Comparing observed and preferred instruction in robotic surgery.

BACKGROUND: The unique setup of robotic surgery challenges the traditional instructional dynamic between surgical learners and teachers. Previous studies have posited difficulties such as reliance on observational learning and ease of takeover. However, we lack understanding of how these instructional challenges manifest and are perceived by learners. Improving instruction has the potential to optimize education and performance in robotic surgery. METHODS: In this qualitative study, we conducted robotic case observations and learner interviews focusing on instruction in robotic surgery. We deductively generated codes in a theory-informed manner after review of the instructional literature in surgery, medicine, and other fields. We applied these codes in a rigorous directed content analysis of field notes and transcripts to identify themes. RESULTS: Thirty-eight faculty, fellows, and residents participated in 10 robotic cases and 20 semistructured interviews. Observed practices on the basis of case observations differed substantially from preferred practices on the basis of interview data. Using 37 codes, we identified 4 main themes related to instruction in robotic surgery: contextualization, individualization, autonomy, and multimodality. We contrasted observed and preferred instruction in each of these areas to generate instructional considerations that may better align preferences and practices. CONCLUSIONS: We observed several suboptimal instructional practices that contradicted preferred ways of learning. We suggested robotic-specific instructional considerations such as using multimodality to promote active learning and to reduce ambiguity. We also provided considerations applicable to all types of surgery, such as to include rationale to promote learning consolidation and to frame operative steps to allow trainees to plan their participation.

Randomized controlled trials in lung cancer surgery: How are we doing?

Objective: Randomized control trials are considered the highest level of evidence, yet the scalability and practicality of implementing randomized control trials in the thoracic surgical oncology space are not well described. The aim of this study is to understand what types of randomized control trials have been conducted in thoracic surgical oncology and ascertain their success rate in completing them as originally planned. Methods: The ClinicalTrials.gov database was queried in April 2023 to identify registered randomized control trials performed in patients with lung cancer who underwent surgery (by any technique) as part of their treatment. Results: There were 68 eligible randomized control trials; 33 (48.5%) were intended to examine different perioperative patient management strategies (eg, analgesia, ventilation, drainage) or to examine different intraoperative technical aspects (eg, stapling, number of ports, port placement, ligation). The number of randomized control trials was relatively stable over time until a large increase in randomized control trials starting in 2016. Forty-four of the randomized control trials (64.7%) were open-label studies, 43 (63.2%) were conducted in a single facility, 66 (97.1%) had 2 arms, and the mean number of patients enrolled per randomized control trial was 236 (SD, 187). Of 21 completed randomized control trials (31%), the average time to complete accrual was 1605 days (4.4 years) and average time to complete primary/secondary outcomes and adverse events collection was 2125 days (5.82 years). Conclusions: Given the immense investment of resources that randomized control trials require, these findings suggest the need to scrutinize future randomized control trial proposals to assess the likelihood of successful completion. Future study is needed to understand the various contributing factors to randomized control trial success or failure.

Reconstruction of Segmental Bone Defect in Canine Tibia Model Utilizing Bi-Phasic Scaffold: Pilot Study.

The reunion and restoration of large segmental bone defects pose significant clinical challenges. Conventional strategies primarily involve the combination of bone scaffolds with seeded cells and/or growth factors to regulate osteogenesis and angiogenesis. However, these therapies face inherent issues related to immunogenicity, tumorigenesis, bioactivity, and off-the-shelf transplantation. The biogenic micro-environment created by implanted bone grafts plays a crucial role in initiating the bone regeneration cascade. To address this, a highly porous bi-phasic ceramic synthetic bone graft, composed of hydroxyapatite (HA) and alumina (Al), was developed. This graft was employed to repair critical segmental defects, involving the creation of a 2 cm segmental defect in a canine tibia. The assessment of bone regeneration within the synthetic bone graft post-healing was conducted using scintigraphy, micro-CT, histology, and dynamic histomorphometry. The technique yielded pore sizes in the range of 230-430 µm as primary pores, 40-70 µm as secondary inner microchannels, and 200-400 nm as tertiary submicron surface holes. These three components are designed to mimic trabecular bone networks and to provide body fluid adsorption, diffusion, a nutritional supply, communication around the cells, and cell anchorage. The overall porosity was measured at 82.61 ± 1.28%. Both micro-CT imaging and histological analysis provided substantial evidence of robust bone formation and the successful reunion of the critical defect. Furthermore, an histology revealed the presence of vascularization within the newly formed bone area, clearly demonstrating trabecular and cortical bone formation at the 8-week mark post-implantation.

