A study of 97 patients who underwent esophagectomy between 2007-2010 found that: 1) Minimally invasive esophagectomy (MIE) was associated with fewer pulmonary and cardiac complications compared to open approaches, but the differences were not statistically significant. 2) Rates of anastomotic leaks, renal complications, wound infections, and in-hospital mortality were similar between MIE and open approaches. 3) Trans-thoracic approaches to esophagectomy, whether open or minimally invasive, were associated with higher morbidity than cervical or transhiatal approaches.

1. Surgical Approaches to
Esophageal Cancer
Alyssa Paetau
PGY-5
GI/Surg Conference
9/2/2011

2. Esophageal Cancer
∗ 16,640 diagnoses; 14,500 deaths yearly
∗ 3:1 male predominance
∗ 5-year survival (SEER data base):
∗ 1975-1977: 5%
∗ 1996-2004: 17%
∗ 30-40% will have potentially resectable disease on
presentation

3. Adenocarcinoma
∗ A consequence of persistent GERD
∗ Distal esophagus undergoes intestinal metaplasia
∗ Hyperproliferation
∗ Acquire DNA damage, become morphologically dyplasic
and then frankly malignant
∗ 94% occur below the tracheal bifurcation
∗ Commonly recur w/ distant dissemination

4. Squamous Cell Carcinoma
∗ Incidence decreasing
∗ Tobacco/EtOH abuse
∗ Epithelial dysplasia, CIS, invasive carcinoma
∗ 65% are located above the tracheal bifurcation
∗ Recur locoregionally first
∗ Tumor location incorporated into the 2010 TNM
staging system for SCC only
∗ Higher stage for middle and upper 1/3

5. Esophagectomy
∗ Various approaches
∗ Open
∗ Minimally invasive
∗ Introduced in 1994
∗ Aim to reduce morbidity but have comparable oncologic
outcomes
∗ Choice depends on:
∗ Surgeon preference
∗ Tumor location

7. Transhiatal esophagectomy
∗ Upper midline laparotomy or laparoscopy to mobilize the
stomach
∗ Blind mediastinal dissection through the hiatus
∗ Neoesophagus is transposed through the posterior
mediastinum
∗ Anastamosis is performed at the level of the clavicles
∗ Pros: proximal margin is well away from the tumor site,
extra-thoracic/extra-pleural anastatomosis, decreased
cardiopulmonary complications
∗ Cons: vocal cord palsy, increased bleeding, arrhythmias,
inability to perform a full thoracic lymphadenectomy

9. Ivor-Lewis Esophagectomy
∗ R-thoracotomy and laparotomy
∗ Pros: direct exposure of the intrathoracic esophagus,
equal long-term survival
∗ Cons: morbidity of a thoracotomy incision, anastomosis is
performed in the chest
∗ Leak rate is <5% but difficult to manage
∗ Complete drainage is not possible
∗ Empyema
∗ Negative intrathoracic P causes higher rates of dysphagia,
reflux
∗ Dilation of conduit over time?

11. 3-Field Esophagectomy
∗ R-thoracotomy, laparotomy, cervical incision
∗ Pros: exposure, anastomosis in the neck, extended
lymphadenectomy
Fujita H, Kakegawa T, Yamana H et al. Mortality and morbidity rates,
postoperative course, quality of life, and prognosis after extended radical
lymphadenectomy for esophageal cancer. Ann Surg 1995; 222: 654-662
∗ Cons: morbidity of 3 large incisions, higher incidence of
recurrent laryngeal N. injury

12. 3-field vs. 2-field Minimally
Invasive Esophagectomy
3-Field MIE 2-field MIE
∗ VATS via a prone ∗ Transcervical videoscope
approach esophageal dissection
∗ Requires single lung (TVED)
ventilation that increases ∗ Decreased operative time
cardiopulmonary ∗ Improved visualization
morbidity ∗ Avoids single-lung
∗ Conduit is intra-pleural ventilation
∗ Conduit is extra-pleural

