AATS Focus on Thoracic Surgery: Minimally Invasive Esophagectomy: Are We Still Getting Better in 2017?

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Dylan Booth
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AATS Focus on Thoracic Surgery: Mastering Surgical

Video Session Minimally Invasive Esophagectomy: Are We

1 AATS Focus on Thoracic Surgery: Mastering Surgical Innovation Las Vegas, NV October 28, 2017 Session VIII: Video Session Minimally Invasive Esophagectomy: Are We Still Getting Better in 2017? James D. Luketich MD, FACS Henry T. Bahnson Professor and Chairman, Department of Cardiothoracic Surgery University of Pittsburgh Medical Center

2 Technique: Laparoscopic-Transhiatal Lap-THE: versus thoracoscopic/laparoscopic N=15, initial approach N=>500 N=>1500 current approach Lap/VATS: MIE Ivor Lewis: PRO: PRO: better exposure /dissection of No repositioning pt 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 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

3 Laparoscopic Portion: Step by Step On the table EGD Laparoscopic staging Crural dissection, nodal dissection, gastric vessels Conduit preparation and construction Pyloroplasty, coverage J-tube Omental flap

4 Laparoscopic Port Placement Self-retaining liver retractor 4 5-mm ports one 10-mm port

5 Left Gastric artery and vein and node dissection (Improved nodal dissection) More aggressive nodal dissection Skeletonize the base of left gastric artery and vein Sweep all fatty and nodal tissue upward with specimen Continue this dissection plane into the retro crural and preaortic areas Old data nodes New: 40 Plus lymph nodes

6 Celiac Nodal Dissection and Gastric Vessel Division 1) More aggressive nodal dissection 2) Skeletonize the base of left gastric artery and vein 3) Sweep all fatty and nodal tissue upward with specimen 4) Continue this dissection plane into the retro crural and pre-aortic areas 5) Old data : lymph nodes 6) New goals: greater than 40 LN

7 Mobilization of Stomach 1) Handle the stomach gently, No touch technique of the final conduit 2) Division of the omentum and omental branches of the gastroepiploic artery Leave 2-3 cm of greater arcade omentsl fat to insulate the gastric conduit with greater curve omentum and keep staple line away from the airway 3) Add omental flap in patients who have received neoadjuvant chemoradiation to completely wrap the anastomosis

Gastric Tubularization: Newer modifications GE junction tumor 1) Division of the omental branches of the gastroepiploic artery -2-3cm of greater arcade fat to insulate the gastric conduit and staple

8 Gastric Tubularization: Newer modifications GE junction tumor 1) Division of the omental branches of the gastroepiploic artery -2-3cm of greater arcade fat to insulate the gastric conduit and staple line from the airway 2) Omental flap in patients who have received neoadjuvant chemoradiation 3) Strict avoidance of vasopressors Antral Reservoir 1) More narrow tube, cm 2) Begin staple line 5-6 cm above pylorus 3) Concept of antral reservoir living below the hiatus 4) Staple line parallel to line of short gastrics 5) Stomach on slight stretch while applying stapler 6) No trauma to the actual new conduit no touch technique

9 Short Gastrics No Touch

10 Construction of the Gastric Conduit

11 Other Steps Needle Catheter Jejunostomy (our standard) Pyloroplasty (our standard, but may not be necessary with narrow gastric tube) Celiac LN dissection (our standard)

12 Pyloroplasty 1) Open perpendicular to muscle band 2) Close on stretch 3) Time Goal: under 10 minutes 4) Omental patch (graham) 5) Single institution randomized trial in progress

13 Laparoscopic J Tube 1) 10 French kit, no more needle J s 2) Time goal: under 10 minutes 3) Witzel all tubes 4) Parachute stitch replaces 4 interrrupted

14 Tack Gastric Tube to Mobilized GE- Junction Tumor For Chest Retrieval Marking stitch Antral reservoir

15 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

16 Conduit Preparation Marking Stitch

17 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)

18 Typical Location of Surgeon and Assistant Instruments During VATS part of Ivor Lewis or Mckeown Approaches

VATS Esophageal Lymph node Dissection (Video) 1) Diaphragm retracting stitch 2) Watch posterior membranous airway 3) We generally leave thoracic duct, if damaged, ligate 4) Aorta, use clips, avoid

19 VATS Esophageal Lymph node Dissection (Video) 1) Diaphragm retracting stitch 2) Watch posterior membranous airway 3) We generally leave thoracic duct, if damaged, ligate 4) Aorta, use clips, avoid tearing small vessels 5) Do not pull up excess gastric conduit, it is important to have a nice straight, non-redundant lie 6) separate staple line from airway with fat if possible 7) Drain,? Type, avoid excess suction? Chest tube and NG tube.

20 VATS Ivor- Lewis Anastomosis (Video)

21 Omental Flap Creation

22 Completed anastomosis with omental pedicle wrap

Completed Reconstruction With Cervical Anastomosis: Consider laparoscopic look at end of Ivor Lewis 1) High intrathoracic anastomosis 2) Avoid redundant conduit

23 Completed Reconstruction With Cervical Anastomosis: Consider laparoscopic look at end of Ivor Lewis 1) High intrathoracic anastomosis 2) Avoid redundant conduit above diaphragm 3) Marking stitch, facilitates leaving antral reservoir 4) Tack gastric tube to hiatus to minimize delayed hernias 5) Consider final laparoscopic look

24 Perioperative Outcomes Mortality Mortality (30 day) for all patients (n=1011): 1.68 % Ivor-Lewis MIE: 0.9 % 30 day 1.9% 90 day James Luketich et al Ann Surg 2012

25 Thank You

26 Ivor Lewis Approach Less gastric tube needed, better margins for cardia involvement, less ischemia Avoid neck dissection and potential recurrent laryngeal nerve injury Less aspiration Downside: intrathoracic leak can be more difficult to manage, no third field of LN dissection Technique, Learning curve to the VATS intrathoracic anastomosis

Minimally Invasive Esophagectomy

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,