MINIMALLY INVASIVE ESOPHAGECTOMY FOR CANCER: where do we stand?
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1 MINIMALLY INVASIVE ESOPHAGECTOMY FOR CANCER: where do we stand? Ph Nafteux, MD Copenhagen, Nov 3rd 2011
2 Department of Thoracic Surgery, University Hospitals Leuven, Belgium W. Coosemans, H. Decaluwé, Ph. Nafteux, D. Van Raemdonck, G. Decker, P. De Leyn
3 Probability Background. Esophagectomy is considered as the gold standard for resectable esophageal and GEJ cancer with long term survival reaching 40% 1 Leuven: 2000 esophagectomies 0,9 0,8 0,7 0,6 0,5 0,4 0,3 41,4 35,5 31,6 31,6 31,6 0,2 0, CS SURVIVAL (Months)
4 Background Results of 2000 Esophagectomies for Cancer K.U.Leuven: The Seventies: decreasing mortality and morbidity The Eighties: better selection by refining staging extent of surgery The Nineties: introduction of multimodality treatment and new technologies
5 Background Leuven Data (2000 esophagectomies)
6 Background. Esophagectomy based treatment is standard of care for resectable esophageal and GEJ cancer. BUT: Complication rate %. Mortality rate 4-7 %. Quality of life?
7 Can we do better? Minimally Invasive Way? Theoretical advantages Less impaired immunity Less invasive = less complications Shortened hospital stay Quicker recovery Improved quality of life
8 History. First publications early 90 ies ( Gossot, Azagra, Cuschieri,..). De Paula (1996): first large series. Increasing experience with laparoscopy Various techniques of MIE
9 Trans-thoracic MIE VATS + laparoscopy +/- mini-laparotomy +/-cervicotomy +/- mini-thoracotomy Hybrid techniques: VATS +/-minithoracotomy + laparotomy +/- cervicotomy Laparoscopy +/- mini-laparotomy + thoracotomy +/-cervicotomy Trans-hiatal MIE Laparoscopy +/-mini-laparotomy + cervical/thoracic anastomosis +/- robotic >28 different operations are called «MIE»
10 Laparoscopic transhiatal esophagectomy Laparoscopic mobilization of stomach. Transhiatal dissection under direct vision. Single lumen ventilation. BUT: Less optimal dissection of the middle and upper esophagus. Limited number of thoracic LN harvested.
11 VATS & laparoscopic MIE N= conversions (7,2%) Hospital stay 7 days (3-75) Mortality 1,4% (n=3) Major morbidity: 32% Atrial fibrillation 11,7% Respiratory complications 11% Anastomotic leakage 11,7% Tracheal tear 0,9% VATS 4 ports Laparoscopy 5 ports No regional LND Luketich J. et al. Ann Surg 2003
12 Quality of life SF 36 QOL (PCS MCS) Mean PCS 44,1 (nl = 43,33) Mean MCS 49,67 (nl 52,68 p<0,01) N=57 pre and post op values preserved GER-HRQOL scale Only 4% GERD (score > 15) Dysphagia measurement (score 1 to 5) Mean score 1,4 Recovery to normal QOL
13 MIE: Ivor Lewis Approach «The omission of a cervical dissection has reduced our recurrent nerve injury rate to 0.» Levy R, Luketich J, Adv Surg 2010
14 MIE-neck vs MIE-chest N=973 pts (49% neck, 51% chest) Hospital stay: 8 days Median LN: 20 Mortality: 2% (chest) vs 4% (neck) p=0.09 MIE Neck (%) Chest (%) p Vocal cord palsy 9 1 <0.001 Sepsis Anast leak Gastric tube necrosis 3 < «Our technique of MIE has evolved such that laparoscopic-thoracoscopic Ivor-Lewis esophagectomy has become our favorite approach.» Luketich J, abstract ASA April 2011
15 But some concerns about systematic use for all operable tumor stages Difficult mobilization if bulky tumor (R status?). LN harvesting is feasible but takes a long time. No randomized studies for oncologic outcome. Quid QOL versus open surgery? 3-year survival stage II <30% stage III Luketich J. et al. Ann Surg 2003
16 MIE for cancer in 2011? - Is MIE less invasive than open surgery? Less morbidity & mortality? Shorter hospital stays? Better Quality of Life? - Similar oncological outcome? - Learning curve issues.
