Technique Of Esophagectomy Research Articles

Transhiatal Esophagectomy in the Profoundly Obese: Implications and Experience

Historically, obesity contraindicated an abdominal approach to the esophagogastric junction. The technique of transhiatal esophagectomy (THE) evolved without specific regard to body habitus. The dramatic increase in obese patients requiring an esophagectomy for complications of reflux disease prompted this evaluation of the impact of obesity on the outcomes of esophagectomy to determine whether profound obesity should contraindicate the transhiatal approach. We used our Esophagectomy Database to identify 133 profoundly obese patients (body mass index [BMI] > or = 35 kg/m2) from among 2176 undergoing a THE from 1977 to 2006. This group was matched to a randomly selected, non-obese (BMI, 18.5 to 30 kg/m2) control population of 133 patients. Intraoperative, postoperative, and long-term follow-up results were compared retrospectively. Profoundly obese patients had significantly greater intraoperative blood loss (mean, 492.2 mL versus 361.8 mL, p = 0.001), need for partial sternotomy (18 versus 3, p = 0.001), and frequency of recurrent laryngeal nerve injury (6 versus 0, p = 0.04). The two groups did not differ significantly in the occurrence of chylothorax, wound infection, or dehiscence rate; length of hospital stay or need for intensive care unit stay; or hospital or operative mortality. Follow-up results for dysphagia, dumping, regurgitation, and overall functional score were also comparable between the two groups. With appropriate instrumentation, transhiatal esophagectomy in obese patients has similar morbidity and outcomes as in non-obese patients. Obesity, even when profound, does not contraindicate a transhiatal esophagectomy.

A new method for intrathoracic anastomosis in laparoscopic esophagectomy

The benefits of laparoscopic procedures over the traditional open technique for esophagectomy in the management of esophageal cancer are well documented. A disadvantage of the laparoscopic technique is longer surgery, particularly in the early part of a surgeon's "learning curve." In a two-stage (Ivor-Lewis) procedure, performance of the esophagogastric anastomosis within the chest can be a "rate-limiting step." A circular stapler is used, which requires placement of a purse-string suture or a manually-tied knot around in the transected proximal esophagus to secure the anvil in place. This is technically demanding and time-consuming in the laparoscopic setting. The authors have devised a method that obviates the need for a purse string or knot, simplifying the intrathoracic esophagogastric anastomosis while still achieving a safe anastomosis.

Robotic-assisted transhiatal esophagectomy

Despite its reduced aggressiveness and excellent results obtained in certain diseases, minimally invasive surgery did not manage to significantly lower the risks of esophageal resections. Further advances in technology led to the creation of robotic systems with their unique maneuverability of the instruments and exceptional view on the operative field, thus setting the prerequisites for performance in complex surgical procedures and offering new possibilities to a disease notorious for its dismal prognosis. The robotic-assisted transhiatal esophagectomy technique was used in a patient with squamous cell carcinoma of the lower esophagus that had high medical risk for surgical therapy. Esophageal resection and reconstruction were possible through a robotic-assisted minimally invasive transhiatal approach. There were no intraoperative incidents, blood loss was minimal, and lymph node dissection and removal was possible during the procedure. Early ambulation and conservative treatment of the mild complications that occurred offered a favorable postoperative outcome. The robotic-assisted transhiatal esophagectomy technique is feasible and safe. Complex procedures become less technically demanding with the help of the robotic system and, thus, the minimally invasive approach can be offered for the benefit of selected patients. Further studies are required to confirm these observations and to establish the role of this procedure in the future.

Robot-Assisted Thoracoscopic Esophagectomy with the Patient in the Prone Position

We describe a new technique of esophagectomy by robot-assisted thoracoscopy with the patient in the prone position, followed by laparoscopy and left cervicotomy with the patient in the supine position. We report two procedures performed November 2002 and September 2003. The technique should allow more thorough lymph node removal while reducing postoperative pain and morbidity. The thoracoscopy is robot-assisted and the articulations within the pleural cavity improve the surgeon's dexterity and reduce trocar movements. The prone position allows mobilization of the esophagus with only three trocars because the lung, which is partially deflated, does not block access. With the patient in the prone position, bleeding does not obscure the operative field. Stomach mobilization, gastric tube creation, and celiac lymphadenectomy are performed by laparoscopy. The esogastric anastomosis is a totally mechanical side-to-side anastomosis realized by left cervicotomy.

