This comprehensive webinar presents updated approaches to esophageal and gastric cancer management, covering endoscopic therapies (EMR, ESD) with size-based triage for lesions >15mm, multimodal therapy evolution from surgery alone to FLOT-based neoadjuvant approaches achieving 47% five-year survival, minimally invasive gastrectomy with D2 lymphadenectomy showing equivalent long-term outcomes to open surgery, and left thoracoabdominal approach for bulky T4 tumors requiring comprehensive lymphadenectomy and negative margins.
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Webinar on Foregut: What’s New in Gastric & Esophageal Cancer CareAdded:
We're going to go ahead and kick this off. Uh, welcome to another Sagees webinar. This one's really unique. Um, something a little different. You're going to see that this is a a co-sponsored webinar with ISD. These are our true esophageal friends, the International Society for Diseases of the Esophagus, a collaborative webinar.
Um, and this is what happens when you join societies. So, through sages, I got to go to Miguel uh invited there to give a lecture and I met uh Dr. Ferry, who now Lorenzo I'd consider a good friend of mine. Um, and through that kind of relationship, uh, we decided to kind of do a combined webinar. Uh, both sponsored, joint sponsored, um, by Sages and ISD. So, I think this is going to be a powerhouse two hours of information.
Uh, get your pens and pencils out, take some notes. It'll be recorded so you can reference it in the future. But we're really going to do a deep dive into for gut uh uh pathophysiology of cancer specifically on gastric and esophageal cancer. A genuine update, what's new, where we're at, what we can do, and maybe even a little bit of what the future looks like. Um I do want to give a little warning after the first speaker, we're going to do some questions and answers. Um and the rest of it, we'll hold the questions and answers to the very end. But uh Dr. Ferry, thanks so much for joining us.
And uh let's do maybe some introductions.
>> Excellent. This is a absolute pleasure to to be part of this. I I am I've been a sages member for over 25 years. Um uh and uh and I've really really enjoyed my membership and it's really important for those who are out there who are not members of seders. It's one to become a a sages member and uh and so we invite you to to look at the the sages website and uh and become membership of of that society. I personally am also a member currently the president of the ISD the international society for disease of the esophagus. And so we thought um Chris and I thought it would be a great idea to try to combine our our our individual expertises into a sort of a um a a a comprehensive overview of uh of upper GI cancers. So as mentioned both Chris Decoin and myself I'm based in McGillian University in Montreal Canada. I'm both an ISD the current ISD president as well as stage member for the past 25 years.
We are really blessed uh with an outstanding international panel of of experts multi-disiplinary experts um in in diseases of the upper GI tract. Um uh there's a mixture of both sages and ISD members um uh from from across the um uh you know across the globe. Um Jeff Moscow is a ISD member. He's an interventional endoscopist and run and is really uh at really one of the premier uh ga interventional gastronenterology units uh in not only North America but globally at St. Mike's Hospital in Toronto and he's a professor at the University of Toronto Canada.
He'll be giving us talk on interventional endoscopy and treatment um uh for this disease. Uh next is Shiraz Marker. He's a professor of surgery at the University of uh of of Oxford in the UK. uh he'll be giving a talk on multimodal therapies and and what the what's the latest treatment uh for cancers of the esophagus and the stomach. Suzanne Garrett's a good friend of mine. She's both a sages and a uh um uh sorry European association of endoscopic surgery board member as well as a board member of the international society for disease esophagus. She's a outstanding upper GI surgeon at the University of Amsterdam Netherlands.
She'll be giving us talk on on laparoscopic gasterectomy. Indeed, Suzanne and I ran a couple of of uh of lap gasterectomy sessions at Sages in past years, and those are all available on the on on Sage TV. Uh this be followed by Wayne Hoffsteader, a um a prominent ISD member um and a thoracic and upper GI surgeon at the MD Anderson Cancer Center in Houston, Texas. Really one of the global leaders in esophageal cancer. And finally, Carmen Mueller, my colleague. She's both a sages and ISD member. She's a a very accomplished upper GI surgeon in my home institution McGillian University and she'll be showing us the opposite side. You know we look both minimally invasive surgery as well as maximally invasive surgery when to do the open operations and particularly the focus on left thorcam esophagetomy are really an important um uh um operation to have in your tool book in your s in your in your shed in order in order to manage these really complex cancers. So this is our um uh I'll pass off to Chris to go over a program and we'll uh we'll get started.
>> Yeah, we'll keep them each to about 20 minutes. So here's the rough outline. Uh we'll go through endoscopic therapy. We talked about multimmoal therapy, minimally invasive gasterectomy followed by secopjecttomy and then the heavy hitter the left thoroinal approach. Um and again fantastic speakers and and we're excited to have them.
>> Um just before we finish off just I want everyone to uh to save the date for Sage is 2027. It's going to be Las Vegas uh April 6th to 9th. Um uh and finally also the International Society of Disease Theophus is a yearly meeting where all endoscopists, oncologists, surgeons, pathologists, anyone's interest in esophageal diseases, whether or not it's benign or malignant, we have our annual meeting in Kyoto um uh in the the end of of this year. So with that um done, we'll actually start with with um with Jeff Moscow. Jeff, are you able to prepare present your share your slides?
>> How's that?
>> Looks great.
>> All right, so let's go. So, Lorenzo, Chris, thank you. Thank you guys for having me. It's fun to be uh the only gastronenterologist um in the session and so pretty much I can say whatever I want. Uh but yeah, it's it's uh fun to talk about what's new in endoscopic uh therapy both for esophagus and uh cancer and uh yeah, I mean I I've loved being a member of ISD.
I've gotten a lot out of it and so I highly recommend it to anyone uh considering it.
All right, here we go. So here are my disclosures. So um we're going to start with esophagus. So what's new? Well, the paradigms have really changed uh in the way we manage dysplasia of the esophagus in Barretts. Um we are looking a lot more. We are biopsying a lot less and we have a much more aggressive approach to resection which I'll talk about. And we actually have a less aggressive approach to both lowgrade dysplasia and T1B adnocarcinoma.
And I think that's an interesting point for discussion with this group because there's a lot of overlap. Um and we're going to talk about some of the data that's come out of our uh center. And so um when we talk about managing T1A esophageal cancer, uh this is something that needs to go to your local uh expert center. Endoscopic eradication therapy or EET has long been known to be um uh for the most part better than a sophagectomy. Uh and but do we really know which resection uh technique is best? And so endoscopic mucosal resection is the tried, tested and true uh approach. It's been done for many many years uh well before I was in practice. We mark the area, we suck it into a varial uh bander type device. Uh we deploy an elastic band and then we cut under the band. It's pretty crude uh but we know that it works and it's effective. And so there's lots of data going back to say that we actually do a pretty good uh job. But just like you guys wouldn't uh you know take a cancer, chop it up into pieces and send it to the pathologist, uh we have now transitioned to new and better ways uh to treat early esophageal cancer. And so we think endoscopic submucosal dissection um may have some benefits in terms of clinical efficacy and even safety with increasing block resection increasing our zero section superior pathological uh assessments and and local recurrence. So this was um a comparison that we do meta analysis that showed higher onblock resection R0 resection rates with ESD and really a trends towards increasing cure and decreasing local recurrence which is really important in patients with a field defect in their Barretts esophagus. And when we looked at our data, we found that there's actually increased recurrence of high-grade dysplasia and intramucal cancer following EMR as opposed to uh ESD which again if we're if our goals are complete eradication of dysplasia and cure of cancer uh this is quite uh alarming and so our guidelines from two most updated guidelines said are like extremely vague saying T1 cancer should be considered for resection and the vast majority ity should be managed by EMR rather than uh ESD. And the reason they say that is mostly because of the lack of expertise um out there. And so you know is this okay? Well, the answer is I think no.
And this is an ongoing paradigm shift as I talked about now. Uh and this is my current colleague Sil Gupta um and Michael Burke, a friend and colleague from Australia looking at the oncological impact of a universal ESD uh for big Barretts cancers. And they looked at an ESD first strategy versus historical selective uh ESD uh approach.
And really what they're finding is that um ESD was favored over uh EMR really no matter uh how you uh slice it. And so you get increasing R0 reception uh you get increasing R0 resection when you just look at T1B cancers uh and you get significantly uh lower recurrence rates.
And so really the take-home message from all of the work that's leading up to now is that for anything that is greater than 15 millimeters, it looks like you need to perform onblock resection which should be no surprise to any of you. And so we sort of use a size based triage uh which seems to be effective. uh it looks like ESD is has the greatest benefit in T1B disease, although I think that T1A disease is uh equally as effective. And this is not really taking away EMRs.
We're still able to EMR visible small lesions, but we're just doing ESD for those larger lesions. Um, and we're doing it because we're able to determine uh the patients that are at risk of lymph node metastases or when we need to send it over to you guys. So, we get to see the vertical margins. We get to see the differentiation uh and we're looking for the depth of invasion as well. So, we can send high-risisk patients on for esophagetomy and the low-risisk ones we can follow over time. So, what about T1B cancers that I mentioned? Um so this is the prefer trial uh which is one by Roose Pow and her uh group and we're just starting to uh enroll patients for this but they were taking um higher risk patients and looking at the five-year disease specific uh survival and really the overall uh survival. So a really important question. So they were they were endoscopically resecting these lesions. They were reststaging it and then they were including it in the study. And this is a very intense surveillance protocol with EU endoscopic uh examination and CT scan over a 5year span. And what are they showing? Well, they're showing that um uh patients with low risk T1B actually have a low risk of metastatic disease and a low annual risk of METS.
