LongTerm FollowUp and Quality of Life After Esophagectomy for High Grade Dysplasia and Intramucosal

1
Surgical Management of Esophageal Cancer
The Value of Standardized Clinical Pathways in an
Era of Evolving Perceptions and Reassessment of
Outcome Parameters
Donald E. Low, FACS FRCS(C) Head, Thoracic
Surgery and Thoracic Oncology Virginia Mason
Medical Center Seattle, Washington
2
Surgical Management of Esophageal Cancer
The Value of Standardized Clinical Pathways in an
Era of Evolving Perceptions and Reassessment of
Outcome Parameters
Donald E. Low, FACS FRCS(C) Head, Thoracic
Surgery and Thoracic Oncology Virginia Mason
Medical Center Seattle, Washington
3
Esophageal Cancer Demographics

• 5 YEAR SURVIVAL _____T1-2 N0___
• Prostate Cancer 90-95
• Colon Cancer 85
• Breast Cancer 80
• Lung Cancer 60
• Esophageal Cancer 25

4
UNOFFICIAL STATEMENT REGARDING EXPECTATIONS WHEN
TREATING ESOPHAGEAL CANCER

• My boy, when you see a patient with esophageal
  cancer, you will do more good with a quart of
  whiskey than with anything the current medical
  establishment has to offer.

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ESOPHAGEAL CANCER DEMOGRAPHICS
OUTCOMES OF OESOPHAGOGASTRIC CANCER IN YOUNG
PATIENTS

• - 50 patients all lt50 years old
• - 20 patients (40) complete resection
• - median survival 7 months
• - 5 year survival 3

Bowrey DJ. Postgrad Med J 19997522
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INCREASING INCIDENCE OF BARRETTS ESOPHAGUS IN
THE GENERAL POPULATION

• Integrated Primary Care Information Database
  (Netherlands)
• 1997 2002
• Barretts Incidence 14.3/100,000 pers/yr 23.1
  /100,000 pers/yr
• of EGDs 7.2/1,000 pers/yr 5.7/1,000 pers/yr
• Barretts/1,000 EGD 19.8 40.5
• Esophageal Adeno CA
• Incidence 1.7/100,00 pers/yr 6.0/100,000 pers/yr

Soest et al. Gut 2005541062
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Hospital Volume and Surgical Mortality in the
United States

• Information from the National Medicare Claims
  Database
• Assessed mortality associated with
• 6 cardiovascular procedures
• 8 major cancer resections

Birkmeyer et al. NEJM 20023461128-1137
9
Hospital Volume and Surgical Mortality in the
United States
Birkmeyer et al. NEJM 20023461128-1137
10
Historical Perspective of Results of Esophageal
Resection for Cancer

• 1975 1988 316 Patients presented with
  esophageal cancer
• Surgical Exploration 134 42
• Tumor Resection 106 79
• Operative Mortality 27
• Median Survival Following Surgical
  Resection 292 Days
• 5-year Survival 7

Gut 1994
11
Strategies For ImprovingSurgical Quality
Should Payers Reward Excellence or Effort?

• Birkmeyer MJ, Birkmeyer JD
• NEJM 2006354864-70

12
Relationship of Volume and Mortality in
Esophageal Resection
13
Outcomes of Esophageal Resection Relationship
to Clinical Volume

• Matthews HR. Br J Surg 198673621-623
• Miller et al. J. Surg Oncol 19976520-21
• Begg et al. JAMA 19982801747-1751
• Patti et al. J. Gastrointest Surg 19982186-192
• Swisher et al. JTCVS 20001191126-1134
• Dudley et al. JAMA 20002831159-1166
• Dimick et al. Ann Thor Surg 200172334-341
• Kuo et al. Ann Thor Surg 2001721118-1124
• Van Lanshot et al. Cancer 2001911574-1578
• Birkmeyer et al. NEJM 20023461128-1137
• Dimick et al. Ann Thor Surg 200375337-341
• Dimick et al. Surgery 2003134534-540
• Birkmeyer et al. Ann Surg, 2006243411-17

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Impact of Hospital Volume on Clinical and
Economic Outcomes for Esophagectomy

• 1992-2000
• 1193 Patients Massachusetts
• NO ESOPHAGECTOMIES
• High volume (gt6/yr) hospitals 3 674
  (56.5)
• Low volume (lt6/yr) hospitals 61 519
  (43.5)
• Average volume ? 1 esophagectomy/year

Kuo et al. Ann Thor Surg 2001721118-1124
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Impact of Hospital Volume on Clinical and
Economic Outcomes for Esophagectomy
Low volume
High volume
9.2
lt 0.001
2.5
Mortality
5 (2-9) 8.4
lt 0.001
2 (1-4) 4.6
ICU stay Median Mean
lt 0.001
15 20.5
13 18.8
Hospital stay Median Mean
NS
24,763
25,518
Cost
Kuo et al. Ann Thor Surg 2001721118-1124
16
Surgical Volume and Quality of Care for
Esophageal Resection DO HIGH VOLUME HOSPITALS
HAVE FEWER COMPLICATIONS?

• STUDY PERIOD 1994-1998 MARYLAND
• HIGH
  VOLUME LOW VOLUME
• Number of hospitals 2 33
• Number of resections 204 (56) 162 (44)
• Mortality (in hospital) 2.5 15.4
• Complications
• Re-intubation 7.8 27.0 (.001)
• Renal failure .5 8.0 (.001)
• Pulmonary failure 2.9 11.8 (.001)
• Aspiration 16.0 34.0 (.001)
• Surgical complications 6.9 14.0 (.03)

Dimick et al 2003
17
HOSPITAL VOLUME AND HOSPITAL MORTALITY FOR
ESOPHAGECTOMY
Dutch National Medical Registry 19931998 ?
310 esophagectomies/year
Van Lanschot et al. Cancer 2001 911574-1578
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Treatment Results of Chemo-radiotherapy for
Clinical Stage I (T1N0M0) Esophageal Carcinoma
Initiated Prospective Trial in 1991 for Operable
Esophageal Carcinoma, Foreseeing Organ
Preservation, to Assess Treatment Results of
Definitive Chemoradiotherapy for Clinical Stage I
(T1N0M0) Esophageal Cancer.
Yamada, et al. Int J Rad Onc, Bio Phy
2006641106-11
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Treatment Results of Chemo-radiotherapy for
Clinical Stage I (T1N0M0) Esophageal Carcinoma

• 1992-2003
• 63 Patients, T1a 23, T1b 40
• Treatment
• Radiotherapy 55-66 Gy
• 1-3 Cycles Cisplatin, 5-FU
• High-Dose Intraluminal Brachytherapy 10-12 Gy/2-3
  Fractions

