Over the last decades, the treatment of resectable esophageal cancer has evolved into a multidisciplinary process in which all players are essential for treatment to be successful. Medical ...oncologists and radiation oncologists have been increasingly involved since the implementation of neoadjuvant therapy, which has been shown to improve survival. Although esophagectomy is still considered the cornerstone of curative treatment for locally advanced esophageal cancer, it remains associated with considerable postoperative morbidity, despite promising results of minimally invasive techniques. In this light, both physical status and response to neoadjuvant therapy may be important factors for selecting patients who will benefit from surgery. Furthermore, it is important to optimize the entire perioperative trajectory: from the initial outpatient clinic visit to postoperative discharge. Enhanced recovery after surgery is increasingly recognized for esophagectomy and emphasizes perioperative aspects, such as nutrition, physiotherapy, and pain management. To date, several facets of esophageal cancer treatment remain topics of debate, such as the preferred neoadjuvant treatment, anastomotic technique, extent of lymphadenectomy, organization of postoperative care, and the role of surgery beyond locally advanced disease. Here, we describe the current and future perspectives in the surgical treatment of patients with esophageal cancer in the context of the available literature.
Robotic-assisted gastrectomy for gastric cancer: a European perspective van Boxel, Gijsbert I.; Ruurda, Jelle P.; van Hillegersberg, Richard
Gastric cancer : official journal of the International Gastric Cancer Association and the Japanese Gastric Cancer Association,
09/2019, Letnik:
22, Številka:
5
Journal Article
Recenzirano
Odprti dostop
Gastrectomy is the mainstay treatment for gastric cancer. To reduce the associated patient burden, minimally invasive gastrectomy was introduced in almost 30 years ago. The increase in the ...availability of surgical robotic systems led to the first robotic-assisted gastrectomy to be performed in 2002 in Japan. Robotic gastrectomy however, particularly in Europe, has not yet gained significant traction. Most reports to date are from Asia, predominantly containing observational studies. These cohorts are commonly different in the tumour stage, location (particularly with regards to gastroesophageal junctional tumours) and patient BMI compared to those encountered in Europe. To date, no randomised clinical trials have been performed comparing robotic gastrectomy to either laparoscopic or open equivalent. Cohort studies show that robotic gastrectomy is equal oncological outcomes in terms of survival and lymph node yield. Operative times in the robotic group are consistently longer compared to laparoscopic or open gastrectomy, although evidence is emerging that resectional surgical time is equal. The only reproducibly significant difference in favour of robot-assisted gastrectomy is a reduction in intra-operative blood loss and some studies show a reduction in the risk of pancreatic fistula formation.
Minimally invasive esophagectomy (MIE) was introduced in the 1990s with the aim to decrease the rate of respiratory complications associated with thoracotomy, along with the benefits of reduced ...morbidity and a quicker return to normal activities provided by minimally invasive techniques. However, MIE is not routinely applied as a standard approach for esophageal cancer worldwide, due to the high technical complexity of this minimally invasive procedure. Therefore, the open transthoracic esophagectomy is considered to be the gold standard for resectable esophageal cancer worldwide nowadays. In this article, the current status of conventional MIE and robot-assisted minimally invasive thoraco-laparoscopic esophagectomy will be reviewed.
Background
Postoperative complications frequently occur after gastrectomy for gastric cancer and are associated with poor clinical outcomes, such as mortality and reoperations. The aim of study was ...to identify the clinically most relevant complications after gastrectomy, using the population-attributable fraction (PAF).
Methods
Between 2011 and 2017, all patients who underwent potentially curative gastrectomy for gastric adenocarcinoma were included from the Dutch Upper GI Cancer Audit. Postoperative outcomes (morbidity, mortality, recovery and hospitalization) were evaluated. The prevalence of postoperative complications (e.g., anastomotic leakage and pneumonia) and of the study outcomes were calculated. The adjusted relative risk and Confidence Interval (CI) for each complication-outcome pair were calculated. Subsequently, the PAF was calculated, which represents the percentage of a given outcome occurring in the population, caused by individual complications, taking both the relative risk and the frequency in which a complication occurs into account.