Comparison of Global Evaluative Assessment of Robotic Surgery with objective performance indicators for the assessment of skill during robotic-assisted thoracic surgery.

BACKGROUND: The Global Evaluative Assessment of Robotic Skills is a popular but ultimately subjective assessment tool in robotic-assisted surgery. An alternative approach is to record system or console events or calculate instrument kinematics to derive objective performance indicators. The aim of this study was to compare these 2 approaches and correlate the Global Evaluative Assessment of Robotic Skills with different types of objective performance indicators during robotic-assisted lobectomy. METHODS: Video, system event, and kinematic data were recorded from the robotic surgical system during left upper lobectomy on a standardized perfused and pulsatile ex vivo porcine heart-lung model. Videos were segmented into steps, and the superior vein dissection was graded independently by 2 blinded expert surgeons with Global Evaluative Assessment of Robotic Skills. Objective performance indicators representing categories for energy use, event data, movement, smoothness, time, and wrist articulation were calculated for the same task and compared to Global Evaluative Assessment of Robotic Skills scores. RESULTS: Video and data from 51 cases were analyzed (44 fellows, 7 attendings). Global Evaluative Assessment of Robotic Skills scores were significantly higher for attendings (P < .05), but there was a significant difference in raters' scores of 31.4% (defined as >20% difference in total score). The interclass correlation was 0.44 for 1 rater and 0.61 for 2 raters. Objective performance indicators correlated with Global Evaluative Assessment of Robotic Skills to varying degrees. The most highly correlated Global Evaluative Assessment of Robotic Skills domain was efficiency. Instrument movement and smoothness were highly correlated among objective performance indicator categories. Of individual objective performance indicators, right-hand median jerk, an objective performance indicator of change of acceleration, had the highest correlation coefficient (0.55). CONCLUSION: There was a relatively poor overall correlation between the Global Evaluative Assessment of Robotic Skills and objective performance indicators. However, both appear strongly correlated for certain metrics such as efficiency and smoothness. Objective performance indicators may be a potentially more quantitative and granular approach to assessing skill, given that they can be calculated mathematically and automatically without subjective interpretation.

WNT-modulating gene silencers as a gene therapy for osteoporosis, bone fracture, and critical-sized bone defects.

Treating osteoporosis and associated bone fractures remains challenging for drug development in part due to potential off-target side effects and the requirement for long-term treatment. Here, we identify recombinant adeno-associated virus (rAAV)-mediated gene therapy as a complementary approach to existing osteoporosis therapies, offering long-lasting targeting of multiple targets and/or previously undruggable intracellular non-enzymatic targets. Treatment with a bone-targeted rAAV carrying artificial microRNAs (miRNAs) silenced the expression of WNT antagonists, schnurri-3 (SHN3), and sclerostin (SOST), and enhanced WNT/ß-catenin signaling, osteoblast function, and bone formation. A single systemic administration of rAAVs effectively reversed bone loss in both postmenopausal and senile osteoporosis. Moreover, the healing of bone fracture and critical-sized bone defects was also markedly improved by systemic injection or transplantation of AAV-bound allograft bone to the osteotomy sites. Collectively, our data demonstrate the clinical potential of bone-specific gene silencers to treat skeletal disorders of low bone mass and impaired fracture repair.

Objective performance indicators of cardiothoracic residents are associated with vascular injury during robotic-assisted lobectomy on porcine models.

Surgical training relies on subjective feedback on resident technical performance by attending surgeons. A novel data recorder connected to a robotic-assisted surgical platform captures synchronized kinematic and video data during an operation to calculate quantitative, objective performance indicators (OPIs). The aim of this study was to determine if OPIs during initial task of a resident's robotic-assisted lobectomy (RL) correlated with bleeding during the procedure. Forty-six residents from the 2019 Thoracic Surgery Directors Association Resident Boot Camp completed RL on an ex vivo perfused porcine model while continuous video and kinematic data were recorded. For this pilot study, RL was segmented into 12 tasks and OPIs were calculated for the initial major task. Cases were reviewed for major bleeding events and OPIs of bleeding cases were compared to those who did not. Data from 42 residents were complete and included in the analysis. 10/42 residents (23.8%) encountered bleeding: 10/40 residents who started with superior pulmonary vein exposure and 0/2 residents who started with pulmonary artery exposure. Twenty OPIs for both hands were assessed during the initial task. Six OPIs related to instrument usage or smoothness of motion were significant for bleeding. Differences were statistically significant for both hands (p < 0.05). OPIs showing bimanual asymmetry indicated lower proficiency. This study demonstrates that kinematic and video analytics can establish a correlation between objective performance metrics and bleeding events in an ex vivo perfused lobectomy. Further study could assist in the development of focused exercises and simulation on objective domains to help improve overall performance and reducing complications during RL.

