- Email: [email protected]
Minimally invasive resection and mechanical cervical esophagogastric anastomotic techniques in the management of esophageal cancer
Minimally Invasive Resection and Mechanical Cervical Esophagogastric Anastomotic Techniques in the Management of Esophageal Cancer James D. Luketich, M.D., Rodney J. Landreneau, M.D. Standard esophagectomy for carcinoma of the esophagus is associated with significant morbidity and mortality rates. Although reports from some individual surgical centers have reported exceptional survival results with standard esophagectomy, a recent report summarizing nationwide statistics identified mortality rates from esophagectomy that ranged from 8% in high-volume centers to as great as 23% in lowvolume centers.1 Morbidity related to the procedure has also been high. The most important morbidity seen is related to the failure of the esophagogastric anastomosis. Minimally invasive esophagectomy (MIE) has the potential to lower the morbidity of open operation and allow quicker return to normal function compared with the use of open surgical approaches. Now that advanced minimally invasive surgical procedures are more frequently being performed, detailed results and outcomes must be reported to the surgical community, to assess potential advantages and disadvantages. Also, the use of mechanical stapled techniques may assist in reducing the postoperative leak and stricture rate with cervical esophagogastric anastomosis after esophagectomy. PATIENTS AND METHODS During a 5-year period from June 1996 through August 2002, we performed MIE in 222 patients. The primary inclusion criterion for esophageal cancer patients fit for operation was the presence of a resectable lesion after evaluation with endoscopic ultrasound and computed tomography staging of the malignancy. Initially, we used a laparoscopic transhiatal approach for patients with smaller tumors or with highgrade dysplasia as an indication for esophagectomy (n ⫽ 8). We have converted to the combined thoracoscopic and laparoscopic approach to esophageal dissection and gastric mobilization as our procedure of choice for MIE in the last 214 patients. We believe that mobilization of the intrathoracic esophagus is safer and that a more complete lymph node dissection
can be accomplished with the inclusion of the thoracoscopic approach. Our current technique of MIE is similar to our previously reported description.2 The difficulty with anastomotic leak and postoperative stricture after cervical esophagogastric anastomosis has led us to explore the use of a totally mechanical stapled technique. It is appreciated that this anastomotic difficulty is primarily related to ischemia of the fundic tip and to the inherent imprecision of a handsewn anastomosis compared with mechanical stapled anastomosis.3,4 Later in this lecture summary, we report a comparison of our mechanical stapled technique versus the hand-sewn or partially stapled approach to cervical esophagogastric anastomosis. Our 222 patients included 186 (83.8%) men and 36 (16.2%) women (median age, 66.5 years; age range, 39–89 years). Preoperative indications for operation included carcinoma in 175 (78.8%) and high-grade dysplasia in 46 (21.2%). Neoadjuvant chemotherapy was used in 78 (35.1%) and radiation in 36 (16.2%). Before MIE, expandable esophageal stents had been placed in 13 patients (5.9%) during induction therapy, and 19 patients (8.6%) had undergone unsuccessful photodynamic therapy to treat high-grade mucosal dysplasia. There was a history of previous open abdominal surgery in 55 (24.8%) of patients. The stomach was used as the esophageal substitute in all patients. The esophageal bed was used for the gastric conduit in 213 cases, and the substernal route was selected in 9 cases to allow postoperative radiation to the esophageal bed without irradiation of the gastric pull-up. Pyloromyotomy was performed in 28 and pyloroplasty in 136 patients (74%). A laparoscopic feeding jejunostomy was placed in 202 patients at the time of MIE (91%).
RESULTS MIE was successfully completed in 206 (92.8%) patients. Minithoracotomy was required in 12 (5.4%) and laparotomy in 4 (1.8%) patients due to
From the University of Pittsburgh Medical Center and the University of Pittsburgh Shadyside Medical Center, Pittsburgh, Pennsylvania. Correspondence: Rodney J. Landrenau, M.D. e-mail: [email protected]
쑖 2004 The Society for Surgery of the Alimentary Tract Published by Elsevier Inc.
