esophagectomy – Thoracic Surgery

Interview with the master: Dr. Benny Weksler

Talking to Dr. Benny Weksler about Minimally invasive esophagectomies, robotic surgery, lung cancer screening and life in the mid-south.

Memphis, Tennessee USA

Recently, I had the great pleasure and privilege to have a sit down interview with one of the thoracic surgeons whose work I have long admired. Loyal readers will certainly recognize the name, Dr. Benny Weksler, one of the modern masters of esophageal surgery.

Minimally invasive esophagectomies (MIE)

He is best known for his minimally invasive esophagectomies which take much of the pain (literally) out of the traditional surgical resection for esophageal cancer. The minimally invasive esophagectomy is the VATS approach to esophagectomy, using smaller 2 to 3cm ‘ports’ instead of large incisions.

In classic thoracic surgery, large open incisions such as the Ivor Lewis esophagectomy were the best way to optimize survival for patients with this aggressive cancer. However, the traditional open surgery itself is particularly arduous and has been likened to the “open heart surgery” of the thoracic specialty. The Ivor Lewis in particular is two full-sized surgeries; a full thoracotomy combined with a transverse laparotomy. While it has been utilized for decades for excellent visualization, staging and resection, the recovery is a long, painful process.

Dr. Weksler in the mid-south

It’s been just over three years since Dr. Benny Weksler was recruited to start a new thoracic surgery program at The University of Tennessee – West Cancer Clinic – Methodist Hospital System here in Memphis, Tennessee. It’s been a big change, and a bit of an eye-opening experience for the Brazilian native and famed thoracic surgeon who has spent much of this career in the northeast. Prior to this, he was part of the renowned University of Pittsburgh Medical Center under the famed Dr. James Luketich. Since Dr. Weksler’s move, he’s still adjusting to the warmer weather here, which is one of the things he likes best about the area along with the traditional Memphis music scene, which the city is famous for.

reflection — Memphis is more than just the home of Elvis Presley

It’s also been a time of great changes and innovations for Memphis and the University of Tennessee, as well. Dr. Weksler started the first thoracic surgery service line for the UT – Methodist Hospital system, which is actually the first real dedicated thoracic surgery service line in the Memphis area – which extends across a tri-state area that also covers parts of northern Mississippi and western Arkansas.

Why is this important and what does it mean for Memphis?

Prior to Dr. Weksler’s arrival, patients were either referred to private cardiothoracic surgery practices in Memphis, they went to larger cities with bigger academic centers or they unwittingly trusted their health to a non-specialty surgeon. Neither of those options were ideal, but now patients in the northern Mississippi delta – metro Memphis area can receive state-of-the-art, surgical excellence close to home. For some patients, this is a matter of life or death.

Now the program is growing; so much so, that Dr. Weksler has two full-time thoracic surgeons and is actively looking for a third. With the addition of the third surgeon, Dr. Weksler hopes to expand the UT program to serve local veterans at the Memphis VA.

MUH-UT-Exterior2015-340 — University of Tennessee affiliated – Methodist Hospital (official UT photo)

While Dr. Weksler doesn’t embrace the principles of uniportal surgery, his work on esophagectomies more than makes up for it. In fact, Dr. Weksler is one of the leading surgeons in the United States for minimally invasive esophagectomies. As discussed in previous posts, an experienced esophageal surgeon is critical for patient survival. (Bare Minimum competency for any esophageal surgeon is 25 cases a year – it’s not a surgery for your ‘average’ thoracic surgeon or any general surgeon).

Memphis’ newest secret weapon against cancer (too bad no one knows that he’s here)

In fact, his presence here in Memphis, among otherwise limited surgical services, is like finding a diamond while scavenging for supper in a metal dumpster in a hundred degree heat. In addition to being one of the foremost surgeons for esophageal disease (cancer and benign esophageal disease like achalasia), Dr. Weksler is also an experienced robotic surgeon.

As a newcomer to town, Dr. Weksler is having to re-build his practice volumes. As he explains, “We do about 30 esophagectomies a year, and I also see approximately 60 patients with esophageal cancer that cannot be operated on. 100% of our esophagectomies since I have been here were done minimally invasive”.

I can only speculate as a knowledgeable outsider that these surgical volumes reflect the lack of the general public and referring physicians knowledge about Dr. Weksler’s presence in the mid-south. Dr. Weksler is the type of surgeon that patients will travel across the country to see. My guess is that many of these potential patients are still traveling to Pittsburgh.

