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Ann Thorac Surg 2006;82:402-407
© 2006 The Society of Thoracic Surgeons
Heart, Lung and Esophageal Surgery Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
Accepted for publication February 22, 2006.
* Address correspondence to Dr Luketich, Heart, Lung and Esophageal Surgery Institute, University of Pittsburgh Medical Center, 200 Lothrop Street, Pittsburgh, PA 15232 (Email: luketichjd{at}upmc.edu).
Presented at the Fifty-second Annual Meeting of the Southern Thoracic Surgical Association, Orlando, FL, Nov 10–12, 2005.
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Abstract |
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METHODS: From 2002 to 2005, a minimally invasive Ivor Lewis esophagectomy was performed in 50 patients. The planned approach included a totally laparoscopic abdominal procedure and either a minithoracotomy or thoracoscopy. Indications for esophagectomy included short segment Barrett's esophagus with high-grade dysplasia or resectable adenocarcinoma of the gastroesophageal junction (GEJ) with minimal proximal esophageal extension. .
RESULTS: The median age was 62.3 years (range, 38 to 79). Twenty-five patients (50%) received either preoperative chemotherapy or chemoradiation. There was one nonemergent conversion to an open procedure during laparoscopy. Planned minithoracotomy was successful in 35 patients; an additional 15 patients had the entire thoracic component performed thoracoscopically. A circular stapled anastomosis was performed in all patients. The operative mortality was 6%. Three patients (6%) developed an anastomotic leak; all were successfully managed nonoperatively. Four patients (8%) developed postoperative pneumonia. There were no recurrent laryngeal nerve injuries.
CONCLUSIONS: Minimally invasive Ivor Lewis esophagectomy was technically feasible and resulted in good initial results in our center, which is experienced in minimally invasive and open esophagectomy. This approach minimizes the degree of gastric mobilization, almost eliminates recurrent laryngeal nerve injury and pharyngeal dysfunction, and allows additional gastric resection margin in the case of cardia extension of GEJ tumors.
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Introduction |
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The operative approach that is chosen also has a significant impact on the type of complications seen after esophagectomy. For example, the incidence of anastomotic stricture and leak are more common in patients with a cervical anastomosis [2]. In addition, injury to the recurrent laryngeal nerve, a complication associated with considerable morbidity, is less common if dissection in the neck is avoided [3, 4]. On the other hand, the incidence of pneumonia is higher with the transthoracic approach [1]. This is significant, as the risk of death in patients who develop a postoperative pneumonia is reported to be as high as 20% [5].
In an attempt to lower morbidity some centers have explored minimally invasive approaches to esophageal resection. A potential benefit of these techniques is the improvement in pain control and pulmonary function by avoiding synchronous thoracotomy and laparotomy incisions. We initially reported our experience with minimally invasive esophagectomy (MIE) in 2003 [6]. In that report of 222 patients, a mortality of 1.4%, an anastomotic leak rate of 11%, and an incidence of pneumonia of 7.7% were observed. The average length of stay was 7 days. All patients in that series underwent laparoscopy and thoracoscopy, with a cervical esophagogastric anastomosis.
In this report we have extended our experience with MIE to include reconstruction with an intrathoracic anastomosis. Early in this series we had performed a minithoracotomy after laparoscopic mobilization of the stomach. As our experience has increased, we have begun performing a completely minimally invasive Ivor Lewis esophagectomy.
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Material and Methods |
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This review encompassed the clinical activities of five thoracic surgeons at the University of Pittsburgh. The indication for an Ivor Lewis esophagectomy versus a standard MIE with a cervical anastomosis was one of individual preference. For one surgeon an Ivor Lewis approach was the preferred method for all patients with esophageal cancer. For the remainder, consideration of an Ivor Lewis esophagectomy was given if there was extension onto the cardia of a GEJ tumor. Those with either midthoracic tumors or long-segment Barrett's were not considered suitable candidates for an Ivor Lewis esophagectomy.
