Hello, I'm Dr. Mark Orringer, University of Michigan, thoracic surgeon. Today's lecture on surgery for esophageal carcinoma, we'll review the current operations used to resect esophageal cancer, including their complications and some of the controversies currently surrounding them. The operations now being used include transthoracic esophagectomy, transhiatal esophagectomy, or THE, radical esophagectomy, minimally invasive esophagectomy, or MIE, and robotic minimally invasive esophagectomy. A prelecture question, which I would like you to consider and hopefully will have better understanding of when the lecture is completed, is shown here. Historically, the two most common complications responsible for death after esophagectomy are a, hemorrhage and infection, b, chylothorax and pneumothorax, c, pneumonia and mediastinitis, d, recurrent laryngeal nerve paralysis and sepsis, and e, wound infection and anastomotic stricture. Now the esophagus is a ten inch long tube of muscle that runs through the posterior mediastinum in front of the spine and adjacent to the aorta. The earliest operation to remove the esophagus required an access to the posterior mediastinum through the chest. In the late 30s, the early 40s, the first procedure described to remove the esophagus was a transthoracic esophagectomy, shown here. An incision between the ribs on the chest to resect various levels of the esophagus, and then a separate incision on the abdomen to prepare the stomach and allow it to be pulled up into the chest and anastomosed to the esophagus at various levels, depending on where the esophagus was divided above the tumor. As an effort to improve the oncologic results with esophageal cancer resection, which were quite poor, the concept of radical esophagectomy was developed by Logan in Great Britain and David Skinner here in the United States. In this procedure, the esophagus within the posterior mediastinum is resected along with it's envelope of surrounding soft tissue, consisting of the pericardium in front, the pleura laterally, and the azygos vein and thoracic duct posteriorly in front of the aorta. While a very attractive concept to resect more tissue and do a better cancer operation, one can see that the concept of a radical esophagectomy, when one is only several millimeters further to the front and back of the esophagus, is somewhat wishful thinking. And nevertheless, the concept of radical esophagectomy does remain important to some surgeons. When a radical esophagectomy is performed through the right chest, the patient's head to the right, the feet to the left, the tumor here being mobilized within the esophagus. Here is what it looks like with the pleura having been divided and the azygos vein divided as well, the intercostal veins divided, and the thoracic duct separated posteriorly. Through the left chest, with the lung retracted anteriorly and the head now to the right, the pleura has been incised around the esophagus, a segment of diaphragm is removed. And again, this attempt is made to remove the esophagus along with an envelope of soft tissues to improve the oncologic aspect of the procedure. Regardless of whether it's a standard transthoracic esophagectomy or a radical esophagectomy, the transthoracic approach has some clear disadvantages. The first is the combined thoracoabdominal operation. This is a physiologic insult, having an incision on the side of the chest and on the abdomen, the resulting post-operative pain makes it difficult to take a deep breath. Patients who don't breathe deeply retain pulmonary secretions and develop atelectasis and pneumonia, which has been the leading cause of death after the transthoracic approach ever since the operation was first described. The second hazard of the operation is mediastinitis resulting from an anastomotic leak. If the patient survives surgery for the first ten days, anastomotic healing is complete. If a leak occurs within those first ten critical days, saliva, oral bacteria, bile from the stomach, salivary enzymes spill into the chest and cause chemical and bacterial mediastinitis which is a fatal complication in 50% of patients in whom this complication occurs. And so, pneumonia and mediastinitis from anastomotic leak are the leading complications of transthoracic esophagectomy. In 1978, we reported our experience with an operation called transhiatal esophagectomy, or esophagectomy without thoracotomy. In this operation, the esophagus is extracted through an abdominal incision and a neck incision without the need to open the chest. This shows the operative exposure and upper midline abdominal incision. The patient's head is up here, and this is a table mounted retractor used to assist with the operation. When the blades of the retractor are inserted, one can see the stomach and the hiatus just above that, and this is how we approach the esophagus, working through the abdominal incision and up through the hiatus, without opening the chest. A separate neck incision is made and the esophagus is encircled in the neck above the clavicles, and reaching down from above and up from below, we free the entire esophagus behind, in front, and laterally. The esophagus is then divided in the neck and drawn out of the mediastinum and placed on the anterior abdominal wall along with the stomach, which is mobilized. One can see the schematic of the tumor within the lower esophagus, and here the stapler is being applied along the lesser curvature of the stomach to construct a gastric tube which will be used to replace the esophagus. This point, the tip of the fundus, is the part of the stomach which will subsequently be pulled to the neck for anastomosis with a cervical esophagus. But once this suture line has been completed with a stapler, the esophagus, its contained tumor, and a small amount of proximal stomach have been removed. One can now see that the stomach is free to reach above the level of the clavicles. It is returned to the abdominal cavity and advanced upward through the mediastinum, so that now the stomach passes upward through the posterior mediastinum where