Research Article
Minimally Invasive Ivor Lewis Esophagectomy Improves Pulmonary Complications Compared to Open Ivor Lewis Esophagectomy
Merritt RE1*
Division of Thoracic Surgery, Ohio State University Wexner Medical Center, USA
*Corresponding author: Robert E. Merritt, Division of Thoracic Surgery, The Ohio State University Wexner Medical Center, N847 Doan Hall, 410 West 10th Avenue Columbus, OH 43210, USA
Published: 21 Sep, 2016
Cite this article as: Merritt RE. Minimally Invasive Ivor
Lewis Esophagectomy Improves
Pulmonary Complications Compared to
Open Ivor Lewis Esophagectomy. Clin
Surg. 2016; 1: 1133.
Abstract
Background: The morbidity and mortality remain relatively high for transthoracic esophagectomy with open thoracotomy. I compared a total laparoscopic and thoracoscopic Ivor Lewis esophagectomy (MIE) cohort with a well matched cohort of open Ivor Lewis esophagectomy (OIE) cases.
Methods: This is a retrospective review 50 patients diagnosed with esophageal carcinoma or high grade dysplasia who underwent minimally invasive or open Ivor Lewis esophagectomy from August 2009 to June 2013. A total of 25 patients underwent MIE and 25 patients underwent OIE. The postoperative morbidity and 60-day mortality were reported for the two groups.
Results: The MIE and OIE groups were well matched for age, gender, FEV-1 % predicted, ejection fraction, coronary artery disease, COPD, and neoadjuvant chemoradiation. The 60 day mortality rate was 0% in the MIE group compared 4% in the OIE group (p=0.98). The mean hospital length of stay was 11 days + 4.3 for the MIE group compared to 13.4 days + 6.9 for the OIE group [p=0.149]. The rate of all pulmonary complications were significantly higher in the OIE group compared to the MIE group (44% compared to 4% [p=0.002].
Conclusion: Total thoracoscopic and laparoscopic Ivor Lewis (MIE) esophagectomy produced
clinical outcomes that are similar to the outcomes for OIE at our institution. The advantage for MIE
appears to be fewer pulmonary complications which may be a function of the deleterious effects of
thoracotomy.
Keywords: Esophagectomy; Minimally invasive surgery; Esophageal surgery
Introduction
The traditional Ivor Lewis esophagectomy combines right thoracotomy and laparotomy with an
intrathoracic anastomosis. The two stage esophagectomy technique was described by Ivor Lewis at
the Hunterian Lecture at the Royal College of Surgeons in 1946 [1]. This operative technique has been
associated with an increase in respiratory complications, such as pneumonia and respiratory failure
requiring prolonged ventilation, in a randomized study comparing transthoracic esophagectomy to
the transhiatal approach [2]. Rizk et al. [3] have demonstrated that procedure related complications
after esophagectomy have adverse effects on overall survival. In recent years, minimally invasive
techniques for esophagectomy have been developed with the hope of minimizing postoperative
morbidity and mortality associated with the procedure. Luketich et al. [4] reported a large series
of over 1000 minimally invasive esophagectomies, which demonstrated a very low mortality rate
and a relatively low rate of pulmonary complications. In theory, minimally invasive esophagectomy
should minimize the pulmonary morbidity associated with open thoracotomy because MIE does
not involve rib-spreading.
There are numerous different techniques of laparoscopic and laparoscopic-thoracoscopic
esophagectomies reported in the literature [5]. Some of these techniques incorporate minithoracotomy
and hand ports in order to conduct the operation. There are a limited number of
reports that describe the total thoracoscopic and laparoscopic Ivor lewis esophagectomy [4,6,7-10].
In this report, I describe the outcomes of a small series of patients with esophageal carcinoma who
underwent total thoracoscopic and laparoscopic Ivor Lewis esophagectomy at a single institution.
The outcomes of the MIE cohort were compared to a well matched cohort of open Ivor Lewis
esophagectomies that were performed by the same surgeon during the same study period.
