Minimally Invasive Esophagectomy Sebastien Gilbert James D Luketich Introduction The incidence of esophageal adenocarcinoma is rising in the western world and has surpassed squamous carcinoma as the most common histologic type(1-3). Reports of esophageal resection and replacement techniques appeared in the scientific literature in the early part of the 20 th century(4). With advancements in surgical knowledge and technology, anesthesiology, and perioperative management strategies, esophagectomies are now performed on a routine basis. Unfortunately, when compared to other malignancies, esophageal cancer is still associated with a relatively poor overall survival irrespective of treatment modality(5). Nevertheless, surgery remains an essential form of local treatment for esophageal cancer, with the best results for curative resection obtained in patients with early-stage (0-IIa) disease. High operative volume and, experience with postoperative management issues have been associated with improved perioperative outcomes(6;7). Nevertheless, traditional open esophagectomy remains associated with high complication and mortality rates.(8;9). In a recent review of the Medicare database in the United States, mortality rates ranged from 8% in high volume centers to an alarming 23% in low volume centers(6). In theory, by decreasing surgical trauma and procedure-related pain, minimally invasive techniques may also improve the postoperative course of esophagectomy patients. Therefore, over the past several years, we have devoted significant efforts toward the development and refinement of a thoracoscopic and laparoscopic approach to esophageal resection. This paper will provide the salient features of our surgical technique, as well as, our postoperative outcomes data. Surgical Technique Thoracic Mobilization of the Esophagus The patient first undergoes an upper endoscopy following intubation with a double-lumen endotracheal tube. The tumor is visualized and its relationship to the trachea, gastroesophageal junction, and curvatures of the stomach is reassessed as part of the operative planning. The patient is then positioned in the left lateral decubitus with the right arm flexed 90 degrees at the shoulder and at the elbow. It is helpful to mark the scapular tip, and to draw a straight line from the anterior edge of the right latissimus dorsi muscle down to the costal margin. When inserting ports, this line serves as an estimate of the position of the esophagus within the right chest. Three 10 mm ports and one 5mm port are needed for access (Figure 1). The ports are introduced in a predetermined
Transcript
Minimally Invasive Esophagectomy
Sebastien GilbertJames D Luketich
Introduction
The incidence of esophageal adenocarcinoma is rising in the western world and has surpassed squamous carcinoma as the most common histologic type(1-3). Reports of esophageal resection and replacement techniques appeared in the scientific literature in the early part of the 20th century(4). With advancements in surgical knowledge and technology, anesthesiology, and perioperative management strategies, esophagectomies are now performed on a routine basis. Unfortunately, when compared to other malignancies, esophageal cancer is still associated with a relatively poor overall survival irrespective of treatment modality(5). Nevertheless, surgery remains an essential form of local treatment for esophageal cancer, with the best results for curative resection obtained in patients with early-stage (0-IIa) disease.
High operative volume and, experience with postoperative management issues have been associated with improved perioperative outcomes(6;7). Nevertheless, traditional open esophagectomy remains associated with high complication and mortality rates.(8;9). In a recent review of the Medicare database in the United States, mortality rates ranged from 8% in high volume centers to an alarming 23% in low volume centers(6). In theory, by decreasing surgical trauma and procedure-related pain, minimally invasive techniques may also improve the postoperative course of esophagectomy patients. Therefore, over the past several years, we have devoted significant efforts toward the development and refinement of a thoracoscopic and laparoscopic approach to esophageal resection. This paper will provide the salient features of our surgical technique, as well as, our postoperative outcomes data.
Surgical Technique
Thoracic Mobilization of the Esophagus
The patient first undergoes an upper endoscopy following intubation with a double-lumen endotracheal tube. The tumor is visualized and its relationship to the trachea, gastroesophageal junction, and curvatures of the stomach is reassessed as part of the operative planning. The patient is then positioned in the left lateral decubitus with the right arm flexed 90 degrees at the shoulder and at the elbow. It is helpful to mark the scapular tip, and to draw a straight line from the anterior edge of the right latissimus dorsi muscle down to the costal margin. When inserting ports, this line serves as an estimate of the position of the esophagus within the right chest. Three 10 mm ports and one 5mm port are needed for access (Figure 1). The ports are introduced in a predetermined
order, and positioned in relationship to the line previously drawn on the chest. First, a 10 mm camera port is inserted in the 8th or 9th interspace anteriorly. Another 10 mm port is inserted 5 cm posterior to the mark, in the 8th or 9th interspace (Ultrasonic shears, EndoStitch, EndoGIA stapler, and Endoclip port). The latter port should be placed higher (8th interspace) when dealing with mid-esophageal tumors. The 5 mm port is placed immediately inferior and posterior to the tip of the scapula (tissue grasper port). The final 10 mm port is positioned in the 4th interspace, anteriorly under direct visualization (fan retractor port). It should be placed anteriorly enough to allow exposure of the esophagus by retraction of the lung parenchyma against the anterior chest wall and mediastinum.
