TY - JOUR
T1 - Modified En Bloc Esophagectomy Compared With Standard Resection After Neoadjuvant Chemoradiation
AU - Corsini, Erin M.
AU - Mitchell, Kyle G.
AU - Zhou, Nicolas
AU - Antonoff, Mara B.
AU - Mehran, Reza J.
AU - Rice, David C.
AU - Roth, Jack A
AU - Sepesi, Boris
AU - Swisher, Stephen G.
AU - Vaporciyan, Ara A.
AU - Walsh, Garrett L.
AU - Maru, Dipen M.
AU - Lin, Steven H.
AU - Ajani, Jaffer A.
AU - Hofstetter, Wayne L.
N1 - Publisher Copyright:
© 2021 The Society of Thoracic Surgeons
PY - 2021/4
Y1 - 2021/4
N2 - Background: Surgeons have shifted away from the practice of en bloc esophagectomy, particularly in the era of neoadjuvant therapies. Although some still advocate for this radical approach, contemporary data establishing its superiority are sparse. We hypothesized that a more complete, radical resection could be completed in the setting of chemoradiation without adding morbidity. Methods: Patients undergoing esophagectomy after neoadjuvant chemoradiation for esophageal adenocarcinoma from 2006-2018 were evaluated. Outcomes after right transthoracic en bloc esophagectomy were compared with standard esophagectomy to determine the impact on outcomes. A Cox proportional hazard model was evaluated, and logistic regression was performed to determine the impact of en bloc resection on postoperative morbidity. Results: A total of 604 patients were identified, including 133 (22%) who underwent modified en bloc esophagectomy. Positive margins were most likely to occur in standard esophagectomy (35 of 471, 7%) vs en bloc (3 of 133, 2%) (P = .026). En bloc resection yielded a greater lymph node harvest (27; interquartile range, 22-36), as compared to standard esophagectomy (22; interquartile range, 17-28), P < .001. Multivariable analysis demonstrated prolonged progression-free survival with en bloc resection (hazard ratio, 0.74; P = .041), with 3-year freedom from locoregional recurrences of 78% and 90% for standard and en bloc approaches (P = .044). There were no differences in cardiopulmonary, gastrointestinal, or wound complications, as well as leak or chylothorax. Conclusions: Our experience demonstrates improved locoregional disease control with en bloc esophagectomy, with equivalent morbidity. Although these results may be multifactorial, including adequate clearance of both primary tumor and nodal micrometastases, this approach is safe and feasible.
AB - Background: Surgeons have shifted away from the practice of en bloc esophagectomy, particularly in the era of neoadjuvant therapies. Although some still advocate for this radical approach, contemporary data establishing its superiority are sparse. We hypothesized that a more complete, radical resection could be completed in the setting of chemoradiation without adding morbidity. Methods: Patients undergoing esophagectomy after neoadjuvant chemoradiation for esophageal adenocarcinoma from 2006-2018 were evaluated. Outcomes after right transthoracic en bloc esophagectomy were compared with standard esophagectomy to determine the impact on outcomes. A Cox proportional hazard model was evaluated, and logistic regression was performed to determine the impact of en bloc resection on postoperative morbidity. Results: A total of 604 patients were identified, including 133 (22%) who underwent modified en bloc esophagectomy. Positive margins were most likely to occur in standard esophagectomy (35 of 471, 7%) vs en bloc (3 of 133, 2%) (P = .026). En bloc resection yielded a greater lymph node harvest (27; interquartile range, 22-36), as compared to standard esophagectomy (22; interquartile range, 17-28), P < .001. Multivariable analysis demonstrated prolonged progression-free survival with en bloc resection (hazard ratio, 0.74; P = .041), with 3-year freedom from locoregional recurrences of 78% and 90% for standard and en bloc approaches (P = .044). There were no differences in cardiopulmonary, gastrointestinal, or wound complications, as well as leak or chylothorax. Conclusions: Our experience demonstrates improved locoregional disease control with en bloc esophagectomy, with equivalent morbidity. Although these results may be multifactorial, including adequate clearance of both primary tumor and nodal micrometastases, this approach is safe and feasible.
UR - http://www.scopus.com/inward/record.url?scp=85100090493&partnerID=8YFLogxK
UR - http://www.scopus.com/inward/citedby.url?scp=85100090493&partnerID=8YFLogxK
U2 - 10.1016/j.athoracsur.2020.06.054
DO - 10.1016/j.athoracsur.2020.06.054
M3 - Article
C2 - 32857997
AN - SCOPUS:85100090493
SN - 0003-4975
VL - 111
SP - 1133
EP - 1140
JO - Annals of Thoracic Surgery
JF - Annals of Thoracic Surgery
IS - 4
ER -