Surya S. A. Y. Biere

Minimally invasive versus open oesophagectomy for patients with oesophageal cancer: a multicentre, open-label, randomised controlled trial

BACKGROUND Surgical resection is regarded as the only curative option for resectable oesophageal cancer, but pulmonary complications occurring in more than half of patients after open oesophagectomy are a great concern. We assessed whether minimally invasive oesophagectomy reduces morbidity compared with open oesophagectomy. METHODS We did a multicentre, open-label, randomised controlled trial at five study centres in three countries between June 1, 2009, and March 31, 2011. Patients aged 18-75 years with resectable cancer of the oesophagus or gastro-oesophageal junction were randomly assigned via a computer-generated randomisation sequence to receive either open transthoracic or minimally invasive transthoracic oesophagectomy. Randomisation was stratified by centre. Patients, and investigators undertaking interventions, assessing outcomes, and analysing data, were not masked to group assignment. The primary outcome was pulmonary infection within the first 2 weeks after surgery and during the whole stay in hospital. Analysis was by intention to treat. This trial is registered with the Netherlands Trial Register, NTR TC 2452. FINDINGS We randomly assigned 56 patients to the open oesophagectomy group and 59 to the minimally invasive oesophagectomy group. 16 (29%) patients in the open oesophagectomy group had pulmonary infection in the first 2 weeks compared with five (9%) in the minimally invasive group (relative risk [RR] 0·30, 95% CI 0·12-0·76; p=0·005). 19 (34%) patients in the open oesophagectomy group had pulmonary infection in-hospital compared with seven (12%) in the minimally invasive group (0·35, 0·16-0·78; p=0·005). For in-hospital mortality, one patient in the open oesophagectomy group died from anastomotic leakage and two in the minimally invasive group from aspiration and mediastinitis after anastomotic leakage. INTERPRETATION These findings provide evidence for the short-term benefits of minimally invasive oesophagectomy for patients with resectable oesophageal cancer. FUNDING Digestive Surgery Foundation of the Unit of Digestive Surgery of the VU University Medical Centre.

Cervical or Thoracic Anastomosis after Esophagectomy for Cancer: A Systematic Review and Meta-Analysis

Background: Cervical anastomosis and thoracic anastomosis are used for gastric tube reconstruction after esophagectomy for cancer. This systematic review was conducted in order to identify randomized trials that compare cervical with thoracic anastomosis. Methods: A literature search for randomized trials was performed in the following databases: Medline, Embase and the Cochrane Library. Results: A total of 4 trials were included. All studies had a small sample size and were of moderate quality. One trial was excluded from the meta-analysis. The following outcomes were significantly associated with a cervical anastomosis: recurrent laryngeal nerve trauma (OR: 7.14; 95% CI: 1.75–29.14; p = 0.006) and anastomotic leakage (OR: 3.43; 95% CI: 1.09–10.78; p = 0.03). None of the following outcomes were associated with the location of the anastomosis: pulmonary complications (OR: 0.86; 95% CI: 0.13–5.59; p = 0.87), perioperative mortality (OR: 1.24; 95% CI: 0.35–4.41; p = 0.74), benign stricture formation (OR: 0.79; 95% CI: 0.17–3.87; p = 0.79) or tumor recurrence (OR: 2.01; 95% CI: 0.68–5.91; p = 0.21). Conclusion: Cervical anastomosis could be associated with a higher leak rate and recurrent nerve trauma. However, the currently available randomized evidence is limited. Further randomized trials are needed to provide sufficient evidence for the preferred location of the anastomosis after esophagectomy.

Traditional invasive vs. minimally invasive esophagectomy: a multi-center, randomized trial (TIME-trial)

BackgroundThere is a rise in incidence of esophageal carcinoma due to increasing incidence of adenocarcinoma. Probably the only curative option to date is the use of neoadjuvant therapy followed by surgical resection. Traditional open esophageal resection is associated with a high morbidity and mortality rate. Furthermore, this approach involves long intensive care unit stay, in-hospital stay and long recovery period. Minimally invasive esophagectomy could reduce the morbidity and accelerate the post-operative recovery.Methods/DesignComparison between traditional open and minimally invasive esophagectomy in a multi-center, randomized trial. Patients with a resectable intrathoracic esophageal carcinoma, including the gastro-esophageal junction tumors (Siewert I) are eligible for inclusion. Prior thoracic surgery and cervical esophageal carcinoma are indications for exclusion. The surgical technique involves a right thoracotomy with lung blockade and laparotomy either with a cervical or thoracic anastomosis for the traditional group. The minimally invasive procedure involves a right thoracoscopy in prone position with a single lumen tube and laparoscopy either with a cervical or thoracic anastomosis. All patients in both groups will undergo identical pre-operative and post-operative protocol. Primary endpoint of this study are post-operative respiratory complications within the first two post-operative weeks confirmed by clinical, radiological and sputum culture data. Secondary endpoints are the operative data, the post-operative data and oncological data such as quality of the specimen and survival. Operative data include duration of the operation, blood loss and conversion to open procedure. Post-operative data include morbidity (major and minor), quality of life tests and hospital stay.Based on current literature and the experience of all participating centers, an incidence of pulmonary complications for 57% in the traditional arm and 29% in the minimally invasive arm, it is estimated that per arm 48 patients are needed. This is based on a two-sided significance level (alpha) of 0.05 and a power of 0.80. Knowing that approximately 20% of the patients will be excluded, we will randomize 60 patients per arm.DiscussionThe TIME-trial is a prospective, multi-center, randomized study to define the role of minimally invasive esophageal resection in patients with resectable intrathoracic and junction esophageal cancer.Trial registration (Netherlands Trial Register)NTR2452