Using the EndoStitch device, an 0 suture is placed in the central tendon of the diaphragm to provide retraction and improve visualization. The suture is brought out to the skin by inserting the EndoClose device just above the diaphragm on the line marking the position of the esophagus on the chest. Gentle downward traction on this suture will pull the dome of the diaphragm downward and afford an excellent view of the esophago-crural junction. The lung is retracted anteriorly and superiorly to expose the lower esophagus. The inferior pulmonary ligament is incised and dissection proceeds cranially, in a plane posterior to the inferior pulmonary vein, between the periesophageal tissues and the pericardium. The next identifiable landmark is the right mainstem bronchus. Dissection continues along the lower border of the bronchus toward the carina. The Ultrasonic shears should be used with caution because of the risk of airway injury. It is safer to place clips placed along side the bronchial to achieve hemostasis in the subcarinal area, which is rich in lymphatic tissue and bronchial vessels. The subcarinal lymph nodes are dissected en bloc with the esophagus. The azygous vein is divided close its junction with the superior vena cava using the EndoGIA vascular stapler. This initial part of the dissection aims to separate the lower esophagus from the pericardium, the right and left mainstem bronchi, and the carina. The next phase involves separation of the esophagus and periesophageal tissues from the lateral structures including the thoracic duct and azygos vein.
The mediastinal pleura is incised to identify the plane of dissection between the esophagus and the thoracic duct. Lymphatic tributaries draining the esophagus are identified and clipped close to the thoracic duct in order to prevent postoperative chylothorax. The dissection plane is extended parallel to the esophagus. The esophagus can then be encircled with a 10 mm Penrose drain (Figure 2). The drain is stapled to itself around the esophagus and cut short. It can be used to retract the esophagus out of the mediastinum to improve exposure. Above the level of the azygous vein, the plane of esophageal mobilization narrows down and remains directly on the esophagus in order to avoid injury to the posterior membranous trachea and the recurrent laryngeal nerves. When dissecting the proximal esophagus above the azygos vein, the mediastinal pleura is preserved by gently separating it from the specimen. This
pleural flap will help seal the thoracic inlet after the gastric tube is pulled through the neck. Once this is completed, attention is focused on the hiatus. The esophagus is freed from its phrenoesophageal attachments without entering the peritoneal cavity. Once the esophagus is completely mobilized, the Penrose drain is placed at the level of the thoracic inlet for later retrieval through the neck incision. A 28F chest tube in positioned at the posterior apex through the camera port, and the intercostals nerves are infiltrated with 0.5% bupivacaine with epinephrine using a thoracoscopic needle.
Gastric Mobilization, Pyloroplasty, Feeding Jejunostomy and Gastric Tubularization
The patient is repositioned supine with the head slightly turned to the right. A footboard is placed to allow use of steep reverse Trendelenburg positioning. Using a skin marker, a line is drawn from the xyphoid to the umbilicus, and it is divided in thirds. Another line drawn from the junction between the upper and middle third to the costal margin approximates the location of the falciform ligament. This simple maneuver helps to avoid placing the 10 mm blunt operating port through the ligament. This first port is inserted using a cut-down technique 3 cm to the right of the junction between the lower and middle third of the line extending from the xyphoid and umbilicus. The pneumoperitoneum is then established using carbon dioxide. All the remaining ports (4) are 5 mm in size (Figure 3). They are inserted in the following locations: 5 cm to the left of the operating port (30o camera port), subcostally on the right and left mid-clavicular lines (tissue grasper ports), and in the right flank (liver retractor port). After a careful metastatic survey of the peritoneal cavity, the left lobe of the liver is retracted anteriorly for better visualization of the stomach and hiatus.
The lesser omentum is incised above the level of the right gastric artery, which is preserved. The right and left crura are exposed using the Ultrasonic shears. Care is taken to avoid entering the right hemithorax in order to prevent decompression of the pneumoperitoneum into the chest. The greater curvature is mobilized starting with the short gastric vessels. Once the fundus of the stomach is free, the body and antrum are mobilized, taking care to preserve the gastroepiploic arcade. The stomach is grasped sparingly to minimize the risk of trauma. Adhesions between the posterior wall of the stomach and the retroperitoneum are divided. The left gastric vascular pedicle is identified and divided at its origin from the celiac trunk using an EndoGIA vascular stapler. Prior to division, lymph nodes are dissected free and remain with the specimen. The pyloric channel is mobilized along with the first and second stages of the duodenum. This “partial kocherization” of the duodenum is sufficient to provide the mobility necessary to the pull the gastric tube up to the neck. Adequate mobilization of the duodenum is confirmed when the pylorus can be pulled up to the level of the right crus without any undue tension. The pyloroplasty is performed by incising the pylorus longitudinally, and closing it transversely (i.e. Heineke-Mikulicz). Two stay sutures are positioned at the edges of the pylorus
to provide traction. The incision is made using the Ultrasonic shears, and the pylorus is closed with interrupted 2-0 sutures using the Endostitch (Figure 4). The next step is creating the feeding jejunostomy.
