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(BQ) Part 2 book “Perioperative management in robotic surgery” has contents: Fetal surgery and robotic surgery, surgical considerations for organ transplantation and robotic surgery, technical skills training and simulation, anesthetic considerations in robotic cardiac anesthesia,… and other contents.
Chapter 12 Robotics in Thoracic Surgery 2 Benign and Malignant Esophageal Disease Farid Gharagozloo ENDOSCOPIC ROBOTIC ESOPHAGECTOMY Historical Background “The history of esophageal surgery is a tale of men repeatedly losing to a stronger adversary yet persisting in this unequal struggle until the nature of the problems became apparent and the war was won.” A discussion on robotic esophagectomy is appropriately prefaced by this quote by Emslie, which provides the most accurate perspective for the struggle of surgeons with this elusive organ (1) The anatomic remoteness of the esophagus, along with the many challenges of intraoperative management, have dictated the approach to esophagectomy through the ages Galen described the patient with esophageal cancer in the second century AD In the tenth century, Avicenna described esophageal tumors as the most common cause of dysphagia (2) Although surgery of the esophagus was first recorded by the Egyptians in 2500 BC with “repair of the gullet,” the first successful resection of cervical esophageal cancer was performed by Czerny in 1877 (3) This work was predicated on Billroth’s work in 1871 who demonstrated the feasibility of resection and re-anastomosis of the cervical esophagus in an animal model (4) However, it was six decades later that a successful esophageal resection with intrathoracic anastomosis was performed (5) In 1913, Torek performed the resection of a squamous cell carcinoma (SCCA) of the thoracic esophagus through the left chest (6) Esophageal gastric continuity was established using a rubber tube that connected the cervical esophagus to the stomach The patient survived 13 years For the first decades of the twentieth century, many techniques for the establishment of continuity of the alimentary tract were investigated In 1911, Kelling described the use of colon for esophageal replacement (7) The use of stomach, based on the right gastroepiploic artery and the right gastric artery, was first demonstrated in the laboratory by Kirschner in 1920 (8) In 1933, Ohsava of Japan performed the first successful esophagectomy with an intrathoracic esophagogastric anastomosis through the left chest (9) This pioneering work was followed by similar reports from Marshall, Adams, Phemister, Churchill, and Sweet in the United States who advocated a left transthoracic approach (10–12) In 1946, Ivor Lewis reported esophageal resection through separate laparotomy and right chest incisions with an intrathoracic anastomosis at the apex of the right chest (5) In order to avoid the consequences associated with an intrathoracic anastomotic leak in 1972, McKeown advocated the placement of the esophagogastric anastomosis in the neck through a separate cervical incision after the Ivor Lewis procedure (13) It is of interest that presently the issue of intrathoracic anastomotic leaks continues to dictate the approach to esophageal resections Furthermore, it should be noted that the present controversy between the advantages of transthoracic esophagectomy (TTE) versus transhiatal esophagectomy (THE) is not new Indeed, this controversy has its roots in two different approaches that were advocated throughout the twentieth century The transhiatal approach (THA) began in 1913 when Denk demonstrated in cadavers the feasibility of blunt dissection of the esophagus by working from the neck down and up through the esophageal hiatus (14) This approach was performed by a laparotomy and a cervical incision and obviated the need for a thoracotomy In 1933, Turner reported the first “blunt” esophagectomy followed by an antethoracic skin tube reconstitution of the esophagogastric continuity (15) Ong and Lee in 1916 and LeQuesne and Ranger in 1966 reported a small series of patients with “blunt” esophagectomy with transhiatal gastric pull up and a cervical esophagogastrostomy (16,17) In 1978, Oringer resected the technique of 014 10:36:42, subject to the Cambridge Core terms of use, 127 Chapter 12: Robotics in Thoracic Surgery 2 transhiatal transcervical esophagectomy without a thoracotomy (18) Epidemiology Cancer of the esophagus is one of the most common malignancies worldwide Approximately 13,000 new cases of esophageal cancer were diagnosed in the United States in 1998 Almost 12,000 patients died within the first year (19) Presently the rate of esophageal cancers has increased dramatically Esophageal cancer is unusual compared to other solid tumors due to the geographic variations in incidence and the cell type Although SCCA is the most common histologic subtype of esophageal cancer globally, the primary esophageal adenocarcinoma (ACA) is the predominant histologic subtype in North America (20) In 1991, Blot and colleagues examined more than 9,000 esophageal cases registered in nine National Cancer Institute surveillance, epidemiology, and end results program areas (21) They found that: Adenocarcinoma of the lower esophagus accounted for 17 