Patients who underwent either a hybrid approach (defined as laparoscopic gastric mobilization combined with a minithoracotomy) or a completely minimally invasive approach (laparoscopy and thoracoscopy) were selected for review. Patients who were converted to an open approach were also included. Demographic features, preoperative treatment, type of surgery, length of stay, and postoperative complications were recorded. We also performed a subgroup analysis of those patients who underwent a completely minimally invasive versus a hybrid esophagectomy for the incidence of complications and length of stay.
Surgical Technique
Our technique of minimally invasive esophagectomy has been well-described elsewhere [6]. The conduct of an Ivor Lewis resection is similar, although we begin this procedure with laparoscopy. The laparoscopic portion is performed as described for the standard MIE, including creation of a 5 cm diameter gastric tube, a pyloroplasty, and placement of a feeding jejunostomy catheter.
Once the abdominal phase has been completed the patient is turned to the left lateral decubitus position. We use the same port sites for thoracoscopy that have been described for our standard esophagectomy [7]. The only modification is to enlarge the posterior, inferior eighth intercostal port site to 3 to 4 cm to allow the introduction of the end-to-end anastomosis (EEA) stapler (US Surgical, Norwalk, CT) and removal of the specimen. A laparoscopic wound protector is used at this site to minimize the risk of port site contamination. Once the esophagus has been mobilized to a level 4 to 5 cm above the azygos vein, the distal esophagus and stomach are brought through the hiatus into the chest, along with the gastric tube that has been sutured to the specimen. The esophagus is elevated and transected 2 to 3 cm above the level of the azygos vein. The specimen is removed using an endo-catch bag (US Surgical) to prevent wound contamination. The anvil of a 25 mm EEA stapler is then placed into the proximal esophagus and secured using a purse-string endo-stitch (US Surgical). The stapler is then placed through the enlarged port, introduced into the tip of the newly created gastric conduit, and a circular anastomosis (side of gastric conduit to end of esophagus) is created at the level of the azygos vein. The redundant portion of the gastric conduit is trimmed using an articulating, linear stapler (Endo-GIA II, US Surgical), and a 28F chest tube and a Jackson-Pratt drain are placed by the anastomosis. The potential space between the conduit and the right crus of the diaphragm is then closed with interrupted stitches to prevent delayed herniation.
For those patients who underwent a hybrid approach, the gastric conduit was prepared laparoscopically. After turning the patient, a 5 cm posterolateral thoracotomy incision was made, dividing a portion of the latissimus and sparing the serratus muscle. Rib-spreading retractors were placed and the thoracic esophagus was mobilized under direct vision. A stapled esophagogastric anastomosis was created in the same fashion as described above.
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Results |
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Among these 50 patients, there were 9 women and 41 men with a median age of 62 (range, 38 to 79) years. Twenty-five (50%) patients were treated with either preoperative chemotherapy or chemoradiation. Final pathologic stage and completeness of resection are listed in Table 1. One patient in this series had a positive proximal esophageal margin. This patient had a bulky distal thoracic tumor that was noted to invade the thoracic aorta at the time of surgery. This was not seen on a preoperative computed tomographic (CT) scan performed three weeks earlier. The esophageal resection was not carried into the neck as the patient was considered unresectable for cure. Three patients in this series had stage IV disease. In one patient, a small nodule on the surface of the liver was discovered during laparoscopy. A biopsy revealed no evidence of tumor on frozen section, and an esophagectomy was subsequently performed. However, on final pathologic review a focus of metastatic adenocarcinoma was detected in the biopsy specimen. In the second patient, a liver metastasis was also discovered during laparoscopy. The patient suffered from significant dysphagia and a palliative esophagectomy was performed. In the final patient, a liver metastasis was detected on presentation. The patient had a dramatic response to chemotherapy and was free of radiographic disease for a year. He was consequently offered an esophagectomy. At the time of surgery multiple liver biopsies showed no evidence of disease and his final stage was T1N0M1.