the esophagus used to be The tip is brought into the neck incision and an anastomosis between the esophagus and stomach carried out. Now, the obvious advantages of the transhiatal approach is that a thoracotomy is avoided. And therefore the pulmonary complications with this operation are far less. Secondly, a cervical anastomosis is carried out. If there should be an anastomotic leak, the neck wound is open, the saliva is allowed to drain. And the neck wound is packed. The result is not mediastinisis. So whereas intrathoracic anastomotic leak carries a 50% mortality. The mortality for an anastomotic leak in the neck is virtually zero. There are contraindications to this operation. Which include evidence of tracheobronchial invasion of a middle esophageal tumor at pre-operative assessment. One cannot bluntly remove the esophagus if it is growing into the airway. If there's proven metastatic disease, stage 4 cancer, we will not perform an esophagectomy. And if there is local invasion found when the surgeon advances a hand upward into the mediastinum. And the esophagus is fixed in place. And growing into the adjacent aorta. Surgical judgment has to dictate that the operation should not be performed. The key to a successful operation to remove the esophagus. Regardless of the approach, we have learned, is pre-operative preparation. Absolute abstinence from smoking for three to four weeks before surgery. Use of an incentive inspirometer to help with deep breathing after surgery. And walking two to three miles every day before the operation to condition the patient for early post operative ambulation. Nutrition can be supplemented with oral diet supplements. But not with intravenous hyperalimentation, which requires a hospitalization. Which we try to avoid at all costs before surgery. This shows a patient using an Incentive Inspirometer practising after surgery what he had been doing before surgery. To keep those lungs well expanded. And to expedite his return to function and an early discharge. In early days when we proposed use of the transiadal approach for removing the esophagus. Part of the initial resistance had to do with the prevailing notion of the day that the stomach would not reach to the neck. In the North American Caucasian patient. We knew from reports in Asia that the stomach in Asians was somewhat longer by two centimetres or so. Than in Caucasian patients. In the 2000 patients which we reported subsequently. You can see that, in 97%, it was possible to carry out an anastomosis between the cervical esophagus and the stomach. Which proved, beyond question in our minds, that the properly mobilized. Otherwise, normal stomach would always reach to the neck for a cervical cervical esophagogastromostis. The only patients Requiring a colon inner position and a cervical esophagocolostomy. Being those who had prior ulcer surgery on the stomach or gastric disease. There was also initial concern expressed that intraoperative bleeding would be a problem. Because blood vessels were not being visualized and ligated under direct vision during mobilization of the esophagus. This has also proven not to be a clinical significance the average patient losing less than a unit of blood. And these patients no longer requiring a blood transfusion with surgery. Regarding postoperative complications, these come with any method of esophagectomy. Those that I would like to address, specifically, have to do with a cervical and anastomotic leak. Which you can see with 14% in incidence in the first thousand nine percent in the second thousand. We'll talk about some of the developments there. And then hoarseness due to recurrent laryngeal nerve injury currently under 2%. And this shouldn't be a major issue so long as the esophagus is mobilized properly. I would like to call your attention to the fact that the incidents of atelectasis. And ammonia prolonging hospitalization in 2000 Esophagectomies was 2%. This was really unprecedented. And speaks to the fact that the operation is less than the physiologic insult to the patient. And allows more prompt mobilization and less pulmonary complications. 71% of patients undergoing a Transhiatal Esophagectomy in our series experience no Postoperative Complication. THE Hospital Mortality in this series is quite noteworthy. 30 years ago, Esophagectomy carried an operative mortality Of 20 to 30%. And it was felt that this was an avoidable consequence of trying to restore people's ability to swallow. And doing the best that you could for the patient even with that price to pay. Now, you can see a mortality of under 5% in skilled centers that do a lot of these operations. And it's just a test of the fact that we've been able to progressively decrease the impact of the operation on the patient. While the average hospitalization is now around a week after surgery. One of the key factors that I'd like to point out is that, in our first thousand patients Intensive care stay was routine. Whereas, as in the last 1000, four percent have seen an intensive care. The majority returning to the general care for after the operation. And being up and mobilized the following day, so the emphasis is on early mobilization. That is possible because of a lesser impact on the patient with surgery. Now, the concerns about the transhiatal approach was that it did not allow visualization of mediastinal lymph nodes. As well as could be achieved when the chest was open. And therefore, perhaps A is oncologic and operation cannot be carried out. Many of us believe, however, that once the esophageal cancer involved mediastinal lymph nodes. That resection of mediastinal lymph nodes is not going to determine survival. Because we're now dealing with systemic disease. And this survival chart for patients, survival curve rather for patients undergoing an esophagectomy with a 51% two years survival. And a 30% five years survival. It is similar to that achieved with transthoracic resections. One of the current trends in esophageal cancer treatment is the use of neoadjuvant chemotherapy. And radiation therapy prior to the esophagectomy. And