Oncological Outcomes After Laparoscopic Trans- Hiatal Resection for pT1 Esophageal Adenocarcinoma Arin Saha, Simon Dexter & Abeezar Sarela Department of Upper GI & Minimally Invasive Surgery, Leeds, UK
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Oncological Outcomes After Laparoscopic Trans-Hiatal
Resection for pT1 Esophageal Adenocarcinoma
Arin Saha, Simon Dexter & Abeezar Sarela
Department of Upper GI &
Minimally Invasive Surgery, Leeds, UK
Laparoscopic Esophagectomy for pT1 adenocarcinoma
Early Esophageal Adenocarcinoma
• Resection is optimum treatment
• Limited lymphadenectomy is adequateStein et al. Ann Surg 2000;232:733-42
• Transhiatal vs. Transthoracic resection – similar long-term survival – lower peri-operative mortality
Chang et al. Ann Surg 2008;85:424-429
• Laparoscopic trans-hiatal esophagectomy is safe and feasible
Sarela et al. SAGES 2007
Laparoscopic Esophagectomy for pT1 adenocarcinoma
Endoscopic Mucosal Resection
• Definitive treatment for esophageal adenocarcinoma limited to mucosa (T1a) or submucosa (T1b)?
• Limitations– Lymph node metastasis– Multi-focal cancer– Lymphovascular invasion
Laparoscopic Esophagectomy for pT1 adenocarcinoma
Aims
• To describe pathological characteristics and clinical outcomes of laparoscopic transhiatal esophagectomy or open esophagectomy for pT1 adenocarcinoma
• To identify patients who might be appropriate candidates for EMR
Laparoscopic Esophagectomy for pT1 adenocarcinoma
Patients & Operations
Jan 2000-Dec 2006Esophagectomies for
Adenocarcinoma172 patients
Pathological stage: T1No neo-adjuvant therapy
44 patients (26%)
Laparoscopic Transhiatal Esophagectomy
16 patients (36%)
Open Ivor Lewis Esophagectomy
24 patients (55%)
Open Transhiatal Esophagectomy
4 patients (9%)
Post-operative follow-up: median 44 months (range, 12-93)
Laparoscopic Esophagectomy for pT1 adenocarcinoma
Laparoscopic vs. Open Resection
Laparoscopic Transhiatal
16 patients
Open
Ivor Lewis
24 patients
Open Transhiatal
4 patients
Post-operative Mortality
0 2 0
Lymph node retrieval
15 (4-41) 19 (10-51) 16 (3-28)
Laparoscopic Esophagectomy for pT1 adenocarcinoma
Pathological CharacteristicsEsophagectomy for pT1 adenocarcinoma
Feature No. of patients (%)
Total: 44 patients
Submucosal invasion (pT1b) 11 (25%)
Poor differentiation 4 (9%)
Long segment Barrett’s (> 3cm) 31 (70%)
Tumor length > 1cm 14 (32%)
Laparoscopic Esophagectomy for pT1 adenocarcinoma
Impediments to
EMR
No. of patients (%)
Total : 44 patients
Lymph node metastasis 2 (5%)
Multifocal carcinoma or HGD 27 (61%)
Lymphovascular invasion 2 (5%)
Pathological Characteristics Esophagectomy for pT1 adenocarcinoma
Aggregate number of patients who may have been
inadequately treated by EMR: 29 (66%)
Laparoscopic Esophagectomy for pT1 adenocarcinoma
Oncological Outcome Esophagectomy for pT1 Adenocarcinoma
Operation Tumor Depth
Differentiation Node status
Time to recurrence
Site of recurrence
Lap. Trans-Hiatal
T1b Poor N0 6 Nodes
Open Ivor Lewis
T1b Poor N1 8 Liver
Open Ivor Lewis
T1a Poor N0 22 Liver
Laparoscopic Esophagectomy for pT1 adenocarcinoma
Conclusions
• Similar lymph node retrieval with laparoscopic trans-hiatal esophagectomy or open esophagectomy
• Small but definite risk (7%) of recurrent disease after esophagectomy for T1 adenocarcinoma
• No evidence of oncological detriment by laparoscopic resection
Laparoscopic Esophagectomy for pT1 adenocarcinoma
Conclusions
• 66% of early esophageal adenocarcinoma
may have been inadequately treated by
EMR
• EMR should be reserved for highly
selected patients
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