Ivor-Lewis Esophagectomy:Debate Lost before it started

T. Brett Reece, MDPomerantz Lecture Sacrificial Lamb

Dr. Pomerantz

Dr. Orringer

Ivor-Lewis Esophagectomy• Advantages

– Superior Oncology• More extensive lymph

node dissection• Margins, Staging

– Less Anastamotic tension• Lower leak rate

– Direct Visualization Dissection

– Avoid neck morbidity– Amenable to minimally

invasive techniques

• Disadvantages– May exacerbate pulmonary

dysfunction– Thoracic Leak – Two Physicians honored

prefer transhiatal

• Meta-Analysis of THE vs TTE published over a 10 year period

• 50 articles with total >7500 patients

• Patients with esophageal neoplasm – upper 1/3 8– Middle 1/3 17– Lower 1/3 55

• Both squamous and adenocarcinoma• En bloc resection with abdominal thoracic

and cervical lymph node

Three Field Dissection

Survival

• 114 Transthoracic• Extended on bloc

resection • (included cervical

LND and cervical anastamosis)

• 106 Transhiatal• Shorter hospital stay• Fewer pulmonary

complications

Disease Free Survival

Overall Survival

Dutch Results

• Disease-free and overall survival curves were virtually identical in the first two years of follow-up. Later during follow-up, both disease-free and overall survival curves diverged, showing a trend in favor of the extended transthoracic approach

• Estimated five-year disease-free survival rates were 27 percent and 39 percent, respectively, whereas five-year overall survival rates were 29 percent and 39 percent.

Dutch Conclusion

“Our data do not permit us to make a clear recommendation of one treatment over the other. Further follow-up of the patients in this study may clarify whether the long-term benefits of the extended approach, in terms of survival, outweigh the increase in early morbidity and associated costs.”

Not Ivor-Lewis

• Previous studies suggest advantage for extended lymph node dissection

• These included cervical lymph node dissection

• Argument may still apply when limited to chest, without the neck complications– recurrent laryngeal nerve injury

A comparison of transhiatal and transthoracic resections on the prognosis in patients with squamous cell carcinoma of the esophagus

European Journal of Surgical Oncology 2006

• 229 patients with squamous cell carcinoma• 70 transhiatal vs 159 TTE

including extended mediastinal lymph node dissection

True Ivor-Lewis Study

• Significantly better long-term survival was observed in patients with transthoracicapproach with curative procedures (R0) (24 versus 13 months), as well as for those either without (pN0) (38 versus 14 months) or with lymph-node involvement (pN1), and for those with > or =16 (=median) dissected thoracic lymph nodes (25 versus 12 months) (p<0.05*)

Transhiatal versus Ivor-Lewis oesophagectomy: is there a difference?

Rindani, Aus NZ J Surgery 1999

• 44 series (1986-1996) 33 papers on 2675 patients having transhiatal and 29 papers on 2808 patients having Ivor-Lewis oesophagectomy (ILO).

• The transhiatal group appeared to have a higher incidence of anastomotic leaks (16% for THO, 10% for ILO), anastomoticstrictures (28% for THO, 16% for ILO) and recurrent laryngeal nerve injuries (11.2% for THO, 4.8% for ILO).

• The 30-day mortality was 6.3% for transhiatal and 9.5% for Ivor-Lewis oesophagectomy. Overall long-term survival at 5 years was similar (24% for THO, 26% for ILO).

• In order to demonstrate a significant difference in morbidity or long-term survival between the two techniques 3100 patients would be required in each arm of a prospective randomized trial

Ivor-Lewis Esophagectomy

• Higher up front mortality • Better oncologic procedure

– Better predict prognosis– Prolong Survival

• Role of Minimally Invasive Surgery