Esophagectomy by thoracoscopy with patient in prone position, laparoscopy and cervicotomy (technique)

BACKGROUND: Authors describe the technique of esophagectomy by thoracoscopy with the patient in the prone position, followed by laparoscopy and cervicotomy in supine position. METHODS: Between October 30, 2002 and August 31 2005, 15 patients (12 males and 3 females) underwent this procedure for esophageal cancer. The median age was 60.4 years (37–86). At the preoperative work-up the tumor was localized at the cervical esophagus in 1 patient, at the mid-esophagus in 3 patients, at the lower esophagus in 6 patients, and at the eso-gastric junction in 5 patients. Preoperative histological examination demonstrated squamous cell carcinoma in 7 patients, adenocarcinoma in 7 patients, and high-grade dysplasia with carcinoma in situ in 1 patient. None of the patients underwent neo-adjuvant therapy. RESULTS: Average total operative time was 377.1 minutes (300–540). Average total perioperative bleeding was 889.3 ml (125–2400). Perioperative complications comprised a conversion to thoracotomy in one patient and an associate splenectomy in another. Postoperative medical morbidity was 1 respiratory failure, 1 deep venous thrombosis, 1 pneumonia, 2 tracheal necroses, and 3 temporary laryngeal paralysis. Postoperative surgical morbidity included 4 leaks at esophagogastrostomy, 1 colic leak, 2 giant hiatal hernias. The median intensive care stay was 5 days and the median total hospital stay was 14 days. Upon histological examination, the margins of all specimens were free and the average number of lymph nodes identified was: 5,1 mediastinal/periesophageal (2–13), 12.2 celiac/perigastric (3–22). Early mortality was 0 %. After a mean follow-up of 19.1 months (8–34), total survival rate is 61.5 % of patients, whom 87.5 % free of disease and 37.5 % on adjuvant therapy. No gastroesophageal reflux was registered and in 4 patients we observed stenosis of the esophagogastrostomy. CONCLUSIONS: Thoracoscopic and laparoscopic esophagectomy with extended lymphadenectomy is technically feasible and safe. Thoracoscopy performed with the patient in the prone position improves the quality of the esophageal dissection and the mediastinal lymphadenectomy.

The current status of esophageal cancer treatment in North America

Cancer of the esophagus and gastroesophageal junction (GEJ) in North America remains a relatively small but challenging clinical problem. It is estimated that, in 2004, 21 000 new esophageal cancers will be diagnosed (of which more than 75% will be in men) and 19 600 deaths from esophageal cancer will occur. In contrast to the Asian experience, adenocarcinomas of the esophagus and GEJ comprise more than half of all esophageal malignancies. Other than surveillance endoscopy in patients with Barrett’s esophagus, there are currently no useful screening techniques for esophageal cancer. The lack of an early detection algorithm determines the distribution of stage at the time of diagnosis: stages 0, I 16%; IIA, IIB 26%; III 26%; IV 32%. Standard staging algorithms currently include computed tomography and sometimes a contrast esophagram. Fewer than 20% of patients undergo endoscopic ultrasonography (EUS), and an even lower incidence of positron emission tomography (PET) scanning is evident. Although data for the utility of neoadjuvant therapy before surgery for esophageal cancer are lacking, as many as 50% of resectable patients undergo such therapy. The choice of the method of resection has not changed for more than a decade, with only one-fourth of operations being performed using a transhiatal technique. Current surgical controversies include the extent of en bloc resection, the extent of nodal dissection, the utility of minimally invasive esophagectomy techniques, and hospital and surgeon case volume as a surrogate for quality outcomes. Unlike Asia and Europe, the free market philosophy of medical care in North America leads to widespread distribution and subsequent dilution of cancer care experience. However, it is likely that market forces will begin to encourage the development of centers of excellence for surgical therapy of esophageal cancer. There is a growing interest in treating localized cancers with chemoradiotherapy alone, and the use of EUS and PET for restaging these patients is being investigated. Some investigators believe that esophagectomy may soon be relegated to the role of a salvage operation. New biological agents are currently being evaluated as part of multimodality therapy for esophageal cancer, including radiation-induced release of TNF-alpha, statins, immunotoxins, and epithelial growth factor receptor (EGFR) tyrosine kinase inhibitors. Current free market forces may slow progress in standard cancer care but perhaps will provide opportunities for new and unique treatment methods that otherwise may not be explored in more traditional centers of excellence.