1091-255X/04/$—see front matter doi:10.1016/j.gassur.2004.09.051
927
928
Journal of Gastrointestinal Surgery
Luketich and Landreneau
Table 1. Major and minor complications following minimally invasive esophagectomy Minor complications
No. (%)
Atrial fibrillation
26 (11.7)
Atelectasis with mucus plug requiring bronchoscopy Pleural effusion requiring tube J-tube infection Clostridium difficile colitis Wound infection Intraoperative tracheal perforation (1–2 mm) Miscellaneous (others)
Total
55 (24)
Major complications
No. (%)
10 (4.5)
Anastomotic leak—overall Normal gastric tube Narrow gastric tube Myocardial infarction
26 10 16 4
(11.7) (6.1) (25.9) (1.8)
14 1 2 2 2
Gastric tip necrosis Delayed gastric emptying Pancreatitis Chylothorax Tracheal tear
7 4 3 7 2
(3.2) (1.8) (1.4) (3.2) (0.9)
3 3 17 4 8 2 4 71
(1.4) (1.4) (7.7) (1.8) (3.6) (0.9) (1.8) (32)
(6.3) (0.5) (0.9) (0.9) (0.9)
5 (2.25)
Deep vein thrombosis Pulmonary embolus Pneumonia ARDS Vocal cord palsy Renal failure Miscellaneous (others) Total
ARDS ⫽ acute respiratory distress syndrome.
the presence of significant cavitary adhesions impeding the progress of the procedure. The 30-day operative mortality rate was 1.4% (n ⫽ 3). The three deaths resulted from pneumonia and multisystem organ failure in one patient, postoperative myocardial infarction in one patient, and pericardial tamponade occurring 3 days after MIE in another patient. Major and minor morbidities are outlined in Table 1. The anastomotic leak rate was affected by the size of the gastric tube. In those patients with our standard diameter gastric tube of 6 cm, anastomotic leaks occurred in 10 of 164 (6.1%). In those patients in whom a narrow tube (3–4 cm) was used (n ⫽ 58), the leak rate was significantly increased (P ⬍ 0.001), occurring in 15 (25.9%) of patients. The median stay in an intensive care unit was 1 day (range, 1–30 days), time to oral intake was 4 days (range, 1–40 days), and length of hospital stay was 7 days (range, 3–75 days). The mean follow-up was 19
months (range, 1–68 months), with cancer-related survival similar to that seen after open esophagectomy on a pathologic stage analysis.
DISCUSSION We recently reanalyzed our anastomotic results with a hand-sewn or partial mechanical stapled cervical esophagogastric anastomosis (n ⫽ 56) versus the use of a totally mechanical stapled anastomotic technique (n ⫽ 125).5 The technique involves the use of the Endo Stapler to create the posterolateral side-toside union between the cervical esophagus and the mobilized stomach. A standard TA stapler is then applied across the anterior walls of the esophagus and stomach to complete the anastomosis. The results of this anastomotic comparison are depicted in Table 2, where we noted a significant reduction in anastomotic failure and postoperative stricture among our patients
Table 2. Results of total mechanical (TMA) versus hand-sewn/partial mechanical (HSM) anastomotic techniques5
Median ⫾ SEM operative time (min) Postoperative leak (%) Median length of hospital stay (days) Anastomotic stricture (%)
TMA (n ⫽ 125)
HSM (n ⫽ 56)
259 ⫾ 89 (range, 84–480) 5.6 11 17.6
347 ⫾ 94 (range, 115–555) 23.2 13 44.6
P value
⬍0.0001 0.001 0.002 0.002
Vol. 8, No. 8 2004
undergoing a totally mechanical stapled anastomotic approach. We have demonstrated that MIE is feasible and can produce therapeutic outcomes comparable to those reported in most open surgical series. The use of a full gastric tube and a totally mechanical stapled cervical esophagogastric anastomotic technique can reduce anastomotic morbidity following esophagectomy. It is important to note that our results with MIE originate from a center with extensive experience in both benign and malignant esophageal surgery and daily exposure to advanced minimally invasive surgical techniques. It will be important to determine whether MIE can be developed in other centers with similar outcomes. A phase II INTERGROUP study (Eastern Cooperative Oncology Group, E2202) is
Management of Esophageal Cancer
929
currently being developed with plans to study this issue. REFERENCES 1. Birkmeyer JD, Siewers AE, Finlayson EVA, et al. Hospital volume and surgical mortality in the United States. N Engl J Med 2002;346:1128–1137. 2. Luketich JD, Schauer PR, Christie NA, et al. Minimally invasive esophagectomy. Ann Thorac Surg 2000;70:906–912. 3. Orringer MB, Marshall B, Iannettoni MD. Eliminating the cervical esophagogastric anastomotic leak with a side-to-side stapled anastomosis. J Thorac Cardiovasc Surg 2000;119: 277–288. 4. Singh D, Maley RH, Santucci T, et al. Experience and technique of stapled mechanical cervical esophagogastric anastomosis. Ann Thorac Surg 2001;71:419–424. 5. Santos RS, Raftopoulos Y, Singh D, et al. Utility of totally mechanical cervical stapled esophagogastric anastomosis after esophagectomy: a comparison to conventional anastomotic techniques. Surgery 2004;136:917–925.
