Original article
General thoracic
Outcomes of Minimally Invasive Esophagectomy in Esophageal Cancer After Neoadjuvant Chemoradiotherapy

https://doi.org/10.1016/j.athoracsur.2013.09.042Get rights and content

Background

Minimally invasive esophagectomy (MIE) is accepted for resection of early esophageal cancers. The optimal surgical approach for more advanced disease is unknown. An evaluation of MIE in patients with advanced tumors having undergone neoadjuvant chemoradiotherapy (nCRT) is presented.

Methods

A retrospective review of patients with esophageal cancer who underwent MIE from November 2006 to November 2011 was performed

Results

In total, 96 consecutive patients underwent MIE for malignancy. Median age was 65 years (range 26 to 88), and 86% were male. Adenocarcinoma represented 87% of patients. Eighty-three percent of patients were staged IIa or higher and 62 (65%) patients received neoadjuvant chemoradiotherapy. Four (6%) patients additionally received intraoperative electron beam radiotherapy. Twenty-six (27%) patients received postoperative adjuvant therapy with 22 (85%) of these having also received neoadjuvant chemoradiotherapy. All cases were completed thoraco-laparoscopically except for 2 conversions to mini-laparotomy. Twelve (12%) cervical anastomoses and 84 (88%) thoracic anastomoses were performed. Median operative time was 326 minutes (range 193 to 567) and did not differ significantly between those with and without nCRT. Complete pathologic response was seen in 21 (34%) of the 62 patients receiving neoadjuvant treatment. Major and minor morbidities were experienced in 28% and 38.5% of patients. There were 2 (2%) in-hospital mortalities; 1 each having received or not received neoadjuvant therapy. At median follow-up 24 months (range 3 to 70 months), overall survival was 58% and 55 (57%) patients were alive without recurrence.

Conclusions

Minimally invasive esophagectomy is an acceptable surgical therapy for advanced-stage esophageal malignancies after nCRT without evidence for increased morbidity or mortality.

Section snippets

Material and Methods

A retrospective review was conducted of patients treated consecutively for esophageal carcinoma with MIE by a single surgeon November 2006-November 2011. Benign esophageal disease was excluded. Patients developing metastasis, local progression during nCRT or became medically inoperable were excluded. The treatment and selection algorithms were identical whether surgery was planned as minimally invasive esophagectomy (MIE) versus open surgery. All patients presented as surgical candidates to

Patient Characteristics and Adjuvant Therapy

In total, 111 patients were evaluated and planned treatment. Fifteen patients were excluded (8 patients went to open esophagectomy by another surgeon; 4 patients died from chemoradiation toxicities; 3 progressed to metastatic disease). The 96 patient demographics are reviewed in Table 1. Staging and pathologic response to neoadjuvant therapy are detailed in Table 2. All but 7 tumors were located in the distal esophagus or at the gastroesophageal junction, with a median located at 36 cm from the

Comment

Controversy persists over the use of MIE to resect advanced tumors after nCRT 9, 10, 12, 13, 14. Two-thirds of our MIE patients underwent neoadjuvant treatment and no statistically significant increase in morbidity or mortality was observed compared with surgery alone. Our operative outcomes and complication rates (morbidity 38%, 30-day mortality of 2%) were consistent with published trials comparing open surgical resection alone to surgical resection after nCRT [8]. Postoperative mortality

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