Minimally Invasive Esophagectomy

Updated: Aug 14, 2019
  • Author: Michael Scott Halbreiner, MD; Chief Editor: Kurt E Roberts, MD  more...
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Overview

Background

The incidence of esophageal cancer has increased over the last several decades, and adenocarcinoma now surpasses the incidence of squamous cell carcinoma. Treatment of esophageal carcinoma has become more aggressive and effective, and the overall morbidity and mortality in those who are surgically treated have declined, approaching 8-11% and 40-50%, respectively. [1, 2]

The history of esophageal disease and its surgical treatment dates back to 2500 BCE in ancient civilizations. However, it was not until the 17th century that the first cervical esophagotomy was reported; in the latter part of the 19th century, the first cervical esophagectomy was performed by Johann Nepomuk Czerny. [3]

In 1913, Franz Torek, a German-born surgeon, performed the first thoracic esophagectomy for cancer in the German (now Lenox Hill) Hospital in New York City. Although advised against performing such a procedure, Torek was successful in part because of the recent developments in intratracheal anesthesia and asepsis. [4]  Over the next several decades, open surgical esophagectomy developed as an acceptable treatment for benign disease as well as esophageal cancer.

In 1989, interest in laparoscopic surgical techniques was sparked, as the first laparoscopic cholecystectomy was performed. [5]  This technique was first adapted into the field of esophageal disease in 1991 with laparoscopic fundoplication, performed by Dallemagne et al. [6]  With this, the shift toward minimally invasive esophageal surgery began.

Traditional approaches via open transhiatal or transthoracic (Ivor Lewis) resections were first "hybridized" with minimally invasive techniques, where parts of the procedure were performed in a minimally invasive fashion and other parts via standard incisions. [7]

Dallemagne et al performed the first mini-invasive subtotal esophagectomy in 1992, using both thoracoscopy (for dissecting the esophagus) and laparoscopy (for the gastroplasty). [8] The first esophagectomy performed completely via laparoscopy through a transhiatal approach was in 1995 by DePaul et al. [9]  In 1999, Watson et al described a completely minimally invasive Ivor Lewis technique. [10]  Subsequently, robotic-assisted approaches were described [11, 12] (see the video below).

Advantages of robotic-assisted minimally invasive surgery. Video courtesy of Memorial Sloan-Kettering Cancer Center, featuring Inderpal S Sarkaria, MD.
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Indications

Traditionally, esophagectomy has been performed via open transthoracic or transhiatal approaches, with randomized trials showing no significant difference in overall survival or disease-free survival. Furthermore, outcomes in minimally invasive esophagectomy (MIE) compare favorably to the reported series of open esophagectomy. [13]

Minimally invasive approaches to treatment of benign esophageal diseases have been met with widespread acceptance. This includes diseases such as achalasia, paraesophageal hernia, and other complex esophageal disorders. [14, 15, 16, 17] This has not been the case with malignant disease of the esophagus. Currently, no criteria define when a minimally invasive procedure should be performed in preference to an open procedure. [18]  However, there is growing support for the feasibility of employing MIE in esophageal cancer. [19]

An increasing trend exists for many high-volume institutions to use MIE in treatment of Barrett disease with high-grade dysplasia and in patients with small resectable lesions that have limited nodal involvement (N0-1). This includes T1 (invasion of the lamina propria or submucosa), T2 (invasion of the muscularis propria), and some instances of T3 lesions (invasion of the adventitia). Neoadjuvant chemoradiation is not a contraindication for MIE. [20, 21] For more information, see Esophageal Cancer Guidelines.

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Contraindications

Currently, no standardized contraindications exist regarding the use of MIE. However, T4 lesions (invasion of surrounding tissues) are generally not amenable to any form of surgical resection. Extensive nodal disease and metastatic disease are also advanced stages that may require an open surgical approach or even endoscopic stenting for palliation instead of an attempt at MIE. [21]  Furthermore, any patient with a lesion that bridges the esophagogastric junction (EGJ) may not be considered a candidate for this approach unless the gastric margin can be cleared and an esophagogastrectomy can be done either via open approach or minimally invasively.

As with other laparoscopic procedures, patients with extensive adhesions and scar tissue over the abdomen or chest wall, particularly in areas where the thoracoscope or laparoscope would be placed, are a higher-risk group for treatment with MIE. Older patients and those with comorbid conditions are not candidates for surgery, because of the high morbidity with either an MIE or a standard procedure, but they may benefit more from nonsurgical therapy. [22]

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Outcomes

Minimally invasive techniques for esophageal resection have been reported to have acceptably reduced procedure-related morbidity without compromising disease-free survival rates. [13]

Luketich et al have an extensive reported experience; their initial series of 222 patients has grown to more than 1000. [23]  In the initial series, mortality was 1.4% versus 5.5% for an open approach. [22, 24, 25]  Furthermore, the survival curve at 19-month follow-up was comparable in the two groups. [22]  In their 2012 report of 1011 patients who underwent MIE via either a modified McKeown minimally invasive approach or an MIE Ivor Lewis approach, the authors cited a 0.9% mortality for the MIE Ivor Lewis approach. [23]

In another analysis of 41 elderly patients over the age of 75 years who underwent MIE, no operative deaths occurred, with a survival of 81% at 20 month follow-up. [26]  These findings suggest that MIE can be safely performed in selected patients and even those considered high-risk that might not otherwise be considered for an open surgery.

