esophageal cancer – Thoracic Surgery

The Mediterranean IV thoracic oncology symposium

It’s not too late to register for the upcoming Thoracic Oncology Symposium in Catania, Italy. The symposium is being held April 6th and 7th and is sponsored by the University of Catania and Policlinico University Hospital.

This year’s topic is “Surgery for “advanced” lung and esophageal cancer: New horizons or a false dawn?” Lectures include a presentation by Dr. Migliore on HITHOC for M1 lung cancer, a discussion on the use of hyperthermia, as well as several lectures on the use of VATS in advanced lung cancer and a segment devoted to esophageal cancer that includes the presentation of research findings by Dr. Toni Lerut based on findings from 3000 esophagectomies.

The full program and registration information can be seen Here. Potential registrants may also contact Dr. Migliore at mmiglior@unict.it

A guest post on last year’s conference is viewable here.

The latest STS guidelines on multimodality treatment of esophageal cancer

Cirugia de torax invites readers for an open discussion on the latest STS guidelines on multimodality treatment of esophageal cancer.

Guidelines for esophageal cancer?

Guidelines, guidelines, guidelines.. It seems like much of American medicine is now directed by guidelines, committees and government agencies. We have pay-for-performance, “Core Measures” and even more guidelines, recommendations and requirements that attempt to pre-script the care that we provide. This often leaves clinicians and surgeons feeling more like technicians following recipes for “cookbook medicine” to treat anonymous, “standardized” patients rather than highly skilled, extensively trained and experienced medical providers using clinical judgment, intellect and training to treat unique individuals.

Guideline fatigue, questionable “evidence” and mandated medicine

With that in mind, many healthcare providers are sick of reading and writing about “evidence-based practice recommendations and clinical guidelines”. Some of this frustration comes from the sometimes contradictory clinical evidence regarding these mandates, such as pre-operative beta blockade. While this medication is now mandated by the federal government, multiple studies* question the benefit of this treatment in patients undergoing noncardiac surgery.

As the debate continues to rage over this therapy, is it fair that surgeons must continue to risk their hospital’s performance scores, and surgical reimbursement for challenging the blanket administration of this medication to their patients?**

Not all guidelines created equally

The concept of clinical guidelines have its origins in the 1960’s. While differing political camps explain the emergence of these guidelines according to their individual bias (insurance cost-cutting versus autonomy etc.), it seems obvious that these guidelines were at least, initially, designed to improve the overall care of patients with similar diagnoses, symptoms or clinical scenarios.

But when it comes to these clinical guidelines – not all guidelines are created equally. In addition to criticism that many clinical guidelines are poorly supported by the existing literature, or based on poor quality studies, allegations of cronyism, obvious bias/ self-serving have plagued guideline committees particularly in the field of cardiology.

But what does this mean for thoracic surgery? We have our own organizational committees such as the Society for Thoracic Surgeons, (aka STS), our own recommendations, guidelines and ratings systems (national and international database). STS and thoracic surgery based clinical guidelines address the very lifeblood of our specialty and our clinical practice.

It behooves us as a professional specialty to read, review and know these guidelines so that we can determine when and if these guidelines serve our practices and our patients. If not, as representatives of thoracic surgery; it is our responsibility to participate and to voice our concerns and criticisms of these guidelines. We are the watchdogs, to prevent the over-representation of commercial interests or bias into our arena of patient care.

It is also crucial that we attempt to support the crafting of recommendations to support and adopt the best practices in thoracic surgery; after all, as practicing clinicians, we know thoracics better than any outside agencies, organizations or other specialties. With this philosophy in mind, Cirugia de Torax invites readers to become more familiar with the latest STS guidelines.

Society of Thoracic Surgeons guidelines

Thus far, the Society of Thoracic Surgeons has published eighteen guidelines on a wide variety of topics’ from antibiotic use, to cerebral protection of infants undergoing cardiac surgery, the use of TMR, to the newest guidelines on the treatment of esophageal cancer.

Cirugia de Torax would like to invite our American and International readers to participate in a review of the most recent guidelines in our next post. What do you think of trend towards guidelines in general? What about the guidelines for multi-modality treatment in esophageal cancer? Love them? Hate them? Any omissions or errors? Any changes or suggestions for future versions?

Deadline for submission of commentary, criticism or other remarks is January 15, 2015.

Notes:

* Link requires (free) subscription

** Surgeons can document a ‘variance’ on a case-by- case basis when omitting this and other prescribed core measures under a limited set of circumstances.

Article for Review

The Society of Thoracic Surgeons Practice Guidelines on the Role of Multimodality Treatment for Cancer of the Esophagus and Gastroesophageal Junction.

Little, Alex G. et al. (2014). The Annals of Thoracic Surgery , Volume 98 , Issue 5 , 1880 – 1885. pdf version.

