Annals of Surgical Oncology

, Volume 16, Issue 4, pp 1017–1025 | Cite as

Surgical Factors Influence the Outcome After Ivor-Lewis Esophagectomy with Intrathoracic Anastomosis for Adenocarcinoma of the Esophagogastric Junction: A Consecutive Series of 240 Patients at an Experienced Center

  • Katja Ott
  • Franz G. Bader
  • Florian Lordick
  • Marcus Feith
  • Holger Bartels
  • J. Ruediger Siewert
ORIGINAL ARTICLE-THORACIC ONCOLOGY

Abstract

Background

Despite a considerable number of randomized studies, the surgical approach to locally advanced adenocarcinoma of the esophagogastric junction (AEG) I and II is still discussed controversially. Thus, we evaluated the surgical risk and outcome after an abdominothoracic esophagectomy (Ivor-Lewis) with intrathoracic anastomosis as standard procedure.

Methods

Between 1998 and 2006, a total of 240 consecutive patients underwent standardized right thoracoabdominal esophagectomy with two-field lymphadenectomy and intrathoracic anastomosis (Ivor-Lewis operation) for AEG I (n = 206) or AEG II (n = 34). A total of 157 patients (65.4%) had neoadjuvant chemotherapy.

Results

Postoperative morbidity occurred in 17.9% (43 of 240). Overall mortality was 3.8% (9 of 240). The majority of patients (4 of 9) died because of severe pulmonary complications (44.4%) irrespective of surgical complications. Neoadjuvant chemotherapy did not increase morbidity or mortality. The median overall survival was 51 months. Multivariate analysis including age >75 years, clinical response to chemotherapy, complications, R-category and N-category revealed R-category (P = .005; relative risk [RR] 0.32, 95% confidence interval [95% CI] 0.14–0.70) and complications (P < .001, RR 0.16, 95% CI 0.08–0.35) as independent prognostic factors for all patients. Complications was the only independent prognostic factor (P < .001, RR 0.09, 95% CI 0.08–0.35) for the R0 resected patients.

Conclusions

At an experienced center, Ivor-Lewis resection is a safe surgical procedure. Outcome of patients was significantly influenced by surgical factors such as complete resection and complications. Neoadjuvant chemotherapy did not lead to higher morbidity and mortality. The high mortality from non-surgery–related complications emphasizes the importance of careful preoperative evaluation of comorbidities and patient selection.

