Minimally Invasive Ivor Lewis Esophagectomy

Esophageal cancer is a growing problem in the United States. Surgical resection, often in combination with chemoradiotherapy, provides the only approach to offer a cure for these patients. Traditional open approaches are burdened by high levels of morbidity and mortality. Minimally invasive esophagectomy (MIE) has been proposed as an alternative approach. Although MIE is complex and perhaps more time-consuming, perioperative results are encouraging and generally trend toward fewer pulmonary complications, lower blood loss, shorter ICU stays, and shorter overall hospitalization durations. There appears to be little cost in terms of oncologic efficacy. Although technically demanding, it appears that the learning curve is approximately 40 cases. With these considerations in mind, it is likely that MIE will continue to grow in favorability for patients with surgically resectable esophageal cancer.^1,2 Recent advancements include the robotic Ivor Lewis procedure, which facilitates precise intrathoracic anastomosis with comparable complication rates and oncological outcomes. Its feasibility and safety highlight its potential, pending further validation in controlled studies.¹⁰

The incidence of esophageal cancer has increased over the previous four decades. In 2018 alone, it is estimated that there will be 18,000 patients diagnosed with esophageal cancer, and 15,000 deaths from the disease.¹ Esophagectomy, most commonly with adjuvant chemotherapy and radiation for locoregional spread, is the only vehicle to offer patients a cure.² The major open approaches are the transthoracic Ivor Lewis, transhiatal, left thoracoabdominal, and “three phase” McKeown esophagectomies. Historically, open esophagectomy has been associated with high rates of morbidity and mortality. A recent review of the Medicare claims database and the Nationwide Inpatient Sample suggested that mortality rates for esophagectomy range from 8.1% to 23.1%.³ A review of the Society of Thoracic Surgeons General Thoracic Database estimated a mortality rate of 2.7% and a postoperative major morbidity rate of 24%.⁴ Given the high rates of morbidity and mortality, minimally invasive esophagectomy (MIE) has attracted the attention of the part of the surgical community as a potential approach to minimize postoperative morbidity without compromising long-term outcomes.

The patient presented in this case is an otherwise healthy 42-year-old woman. She had no previous medical history, particularly no long-standing gastroesophageal reflux disease. She has no family history of malignancy. She initially presented with increasing dysphagia. This prompted an endoscopy that revealed a distal esophageal adenocarcinoma that was staged using CT, positron emission tomography (PET), and endoscopic ultrasound US. The tumor was determined to be a locally advanced T3N1 adenocarcinoma. For these reasons, she was treated with neoadjuvant chemoradiotherapy and was subsequently brought to the operating room for a minimally invasive esophagectomy as a component of her trimodality therapy.

The patient was well-appearing and in no distress. She had no cervical or supraclavicular adenopathy. She had normal breath sounds bilaterally. Her heart sounds were regular. Her abdomen was soft. Her extremities were warm, and she was neurologically intact.

CT imaging of the chest, abdomen, and pelvis revealed thickening of the lower esophagus with periesophageal adenopathy around the celiac access. PET revealed that these areas were fluorodeoxyglucose-avid but with no evidence of distant metastatic disease. She underwent an upper GI endoscopy that revealed a short-segment Barrett’s esophagus from which the tumor arose; it was staged as T3N1 using endoscopic ultrasound.

The majority of patients identified as having esophageal adenocarcinoma present with metastatic disease. For those with locally advanced disease, a trimodal regimen of neoadjuvant chemoradiotherapy followed by surgery is thought to give the best opportunity for cure. Surgery remains the mainstay of treatment, given the low complete pathologic response rates to neoadjuvant chemoradiotherapy.

For those with early stage disease, primary surgical resection is an option. However, most patients present with dysphagia and at least locally advanced disease. These patients are best served by a regimen of neoadjuvant chemoradiotherapy followed by surgical resection if the patient can tolerate surgery. If not, the patient will be given definitive doses of chemotherapy radiation in an attempt at cure.

The earliest reports of MIE date back to 1992, when Cuschieri et al. reported a five-patient series and described a technique of esophagectomy via a right thoracoscopic approach.⁵ They noted “unmeasurable” blood loss in four patients and 300 cc loss in the fifth study participant. The mean procedure time was 5.5 hours, ICU stay was 1 day, and hospital stay was 11 days. In 1995, DePaula et al. reported their experience with 12 patients with benign and malignant esophageal diseases (squamous cell carcinomas and adenocarcinomas of the esophagus) who were treated with transhiatal esophagectomy without thoracotomy, using abdominal-mediastinal dissection.⁶ Overall, their results were similarly encouraging.

In 1998, Luketich et al. at the University of Pittsburgh Medical Center described their experience with transhiatal approaches involving a combined laparoscopic/thoracoscopic approach to esophagectomy that implements thoracoscopic mobilization of the esophagus with laparoscopic creation of the gastric conduit and a cervical anastomosis.⁷ In 1999, Watson et al. reported on their preliminary experience of two patients undergoing minimally invasive Ivor Lewis esophagectomy, an approach that incorporates a hand-assisted laparoscopic approach for gastric mobilization and a thoracoscopic approach for esophageal dissection and anastomosis.⁹ Luketich went on to publish a landmark series of his initial 222 minimally invasive esophagectomies, demonstrating the feasibility of the technique.8 Over the subsequent 15 years, enthusiasm has exploded; a PubMed search of “minimally invasive esophagectomy” revealed more than 600 primary articles.

The patient in this study underwent an uneventful esophagectomy with an intrathoracic esophagogastric anastomosis using an EEA stapler. While EEA staplers are commonly used, other techniques such as handsewn and intraluminal stapler methods are also employed. The choice of technique can influence outcomes, including anastomotic leak rates and complications. However, current evidence remains inconclusive regarding which anastomosis technique is superior in preventing anastomotic leaks.¹¹

The patient’s hospital stay lasted six days. No chylothorax, thoracic empyema, or cardiac arrhythmias were observed. A swallow study conducted on postoperative day 5 revealed no evidence of an esophageal anastomotic leak or issues with gastric emptying. She started on an advancing diet. The pathology report indicated a residual T1b N0 (0/15) moderately differentiated adenocarcinoma with all margins negative (R0). Several months after surgery, she began surveillance with CT imaging and returned to work. At her one-year postoperative follow-up, CT imaging showed no signs of tumor recurrence.

A minimally invasive esophagectomy requires standard laparoscopic instruments for the abdominal portion with endoscopic staplers used to create the gastric conduit. The patient required single-lung ventilation, and standard thoracoscopic instruments were used for the mobilization and resection of the esophagus. The anastomosis between the esophagus and gastric conduit was achieved using an EEA stapler.

None.

The patient referred to in this video article has given his informed consent to be filmed and is aware that information and images will be published online.