoracotomy; thoracoscopy subsequently replaced thoracotomy. RESULTS Indications included esophageal carcinoma (n = 54), Barretts high-grade dysplasia or carcinoma in situ (n = 17), and benign miscellaneous (n = 6). There were 50 men and 27 women with an average age of 66 years (range 30 to 94 years). Median operative time was 7.5 hours (4.5 hours with > 20 case experience). Median intensive care unit stay was 1 day (range 0 to 60 days); median length of stay was 7 days (range 4 to 73 days) with no operative or hospital mortalities. There were four nonemergent conversions to open esophagectomy; major and minor complication rates were 27% and 55%, respectively. CONCLUSIONS Minimally invasive esophagectomy is technically feasible and safe in our center, which has extensive minimally invasive and open esophageal experience. Open surgery should remain the standard until future studies conclusively demonstrate advantages of minimally invasive approaches.

Laparoscopic repair of giant paraesophageal hernia: 100 Consecutive cases

ObjectiveTo summarize the authors’ laparoscopic experience for paraesophageal hernia (PEH). Summary Background DataLaparoscopic antireflux surgery and repair of small hiatal hernias are now routinely performed. Repair of a giant PEH is more complex and requires conventional surgery in most centers. Giant PEH accounts for approximately 5% of all hiatal hernias. Medical management may be associated with a 50% progression of symptoms and a significant death rate. Conventional open surgery has a low death rate, but complications are significant and return to routine activities is delayed in this frequently elderly population. Recently, short-term outcome studies have reported that minimally invasive approaches to PEH may be associated with a lower complication rate, a shorter hospital stay, and faster recovery. MethodsFrom July 1995 to February 2000, 100 patients (median age 68) underwent laparoscopic repair of a giant PEH. Follow-up included heartburn scores and quality of life measurements using the SF-12 physical component and mental component summary scores. ResultsThere were 8 type II hernias, 85 type III, and 7 type IV. Sac removal, crural repair, and antireflux procedures were performed (72 Nissen, 27 Collis-Nissen). The 30-day death rate was zero; there was one surgery-related death at 5 months from a perioperative stroke. Intraoperative complications included pneumothorax, esophageal perforation, and gastric perforation. There were three conversions to open surgery. Major postoperative complications included stroke, myocardial infarction, pulmonary emboli, adult respiratory distress syndrome, and repeat operations (two for abscess and one each for hematoma, repair leak, and recurrent hernia). Median length of stay was 2 days. Median follow-up at 12 months revealed resumption of proton pump inhibitors in 10 patients and one repeat operation for recurrence. The mean heartburn score was 2.3 (0, best; 45, worst); the satisfaction score was 91%; physical and mental component summary scores were 49 and 54, respectively (normal, 50). ConclusionThis report represents the largest series to date of laparoscopic repair of giant PEH. In the authors’ center with extensive experience in minimally invasive surgery, laparoscopic repair of giant PEH was successfully performed in 97% of patients, with a minimal complication rate, a 2-day length of stay, and good intermediate results.

Results of laparoscopic repair of giant paraesophageal hernias: 200 consecutive patients

BACKGROUND Giant paraesophageal hernias (GPEH) have traditionally required open operations. Increasingly, a laparoscopic approach is being applied to more complex esophageal surgery. Our objective was to update our growing experience with laparoscopic repair of GPEH. METHODS We performed a retrospective review at our institution of patients undergoing laparoscopic repair of GPEH from July 1995 to July 2001. The GPEH was defined as greater than one-third of the stomach in the chest. RESULTS Elective laparoscopic repair of a GPEH was attempted in 203 patients. Mean age was 67 years. The most common symptoms included heartburn (96 patients), dysphagia (72), epigastric pain (56), and vomiting (47 patients). Laparoscopic procedures included 69 Nissens, 112 Collis-Nissens, and 19 other procedures. There were three open conversions due to adhesions, but no intraoperative emergencies. Median length of stay was 3 days (range, 1 to 120 days). Minor or major complications occurred in 57 patients (28%). There were six postoperative esophageal leaks (3%), and 1 death. Median follow-up was 18 months. Five patients required reoperation for recurrent hiatal hernia. Excellent results were reported in 128 (84%) patients, 12 (8%) had a good result, 7 (5%) fair, and 5 (3%) poor (based on postoperative follow-up and GERD questionnaire). The mean postoperative GERD Health-related Quality of Life Score was 2.4 (scale 0 to 45; 0 = no symptoms, 45 = worst). CONCLUSIONS Laparoscopic repair of GPEH is possible in the majority of patients with acceptable morbidity, a median length of hospital stay of 3 days and excellent intermediate-term results in an experienced center.