Additional reference articles

1. Weisz G¹, Cambrosio A, Keating P, Knaapen L, Schlich T, Tournay VJ. (2007). The emergence of clinical practice guidelines. Milbank Q. Dec;85(4):691-727.

2. The Society of Thoracic Surgeons Esophageal Cancer Guideline Series. Mitchell, John D. et al. The Annals of Thoracic Surgery , Volume 96 , Issue 1 , 7

3. The Society of Thoracic Surgeons Guidelines on the Diagnosis and Staging of Patients With Esophageal Cancer. Varghese, Thomas K. et al. The Annals of Thoracic Surgery , Volume 96 , Issue 1 , 346 – 356

Copies of all STS guidelines are available on-line here.

Another home run: Dr. Gonzalez Rivas does it again!

the Babe Ruth of thoracic surgery continues his winning streak; and Dr. Benny Weksler heads south to the University of Tennessee. Kudos to both of these fine surgeons!

I am beginning to feel like a bit of a sports reporter when it comes to Dr. Gonzalez Rivas and innovations in thoracic surgery..

The Babe Ruth of modern thoracic surgery

It’s another home run for Dr. Gonzalez Rivas as he and his team perform a single port (uni-port) thoracoscopic lobectomy with under local anesthesia, as reported by a recent story, “Operan un tumor e pulmón con una sola incisión y anestesia local” by Raul Romar in La Voz de Galicia.

Dr. Gonzalez Rivas demonstrates uniportal VATS

The answer is International collaboration and sharing of ideas

Dr. Gonzalez Rivas is used to sharing his ideas. After all, he spends a considerable amount of time traveling the world doing just that; sharing information about and teaching surgeons how to perform the single port thoracoscopic technique. But that doesn’t mean that he does find time to learn from his peers during his travels.

The article above highlights the importance of this international collaboration as it details how Dr. Gonzalez Rivas began to consider applying a local anesthesia approach to the single port surgical technique after talking (and visiting) surgeons in Taiwan and China.

Once he found the perfect candidate, he was ready to implement local anesthesia into his single port approach.. The rest, as they say – is now headed for the Annals of Thoracic Surgery.

Click here for English translation (note translation is not exact).

In other news:

Welcome to Tennessee!

Dr. Benny Weksler, our own American (via Brazil) superstar surgeon recently made the move to the University of Tennessee. Dr. Weksler made the move in November of 2013 and is now settling in to his new position as Chief of Thoracic Surgery for the University of Tennessee (UT) Health Science Center and UT – Methodist.

Dr. Weksler, one of the United States most prominent thoracic surgeons, particularly in the area of esophageal surgery reports that he has big plans for the UT health system and the thoracic surgery department.

Big Plans for UT and the city of Memphis

These plans include a lung cancer screening program targeting vulnerable populations in Memphis including the uninsured/ underinsured, African-Americans (who are disproportionately affected) and smokers.

Related: Dr. Weksler talks about smoking cessation

Minimally invasive techniques for esophageal surgery

He has also started a new minimally invasive esophageal surgery program for esophageal cancer and reports “that there is almost an epidemics of squamous cell carcinoma of the esophagus” which is something tha was more rare in his previous practice in Pittsburgh, Pennsylvania.

Dr. Weksler and his colleagues are putting together a multi-disciplinary treatment plan to try to get these patients to a complete evaluation with a surgeon, an oncologist, and a radiation oncologist to provide patients with comprehensive, multi-faceted and coördinated care.

“The Surgeon Speaks” – Dr. Weksler talks about robotic surgery in this 2009 Jefferson University publication.

As a former Memphis resident, I want to say, “Welcome to the mid-south.. Hope you find time in your busy schedule to enjoy Beale Street, visit the Pink Palace and tour Graceland.. On behalf of all current Memphians, we are glad you are here.”

*This article was written by the author of this post.

“General Thoracic Surgery” is thoracic surgery

what is the future of thoracic surgery education? A new American study asks the if it is time to separate the specialties of cardiac and thoracic surgery.

A new study by Cooke & Wisner performed at a large medical center in California (UC Davis) and published in the Annals of Thoracic Surgery provides additional weight to the idea that Thoracic Surgery has increasingly developed into it’s own subspecialty away from the traditional cardiothoracic surgery model (seen in the United States and several other countries.)

In an article published in Medical News Today, the authors of the study explained that the increased complexity of (noncardiac) thoracic surgery procedures for general thoracic conditions has led to increased referrals and utilization of general thoracic surgeons (versus cardiac or general surgeons). This shows a reversal in a previous trend away from specialists – with more patients now receiving “complex” thoracic surgery procedures from specialty trained, board-certified thoracic surgeons. Previously up to 75% of all thoracic surgery procedures were performed by general surgeons.