23
Present Status of Photodynamic Therapy for
High-Grade Dysplasia in Barretts Esophagus

• Recent studies have emphasized the risks
  associated with surgical resection, the poor
  quality of life after extended esophageal and
  gastric resections, and the morbidity of the
  procedures which still exceeds 40 in experienced
  hands clearly indicate the need for less invasive
  treatment techniques.
• Birkmeyer NEJM 2002

Wolfsen et al. J Clin Gastro 200539189
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Background

• Management for Barretts esophagus with
  High-Grade Dysplasia (HGD) includes
• Close endoscopic surveillance
• Esophagectomy
• Endoscopic ablative therapy (ET)

26
Current Study

• Goal To compare patients who have undergone
  endotherapy or esophagectomy for Barretts with
  HGD or IMC
• Overall and cancer-related mortality
• Eradication of BE and dysplasia
• Procedure-related morbidity and mortality
• Hospital and follow-up charges

27
Methods

• IRB approved esophageal resection database that
  has been in place since 1991
• IRB approved endoscopic therapy database that has
  been in place since 1998
• All appropriate patients received both surgical
  and GI consultations
• Information harvested on all patients w/HGD and
  IMC undergoing esophagectomy and ET with curative
  intent from 1998-2005

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Methods-ET

• From 1998 to 2000, PDT (porfimer sodium 2 mg/kg
  200 j/cm at 630 nm) was the primary treatment for
  BE w/ HGD or IMC
• After 2000, EMR for focal nodular disease
  followed by PDT for residual Barretts

29
Methods-ET

• After 2003, large area EMR for Barretts lt 5 cm
  with PDT reserved for disease gt 5 cm
• APC at 90 watts used to treat small-area residual
  disease

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Methods - Surgery

• Preoperative investigations
• CT PET
• EGD/EUS
• Objective cardiac testing in patients gt 50 y.o.
• Presentation at thoracic oncology tumor board
• Resectional approach (Ivor-Lewis, left
  thoracoabdominal, or transhiatal) was
  individualized according to patient physiology
  and characteristics

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Results

• Median follow-up
• 20 months for endotherapy (range 6 to 84 months)
• 48 months for surgical patients (range 6 to 88
  months)
• 2 ET patients lost to endoscopic follow-up after
  1 year, 3 at 2 years, and 3 after 3 years
• Survival data complete on all patients

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Results

• 61 patients (48 HGD/13 IMC) underwent ET
• 2 argon plasma coagulation alone
• 18 EMR
• 21 PDT
• 20 EMRPDT
• 32 patients (15 HGD/17 IMC) underwent
  esophagectomy
• 4 trans-hiatal
• 10 Ivor-Lewis
• 18 left thoraco-abdominal

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Average ASA
P ns
34
Average Length of Barretts Segment (cm)
Plt0.05
35
Median Patient Age
Plt0.01
36
Results

• No death from esophageal cancer occurred in
  either group
• All surgical patients had R0 resections for
  cancer and BE
• No cancers developed in the surgical cohort
  (plt0.05)
• Previously unrecognized invasive cancer was found
  in 8 (25) of esophagectomy patients at surgery

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Results

• 30-day mortality occurred in 1 patient in the
  endotherapy group (2) and none of surgical group
  (pns).
• Invasive cancer developed in 4 EndoTx patients
  (7)
• 1 underwent chemo/xrt
• 1 underwent xrt/stenting
• 1 is still undergoing attempts at ablative
  therapy
• 4 patients in the EndoTx group went on to surgery
• 1 for invasive cancer
• 3 for persistent HGD
• 1 of these had no HGD or Barretts at surgery

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Minor Complications
EndoTx 33
Surgery 63
Plt0.01
39
Major Complications
EndoTx 8
Surgery 12.5
Pns
40
Average Length of Persistent Barretts Tissue
41
Median Charges (to date)
42
Overall Survival
43
Conclusions

• Both therapies effectively treat BE w/HGD or IMC
• Both therapies carry risk of morbidity and
  mortality
• ET is associated with a 7 2-year failure rate
• Esophagectomy eliminates BE, treats unsuspected
  invasive cancer, and can be performed with very
  low risk of mortality

44
Conclusions

• Esophagectomy is probably associated with higher
  morbidity than ET
• Patients appear to do well at a high-volume
  referral center
• Costs of both therapies are significant
• Prospective trials of ET versus esophagectomy are
  needed

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Combined Endoscopic Mucosal Resection and
Photodynamic Therapy vs. Esophagectomy for
Management of Early Adenocarcinoma in Barretts
Esophagus

• Mayo Clinic
• Retrospective Review 1996-2001
• PROCEDURE RELATED CANCER FREE AT
• N Complications Deaths 12 mo F/U
• Esophagectomy 64 31 1 (1.6) 100
• EMR/PDT 24 4 0 83

Pacifico et al. Clin Gastro Hep 20031252
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Advances in Barretts Esophagus and Esophageal
Adenocarcinoma

• The patients that progress to cancer during
  followup would go on to get the surgery that they
  would have gotten anyway and be cured of the
  disease, whereas the remainder of the cohort is
  spared a morbid surgery and the subsequent
  attendant decrease in quality of life from living
  after esophagectomy.

Shaheen et al. Gastro 20051281554
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Quality of Life after Esophagectomy and
Endoscopic for Barretts Esophagus with
High-Grade Dysplasia or Intra-Mucosal Carcinoma

• 1988 2006
• 32 Esophagectomy (EG)62 Endoscopic Therapy (ET)
• 11 died 1 ET secondary to treatment 1 ET
  secondary to esophageal cancer
• Follow Up (Mean) 4 Yr ET 5 Yr EG
• Assessment Tools SF 36 GIQLI
• Assessment Groups Age (1) 45-65 (2) gt65 Yr

Schembre/Low, et al.
49
Quality of Life after Esophagectomy and
Endoscopic for Barretts Esophagus with
High-Grade Dysplasia or Intra-Mucosal Carcinoma

• Results
• SF 36 - No significant difference except for
  superior physical functioning in older EG
  patients
• GIQLI - Tends to be higher in ET patients in 45-5
  age group but did not reach statistical
  significance p0.08
• Conclusions - No significant difference in
  long-term Q.O.C. parameters between EG and ET
  patients.