Materials and Methods
Study design
This study is a retrospective review of 50 patients who underwent
Ivor Lewis esophagectomy for esophageal carcinoma on the General
Thoracic Surgery Service at the Stanford Hospitals and Clinics
between August 2009 and June 2013. A total of 25 patients underwent
total thoracoscopic and laparoscopic Ivor Lewis esophagectomy and
25 patients underwent open Ivor Lewis Esophagectomy with right
thoracotomy. The charts and electronic medical records of all patients
identified were reviewed and data was collected in de-identified
fashion. The study was approved by the Stanford Institutional Review
Board and the requirement for informed consent was waived. All of
the patients were clinically staged before the initiation of treatment
with endoscopy, Computed Tomography (CT) scans, and clinical
history and exam. Endoscopic Ultrasound (EUS) and Positron
Emission Tomography (PET) scans were performed in all 50 patients
prior to esophagectomy. Patients who underwent transhiatal, a
modified McKeown (3-hole), or thoracoabdominal esophagectomy
techniques were excluded. Patients were eligible for either OIE or
MIE based on preoperative assessment of comorbidities and the
clinical stage of esophageal cancer. The inclusion and exclusion
criteria were the same for the MEI and OIE groups. Patients with
FEV-1 values less than 40% predicted, ejection fraction less than 30%,
home oxygen use, or stage IV esophageal cancer were excluded from
consideration for esophagectomy. The decision to perform MIE or
OIE was random, although patients with a previous history previous
laparotomy were more likely to undergo OIE due to concern for
adhesions. The esophagectomy cases in this report were performed
by the author and represent a fraction of the total number of
esophagectomy cases performed at our institution by other thoracic
surgeons. The MIE cases reported in this report represent the early
experience of the author who is an experienced esophageal surgeon
who routinely performed laparoscopic foregut procedures and open
esophagectomy procedures.
Cardiac comorbidity was defined by a history of acute
myocardial infarction or a previous coronary artery bypass grafting
or percutaneous coronary stenting procedure. Chronic obstructive
pulmonary disease (COPD) was defined by a prior diagnosis of
asthma, emphysema, or chronic bronchitis. The patients’ ages and
genders were recorded. The preoperative ejection fractions were
obtained from echocardiogram reports. The FEV-1 percent predicted
values were recorded from the preoperative pulmonary function
test reports. A prior history of mid-line laparotomy incision for an
abdominal operation was also recorded. The decision to perform a
MIE or OIE was at the surgeon’s discretion, but all of the patients
with a previous laparotomy for an abdominal operation underwent
on open Ivor Lewis. The concern for abdominal adhesions and
potential inadvertent injury to the right gastroepiploic artery was the
primary reasons for the choice of performing an OIE. A total of 20 of
the OIE cases were performed with general surgery colleagues who
performed the abdominal portion of the Ivor Lewis esophagectomy.
All 50 of the intrathoracic anastomoses were performed by a single
surgeon (the author) during the same period.
Surgical technique for total thoracoscopic and
laparoscopic Ivor Lewis esophagectomy
The patient is positioned on the operating room table in the supine
position. A double lumen tube, central line, arterial line, and epidural
are placed by the anesthesiologist. An esophagogastroduodenoscopy
(EGD) is performed initially to confirm the location of the esophageal
tumor. A total of five laparoscopic ports are placed for laparoscopic
mobilization of the gastric conduit. A 12 mm port is placed to the left
of the mid-line approximately 4 cm above the umbilicus using the
Hasson cut-down technique. A 12 mm port is placed to the right of
the mid-line. A 5mm port is placed at the left costal margin, the right
costal margin, and the right flank area. A 5mm laparoscopic liver
retractor is used to retract the left lateral segment of the liver cephalad.
The greater curvature of the stomach is mobilized by dividing the
gastrocolic ligament using the LigaSure device (Covidien, Mansfield,
MA) while avoiding injury to the right gastroepiploic artery. The
short gastric vessels are then divided along the greater curvature of
the stomach with the LigaSure device. The lesser omentum is then
incised with the Harmonic Scalpel (Ethicon Endosurgery, Cincinnati,
OH) and the esophagus is encircled with penrose drain the hiatus.
In addition, a pyloric drainage procedure is not performed routinely.
A 5 cm gastric conduit is then formed with multiple applications of
the Endo GIA endoscopic stapler (Covidien, Mansfield, MA) along
the lesser curvature. A 10-French jejunostomy tube is placed over a
seldenger wire into the proximal jejunum and secured with a 2-0 silk
purse string using the Endo Stich device (Covidien, Mansfield, MA).
