the best esophagectomy: open ivor lewis

Controversies in the Esophageal Surgery
THE BEST ESOPHAGECTOMY:
OPEN IVOR LEWIS
Wayne Hofstetter
Nov 16, 2013
DISCLOSURES

Ethicon consultant
SURGEON’S CONCERNS/RESPONSIBILITIES
Morbidity
Local
Regional
Control
Quality of
Life
Mortality
GOALS
 What
are the potential advantages to open
surgery?
 Have
we overcome the disadvantages of a
thoracotomy and intra-thoracic anastomosis?
OPEN RESECTION:
TECHNICAL ASPECTS

Abdomen





Complete lymphadenectomy
Omental transfer based on pedicles of R Gastroepiploic
Pyloric drainage procedure
Easy to preserve replaced or accessory L hepatic
Thoracic
Modified en bloc resection with lymphadenectomy in relevant
fields (includes thoracic duct ligation)
 Anastomosis on the well perfused portion of the stomach
 Can control amount of preserved esophagus
 Potential for a wider gastric margin (re lower tumor locations)

T Rice et al (WECC) 2009
Nigro et al JTCVS 1999
RESECTION MARGINS: CORONAL
-Pleura to Pleura
-Pericardium to Spine
-Diaphragm to Arch
RESECTION MARGINS: AXIAL
Hofstetter, MDACC 2013
Hofstetter, MDACC 2013
Improving
OS with
number of
resected
nodes in
N+ patients
Rizk et al (WECC) Ann Surg 2010 Jan
251(1)
Improving
OS with
number of
resected
nodes in Npatients
Rizk et al (WECC) Ann Surg 2010 Jan
251(1)
TRANSTHORACIC VERSUS TRANSHIATAL
RESECTION
5-year estimated
disease-free survival:
TTE = 39%
THE= 27%
p = 0.15
No. of lymph nodes
N=220
dissected
16±9 31±14 <0.001
Hulscher JBF, et al, NEJM,
2002
Urba trial results
100
80
%
60
Local Failure
Systemic Failure
40
20
0
Surgery Alone
CRT + Surgery
Urba SG, et al. J Clin Oncol, 2001
Local-Regional Recurrence

Transhiatal
Van Sandick (JACS, 2002):
 Urba (J Clin Oncology, 2001):
 Hulscher (JACS, 2000):
 Hulscher (NEJM, 2002):


34%
42%
35%
14%
En-bloc Transthoracic






USC (Hagen; Ann Surg, 2001):
Collard (Ann Surg, 2001):
Swanson (Ann Thorac Surg, 2001):
Altorki (Ann Surg, 2001):
Hulscher (NEJM, 2002):
Lerut (Ann Surg, 2004):
1%
7%
5.6%
4.5%
12%
5.2%
Local-Regional Recurrence:
Associated with significant morbidity
 Obstruction of gastric pull-up or proximal
anastomosis
 Gastric-airway fistula formation
 Invasion of involved mediastinal nodes into
adjacent structures
 Very poor prognosis

REGIONAL RECURRENCE POST HYBRID MIE
OMENTAL TRANSFER
OPEN ESOPHAGECTOMY
OMENTAL TRANSPOSITION
Courtesy of David Rice MD
OPEN ESOPHAGECTOMY
OMENTAL FLAP
ESOPHAGECTOMY
OMENTAL TRANSPOSITION
Courtesy of David Rice MD
THE OMENTUM
Function:

Anti-inflammatory

Immunologic

Angiogenic

Drainage
ANASTOMOTIC LEAK
12%
10%
8%
6%
4%
2%
0%
Leak
p=0.014
10
Omentum
(N=215)
4.7%
41
No Omentum
(N=392)
10.5%
COMPARISONS
Robust control arm
 Historical controls

Timing bias (era of surgery)
 ICU utilization


Standardization of nomenclature
What constitutes leak
 What constitutes a positive margin


Heterogeneity in neoadjuvant therapy and patients


Selection bias
Reported data

Publication bias
SINGLE INSTITUTION RESULTS:
ILE IN CHEMORADIATED PATIENTS
ESOPHAGECTOMY POST CXRT:
2008 – 2011 (POST-LEARNING CURVE)
ILE
(N=173)
Modified en
bloc
(N=43)
MIE
(N=60)
Pvalue
9.5
9
7.5
0.005
A fib
20%
23%
15%
NS
Any Leak
6.4%
4.7%
20%
0.000
19%
16%
32%
0.045
2.9%
2.7%
0%
NS
Median LOS
Pulmonary
Event
30-day
mortality
MDACC database
QUALITY OF ESOPHAGECTOMY
2008 – 2011 (POST-LEARNING CURVE)
Lymph
Nodes
Harvested
(median #)
Any Margin +
ILE
(N=173)
Modified en
bloc
(N=43)
MIE
(N=60)
P-value
23
31
18
0.000
12%
7%
13%
NS
MDACC database