And if you follow these patients over time at at like with the frequency that I said, you are likely able to catch these patients uh before they run into trouble. And a lot more to come on this, but I think you know some of the future uh as it uh relates to management of these cancers is that we need to be resecting them on block. any visible lesion um needs to be removed by uh ESD for various reasons the oncological outcomes and also reducing risk of neo neoplasia uh recurrence and again this I is exciting to me is can we avoid esophagectomy in all comers with T-1B cancer and can we actually select these patients by following them closely over time uh that are at risk of uh developing or when they develop uh metastatic disease Okay, I'm on a tight timeline here, so I'll keep rolling. So, what's new in the endoscopic therapy for gastric cancer?
Well, what's not new is that endoscopic resection is absolutely a must uh for early gastric cancer. Delivers onblock, R0, and curative uh uh for many lesions.
Um ESD uh is a technically challenging feat in many areas of the stomach. uh but you know most high volume resection uh practices should have someone uh who is doing this now. So you know the guidelines say well who's a candidate and who's not. It's really T1A uh cancers that don't appear to be uh diffuse gastric cancers if they're ulcerated they have to be a certain size and that aren't at risk of having lymphascular uh invasion. And again this outperforms ESD uh dramatically. So we're looking for the lesions that are not deep and do not have a high risk of uh deep submucosal invasive cancer that need a true oncologic surgery. We're looking for the more superficial lesions that that you can follow after removing their uh early cancer. And again, when you compare like our old endoscopic resection techniques to the newer ones, uh even though this takes longer, the R0ero resection rates are way better and the P even though the procedure time is longer, um you know, we're able to cure these uh patients and we know that they're cured, right? We're not again uh questioning the margins. Um and then when we look at it compared to gasterectomy obviously you have slightly higher recurrence rates with ESD um and there's obviously risk of metacronist disease in other areas of the stomach.
Uh but uh from a quality of life standpoint uh you're obviously providing minimally invasive care which is again one of the things we're trying to uh push and uh talk about. And so, uh, again, these are similar guidelines which I talked about before, but we're able to take the specimen and like punch it into these guidelines and decide if this was a uh very low risk cure or a low risk cure and what needs to be uh the follow-up after that. And this should really be discussed both before and after at a multi-disiplinary RANs.
Okay. So, what's new? Well, what's new is the light modes for detection and treatment. This is from Fuji uh which has their new 8000 series scopes with multi-light technology. So they add high definition and white light to their LCI linked color imaging uh which is really making red things redder. Their blue light imaging which is the MBI uh equivalent for characterization. And they're adding this new uh light which is um amber red color imaging. Again they're just changing the wavelength light that's happening inside the scope.
It's not post-processing and they made this really for uh hemostasis but it's actually uh quite excellent at helping you see the submucosal space. So ACI is sort of our new submucosal dissection uh light and that's available again on and with all of your uh once you have the 8000 series with the new Fuji scopes. Um so this is a demonstration from our live course. Uh, this is a Fuji scope, a zoom scope.
So, what you're seeing is a very subtle early gastric cancer. Uh, this is bli and you can see the normal stuff here and the abnormal stuff here. So we get close and we look with near focus to be able to uh differentiate normal from abnormal and mark things out.
And this is an example of ACI during our live course as well.
And this is what it was designed to do.
This is just a co-ag grasper uh soft coag.
Anyways, so uh we showed you an example of ACI or the amber red uh color imaging. It's just emphasizing short wavelength light uh to focus on the surface layer. Um and then ACI is the long wavelength to focus on the deeper layers and then I think the benefits are again uh with blood flow and vessel recognition. What about Olympus? Well, the new Olympus X1 uh and 1500 series scopes have also brought like amazing uh improvements in term in the world of esophageal and early gastric cancer. It starts with EDOF. Um, EDOF is a technology that allows you to have continuous focus uh with sort of seamless magnification. So, this is what we're used to uh in the past. This is the old processor with an old scope. Uh, this is normal mode uh with a new scope.
This is TXI. So, we've now enhanced the texture and color. This is an old scope.
And this is new both new scope and new texture and color enhancement. So we've gone from this hopefully I can convince you up here is what we used to be looking at and this is what we're looking at now and exactly the same uh patient. So dramatically different and subsequent ability to pick things up is changed as well as opposed to what I was showing you before. uh TXI is a post-processing technique although it is not there is no delay at all um and it really helps you depict man differences uh more distinctly. So it's taking the images it's adjusting the brightness it's adjusting the texture and adjusting the color tone and giving it to you in real time. This is a patient that had four endoscopies with random biopsies showing uh diffuse gastric cancer was sent to me for a final opinion before total gasterectomy and I was using um the new X1 processor. for a family area, you know, within minutes. Very, very subtle, uh, but clear to me. Uh, and then I was able to mark it, remove it with, uh, ESD, and it ended up being curative resection and saving this patient, uh, a total gasterectomy, which she wasn't, uh, so excited to have. So again uh new lights seem to be better and the data is slowly flowing in but TXI as I said that's texture color enhancement improves visibility in uh gastric cancer and these are um obviously small studies but uh studies coming uh from the east and it seems to improve visibility as well in atrophic gastritis and intestinal metiplasia. So, we find it very hard to pick up early gastric cancer uh in these patients with severe atrophy, but these lights seem to make it uh better for us. And I'm going to end just talking about closure techniques. So, uh one of the issues with resection is obviously both meeting and perforation. And so, we have new ways endoscopically to close defects. Um and uh these devices are uh new to our market, not quite as new to the uh US market, which most of you are uh tuning in for. And so, but these abilities have allowed us to dramatically decrease our uh complication uh rates as well as as our ability to send patients home. So, these procedures become like an outpatient procedure when you're able to close the defect as after. This is the XTAX. is a mucosal um approximation device. We use these four helical tacks which are pre-rung with a s suture and you just really pull them together over a suture and uh cinch them in place. And again, it allows you to um approximate this tissue in and then supplement with clips. And then there's also new endoscopic suturing devices. Now, don't get me wrong, this is nothing like what you guys can do um in the O, but it allows us to close uh things on our own in areas that are maybe too big or too challenging for us to close with our little dinky uh through the scope clip.
So, these this goes on the um edge of our uh gastroscope here. I've switched to a double channel scope. Uh and there's the tower and you just pass you're able to pass this needle back and forth. So some of you on the uh in the audience may be doing this already. Uh but again in patients who are high risk for uh post uh procedure complications, I now have the ability to do a full thickness uh closure to prevent those things uh to prevent bleeding, to prevent delayed perforation, and also to be able to send these uh patients home.
So again, uh it's early in my learning curve, but even early on, I'm able to cinch it together, and it looks like uh this uh at the end. And I'm slowly learning uh from the surgeons to not uh suture the pilot is closed. And there's the defect after. So I'm going to stop there uh or else everyone will be mad at me for going over time. But thank you so much for having me and I'm happy to answer any questions that people have.
That was great.
>> Absolutely phenomenal. What really remarkable, Jeeoff, what what you're what you're doing there. Um uh Chris, are we are we going to have entertained um questions on the chat line? Is that is that uh >> Yeah. I haven't seen any come through, so we could throw a couple if you want or >> Yeah. Yeah. Yeah. So, Jeeoff, I I I have a quick question to start off with. So, the the imaging technique has changed so much since I started doing ESC's 25 years, 20 years ago. Um and so as one made for for the audience and for me um have we stopped doing EUS's on these because you you can really look at the depth based on unless you're going to go after on lymph node that you see on CT scan. Have you stopped doing the US completely and and just use image based um uh you know pit patterns to look at the the depth or is there >> it it's a great question. I I believe um in both the I'll treat esophagus and stomach are a little bit different.
Stomach is a bit easier. I use E US only to look for muscle involvement. So if I think that this might be a T2 uh cancer, then uh I'm going to put down EU to look to see if the muscle is preserved or not. If the muscle is involved, then that patient has a T2 disease and needs to, you know, is above my pay grade. Um if this ends up being if I don't think there's any muscle involvement, then I'm going to resect that lesion as kind of a staging plus or minus. curative resection >> and so and obviously need some multi-disiplinary uh discussion what's best for the patient etc but I usually you know doesn't burn your any bridges now in the esophagus we used to eus everything right we're looking for uh depth we're looking for lymph nodes we're doing but to be honest I'm looking at everything endoscopically now I'm often doing a PET scan uh pre-rection to look for lymph nodes and if something lights up on lymph n on the PET scan then I'm bringing them to do uh us potentially for sampling. But our um so what we know is that we're terrible at differentiating between T1A and T1B disease and I was part of a big international study trying to uh look at that. So endoscopically good luck but all these patients should really be resected also because we're learning more about which T1B disease doesn't need uh subsequent um chemo radiation uh surgery and the only time again is if I'm worried about a T2 disease in a patient who is a poor surgical candidate then I might do ES to look for muscle involvement uh before I take them for resection but I'm I I prefer not to cut through the muscle in the esophagus.