13. MIE vs. Open
∗ No oncologic difference noted in recent retrospective
comparison of 64 patients w/ stage 2 or 3 disease
(33MIE and 31 Ivor-Lewis)
∗ Survival at 2 years: 55% vs. 32%
∗ Did not reach statistical significance but concluded that
outcomes were comparable
Sing RK, et al. Minimally invasive esophagectomy provides equivalent
oncologic outcomes to open esophagectomy for locally advanced
esophageal carcinoma. Arch Surg 2011 Jun; 146(6):711-4

14. MW 47032693
∗ 75yo M c/o odynophagia and epigastic pain
∗ Long h/o dysphagia and occasional regurgitation managed w/
dietary and behavior modifications
∗ PMH: HTN, gout, h/o tobacco use
∗ PSH: L5 diskectomy
∗ EGD (OH): suspicious esophageal nodule at 42cm
∗ Path: Moderately differentiated SCC
∗ EUS (OH): T1B or possible T2 lesion
∗ CT/PET-CT (OH): negative for metastatic disease

15. MW
∗ EUS:
∗ 3cm mass at the GEJ
involving half the luminal
circumference
∗ Invading the muscularis
propria
∗ T2N0
∗ Path: Moderately
differentiated SCC
∗ Referral to
Oncology/Radiation
Oncology

16. Neoadjuvant Therapy for Regionally
Advanced Disease
∗ Purpose of XRT:
∗ reduce tumor size
∗ decrease risk of spread during surgical manipulation
∗ Purpose of chemo:
∗ eliminate micromets
∗ downstage the tumor
∗ improve resectability

17. Neoadjuvant Therapy for
Regionally Advanced Disease
∗ Multiple RCTs that have evaluated chemo followed by
surgery vs. surgery alone
∗ Meta-analysis that included 8 RCTs and 1724 patients
demonstrated a statistically significant survival
benefit
Urschel JD et al. A meta analysis of randomized controlled trials that compared
neoadjuvant chemotherapy and surgery to surgery alone for resectable esophageal
cancer. Am J of Surg 2003; 185:538.
∗Absolute 2-year survival benefit of 7 %
∗20-25% of patients will have a pathologic complete
response

18. Neoadjuvant Therapy for
Regionally Advanced Disease
∗ Preoperative Chemotherapy or Radiochemotherapy
in Esophagogastric Adenocarcinoma Trial (POET)
∗ R0 resection in 70 and 72%
∗ 3-year survival was better in the chemo/XRT group (47
vs. 28%, p=0.07)
∗ Closed because of poor accrual (126 of 394 patients)
Stahl M et al. Phase III comparison of preoperative chemotherapy compared with
chemoradiotherapy in patients with locally advanced adenocarcinoma of the EG
junction. J of Clin Onc. 2009; 27:851
∗ National Comprehensive Cancer Network
recommends preoperative chemoradiation for T2-3N0
stage 1 to stage 3 SCC and adenocarcinoma

19. MW
∗ Elected to undergo neoadjuvant tx
∗ Cisplatin/ 5-FU
∗ 50Gy
∗ Re-staged:
∗ CT/PET-CT
∗ EUS: mucosal irregularity w/ the application of Lugol’s
but no gross dx

20. MW
∗ To OR 8/4/11 for a 3-field MIE:
∗ Thoracoscopic esophageal mobilization
∗ Lap pyloroplasty
∗ Lap gastric mobilization and creation of a gastric
conduit
∗ Cervical esophageal mobilization and
esophagogastrostomy
∗ EGD w/ NGT placement

21. MW
∗ Extubated but re-intubated secondary to over-sedation
and hypoxemia/hypoventilation on PACU
∗ Extubated in ICU on POD #1
∗ Transferred to the floor POD #2
∗ A-fib w/ RVR on POD #3
∗ Rate controlled w/ diltiazem
∗ Spontaneously converted to NSR in 24h
∗ Esophagram on POD #4 showed no leak/delay
∗ Discharged home POD #8