Margin and Local Recurrence After Sublobar Resection of Non-Small Cell Lung Cancer

BackgroundLocal recurrence is a major concern after sublobar resection (SR) of non-small cell lung cancer (NSCLC). We postulate that a large proportion of local recurrence is related to inadequate resection margins. This report analyzes local recurrence after SR of stage I NSCLC. Stratification based on distance of the tumor (<1 cm vs ≥1 cm) to the staple line was performed.MethodsWe reviewed 81 NSCLC patients (44 female) who underwent operation over an 89-month period (January 1997 to June 2004). Mean forced expiratory volume in one second percentiles (FEV1) was 57%. Mean age was 70 (46–86) years. There were 55 wedge and 26 segmental resections. There were 41 tumors with a margin <1 cm and 40 with a margin ≥1 cm. Local recurrence was defined as recurrence within the ipsilateral lung or pulmonary hilum.ResultsThere were no perioperative deaths. Mean follow-up was 20 months. Margin distance significantly impacted local recurrence; 6 of 41 patients (14.6%) developed local recurrence in the group with margin less than 1 cm versus 3 of 40 patients (7.5%) in the group with margin equal to or more than 1 cm (P = .04). Of the 41 patients with margins <1 cm, segmentectomy was used in 7 (17%), whereas in the 40 patients with the ≥1 cm margins, segmentectomy was used in 19 (47.5%).ConclusionsMargin is an important consideration after SR of NSCLC. Wedge resection is frequently associated with margins less than 1 cm and a high risk for locoregional recurrence. Segmentectomy appears to be a better choice of SR when this is chosen as therapy.

Results of expandable metal stents for malignant esophageal obstruction in 100 patients: short-term and long-term follow-up

BACKGROUND Expandable metal stents palliate malignant dysphagia in most cases, but early complications and outcomes in long-term survivors have not been well described. This report summarizes our experience with expandable metal stents for malignant dysphagia. METHODS Over a 48-month period, 127 stents were placed in 100 patients with dysphagia from esophageal cancer (93%) or lung cancer. Most had undergone prior treatment. Dysphagia scores, duration of palliation, complications, and reintervention were evaluated. RESULTS Immediate improvement in dysphagia was observed in 85% of patients with no procedure-related deaths. Dysphagia score decreased from 3.3 before stent to 2.3 (p < 0.005). Average interval to reintervention was 80 days. In 40 patients surviving more than 120 days, 31 (78%) required reintervention. Major complications occurred in 3 patients receiving poststent chemoradiation (tracheoesophageal fistula, T1 vertebral body abscess, mediastinal abscess). Other complications included unsatisfactory deployment requiring immediate removal (3 patients), migration (11 patients), pain requiring removal (2 patients), food impaction (10 patients), and tumor ingrowth (37 patients). CONCLUSIONS Expandable metal stents offer excellent short-term palliation of malignant dysphagia. In long-term survivors, recurrent dysphagia requiring reintervention is common. In a small subset of patients receiving chemoradiation after stent placement, major complications were observed.

