Hi, my name is Rishi Reddy, I'm one of the Thoracic Surgeons here at the University of Michigan. Thank you for joining us today. Today, I'll be going over, what is a minimally invasive esophagectomy. These are my disclosures, none of which should be relevent to this talk. The objectives of today's talk is to review the different types of esophagectomy and to understand the different types of minimally invasive esophagectomy. We will also review the benefits of a minimally invasive approach compared to a traditional open approach. First, we'll go over a pre-lecture question. The benefits associated with a Minimally Invasive Esophagectomy regardless of the type of esophagectomy include. A, lower pulmonary complication rates. B, lower anastomotic leak rates. C, shorter length of operation. D, decreased number of re-operations after surgery. Or E, improved cosmesis. To begin, we'll go over the principles of an esophagectomy irregardless of the approach whether it's open or minimally invasive. The key principles of any esophagectomy include focusing on the lymph node dissection to ensure as many lymph node dissected both for curative intent, but also prognostic information. The creation of a conduit whether it's the stomach or an alternative conduit such as the colon and ensuring that conduit has adequate blood supplies where as adequate reach to the esophagus. Placing the anastomosis above your conduit to the esophagus at or above the azygous vein is key for emptying of the conduit itself. And then also having a pylorus emptying procedure, as almost every esophagectomy also has a vagotomy as a part of the operation. Making sure that the pylorus is released either through a pyloromyotomy, pyloroplasty, or sometimes a botox injection is critical to reduce the rate of post-operative gastric outlet obstruction. The complications of any esophagectomy again, irregardless of approach, include things like dysphagia, difficulty with a conduit emptying, pyothorax or lymphatic leak, and anastomotic leak between the esophagus and the conduit or pneumonia. Now, I'd like to define exactly what a transthoracic esophagectomy is, also commonly known as Ivor Lewis Esophagectomy. Here we have two pictures. One of person's abdomen and the other of a person's chest. In a transthoracic esophagectomy approach, an incision is made in the abdomen first, mobilizing the conduit, usually the stomach which is then fed up into the chest. After the abdomen is closed, the patient is usually repositioned on their side, and then a chest incision is made, usually a posture lateral incision. And then the anastomosis where the stomach is hook up to the esophagus is performed in the chest. The transhiatal esophagectomy is a very in that has been popularize here at the University of Michigan over the last 40 years. Here, we begin at the abdomen also and make an abdominal incision as shown here. But we avoid the chest incision bringing the gastric conduit up to the neck and then perform the anastomosis between the esophagus and the stomach and the neck resulting in an incision as shown here. A 3 field esophagectomy is a combination of both approaches. Instead of beginning in the abdomen first though, the initial incision is made in the chest again, usually through a posterior lateral thoracotomy. After the chest incision is completed and the esophagus is mobilized in the chest and all the lymph nodes are dissected the patient is repositioned supine on their back. And then the abdominal phase is completed, mobilizing the stomach and then the stomach is brought up and the anastomosis is completed in the neck is done in the transhiatal. There is no consensus definition of what defines a minimally invasive esophagectomy. An initial definition, which is more inclusive is considered any portion of the chest or abdominal operation that is performed by a minimally invasive approach whether it's thoracoscopic, laparoscopic or robotic. Some surgeons have fought for a more specific definition that requires all portions of the chest or abdominal portions being performed only by a minimally invasive approach. There is again no consensus on what specific definition is of an MIE. There are pros with any minimally invasive esophagectomy including having smaller incisions which can result in less pain, especially for the chest incision. Depending on the studies there has also been shown to have reduced rates of pneumonia, specifically for transthoracic minimally invasive esophagectomies. There's also felt to be a better mediastinal visualization when using a minimally invasive approach for the transhiatal approach. And depending on the study there has been shown to be a lower length of stay with a minimally invasive esophagectomy. There are some cons also to an MIE approach though. The benefit versus a transhiatal open approach is less clear, given the lack of a chest incision in either approach and reduced rates of pneumonia from a transhiatal approach. There is a decreased ability to assess the blood supply for the conduit with a minimally invasive approach because you're not able to fully assess or feel the gastroepiploic artery along the greater curve of the stomach. There's also a much higher learning curve to perform a safe operation on a minimally invasive approach and there have been numerous studies that have shown a longer operation time with the minimally invasive approach and higher equipment costs. Here is one paper from Perry et al comparing laparoscopic transhital esophagectomy to open transhital esophagectomies. And this is a systematic review of the literature that was published in 2016. There are a couple of things I'd like to highlight here in terms of morbidity, in terms of comparison. In either the laparoscopic or the open approach, morbidity rates here vary from either 39% to as high as 81%, irregardless of the approach. There is very few studies that showed a difference in the transhiatal approach in terms of the pulmonary complications or anastomotic leak rates. The ICU stays were comparable, but the hospital median length of stay appeared to be slightly lower in the minimally invasive approach at least in this study. In another study that evaluated outcomes from the Society of Thoracic Surgery database from Sihag et al. Here, they looked at any definition of minimally invasive esophagectomy compared to any open esophagectomy. This was a little less specific because it did not compare the different types of esophagectomy. But here you can see there was a statistically significant decrease in the length of stay with a minimally invasive approach. Although it was only one day it was statistically significant. There was a much longer length of operation or procedure duration, noted here with the minimally invasive approach. And an interesting note is that there were more events requiring re-operation, in this case almost 10%, with a minimally invasive approach. All other comparisons here have no statistical significance in terms of their differences. Now, going back to our post-lecture question again, benefits associated with a minimally invasive esophagectomy, regardless of the type of esophagectomy, include. A, lower pulmonary complication rates. B, lower anastomotic leak rates. C, shorter length of operation. D, decreased number of re-operations after surgery. Or E, improved cosmesis. The answer is E, improved cosmesis. Going briefly through the answers again. When we do a transhiatal approach, there is not necessarily a difference in pulmonary complication rates comparing an open to a minimally invasive approach. There is no difference in anastomotic leak rates between approaches. There may be a shorter length of operation with a minimally invasive esophagectomy, though not all studies have shown that. And actually some studies have shown an increase number of re-operations after surgery. So improved cosmesis is the correct answer. The take home points from this lecture should be that there is no consensus definition on what a minimally invasive esophagectomy is. With higher volume and improvement on the learning curve, comes higher success with regards to patient outcomes. And higher volume does result in improved outcomes in this case.