Reconstruction of the Maxillary Sinus After Previous Major Sinus Elevation Failure: A Study with a 3-Year Follow-up.

Fourteen maxillary sinuses were reconstructed in 12 patients who presented with a previous sinus elevation failure. In all cases, large perforations of the sinus membrane occurred during removal of the failed graft from the sinus; the perforations were sealed with fibrin glue, then the site was grafted using homologous fibrin glue (HFG) mixed with a calcium phosphate scaffold (CPS). Histologic analyses revealed that the CPS-HFG graft was followed by an ossification process, with the formation of spongy bone similar to that of the normal skeleton. Twenty-four endosseous implants were successfully placed into the newly regenerated bone. All implants were successfully restored with ceramic crowns 6 months after placement. At the 3-year follow-up, no infections or implant failures were reported. The described technique offers several clinical advantages, as the removal of the failed graft, the sinus perforation repair, and the sinus elevation can be achieved in the same surgery without needing to postpone the regenerative surgery phase.

Impact of type of minimally invasive approach on open conversions across ten common procedures in different specialties.

BACKGROUND: Conversion rates during minimally invasive surgery are generally examined in the limited scope of a particular procedure. However, for a hospital or payor, the cumulative impact of conversions during commonly performed procedures could have a much larger negative effect than what is appreciated by individual surgeons. The aim of this study is to assess open conversion rates during minimally invasive surgery (MIS) across common procedures using laparoscopic/thoracoscopic (LAP/VATS) and robotic-assisted (RAS) approaches. STUDY DESIGN: Retrospective cohort study using the Premier Database on patients who underwent common operations (hysterectomy, lobectomy, right colectomy, benign sigmoidectomy, low anterior resection, inguinal and ventral hernia repair, and partial nephrectomy) between January 2013 and September 2015. ICD-9 and CPT codes were used to define procedures, modality, and conversion. Propensity scores were calculated using patient, hospital, and surgeon characteristics. Propensity-score matched analysis was used to compare conversions between LAP/VATS and RAS for each procedure. RESULTS: A total of 278,520 patients had MIS approaches of the ten operations. Conversion occurred in 5% of patients and was associated with a 1.77 day incremental increase in length of stay and $3441 incremental increase in cost. RAS was associated with a 58.5% lower rate of conversion to open surgery compared to LAP/VATS. CONCLUSION: At a health system or payer level, conversion to open is detrimental not just for the patient and surgeon but also puts a significant strain on hospital resources. Use of RAS was associated with less than half of the conversion rate observed for LAP/VATS.

Clinical and Economic Outcomes of Using Robotic Versus Hand-Held Staplers During Robotic Lobectomy.

OBJECTIVE: During robotic lobectomy (RL), the surgeon can elect to use either robotic staplers or hand-held laparoscopic staplers. It is assumed that either will result in similar outcomes, while robotic staplers increase cost. We sought to compare perioperative outcomes and costs between RL cases that utilized robotic staplers versus hand-held staplers in real-world clinical practice. METHODS: Patients who underwent an elective RL between October 2015 and December 2017 were identified in the Premier Hospital Perspective Database. Propensity score matching (PSM) analysis was performed to compare perioperative outcomes, healthcare resource utilization, and costs between cases using robotic staplers and hand-held staplers during RL. RESULTS: In the PSM analysis, RL cases that fully utilized robotic staplers compared to hand-held staplers were associated with significantly lower risks of developing bleeding (5.6% vs 9.8%, P = 0.03) and conversion to open surgery (0.3% vs 5.9%, P = 0.004). Additionally, in a multivariable regression analysis, robotic stapler was associated with reduced risk for air leak (OR 0.70, 95% CI 0.50-0.98) and overall complications (OR 0.76, 95% CI 0.58-0.99). The total index hospitalization costs were comparable between the 2 groups (median [IQR], $21,667 [$16,860-$29,033] in robotic stapler vs $21,398 [$17,258-$29,406] in hand-held stapler, P = 0.22). CONCLUSIONS: Among RL cases, utilization of robotic staplers was associated with significantly lower risks of perioperative bleeding, conversion, and possibly air leak and overall complications compared to RL cases utilizing hand-held staplers. The choice of stapler may have an impact on outcomes and robotic staplers do not increase total costs.

