Abstract. Background: Minimally invasive esophagectomy has the potential to minimize the morbidity of esophageal resection and is particularly suited to the ...
Surg Endosc (2007) 21: 1190–1193 DOI: 10.1007/s00464-007-9312-y Ó Springer Science+Business Media, LLC 2007
Minimally invasive transhiatal esophagectomy: lessons learned Grant Sanders, Frederic Borie, Emanuel Husson, Pierre Marie Blanc, Gianluca Di Mauro, Christiano Claus, Bertrand Millat Department of Gastrointestinal Surgery, St. Eloi Hospital, University Hospital of Montpellier, Montpellier, France Received: 4 January 2007/Accepted: 27 January 2007/Online publication: 4 May 2007
Abstract Background: Minimally invasive esophagectomy has the potential to minimize the morbidity of esophageal resection and is particularly suited to the transhiatal approach. This report details our experience with this technique and the lessons we have learned. Methods: A retrospective analysis of patients who underwent minimally invasive transhiatal esophagectomy was performed. Parameters assessed included patient demographics, tumor pathology, operative and postoperative course, and survival. Results: Eighteen patients underwent minimally invasive transhiatal esophagectomy [median age = 69 years (range = 36–79)]. Seventeen were operated on for cancer, including 13 adenocarcinomas and 4 squamous cell carcinomas (median histological stage = 2, range = 1–3), and 1 for high-grade dysplasia in BarrettÕs. One patient had neoadjuvant chemotherapy. Two patients underwent nonemergency conversion to open surgery. The median duration of operation was 300 min (range = 180–450). All anastomoses were endto-side hand-sewn. No patients received a red cell transfusion. The 30-day mortality was zero. Complications developed in 15 patients, including 7 respiratory and 10 recurrent laryngeal nerve injuries. There were two anastomotic leaks. Six patients developed stenosis requiring dilatation. The median length of stay was 15 days (range = 10–39). The median number of nodes harvested was 10 (range = 2–26). At a median followup of 13 months (range = 4–42), 13 patients were alive. Conclusions: Minimally invasive transhiatal esophagectomy is feasible in our unit, with acceptable mortality. The high rate of anastomotic stenosis has resulted in a change to a semimechanical, side-to-side isoperistaltic technique. The high rate of recurrent laryngeal nerve injuries has resulted in the avoidance of metal retractors at the tracheo-esophageal groove.
Key words: Minimally invasive esophagectomy Transhiatal esophagectomy — Esophageal cancer
—
Minimally invasive esophagectomy (MIE) has the potential to minimize the morbidity of esophageal resection and allow a quicker return to normal activity. Transhiatal esophagectomy is ideally suited to the laparoscopic approach, allowing the lower mediastinal dissection to be performed under direct vision. This report details our experience with this technique and the lessons we have learned. Materials and methods A retrospective review was performed of all patients who underwent transhiatal MIE in our unit from February 2000 to July 2005. Preoperative investigations included oesogastroduodenoscopy and biopsy, computed tomography (CT) of the chest and abdomen, and endoscopic ultrasound (EUS) when feasible, during the last three years of the study. All the resections were performed by two digestive surgeons experienced in advanced minimally invasive surgery. Parameters assessed included patient demographics, tumor pathology, operative and postoperative course, and survival.
Positioning and port placement The patient is placed in a 30° anti-Trendelenburg position with the operating surgeon between the patientÕs legs, the camera holder and instrument nurse on the patientÕs left, and the second assistant on the right. The screen is placed on the patientÕs right and the patientÕs left arm is by the side. The operative field is draped to allow access to the abdomen, anterior thorax, and left neck. A 14-mmHg pneumoperitoneum is induced after open insertion of the first 10-mm trocar. Five trocars are used: three subcostal on the left (10 mm, 10 mm, and 5 mm going from right to left) and 2 subcostal on the right, both 5 mm. A 0° optic is introduced via the trocar close to the xyphoid. A 30° optic may be needed to aid with a very high mediastinal dissection. We feel it is vital to place the trocars close to the subcostal margin to facilitate the transhiatal dissection.