One additional 11 mm port is placed in the right lower quadrant just below the umbilicus in the mid-clavicular line. From the left side, the greater omentum is grasped near the transverse colon, and retracted cranially in order to expose the ligament of Treitz. The anti-mesenteric border of the jejunum is grasped 30-40 cm away from the ligament. The jejunal loop is stretched to the anterior abdominal wall to ensure that the jejunostomy can be created without tension. A fine needle is inserted through the abdominal at the chosen location as a marker. The jejunum is then secured to the abdominal wall using the EndoStitch with 2-0 interrupted stitches. The anti-mesenteric border is then grasped distal to the jejunostomy site so that the jejunum can be straightened in preparation for the insertion of the feeding tube. We routinely use a 5F percutaneous feeding jejunostomy tube. Intraluminal position is confirmed by insufflating 10 mL of air through the jejunostomy tube. Additional sutures are used to secure the jejunum to the abdominal wall around the tube (Kathy to provide figure of jejunostomy). The jejunum is then sutured again approximately 3 cm distal to the insertion site, in order to prevent torsion. We then proceed with gastric tubularization.
The stomach needs to be positioned carefully to achieve optimal tubularization. The tip of the fundus is grasped gently and the stomach is stretched toward the spleen. Counter-traction is applied with a grasper positioned on the distal antrum. An EndoGIA stapler is used to divide the stomach parallel to the greater curvature, and at least 4-5 cm away from it. Attention must be focused on maintaining the orientation of the stomach (Figure 6). It is easy to misdirect the stapler toward the anterior or posterior surface of the stomach, thereby creating a spiraling staple line. Subsequently, the tip of the gastric tube is sutured to the distal resection margin using an 0 suture. At this point, the hiatal dissection is completed in order to free the esophagus and gastroesophageal junction. The right and or left crura may have to be partially divided in order to increase the size of the hiatus, and allow easy passage of the gastric conduit. The pneumoperitoneum is decompressed through the abdominal ports, and neck dissection is started.
Neck dissection, gastric pull-up, and anastomosis
The neck incision is oriented transversely along a skin crease approximately 1 finger breath above the sternal notch. After raising platysmal flaps, dissection is continued deeper along the anterior border of the sternocleidomastoid muscle. The omohyoid muscle and the inferior thyroid artery are divided. We do not routinely divide the left strap muscles. The esophagus is dissected circumferentially, taking care not to apply any direct retraction to the tracheoesophageal groove. The Penrose drain encircling the thoracic
esophagus is retrieved through the neck incision. The pneumoperitoneum is then re-established and the gastric tube pulled up through the neck by applying traction on the proximal esophagus. Simultaneously, the laparoscopic view is re-established and the assistant carefully guides the tube into the hiatus avoiding any spiraling or tension on the gastro-epiploic arcade (Figure 7). The gastric tube is then separated from the proximal stomach in the neck. Using the thoracic esophagus as a handle, the cervical esophagus is dissected free, up to the level of the cricopharyngeus muscle. A purse string suture is applied to the proximal cervical esophagus distal to the cricopharyngeus. The proximal esophagus is cut, and the specimen is sent for pathologic assessment of surgical margins. The anvil of the EEA stapler is inserted into the proximal esophagus and the purse string tied. Gentle dilation of the proximal esophagus with the index finger helps deliver a 25 mm anvil in most patients. Subsequently, the tip of the gastric tube is opened and the stapler is inserted through the lumen. The stapler spike is brought out through the posterior wall of the stomach, away from the greater curve. The stapler is joined to the anvil and fired to create an end-to-side esophagogastric anastomosis. Care is taken not to intersect the anastomosis with the gastric staple line. A nasogastric tube is inserted across the anastomosis under direct visualization through the opening in the gastric tube. Closure of this opening is achieved by stapling off the tip of the gastric conduit. Any redundancy in the gastric conduit is reduced back into the abdomen under laparoscopic visualization. Once this is accomplished, the gastric tube is secured to the hiatus using 3 interrupted 2-0 sutures. A 5 mm Jackson-Pratt drain is placed alongside the neck anastomosis. All incisions are closed and the procedure is completed.