Poland's a totally different story. So much less US now.
>> Yeah, that makes sense. I have I have more questions. Chris, you have you have one on your own or >> Yeah, go for it if you're far away. Go for it.
>> Yeah. Yeah. So, so do Jeff, what about if maybe for the for the audience as well and me again? Um, so you have a long segment of Barrett esophagus and you see an obvious nodule area around two or three centimeters, but there's high graasia everywhere. So, how what's your sort of strategy of dealing with a cancer and the barretts like work us through that. Um, and and and and finally, I like to say who what when do you admit failure?
>> When when do you give up? Yes. For a long bar.
>> Uh, is is there is never an option?
Never. Um, >> you're a surgeon. Yes. There you go, Jen.
>> I know. Foolishly. I mean, I'm much closer to a surgeon than I am a gastronenterologist. My GI colleagues are like, you're insane. Um, so the answer is a lot depends on what's going on in the rest of the esophagus. So I actually spend more time examining the rest of the barretts than I do examining this lesion because I often know that I can get the lesion out, but what am I going to do with the rest? So if I either if the rest of the if there's nodules or I think this is either multif focal high-grade or intramucal cancer in the rest of the segment I'm considering removing the entire area of barretts in one shot uh with ESD and you know now I'm circumferential and now I'm often prophylactically putting in stances to prevent uh strictctures and suturing them in place. So I'm even like last week I did a 22 cm segment of barretts right like pretty much up to the uees and I just put a stent in there two stances overlapping stances to prevent stricture. So the amount of barretts that we're able to take now is unlimited. Um but the question is do you put that patient through the risk of strictcture but I we have like new medications and new things coming to prevent stricture.
If I don't see any dramatic disease elsewhere in the barretts, then I will rect only the cancer especially if there's a demarcation line. Uh and then I will ablate the rest of the barretts after. So I cut out the cancer. Small one I'm doing EMR, bigger one I'm doing ESD. Bring the patient back after it heals and I'm doing radio frequency ablation or cryotherapy to the remainder of the segment of Barretts. And that the outcomes for that are still quite good at eradicating everything. Yep. Hey, one last question before we go on the next before we let you let you go off. Um is now you you referred to the preferred trial um that the high-risisk T1Bs >> um I don't necessarily >> uh not that I don't trust that that data. uh the higher S1Bs with LVI. Um I we see lymph nodes like when we resect them.
>> Um I I I have gone in my in my career to doing um you know uh referred everything with who had T1B for surgery. I was like dogmatic and then I'm like I'm not operating on any of these uh until until I have cancer and then I've >> right >> we've had some that that have have metastased out uh and and and so what are you doing? Is there another option other than following for your highest Q andBS, do you ever send them for chemo radiation or do you or do you I mean operation is always option but like like for those who really don't want operation what what are the other options just following them? You feel like you're you're you're like we're we're just waiting for for the you know the sort of damic leads to fall.
>> Yeah, I I it's a good question honestly.
Like I think you guys probably have a better perspective on this than I do. I I still have any like all T1Bs uh I will like get thoracic surgery oncology like I'll get everyone involved because I think it you know this is often a personal decision. I think what we're going to see from the preferred trial and some of it was just I was just in Milan a couple of days ago for our ESG and they presented the most recent update. I didn't have time to put it in here, but I think it's the really the lowrisk T1B patients that are probably good to follow and you're able to capture those patients over time and probably the high-risk T1Bs you maybe need to operate, but there's some, you know, the signal is that they might be dying of other things also because these patients are often comorbid and sick.
So, you know, we got to think about the disease specific mortality. So I I I think absolutely we need to think about other things and maybe chemo rads is the answer. I don't know. But but I I just you know the everyone the T1B's everyone needs surgery thing I think is is you probably agree is a thing of the past and we just need a better way to risk stratify and I think >> staging ESD is the way and then figuring out well what how can we actually capture the patients who are going to develop like lymph node meths over time is intensive u like us the answer is it not is it other imaging is it Not I don't think we know.
>> One last caveat. Squams. You have is that the same question for squams or or is that different? T1B squams.
>> No no squams are a much different ballgame. And so even in Japan they're they don't do circumferential squams.
These patient patients go to the O. Uh there's there's almost nothing new in squams which is why I didn't talk about it. Uh but we you know the curative criteria are different as well. And so they're just it's a different beast. And so anything that is into the submucosa in my opinion the risk of lymph nodes is high enough that probably needs something operation rad something like that.
>> Yep. Thanks so much Jeff. That was an outstanding you guys. This is an absolute treat to have someone of this caliber speaking and giving us incredible um overview of of endoscopic therapies. This is uh this is really really uh state-of-the-art. Thanks so much Jeff.
>> Amazing pleasure. Thank you so much for having me. Bye >> bye. Bye.
So I think the next speaker is uh is Shiraz Marker you can talk to on multimodal therapies. Uh it's unfortunately the middle of the night for him. So he has a pre-recorded um uh lecture which I will provide right now. We will be taking the rest of the questions um uh at the end of the all the the talk. So and I can definitely and all the speakers can definitely attest to uh to the his and the next speakers. Uh so first of all we like to thank sages and ID for the opportunity and the privilege uh to present here today. My name is Raz Mark. I'm professor of GI surgery in the University of Oxford. So I'm going to talk to you about Oops.
Apologies.
Uh >> so first of all I'd really like to thank uh sages and ID for the opportunity and the privilege uh to present here today.
Uh my name is Shaz Marer. I'm professor of GI surgery in the University of Oxford. So I'm going to talk to you about modern multimodality therapy for esophageal and gastric cancer and where we stand now.
So what's important to really state right from the outset is that multimodality therapy has really transformed overall survival. We've seen massive improvements in five year overall survival going from around 15% traditionally with with surgery alone to over 47% with a multimodality approach.
This is really driven by the Arnort resection margin rates which have dramatically improved associated with modern based chemotherapy and chemotherapy. And also what's really important uh is that neoagivant therapy is actually enhancing the quality of surgery we're able to uh produce by improving overall rectability.
What I believe and I think is really important is that when we start to look at the literature we must and I I state this absolutely is that we must be very clear in distinguishing adocrine.
We need to stop grouping these together in clinical trials. It doesn't work and it's completely pointless in my opinion.
um um in terms of trying to talk about disease biology. So in my practice in Oxford currently what we use is use adenocarcinoma as for adnocaroma thetysophagus or the gastrooft junction or the stomach we we traditionally would use flot for local regional cancer cross if the tumor is very proximal with adnoc but traditionally fla we see a five year a three-year oval survival of 15% and a 67% Arnold resection margin rate in most published literature square effect in the mid to proximal esophagus in the western world we would advocate for a chemotherapy approach in most situations or def or um DCF in in the um bar east which I'll talk a little bit about well as well um the um three survival is 72% with sarcast with an reception margin rate of 85%.
So I'm going to walk you through the published literature on where we where we started and where we are now to uh where we are now. So the EA2 trial uh basically randomized patients between surgery alone versus surgery plus CF. We saw an improvement in overall survival with um uh hazard ratio of 0.79 translating to a 3-month um approval of absolute gain in overall survival. Um it was mixed hisystologology um at the time. However, there was a slight favorance towards adnoc within the trial.
Moving swiftly on we then moved towards the magic trial. magic trial um uh really compared ECF to CF for the um sorry ECF plus surgery versus surgery alone showed a real improvement in overall survival with um uh 36% versus 26 23% of five year overall survival with a had a ratio of 0.75 what should be stated is now is that the magic regime of ECF has been superseded by a flot which I'll talk about um but this is an important trial um in in the in the UK at least because it really established our ability to recruit to a cumulative therapy trial um um as part of um our portfolio I guess in many ways and then came across flot 4. Flot 4 really um has become the standard of care. So essentially flot 4 compared peropive flot with um versus ECF or ECX and reectable gastric and junctional adenoc published in 2019. it showed a 15-month um overall survival improvement translating to a hazard ratio of 0.77.
What's important to acknowledge and I'll come back to this at multiple times during the talk is that only 50% of the court actually achieved um the four eight cycles of flot i.e. they didn't have the adventic component of the therapy and that that's really important when we start to think about this and also really your service and what you were able to deliver in terms of perop pre-optive lot whether or not your patient population can tolerate it and again we'll get into this as we go further into the talk what can't be ignored is that um in 2021 we published a 10-year overall survival from cross was a landmark trial comparing therapy plus surgery versus surgery alone What should be noted within the trial is that a substantial proportion of patients had a trans hyal resection. So therefore it could be argued that perhaps patients didn't have modern-day surgery combined with chemotherapy.
