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Minimally Invasive Esophagectomy

Minimally Invasive Esophagectomy. Dmitry Oleynikov M.D. Professor of Surgery Joseph and Richard Still Faculty Fellow in Medicine Director of Minimally Invasive And Computer Assisted Surgery University Of Nebraska School Of Medicine. Esophageal Cancer. Endoscopic diagnosis

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Minimally Invasive Esophagectomy

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  1. Minimally Invasive Esophagectomy Dmitry Oleynikov M.D. Professor of SurgeryJoseph and Richard Still Faculty Fellow in MedicineDirector of Minimally Invasive AndComputer Assisted Surgery University Of Nebraska School Of Medicine

  2. Esophageal Cancer

  3. Endoscopic diagnosis Barretts adeno CA EUS + PET/CT Stage I Stage II Stage IIIA Stage IIIB Stage IV and Barretts HGD Laparoscopic staging U/S, node dissection, Left gastric division Feeding jejunostomy Chemo/rad or palliation Intraoperative Staging/ Laparoscopic resection Stage IV Stage IIIA, IIIB Stage II, IIIA Laparoscopic Or Open resection Neoadjuvant Chemo/radiation

  4. Laparoscopic esophagectomy: 2 options • Totally laparoscopic techniques: • laparoscopic transhiatalesophagectomy (DePaula, Swanstrom, Sadanaga, Jagot, Yahata) • Laparoscopic/thoracoscopic technique (Cuscieri, Luketich, Dellemagne, Watson)

  5. Survival after open esophagectomy

  6. Background:esophagectomy patients • Perioperative complications in 58% * • Perioperative mortality is 4% * • Mean length of stay 13.7 days** • 31% of patients require post hospital care** * Finley, AM J Surg, 1995 ** OR state tumor registry, 1998

  7. Expected advantages of laparoscopy • Accurate staging • Minimally invasive determination of resectability • Decreased tissue trauma • less pain • less pulmonary compromise • Decreased need for critical care / hospital care • A more rapid return to normal life

  8. Theoretical advantages: • Better node dissection • Less tumor manipulation • Preservation of host immune response • lower blood loss • quicker enteral feedings • less inflammatory mediator release • Quicker application of adjuvant therapy • Psychological impact

  9. Alternative Therapies: • Chemo / radiation • Photoablation • Cryotherapy • Endoscopic Mucosal Stripping • Full thickness endoscopic resection • Laparoscopic / thoracoscopic esophagectomy

  10. Survival after open esophagectomy “Results of 100 radical en bloc resections for adenocarcinoma” Hagen JA et al. Ann Surg 2001 • A radical lymphadnectomy was used on a series of resectable cancer pts • 5 year survival = 54% • Local recurrence rate <8% *68% major morbidity

  11. Benefit of Laparoscopy / Thoracoscopy • General • Less pain • Shorter LOS/recovery • Better view • Benign disease • Increasing volumes of end stage disease • Increasing comfort and reliance on MI approaches • Lower morbidity / mortality

  12. Benefit of Laparoscopy / Thoracoscopy Cancer • Better staging • Better residual QOL • Less frightening to patient and their physicians • Earlier start to adjuvant therapy and nutrition • Decreased immunosuppression • Potential for improved cure rates

  13. Staging / Determining Resectability: • Laparoscopic/ thoracoscopic staging is accurate • 94% correlation with operative pathology* • It is the best method, short of laparotomy, to determine resectability • 30% (6/20) positive nodes in imaging negative patients* * Krasna; 1995, 1998.

  14. Transhiatal Esophagectomy • No need to reposition • Easier anesthesia (no epidural, no double lumen ET tube) • Faster?

  15. Intra-abdominal Ports

  16. Creation of Gastric Tube

  17. Thoracoscopic Ports

  18. Cervical Anastamosis

  19. Mediastinal Dissection

  20. Antireflux Mechanism

  21. To surgery floor Gastrografin swallow POD 2 Tube feeds POD2 D/C abd drain POD3 Pureed diet POD 3 Remove neck drain when goes home Postoperative Care:

  22. Review of outcomes for Minimally Invasive esophagectomy • This study evaluated 104 MIS for malignant and benign esophageal diseases between 1998 – 2007 • 3 patients required conversion to laparotomy, median ICU & hospital stays were 2 & 8 days respectively. • Major complications in 12.5% pts. Minor complications in 15.4%pts. • Incidence of leak was 9.6% and anastomotic stricture was 26%. • 30 day mortality was 1.9% and in hospital mortality 2.9% Nguyen 2008

  23. Endoscopic therapies in T1 esophageal cancers • Wsophagectomy is the standard treatment for T1 esophageal cancers with good long term results • Many patients with T1 EC have several risk factors that preclude treatment with endoscopic therapy • Many prospective studies needed to evaluate endoscopic therapies until then esophagectomy should remain the standard treatment in patients with T1 EC. Pennathur A 2009

  24. Open versus minimally invasive esophagectomy: a single-center case controlled study • Case controlled pair-matched study conducted comparing 62 patients who had undergone either minimally invasive (MIE) or open esophagectomy (OE) between 2004 and 2007 • Surgical morbidity, transfusion rate and the rate of post operative respiratory complications were significantly lower in the MIE group • The ICU and hospital stay were also significantly lower in the MIE group. Schoppmann SF 2010

  25. Conclusion: • Open esophagectomy with en bloc lymphadenectomy may provide the best surgical cure rate for resectable esophageal cancer • These results can be replicated by the thoracoscopic / laparoscopic approach • Laparoscopic esophagectomy offers theoretical potential for improved outcomes, possibly even improved survival for esophageal cancer patients and is an excellent technique for benign disease • Currently, the technical difficulty of laparoscopic esophagectomy make it less likely to be widely applied outside of tertiary referral centers.

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