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The mean number of lymph nodes harvested was 16 per patient. The median length of stay for the entire cohort was 9 days: 7 days in the minimally invasive group versus 9 days in the hybrid group (p = 0.015, Mann-Whitney rank sum test). The median intensive care unit stay was one day in both groups.
There were three deaths (6%) in the series. The first was a patient who underwent a hybrid approach and developed a massive stroke. He subsequently developed pneumonia and expired on postoperative day 13. The second patient also underwent a hybrid esophagectomy. A barium swallow performed on postoperative day 7 revealed no evidence of leak. He remained in the hospital with significant nausea, although multiple computed tomographic CT scans showed no evidence of bowel obstruction. He developed severe abdominal pain on postoperative day 23 and expired soon thereafter. Unfortunately, a postmortem examination was refused by the family. The final patient underwent a completely minimally invasive esophagectomy. Intraoperatively he was noted to have a small ventral hernia. The patient did well in the immediate postoperative period and had a barium swallow exam that showed no leak. On postoperative day 5 he developed acute incarceration of the small bowel within the ventral hernia. As a result of small bowel obstruction he developed a leak from his pyloroplasty, had subsequent multisystem organ failure, and expired the following day. During reexploration the patient was noted to have leaked between the stitches of an intact pyloric suture line.
Major complications occurred in 20% of patients (see Table 2). These complications included pneumonia, stroke, pulmonary embolism, and anastomotic leak. There was no mortality among the three patients who developed an anastomotic leak and none of these patients required reoperation for drainage or decortication. Two of these three patients developed a small, contained leak that was well-drained by the existing chest tube. These two patients were managed with prolonged chest tube drainage and enteral nutrition until the leak resolved. The final patient underwent an esophagectomy three years after definitive chemoradiation for an early-stage cancer. Surveillance endoscopy documented a local recurrence with no evidence of distant disease and esophagectomy was recommended. At the time of surgery the esophagus was noted to have significant fibrosis from prior radiation therapy. He developed an anastomotic leak one week postoperatively that drained into the mediastinum. This was drained by a trans-pharyngeal Jackson-Pratt drain that was endoscopically guided into the abscess cavity. His leak closed after three weeks of drainage.
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Notably, all four patients diagnosed with a postoperative pneumonia had undergone a thoracotomy. No patients developed a recurrent laryngeal nerve injury. The most common complication in this series was atrial fibrillation (14%). Two patients (4%) developed a hernia in a laparoscopic port site; this was repaired without sequelae. Six patients (12%) developed an anastomotic stricture, defined as the need for more than one dilation postoperatively.
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Comment |
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In the largest study to assess morbidity and survival after different techniques of esophagectomy, 220 patients were randomly assigned to undergo either open transhiatal or transthoracic esophagectomy [1]. The morbidity was significant in both groups: an anastomotic leak of 14% in the transhiatal versus 16% in the transthoracic group, a vocal cord paralysis rate of 14% vs 24%, and a cardiac complication rate of 16% vs 26%. The transhiatal group did suffer less pulmonary morbidity (27% vs 57%), although there was no statistically significant difference in the perioperative mortality or 5-year survival between the two groups.
Given the high morbidity of standard esophagectomy, some centers have sought to extend the techniques of minimally invasive surgery to patients with esophageal cancer. However, the steep learning curve of minimally invasive esophagectomy has limited the applicability of this technique to specialized centers. Nonetheless, the past several years have shown clearly that procedures once considered extremely difficult, such as laparoscopic repair of giant paraesophageal hernia, laparoscopic gastric bypass, and thoracoscopic lobectomy, have become accepted alternatives to an open procedure.
The early efforts with minimally invasive esophageal resection were hybrid approaches, combining thoracoscopic mobilization of the esophagus, an open laparotomy for creation of the gastric tube, and a cervical anastomosis [8–11]. No conclusive benefit was seen with this approach compared with standard esophagectomy, although the number of patients studied was small and likely the learning curve of the technique had not yet been surpassed.
