Esophagectomy: Modern surgical approaches

A brief discussion of the variety of surgical approaches used for esophagectomy for esophageal cancer including Ivor Lewis, Transhiatal and minimally invasive techniques.

An esophagectomy is surgical resection of the esophagus.  If this includes the upper portion of the stomach (for cancers in the distal third) it is sometimes called an esophagogastrectomy.  This procedure is often performed as part of treatment for early stage esophageal cancers.  This procedure is technically challenging and requires advanced surgical skill and training in esophageal surgery.  The general consensus among surgeons and published literature is that a surgeon needs to perform a minimum of 12- 25 esophagectomies per year to maintain proficiency.

Who does the most esophageal surgeries in the USA?  The University of Pittsburgh (UPMC) and Dr. Benny Weksler*.

There are several surgical approaches for this procedure, and the “best” approach is a topic that is widely debated among thoracic surgeons.  As technology continues to advance, and newer techniques emerge, esophagectomy/ esophagogastrectomy continues to evolve.

Ivor Lewis Esophagectomy

The Ivor Lewis esophagectomy or the transthoracic approach is considered the ‘Gold standard’ among many thoracic surgeons.  Named for the surgeon that popularized this approach in 1946, this surgical procedure is actually a combination of two separate surgical procedures – a laparotomy incision to allow for mobilization of the stomach, and a right-sided thoracotomy for excision and resection of the esophagus.  In the modified approach discussed by David & Marshall (2010), the need for patient repositioning in eliminated, allowing for a faster, more efficient operation without sacrificing visibility or accessibility for lymph node dissection.  (During the standard approach – the patient is re-positioned after the laparotomy portion of the operation is complete.)

The Ivor Lewis is often considered superior to other techniques for esophageal cancer because the open laparotomy allows for good abdominal exposure for wider lymph node dissection.  This examination of the abdomen and abdominal lymph nodes is critical for the detection of more widespread (or metastatic disease.) In fact, if metastatic disease is detected during this portion of the operation, most surgeons will abandon the procedure*.

* The presence of metastatic disease drastically changes longevity outcomes, and makes esophagectomy ineffective for cancer treatment.

The main disadvantage is that the Ivor Lewis approach is a big operation (actually two operations) and carries the complications of both a large abdominal operation and a large thoracic procedure (with a thoracotomy.)  One of these complications is increased pain.  In addition to being burdensome for the patient to endure, the increased pain leads to increased pneumonias, respiratory and other complications due to ineffective pulmonary toileting and limited mobility secondary to this discomfort.)

This procedure is contraindicated in patients who have undergone a previous thoracotomy (due to adhesions).  As alluded to above, all surgical resections (Ivor Lewis, Transhiatal and other approaches) are contraindicated in patients with evidence of metastatic disease.

Cerfolio, R. J., Bryant, A. S., Bass, C. S., Alexander, J. R. & Bartolucci, A. A. (2004). Fast tracking after Ivor Lewis esophagogastrectomy.  Chest 2004 Oct; 126 (4) 1187 – 94.  As the article explains – another advantage of high volume centers is fast-tracking after surgery for a day seven (POD#7) discharge.  This also promotes standardization of care which is essential in teaching facilities and other healthcare centers with residents/ students/ frequent staff turnover.

Crofts, T. J. (2000). Ivor Lewis esophagectomy for middle and lower third esophageal lesions – how we do it.  J. R. Coll Surg Edinb. 45 Ocotober 2000, 296 – 303.  Excellent article with overview of Ivor Lewis procedure.  Link in text above.

David, E. A., & Marshall, M. B. (2010).  Modifications to Ivor Lewis esophagectomyInteractive CardioVascular and Thoracic Surgery 11 (2010) 529 – 531.

Transhiatal esophagectomy

The transhiatal approach was first discussed in the literature in 1933, but fell out of favor for a number of years before making a resurgence in the 1970’s.

In the transhiatal approach, the surgeon still makes two separate incisions – one in the anterior cervical area (neck) and a laparotomy for mobilization of the stomach.  The main advantage to this approach is the avoidance of a thoracostomy incision, and a shorter duration of the operation.  (The use of a thoracotomy incision is believed to increase the risk of post-operative pulmonary complications).  The other advantages of the transhiatal approach are less pain (thoracotomy incision is more painful than cervical approach).  This approach also eliminates the possibility of mediastinitis from an anastamotic leak since the anastamosis is not in the thoracic cavity.

However, detractors of this procedure cite the difficulties due to poor visualization of the esophageal tumors during the operation, the increased rate of anastamosis leak and development of post-operative strictures (Barreto & Posner, 2010).

