Radu NEAGOE, Daniela Tatiana SALA, Serban BANCU, Gheorghe MULHFAY, Septimu VOİDAZAN, Mihaly SZOCS

Outcomes after transhiatal esophagectomies in an eastern-european low-volume center

Background: The present study proposes to analyze the results obtained after transhiatal esophagectomies (THE), from the perspective of an Eastern European surgical center with low esophageal resection volume (LV). Aims: Our analysis, which to the authors knowledge is the first of its kind in Romania, has the purpose of comparing our results with those obtained in higher or similar volume centers, in order to derive conclusions regarding the quality of therapeutic management for patients diagnosed with esophageal cancer in Romania. Study Design: Retrospective observational study. Methods: In total, 70 patients were included, in whom THE was performed during the period 1997-2013 by six senior surgeons. The majority of our patients had esophageal cancers (n=66; 94.3%); we also performed 4 THE procedures for benign conditions (n=3; 4.27%) and esophageal perforation (n=1; 1.42%). Results: The majority of cancer-group patients had T3/ N+ tumors. The nodal involvement in the T2, T3 and T4 categories was 9.9%, 21.6% and 35.1%, respectively. Complications were identified in 45 patients (68.2%), with the majority being represented by pulmonary complications (16 patients; 24.3%) and cervical leaks (15 cases; 22.7%). In-hospital mortality was 9.09%. We found a one-year overall survival rate of 58.7% (95%CI: 51.7-65.7%), 27.2% at 2 years (95%CI: 21.2- 36.2%) and 10.5% at 3 years (95%CI: 6.5-14.5%). The median survival rate was estimated to be 16 months. Conclusion: Morbidity and in-hospital mortality after THE was performed in low-volume centers, despite be- ing significantly higher than reported in HV centers, could be kept at reasonable rates. In our opinion, the measures which have the potential to raise the standard of care for patients diagnosed with esophageal cancer in Romania are represented by the standardization of therapeutic and diagnostic protocols for esophageal cancer and the centralization of these major oncologic interventions in surgical excellence centers. Keywords: Low-volume center, morbidity, survival transhiatal esophagectomy