References

  1. 1.
    Gebski V, Burmeister B, Smithers BM, Foo K, Zalcberg J, Simes J. Survival benefits from neoadjuvant chemoradiotherapy or chemotherapy in oesophageal carcinoma: a meta-analysis. Lancet Oncol. 2007;8:226–34.PubMedCrossRefGoogle Scholar
  2. 2.
    Hulscher JB, Tijssen JG, Obertop H, van Lanschot JJ. Transthoracic versus transhiatal resection for carcinoma of the esophagus: a meta-analysis. Ann Thorac Surg. 2001;72:306–13.PubMedCrossRefGoogle Scholar
  3. 3.
    Hulscher JB, van Sandick JW, de Boer AG, Wijnhoven BP, Tijssen JG, Fockens P, et al. Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the esophagus. N Engl J Med. 2002;347:1662–9.PubMedCrossRefGoogle Scholar
  4. 4.
    Chu KM, Law SY, Fok M, Wong J. A prospective randomized comparison of transhiatal and transthoracic resection for lower-third esophageal carcinoma. Am J Surg. 1997;174:320–4.PubMedCrossRefGoogle Scholar
  5. 5.
    Goldminc M, Maddern G, Le Prise E, Meunier B, Campion JP, Launois B. Oesophagectomy by a transhiatal approach or thoracotomy: a prospective randomized trial. Br J Surg. 1993;8:367–70.CrossRefGoogle Scholar
  6. 6.
    Jacobi CA, Zieren HU, Muller JM, Pichlmaier H. Surgical therapy of esophageal carcinoma: the influence of surgical approach and esophageal resection on cardiopulmonary function. Eur J Cardiothorac Surg. 1997;11:32–7.PubMedCrossRefGoogle Scholar
  7. 7.
    de Boer AG, van Lanschot JJ, van Sandick JW, Hulscher JB, Stalmeier PF, de Haes JC, et al. Quality of life after transhiatal compared with extended transthoracic resection for adenocarcinoma of the esophagus. J Clin Oncol. 2004;22:4202–8.PubMedCrossRefGoogle Scholar
  8. 8.
    Omloo JM, Lagarde SM, Hulscher JB, Reitsma JB, Fockens P, van Dekken H, et al. Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the mid/distal esophagus: five-year survival of a randomized clinical trial. Ann Surg. 2007;246:992–1000; discussion 1000–1.Google Scholar
  9. 9.
    Siewert JR, Stein HJ, Feith M. Surgical approach to invasive adenocarcinoma of the distal esophagus (Barrett’s cancer). World J Surg. 2003;27:1058–61.PubMedCrossRefGoogle Scholar
  10. 10.
    Bader FG, Lordick F, Fink U, Becker K, Hofler H, Busch R, et al. Paclitaxel in the neoadjuvant treatment for adeno carcinoma of the distal esophagus (AEG I). A comparison of two phase II trials with long-term follow-up. Onkologie. 2008;31:366–72.PubMedCrossRefGoogle Scholar
  11. 11.
    Ott K, Sendler A, Becker K, Dittler HJ, Helmberger H, Busch R, et al. Neoadjuvant chemotherapy with cisplatin, 5-FU, and leucovorin (PLF) in locally advanced gastric cancer: a prospective phase II study. Gastric Cancer. 2003;6:159–67.PubMedCrossRefGoogle Scholar
  12. 12.
    Bartels H, Stein HJ, Siewert JR. Preoperative risk analysis and postoperative mortality of oesophagectomy for resectable oesophageal cancer. Br J Surg. 1998;85:840–4.PubMedCrossRefGoogle Scholar
  13. 13.
    Bartels H, Stein HJ, Siewert JR. Risk analysis in esophageal surgery. Recent Results Cancer Res. 2000;155:89–96.PubMedGoogle Scholar
  14. 14.
    Ott K, Weber WA, Lordick F, Becker K, Busch R, Herrmann K, et al. Metabolic imaging predicts response, survival, and recurrence in adenocarcinomas of the esophagogastric junction. J Clin Oncol. 2006;24:4692–8.PubMedCrossRefGoogle Scholar
  15. 15.
    Weber WA, Ott K, Becker K, Dittler HJ, Helmberger H, Avril NE, et al. Prediction of response to preoperative chemotherapy in adenocarcinomas of the esophagogastric junction by metabolic imaging. J Clin Oncol. 2001;19:3058–65.PubMedGoogle Scholar
  16. 16.
    Ott K, Fink U, Becker K, Stahl A, Dittler HJ, Busch R, et al. Prediction of response to preoperative chemotherapy in gastric carcinoma by metabolic imaging: results of a prospective trial. J Clin Oncol. 2003;21:4604–10.PubMedCrossRefGoogle Scholar
  17. 17.
    Becker K, Mueller JD, Schulmacher C, Ott, K, Fink U, Busch R, et al. Histomorphology and grading of regression in gastric carcinoma treated with neoadjuvant chemotherapy. Cancer. 2003;98:1521–30.PubMedCrossRefGoogle Scholar
  18. 18.
    Kauer WK, Stein HJ, Dittler HJ, Siewert JR. Stent implantation as a treatment option in patients with thoracic anastomotic leaks after esophagectomy. Surg Endosc. 2008;22:50–3.PubMedCrossRefGoogle Scholar