Transhiatal dissection Correspondence to: B. Millat
We begin with the transhiatal dissection using an electronic dissector, either the 10-mm Ligasure (Valleylab, Boulder, CO, USA) or 5-mm
1191 Ultracision (Ethicon Endo-Surgery) throughout. We have found that the blunt end of the 10-mm Ligasure facilitates a safe dissection. It is a long instrument, which helps with the high mediastinal dissection. The left lobe of the liver is elevated using an atraumatic liver retractor. The pars flaccida and pars condensa are divided to allow access to the right crus. If the tumor is cardial and greater than T2, the crura are either opened or partially excised to expose the lower mediastinum. A tape is passed around the abdominal esophagus, as per an antireflux procedure, and held by a grasper introduced via the left lateral trocar to aid with retraction. The esophagus is dissected free from the mediastinum using a combination of division with the electronic dissector and a sweeping action, in a similar fashion to the dissection of a large hiatal hernia sac. The limits of the dissection are as follows: anteriorly, the left pulmonary vein, pericardium, and carina; posteriorly, the aorta; and on each side, the pleura. Once again, if the tumor is large, the pleura in contact is resected en bloc. The dissection continues until the level of the azygos vein, which can usually be visualized.
Abdominal dissection The dissection continues down the gastrohepatic ligament as far as the hepatic artery. The greater curve is fully mobilized, dividing the short gastric arteries and gastrocolic ligament using the electronic dissector, taking care to avoid the right gastroepiploic arcade. The stomach is now elevated with the aid of the atraumatic liver retractor and the posterior aspect of the stomach is mobilized. The left gastric vein is clipped and divided at its distal end and the artery is clipped and divided at its origin. A more extensive lymphadenectomy is not performed.
Cervical dissection After a J-shaped incision, the esophagus is identified posterior to the trachea, encircled with tape, and mobilized distally, using a combination of blunt and sharp dissection, ensuring the dissection stays on the surface of the esophagus. Once the lower dissection is done, the cervical esophagus is divided with a linear stapler using 3.5-mm staples. Tape is placed on the staple line.
Specimen retrieval and anastomosis A transverse left subcostal incision is made up to and including the two 10-mm trocars. The esophagus is then reduced into the abdomen and the entire stomach and esophagus is produced through the abdominal wound. Duodenopancreatic bloc mobilization and pyloroplasty are performed extracorporeally. The gastroplasty is fashioned with a linear stapler using 4.5-mm staples, with the first firing perpendicular to the lesser curve because this allows a longer tube to be fashioned. The remainder of the staples run parallel to the greater curve toward the gastric fundus, creating a tube at least 6-cm wide. The staple line is oversewn with 3-0 monofilament absorbable suture. If the pleura has been breached, a tube drain is placed into the thoracic cavity, one on each side if needed, through the mediastinum and exteriorized using the lateral port incisions. The stomach is introduced into a laparoscopic camera sleeve, and the tape stapled to the esophagus in the neck during transection is tied around the camera sleeve and the gastroplasty fed up inside the sleeve to the neck, taking care to avoid rotation. The anastomosis is fashioned end to side with interrupted 4-0 PDS. A feeding jejunostomy is placed in all patients.
Results Eighteen patients underwent the procedure (Table 1) [median age = 69 years (range = 36–79)]. There were 14 males and 4 females with a median American Society of Anesthesiologists (ASA) grade of 2 and body mass
Table 1. Characteristics of the 18 patients Age
69 (36–79) years
Gender ASA 1 2 3 BMI Neoadjuvant therapy Operation time Conversions (2)
4 female, 14 male
Conduit Anastomosis Transfusion Length of stay
5 7 6 25 (20–34) kg/m2 1 patient: 5 FU, cisplatin 300 (180–450) min (1) Siewert 3, adhesions due to previous AAA repair (2) intolerance pneumoperitoneum 16 gastric 2 colon: total esophagogastrectomy Siewert 3 tumors End to side 18 (hand-sewn) 0 15 (10–39) days
index (BMI) of 25 (range = 20–34). Seventeen were operated on for cancer, 13 adenocarcinomas and 4 squamous cell carcinomas, and 1 for high-grade dysplasia in BarrettÕs. One patient had neoadjuvant chemotherapy (6 cycles of 5 folinic acid and cysplatin). In 16 patients a gastroplasty was performed. In the remaining two the colon was used because a total esophagogastrectomy was performed for extensive junctional tumors classified as Siewert 3 [1], where proximal clearance could not be achieved by an extended gastrectomy. Two patients underwent nonemergency conversion to open surgery; the first had had a previous abdominal aortic aneurysm repair and extensive adhesions made it impossible to proceed and the second would not tolerate the pneumoperitoneum. The median duration of operation was 300 min (range = 180–450). No patients received a red blood cell transfusion. The 30-day mortality was 0. Complications developed in 15 patients (Table 2). The median length of hospital stay was 15 days (range = 10–39). The median number of nodes harvested was 10 (range = 2–26). The sites of the tumors resected and pathologic stages are given in Table 3. At a median follow-up of 13 months (range = 4–42), 13 patients were alive.