Postoperative outcomes
The perioperative outcomes of minimally invasive esophagectomy (MIE) at the University of Pittsburgh have been discussed extensively in our most recent report of 222 patients(10). Conversions to open thoracotomy or laparotomy were required in 7%, and none were emergent. The 30-day operative mortality was 1.4%, which compares favorably to the results of open techniques (4-9.5%)(8;9;11). The median length of hospital stay was also relatively short (7 days) when compared to open esophagectomy(8). The median intensive care unit stay was 1 day (range = 1–30 days). The incidence of pulmonary complications (21.6%) was similar to the open transthoracic technique and, slightly higher than the open transhiatal technique(8;9). The mean follow-up was 19 months (range = 1–68 months). Kaplan-Meier survival curves based on cancer stage are included (Figure 8).
Discussion
The role of esophagectomy in the treatment of esophageal cancer has been challenged by previous observations that chemoradiotherapy (CRT) alone could result in equivalent long-term survival (RTOG 8501)(12). The latter trial did not
have a surgical treatment arm. Therefore, comparisons with the results of previously published surgical trials are inherently biased. Future randomized trials may lend support to such arguments but, until then, patients with resectable esophageal tumors should still be offered surgery(13)§.
It makes intuitive sense to think that patients with residual local disease following CRT would benefit from esophageal resection. On the other hand, it is difficult to understand how patients with a complete pathologic response to CRT can derive any further survival benefit from esophagectomy. However, determining which patients have a true complete pathologic response is not possible by PET scanning or by endoscopic ultrasound or simple endoscopy with superficial biopsies and at the present time requires esophagectomy to confirm. Perhaps future challenges in the treatment of esophageal cancer reside in predicting or accurately measuring the response to multimodality treatment, rather than attempting to prove that one component is superior to the others.
Within the surgical community, there is still debate about the therapeutic value of performing an extended (three-field) lymphadenectomy. A the present time, our MIE technique includes lymph node dissection in the abdomen and mid to lower thoracic areas including the lesser curve, left gastric artery, lower esophagus, and subcarinal area. It is not as extensive as the three-field lymphadenectomy. The rationale for extended lymphadenectomy comes from reports that up to 30% of patients with cancer of the esophagogastric junction have lymph node metastases in the neck ADDIN REFMGR.CITE <Refman><Cite><Author>Lerut</Author><Year>1999</Year><RecNum>58</RecNum><IDText>Reflections on three field lymphadenectomy in carcinoma of the esophagus and gastroesophageal junction</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>58</Ref_ID><Title_Primary>Reflections on three field lymphadenectomy in carcinoma of the esophagus and gastroesophageal junction</Title_Primary><Authors_Primary>Lerut,T.</Authors_Primary><Authors_Primary>Coosemans,W.</Authors_Primary><Authors_Primary>De Leyn,P.</Authors_Primary><Authors_Primary>Deneffe,G.</Authors_Primary><Authors_Primary>Topal,B.</Authors_Primary><Authors_Primary>Van,de,V</Authors_Primary><Authors_Primary>van Raemdonck,D.</Authors_Primary><Date_Primary>1999/3</Date_Primary><Keywords>*Adenocarcinoma</Keywords><Keywords>su [Surgery]</Keywords><Keywords>*Carcinoma,Squamous Cell</Keywords><Keywords>su [Surgery]</Keywords><Keywords>*Esophageal Neoplasms</Keywords><Keywords>su [Surgery]</Keywords><Keywords>*Esophagogastric Junction</Keywords><Keywords>su [Surgery]</Keywords><Keywords>*Lymph Node Excision</Keywords><Keywords>mt [Methods]</Keywords><Keywords>Adenocarcinoma</Keywords><Keywords>mo [Mortality]</Keywords><Keywords>Adenocarcinoma</Keywords><Keywords>pa