  19. 19.
    Green F, Page D, Fleming I. AJCC cancer staging manual,. 6th ed. New York: Springer, 2002.Google Scholar
  20. 20.
    Bizekis C, Kent MS, Luketich JD, Buenaventura PO, Landreneau RJ, Schuchert MJ, Alvelo-Rivera M. Initial experience with minimally invasive Ivor Lewis esophagectomy. Ann Thorac Surg. 2006;82:402–6; discussion 406–7.Google Scholar
  21. 21.
    Griffin SM, Shaw IH, Dresner SM. Early complications after Ivor Lewis subtotal esophagectomy with two-field lymphadenectomy: risk factors and management. J Am Coll Surg. 2002;194:285–97.PubMedCrossRefGoogle Scholar
  22. 22.
    Junemann-Ramirez M, Awan MY, Khan ZM, Rahamim JS. Anastomotic leakage post-esophagogastrectomy for esophageal carcinoma: retrospective analysis of predictive factors, management and influence on long-term survival in a high volume centre. Eur J Cardiothorac Surg. 2005;27:3–7.PubMedCrossRefGoogle Scholar
  23. 23.
    Karl RC, Schreiber R, Boulware D, Baker S, Coppola D. Factors affecting morbidity, mortality, and survival in patients undergoing Ivor Lewis esophagogastrectomy. Ann Surg. 2000; 231:635–43.PubMedCrossRefGoogle Scholar
  24. 24.
    Lozac’h P, Topart P, Perramant M. Ivor Lewis procedure for epidermoid carcinoma of the esophagus. A series of 264 patients. Semin Surg Oncol. 1997;13:238–44.PubMedCrossRefGoogle Scholar
  25. 25.
    Sarela AI, Tolan DJ, Harris K, Dexter SP, Sue-Ling HM. Anastomotic leakage after esophagectomy for cancer: a mortality-free experience. J Am Coll Surg. 2008;206:516–23.PubMedCrossRefGoogle Scholar
  26. 26.
    Stilidi I, Davydov M, Bokhyan V, Suleymanov E. Subtotal esophagectomy with extended 2-field lymph node dissection for thoracic esophageal cancer. Eur J Cardiothorac Surg. 2003;23:415–20.PubMedCrossRefGoogle Scholar
  27. 27.
    Suttie SA, Li AG, Quinn M, Park KG. The impact of operative approach on outcome of surgery for gastro-oesophageal tumours. World J Surg Oncol. 2007;5:95.PubMedCrossRefGoogle Scholar
  28. 28.
    Visbal AL, Allen MS, Miller DL, Deschamps C, Trastek VF, Pairolero PC. Ivor Lewis esophagogastrectomy for esophageal cancer. Ann Thorac Surg. 2001;71:1803–8.PubMedCrossRefGoogle Scholar
  29. 29.
    Ferri LE, Law S, Wong KH, Kwok KF, Wong J. The influence of technical complications on postoperative outcome and survival after esophagectomy. Ann Surg Oncol. 2006;13:557–64.PubMedCrossRefGoogle Scholar
  30. 30.
    Brucher BL, Becker K, Lordick F, Fink U, Sarbia M, Stein H, et al. The clinical impact of histopathologic response assessment by residual tumor cell quantification in esophageal squamous cell carcinomas. Cancer. 2006;106:2119–27.PubMedCrossRefGoogle Scholar
  31. 31.
    Atkins BZ, Shah AS, Hutcheson KA, Mangum JH, Pappas TN, Harpole DH, Jr., D’Amico TA. Reducing hospital morbidity and mortality following esophagectomy. Ann Thorac Surg. 2004;78:1170–6. discussion 1170–6.Google Scholar
  32. 32.
    Dumont P, Wihlm JM, Hentz JG, Roeslin N, Lion R, Morand G. Respiratory complications after surgical treatment of esophageal cancer A study of 309 patients according to the type of resection. Eur J Cardiothorac Surg. 1995;9:539–43.PubMedCrossRefGoogle Scholar
  33. 33.
    Smetana GW. Preoperative pulmonary evaluation. N Engl J Med. 1999;340:937–44.PubMedCrossRefGoogle Scholar
  34. 34.
    Whooley BP, Law S, Murthy SC, Alexandrou A, Wong J. Analysis of reduced death and complication rates after esophageal resection. Ann Surg. 2001;233:338–44.PubMedCrossRefGoogle Scholar
  35. 35.
    Paterson IM, Wong J. Anastomotic leakage: an avoidable complication of Lewis-Tanner oesophagectomy. Br J Surg. 1989;76:127–9.PubMedCrossRefGoogle Scholar
  36. 36.
    Sauvanet A, Baltar J, Le Mee J, Belghiti J. Diagnosis and conservative management of intrathoracic leakage after oesophagectomy. Br J Surg. 1998;85:1446–9.PubMedCrossRefGoogle Scholar
  37. 37.
    Urschel JD. Esophagogastrostomy anastomotic leaks complicating esophagectomy: a review. Am J Surg. 1995;169:634–40.PubMedCrossRefGoogle Scholar
  38. 38.
    Liebermann-Meffert DM, Meier R, Siewert JR. Vascular anatomy of the gastric tube used for esophageal reconstruction. Ann Thorac Surg. 1992;54:1110–5.PubMedCrossRefGoogle Scholar
  39. 39.
