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- Defining the Learning Curve for Robotic-assisted Esophagogastrectomy. [JOURNAL ARTICLE]
- J Gastrointest Surg 2013 May 21.
INTRODUCTION:The expansion of robotic-assisted surgery is occurring quickly, though little is generally known about the "learning curve" for the technology with utilization for complex esophageal procedures. The purpose of this study is to define the learning curve for robotic-assisted esophagogastrectomy with respect to operative time, conversion rates, and patient safety.
METHODS:We have prospectively followed all patients undergoing robotic-assisted esophagogastrectomy and compared operations performed at our institutions by a single surgeon in successive cohorts of 10 patients. Our measures of proficiency included: operative times, conversion rates, and complications. Statistical analyses were undertaken utilizing Spearman regression analysis and Mann-Whitney U test. Significance was accepted with 95 % confidence.
RESULTS:Fifty-two patients (41 male: 11 female) of mean age 66.2 ± 8.8 years underwent robotic-assisted esophagogastrectomies for malignant esophageal disease. Neoadjuvant chemoradiation was administered to 30 (61 %) patients. A significant reduction in operative times (p <0.005) following completion of 20 procedures was identified (514 ± 106 vs. 397 ± 71.9). No conversions to open thoracotomy were required. Complication rates were low and not significantly different between any 10-patient cohort; however, no complications occurred in the final 10-patient cohort. There were no in-hospital mortalities.
CONCLUSIONS:For surgeons proficient in performing minimally-invasive esophagogastrectomies, the learning curve for a robotic-assisted procedure appears to begin near proficiency after 20 cases. Operative complications and conversions were infrequent and unchanged across successive 10-patient cohorts.
- Esophagojejunostomy after total gastrectomy for caustic injuries. [JOURNAL ARTICLE]
- Dis Esophagus 2013 Apr 26.
The objective of the study was to compare outcomes of emergency esophagogastrectomy (EGT) and total gastrectomy with immediate esophagojejunostomy (EJ) in patients with full-thickness caustic necrosis of the stomach and mild esophageal injuries. After caustic ingestion, optimal management of the esophageal remnant following removal of the necrotic stomach remains a matter of debate. Between 1987 and 2012, 26 patients (men 38%, median age 44 years) with isolated transmural gastric necrosis underwent EGT (n = 14) or EJ (n = 12). Early and long-term outcomes of both groups were compared. The groups were similar regarding age (P = 0.66), gender (0.24), and severity of esophageal involvement. Functional success was defined as nutritional autonomy after removal of the jejunostomy and tracheotomy tubes. Emergency morbidity (67% vs. 64%, P = 0.80), mortality (17% vs. 7%, P = 0.58), and reoperation rates (25% vs.14%, P = 0.63) were similar after EJ and EGT. One patient (8%) experienced EJ leakage. One patient in the EJ group and 13 patients in the EGT group underwent esophageal reconstruction (P < 0.0001). Aggregate in hospital length of stay was significantly longer in patients who underwent EGT (median 83 [33-201] vs. 36 [10-82] days, P = 0.001). Functional success after EJ and EGT was similar (90% vs.69%, P = 0.34). Immediate EJ can be safely performed after total gastrectomy for caustic injuries and reduces the need of further esophageal reconstruction.
- Initial experience from a large referral center with robotic-assisted Ivor Lewis esophagogastrectomy for oncologic purposes. [JOURNAL ARTICLE]
- Surg Endosc 2013 Apr 3.
BACKGROUND:We report our initial experience of patients undergoing robotic-assisted Ivor Lewis esophagogastrectomy (RAIL) for oncologic purposes at a large-referral center.
METHODS:A retrospective review of all consecutive patients undergoing RAIL from 2010-2011 was performed. Basic demographics were recorded. Oncologic variables recorded included: tumor type, location, postoperative tumor margins, and nodal harvest. Immediate 30-day postoperative complications also were analyzed.