eriodical>Journal of Thoracic & Cardiovascular Surgery.</Periodical><Volume>113</Volume><Issue>3</Issue><ZZ_JournalFull><f name="System">Journal of Thoracic & Cardiovascular Surgery.</f></ZZ_JournalFull><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>µ(14;15)§. In non-randomized case series, investigators suggested an improved survival with no significant increase in morbidity or mortality following three-field lymphadenectomy ADDIN REFMGR.CITE <Refman><Cite><Author>Lerut</Author><Year>1998</Year><RecNum>30</RecNum><IDText>Esophageal surgery at the end of the millennium. [Review] [106 refs]</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>30</Ref_ID><Title_Primary>Esophageal surgery at the end of the millennium. [Review] [106 refs]</Title_Primary><Authors_Primary>Lerut,T.</Authors_Primary><Date_Primary>1998/7</Date_Primary><Keywords>*Esophageal Diseases</Keywords><Keywords>su [Surgery]</Keywords><Keywords>*Esophagectomy</Keywords><Keywords>*Esophagoplasty</Keywords><Keywords>*Esophagostomy</Keywords><Keywords>Esophageal Diseases</Keywords><Keywords>di [Diagnosis]</Keywords><Keywords>Esophagectomy</Keywords><Keywords>hi [History]</Keywords><Keywords>Esophagectomy</Keywords><Keywords>td [Trends]</Keywords><Keywords>Esophagoplasty</Keywords><Keywords>hi [History]</Keywords><Keywords>Esophagoplasty</Keywords><Keywords>td [Trends]</Keywords><Keywords>Esophagoscopy</Keywords><Keywords>Esophagostomy</Keywords><Keywords>hi [History]</Keywords><Keywords>Esophagostomy</Keywords><Keywords>td [Trends]</Keywords><Keywords>History of Medicine,17th Cent.</Keywords><Keywords>History of Medicine,20th Cent.</Keywords><Keywords>History of Medicine,Ancient</Keywords><Keywords>Human</Keywords><Keywords>Laparoscopy</Keywords><Keywords>mt [Methods]</Keywords><Keywords>Laparoscopy</Keywords><Keywords>td [Trends]</Keywords><Keywords>Thoracic Surgical Procedures</Keywords><Keywords>mt [Methods]</Keywords><Keywords>Thoracic Surgical Procedures</Keywords><Keywords>td [Trends]</Keywords><Reprint>Not in File</Reprint><Start_Page>1</Start_Page><End_Page>20</End_Page><Periodical>Journal of Thoracic & Cardiovascular Surgery.</Periodical><Volume>116</Volume><Issue>1</Issue><ZZ_JournalFull><f name="System">Journal of Thoracic & Cardiovascular Surgery.</f></ZZ_JournalFull><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite><Cite><Author>Swanson</Author><Year>2001</Year><RecNum>60</RecNum><IDText>Transthoracic esophagectomy with radical mediastinal and abdominal lymph node dissection and cervical esophagogastrostomy for esophageal carcinoma</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>60</Ref_ID><Title_Primary>Transthoracic esophagectomy with radical mediastinal and abdominal
Staging</Keywords><Keywords>Postoperative Complications</Keywords><Keywords>Precancerous Conditions</Keywords><Keywords>mo [Mortality]</Keywords><Keywords>Precancerous Conditions</Keywords><Keywords>pa [Pathology]</Keywords><Keywords>Retrospective Studies</Keywords><Keywords>Survival Rate</Keywords><Keywords>Thoracotomy</Keywords><Keywords>United States</Keywords><Reprint>Not in File</Reprint><Start_Page>1918</Start_Page><End_Page>1924</End_Page><Periodical>Annals of Thoracic Surgery.</Periodical><Volume>72</Volume><Issue>6</Issue><ZZ_JournalFull><f name="System">Annals of Thoracic Surgery.</f></ZZ_JournalFull><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite><Cite><Author>Altorki</Author><Year>2002</Year><RecNum>61</RecNum><IDText>Three-field lymph node dissection for squamous cell and adenocarcinoma of the esophagus</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>61</Ref_ID><Title_Primary>Three-field lymph node dissection for squamous cell and adenocarcinoma of the esophagus</Title_Primary><Authors_Primary>Altorki,N.</Authors_Primary><Authors_Primary>Kent,M.</Authors_Primary><Authors_Primary>Ferrara,C.</Authors_Primary><Authors_Primary>Port,J.</Authors_Primary><Date_Primary>2002/8</Date_Primary><Keywords>*Adenocarcinoma</Keywords><Keywords>su [Surgery]</Keywords><Keywords>*Esophageal Neoplasms</Keywords><Keywords>su [Surgery]</Keywords><Keywords>*Esophagectomy</Keywords><Keywords>mt [Methods]</Keywords><Keywords>*Lymph Node Excision</Keywords><Keywords>mt [Methods]</Keywords><Keywords>*Neoplasm Recurrence,Local</Keywords><Keywords>*Neoplasms,Squamous Cell</Keywords><Keywords>su [Surgery]</Keywords><Keywords>Adenocarcinoma</Keywords><Keywords>ep [Epidemiology]</Keywords><Keywords>Adenocarcinoma</Keywords><Keywords>mo [Mortality]</Keywords><Keywords>Adenocarcinoma</Keywords><Keywords>pa [Pathology]</Keywords><Keywords>Adult</Keywords><Keywords>Aged</Keywords><Keywords>Combined Modality Therapy</Keywords><Keywords>Disease-Free Survival</Keywords><Keywords>Esophageal Neoplasms</Keywords><Keywords>ep [Epidemiology]</Keywords><Keywords>Esophageal Neoplasms</Keywords><Keywords>mo [Mortality]</Keywords><Keywords>Esophageal Neoplasms</Keywords><Keywords>pa [Pathology]</Keywords><Keywords>Esophagectomy</Keywords><Keywords>F
