1. Minimally Invasive Esophagectomy Dmitry Oleynikov M.D. Associate Professor of Surgery Joseph and Richard Still Faculty Fellow in Medicine Director of Minimally Invasive And Computer Assisted Surgery University Of Nebraska School Of Medicine

2. Esophageal Cancer

3. Staging / determining resectability : Laparoscopic/ thoracoscopic staging is accurate –94% correlation with operative pathology* It is the best method, short of laparotomy, to determine resectability –30% (6/20) positive nodes in imaging negative patients* * Krasna; 1995, 1998

4. Node dissection

5. Endoscopic diagnosis Barretts adeno CA EUS + PET/CT Stage IStage II Stage IIIA Stage IIIB Stage IV and Barretts HGD Chemo/rad or palliation Intraoperative Staging/ Laparoscopic resection Laparoscopic staging U/S, node dissection, Left gastric division Feeding jejunostomy Stage II, IIIAStage IIIA, IIIB Stage IV Laparoscopic Or Open resection Neoadjuvant Chemo/radiation

6. Endoscopic esophagectomy: which approach? Totally Endoscopic techniques: – laparoscopic transhiatal esophagectomy (DePaula, Swanstrom, Sadanaga, Jagot, Yahata) – Laparoscopic/thoracoscopic technique (Cuscieri, Luketich, Dellemagne, Watson)

7. Survival after open esophagectomy

8. Background: esophagectomy patients Perioperative complications in 58% * Perioperative mortality is 4% * Ave length of hospital stay 13.7 days** 31% of patients require post hospital care** * Finley, AM J Surg, 1995 ** OR state tumor registry, 1998

9. Expected advantages: Accurate staging Minimally invasive determination of resectability Decreased tissue trauma –less pain –less pulmonary compromise Decreased need for critical care / hospital care  A more rapid return to normal life

10. Theoretical advantages: Better node dissection Less tumor manipulation Preservation of host immune response –lower blood loss –quicker enteral feedings –less inflammatory mediator release Quicker application of adjuvant therapy Psychological impact

11. Alternative Therapies: Chemo / radiationChemo / radiation PhotoablationPhotoablation CryotherapyCryotherapy Endoscopic Mucosal StrippingEndoscopic Mucosal Stripping Full thickness endoscopic resectionFull thickness endoscopic resection Laparoscopic / thoracoscopic esophagectomy

12. Survival after open esophagectomy “Results of 100 radical en bloc resections for adenocarcinoma” Hagen JA et al. Ann Surg 2001 A radical lymphadnectomy was used on a series of resectable cancer pts 5 year survival = 54% Local recurrence rate <8% *68% major morbidity

13. Benefit of Laparoscopy / Thoracoscopy General –Less pain –Shorter LOS/recovery –Better view Benign disease –Increasing volumes of end stage disease –Increasing comfort and reliance on MI approaches –Lower morbidity / mortality

14. Benefit of Laparoscopy / Thoracoscopy Cancer Best staging Better residual QOL Less frightening to patient and their physicians Earlier start to adjuvant therapy and nutrition Decreased immunosuppression –Improved cure rates

15. Staging / Determining Resectability: Laparoscopic/ thoracoscopic staging is accurate –94% correlation with operative pathology* It is the best method, short of laparotomy, to determine resectability –30% (6/20) positive nodes in imaging negative patients* * Krasna; 1995, 1998.

16. Transhiatal Esophagectomy No need to reposition Easier anesthesia Faster?

17. Ports

19. Mediastinal Dissection

24. Antireflux Mechanism

26. Postoperative Care: To surgery floor Gastrografin swallow POD 2 Tube feeds POD2 D/C abd drain POD3 Pureed diet POD 3 Remove neck drain when goes home

27. Review of outcomes for Minimally Invasive osophagectomy This study evaluated 104 MIS for malignant and benign esophageal diseases between 1998 – 2007 3 patients required conversion to laparotomy, median ICU & hospital stays were 2 & 8 days respectively. Major complications in 12.5% pts. And minor complications in 15.4%pts. Incidence of leak was 9.6% and anastomotic stricture was 26%. 30 day mortality was 1.9% and in hospital mortality 2.9% Nguyen 2008

28. Endoscopic therapies in T1 oesphageal cancers Osophagectomy is the standard treatment for T1 oesophageal cancers with good long term results Many patients with T1 OC have several risk factors that preclude treatment with endoscopic therapy Many prospective studies needed to evaluate endoscopic therapies until then esophagectomy should remain the standard treatment in patients with T1 EC. Pennathur A 2009

29. Open versus minimally invasive esophagectomy: a single-center case controlled study Case controlled pair-matched study conducted comparing 62 patients who had undergone either minimally invasive (MIE) or open esophagectomy (OE) between 2004 and 2007 Surgical morbidity, transfusion rate and the rate of post operative respiratory complications were significantly lower in the MIE group The ICU and hospital stay were also significantly lower in the MIE group. Schoppmann SF 2010

30. Conclusion: Open esophagectomy with en bloc lymphadnectomy may provide the best surgical cure rate for resectable esophageal cancer This can be replicated by the thoracoscopic / laparoscopic approach Laparoscopic esophagectomy offers theoretical potential for improved outcomes, possibly even improved survival for esophageal cancer patients and is an excellent technique for benign disease Currently, the technical difficulty of laparoscopic esophagectomy make it unlikely to be widely applied outside of regional laparoscopic referral centers.