Minimally Invasive Esophagectomy

Transcription

1 American Association of Thoracic Surgery (AATS) 95 th Annual Meeting Seattle, WA April 29, 2015 General Thoracic Masters of Surgery Video Session Minimally Invasive Esophagectomy James D. Luketich MD, FACS Henry T. Bahnson Professor and Chairman, Department of Cardiothoracic Surgery University of Pittsburgh Medical Center

2 Overview Pathology: occasional mid-esophageal squamous cell cancers Most are operable distal esophageal adenoca, this is why I prefer an Ivor Lewis in most cases Definition of a Minimally Invasive esophagectomy, what steps I include Evolution of technique Contraindications to MIE Technique of MIE Results

3 On the table EGD Step by Step Laparoscopic staging Crural dissection, nodal approach, gastric vessels Conduit preparation and construction Pyloroplasty, coverage J-tube, you cannot have complications here, gain more experience, watch videos, do not re-invent the wheel, be better than that Omental flap

4 Technique: Laparoscopic-Transhiatal Lap-THE: versus thoracoscopic/laparoscopic N=15, initial approach N=>500 N=>500, current approach Lap/VATS: PRO: PRO: better exposure /dissection of No repositioning mediastinum No single lung Better esophageal margins ventilation? Survival/local recurrence CON: benefit small working space CON: Limited access to repositioning required thoracic nodes double lumen tube required Gastric tip ischemia Delayed abdominal assessment RLN injury Gastric tip ischemia Gastric margins RLN injury MIE Ivor Lewis: PRO: pros of lap/vats No pharyngeal/rln issues Less gastric tip ischemia Larger diameter anastomosis, less strictures Better gastric margins CON: Esophageal margins (SCC, or high Barrett s Technical challenge of VATS anastomosis

5 Contraindications to MIE Multiple previous abdominal surgeries are a relative contraindication, place port and look, open if not safe Damage or adhesed gastroepiploic artery, may not be safe to proceed laparoscopically Previous gastric resection: BI and B II, gastric bypass, gastrectomy All colon interpositions I do open, not enough to get over the learning curve in my opinion

6 Mobilization of Stomach - Handle the stomach gently - Division of the omentum and omental branches of the gastroepiploic artery - Avoid injury to the gastroepiploic arcade - Avoid injury to the greater curvature of the stomach while dividing the short gastrics

7 Right Crural Dissection and Division of Left Gastric Vessels

8 Short Gastrics No Touch

9 Creation of the gastric tube Construct narrow tube, 3-4 cm max Begin 3-4 cm above pylorus Run staple line parallel to the line of the short gastrics Keep stomach on slight stretch while applying stapler Minimize trauma to the actual new conduit, no touch technique

10 Construction of the Gastric Conduit

11 Antral Mobilization and Pyloroplasty, Cover with Omental Patch

12 Preparation of the Conduit and Final Inspection 1. Tack Tip to Stapled gastric line 2. Assess crural opening, wider vs. narrow 3. Tuck specimen and tip Into mediastinum 4. Final exam of conduit orientation, suture mark, bleeding, tack omental flap

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14 VATS Esophageal Lymph node Dissection (Video)

15 Ivor Lewis: VATS Portion of Operation Standard LN dissection Open phrenoesophageal ligament and retrieve specimen and deliver gastric tube into chest Transect esophagus Remove specimen Insert anvil and perform intrathoracic EEA anastomosis (preferably 28 mm, or 25 EEA)

16 Creation of the esophagogastric anastomosis Mastery Techniques in Surgery: Esophageal Surgery. Edited by Luketich JD. Wolters Kluwer Health, 2014

17 The gastrotomy is closed with Endo GIA stapler Mastery Techniques in Surgery: Esophageal Surgery. Edited by Luketich JD. Wolters Kluwer Health, 2014

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19 Completed anastomosis with omental pedicle wrap

20 Important Points in the Chest Diaphragm retracting stitch Watch posterior membranous airway Inferior pulmonary vein Watch thoracic duct, if near or damaged, ligate carefully Aorta, use clips, avoid tearing small vessels Do not pull up excess gastric conduit, it is important to have a nice straight, non-redundant lie, separate staple line from airway with fat if possible Drain,? Type, avoid excess suction? Chest tube and NG tube.

21 Updated Series U Pittsburgh American Surgical Association 2011 (n=1011) Approaches McKeown 3 incision Minimally invasive esophagectomy with neck anastomosis (n=481; 48%) Ivor-Lewis Minimally invasive esophagectomy with chest anastomosis (n=530; 52%) James Luketich et al ASA 2011, Ann Surg 2012

22 Perioperative Outcomes Mortality Mortality (30 day) for all patients (n=1011): 1.68 % Ivor-Lewis MIE: 0.9 % James Luketich et al ASA 2011, Ann Surg 2012

23 Thank You