Laparoscopic trans hiatal esophagectomy for early cancer-final

Laparoscopic Trans-Hiatal Esophagectomy for Early Cancer Abeezar I. Sarela Department of Upper GI & Minimally Invasive Surgery Leeds, UK

SAGES Presenter Disclosure Slide Abeezar I. Sarela Nothing To Disclose

Agenda Early Esophageal Carcinoma ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

What is Early Esophageal Cancer? Superficial Esophageal Carcinoma Japanese Esophageal Society Esophagus 2009;6:1-25 T1a + T1b AJCC/TNM 7 th Edition Early Esophageal Carcinoma Japanese Esophageal Society Esophagus 2009;6:1-25 T1a AJCC/TNM 7th Edition

pT1 Esophageal Carcinoma Depth of primary tumor and lymph node metastasis ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],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 Specimens sm1 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 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Westerterp et al. Virchows Arch 2005;446:497-504

Oncological Outcomes Esophagectomy for pT1 Adenocarcinoma Saha et al. Surg Endosc 2009;23:119-124 40 patients - T1b 11 patients - N1 20% of T1b - Poor differentiation 4 patients Liver 22 N0 Poor T1a Trans-thoracic Liver 8 N1 Poor T1b Trans-thoracic Nodes 6 N0 Poor T1b Trans-Hiatal Site of recurrence Time to recurrence Node status Differentiation Tumor Depth Operation

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 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Takubo et al. Histopathology 2007;51:733-742

Endoscopic Ultrasound (EUS) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Endoscopic Mucosal Resection ,[object Object],[object Object]

Emerging Treatment Paradigm EMR of all resectable dysplastic lesions Favourable histology? Multifocality? Ablation of the remaining Barrett‘s - ?RFA Endoscopic Surveillance

Indications for Esophagectomy ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Transhiatal vs. Transthoracic? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Hulscher et al. N Eng J Med 2002;347:1662-9; Omloo et al. Ann Surg 2007;246:992-1000

Laparoscopic Transhiatal Esophagectomy ,[object Object],[object Object],[object Object],[object Object],[object Object],Decker et al. European Journal of Cardio-Thoracic Surgery. 2009;35:13-21

Laparoscopic Esophagectomy Transhiatal vs. Transthoracic Decker et al. European Journal of Cardio-Thoracic Surgery. 2009;35:13-21 17 (7-62) 10 (5-15) Lymph node count 2.4% 4.6% Mortality 6.8% 3% Re-operation 22% 22% Respiratory complic. 7.6% 13% Leakage 6.4% 10% Vocal cord palsy Transthoracic 1499 patients Transhiatal 433 patients

What is the Aim of Esophagectomy? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Laparoscopic Vagus-Sparing Esophagectomy ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Peyre 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) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Stein et al. Ann Surg 2000;232:733-742

Conclusions ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Laparoscopic trans hiatal esophagectomy for early cancer-final

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Laparoscopic trans hiatal esophagectomy for early cancer-final