    Law SY, Fok M, Wong J. Risk analysis in resection of squamous cell carcinoma of the esophagus. World J Surg. 1994;18:339–46.PubMedCrossRefGoogle Scholar
  40. 40.
    Binkert CA, Yucel EK, Davison BD, Sugarbaker DJ, Baum RA. Percutaneous treatment of high-output chylothorax with embolization or needle disruption technique. J Vasc Interv Radiol. 2005;16:1257–62.PubMedGoogle Scholar
  41. 41.
    Cope C, Kaiser LR. Management of unremitting chylothorax by percutaneous embolization and blockage of retroperitoneal lymphatic vessels in 42 patients. J Vasc Interv Radiol. 2002;13:1139–48.PubMedCrossRefGoogle Scholar
  42. 42.
    Bona D, Sarli D, Saino G, Quarenghi M, Bonavina L. Successful conservative management of benign gastro-bronchial fistula after intrathoracic esophagogastrostomy. Ann Thorac Surg. 2007;84:1036–8.PubMedCrossRefGoogle Scholar
  43. 43.
    Orringer MB, Marshall B, Chang AC, Lee J, Pickens A, Lau CL. Two thousand transhiatal esophagectomies: changing trends, lessons learned. Ann Surg. 2007;246:363–72. discussion 372–4.Google Scholar
  44. 44.
    Sakakura C, Hagiwara A, Kato D, Deguchi K, Hamada T, Itoi Y, et al. Successful treatment of intractable esophagothoracic fistula using covered self-expandable stent. Hepatogastroenterology. 2003;50:77–9.PubMedGoogle Scholar
  45. 45.
    Law S, Wong KH, Kwok KF, Chu KM, Wong J. Predictive factors for postoperative pulmonary complications and mortality after esophagectomy for cancer. Ann Surg. 2004;240:791–800.PubMedCrossRefGoogle Scholar
  46. 46.
    Ruol A, Portale G, Castoro C, Merigliano S, Cagol M, Cavallin F, et al. Effects of neoadjuvant therapy on perioperative morbidity in elderly patients undergoing esophagectomy for esophageal cancer. Ann Surg Oncol. 2007;14:3243–50.PubMedCrossRefGoogle Scholar
  47. 47.
    Cunningham D, Allum WH, Stenning SP, Thompson JN, Van de Velde CJ, Nicolson M, et al. Perioperative chemotherapy versus surgery alone for resectable gastroesophageal cancer. N Engl J Med. 2006;355:11–20.PubMedCrossRefGoogle Scholar
  48. 48.
    Berger AC, Scott WJ, Freedman G, Konski A, Weiner L, Cheng JD, Goldberg M. Morbidity and mortality are not increased after induction chemoradiotherapy followed by esophagectomy in patients with esophageal cancer. Semin Oncol. 2005;32(6 Suppl 9): S16–20.Google Scholar
  49. 49.
    Kelley ST, Coppola D, Karl RC. Neoadjuvant chemoradiotherapy is not associated with a higher complication rate vs. surgery alone in patients undergoing esophagectomy. J Gastrointest Surg. 2004;8:227–31; discussion 231–2.Google Scholar
  50. 50.
    Low DE, Kunz S, Schembre D, Otero H, Malpass T, Hsi A, et al. Esophagectomy—it’s not just about mortality anymore: standardized perioperative clinical pathways improve outcomes in patients with esophageal cancer. J Gastrointest Surg. 2007;11:1395–402. discussion 1402.Google Scholar
  51. 51.
    Bonavina L, Via A, Incarbone R, Saino G, Peracchia A. Results of surgical therapy in patients with Barrett’s adenocarcinoma. World J Surg. 2003;27:1062–6.PubMedCrossRefGoogle Scholar
  52. 52.
    Lagarde SM, Maris AK, de Castro SM, Busch OR, Obertop H, van Lanschot JJ. Evaluation of O-POSSUM in predicting in-hospital mortality after resection for oesophageal cancer. Br J Surg. 2007;94:1521–6.PubMedCrossRefGoogle Scholar
  53. 53.
    Lagarde SM, Reitsma JB, de Castro SM, Ten Kate FJ, Busch OR, van Lanschot JJ. Prognostic nomogram for patients undergoing oesophagectomy for adenocarcinoma of the oesophagus or gastro-oesophageal junction. Br J Surg. 2007;94:1361–8.PubMedCrossRefGoogle Scholar
  54. 54.
    Siewert JR, Stein HJ, Feith M. Adenocarcinoma of the esophago-gastric junction. Scand J Surg. 2006;95:260–9.PubMedGoogle Scholar

Copyright information

© Society of Surgical Oncology 2009

Authors and Affiliations

  • Katja Ott
    • 1
    • 2
  • Franz G. Bader
    • 2
  • Florian Lordick
    • 2
    • 3
  • Marcus Feith
    • 2
  • Holger Bartels
    • 2
  • J. Ruediger Siewert
    • 2
  1. 1.Department of SurgeryUniversity of HeidelbergHeidelbergGermany
  2. 2.Department of Surgery, Klinikum rechts der IsarTechnische UniversitätMunichGermany
  3. 3. Department of Medical Oncology, National Centre for Tumor DiseasesUniversity of HeidelbergHeidelbergGermany

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