RESULTS:Fifty patients underwent RAIL with median age of 66 (range 42-82) years. The mean body mass index was 28.6 ± 0.7 kg/m(2); 54 % and the majority had an American Society of Anesthesiologists classification of 3. The mean and median number of lymph nodes retrieved during surgery was 20 ± 1.4 and 18.5 respectively. R0 resections were achieved in all patients. Postoperative complications occurred in 14 (28 %) patients, including atrial fibrillation in 5 (10 %), pneumonia in 5 (10 %), anastomotic leak in 1 (2 %), conduit staple line leak in 1 (2 %), and chyle leak in 2 (4 %). The median ICU stay and length of hospitalization (LOH) were 2 and 9 days respectively. Total mean operating time calculated from time of skin incision to wound closure was 445 ± 85 minutes; however, operative times decreased over time. Similarly, there was a trend toward lower complications after the first 29 cases but this did not reach statistical significance. There were no in-hospital mortalities.
CONCLUSIONS:We demonstrated that RAIL for esophageal cancer can be performed safely and may be associated with fewer complications after a learning curve, shorter ICU stay, and LOH.
- A prospective randomized controlled trial of semi-mechanical versus hand-sewn or circular stapled esophagogastrostomy for prevention of anastomotic stricture. [Journal Article]
- World J Surg 2013 May; 37(5):1043-50.
Successful anastomosis is essential in esophagogastrectomy, and the application of the circular stapler effectively reduces the anastomotic leakage, although stricture formation has become more frequent. The present study, a randomized controlled trial, compared the recently developed semi-mechanical anastomosis with a hand-sewn or circular stapled esophagogastrostomy in prevention of anastomotic stricture.Between November 2007 and September 2008, 160 consecutive patients with esophageal carcinoma underwent surgical treatment our department. Five patients were excluded from this study, and the remaining 155 patients were completely randomized to receive either an everted plus side extension esophagogastrostomy (semi-mechanical [SM] group) or a conventional hand-sewn esophagogastric anastomosis ([HS] group) or a circular stapled ([CS] group) esophagogastric anastomosis, after dissection of the esophageal tumor and construction of a tubular stomach. The primary outcome was the incidence of an anastomotic stricture at 3 months after the operation (defined as the diameter of the anastomotic orifice ≤ 0.8 cm on esophagogram). Secondary outcomes were the dysphagia score and reflux score, as well as the anastomotic diameter.The anastomotic stricture rate was 0 % (0/45) in the SM group, 9.6 % (5/52) in the HS group, and 19.1 % (9/47) in the CS group (p < 0.001). The mean diameter of the anastomotic orifice was 18.2 ± 4.7 mm in the SM group, 11.5 ± 2.4 mm in the HS group, and 9.5 ± 3.0 mm in the CS group (p < 0.001). The reflux/regurgitation score among the three groups was similar.Semi-mechanical esophagogastric anastomosis could prevent stricture formation more effectively than hand-sewn or circular stapler esophagogastrostomy, without increasing gastroesophageal reflux.
- Surgery of esophageal cancer. [Journal Article]
- Langenbecks Arch Surg 2013 Feb; 398(2):189-93.
Surgery is the only option for curative treatment in patients with esophageal carcinoma. Despite the debates related to the peri-operative therapy regime, a generally accepted consensus on surgical approach is not reached yet. The debate focuses mainly on pros and cons between radical transthoracic resection and the (limited) transhiatal resection in the last decade.The PubMed database was searched for randomized trials, meta-analyses, and retrospective single-center studies. The search terms were "esophageal carcinoma," "esophageal junction carcinomas," "transhiatal," "transthoracic," "morbidity," "mortality," and "surgery."The radical transthoracic approach should be the standard of care for esophageal carcinoma since it does not go along with an increased risk of postoperative morbidity or mortality but reveals an improved survival. Patient-related co-morbidities are the most influencing factors for the postoperative outcome. For type II esophageal junction carcinoma, treatment options from transhiatal extended gastrectomy to esophagectomy with hemigastrectomy or esophagogastrectomy with colonic interposition are existing. In type III esophagogastric junction carcinomas, the transhiatal extended gastrectomy is the standard of care, and the minimally invasive approach should be performed in specialized centers.Based on current available study results, this expert review provides a decision support for the best surgical strategy depending on tumor localization and patients' characteristics.
- Gastric ischemic conditioning increases neovascularization and reduces inflammation and fibrosis during gastroesophageal anastomotic healing. [Journal Article, Research Support, Non-U.S. Gov't]
- Surg Endosc 2013 Mar; 27(3):753-60.