Schembre/Low, et al.
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A Prospective Evaluation of Dietary Status and
Symptoms after Near Total Esophagectomy

• 48 patients having esophagectomy between 1991 and
  1995
• Mean F/U 36 months
• 85 characterized diet as normal or minimally
  limited
• Mean daily caloric intake 2180 cal (98 of
  recommended)

Ludwig/Low Am J Surg 2001181454-58
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Outcomes and Health Related Quality of Life
after Esophagectomy for High Grade Dysplasia and
Intramucosal Cancer

• DEMOGRAPHICS 1991-2003
• 36 patients with Barretts
• with HGD 23 (64) or IMC 13 (36)
• Mean age 66 years (43-88)
• MF 333
• MEAN FOLLOWUP 5 years
• INVASIVE CANCER 39

Moraca and Low. Arch Surg 2005141545-51
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Outcomes and Health Related Quality of Life
after Esophagectomy for High Grade Dysplasia and
Intramucosal Cancer

• GASTROINTESTINAL SYMPTOM QUESTIONNAIRE RESULTS
• Mean followup 4.9 years (range 0.5-12 years)
• SYMPTOMS PRE-OP CURRENT
• Heartburn 77 18 plt0.001
• Dysphagia 25 43 NS
• Slow speed of eating 11 93 plt0.001
• Regurgitation 36 54 NS
• Increased stool frequency 11 32 NS
• Perception of eating as normal
• or insignificantly impacted 72 79 NS

Moraca and Low. Arch Surg 2005141545-51
NSNon-Significant
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POSTOPERATIVE SF-36 RESULTS

• DOMAINS Population Mean Esophagectomy Mean
• General Health Perceptions 48.6 ( 1.09) 50.7 (
  12.2) NS
• Physical Functioning 46.3 ( 3.23) 49.8 (
  10.2) NS
• Role Limitations
• Attributed to Physical Health 46.8 ( 3.06) 49.4
  ( 10.3) NS
• Role Limitations
• Attributed to Emotional Problems 49.1 (
  2.10) 51.8 ( 8.26) NS
• Social Functioning 49.9 ( 0.89) 49.7 ( 10.7) NS
• Mental Health 52.1 ( 1.04) 53.0 ( 10.3) NS
• Bodily Pain 48.7 ( 1.03) 53.1 ( 11.0) plt0.04
• Vitality 51.2 ( 3.62) 53.4 ( 9.48) NS
• Physical Component Summary 45.1 ( 3.62) 49.9 (
  10.6) plt0.03
• Mental Component Summary 52.0 ( 1.54) 52.8 (
  8.94) NS
• Age and Sex Matched 1998 United States General
  Population Normal Values
• NS Non-Significant

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PREOPERATIVE AND POSTOPERATIVE BODY MASS INDEX

• Preoperative Postoperative
• Mean BMI (kg/m2) 28.9 (4.3) 25.6 (3.6) p lt
  0.003
• Distribution
• Underweight (lt 18.5 kg/m2) 0 0
• Ideal Weight (18.5-24.9 kg/m2) 7 42
• Overweight (25.0-29.9 kg/m2) 64 50
• Obese ( gt 30 kg/m2) 29 8
• Range 23-45 kg/m2 20-39 kg/m2

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Long-Term Outcome of Esophagectomy for HGD or
Cancer Found During Surveillance for Barretts
Esophagus

• 34 patients 1995-2003
• Mean F/U 48 Mos. Q.O.L. Assessment SF-36
• Mortality 0
• Major Complications 29
• SF-36 scores Equal to or better than general
  population

Chang, et al. J Gastrointest Surg 200610341
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Mortality after Esophagectomy for High-Grade
Dysplasia in Barretts Esophagus

• OPERATIVE 5-YR SURVIVAL
• N MALIGNANT MORTALITY IN PTS W/HGD
• Headrick 2002 54 35 1.8 96
• Mayo Clinic
• Tseng 2003 60 30 1.7
• Johns Hopkins
• Reed 2006 49 37 2.0
• MGH
• Chang 2006 39 - 0 100
• UW
• Moraca 2006 36 39 0 100
• VMMC

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Postoperative Pathology Following Resection for
High-Grade Dysplasia in Barretts Esophagus

• STAGE
• 0-I II III
• Headrick 22 8 6
• Reed 20 12 4
• Moraca 33 4

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Esophageal Resection Standardized Clinic Pathway

• Pre-Op Arrangements
• Initiate chemotherapy or chemoradiotherapy
• Referral for neoadjuvant therapy
• Reassessment following completion of neoadjuvant
  therapy
• CT scan
• EGD US
• Reassessment done 2-4 weeks prior to operative
  date
• Individualized operative approach according to
• Tumor/Barrett's characteristics
• Patient Physiology
• Previous Surgery
• Surgery
• Thoracic epidural placed pre-operatively
• Minimize blood loss/transfusions
• Conservative intra-operative fluid administration
• Immediate extubation
• Post-op anesthesia PCEA
• Admit to ICU
• Post-Op

• Initial Contact (Referral)
• Interview patient within 48 hours of referral
• Verbal Review (telephone interview)
• PMH
• Current Symptoms ? Swallowing/Wt Loss
• Current Investigations
• Travel Arrangements Seattle accommodations
• Initial description of surgery/VM
• Patient Appointment made with respect to
  patient/referring physician wishes, patient
  symptoms/status, patient availability
• Prior to VM Appointment
• Arrangements for previous notes, investigations,
  films, path sent or brought to VM
• Arrange patient tailored schedule which is
  forwarded to patient
• Initial Encounter (completes within 2-3 working
  days)
• Consultations
• Thoracic surgery
• Medical oncology
• Radiation Oncology
• Cardiology (gt50 y.o. (risk factors))
• Path Review

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Initial Contact (Referral)

• Talk to patient within 48 hours
• Verbal Review (telephone interview)
• PMH
• Current Symptoms ? Swallowing/Wt Loss
• Current Investigations
• Travel Arrangements Seattle accommodations
• Initial description of surgery/VM
• Patient Appointment made with respect to
  patient/referring physician wishes, patient
  symptoms/status, patient availability

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Esophageal Resection Standardized Clinic Pathway

• Pre-Op Arrangements
• Initiate chemotherapy or chemoradiotherapy
• Referral for neoadjuvant therapy
• Reassessment following completion of neoadjuvant
  therapy
• CT scan
• EGD US
• Reassessment done 2-4 weeks prior to operative
  date
• Individualized operative approach according to
• Tumor/Barrett's characteristics
• Patient Physiology
• Previous Surgery
• Surgery
• Thoracic epidural placed pre-operatively
• Minimize blood loss/transfusions
• Conservative intra-operative fluid administration
• Immediate extubation
• Post-op anesthesia PCEA
• Admit to ICU
• Post-Op

