Vernon Horst, MD1, Hetal Patel, MD1, John G Touliatos, MD, FACS2. 1Baptist Health System, 2Advanced Surgeons, PC
INTRODUCTION: We set out to compare our minimally invasive trans-hiatal esophagectomy outcomes with minimally-invasive Ivor-Lewis esophagectomy outcomes. Esophageal cancer is an uncommon but highly lethal disease. Invasive esophageal cancer (greater than Stage II) has a low 5-year survival rate. Treatment options are both surgical and non-surgical, with surgical options including esophageal stents, endoscopic ablation, and surgical resection, with resection being the gold standard of therapy. Resection is also indicated for palliation. Esophagectomy, traditionally performed by laparotomy and right thoracotomy, carries an expected prolonged convalescence with complicated hospitalization and high peri-operative morbidity and mortality rates. Some studies have demonstrated benefit with minimally invasive esophagectomy.
METHODS AND PROCEDURES: Charts for all patients who underwent esophagectomy by our attending surgeon, John Touliatos, from 2008-2014 were reviewed. Data collected included cancer stage, number of nodes resected, anastomotic leak rates, mean duration of naso-gastric tube, length of stay, and 30-day peri-operative mortality.
RESULTS: We demonstrated a considerably improved outcome with minimally-invasive trans-hiatal esophagectomy when compared to Ivor-Lewis esophagectomy. Patients who underwent minimally-invasive trans-hiatal esophagectomy had fewer anastomotic leaks, a lower 30-day peri-operative mortality, and a mediastinal node harvest that was equivalent to or greater than patients who underwent Ivor-Lewis esophagectomy.
CONCLUSION: Trans-hiatal esophagectomy shows promise as a valid option for esophageal resection, including in advanced stages of cancer. We recognize the small sample size of both groups; however, in our patient population the trans-hiatal approach had a significantly improved benefit when comparing peri-operative mortality and morbidity, hospitalization length of stay, naso-gastric tube duration, and anastomotic leak rates. We propose that this a safe and appropriate approach for esophageal resection in all advanced stages of cancer in the hands of the experienced laparoscopic surgeon.