Caractéristiques des hernies diaphragmatiques après œsophagectomie pour cancer

Introduction. – Diaphragmatic hernia is a rare complication of oesophagectomy for cancer. We report a series of seven patients to determine characteristics of this entity. Patients and methods. – Seven patients (six male and one female, 61 to 68 years old) were operated on for diaphragmatic hernia following oesophagectomy for carcinoma (adenocarcinoma N =4, squamous-cell carcinoma N =3). Oesophagectomy had been performed through abdominal transhiatal approach in four patients and transthoracically in three, with hiatal enlargement in all cases. Results. – Three patients, all symptomatic, underwent emergency surgery within two years following oesophagectomy. Of the four patients operated between two and seven years after oesophagectomy, two were symptomatic. Presence of symptoms were neither related with technique of oesophagectomy, nor to type of hiatal enlargement (anterior, or by crura division). All patients with hernia containing small bowel were symptomatic. All patients were operated through abdominal approach. Hernia contained colon three times, small bowel once, and both three times. Hernia reduction needed additional phrenotomy in six patients. Two patients underwent colectomy to treat peroperative colonic ischemia. Diaphragmatic hiatus was calibrated around the gastric tube by direct suture in six patients or with absorbable mesh in one. There was no death. No recurrences occurred with a follow up ranging from one to five years. Conclusion. – The diaphragmatic hernia after œsophagectomy is due to excessive hiatal enlargement. Hernias occurring early after oesophagectomy are badly tolerated and need urgent reoperation. To prevent this complication of oesophagectomy, we advocate calibration of diaphragmatic hiatus fit to width of gastroplasty.

Section V: Techniques of esophageal resection

Esophagectomy the treatment of choice for esophageal cancer, is a procedure which, nationwide, carries a mortality rate of 10% and a morbidity rate of 50%. The five-year survival rate for esophagectomy for cancer remains at 20%. With great care in surgical planning, technique, and patient care, the mortality rate has been lowered to 3% at several large academic centers. The methods of esophagectomy including Ivor-Lewis, transhiatal, left thoracoabdominal, and cervical exenteration are discussed. The technique of tri-incisional esophagectomy is detailed in this chapter. This technique combines the best aspects of the Ivor-Lewis and transhiatal approaches, those being a cervical anastomosis (avoiding an intrathoracic leak, minimizing reflux, and allowing for a complete esophagectomy) and transthoracic dissection of the esophagus (allowing for a safe dissection and complete lymphadenectomy). © 2003 Elsevier Inc. All rights reserved.

Prophylactic esophagectomy in Barrett esophagus with high-grade dysplasia.

We review the significance of Barrett mucosa with high-grade dysplasia, management options, rationale for prophylactic esophagectomy, and results of surgical treatment. The surgical results of prophylactic esophagectomy are presented from two previous studies, involving 60 patients over 1982-2001 at a single institution. These results are compared with nonsurgical treatment options. The transhiatal esophagectomy technique was the most commonly used surgical approach (81.7% of patients). Operative mortality was 1.7%. The incidence of occult adenocarcinoma for 1982-1994 and 1994-2001 was 43% and 16.7%, respectively. The overall incidence of occult adenocarcinoma for the entire study period was 30%. Prophylactic esophagectomy for patients with Barrett esophagus and high-grade dysplasia, performed at a center of high volume and experience, can be accomplished with low mortality and excellent long-term survival. Incidence of occult adenocarcinoma is decreasing, but still 16.7-30%.