As the authors of the study discussed; this has serious implications for the curriculum of thoracic surgery fellowship programs, particularly as the specialty tries to attract more residents to stem an on-going and critical shortage.

With lung cancer rates expected to climb dramatically in North America and Europe, particularly in women – along with esophageal cancer, and long waits already common, support and on-going discussion about the evolution of resident and fellow education is desperately needed.

Reference

Cooke, D. T. & Wisner, D. H. (2012). Who performs complex noncardiac thoracic Surgery in United States Academic Medical Centers? Ann Thorac Surg 2012;94:1060-1064. doi:10.1016/j.athoracsur.2012.04.018

Talking with Dr. Daniela Molena

at John Hopkins, talking with Dr. Daniela Molena about minimally invasive thoracic surgery.

Baltimore, Maryland

John Hopkin’s newest recruit to the Department of Thoracic Surgery, Dr. Daniela Molena is a bright point in the future of thoracic surgery. While she has only been at Hopkins for a few short months (since September) she is already innovating and bringing positive changes to the institution. In fact, there is too much to say about this fascinating and charming surgeon in just one article.

A practicing general surgeon in her native Italy, Dr. Molena rapidly became interested and proficient in the surgical treatment of benign esophageal diseases. As a specialist in diseases of the esophagus, she has extensive training in both gastrointestinal and thoracic surgery. Pursuit of this education brought her to the United States.

Once here, Dr. Molena took advantage of the opportunities to train with some of the most renown surgeons in the country; with Dr Marco Patti in San Francisco, with Dr Peters Jeffrey in Rochester, Memorial Sloan Kettering Cancer Center in NY with Dr Rusch Valerie and Dr. James Luketich at the University of Pittsburgh Medical Center, and now here at John Hopkins with Dr. Stephen Yang. She believes this gave her a better appreciation for all the different techniques and schools of though in thoracic surgery. “I don’t just use a specific surgeon’s approach, I can use the best I have learnt from each mentor and apply it to best fit the individual patient and their needs.”

Once she arrived here, she hit the ground running; gathering research on esophageal surgery; starting a lung cancer screening program for some of Baltimore’s more poverty-stricken communities, arranging for patient outreach sessions for cancer patients, working with Dr. Avo Meneshian’s robot-assisted thoracic surgery (RATS) program at the John Hopkins Bayview facility, and quickly advancing, promoting and heading a new program for minimally invasive esophageal surgery (including minimally invasive esophagectomy (MIE) for esophageal cancer). She favors the Ivor-Lewis style procedure but performs it via thoracoscopy and laparoscopic approaches. She thinks it is important to stress that minimally invasive surgery is just the approach or the tool to gain access to the chest to complete a surgical procedure. Thus, a minimally invasive procedure does not mean a lesser or inferior resection. “It’s how we get in – once we get in [to the chest], we can do whatever surgery is needed, respecting oncologic principles.”

While the MIE program is young, Dr. Daniela Molena hopes to grow this program with time, as part of a multi-disciplinary program for esophageal cancer patients. This holistic approach which combines diagnosticians, oncologists, dietitians, nutritionists, nurses, and surgeons is also an immensely practical one. This multi-specialty clinic ensures that the patient/ and their family is able to meet with, consult with and work collaboratively with all of these specialties to determine their course of treatment on the same day during a single trip. This alleviates much of the financial and transportation hardships experienced by many of the families travelling from around the country (and around the world[1]) for treatment at John Hopkins.

Dr. Molena takes this holistic approach to thoracic disease very seriously. As she explains, “Even benign (non-cancerous) esophageal diseases are terrible for patients and their families. They have to learn to adapt and accept that even with treatment, life may never be the same”. She feels that it is essential that we speak to patients openly, and honestly and set realistic expectations, stating “People, especially our patients, are remarkably resilient if we communicate clearly with them during this process.” She also feels that as a surgeon she is here to do more for her patients that operate, that it’s not just about cutting. She is here to help patients (and their loved ones) find all the resources they need to regain optimal health and promote wellness. “It is more than just surviving the surgery. It’s about health & wellness,” she finishes.

It’s a strong, profound statement and a reminder for surgery but one that reflects the thoughts and feelings of many of the wonderful thoracic surgeons I have met, interviewed or worked with. But in Medicine, with many of it’s rigid definitions and delineations; too often the surgeons themselves, their motivations, and their desire to heal gets lost among the surgeries, and the procedures.