New ideas, new programs and new service lines

Dr. Weksler brings with him new ideas and new programs aimed at treating all Memphians. This includes community programs aimed at underserved and at-risk communities. One of these programs focuses on the diagnosis and treatment of lung cancer in African -American communities, which are disproportionately affected by advanced lung cancer, particularly in middle-aged males. By creating and implementing screening programs in these communities, Dr Weksler and his team are able to diagnose and treat lung cancers at earlier stages and improve patient survival. Despite being in its infancy, the program (which does not have a formal name) has screened over 100 patients and diagnosed eight cancers.

If you are a Memphis resident and would like information on this screening program or lung cancer screening: Contact the Lung Cancer Screening Navigator at Dr. Weksler’s office at 901-448- 2918.

Changing the art of Medicine & Surgery in Memphis

Dr. Weksler has been instrumental in creating at atmosphere of multidisciplinary collaboration. For example, programs have been streamlined and designed with patients in mind, to be the most effective, informative and efficient. This means that patients receive a “one stop shopping” experience as Dr. Weksler describes it. Patients are able to see their medical oncologist, thoracic surgeon and radiation oncologist on the same visit. All patients and their cases are presented at tumor board, to determine that treatment is individualized to the patient’s condition, functional status and tumor type which adhering to the clinical guidelines and evidence-based practice to optimize patient outcomes and long-term survival.

Q & A with Dr. Weksler – What patients should expect

Dr. Weksler talked to me at length about this multidisciplinary team approach as well as what patients should expect when they come to Methodist/ West Cancer center for care.

Question: What is the general process/ timeline for patient who has been referred to your clinic for evaluation?

Dr. Weksler: When patients come into the multidisciplinary clinic, patients / families with esophageal cancer will leave the office with a pretty good idea of what is going to happen. Depending on the work up done before they see me [which includes identification of tumor/ cancer staging], we will do the radiation therapy simulation the following
week, and start chemotherapy and/or radiation therapy the next week.

Question: What diagnostics/ medical records should they bring with them?

Dr. Weksler: We would like to see all available records, including previous surgeries, all scans, PET/ CT scans, barium esophagram, endoscopy report and all biopsy reports.

Question: What should patients anticipate? (will they get feeding tubes prior to surgery, etc)?

Dr Weksler: Most patients will get a port for chemotherapy*. We place feeding tubes in patients that loss more than 10% of their weight, or if they suffer from severe dysphagia. Patients can expect a 5 week course of chemotherapy and/or radiation therapy, followed by an interval of 6 to 8 weeks, followed by surgery.

*Editor’s note: A port is a long-term but temporary and completely removable central intravenous access for chemotherapy administration. It is placed underneath the skin with no cords, or lines visible externally. Feeding tubes are also temporary tubes that are easily removed/ reversible but help the patient to maintain adequate nutrition necessary for healing.

Dr. Benny Weksler, MD , Thoracic Surgeon

He has multiple offices including the West Cancer Center. For an appointment, please contact 901-448-2918.

Unfortunately, while Dr. Weksler and his thoracic surgery program are state-of-the-art, the Methodist website is not.

Additional references and resources (this is a selective list)

1. Oncologic efficacy is not compromised, and may be improved with minimally invasive esophagectomy.
Berger AC, Bloomenthal A, Weksler B, Evans N, Chojnacki KA, Yeo CJ, Rosato EL.
J Am Coll Surg. 2011 Apr;212(4):5606; discussion 5668. doi: 10.1016/j.jamcollsurg.2010.12.042. PMID: 21463789

2. Outcomes after minimally invasive esophagectomy: review of over 1000 patients.
Luketich JD, Pennathur A, Awais O, Levy RM, Keeley S, Shende M, Christie NA, Weksler B, Landreneau RJ, Abbas G, Schuchert MJ, Nason KS. Ann Surg. 2012 Jul;256(1):95103.
doi: 10.1097/SLA.0b013e3182590603. PMID: 22668811 Free PMC Article – attached. Recommended reading. If you are only going to read one article on MIE, this is a nice project looking at a large number of patients.

