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Minimally invasive total adventitial resection of the cardia for tumours of the oesophagogastric junction

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Abstract

Purpose

A cohort study analysing phases and outcomes of the learning curve required to master minimally invasive total adventitial resection of the cardia.

Methods

Data from 198 consecutive oesophagectomies performed by a single surgeon was collected prospectively. Patients’ stratification reflected chronologically and technically the four main phases of the learning curve: open surgery (open total adventitial resection of the cardia (TARC), n = 45), hybrid Ivor Lewis oesophagectomy (HILO, n = 50), laparoscopic-thoracoscopic assisted (LTA, n = 56) and totally minimally invasive TARC (TMI TARC, n = 47). Operating time, hospital stay, specimen lymph nodes and resection margins were analysed. Five-year survival was the main long-term outcome measured.

Results

Overall 5-year survival was 45%. Perioperative mortality was 1.5% (n = 3). Hospital stay was 22 ± 23 days. Specimen lymph node median was 20 (range: 15–26). Resection margins were negative (R = 0, American College of Pathologists) in 193 cases (97.4%). Five-year survival in the four phases was 37.8%, 44.9%, 42.9% and 55.3%, showing a positive trend towards the end of the learning curve (p = 0.024). Median specimen lymph nodes was 20 (range: 15–22) for open TARC, 18.5 (13–25) for HILO, 19.5 (15–25) for LTA and 23 (18–30) for TMI TARC (p = 0.006). TMI TARC, adenocarcinoma, R >0, T >2, N >0 and LyRa (ratio positive/total specimen nodes) were associated with survival on univariate analysis. T >2 and LyRa independently predicted worse survival on multivariate analysis. CUSUM analysis showed surgical proficiency gain since laparoscopy was introduced.

Conclusion

Mastering minimally invasive TARC requires a long learning curve. TMI TARC is safe and oncologically appropriate and may benefit long-term survival: it should be validated by randomised trials as a standardised anatomical resection for tumours of the oesophagogastric junction.

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Data availability

This study was registered with London South East London Cancer Network and as a Guy’s and St Thomas’ NHS Foundation Trust Quality Improvement Project.

Abbreviations

CAP:

College of American Pathologists

CUSUM:

Cumulative sum

ECF:

Epirubicin, cisplatin and fluorouracil

ECX:

Epirubicin, cisplatin and capecitabine

HILO:

Hybrid Ivor Lewis oesophagectomy

LTA:

Laparoscopic-thoracoscopic assisted

LyRa:

Lymph node ratio (% of positive lymph nodes of the specimen total)

OGJ:

Oesophagogastric junction

TARC:

Total adventitial resection of the cardia

TMI:

Totally minimally invasive

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Acknowledgements

The authors are thankful to Mr. Mark Kelly and Ms. Liza Nkwoliza for their advice and support and to Ms. Cara Baker for the anatomical illustrations.

Code availability

QIP 8692

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Authors and Affiliations

  1. Department of Upper GI Surgery, St Thomas’ Hospital, Guy’s and St Thomas’ NHS Foundation Trust, Westminster Bridge Road, London, London, SE1 7EH, UK

    Francesco Di Maggio, Ai Ru Lee, Gavriella Zoi Vrakopoulou & Abraham J Botha

  2. King’s College University, London, UK

    Francesco Di Maggio

  3. Pathology Department, St Thomas’ Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London, UK

    Harriet Deere

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  1. Francesco Di Maggio
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Contributions

FDM collected the data, performed the analysis and wrote the paper; ARL collected and analysed some data; ZV contributed to the data collection and analysis; HD collected the data; AB conceived and designed the study, performed the surgery and supported the analysis and writing.

Corresponding author

Correspondence to Francesco Di Maggio.

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This article does not contain any studies with animals performed by any of the authors. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments. Informed consent was obtained from all individual participants included in the study.

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The authors declare no competing interests.

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Supplementary Information

Supplementary Fig. 1

(A) Kaplan Meier analysis of chemotherapy regimen 1 (ECF) vs chemotherapy regimen 2 (ECX). Difference is not statistically significant (P = 0.3 Log Rank Mantel Cox test). (B) Kaplan Meier analysis of TARC (open or minimally invasive, learning groups 1 + 4) vs non-TARC (groups 2 and 3) showing no statistical difference in long-term survival between the two groups. (PNG 477 kb)

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Di Maggio, F., Lee, A.R., Deere, H. et al. Minimally invasive total adventitial resection of the cardia for tumours of the oesophagogastric junction. Langenbecks Arch Surg 406, 2273–2285 (2021). https://doi.org/10.1007/s00423-021-02174-0

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