you can see that In 1480 patients undergoing a transhiatal esophagectomy, 39% had chemotherapy and radiation therapy, prior to their surgery. Among this group 12% or what we call complete responders no remaining tumor in the respected specimens T0, N0. And in this group, the 2 year survivals 80% and the 5 year survival are granted 58% far from ideal but far better than the survivals in the 2 to 3% at 5 years that we had 20 to 30 years ago with surgery alone or chemotherapy or radiation therapy alone. So multimodal therapy has made a substantial improvement in overall survival. One of the important topics that needs to be addressed is the anastomotic leak after surgery. This barium swallow examination shows a leak occurring or picked up on a barium swallow examination performed after a surgery. And in this patient the leak is right at the junction between the esophagus and the stomach. Now, we initially felt that this was not a very significant event because the neck should be opened, the wound back and the leak would heal. However, we now know that 50% of patients who leak as they heal, they end with a scar. A stretcher of the esophagus where the leak was as a consequence of healing. And this leaves the patient with a very narrow swallowing passage, requiring esophageal dilations, not having comfortable swallowing. And the operation that's been done to restore comfortable swallowing, but leaves the patient unable to swallow comfortably, really represents a functional failure. To address this problem, we try every variation of anastomosis that we could between the esophagus and the stomach, using a single layer anastomotic technique. A double layer anastomotic technique, interrupted sutures, permanent sutures and we continue to have a 12 to 14% anastomotic recreate in the neck. Until the Endo GIA stapler came along. We adapted use of this stapler to the anastomosis. This stapler, when it's fired, delivers six rows of staples and cuts down the middle. So that one has three rows on either side of tissue that have been stapled. So when performing the anastomosis we would deliver the stomach into the neck as show here, pulling it up through the clavicle. This is a left neck incision and the head is at this end. We would make an incision on the front of the stomach and this part of the stomach is down in the chest. This is the neck end up here, and this is the end of the enclosed stomach. The staple line on the esophagus where we had divided it is now removed and suture is placed in the opening of the stomach. And then into the opening of the esophagus so that when the state suture is pulled up, the back wall of the esophagus and the front wall of the stomach are pulled together. This then allows both place of the stapler to be inserted one into the esophagus, one into the stomach and the esophagus and the stomach are then aligned with the stapler in place. And as the stapler is fired, the back wall of the oesophagus and the front wall of the stomach are cut, resulting in a three centimeter long connection or anastomosis. The open portion of the esophagus and the stomach is now closed in layers using interrupted suture. So this hood of stomach covers the anastomosis, which is now within the confines of the overlying esophagus. This has proved to be a dramatic advance in the operation with 100 consecutive stapled anastomosis. The leak rate was 2.6% and in the previous 100 manually sewn anastomosis, the leak rate was 14%, a major improvement. Less leak means less stricture and more comfortable swallowing long term. I showed the colon as a reminder that in those situations and which the stomach is not as suitable esophageal substitute. The colon shown here with this barium enema is a whole organ. A portion of which can be remove to replace the esophagus that is shown here. The colon is a lower GI organ of course and doesn't function as well in the upper GI track which is thick wall, the stomach and the esophagus, and a custom to caring semi solid chewed food. The colon being flappier and the water absorption chamber tends to become redundant over the years. But nevertheless, the colon can be use as a great second best if the stomach is not available for that so much bigger operation. I like to move on to the next type of operation which is in minimally invasive esophagectomy or as called as MIE. Now, there are number of different procedures carried out that goes under this term but the most widely used now involves mobilizing the stomach through laparoscopy with the scopes. Preparing the stomach similar to what you saw in the open operation. Then using video assisted approaches to remove the esophagus in the chest and bringing the stomach up in the chest for an anastomosis. So this depicts the ports as they're called the openings, the small openings that are made on the abdominal wall to insert the instruments and the ports that are used on the chest to insert the instruments into the chest. Some like to argue that if one adds up the length of these small port incisions. They total what one would do if one were making an upper midline abdominal incision used for transhiatal esophagectomy, this may or may not be the case. And nevertheless, this shows the stapler being advanced into the abdomen through one of this ports and dividing the stomach similar to what I had shown you using the transhiatal approach. The difference however is that, with the transhiatal approach, the stomach is straightened on the anterior abdominal wall as the stapler is applied. Here, because the stomach cannot be straightened because its contained within the abdominal cavity. One winds up preserving this curvature of the stomach, which is a normal occurrence rather than straightening the stomach. And as a result, once the esophagus and stomach have been removed, this curved stomach does not reach as readily to the level of the neck as we achieve with the transhiatal mobilization. So this shows the thoracic approach with instruments inserted into the chest through the small port incisions, freeing up the esophagus and allowing its removal. At the