The incidence of anastomotic leak and stricture after esophagectomy remains high. Gastric devascularization followed by delayed esophageal resection has been proposed to minimize these complications. We investigated the effect of ischemic conditioning duration on anastomotic wound healing in an animal model of esophagogastrectomy.North American opossums were randomized to four study groups. Group A underwent immediate resection and gastroesophageal anastomosis. Groups B, C, and D were treated with delayed resection and anastomosis after a gastric ischemic conditioning period of 7, 30, and 90 days, respectively. Gastric conditioning was performed by ligating the left, right, and short gastric vessels. An intraabdominal esophagogastric resection and anastomosis was performed, followed by euthanasia 10 days later. Outcome variables included anastomotic bursting pressure, microvessel concentration, tissue inflammation, and collagen deposition.Twenty-four opossums were randomized to groups A (n = 7), B (n = 8), C (n = 5), and D (n = 4). Subclinical anastomotic leak was discovered at necropsy in 5 animals: 3 in group A, and 1 each in groups B and C (p = 0.295). The anastomotic bursting pressure did not differ significantly between groups (p = 0.545). A 7 day ischemic conditioning time did not produce increased neovascularity (p = 0.900), but animals with a 30 day conditioning time showed significantly increased microvessel counts compared to unconditioned animals (p = 0.016). The degree of inflammation at the healing anastomosis decreased significantly as the ischemic conditioning period increased (p = 0.003). Increasing delay interval was also associated with increased muscularis propria preservation (p = 0.001) and decreased collagen deposition at the healing anastomosis (p = 0.020).Animals treated with 30 days of gastric ischemic conditioning showed significantly increased neovascularity and muscularis propria preservation and decreased inflammation and collagen deposition at the healing anastomosis. These data suggest that an ischemic conditioning period longer than 7 days is required to achieve the desired effect on wound healing.
- Expression of β-Adrenoceptors in Human Lower Esophageal Sphincter. [JOURNAL ARTICLE]
- Hepatogastroenterology 2012 Dec 16; 60(122)
Background/Aims:Beta-adrenoceptor is considered to be an important modulator of smooth muscle function. It is widely present in the mammalian gastrointestinal tract and nervous system. The aim of this study was to explore the expression of β-adrenoceptors (β1-AR, β2-AR, β3-AR) in sling fibers and clasp fibers from human lower esophageal sphincter (LES). Methodology: Sling and clasp fibers from the LES were obtained from patients undergoing esophagogastrectomy; circular muscle strips from the esophagus and stomach were used as controls. Reverse transcription-polymerase chain reaction and western blotting were used to determine the expression of the three subtypes of β-adrenoceptors.
Results:Messenger RNA and protein for three subtypes of β-adrenoceptors were all identified in the sling and clasp fibers of the LES. Expression was highest for β3-AR, then β1-AR and β2-AR in decreasing levels.
Conclusions:β1-AR, β2-AR, β3-AR can be detected in human lower esophageal sphincter and contribute to LES function.
- Omentoplasty for esophagogastrostomy after esophagectomy. [Journal Article, Meta-Analysis, Research Support, Non-U.S. Gov't, Review]
- Cochrane Database Syst Rev 2012.:CD008446.
