laparoscopic trans hiatal esophagectomy for early cancer-final
TRANSCRIPT
Laparoscopic Trans-Hiatal Esophagectomy for Early Cancer
Abeezar I. SarelaDepartment of Upper GI & Minimally Invasive Surgery
Leeds, UK
SAGES Presenter Disclosure SlideSAGES Presenter Disclosure Slide
Abeezar I. Sarela
Nothing To Disclose
AgendaEarly Esophageal Carcinoma
• Pathology• Diagnosis and Staging• Role of Endoscopic Therapy• Indications for surgery• Type of surgery
– Transhiatal vs. Transthoracic esophagectomy– Conventional laparoscopic trans-hiatal esophagectomy– Vagus-sparing esophagectomy– Merindino operation
Superficial Esophageal CarcinomaJapanese Esophageal SocietyEsophagus 2009;6:1-25
T1a + T1bAJCC/TNM 7th Edition
Early Esophageal CarcinomaJapanese Esophageal SocietyEsophagus 2009;6:1-25
T1aAJCC/TNM 7th Edition
What is Early Esophageal Cancer?
pT1 Esophageal CarcinomaDepth of primary tumor and lymph node metastasis
Adenocarcinoma
• 157 patients
• T1a: 45%, N+ 0%
• T1b: 55%, N+ 21%
• Distant N+ < 2%
• 5 year survival: 83%
Squamous Carcinoma
• 133 patients
• T1a: 20%, N+8%
• T1b: 80%, N+36%
• Distant N+: 4-11%
• 5 year survival: 63%
Stein et al. Ann Surg 2005;242:566-573
Subclassification of Depth of Invasion by Superficial Carcinoma of the Esophagus in
Surgically Resected Specimens
Endoscopic Resection Specimenssm1 carcinoma: invades less than 200 microns into the submucosa
Japanese Esophageal Society. Japanese Classification of Esophageal Cancer. !0 th Ed.Esophagus 2009;6:1-25
Relationship between Depth of Invasion and Lymph Node Metastasis in
Superficial Squamous Carcinoma
Takubo et al. Histopathology 2007;51:733-742
Relationship between Depth of Invasion and Lymph Node Metastasis
in Superficial Adenocarcinoma
• Transhiatal Esophagectomy: 120 patients
• m1-sm1 : 79 patients, N+ 1 patient (1%)
• sm2-sm3: 41 patients, N+ 18 patients (44%)
• 5 yr survival
– N0: 97%
– N+: 57%
Westerterp et al. Virchows Arch 2005;446:497-504
Oncological Outcomes Esophagectomy for pT1 Adenocarcinoma
Operation Tumor Depth
Differentiation Node status
Time to recurrence
Site of recurrence
Trans-Hiatal
T1b Poor N0 6 Nodes
Trans-thoracic
T1b Poor N1 8 Liver
Trans-thoracic
T1a Poor N0 22 Liver
Saha et al. Surg Endosc 2009;23:119-124
40 patients - T1b 11 patients - N1 20% of T1b - Poor differentiation 4 patients
Diagnosis and Staging of Early (T1a) and
Superficial (T1a+T1b)Esophageal Carcinoma
Endoscopic Diagnosis of Early Esophageal Carcinoma
Fujinon “FICE”
Olympus “Tri-Modality”
Can we predict the risk of lymph node metastasis?
27%
50%
20%
10%
10%
Incidence of nodal metastasis
Takubo et al. Histopathology 2007;51:733-742
High Risk Factors for Lymph Node Metastasis
• Depth of invasion – T1b
• Morphology – types 0-I and 0-III
• Lymphatic permeation
• Poor histological differentiation
• Tumor size
• Infiltrative growth pattern
Takubo et al. Histopathology 2007;51:733-742
Endoscopic Ultrasound (EUS)
• Conventional EUS– 5 layers– Poor distinction:
T1a vs. T1b
• High Frequency Ultrasound Probe Sonography (HFUPS)– 9 layers
• Ultrasound-guided FNA of peri-esophageal nodes?
Endoscopic Mucosal Resection
• Definitive treatment for
early (T1a) esophageal
adenocarcinoma
• Intermediate staging
strategy
Emerging Treatment Paradigm
EMR of all resectable dysplastic lesions
Favourable histology? Multifocality?
Ablation of the remaining Barrett‘s - ?RFA
Endoscopic Surveillance
Indications for Esophagectomy
• Complete EMR not feasible/not achieved
• T1b: ≥20% incidence of nodal metastasis (? T1a-MM)
• Unfavorable histological characteristics– Poor differentiation– Lymphovascular invasion
• Multi-focal cancer
• Peri-esophageal lymphadenopathy at EUS
Transhiatal vs. Transthoracic?
• Randomised clinical trial• Adenocarcinoma: Siewert types 1 or 2• Final analysis on 205 patients• No difference in post-operative mortality• 5 year actual survival benefit for
transthoracic operation– Limited to patients with 1-8 positive nodes– Overall survival: 14% benefit– Recurrence-free survival: 41% benefit
Hulscher et al. N Eng J Med 2002;347:1662-9; Omloo et al. Ann Surg 2007;246:992-1000
Laparoscopic Transhiatal Esophagectomy
• 17 series
• 433 patients [median 20 (10-68)]
• Exclusively trans-abdominal: mediastinal anastomosis after segmental resection
• Laparoscopic dissection, mini-laparotomy and neck anastomosis
• Entirely laparoscopic: specimen retrieval via the neck
Decker et al. European Journal of Cardio-Thoracic Surgery. 2009;35:13-21
Laparoscopic EsophagectomyTranshiatal vs. Transthoracic
Transhiatal
433 patients
Transthoracic
1499 patients
Vocal cord palsy 10% 6.4%
Leakage 13% 7.6%
Respiratory complic. 22% 22%
Re-operation 3% 6.8%
Mortality 4.6% 2.4%
Lymph node count 10 (5-15) 17 (7-62)
Decker et al. European Journal of Cardio-Thoracic Surgery. 2009;35:13-21
What is the Aim of Esophagectomy?
• T1a/Low-risk for lymph node metastasis – to eradicate the primary tumor– Conventional laparoscopic transhiatal operation
– Vagus-preserving esophagectomy
– Merindino operation
• T1b/High-risk for lymph node metastasis – to achieve radical lymphadenectomy– Trans-thoracic esophagectomy
Laparoscopic Vagus-Sparing Esophagectomy
• Less extensive operation
• Enhanced perfusion of gastric conduit
• No need for pyloroplasty
• Dumping & diarrhoea in less than 10%
• Less weight loss
• Less infectious complications
• ? cardioprotectivePeyre et al. Ann Surg 2007;246:665-671
DeMeester S. Personal communication, 2010
Segmental Resection of the Gastroesophageal Junction and
Reconstruction with a Pedicled Flap of Jejunum (Merindino Operation)
• 94 patients• T1a or T1b adenocarcinoma• Transhiatal (11) vs. Transthoracic (60) vs.
Merindino (24)• Similar lymph node retrieval • Merindino operation:
– Less complications– No mortality
Stein et al. Ann Surg 2000;232:733-742
Conclusions
• Early esophageal carcinoma – mucosal disease (T1a)
• Very low risk of lymph node metastasis (limited to T1a-MM)
• EMR: staging and treatment strategy• Laparoscopic trans-hiatal esophagectomy
for incomplete definitive ensocopic therapy• Minimize morbidity
– Vagus-sparing esophagectomy– Merindino operation