Since these early reports, several modifications have been proposed including laparoscopic transhiatal esophagectomy [12, 13] and robotic-assisted esophagectomy [14]. We have developed extensive experience with a three-field approach in which the esophagus is mobilized thoracoscopically, followed by laparoscopic creation of the gastric tube and pyloroplasty, and finally creation of a cervical esophagogastric anastomosis. Although no randomized studies have been done, we have found that this approach is associated with a very low mortality and morbidity when compared with series of open esophagectomies [3, 5, 15, 16].
Regardless of the type of incision used, creation of an anastomosis in the neck is associated with unique complications. As seen in open series, the rates of anastomotic leak, stricture, and injury to the recurrent laryngeal nerve are relatively frequent when dissection is performed in the neck [5, 17]. In addition, a small group of patients will develop significant problems with esophageal transit and aspiration, despite intact recurrent laryngeal nerves [18, 19]. Although these complications are rarely reported as fatal, they may have a profound impact on the risk of aspiration pneumonia, clearance of pulmonary secretions, and overall quality of life.
Placement of the anastomosis within the chest may potentially lower, although not entirely prevent, the incidence of these complications. In addition, creation of a lower anastomosis may be necessary in patients with significant gastric extension of GEJ tumors to involve the cardia. In these cases, more stomach must be resected to obtain an adequate margin and the remaining gastric tube may not have sufficient length to reach the neck. Many esophageal surgeons, however, have been reluctant to construct an intrathoracic anastomosis, due to the perceived high mortality associated with a leak, as well as the pulmonary complications associated with synchronous thoracotomy and laparotomy incisions.
To date the published experience with minimally invasive Ivor Lewis esophagectomy has been limited to case reports and small case series. The first such report was published in 1996 [20]. In that series, six patients underwent laparoscopic mobilization of the stomach combined with a right thoracotomy and intrathoracic anastomosis. There were no conversions to an open procedure and all patients had an uneventful recovery. The first description of a complete minimally invasive approach was reported in 1999, when Watson and colleagues [21] described two patients in whom a hand-assisted laparoscopic approach was combined with a thoracoscopic anastomosis. No complications were reported. More recently, Nguyen and colleagues [22, 23] described a total of three patients who had a completely laparoscopic procedure combined with a thoracoscopic anastomosis. All three patients had an uneventful postoperative course.
In our experience of fifty patients undergoing a minimally invasive Ivor Lewis esophagectomy, a mortality of 6% was observed. None of the deaths were attributable to either an anastomotic leak or pneumonia. In fact, all three patients who developed an anastomotic leak were successfully managed without the need for reoperation. Although the sample size was small, we also observed a reduction in the length of stay of those who had a complete minimally invasive resection. Also, among these 15 patients none developed pneumonia or pulmonary embolism. Importantly, no patient in this series developed a recurrent nerve injury. As mentioned earlier, there were 2 patients who developed a laparoscopic port site hernia. This is an unusual complication in our experience. Among 222 patients that we had reported earlier who had undergone MIE none had developed this complication. Of note, no patient in this series developed herniation of abdominal viscera along the conduit into the mediastinum. This is a potential concern given the difficulty of circumferentially closing the hiatus through the right chest. Longer term follow-up will be required to determine if this is a significant issue.
In this report we have shown that a minimally invasive Ivor Lewis esophagectomy is feasible and that the technique is reproducible. The rate of perioperative complications, including anastomotic leak, pneumonia, and recurrent nerve injury were quite low, especially with a completely minimally invasive approach. These results were comparable with our established technique of MIE. However, this is a relatively small series, with insufficient follow-up to determine patterns of recurrence and overall survival. At the present, this has not become the standard approach to esophagectomy at our institution However, as further experience is gained we will be better able to define the specific advantages of this approach, compared with open and other forms of MIE.