emale</Keywords><Keywords>Hospital Mortality</Keywords><Keywords>Human</Keywords><Keywords>Lymphatic Metastasis</Keywords><Keywords>Male</Keywords><Keywords>Middle Aged</Keywords><Keywords>Morbidity</Keywords><Keywords>Mortality</Keywords><Keywords>Neoplasm Staging</Keywords><Keywords>Neoplasms,Squamous Cell</Keywords><Keywords>ep [Epidemiology]</Keywords><Keywords>Neoplasms,Squamous Cell</Keywords><Keywords>mo [Mortality]</Keywords><Keywords>Neoplasms,Squamous Cell</Keywords><Keywords>pa [Pathology]</Keywords><Keywords>Prevalence</Keywords><Keywords>Prospective Studies</Keywords><Keywords>Recurrence</Keywords><Keywords>Survival Analysis</Keywords><Keywords>Survival Rate</Keywords><Keywords>United States</Keywords><Reprint>Not in File</Reprint><Start_Page>177</Start_Page><End_Page>183</End_Page><Periodical>Annals of Surgery.</Periodical><Volume>236</Volume><Issue>2</Issue><ZZ_JournalFull><f name="System">Annals of Surgery.</f></ZZ_JournalFull><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>µ(16-18)§. To the best of our knowledge, only one prospective randomized trial has examined the role of extended lymphadenectomy. The results showed a non-significant trend toward better survival following extended lymphadenectomy ADDIN REFMGR.CITE <Refman><Cite><Author>Nishihira</Author><Year>1998</Year><RecNum>62</RecNum><IDText>A prospective randomized trial of extended cervical and superior mediastinal lymphadenectomy for carcinoma of the thoracic esophagus.[see comment]</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>62</Ref_ID><Title_Primary>A prospective randomized trial of extended cervical and superior mediastinal lymphadenectomy for carcinoma of the thoracic esophagus.[see comment]</Title_Primary><Authors_Primary>Nishihira,T.</Authors_Primary><Authors_Primary>Hirayama,K.</Authors_Primary><Authors_Primary>Mori,S.</Authors_Primary><Date_Primary>1998/1</Date_Primary><Keywords>*Carcinoma,Squamous Cell</Keywords><Keywords>su [Surgery]</Keywords><Keywords>*Esophageal Neoplasms</Keywords><Keywords>su [Surgery]</Keywords><Keywords>*Lymph Node Excision</Keywords><Keywords>Aged</Keywords><Keywords>Carcinoma,Squamous Cell</Keywords><Keywords>dt [Drug Therapy]</Keywords><Keywords>Carcinoma,Squamous Cell</Keywords><Keywords>rt [Radiotherapy]</Keywords><Keywords>Carcinoma,Squamous Cell</Keywords><Keywords>mo [Mortality]</Keywords><Keywords>Chemotherapy,Adjuvant</Keywords><Keywo
rds>Combined Modality Therapy</Keywords><Keywords>Comparative Study</Keywords><Keywords>Double-Blind Method</Keywords><Keywords>Esophageal Neoplasms</Keywords><Keywords>dt [Drug Therapy]</Keywords><Keywords>Esophageal Neoplasms</Keywords><Keywords>mo [Mortality]</Keywords><Keywords>Esophageal Neoplasms</Keywords><Keywords>rt [Radiotherapy]</Keywords><Keywords>Evaluation Studies</Keywords><Keywords>Follow-Up Studies</Keywords><Keywords>Human</Keywords><Keywords>Lymph Node Excision</Keywords><Keywords>mt [Methods]</Keywords><Keywords>Lymphatic Metastasis</Keywords><Keywords>Mediastinum</Keywords><Keywords>Middle Aged</Keywords><Keywords>Neck</Keywords><Keywords>Neoplasm Recurrence,Local</Keywords><Keywords>Postoperative Complications</Keywords><Keywords>Prognosis</Keywords><Keywords>Prospective Studies</Keywords><Keywords>Radiotherapy,Adjuvant</Keywords><Keywords>Recurrence</Keywords><Keywords>Thorax</Keywords><Keywords>Time Factors</Keywords><Keywords>United States</Keywords><Reprint>Not in File</Reprint><Start_Page>47</Start_Page><End_Page>51</End_Page><Periodical>American Journal of Surgery.</Periodical><Volume>175</Volume><Issue>1</Issue><ZZ_JournalFull><f name="System">American Journal of Surgery.</f></ZZ_JournalFull><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>µ(19)§. However, the trial was small (n=62) and patients were further randomized after surgery to either CRT or chemotherapy alone, which makes interpretation of the results difficult. At present, it is still unclear if lymphadenectomy is beneficial in and of itself, or because it results in a more accurate determination of nodal status. Additional randomized controlled data is needed to clarify this issue.