But however the um 10 year overall survival with the cross regime uh reaches 38% versus 25% in the surgery alone group with a pathological complete response rate which was impressive at 29% and an Arnold resection margin rate in the crossarm which again was very impressive at 92%. So what we can take away from this is that if you are counseling your patients to have a chem radiotherapy there is a durable survival benefit up to 10 years in this patient population compared to surgery alone and also you're able to achieve an arnal reception margin rate in 92% of your patients and a good pathological complete response rate however um that may not be correlated with a survival as I will talk about as well and John Reynolds of the new ages trial um which was an important trial published in lens of gastronology in 2023. It was stopped early due to futility but essentially it compared patients who had chemotherapy with chem radiotherapy which of course crosses um as you can see was three over survivals 55% in the chemotherapy group versus 57% in the chemotherapy group and what's important to note within this trial is that the majority of patients had ECF and transition towards flot in the latter part of the trial after flot 4 was published. So that was fundamentally why the trial was stopped because they were not powered to really um assess the issue of whether or not flu versus cross is better.
However, ESOPEC were followed up in 2025 in its New England paper and really this is the this is the landmark paper which has changed practice because ultimately what we know is that flop is superior to cross in patients with pure adenocarcinoma with a um three-year oval survival 57% versus 50% in the post Hey Dr. Furry, I think you got muted somehow.
Now what should is that the quality of surgery in this trial was very high compared to what we may see in a western population. Um and therefore um whether or not the results were applicable in a western population uh does remain slightly questionable.
So when we look at the 20 years of um evidence in esophageal cancer, we've really moved from essentially quite basic chemotherapy with CF towards more complicated chemotherapy with flot um becoming the stand of care for adnoc cost in the west and perhaps chemotherapy for um scram carcinoma in the west. I won't get into organ preservation and the san trial partly because um I I really don't have time to tell you what I think of that trial. um and it's um in conclusions in many ways which I think are um in many ways are falsehood. So um really what I'll focus on um for the rest of the talk is basically where we are and what the um uh evidence really means around um surrogates potentially for overall survival.
Completion rates do matter and I think it's critical. What can't be ignored is that in the flu four trial only 50% of patients completed their adifant cycles of um flot um and therefore we know in real world data that around 50 to 60% of patients actually complete adant flot however when we look at the overall package of cross because a lot of it's all up front I mean I appreciate checkmate 577 has provided adivant imunotherapy in this population as well but uh at least with cross is a much better tolerator regime with 93% of patients completing their overall cycle and DCF again is very robust completion rates at 75%.
So at the moment in my center as I go back to the original is that we're largely been using flock for adnocaroma and for squamous cellar cast largely using cumulative therapy. appreciate in Japan this would be different with DCF using in the um in the squel population but there remains three unanswered questions which I think are fascinating for the future. One is total neoagimal therapy. Um we have a trial which has just opened in Scotland looking at the utilization of TM2 as a primary treatment approach for patients with adenocaroma of these. Also the combination of chemotherapy and imunotherapy particularly as matter horn has been published. Um this has now been nice approved as of 3 days ago. So um we finally have now fener as a upfront regime for our patients for esophageal and gastric adnoc. Also, we're going to start to move towards more bio biomarker guided um therapy. We tend to use this a lot in our patients with metastatic disease um particularly um looking at their EDR1 expression uh cloudin and her tu. However, I think this will move out of the metastatic setting and more into the new agent setting as we move forward over the next few years.
So there are four key messages I think um from from this overall kind of review of the literature that flot is um the ad is the standard for adnicoma cross however does have a durable 10-year data and that cannot be ignored for squamous cellar carcinoma we can use DCF in the far east or chemotherapy in the west really depend upon your practice and also your I think your ability to achieve good surgical outcomes with the three stages of the center expertise will ultimately show the outcomes particular particularly with the adherence to block based chemotherapy.
What I I'll sort of sort of move towards and sort of lastly finish on is really talking about pathological complete response. What what cannot be ignored is that um oncologists who tell you that the high the complete the pathological complete response rate is higher with um chemotherapy are correct. But that does not translate into a disease-free overall survival as shown by this paper which shows that the recurrence free survival with a chemotherapy cohort to achieve a pathological complete response is 87% versus those that um in chemo radiotherapy which is 75%.
Also when we start to think about that patient population which actually didn't get the um uh adivant flot really what's the value of the advent and I've often thought that in my own practice and I think the space flot study which included just under 1,890 patients is really really important because what it shows is is that if you have a complete response to flot there's no benefit to giving you a blot. If you have minimal response to flot and new advent again there's no benefit to giving you advent. However, if you have a partial response there is the benefit.
So that's the group whereby you should try to maximize their outcome from surgery and therefore ultimately um maximize their ability to receive adgivant um chemotherapy or advent and complete their full cycles of advent.
And the elephant in the room um which is now I alluded to in the briefly is that matter horn was published um in New England journalism in 2025 showed a hazard ratio of 0.71 for event free survival and I'm so uh thankful and excited to tell you that now in the UK we have finally have approval uh as of two days ago to give this to our patients for esophageal and gastric adosoma um so uh flot and has been established as a standard of care um probably moving forward forward at least within um the UK.
The other thing that we cannot get away from is that the quality of surgery is so important in when we start to talk about outcomes for these patients. Um so it's not just giving them multimodality therapy because the multimodality therapy includes quality surgery. This is data from our ALS study which we've just uh presented which shows that if you have a lymph node yield of 25 uh lymph nodes that that actually improves your overall survival. um um with a 15% improvement in overall survival in patients receiving new agent chem chemotherapy. However, what I always wanted to know was was that if you had a radical resection and you had good systemic control with good chemotherapy such as flaunt, does that outperform chemotherapy alone? And this is what we showed within this paper that if you have um chemotherapy plus a radical dissection that dramatically improves your avocable compared to chemotherapy alone which is important and really this is driven by the fact that when patients have just chemotherapy they recur distantly because you don't have good systemic control. Um and this is what we've seen with this paper looking at pathological complete response which has just been accepted for publication in JAMAMA surgery. um which I think is exciting because it shows quite definitively in a large cohort of European patients that um patients who have chemotherapy will occur distantly. So it's it's really in adenoc control of the systemic component of the disease.
So in summary, plot is central for um adenoc cross does remain an important benchmark and pathological response does guide decision making. Um surgical quality metrics I do rem do believe remain absolutely critical and as I've alluded to I think future biomarker adaptive therapy is so so important. So with that I'd really like to thank you for your time and I'm really um sorry I can't be there in person. Uh but if you wish to email me anytime, I'd be very happy to take questions and I look forward to watching uh the recording around this.
So thank you again.
>> That was a wonderful overview of of of multimodal management of esophageal and gastric cancer. And just as a summary really has a flot or chemian therapy uh has really been replaced by peroperative chemo and now chemunotherapy for adocaromas and squam chemation therapy still has a large role for squa we can uh interesting questions at the end I think the next uh Chris you want to introduce >> yeah go for it Dr. Gizba's next. Uh, same deal. This is going to be a recorded one. Um, and she is, uh, in the middle of the night. Um, and we're going through laparoscopic minimally invasive gasterectomy.
>> Today, my name is Suzan. I'm an urbi cancer surgeon in Amsterdam. I'm sorry I cannot be present live, but it is 1:00 a.m. So, I have a pre-recorded lecture.
I will share my screen.
So, I will talk about the minimally invasive gastroctomy. So what's about this in the guidelines currently? Well, the Japanese uh gastric cancer guideline the most recent one minimally invasive gasterectomy is uh recommended strongly for all stage stages for distal gasterectomy and for total gasterectomy is clinically stage one and for more advanced stages it's weekly recommended.
For the robotic gasterectomy, there's a separate paragraph and it's for all stages weekly recommended in both subtotal and total gasterectomy.
This is the algorithm in the Korean gastroantric gastric cancer guideline and this is the zoomed in on the surgical treatment. And here you see that for clinically T2 and until 24A both laparoscopic and the Dainci robot constractomy is advised but also open is still an option. In our Dutch gastric cancer guideline it's um minimally invasive gasterectomy is considered for patients with reectable gastric cancer for all subgroups provided um it's performed in centers with with expertise.
So what's the evidence? If we look at early and advanced gastric cancer in which a subtotal gasterectomy is performed, there's a lot of randomized control trials that show short-term benefits and long-term results comparable. And then if we look at other trials for subtotal gasterectomy, all these have been performed and they they these show and long-term outcomes comparable.
Then if we look at total grectomy there's also some randomized control trial tri trials although much less these trials uh show-term benefits with long-term outcomes comparable and these uh randomized control trials concerning total gasterectomy both in early and advanced gastric cancer have short and long-term outcomes comparable. So in total around 7,000 patients randomized it has been shown to be safe and feasible with good adherence to D2 lymph nectomy and shortterm uh res results verifi from comparable to superior and long-term results are comparable and this is for both early and advanced gastro cancer and both strepto and to gasterectomy and um there's still a limited number of patients included with perioperative chemotherapy.
So what about the robot? Well, there's an increasing rate of a minimally invasive gasterectomy also here in the Netherlands as you can see over the years that the open surgery really decreases. That's in the light green and in the bluish you see the increase of and adoption of minimally invasive gasterectomy. And we start also to do more difficult p patients both on patient factor and tumor factors. And maybe in these more difficult patients the robot can offer a solution with of course the wrist and improved visualization.
We started with the robotic surgery in 2019 and have now a lot of experience with this. And there's of course also a lot of developments with regard to the robot, new robotic systems, incorporation of new techniques and also um increasing possibilities with uh instruments and uh image guided surgery.