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Discussion |
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TopAbstractIntroductionMaterial and MethodsResultsCommentDiscussionReferences |
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DR BIZEKIS: The first comment is we are pretty liberal about dilating these patients at least once, and what we define as stricture is more than two dilations in these patients, at least two or more dilations. The size of the stapler that we used in the thoracoscopy group was a 25 EEA stapler. I think there are definitely opportunities and situations that we probably could have used a larger size stapler, like a 28, and that might have impacted on the stricture rate. The thought of using the other stapling device is something that has occurred to us. We haven't used it in this particular case, but it is something to think about. At this point in time I think we can probably be a little bit more aggressive in using a larger size EEA in that case, and I think the thought of using that power stapler is something that we will definitely look at in the future.
DR MILLER: Just two other quick comments. Also, too, our laparoscopic guys when we are doing this, we have gotten away from doing a pyloroplasty, because that is a labor-intensive part of the procedure, and actually they have gone to actually Botox injections of the pylorus, and that actually lasts for about three or four months. So it is going to be interesting to see over time in regards to the relationship of emptying, dumping syndrome and so forth. So that is going to be something to look at in the future. And also, too, in regards to your conduit size, I know that Jim for a while was making a very, very skinny conduit, and that picture was a lot larger, but I am very concerned you have got the EEA stapler, you have got your original stapler line, you have got this other stapler line, and I know you had three deaths. Was this from gastric conduit ischemia, because you have got a lot of techniques limiting your blood supply?
DR BIZEKIS: Dr Landreneau actually, in this series, has performed Botox injections in three patients, and clearly the follow-up is very early but it is something that we are starting to entertain and look at.
In terms of the conduit size, we did notice in the early series that with the small conduit size we did have an increased incidence of complications and leak rates. In this particular series, the three deaths were not related to any issues with the gastric conduit. One was related to a patient who had a large cerebrovascular accident and subsequently developed multisystem organ failure and died. Another patient, and it is not clear exactly what the issue was because they did have a subsequent evaluation with barium swallows that did not show a leak, but this patient had persistent issues with nausea and vomiting. We did do endoscopic evaluation of the gastric conduit with no evidence of any necrosis, and the patient initially did not have a feeding jejunostomy tube based on that surgeon's preference, went back to the operating room, and ended up having an operative feeding tube placed and then subsequently developed complications from that and died. And the other gentleman made an uneventful recovery postop day five. He did have a ventral hernia that was small in size and initially was not repaired intraoperatively, and subsequently developed a small bowel obstruction and died from complications of that.
DR MALCOLM M. DECAMP (Boston, MA): I want to congratulate you in extending your center's experience in minimally invasive esophagectomy. In Dr Luketich's earlier paper of over 200 cases he had reduced the operative time down to a median of about five hours. Does this technique result in times even shorter than that? Also, you started doing quality of life analyses in that totally endoscopic approach. Do you have any quality of life information to share with us about this MIS (minimally invasive surgery) Ivor Lewis approach?
DR BIZEKIS: We don't have any objective quality of life to share with you. I think the thing that we have noticed, at least in this small series, is that having not performed the anastomosis in the neck, there is less of an issue with difficulty in swallowing and swallowing difficulties just based on speaking to the patients, but we don't have any objective data on that.
The operative times I think are comparable and even less. I think a lot of that has to do with the fact that it is done in a very experienced center with surgeons that have performed hundreds of these procedures, and I think in an uncomplicated case you can definitely do this procedure in about three to three and a half hours.
DR THOMAS M. EGAN (Chapel Hill, NC): Nice presentation. A lot of our patients, in fact all of them, have had preop radiation chemotherapy, which really makes things very stuck. Is that a problem? The second issue is Dr Orringer presented data years ago about a side-to-side anastomosis, which eliminated leaks and strictures in the neck and it works extremely well in the chest. Have you had any experience with that?
DR BIZEKIS: In this particular series we did not perform that side-to-side anastomosis. Dr Landreneau is a proponent of that and performs that when he does do his cervical anastomosis, but in this particular series we did not, so I can't really give you an answer to that question.
As for the preop neoadjuvant therapy, those patients, there is a little bit more scarring there and the dissection in those cases does take probably about a half an hour more or so in the chest, but we really haven't had any complications secondary to that.
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References |
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