Although achieving complete resection is important, the impact of an operation of this magnitude of the patient’s daily activities cannot be overlooked. Despite the best available treatment, a significant proportion of patients will still only enjoy a limited survival. Unfortunately, objective data on the quality of life data following esophagectomy is not yet available for large open surgical series ADDIN REFMGR.CITE <Refman><Cite><Author>Altorki</Author><Year>2001</Year><RecNum>47</RecNum><IDText>Should en bloc esophagectomy be the standard of care for esophageal carcinoma?[see comment]</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>47</Ref_ID><Title_Primary>Should en bloc esophagectomy be the standard of care for esophageal carcinoma?[see comment]</Title_Primary><Authors_Primary>Altorki,N.</Authors_Primary><Auth
ors_Primary>Skinner,D.</Authors_Primary><Date_Primary>2001/11</Date_Primary><Keywords>*Carcinoma</Keywords><Keywords>su [Surgery]</Keywords><Keywords>*Esophageal Neoplasms</Keywords><Keywords>su [Surgery]</Keywords><Keywords>*Esophagectomy</Keywords><Keywords>*Lymph Node Excision</Keywords><Keywords>Adult</Keywords><Keywords>Aged</Keywords><Keywords>Aged,80 and over</Keywords><Keywords>Carcinoma</Keywords><Keywords>mo [Mortality]</Keywords><Keywords>Carcinoma</Keywords><Keywords>sc [Secondary]</Keywords><Keywords>Chemotherapy,Adjuvant</Keywords><Keywords>Esophageal Neoplasms</Keywords><Keywords>mo [Mortality]</Keywords><Keywords>Esophageal Neoplasms</Keywords><Keywords>pa [Pathology]</Keywords><Keywords>Esophagectomy</Keywords><Keywords>Esophagectomy</Keywords><Keywords>ae [Adverse Effects]</Keywords><Keywords>Esophagectomy</Keywords><Keywords>mt [Methods]</Keywords><Keywords>Female</Keywords><Keywords>Hospital Mortality</Keywords><Keywords>Human</Keywords><Keywords>Lymphatic Metastasis</Keywords><Keywords>Male</Keywords><Keywords>Middle Aged</Keywords><Keywords>Neoplasm Recurrence,Local</Keywords><Keywords>Postoperative Complications</Keywords><Keywords>Recurrence</Keywords><Keywords>Retrospective Studies</Keywords><Keywords>Survival Rate</Keywords><Keywords>United States</Keywords><Reprint>Not in File</Reprint><Start_Page>581</Start_Page><End_Page>587</End_Page><Periodical>Annals of Surgery.</Periodical><Volume>234</Volume><Issue>5</Issue><ZZ_JournalFull><f name="System">Annals of Surgery.</f></ZZ_JournalFull><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite><Cite><Author>Lerut</Author><Year>1998</Year><RecNum>30</RecNum><IDText>Esophageal surgery at the end of the millennium. [Review] [106 refs]</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>30</Ref_ID><Title_Primary>Esophageal surgery at the end of the millennium. [Review] [106 refs]</Title_Primary><Authors_Primary>Lerut,T.</Authors_Primary><Date_Primary>1998/7</Date_Primary><Keywords>*Esophageal Diseases</Keywords><Keywords>su [Surgery]</Keywords><Keywords>*Esophagectomy</Keywords><Keywords>*Esophagoplasty</Keywords><Keywords>*Esophagostomy</Keywords><Keywords>Esophageal Diseases</Keywords><Keywords>di [Diagnosis]</Keywords><Keywords>Esophagectomy</Keywords><Keywords>hi [History]</Keywords><Keywords>Esophagectomy</Keywords><Keywords>td [Trends]</Keywords><Keywords>Esophagoplasty</Keywords><Keywords>hi [History]</Keywords><Keywords>Esophagoplasty</Keywords><Keywords>td [Trends]</Keywords><Keywords>Esophagoscopy</Keywords><Keywords>Esop
hagostomy</Keywords><Keywords>hi [History]</Keywords><Keywords>Esophagostomy</Keywords><Keywords>td [Trends]</Keywords><Keywords>History of Medicine,17th Cent.</Keywords><Keywords>History of Medicine,20th Cent.</Keywords><Keywords>History of Medicine,Ancient</Keywords><Keywords>Human</Keywords><Keywords>Laparoscopy</Keywords><Keywords>mt [Methods]</Keywords><Keywords>Laparoscopy</Keywords><Keywords>td [Trends]</Keywords><Keywords>Thoracic Surgical Procedures</Keywords><Keywords>mt [Methods]</Keywords><Keywords>Thoracic Surgical Procedures</Keywords><Keywords>td [Trends]</Keywords><Reprint>Not in File</Reprint><Start_Page>1</Start_Page><End_Page>20</End_Page><Periodical>Journal of Thoracic & Cardiovascular Surgery.