Role of Surgery in CA Oesophagus
-
Upload
rrsolution -
Category
Health & Medicine
-
view
71 -
download
1
Transcript of Role of Surgery in CA Oesophagus
Surgery for Carcinoma Esophagus
Dr L.AnandMS MCh FRCS DNB
Associate Professor
Institute of Surgical Gastroenterology
Madras medical College
Still undetermined
Paucity of scientific information
Raging debates
________________________
No consensus
Issues:
1. Relief of dysphagia
2. Aim towards zero operative mortality
3. Reduced hospital stay and morbidity
4. Better ‘Q O L’
5. Protection against recurrence
6. Prolong survival if possible
The two ends in Surgery…….
• Transhiatal Oesophagectomy
• En-bloc oesophagectomy with two or three field
lymphadenectomy
Access –OPEN
• Thorax – Abdomen(Iwor Lewis)
• Thorax – Abdomen – Neck(McKeown)
• Thoracoabdominal(Sweet procedure)
• Transhiatal(Orringer)
Access -MAS
• Thoracoscopy & Laparotomy
• Laparoscopy and Thoracotomy
• VATS & Laparoscopy
• Total MIS
OPENIvor Lewis
Adjacent organs
• What can be removed ?
–Pleura
–Pericardium
–Diaphragm
–Crura
–Thoracic duct with lymphnodes
Complications - 2 F L N D
n Leak Pulmonary RLN
Injury
Death
Lerut et al. 54 12 11 - 7.4
Nishihara et al. 30 8 13 - 7
Altorki 78 13 24 4 5.1
Fujita 65 11 49 48 3
T H E Complications
n Year leak R L N Pulmon
aryDeath
Orringer MB 800 2001 13 7 2 4
Gupta 250 1996 15 14 3 6
Tilanus 141 1993 26 16 17 5
Vigneswaran 131 1993 24 12 12 2.3
44 Series 1986-1996
• 2675 THE
• 2808 TTE
No difference in mortality and
long term survival
Simon Law & John Wong, 2001
• Altorki et al (non randomised trial)
– 4 yr survival – Enbloc esophgectomy
– 37% - TTE vs 11% THE
• Hulscher et al 2002(RCT)
– RCT : TTE vs THE
– 5 yr survival
– TTE: 39% THE: 27% p= 0.08
– MARGINAL STATISCAL SIGNIFICANCE
– Morbidity upto 60% for TTE
Issues for Enbloc Esophgectomy
• Increase time of surgery and anesthesia
• Prolonged Post op ICU Stay
• Length of hospitalisation >14 days
• Morbidity significantly higher
– needs close monitoring with various specialists
• Mortality – similar (TTE vs THE)
• Survival – marginally better
– (Altorki et al and Skinner et al )
• ?QOL
Justification for T H E
Subtotal oesophagectomy possible
Adjacent organ removal
Abdominal and lower mediastinal node removal
(PINOTTI)
Relief of dysphagia
BETTER Q O L
Justification for T H E
Avoiding Thoracotomy
Has it made any difference ?
Hulscher JBF et al. T H E has lower pulmonary complications…
N Eng J Med 2002;347:1662-69
Palanivelu et al 2006
J Am Coll Surg 2006 Vol :203 (1) : 7 -16
Minimally Invasive Esophagectomy : Thoracoscopic
mobilisation of the EsophagusAnd Medicastinal
Lymphadenectomy in prone Position :
Experience of 130 patients
Palanivelu et al 2006
• Respiratory complications: Very minimal
• Anastomotic leak 2.31 %
• Peri- operative mortality 1.54%
• Median Hospital stay : 8Days
• No tracheal/ lung injury
• Stage specific survival was similar
– between open/MAS at 20 months fU