Discussion Transhiatal esophagectomy was popularized as a way to decrease morbidity during an esophagectomy. The largest randomized study comparing transhiatal with transthoracic esophagectomy for patients with esophageal cancer demonstrated a lower rate of pneumonia with the transhiatal approach, and no significant difference in 5-year survival [2]. It appears that it is the stage of the tumor and its biological behavior when diagnosed that determine survival and not the number of nodes resected or size of the specimen [3]. In an attempt to further lower morbidity, some centers have explored minimally invasive approaches. The transhiatal approach is ideally suited to laparo-
1192 Table 2. Morbidity in 15 patients Pulmonary Pneumonia Atelectasis Chylothorax Anastomotic leak Stenosis requiring dilatation Vocal cord paralysis MI PE
5 2 1 2 2 4 8 2 1 1
(2 requiring ventilation) (settled spontaneously) (surgical drainage) following leaks spontaneous temporary permanent
MI = myocardial ischemia; PE = pulmonary embolism
Table 3. Tumor characteristics and survival Type/position of tumor (AdenoCa unless stated) TNM stage Esophageal (14) I Iia Iib III Gastric for S3 (3) II IIIa Number lymph nodes Survival at median 13-month follow-up (range = 4–42)
Middle 3 (2 SCC) Lower 6 (2 SCC) S1 (2), S2 (3), S3 (3) HGD in BarrettÕs (1) 2 5 2 5 1 2 10 (2–26) 13 of 18 patients
S = Siewert [1]
scopic surgery because the transhiatal dissection can be performed under magnified, direct vision to the level of the azygos vein in almost all cases. We do, however, use an 8-cm transverse abdominal incision to safely remove the specimen. Furthermore, this allows us to kocherize the duodenum, fashion the gastroplasty including oversewing of the staple line, and perform the pyloroplasty extracorporeally. This is not only easier to perform extracorporeally, it saves time and is cheaper because the endostaplers are not required. In our series the mortality rate was zero and the complication rate was acceptable, except for the relatively high rate of stenosis requiring dilatation and recurrent laryngeal nerve (RCLN) injury. Both these complications have a large negative impact on quality of life [4]. Furthermore, RCLN injury is a serious complication because it leads to an increased rate of pneumonia [5, 6], which may in part explain our 28% rate of pneumonia (40% of our patients with pneumonia had an associated RCLN injury). Stenosis is unfortunately a common complication after esophagectomy. Orringer reported a dilatation rate of 77% in 1085 patients undergoing transhiatal esophagectomy [3]. The Mayo clinic [7] reported a dilatation rate of 28.6% in their 280 patients undergoing a variety of surgical approaches. In an attempt to minimize the rate of stenosis, a variety of different anastomotic techniques have been tried and reported. When the Mayo clinic [7]
analyzed their results by type of anastomosis, hand-sewn or mechanical side–to-side using a 3.5-mm linear stapler, the rate of stenosis was significantly higher in the handsewn group (34.1% vs. 14.7%). LuketichÕs unit [8] has reported its results in 181 patients who underwent open transhiatal (n = 146) and three-stage (n = 35) esophagectomy. They used a totally mechanical side-to-side isoperistaltic anastomosis (TMA) or hand-sewn (HSM), which included a semimechanical side-to-side technique in 15 patients. Stenosis was defined as symptomatic, unable to pass the endoscope, and the need for more than one dilatation. They found a higher rate of stenosis in the hand-sewn group (45%) compared with the totally mechanical