Thoraco-laparoscopic esophagectomy: thoracic stage in prone position / Esofagectomia vídeo-tóraco-laparoscópica com tempo torácico em posição pronada

ABSTRACT Objective: to analyze the National Cancer Institute Abdominopelvic Division (INCA / MS/HC I) initial experience with thoraco-laparoscopic esophagectomy with thoracic stage in prone position. Methods: we studied 19 consecutive thoraco-laparoscopic esophagectomies from may 2012 to august 2014, including ten patients with squamous cells carcinoma (five of the middle third and five of the lower third) and nine cases of gastroesophageal junction adenocarcinoma (six Siewert I and three Siewert II). All procedures were initiated by the prone thoracic stage. Results: There were minimal blood loss, optimal mediastinal visualization, oncological radicality and no conversions. Surgical morbidity was 42 %, most being minor complications (58% Clavien I or II), with few related to the technique. The most common complication was cervical anastomotic leak (37%), with a low anastomotic stricture rate (two stenosis: 10.53%). We had one (5.3%) surgical related death, due to a gastric tube`s mediastinal leak, treated by open reoperation and neck diversion. The median Intensive Care Unit stay and hospital stay were two and 12 days, respectively. The mean thoracoscopic stage duration was 77 min. Thirteen patients received neoadjuvant treatment (five squamous cells carcinoma and eight gastroesophageal adenocarcinomas). The average lymph node sample had 16.4 lymph nodes per patient and 22.67 when separately analyzing patients without neoadjuvant treatment. Conclusion: the thoraco-laparoscopic approach was a safe technique in the surgical treatment of esophageal cancer, with a good lymph node sampling.

RESUMO Objetivo: analisar a experiência inicial do Serviço de Cirurgia Abdomino-Pélvica do Instituto Nacional de Câncer (INCA/MS/HC I) na esofagectomia vídeo-tóraco-laparoscópica com tempo torácico pronado. Métodos: estudo de 19 esofagectomias vídeo-tóraco-laparoscópicas realizadas de maio de 2012 a agosto de 2014, em dez pacientes portadores de carcinoma epidermoide esofágico (cinco do 1/3 médio e cinco do 1/3 inferior) e em nove portadores de adenocarcinoma da cárdia (seis Siewert I e três Siewert II). Todas as cirurgias foram iniciadas pelo tempo torácico em posição pronada, com mínima perda sanguínea, adequada visualização das estruturas mediastinais, radicalidade oncológica e sem conversões. Resultados: a morbidade cirúrgica foi de 42%, sendo a maioria complicações menores (58% Clavien I ou II). A complicação mais comum foi a fístula cervical em sete casos (37%), com baixa incidência de estenose anastomótica (duas estenoses: 10,53%). Houve um óbito (5,3%), relacionado a uma fístula mediastinal do tubo gástrico, tratada com reoperação e exteriorização cervical. As medianas de permanência em Centro de Terapia Intensiva e hospitalar foram respectivamente dois e 12 dias. A mediana do tempo vídeo-toracoscópico foi de 77min. Treze pacientes (68.4%) receberam tratamento neoadjuvante (cinco portadores de carcinomas epidermoides e oito de adenocarcinomas cárdia). A amostragem linfonodal média foi de 16,4 linfonodos por paciente e 22,67 quando analisados isoladamente os casos que não receberam tratamento neoadjuvante. Conclusão: a técnica vídeo-tóraco-laparoscópica se mostrou método seguro no tratamento cirúrgico do câncer do esôfago e proporcionou boa amostragem linfonodal em nossa casuística inicial.

Aggressive surgical approach to treat Gallbladder cancer: is it worth it?

The treatment of locally advanced gallbladder cancer has shifted in the past years, leading to a more aggressive surgical approach. We report a case of a 61-year-old woman diagnosed as having a locally advanced gallbladder cancer who was submitted to an aggressive surgical procedure in order to achieve complete resection (R0 resection). At laparotomy, a huge gallbladder tumor was seen with gross invasion of the transverse colon, distal part of stomach, pancreatic head, duodenum and liver. No distant metastases were seen. Surgical approach consisted in an en bloc tumor resection, including pancreatoduodenectomy, distal gastrectomy, right colectomy, hepatic resection (segments IVb, V and VI) and radical lymphadenectomy. The final pathology report revealed adenocarcinoma of the gallbladder with invasion to the nearby organs (liver, stomach, duodenum, head of the pancreas and colon) and no lymph nodes metastases (T4N0M0). All margins were free (R0 resection). Adjuvant chemotherapy was given (cisplatin and gemcitabine). The patient had been well (asymptomatic and with good quality of life) for 10 months when developed liver metastases not amenable to resection. The patient is being treated with palliative chemotherapy (gemcitabine and oxaliplatin). A marked improvement in outcome (survival and quality of life) of patients with gallbladder cancer has been achieved over the past years, primarily due to a shift towards more aggressive surgery. Therefore, this approach might be beneficial for selected patients with locally advanced gallbladder cancer.