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Diagnostic evaluation, surgical technique, and perioperative management after esophagectomy: consensus statement of the German Advanced Surgical Treatment Study Group

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Abstract

Purpose

Correct diagnosis, surgical treatment, and perioperative management of patients with esophageal carcinoma remain crucial for prognosis within multimodal treatment procedures. This study aims to achieve a consensus regarding current management strategies in esophageal cancer by questioning a panel of experts from the German Advanced Surgical Treatment Study (GAST) group, comprised of 9 centers specialized in esophageal surgery, with a combined total of >220 esophagectomies per year.

Materials and methods

The Delphi method, a systematic and interactive, evidence-based approach, was used to obtain consensus statements from the GAST group regarding ambiguities and disparities in diagnosis, patient selection, surgical technique, and perioperative management of patients with esophageal carcinoma. After four rounds of surveys, agreement was measured by Likert scales and defined as full (100% agreement), near (≥66.6% agreement), or no consensus (<66.6% agreement).

Results

Full or near consensus was obtained for essential aspects of esophageal cancer staging, proper surgical technique, perioperative management and indication for primary surgery, and neoadjuvant treatment or palliative treatment. No consensus was achieved regarding acceptability of minimally invasive technique and postoperative nutrition after esophagectomy.

Conclusion

The GAST consensus statement represents a position paper for treatment of patients with esophageal carcinoma which both contributes to the development of clinical treatment guidelines and outlines topics in need of further clinical studies.

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References

  1. Schuchert MJ, Luketich JD, Landreneau RJ (2010) Management of esophageal cancer. Curr Probl Surg 47(11):845–946

    Article  PubMed  Google Scholar 

  2. Jones J, Hunter D (1995) Consensus methods for medical and health services research. BMJ 311(7001):376–380

    PubMed  CAS  Google Scholar 

  3. Colombo-Benkmann M, Vowinkel T, Palmes D et al (2006) Surgical endoscopy compared to non-surgical endoscopy in patients with esophageal cancer. Is it any better? 27. Deutscher Krebskongress (abstract)

  4. Lowe VJ, Booya F, Fletcher JG et al (2005) Comparison of positron emission tomography, computed tomography, and endoscopic ultrasound in the initial staging of patients with esophageal cancer. Mol Imaging Biol 7(6):422–430

    Article  PubMed  Google Scholar 

  5. Choi J, Kim SG, Kim JS et al (2010) Comparison of endoscopic ultrasonography (EUS), positron emission tomography (PET), and computed tomography (CT) in the preoperative locoregional staging of resectable esophageal cancer. Surg Endosc 24(6):1380–1386

    Article  PubMed  Google Scholar 

  6. Thurau K, Palmes D, Franzius C et al (2011) Impact of PET–CT on primary staging and response control on multimodal treatment of esophageal cancer. World J Surg 35(3):608–616

    Article  PubMed  Google Scholar 

  7. Noble F, Bailey D, SWCIS Upper Gastrointestinal Tumour Panel et al (2009) Impact of integrated PET/CT in the staging of oesophageal cancer: a UK population-based cohort study. Clin Radiol 64(7):699–705

    Article  PubMed  CAS  Google Scholar 

  8. Riedel M, Hauck RW, Stein HJ et al (1998) Preoperative bronchoscopic assessment of airway invasion by esophageal cancer: a prospective study. Chest 113:687–695

    Article  PubMed  CAS  Google Scholar 

  9. Ott K, Bader FG, Lordick F et al (2009) Surgical factors influence the outcome after Ivor-Lewis esophagectomy with intrathoracic anastomosis for adenocarcinoma of the esophagogastric junction: a consecutive series of 240 patients at an experienced center. Ann Surg Oncol 16(4):1017–1025

    Article  PubMed  Google Scholar 

  10. Kranzfelder M, Büchler P, Friess H (2009) Surgery within multimodal therapy concepts for esophageal squamous cell carcinoma (ESCC): the MRI approach and review of the literature. Adv Med Sci 54(2):158–169

    Article  PubMed  CAS  Google Scholar 

  11. van Heijl M, van Lanschot JJ, Koppert LB et al (2008) Neoadjuvant chemoradiation followed by surgery versus surgery alone for patients with adenocarcinoma or squamous cell carcinoma of the esophagus (CROSS). BMC Surg 8:21