</Periodical><Volume>116</Volume><Issue>1</Issue><ZZ_JournalFull><f name="System">Journal of Thoracic & Cardiovascular Surgery.</f></ZZ_JournalFull><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite><Cite><Author>Orringer</Author><Year>1999</Year><RecNum>45</RecNum><IDText>Transhiatal esophagectomy: clinical experience and refinements</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>45</Ref_ID><Title_Primary>Transhiatal esophagectomy: clinical experience and refinements</Title_Primary><Authors_Primary>Orringer,M.B.</Authors_Primary><Authors_Primary>Marshall,B.</Authors_Primary><Authors_Primary>Iannettoni,M.D.</Authors_Primary><Date_Primary>1999/9</Date_Primary><Keywords>*Esophageal Diseases</Keywords><Keywords>su [Surgery]</Keywords><Keywords>*Esophageal Neoplasms</Keywords><Keywords>su [Surgery]</Keywords><Keywords>*Esophagectomy</Keywords><Keywords>mt [Methods]</Keywords><Keywords>Adolescent</Keywords><Keywords>Adult</Keywords><Keywords>Aged</Keywords><Keywords>Aged,80 and over</Keywords><Keywords>Esophageal Neoplasms</Keywords><Keywords>mo [Mortality]</Keywords><Keywords>Esophagectomy</Keywords><Keywords>Esophagectomy</Keywords><Keywords>mo [Mortality]</Keywords><Keywords>Esophagus</Keywords><Keywords>su [Surgery]</Keywords><Keywords>Female</Keywords><Keywords>Human</Keywords><Keywords>Incidence</Keywords><Keywords>Intensive Care</Keywords><Keywords>Intraoperative Complications</Keywords><Keywords>ep [Epidemiology]</Keywords><Keywords>Length of Stay</Keywords><Keywords>Male</Keywords><Keywords>Middle Aged</Keywords><Keywords>Postoperative Complications</Keywords><Keywords>ep [Epidemiology]</Keywords><Keywords>Retrospective
Studies</Keywords><Keywords>Safety</Keywords><Keywords>Stomach</Keywords><Keywords>tr [Transplantation]</Keywords><Keywords>Survival Rate</Keywords><Keywords>United States</Keywords><Reprint>Not in File</Reprint><Start_Page>392</Start_Page><End_Page>400</End_Page><Periodical>Annals of Surgery.</Periodical><Volume>230</Volume><Issue>3</Issue><ZZ_JournalFull><f name="System">Annals of Surgery.</f></ZZ_JournalFull><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>µ(11;16;20)§. The MIE described above does not require any compromise in the extent of resection when compared to standard open TTE. Nevertheless, using this approach, quality of life is preserved to a level equal to the general population of the same age group.
The operation described in this paper is the minimally invasive equivalent of a transthoracic esophagectomy (TTE) with standard lymphadenectomy and a cervical anastomosis. Aside from the theoretical risk of port site recurrence, MIE should be equivalent to TTE from an oncologic standpoint. Obvious advantages of the minimally invasive approach include the avoidance of both thoracotomy and laparotomy, which may translate into improved postoperative recovery. The answer to such questions will come from prospective comparisons of minimally invasive and open operations. However, prior to initiating such trials, the feasibility of the technique and reproducibility of the results need to be studied in multi-center trials. Moreover, by allowing surgeons to gain technical expertise, this approach can potentially eliminate the effects of the technical “learning curve” on future studies. In collaboration with other investigators, our group has designed a phase II trial (ECOG 2202) to evaluate MIE in a multi-institutional setting. Once it is completed, the infrastructure will be in place to compare MIE to open techniques, and determine which patients will benefit the most from this innovative approach.
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Figure 1. Thoracic Port Placement SHAPE \* MERGEFORMAT µ §
Figure 2. Thoracoscopic Esophageal Mobilization
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Figure 3. Laparoscopic Port Placement
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Figure 4. Laparoscopic Pyloroplasty
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Figure 5. Laparoscopic Jejunostomy
Figure 6. Gastric Tubularization
SHAPE \* MERGEFORMAT µ §
Figure 7. The specimen and attached gastric tube are pulled through the hiatus up to the neck.
