Outcomes After Minimally Invasive Esophagectomy :

Background—Esophagectomy is a complex operation and is associated with significant morbidity and mortality. In an attempt to lower morbidity, we have adopted a minimally invasive approach to esophagectomy. Objectives—Our primary objective was to evaluate the outcomes of minimally invasive esophagectomy (MIE) in a large group of patients. Our secondary objective was to compare the modified McKeown minimally invasive approach (videothoracoscopic surgery, laparoscopy, neck anastomosis [MIE-neck]) with our current approach, a modified Ivor Lewis approach (laparoscopy, videothoracoscopic surgery, chest anastomosis [MIE-chest]). Methods—We reviewed 1033 consecutive patients undergoing MIE. Elective operation was performed on 1011 patients; 22 patients with nonelective operations were excluded. Patients were stratified by surgical approach and perioperative outcomes analyzed. The primary endpoint studied was 30-day mortality. Results—The MIE-neck was performed in 481 (48%) and MIE-Ivor Lewis in 530 (52%). Patients undergoing MIE-Ivor Lewis were operated in the current era. The median number of lymph nodes resected was 21. The operative mortality was 1.68%. Median length of stay (8 days) and ICU stay (2 days) were similar between the 2 approaches. Mortality rate was 0.9%, and recurrent nerve injury was less frequent in the Ivor Lewis MIE group (P < 0.001). Conclusions—MIE in our center resulted in acceptable lymph node resection, postoperative outcomes, and low mortality using either an MIE-neck or an MIE-chest approach. The MIE Ivor Lewis approach was associated with reduced recurrent laryngeal nerve injury and mortality of 0.9% and is now our preferred approach. Minimally invasive esophagectomy can be performed safely, with good results in an experienced center. © 2012 by Lippincott Williams & Wilkins Reprints: James D. Luketich, MD, Department of Cardiothoracic Surgery, University of Pittsburgh, 200 Lothrop St, C800 PUH, Pittsburgh, PA 15213. [email protected]. Disclosure: The authors declare no conflicts of interest. Presented at American Surgical Association, 131st Annual Meeting, April 14–16, 2011, at Boca Raton, Florida. NIH Public Access Author Manuscript Ann Surg. Author manuscript; available in PMC 2014 July 18. Published in final edited form as: Ann Surg. 2012 July ; 256(1): 95–103. doi:10.1097/SLA.0b013e3182590603. N IH -P A A uhor M anscript N IH -P A A uhor M anscript N IH -P A A uhor M anscript The incidence of esophageal cancer has been increasing over the past 3 decades.1,2 In the United States and the western world, this profound increase has been due to an increase in the incidence of adenocarcinoma of the esophagus. This major epidemiologic shift is thought to be related to gastroesophageal reflux disease, obesity, and Barrett’s esophagus, the dominant risk factors for esophageal adenocarcinoma.1, 2 Outcomes after diagnosis of esophageal cancer are suboptimal, with a 5-year survival rate of 15% to 25%, although an improvement in survival, associated with early-stage disease, was seen in recent surgical series.1–3 Esophagectomy is a primary curative modality for localized esophageal cancer. However, esophagectomy is a complex operation and the mortality of esophageal resection has been significant. Birkmeyer and colleagues4 reported that the mortality of esophagectomy ranged from 8% to 23% in the United States and depended on the hospital volume. The morbidity associated with esophagectomy has raised concerns about the procedure and referral for esophagectomy. This is becoming increasingly important with an emerging interest in nonsurgical options for early-stage disease, such as endomucosal resection, endoscopic ablative strategies such as photodynamic therapy, and for more advanced disease, definitive chemoradiation.3 Frequently, due consideration for surgical resection may not be given because of concerns with regard to the morbidity of open esophagectomy. If we can safely accomplish esophageal resection with a less-invasive approach, this could provide an effective treatment modality—esophagectomy with lesser morbidity for both early-stage disease and for patients with more locally advanced stages, who might be candidates for a lower morbidity resection option. In an effort to decrease the morbidity associated with esophagectomy, we and others have adopted a minimally invasive approach to esophageal resection.5–8 Over the last 2 decades, minimally invasive approaches have been described for the performance of several surgical procedures for the treatment of both benign and malignant diseases.9–12 With the introduction of laparoscopic fundoplication by Dallemagne and coworkers13 in 1991, several esophageal diseases, such as achalasia, paraesophageal hernias, and redo antireflux surgery, have been treated with minimally invasive approaches.9–11,13 A minimally invasive approach to esophagectomy was originally described by Cuschieri et al14 and DePaula et al.15 Since then, MIE has been performed with increasing frequency.5–8,16,17 We had originally adopted a modified McKeown 3-incision MIE and more recently transitioned to a minimally invasive Ivor Lewis approach.5,7 The primary objective of this study was to evaluate the outcomes after MIE with a focus on perioperative outcomes in a large group of patients. Our secondary objective was to do a preliminary comparison of the results between the modified McKeown MIE and our current approach, a modified Ivor Lewis MIE. PATIENTS AND METHODS