    Article  PubMed  Google Scholar 

  12. Gebski V, Burmeister B, Smithers BM et al (2007) Survival benefits from neoadjuvant chemoradiotherapy or chemotherapy in oesophageal carcinoma: a meta-analysis. Lancet Oncol 8(3):226–234

    Article  PubMed  CAS  Google Scholar 

  13. Lorenzen S, Brücher B, Zimmermann F et al (2008) Neoadjuvant continuous infusion of weekly 5-fluorouracil and escalating doses of oxaliplatin plus concurrent radiation in locally advanced oesophageal squamous cell carcinoma: results of a phase I/II trial. Br J Cancer 99(7):1020–1026

    Article  PubMed  CAS  Google Scholar 

  14. Fiorica F, Di Bona D, Schepis F et al (2004) Preoperative chemoradiotherapy for oesophageal cancer: a systematic review and meta-analysis. Gut 53(7):925–930

    Article  PubMed  CAS  Google Scholar 

  15. Urschel JD, Vasan H (2003) A meta-analysis of randomized controlled trials that compared neoadjuvant chemoradiation and surgery to surgery alone for resectable esophageal cancer. Am J Surg 185(6):538–543

    Article  PubMed  Google Scholar 

  16. Rice TW, Blackstone EH, Rusch VW (2010) 7th edition of the AJCC Cancer Staging Manual: esophagus and esophagogastric junction. Ann Surg Oncol 17(7):1721–1724

    Article  PubMed  Google Scholar 

  17. Seto Y, Fukuda T, Yamada K et al (2008) Celiac lymph nodes: distant or regional for thoracic esophageal carcinoma? Dis Esophagus 21(8):704–707

    Article  PubMed  CAS  Google Scholar 

  18. Wittekind C, Tannapfel A (2010) The current TNM system for gastrointestinal tumors part I. Pathologe 31(5):344–347

    Article  PubMed  CAS  Google Scholar 

  19. Schomas DA, Quevedo JF, Donahue JM et al (2010) The prognostic importance of pathologically involved celiac node metastases in node-positive patients with carcinoma of the distal esophagus or gastroesophageal junction: a surgical series from the Mayo Clinic. Dis Esophagus 23(3):232–239

    Article  PubMed  Google Scholar 

  20. Bedenne L, Michel P, Bouché O et al (2007) Chemoradiation followed by surgery compared with chemoradiation alone in squamous cancer of the esophagus: FFCD 9102. J Clin Oncol 25(10):1160–1168

    Article  PubMed  CAS  Google Scholar 

  21. Stahl M, Stuschke M, Lehmann N et al (2005) Chemoradiation with and without surgery in patients with locally advanced squamous cell carcinoma of the esophagus. J Clin Oncol 23(10):2310–2317

    Article  PubMed  Google Scholar 

  22. Ott K, Lordick F, Molls M et al (2009) Limited resection and free jejunal graft interposition for squamous cell carcinoma of the cervical oesophagus. Br J Surg 96(3):258–266

    Article  PubMed  CAS  Google Scholar 

  23. Malthaner R, Wong RK, Spithoff K et al (2010) Preoperative or postoperative therapy for resectable oesophageal cancer: an updated practice guideline. Clin Oncol (R Coll Radiol) 22(4):250–256

    CAS  Google Scholar 

  24. Arnott SJ, Duncan W, Gignoux M et al (2005) Oeosphageal Cancer Collaborative Group. Preoperative radiotherapy for esophageal carcinoma. Cochrane Database Syst Rev 19(4):CD001799

    Google Scholar 

  25. Heise JW, Heep H, Frieling T et al (2001) Expense and benefit of neoadjuvant treatment in squamous cell carcinoma of the esophagus. BMC Cancer 1:20

    Article  PubMed  CAS  Google Scholar 

  26. Urschel JD, Vasan H, Blewett CJ (2002) A meta-analysis of randomized controlled trials that compared neoadjuvant chemotherapy and surgery to surgery alone for resectable esophageal cancer. Am J Surg 183(3):274–279

    Article  PubMed  Google Scholar 

  27. Malthaner RA, Wong RK, Rumble RB et al (2004) Neoadjuvant or adjuvant therapy for resectable esophageal cancer: a clinical practice guideline. BMC Cancer 24(4):67