17 Trans-thoracic MIE VATS + laparoscopy +/- mini-laparotomy +/-cervicotomy +/- mini-thoracotomy Hybrid techniques: VATS +/-minithoracotomy + laparotomy +/- cervicotomy Laparoscopy +/- mini-laparotomy + thoracotomy +/-cervicotomy Trans-hiatal MIE Laparoscopy +/-mini-laparotomy + cervical/thoracic anastomosis +/- robotic >28 different operations are called «MIE» Comparison extremely difficult!!
18 Schoppmann, Surg Endosc 2009
19 Schoppmann, Surg Endosc 2009
20 Nagpal, Surg Endoscopy 2010
21 «Meta-analysis» based on 5 retrospective studies (18-47 MIE pat.) Surgical outcome comparison after MIE vs OE (historical controls) Nagpal, Surg Endoscopy 2010
22 Systematic review: 46 original series (1932 patients)
23 Outcome of MIE: Literature review 46 studies; 1932 patients Mortality Morbidity ICU stay Hospital stay (total *) (days) Median (days) Overall MIE 2.9% 46% (18-100%) (0.5-5) (5.5-29) VATS+laparoscopy 2.4% 43% 1 9 (6.5-16) VATS+laparotomy 2.1% 47% 1 18 (10-28) Laparoscop+thoracot 4.8% 48% 2 18 (11-29) Laparoscopic THE 4.9% 40% (5.5-17) * only major complications reported in many studies Decker, Nafteux; Eur J Cardiothor Surg 2009
24 Outcome of MIE: updated review Mortality Morbidity total (*) Respiratory compl.(*) Vocal cord palsy Anastom leaks EJCTSurg series 1932 patients Update 14 series 523 patients Overall literature update series 2448 patients 2.9% N=56 2.7% N= % N=70 46% (18-100%) 48% (14-93%) 46.4% (14.5%-100%) * only major complications reported in many studies 22% (0-76%) 12% ( 0-43% ) 19.2% (0-76%) 7.1% (0-55%) 9.6% ( 0-28% ) 9.2% (0-55%) 8.8% (0-25%) 11% (2.7-27%) 9% (0-33%) Updated from Decker, Nafteux; Eur J Cardiothor Surg 2009
25 Outcome of MIE: updated review Conversion rate Reoperations Tracheal injuries LN yield (median) Hospital stay (median/days) EJCTSurg % 6.1% 0.8% series (0-36%) N=15 (5-62) (5.5-29) 1932 patients Update 4.6% 5.2% 1.3% series (0-17%) (3-12%) N=7 (10-50) (9-21) 523 patients Overall literature update % 6% 0.9% N= (5-62) 12 (5.5-29) 58 series 2448 patients Updated from Decker, Nafteux; Eur J Cardiothor Surg 2009
26 Fast-track open esophagectomy - Literature Cerfolio B, Chest 2004 N=90 pat. median hospital stay 7 days (6-74) Jiang K, World J Gastroenterol N=88 pat. median hospital stay 7 days (5-28) Tomaszek S, EurJ Cardioth. Surg 2010 N= 110 pat. median hospital stay 7 days (4-54) Lerut, Nafteux et al. UZ Leuven (unpublished data) N=150 pat. ( ) median hospital stay 8 days Luketich J, abstract ASA April 2011 (973 MIE) N=973 pat median hospital stay 8 days
27 MIE: Learning curve Mortality Morbidity Respiratory complications Conversion rate LN yield median Series with < 25 cases 3.9% 60% 31% 6.6% 12 (5-17) 50 or > cases 2.1% 44% 20% 4.5% 22.5 (16-62) 100 or > cases 2.2% 46% 19.7% 3.6% 18 (17-62) * only major complications reported in many studies Decker, Nafteux; Eur J Cardiothor Surg 2009
28 MIE: the lymph node issue LN retrieval reported in 36 MIE series / 58 (62%) Overall LN (median) 14.1 (5-62) Transthoracic MIE Trans-hiatal MIE Median LN retrieved 17.9 (7-62) 10.5 (5-15) Peyre et al. Ann Surg 2009 Minimum of 23 LN is needed!
