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Laparoscopic and Thoracoscopic Esophagectomy

2010; Elsevier BV; Volume: 44; Issue: 1 Linguagem: Inglês

10.1016/j.yasu.2010.05.002

1878-0555

Ryan M. Levy, Joseph J. Wizorek, Manisha Shende, James D. Luketich,

Gastric Cancer Management and Outcomes

During the past decade, minimally invasive approaches to esophagectomy have emerged as safe, technically feasible alternatives to open esophageal resection. There has been a significant evolution in technique since the initial descriptions of hybrid approaches using thoracoscopic esophageal mobilization with a laparotomy [ 1 McAnena O.J. Rogers J. Williams N.S. Right thoracoscopically assisted oesophagectomy for cancer. Br J Surg. 1994; 81: 236-238 Crossref PubMed Scopus (107) Google Scholar , 2 Collard J.M. Lengele B. Otte J.B. et al. En bloc and standard esophagectomies by thoracoscopy. Ann Thorac Surg. 1993; 56: 675-679 Abstract Full Text PDF PubMed Scopus (137) Google Scholar , 3 Peracchia A. Rosati R. Fumagalli U. et al. Thoracoscopic esophagectomy: are there benefits?. Semin Surg Oncol. 1997; 13: 259-262 Crossref PubMed Scopus (58) Google Scholar , 4 Cuschieri A. Endoscopic subtotal oesophagectomy for cancer using the right thoracoscopic approach. Surg Oncol. 1993; 2: 3-11 Abstract Full Text PDF PubMed Scopus (50) Google Scholar ]. Although technically demanding and associated with a significant operator learning curve, totally minimally invasive esophagectomy (MIE) has been shown to be a viable option for esophageal resection while reducing blood loss, length of hospital stay, and narcotic requirements [ 5 Law S. Wong J. Use of minimally invasive oesophagectomy for cancer of the oesophagus. Lancet Oncol. 2002; 3: 215-222 Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar , 6 Atkins B.Z. Shah A.S. Hutcheson K.A. et al. Reducing hospital morbidity and mortality following esophagectomy. Ann Thorac Surg. 2004; 78 ([discussion: 1170–6]): 1170-1176 Abstract Full Text Full Text PDF PubMed Scopus (355) Google Scholar , 7 Law S. Wong K.H. Kwok K.F. et al. Predictive factors for postoperative pulmonary complications and mortality after esophagectomy for cancer. Ann Surg. 2004; 240: 791-800 Crossref PubMed Scopus (332) Google Scholar , 8 Bailey S.H. Bull D.A. Harpole D.H. et al. Outcomes after esophagectomy: a ten-year prospective cohort. Ann Thorac Surg. 2003; 75 ([discussion: 222]): 217-222 Abstract Full Text Full Text PDF PubMed Scopus (380) Google Scholar , 9 Narumiya K. Nakamura T. Ide H. et al. Comparison of extended esophagectomy through mini-thoracotomy/laparotomy with conventional thoracotomy/laparotomy for esophageal cancer. Jpn J Thorac Cardiovasc Surg. 2005; 53: 413-419 Crossref PubMed Scopus (13) Google Scholar ]. In our experience, a minimally invasive approach reduces postoperative pain and pulmonary complications while comparing favorably with the best published open series with regard to morbidity, mortality, and oncologic outcomes [ [10] Luketich J.D. Alvelo-Rivera M. Buenaventura P.O. et al. Minimally invasive esophagectomy: outcomes in 222 patients. Ann Surg. 2003; 238 ([discussion: 494–5]): 486-494 Crossref PubMed Google Scholar ]. At present, minimally invasive techniques include laparoscopic transhiatal, laparoscopic-thoracoscopic 3-hole (McKeown), and laparoscopic-thoracoscopic (Ivor Lewis) esophagectomy. Each of these can be performed with lymph node sampling or a more complete lymph node dissection. Although the choice between approaches is, to a large degree, based on surgeon preference, the operative approach is at times dictated by anatomic location of the tumor margins. For example, a midthoracic esophageal tumor or long segment of Barrett's esophagus may require a more proximal resection margin and mandate a cervical anastomosis, whereas a gastroesophageal (GE) junction tumor extending onto the gastric cardia might limit conduit length and thus require an intrathoracic anastomosis. The choice of operative approach also impacts postoperative morbidity depending on which body cavities are entered. Specifically, approaches that include a cervical anastomosis have been shown to have a higher incidence of anastomotic stricture, leak, recurrent nerve injury, and pharyngoesophageal swallowing dysfunction [ 6 Atkins B.Z. Shah A.S. Hutcheson K.A. et al. Reducing hospital morbidity and mortality following esophagectomy. Ann Thorac Surg. 2004; 78 ([discussion: 1170–6]): 1170-1176 Abstract Full Text Full Text PDF PubMed Scopus (355) Google Scholar , 11 Hulscher J.B. Tijssen J.G. Obertop H. et al. Transthoracic versus transhiatal resection for carcinoma of the esophagus: a meta-analysis. Ann Thorac Surg. Jul 2001; 72: 306-313 Abstract Full Text Full Text PDF PubMed Scopus (491) Google Scholar , 12 Martin R.E. Letsos P. Taves D.H. et al. Oropharyngeal dysphagia in esophageal cancer before and after transhiatal esophagectomy. Dysphagia. 2001; 16: 23-31 Crossref PubMed Scopus (37) Google Scholar , 13 Easterling C.S. Bousamra 2nd, M. Lang I.M. et al. Pharyngeal dysphagia in postesophagectomy patients: correlation with deglutitive biomechanics. Ann Thorac Surg. 2000; 69: 989-992 Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar ]. In comparison, transthoracic approaches have an increased incidence of cardiopulmonary complications and more morbid consequences when an anastomotic leak does occur [ [14] Hulscher J.B. van Sandick J.W. de Boer A.G. et al. Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the esophagus. N Engl J Med. 2002; 347: 1662-1669 Crossref PubMed Scopus (1339) Google Scholar ].