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  Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 54  |  Issue : 2  |  Page : 439-441
 

Perioperative complications of esophagectomy: Postneoadjuvant treatment versus primary surgery – Our experience and review of literature


Centre for Cancer, Kokilaben Dhirubhai Ambani Hospital, Mumbai, Maharashtra, India

Date of Web Publication21-Feb-2018

Correspondence Address:
Dr. R C Mistry
Centre for Cancer, Kokilaben Dhirubhai Ambani Hospital, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijc.IJC_228_17

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 » Abstract 


AIMS: To compare perioperative complications in esophagectomy after neoadjuvant therapy v/s primary surgery. SETTINGS AND DESIGN: Retrospective analysis of perioperative complications in a prospectively maintained data base of patients who underwent esophagectomy as Primary surgery or after neoadjuvant therapy was done. METHODS AND MATERIAL: 238 cases of esophagectomies performed for esophageal carcinoma were analysed and compared, out of which 125(52.5%) were given neoadjuvant therapy followed by surgery and 113(47.5%) underwent primary surgery. Surgical procedure was standard for both the groups. All the cases were analysed for perioperative complications. STATISTICAL ANALYSIS USED: Data was analysed using Open Epi soft ware. Association between the two study group was assessed with Chi square test. RESULTS: On comparison, both the groups were comparable in demographic profile and type of surgery performed. However, tumour stage was higher for cases who received neoadjuvant therapy as expected. On analysis there was no significant difference in overall morbidity and 30 days mortality. CONCLUSIONS: Neoadjuvant Chemo/chemoradiotherapy is a feasible option in esophageal carcinoma without increase in incidence of peri operative morbidity or mortality.


Keywords: Carcinoma esophagus, neoadjuvant therapy, perioperative complications


How to cite this article:
Patil A S, Gulavani N V, Dharmadhikari N P, Polavarapu K C, Sharma S S, Mistry R C. Perioperative complications of esophagectomy: Postneoadjuvant treatment versus primary surgery – Our experience and review of literature. Indian J Cancer 2017;54:439-41

How to cite this URL:
Patil A S, Gulavani N V, Dharmadhikari N P, Polavarapu K C, Sharma S S, Mistry R C. Perioperative complications of esophagectomy: Postneoadjuvant treatment versus primary surgery – Our experience and review of literature. Indian J Cancer [serial online] 2017 [cited 2019 Sep 21];54:439-41. Available from: http://www.indianjcancer.com/text.asp?2017/54/2/439/225795





 » Introduction Top


Carcinoma of esophagus is an aggressive malignancy and is the 6th most common cause of death due to cancer worldwide. Despite recent advances in medical and surgical management the 5 year survival rate of patients ranges from 15-30%.[1] Incidence of esophageal carcinoma has increased by five times in western countries with adenocarcinoma being the most predominant histology. The exact incidence of esophageal carcinoma in India is not known but squamous cell carcinoma is still the most common type in india.

Surgery is the standard of care for patients with localized carcinoma of the esophagus who are medically fit. For patient with operable but locoregionally advanced disease the current recommendation is induction therapy followed by surgery. Neoadjuvant therapy has proven to be effective in the reduction of locoregional recurrence and improved overall survival for carcinoma of esophagus. The purpose of induction therapy chemotherapy (CT) alone or chemoradiation therapy (CRT) is to downstage the disease and treat occult micrometastasis. Several studies have reported improved overall survival with this strategy. However, there is perceived impression among surgeons that induction therapy, particularly chemoradiation, increases postoperative morbidity and mortality. We report our experience of postoperative outcomes following esophagectomy with and without induction therapy performed at our center.


 » Subjects and Methods Top


This is a retrospective analysis of prospectively maintained database of 238 cases of carcinoma esophagus that underwent esophagectomy between 2009 and 2016. All patients who underwent esophagectomy after neoadjuvant therapy or as primary surgery were included in the study. Both squamous cell carcinoma and adenocarcinoma of the esophagus were included in the study. Patient with resectable carcinoma or those who refused neoadjuvant therapy underwent primary surgery. Patients who had relatively advanced carcinoma were treated with neoadjuvant therapy (CT/CRT) followed by surgery. Patients with carcinoma esophagus underwent standard investigations for staging and evaluating the fitness for surgery. Surgical procedure performed was esophagectomy with mediastinal lymph node dissection. The majority of patient had video-assisted thoracoscopic mobilization of esophagus. Reconstruction was performed with gastric conduit; esophagogastric anastomosis was in the neck in most of the patient and intrathoracic in a few. A feeding jejunostomy was performed in all cases. Our policy was to extubate patient at the end of the procedure.