More about Dr. Daniela Molena

John Hopkins – Department of Thoracic Surgery, Surgeon profile

Medical School: Faculty of Medicine University of Padova (Padova Italy)
(1996)

General Surgery residencies:

University of Rochester Medical Center (Rochester NY) – General Surgery (2009)

Faculty of Medicine University of Padova (Padova Italy) – General Surgery (2001)

Faculty of Medicine University of Padova (Padova Italy) – General Surgery (1999)

Fellowships:

Memorial Sloan-Kettering Cancer Center (New York NY) – Cardiothoracic Surgery (2011)

University of Pittsburgh Medical Center (Pittsburgh PA) – Cardiothoracic Surgery (2010)

New York Presybterian Hospital (New York NY) – Cardiothoracic Surgery (2011)

Memorial Sloan-Kettering Cancer (New York NY) – Cardiothoracic Surgery (2009)

Universita Degli Studi di Padova (Padova Italy) – Minimally Invasive Surgery (2002)

[1] John Hopkins has a separate department called the International Patient Center which is devoted to detangling and simplifying the health care process for overseas patients.

Contact Information:

The Johns Hopkins Hospital

600 N. Wolfe Street

Baltimore, MD 21287

Phone: 410-614-3891

Appointment Phone: 410-933-1233

Selected publications

Dubecz A, Molena D, Peters JH. Modern surgery for esophageal cancer. Gastroenterol Clin North Am. 2008 Dec;37(4):965-87, xi. Review.

Zaninotto G, Annese V, Costantini M, Del Genio A, Costantino M, Epifani M, Gatto G, D’onofrio V, Benini L, Contini S, Molena D, Battaglia G, Tardio B, Andriulli A, Ancona E. Randomized controlled trial of botulinum toxin versus laparoscopic heller myotomy for esophageal achalasia. Ann Surg. 2004 Mar;239(3):364-70.

Zaninotto G, Costantini M, Portale G, Battaglia G, Molena D, Carta A, Costantino M, Nicoletti L, Ancona E. Etiology, diagnosis, and treatment of failures after laparoscopic Heller myotomy for achalasia. Ann Surg. 2002 Feb;235(2):186-92.

Patti MG, Molena D, Fisichella PM, Whang K, Yamada H, Perretta S, Way LW. Laparoscopic Heller myotomy and Dor fundoplication for achalasia: analysis of successes and failures. Arch Surg. 2001 Aug;136(8):870-7.

Williams VA, Watson TJ, Gellersen O, Feuerlein S, Molena D, Sillin LF, Jones C, Peters JH. Gastrectomy as a remedial operation for failed fundoplication. J Gastrointest Surg. 2007 Jan;11(1):29-35. [no free full-text available].

Esophagectomy: Modern surgical approaches

A brief discussion of the variety of surgical approaches used for esophagectomy for esophageal cancer including Ivor Lewis, Transhiatal and minimally invasive techniques.

An esophagectomy is surgical resection of the esophagus. If this includes the upper portion of the stomach (for cancers in the distal third) it is sometimes called an esophagogastrectomy. This procedure is often performed as part of treatment for early stage esophageal cancers. This procedure is technically challenging and requires advanced surgical skill and training in esophageal surgery. The general consensus among surgeons and published literature is that a surgeon needs to perform a minimum of 12- 25 esophagectomies per year to maintain proficiency.

Who does the most esophageal surgeries in the USA? The University of Pittsburgh (UPMC) and Dr. Benny Weksler*.

There are several surgical approaches for this procedure, and the “best” approach is a topic that is widely debated among thoracic surgeons. As technology continues to advance, and newer techniques emerge, esophagectomy/ esophagogastrectomy continues to evolve.

Ivor Lewis Esophagectomy

The Ivor Lewis esophagectomy or the transthoracic approach is considered the ‘Gold standard’ among many thoracic surgeons. Named for the surgeon that popularized this approach in 1946, this surgical procedure is actually a combination of two separate surgical procedures – a laparotomy incision to allow for mobilization of the stomach, and a right-sided thoracotomy for excision and resection of the esophagus. In the modified approach discussed by David & Marshall (2010), the need for patient repositioning in eliminated, allowing for a faster, more efficient operation without sacrificing visibility or accessibility for lymph node dissection. (During the standard approach – the patient is re-positioned after the laparotomy portion of the operation is complete.)

The Ivor Lewis is often considered superior to other techniques for esophageal cancer because the open laparotomy allows for good abdominal exposure for wider lymph node dissection. This examination of the abdomen and abdominal lymph nodes is critical for the detection of more widespread (or metastatic disease.) In fact, if metastatic disease is detected during this portion of the operation, most surgeons will abandon the procedure*.

* The presence of metastatic disease drastically changes longevity outcomes, and makes esophagectomy ineffective for cancer treatment.

