Minimally Invasive Esophagectomy- Valuable. Jayer Chung, MD University of Colorado Health Sciences Center December 11, 2006

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1 Minimally Invasive Esophagectomy- Valuable Jayer Chung, MD University of Colorado Health Sciences Center December 11, 2006

2 Overview Esophageal carcinoma What is minimally invasive esophagectomy (MIE)? Oncologic comparisons Lymph node clearance Resection to negative margins Tumor-free survival Overall survival Operative & peri-operative details Postoperative complications QOL & cost comparisons Comparative studies Learning curve & selection bias Conclusions- why is MIE valuable?

3 Esophageal Carcinoma 1 Epidemiology As of 2001, US incidence 13,200, deaths 12,500 3:1 male predominance Anatomy & histology Adenocarcinoma now the most prevalent carcinoma of the esophagus in Western countries Largest increase seen in distal 1/3 of esophagus Risk factors Tobacco, EtOH,, Obesity (via increase in GERD), h/o caustic injury, achalasia Presentation, Staging, & Work-up >50% present with metastatic or unresectable disease Dysphagia,, wt loss Endoscopy c biopsy, EUS, PET, and CT utilized to assess depth of invasion, histological type, local invasion, and distant metastases Treatment Esophagectomy- Transhiatial (THE), Transthoracic (Ivor-Lewis- TTE), or Minimally invasive (MIE) Chemotherapy- neoadjuvant often utilized in spite of minimal evidence of benefit

4 Minimally Invasive Esophagectomy (Ivor-Lewis) 3,4,5 First described by Depaula in 1995 Combined thoracoscopic and laparoscopic approach Double lumen ETT, left lateral decubitus position Port placement

5 3,4 Thoracoscopic portion 3,4 Retract lung anteriorly, diaphragm inferiorly Expose, penrose, staple azygos, resect all periesophageal tissue Chest tube (28F)

6 Laparoscopic portion 3,4,5 Supine, port placement as for laparoscopic Nissen Divide gastrohepatic ligament, and short gastric arteries, divide along g curvature preserving gastroepiploics Pyloroplasty- Heinecke- Mickulucz

esophagus, deliver specimen Laparascopically place gastric tube into the

7 Laparoscopic portion 3,4 (continued) Gastric tubularization- preserve R gastric (5-6 6 cm in diameter) Horizontal collar incision, dissect to esophagus, deliver specimen Laparascopically place gastric tube into the neck, and perform anastamosis via collar incision Feeding jejunostomy placed

8 Why debate? Highly morbid procedure 4,5,6-5-23% mortality, with up to 60-80% morbidity for open procedures Surgery is the only therapy that can effect cure 5 yr overall survival 20%, so emphasis is upon minimizing morbidity to maximize remaining quality of life Can we perform the operation via smaller incisions, minimizing operative trauma and hence morbidity without violating the operative principles and results of the original operation?

9 Oncological comparisons Nodal clearance- mean of nodes 3,7 with 15 being required 6 Decrease loco-regional recurrence 6 Perhaps improved visualization of nodal basins 3,4 Increased number of nodes removed relative to TT and THE arms 5 Ability to remove all tumor Successful for all cases of T3 or less (71 pts) 3 Tumor free survival Need better data- Overall survival 3 yr overall survival approximately 32% 6 5yr overall 29% & 39% for THE and TT 8 similar to MIE

10 Operative & perioperative details Author n OR time Luketich (2000) 3 Luketich (2003) 4 Swanstrom (2002) 7 Nguyen (2003) 5 Senkowski (2006) 9 Collins (2006) NR Mean ICU stay h 1d 1d Mean hospital stay Conversion to open 7d 7.2% h NR 5.5d 3.8% h 2d h 2d 7d NR 8d 2.2% 12d 10% h 1d 9d 8% Hulcher, et al subjects randomized to THE (106) and TT (114) OR time was 3h and 6h respectively Median ICU stay 2d and 6d respectively Median hospital stay 15d and 19d respectively

11 Post-op op complications Postoperative 3,4,6 32%) 3,4,6 (17 (17- Mortality (0-4.3%) Anastomotic leak- (8-11.7%) PNA- ( %) markedly lower than for open techniques (approx 1/3) 3,4 in retrospective case series RLN injury- ( %) Chylous leakage- 3.2% 9

12 QOL & Cost analyses Overall 25% 5yr survival 13 SF-36, GERD HRQOL forms Median f/u 63 months Similar SF-36 physical functioning and cognitive scores to age-matched normals Minimal GERD No formal cost analyses- equipment & OR time vs decrease in ICU & hospital stay.