• Initial Contact (Referral)
• Interview patient within 48 hours of referral
• Verbal Review (telephone interview)
• PMH
• Current Symptoms ? Swallowing/Wt Loss
• Current Investigations
• Travel Arrangements Seattle accommodations
• Initial description of surgery/VM
• Patient Appointment made with respect to
  patient/referring physician wishes, patient
  symptoms/status, patient availability
• Prior to VM Appointment
• Arrangements for previous notes, investigations,
  films, path sent or brought to VM
• Arrange patient tailored schedule which is
  forwarded to patient
• Initial Encounter (completes within 2-3 working
  days)
• Consultations
• Thoracic surgery
• Medical oncology
• Radiation Oncology
• Cardiology (gt50 y.o. (risk factors))
• Path Review

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Esophageal Resection Standardized Clinic Care
Pathway Summary

• Interview patient within 48 hours of referral
• Presentation at thoracic tumor board
• Individualized operative approach according to
• Tumor/Barrett's characteristics
• Patient Physiology
• Previous Surgery
• Conservative intra-operative fluid administration
  minimize blood loss
• Immediate extubation
• Post-op analgesia PCEA
• Patient walks in hall morning POD 1
• Discharge Day 7-8

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ESOPHAGEAL RESECTION
What approach is best?
67
DECISIONS IN SURGICAL MANAGEMENT OF ESOPHAGEAL
CANCER

• Surgical candidate
• Neoadjuvant therapy
• Standard vs. Radical/En bloc resection
• Transthoracic/Transhiatal/Video assisted
• Conduit Stomach/Colon/Small bowel
• Anastomosis - Chest/Neck Stapled/Hand-sewn
• Pyloroplasty
• Jejunostomy

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DIVERSIFIED APPROACH TO ESOPHAGEAL RESECTION

• IMPORTANT ISSUES
• TUMOR
• Location proximal ? distal
• Length
• Size
• Invasion T3 / T4
• Other factors - liver lesions
• - pulmonary nodules
• - lymphadenopathy
• Histology EG junction/Signet

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DIVERSIFIED APPROACH TO ESOPHAGEAL RESECTION

• IMPORTANT ISSUES SURGEON
• Training/Philosophy
• Experience
• Facilities (video assisted, robotics)
• Anesthesiology support

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DIVERSIFIED APPROACH TO ESOPHAGEAL RESECTION
IMPORTANT ISSUES PATIENT

• Body habitus
• Co-morbidities - Cardiac
• - Pulmonary
• Previous surgery
• Previous resections
• Abnormal anatomy

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RISK ANALYSIS IN RESECTION OF THORACIC ESOPHAGEAL
CANCER IN THE ERA OF THORASCOPIC SURGERY

• 153 Patients 1995-2004
• Op Time Blood Loss Resp
• Esophagectomy Min ML Comp Mortality
• 1) Standard Thoracotomy 487 882 32.4 13.5
• 2) Assisted Thoracoscopic/
• Minithoracotomy 461 640 23.7 10.5
• 3) Thoracoscopic 426 670 20.5 2.6
• p .174 p .003
• Thoracoscopic approach improved mortality but not
  incidence of respiration complications

Shiraishi et al. Ann Thor Surg 2006811083
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Comparisons of Outcomes Between Transhiatal and
Transthoracic Esophageal Resection
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Esophageal Resection Standardized Clinic Care
Pathway Summary

• Interview patient within 48 hours of referral
• Presentation at thoracic tumor board
• Individualized operative approach according to
• Tumor/Barrett's characteristics
• Patient Physiology
• Previous Surgery
• Conservative intra-operative fluid administration
  minimize blood loss
• Immediate extubation
• Post-op analgesia PCEA
• Patient walks in hall morning POD 1
• Discharge Day 7-8

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ESOPHAGECTOMY FLUID MANAGEMENT

• May 1991 62 y/o 82kg male
• T3N1 distal esophageal cancer
• operative time 6.5 hours
• blood loss 350cc
• crystalloid administration 11.2L
• Feb 2006 67 y/o 85kg female
• T3N1 distal esophageal cancer
• operative time 5.6 hours
• blood loss 175cc
• crystalloid administration 2.8L

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INTRAVENOUS FLUID ADMINISTRATION AND URINE OUTPUT
DURING RADICAL NECK SURGERY

• HISTORICAL PERSPECTIVE General anesthetics
  thought to decrease renal blood flow.
• CURRENT PERSPECTIVE Anesthetics do not decrease
  renal blood flow, but does decrease glomerular
  filtration rate resulting in decreased urine
  output (oliguria).
• QUESTION Is oliguria harmful to renal function?
  
• HYPOTHESIS Urine output is not important in
  patients with normal renal function as long as
  hemodynamics are maintained.

Priano et al. Head and Neck 199315208
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INTRAVENOUS FLUID ADMINISTRATION AND URINE OUTPUT
DURING RADICAL NECK SURGERY

• 24 PATIENTS UNDERGOING RADICAL HEAD AND NECK
  SURGERY
• 13 patients wet protocol received hourly
  maintenance NPO deficit 31 blood loss
  replacement third space replacement at
  6mL/kg/hr with additional 200mL boluses if urine
  output below 0.5mL/kg/hr for gt 30 minutes.
• 11 patients dry protocol received hourly
  maintenance ½ NPO deficit, 11 blood loss
  replacement third space replacement at
  2mL/kg/hr.
• Oliguria ignored as long as MAP gt50mmHg. 200mL
  given if MAP lt50mmHg gt10 minutes.

Priano et al. 1993
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INTRAVENOUS FLUID ADMINISTRATION AND URINE OUTPUT
DURING RADICAL NECK SURGERY

• No difference between groups in demographics,
  operations, and intraoperative cardiovascular
  data.
• Urine output and decrease in hematocrit
  statistically greater in wet group.
• Postoperative urine output normal in both groups.
  
• No statistically significant difference in BUN or
  creatinine 24 or 72 hours post-op.