can be accomplished with the inclusion of the thoracoscopic approach. Our current technique of MIE is similar to our previously reported description.2 The difficulty with anastomotic leak and postoperative stricture after cervical esophagogastric anastomosis has led us to explore the use of a totally mechanical stapled technique. It is appreciated that this anastomotic difficulty is primarily related to ischemia of the fundic tip and to the inherent imprecision of a handsewn anastomosis compared with mechanical stapled anastomosis.3,4 Later in this lecture summary, we report a comparison of our mechanical stapled technique versus the hand-sewn or partially stapled approach to cervical esophagogastric anastomosis. Our 222 patients included 186 (83.8%) men and 36 (16.2%) women (median age, 66.5 years; age range, 39–89 years). Preoperative indications for operation included carcinoma in 175 (78.8%) and high-grade dysplasia in 46 (21.2%). Neoadjuvant chemotherapy was used in 78 (35.1%) and radiation in 36 (16.2%). Before MIE, expandable esophageal stents had been placed in 13 patients (5.9%) during induction therapy, and 19 patients (8.6%) had undergone unsuccessful photodynamic therapy to treat high-grade mucosal dysplasia. There was a history of previous open abdominal surgery in 55 (24.8%) of patients. The stomach was used as the esophageal substitute in all patients. The esophageal bed was used for the gastric conduit in 213 cases, and the substernal route was selected in 9 cases to allow postoperative radiation to the esophageal bed without irradiation of the gastric pull-up. Pyloromyotomy was performed in 28 and pyloroplasty in 136 patients (74%). A laparoscopic feeding jejunostomy was placed in 202 patients at the time of MIE (91%).
RESULTS MIE was successfully completed in 206 (92.8%) patients. Minithoracotomy was required in 12 (5.4%) and laparotomy in 4 (1.8%) patients due to
From the University of Pittsburgh Medical Center and the University of Pittsburgh Shadyside Medical Center, Pittsburgh, Pennsylvania. Correspondence: Rodney J. Landrenau, M.D. e-mail: [email protected]
쑖 2004 The Society for Surgery of the Alimentary Tract Published by Elsevier Inc.
1091-255X/04/$—see front matter doi:10.1016/j.gassur.2004.09.051
927
928
Journal of Gastrointestinal Surgery
Luketich and Landreneau
Table 1. Major and minor complications following minimally invasive esophagectomy Minor complications
No. (%)
Atrial fibrillation
26 (11.7)
Atelectasis with mucus plug requiring bronchoscopy Pleural effusion requiring tube J-tube infection Clostridium difficile colitis Wound infection Intraoperative tracheal perforation (1–2 mm) Miscellaneous (others)
Total
55 (24)
Major complications
No. (%)
10 (4.5)
Anastomotic leak—overall Normal gastric tube Narrow gastric tube Myocardial infarction
26 10 16 4
(11.7) (6.1) (25.9) (1.8)
14 1 2 2 2
Gastric tip necrosis Delayed gastric emptying Pancreatitis Chylothorax Tracheal tear
7 4 3 7 2
(3.2) (1.8) (1.4) (3.2) (0.9)
3 3 17 4 8 2 4 71
(1.4) (1.4) (7.7) (1.8) (3.6) (0.9) (1.8) (32)
(6.3) (0.5) (0.9) (0.9) (0.9)
5 (2.25)
Deep vein thrombosis Pulmonary embolus Pneumonia ARDS Vocal cord palsy Renal failure Miscellaneous (others) Total
ARDS ⫽ acute respiratory distress syndrome.