3. Major perioperative morbidity does not affect long-term survival in patients undergoing esophagectomy for cancer of the esophagus or gastroesophageal junction.
Xia BT, Rosato EL, Chojnacki KA, Crawford AG, Weksler B, Berger AC.
World J Surg. 2013 Feb;37(2):40815. doi: 10.1007/s0026801218236.
PMID: 23052816

4. The revised American Joint Committee on Cancer staging system (7th edition) improves prognostic stratification after minimally invasive esophagectomy for esophagogastric adenocarcinoma.
Zahoor H, Luketich JD, Weksler B, Winger DG, Christie NA, Levy RM, Gibson MK, Davison JM, Nason KS. Am J Surg. 2015 Oct;210(4):6107.
doi: 10.1016/j.amjsurg.2015.05.010. Epub 2015 Jun 26. PMID: 26188709

5. Minimally invasive esophagectomy in a 6 year-old girl for the sequelae of corrosive esophagitis.
Majors J, Zhuge Y, Eubanks JW 3rd, Weksler B.
J Thorac Cardiovasc Surg. 2016 Jun 22. pii: S00225223(
16)305657. doi: 10.1016/j.jtcvs.2016.06.011. [Epub ahead of print] No abstract available.
PMID: 27406439

Dental hygeine and post-operative pneumonia in esophageal cancer patients

In an investigational study, Akutsu et. al. (2010) demonstrated a significant reduction in post-operative pneumonia through the implementation of a dental hygiene program.

A Japanese study suggests that one of the most important ways to reduce post-operative risk is also the easiest – by practicing good dental hygiene. While research has previously linked coronary artery disease (CAD) with dental plaque and chronic gum inflammation – two articles by Akutsu et. al (2010) in Japan have shown a reduction in post-operative pneumonia in esophageal cancer patients through the use of dental hygiene regimens.

The first of these articles in an overview of several factors to reduce post-operative risk, and was previously mentioned in another post:

Akutsu, Y. & Matsubara, H. (2009) Perioperative Management for the Prevention of Postoperative Pneumonia with Esophageal Surgery. Ann Thorac Cardiovasc Surg. 2009 Oct;15(5):280-5. (free full text). This is a well written report by Japanese surgeons on several techniques to reduce post-operative pneumonia. Several of these items can be directly implemented by patients – such as pre-operative smoking cessation, pulmonary rehabilitation and good dental hygiene.

The second article, “Pre-operative dental brushing can reduce the risk of post-operative pneumonia in esophageal cancer patients” was published in Surgery (2010, Apr; 147(4) 497-502.) The authors conducted an investigational study using 86 thoracic surgery patients scheduled to undergo esophagectomy. A control group of 41 patients and the dental hygiene (treatment) group consisting of 45 patients.

The dental hygiene group underwent no special dental procedures or cleanings but were instructed to brush their teeth five times a day.

The results showed a dramatic decrease in the incidence of post-operative pneumonia in the treatment group. 32% of the control group developed pneumonia post-operatively compared to only 9% of the toothbrushing group. 12% of the patients in the control group required tracheostomy due to the development of pneumonia (and prolonged respiratory support). No members of the treatment group required tracheostomy.

While the study size is relatively small – the results show an impressive reduction in post-operative pneumonia for a fairly small investment (increased tooth brushing/ dental hygiene.)

Esophageal surgery and esophageal surgery centers

Discussion of article by Bilimoria and the importance of high volume esophageal surgery programs for successful post-operative outcomes.

Here’s another study highlighting the importance of having esophagectomies (esophageal surgery) at high volume centers. It’s a topic we’ve talked about before, and as it’s something I feel very strongly about – something readers will probably see mentioned again. It also helps answer the question – “Do I need to travel to X for surgery or can I have it at the local hospital?” This was the main questions the researchers were looking at for this study in terms of costs, logistics and burdens on patient and family.

This article by Bilimoria et. al (2010), published in the Annals of Surgery, was actually comparing outcomes for multiple surgery types at small community hospital versus large specialty center, not just thoracic surgeries but the research findings are similar to what we have reported previously. The irony of this study is that the researchers were expressly trying to prove the opposite, that small hospitals are safe for high complexity, high morbidity/ mortality operations – as a way to cut costs, and save money by preventing additional patient shifting to larger institutions that may be at a considerable distance for patients. They demonstrated limited success in their results for other surgeries – but the need for high volume esophagectomy programs for successful surgical outcomes remains unchanged. (Some of this may be due to the fact that many of these esophagectomies at smaller hospitals are performed by general, not thoracic surgeons.)

The answer for patients with esophageal cancer is: Yes – you do need to go to the esophageal cancer center (not your local community hospital). This is regardless of classification of low or high risk (which is based on age, and a Charlson score – which is a score used to add up other risk factors). This is something I have had to address with patients in my own personal practice as both a referring provider (at a smaller facility) and as a receiving provider (when I was at a larger esophageal surgery center.)

