Minimally invasive oesophagectomy

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Minimally invasive oesophagectomy

  1. 1. Laparoscopic Oesophagectomy Abeezar I. Sarela Department of Upper GI & Bariatric Surgery St James’s University Hospital, Leeds, UK
  2. 2. Development of Minimally Invasive Oesophagectomy <ul><li>Cushieri et al. Endoscopic oesophagectomy through a right thoracoscopic approach. J R Coll Surg Edin. 1992 ;37:7-11 </li></ul><ul><li>Dexter & McMahon . Radical thoracoscopic oesophagectomy. Surg Endosc 1996 ;10:147-51 </li></ul><ul><li>Luketich et al . Minimally invasive esophagectomy. Outcomes in 222 patients. Ann Surg 2003 ;238:486-495 </li></ul><ul><li>Palanivelu et al . Minimally invasive esophagectomy: thoracoscopic mobilization of the esophagus and mediastinal lymphadenectomy in prone position 130 patients. J Am Coll Surg 2006 ;203:7-16 </li></ul>
  3. 4. Is Minimally Invasive Oesophagectomy Superior to Open Surgery?
  4. 7. No published randomised clinical trial of minimally invasive versus open oesphagectomy
  5. 8. Terminology <ul><li>Minimally invasive oesophagectomy (MIO) with cervical anastomosis </li></ul><ul><li>MIO with intra-thoracic anastomosis </li></ul><ul><li>Laparoscopically-assisted oesophagectomy (LAO) with standard thoracotomy and intra-thoracic anastomosis </li></ul><ul><li>LAO with mini-thoracotomy and intra-thoracic anastomosis </li></ul><ul><li>LAO with thoracotomy and cervical anastomosis </li></ul><ul><li>Thoracoscopically-assisted oesophagectomy with laparotomy and cervical anastomosis </li></ul>
  6. 9. Technical Variations <ul><li>Construction of gastric conduit </li></ul><ul><ul><li>Intra-corporeal </li></ul></ul><ul><ul><li>Extra-corporeal </li></ul></ul><ul><li>Specimen removal </li></ul><ul><ul><li>Neck </li></ul></ul><ul><ul><li>Chest </li></ul></ul><ul><ul><li>Abdomen </li></ul></ul><ul><li>Anastomosis </li></ul><ul><ul><li>Stapled </li></ul></ul><ul><ul><li>Sutured </li></ul></ul>
  7. 10. Learning Curve Decker et al. Europ J Cardiothoracic Surgery. 2009;35:13-21 3.6% 46% 2.2% 4 ≥ 100 4.5% 44% 2.1% 8 ≥ 50 9.6% 60% 3.9% 29 ≤ 25 Conversion Morbidity Mortality Series Number of patients
  8. 12. Access versus Radicality Transhiatal versus Transthoracic
  9. 14. Quo Vadis? <ul><li>Sentinel node for carcinomas of the oesphagus and gastroesophageal junction. Grotenhuis et al. J Thorac Cardiovasc Surg. 2009;138:608-12 </li></ul><ul><li>Vagal sparing oesophagectomy Peyre et al (DeMeeser TR). Ann Surg 2007;246:665-74 </li></ul><ul><li>Merindino operation – Jejunal interposition </li></ul>
  10. 15. Laparoscopic Vagus-Preserving Merindino Operation with Sentinel Lymph Node Biopsy
  11. 16. Conclusions Minimally Invasive Oesophagectomy <ul><li>Heterogeneous group of operations </li></ul><ul><li>Several technical variations </li></ul><ul><li>Challenging & high-risk </li></ul><ul><li>Oncological principles critical </li></ul><ul><li>Wide patient-benefit uncertain </li></ul><ul><li>Avenues for progress </li></ul>

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