The main disadvantage is that the Ivor Lewis approach is a big operation (actually two operations) and carries the complications of both a large abdominal operation and a large thoracic procedure (with a thoracotomy.) One of these complications is increased pain. In addition to being burdensome for the patient to endure, the increased pain leads to increased pneumonias, respiratory and other complications due to ineffective pulmonary toileting and limited mobility secondary to this discomfort.)

This procedure is contraindicated in patients who have undergone a previous thoracotomy (due to adhesions). As alluded to above, all surgical resections (Ivor Lewis, Transhiatal and other approaches) are contraindicated in patients with evidence of metastatic disease.

Cerfolio, R. J., Bryant, A. S., Bass, C. S., Alexander, J. R. & Bartolucci, A. A. (2004). Fast tracking after Ivor Lewis esophagogastrectomy. Chest 2004 Oct; 126 (4) 1187 – 94. As the article explains – another advantage of high volume centers is fast-tracking after surgery for a day seven (POD#7) discharge. This also promotes standardization of care which is essential in teaching facilities and other healthcare centers with residents/ students/ frequent staff turnover.

Crofts, T. J. (2000). Ivor Lewis esophagectomy for middle and lower third esophageal lesions – how we do it. J. R. Coll Surg Edinb. 45 Ocotober 2000, 296 – 303. Excellent article with overview of Ivor Lewis procedure. Link in text above.

David, E. A., & Marshall, M. B. (2010). Modifications to Ivor Lewis esophagectomy. Interactive CardioVascular and Thoracic Surgery 11 (2010) 529 – 531.

Transhiatal esophagectomy

The transhiatal approach was first discussed in the literature in 1933, but fell out of favor for a number of years before making a resurgence in the 1970’s.

In the transhiatal approach, the surgeon still makes two separate incisions – one in the anterior cervical area (neck) and a laparotomy for mobilization of the stomach. The main advantage to this approach is the avoidance of a thoracostomy incision, and a shorter duration of the operation. (The use of a thoracotomy incision is believed to increase the risk of post-operative pulmonary complications). The other advantages of the transhiatal approach are less pain (thoracotomy incision is more painful than cervical approach). This approach also eliminates the possibility of mediastinitis from an anastamotic leak since the anastamosis is not in the thoracic cavity.

However, detractors of this procedure cite the difficulties due to poor visualization of the esophageal tumors during the operation, the increased rate of anastamosis leak and development of post-operative strictures (Barreto & Posner, 2010).

Bareto, J. C., & Posner, M. C. (2010). Transhiatal versus transthoracic esophagectomy for esophageal cancer. World Journal of Gastroenterology 2010 Aug 14; 16 (30) 3804 – 3810.

Pines, G., Klein, Y., Metzer, E., Idelevich, E., Buyeviv, V., et. al (2011). One hundred transhiatal esophagectomies: a single institution experience. Isr Med Assoc J. 2011 Jul; 13 (7) 428 – 33.

Minimally invasive esophagectomy

Currently, there are several large randomized studies comparing newer surgical techniques with the Ivor Lewis esophagectomy. The MIRO trial and the TIME trials are on-going. (Enrollment in both of these trials are on-going with more information for interested patients available at clinicaltrials.gov).

There are multiple varieties of approaches for ‘minimally invasive’ esophageal surgery. These procedures are Ivor Lewis or Transhiatal approaches that have been modified by the use of laparoscopic equipment (for the abdominal portion) or thoracoscopic equipment for the transthoracic or transhiatal portion, or a combination of the above. Robot-assisted technologies have also been used in modified approaches to reduce incision size, (thus post-operative pain/ pulmonary complications.) A recent study by Dr. Luketich showed favorable outcomes in a large series of patients undergoing minimally-invasive procedures (link to article abstract below.)

Akiyama, S., Kodera, Y., Koike, M., Kasai, Y., et al. (2001). Small incisional esophagectomy with endoscopic assistance: evaluation of a new technique. Surgery Today, 31 (4) 378 – 382. [no free full text available.] Description of the ‘Akiyama’ approach.

Gao, Y., Wang, Y., Chen, L. & Zhao, Y. (2011). Comparison of open three-field and minimally invasive esophagectomy for esophageal cancer. Interact CardioVasc Thorac Surg 2011, 12: 366 – 369. I would have to argue against the authors contention that the McKeown approach is the preferred open surgical technique of most thoracic surgeons. (The McKeown is a modification of the Ivor Lewis). Surgeons: Care to comment?

Herbella, F. A., & Patti, M. G. (2010). Minimally invasive esophagectomy. World Journal of Gastroenterology,2010 Aug 14; 16 (30) 3811 – 3815.

Jarral, O. A., Purkayastha, S., Athanasiou, T., & Zacharakis, E. (2011). Should thoracoscopic three-stage esophagectomy be performed in the prone or left lateral decubitus position? Interact Cardiovasc Thorac Surg 2011, Jul 13 (1) 60 – 5. A review of the literature surrounding patient positioning for esophagectomy.