Priano et al. 1993
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Near-total esophagectomy The influence of
standardized multimodal management and
intraoperative fluid restriction Joseph M. Neal,
M.D., Robert T. Wilcox, M.D., Hugh W. Allen,
M.D., and Donald E. Low, M.D. Background and
Objectives Esophagectomy can be associated
with high morbidity and mortality. We present our
experience managing these patients using a
standardized multimodal approach that emphasizes
intraoperative fluid restriction and early
extubation. Methods This case series includes
56 consecutive patients over a 2-year period
(1999-2000) that underwent near-total
esophagectomy at a high-volume center. Surgical
approach was determined by patient and tumor
characteristics intraoperative fluid replacement
was conservative and patient-controlled epidural
anesthesia/analgesia was used to promote early
extubation, enteral feeding, and
ambulation. Results Overall morbidity was
18 in-hospital and 30-day mortality was zero.
Intraoperative urinary volume averaged 0.57
mL/kg/h. No patient developed postoperative renal
dysfunction or pulmonary complications. All
patients were extubated in the operating room.
First ambulation averaged 1.6 days after surgery.
Median intensive care unit and hospital stays
were 1 and 10 days, respectively. Side effects
from thoracic epidural analgesia were
minimal. Conclusions Significant reduction in
esophagectomy-related morbidity is possible using
a standardized multimodal approach in routine
clinical practice. Intraoperative fluid
restriction may facilitate early extubation and
reduce pulmonary complications without
compromising renal function. This preliminary
observation warrants further study in a
randomized clinical trial. Reg Anesth Pain Med
200328328-334. Keywords Esophagectomy,
Epidural analgesia, Perioperative outcome, Fluid
management, Multimodal management
84
NEAR TOTAL ESOPHAGECTOMYTHE INFLUENCE OF
STANDARDIZED MULTIMODAL MANAGEMENT AND
INTRAOPERATIVE FLUID RESTRICTION

• 56 CONSECUTIVE PATIENTS OVER TWO YEARS
  1999-2000
• INTRAOPERATIVE MANAGEMENT
• Mid thoracic epidural catheters placed
  preoperatively, used intraoperatively
• Combined general/epidural anesthetic
  isoflurane/epidural lidocaine (1.5-2.0)
• Fluids/vasopressors used to maintain
  intraoperative BPS within 20 of baseline
• Fluids administered to maintain hemodynamic
  balance rather than to adhere to standardized
  mL/kg/hr formula
• All patients extubated in OR

Neal et al. Reg Anes Pain Med 200328328
85
NEAR TOTAL ESOPHAGECTOMYTHE INFLUENCE OF
STANDARDIZED MULTIMODAL MANAGEMENT AND
INTRAOPERATIVE FLUID RESTRICTION

• RESULTS OPERATIVE APPROACH
• Left thoracoabdominal 30
• Ivor Lewis 14
• Transhiatal 11
• Right three stage 1
• OPERATIVE DETAILS MEAN
• Operative length (hours) 6.5
• Blood loss (mL) 175
• Intraoperative transfusions 0
• Postoperative transfusions 3

All three patients had neoadjuvant therapy and
pre-op hematocrits lt30
Neal et al. 2003
86
NEAR TOTAL ESOPHAGECTOMYTHE INFLUENCE OF
STANDARDIZED MULTIMODAL MANAGEMENT AND
INTRAOPERATIVE FLUID RESTRICTION

• RESULTS INTRAOPERATIVE FLUID MANAGEMENT
• (MEAN)
• Crystalloid infusion (mL) 4180 (2000-8100)
• Intraoperative fluids/hr (mL) 661
• Urine output mL/kg/hr 0.57mL/kg/hr
• Urine output (mL) 260 (60-1100)
• Creatinine pre-op 0.9 (0.5-1.6)
• post-op day 1 0.9 (0.4-1.7)
• discharge 0.9 (0.5-1.4)
• Immediate post-op extubation 56 (100)
• POD 1 mobilization 53 (95)
• Approximately 20-25 of total crystalloid
  volume administered in first 30-45 minutes
  secondary to epidural local anesthetic dosing

Neal et al. 2003
87
Pulmonary Complications and Mortality in
Esophageal Resection

• Dumont P, Wihlm JM, Hentz JG, Roeslin N, Lion R,
  Morand G. Respiratory complications after
  surgical treatment of esophageal cancer A study
  of 309 patients according to the type of
  resection. Eur J Cardiothorac Surg
  19959(10)539-543.
• Avendano CE, Flume PA, Silvestri GA, King LB,
  Reed CE. Pulmonary complications after
  esophagectomy. Ann Thorac Surg 200273922-926.
• Whooley BP, Law SMB, Murthy SC, Alexandrou A,
  Wong J. Analysis of reduced death and
  complication rates after esophageal resection.
  Ann Surg 2001 March233(3)338-344.
• Law S, Wong KH, Kwok KF, Chu KM, Wong J.
  Predictive factors for postoperative pulmonary
  complications and mortality after esophagectomy
  for cancer. Ann Surg 2004 Nov240(5)791-800.
• Mariette C, Taillier G, Van Seuningen I,
  Triboulet JP. Factors affecting postoperative
  course and survival after en bloc resection for
  esophageal carcinoma. Ann Thorac Surg
  2004781177-1183.
• Atkins BZ, Shah AS, Hutcheson KA, Mangum JH,
  Pappas TN, Harpole DH et al. Reducing hospital
  morbidity and mortality following esophagectomy.
  Ann Thorac Surg 2004781170-1176.

88
POSTOPERATIVE SURGICAL COMPLICATIONS

• TECHNICAL COMPLICATIONS ()
• Anastomotic leak 1 (1.8)
• Chyle leak 1 (1.8)
• MEDICAL COMPLICATIONS ()
• CARDIOVASCULAR
• Cardiac dysrhythmias 4 (7.1)
• Hypertension 1 (1.8)
• Pulmonary edema 0 (0)
• RESPIRATORY
• Pneumonia 3 (5.4)
• Reactive airway disease 2 (3.5)
• Pulmonary embolus 1 (1.8)
• Pneumothorax 1 (1.8)
• Re-intubation (aspiration) 1 (1.8)
• Respiratory failure 0 (0)
• RENAL
• Urinary tract infection 5 (8.9)
• Urinary retention 3 (5.4)

Neal et al. 2003
89
NEAR TOTAL ESOPHAGECTOMYTHE INFLUENCE OF
STANDARDIZED MULTIMODAL MANAGEMENT AND
INTRAOPERATIVE FLUID RESTRICTION

• VERBAL ANALOG PAIN SCORES AND PCEA BACKGROUND
• INFUSION RATES
• POST-OP NUMBER OF BACKGROUND PCEA
• DAY PATIENTS STATIC VAS DYNAMIC
  VAS INFUSION RATE (mL/h)
• 1 56 2 /- 3
  5 /- 3 9.2 /- 2.4
• 2 56 2 /-
  2 4 /- 3
  9.4 /- 2.7
• 3 53 2 /-
  2 4 /- 3
  9.3 /- 2.8
• 4 49 1 /-
  1 2 /- 4
  9.1 /- 3.1
• 5 40 2 /-
  2 4 /- 2
  9.0 /- 2.1
• 6 29 1 /-
  2 3 /- 2
  8.7 /- 2.1
• 7 13 1 /-
  1 4 /- 2
  7.1 /- 2.6
• 8 7 2 /-
  3 3 /- 2
  9.0 /- 2.6
• 9 1 0 /-
  0 1 /- 0
  6.0 /- 0.0
• NOTE Values are mean /- standard deviation.
• Abbreviations VAS, verbal analog pain score
  (0no pain, 10worst imaginable pain).
• PCEA, patient controlled epidural analgesia.

