Minimally Invasive Esophagectomy: OVERRATED!!! Sagar Damle UCHSC December 11, 2006

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Frederica Ferguson
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1 Minimally Invasive Esophagectomy: OVERRATED!!! Sagar Damle UCHSC December 11, 2006

2 Esophageal Cancer - Est. 15,000 cases in Est. 14,000 deaths - Overall 5-year survival: 15.6% % for local Dx % for regional Dx % for Dx

3 Esophageal Cancer Tidbits S/SX: Insidious Dx: EGD with biopsy CT +/- PET Barium Swallow Endoscopic Ultrasound Histologic Types Adenocarcinoma US and Europe mostly Squamous Cell Carcinoma Asian countries and worldwide

4 Staging: TNM T: Tis = Carcinoma in situ T1 = Invades lamina propria T2 = Invades muscularis propria T3 = Invades adventitia T4 = Invades adjacent structures N: M: N0 = No regional nodes N1 = Regional mets M0 = No distant mets M1a = Tumors in celiac nodes, cervical nodes or other non-regional nodes. M1b = Other distant mets.

5 Stages and Typical Tx: Stage 0: Tis, NO, MO Surgery (Esophagectomy, PDT, EMR) Stage 1: T1, N0, M0 Surgery (Esophagectomy, PDT, EMR) Stage IIA: T2 or T3, N0, M0 Neoadjuvant chemotx +/- surgery Stage IIB: T1 or T2, N1, M0 Same as IIA Stage III: T3N1 or T4 Same as IIA Stage IV: M any Palliation

6 A Little History Lesson Limited body cavity exams in mid-1800s with hollow tube + refractive lens Greatest strides came from George Kelling and achieved celioscopy. 1960s used for GYN but limited due to instrumentation 1980s improved instruments allowed procedures the rest is history.

7 Proposed benefits (ie MYTHS) of MIE Smaller incisions => less pulmonary complications Magnification => safer operation => decreased surgical mortality Decreased ICU and hospital LOS Improved or equivalent survival

8 Debunking the Myths Morbidity Hospital LOS Pulmonary Complications Anastamotic Leak Mortality Surgical (Short-term) Oncologic (Long-term)

9 Length of Stay (ICU and Hospital) MIE vs. Traditional Georgia (Senkowski 2006) 2 d / 18 d Australia (Leibman 2006) 1 d / 11 d Belgium (Lerut 2004) 2 d / 20 d MD Anderson (Hofstetter 2002) LOS 12 days Minneapolis (Collins 2006) 1 d / 9 d Pittsburgh (Luketich 2003) 1 d / 7 d

10 Pulmonary Complications MIE vs. Traditional Australia (Liebman 2005) > 50% pts Japan (Tachibana 2003) ~ 37 % Pittsburgh (Luketich 2003) > 20% Kentucky < 20% Minneapolis (Collins 2006) > 30%

11 19 % Leak Rate Only 36 pts Leaks MIE vs. Traditional Australia (Martin 2005) Transhiatal Initially 15% Now: Pittsburgh (Luketich 2003) 12 % Leak Rate > 200 pts Minneapolis (Collins 2006) 12% Leak Rate 25 pts 3% - (Orringer 2000) 8% (Casson 2002) Transthoracic 11% (Altorki 2005) 4.2 % (Lerut 2004) Overall(Tx MDA) 6 % (Hofstetter 2002)

12 The Ultimate Outcome: Survival

13 Surgical Mortality: 30-day MIE vs. Traditional Georgia (Early exp) 5% Pittsburgh (222 pts) 1.3 % Minneapolis 4% Belgium 1% (Lerut 2004) Kentucky- 10 yr experience 1% (Bousamra 2002) MD Anderson 5-6%

14 Oncologic Survival MIE vs. Traditional Australia Median Survival 32 months 20% 4 yrs for invasive CA Pittsburgh (222 pts) Est. 40 months for invasive CA Japan 5 yrs MD Anderson > 4 yrs

15 Problems with the Literature: Apples to Oranges Comparison of MIE with TTE and THE Retrospective. MIE group got supplemental nutrition. THE and TTE groups had > 90% cancer while MIE group had > 20% benign. MIE group MUST tolerate single-lung ventilation and so have better CP status. MIE group typically have had smaller tumors that do NOT invade local tissues. MIE procedures only being done by full-time MIE surgeons Difficult to get RCT for many reasons Nguyen, Follette, Wolfe. Arch Surg. 2000

16 Summary MIE does NOT offer decreased pulmonary complications. MIE does NOT offer decreased mortality MIE is NOT better than traditional open esophagectomy for long-term survival

17 Conclusions Open esophagectomy, should remain the standard of care for esophageal cancer. This is because the M&M associated with these procedures stems from the esophagectomy and dissection and not the incisions themselves. The open approach allows for better overall exposure with better short- and long-term results.

18 References Bailey, S., D. Bull, et al. (2003). "Outcomes after esophagectomy: A ten-year prospective cohort." Ann Thorac Surg 75: Bousamra, M., G. Haasler, et al. (2002). "A decade of experience with transthoracicand transhiatal esophagectomy." The American Journal of Surgery 183: Collins, G., E. Johnson, et al. (2006). "Experience with minimally invasive esophagectomy." Surgical Endoscopy 20: Espat, N., G. Jacobsen, et al. (2005). "Minimally invasive treatment of esophageal cancer: Laparoscopic staging to robotic esophagectomy." The Cancer Journal 11(1). Hofstetter, W., S. Swisher, et al. (2002). "Treatment outcomes of resected esophageal cancer." Annals of Surgery 236(3): Law, S., M. Fok, et al. (1997). "Thoracoscopic esophagectomy for esophageal cancer." Surgery 122: Leibman, S., B. M. Smithers, et al. (2006). "Minimally invasive esophagectomy: Short- and longterm outcomes." Surgical Endoscopy 20: Lerut, T., P. Nafteux, et al. (2004). "Three-Field Lymphadenectomy for Carcinoma of the Esophagus and Gastroesophageal Junction in 174 R0 Resections: Impact on Staging, Disease-Free Survival, and Outcome." Annals of Surgery 240(6): Luketich, J. D., M. Rivera-Alvelo, et al. (2003). "Minimally Invasive Esophagectomy- Outcomes in 222 Patients." Annals of Surgery 238(4): 486. Martin, D. J., J. R. Bessell, et al. (2005). "Thoracoscopic and laparoscopic esophagectomy: Initial experience and outcomes." Surgical Endoscopy 19: Nguyen, N., D. Follette, et al. (2000). "Comparison of Minimally Invasive Esophagectomy with Transthoracic and Transhiatal Esophagectomy." Archives of Surgery 135:

19 Oncologic Perspective: Nodes MIE vs. Traditional 9 per specimen Collins per patient Law per patient Law 1997

Determining the Optimal Surgical Approach to Esophageal Cancer

Determining the Optimal Surgical Approach to Esophageal Cancer Amit Bhargava, MD Attending Thoracic Surgeon Department of Cardiovascular and Thoracic Surgery Open Esophagectomy versus Minimally Invasive