This is just an example the Hintoi that is not um on the market yet in Europe but um we in Asia in Japan it's already um and other countries it's already in use and you see also that I did a kadaavver gastractomy with it which was actually also very good machine there's also already trials uh that um compare laparoscopic with robotic arctomy and show the short-term no differences and in the for the survival endpoint there was an even an improved survival in the robotic compared to the laparoscopic group which I cannot completely explain but it's very interesting so what about the technique well u the minimally invasive we perform in French position while the robotic in supine and we use four troll cars in the upper abdomen and the native livery tractor term also for the robot with the assistant port on the left side of the patient and the robot coming in from the right side looks a little bit like this then and the lymphattomy we adhere to the Japanese gastric cancer treatment guidelines so we perform a D2 lymph nectomy um for both total and subtotal gasterectomy and in the most recent versions patient 10 is omitted in total gasterectomy there are still indications when to do And there's also some other indications to do a more extended lymph anctomy as you can see here.
So this is what it can look like inoperatively here the portal vein completely exposed and here the towards the the spleen you see in this case station 10 was still resected.
This is an robotic video for total gastroctomy.
And you see the hiatal dissection.
Here you see the pancreatic upper margin here. The common hypotic artery.
There's the portal vein.
Here the left gastric artery.
And in this case we use the vessel sealer. You have of course also the synchro seal or you can also use scissors. For an more advanced lymph nectomy in the chest for example I prefer to use the scissors.
We still use the lips for the left gastric artery.
You see the adrenal gland splenic artery towards the spleen.
And here the short gastrics that are being divided and then looks like this in the upper abdomen and here the spanic artery followed till the spleen.
So you can also use the robot very well in a more extended lymph nexttomy here and a caveal lymph nectomy.
The video is from Frank of yellow where you see that it's you can do a very extended lymph anctomy very safely with the robot with very good exposure.
usually from the right side. So you go and some of the small vessels are clipped.
If you did, you can come also very c in the in the in the body.
Here's the aorta.
And it is not always so um easy in the sense of um that some patients are really obese and then it's still possible to do also um lymph nexttomy with the robots.
But sometimes you see that it's the anatomy is not so clear as in other cases. And that's this is just to show that um not all patients have the most easy and beautiful anatomy, but that you can still recognize your your planes.
Here's the portal vein, the left gastric vein, left gastric artery.
Here's the orbital vein again.
Station one and then here the mascolon.
Usually that is still even in obese patients very well identifiable.
And then what's also interesting to acknowledge is that the celiac trunk is usually much deeper than when you just transsect the left gastric artery as here. Here's the left gastric artery.
This is the common hypotic artery in the spanic artery. But the real celiac trunk is much more centrally with here the aorta.
And this uh is also a tiff you can use the follow the superior colic vein and then you can see that it enters the handless trunk together with the right gastroploic vein. So you can do a very central lymph nectomy station six.
You can also um if you do need to do a distal east of ejectctomy, you can also do that laparoscopically very well um by opening the diaphragm ventrally and they have very good exposure uh to the to the mediainum over the aorta.
here pericardium and you can open both pluras and re resect a part of those.
Here you see the dominary vein even. So you can get get really high if necessary. Of course, the amos will then be very uh difficult to make with the dissection you can get very high. So about this anesmosis and if the anesmosis is that high usually the only option is to use the orville which is inserted through the mouth and then the circle tapers insert. in it in the small bow.
And this is very difficult because you have very limited view and it's very high in this narrow confined space.
And I staple off this part. Um this is another technique linear stapler and this is also what the beriatric surgeons often performed.
Then the entr uh entrostomy is made with uh without dissecting yet the the small bowel so that it's nice and high and easier to suture. Then the distance is measured and as the most made and then is closed and then finally the small bubbles between the antimos is transacted.
Robotic is of course also a possible You can do it completely hand soon and then use the same technique as shown previously for the dissection of the and the entrendenttomy and the dissection of the small bowel.
Um sometimes it's easier to perform the entroendrosttomy via open procedure so that you can see the argate and this is especially useful if you need to go very high.
So you can also use ICG both for uh to guide your lymph nectomy.
As you can see here that you can find really your green lymph nodes one more time to show this very big lymph node package. This is still under investigation and you can also use it in sentinelon note uh navigation surgery which has been shown useful in early uh gastric cancer.
As you can see here, usually a sentinel basin dissection is performed. In this case, we separ separated the green and hot note um to send it separately for a pathological investigation. Also, new techniques are available. Um this is from Yin Hung from Korea where you have detailed anatomical information based on the previously identified CT scan or uploaded CT scan where these uh extractions are made which you can be used uh in the in the Dainci during your operation. So in conclusion um there's strong evidence for minimally invasive gasterectomy both total and subtotal robotic surgery may be a solution for certain patient and tumor factors and it allows for integration of technical developments and um there are a lot of these technical developments among others fluesence guided surgery and image guided surgery and I think yeah we live in a very exciting time with a lot of new possibilities and uh I'm very curious what the future So, um, thank you very much. Um, I've tried to stop sharing my screen.
Um, >> great talk >> there.
All right, another good one.
I believe up next, uh, Dr. Hoffsetter MD Anderson giving a talk on minimally invasive esophagetomy.
>> All right, let me share my screen here.
>> Give me a second to get organized.
>> Take your time. All I had to do is hit play.
>> Yeah.
Okay, tell me that you're seeing this.
>> Yeah, just not in presenter mode. We can see your slides on the left panel.
>> Okay, let's do that. Let's let's put that. How's that?
>> Perfect.
>> Perfect. Great. So, uh, thank you for the invite and the um chance to come and speak to you all about um MIE, which is interesting that I would be chosen for this topic because I think that I was probably the latest adopter of minimally invasive esophagetomy or even robotic.
Uh, my story starts in, you know, residency when I trained with Tom Deester. We did everything as you know maximally invasive and um here's my disclosures but you know at that point big surgeon was equal to big incisions.
So we were doing 16-hour colon positions for high-grade dysplasia and the idea was that we were taking out every bit of uh you know the mezzentary around the esophagus and the stomach as possible and what you were seeing in Suzan's talk for gasterectomy we were including that in the chest for esophagetomy.
So fast forward to when I started my own um you know foray and experience into esophagus as an attending. I began doing minimally invasive esophagetomies on a Zeus in 2002 but quickly realized that I wasn't technically able to do the same operation that I was doing open and then I spent the next 15 years alone as everybody went forward as Lucatic popularized minimally invasive esophagetomy. was trying to prove that maximally invasive esophagetomies along with chemo radiation was really where it was at and that that was going to be an improvement over doing a minimally invasive operation where I was watching surgeons blow by lymph nodes not do a lympadenectomy and say well if you give lymph nodes are involved then you're not going to get a cure anyways so I I started out with a complete 180 degree from what the industry was doing as they were moving towards MIE adoption I was moving towards maximal esophagetomy and open esophagectomy to try to prove that a bigger lymph node dissection was better in terms of overall survival.
So you know in having this discussion about what my transition was and you'll notice that this talk isn't really heavy on technical it's more like why we should be moving as an industry towards MIE and why also we need to be hanging on to open. So those of you who are doing a lot of esophageal surgery shouldn't be considering just doing one type of esophagetomy. There's two field, three field, minimally invasive times when you have to do maximally invasive and open just because of the surrounding structures. So we should be able to do all of them. But we need to know what the advantages are of open surgery and what the disadvantages of MIE that you need to overcome as you convert from an open to an MIE or as you just start out in MIE. So the resection, the technical aspects, you know, within the abdomen, you want to do a complete lympagctomy. I don't think that there's any more complete than you just saw with Dr. Gizert's. um we don't do around the aorta for an esophagectomy but clearly a D1.5 along the splenic artery common hpatic all the way down to the celiac axis and all the way up to the to the um hiatus. Um I think it's been a gamecher for us to include a momental tissue transfer so that we bring momentum up so that we separate the esophagus from the airway. So in case we do have leaks that decreases our incidence of severe leaks, the need to go back and reoperate and potentially the incidence of TE fistulas which was quite a problem initially with robotic surgery and one of the things that kind of steered me away from doing a thorazzic robotic lympadenectomy was that there was a lot of TEFs initially.
Um, I at first when I was in this process, I thought, well, it was much easier to preserve or replace or accessory left a paddock open, but I've since realized that I'm probably a little bit faster on it with the robot than I am open, although it's probably easier either way. Um, but moving over towards an MIE, I've learned to eliminate certain parts of the operation that I thought were extremely important when I was doing open operation. I always did a pyloriottomy. I always placed a feeding tube because you're open, you might as well do it anyway.
but minimally invasive. I eliminate those procedures and I think they're probably extraneous and maybe even add to potential complications in the short and long run within the thoracic portion of the operation. You know, we're doing a modified onblock. the benefit um of what I'm doing and I'm going to tell you I'm going to admit right to everyone right here in the open that I do a hybrid and I've been doing a hybrid now for the last 10 years or so because when I do convert over to a minimally invasive I can't see the mucosal color as well which is how I gauge where my anastmosis is going to go I use spy I can't gauge the tension as well as I can because I'm just not as used to it yet and there's a there's a big learning curve and we're going to talk about that in a minute so I'm still doing hybrids within the uh chest. The resection margins for me plur to plural paricardium to spine and diaphragm to the arch of the asigus and then if you need to go higher because you have a mid or upper esophageal lesion and Suzanne would argue that any lesion you need to dissect in the levels fours and twos but we do not routinely for GE junction tumors uh do lift and dissections above the airway unless there's clinical indication.