I’ve reposted the abstract below, so you can read for yourself. (The article itself is several pages long). [Italics are mine..]

Bilimoria, et. al. (2010). Risk-based Selective Referral for Cancer Surgery: A Potential Strategy to Improve Perioperative Outcomes Annals of Surgery. 2010;251(4):708-716.

Abstract

Background: Studies have demonstrated volume-outcome relationships for numerous operations, providing an impetus for regionalization; however, volume-based regionalization may not be feasible or necessary. Our objective was to determine if low-risk patients undergoing surgery at Community Hospitals have perioperative mortality rates comparable with Specialized Centers.

Methods: From the National Cancer Data Base, 940,718 patients from ~1430 hospitals were identified who underwent resection for 1 of 15 cancers (2003–2005). Patients were stratified by preoperative risk according to age and comorbidities. Separately for each cancer, regression modeling stratified by high- and low-risk groups was used to compare 60-day mortality at Specialized Centers (National Cancer Institute-designated and/or highest-volume quintile institutions), Other Academic Institutions (lower-volume, non-National Cancer Institute), and Community Hospitals.

Results: Low-risk patients had statistically similar perioperative mortality rates at Specialized Centers and Community Hospitals for 13 of 15 operations. High-risk patients had significantly lower perioperative mortality rates at Specialized Centers compared with Community Hospitals for 9 of 15 cancers. Regardless of risk group, perioperative mortality rates were significantly lower for pancreatectomy and esophagectomy at Specialized Centers. Risk-based referral compared with volume-based regionalization of most patients would require fewer patients to change to Specialized Centers.

Conclusions: Perioperative mortality for low-risk patients was comparable at Specialized Centers and Community Hospitals for all cancers except esophageal and pancreatic, thus questioning volume-based regionalization of all patients. Rather, only high-risk patients may need to change hospitals. Mortality rates could be reduced if factors at Specialized Centers resulting in better outcomes for high-risk patients can be identified and transferred to other hospitals.

Only TIME will tell: Esophagectomy

There is a new trial on the horizon that sounds promising; the Traditional Invasive versus Minimally Invasive Esophagectomy (TIME). It’s a timely study indeed as the rates of esophageal cancer in western countries continues to increase, due to GERD and obesity.

I really don’t like the ‘cutesy’ way research trials have been named for the last ten years or so – but in this case – I will just have to look past it. There is a new trial on the horizon that sounds promising; the Traditional Invasive versus Minimally Invasive Esophagectomy (TIME) trial based in the Netherlands. It is a multi-center trial taking place at six hospitals in Europe. This trial will compare both morbidity and mortality in patients undergoing traditional esophagectomy (Ivor Lewis) and patients undergoing minimally – invasive (thoracoscopy combined with laparoscopy) after both sets of patients receive adjuvant chemotherapy. (This approach differs from the transhiatal esophagectomy developed at the University of Michigan in the 1970’s).

The researchers are planning for a five-year follow-up to compare both immediate post-operative complications / mortality with long-term effects (QoL) and cancer recurrence.

The full article is detailed on Medscape. (Also published in BMC Surgery. 2011;11 ). This couldn’t come at a more appropriate time, with recent data showing an abrupt rise in the incidence of esophageal cancer.

In an article (Chustecka) dated from September 2010, British researchers at Cancer Research UK reported a 50% increase in diagnoses of esophageal cancer in the last 25 years, particularly in men in their 50’s. (with an incidence of 14.4 men per 100,000, to put it into perspective, up from 9.9 in 1983.)

More concerning, is the fact that the prevalence of the types of cancer are changing. Previously, the majority of esophageal cancers were caused by squamous cell carcinoma which is linked to smoking and alcohol use. This study, along with an American study, shows an increasing incidence of adenocarcinoma, which is more commonly attributable to gastroesophageal reflux (Barrett’s esophagus). Researchers (Dr. Mark Orringer) estimate that the incidence of adenocarcinoma of the esophagus has increased by 350% in the last thirty years – and is directly related to huge increases in obesity. It now accounts for over 85% of esophageal cancers in the USA.

We’ll bring you more as the trial continues, and preliminary results are reported.

(Dr. Mark Orringer, who was quoted in the original medscape article from 2007 is one of several pioneering surgeons in thoracic surgery. He invented two of the surgical techniques in use today; the aforementioned transhiatal esophagectomy and the Collis -Nissen hiatal hernia repair.)