Neal et al. 2003
90
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91
RESULTS JANUARY 1996-DEC 2002

• EG PD
• Number of cases 174 215
• Cases/year 25/year 33/year
• Neoplasm malignant 87 50
• Neoplasm benign 13 26
• Chronic pancreatitis N/A 24
• Reports reviewed 10 16
• 1997-2002 1997-2002

92
ESOPHAGOGASTRECTOMY
N 2783
N 174
Outcome
309 min
394 min
OR time
964 mL
200 mL
EBL
34
0, 3.5
OR and post-op transfusion
16.4 d
10 3.1 d
Mean LOS
5.5
0
Mortality
not stated
0
Re-operation
93
Esophageal Resection Standardized Clinic Care
Pathway Summary

• Interview patient within 48 hours of referral
• Presentation at thoracic tumor board
• Individualized operative approach according to
• Tumor/Barrett's characteristics
• Patient Physiology
• Previous Surgery
• Conservative intra-operative fluid administration
  minimize blood loss
• Immediate extubation
• Post-op analgesia PCEA
• Patient walks in hall morning POD 1
• Discharge Day 7-8

94
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95
Patient Population

• Single surgeon series of 340 consecutive patients
  underwent esophagectomy for esophageal cancer or
  high grade dysplasia 05/91-05/06
• Data prospectively entered in an IRB-approved
  database

96
Patient Demographics

• Patients 340
• Age Mean 64 33-90
• Male/Female 281/59
• ASA I 1 II 126 III 204 IV 9

63
97
Patients Clinical Stage

• Stage I - 87
• II - 133
• III - 94
• IV - 9

68
98
Patients Treatment

• 323 Patients with Invasive Cancer
• Neoadjuvant Therapy 139 (43)
• Chemo Radiation 88
• Chemo Alone 50
• Radiation Alone 1
• Complete Response 25 (18)

99
Operative Approach

• Left Thoracoabdominal 214
• Ivor Lewis 91
• Transhiatal 24
• Right Thoracotomy/Transhiatal 8
• Retrosternal 3
• Secondary Procedures 111 (33)

100
Operative Approach

• Anastomosis Cervical 204 60
• Pylorus Procedure Myotomy 6 4.4 Pyloroplasty 9
• Conduit Stomach 334 98 Small Bowel 4 Colon 2
• Jejunostomy 283 83

101
Results

• Mean Median Range
• Operative Time (min) 399 396 108-746
• O.R. Fluid (cc) 4410 4200 1200-11,100
• O.R. Blood Loss (cc) 229 230 50-2000
• O.R. Hospital Transfusions 30 (8.8)
• ICU Los (days) 2.25 2.00 1-30
• Hospital Los (days) 11.52 10.0 6-49

102
Results Complications

• Patients with complications 153 (45)
• Total number of complications 260
• TOTAL
• Cardiac 53 (15.6)
• Atrial Dysrhy 46
• Vent Arhy 3
• CHF 3
• MI 1

103
Results Complications

• TOTAL
• Resp 58 (17.1)
• Pneumonia 20
• Pneumothorax Req Tx 11
• Pleural Effusion Req Tx 11
• Re-Intubation 7
• Pulm Embolus 5
• Prolonged Air Leak 2
• Respiratory Failure (ARDS) 2

104
Results Complications

• TOTAL
• GI 34 (10)
• Ileus 16
• Urinary 29 (8.5)
• UTI 20
• Vascular 5 (1.5)
• DVT 3
• Other 81 (23.8)
• Post Op Delirium 36
• Wound Infection 10

105
Effect of Neoadjuvant Therapy on Post-Operative
Complications

Neoadjuvant Therapy YES NO Pulmonary
Complications Yes 19 21 No 127 173 Chi
Square 0.38 p 0.535 Cardiac
Complications Yes 18 33 No 128 161 Chi
Square 0.19 p 0.667
106
Results Major Complications / Mortality

• Anastomotic Leak 13 (3.8)
• Requiring Re-Op 2
• Chyle Leak 14 (4.1)
• Requiring Re-Op 6
• Bleeding 2
• Requiring Re-Op 2
• In-Hospital and 90-Day Mortality 1 (0.3)

107
Results

• PCEA 335 98.5
• O.R. Extubation 338 99.5
• Mobilizes POD 1 292 85.9

108
Results Assessment Over Time
a vs. Cohort 1 Operative blood loss (p .000)
Operative fluids (p .005) LOS (p .034), by
t-test. b vs. Cohort 1 Operative blood loss (p
.000) Operative fluids (p .000) LOS (p
.002), by t-test. c vs. Cohort 2 Operative time
(p .022) Operative fluids (p .035), by
t-test.
109
Patient Survival
Stage 1 (n27)
All patients (n127)
54.45
Stage 2 (n72)
Stage 3 (n55)
110
Results Survival 1998-2004
111
Modern 5-year Survival of Resectable Esophageal
Adenocarcinoma Single Institution Experience
With 263 Patients

• 5-Year Survival
• Overall 1992-2002 46.5
• Overall 1998-2002 50.4
• Stage I 81
• Stage II 51
• Stage III 14

Portale, et al. J Am Coll Surg 2006202588
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113
Standardized Clinical Care Pathways for Major
Thoracic Cases Reduce Hospital Costs
Zehr, et al. Ann Thorac Surg 199866914-9
114
Conclusions

• High-volume esophageal centers can carry out
  esophageal resection with acceptable levels of
  morbidity and very low mortality
• Patients undergoing surgical therapy for
  esophageal cancer either alone in clinical Stage
  I IIa disease or in association with combined
  modality therapy in clinical Stage IIb and III
  disease can expect improved survival in the
  current era.
• Standardized clinical care pathways provide an
  infrastructure to improve efficiency and outcomes
  in patients undergoing esophageal resection.

