Samuel B. Keeley

Outcomes After Minimally Invasive Esophagectomy Review of Over 1000 Patients

Background: Esophagectomy is a complex operation and is associated with significant morbidity and mortality. In an attempt to lower morbidity, we have adopted a minimally invasive approach to esophagectomy. Objectives: Our primary objective was to evaluate the outcomes of minimally invasive esophagectomy (MIE) in a large group of patients. Our secondary objective was to compare the modified McKeown minimally invasive approach (videothoracoscopic surgery, laparoscopy, neck anastomosis [MIE-neck]) with our current approach, a modified Ivor Lewis approach (laparoscopy, videothoracoscopic surgery, chest anastomosis [MIE-chest]). Methods: We reviewed 1033 consecutive patients undergoing MIE. Elective operation was performed on 1011 patients; 22 patients with nonelective operations were excluded. Patients were stratified by surgical approach and perioperative outcomes analyzed. The primary endpoint studied was 30-day mortality. Results: The MIE-neck was performed in 481 (48%) and MIE-Ivor Lewis in 530 (52%). Patients undergoing MIE-Ivor Lewis were operated in the current era. The median number of lymph nodes resected was 21. The operative mortality was 1.68%. Median length of stay (8 days) and ICU stay (2 days) were similar between the 2 approaches. Mortality rate was 0.9%, and recurrent nerve injury was less frequent in the Ivor Lewis MIE group (P < 0.001). Conclusions: MIE in our center resulted in acceptable lymph node resection, postoperative outcomes, and low mortality using either an MIE-neck or an MIE-chest approach. The MIE Ivor Lewis approach was associated with reduced recurrent laryngeal nerve injury and mortality of 0.9% and is now our preferred approach. Minimally invasive esophagectomy can be performed safely, with good results in an experienced center.

Photodynamic Therapy with Curative Intent for Barrett’s Esophagus with High Grade Dysplasia and Superficial Esophageal Cancer

BackgroundPhotodynamic therapy (PDT) has been used to palliate advanced, obstructing, or bleeding esophageal cancers (ECs) and Barrett’s high-grade dysplasia (HGD). Few investigators, though, have described using PDT to cure either disease.MethodsWe performed a retrospective review from 1997–2005 of 50 patients with HGD or EC. All patients refused surgical resection or were physiologically unfit. They were instead treated using PDT with curative intent. Clinical follow-up, long-term survival, complications, and recurrence were evaluated.ResultsThirteen patients (26%) had Barrett’s HGD, 6 (12%) had small, intramural carcinomas, 16 (32%) had T1 N0 tumors, 14 (28%) had T2 N0 tumors, and 1 (2%) had a small, polypoid T3 lesion. The mean length of follow-up was 28.1 months. Sixteen patients (32%) are alive without recurrence, 15 (30%) are living with residual or recurrent disease and have received additional PDT, and the remainder (38%) died of recurrent EC or other causes and had known recurrence. Sixteen (32%) patients received adjuvant chemotherapy, radiation, or both. Esophageal stricture occurred in 21 (42%) patients. There was no procedure-related mortality.ConclusionsPDT may represent a reasonable alternate to esophagectomy for high-risk patients with HGD or superficial esophageal cancer. Due to superior survival and local control, we still favor esophagectomy for patients without physiologic impairment. However, PDT appears to potentially cure approximately one-third of superficial esophageal cancers and provide local control of high-grade dysplasia in a similar subset of patients.

Cervical pharyngostomy: an old technique revisited.

Objective:To review our experience with pharyngostomy tubes used to manage complications following foregut surgery and to discuss technical aspects of insertion. Summary Background Data:Cervical pharyngostomy tubes are percutaneously placed through the hypopharynx and directed into the stomach or small bowel. Historically, these tubes were placed during resection of head and neck cancer for postoperative nutrition. The technique may also be used to manage a variety of complications following esophagectomy or gastric surgery. Methods:A retrospective review identified all patients who underwent pharyngostomy tube placement at the University of Pittsburgh Medical Center from 1995 to 2007. Indications, procedure-related complications, and duration of tube placement were recorded. Results:Thirty-eight patients were identified. Indications for tube placement were: access for enteral nutrition (n = 18), drainage of mediastinal abscess (n = 4), gastric decompression (n = 13), and other (n = 3). Procedure-related complications included: cellulitis (n = 1), esophagitis (n = 1), aspiration pneumonia (n = 1), and tube migration (n = 9). Duration of tube placement was 51 days (range 1–279). No major complications occurred. Conclusions:Pharyngostomy tubes may be useful in the management of complications following esophageal or gastric surgery. They are more comfortable than nasogastric tubes and may be kept in place for several months if necessary. Bleeding or other major complications have not occurred in our experience.

Minimally invasive esophagectomy@@@Minimal invasive Ösophagektomie

ZusammenfassungGRUNDLAGEN: Die konventionelle Ösophagektomie ist technisch aufwendig und ist mit einer entsprechenden Morbidität und Mortalität verbunden. METHODIK: Kritische Beurteilung der minimal invasiven Ösophagektomie. ERGEBNISSE: Die minimal invasive Ösophagektomie ist technisch anspruchsvoll, kann aber dazu beitragen, postoperative Komplikationen zu minimieren und die postoperative Lebensqualität zu verbessern. Die größte publizierte Serie zeigte eine Mortalität von 1,4 %, 11 % Anastomosendehiszenzrate und eine Verkürzung des Spitalsaufenthaltes nach minimal invasiver Ösophagektomie. Die Erfahrungen aus Pittsburg haben zu technischen Verbesserungen geführt, wie die Anlage eines engeren Magenpouches, Durchführung der Ivor-Lewis-Anastomose und eine radikalere Lymphknoten Resektion. SCHLUSSFOLGERUNGEN: In dieser Arbeit werden Hintergrund, Technik, Probleme und die Zukunft der minimal invasiven Ösophagektomie kritisch beleuchtet.SummaryBACKGROUND: Esophagectomy can be a formidable operation even in experienced hands. METHODS: Critical appraisal towards minimal invasive esophagectomy. RESULTS: The complications are often lethal. Patients developing postoperative pneumonia after open esophagectomy have up to a 20% mortality rate. In an effort to reduce the morbidity and mortality of open esophagectomy, minimally invasive techniques have been developed. This is a challenging procedure technically, but offers the chance to lessen complications and improve survival. The learning curve is steep. Proper port placement, patient positioning, and facile use of mechanical staplers is mandatory. However, the largest published series to date of minimally invasive esophagectomies [MIE] showed a 1.4% mortality rate, an 11% anastamotic leak rate, and lowered lengths of stay. The evolving Pittsburgh experience has resulted in technical modifications like narrower gastric pouches, Ivor Lewis type anastamoses, and more complete lymph node resection. CONCLUSIONS: This paper discusses the background, techniques, challenges, and future direction for using this technique to treat esophageal disease.

Homograft root replacement for juvenile rheumatoid aortic valve incompetence

We report a case of severe, crippling juvenile rheumatoid arthritis and aortic insufficiency in a young woman. Homograft replacement of the aortic root offered both long-term durability and the freedom from thromboembolism that her systemic illness required.