So within the uh within the resection margins so uh depending on the tumor I used to always include the asigus vein was how I was trained and onblock included everything all the way 180 240 degrees around the aorta including the asigus vein I modified that to include the thoracic duct when I became an attending and now I'm even eliminating the thoracic duct lation because you can see the messentary around it and still do a good lymph node dissection and I have to be honest I don't think I've ever seen a thoracic duct lymph node come up positive in the pathol ology.
So, you already saw what this should look like. Suzanne talked about where the left gastric is and that you should be dissecting into this area to get down to the celiac axis down through here is the celiac axis and getting the celiac lymph node all the way out to the liver on the common hpatic all the way out to the spleen on the on the splenic artery.
Some of the things that discouraged me initially, I was doing a minimally invasive hybrid MIE. This is an operation that was from back in 2009.
And I did a really nice ille on a patient with squam and I was pretty proud of myself. And then 3 months later, she popped up with this recurrence. And I was angry because this was a lymph node that I would have easily taken out um if I was doing it open. If I was doing a radicon block, I would have I would have taken that out.
But I missed it and had to go back later. Now, since she was cured, we got her taken care of and cured. But I thought this was a reason why I should be still sticking to an onb block and open not realizing that part of it was my technique and also part of it was that I just hadn't embrace the robot yet and I was still using straight sticks.
So along comes sort of you know my opus is that you know I worked on this for about 10 years. We finally published a study after getting what we thought was enough cases and it compared what my partners were doing which was a standard IL versus what I was doing which was an onblock maximally invasive open IL and compared groups that were similar stage and you know was lo and behold able to show that you know my outcomes seemed to be a little bit better in terms of prognosis compared to just doing a standard IE and not taking as many lymph nodes out.
Not too long after, virtually simultaneously, the European group in 2012 came out with a time trial. And although this has been looked at in many different lights, some critical and others, you know, heroic, the time trial did show that there was uh less pulmonary uh uh rate, pulmonary complication rates with minimally invasive versus open. And I think it was the first trial that was really trying to push people into say, hey, look, the outcomes are better. It's not just a different technique. You can actually get better outcomes.
Not too long after that, Sherz Marker wrote this paper up for the French group. Kristoff Marriott was first author in inosimus and showing that within the group within the French group that they were able to take similar patients and found that this is a well-run standardized trial.
It was hybrid which is more akin to what I like to do at this point but showed that among major posttop complications that there was a 77% lower incense but an equal number of overall complications such that showing that minimally invasive really was coming up with shorter hospital stays lower uh blood loss and lower chance of major post-operative complications. So I think between these two trials and the whole industry starting to move forward and actually moving away from me and open surgery, it was became pretty obvious that if you're not embracing a minimally invasive esophagetomy, you're going to be left behind. So you know what's important in terms of comparison is that there's a robust control arm. There's historical controls. You know we have to have a standardization of nummenature which is what Don Low really worked on it. You know what constitutes a leak?
grade of leak. Is it a leak if you're doing a swallow study on every single patient or is it only a leak if you've got a symptomatic patient that you're only studying those patients that you think have a leak? Um, there's selection bias involved and there's also reporting bias and publication bias and this was something that I still complain about to today and I'm going to show you some of our data because of that. So I think that in the early um sort of go of MIE and especially robotic operations that there was a lot of people that were talking to me at conferences and saying yeah we're having a real problem with our learning curve and our leak rates have gone really high but the only people that were publishing on actual MIE versus open were those that were experienced they were in randomized trial. It was a very select group of surgeons uh and they were showing the better results but in reality this is what was going on at our institution. We started embracing MIE uh admittedly about twothirds of this is straight sticks versus one-third robotic and comparing it to our open and this is actually contemporaneous open not just historical and found better AIB rates but not statistical but you can see that the leak rates were significantly higher during this phase of what you would consider a learning curve of that you know in my open operations it was about 6% in our MIEs it was 24%. So we were really having some difficulty with that conversion and I think if you talk to a lot of groups uh there was a lot of learning that needed to be done. What I think was most interesting too is that although the mortal mortality rate was non-significant the mortality rate consistently for MIE is like in the 0ero to 1% mo closer to zero most times and the 30-day mortality for open seems to be higher in every publication and that was true for our um data as well. uh harvested lymph nodes from this period of time there were um you know less lymph nodes with MIE again I think this is a this is an experience thing it's a matter of who was doing it how often you were going after lymph nodes versus you know those of us who are doing doing open maybe pushing our pathologists a little bit more um margins were about the same so then we decided to take out kind of our learning curve and say let's let's eliminate the first 20 cases now um I would argue that 20 cases is not a learning learning curve for an MIE, it's probably closer to 40 or 50 and you're even better after 100 than you are after the first 50. Uh the leak rate was still high and this was this was sort of uh you know kudos to what you know made me feel good is that my modified on block my leak rates were about 5% 6 and MIE at that point was 20%. So I was still kind of you know shooting from the hip saying guys you know until you show me that your outcomes are better my outcomes are pretty good or maybe better. So, it took me a while to to become an adopter of MIE.
Nonetheless, again, it depends on what you're doing during surgery. If you're pushing for lymph nodes, you're going to get more. If you're pushing for negative margins, you're going to get fewer negative margins if you're doing modified on block. So, uh this is sort of where we were at in our heads.
However, despite the fact that open surgery can be better, it all came from adaptation. And I think that my experience with, you know, doing minimally invasive skills through other other avenues and understanding how far I could push minimally invasive in terms of what it could do and seeing the industry moving away from me as I was doing open surgery, that just, you know, basically pushed me in the requirements for me to move over to minimally invasive and robotic. I just had to be patient. I had to learn what I could do with the equipment. I had to learn that it was okay to spend. You know, Lorenzo, you can talk more about this. Up in Canada, you guys were having to raise money so you could do robotic operations and pay the hospital so that you could operate there with a with a robot. Um, and I think that you have to have good minimally invasive skills. You also have to be motivated to make the change. I I would say starting with benign disease, uh, you all who are, you know, residents and fellows on the on the call, uh, you're getting a lot more robot experience than I ever did even in attending. There was no such thing as a robot when I was a resident. uh and minimally invasive esophagetomies didn't really exist until I was finishing up uh my fellowship. So, you have to be pretty motiv motivated to embrace that change.
Follow through with the change. Make sure you're going and get expert coaching. Go to get go to take courses.
Watching videos such as Suzanne showed are are excellent, but it's not as good as actually having hands-on training.
Uh, and I would even recommend that when you're doing uh first-time robotic operations that there's two people on dual consoles so that there's uh more than one set of eyes because the change between what you're seeing open and then seeing it under magnification is significant. You know, things look like it looks like it's a lot more bleeding.
You're not moving your tissues as well.
Takes a long time to get used to that magnification and what you're seeing.
It's like seeing the anatomy from a different from a different lens.
So a short sort of just kind of summary because you know I would say I'm the last person or the last expert on the earth to tell you about the technique of MIE. Um I finally adopted robotic MIE I think in 2020 or 2021. Um, I'm about maybe about 80 cases in on my esophageal experience for MIE and I'm loving it, but I'm still doing a hybrid and at some point I'll switch over to doing complete MIE, but it's going to take me a while because my results are pretty good, so I don't want to change. Thank you.
Thank thanks so much um Wayne for for a very nice presentation uh and really a candid approach to to this a very pragmatic approach to to adopting new technologies. Um our last speaker is uh is um my uh colleague and partner Carmen Mueller. She will be speaking on on the big big operation left throat abdominal and when to use it.
>> Great. Thank you very much. Um I hope you can hear me. Um all right. Um I'll just uh I'll share my screen as well.
Sorry.
I don't know why it doesn't seem to be letting me um share. I'm not sure why.
Um it looks like I'm getting a an error message when I'm trying to share my screen. I'm not sure why that's a You're you're now the co-host, uh, K.
>> Okay, let me try again.
>> Sorry about that.
I apologize for the delay.
Okay. Um, good. Can you see it now?
>> Yeah. Yes, we we we can see your >> great. Okay. Okay. Apologize for that.
Um, okay. So thank you very much for the uh opportunity to join this really um excellent and comprehensive webinar. Um it's a supposed to be about what's new in gastric and esophageal cancer and but uh what I'm talking about isn't new at all. It's a very uh uh classic and uh um traditional approach. Um but uh actually um despite all my my training and years in practice, it still remains one of my favorite operations.
