Primary Motility  Disorders of the  Esophagus
 The Esophageal
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 Barrett's
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OESO©2015
 
Volume: Barrett's Esophagus
Chapter: Dysplasia
 

Should thoracoscopically assisted esophagectomy, without extended lymph node clearance, be indicated in resection for high-grade dysplasia?

R. Romagnoli, C. Gutschow, J.-M. Collard (Brussels)

The current question addresses three issues:

- is high-grade dysplasia (HGD) arising in Barrett's esophagus an indication for esophagectomy? In other words, is there a risk for detecting an invasive carcinoma in resection specimens from patients who undergo an esophagectomy because HGD has been found in endoscopic biopsy material?

- if yes, should esophagectomy include extended lymph node clearance? In other words, is there a risk for discovering a locally-advanced carcinoma with loco-regional lymph node involvement in patients operated on for HGD?

- should esophagectomy be thoracoscopically video-assisted? In other words, does videoassisted thoracic surgery (VATS) offer substantial advantages over conventional open techniques of esophageal resection?

First issue

In-depth review of the literature, including 22 series published from 1983 to 2000, indicates that the risk for the detection of an invasive carcinoma in resection specimens from patients who undergo an esophagectomy because of the presence of HGD in endoscopic biopsy material is around 40% [1]. As a consequence, HGD arising in a Barrett's area must be resected rather than followed up endoscopically until invasion beyond the basement membrane becomes evident in one of the subsequent biopsy samples.

Second issue

Meta-analysis of both medical and surgical literature totalizing 171 patients for whom complete histologic data are available indicates that almost all invasive carcinomas detected in resection specimens for HGD are intramural [1], so that the risk for the presence of a locally-advanced carcinoma with metastatic lymph nodes does not exceed 3.5%.

Consequently, from an histologic standpoint, extended lymph node clearance would be useless in most of the patients who are candidates for an esophagectomy because having HGD.

Arguments against such a mass health care policy include the following:

- first, the absence of any neoplastic cells in a single histological section of a given lymph node does not necessarily mean that this lymph node is cancer-free. Indeed, neoplastic cells may exist in another part of the lymph node, and we know that biological micrometastases may be detected by immunohistological techniques in histologically negative nodes [2, 3]. The presence of such micrometastases has been shown to worsen long-term survival significantly in patients who had been staged pNo on the basis of a classic histological examination, so that the long-term outcome of these patients is similar to that of those classified pN1 [4];

- second, recent data from our institution [5] suggest that a risk factor for finding a locallyadvanced neoplasm in resection specimens from patients with a history of HGD is the adoption of an expectant attitude rather than a prompt surgical attitude. Indeed, the 4 invasive carcinomas discovered in a set of 11 patients operated on a few weeks after disclosure of HGD were confined to the esophageal mucosa (pT1a). In contradistinction, four of the 6 invasive carcinomas detected in another set of 13 HGD patients operated on because of the persistence of dysplastic lesions over a long period of endoscopic followup or only after obstructive symptoms had justified an endoscopic control, extended into loco-regional lymph nodes. Therefore, extended lymph node clearance [6, 7] should be added to removal of the esophageal tube only in patients with a long history of HGD or in whom HGD has been disregarded until obstructive esophageal symptoms develop.

Third issue

Over the last decade, numerous surgical teams have applied video-assistance to esophageal resection [8-18]. So, different techniques have been described that aimed to reduce the parietal damage in relation to the classic incisions. These techniques include full thoracoscopic esophageal dissection, minithoracotomy in combination with video-assisted thoracoscopy, video-laparoscopy with cervicotomy, and video-mediastinoscopy from a cervical incision with laparotomy. A few years ago, in the excitement of the so-called video-endoscopic boom, several potential advantages of the video-assisted over the conventional techniques of esophageal resection have been claimed, without scientific background, by some of the early proponents of video-assisted surgery. These new approaches to the esophagus were supposed to reduce the risk for postoperative respiratory complication, postoperative mortality, duration of the in-hospital stay, cosmetic sequellae, and residual chest pain.

