Objectives: Ivor Lewis esophagogastrectomy is a well established oncologic procedure for cancers at or near the gastro-esophageal junction. However, this procedure is associated with significant morbidity related to the thoracotomy, especially following induction chemo/radiation therapy. A thoracoscopic approach may obviate this problem. Currently, thoracoscopic approaches are limited by 2-D visualization and lack of instrument maneuverability. Robotics, by virtue of 3-D visualization and greater dexterity may facilitate the thoracoscopic portion of the Ivor Lewis esophagogastrectomy.
Methods: Between 1/04 and 10/08, 36 patients underwent robotic-assisted esophagectomy with intrathoracic esophagogastrostomy (27 men, 9 women, age 37-77). Robot-assisted thoracoscopic esophageal dissection, mediastinal nodal dissection and intrathoracic anastomosis were performed via 4 ports in the right chest.
Results: 14 patients had induction therapy. Median operative time: 9 hours (range 8-17 hours). Esophagogastrostomy was performed in the right chest above the azygous vein. There were 8 nonemergent conversions to a thoracotomy due to technical difficulty with the anastomosis. Cell type were 27 ACA, 5 SCCA, 2 poorly differentiated CA, 1 carcinoma in situ, 1 high grade dysplasia. Median hospitalization was 11 days (range 8-60 days). Complications: 1 anastomotic leak (3%), 5 atrial fibrillation, 2 pulmonary emboli, 1 gastric staple line dehiscence > 30 days, 1 ileus, 1 respiratory failure, 1 reversible renal failure, 2 C-Diff colitis. There was one death (3%). Six patients (18%) required dilation of the esophagogastrostomy, 1 (3%) required pyloric dilatation. Follow up was complete in 34 patients (94%). At follow up, distant mets were seen in 6 (17%) patients, there was no local recurrence, and 22 (61%) were alive. Six patients died of their cancer (17%) and 5 died of other causes (17%).
Conclusions: Robot assistance significantly facilitates the thoracoscopic mobilization of the esophagus during an Ivor Lewis esophagogastrectomy. Robotic intrathoracic anastomosis is feasible but remains a challenge. More studies and further follow up are necessary to fully assess the role of robotics in the minimally invasive treatment of esophageal cancer.
Program Number: P335