James D Luketich, MD, Omar Awais, DO*, Manisha Shende, MD*, Neil A Christie, MD*, Benny Weksler, MD*, Rodney J Landreneau, MD, Blair A Jobe, MD*, Ghulam Abbas, MD*, Arjun Pennathur, MD*, Matthew J Schuchert, MD*, Katie S Nason, MD, MPH*
University of Pittsburgh, Pittsburgh, PA Outcomes after minimally invasive esophagectomy. Presented at the 131 annual meeting of the American Surgical Association, April 14th – 16th, 2011 in Boca Raton, Fla.

We, B., Xue, L., Qiu, M., Zheng, X., Zhong, L., Qin, X., & Xu, Z. (2010). Video-assisted mediastinoscopic transhiatal esophagectomy combined with laparoscopy for esophageal cancer. J Cardiothorac Surg 2010 Dec 31; 5, 132. Report of forty cases using combined minimally invasive techniques for better visualization and mediastinal lymph node dissection.

Additional References:

More about esophagectomies – a short promotional video by Mayo Clinic. [Nicely illustrated.]

Dumont, P., Wihlm, J. M., Hentz, J. G., Roeslin, N., Lion, R., & Morand, G. (1995). Respiratory complications after surgical treatment of esophageal cancer: a study of 309 patients according to the type of resection. Eur J Cardiothorac Surg 1995; 9 (10) 539 – 43. Comparison of Ivor Lewis and the Akiyama procedure.

Kim et al. (2001). Esophageal resection: Indications, techniques, and radiologic assessment. Radiographics, Sept 2001, 21 (5): 1119 – 1137. See table 1 for summary of surgical techniques and outcomes.

Suttie, S. A., Li, A. G. K., Quinn, M., & Park, K. G. M. (2007). The impact of operative approach on outcome of surgery for gastro-oesophageal tumours. World Journal of Surgical Oncology. 2007; 5: 95. Comparison of Ivor Lewis, transhiatal and left thoraco-laparotomy approaches.

*Update: Dr. Benny Weksler is now at the University of Tennessee, Memphis.

Minimally invasive fundoplication for GERD: the transoral esophagogastric approach

the transoral esophagastric fundoplication procedure and Dr. Darren Rohan, a thoracic surgeon performing this minimally invasive technique.

A cardiothoracic surgeon in New York, Dr. Darren Rohan has started a new minimally invasive program for reflux surgery (called fundoplication.) With the transoral esophagogastric fundoplication procedure, he can tighten the sphincter (valve) between the stomach and the esophagus by endoscopy (instead of laparoscopic surgery) to prevent acid from refluxing into the esophagus. This is an important development in the treatment of gerd (gastroesophageal reflux disease) since the incidence of gerd is on the rise – due to obesity and this has led to an increase in esophageal cancer (as discussed in a previous post).

(Now, Dr. Rohan isn’t the first person to perform this procedure but I thought he’s be a great person to tell us more about it here at Cirugia de Torax, so I’ve written to him to request more information and to invite him to contribute a guest post.)

We also know that in addition to esophageal cancer (and Barrett’s esophagus) that reflux does more than destroy tooth enamel. Work by researchers at Duke has linked reflux with problems with lung transplant recipients, and then to reactive airway disease itself. While the degree of this relationship is not fully understood and is still debated – it is clear that there is a correlation to reflux disease and airway disease. It has also been associated with aspiration pneumonia, particularly in patients on reflux suppressing medications.

I’ll be updating this story soon with more information.

Additional references and resources:

World J Gastrointest Endosc. 2010 Dec 16;2(12):388-96. Gastroesophageal reflux disease: Important considerations for the older patients. Chait MM. (free full text). This article talks about the range of complications and how elderly patients may present with more severe symptoms.

Saudi J Gastroenterol. 2010 Apr-Jun;16(2):84-9. Study of respiratory disorders in endoscopically negative and positive gastroesophageal reflux disease. Maher MM, Darwish AA. 9free full text). An Egyptian study looking at the relationship between relux and lung disease.

This 2009 review of the literature, by Kumar and Gupta out of India claims no association between reflux and asthma (but uses the effectiveness of acid suppressing medications in treating asthma as their proof of this theory – which is a faulty premise, in my opinion since these medications often don’t effectively treat reflux.)

More about the transoral esophagogastric fundaplication:

Surg Endosc. 2011 Jun;25(6):1975-84. Epub 2010 Dec 8. Clinical and pH-metric outcomes of transoral esophagogastric fundoplication for the treatment of gastroesophageal reflux disease. Bell RC, Freeman KD. (Bell and Freeman also authored the article cited in the text above.) Free full-text.