Um so we'll start off with the clinical problem. So we've heard a lot about from all the other speakers about every other approach to uh esophageal and G junction tumors and um the uh really large variety of minimally invasive and uh even organ sparing approaches that are available now. But um G junction classification uh definitely does impact the surgical approach in uh in many ways. And uh what I'm going to be talking about is mostly the um uh type two lesions that extend in both directions uh where you might be concerned about margins and definitely the type 3 seawward type tumors which are large and bulky and don't necessarily uh not necessarily conducive to a minimally invasive uh traditional MIE approach. So how can we um deal with this? because the mage survival after uh surgery for EG junction cancers um this is an old paper but it still remains true and regardless of how many uh clinical trials we have in evolving chemotherapy uh uh sphere for G junction cancers all of them still include a radical resection with negative uh spec very importantly negative margins and also um a true lymph node negative disease which requires a a comprehensive of lymphatenectomy to be sure that you haven't understaged the patient during the surgery and for um laparoscopic and and now robotic procedures. These are this is very achievable for the majority of patients. Uh and you can get really beautiful uh uh onblock resections with take all the lymph node stations but it presents some problems still today for bulky T4 tumors that invade other organs both in the abdomen and the thorax. uh for D3 lymph node disease where the the lymph nodes are perhaps tucked behind the pancreas or around the renal veins.
Um, and particularly if you're concerned about the proximal or distal margins, if you're approaching a cancer that is uh a Cword3 that's extending quite distally down the down the stomach, um, trying to plan an upfront uh, two field uh, uh, esophagetomy. Using the gastric conduit can be very tricky in that type of patient if you're concerned about your distal margin. Um and uh and that leads into the choice of the conduit and what how are you going to reconstruct a patient if your margin approximately distill is positive and you have to change your plans and so sometimes we can't foresee these things but um sometimes we can and um particularly if we have tumors that are um as in the the endoscopic picture here that's clearly uh this stomach is not going to be usable as a conduit um or you have bulky retroparitinal uh uh lymph node disease or um other organ invasion. These things can be quite challenging to approach from a even a a traditional open uh abdominal incision, but definitely from a minimally invasive approach. And so these are some of the situations where you might consider using a uh left thoracical abdominal incision. And that includes opening the patient's abdomen.
uh usually starts somewhere above the umbilicus extending it in an oblique fashion across the costal uh margin and onto the thorax somewhere in the usually around the seventh interpace. And that gives you this type of exposure where you can see into both uh the abdominal and the thoracic cavity simultaneously.
um and uh and allows for the resection of large and bulky tumors such as the one shown in this picture where you have involvement of the entire stomach um and invasion into the into the body of the pancreas and you can um actually quite nicely uh access all of those organs through this incision and and if the tumor extends proximally um you can be quite sure that you're going to get a negative margin uh from this approach because you can really go as I'll show later um almost as high as you want from uh from this side.
So to talk about the technique um we start with the patient in a semi-ateral position. So they're positioned very similarly to the way they would be for the thoracic portion of an esophagetomy but um a little bit more tilted towards their back so that you have nice access to the abdomen. Um we use an arm board and um make sure that the patient is on a bean bag and as well uh very securely fastened to the operating room table because um this uh approach requires a lot of turning of the of the O table to depending on which uh cavity you want to focus on at which stage in the operation. So patient needs to be very secured uh to the table and um and you can have want to have access to uh the um the midline of the abdomen as well as as far back um uh you can even as far back as the scapular further on the thorax depending on how much work you need to do.
And um and you can really get an extremely good view of um both major body cavities at the same time with the diaphragm in the middle. So we don't divide the diaphragm completely just just enough to be able to spread the ribs. The costal margin is divided and then the incision is extended in either direction as much as you need usually more towards the thorax. Uh and that um with the good retractor you can really open the person up and have a beautiful view of uh of both body cavities. And that um uh really helps if the tumor is bulky. Uh especially if it's invading into the diaphragm or other um abdominal organs. Uh you um can do a very extensive lympadenectomy uh uh particularly in the abdomen, less so in the upper thorax, but in the lower thorax you have a nice exposure. And um and you can go even um as high as uh the thoracic inlet on the esophagus if you needed to. It allows you uh to uh remove the entire stomach uh if you need to and gives you a choice of reconstruction of whether you're using junum uh traditional stomach or uh or colon and um and so these would be some of the options in terms of the reconstruction.
So if we can we will do a ped we will uh uh elongate the tubularize the stomach as we would traditionally for uh any other esophagectomy but if that's not an option then you can go for pedacleized to junum and this is one arcade liated this would be more arcades and if that's not a suitable option because the arcades are not good or you really um uh need to go higher then uh the colon is right there as well.
Um and uh this is a just a beautiful picture from many years ago that we we use over and over again because it's it really highlights so beautifully the um options for pedacizing the junum. It's as um Dr. Dr. Ginsburg mentioned it's much easier to do this open than uh than minimally invasively because you really rely on trans illumination to see the arcades and that you just can't achieve uh when you're using the uh the laparoscope or the uh uh looking straight on the uh the mezent of the bowel. You need to bring the light from behind and um and so the the contrast between normal interoperative lighting and transillumination is drastic. And here you can see beautifully all the the vessels and where you might want to base the profusion of this um this junimon.
And here the plan would be to transsect it in this location and then uh liate the vessel here and you have all this extra length. So you can go really really far with this um without supercharging. So um we've had uh patients uh in many instances where we've actually been able to bring uh nons supercharged adjun up to the uh uh up to the neck if needed and uh definitely um in from the left thoracic abdominal approach uh to the uh super aortic um uh esophagus if um uh if the margin was uh required to go above the aortic arch.
Um if that's not an option because the patient has poor arcades, then as said the colon is really accessible and easily with by extending the incision inferiorly a little bit, you can easily uh mobilize the right colon um or the left colon if you had to. But this is a picture of the right colon and um liate the ilio pedicle and then rotate the colon up to uh to complete your um your reconstruction.
Um and this is uh another uh picture of uh uh um so the anastmosis that we like to do which is um uh usually from this approach we'll do a handsewn anastmosis although you can certainly do uh linear or circular stapled as well. Uh but um it's quite uh everything's so uh easy to access. So um we usually try prefer to do a handson anastmosis um from this operation and it's also um a lot of fun.
Um and that's what it looks like. So it's a it's it's a very um uh enjoyable operation. It's very usually very uh easy because in comparison to minimally invasive, you have your you can have as many hands in the field as you want and you have all your instruments and your exposure is uh is just excellent. But it it appears to be quite um uh maximally invasive and perhaps uh it's worse outcomes for the patient. So we have to remember to look at outcomes. Um first of all uh one of the uh historical concerns about this approach for a for G junction cancers is that using the stomach as a as a reconstructive choice may result in the uh uh in the symptoms associated with a traditional proximal gasterectomy which are considered um uh uh to be unacceptable from a quality of life standpoint. But in actuality, if you pres if you preserve the stomach and and tubularize the stomach in the way that we would normally do for an esophagectomy, the quality of life outcomes are are equivalent, the oncological outcomes are equivalent and in comparison to a total gasterectomy actually has fewer physiological derangements um particularly anemia and weight loss. So, uh it's important um that regardless of if you're taking just the distal part of the esophagus, we feel it's important that you still um tubularize the stomach uh the way you would for an esophagectomy to to make sure that there's good drainage and less reflux. Um this is a a um another uh uh paper the international uh group looking at the outcomes between left or abdominal in the era of minimally invasive esophagectomy and more or less showing that there's still relevance that um minimally invasive has not uh uh eclipsed this approach uh dramatically in terms of length of stay major complications and mortality and this has really reflected in our experience just at the bedside is that despite the size of the incision um it's actually uh significantly less painful than a traditional posterior lateral thoricottomy because it's muscle sparing and because the um you're cutting across numerous uh dermatomes and so actually because of the denervation uh uh the the pain is less than if you're doing a single uh rib space poster lateral dorctomy um and um anecdotally and also shown in our own data we find the patients are going home uh more or less at the same time as they do from an MIE that it's not the size of the incision that is keeping people in hospital it's the complications associated with major surgeries such as leaks pneumonia and and other things and that those there's no difference u regardless of the approach um and um and finally um we uh we've been seeing a lot of uh despite the improvement ments in chemotherapy uh in G junction in adnocarcinomaomas recently there's still a portion of patients that have very bulky tumors at presentation and and these are bad actors and they're they're affecting the uh a large portion of the stomach and so we have a um a number of people in whom we we could not uh preserve the stomach and had to do an extended total gasterectomy and anecdotally we're observing that those patients actually have uh less complications than the ones in which we could preserve the stomach. And so um a few years ago one of our fellows James Tenkle decided to tackle that problem and examined our own data. And indeed it is true um with we found that um the patients who had um uh junum uh interposition versus gastric actually performed better in terms of early post-operative complications.
Although in the long run uh they were uh they they did have a little bit better quality of life in terms of eating if they preserve their stomach. Um so in our center despite uh while we've transitioned away from maximally invasive open ibuisctomy or softctomies free oral softctomies over the uh the previous uh decade and a half and transitioned largely towards uh minimally invasive for uh for everybody that we can uh we can accommodate. Um and despite the advent of um of uh uh endoscopic approaches which has increased in proportion, the proportion of lefto has really not changed very much over the uh the the past many years because the patients who present with these type of cancers like the one that's pictured here that are bulky that are um that are uh require multivisceral uh resection or that extend in multiple directions uh still pose the same challenges that they always have from a surgical standpoint.