side-to-side isoperistaltic group (18%) (p = 0.0002). Furthermore, their leak rate was 11% and was higher in the hand-sewn group (23% vs. 6%). A Canadian unit [9] has also reviewed its series, comparing hand-sewn and mechanical side-to-side isoperistaltic anastomosis in 91 patients over ten years with cardia Siewert 1 lesions who had undergone Ivor-Lewis (n = 49) and transhiatal (n = 42) esophagectomy. The stricture rate was 13.2% and was higher in the handsewn group (17% vs. 7.9%), and the leak rate was 16.5% and also was higher in the hand-sewn group (22.6% vs. 7.9%), although their differences were not statistically significant. Although the results of the above-mentioned studies are compelling, the trials were not randomized. A metaanalysis [10] of randomized controlled trials comparing hand-sewn and stapled anastomoses demonstrated no difference in rate of stenosis or leaks; however, all the stapled anastomoses were circular and all the anastomoses were intrathoracic. Although a prospective randomized trial is needed, it may never happen; the Mayo clinic [7] is so convinced by their results, all their surgeons have adopted the stapled technique. As a result of the encouraging reports with a mechanical anastomosis, we have changed our technique to a semimechanical, side-to-side isoperistaltic anastomosis. The rate of RCLN injury depends on the definition and how hard one looks for it. In our series all patients with dysphonia after the operation were classified as having an injury; most were temporary and two were permanent and confirmed by indirect laryngoscopy. Luketich et al. [11] reported a rate of permanent injury of 3.6%. Other authors have reported a permanent rate of 2% [12] and 5% [13]. However, the median rate of injury, including temporary, in published series is 10%, with a range between 5% and 24% [3, 5, 6, 14–17]. The rate is less common when the neck dissection is avoided. Rindani et al. [18] reviewed the results of 44 papers with over 5000 patients that reported on either transhiatal or transthoracic esophagectomies and demonstrated nerve injury rates of 11.2% after transhiatal versus 4.8% after thoracic esophagectomies. This indicates that, in general, the injury occurs during the neck dissection. This has led other authors to change their practice; Smithers et al. [15] reported a halving in their rate of permanent nerve injury from 5% to 2.5% after they implemented the avoidance of metal retractors near the tracheoesophageal groove. The rate of injury in OrringerÕs series [3] decreased from 32% to less than 3% with increased
1193
experience and avoidance of metal retractors placed at tracheo-esophageal groove and the use of ‘‘finger only’’ retraction. As a result we have also changed our technique, with the above comments in mind. Minimally invasive surgery has been applied in a number of ways to esophagectomy for cancer: transhiatal [1, 3], thoracoscopy with laparotomy and cervical anastomosis [15], laparoscopy with thoracotomy [19], and laparoscopy and thoracoscopy with cervical anastomosis [11, 12] or intrathoracic anastomosis [12, 20]. Each technique has its proponents. In reality, as long as the technique has a low mortality and morbidity rate, whatever the technique, the real differences are likely to come from further advances in neoadjuvant therapy [21]. In summary, minimally invasive transhiatal esophagectomy is feasible in our unit, with acceptable mortality. The high rates of anastomotic stenosis and recurrent laryngeal nerve injury have resulted in a change of practice.
8.
9. 10.
11.
12.
13. 14.