29 Lymph node retrieval in MIE Eastern versus Western series? Lymph nodes yield (median of series) Eastern Asia series 34.5 (23-62) (14 series, 733 patients) Western series 13 (5-18) (44 series, 1715 patients)
30 LN yield: Leuven MIE experience N=65 pts (pt<2 and N0) Mean Median Min Max , , , , , : median 27 LN (17pts) Nafteux, Eur J Cardiothor Surg 2011: in press
31 Leuven MIE experience January January 2010 pt<2 and pn0 175 patients Mean age 63,7y 74 pts started MIE Open (OE) N=101 Conversion N=9 MIE N=65 Bleeding (N=1) Technical (N=2) Adhesions (N=6) Excluded Nafteux, Eur J Cardiothor Surg 2011: in press
32 Installation Abdominal Thoracic
33 Abdominal part
34 Thoracic part Subcarinal Recurrent nerve Thoracic duct
35 Neck anastomosis
36
37 Population: surgery Minimally invasive esophagectomy: N=65 Open esophagectomy: Right thoracotomy- laparotomy: N=18 Left thoracoabdominal: N=83 Nafteux, Eur J Cardiothor Surg 2011: in press
38 Outcome Hospital stay: 19,2 d (OE) vs. 14,4 d (MIE) p = 0.1 Mortality: 1,98% (OE) vs. 3,08% (MIE) p = 0.65 Morbidity: 40% (OE) vs. 32% (MIE) p = 0.34 Nafteux, Eur J Cardiothor Surg 2011: in press
39 Outcome Surgical parameters: OE MIE p=0,01 p=0,001 Nafteux, Eur J Cardiothor Surg 2011: in press
40 Outcome Morbidity: OE MIE p=0,02 p=0,008 p=0,005 Nafteux, Eur J Cardiothor Surg 2011: in press
41 QoL evaluation EORTC approved QLQ-C30 and EOS-18 questionnaires At baseline and three monthly post surgery for the first year Response rate: >85% Nafteux, Eur J Cardiothor Surg 2011: in press
42 Role Functioning Quality of Life MIE OE Fatigue Pain general P=0,09 P=0,05 GI pain P=0, PreOP PostOP 1-3 mo Role functioning PostOP 4- PostOP 7-6 mo 9 mo PostOP mo p=0.02 Nafteux, Eur J Cardiothor Surg 2011: in press
43 Oncological outcome: MIE vs OE
44 Oncological outcome: MIE vs OE Review of 58 papers, N= patients Median follow-up in MIE series: 19 m (4-42) 15 papers report 1 y overall survivals: 77% (65-94%) 8 papers reported 3 y survivals: 43% (25-62%) 5 papers reported 5 y survivals: 41% (22-52%) the later had a median LN yield of 17.5 (17 to 62) Updated from Decker, Nafteux; Eur J Cardiothor Surg 2009
45 Survival after VATS+laparotomy +3-F LND MIE N=112 VATS 5-6 ports +/- mini-thoracotomy 8 cm mini-laparotomy 3 Field LN dissection median 62 lymph nodes overall 5y-survival 62% Yamamoto et al. Ann Thor Surg 2005
46 Early cancer (Leuven experience) Survival and recurrence rate 5 year cancer specific survival ptis/1a 95.4% (OE) vs. 95.1%(MIE) p = 0.90 pt1b 76.2% (OE) vs. 100% (MIE) p = year recurrence-free survival ptis/1a 94.1% (OE) vs. 96.9%(MIE) p = 0.75 pt1b 81.5% (OE) vs. 100% (MIE) p = 0.14 Nafteux, Eur J Cardiothor Surg 2011: in press
47 Conclusion: MIE status in 2011 No reduction in overall complications Potentially less pulmonary complications Hospital stay not shorter than for open fast-track series Potentially better HR-QoL after 1 to 3 months post-op. but no difference after 1 year Oncological valid for stage I, validity for stage II-III still unknown Learning curve: MIE restriction to highvolume units?
48 This is the future of Open Surgery! Surgeons must evolve and develop less morbid procedures and embrace new technology! J. Luketich
49 Surgical approach may be of little importance for outcome! Surgeons should perform en-bloc resections with adequate lymph node dissections! or the future of esophageal cancer Surgery might be chemo-radiotherapy!
50
51
52 Background Morbidity and mortality have declined markedly Historical Data EARLAM/CUNHA MELO MULLER JAMIESON N = N = N = Operability 58% Resectability 19% 56% Oper. mort. 19% 13% 8.8% 5-yr survival 4% 8% 10% 20% 28%
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