Postoperative opioid use after lobectomy for primary lung cancer: A propensity-matched analysis of Premier hospital data.

OBJECTIVE: To evaluate opioid administration after robotic lobectomy (RL) compared with video-assisted thoracic surgery (VATS) and open lobectomy in patients with lung cancer. METHODS: Patients undergoing lobectomy for primary lung cancer between January 1, 2013, and September 30, 2015, were identified from the US Premier Hospital Perspective Database. The primary outcome was the average daily dose of opioids received from postoperative day (POD) 1 until discharge. Opioid doses were converted to morphine equivalent daily doses (MEDDs). Propensity score matching was performed to balance patient, hospital, and surgeon characteristics when comparing opioid administration by surgical approach. RESULTS: The open versus RL cohort included 2061 matched pairs, and the VATS versus RL cohort included 2142 matched pairs. From POD 1 until discharge, the patients undergoing open lobectomy had a higher rate of opioid use compared with those undergoing RL (94.8% vs 87.2%; P < .001), with a higher total dose (median MEDD, 225.0 vs 100.0; P < .001) and average daily dose (median MEDD, 41.3 vs 30.0; P < .001). Similarly, from POD 1 until discharge, patients undergoing VATS lobectomy had a slightly higher rate of opioid use compared with those undergoing RL (89.6% vs 87.0%; P = .008), with a higher total dose (median MEDD, 130.0 vs 100.0; P < .001) and average daily dose (median MEDD, 33.8 vs 28.8; P < .001). CONCLUSIONS: Patients undergoing RL for primary lung cancer received opioids less frequently, and with lower total and average daily doses, compared with those undergoing VATS and open lobectomy. Studies are needed to determine whether early opioid dosage reductions translate into less chronic opioid use.

Adequacy of EGD Reporting: a Review of 100 Reports from 100 Endoscopists.

INTRODUCTION: Esophagogastroduodenoscopy (EGD) is commonly performed in patients with gastroesophageal reflux disease (GERD). An EGD report should document pertinent findings such as esophagitis, a columnar-lined esophagus (CLE), the location of the squamo-columnar and gastroesophageal junctions, the size and type of a hiatal hernia and the number and location of any biopsies. The aim of this study was to evaluate how commonly these findings were noted in the EGD reports of patients referred for antireflux surgery. METHODS: A retrospective review was performed of patient charts from 2012 to 2015 to identify 100 consecutive EGD reports from different endoscopists in different patients. Each EGD report was reviewed for pertinent findings and the use of a classification system for esophagitis (Savory-Miller or Los Angeles) and for reporting a CLE (Prague). RESULTS: In 100 EGD reports, esophagitis was noted in 33 patients, but was graded in only 14 (42%). A CLE was noted in 28 patients, but the length was reported in only 16 (57%) and no report used the Prague classification system. A hiatal hernia was noted in 61 patients, measured in 31 (51%) and the type classified in 26%. A biopsy was taken in 93 patients and the location noted in 86 patients (93%). The number of biopsies was recorded in only 20 patients (22%). In 12 patients the EGD was for Barrett's surveillance, yet a Seattle biopsy protocol was reported to be used in only 3 patients. CONCLUSION: Endoscopy reports frequently do not include the use of a grading system for esophagitis or the Prague system for CLE. This hampers the assessment of change with therapy or over time. The size of a hiatal hernia was typically reported in a subjective fashion and only infrequently was the type specified. Lack of clarity about the presence of a paraesophageal hernia can impede evaluation of acute symptoms. In patients with Barrett's esophagus a standard biopsy protocol was infrequently reported to be used. These findings raise concern about the quality of upper endoscopy, both in the performance of the procedure and the documentation of findings. A consistent reporting system is recommended for routine use with upper endoscopy.

Clinical and economic comparative effectiveness of robotic-assisted, video-assisted thoracoscopic, and open lobectomy.