PDF

___

1.Almhanna K, Shridhar R, Meredith KL. Neoadjuvant or adju- vant therapy for resectable esophageal cancer: is there a standard of care? Cancer Control 2013;20:89-96.
2.Kawoosa NU, Dar AM, Shama ML, Ahangar AG, Lone GN, Bhat MA, et al. Transthoracic versus transhiatal esophagectomy for Esophageal carcinoma: Experience from a single tertiary care institution. World J Surg 2011;35:1296-302. [CrossRef]
3.Neagoe RM, Sala D, Voidazan S, Bancu S, Kiss L, Suciu H. Trans- thoracic versus Transhiatal esophagectomy: a permanent dilemma. Our 15-year experience. Chirurgia (Buc) 2013;108:780-87.
4.Barreto JC, Posner MC. Transhiatal versus transthoracic esophagectomy for esophageal cancer. World J Gastroenterol 2010;16:3804-10. [CrossRef]
5.Birkmeyer JD, Siewers AE, Finlayson EV, Stukel TA, Lucas FL, Batista I, et al. Hospital volume and surgical mortality in the United States. N Engl J Med 2002;346:1128-37. [CrossRef]
6. Begg CB, Cramer LD, Hoskins WJ, Brennan MF. Impact of hos- pital volume on operative mortality for major cancer surgery. JAMA 1998;280:1747-51. [CrossRef]
7. Orringer MB, Sloan H. Esophagectomy without thoracotomy. J Thorac Cardiovasc Surg 1978;76:643-54.
8. Müller JM, Erasmi H, Stelzner M, Zieren U, Pichlmaier H. Surgical ther- apy of oesophageal carcinoma. Br J Surg 1990;77:845-57. [CrossRef]
9. Orringer MB, Marshal B, Chang AC, Lee J, Pickens A, Lau CL. Two thousand transhiatal esophagectomies: changing trends, lessons learned. Ann Surg 2007;246:363-72. [CrossRef]
10. Constantinoiu S. Subtotal abdomino-cervical esophagectomy (transhiatal, without thoracotomy, or Orringers technique). Chirurgia (Bucur) 2005;100:479-87.
11. Halm EA, Lee C, Chassin MR. Is volume related to outcome in health care? A systematic review and methodologic critique of the literature. Ann Intern Med 2002;137:511-20. [CrossRef]
12. Dimick JB, Goodney PP, Orringer MB, Birkmeyer JD. Specialty training and mortality after esophageal cancer resection. Ann Thorac Surg 2005;80:282-86. [CrossRef]
13. Valean S, Armean P, Resteman S, Nagy G, Muresan A, Mircea PA. Cancer mortality in Romania,1995-2004. Digestive sites: esophagus, stomach, colon and rectum, pancreas, liver, gallblad- der and billiary tree. J Gastrointestin Liver Dis 2008;17:9-14.
14. Gaillard J, Bouchayer M, Haguenauer JP. Le risqué de dege- nerescence cancereuse tardive dans les stenosescaustique de loesophage. Ann Otol Rhyno Laryng 1970;87:634-44.
15. Ti TK. Oesophageal carcinoma associated with corrosive inju- ry- prevention and treatment by esophageal resection. Br J Surg 1983;70:223-25. [CrossRef]
16. Zamfir D, Bancu: Urgenţe medico-chirurgicale în patologia es- ofagului, ed. Veritas, Tg. Mureş, 2000.
17. Howard JM, Ryan L, Lim KT, Reynolds JV. Oesophagectomy in the management of end-stage achalasia - case reports and a review of the literature. Int J Surg 2011;9:204-8. [CrossRef]
18. Molena D,Yang SC. Surgical management of end-stage achala- sia. Semin Thorac Cardiovasc Surg 2012;24:19-26. [CrossRef]
19. Neagoe R, Zamfir D, Toma L, Esianu M, Popescu G, Daniela Sala. Revascularizarea grefonului colic-o soluţie de îmbunătăţire a viabilităţii substitutului esofagian. Jurnalul de Chirurgie (Iaşi) 2007;3:360-63.
20. Kesler KA, Pillai ST, Birdas TJ, Rieger KM, Okereke IC, Ceppa D, et al. Supercharged isoperistaltic colon interposition for long-segment esophageal reconstruction. Ann Thorac Surg 2013;95:1162-69. [CrossRef]
21. Davies AR, Forshaw MJ, Khan AA, Noorani AS, Patel VM, Strauss DC, et al. Transhiatal esophagectomy in a high volume institution. World J Surg Oncol 2008;6:88. [CrossRef]
22. HSCIC. 2013. National Oesophago-Gastric Cancer Audit 2013 [online]. Available from: http://www.hscic.gov.uk/catalogue/ PUB11093/clin-audi-supp-prog-oeso-gast-2013-rep.pdf
23. Wouters MW, Wijnhoven BP, Karim-Kos HE, Blaawgeers HG, Stassen LP, Steup WH, et al. High-volume versus low-vol- ume for esophageal resections for cancer: the essential role of case-mix adjustments based on clinical data. Ann Surg Oncol 2008;15:80-7. [CrossRef]
24. Dindo D, Demartines N, Clavien PA. Classification of surgical com- plications: a new proposal with evaluation in a cohort of 6336 pa- tients and results of a survey. Ann Surg 2004;240:205-13. [CrossRef]
25. Hsu HH, Chen JS, Huang PM, Lee JM, Lee YC. Comparison of manual and mechanical cervical esophagogastric anastomosis after esophageal resection for squamous cell carcinoma: a pro- spective randomized controlled trial. Eur J Cardiothorac Surg 2004;25:1097-101. [CrossRef]
26. Chang AC, Ji H, Birkmeyer NJ, Orringer MB, Birkmeyer JD. Outcomes after transhiatal and transthoracic esophagectomy for cancer. Ann Thorac Surg 2008;85:424-9. [CrossRef]
27. Gebski V, Burmeister B, Smithers BM, Foo K, Zalcberg J, Simes J; Australian Gastro-intestinal Trials Group: Survival benefirs from neoadjuvant chemotherapy or chemotherapy in oesopha- geal carcinoma: a meta-analysis. Lancet Oncol 2007;8:226-34. [CrossRef]
28. Donohoe CL, OFarrell NJ, Ravi N, Reynolds JV. Evidence- based selective application of transhiatal esophagectomy in a high-volume esophageal center. World J Surg 2012;36:98- 103. [CrossRef]
29. Feo CV, Villaflor VM, Patti MG. Should esophageal resections for cancer be performed in high-volume centers only? Updates Surg 2011;63:147-50. [CrossRef]
30. Wouters MW, Gooiker GA, van Sandick JW, Tollenaar RA. The volume-outcome relation in the surgical treatment of esopha- geal cancer: a systematic review and meta-analysis. Cancer 2012;118:1754-63. [CrossRef]
31. Funk LM, Gawande AA, Semel ME, Lipsitz SR, Berry WR, Zinner MJ, et al. Esophagectomy outcomes at low-volume hos- pitals: the association between systems characteristics and mor- tality. Ann Surg 2011;253:912-7. [CrossRef]
32. Courrech Staal EF, van Coevorden F, Cats A, Aleman BM, van Velthuysen ML, Boot H, et al. Outcome of low-volume surgery for esophageal cancer in a high-volume referral center. Ann Surg Oncol 2009;16:3219-26. [CrossRef]