The jejunostomy insertion site is secured to the abdominal wall with
two interrupted 2-0 silk sutures taking great care to avoid torsion of
the small bowel.
The thoracoscopic portion of the procedure is performed with the
patient in the left lateral decubitus position with three thoracoscopic
ports and a small access incision without rib-spreading. A 12 mm
port is placed in the 8th intercostal space posterior axillary line for the
12 mm thoracoscope. A 12 mm port is placed in the 5th intercostal
space anterior-line for retraction of the lung. A 3-4 cm access incision
is made in the 9th intercostal space for removal of the specimen and
placement of the EEA circular stapler. A 5mm port is placed below
the tip of the scapula. The azygous vein is dissected and divided with
Endo GIA endoscopic stapler. The esophagus and the lymphatic
tissue are dissected circumferentially from the hiatus to about 2-3
cms above the azygous vein. The conduit and specimen are then
pulled gently into the chest, taking great care not to twist the gastric
conduit. A 25 mm anvil (OrVil, Covidien, Mansfield, MA) is passed
trans-orally, which his connected to a 90 cm polyvinyl chloride
delivery tube, through a small opening in the esophageal stump staple
line. The anastomosis is completed by joining the anvil with the 25
mm end-to-end anastomosis (EEA) stapler (Covidien, Mansfield,
MA) inserted through a gastrotomy at the tip of the gastric conduit.
A nasogastric tube is then passed under direct vision into the gastric
conduit. The gastrotomy is then resected with 2-3 applications
of the Endo GIA stapler. The anastomosis is either covered with
redundant omentum or mediastinal pleura. A barium swallow
study was obtained on postoperative day number 6 to evaluate the
esophagogastric anastomosis.
Surgical technique for open Ivor Lewis esophagectomy
The open Ivor Lewis esophagectomy was performed with a midline
laparotomy incision and a posterior-lateral right thoracotomy
incision. The conduct of the operation is the same as described
above for the MIE technique. The key differences for the OIE
technique include the frequency of drainage procedure and the
technique for anastomosis. In the MIE technique, a 25 mm end-toend
anastomosis (EEA) stapler (Covidien, Mansfield, MA) was used
to create an esophago-gastric anastomosis in all of the 25 patients.
In the OIE group, a total of 7 patients underwent two-layer hand
sewn anastomoses and 18 patients had 25 mm end-to-end stapled
anastomosis (EEA) anastomoses. A total of 20 patients in the OIE
group underwent a pyloroplasty and none of the patients in the MIE
group underwent a drainage procedure. None of the MIE patients
developed a post-operative gastric outlet obstruction requiring
pyloric dilation.
Postoperative complications were classified as anastomotic leak,
pneumonia, respiratory failure, prolonged ventilation (>48 hours),
thoracic duct leak, pulmonary embolus, myocardial infarction, atrial
fibrillation, and symptomatic pleural effusion requiring drainage.
Anastomotic leaks were diagnosed by observing extravasation of
oral contrast at the esophagogastric anastomosis on a contrast
esophagram and/or by direct clinical observation. Respiratory failure
was defined as the need for re-intubation for isolated respiratory
dysfunction during the postoperative period. Pneumonia was
diagnosed if patients developed an infiltrate on chest imaging studies
with associated fever and received antibiotic therapy. A postoperative
mortality was defined as a death occurring during hospitalization
or within 60 days of esophagectomy. Deaths were verified with the
Social Security Death Index.
Statistical analysis
Categorical variables were analyzed with the Fisher exact test and
continuous variables were analyzed with an unpaired student t test.
The arithmetic means were reported with the standard deviation.
Univariate analyses were performed to determine the potential
preoperative risk factors for overall pulmonary complications. The
independent variables with a p < 0.2 on univariate analysis were
entered into a forward stepwise multiple logistic regression analysis.
The statistical analyses were performed using the MedCalc statistical
software (MedCalc Software, Mariakerke, Belgium). Differences were
considered significant when the probability was less than 0.05.
