Minimally invasive esophagectomy has advanced to the point where it offers significant advantages over open esophagectomy in terms of operative morbidity and mortality, judging by the results of a single-center review of 980 cases headed by
McGowan Institute for Regenerative Medicine
affiliated faculty member James D. Luketich, M.D., F.A.C.S. (pictured top), the Henry T. Bahnson Professor of cardiothoracic surgery, chief of the division of thoracic and foregut surgery at the University of Pittsburgh School of Medicine, and director of the Heart, Lung and Esophageal Surgery Institute at the University of Pittsburgh Medical Center (UPMC). The published series indicate that the operative mortality of open esophagectomy is 8%-21%, although a very few high-volume medical centers have reported rates as low as 3%. McGowan Institute for Regenerative Medicine affiliated faculty member Blair Jobe, M.D. (pictured bottom), associate professor of surgery at the University of Pittsburgh and in the Heart, Lung and Esophageal Surgery Institute at the UPMC, is a co-author on the study.
"There is a perception among patients and physicians that open esophagectomy is to be avoided at all costs because of it substantial morbidity," Dr. Luketich said at the annual meeting of the American Surgical Association.
In his review of 980 consecutive, elective, nonurgent, minimally invasive esophagectomies, the 30-day mortality was just 1.8%. Median operative time was 6.7 hours, which dropped to 4 hours in cases that were not done by residents. The median ICU stay was 2.0 days, with a median hospital length of stay of 8 days. A median 21 lymph nodes were dissected, and 98% of cases had negative surgical margins.
"A less invasive surgical approach for esophageal cancer would improve the standard of care by reducing morbidity and shortening hospital stays and time to return to daily activities. If successful, surgeons might see more early-stage referrals from Barrett’s patients now in surveillance," added Dr. Luketich.
A modified Ivor-Lewis approach involving laparoscopic conduit preparation, videothoracoscopic esophageal mobilization, and intrathoracic anastomosis is preferable to the McKeown approach when the minimally invasive route is chosen. It entails fewer conduit complications and lower mortality, according to Dr. Luketich.
In this series, 49% of patients underwent a modified McKeown approach involving videothoracoscopic esophageal mobilization, laparoscopic conduit preparation, and neck anastomosis, whereas 51% were treated via the modified Ivor-Lewis approach.
This was a nonrandomized study, but patients in the two study arms were essentially the same in terms of baseline characteristics. In all, 95% were operated on for malignant disease, 80% were men, and 31% received preoperative chemotherapy and/or radiotherapy. Patients who were operated on in the most recent years of the series underwent the Ivor-Lewis approach because Dr. Luketich has come to prefer it. He noted that most trainees are more comfortable with it; they have far more experience with operating in the chest than the neck.
Furthermore, outcomes are better than results with the McKeown approach. Indeed, the 30-day mortality rate was just 1.2% with the Ivor-Lewis minimally invasive esophagectomy chest (MIE-chest) approach vs. 2.5% with the McKeown MIE-neck approach. The major morbidity rate was 31% in the MIE-chest group, significantly less than the 36% with the MIE-neck group. This difference was driven by the increased risk of laryngeal nerve injury with the McKeown approach. The incidence of vocal cord paresis or paralysis was 8% in the MIE-neck patients, compared with 1% in the MIE-chest group.
Rates of other complications were closely similar in the two groups: 6% for empyema, 5% for acute respiratory distress syndrome, 5% for pulmonary embolism, 2% for acute MI, 3% for heart failure, and 5% for anastomotic leak requiring surgery.
Quality of life assessments using the Short Form-36 indicate that by 90 days, post-MIE patients scored in the age-adjusted normal range.
"I think by 90 days the patients have bounced back," he concluded. "Laparoscopy–VATS [video-assisted thoracic surgery]–chest anastomosis is now our preferred approach to most esophageal cancers."
At the meeting, discussant Dr. David J. Sugarbaker called Dr. Luketich’s study "a landmark paper."
"Dr. Luketich has been a pioneer in esophageal resection, and I think has developed a procedure that is rapidly becoming a standard of care worldwide. This is the largest experience reported to date," noted Dr. Sugarbaker, professor of surgical oncology and chief of the division of thoracic surgery at Brigham and Women’s Hospital and Harvard Medical School, Boston.
"He’s set the standard, both in quantity and quality, for this operation," agreed Dr. John G. Hunter, professor and chairman of the department of surgery at Oregon Health and Science University, Portland.
Illustration: McGowan Institute for Regenerative Medicine.
Internal Medicine News (05/02/11)
Bio: Dr. James Luketich
Bio: Dr. Blair Jobe
Abstract (American Surgical Association 131st Annual Meeting, April 14-16, 2011)