percent of primary esophageal cancers overall From 1976 to 1987, the average rate of increase for primary esophageal adenocarcinoma exceeded that of any other cancer During the last 3 years of this study, 1984–1987, adenocarcinoma accounted for 34 percent of all esophageal tumors in white males By 1993, adenocarcinoma accounted for 48.1 percent of all cancers of the lower esophagus in the United States (22) In the 1998 update of the original study by Blot, Devasa et al reported a 350 percent increase in the rate of adenocarcinoma of the esophagus in white North American males from 1976 to 1994 (23) With the observation that many adenocarcinomas of the esophagus occur in association with Barrett’s epithelium, the metaplasia–dysplasia– carcinoma sequence has been clearly demonstrated (24) Prospective studies estimate that patients with Barrett’s epithelium have at least a 30- to 40-fold higher risk for development of invasive adenocarcinoma (25) Presently Barrett’s epithelium, which exhibits mutation of the P53 tumor suppressor gene, is considered premalignant (26) This marked change in the biology and epidemiology of esophageal cancer has impacted the therapeutic strategy for this disease significantly As noted, there has been a shift from predominance of SCCA associated with tobacco and alcohol exposure to adenocarcinoma arising in a Barrett’s esophagus as a consequence of reflux disease In contrast to SCCA, the clearly delineated metaplasia–dysplasia–carcinoma sequence with adenocarcinoma provides an opportunity for early detection and better outcomes after resection Historically the role of surgery in SCCA of the esophagus has been one of palliation The risk of surgical procedures associated with the locally advanced nature of SCCA of the mid-esophagus has prevented oncologically efficacious procedures The shift from SCCA of the mid-esophagus to adenocarcinoma of distal esophagus and gastroesophageal junction makes these tumors more amenable to complete resection Furthermore, recent refinements in operative technique and perioperative management have enabled greater safety in accomplishing the more efficacious en bloc tumor resection and nodal exoneration Not only has there been a shift in the cell type and location of esophageal carcinoma, there has also been a shift in the surgical approach from palliation to one with curative intent Therapeutic Strategies Although surgery has been the mainstay of treatment of esophageal carcinoma, the high morbidity and mortality rates associated with surgery have necessitated more palliative procedures as well as the search for nonsurgical therapies Results of surgical resection have improved In the 1960s and 1970s, the operability rate of esophageal carcinoma was 58 percent, resectability rate was 39 percent, mortality associated with resection was 29 percent, with an overall 5-year survival of 4 percent (27) In the 1980s, the resectability rate was 56 percent, mortality rate with resection was 13 percent, and 5-year survival was 10 percent (28) Presently in specialized centers that perform greater than 50 procedures per year, the mortality rate is reported at 4.5 percent with a 5-year survival of 50.4 percent overall (29) Clearly, this dramatic change in the overall survival and operative risk is due to the earlier diagnosis of esophageal carcinoma, refinement of surgical technique and perioperative care, and greater use of multimodality therapy Preoperative Neoadjuvant Chemotherapy Alone The use of preoperative chemotherapy in locally advanced esophageal carcinoma has been the subject of numerous trials Most trials have evaluated 014 127 10:36:42, subject to the Cambridge Core terms of use, Chapter 12: Robotics in Thoracic Surgery 2 preoperative chemotherapy, given for one to six cycles followed by a definitive surgical procedure (30–33) Later trials have given chemotherapy both preoperatively and postoperatively Overall preoperative chemotherapy with cisplatin-based combination therapy has achieved a major response in 17–66 percent of patients with pathologically confirmed complete response of 3–10 percent Operability has ranged from 50 to 100 percent with resectability of tumors ranging from 40 to 90 percent Operative mortality after preoperative chemotherapy has been comparable to surgery alone However, the overall survival of patients treated with preoperative chemotherapy has been disappointing The median 5-year survival has ranged from 10 to 26 percent In support of smaller studies, the landmark American Intergroup Trial reported by Kelsen and colleagues showed no benefit for neoadjuvant chemotherapy over surgery alone (34) Preoperative Neoadjuvant Radiotherapy Alone Trials of neoadjuvant radiotherapy have failed to show increased resection rate or improved survival compared to surgery alone (35) Preoperative Neoadjuvant Combined Chemoradiation Therapy The Radiation Therapy Oncology Group (RTOG 8501) randomized trial showed superiority of neoadjuvant chemoradiation therapy over radiation alone (36,37) The combination of chemoradiation with surgery has resulted in significant disease downstaging and has increased the proportion of R0 resections However, a consistent survival advantage for neoadjuvant chemoradiation followed by surgery has not been demonstrated