Laparoscopic Trans-Hiatal Esophagectomy for Early Cancer

Abeezar I. SarelaDepartment of Upper GI & Minimally Invasive Surgery

Leeds, UK

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Abeezar I. Sarela

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AgendaEarly Esophageal Carcinoma

• Pathology• Diagnosis and Staging• Role of Endoscopic Therapy• Indications for surgery• Type of surgery

– Transhiatal vs. Transthoracic esophagectomy– Conventional laparoscopic trans-hiatal esophagectomy– Vagus-sparing esophagectomy– Merindino operation

Superficial Esophageal CarcinomaJapanese Esophageal SocietyEsophagus 2009;6:1-25

T1a + T1bAJCC/TNM 7th Edition

Early Esophageal CarcinomaJapanese Esophageal SocietyEsophagus 2009;6:1-25

T1aAJCC/TNM 7th Edition

What is Early Esophageal Cancer?

pT1 Esophageal CarcinomaDepth of primary tumor and lymph node metastasis

Adenocarcinoma

• 157 patients

• T1a: 45%, N+ 0%

• T1b: 55%, N+ 21%

• Distant N+ < 2%

• 5 year survival: 83%

Squamous Carcinoma

• 133 patients

• T1a: 20%, N+8%

• T1b: 80%, N+36%

• Distant N+: 4-11%

• 5 year survival: 63%

Stein et al. Ann Surg 2005;242:566-573

Subclassification of Depth of Invasion by Superficial Carcinoma of the Esophagus in

Surgically Resected Specimens

Endoscopic Resection Specimenssm1 carcinoma: invades less than 200 microns into the submucosa

Japanese Esophageal Society. Japanese Classification of Esophageal Cancer. !0 th Ed.Esophagus 2009;6:1-25

Relationship between Depth of Invasion and Lymph Node Metastasis in

Superficial Squamous Carcinoma

Takubo et al. Histopathology 2007;51:733-742

Relationship between Depth of Invasion and Lymph Node Metastasis

in Superficial Adenocarcinoma

• Transhiatal Esophagectomy: 120 patients

• m1-sm1 : 79 patients, N+ 1 patient (1%)

• sm2-sm3: 41 patients, N+ 18 patients (44%)

• 5 yr survival

– N0: 97%

– N+: 57%

Westerterp et al. Virchows Arch 2005;446:497-504

Oncological Outcomes Esophagectomy for pT1 Adenocarcinoma

Operation Tumor Depth

Differentiation Node status

Time to recurrence

Site of recurrence

Trans-Hiatal

T1b Poor N0 6 Nodes

Trans-thoracic

T1b Poor N1 8 Liver

Trans-thoracic

T1a Poor N0 22 Liver

Saha et al. Surg Endosc 2009;23:119-124

40 patients - T1b 11 patients - N1 20% of T1b - Poor differentiation 4 patients

Diagnosis and Staging of Early (T1a) and

Superficial (T1a+T1b)Esophageal Carcinoma

Endoscopic Diagnosis of Early Esophageal Carcinoma

Fujinon “FICE”

Olympus “Tri-Modality”

Can we predict the risk of lymph node metastasis?

27%

50%

20%

10%

10%

Incidence of nodal metastasis

Takubo et al. Histopathology 2007;51:733-742

High Risk Factors for Lymph Node Metastasis

• Depth of invasion – T1b

• Morphology – types 0-I and 0-III

• Lymphatic permeation

• Poor histological differentiation

• Tumor size

• Infiltrative growth pattern

Takubo et al. Histopathology 2007;51:733-742

Endoscopic Ultrasound (EUS)

• Conventional EUS– 5 layers– Poor distinction:

T1a vs. T1b

• High Frequency Ultrasound Probe Sonography (HFUPS)– 9 layers

• Ultrasound-guided FNA of peri-esophageal nodes?

Endoscopic Mucosal Resection

• Definitive treatment for

early (T1a) esophageal

adenocarcinoma

• Intermediate staging

strategy

Emerging Treatment Paradigm

EMR of all resectable dysplastic lesions

Favourable histology? Multifocality?

Ablation of the remaining Barrett‘s - ?RFA

Endoscopic Surveillance

Indications for Esophagectomy

• Complete EMR not feasible/not achieved

• T1b: ≥20% incidence of nodal metastasis (? T1a-MM)

• Unfavorable histological characteristics– Poor differentiation– Lymphovascular invasion

• Multi-focal cancer

• Peri-esophageal lymphadenopathy at EUS

Transhiatal vs. Transthoracic?

• Randomised clinical trial• Adenocarcinoma: Siewert types 1 or 2• Final analysis on 205 patients• No difference in post-operative mortality• 5 year actual survival benefit for

transthoracic operation– Limited to patients with 1-8 positive nodes– Overall survival: 14% benefit– Recurrence-free survival: 41% benefit

Hulscher et al. N Eng J Med 2002;347:1662-9; Omloo et al. Ann Surg 2007;246:992-1000

Laparoscopic Transhiatal Esophagectomy

• 17 series

• 433 patients [median 20 (10-68)]

• Exclusively trans-abdominal: mediastinal anastomosis after segmental resection

• Laparoscopic dissection, mini-laparotomy and neck anastomosis

• Entirely laparoscopic: specimen retrieval via the neck

Decker et al. European Journal of Cardio-Thoracic Surgery. 2009;35:13-21

Laparoscopic EsophagectomyTranshiatal vs. Transthoracic

Transhiatal

433 patients

Transthoracic

1499 patients

Vocal cord palsy 10% 6.4%

Leakage 13% 7.6%

Respiratory complic. 22% 22%

Re-operation 3% 6.8%

Mortality 4.6% 2.4%

Lymph node count 10 (5-15) 17 (7-62)

Decker et al. European Journal of Cardio-Thoracic Surgery. 2009;35:13-21

What is the Aim of Esophagectomy?

• T1a/Low-risk for lymph node metastasis – to eradicate the primary tumor– Conventional laparoscopic transhiatal operation

– Vagus-preserving esophagectomy

– Merindino operation

• T1b/High-risk for lymph node metastasis – to achieve radical lymphadenectomy– Trans-thoracic esophagectomy

Laparoscopic Vagus-Sparing Esophagectomy

• Less extensive operation

• Enhanced perfusion of gastric conduit

• No need for pyloroplasty

• Dumping & diarrhoea in less than 10%

• Less weight loss

• Less infectious complications

• ? cardioprotectivePeyre et al. Ann Surg 2007;246:665-671

DeMeester S. Personal communication, 2010

Segmental Resection of the Gastroesophageal Junction and

Reconstruction with a Pedicled Flap of Jejunum (Merindino Operation)

• 94 patients• T1a or T1b adenocarcinoma• Transhiatal (11) vs. Transthoracic (60) vs.

Merindino (24)• Similar lymph node retrieval • Merindino operation:

– Less complications– No mortality

Stein et al. Ann Surg 2000;232:733-742

Conclusions

• Early esophageal carcinoma – mucosal disease (T1a)

• Very low risk of lymph node metastasis (limited to T1a-MM)

• EMR: staging and treatment strategy• Laparoscopic trans-hiatal esophagectomy

for incomplete definitive ensocopic therapy• Minimize morbidity

– Vagus-sparing esophagectomy– Merindino operation