Tag: esophajectomy

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.

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..

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.