Table 1
Table 2
Table 3
Table 4
Results
A total of 25 patients underwent total thoracoscopic and
laparoscopic Ivor Lewis esophagectomy (MIE) and 25 patients
underwent an open Ivor Lewis esophagectomy (OIE). A total of
13/25 (52%) of the MIE patients and 17/25 (68%) of the OIE patients
underwent preoperative chemoradiation. The radiation doses in all
the cases ranged from 45 Gray to 50.4 Gray.
Two patients in the MIE group were converted to an open Ivor
Lewis esophagectomy and were included in the OIE group. The patient
demographics are listed on Table 1. The patients in the two groups were
well matched for age, gender, preoperative ejection fraction, FEV-1
percent predicted, coronary artery disease, COPD, and neoadjuvant
chemoradation. The 10/25 (40%) of the patients in the OIE group had
a prior laparotomy incision for a cholecystectomy, bariatric surgery,
trauma, or small bowel obstruction. Adenocarcinoma was the most
common histologic diagnosis in the MIE group (20/25 [80%]) and
the OIE group (24/25 [96%]) (Table 2). The clinical staging base
in endoscopic ultrasound and PET CT scan is listed in Table 3.
Nodal involvement was based on abnormal radiotracer uptake on
PET CT scans and endoscopic ultrasound findings of suspicious
peri-esophageal lymphadenopathy. Fine needle aspiration was not
attempted in most cases because the needle would have to be passed
through large bulky tumors to reach the lymph nodes.
The mean total operative time for the MIE group was 479 minutes
± 65 minutes and the median total operative time was 480 minutes
compared to a mean operative time of 460 minutes ± 76 and median
time of 468 minutes (p=0.343) for the OIE group. The mean estimated
blood loss was and intraoperative intravenous volume was the similar
between the two groups (Table 4). The mean number of lymph nodes
dissected in the MIE group was 14.2 nodes ± 7.5 compared to 16.3
nodes ± 5.3 nodes in the OIE group. All of the patients in the MIE
and OIE groups had a R0 resection with negative proximal, distal, and
radial margins on final pathology.
The mean ICU length of stay was significantly higher in the OIE
group (4.3 days ± 6.8 compared to 1.5 days ± 1.8 [p=0.05]) for the
MIE group). The mean ventilator days and length of hospital stay was
similar between the groups (Table 4). The overall operative 60–day
mortality rate was 0% in the MIE group compared to 1/25 (4%) in
the MIE group (p=0.988). The single postoperative death in the OIE
group was related to Acute Respiratory Distress Syndrome (ARDS).
A summary of the complications are summarized in Table 5. The
total pulmonary complication rate was 11/25 (44%) in the OIE group
compared to 1/25 (4%) in the MIE group (p=0.002). The anastomotic
leak rate was 1/25 (4%) in both groups.
A forward stepwise multiple logistic regression analysis was
performed to determine the independent risk factors for postoperative
pulmonary complications. Only open Ivor Lewis esophagectomy
was significantly associated with the occurrence of a postoperative
pulmonary complication (p=0.015 [odds ratio = 9.33]). Neoadjuvant
chemoradiation, age, preoperative COPD, and preoperative coronary
artery disease were not significant risk factors for the development of
postoperative respiratory complications.
Table 5
Comment
Since the first description of the two stage Ivor Lewis
esophagectomy in 1946 [1], the procedure has become the procedure
of choice at most centers for the resection of esophageal carcinoma
involving the distal third of the esophagus. The main disadvantage
of the open Ivor Lewis esophagectomy is the deleterious effects of
the right thoracotomy. In a randomized clinical trial comparing
transthoracic and transhiatal esophagectomy, Hulscher et al.
[2] demonstrated that patients undergoing esophagectomy with
open thoracotomy had a significantly higher rate of pulmonary
complications which resulted in more ventilator days, ICU days, and
hospital days. In an attempt to minimize the perioperative morbidity
associated with esophagectomy, some centers have developed
Minimally Invasive Esophagectomy (MIE) techniques for surgical
resection of esophageal carcinoma. Luketich et al. [4] reported their
extensive experience with the total laparoscopic and thoracoscopic
Ivor Lewis esophagectomy. In this series, 530 patients with high grade
dysplasia or esophageal carcinoma underwent minimally invasive
Ivor Lewis esophagectomy with relatively low operative mortality
(0.9%). The median ICU days were 2 days and the median hospital
length of stay was 7 days. These results for operative mortality rate
and length of stay were superior to two large contemporary series
involving open transthoracic and transhiatal esophagectomy [11-12].