 » Results Top


Neoadjuvant therapy was administered in 125 (52.5%) patients and 113 (47.5%) patient underwent primary surgery. Esophagectomy was performed 3–6 weeks after completion of neoadjuvant therapy. Both groups were comparable in terms of male to female ratio, median age and type of surgery [Table 1]. Difference in T-stage and N-stage in the two groups was expected as patient with advanced disease received neoadjuvant therapy and those with early disease underwent primary surgery.
Table 1: Demographic and clinical data

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Perioperative complications were documented in all the patients. Complications were divided into medical (bronchopneumonia, respiratory failure, major effusion, pulmonary embolism, arrhythmias, congestive cardiac failure, myocardial ischemia, renal failure, sepsis, hepatic failure, stroke, and metabolic acidosis.) and surgical (anastomotic leak, nonanastomotic leak, gangrene of conduit, hemorrhage, chylothorax, gastric outlet obstruction, intestinal obstruction, tracheobronchial injury, cord paresis, and wound infection). Anastomotic leak was detected either clinically or on contrast gastrografin study which was done on 5th or 6th postoperative day.

In our analysis, of 238 patients who underwent esophagectomy the overall morbidity was 37.39% (89/238) and overall 30-day mortality was 2.94% (7/238). Incidence of medical complications was same in both groups. Bronchopneumonia, pleural effusion, and arrhythmias were most frequently encountered. Respiratory complications were the most frequent cause of morbidity [Table 2].
Table 2: Perioperative medical complications

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Anastomotic leak was seen in five patients in neoadjuvant treatment group and nine patients of primary surgery group, (P = 0.30). Among other complications, frequently seen were hemorrhage, minor wound infection, and cord paresis. There was no significant difference in both groups regarding surgical complications. All cases of hemorrhage were intraoperative and were managed on table. Total six patients underwent re-exploration; three for thoracic duct leak, two for jejunostomy site obstruction. One patient underwent reexploration twice, once for colon herniation into thorax and once for adhesive obstruction [Table 3].
Table 3: Surgical complications

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Perioperative mortality was seen in seven out of 238 patients after esophagectomy. Mortality was seen in two patients in neoadjuvant group and in five patients in primary surgery group. Mortality due to leak was observed in one patient from neoadjuvant treatment group and in two patients in primary surgery group. Sepsis leading to death was seen in two patients in primary surgery group [Table 4].
Table 4: Mortality and its causes

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 » Discussion Top


Esophageal surgery for cancer is associated with significant morbidity and relatively high mortality.[1] The addition of induction therapy before definitive surgery has potential to increase both morbidity and mortality.[2] There are conflicting reports in the literature regarding the impact of neoadjuvant CT and CRT on morbidity and mortality following esophagectomy. Several publications have reported increased postoperative morbidity and mortality in patient undergoing surgery following induction therapy compared to surgery alone. MRC OE02 trial randomized 802 patients with induction CT versus surgery alone. The postoperative complication was 42% and 41% and mortality was 10% each in induction CT group and surgery alone group, respectively.[3] Kelsen et al. reported similar postoperative morbidity and mortality in randomized trial comparing induction CT followed by surgery versus surgery alone in 467 patients.[4] Burmeister et al. conducted a randomized controlled trial of 256 patients comparing surgery alone with preoperative CRT followed by surgery. In both groups, there was no difference in perioperative morbidity and mortality.[5]