Esophageal surgery and esophageal surgery centers

Discussion of article by Bilimoria and the importance of high volume esophageal surgery programs for successful post-operative outcomes.

Here’s another study highlighting the importance of having esophagectomies (esophageal surgery) at high volume centers. It’s a topic we’ve talked about before, and as it’s something I feel very strongly about – something readers will probably see mentioned again. It also helps answer the question – “Do I need to travel to X for surgery or can I have it at the local hospital?” This was the main questions the researchers were looking at for this study in terms of costs, logistics and burdens on patient and family.

This article by Bilimoria et. al (2010), published in the Annals of Surgery, was actually comparing outcomes for multiple surgery types at small community hospital versus large specialty center, not just thoracic surgeries but the research findings are similar to what we have reported previously. The irony of this study is that the researchers were expressly trying to prove the opposite, that small hospitals are safe for high complexity, high morbidity/ mortality operations – as a way to cut costs, and save money by preventing additional patient shifting to larger institutions that may be at a considerable distance for patients. They demonstrated limited success in their results for other surgeries – but the need for high volume esophagectomy programs for successful surgical outcomes remains unchanged. (Some of this may be due to the fact that many of these esophagectomies at smaller hospitals are performed by general, not thoracic surgeons.)

The answer for patients with esophageal cancer is: Yes – you do need to go to the esophageal cancer center (not your local community hospital). This is regardless of classification of low or high risk (which is based on age, and a Charlson score – which is a score used to add up other risk factors). This is something I have had to address with patients in my own personal practice as both a referring provider (at a smaller facility) and as a receiving provider (when I was at a larger esophageal surgery center.)

I’ve reposted the abstract below, so you can read for yourself. (The article itself is several pages long). [Italics are mine..]

Bilimoria, et. al. (2010). Risk-based Selective Referral for Cancer Surgery: A Potential Strategy to Improve Perioperative Outcomes Annals of Surgery. 2010;251(4):708-716.

Abstract

Background: Studies have demonstrated volume-outcome relationships for numerous operations, providing an impetus for regionalization; however, volume-based regionalization may not be feasible or necessary. Our objective was to determine if low-risk patients undergoing surgery at Community Hospitals have perioperative mortality rates comparable with Specialized Centers.

Methods: From the National Cancer Data Base, 940,718 patients from ~1430 hospitals were identified who underwent resection for 1 of 15 cancers (2003–2005). Patients were stratified by preoperative risk according to age and comorbidities. Separately for each cancer, regression modeling stratified by high- and low-risk groups was used to compare 60-day mortality at Specialized Centers (National Cancer Institute-designated and/or highest-volume quintile institutions), Other Academic Institutions (lower-volume, non-National Cancer Institute), and Community Hospitals.

Results: Low-risk patients had statistically similar perioperative mortality rates at Specialized Centers and Community Hospitals for 13 of 15 operations. High-risk patients had significantly lower perioperative mortality rates at Specialized Centers compared with Community Hospitals for 9 of 15 cancers. Regardless of risk group, perioperative mortality rates were significantly lower for pancreatectomy and esophagectomy at Specialized Centers. Risk-based referral compared with volume-based regionalization of most patients would require fewer patients to change to Specialized Centers.

Conclusions: Perioperative mortality for low-risk patients was comparable at Specialized Centers and Community Hospitals for all cancers except esophageal and pancreatic, thus questioning volume-based regionalization of all patients. Rather, only high-risk patients may need to change hospitals. Mortality rates could be reduced if factors at Specialized Centers resulting in better outcomes for high-risk patients can be identified and transferred to other hospitals.

Only TIME will tell: Esophagectomy

There is a new trial on the horizon that sounds promising; the Traditional Invasive versus Minimally Invasive Esophagectomy (TIME). It’s a timely study indeed as the rates of esophageal cancer in western countries continues to increase, due to GERD and obesity.

I really don’t like the ‘cutesy’ way research trials have been named for the last ten years or so – but in this case – I will just have to look past it. There is a new trial on the horizon that sounds promising; the Traditional Invasive versus Minimally Invasive Esophagectomy (TIME) trial based in the Netherlands. It is a multi-center trial taking place at six hospitals in Europe. This trial will compare both morbidity and mortality in patients undergoing traditional esophagectomy (Ivor Lewis) and patients undergoing minimally – invasive (thoracoscopy combined with laparoscopy) after both sets of patients receive adjuvant chemotherapy. (This approach differs from the transhiatal esophagectomy developed at the University of Michigan in the 1970’s).

The researchers are planning for a five-year follow-up to compare both immediate post-operative complications / mortality with long-term effects (QoL) and cancer recurrence.

