Minimally Invasive Esophagectomy Improves Outcomes, But Remains Underutilized

Jae Kim, MD

Chief and Assistant Professor

Division of Thoracic Surgery

City of Hope

Surgery remains the most effective curative treatment for esophageal cancer. Yet, many eligible patients do not undergo esophagectomy. An analysis of the NCI's SEER database found that Black and Hispanic patients were significantly less likely to undergo surgery for esophageal cancer compared with whites and that this difference was the underlying cause of disparate survival for esophageal cancer.¹

Unlike other solid tumors like breast or colon cancer, fewer than half of patients with local or regional disease undergo esophagectomy. Even when surgery is recommended, a significant percentage of patients with esophageal cancer do not undergo surgery.

Patients may be less likely to undergo esophagectomy for a variety of reasons. European studies have found limited benefit for surgery following chemoradiotherapy for esophageal squamous cell carcinoma.^2,3 Compared with other solid tumors, esophagectomy has historically had relatively high morbidity and mortality rates. Even when there are no complications, the procedure has a major impact on quality of life. However, recent advances in surgical care, particularly the advent of minimally invasive esophagectomy (MIE) may ameliorate many of these concerns, potentially allowing more patients to receive curative therapy.

Some European studies, primarily involving squamous cell carcinoma, have failed to demonstrate a survival advantage for esophagectomy after chemoradiation.

However, these results should be interpreted with caution and surgery remains the standard of care for most resectable esophageal cancer in the United States. The pathologic complete response rate is much lower for adenocarcinoma, which is the predominant histology of esophageal cancer in the United States. The other main criticism of these studies is the relatively high rate of perioperative mortality, potentially negating the benefits of surgery. Multiple studies have demonstrated improved mortality rates for esophagectomy at high-volume centers. Yet, the majority of esophagectomies in the United States are still performed at low-volume centers. Over the last decade, though, there has been a shift of cases to higher volume centers and an overall decrease in mortality from 8% to 4%.⁴ This has corresponded with a modest increase in the total number of esophagectomies performed annually.

Beyond volume outcomes, a growing body of literature has found reduced complication rates with minimally invasive esophagectomy compared with open. In the first randomized controlled trial of open versus minimally invasive esophagectomy, the MIE group had one-third the rate of pulmonary complication that the open group had.⁵ Short-term quality of life was better in the MIE group, as well. Mortality rates were below 4% in both groups. More importantly, MIE does not compromise oncologic outcomes.

Comparisons of long-term survival seem to show no statistically significant difference in overall survival or recurrence rates between open and minimally invasive esophagectomy, which is similar to the experience in other solid tumors.⁶ In terms of long-term quality of life, results from a study of more than 400 patients after esophagectomy recently presented at the World Congress of the International Society for Diseases of the Esophagus found significant benefits in health-related quality of life persisted even 2 years after surgery for patients undergoing MIE compared to thoracotomy.⁷ At 24 months, pain scores of patients in the MIE group had returned to baseline, but remained elevated in the open group.

The use of robotic esophagectomy, an adjunct to MIE, has also been increasing. The wristed motion of robotic instrumentation allows greater dexterity compared to standard laparoscopic tools (Figure 1).

Figure 1

Schematic of roboticassisted minimally invasive esophagectomy mobilization of the thoracic esophagus.

The robotic optical platform also gives surgeons a three-dimensional view and permits use of other wavelengths that have the potential to improve assessment of organ perfusion and tumor location (Figure 2). City of Hope was one of the first institutions to report outcomes of robotic esophagectomy.⁸

Since then, we have performed over a hundred robotic esophagectomies and have continued to improve surgical techniques.⁹ In recent years, we have performed more than 90% of our esophagectomies minimally invasively with laparoscopy and thoracoscopy. The mortality rate has been less than 5%, with an anastomotic leak rate less than 10%. Patients are able to recover better and resume normal activities faster. We have been able to decrease our median length of stay to 7 days, which is less than half the national average of 16 days. These results have come despite almost 90% of our patients receiving neoadjuvant chemoradiation during this time.

Figure 2

Intraoperative image using near-infrared fluorescence imaging fluorescence angiography during robotic-assisted minimally invasive esophagectomy after administration of indocyanine green.

Esophagectomy continues to be the most effective treatment for esophageal cancer confined to local and regional disease. Improvements in surgical technique, including minimally invasive and robotic esophagectomy, have greatly reduced morbidity and mortality after esophagectomy over the last decade.

However, many eligible patients have not been able to take advantage of these advances, either by undergoing esophagectomy at low-volume centers where these techniques are not offered or by not undergoing esophagectomy at all. Hopefully, greater focus on quality metrics and outcomes will help to centralize surgical care of esophageal cancer at centers of excellence.

References

1. Revels SL, Morris AM, Reddy RM, et al. Racial disparities in esophageal cancer outcomes. Ann Surg Oncol. 2013;20(4):1136-1141.
2. Bedenne L, Michel P, Bouché O, et al. Chemoradiation followed by surgery compared with chemoradiation alone in squamous cancer of the esophagus: FFCD 9102. J Clin Oncol. 2007;25(10):1160-1168.
3. Stahl M, Stuschke M, Lehmann N, et al. Chemoradiation with and without surgery in patients with locally advanced squamous cell carcinoma of the esophagus. J Clin Oncol. 2005;23(10):2310-2317.
4. Jafari MD, Halabi WJ, Smith BR, et al. A decade analysis of trends and outcomes of partial versus total esophagectomy in the United States. Ann Surg. 2013;258(3):450-458.
5. Biere SS, van Berge Henegouwen MI, Maas KW, et al. Minimally invasive versus open oesophagectomy for patients with oesophageal cancer: a multicentre, open-label, randomised controlled trial. Lancet. 2012;379(9829):1887-1892.
6. Dantoc M, Cox MR, Eslick GD. Evidence to support the use of minimally invasive esophagectomy for esophageal cancer: a meta-analysis. Arch Surg. 2012;147(8):768-776.
7. McCormack O, Barbour A, Baker P, et al. Long-term health related quality of life outcomes following esophagectomy: a comparison between thoracoscopically assisted and open esophagectomy. Diseases of the Esophagus. 2014; 27(suppl S1):75A.
8. Kernstine KH, DeArmond DT, Shamoun DM, et al. The first series of completely robotic esophagectomies with threefield lymphadenectomy: initial experience. Surg Endosc. 2007;21(12):2285-2292.
9. Kim J, Lin J, Paz I, et al. Prophylactic pyloric dilation and endoscopic botulinum toxin injection for minimally invasive esophagectomy. Diseases of the Esophagus. 2014; 27(suppl S1):67A-68A.