MIE – 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

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 esophagectomy. Interactive 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 experience. Isr 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 cancer. J 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 resection. Eur 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.