American College of Chest Physicians and Society of Thoracic Surgeons Consensus Statement for Evaluation and Management for High-Risk Patients with Stage I Non-small Cell Lung Cancer

BACKGROUND The standard treatment of stage I non-small cell lung cancer (NSCLC) is lobectomy with systematic mediastinal lymph node evaluation. Unfortunately, up to 25% of patients with stage I NSCLC are not candidates for lobectomy because of severe medical comorbidity. METHODS A panel of experts was convened through the Thoracic Oncology Network of the American College of Chest Physicians and the Workforce on Evidence-Based Surgery of the Society of Thoracic Surgeons. Following a literature review, the panel developed 13 suggestions for evaluation and treatment through iterative discussion and debate until unanimous agreement was achieved. RESULTS Pretreatment evaluation should focus primarily on measures of cardiopulmonary physiology, as respiratory failure represents the greatest interventional risk. Alternative treatment options to lobectomy for high-risk patients include sublobar resection with or without brachytherapy, stereotactic body radiation therapy, and radiofrequency ablation. Each is associated with decreased procedural morbidity and mortality but increased risk for involved lobe and regional recurrence compared with lobectomy, but direct comparisons between modalities are lacking. CONCLUSIONS Therapeutic options for the treatment of high-risk patients are evolving quickly. Improved radiographic staging and the diagnosis of smaller and more indolent tumors push the risk-benefit decision toward parenchymal-sparing or nonoperative therapies in high-risk patients. Unbiased assessment of treatment options requires uniform reporting of treatment populations and outcomes in clinical series, which has been lacking to date.

Photodynamic therapy as palliation for esophageal cancer: experience in 215 patients

BACKGROUND Photodynamic therapy (PDT) utilizes a photosensitizing agent, light, and oxygen to endoscopically ablate cancer cells. This review summarizes our experience with PDT for the palliation of bleeding or obstructing esophageal cancer (EC). METHODS All patients with bleeding or obstructing EC treated with PDT from November 1996 through June 2002, were reviewed. After Photofrin II injection, nonthermal light treatment was delivered endoscopically. Dysphagia scores, duration of palliation, reinterventions, complications, and survival after treatment were reviewed. RESULTS A total of 215 patients underwent 318 courses of PDT for bleeding (n = 15), obstruction (n = 277), bleeding and obstruction (n = 18), or other indications (n = 8). Tumor histology included 179 adenocarcinomas, 33 squamous cell carcinomas, and 3 undifferentiated. Seventy-five percent of EC were in the distal esophagus. In 85% of courses for obstruction, mean dysphagia scores improved pre- and post-PDT. The mean dysphagia-free interval was 66 days. Supplemental nutrition was discontinued after PDT in 8 of 27 patients (30%). Thirty-five patients required stent placement after PDT with a mean interval to reintervention of 58.5 days. PDT complications included perforation (2% of treatment courses), stricture (2%), Candida esophagitis (2%), pleural effusions (4%), and sunburn (6%). The procedure-related mortality rate was 1.8%, and median survival was 4.8 months. CONCLUSIONS PDT offers effective palliation for patients with obstructing EC in 85% of treatment courses. The ideal EC patient for PDT palliation has an obstructing endoluminal cancer. Patients living more than 2 months may require reintervention to maintain palliation of malignant dysphagia, and a multimodality treatment approach is common.

Treatment of stage I lung cancer in high-risk and inoperable patients: Comparison of prospective clinical trials using stereotactic body radiotherapy (RTOG 0236), sublobar resection (ACOSOG Z4032), and radiofrequency ablation (ACOSOG Z4033)