BACKGROUND: We sought to evaluate trends and clinical and economic outcomes between robotic-assisted lobectomy (RL), video-assisted thoracoscopic lobectomy (VL), and open pulmonary lobectomy (OL). METHODS: Patients who underwent a lobectomy for malignancy from January 1, 2008, to September 30, 2015, were identified in the Premier Healthcare Database. Propensity score matched (PSM) comparisons were performed between RL versus VL and RL versus OL. Patient characteristics were applied to generate propensity scores. In-hospital and perioperative 30-day outcomes and costs were compared within matched cohorts. RESULTS: From 2008 to 2015, there was a marked decline for OL (71% to 43%, P<0.0001) with a significant increase in RL (1% to 17%, P<0.0001) and VL (28% to 41%, P<0.0001). In the early period (January 2008 to December 2012), total operating room time was longer (P<0.0001) and admission to ICU was more common for RL compared to VL or OL (P<0.0001) although the total length of ICU stay was shorter for RL compared to VL or OL (P<0.0001). In the late period (January 2013 to September 2015), RL was associated with significantly lower rates of complications (P<0.05), conversions, and shorter length of stay than VL and OL. When hospital volume was not considered, costs were higher for RL than VL and OL. In hospitals where >25 lobectomies were performed annually, the total cost of RL was comparable to VL (P=0.09) and OL (P=0.11). CONCLUSIONS: During the study period, the utilization of RL increased substantially and was associated with improved perioperative outcomes compared with VL and OL. When annual hospital volume was >25 cases, these clinical advantages persisted and there was no significant cost difference between RL, VL, or OL. RL is an effective and cost-comparable approach for lobectomy in patients with lung malignancy.

Port Strategies for Robot-Assisted Lobectomy by High-Volume Thoracic Surgeons: A Nationwide Survey.

OBJECTIVE: Robot-assisted lobectomy is the fastest growing technique for pulmonary lobectomy, but the diversity of approaches has led to apprehension about port placement among learning surgeons. The aim of this study was to survey high-volume thoracic surgeons who perform robot-assisted lobectomy to understand and consolidate common themes of port placement. METHODS: An electronic online survey was created, and the link was emailed to the 100 highest volume robotic thoracic surgeons in the United States. The survey included an interactive graphical interface, which allowed each respondent to mark the preferential robotic port placement in the chest wall for each of the 5 pulmonary lobectomies. Results were analyzed individually and in aggregate. A heat map was generated to show trends. RESULTS: One hundred surgeons were surveyed (response rate: 62%). Most (90%) respondents utilized a 4-arm approach and 79% used a completely 4-arm portal approach with CO2 insufflation. Exact locations for each robotic port were reported by 60% of the surveyed surgeons and the results varied; however, most surgeons generally used the seventh to ninth interspaces for the camera and instruments. The use of multiple different interspace levels was common. Ninety-four percent of respondents used an additional nonrobotic assistant port. CONCLUSIONS: There is not a universal port strategy for robot-assisted lobectomy. However, placement of the camera and robotic ports low in the seventh to ninth interspaces is the most common approach. There are some nuances of stapling port strategies and sequence of port placement, which are identified.

A Step-by-Step Procedure for Bone Regeneration Using Calcium Phosphate Scaffolds: From Site Preparation to Graft Placement.

Hydroxyapatite (HA) is the main mineral component of bone and teeth. HA is often used as a bone substitute and especially in its granular form it is osteoconductive and osseointegrating as shown by many investigations in animals and humans. HA granules are used for filling bone defects, but they have poor handling qualities and retention at the surgical site, leading to graft voids between the granules and bone tissue and resulting in mechanical instability. Furthermore HA implantation is not constantly followed by favorable results, especially when it is carried out for augmentation of the alveolar ridge. This article offers a protocol for bone reconstruction and predictable implant treatment outcomes. We provide a step-by-step description of both the recipient site and composite graft preparations using coralline HA granules (CHAG) and homologous fibrin glue (HFG). In the present study, 20 randomly selected patients (12 women and 8 men) underwent bone regeneration using CHAG-HFG before a dental implant procedure. Radiographic imaging, physical examination, and histological analysis were performed during a 2-year period. Biopsies were obtained at second-stage surgery before implant insertion using a 2.8-mm trephine bur. A morphological study of 20 bioptic human specimens was performed. Our results demonstrate that this surgical protocol for the preparation of the recipient site associated with a mixture of coralline HA granules with homologous fibrin glue provides reliable bone regeneration, thus reducing failures and minimizing risks of postoperative morbidity.