Invited commentary

This article succeeds in fulfilling its stated goal of establishing a benchmark for the results of surgical treatment of esophageal carcinoma using an Ivor Lewis esophagectomy technique in all patients. The value of this lies in the authors’ observation that having such a benchmark in patients not receiving any neoadjuvant or preoperative therapy can be used for comparison purposes both for other techniques of esophageal resection and to outcomes in patients receiving multimodality therapy. The demographics of the patients in this article are representative; most patients were elderly and had adenocarcinoma of the distal esophagus, most had dysphagia, many had lost weight and there are more men than women. Consequently the outcomes in these patients can credibly be compared to the outcomes in the patient population in the typical surgeon’s practice. Not surprisingly, the Mayo Clinic group has set the bar rather high. The mortality rate is quite low as is the complication rate. As a result, the median hospital stay was only eleven days and there were few serious complications. Of importance, despite the skill of the surgeons as documented by the low morbidity and mortality rates, long term outcome is poor for patients with disease Stages IIB and higher. This is an old message but deserves emphasis; once lymph nodes are involved, cure with surgical therapy alone is unlikely. As referenced in the manuscript, these outcomes are quite similar to those previously reported with other types of operations, such as transhiatal esophagectomy at one end of the aggressiveness spectrum to resections with extensive lymphadenectomy at the other end. This again confirms that long term prognosis is more dependent upon the biology, as reflected by the postoperative stage, of the cancer than the operative technique. Another implication of this article is that operative and hospital results are dependent to some extent upon the volume of surgery performed by the operating surgeon. Each surgeon in this study appears to have done at least 40 and perhaps 50 esophagectomies over a two-year time span. This suggests, as has been stated before, that patients do best when treated in institutions with relatively high volumes of these challenging operations and complex patients.

Neoadjuvant Chemoradiation Therapy in Patients with Surgically Treated Esophageal Cancer

Over the past 10 years, 232 patients were treated at the East Carolina School of Medicine for cancer of the esophagus. Of these, 73 received neoadjuvant chemoradiation therapy and subsequent surgical resection. The results in this group suggest improved cancer control, with 18 patients (25%) remaining free of recurrence 3 years after treatment, compared with 11 out of 159 patients (7%) in the group that was not treated with neoadjuvant therapy (p < 0.0001). The 5-year recurrence-free survival with neoadjuvant chemoradiotherapy and surgery was 16% (12/73) compared with 3% (5/159) with other types of therapy. Two protocols of neoadjuvant chemoradiotherapy with subsequent surgery were compared: I: Split-course, once-a-day radiotherapy and concomitant cisplatinum/5-fluorouracil followed by esophagectomy. II: Accelerated, twice-a-day radiotherapy with concomitant triple chemotherapy using cisplatinum/5-fluorouracil/vinblastine followed by transhiatal extrathoracic esophagectomy. The survival rate was similar in the two groups of patients but the complication rate was higher in group II. Neoadjuvant chemoradiation therapy and the techniques of transhiatal esophagectomy may have contributed to the improved results in the treatment of esophageal carcinoma. Accelerated radiotherapy with triple chemotherapy was more toxic and did not give better survival rates than split-course, once-a-day, conventional, fractionated-protracted radiotherapy combined with two drugs.

Thoracoscopic and laparoscopic esophagectomy.

Esophagectomy is both complex and challenging, and it may be associated with significant morbidity and mortality. With improvements in instrumentation and increasing experience with laparoscopic and thoracoscopic techniques, minimally invasive approaches to esophagectomy are being explored to determine feasibility, results, and potential advantages. Most of this experience has been with case studies or small series, with many surgeons using thoracoscopy in combination with standard laparotomy. Many of the patients have been carefully selected for these procedures because they have small tumors or high-grade dysplasia. Our technique for esophagectomy has evolved from a laparoscopic transhiatal approach to a combined laparoscopic and thoracoscopic approach. Our experience with this procedure has increased, and now we offer this approach to the majority of patients with resectable cancers. We review our operative technique and the results of surgery in our first 50 patients who underwent minimally invasive esophagectomy for cancer or high-grade dysplasia.