13 Comparative studies Nguyen (2000 )5-18 consecutive minimally invasive esophagectomy compared to 16 and 20 historical controls in the transthoracic and transhiatial arms Similar operative times (approx 6h), decreased intraoperative blood loss, decreased intraoperative transfusions, decreased ICU stay (6d vs 10 & 11 for TT and THE respectively), and decreased hospital stay (11d vs 23d and 22d) Braghetto (2006 ) consecutive patients undergoing TT (60), THE (59), and MIE (47) from Similar mortality when patients normalized for disease stage, with decreased major and minor complications Trending towards statistical significance

14 Learning Curve & Selection bias Number of procedures needed to learn the procedure effectively?- unknown, but steep- very difficult 6 Chose patients with early-stage disease, partly because to make it easier to learn 62% of patients have early stage disease 4

15 The Future ECOG See if single-center results can be replicated by other institutions Long term results- particularly survival, disease free survival Further QOL- main objective for MIE If single-center results can be replicated, then prospective randomized trials may ensue

16 Conclusions Open techniques still the gold standard by which others will be measured by Valuable?- Yes. Minimally invasive techniques offer exciting new methods with potentially similar oncologic soundness and decreased morbidity and mortality 1 Some surgeons limiting open resections to T4 tumor, history of multiple m prior surgeries, or any indication that the gastric conduit would d be unusable. 2 Potential role in Barrett s s with high-grade grade dysplasia (approx 50% have occult carcinoma) 12 Presently, still should be considered an experimental procedure 2,5,6 Retrospective case series demonstrate outcomes that appear superior to open techniques in the short term, though require prospective randomized trials for comparison

17 References 1. Koshy M, et al. Multiple Management Modalities in Esophageal Cancer: Epidemiology, Presentation, and Progression, Work-up and Surgical Approaches. Oncologist. 2004; 9: Hugh TB, et al. Caustic ingestion and the Surgeon. JACS. 1999; 189(5): Luketich JD, et al. Minimally Invasive Esophagectomy. Ann Thorac Surg. 2000; 70: Luketich JD, et al. Minimally Invasive Esophagectomy: : Outcomes in 222 patients. Ann Surg. 2003; 238: Nguyen NT, et al. Thoracosopic and Laparoscopic Esophagectomy for Benign and Malignant Disease: Lessons Learned from 46 Consecutive Procedures. JACS. 2003; 197: Hulscher JBF, et al. Extended transthoracic resection compared with limited transhiatial resection for adenocarcinoma of the esophagus. NEJM. 2002; 347(21): Nguyen NT, et al. Comparison of Minimally Invasive Esophagectomy with Transthoracic and Transhiatial esophagectomy. Arch Surg. 2000; 135: Swanstrom,, LL. Minimally Invasive Surgical Approaches to Esophageal Cancer. Journal of Gastrointestinal Surgery. 2002; 6(4): Senkowski CK, et al. Minimally Invasive Esophagectomy: : Early Experience and Outcomes. The American Surgeon. 2006; 72: Collins G, et al. Experience with minimally invasive esophagectomy. Surg Endosc. 2006; 20: Fernando HC, et al. Outcomes of minimally invasive esophagectomy (MIE) for high-grade grade dysplasia of the esophagus. European Journal of Cardiothoracic Surgery. 2002; 22: Braghetto I, et al. Open transthoracic or transhiatial esophagectomy versus minimally invasive in terms of morbidity, mortality, and survival. Surg Endosc. 2006; 20: Nguyen NT, et al. Minimally Invasive Ivor-Lewis Esophagectomy. Ann Thor Surg. 2001; 72: Nguyen NT, et al. Minimally invasive esophagectomy for Barrett s s esophagus with high-grade grade dysplasia. Surgery. 2000; 127: Wu PC, et al. The role of surgery in the management of oesophageal cancer. Lancet Oncol. 2003; 4:

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