The full article is detailed on Medscape. (Also published in BMC Surgery. 2011;11 ). This couldn’t come at a more appropriate time, with recent data showing an abrupt rise in the incidence of esophageal cancer.

In an article (Chustecka) dated from September 2010, British researchers at Cancer Research UK reported a 50% increase in diagnoses of esophageal cancer in the last 25 years, particularly in men in their 50’s. (with an incidence of 14.4 men per 100,000, to put it into perspective, up from 9.9 in 1983.)

More concerning, is the fact that the prevalence of the types of cancer are changing. Previously, the majority of esophageal cancers were caused by squamous cell carcinoma which is linked to smoking and alcohol use. This study, along with an American study, shows an increasing incidence of adenocarcinoma, which is more commonly attributable to gastroesophageal reflux (Barrett’s esophagus). Researchers (Dr. Mark Orringer) estimate that the incidence of adenocarcinoma of the esophagus has increased by 350% in the last thirty years – and is directly related to huge increases in obesity. It now accounts for over 85% of esophageal cancers in the USA.

We’ll bring you more as the trial continues, and preliminary results are reported.

(Dr. Mark Orringer, who was quoted in the original medscape article from 2007 is one of several pioneering surgeons in thoracic surgery. He invented two of the surgical techniques in use today; the aforementioned transhiatal esophagectomy and the Collis -Nissen hiatal hernia repair.)

Here’s your helmet

If you knew now that you were going to be in a horrible but completely unavoidable car accident in a few weeks -you’d do things differently, wouldn’t you? You’d make sure to be in a car with the maximum amount of safety features (we’d all be in Volvos) with 6 air bags, automatic assisted braking, five point seatbelts and helmets. You’d do all of this, to ensure your survival. You wouldn’t just hop into a pinto and drive off to work..

I’ve always considered esophagectomies (surgical treatment for esophageal cancer) to be the ‘open heart’ procedure of Thoracic Surgery. It’s a big surgery on precariously positioned patients, which often represents the only hope for definitive treatment or potential cure.

Due to the nature of the disease and it’s presentation, these patients are usually quite fragile pre-operatively. Early in my career, I was fortunate enough to work with Dr. Ronald Hill and Dr. Geoffrey Graeber, who stressed the absolute importance of early and aggressive pre-operative optimization and nutritional rehabilitation in these patients. I learned that albumin and pre-albumin (nutritional labs) were just as important that almost any other factor in predicting outcomes (independent of catastrophic bleeding or other surgical events).

This training, more than anything else, changed the way I practice – and changed the way I view surgery. Before working with esophageal cancer patients – I viewed surgery the way many people see surgery – as a treatment for a condition, a means to a desired outcome.

I understood physiological stress, and the stress response and all of these concepts – but I still viewed surgery as a treatment. Now I see surgery, particularly large surgeries such as this for what it really is – a profound, manmade injury. The benefits only come later – if your patient survives the initial injury and recovery phase.
This paradigm shift was absolutely essential for the continued health and well-being of my patients – and it’s something I really try to impart to my patients (without terrifying them). This paradigm makes us truly understand why all the advance planning is necessary, vital and absolutely essential.

Pre-optimization is giving your patient a helmet, a seatbelt, and array of airbags, and understanding that they are about to be in a severe roll-over crash.

When you do these things for your esophagectomy patients – you do this for all your patients – and take the time to explain and impart this knowledge to the patients, so they can be active participants in this process. This pre-operative training/ planning, in my experience is the one crucial factor; (more than surgical technique, surgeon* or hospital facility) in ultimately determining outcomes.

K. Eckland, ACNP

Abstract (in advance of publication) on preoperative prevention of pulmonary complications

* All of the factors listed above have been postulated to predict post-operative outcomes. In particular, data shows that thoracic surgeons with greater than 12 – 25 cases (esophagectomies) per year have better outcomes than nonthoracic surgeons. Some argue that these successes are due to the widespread use of aggressive pre-operative strategies within the thoracic surgery specialty, and a better understanding of intra-operative factors; such as anatomy of the chest, leading to better understanding of tumors eligible for resection, and less intra-operative blood loss. For more information on the impact of thoracic surgery training on thoracic surgery outcomes, please see the post: Who is performing your thoracic surgery?

Additional Resources: Pre-operative management/ prevention of post-operative complications in patients undergoing esophagectomy

Akutsu, Y. & Matsubara, H. (2009) Perioperative Management for the Prevention of Postoperative Pneumonia with Esophageal Surgery. Ann Thorac Cardiovasc Surg. 2009 Oct;15(5):280-5. (free full text). This is a well written report by Japanese surgeons on several techniques to reduce post-operative pneumonia. Several of these items can be directly implemented by patients – such as pre-operative smoking cessation, pulmonary rehabilitation and good dental hygeine.