Esophagectomy followed by esophagogastrostomy is the preferred treatment for early-stage esophageal cancer. It carries the risk of anastomotic leakage after esophagogastric anastomosis, which is one of the most dangerous complications and causes considerable morbidity and mortality. Omentoplasty was recommended in some studies to preventing anastomotic leaks associated with esophagogastrostomy. However, the value of omentoplasty for esophagogastrostomy after esophagectomy has not been systematically reviewed.To assess the effects of omentoplasty for esophagogastrostomy after esophagectomy in esophageal cancer patients.A comprehensive search strategy was carried out to identify eligible studies for inclusion in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PubMed and other reliable resources.Randomized controlled trials comparing omentoplasty with no omentoplasty for esophagogastrostomy after esophagectomy in esophageal cancer patients were eligible for inclusion.Two review authors (Yong Yuan and Xiaoxi Zeng) independently assessed the quality of included studies and extracted data, with disagreements resolved by arbitration by another review author. Results of dichotomous outcomes were expressed as risk ratios (RR) with 95% confidence intervals (CI), while continuous outcomes were expressed as mean differences (MD) with 95% CI. Meta-analysis was performed where the data available were sufficiently similar. Subgroup analysis was carried out based on different operation approaches.Two randomized controlled trials (449 participants) were included in the review. There was no significant difference for hospital mortality between the study (with omentoplasty) and the control group (without omentoplasty) (RR 1.00; 95% CI 0.25 to 3.92). Neither of the included studies reported the difference of long-term survival between two groups. The incidence of postoperative anastomotic leakage was significantly lower in patients treated with omentoplasty than those without (RR 0.22; 95% CI 0.08 to 0.58); but the additional benefit only showed in patients receiving a transhiatal esophagogastrectomy (THE) procedure in subgroup analysis (THE: RR 0.23; 95% CI 0.07 to 0.79; transthoracic esophagogastrectomy (TTE): RR 0.19; 95% CI 0.03 to 1.03). Omentoplasty did not significantly improve other surgical-related complications, anastomotic strictures (RR 0.73; 95% CI 0.21 to 2.58) and duration of hospitalization (MD -2.70; 95% CI -6.01 to 0.61).Omentoplasty may provide an additional benefit to decrease the incidence of anastomotic leakage after esophagectomy and esophagogastrostomy for esophageal cancer patients without increasing or decreasing other complications, especially for those patients treated with THE. Further randomized controlled trials are still needed to investigate the influences of omentoplasty in different operation procedures of esophagectomy and esophagogastrostomy on the incidence of anastomotic leakage, anastomotic stricture, long-term survival rate and quality of life after esophagectomy and esophagogastrostomy.
- Major perioperative morbidity does not affect long-term survival in patients undergoing esophagectomy for cancer of the esophagus or gastroesophageal junction. [Journal Article]
- World J Surg 2013 Feb; 37(2):408-15.
The incidence of cancer of the esophagus/GE junction is dramatically increasing but continues to have a dismal prognosis. Esophagectomy provides the best opportunity for long-term cure but is hampered by increased rates of perioperative morbidity. We reviewed our large institutional experience to evaluate the impact of postoperative complications on the long-term survival of patients undergoing resection for curative intent.We identified 237 patients who underwent esophagogastrectomy, with curative intent, for cancer between 1994 and 2008. Complications were graded using the previously published Clavien scale. Survival was calculated using Kaplan-Meier methodology and survival curves were compared using log-rank tests. Multivariate analysis was performed with continuous and categorical variables as predictors of survival, and examined with logistic regression and odds ratio confidence intervals.There were 12 (5 %) perioperative deaths. The average age of all patients was 62 years, and the majority (82 %) was male. Complication grade did not significantly affect long-term survival, although patients with grade IV (serious) complications did have a decreased survival (p = 0.15). Predictors of survival showed that the minimally invasive type esophagectomy (p = 0.0004) and pathologic stage (p = 0.0007) were determining factors. There was a significant difference in overall survival among patients who experienced pneumonia (p = 0.00016) and respiratory complications (p = 0.0004), but this was not significant on multivariate analysis.In this single-institution series, we found that major perioperative morbidity did not have a negative impact on long-term survival which is different than previous series. The impact of tumor characteristics at time of resection on long-term survival is of most importance.
- [Multimodality therapy for adenocarcinoma of the esophagogastric junction]. [Editorial, English Abstract]
- Zhonghua Wei Chang Wai Ke Za Zhi 2012 Sep; 15(9):877-80.
The definition of esophagogastric junction (EGJ) adenocarcinoma and progress in multidisciplinary treatment for the tumor were revised in this review. Siewert classification is especially useful for the surgical approach of EGJ adenocarcinoma. SiewertI( should be treated as esophageal cancer, and Ivor-Lewis esophagogastrectomy (right thoracotomy and laparotomy) is recommended as an extended two-field lymphadenectomy. For SiewertII( or III( tumors, left thoracophrenolaparotomy is preferred, especially in case of positive thoracic lymph nodes or positive resection margin. If there is any contraindication against thoracotomy, or a high operating risk, a transhiatal esophagectomy with lower mediastinal lymphadenectomy is an alternative. Preoperative chemoradiotherapy or perioperative chemotherapy improves overall survival and the rate of complete resection for patients with large tumor or lymph node metastasis. Neoadjuvant chemoradiotherapy is associated with high but acceptable postoperative complications. Adjuvant chemoradiotherapy remains a rational standard therapy for curatively resected EGJ cancer with T3 or greater lesion or positive nodes.