Minimally Invasive Esophagectomy in the Community Hospital Setting

Open esophagectomy techniques

The 3 most commonly performed open esophagectomy procedures are the transhiatal esophagectomy, transthoracic (Ivor Lewis) esophagectomy, and the 3-stage (McKeown) esophagectomy. All 3 operations begin with a midline laparotomy for mobilization of the stomach and formation of a gastric conduit. A transhiatal esophagectomy uses a cervical incision to mobilize the cervical esophagus. The thoracic esophagus is then mobilized by blunt dissection from the abdominal and cervical incisions. The gastric

Minimally invasive esophagectomy techniques

Increasing experience with laparoscopic surgery in the 1990s led to the development of MIE techniques. The precursor to this was the thoracoscopic mobilization of the esophagus in 1992 by Cuschieri and colleagues.² Later work by Dallemagne³ combined laparoscopic and thoracoscopic resection of esophageal cancer, which led to the current techniques used in MIE. In modern practice, the 3 most frequently performed procedures for MIE include the thoracoscopic/laparoscopic esophagectomy with a

Minimally invasive versus open esophagectomy

To date, no randomized trials have compared outcomes of esophageal resection using a minimally invasive approach with open esophagectomy.⁴ Several nonrandomized comparative reports have been published, which have generally compared the two techniques with the same institution, often using historical experience within open esophagectomy. A meta-analysis of 12 comparative reports encompassing 672 MIEs and 612 open esophagectomies found shorter hospital stay, less blood loss, and fewer

Operative technique

The operative technique used for a minimally invasive Ivor Lewis esophagectomy at Carolinas Medical Center is performed in 2 phases, beginning with laparoscopic mobilization of the stomach and dissection of the mediastinum from the abdomen. The technique is similar to that described by Bizekis and colleagues.⁸ The operation is conducted by 2 surgical teams including fellows and residents, each led by an attending thoracic surgeon and gastrointestinal surgical oncologist.

Postoperative care

All patients are admitted to the surgical intensive care unit for postoperative monitoring, where they are cared for in coordination with a group of surgical intensivists who provide around-the-clock coverage. Central venous and arterial lines are placed by anesthesia before the operation and are used for invasive hemodynamic monitoring in the postoperative period. Swan-Ganz catheters are not routinely placed for monitoring purposes. To a varying degree patients are left intubated in the

Outcomes

A total of 32 patients underwent some variant of MIE. Two patients early in the authors’ experience underwent a hybrid procedure with laparoscopic mobilization of the stomach followed by thoracotomy. Transthoracic Ivor Lewis esophagectomy with laparoscopy and thoracoscopy were performed in 28. A 3-phase esophagectomy was performed in 1 patient and laparoscopic transhiatal esophagectomy in 1. Indications for operation were adenocarcinoma in 27 patients, squamous cell carcinoma in 3, and benign

Discussion

For a community cancer center, the decision to establish a program in complex gastrointestinal surgery such as esophageal resection is one that must weigh the demand for services of an uncommon neoplasm with an assessment of the available resources. The resources available in a community cancer center will also need to be assessed relative to the availability of esophageal cancer services at referral institutions, which may treat a larger volume of cases. Particularly with cancers of lower

Summary

The authors’ current average volume of 13 esophageal resections per year could best be characterized as moderate to high. This average annual volume is certainly less than some centers, but is also greater than many of the suggested volume thresholds, including that set by the Leapfrog group. Data from the National Inpatient Sample would suggest at as of 2006, only 12.4% of hospitals had esophagectomy volumes greater than 13 per year.³⁵

Although the series is small, outcomes of mortality and