Minimally Invasive Esophagectomy for Carcinoma of Esophagus

1. Minimally Invasive Esophagectomy for Carcinoma of Esophagus • HC Yip Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong

2. Minimally Invasive Esophagectomy (MIE) • Surgery for esophagus – one of the most challenging operations • High morbidity and mortality • Little margin for error • Minimally invasive approach for esophagectomy • First reported in 1992 by Cuschieri et al1 • Aims to reduce the postoperative morbidity • Last 2 decades, interest and utilization of MIE continues to grow worldwide • Cuschieri A, Shimi S, Banting S. Endoscopic oesophagectomy through a right thoracoscopic approach. J R Coll Surg Edinb. 1992;37:7-11.

3. Lazzarino AI, Nagpal K, Bottle A, et al. Ann Surg. 2010;252: 292–298.

4. Utilization of MIE in Hong KongSOMIP data Data retrieved from SOMIP report 2008-2013

5. MIE – good or bad? • Theoretical advantage • Smaller wound, less wound pain • Reduced respiratory complication • Faster recovery • Potential drawbacks • Oncological clearance • Technical difficulties

6. Questions • Can it achieve equivalent / superior survival results compared to open esophagectomy • Does it truly improve the short term perioperative outcomes?

7. Nomenclature of MIEs • Minimally invasive esophagectomy (MIE) • Heterogeneous group of procedures • Thoracoscopic Ivor Lewis (Two stage) esophagectomy • Thoracoscopic McKeown (Three stage) esophagectomy • Hybrid approach – open incision in conjunction with a minimal access approach (Laparotomy or thoracotomy) • Laparoscopic transhiatal esophagectomy • Robotic assisted esophagectomy • Direct comparisons of outcomes could be difficult • Important to clarify the procedures referring to in the literature

8. MIE for CA esophagus Survival

9. TLSE: Thoraco-laparoscopic esophagectomy • VATS: Video-assisted thoracoscopicesophagectomy • HALS: Hand-assisted laparoscopic esophagectomy • TSE: Thoracoscopic assisted esophagectomy • LIE: laparoscopic inversion esophagectomy • THE: transhiatalesopahgectomy J Gastrointest Surg (2012) 16:486–494 Arch Surg. 2012;147(8):768-776.

10. Survival All survival 5 year survival Arch Surg. 2012;147(8):768-776. J Gastrointest Surg (2012) 16:486–494

11. LAO – Laparoscopic assisted oesophagectomy (Open thoracotomy) MIO – Minimally invasive oesophagectomy (Thoracolaparoscopic) Corrected for T and N stage Surg Endosc. 2014 Aug 15. [Epub ahead of print]

12. Summary - survival • Inadequate evidence to suggest a survival benefit / equivalence of minimally invasive esophagectomy

13. MIE for CA esophagus Perioperative outcomes

14. 30-day Mortality • Single center series – 1011 patients • Overall 30 day mortality: 0.9% • 1155 MIE versus 6347 open esophagectomy • Mortality: 4.3% vs 4.0%, p=0.605 • Meta-analysis of case control studies1,2 • No difference in 30 day mortality Ann Surg 2012;256:95–103 Ann Surg 2012;255:197–203 Nagpal et al. Surg Endosc (2010) 24:1621-1629 Sgourakis et al. Dig Dis Sci (2010) 55:3031-3040

15. Post-operative complications • Meta-analysis by Nagpal et al1 • 12 studies, 672 MIE vs 612 open • Lower blood loss, reduced total morbidity, respiratory complications and shorter hospital stay • Meta-analysis by Sgourakis et al2 • Reduced overall morbidity comparing open thoracotomy vs total MIE Surg Endosc (2010) 24:1621-1629 2. Dig Dis Sci (2010) 55:3031-3040

16. Traditional Invasive vs Minimally Invasive Esophagectomy: TIME-trial • June 2009 – March 2011 • Three centres in Netherlands, one centre in Spain, Italy • Resectable (cT1-3, N0-1, M0) esophageal cancers • AdenoCA, SCC, undifferentiated carcinoma • Intra-thoracic tumors and GEJ tumors Lancet 2012;379:1887-92

17. TIME-trial • No difference in 30 day mortality, R0 resection rate, number of LN harvested, pathological staging Lancet 2012;379:1887-92

18. TIME-trial • Author’s conclusion • The findings provide evidence of short term benefits of minimally invasive compared to open esophagectomy for patients with resectable esophageal cancer Lancet 2012;379:1887-92

19. Technical considerations –Prone position • Better visualization of esophagus and aortopulmonary window and better quality dissection • Comparative studies showed no difference in perioperative outcomes Palanivelu et al. J Am Coll Surg 203:7-16 Fabian et al. Surg Endosc (2008) 22:2485–2491

20. Technical consideration – Two stage vs three stage Luketich et al. Ann Surg 2012;256:95–103

21. Technical consideration –Robotic assistance • No significant benefit identified compared with thoracoscopic MIE

22. MIE for CA esophagus PWH experience

23. MIE: PWH experienceJanuary 2004 – October 2012: 32 MIE HC Yip, PW Chiu, EK Ng et al. Presented at ASM 2013

24. 16 open esophagectomy performed in the same period compared with results of recent MIE MIE: PWH experience HC Yip, PW Chiu, EK Ng et al. Presented at ASM 2013

25. Conclusion • Minimally invasive esophagectomy is technically demanding but feasible • Reduction in perioperative morbidity, faster recovery • Long term outcome is lacking • Need for good quality RCT – non-inferiority / equivalence design • Should be performed in centres with experience in MIS

26. Thank you!