Other outcome improvements seen with MIE include decreased intensive care unit (ICU) and hospital length of stay, reduced blood loss, and shorter operating times. In particular, Luketich et al reported a median ICU stay of 1 day and a total length of hospital stay of 7 days, compared with the average hospital stay of 16.6 days in the open approach. Operating room times in the same study averaged 306 minutes, whereas the average for an open procedure is 336 minutes. [22, 24]  Similar results can be seen in multiple other series as compared with open procedures (see the table below).

Outcomes based on procedure type. Outcomes based on procedure type.

Complications and outcomes are significantly influenced by the volume of patients, because a large learning curve exists. High-volume centers tend to have more experience and, therefore, better outcomes than smaller-volume hospitals.

Wang et al carried out a propensity score-matched comparison of MIE and open esophagectomy with respect to outcomes, quality of life, and survival in patients with squamous cell carcinoma. [27]  They found that MIE was associated with a shorter operating time (191 ± 47 minutes vs 211 ± 44 minutes), reduced blood loss (135 ± 74 mL vs 163 ± 84 mL), a similar lymph node harvest (24.1 ± 6.2 vs 24.3 ± 6.0), a shorter postoperative hospital stay (11 days vs 12 days), a lower rate of major complications (30.4% vs 36.9%), a lower rate of readmission to the ICU (5.6% vs 9.7%), and comparable perioperative mortality.

van der Sluis et al assessed the long-term oncologic results of robot-assisted minimally invasive thoracolaparoscopic esophagectomy (RAMIE) with two-field lymphadenectomy in 108 patients with potentially resectable esophageal cancer. [28]  They found RAMIE to be oncologically effective and capable of providing good local control with a low percentage of local recurrence at long-term follow-up.

In a subsequent randomized controlled trial that included 112 patients with resectable intrathoracic esophageal cancer who were treated with either RAMIE or open transthoracic esophagectomy (OTE), van der Sluis et al found RAMIE to be associated with lower rates of overall surgery-related and cardiopulmonary complications, less postoperative pain, better short-term quality of life, and superior short-term postoperative functional recovery compared to OTE. [29] Oncologic outcomes were comparable for the two approaches. 

In a prospective phase II study (coordinated by the Eastern Cooperative Oncology Group) aimed at assessing the feasibility of MIE in a multi-institutional setting, Luketich et al reported the following results [30] :

  • The 30-day mortality in eligible patients who underwent MIE was 2.1%
  • The median ICU stay was 2 days
  • The median hospital stay was 9 days
  • Adverse events classified as grade 3 or higher included anastomotic leakage (8.6%), acute respiratory distress syndrome (ARDS; 5.7%), pneumonitis (3.8%), and atrial fibrillation (2.9%)
  • The estimated 3-year overall survival (median follow-up, 35.8 months) was 58.4%
  • Locoregional recurrence occurred in only 7 patients (6.7%)

In a nationwide retrospective analysis from Japan that included 14,880 patients who underwent esophagectomy for clinical stage 0 to III esophageal cancer, Sakamoto et al compared in-hospital mortality and morbidity for MIE vs open esophagectomy. [31]  MIE was associated with lower incidences of in-hospital mortality, surgical-site infection (SSI), anastomotic leakage, blood transfusion, reoperation, tracheotomy, and unplanned intubation, as well as a shorter postoperative length of stay. However, MIE was also associated with higher rates of vocal cord dysfunction and prolonged intubation after esophagectomy, as well as a longer duration of anesthesia.

In a systematic review and meta-analysis of 14 studies (N = 3468), Deng et al evaluated short-term outcomes for minimally invasive McKeown esophagectomy (MIME) vs minimally invasive Ivor Lewis esophagectomy (MILE) in patients with resectable esophageal or junctional tumors. [32] ​ MIME led to more blood loss, longer operating times, and longer hospital stays, as well as higher rates of pulmonary complications, total anastomotic leak, stricture, and vocal cord injury/palsy. No significant differences were found in R0 resection rate; number of lymph modes retrieved; blood transfusion rate; length of ICU stay; incidence of cardiac arrhythmia, chyle leak, or severe anastomotic leak; 30-day/in-hospital mortality; or 90-day mortality.

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