115
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116
Satisfaction With Care An Independent Outcome
Measure in Surgical Oncology

• Traditional outcome measures for treatment of
  upper gastrointestinal cancer
• Procedure-related morbidity
• Mortality
• Long-term survival
• This study examined how patient satisfaction
  related to
• Surgical morbidity
• Treatment type
• Quality of life
• Questionnaires European Organization for
  Research and Treatment of Cancer
• QLQ-PATSAT32
• ALA-C30

Avery/Blazeby, et al. Ann Surg Onc 200613817
117
Satisfaction With Care An Independent Outcome
Measure in Surgical Oncology

• 162 eligible patients 139 returned both
  questionnaires within 2 mos. of discharge
• 67 esophagectomy
• 38 D2 gastrectomy
• 34 palliative treatment
• 37 patients (27) had major complications
• Patients receiving palliative treatment reported
  satisfaction and quality of life scores similar
  to patients receiving curative therapy. However,
  patients experiencing major morbidity reported
  significantly worse quality of life than those
  without complications

118
Satisfaction with Care An Independent Outcome
Measure in Surgical Oncology

• Patient satisfaction with hospital care is
  independent of morbidity, treatment type and
  quality of life outcomes.

Avery/Blazeby Ann Surg Onc. 200613817.
119
Treatment Success is about the Patients, Not the
Doctors
120
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121
Patient Satisfaction An Increasingly Important
Measure of Quality

• Surgeons have a natural bias that patient
  satisfaction along with our own is tied to
  surgical and physical outcome
• Most believe patient satisfaction inherently tied
  to patient expectations

Tomlinson/Ko. Am Surg Oncol 200613764
122
Providing Practitioner-Specific Outcomes is
Associated With Higher Patient Satisfaction With
Information About Prostate Cancer Treatment

• Satisfaction with information (SWI) is a
  patients cognitive evaluation of information
  sources used to understand and select therapy
• In multivariate models, patient age (p0.005) and
  information provided by the physician regarding
  their own outcomes (p0.01) were independently
  associated with SWI
• ASCO 2007

123
What Patients Want When it Comes to Cancer Care

• Good Outcomes ? Cure
• Strong personal and emotional relationship with
  caregivers ? Good communication
• Minimize pain and suffering ? During Treatment ?
  Secondary to disease process
• Minimize morbidity and maintain quality of life
• Avoid family financial burden

124
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125
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126
NEOADJUVANT CHEMORADIOTHERAPY FOR ESOPHAGEAL
CARCINOMA A META-ANALYSIS

• Reviewed randomized trials of chemorad Surgery
  versus surgery alone 1966-2003
• 6 Studies 374 patients
• Summary - Small non-statistically significant
  trend toward improved long-term survival in
  chemorad surgery group

Greer/Birkmeyer et al. Surgery 2005137172
127
Multimodality Therapy for Resectable Cancer of
the Thoracic Esophagus

• Although pre-operative chemoradiation therapy is
  commonly used for locally-advanced disease, few
  data support its superiority over surgical
  resection alone, followed by adjuvant therapy
  where appropriate. Hence the regimen should be
  limited to patients enrolled in controlled,
  randomized studies until data supports its
  widespread use.

Entwistle/Goldberg Ann Thorac Surg 2002731009.
128
COST COMPARISON VMMC CHEMORAD PLUS SURGERY VERSUS
SURGERY ALONE 2005

• Surgery Alone 58,761
• (53,585 64,118)
• Neoadjuvant Therapy 156,218and Surgery (115,380
  197,056)

129
COMPLETE RESPONSE TO NEOADJUVANT
CHEMORADIOTHERAPY IN ESOPHAGEAL CARCINOMA IS
ASSOCIATED WITH SIGNIFICANTLY IMPROVED SURVIVAL

• 171 Patients 1994-2002 Esophagectomy for Invasive
  Cancer
• 131 Had Pre-Op Chemo-Rad
• IL (60) TH (8) Three Hole (23)
  LTA 8
• Perioperative Mortality 5
• Univariate Multivariate Analysis Demonstrated
• 2 Issues most closely associated with long
  term survival
• Downstaging to path stage 0 or 1
• R0 Resection

Berger et al. J Clin Oncol, 2005234330
130
PATHOLOGIC RESPONSE AFTER INDUCTION
CHEMORADIOTHERAPY AND RESECTION FOR ESOPHAGEAL
CANCER PREDICTS SURVIVAL

• 209 Patients 1985-2002 with esophageal cancer
• Induction chemotherapy (5 FU Cisplatin)
  radiotherapy 5040 (cGy)
• p CR - 40
• p PR - (microscopic tumor, neg nodes) 25
• Multivariate Analysis (63 Mo) age, pPR, and pCr
  significant predictors of survival
• Onaitis M Duke University, WTSA June 2006

131
What Patients Want When it Comes to Cancer Care

• Good Outcomes ? Cure
• Strong personal and emotional relationship with
  caregivers ? Good communication
• Minimize pain and suffering ? During Treatment ?
  Secondary to disease process
• Minimize morbidity and maintain quality of life
• Avoid family financial burden

132
A RETROSPECTIVE ANALYSIS OF LOCALLY ADVANCED
ESOPHAGEAL CANCER PATIENTS TREATED WITH
NEOADJUVANT CHEMORADIATION THERAPY FOLLOWED BY
SURGERY OR SURGERY ALONE

• 176 Patients clinical stage IIA-IVA - Rx
  esophageal resections
• 85 (48.3) had neoadjuvant chemorad
• Overall mortality 5.1
• Median survival 16.8 mo. With no survival
  difference between patients having chemorad and
  those having surgery alone
• 25 patients 29.4 had pCR following chemorad
  demonstrated median survival 57.6 mo. Plt.01
• Kesler et al. Ann Thor Surg 2005791116

133
Pulmonary Complications After Esophagectomy

• 61 PATIENTS
• Pleural effusion/atelectasis 53 87 - requiring
  drainage 10 16
• Pneumonia 20 33
• Mechanical ventilation gt48 HM 12 20
• ARDS 6 10
• Chylothorax 5 8
• Mortality 7 12
• All patients who died had developed pneumonia

Avendano et al. Ann Thor Surg 200273922-926
134
Pulmonary Complications After Esophagectomy
CLINICAL OUTCOMES
Avendano et al. Ann Thor Surg 200273922-926
135
ANALYSIS OF REDUCED DEATH AND COMPLICATION RATES
AFTER ESOPHAGEAL RESECTION
1982-1998 710 patients one stage esophageal
resection for squamous cell cancer OVERALL
MORTALITY 11.0 MOST COMMON CAUSE OF
DEATH Pulmonary complication 45.5
Whooley et al. Ann Surg 2001 233338-344
136
Recurrence Following Endoscopic Therapy