Um and so uh we're still relying on this uh very uh classic uh approach in um in that cohort of patients. Uh and so in summary um I would say the left abdominal approach is a very important operation to know for anybody who's going to approach stomach and esophageal cancers uh from a um holistic perspective. If you're going to be an upper GI surgeon, this is an operation that uh you should know. Uh there are times where it really uh gets you out of trouble and it changes what would otherwise be a uh um a inacceptable oncologic operation or an unfeasible surgery minimally invasively into a pretty straightforward and um and uh uh oncologically appropriate procedure. um with um uh very similar outcomes to uh minimally invasive approaches. Um so with that I would like to thank the organizers again and all the participants for uh for including me and inviting me to participate. Thank you.
>> That was an awesome talk.
>> Thanks so much Carmen. That's that was really great. Great overview. I do I must give a lot of credit to um to Dr. Ferry for all the all the beautiful pictures because um he's really collected an incredible library. Uh and I I've relied very heavily on it in this time.
>> You don't have to give me any a lot of those are your patience.
>> Um uh let me share let me share uh no one place card share.
Good. Okay. Um so um I don't see any questions in the chat. I I'll this is again just our overview here. Um uh I will um ask um actually Wayne if you can um give us a bit more of your sort of tips and tricks of of your anastmosis like what what things you look for in a conduit like how wide you make a conduit. uh uh any adjuncts you do, what type of nasmosis you do uh in order to get those out good outcomes that you discussed and any adjuncts you you can you know um when do you switch conduits?
Uh any anything else you use?
>> Yeah, thanks. Uh you know actually it's important that you mention that because I was having this conversation with my fellow today. It's all the things that you don't recognize that your attending is doing that make the difference in how the anastmosis comes together and whether it's going to be a completely hermetic non-leaking anastmosis or one that's going to fall apart and need to go back to surgery and be diverted. Um, I'm a really big proponent on looking at the mucosa. Um, so when I'm doing a join, I actually open the stomach up.
The color of the stomach is not going to be gray. It's not even blue or purple or pink. It's actually a salmon orange color and that's the healthiest color of the stomach. And so you can actually see that transition in the stomach as it's going from salmon orange to kind of pink. You think, "Oh, it's pink. It looks good." That's actually a schemic and it goes from pink to blue to gray and that's totally eskeemic and but you can't see that from the outside. So if you're looking from the sorosal side, it all looks pink. It all looks wonderful.
It all looks perfectly healthy. Um, I make sure that I get enough mobilization on my gastric conduit that I'm doing my anastmosis either right at the end of the right gastroplo or maybe one short gastric up. Um, you could probably go and get away with two short gastrics up if you've saved more of the um right gastric artery. So, if I'm doing a three field, Akiyama did all these anatomic studies showing that the actual um blood supply up to the fundus is not just on the right gastroplo. there's a heavy contribution of the right gastric. So when you're doing a three- field, if you cut all the way down onto the lesser curve into the insurer like we do for an ivoris, you'll end up with a bad leak in the neck. So if you're doing a three- field, you want to save all that right gastric. If you're doing a two field, you can come down the incizur make a thinner conduit. I make between a three and four centimeter conduit, not narrower, not fatter. If it's any bigger, it's going to be redundant. And make sure that when I'm in the chest, I'm feeling for tension. I use a uh sucker to put into the stomach and push it up and see what my tension's going to be like. And it should be under not tension but also not floppy because if it's floppy it'll become redundant and you'll get a hernia of the conduit up onto the right diaphragm and it won't empty well. So for me make a nice thin conduit. Start at the inazura. Save as much of the right gastric as you can especially if you're doing a three field. Um make sure you're looking at your blood supply. look at the mucosa and do a tension-free uh join, but don't leave any redundancy.
You asked about changing conduits over.
Uh it's interesting because oftentimes we'll plan on putting a small bowel in uh but we often don't need to because you know the ones that are lower into the stomach typically aren't that high into the esophagus. And you can get quite a ways up by getting your small bowel up to the you know the back of the heart without having to do a supercharged you know pedical jigunal position. It's almost like an extended transital gasterectomy. So I'll take the esophagus four five six centimeters up into the um mediainum before I'll switch over to doing a full three field if it's a GE junction or type three tumor heavy gastric extension.
>> Thanks a lot Wayne. That's that's very good wise wise uh wise advice.
>> Yeah. And then again incredible presentations Dr. Miller um those photos the technique the logic behind it I think was was just super smart. Just to kind of recap and review um you're not really doing like a this is not like an MIE or an alternate approach and then converting to a thorico abdominal.
You've got some hard criteria you use to start right out with a thorico abdominal. And so just reviewing one more time, what are those indications that you use for for that approach? And then um it seems like the the gastric conduit was preferred conduit with uh small bell being the secondary if I was kind of gathering that right. And then kind of what Dr. Hoff said was is did I miss it? Is that a supercharged anastmosis or is that just a standard uh anastmosis there that you're using that massive uh beautiful pedacle that you guys were able you were able to create?
>> Um yeah. So um so to answer your first question um we uh we really it is it's absolutely much easier to identify you know to correctly select the patient before you get to the O because um the the nurses will be really frustrated with us if we want to convert from a planned MIE to a planned uh major uh like a left throd abdominal and the anesthetist as well because the lung isolation is different also and so um it is a lot easier to just decide up front.
Um things that would make us go straight to that would be um so uh bulky uh gastric cancers like a linitis plastica that's the classic cword 3 that's extending um so you can see that the whole stomach or the enough of the stomach is involved that you're not going to be able to use it and it's in and it's creeping up the esophagus. Um especially we like to scope all of our patients ourselves if we can. Sometimes they're coming from far away and it's not feasible. But we really try to have a pre-treatment endoscopy so that we can see those cases coming because the worst um well not the worst they're much worse things but but an an unfortunate situation is to do go in for a planned total gasterectomy and then find out that your proximal margin is inadequate and now you're stuck um turning the patient over and prolonging everything.
You would have been much better off just knowing that up front. Um, we use endoscopy in the O heavily, especially if we're uh planning a uh predominantly abdominal uh gasterectomy approach, but we're worried about the proximal margin.
We we're we really rely heavily on endoscopy before we start the case and we will change the plan on the table before we cut to uh if we have to. Um, if they have a bulky uh G-junction tumor that is invading a large amount of the diaphragm, uh, that would be a reason because you can get a nice big cuff around the diaphragm very easily through this incision. Um, multivisceral resections. Um, I don't really see the point of doing anything that we think is going to require a total gasterectomy with a with a multivisceral resection except maybe a wedge of the colon. I don't see the point of doing that laparoscopically because you have to make a huge incision to take it out anyway. So um so for that uh that would be another indication um those and and lymph node disease that extends um where we we we know we're going to have to do a we want to take a lymphatic maybe see one around the renal vein or we see one in the uh um uh behind the body of the pancreas. Uh that's very difficult uh to access laparoscopically. Um so that those might be things that push us towards this approach. And then um no uh we almost never use supercharge to Juno.
So the pictures that you saw are all um not all patients have that pedacle.
We're we're very happy when we see that not everybody brings their arcades on their day of surgery but when they do it it really helps.
>> Excellent.
>> Thank thanks so much Carmen. There's one question in the uh in the chat which I I can um uh from Joy Gerard asking um if anyone has experienced using ESOG guard for screening. Um I give my own perspective on this. I think for screening there's still no at least in uh North America or Europe there's no um uh none of the main endoscopic um societies recommend screening for esophageal cancer or screening for Barretts. Uh but ESOG guard is a it's a great new technology. Um uh it's probably a little too expensive to use at a screening level. Um, one area that has come out which is was relatively cheap as the um is a um is a sponge a cytosponge developed in Cambridge by um Rebecca Fitzgerald which is a relatively simple um cytology and tree foil factor 3 um analysis uh for people in high-risisk endemic areas such as northern UK and that's really taking off. I I we have I don't have any experience with these guard Wayne what about you or Chris?
Yeah, we actually have we started a couple screening uh protocols but more in the experimental phase looking at the positive predictive uh and then negative predictive value. So still much more in kind of like the not even science of it like the math of it like what does it mean when's positive and you're screening EGD is negative and what do you do with that patient? So, but I don't know. I would I would kind of say I think that's where we're lacking in this this area, right? Is like our our screening protocols and and we're getting, you know, incredible results with our our multimodal treatment modalities now. But the real win is going to be when we've got good screening protocols where we're picking up these patients earlier. So, >> yeah, I agree 100%. That makes a lot of sense.
>> All right. I think uh if you guys are okay, we'll we'll wrap it up. Uh biggest thank you is to our our listeners who are on and those who are going to uh engage in this uh webinar in the future.
A tremendous amount of information coming from all of our our speakers. A very profound thank you to the speakers for their time. Um getting to know you guys better has been absolutely a gift.
Um and then to my my dear friend and co-odderator uh Dr. Ferry um I can't thank you enough for your time and helping set this up. It's a yman's effort to put one of these things together and thank you. And then the uh two societies working together as one group is is just a gift to the the patients. I think we learn a lot better in that medium where sages sages and ISD function better. Uh great work in the esophageal and gastric space and we hope everyone took a little something away tonight. Uh thank you everybody for your time.
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