    Article  Google Scholar 

  28. Allum WH, Stenning SP, Bancewicz J et al (2009) Long-term results of a randomized trial of surgery with or without preoperative chemotherapy in esophageal cancer. J Clin Oncol 27(30):5062–5067

    Article  PubMed  Google Scholar 

  29. Schneider PM, Metzger R, Schaefer H et al (2008) Response evaluation by endoscopy, rebiopsy, and endoscopic ultrasound does not accurately predict histopathologic regression after neoadjuvant chemoradiation for EC. Ann Surg 248:902–908

    Article  PubMed  Google Scholar 

  30. Sloof GW (2006) Response monitoring of neoadjuvant therapy using CT, EUS, and FDG PET. Best Pract Res Clin Gastroenterol 5:941–957

    Article  Google Scholar 

  31. Kelsen DP, Winter KA, Gunderson LL et al (2007) Long-term results of RTOG trial 8911 (USA Intergroup 113): a random assignment trial comparison of chemotherapy followed by surgery compared with surgery alone for esophageal cancer. J Clin Oncol 25(24):3719–3725

    Article  PubMed  Google Scholar 

  32. Weigel TL, Frumiento C, Gaumintz E (2002) Endoluminal palliation for dysphagia secondary to esophageal carcinoma. Surg Clin North Am 82(4):747–761

    Article  PubMed  Google Scholar 

  33. Javle M, Ailawadhi S, Yang GY et al (2006) Palliation of malignant dysphagia in esophageal cancer: a literature-based review. J Support Oncol 4(8):365–373

    PubMed  Google Scholar 

  34. Wolff CS, Castillo SF, Larson DR et al (2008) Ivor Lewis approach is superior to transhiatal approach in retrieval of lymph nodes at esophagectomy. Dis Esophagus 21(4):328–333

    Article  PubMed  CAS  Google Scholar 

  35. Omloo JM, Lagarde SM, Hulscher JB et al (2007) Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the mid/distal esophagus: five-year survival of a randomized clinical trial. Ann Surg 246:992–1000

    Article  PubMed  Google Scholar 

  36. Omloo JM, Law SY, Launois B et al (2009) Short and long-term advantages of transhiatal and transthoracic oesophageal cancer resection. Eur J Surg Oncol 35(8):793–797

    PubMed  CAS  Google Scholar 

  37. Pennathur A, Zhang J, Chen H et al (2004) The "best operation" for esophageal cancer? Ann Thorac Surg 89(6):S2163–S2167

    Article  Google Scholar 

  38. Igaki H, Tachimori Y, Kato H (2004) Improved survival with upper and/ or middle mediastinal lymph node metastasis of squamous cell carcinoma of the lower thoracic esophagus treated with 3-field dissection. Ann Surg 239:483–490

    Article  PubMed  Google Scholar 

  39. Santillan AA, Farma JM, Meredith KL et al (2008) Minimally invasive surgery for esophageal cancer. J Natl Compr Canc Netw 6(9):879–884

    PubMed  Google Scholar 

  40. Nagpal K, Ahmed K, Vats A et al (2010) Is minimally invasive surgery beneficial in the management of esophageal cancer? A meta-analysis. Surg Endosc 24(7):1621–1629

    Article  PubMed  Google Scholar 

  41. Sgourakis G, Gockel I, Radtke A et al (2010) Minimally invasive versus open esophagectomy: meta-analysis of outcomes. Dig Dis Sci 55(11):3031–3040

    Article  PubMed  Google Scholar 

  42. Urschel JD, Blewett CJ, Bennett WF et al (2001) Handsewn or stapled esophagogastric anastomoses after esophagectomy for cancer: meta-analysis of randomized controlled trials. Dis Esophagus 14(3–4):212–217

    Article  PubMed  CAS  Google Scholar 

  43. Korolija D (2008) The current evidence on stapled versus hand-sewn anastomoses in the digestive tract. Minim Invasive Ther Allied Technol 17(3):151–154

    Article  PubMed  Google Scholar 

  44. Law S, Fok M, Chu KM (1997) Comparison of hand-sewn and stapled esophagogastric anastomosis after esophageal resection for cancer: a prospective randomized controlled trial. Ann Surg 226(2):169–173