• Krishnadath Gastro 2000119624
• Van Laetham Gut 200046574
• Shand Gut 200148580
• Selvasekar Aliment Pharm Ther 200115899
• Macey Gastro Clin Biol 200125204
• Van Hillegersberg Dig Surg 200320440
• Hage J Path 2005157

137
A CRITICAL REVIEW OF THE DIAGNOSIS AND
MANAGEMENT OF BARRETTS ESOPHAGUS THE AGA
CHICAGO WORKSHOP

• 18 participants evaluating 42 statements
  regarding
• diagnosis, screening, and treatment of Barretts
  esophagus (BE)
• Screening for BE improves mortality REJECTED
• Acid reduction therapy reduces risk of
• developing adenocarcinoma REJECTED
• Surveillance detects curable neoplasia
• and can be cost effective AGREED
• Mucosal ablation with acid suppression
• prevents adenocarcinoma in BE REJECTED

Sharma et al. Gastro 2004127310
138
A Critical Review of the Diagnosis and Management
of Barretts Esophagus The AGA Chicago Workshop
GASTROENTEROLOGY
SURGEONS

• P. Sharma G. Falk
• K. McQuaid J. Goldblum
• J. Dent J. Jankowski
• M.B. Fennerty B. Reid
• R. Sampliner M.J. Shaheen
• S. Spechler A. Sonnenberg
• D. Corley K. Wang

• J. Hunter
• L. Lundell

139
Present Status of Photodynamic Therapy for
High-Grade Dysplasia in Barretts Esophagus

• CONCLUSION
• While the risk of incomplete dysplasia ablation
  and subsequent carcinoma development requires
  careful endoscopic surveillance after PDT,
  several large series have consistently found this
  risk to be less than the mortality associated
  with esophagectomy.

Wolfsen et al. J Clin Gastro 200539189
140
Cost Effectiveness of Photodynamic Therapy for
High-Grade Dysplasia in Barretts Esophagus

• Quality Adjusted
• Life Years Cost
• Esophagectomy 11.82 24,045
• PDT/Surveillance 12.31 47.310

Vij et al. Gastroint Endo 200460739
141
High-Grade Dysplasia Long-Term Survival and
Quality of Life after Esophagectomy

• 1991-1997 - 54 PATIENTS
• Post-op Path Invasive cancer 35
• 5 YEAR SURVIVAL
• HGD only 96
• Cancer 68
• Q.O.L. Post esophagectomy Median followup 63
  months
• 2/8 criteria better than general population
• 1/8 criteria worse than general population
• 5/8 criteria no significant difference

Headrick et al. Ann Thor Surg 2002731697
142
Long-Term Outcome after Esophagectomy for
High-Grade Dysplasia or Cancer Found During
Surveillance for Barretts Esophagus

• 1995-2003 39 patients underwent esophagectomy for
  HGD or cancer found during Barretts
  surveillance.
• Mean Surveillance EGDs 13 (3-30)
• Operative Mortality 0

Chang/Pellegrini et al., J. Gastrointest Surg
200610341
143
High-Grade Dysplasia in Barretts Esophagus
Surveillance or Operation?

• Review of 15 reports of resection for HGD
  1983-1999
• 184 patients80 patients (43) found to have
  adenocarcinoma

Pellegrini et al. J Gastroint Surg 20004131
144
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145
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146
A PROSPECTIVE EVALUATION OF DIETARY STATUS AND
SYMPTOMS AFTER NEAR TOTAL ESOPHAGECTOMYWITHOUT
GASTRIC EMPTYING PROCEDURE

• MEAN FOLLOWUP 36 MONTHS /- 25
• Diet normal or minimally limited 85.
• No difference in return to dietary baseline in
  patients receiving neoadjuvant therapy.
• Patients lost weight for six months post-op, then
  stabilized at a mean level above IBW.
• Mean daily caloric intake 2,179 calories or 98
  of recommended according to IBW.
• Most common post-op symptoms
• Periodic dysphagia 38
• Mild increase in stool frequency 15
• Occasional regurgitation 25

Ludwig et al. 2001
147
A PROSPECTIVE EVALUATION OF DIETARY STATUS AND
SYMPTOMS AFTER NEAR TOTAL ESOPHAGECTOMYWITHOUT
GASTRIC EMPTYING PROCEDURE

• 48 PATIENTS FOLLOWED UP
• SYMPTOM INDEX AND FORMAL 3-DAY NUTRITIONAL
  ASSESSMENT
• Tumor Stage I 18
• II 50
• III 30
• IV 2
• Preoperative Radiochemotherapy 21

Ludwig et al. Am J Surg 2001181454
148
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149
Esophageal Cancer Demographics

• American Cancer Society 2005
• New Cases 14,250
• Deaths 13,570
• WHITES BLACKS
• 5 year survival 1960s 4 1
• 2000-2004 16 9

150
PREVALENCE OF BARRETTS ESOPHAGUS IN
ASYMPTOMATIC INDIVIDUALS

• 408 Patients invited to have EGD (VA hospital)
  undergoing screening colonoscopy
• Exclusion criteria Symptoms of GERD gt 1 mo.
• Use of medication for GERD
• Previous EGD
• 110 Subjects 101 men, 9 women
• Biopsy proven I.M. in 27 (25)
• Long segment gt 3 cm 8 (7)
• No increased incidence of obesity, tobacco, or
  alcohol consumption or family history of GERD in
  Barretts group

Gerson L. B. et al. Gastro 2002123636
151
Results ET
152
NEAR TOTAL ESOPHAGECTOMYTHE INFLUENCE OF
STANDARDIZED MULTIMODAL MANAGEMENT AND
INTRAOPERATIVE FLUID RESTRICTION

• RESULTS - 1999-2000 - 56 CONSECUTIVE RESECTIONS
• Mean age 63 years (15-82) Men 44
• Women 12
• ASA Classification II 21
• III 33
• IV 2
• Resection for cancer 89
• Stage I 12
• Stage II/III 88
• Preoperative chemotherapy 54

Neal et al. 2003
153
EFFECTS OF INTRAVENOUS FLUID RESTRICTION ON
POSTOPERATIVE COMPLICATIONS

• REGULAR FLUID RESTRICTED FLUIDCOMPLICATIONS REGI
  MEN REGIMEN
• Cardiopulmonary 24 7 P0.007
• Tissue healing 31 16 P0.04
• Overall complications 56 30 P0.003
• Mortality 4.7 0 P0.12

Brandstrup et al. Ann Surg 2003