the presence of significant cavitary adhesions impeding the progress of the procedure. The 30-day operative mortality rate was 1.4% (n ⫽ 3). The three deaths resulted from pneumonia and multisystem organ failure in one patient, postoperative myocardial infarction in one patient, and pericardial tamponade occurring 3 days after MIE in another patient. Major and minor morbidities are outlined in Table 1. The anastomotic leak rate was affected by the size of the gastric tube. In those patients with our standard diameter gastric tube of 6 cm, anastomotic leaks occurred in 10 of 164 (6.1%). In those patients in whom a narrow tube (3–4 cm) was used (n ⫽ 58), the leak rate was significantly increased (P ⬍ 0.001), occurring in 15 (25.9%) of patients. The median stay in an intensive care unit was 1 day (range, 1–30 days), time to oral intake was 4 days (range, 1–40 days), and length of hospital stay was 7 days (range, 3–75 days). The mean follow-up was 19
months (range, 1–68 months), with cancer-related survival similar to that seen after open esophagectomy on a pathologic stage analysis.
DISCUSSION We recently reanalyzed our anastomotic results with a hand-sewn or partial mechanical stapled cervical esophagogastric anastomosis (n ⫽ 56) versus the use of a totally mechanical stapled anastomotic technique (n ⫽ 125).5 The technique involves the use of the Endo Stapler to create the posterolateral side-toside union between the cervical esophagus and the mobilized stomach. A standard TA stapler is then applied across the anterior walls of the esophagus and stomach to complete the anastomosis. The results of this anastomotic comparison are depicted in Table 2, where we noted a significant reduction in anastomotic failure and postoperative stricture among our patients
Table 2. Results of total mechanical (TMA) versus hand-sewn/partial mechanical (HSM) anastomotic techniques5
Median ⫾ SEM operative time (min) Postoperative leak (%) Median length of hospital stay (days) Anastomotic stricture (%)
TMA (n ⫽ 125)
HSM (n ⫽ 56)
259 ⫾ 89 (range, 84–480) 5.6 11 17.6
347 ⫾ 94 (range, 115–555) 23.2 13 44.6
P value
⬍0.0001 0.001 0.002 0.002
Vol. 8, No. 8 2004
undergoing a totally mechanical stapled anastomotic approach. We have demonstrated that MIE is feasible and can produce therapeutic outcomes comparable to those reported in most open surgical series. The use of a full gastric tube and a totally mechanical stapled cervical esophagogastric anastomotic technique can reduce anastomotic morbidity following esophagectomy. It is important to note that our results with MIE originate from a center with extensive experience in both benign and malignant esophageal surgery and daily exposure to advanced minimally invasive surgical techniques. It will be important to determine whether MIE can be developed in other centers with similar outcomes. A phase II INTERGROUP study (Eastern Cooperative Oncology Group, E2202) is
Management of Esophageal Cancer
929
currently being developed with plans to study this issue. REFERENCES 1. Birkmeyer JD, Siewers AE, Finlayson EVA, et al. Hospital volume and surgical mortality in the United States. N Engl J Med 2002;346:1128–1137. 2. Luketich JD, Schauer PR, Christie NA, et al. Minimally invasive esophagectomy. Ann Thorac Surg 2000;70:906–912. 3. Orringer MB, Marshall B, Iannettoni MD. Eliminating the cervical esophagogastric anastomotic leak with a side-to-side stapled anastomosis. J Thorac Cardiovasc Surg 2000;119: 277–288. 4. Singh D, Maley RH, Santucci T, et al. Experience and technique of stapled mechanical cervical esophagogastric anastomosis. Ann Thorac Surg 2001;71:419–424. 5. Santos RS, Raftopoulos Y, Singh D, et al. Utility of totally mechanical cervical stapled esophagogastric anastomosis after esophagectomy: a comparison to conventional anastomotic techniques. Surgery 2004;136:917–925.