22. MW
∗ Path:
∗ Ulcer and associated acute and chronic inflammation at
the GEJ
∗ No evidence of residual carcinoma
∗ 0/28 LNs

23. RH 75360693
∗ 78 yo M c/o dysphagia
∗ PMH: HTN, OA
∗ PSH: Open appy
∗ EGD: Intrathoracic stomach; Barrett’s w/ HGD and a
focus of adenocarcinoma
∗ EUS: 1.5cm nodular area at the GEJ; extension into
submocosa; no lympadenopathy

24. RH
∗ EMR: Moderately differentiated adenocarcinoma involving
the muscularis mucosa; at least high-grade dysplasia at the
lateral margin
∗ EMR repeated:
∗ Lateral margin positive for HGD
∗ Cardia: adenocarcinoma involving the submucosa; lateral and
deep margins are focally positive
∗ PET/CT
∗ Intrathoracic stomach w/ organoaxial rotation
∗ Referred to Surgery

26. RH
∗ To OR on 7/25 for a 2 field MIE:
∗ Transcervical videoscopic antegrade esophageal
dissection
∗ Lap gastric mobilization and creation of a neoesophagus
∗ Lap pyloroplasty
∗ Transcervical esophagogastrostomy
∗ EGD w/ NGT placement

27. RH
∗ Extubated immediately post-op
∗ Transferred out of ICU POD #1
∗ POD #3: Esophagram
∗ Contrast delayed through pyloroplasty

29. RH
∗ POD #5: Esophagram repeated
∗ Minimal delay
∗ Blenderized diet started
∗ Discharged home POD #8

30. RH
∗ Final Path:
∗ Focal residual moderately differentiated
adenocarcinoma (0.5cm) involving the muscularis
mucosa
∗ Negative margins
∗ 0/26 LNs
∗ T1aN0

31. Our 3-field MIE Experience
1/07-8/10
Goldberg RF, Bowers SP, et al. Technical and Perioperative Outcomes of Minimally Invasive Esophagectomy
in the Prone Position.
∗ 42 patients
∗ Average age 68 years (37-87y)
∗ Diagnoses:
∗ 35 adenocarcinoma
∗ 4 Barrett’s w/ HGD
∗ 2 achalasia
∗ 1 SCC
∗ 38% underwent neo-adjuvant chemo
∗ Classified as low, medium, or high risk via the
Modified Charlson Comorbidity Index

32. Our 3-field MIE Experience
1/07-8/10
∗ Median LOS: 8 days (6-51d)
∗ Median ICU stay: 2 days (1-26)
∗ Mean Operative Time (includes positioning): 402min
(261-650min)
∗ Mean positioning time: 90min (46-148min)
∗ Mean prone surgical time: 108min (67-198min)
∗ Mean supine surgical time: 224min (120-364min)
∗ Mean EBL: 180mL
∗ 88% were extubated POD #0
∗ Chest drainage needed for a median of 6 days (3-30d)

33. Our 3-field MIE Experience
1/07-8/10
∗ Predominant complications:
∗ 14 arrhythmias
∗ 7 pneumonias
∗ 5 anastomotic leaks
∗ 2 post-op 30-day mortalities
∗ Higher risk patients had a higher risk of major complications
∗ Higher BMI did not correlate to longer operative times
∗ Of the 15 patients who had major complications, 12 were former
smokers and 1 was still smoking at the time of surgery

34. Our Experience at MCJ: TVED
Parker M, Bowers SP, Goldberg RF, et al. Transcervical videoscopic esophageal dissection during two-field minimally invasive
esophagectomy: early patient experience. J Surg Endoscopy. ePub 24 June 2011.
∗ Retrospective cohort study of 8 patients over a 10-month period
∗ Mean age: 63 +/- 12 yrs
∗ Mean BMI 30.2 +/- 5.1 kg/m2
∗ 2 w/ HGD, 6 w/ adenocarcinoma, 1 s/p chemo/XRT
∗ Results:
∗ Mean operative time: 292min (174-375min) (402 minutes)
∗ Mean blood loss: 119mL (180mL)
∗ Median ICU stay: 1 day (1-5days) (2 days)
∗ Median hospital stay: 7 days (5-16days) (8days)
∗ None required a chest tube
∗ 2 cervical anastomotic leaks
∗ 1 patient with leak, MI, and pneumonia
∗ 2 patients with vocal cord dysfunction