Bosset et al., also randomized 297 patients, comparing neoadjuvant CRT followed by surgery with surgery alone, in stage I and II esophageal squamous cell cancer. He found higher mortality rate in patients who received preoperative CRT (17 of 138 as compared with 5 of 137, P = 0.012).[6] Groups did not differ in terms of perioperative morbidity. The Federation Francophone de la Cancerologie digestive (FFCD 9901) was a randomized trial of 195 patients, where preoperative CRT was compared to surgery alone in patient with localized esophageal cancer. While the postoperative morbidity was similar (49.5% in surgery alone and 43.9% CRT; P = 0.17) the mortality was 1.1% in surgery group versus 7.3% in CRT group (P = 0.054).[7] The CROSS trial which was a large randomized trial of CRT followed by surgery versus surgery alone reported similar postoperative complications and in-hospital mortality.[8] Pooled analysis of salvage esophagectomy versus planned resection following definitive CRT by Markar et al. have reported significantly increased postoperative respiratory morbidity and mortality.[9] In this study of 238 patients who underwent esophagectomy we did not find any increase in morbidity or mortality between the cohort undergoing surgery alone and those undergoing surgery following induction therapy. The majority of patient who had induction therapy had CT alone; however, in few patients who had induction CRT there was no difference in perioperative morbidity or mortality. These findings were comparable to findings of major published reports.

Based on our findings and review of published literature, we suggest all patients with locally advanced operable cancer of the esophagus with good performance status be offered induction therapy. It has potential to improve overall survival without increasing operative morbidity or mortality.


 » Conclusion Top


Neoadjuvant CT or chemoradiotherapy is feasible option in locally advanced esophageal cancer without increase in incidence of perioperative complication.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 » References Top

1.
Togo S, Li J, Ligang L, Weix X, Tiechang P, Chen T, et al. Complications and mortality after esophagectomy for esophageal carcinoma: Risk factor analysis in a series of 378 patients. Chir Thorac Cardiovasc 2010;14:25-8.  Back to cited text no. 1
    
2.
Avendano CE, Flume PA, Silvestri GA, King LB, Reed CE. Pulmonary complications after esophagectomy. Ann Thorac Surg 2002;73:922-6.  Back to cited text no. 2
    
3.
Medical Research Council Oesophageal Cancer Working Group. Surgical resection with or without preoperative chemotherapy in oesophageal cancer: A randomised controlled trial. Lancet 2002;359:1727-33.  Back to cited text no. 3
    
4.
Kelsen DP, Ginsberg R, Pajak TF, Sheahan DG, Gunderson L, Mortimer J, et al. Chemotherapy followed by surgery compared with surgery alone for localized esophageal cancer. N Engl J Med 1998;339:1979-84.  Back to cited text no. 4
    
5.
Burmeister BH, Smithers BM, Fitzgerald L, Gebski V, Devitt P, Ackland S, et al. Trans Tasman Radiation Oncology Group, Australasian Gastrointestinal Trials Group and Clinical Trials Center: A randomized phase III trial of preoperative chemoradiation followed by surgery (CR-S) versus surgery alone (S) for localized resectable cancer of the esophagus. Proc Annu Meet Am Soc Clin Oncol 2002;21:130.  Back to cited text no. 5
    
6.
Bosset JF, Gignoux M, Triboulet JP, Tiret E, Mantion G, Elias D, et al. Chemoradiotherapy followed by surgery compared with surgery alone in squamous-cell cancer of the esophagus. N Engl J Med 1997;337:161-7.  Back to cited text no. 6
    
7.
Mariette C, Dahan L, Mornex F, Maillard E, Thomas PA, Meunier B, et al. Surgery alone versus chemoradiotherapy followed by surgery for stage I and II esophageal cancer: Final analysis of randomized controlled phase III trial FFCD 9901. J Clin Oncol 2014;32:2416-22.  Back to cited text no. 7
    
8.
van Hagen P, Hulshof MC, van Lanschot JJ, Steyerberg EW, van Berge Henegouwen MI, Wijnhoven BP, et al. Preoperative chemoradiotherapy for esophageal or junctional cancer. N Engl J Med 2012;366:2074-84.  Back to cited text no. 8
    
9.
Markar SR, Karthikesalingam A, Penna M, Low DE. Assessment of short-term clinical outcomes following salvage esophagectomy for the treatment of esophageal malignancy: Systemic review and pooled analysis. Ann Surg Oncol 2014;21:922-31.  Back to cited text no. 9
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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