Bareto, J. C., & Posner, M. C. (2010). Transhiatal versus transthoracic esophagectomy for esophageal cancer. World Journal of Gastroenterology 2010 Aug 14; 16 (30) 3804 – 3810.

Pines, G., Klein, Y., Metzer, E., Idelevich, E., Buyeviv, V., et. al (2011).  One hundred transhiatal esophagectomies: a single institution experienceIsr Med Assoc J. 2011 Jul; 13 (7) 428 – 33.

Minimally invasive esophagectomy

Currently, there are several large randomized studies comparing newer surgical techniques with the Ivor Lewis esophagectomy.  The MIRO trial and the TIME trials are on-going. (Enrollment in both of these trials are on-going with more information for interested patients available at clinicaltrials.gov).

There are multiple varieties of approaches for ‘minimally invasive’ esophageal surgery.  These procedures are Ivor Lewis or Transhiatal approaches that have been modified by the use of laparoscopic equipment (for the abdominal portion) or thoracoscopic equipment for the transthoracic or transhiatal portion, or a combination of the above.  Robot-assisted technologies have also been used in modified approaches to reduce incision size, (thus post-operative pain/ pulmonary complications.)  A recent study by Dr. Luketich showed favorable outcomes in a large series of patients undergoing minimally-invasive procedures (link to article abstract below.)

Akiyama, S., Kodera, Y., Koike, M., Kasai, Y., et al. (2001). Small incisional esophagectomy with endoscopic assistance: evaluation of a new technique. Surgery Today, 31 (4) 378 – 382.  [no free full text available.] Description of the ‘Akiyama’ approach.

Gao, Y., Wang, Y., Chen, L. & Zhao, Y. (2011). Comparison of open three-field and minimally invasive esophagectomy for esophageal cancer.  Interact CardioVasc Thorac Surg 2011, 12: 366 – 369.  I would have to argue against the authors contention that the McKeown approach is the preferred open surgical technique of most thoracic surgeons.  (The McKeown is a modification of the Ivor Lewis).  Surgeons: Care to comment?

Herbella, F. A., & Patti, M. G. (2010). Minimally invasive esophagectomy.  World Journal of Gastroenterology,2010 Aug 14; 16 (30) 3811 – 3815.

Jarral, O. A., Purkayastha, S., Athanasiou, T., & Zacharakis, E. (2011).  Should thoracoscopic three-stage esophagectomy be performed in the prone or left lateral decubitus position?  Interact Cardiovasc Thorac Surg 2011, Jul 13 (1) 60 – 5.  A review of the literature surrounding patient positioning for esophagectomy.

James D Luketich, MD, Omar Awais, DO*, Manisha Shende, MD*, Neil A Christie, MD*, Benny Weksler, MD*, Rodney J Landreneau, MD, Blair A Jobe, MD*, Ghulam Abbas, MD*, Arjun Pennathur, MD*, Matthew J Schuchert, MD*, Katie S Nason, MD, MPH*
University of Pittsburgh, Pittsburgh, PA    Outcomes after minimally invasive esophagectomy. Presented at the 131 annual meeting of the American Surgical Association, April 14th – 16th, 2011 in Boca Raton, Fla.

We, B., Xue, L., Qiu, M., Zheng, X., Zhong, L., Qin, X., & Xu, Z. (2010). Video-assisted mediastinoscopic transhiatal esophagectomy combined with laparoscopy for esophageal cancerJ Cardiothorac Surg 2010 Dec 31; 5, 132.  Report of forty cases using combined minimally invasive techniques for better visualization and mediastinal lymph node dissection.

Additional References:

More about esophagectomies  – a short promotional video by Mayo Clinic.  [Nicely illustrated.]

Dumont, P., Wihlm, J. M., Hentz, J. G., Roeslin, N., Lion, R., & Morand, G. (1995).  Respiratory complications after surgical treatment of esophageal cancer: a study of 309 patients according to the type of resectionEur J Cardiothorac Surg 1995; 9 (10) 539 – 43. Comparison of Ivor Lewis and the Akiyama procedure.

Kim et al. (2001).  Esophageal resection: Indications, techniques, and radiologic assessment.  Radiographics, Sept 2001, 21 (5): 1119 – 1137.  See table 1 for summary of surgical techniques and outcomes.

Suttie, S. A., Li, A. G. K., Quinn, M., & Park, K. G. M. (2007).  The impact of operative approach on outcome of surgery for gastro-oesophageal tumours.  World Journal of Surgical Oncology. 2007; 5: 95.  Comparison of Ivor Lewis, transhiatal and left thoraco-laparotomy approaches.

*Update:  Dr. Benny Weksler is now at the University of Tennessee, Memphis.

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.)