Benjamin M Motz, MD, Patrick Lorimer, MD, Joshua Hill, MD, Mark Reames, MD, Danielle Boselli, James Symanowski, PhD, Jonathan C Salo, MD. Carolinas Medical Center
Introduction: The standard operative technique for Ivor-Lewis minimally-invasive esophagectomy involves a two-stage approach necessitating repositioning mid-procedure. We describe our technique for a one-stage Ivor-Lewis minimally-invasive esophagectomy that allows simultaneous access to the chest and abdomen, eliminating the need for repositioning. Additionally, this allows for extracorporeal construction of the gastric conduit, which has been shown to reduce anastomotic leak rates. We hypothesized that this approach would decrease operative time and postoperative complications without compromising oncologic outcomes.
Methods: From 2007 through 2016, a single surgical team performed 83 two-stage minimally-invasive esophagectomies followed by 97 performed with the one-stage technique. Categorical variables were compared with Fisher’s exact test and continuous variables with Wilcoxon rank test. Multivariable analysis used generalized linear models and linear regression.
Results: The one-stage group was older (median 65 vs 62 years, p = 0.0027), however there were no differences in gender, race, or tumor characteristics. In the one-stage group, neoadjuvant chemoradiation was utilized more frequently (p = 0.03), and adjuvant chemotherapy less frequently (p = 0.0085). Margin status did not differ. Median node harvest was greater in the one-stage group (15 vs 12 nodes, p = 0.0009) and median operative time was shorter (416 vs 534 minutes, p < 0.0001). There were fewer anastomotic leaks in the one-stage group (3.1% vs 14.5%, p = 0.0069). Likewise, there were fewer cases of pneumonia in the one-stage group (12.4% vs 25.3%, p = 0.03). However, for each of these variables, multivariable analysis demonstrated that operative experience (measured by case number) had the most significant association with improvement of outcomes.
Conclusions: This is the largest published series utilizing a one-stage Ivor-Lewis minimally-invasive esophagectomy. This technique was associated with shorter operative times, more harvested nodes, and fewer complications. These outcomes also improved during the course of our series, however, and it was not possible to distinguish the contributions of surgical technique compared with operative experience. Nonetheless, we find this technique to be useful and facile; furthermore, it does not appear to be inferior to other approaches from either a surgical or oncologic standpoint.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 80285
Program Number: S146
Presentation Session: Foregut 3
Presentation Type: Podium