Robotic-Assisted Versus Thoracoscopic Lobectomy Outcomes From High-Volume Thoracic Surgeons.

BACKGROUND: Reports of surgical outcomes comparing proficient surgeons who perform either robotic-assisted or video-assisted thoracoscopic lobectomy are lacking. We evaluate the comparative effectiveness of robotic-assisted and video-assisted thoracoscopic lobectomies by surgeons who performed 20 or more annual surgical procedures in a national database. METHODS: Patients 18 years or older, who underwent elective lobectomy by surgeons who performed 20 or more annual lobectomies by robotic-assisted or thoracoscopic approach from January 2011 through September 2015, were identified in the Premier Healthcare database with the use of codes from the ninth revision of the International Statistical Classification of Diseases and Related Health Problems. Propensity-score matching based on patient and hospital characteristics and by year was performed 1:1 to identify comparable cohorts for analysis (n = 838 in each cohort). All tests were two-sided, with statistical significance set at p less than 0.05. RESULTS: A total of 23,779 patients received an elective lobectomy during the study period: 9,360 were performed by video-assisted thoracoscopic approach and 2,994 were by robotic-assisted approach. Propensity-matched comparison of lobectomies performed by surgeons who performed 20 or more procedures annually (n = 838) showed that robotic-assisted procedures had a longer mean operative time by 25 minutes (mean 247.1 minutes vs 222.6 minutes, p < 0.0001) but had a lower conversion-to-open rate (4.8% vs 8.0%, p = 0.007) and a lower 30-day complication rate (33.4% vs 39.2%, p = 0.0128). Transfusion rates and 30-day mortality rates were similar between the two cohorts. CONCLUSIONS: When surgical outcomes are limited to surgeons who perform 20 or more annual procedures, the robotic-assisted approach is associated with a lower conversion-to-open rate and lower 30-day complication rate when than video-assisted thoracoscopic surgeons, with a mean operative time difference of 25 minutes.

Wicking Property of Graft Material Enhanced Bone Regeneration in the Ovariectomized Rat Model.

BACKGROUND: Recruitment and homing cells into graft materials from host tissue is crucial for bone regeneration. METHODS: Highly porous, multi-level structural, hydroxyapatite bone void filler (HA-BVF) have been investigated to restore critical size bone defects. The aim was to investigate a feasibility of bone regeneration of synthetic HA-BVF compared to commercial xenograft (Bio-Oss). HA-BVF of 0.7 mm in average diameter was prepared via template coating method. Groups of animals (n = 6) were divided into two with normal (Sham) or induced osteoporotic conditions (Ovx). Subsequently, subdivided into three treated with HA-BVF as an experiment or Bio-Oss as a positive control or no treatment as a negative control (defect). The new bone formation was analyzed by micro-CT and histology. RESULTS: At 4 weeks post-surgery, new bone formation was initiated from all groups. At 8 weeks post-surgery, new bone formation in the HA-BVF groups was greater than Bio-Oss groups. Extraordinarily greater bone regeneration within the Ovx-HA group than Sham-Bio-Oss or Ovx-Bio-Oss group (p < 0.05). CONCLUSION: This study suggests that the immediate wicking property of HA-BVF from host tissue activates a natural healing cascade without the addition of exogeneous factors or progenitor cells. HA-BVF may be an effective alternative for repairing bone defects under both normal and osteoporotic bone conditions.

Accuracy of Clinical Staging and Outcome With Primary Resection for Local-Regionally Limited Esophageal Adenocarcinoma.