This report describes a series of total thoracoscopic and
laparoscopic Ivor Lewis esophagectomy compared to a contemporary
cohort of open Ivor Lewis esophagectomies performed by the same
surgeon. The author wanted to determine if the minimally invasive
Ivor Lewis esophagectomy technique was at least equivalent in terms
of operative outcomes, such as postoperative morbidity and mortality.
The expectant outcome would be a decrease in postoperative
pulmonary complications in the patients who underwent minimally
invasive Ivor Lewis esophagectomy. Shirag et al. [13] reported the
operative results of 38 minimally invasive Ivor Lewis esophagectomies
compared to 73 open Ivor Lewis esophagectomies. Overall pulmonary
complications were significantly higher in the open Ivor Lewis group
compared to the minimally invasive group [43.4% versus 2.6%] p
< 0.001)
In this report, the operative times, estimated blood loss, an
intraoperative fluid was similar between the two groups. The ICU
length of stay was significantly less in the minimally invasive Ivor Lewis
group. The total ventilator days and hospital length of stay were lower
in the minimally invasive Ivor Lewis group, but the differences were
not statistically significant. This finding is likely related to the small
sample size of the study. The overall 60 day mortality rate was 4% in
the open Ivor Lewis group. A single patient died on postoperative day
number 32 from Adult Respiratory Distress Syndrome. There were
no 60 day mortalities in the minimally invasive Ivor Lewis cohort.
The anastomotic leak rates (4%) were the same in each group. One
patient in the MIE group and one patient in the OIE group developed
an anastomotic leak requiring reoperation and primary repair of
the anastomosis using a right thoracotomy. The overall pulmonary
complication rate was significantly higher in the OIE group compared
to the MIE group. On multiple logistic regression analysis, the open
Ivor Lewis esophagectomy technique was predictive of postoperative
pulmonary complications (odd ratio = 9.3 [p=0.015]). This result
is likely related to the negative impact of open thoracotomy on
postoperative pulmonary toilet. Transthoracic esophagectomy
resulted in significantly higher rates of pulmonary complications
compared to transhiatal esophagectomy in a randomized study [2].
In addition, Avendano et al. [14] demonstrated 20% rate of prolonged
ventilation after open transthoracic esophagectomy. The deleterious
effects of thoracotomy are likely caused by a decrease in the functional
reserve capacity in the postoperative period. This negative impact is
probably mitigated by the less invasive thoracoscopic approach.
The oncologic results of the MIE approach were comparable to
the OIE technique in this report. The mean and median numbers of
lymph nodes that were dissected in the MIE group were similar to the
OIE group. All of the patients in both cohorts underwent a complete
R0 resection with negative margins on final pathology. The long term
overall survival data was not reported given the small sample size of
this retrospective review and the relatively short follow up time. A
randomized phase III clinical trial would be the most appropriate way
to determine the long term survival impact of MIE compared to OIE.
The results of this report comparing minimally invasive Ivor
Lewis esophagectomy to open Ivor Lewis esophagectomy determined
that our MIE technique is equivalent to our OIE. The primary
advantage of the MIE technique appears to be a mitigation of the
adverse effects of open thoracotomy. In this report, the patients in the
MIE group experienced minimal pulmonary complications and spent
less time in the ICU. The overall mean hospital length of stay was two
days less in the MIE group. This retrospective study is unique because
a single surgeon serves as a control, which limits the variability of
individual technique and postoperative management. The operative
technique of the Ivor Lewis is virtually the same with a few exceptions,
regardless of the degree of invasiveness. In addition, the postoperative
management was uniform between the two techniques. Regardless,
the results of this report are limited by selection bias that is inherent
to retrospective studies and a small sample size. The author
believes that the MIE Ivor Lewis technique is a suitable alternative
to the open Ivor Lewis technique. The MIE technique appears to
minimize postoperative pulmonary complications; therefore, MIE
may particularly advantageous in elderly patients and patients with
compromised respiratory function.
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