In the same time, the old debate of whether extended lymph node dissection is valuable in terms of long-term survival or not has been revived. In this respect, we showed that a real skeletonizing en-bloc esophagectomy was feasible using a full thoracoscopic approach [18]. So, the number of loco-regional lymph nodes seen in the resected specimens (ranging from 21 to 51) was as large as that usually found after esophagectomy by conventional thoracotomy, and both the long-term survival and local recurrence rates did not differ from those previously observed after classic removal of the esophageal tube en-bloc with related lymph glands [19]. In contradistinction, poor survival rates have been reported after resection of the esophageal tube without radical lymph node dissection [20]. This emphasizes once more the fact that the long-term postoperative outcome after esophagectomy for cancer is related to the extent of the internal dissection rather than to the approach to the esophagus [21]. In any case, the new approaches to the esophagus are unlikely to improve long-term survival and cure of cancer patients because lymph node clearance cannot be done more extensively than it is by conventional thoracotomy for years. Rather, parietal seeding probably due to repetitive passage of the instruments through the thoracic ports may jeopardize the final outcome of a potentially curative esophagectomy [14, 15, 22, 23].

Concerning the aforementioned potential advantages of the videoendoscopic over the conventional approaches to the esophagus, data from the literature indicate that they are much less impressive than initially claimed [10-16, 18, 24-26].

Chest pain

Even though early postoperative chest pain can be reduced by video-assisted thoracic surgery as compared to thoracotomy [27], recent developments in postoperative analgesia techniques such as epidural analgesia using a combination of morphine with clonidine have improved postoperative comfort after conventional thoracic surgery [28]. On the other hand, persistent chest wall discomfort may be experienced after thoracoscopic esophagectomy [18], probably because of injury to the intercostal nerve by a trocar inserted through a narrow interspace.

Respiratory complications

They are the most common complications of major esophageal surgery. Contrary to what was expected in the early nineties, we have learned from the experience of several surgical teams [11-18, 29, 30] that the risk for the development of respiratory problems after thoracoscopic esophagectomy is similar to that after esophageal resection by thoracotomy. Actually, postesophagectomy respiratory complications are not simply linked to parietal discomfort due to size of the thoracic incision. Rather, respiratory complications are multifactorial in origin and several conditions may predispose to their development:
- poor initial respiratory condition,
- alcohol-induced weak immunologic barrier,
- extended mediastinal dissection close to the respiratory airways,
- peritracheal lymph node dissection leading to lymphatic stasis within the lung parenchyma,
- intraoperative damage to the lung parenchyma (intrumental retraction),
- postoperative aspiration of gastric juice,
- sepsis secondary to necrosis of the esophageal substitute or anastomotic leakage,
- parietal discomfort and pain (drains, incisions, etc.).

Postoperative mortality

Here again, reduction of the parietal damage fails to lower the risk for the development of lethal complications [14-16, 18, 24, 29]. Even, life-threatening intraoperative technical complications that are unusual when removing the esophagus through a large parietal incision have been reported after thoracoscopic esophagectomy [11, 18, 30]. These technical complications include injury to the respiratory airways, necrosis of the membranous wall of the trachea secondary to excessive coagulation in the upper part of the mediastinum, and injury to either the aorta itself or its branches such as the subclavian and intercostal arteries. Actually, prompt management of untoward injury to any mediastinal structure adjacent to the esophagus is by far less easy by thoracoscopy than by a large thoracotomy, the former does not allow the use of the index finger for immediate coverage of any inadvertent injury.

Duration of the postoperative in-hospital stay

The postoperative in-hospital stay after video-assisted esophagectomy has been shown not to be shorter than after conventional esophagectomy [16, 29, 30].

Cosmetic sequellae

Unlike most of the patients operated on to improve the functioning of the foregut, those operated on for an esophageal cancer do not attach importance to the length of the parietal incisions but expect the best chance of cure from the operation.

Conclusion

Extended lymph node dissection is not to be recommended when performing an esophagectomy in patients having HGD on endoscopic biopsy material, except in those whose HGD has been followed up endoscopically for a long period of time. Retrospective evaluation of the video-endoscopic approaches to the esophagus indicates that although exciting from a technical standpoint, they improve neither the immediate nor the long-term postoperative outcomes. These outcomes are mainly related to the patient's preoperative general status, extent of the internal dissection, and final stage of the neoplastic process. Therefore, video-endoscopic approaches to the esophagus are optional for the management of early neoplastic esophageal disease.

References

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3. Izbicki JR, Hosch SB, Pichlmeier V, et al. Prognostic value of immuno-histochemically identifiable tumor cells in lymph nodes of patients with completely resected esophageal cancer. N Engl J Med 1997;337:1188-1194.

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7. Collard JM, Otte JB, Fiasse R, et al. Skeletonizing en-bloc esophagectomy for cancer. Ann Surg 2001;234:25-32.

8. Buess GF, Becker HD, Naruhn MB. Endoscopic esophagectomy without thoracotomy. Prob Gen Surg 1991;8:478.

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Publication date: August 2003 OESO©2015