Talking with Dr. Daniela Molena

at John Hopkins, talking with Dr. Daniela Molena about minimally invasive thoracic surgery.

Baltimore, Maryland

John Hopkin’s newest recruit to the Department of Thoracic Surgery, Dr. Daniela Molena is a bright point in the future of thoracic surgery.  While she has only been at Hopkins for a few short months (since September) she is already innovating and bringing positive changes to the institution.  In fact, there is too much to say about this fascinating and charming surgeon in just one article.

A practicing general surgeon in her native Italy, Dr. Molena rapidly became interested and proficient in the surgical treatment of benign esophageal diseases.  As a specialist in diseases of the esophagus, she has extensive training in both gastrointestinal and thoracic surgery.    Pursuit of this education brought her to the United States.

Once here, Dr. Molena took advantage of the opportunities to train with some of the most renown surgeons in the country; with Dr Marco Patti in San Francisco, with Dr Peters Jeffrey in Rochester, Memorial Sloan Kettering Cancer Center in NY with Dr Rusch Valerie and  Dr. James Luketich at the University of Pittsburgh Medical Center, and now here at John Hopkins with Dr. Stephen Yang.  She believes this gave her a better appreciation for all the different techniques and schools of though in thoracic surgery.  “I don’t just use a specific surgeon’s approach, I can use the best I have learnt from each mentor  and apply it to best fit the individual patient and their needs.”

Once she arrived here, she hit the ground running; gathering research on esophageal surgery; starting a lung cancer screening program for some of Baltimore’s more poverty-stricken communities, arranging for patient outreach sessions for cancer patients, working with Dr. Avo Meneshian’s robot-assisted thoracic surgery (RATS) program at the John Hopkins Bayview facility, and quickly advancing, promoting and heading a new program for minimally invasive esophageal surgery (including minimally invasive esophagectomy (MIE) for esophageal cancer).  She favors the Ivor-Lewis style procedure but performs it via thoracoscopy and laparoscopic approaches.  She thinks it is important to stress that minimally invasive surgery is just the approach or the tool to gain access to the chest to complete a surgical procedure.  Thus, a minimally invasive procedure does not mean a lesser or inferior resection.  “It’s how we get in – once we get in [to the chest], we can do whatever surgery is needed, respecting oncologic principles.”

While the MIE program is young, Dr. Daniela Molena hopes to grow this program with time, as part of a multi-disciplinary program for esophageal cancer patients. This holistic approach which combines diagnosticians, oncologists, dietitians, nutritionists, nurses, and surgeons is also an immensely practical one.  This multi-specialty clinic ensures that the patient/ and their family is able to meet with, consult with and work collaboratively with all of these specialties to determine their course of treatment on the same day during a single trip.  This alleviates much of the financial and transportation hardships experienced by many of the families travelling from around the country (and around the world[1]) for treatment at John Hopkins.

Dr. Molena takes this holistic approach to thoracic disease very seriously.  As she explains, “Even benign (non-cancerous) esophageal diseases are terrible for patients and their families.  They have to learn to adapt and accept that even with treatment, life may never be the same”.  She feels that it is essential that we speak to patients openly, and honestly and set realistic expectations, stating “People, especially our patients, are remarkably resilient if we communicate clearly with them during this process.” She also feels that as a surgeon she is here to do more for her patients that operate, that it’s not just about cutting.  She is here to help patients (and their loved ones) find all the resources they need to regain optimal health and promote wellness.  “It is more than just surviving the surgery.  It’s about health & wellness,” she finishes.

It’s a strong, profound statement and a reminder for surgery but one that reflects the thoughts and feelings of many of the wonderful thoracic surgeons I have met, interviewed or worked with.  But in Medicine, with many of it’s rigid definitions and delineations; too often the surgeons themselves, their motivations, and their desire to heal gets lost among the surgeries, and the procedures.

More about Dr. Daniela Molena

John Hopkins – Department of Thoracic Surgery, Surgeon profile

Medical School: Faculty of Medicine University of Padova (Padova Italy)
(1996)

General Surgery residencies:

University of Rochester Medical Center (Rochester NY) – General Surgery (2009)

Faculty of Medicine University of Padova (Padova Italy) – General Surgery (2001)

Faculty of Medicine University of Padova (Padova Italy) – General Surgery (1999)

Fellowships:

Memorial Sloan-Kettering Cancer Center (New York NY) – Cardiothoracic Surgery (2011)

University of Pittsburgh Medical Center (Pittsburgh PA) – Cardiothoracic Surgery (2010)

New York Presybterian Hospital (New York NY) – Cardiothoracic Surgery (2011)

Memorial Sloan-Kettering Cancer (New York NY) – Cardiothoracic Surgery (2009)

Universita Degli Studi di Padova (Padova Italy) – Minimally Invasive Surgery (2002)

[1] John Hopkins has a separate department called the International Patient Center which is devoted to detangling and simplifying the health care process for overseas patients.

Contact Information:

The Johns Hopkins Hospital

600 N. Wolfe Street

Baltimore, MD 21287

Phone: 410-614-3891

Appointment Phone: 410-933-1233

Selected publications

Dubecz A, Molena D, Peters JH.  Modern surgery for esophageal cancer.  Gastroenterol Clin North Am. 2008 Dec;37(4):965-87, xi. Review.

Zaninotto G, Annese V, Costantini M, Del Genio A, Costantino M, Epifani M, Gatto G, D’onofrio V, Benini L, Contini S, Molena D, Battaglia G, Tardio B, Andriulli A, Ancona E.  Randomized controlled trial of botulinum toxin versus laparoscopic heller myotomy for esophageal achalasia. Ann Surg. 2004 Mar;239(3):364-70.

Zaninotto G, Costantini M, Portale G, Battaglia G, Molena D, Carta A, Costantino M, Nicoletti L, Ancona E. Etiology, diagnosis, and treatment of failures after laparoscopic Heller myotomy for achalasia.  Ann Surg. 2002 Feb;235(2):186-92.

Patti MG, Molena D, Fisichella PM, Whang K, Yamada H, Perretta S, Way LW.  Laparoscopic Heller myotomy and Dor fundoplication for achalasia: analysis of successes and failures.  Arch Surg. 2001 Aug;136(8):870-7.

Williams VA, Watson TJ, Gellersen O, Feuerlein S, Molena D, Sillin LF, Jones C, Peters JH.  Gastrectomy as a remedial operation for failed fundoplication.  J Gastrointest Surg. 2007 Jan;11(1):29-35. [no free full-text available].

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.