|
Back to 2014 Annual Meeting Posters
Learning Curve for Minimally Invasive Trans-Thoracic Esophagectomy: a Single Center Experience
Kush R. Lohani*, Abhishek Sundaram, Se Ryung Yamamoto, Sumeet K. Mittal
Surgery, Creighton University School of Medicine, Omaha, NE
Background:
Minimally invasive esophagectomy is rapidly gaining acceptance as the procedure of choice for esophageal resection. However, it requires advanced laparoscopic and thoracoscopic skills. A learning curve has not been defined for safety and oncological efficacy.
Purpose:
Describe a learning curve for minimally invasive trans-thoracic esophagectomy (MIE) in terms of safety and oncological efficacy.
Methods:
After Institutional review board approval, a prospectively maintained database was queried to identify patients who underwent MIE for esophageal cancer between July 2003 and August 2013. Patients underwent either MIE or a hybrid procedure (either laparotomy or thoracotomy). Study patients were sequentially divided into 4 cohorts (24, 24, 24 and 23 respectively). Sigma plot® version 12.3 was used for statistical analysis.
Results:
Ninety-five patients (82 males) with a median age of 63 years (34-84) met inclusion criteria. There was no significant difference in terms of age, gender and diagnosis among the cohorts (refer table 1). Seventy nine patients (83%) had adenocarcinoma and 63 patients (66.3%) received neo-adjuvant therapy. There were 23 hybrids (12 planned and 11 conversions) and 72 totally MIE procedures with 53 intra-thoracic and 42 cervical anastomosis. Patients in the first cohort had more neck anastomosis than the following patients. There were no conversions in the most recent cohort (refer table 1).
There was a significant decrease in mean operative time (429 ± 57 min to 340 ± 49 min, p<0.001), decrease in median estimated blood loss (500 ml to 300 ml, p=0.004), and increase in mean Lymph Node yield (18.5 ± 11.2 to 36 ± 26, p<0.001) from the first to the last cohort. However, second cohort of patients experienced significantly higher intra-operative complications and severe post-operative complications (Clavien grade ≥ III). The second cohort of patients also experienced higher anastomotic leaks, chyle leaks, new onset atrial fibrillations and pulmonary complications (p= not significant) . Resection status was similar among the cohorts. Hospital stay ranged from 13 days (1st cohort) to 17 days (2nd cohort) (p=0.06). There was an overall 5% in-hospital/ 30-day post-operative mortality (refer table 2).
Conclusion:
Progressive improvement in operative parameters along with improved lymphatic clearance was noted in our single center experience of Minimally Invasive Transthoracic Esophagectomies. Oncological efficacy was noticeable after the initial 24 patients, whereas more patient experience (up to 48) was needed to improve on intra-operative and post-operative complications. Table 1 | Variables | Cohort 1 (n=24) | Cohort 2 (n=24) | Cohort 3 (n=24) | Cohort 4 (n=23) | P-value | | Age (years) | 60.9 ± 10 | 62.8 ± 10 | 66.6 ± 9.5 | 65.2 ± 10.8 | 0.23 | | Gender - Male | 20 (83.3%) | 19 (79%) | 22 (91.6%) | 21 (91.3%) | 0.5 | | Neo-adjuvant treatment | 17 (70.8%) | 18 (75%) | 18 (75%) | 10 (43.5%) | 0.06 | | Diagnosis (Adenocarcinoma) | 20 (83%) | 19 (79%) | 22 (91.6%) | 18 (78%) | 0.59 | | Neck anastomosis | 24 (100%) | 9 (37.5%) | 5 (20.8%) | 4 (17.4%) | <0.001 | | Conversion Hybrids | 1 (4%) | 6 (25%) | 4 (16.6%) | 0% | .028 |
Table 2 | Operative Outcome | Cohort 1 (n=24) | Cohort 2 (n=24) | Cohort 3 (n=24) | Cohort 4 (n=23) | P-value | | Operative time (min) | 429 ± 57 | 402 ± 48 | 373.5 ± 42 | 340 ± 49 | <0.001 | | Blood Loss (ml) | 500 (300-4500) | 550 (225-1800) | 400 (100-1450) | 300 (75-1100) | 0.004 | | Lymph node yield | 18.5 ± 11.2 | 23 ± 16.5 | 22 ± 19.5 | 36 ± 26 | <0.001 | | R0 resection | 24 (100%) | 21 (87.5%) | 21 (87.5%) | 20 (87%) | 0.33 | | Intra-operative complication | 4 (16.6%) | 6 (25%) | 9 (37.5%) | 1 (4.3%) | 0.04 | | Anastomotic leaks | 2 (8.3%) | 6 (25%) | 6 (25%) | 1 (4.3%) | 0.09 | | Chyle leaks | 3 (12.5%) | 6 (25%) | 5 (20.8%) | 4 (17.3%) | 0.7 | | New onset Atrial Fibrillation | 7 (29%) | 6 (25%) | 7 (29%) | 7 (30.4%) | 0.9 | | Pulmonary complications | 6 (25%) | 7 (29%) | 4 (16.6%) | 5 (21.7%) | 0.7 | | Severe post-operative complications (Clavien ≥ III) | 5 (20.8%) | 14 (58.3%) | 8 (33.3%) | 9 (39%) | 0.05 | | Hospital stay (days) | 13 (7-70) | 17 (9-92) | 15.5 (3-44) | 15 (8-41) | 0.06 |
Back to 2014 Annual Meeting Posters
|