end, because the stomach does not reach to the neck with a minimally invasive approach, the anastomosis is done in the chest. With a transhiatal esophagectomy the anastomosis is typically done in the neck. So those who use the minimally invasive approach, entouted as an advance because it represents new technology. And really step back in terms of accepting an intrathoracic esophagogastric anastomosis and the hazards of what a leak in this area can mean, which are still far greater than those leak in the neck. We know however, that minimally invasive esophagectomy is possible in experienced hands with good results. It's safe, but is has no significant benefits in either morbidity or mortality. It is a good marketing tool because patients like to hear that our operation is being performed minimally invasively. And that of course sounds like something anybody would want to have, an operation that is less invasive. Carrying this idea of minimally invasive one step further, robotic oesophagectomy has come on the scene, the da Vinci robot. With this procedure through a computerised council, the surgeon sitting here in a remote corner of the operating room or next to the patient, operates the arms of the robot which has many miniaturized instruments attached. And carries out the operation through the view box here, where the patient over her and an assistant standing at the table helping to operate the camera which shows what is happening inside the patient. This sounds like Star Wars, it's tremendous technology. The equipment has just burgeoned in its use of over 400% by 2011 in four years, millions of these operations having been performed. And I'm going to show you some of the concerns about robotic esophagectomy that include its cost, equipment malfunction. The aggressive marketing, to hospitals, surgeons and patients who feel that, if they don't have one or more robots that they're not really a good hospital because a hospital down the street has multiple robots. And then the surgical concerns about thermal burns of the stomach that occur with the robot. And then the reach of the stomach to the neck, as we've discussed, being less than adequate. If one just looks at the cost, right now, to buy a robot with a teaching console is $2.5 million. This comes with a $165,000 annual service contract. One has to hire one or two people to service the robot and clean it between the uses, and then simply to roll the robot into the operating room, the equipment setup is $5,000. So when one talks about the burgeoning cost of medical care in the United States, this is certainly one of the factors, this technology that is contributing to this. There are real safety implications of the DaVinci Robot system. This is new technology and after all, the robot is like any other surgical instrument, it's an instrument used by man and it has to be perfected. This recent report from 2014 at one of the major thoracic surgery meetings by Almenzadeh and colleagues reported adverse events that had been collated after being reported to the FDA. You can see that there are thousands of device malfunctions, injuries and some deaths that have occurred, and these data were compared to the aviation industry. Safety-critical events that is injury to the patient or death to the patient increased from 13 per 100,000 procedures to 50 per 100,000 procedure in an 8 year period of time. The number of deaths now associated with the robot exceeds 150. It's not a totally benign undertaking, and this was compared with accidents in aviation, which have remained relatively constant over the years at under 2 per 100,000 flight departures. So there still is a way to go in improving safety with the robot. And all that sounds good, may not necessarily be wonderful when one looks at the more granular detail about the procedure. Now, as we come to the end of this lecture, I would like to review with you again the pre-lecture question which I posed before. Historically, the 2 most common complications responsible for death after esophagectomy are, hemorrhage and infection, chylothorax and pneumothorax, pneumonia and mediastinitis, recurrent nerve paralysis and sepsis or wound infection and an anastomotic stricture. The correct answer? C, pneumonia from a combined chest and abdominal incision causing atelectasis and pneumonia from the pain and mediastinitis resulting from an anastomotic leak within the chest. So in conclusion, regardless of the approach used to remove the esophagus, Esophagectomy and reconstruction constitutes a major physiologic insult to the patient. Which carries the potential morbidity of pulmonary complications, an anastomotic leak, recurrent nerve injury, post-operative difficulty swallowing, post-vagotomy dumping, and adaptation to decreased gastric capacity. The morbidity and mortality of esophagectomy, regardless of the approach, is independent of the number of port sites versus a 5 to 6 inch laparotomy incision. If the stomach is mobilized gently and not contused when it is brought to the esophagus and is prepared gently, a healthy anastomosis will ensue with the likelihood of an anastomotic leak greatly reduced. It is extremely important to condition these patients for surgery by avoiding smoking for several weeks before surgery, having the patient walk three miles a day so that they'll be prepared to walk afterwards, and use of an incentive inspirometer. The annual case volume is an important guide for patients considering esophagectomy because the more operations a hospital and the surgeon do for year, the more experience the surgeon and his team have. And the more experienced they are in dealing with complications and in lowering the morbidity should a leak or a major complication, occur. That is a more experienced team has less failure to rescue should an adverse event occur. So that concludes today's discussion on surgery for esophageal carcinoma. I hope you have had an opportunity to consider the different approaches available and have a greater understanding of what these operations are and their potential morbidity and mortality. Thank you.
