Significant disagreement and debate persist regarding several aspects of the optimal surgical management of oesophageal cancer. We address some of these issues based on our consecutive series of 165 patients undergoing oesophageal resection (reported in full elsewhere) and the available literature. The areas considered are controversial but we argue in favour of a 'traditional' two-stage open approach (Ivor-Lewis), leaving the pylorus alone, making no attempt to perform a radical lymphadenectomy and fashioning a hand sewn anastomosis. KEYWORDSOesophagectomy -Ivor-Lewis -Oesophageal cancer -Gastro-oesophageal anastomosisPyloroplasty -Lymphadenectomy The aim of this paper is to outline and justify the approach we favour for oesophageal resection in malignant disease. In order to accomplish this aim, we draw on our own experience 1 and review of the relevant literature. Surgical approachPerhaps because the oesophagus is present in the neck, the thorax and the abdomen, multiple surgical approaches (and combination of approaches) to oesophageal resection are described. Inevitably, there is controversy over the optimal approach. We favour a laparotomy and right lateral thoracotomy. This is preferred to other approaches such as a threestage, transhiatal or minimally invasive oesophagectomy (MIO).In the three-stage (McKeown) approach, gastro-oesophagectomy is followed by a further cervical incision and an anastomosis fashioned in the neck. We are unable to identify any compelling argument to support this approach. It is claimed that anastomosis is technically easier in the neck than in the chest. In south Wales, the majority of patients with oesophageal cancer are overweight with a barrel chest and a short neck. In our experience, no matter how high in the chest it located, an intrathoracic anastomosis is unarguably technically easier than in the neck.It is also argued that anastomotic leakage following cervical anastomosis is less dangerous than in the chest. Not all oesophageal surgeons accept this. There is evidence that a cervical anastomosis often comes to lie in the upper part of the thoracic cavity.2 Since our rate of anastomotic leakage is, fortunately, very low (overall leak rate 1.2%, clinical leak rate 0.6%), this is not an issue in our practice.A further potential argument in favour of the three-stage approach is a greater proximal resection margin; the advantage has been estimated at 1cm.2 No patient in our series had an involved proximal margin, which suggests that adequate clearance can be obtained with an intrathoracic approach. The majority of the available evidence suggests that the rate of benign anastomotic stricture is significantly lower in intrathoracic than in cervical anastomoses.3-5 (See 'Anastomotic technique' section below.) We can identify no advantages to a three-stage procedure. In our series of 165 patients, access to the neck was needed in only two patients who developed significant complications. It is claimed that a transhiatal approach to oesophageal resection is associated wi...
Excellent outcomes are achievable following open transthoracic oesophagectomy without radical lymphadenectomy using a hand sewn gastro-oesophageal anastomosis and without disrupting the pylorus.
Traditionally, general paediatric surgery (GPS) has been delivered by general surgeons, often in district general hospitals (DGHs). Changes to higher training in general surgery as a result of Calmanisation, the European Working Time Regulations and Modernising Medical Careers has meant that fewer general surgical higher trainees are being exposed to GPS Together with changes in paediatric anaesthesia working practices and guidelines, the future delivery of GPS services in DGHs is in jeopardy. The burden on specialist paediatric surgical units (SPSUs) will increase with implications for the training of paediatric surgical trainees. Evidence from England has shown that there has been a shift of paediatric surgical services from DGHs to SPSUs.
First, the Fisher's exact test might have been more appropriate, and second there is the risk of confusing clinically significant differences with statistically significant differences. This is relevant in the consideration of haematoma (no statistically significant difference in proportions). Were the necks re-explored (a clinically significant outcome not commented upon) and, if so, was there a clear cause for the haematoma that would differ between the groups (e.g. a slipped ligature on the facial vein)? I agree with the conclusion that a much larger series would be needed to evaluate fully the difference in rates of nerve injury complications, but would suggest that a better conclusion would be that, in experienced hands, local anaesthetic carotid endarterectomy has a very low rate of permanent cranial nerve injury irrespective of approach.
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.
hi@scite.ai
10624 S. Eastern Ave., Ste. A-614
Henderson, NV 89052, USA
Copyright © 2024 scite LLC. All rights reserved.
Made with 💙 for researchers
Part of the Research Solutions Family.