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It’s not always too late: a case for minimally invasive salvage esophagectomy

  • 2020 SAGES Oral
  • Published:
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Abstract

Introduction

Standard of care for locally advanced esophageal carcinoma is neoadjuvant chemoradiation (nCRT) and surgical resection 4–8 weeks after completion of nCRT. It is recommended that the CRT to surgery interval not exceed 90 days. Many patients do not undergo surgery within this timeframe due to patient/physician preference, complete clinical response, or poor performance status. Select patients are offered salvage esophagectomy (SE), defined in two ways: resection for recurrent/persistent disease after complete response to definitive CRT (dCRT) or esophagectomy performed > 90 days after completion of nCRT. Salvage esophagectomy reportedly has higher postoperative morbidity and poor survival outcomes. In this study, we assessed outcomes, overall, and disease-free survival of patients undergoing salvage esophagectomy by both definitions (recurrent/persistent disease after dCRT and/or > 90 days), compared to planned (resection after nCRT/within 90 days) esophagectomy (PE).

Materials and methods

Retrospective review of a prospectively maintained database identified patients who underwent minimally invasive esophagectomy at a single institution from 2009 to 2019. Esophagectomy for benign disease and patients who did not receive nCRT were excluded. Outcomes included postoperative complications, length of stay (LOS), disease-free survival, and overall survival.

Results

97 patients underwent minimally invasive esophageal resection for esophageal carcinoma. 89.7% of patients were male. Mean age was 64.9 years (range 36–85 years). 94.8% of patients had adenocarcinoma, with 16 transthoracic and 81 transhiatal approaches. On comparing planned esophagectomy (n = 87) to esophagectomy after dCRT failure (n = 10), no significant differences were identified in overall survival (p = 0.73), disease-free survival (p = 0.32), 30-day or major complication rate, anastomotic leak, or LOS. Similarly, when comparing esophagectomy < 90 days after CRT (n = 62) to > 90 days after CRT completion (n = 35), no significant differences were identified in overall survival (p = 0.39), disease-free survival (p = 0.71), 30-day or major complication rate, LOS, or anastomotic leak rate between groups. In this comparison, local recurrence was noted to be elevated with SE as compared to PE (64.3% vs. 25.0%, p = 0.04).

Conclusion

Overall survival and disease-free survival were equivalent between SE and PE. Local recurrence was noted to be increased with SE, though this did not appear to affect survival. Although planned esophagectomy remains the standard of care, salvage esophagectomy has comparable outcomes and is appropriate for selected patients.

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Authors and Affiliations

  1. Department of Surgery, Division of Minimally Invasive Surgery, UC San Diego School of Medicine, MET Building, Lower Level, 9500 Gilman Drive MC 0740, La Jolla, CA, 92093-0740, USA

    Ryan C. Broderick, Arielle M. Lee, Beiqun Zhao, Jenny Lam, Joslin N. Cheverie, Bryan J. Sandler, Garth R. Jacobsen & Santiago Horgan

  2. Division of Surgical Oncology, Department of Surgery, University of California, San Diego, CA, USA

    Rachel R. Blitzer, Kaitlyn J. Kelly & Michael Bouvet

  3. Division of Cardiothoracic Surgery, Department of Surgery, University of California, San Diego, CA, USA

    Mark W. Onaitis

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  1. Ryan C. Broderick
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  2. Arielle M. Lee
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Correspondence to Arielle M. Lee.

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Disclosures

Dr. Santiago Horgan is a consultant for Stryker Corporation, Intuitive Surgical, Fortimedix Surgical, and Medtronic. Dr. Jacobsen receives a teaching honorarium from Gore Medical. Dr. Sandler is a consultant for Intuitive Surgical and Boston Scientific. Dr. Onaitis is a consultant for Intuitive Surgical. Dr. Bouvet is a consultant for Stryker Corporation. Drs. Broderick, Lee, Zhao, Blitzer, Lam, Cheverie, and Kelly have no conflicts of interest or financial ties to disclose.

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Broderick, R.C., Lee, A.M., Blitzer, R.R. et al. It’s not always too late: a case for minimally invasive salvage esophagectomy. Surg Endosc 35, 4700–4711 (2021). https://doi.org/10.1007/s00464-020-07937-2

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