Advances in esophagectomy LUIS J HERRERA MD SECTION HEAD, THORACIC - - PowerPoint PPT Presentation

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Advances in esophagectomy LUIS J HERRERA MD SECTION HEAD, THORACIC - - PowerPoint PPT Presentation

Apr 06, 2024 586 likes •867 views

Advances in esophagectomy LUIS J HERRERA MD SECTION HEAD, THORACIC SURGERY UF HEALTH CANCER CENTER/ORLANDO HEALTH Disclosure -Consultant and Epicenter Surgeon Intui5ve Surgical Incidence Esophageal Adenocarcinoma Dramatic increase in

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Advances in esophagectomy

LUIS J HERRERA MD SECTION HEAD, THORACIC SURGERY UF HEALTH CANCER CENTER/ORLANDO HEALTH

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Disclosure

  • Consultant and Epicenter Surgeon Intui5ve Surgical
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  • Dramatic increase in incidence of EA in

US and Western Europe

  • In the US 600% increase in the incidence
  • f EA over last 40 years.
  • Risk factors
  • GERD weekly symptoms, > 20 yr Hx
  • Barrett’s
  • Tobacco
  • Obesity

Incidence Esophageal Adenocarcinoma

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ESOPHAGEAL CANCER BARRETT’S Metaplasia-Dysplasia-Adenocarcinoma

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The Problem

75-85% of pa5ents with esophageal cancer present with advanced disease Early disease usually found during rou5ne endoscopies and surveillance of Barre@’s esophagus Single modality treatments unlikely to achieve long term survival in advanced disease Significant morbidity and mortality aFer esophagectomy s5ll occurs despite recent improvements

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ESOPHAGEAL CANCER: Symptoms at presentaOon

Dysphagia (74%) Weight loss (57%) Odynophagia (17%) Regurgita5on or vomi5ng GI bleeding GERD

Daly JM et al. J Am Coll Surg 2000;190:562-72.

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EUS- Staging

Accuracy T stage 84% Accuracy N stage 80%

Reed CE Ann Thor Surg 1999

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Imaging: CT and PET/CT

Useful for diagnosis and staging Useful for ruling out unsuspected metastases (15%) Useful for restaging aFer CRT

  • Best predictor of post-therapy response
  • Best predictor of 2yr survival
  • SUV >4 34%
  • SUV ≤4 64%
  • Clinical stage T3N1M0 (IIIa)

Luketich JD et al. Ann Thor Surg 1999 Swisher SG et al. Ann Thor Surg 2004

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Pa Pathologic CR- Survival

Study Patients who underwent surgery Median survival (mo) Survival % P value

Urba (2001) pCR 14 No pCR 36 49.7 12 3y 64 19 P = 0.01 Chirieac (2005) pCR 77 No pCR 158 133 10.5 to 38.1 5y 65 29 P = 0.003 Swisher (2005) pCR 86 PR 98 > 50% Residual 53 3y 74 54 24 P < 0.001 Berger (2005) pCR 42 PR 13 No response 76 50 49 25 5y 48 34 15 P = 0.015

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Th The g e goa

  • als:

Ge Get a a g good

  • od p

pathol

  • log
  • gic r

c res espon

  • nse

e Re ResecOon of residual disease

  • Pathologic CR in randomized clinical trials
  • Neoadjuvant chemotherapy – 2.5% to 15%
  • Neoadjuvant chemoradiotherapy – 10-28%
  • Several trials have demonstrated improved survival in patients achieving pCR
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So, what is standard of care?

For stage IIb and higher, most ins5tu5ons would use induc5on therapy American trial comparing surgery to chemoradia5on followed by surgery closed early due to poor accrual to the surgery alone arm (CALGB 9781) Analysis of 56 enrolled in CALGB, results favored neoadjuvant therapy (5 yr survival 39% vs 16% in surgery alone arm)

Tepper J et al. J Clin Oncol. 2008 Mar 1;26(7):1086-92

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Surgical Approaches to Esophageal Cancer (INCISIONS AND ANASTOMOSIS)

Oncologic clearance Anastomotic complication Pulmonary complication “Teachability” Cervico- Abdominal (THE)

+ ++ + +

Abdomino- Thoracic (ILE)

++ + ++ +++

Cervico- Abdomino- Thoracic (MCKEWON)

+++ ++ +++ ++

OPEN MINIMALLY INVASIVE

TRANSHIATAL/ OPEN NECK LAPAROSOPY/ OPEN NECK LAPAROTOMY/ THORACOTOMY LAPAROSCOPY/ THORACOSCOPY LAPAROTOMY/ THORACOTOMY/ OPEN NECK LAPAROSCOPY/ THORACOSCOPY/ OPEN NECK

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Treatment opOons- Medically fit

Tis- HGD

  • Focal- EMR or ESD if feasible

Minimally invasive esophagectomy (MIE) Transhiatal esophagectomy (THE) Stage I Minimally invasive esophagectomy (MIE) Transhiatal esophagectomy (THE) Ivor Lewis esophagectomy (ILE) Stage IIA-IIIB

  • Neoadjuvant chemo-radiation (CRT)
  • Esophagectomy with LN dissection
  • Ivor Lewis esophagectomy (ILE)
  • Three field esophagectomy (3FE)
  • Minimally invasive esophagectomy (MIE)

NEOADJUVANT THERAPY

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Technical Aspects Esophagectomy

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Laparoscopic approach: Gastric mobilizaOon, hiatal dissecOon, pyloric drainage, leW gastric artery division, node dissecOon, conduit creaOon, feeding tube

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Thoracoscopic Approach: Esophageal mobilizaOon, node dissecOon, creaOon of anastomosis

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RoboOc Approaches

  • Imaging and perfusion assessment
  • Less need for skilled assistants
  • Mul5-arm control
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RoboOc (ILE)Abdominal approach

Courtesy David Rice, MD Anderson

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RoboOc (ILE) thoracic approach

Courtesy David Rice, MD Anderson

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RoboOc Ivor-Lewis Esophagectomy (Thoracic hand Sewn Anastomosis)

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Huang et al. J of Thoracic Disease 2014

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Summary

Esophageal adenocarcinoma is most common histology in US Accurate staging essen5al to plan treatment Surgical approach according to pa5ent comorbidi5es, disease extent and loca5on and surgeons preference Neoadjuvant treatment commonly used in locally advanced tumors although defini5ve data lacking Esophagectomy can be performed with acceptable morbidity and mortality, despite induc5on therapy

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Thank You!