Minimal Access Esophagectomy: Where Are We Up To?

Endoscopic techniques for esophagectomy are disparate. The aim of this article is to describe the main surgical endoscopic techniques applied to esophagectomy and to report their results. In most published series, the benefit in terms of postoperative morbidity cannot be demonstrated. This reflects the fact that postoperative morbidity after esophagectomy is related not only with the type of surgical approach but also with other factors related to the patient's status. Finally, the lack of long-term follow-up in most series does not permit to draw conclusion about the relevance of endoscopic esophagectomy. Contrary to other advanced surgical endoscopic procedures, endoscopic esophagectomy has not yet been convincing.

Minimal access esophagectomy: where are we up to?

Endoscopic techniques for esophagectomy are disparate. The aim of this article is to describe the main surgical endoscopic techniques applied to esophagectomy and to report their results. In most published series, the benefit in terms of postoperative morbidity cannot be demonstrated. This reflects the fact that postoperative morbidity after esophagectomy is related not only with the type of surgical approach but also with other factors related to the patient's status. Finally, the lack of long-term follow-up in most series does not permit to draw conclusion about the relevance of endoscopic esophagectomy. Contrary to other advanced surgical endoscopic procedures, endoscopic esophagectomy has not yet been convincing.

Standard Resection for Cancer of the Esophagus and Cardia

Standard techniques of esophagectomy are the most common operations currently performed for cancer of the esophagus and cardia. A review of the recent literature discloses a wide difference in findings and postoperative results. A review of the findings and results in 505 operations for cancer of the esophagus on one surgical service from January 1, 1970 to January 1, 1997 reveals a resectability rate of 90%, a hospital mortality rate of 3.3%, a postoperative complication rate of 33.9%, and an adjusted actuarial 5-year survival rate of 24. 7%. As yet, neither the use of neoadjuvant therapy nor extended techniques or resection, even when applied only in patients with low-grade lesions, have provided convincing evidence of their superiority over standard resection techniques.

Transhiatal esophagectomy for squamous cell carcinoma of the esophagus.

Eighty patients underwent transhiatal esophagectomy for squamous cell carcinoma of the esophagus. Dysphagia for solids was the presenting symptom in 90% of the patients. The standard technique of transhiatal esophagectomy was used and cervical anastomosis were hand sewn. The average operative time and blood loss were 190 min and 350 cc respectively. The 30 day mortality rate was 7.5% (six patients). Major respiratory complications were observed in 15 (18.7%) patients. Anastomotic leak rate was 10% (eight patients). The incidence of recurrent laryngeal nerve injury was 6.2% (five patients). The average hospital stay was 14 days. Four patients had stage I, 30 had stage II and 46 had stage III disease. Forty-nine patients (60%) had lymph node involvement. The overall actual survival at 2 years was 55% and at 5 years was 37%. Of the operative survivors, 87% patients resumed normal swallowing and 10 patients (13.5%) required dilatation for anastomotic stricture. Transhiatal esophagectomy can be performed with low operative mortality, acceptable morbidity and offers good long-term functional results without compromising the survival of patients.

Comparison of three techniques of esophagectomy within a residency training program

Residency training programs commonly emphasize a single technique of esophagectomy, as the safety and the efficacy of teaching or performing more than one type of esophagectomy are unclear. Between 1986 and 1992, 248 patients were explored for possible esophageal resection. Thoracic surgical residents or fellows performed major components of all resections. Two hundred twenty-one patients (adenocarcinoma, 146; squamous cell carcinoma, 72; and other, 3) underwent transthoracic esophagectomy (n = 134), transhiatal esophagectomy (n = 42), or total thoracic esophagectomy (n = 45), a resectability rate of 89.1% ( 221 / 248 ). Complications occurred in 75% of patients with transthoracic esophagectomy, in 69% with transhiatal esophagectomy, and in 80% with total thoracic esophagectomy. The overall operative mortality rate was 6.8% ( 15 / 221 ). Patients with a cervical anastomosis had a higher leak rate (13%) than those with an intrathoracic anastomosis (6%). Median survival was 22 months (19% 5-year survival) and did not differ by operation type or stage. No patient with unresectable disease (n = 27) survived longer than 10 months. Survival for patients with adenocarcinoma stages 3 and 2a suggested a trend toward improved survival after transthoracic esophagectomy despite similar rates of local and distant recurrence. Transthoracic esophagectomy, transhiatal esophagectomy, and total thoracic esophagectomy performed within a residency training program have similar morbidity, mortality, and recurrence rates as those in other modern series. A specific technique of esophagectomy can be selected for individual patients. Survival and sites of recurrence primarily reflect disease stage, not the technique of esophagectomy used.

