This study is a retrospective observational study of 112 patients who underwent total thoracoscopic and laparoscopic Ivor Lewis esophagectomy for esophageal carcinoma at the Ohio State Wexner Medical Center between May 2014 and June 2018. During this period, 171 Ivor Lewis esophagectomy procedures were performed for esophageal carcinoma. There were 41 open (right posterior lateral thoracotomy) and 130 laparoscopic and thoracoscopic Ivor Lewis esophagectomies performed. We selected 112 patients who received neoadjuvant chemoradiation before undergoing a laparoscopic and thoracoscopic Ivor Lewis Esophagectomy for this study. The charts and electronic medical records of all patients were reviewed and data was collected in a de-identified fashion. The study was approved by the Ohio State Institutional Review Board and the requirement for informed consent were waived. All of the patients were clinically staged before the initiation of treatment with endoscopy, Computed Tomography (CT) scans, clinical history, and physical exam. Endoscopic Ultrasound (EUS) was performed in 83.93% (94/112) of the patients and Positron Emission Tomography (PET) scans were performed in all 112 (100%) patients prior to esophagectomy. All of the patients received neoadjuvant chemoradiation prior to total thoracoscopic and laparoscopic esophagectomy. The neoadjuvant chemoradiation regimen consisted of Carboplatin and Paclitaxel and concurrent radiation doses that ranged from 45 Gray to 50.4 Gray. The neoadjuvant chemoradiation regimen was completed in 6–8 weeks.
All of the patients underwent preoperative risk assessment with a cardiac stress test, pulmonary function test, and a history and physical. Cardiac comorbidity was recorded if there was a history of acute myocardial infarction or a previous coronary artery bypass grafting or percutaneous coronary stenting procedure. Chronic obstructive pulmonary disease (COPD) was recorded as a comorbidity if there was a prior diagnosis of asthma, emphysema, or chronic bronchitis. The preoperative ejection fractions were obtained from echocardiogram reports. The forced expiratory volume in 1 s (FEV1) and diffusion capacity (DLCO) percent predicted values were recorded from the preoperative pulmonary function test reports. Patients with an ECOG performance status score of greater than 2 were not typically selected to undergo laparoscopic and thoracoscopic Ivor Lewis esophagectomy. The patients underwent a diagnostic laparoscopy and gastric devascularization procedure a mean of 18.2 days ± 14.7 prior to esophagectomy. The left gastric artery, the coronary vein, and the short gastric vessels were divided during the gastric devascularization procedure .
Surgical technique for total laparoscopic and thoracoscopic Ivor Lewis esophagectomy.
The laparoscopic mobilization and preparation of the gastric conduit for all of the cases in this series was performed by author KAP, who is a minimal access general surgeon. The patient is positioned on the operating room table in the supine position. A double lumen tube, arterial line, and epidural catheter are placed by the anesthesiologist. An esophagogastroduodenoscopy (EGD) is performed to confirm the location of the esophageal tumor. Following needle insufflation of the abdomen, five laparoscopic ports are placed for the abdominal portion of the procedure. These include a 10 mm port to the left of the mid-line approximately 4 cm above the umbilicus, a 12 mm port in the left upper quadrant, a 5 mm port in the left mid-abdomen, and a 15-mm port in the right upper quadrant. A self-retaining retractor is placed in the epigastric position to retract the left lateral segment of the liver and expose the esophageal hiatus. The greater curvature of the stomach is mobilized by dividing the gastrocolic ligament using ultrasonic dissection while taking care to preserve the right gastroepiploic artery. This dissection is carried out to the level of the origin of the gastroepiploic artery. A formal Kocher maneuver is not performed unless required to allow the pylorus to reach the level of the esophageal hiatus. The gastrohepatic ligament is incised and the hiatus is dissected circumferentially and a Penrose drain is placed around the distal esophagus. The distal esophagus is mobilized to the level of the inferior pulmonary vein and care is taken to maintain the upper abdominal and lower mediastinal lymph nodes with the specimen. Following complete gastric mobilization, a 5 cm wide gastric conduit is created using multiple applications of the Endo GIA endoscopic stapler (Medtronic, Boulder, CO) along the lesser curvature. The gastric conduit is then sutured to the distal aspect of the esophagogastrectomy specimen. Gastric emptying procedures and feeding jejunostomy tube placement is not routinely performed.
The thoracoscopic portion of all of the cases were performed by author REM, who is a general thoracic surgeon. For the right thoracoscopy, the patients were positioned in the left lateral decubitus position and three right thoracoscopic ports and a small access incision without rib-spreading were utilized. A 12 mm port is placed in the 8th intercostal space posterior axillary line for the 10 mm thoracoscope. A 12 mm port is placed in the 5th intercostal space anterior-axillary line, and a 3 cm access incision is made in the 9th intercostal space for removal of the specimen and placement of the EEA circular stapler. A 12 mm port is placed below the tip of the scapula. The esophagus and the lymphatic tissue are dissected circumferentially from the hiatus to about 2 cm above the azygous vein. The esophagus is divided with a linear Endo GIA stapler at the level of the azygous vein. The conduit and specimen are then pulled gently into the right chest, taking great care not to twist the gastric conduit. A 25 mm anvil (OrVil, Medtronic, Boulder, CO) is passed trans-orally through a small esophagotomy in the esophageal stump staple line. The anastomosis is completed by joining the anvil with the 25 mm end-to-end anastomosis (EEA) stapler (Medtronic, Boulder, CO) inserted through a gastrotomy at the tip of the gastric conduit. The EEA stapler pin is deployed along the greater curvature and the esophagogastric anastomosis is created. 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 covered with redundant omentum or mediastinal pleura. A barium swallow study is obtained on postoperative day number 6 to evaluate the esophagogastric anastomosis for a leak.
Postoperative complications were reported as anastomotic leak, conduit necrosis, anastomotic stricture, pneumonia, respiratory failure, pneumothorax, airway fistula, atrial fibrillation, chylothorax, and atelectasis. The Clavien-Dindo severity stratification system was used to describe the severity of postoperative complications . Anastomotic leaks were diagnosed by observing extravasation of oral contrast at the esophagogastric anastomosis on a contrast esophagram and/or by direct clinical observation. Conduit necrosis was reported in cases involving complete anastomotic dehiscence and conduit ischemia requiring completion gastrectomy and esophageal diversion. Respiratory failure was defined as the need for re-intubation for isolated respiratory dysfunction during the postoperative period or the initiation of high flow oxygen for acute hypoxemia. 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 90 days of esophagectomy. Admission to the ICU during the postoperative period and readmission to the hospital within 30 days of discharge were recorded as well.
Categorical variables were reported in absolute numbers and frequencies. Continuous variables were tested for presence of normal distribution, and reported as arithmetic means with standard deviation (SD), or median and interquartile range (IQR), as appropriate. Overall survival was calculated from the day of surgery to day of death, and censored at day of last follow-up for survivors. Disease-free survival was defined as the time from surgery to either disease recurrence or death, and censored at last follow-up. Overall and disease-free survival times were estimated by Kaplan Meier technique, and compared using log-rank test. The statistical analyses were performed using the SAS 9.2 statistical software package (SAS Institute, Cary, NC). Differences were considered significant when the probability was less than 0.05.