Minimally invasive esophagectomy for esophageal cancer

Abstract

Esophagectomy remains the mainstay treatment of esophageal cancer. Minimally invasive techniques including thoracoscopic (VATS) +/- laparotomy or laparoscopy are popular. Many controversies exist with regards to the optimal esophagectomy methods. For advanced squamous cell cancers, neoadjuvant chemotherapy or chemoradiation (CRT) has become standard-of-care. This series of studies addressed some technical issues of minimally invasive esophagectomy, its relevance in the context of neoadjuvant CRT therapy, as well as its role when compared to traditional open surgery.

Ischemia of the conduit (stomach or colonic loop) used to restore intestinal continuity after esophagectomy predisposes to anastomotic leak and ischemic necrosis of the conduit. Intraoperative visual assessment of conduit vascularity is not reliable. Laser-assisted indocyanine green (ICG) fluorescence (LA-ICG) was tested in 33 patients (29 with gastric and 4 right ileo-colonic loops). In 8 patients with gastric conduit, suboptimal tissue vascularity was found by LA-ICG. In all, the relatively poorly perfused segment was resected before anastomosis. No patient developed conduit necrosis and only one patient had a minor anastomotic leak. LAICG fluorescence imaging is a potentially useful adjunct to help intraoperative decision for esophagectomy.

Extended lymphadenectomy is essential especially for squamous cell cancers. Bilateral recurrent laryngeal nerve (RLN) nodal dissection carries with it substantial risk of nerve injury. Intermittent nerve stimulation for mapping together with Continuous Intraoperative Nerve Monitoring (CIONM) using a system of vagus nerve stimulation was tested in 40 patients who had VATS esophagectomy, of whom 10 had nerve injury (right RLN palsy in 5% and left RLN in 25.9%). In 4 out of the 10 patients who had nerve palsies, RLN recovered at less than 9 weeks postoperatively. These findings are compatible with data in published literature. CIONM has potential to further improve results of RLN lymphadenectomy.

In another study, 84 patients who underwent VATS esophagectomy were compared with 105 who had neoadjuvant CRT and VATS esophagectomy (CRT + VATS). CRT + VATS had longer operating duration and thoracoscopy time. VATS group had more pneumonia and tracheostomy rates although the differences were not significant when adjusted for time period of operation. Multivariate analysis showed that pT-stage, number of involved nodes, and R-category were independent prognostic factors.

The outcome of 85 patients who had VATS esophagectomy (VATS), 104 VATS and laparoscopic gastric mobilization (total MIE), and 449 open esophagectomy (OPEN) were compared. Open esophagectomy resulted in more blood loss but shorter operation duration, and more wound infections. Total MIE had higher incidence of ischemic stomach compared with OPEN surgery (8.7% vs. 1.8%), and also more recurrent laryngeal nerve palsies (19.2% vs. 10.5%). These were related to a change in gastric tubularization method and more aggressive policy of RLN nodal dissection rather than the VATS or laparoscopic method per se. Lymph node yield was highest with total MIE. On multivariate analysis, gender, pT-stage, number of lymph nodes sampled, number of involved nodes, and R-category were independent prognostic factors.

Minimally invasive esophagectomy is safe and has survival comparable to open surgery. Further work is needed to refine its technique and integrate with multimodality therapies.