Thoracoscopic esophagectomy: Technique and initial results

To reduce the high morbidity rate associated with esophageal surgery, we have developed a technique of thoracoscopic esophagectomy. A feasibility study was first carried out in an animal model and a specific instrument was developed for this purpose. Esophagectomy using a right thoracoscopic approach was attempted in 15 patients, 13 males and 2 females whose average age was 48 years. Indications consisted of squamous cell carcinoma in 10 patients, adenocarcinoma in 1, and caustic stenosis in 4. We used a technique that consisted of double-lumen tracheal intubation and the creation of five ports. The whole esophagus was mobilized thoracoscopically and the esophagectomy was completed through the abdomen. The reconstruction was achieved using a gastric pull-through, and the anastomosis was made in the neck. There were three failures: in 1 patient there was a large tumor, making the exposure unsafe, and, in 2 patients, incomplete lung collapse made exposure of the posterior mediastinum difficult. These 3 cases were converted into a thoracotomy. The thoracoscopic dissection was successful in the remaining 12 patients. The average time of the thoracoscopic stage was 125 minutes. The postoperative course was uneventful in 10 patients. Two patients had a left atelectasis. Although our series is limited, these initial results indicate that thoracoscopic esophagectomy is feasible. However, further evaluation of the technique is needed to assess its benefit in terms of respiratory morbidity.

Transmediastinal Esophagectomy without Thoracotomy: Indication, Technique and Results

A brief historical review of the transmediastinal esophagectomy without thoracotomy and cervical esophagogastroplasty is presented. The transdiaphragmatic approach of the esophagus was performed in 576 patients with several indications. The technique of transdiaphragmatic esophagectomy performed in 366 cases for benign and malignant diseases is described, with the operative mortality (8.4%) and complications like cervical fistula (14.5%). The late follow-up for esophageal cancer treated with this technique showed an overall 5-year survival rate of 27% (stages I = 100%, II = 55%, III = 9%). This operation is a safe procedure for esophageal cancer and benign lesions of the esophagus.

Transhiatal esophagectomy for benign disease

Transhiatal esophagectomy without thoracotomy has been performed in 65 adult patients with dysphagia from benign esophageal disease: strictures (30), neuromotor dysfunction (24), acute iatrogenic perforation (five), acute caustic injury (four), and recurrent gastroesophageal reflux (two). Nearly 70% (45) had undergone at least one prior esophageal operation, and 26% (17) had a history of between two and four esophageal operations. The esophagus was replaced with stomach in 53 patients (82%), colon being used only when there was a history of either prior gastric resection or caustic injury to the stomach (10 patients). Intraoperative blood loss averaged 1,050 ml. Intraoperative complications included pneumothorax in 38 patients (58%) and a tracheal laceration in one patient. Postoperative complications included transient recurrent laryngeal nerve paresis (11 patients, 17%), chylothorax (four patients, 6%), anastomotic leak (four patients, 6%), and small bowel obstruction (two patients). There were five hospital deaths (8% mortality), none related to the technique of esophagectomy. Follow-up ranges from 1 to 84 months (average 28 months). Of 46 patients with a cervical esophagogastric anastomosis in the original esophageal bed, 42 have had an excellent functional result although 17 have required at least one postoperative esophageal dilation. Two have developed true anastomotic strictures. Clinically significant gastroesophageal reflux has not occurred. Transhiatal esophagectomy for benign disease is feasible and safe, even after multiple previous esophageal operations. The stomach appears to be a better visceral esophageal substitute than colon, because it allows an initially easier technical operation and superior long-term functional results.