OBJECTIVE The purpose of the present study was to compare the selection criteria and short-term outcomes among 3 prospective clinical trials using stereotactic body radiotherapy (Radiation Therapy Oncology Group [RTOG] trial 0236), sublobar resection (American College of Surgeons Oncology Group [ACOSOG] trial Z4032), and radiofrequency ablation (ACOSOG trial Z4033). METHODS The selection criteria and outcomes were compared among RTOG 0236 (n = 55), ACOSOG Z4032 (n = 211), and ACOSOG Z4033 (n = 51). Age, Eastern Cooperative Oncology Group performance status, percentage of predicted forced expiratory volume in 1 second, and percentage of predicted carbon monoxide diffusing capacity of the lung were used to perform a propensity-matched analysis among patients with clinical stage 1A in RTOG 0236 and ACOSOG Z4032. RESULTS The patients in ACOSOG Z4033 undergoing radiofrequency ablation were older (75.6 ± 7.5 years) than those in RTOG 0236 (72.5 ± 8.8 years) and ACOSOG Z4032 (70.2 ± 8.5 years; P = .0003). The pretreatment percentage of predicted forced expiratory volume in 1 second was 61.3% ± 33.4% for RTOG 0236, 53.8% ± 19.6% for ACOSOG Z4032, and 48.8% ± 20.3% for ACOSOG Z4033 (P = .15). The pretreatment percentage of predicted carbon monoxide diffusing capacity of the lung was 61.6% ± 30.2% for RTOG 0236, 46.4% ± 15.6% for ACOSOG Z4032, and 43.7% ± 18.0% for ACOSOG Z4033 (P = .001). The overall 90-day mortality for stereotactic body radiotherapy, surgery, and radiofrequency ablation was 0%, 2.4% (5/211), and 2.0% (1/51), respectively (P = .5). Overall, the unadjusted 30-day grade 3+ adverse events were more common with surgery than with stereotactic body radiotherapy (28% vs 9.1%, P = .004), although no difference was between the 2 groups at 90 days. Among the patients with clinical stage IA in ACOSOG Z4032, 29.3% had a more advanced pathologic stage at surgery. A propensity-matched comparison showed no difference between stereotactic body radiotherapy and surgery for 30-day grade 3+ adverse events (odds ratio, 2.37; 95% confidence interval, 0.75-9.90; P = .18). CONCLUSIONS Among appropriately matched patients, no difference was seen in early morbidity between sublobar resection and stereotactic body radiotherapy. These results underscore the need for a randomized trial to delineate the relative survival benefit of each modality and to help stratify patients considered high risk.

Outcomes after minimally invasive esophagomyotomy.

BACKGROUND Thoracic surgeons traditionally performed thoracotomy and myotomy for achalasia. Recently minimally invasive approaches have been reported with good success. This report summarizes our single-institution experience using video-assisted thoracoscopy (VATS) or laparoscopy (LAP) for the treatment of achalasia. METHODS A review of 62 patients undergoing minimally invasive myotomy for achalasia was performed. There were 27 male and 35 female patients. Mean age was 53 years (range 14 to 86). Thirty-seven (59.7%) had failed prior treatments (balloon dilation, botulinim toxin injection, or prior surgery). Outcomes studied were dysphagia score (1 = none, 5 = severe), Short-Form 36 quality of life (SF36 QOL) score, and heartburn-related QOL index (HRQOL). RESULTS Surgery included myotomy and partial fundoplication (5 VATS and 57 LAP). Mortality was zero, and complications occurred in 9 (14.5%) patients. There were 6 perforations (4 repaired by LAP and 2 open). Median length of stay was 2 days, time to oral intake was 1 day. At a mean of 19 months follow-up, 92.5% of patients were satisfied with outcome. Dysphagia scores improved from 3.6 to 1.5 (p < 0.01) but 3 patients ultimately required esophagectomy for recurrent dysphagia. HRQOL scores for heartburn and SF-36 QOL scores were comparable with control populations. CONCLUSIONS Minimally invasive myotomy and partial fundoplication for achalasia improved dysphagia in 92.5% of patients with heartburn and QOL scores were comparable with normal values at 19-month follow-up. The laparoscopic approach offers excellent results and was the preferred approach by our thoracic group for treating achalasia. Thoracic residency training should strive to include laparoscopic esophageal experience.