Results
In total, 2176 patients were analyzed. Anastomotic leakage and pulmonary complications had the greatest overall impact on postoperative mortality (PAF 29.2% 95% CI 19.3–39.1 and 21.6% 95% CI 10.5–32.7, respectively) and prolonged hospitalization (PAF 12.9% 95% CI 9.7–16.0 and 14.7% 95% CI 11.0–18.8, respectively). Anastomotic leakage had the greatest overall impact on re-interventions (PAF 25.1% 95% CI 20.5–29.7) and reoperations (PAF 30.3% 95% CI 24.3–36.3). Intra-abdominal abscesses had the largest impact on readmissions (PAF 7.0% 95% CI 3.2–10.9). Other complications only had a small effect on these outcomes.
Conclusion
Surgical improvement programs should focus on preventing or managing anastomotic leakage and pulmonary complications, since these complications have the greatest overall impact on clinical outcomes after gastrectomy.
Summary Background Early enteral feeding following surgery can be given orally, via a jejunostomy or via a nasojejunal tube. However, the best feeding route following esophagectomy is unclear. ...Objectives To determine the best route for enteral nutrition following esophagectomy regarding anastomotic leakage, pneumonia, percentage meeting the nutritional requirements, weight loss, complications of tube feeding, mortality, patient satisfaction and length of hospital stay. Design A systematic literature review following PRISMA and MOOSE guidelines. Results There were 17 eligible studies on early oral intake, jejunostomy or nasojejunal tube feeding. Only one nonrandomized study ( N = 133) investigated early oral feeding specifically following esophagectomy. Early oral feeding was associated with a reduced length of stay with delayed oral feeding, without increased complication rates. Postoperative nasojejunal tube feeding was not significantly different from jejunostomy tube feeding regarding complications or catheter efficacy in the only randomised trial on this subject ( N = 150). Jejunostomy tube feeding outcome was reported in 12 non-comparative studies ( N = 3293). It was effective in meeting short-term nutritional requirements, but major tube-related complications necessitated relaparotomy in 0–2.9% of patients. In three non-comparative studies ( N = 135) on nasojejunal tube feeding only minor complications were reported, data on nutritional outcome was lacking. Data on patient satisfaction and long-term nutritional outcome were not found for any of the feeding routes investigated. Conclusion It is unclear what the best route for early enteral nutrition is after esophagectomy. Especially data regarding early oral intake are scarce, and phase 2 trials are needed for further investigation. Registration International prospective register of systematic reviews, CRD42013004032.
Background
Robot-assisted minimally invasive esophagectomy (RAMIE) with intrathoracic anastomosis is gaining popularity as a treatment for esophageal cancer. The aim of this study was to describe ...postoperative complications and short-term oncologic outcomes for RAMIE procedures using the da Vinci Xi robotic system 4-arm technique.
Methods
Data of 100 consecutive patients with esophageal or gastro-esophageal junction carcinoma undergoing modified Ivor Lewis esophagectomy were prospectively collected. All operations were performed by the same surgeon using an identical intrathoracic anastomotic reconstruction technique with the same perioperative management. Intraoperative and postoperative complications were graded according to Esophagectomy Complications Consensus Group (ECCG) definitions.
Results
Mean duration was 416 min (±80); 70% of patients had an uncomplicated postoperative recovery. Pulmonary complications were observed in 17% of patients. Anastomotic leakage was observed in 8% of patients. Median ICU stay was 1 day and median overall postoperative hospital stay was 11 days. The 30-day mortality was 1%; 90-day mortality was 3%. A R0 resection was reached in 92% of patients with a median number of 29 dissected lymph nodes. All patients had at least 7 months of follow-up with a median follow-up of 17 months. Median overall survival was not reached yet.
Conclusion
RAMIE with intrathoracic anastomosis (Ivor Lewis) for esophageal or gastro-esophageal junction cancer was technically feasible and safe. Postoperative complications and short-term oncologic results were comparable to the highest international standards nowadays.
OBJECTIVE:To evaluate the impact of lymph node yield (LNY) on survival in patients treated with neoadjuvant chemoradiotherapy (nCRT) followed by esophagectomy for cancer.
BACKGROUND:The value of an ...extended lymphadenectomy after nCRT for esophageal cancer is debated. Recent reports demonstrate no association between LNY and survival. This association has not yet been evaluated in larger cohorts.
METHODS:All patients who underwent nCRT followed by esophagectomy between 2005 and 2014 were identified from the Netherlands Cancer Registry. The association between LNY and overall survival was analyzed using multivariable Cox regression analyses, adjusting for diagnosis year, referral, hospital volume, age, sex, malignancy history, tumor location, histology, cTN-stage, surgical approach, radicality, and ypTN-stage. Analyses were performed with LNY as categorized predictor (<15 vs ≥15 nodes) and continuous predictor (per 10 additionally nodes).