References 15. 1. Siewert JR, Stein HJ (1998) Classification of adenocarcinoma of the oesophagogastric junction. Br J Surg 85: 1457–1459 2. Hulscher JB, van Sandick JW, de Boer AG, Wijnhoven BP, Tijssen JG, Fockens P, Stalmeier PF, ten Kate FJ, van Dekken H, Obertop H, Tilanus HW, van Lanschot JJ (2002) Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the esophagus. N Engl J Med 347: 1662–1669 3. Orringer MB, Marshall B, Iannettoni MD (1999) Transhiatal esophagectomy: clinical experience and refinements. Ann Surg 230: 392–400 4. Baba M, Natsugoe S, Shimada M, Nakano S, Noguchi Y, Kawachi K, Kusano C, Aikou T (1999) Does hoarseness of voice from recurrent nerve paralysis after esophagectomy for carcinoma influence patient quality of life? J Am Coll Surg 188: 231–236 5. Gockel I, Kneist W, Keilmann A, Junginger T (2005) Recurrent laryngeal nerve paralysis (RLNP) following esophagectomy for carcinoma. Eur J Surg Oncol 31: 277–281 6. Hulscher JB, van Sandick JW, Devriese PP, van Lanschot JJ, Obertop H (1999) Vocal cord paralysis after subtotal oesophagectomy. Br J Surg 86: 1583–1587 7. Behzadi A, Nichols FC, Cassivi SD, Deschamps C, Allen MS, Pairolero PC (2005) Esophagogastrectomy: the influence of
16.
17. 18. 19. 20.
21.
stapled versus hand-sewn anastomosis on outcome. J Gastrointest Surg 9: 1031–1040 Santos RS, Raftopoulos Y, Singh D, DeHoyos A, Fernando HC, Keenan RJ, Luketich JD, Landreneau RJ (2004) Utility of total mechanical stapled cervical esophagogastric anastomosis after esophagectomy: a comparison to conventional anastomotic techniques. Surgery 136: 917–925 Casson AG, Porter GA, Veugelers PJ (2002) Evolution and critical appraisal of anastomotic technique following resection of esophageal adenocarcinoma. Dis Esophagus 15: 296–302 Urschel JD, Blewett CJ, Bennett WF, Miller JD, Young JE (2001) Handsewn or stapled esophagogastric anastomoses after esophagectomy for cancer: meta-analysis of randomized controlled trials. Dis Esophagus 14: 212–217 Luketich JD, Alvelo-Rivera M, Buenaventura PO, Christie NA, McCaughan JS, Litle VR, Schauer PR, Close JM, Fernando HC (2003) Minimally invasive esophagectomy: outcomes in 222 patients. Ann Surg 238: 486–494 Nguyen NT, Roberts P, Follette DM, Rivers R, Wolfe BM (2003) Thoracoscopic and laparoscopic esophagectomy for benign and malignant disease: lessons learned from 46 consecutive procedures. J Am Coll Surg 197: 902–913 Avital S, Zundel N, Szomstein S, Rosenthal R (2005) Laparoscopic transhiatal esophagectomy for esophageal cancer. Am J Surg 190: 69–74 Bann S, Moorthy K, Shaul T, Foley R (2005) Laparoscopic transhiatal surgery of the esophagus. JSLS 9: 376–381 Smithers BM, Gotley DC, McEwan D, Martin I, Bessell J, Doyle L (2001) Thoracoscopic mobilization of the esophagus. A 6 year experience. Surg Endosc 15: 176–182 Swanson SJ, Batirel HF, Bueno R, Jaklitsch MT, Lukanich JM, Allred E, Mentzer SJ, Sugerbaker DJ (2001) Transthoracic esophagectomy with radical mediastinal and abdominal lymph node dissection and cervical esophagogastrostomy for esophageal carcinoma. Ann Thorac Surg 72: 1918–1924 Yamamoto S, Kawahara K, Maekawa T, Shiraishi T, Shirakusa T (2005) Minimally invasive esophagectomy for stage I and II esophageal cancer. Ann Thorac Surg 80: 2070–2075 Rindani R, Martin CJ, Cox MR (1999) Transhiatal versus IvorLewis oesophagectomy: is there a difference? Aust N Z J Surg 69: 187–194 Bonavina L, Bona D, Binyom PR, Peracchia A (2004) A laparoscopy-assisted surgical approach to esophageal carcinoma. J Surg Res 117: 52–57 Bizekis C, Kent MS, Luketich JD, Buenaventura PO, Landreneau RJ, Schuchert MJ, Alvelo-Rivera M (2006) Initial experience with minimally invasive Ivor-Lewis esophagectomy. Ann Thorac Surg 82: 402–406 Mariette C, Triboulet JP (2006) Should resectable esophageal cancer be resected? Ann Surg Oncol 13: 447–449