Minimally invasive intrathoracic anastomosis after Ivor Lewis esophagectomy for cancer: a review of transoral or transthoracic use of staplers

BackgroundMinimally invasive Ivor Lewis esophagectomy is one of the approaches used worldwide for treating esophageal cancer. Optimization of this approach and especially identifying the ideal intrathoracic anastomosis technique is needed. To date, different types of anastomosis have been described. A literature search on the current techniques and approaches for intrathoracic anastomosis was held. The studies were evaluated on leakage and stenosis rate of the anastomosis.MethodsThe PubMed electronic database was used for comprehensive literature search by two independent reviewers.ResultsTwelve studies were included in this review. The most frequent applied technique was the stapled anastomosis. Stapled anastomoses can be divided into a transthoracic or a transoral introduction. This stapled approach can be performed with a circular or linear stapler. The reported anastomotic leakage rate ranges from 0 to 10%. The reported anastomotic stenosis rate ranges from 0 to 27.5%.ConclusionsThis review has found no important differences between the two most frequently used stapled anastomoses: the transoral introduction of the anvil and the transthoracic. Clinical trials are needed to compare different methods to improve the quality of the intrathoracic anastomosis after esophagectomy.

Randomised trial, Minimally Invasive Oesophagectomy versus open oesophagectomy for patients with resectable oesophageal cancer

In 1991, Dallemagne introduced the right thoracoscopic approach for oesophageal cancer with total lung block, thereby mimicking the conventional approach (1). Initial reports showed a high conversion rate to thoracotomy of 10% to 17% and a high respiratory morbidity of 17% to 42% (2-3). Searching for reduction of the conversion rate and the respiratory infection rate, Cuschieri et al. designed the thoracoscopic approach in prone decubitus position so that a total collapse of the lung was no longer necessary for dissecting the oesophagus and thereby possibly reducing the rate of respiratory infections (4).

Predictive factors for post-operative respiratory infections after esophagectomy for esophageal cancer: outcome of randomized trial

BACKGROUND The first and only randomized trial comparing open esophagectomy (OE) with minimally invasive esophagectomy (MIE) showed a significant lower incidence of post-operative respiratory infections in the patients who underwent MIE. In order to identify which specific factors are related to a better respiratory outcome in this trial an additional analysis was performed. METHODS This was a prospective, multicenter, randomized controlled trial. Eligible patients, with a resectable intrathoracic esophageal carcinoma, including the gastro-esophageal (GE) junction tumors and Eastern Cooperative Oncology Group ≤2, were randomized to either MIE or OE. Respiratory infection investigated was defined as a clinical manifestation of (broncho-) pneumonia confirmed by thorax X-ray and/ or Computed Tomography scan and a positive sputum culture. A logistic regression model was used. RESULTS From 2009 to 2011, 115 patients were randomized in 5 centers. Eight patients developed metastasis during neoadjuvant therapy or had an irresectable tumor and were therefore excluded from the analysis. Fifty-two OE patients were comparable to 55 MIE patients with regard to baseline characteristics. In-hospital mortality was not significantly different [2% (open group) and 4% (MIE group)]. A body mass index (BMI) ≥26 and OE were associated with a roughly threefold risk of developing a respiratory infection. CONCLUSIONS Overweight patients and OE are independently associated with a significant higher incidence of post-operative respiratory infections, i.e., pneumonia.

Case on Cervical Leakage of an Esophago-gastric Conduit Anastomosis

A 64-year-old female was evaluated for dysphagia, revealing a squamous cell carcinoma of the mid-esophagus. Tumor was staged as T3-4N2M0. She was treated by neoadjuvant chemoradiotherapy and after an interval of six weeks she underwent a three stage thoraco-laparoscopic esophageal resection with a cervical anastomosis. On the 8th postoperative day patient developed an infection of the cervical wound.

Case on Suspicion of an Anastomotic Problem After Esophageal Resection for Cancer

A 60-year-old male was evaluated for dysphagia of 3 months duration and was consequently diagnosed for having a resectable adenocarcinoma of the distal oesophagus. After neoadjuvant chemoradiotherapy he underwent an Ivor Lewis esophageal resection. On the 6th postoperative day he became respiratory insufficient.

Case on Postoperative Hiatal Herniation After Esophageal Resection

A 56-year-old female was evaluated for dysphagia, revealing an adenocarcinoma of the distal esophagus. The patient received neoadjuvant chemoradiotherapy and after a period of 6 weeks he underwent a three stage open transthoracic esophagectomy with a cervical anastomosis. Progressively, the patient developed an important pleura effusion of the left hemithorax on the chest radiography.

Long‐term health‐related quality of life following surgery for oesophageal cancer (Br J Surg 2008; 95: 1121–1126)

Sir We read this article with great interest and were surprised and somewhat concerned about the stated risk of cancer induction in 25-year-olds being as high as 1 in 900 for a single CT abdomen1,2. If this is accurate then it behoves the clinician to always weigh up the risk–benefit of CT scans, especially in the young. Currently in our region, MRI is significantly slower (30 min for abdominal protocol) compared with the 32 multi-slice CT (2–5 min for a contrast enhanced protocol), is more challenging to report and is rarely available in the acute setting. So, in the ill patient, sometimes the best test is the one that gets done. Not forgetting that the stated single CT scan radiation dose in the young corresponds to a minimal change in lifetime cancer risk from 1 in 33 to 1 in 2·99. R. J. Alexander 1, C. Lee-Elliott2 and G. F. Nash1 1Department of General Surgery and 2Department of Radiology, Poole General Hospital NHS Trust, Longfleet Rd, Poole, Dorset BH15 2JB, UK DOI: 10.1002/bjs.6474