35. Trans-thoracic Approaches to Esophagectomy Associated
With Higher Morbidity
Ross F Goldberg MD, Steven P Bowers MD, Michael Parker MD, John A Stauffer MD, Michael
Heckman MS, Colleen Thomas MS, Horacio J Asbun MD, John A Odell MD, C Daniel Smith MD
∗ Retrospective cohort study of 97 patients undergoing
esophagectomy between 1/07-8/10
∗ 3-field MIE: 48
∗ 2-field MIE: 8
∗ Transhiatal Open: 12
∗ Ivor-Lewis: 10
∗ Thoracoabdominal approach w/ cervical incision: 11
∗ 3-field: 8

36. MIE Open Difference [Open-MIE]
Outcome P-value
(N=56) (N=41) (95% CI)
Cardiac complications 18 (32%) 17 (41%) 9% (-10%, 29%) 0.40
Pulmonary complications 19 (34%) 18 (44%) 10% (-10%, 30%) 0.40
Pulmonary intervention 17 (30%) 14 (34%) 4% (-15%, 23%) 0.83
Pulmonary embolism or deep vein thrombosis 4 (7%) 1 (2%) -5% (-13%, 4%) 0.39
Leak 6 (11%) 4 (10%) -1% (-13%, 11%) 1.00
Leak intervention 3 (5%) 0 (0%) -5% (-11%, 1%) 0.26
Renal complications 2 (4%) 2 (5%) 1% (-7%, 9%) 1.00
Wound infection 3 (5%) 4 (10%) 4% (-6%, 15%) 0.45
Pharmacologic interventions* 22 (39%) 21 (51%) 12% (-8%, 32%) 0.30
Delayed gastric emptying 1 (2%) 1 (2%) 1% (-5%, 7%) 1.00
Voice hoarseness/laryngeal injury 5 (9%) 3 (7%) -2% (-13%, 9%) 1.00
In-hospital mortality 2 (4%) 2 (5%) 1% (-7%, 9%) 1.00
Discharged on total parental nutrition 2 (4%) 1 (2%) -1% (-8%, 6%) 1.00
Discharged on tube feeding 2 (4%) 10 (24%) 21% (7%, 35%) 0.004
Clavien classification (Grade III or higher) 19 (34%) 17 (41%) 8% (-12%, 27%) 0.53
30-day mortality** 2 (4%) 3 (7%) 4% (-6%, 13%) 0.65
90-day follow-up
Dilatations for stricture 5 (9%) 5 (12%) 3% (-9%, 16%) 0.74
- P-values result from Fisher’s exact test. *Pharmacologic intervention includes total parental nutrition, tube feeding, and blood
transfusion.
**30-day mortality includes those patients who died in the hospital.

37. Intrathoracic vs. Extrathoracic

38. Aftercare
∗ Endoscopic Surveillance: at least annually
∗ After EMR: every 3 months for 1 year, then annually
∗ Early strictures (<1 yr) are common (48/177 patients over a
3-year period) and usually benign
∗ Pyloric and anastomotic
∗ Can be a consequence of leak but not always
∗ >90% respond to dilation
Sutliffe RP, et al. Anastamotic strictures and delayed gastric emptying after esophagectomy. Dis of the
Esophagus (2008) 21, 712-717.
∗ Self expanding plastic stents for anastamotic leak
∗ Earlier PO intake, shorter hospital course, decreased
mortality
Hunerbien M, et. Al. Treatment of Thoracic Anastomotic Leaks After Esophagectomy With Self-expanding
Plastic Stents. Ann Surg. 2004 November; 240(5): 801–807