OBJECTIVE: The aim of this study was to determine the accuracy of clinical staging, to assess survival with surgical resection alone, and to determine factors associated with understaging in patients with esophageal adenocarcinoma thought to have limited local-regional disease. BACKGROUND: Primary surgical resection is the preferred treatment in patients with esophageal adenocarcinoma clinically staged to have limited nodal disease. This approach requires reliable clinical staging. METHODS: A retrospective chart review was performed of all patients who had primary esophagectomy for clinical stage T1-3 N0-1 adenocarcinoma (seventh edition AJCC) from January 2002 to May 2013. Clinical and pathologic stages were compared and overall survival was analyzed. RESULTS: There were 88 patients who met inclusion criteria. Final pathology confirmed appropriate clinical staging (≤T3N1) in 76% of patients (67/88). There were 21 patients who were understaged (>T3N1), and in all cases, understaging was based on the presence of advanced nodal (N2 or N3) disease. Factors independently associated with understaging were the presence of dysphagia, tumor length >3 cm, and poor differentiation. At a median follow-up of 35 months, 63% of all patients (55/88) remain alive. The 5-year survival in correctly staged patients was 67%, compared with 33% for those who were understaged (P < 0.0001). CONCLUSIONS: Modern clinical staging will accurately identify the majority of patients with esophageal adenocarcinoma and limited local-regional disease (≤pT3N1). Survival with surgery alone in correctly staged patients was excellent and unlikely to be improved with neoadjuvant therapy. A combination of dysphagia, poor differentiation, and tumor length >3 cm was associated with understaging in 92% of patients. Patients with these factors are likely to have more advanced disease than clinically suspected and may benefit from neoadjuvant therapy before resection.

Esophageal adenocarcinoma stage III: Survival based on pathological response to neoadjuvant treatment.

BACKGROUND: Neoadjuvant chemoradiotherapy is the standard treatment for locally advanced esophageal adenocarcinomas (EAC). Pathological response is thought to be a major prognostic factor. Aims of this study were to determine the frequency of complete response and to compare the survival of complete and incomplete responders in stage III EAC. METHODS: A retrospective review was performed of all stage III patients that underwent neoadjuvant therapy followed by esophagectomy between 1999 and 2015. Patients were classified into complete (pCR) versus incomplete responders (pIR). RESULTS: 110 patients were included. Neoadjuvant chemotherapy was applied in 25 (23%) and chemoradiotherapy in 85 (77%) patients. Pathologic response was complete in 25% (n = 27) and was more common after chemoradiotherapy. Mean F/U interval was 36 months (0.3-173). There was a significant difference in the overall survival between complete and incomplete responders (p = 0.036). Median survival in the pIR group was 24.4 months and the median survival was not reached during the observation time in pCR. The 3-year-survival-rate was 70% in pCR and 40% in pIR (p = 0.01). Positive lymph nodes (ypN+) were present in 56 patients (51%). The 3-year-survival-rate was 59% in pIR with ypN0 and 29% in pIR with ypN+ (p = 0.005). CONCLUSIONS: Complete response to neoadjuvant therapy has a significantly better overall and 3-year-survival after esophagectomy than incomplete response. In incomplete responders, residual lymph node disease was associated with a significantly worse survival. These findings suggest that the degree of pathologic response and lymph node status are major prognostic factors for survival in EAC patients with stage III disease.

Outcome with Primary En-bloc Esophagectomy for Submucosal Esophageal Adenocarcinoma.

BACKGROUND: Intramucosal esophageal adenocarcinoma can be reliably treated endoscopically. Controversy exists about the use of endotherapy versus esophagectomy for submucosal tumors. Increasingly endotherapy is considered for submucosal tumors in part because of the presumed high mortality with esophagectomy and the perceived poor prognosis in patients with nodal disease. This study was designed to assess survival following primary en bloc esophagectomy (EBE) in patients with submucosal esophageal adenocarcinoma (EAC). METHODS: This is a retrospective review of all patients who underwent EBE for submucosal EAC between 1998 and 2015. No patient had neoadjuvant therapy. RESULTS: There were 32 patients (28M/4F; median age 64 years). The median tumor size was 1.5 cm (0.4-8.0), and the median number of resected nodes was 48 (23-85). There was one perioperative death. Lymph node metastases were present in 7 patients (22%). There was one involved node in four patients and 2, 3, and 31 nodes in one patient each. The one N3 patient received adjuvant therapy. The median follow-up was 87 months. Overall survival at 5 and 10 years was 84 and 70% respectively. Disease-specific survival at 10 years was 90%. Eight patients died, but only three deaths (9%) were related to EAC. Disease-specific survival at 10 years in node-positive patients was 71%. CONCLUSIONS: Survival after primary en bloc esophagectomy for submucosal adenocarcinoma was excellent even in node-positive patients. Mortality with esophagectomy was low and far less than the 22% risk of node metastases in patients with submucosal tumor invasion. Esophagectomy should remain the preferred treatment for T1b esophageal adenocarcinoma.