All these studies have been hampered by the inclusion of both SCCA and adenocarcinoma and inconsistent surgical procedures A survival advantage with neoadjuvant chemoradiation followed by surgery over surgery alone was shown in two trials of patients with adenocarcinoma Three-year survival rates were 32 percent for combined modality therapy versus 6 percent for surgery alone From the limited data available, it seems that chemoradiation may help local disease control, when combined with surgical resection (38) No randomized trials have directly compared chemoradiation with surgery when the surgical procedure has been performed with curative intent rather than palliation Urschell et al performed a meta-analysis of randomized trials comparing neoadjavent chemoradiation and surgery versus surgery alone There were nine studies with 1,116 patients Combined modality therapy was superior to surgery alone with respect to (1) 3-year survival, (2) complete resection, (3) locoregional tumor recurrence, and (4) distant recurrence Twenty-one percent of patients obtained complete pathologic response Results were best when chemo and radiation therapy were given concurrently Operative mortality was higher after multimodality therapy Furthermore, although it has been suggested that chemoradiation alone can be adequate without surgical resection, a number of considerations argue against the omission of surgery: False complete response rates based on imaging modalities are commonly seen, and true complete response can only be determined after resection With chemoradiation alone, persistent local or locally recurrent disease is seen in approximately 50 percent of patients The addition of surgery reduces local disease recurrence (39) Furthermore, even with sterilization of the primary tumor, persistent nodal disease is observed Surgery cleans any persistent nodal disease and provides posttherapy pathologic staging of the disease Surgical treatment following chemoradiation provides far more superior relief of dysphagia and resumption of oral intake compared to chemoradiation alone In one report, solid food intake was 100 percent with surgery as compared to 45 percent without surgery (40) In a perspective study, O’Rourke et al reported incidence of stricture as 16 percent with surgery and 50 percent after chemoradiation alone (41) Furthermore, postoperative anastomotic strictures respond to dilation very easily as compared to postchemoradiation malignant strictures, which not respond to dilation and require stenting or other endoscopic procedures Even though further clinical studies are needed to identify the best multimodality regimens, their dose levels, and methods and schedules of administration, an increasing number of patients are receiving neoadjuvant therapy As shown by Rice et al., patients with advanced disease (T3N1) who respond to neoadjuvant therapy have better outcomes than with surgery 014 10:36:42, subject to the Cambridge Core terms of use, 129 Chapter 12: Robotics in Thoracic Surgery 2 alone (42) These authors have shown that neoadjuvant therapy has not been beneficial in patients with clinical early-stage disease Consequently, at the present time, surgery remains the standard treatment for resectable early-stage cancer of the esophagus Patients with advanced local regional disease should be offered preoperative chemoradiation therapy prior to surgery in order to achieve cytoreduction and improved resectability As a majority of patients with carcinoma of the esophagus are diagnosed at a late stage, the majority of patients are candidates for preoperative neoadjuvant chemoradiation therapy followed by surgery Surgical Therapy Currently, most esophagectomies are carried out either through the transhiatal approach (THE) or through the Ivor Lewis transthoracic approach (TTE) Other procedures such as left thoracoabdominal approach (43), left thoracoabdominal cervical approach (44), left transthoracic approach (45), synchronous combined abdominothoracic cervical approach (46), and transabdominal approach (47) are either of historic interest or reserved for unusual circumstances Transhiatal Esophagectomy Transhiatal esophagectomy without a thoracotomy was resurrected and popularized by Orringer in 1978 This procedure, which uses a laparotomy and cervical incision, removes the esophagus “bluntly” and, after passing the stomach tube through the hiatus and the bed of the esophagus, a cervical esophagogastrostomy is accomplished The advantage of THE is that it avoids the morbidity associated with a thoracotomy Furthermore, the proponents of THE note that cervical anastomotic leaks are not associated with the mediastinitis and high mortality associated with leaks of the intrathoracic anastomosis Although a number of small series has been reported, the largest reported series by Oringer and colleagues presents data on 1,085 patients with THE (48) In this series, THE was possible in 98.6 percent of patients and a stomach was used in 96 percent of patients A total of nine patients (0.8 percent) had excessive intraoperative hemorrhage with three intraoperative deaths Other complications included entry into the pleural spaces (77 percent), splenectomy (3 percent), recurrent laryngeal nerve injury (7 percent), chylothorax (