Surgery News - August 2007 - (Page 17)

AUGUST 2007 • SURGERY NEWS THORACIC Transhiatal Esophagectomy Stands the Test of Time BY BRUCE JANCIN Heart Transplants Successful in Obese N E W O R L E A N S — Obesi- years compared with about ty should not be considered a 6.5 years for the severely relative contraindication to obese. Long-term survival of heart transplantation, con- overweight and obese recipitrary to last year’s revised In- ents was only slightly less ternational Society for Heart than for the normal weight, and Lung Transplantation and that difference wasn’t recommendations, Dr. Mark clinically meaningful. “The data support transJ. Russo said at the annual planting patients meeting of the with a BMI up to American College 35 kg/m2. We say of Cardiology. He presented that recognizing an analysis of that patients with nearly 19,000 U.S. nonnormal BMIs first-time adult face higher risks, heart transplant but if you consider recipients who the alternatives to underwent the transplanting these procedure during The UNOS registry patients, their sur1995-2005. The vival can generally data support data, from the be measured in transplanting United Network weeks or months, patients with a for Organ Sharing so the benefits of BMI up to (UNOS) registry, tr ansplantation 35 kg/m2. showed the obese would be great,” DR. RUSSO subgroup had a said Dr. Russo of 10-year posttransplant sur- the International Center for vival rate similar to that of Health Outcomes and Innooverweight patients and sig- vation Research at Columbia nificantly better than severe- University, New York. ly obese patients with a body “We believe that we’ve mass index between 35 and now provided data better less than 40 kg/m2, those than what was available at who were morbidly obese, the time the [transplant socior underweight patients with ety’s] recommendations were made and hope that future a BMI below 18.5 kg/m2. Patients who were normal recommendations would reweight at transplantation had flect our findings,” the cardiothe best median long-term thoracic surgeon said. survival, well in excess of 10 —Bruce Jancin Else vier Global Medical Ne ws C O L O R A D O S P R I N G S — Dr. Mark B. Orringer can still recall the skeptical reception he received when, as a young academic surgeon in 1978, he presented to some of the nation’s most illustrious surgeons his then-revolutionary concept of esophagectomy without thoracotomy, the operation he named transhiatal esophagectomy. It was a tough crowd. The late Dr. Alton Ocshner dismissed the concept of transhiatal esophagectomy and said, “Taking out the esophagus without opening the chest is like trying to make love in a hammock standing up.” At this year’s annual meeting of the American Surgical Association, Dr. Orringer shared lessons learned in performing 2,007 transhiatal esophagectomies (THEs) over a 30year period at the University of Michigan, Ann Arbor, where he is professor of surgery and head of the section of thoracic surgery. While he initially believed he came up with THE in 1976, Dr. Orringer said he later learned he had independently rediscovered an operation first described 63 years earlier in Germany. In his experience, Dr. Orringer said THE was possible in 98% of patients requiring esophagectomy. The stomach was used to create the substitute esophagus in 97% of cases. Esophageal resection and reconstruction were performed as a single operation 97% of the time. At a prior ASA meeting, Dr. Orringer presented the results of the first 1,063 patients to undergo THE, during 1976-1998. A comparison of outcomes between those patients (group 1) and the next 944 THE patients through 2006 (group 2) showed sharp drops in hospital mortality—4% in the first group, 1.3% in the second— and anastomotic leak—14% vs. 5%. Median intraoperative blood loss fell from 677 to 368 cc. Discharge within 10 days occurred in 52% of patients in group 1 and in 76% in group 2. Dr. Orringer attributed the improved outcomes to surgical refinements, greater operative experience, and the introduction of clinical pathways. “The incidence of recurrent laryngeal nerve injury after THE is clearly influenced by operator volume: It was 32% when we were performing 23 operations annually and a consistent 1%-2% since reaching an annual volume of 80 or more,” said Dr. Orringer, an ACS Fellow. In group 1, a postoperative ICU stay was routine, while only 4% of patients in group 2 went to the ICU. Extubation in the operating room, epidural anesthesia, and aggressive ambulation starting on day 1 have nearly eliminated the need for postop intensive care. The histology of esophageal cancer has changed over time. It was adenocarcinoma in 69% of patients in group 1, compared with 86% of patients in group 2. The prevalence of Barrett’s mucosa with highgrade dysplasia has climbed from 19% to 44% over the years. Discussant Dr. Carlos A. Pellegrini called the lack of formal en bloc lymphadenectomy the Achilles heel of THE in patients with esophageal cancer. How, he asked, can patients accurately be staged without it? With regard to THE for benign disease, using a length of colon instead of stomach as esophageal substitute would eliminate the potential for development of Barrett’s esophagus in the cervical esophagus, noted Dr. Pellegrini, professor and chairman of surgery at the University of Washington Medical Center, Seattle, and an ACS Fellow. Dr. Orringer conceded that the lack of staging lymphadenectomy in THE was a problem in the past, but the ability to stage patients has been vastly improved. With regard to development of Barrett’s esophagus in the cervical esophagus after THE, there has been only a single known case in the 30-year series, he added. 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Contents Drug Developments News From the College Thoracic Surgery Head & Neck Surgery

Surgery News - August 2007

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