Transcervical Videoscopic Esophageal Dissection During Two-Field Minimally Invasive Esophagectomy – Early Patient Experience

Michael Parker, MD, Steven P Bowers, MD, Ross F Goldberg, MD, Jason M Pfluke, MD, John A Stauffer, MD, Horacio J Asbun, MD, C Daniel Smith, MD. Mayo Clinic Florida

Introduction:
Transhiatal esophagectomy (THE) reduces cardio-pulmonary complications by avoiding thoracic access, but requires some degree of blind mediastinal dissection. The authors developed a technique of Minimally Invasive Esophagectomy (MIE) using single-incision technology through the cervical incision to allow complete visualization during extrathoracic esophageal dissection. The operation is performed using laparoscopy and simultaneous transcervical videoscopic esophageal dissection (TVED). Our aim was to demonstrate the feasibility of two-field MIE with TVED for high-grade dysplasia and early esophageal cancer, or to improve the recovery of high-risk patients with severe comorbidities.

Methods and Procedures:
We performed a retrospective cohort study (IRB 10-005473) to review the intraoperative and perioperative outcomes of eight patients undergoing a two-field MIE with TVED between November 2009 and August 2010. There were six males and two females with a median age of 67 years (range 45-77). Median BMI was 30.2 (range 22.8-37.9). Based on preoperative staging, two patients had high-grade dysplasia, five had early-stage adenocarcinoma, and one had received neoadjuvant chemo-radiation. Using an established stratification system for preoperative comorbidity, we identified three patients as low risk and five as high risk for postoperative complications.

The TVED technique was performed by deploying a modified single-incision laparoscopy access device in the left neck incision. The mediastinal esophagus was dissected circumferentially in antegrade fashion. Simultaneously, the transabdominal laparoscopic approach was used for creation of the gastric conduit and distal esophageal dissection. Postoperative patient care was part of a standardized protocol.

Results:
Esophageal dissection was completed using TVED in all patients. The mean operative time was 292 minutes (range 194-375). Two patients with prior foregut surgery had longer operative times than those without prior foregut surgery (mean 349 vs. 273 minutes). In three obese patients, abdominal desufflation was required to avoid extrinsic mediastinal compression, therefore the mediastinal dissection could not be completely performed simultaneously. Median estimated blood loss was 63 mL (range 25-400). A median of 23 lymph nodes (range 13-29) was harvested.

The median ICU stay was 1 day (range 1-5), and the median length of hospital stay was 7 days (range 5-16). Among the three patients stratified as low risk, there were no major complications. Among the five high-risk patients, three had major complications, including two with cervical anastomotic leaks. Major complications were seen in three of the four obese patients (BMI > 30), and in only one of four non-obese patients. No patients required tube thoracostomy, and there were no deaths.

Conclusions:
The TVED approach to MIE may avoid the potential morbidity of transthoracic techniques of esophageal dissection, while decreasing operative time, and improving visualization of the mediastinal esophagus when compared to current transhiatal and blunt cervical approaches. Complications with the TVED approach appear to correlate with obesity and increased comorbidity. Although TVED appears to be a feasible technique, a larger experience is required.