RESULTS:A total of 2698 patients were included with a median overall survival of 34 months (range 4–143). A higher LNY was significantly associated with improved overall survival, both as categorized predictor (hazard ratio 0.77, 95% confidence interval 0.68–0.86) and as continuous predictor (hazard ratio 0.84, 95% confidence interval 0.78–0.90). Furthermore, a higher LNY was associated with favorable hazard ratios across subgroups, including both squamous cell carcinoma and adenocarcinoma, both cN0 and cN+, both transthoracic and transhiatal approaches, and both ypN0 and ypN+.
CONCLUSIONS:This large population-based cohort study demonstrates an association between LNY and overall survival, indicating a therapeutic value of extended lymphadenectomy during esophagectomy. Therefore, an extended lymphadenectomy should be the standard of care after nCRT.
Introduction
Minimally invasive techniques have shown better short term and similar oncological outcomes compared to open techniques in the treatment of gastric cancer in Asian countries. It remains ...unknown whether these outcomes can be extrapolated to Western countries, where patients often present with advanced gastric cancer.
Materials and Methods
A pooled analysis of two Western randomized controlled trials (STOMACH and LOGICA trial) comparing minimally invasive gastrectomy (MIG) and open gastrectomy (OG) in advanced gastric cancer was performed. Postoperative recovery (complications, mortality, hospital stay), oncological outcomes (lymph node yield, radical resection rate, 1‐year survival), and quality of life was assessed.
Results
Three hundred and twenty‐one patients were included from both trials. Of these, 162 patients (50.5%) were allocated to MIG and 159 patients (49.5%) to OG. A significant difference was seen in blood loss in favor of MIG (150 vs. 260 mL, p < 0.001), whereas duration of surgery was in favor of OG (180 vs. 228.5 min, p = 0.005). Postoperative recovery, oncological outcomes and quality of life were similar between both groups.
Conclusion
MIG showed no difference to OG regarding postoperative recovery, oncological outcomes or quality of life, and is therefore a safe alternative to OG in patients with advanced gastric cancer.
Objective
The aim of this study was to investigate the recovery of physical functioning and objective physical activity levels up to 3 months after oncological surgery and to determine the ...association between physical activity levels and the recovery of physical functioning.
Methods
A longditudinal observational cohort study was conducted in patients who underwent gastrointestinal or bladder oncological surgery. Recovery of physical functioning was measured preoperatively, and 1 and 3 months after discharge. Physical activity was objectively measured with an accelerometer during hospitalisation, and 1 and 3 months after discharge.
Results
Between February and November 2019, 68 patients were included. Half of the patients (49%) were not recovered in physical functioning 3 months after surgery. During hospitalisation, physical activity increased from 13 to 46 median active minutes per day. At 1 and 3 months after discharge, patients were physically active for 138 and 159 median minutes per day, respectively. Patients with higher levels of physical activity 1 month after discharge showed to have higher levels of physical functioning up to 3 months after discharge.
Conclusion
At 3 months after surgery, physical functioning is still diminished in half of the patients. It is important to evaluate both physical activity levels and physical functioning levels after surgery to enable tailored postoperative mobility care.
Surgical robotics for esophageal cancer Grimminger, Peter P.; der Horst, Sylvia; Ruurda, Jelle P. ...
Annals of the New York Academy of Sciences,
December 2018, 2018-Dec, 2018-12-00, 20181201, Letnik:
1434, Številka:
1
Journal Article
Recenzirano
We present an update on robotic techniques and their advantages and use in esophageal cancer surgery. Recent work has shown tremendous progress in robotic‐assisted minimally invasive esophagectomy ...(RAMIE) and lymphadenectomy for esophageal cancer, as well as benefits of robotic surgery in high upper esophageal tumors and T4b disease. We discuss the different RAMIE techniques, especially for intrathoracic anastomosis. The ongoing ROBOT trial had demonstrated superiority of robotic esophageal cancer surgery over open esophagectomy. There are various putative technical advantages of RAMIE over minimally invasive esophagectomy, which need to be proven in future trials.
Recent work has revealed tremendous progress in robotic‐assisted minimally invasive esophagectomy (RAMIE) and lymphadenectomy for esophageal cancer, as well as benefits of robotic surgery in high upper esophageal tumors and T4b disease. We discuss different RAMIE techniques, especially for intrathoracic anastomosis. There are putative technical advantages of RAMIE over minimal invasive esophagectomy, which need to be proven in future trials.
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