A preliminary experience with minimally invasive Ivor Lewis esophagectomy

Abstract

With several small series examining minimally invasive Ivor Lewis esophagectomies, we look to contribute to a growing experience. In reporting our initial results, safety, initial oncologic completeness, and preliminary outcomes with a minimally invasive Ivor Lewis esophagectomy were demonstrated. From 2007 to 2010, 40 minimally invasive Ivor Lewis esophagectomies were carried out. The approach was a laparoscopic mobilization of the stomach and a thoracoscopic esophageal mobilization and creation of a high intrathoracic anastomosis. Indications included esophageal cancer in 39 patients and esophageal gastrointestinal stromal tumor in one patient. Median age was 62 (range 39-77) with 31 (78%) male patients. Non-emergent conversion was required in two (5%) patients. Twenty-five (63%) patients underwent neoadjuvant therapy. Mean operative time was 364 minutes (range 285-455), and mean blood loss was 205 cc (range 100-400). All patients underwent an R0 resection including the removal of all Barrett's esophagus, and mean number of nodes harvested was 21 (range 11-41). Median intensive care unit stay was 1 day (range 1-3), and hospital stay was 7 days (range 6-19). There were no anastomotic leaks and no 30-day mortality. Postoperative complications included eight (21%) patients with atrial fibrillation and two (5%) chylothorax, one requiring ligation. At a mean follow-up of 16.5 months (range 1-39 months), five (13%) patients have had a distant recurrence; there have been no local recurrences. Minimally invasive Ivor Lewis esophagectomy, although technically challenging, can be carried out with reasonable operative times, a short length of stay, and minimal complication. Final oncologic validity is pending longer follow-up and a larger series.

Epidemiology, Diagnosis, and Management of Esophageal Adenocarcinoma

“…142–144 Single-center studies from groups with expertise in each of the 3 approaches have provided excellent results. 139, 145, 146 There is no level-1 evidence that any approach increases survival times, compared with the others. Randomized studies have associated trans-hiatal approaches with less morbidity than transthoracic approaches, but percentages of patients with long-term survival did not differ significantly.…”

A prospective comparison of totally minimally invasive versus open Ivor Lewis esophagectomy

“…Up to 30% of esophageal resections in the UK are presently conducted using minimally invasive techniques, but only a small proportion have reported thoracoscopic esophageal mobilization 8 . The majority of published series report the outcomes of hybrid‐type or three‐stage MIE, 5,7,9,13–21 with few series of MIE‐2 in the literature 2,3,5,22–27 …”

Laparoscopic ischemic conditioning of the stomach prior to esophagectomy

“…In this series of 24 consecutive patients, LIC is shown to be technically feasible and safe. When evaluating minimally invasive procedures, reasonable operative times, low conversion rates, short lengths of hospital stay, and comparable rates of morbidity and mortality are often considered essential criteria in primary review; 17 our data with LIC were associated with favorable operative times, no requirement for open conversion, and short lengths of hospital stay (median 2 days). Our initial experience thus supports that gastric devascularization procedures can be implemented with esophageal replacement in regards to feasibility and safety.…”

“…The most common method of esophageal replacement following esophagectomy is gastric pull‐up reconstruction following resection 14 . No matter the chosen approach or technique, the procedure is technically challenging and carries a high postoperative morbidity and increased mortality 17 . Gastric reconstruction also carries a risk of gastric conduit morbidity: anastomotic leak, regional ischemia, or delayed gastric emptying.…”