    Article  PubMed  CAS  Google Scholar 

  45. Luechakiettisak P, Kasetsunthorn S (2008) Comparison of hand-sewn and stapled in esophagogastric anastomosis after esophageal cancer resection: a prospective randomized study. J Med Assoc Thai 91(5):681–685

    PubMed  Google Scholar 

  46. Kondra J, Ong SR, Clifton J (2008) A change in clinical practice: a partially stapled cervical esophagogastric anastomosis reduces morbidity and improves functional outcome after esophagectomy for cancer. Dis Esophagus 21(5):422–429

    Article  PubMed  CAS  Google Scholar 

  47. Cooke DT, Lin GC, Lau CL et al (2009) Analysis of cervical esophagogastric anastomotic leaks after transhiatal esophagectomy: risk factors, presentation, and detection. Ann Thorac Surg 88(1):177–184

    Article  PubMed  Google Scholar 

  48. Palmes D, Weilinghoff M, Colombo-Benkmann M et al (2007) Effect of pyloric drainage procedures on gastric passage and bile reflux after esophagectomy with gastric conduit reconstruction. Langenbecks Arch Surg 392(2):135–141

    Article  PubMed  Google Scholar 

  49. Ng JM (2008) Perioperative anesthetic management for esophagectomy. Anesthesiol Clin 26(2):293–304

    Article  PubMed  Google Scholar 

  50. Michelet P, Roch A, D’Journo XB et al (2007) Effect of thoracic epidural analgesia on gastric blood flow after oesophagectomy. Acta Anaesthesiol Scand 51:587–594

    Article  PubMed  CAS  Google Scholar 

  51. Lazar G, Kaszaki J, Abraham S et al (2003) Thoracic epidural anesthesia improves the gastric microcirculation during experimental gastric tube formation. Surgery 134:799–805

    Article  PubMed  Google Scholar 

  52. Neal JM, Wilcox RT, Allen HW et al (2003) Near-total esophagectomy: the influence of standardized multimodal management and intraoperative fluid restriction. Reg Anesth Pain Med 28:328–334

    PubMed  Google Scholar 

  53. McKevith JM, Pennefather SH (2010) Respiratory complications after oesophageal surgery. Curr Opin Anaesthesiol 23:34–40

    Article  PubMed  Google Scholar 

  54. Atkins BZ, Shah AS, Hutcheson KA et al (2004) Reducing hospital morbidity and mortality following esophagectomy. Ann Thorac Surg 78:1170–1176

    Article  PubMed  Google Scholar 

  55. Shackcloth MJ, McCarron E, Kendall J et al (2006) Randomized clinical trial to determine the effect of nasogastric drainage on tracheal acid aspiration following oesophagectomy. Br J Surg 93:547–552

    Article  PubMed  CAS  Google Scholar 

  56. Nguyen NT, Slone J, Wooldridge J et al (2009) Minimally invasive esophagectomy without the use of postoperative nasogastric tube decompression. Am Surg 75:929–931

    PubMed  Google Scholar 

  57. Sato T, Takayama T, So K et al (2007) Is retention of a nasogastric tube after esophagectomy a risk factor for postoperative respiratory tract infection? J Infect Chemother 13(2):109–113

    Article  PubMed  Google Scholar 

  58. Gabor S, Renner H, Matzi V et al (2005) Early enteral feeding compared with parenteral nutrition after oesophageal or oesophagogastric resection and reconstruction. Br J Nutr 93(4):509–513

    Article  PubMed  CAS  Google Scholar 

  59. Baker A, Wooten LA, Malloy M (2011) Nutritional considerations after gastrectomy and esophagectomy for malignancy. Curr Treat Options Oncol 12(1):85–95

    Article  PubMed  Google Scholar 

  60. Kamei H, Hachisuka T, Nakao M et al (2005) Quick recovery of serum diamine oxidase activity in patients undergoing total gastrectomy by oral enteral nutrition. Am J Surg 189(1):38–43

    Article  PubMed  CAS  Google Scholar 

  61. Jiang K, Cheng L, Wang JJ (2009) Fast track clinical pathway implications in esophagogastrectomy. World J Gastroenterol 15(4):496–501

