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Minimally Invasive Ivor Lewis Esophagectomy

Christopher Morse, MD
Massachusetts General Hospital

Abstract

The two main types of esophageal cancer are squamous cell carcinoma, which comprises the majority of cases world-wide, and adenocarcinoma, which is diagnosed with increasing frequency and now accounts for more than 50% of cases in the western hemisphere. Smoking and alcohol consumption are strongly linked to squamous cell carcinoma, and the most important etiologic risk factor for adenocarcinoma is Barrett's esophagus, which occurs in 10 to 15% of patients with gastro-oesophageal reflux disease. Patients generally present with dysphagia and weight loss, and diagnosis is made via endoscopy and biopsy. The surgical treatment of esophageal cancer is dependent upon the location of the cancer, the depth of invasion, and the presence of lymph node metastasis. Smaller tumors that only involve the mucosal layer of the esophagus may be removed by endoscopic mucosal resection, but larger, more invasive tumors require esophageal resection. Esophagectomy can be approached via the trans-hiatal (Orringer), trans-thoracic (Ivor-Lewis), or three-field (McKeown) techniques, and anastomosis between the stomach and the shortened esophagus is achieved through either a gastric pull up or colonic/jejunal interposition. The addition of neoadjuvant chemotherapy for locally-advanced adenocarcinoma has been shown to increase survival compared with surgery alone, and is the standard treatment in these cases. Here, we present the case of a female patient with dysphagia who was found to have a locally-advanced distal esophageal adenocarcinoma. In this case, a minimally-invasive Ivor Lewis esophagectomy was performed with neoadjuvant chemotherapy.

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