Minimally Invasive Esophagectomy
Reduces Trauma, Speeds Recovery

The Challenge

Treatment of esophageal cancer is associated with poor survival (Table). According to data from the American Cancer Society and the National Cancer Institute, each year an estimated 16,500 Americans receive a diagnosis of esophageal cancer and 14,500 die from it.

A major reason for the poor outcomes is that most patients present with late-stage disease that is refractory to treatment. The most common clinical presentation is dysphagia, which typically manifests in advanced stages with nodal metastases. Occasionally, more treatable early-stage lesions are detected during surveillance protocols for gastroesophageal reflux disease or Barrett esophagus.

Conventional Treatment

Conventional treatment is difficult for patients to tolerate. Invasive tumors with nodal involvement have been traditionally treated by neo-adjuvant concomitant chemotherapy and radiotherapy followed by open surgery. The resection typically occurs in two or three body cavities: in the abdomen to fashion a new tube from the stomach; in the chest to remove the esophagus; and in the chest or neck to reconnect the remaining esophagus to the stomach.

Recovery may require 10 or more days in the hospital. It typically is months before the patient is eating well, the incisions are fully healed and the patient's energy returns. Open esophagectomy is associated with an average mortality of 10 percent or higher in the United States, particularly when performed by surgeons who do fewer than 10 of the procedures a year. At Mayo Clinic, the mortality rate is less than 3 percent.

Open esophagectomy incisions

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A New Approach

Mayo Clinic's highly experienced multidisciplinary teams have refined both open procedures and minimally invasive techniques. Encouraging results indicate that minimally invasive esophagectomy is a viable alternative to open surgery. Mayo Clinic is one of a few centers to offer the new approach of combined laparoscopic and thoracoscopic esophagectomy.

Advantages of Minimally Invasive Esophagectomy

While the procedure still involves resections in two or three body cavities, the operations are done through smaller incisions using laparoscopic and thoracoscopic visualization and resecting tools. For example, in the abdomen, instead of a full midline resection, the laparoscopic surgeon makes four or five ports, each 1 cm long, for placement of the laparoscopic instruments. Thoracoscopic ports are placed in the chest in a similar manner.

Laparoscopic incisions

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Minimally invasive advantages include achieving oncologic outcomes that are at least equal to Mayo Clinic's open procedures, reducing pain, speeding recovery, and cutting costs by reducing the hospital stay to six days or less versus seven to 10 days after conventional treatment.

Because the minimally invasive approach is new and performed only at select referral centers, outcome data are just emerging.

Indications

Patients with advanced lesions that cannot be treated by endoscopy or photodynamic therapy (PDT) and who are well enough to withstand surgery are eligible for consideration as candidates for the minimally invasive alternative.

Those who have undergone previous surgical procedures and have considerable scar tissue are not typically suitable candidates for minimally invasive treatment approaches.

Stratifying Patients on the Basis of Mucosal or Submucosal Lesions

Choosing among treatment options can be guided by several pathological presentations. Early, noninvasive mucosal lesions are potentially treatable by endoscopy or PDT. Older patients and those with comorbid conditions who are not candidates for surgery may likewise be suited to treatment by endoscopy or PDT. Submucosal lesions are not treated with these approaches because it is difficult to get good margins with endoscopy in the submucosa.

The majority of patients diagnosed with esophageal cancer present with more invasive stages and nodal spread. They are generally no longer suitable for treatment by endoscopy or PDT. Data show that patients with nodal spread and Stage II or Stage III tumors benefit from neo-adjuvant chemoradiation therapy followed by esophagectomy. The majority of patients referred to Mayo Clinic for possible esophagectomy present after chemoradiation therapy.

Points to Remember

• According to the American Cancer Society, approximately 16,500 Americans are diagnosed each year with esophageal cancer.
• Most cases are diagnosed in late stages with nodal metastases, often presenting clinically with dysphagia.
• Treatment for stage IIB and above typically involves concomitant neo-adjuvant chemotherapy and radiotherapy, followed by open surgery. Nationwide, the mortality rate for this demanding surgery is 10 percent. At Mayo Clinic, the mortality rate is less than 3 percent.
• Minimally invasive esophagectomy at Mayo Clinic has not only reduced surgical morbidity but also decreased hospitalization time from up to 10 days to six days or less.