    Article  PubMed  Google Scholar 

  62. Cerfolio RJ, Bryant AS, Bass CS (2004) Fast tracking after Ivor Lewis esophagogastrectomy. Chest 126(4):1187–1194

    Article  PubMed  Google Scholar 

  63. Wani ML, Ahangar AG, Lone GN (2010) Feeding jejunostomy: does the benefit overweight the risk (a retrospective study from a single centre). Int J Surg 8(5):387–390

    Article  PubMed  Google Scholar 

  64. Gupta V (2009) Benefits versus risks: a prospective audit. Feeding jejunostomy during esophagectomy World J Surg 33(7):1432–1438

    Google Scholar 

  65. Deitmar S, Anthoni C, Palmes D et al (2009) Are leukocytes and CRP early indicators for anastomotic leakage after esophageal resection? Zentralbl Chir 134(1):83–89

    Article  PubMed  CAS  Google Scholar 

  66. Hölscher AH, Fetzner UK, Bludau M et al (2011) Complications and management of complications in oesophageal surgery. Zentralbl Chir (in press)

  67. Wedemeyer J, Schneider A, Manns MP et al (2008) Endoscopic vacuum-assisted closure of upper intestinal anastomotic leaks. Gastrointest Endosc 67(4):708–711

    Article  PubMed  Google Scholar 

  68. Truong S, Böhm G, Klinge U et al (2004) Results after endoscopic treatment of postoperative upper gastrointestinal fistulas and leaks using combined Vicryl plug and fibrin glue. Surg Endosc 18(7):1105–1108

    Article  PubMed  CAS  Google Scholar 

  69. Ahrens M, Schulte T, Egberts J et al (2010) Drainage of esophageal leakage using endoscopic vacuum therapy: a prospective pilot study. Endoscopy 42(9):693–698

    Article  PubMed  CAS  Google Scholar 

  70. Tuebergen D, Rijcken E, Mennigen R et al (2008) Treatment of thoracic esophageal anastomotic leaks and esophageal perforations with endoluminal stents: efficacy and current limitations. J Gastrointest Surg 12(7):1168–1176

    Article  PubMed  Google Scholar 

  71. Barkley C, Orringer MB, Iannettoni MD et al (2003) Challenges in reversing esophageal discontinuity operations. Ann Thorac Surg 76(4):989–994

    Article  PubMed  Google Scholar 

  72. Siewert JR, Stein HJ, Bartels H (2004) Anastomotic leaks in the upper gastrointestinal tract. Chirurg 75(11):1063–1070

    Article  PubMed  CAS  Google Scholar 

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Authors and Affiliations

  1. Department of General and Visceral Surgery, University of Münster, Waldeyerstrasse 1, 48149, Münster, Germany

    Daniel Palmes, Matthias Brüwer & Norbert Senninger

  2. Department of Surgery, University of Schleswig Holstein, Campus Lübeck, Lübeck, Germany

    Franz G. Bader & Hans-Peter Bruch

  3. Department of Surgery, Alfried Krupp Hospital, Essen, Germany

    Michael Betzler

  4. Department of Surgery, University of Heidelberg, Heidelberg, Germany

    Markus Büchler & Katja Ott

  5. Department of General, Vascular and Thoracic Surgery, Charité—Campus Benjamin Franklin, Berlin, Germany

    Heinz Buhr & Jörg-Peter Ritz

  6. Department of General and Visceral Surgery, Göttingen University Medical Center, Göttingen, Germany

    Heinz Becker & Β. Michael Ghadimi

  7. Department of General and Visceral Surgery, University of Freiburg, Freiburg im Breisgau, Germany

    Ulrich T. Hopt

  8. Department of General, Thoracic and Vascular Surgery, School of Medicine, Dresden University of Technology, Dresden, Germany

    Ralf Konopke & Hans-Detlev Saeger

  9. Department of Surgery, Medical Faculty Mannheim, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany

    Stefan Post & Ulrich Ronellenfitsch

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  1. Daniel Palmes
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  2. Matthias Brüwer
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German Advanced Surgical Treatment Study Group

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Correspondence to Daniel Palmes.

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Palmes, D., Brüwer, M., Bader, F.G. et al. Diagnostic evaluation, surgical technique, and perioperative management after esophagectomy: consensus statement of the German Advanced Surgical Treatment Study Group. Langenbecks Arch Surg 396, 857–866 (2011). https://doi.org/10.1007/s00423-011-0818-3

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