Q&A: Minimally Invasive Esophagectomy
CancerWise - October 2007
Cancer patients needing surgery to remove their esophagus (esophagectomy) should ask their doctors about minimally invasive surgery. Although not for every patient, the procedure has been found to offer some benefits over traditional open surgery.
Answering questions about minimally invasive esophagectomy (MIE) is Reza Mehran M.D., an associate professor in M. D. Anderson's Department of Thoracic and Cardiovascular Surgery.
What is esophagectomy?
Esophagectomy is surgery to remove the esophagus. It is used in treating patients with esophageal cancer and patients with premalignant conditions such as Barrett’s esophagus.
What is MIE?
In MIE, small incisions are made and video-assisted thoracic surgery (VATS) is performed with laparoscopic instruments to remove the esophagus.
What are the benefits of MIE?
Minimally invasive surgery uses smaller incisions than open surgery, which can have several benefits.
MIE has been shown to:
- Minimize trauma to the body
- Reduce blood loss
- Reduce need for transfusion
- Speed the patient recovery process
- Decrease post-operative pain
- Shorten hospital stays
Having a lower degree of inflammatory insult (the response of the body to the trauma of surgery) can result in faster healing and perhaps less chance of a tumor recurrence.
The more trauma caused by surgery, the more the body has to build up a healing mechanism. It’s a vicious cycle. Surgery of any kind allows the body to heal, but it creates an environment that puts patients at risk.
How long is the hospital stay?
With MIE, it can be three to seven days versus seven to 10 days for traditional surgery, but it depends on the patient.
Are all patients eligible for the procedure?
It’s an option that’s available to a certain group of patients – mostly those who are healthy enough to withstand surgery. With any surgery there are risks, and this is a complicated surgery, whether it’s traditional or minimally invasive.
How does MIE differ from traditional esophagectomy?
Traditional or open esophagectomy requires large incisions in the chest and abdomen, which require more healing from the body.
Which surgery is better?
There is only one study that I know of that compares MIE and traditional surgery. It shows MIE is more beneficial. However, MIE is not right for everyone.
The key thing is to have the tumor completely resected (removed). It doesn’t matter how it’s resected – whether it's done with open or minimally invasive surgery. What is important is to be in a hospital that treats a large volume of patients with esophagectomy, so they are treated by experts in all levels of care – including the anesthesiologists, nursing staff and dietitians.
It's also important that patients get the chemotherapy and radiation the tumor requires.
M. D. Anderson has conducted a study showing that people treated in high volume centers have better outcomes.
How many MIEs are performed at M. D. Anderson annually?
We perform about 200 a year. A high number of people come here each year to undergo esophagectomy, but not everyone is a candidate for it.
Three of our doctors perform MIE, but patients who come to M. D. Anderson have the option of having either a traditional surgery or MIE. We began performing MIE in 2004 and use the recommended technique popularized by the University of Pittsburgh.
How difficult a surgery is esophagectomy?
It’s a massive procedure – whether it’s open or MIE. (The surgeries are similar in length, taking between five to seven hours.)
There is simultaneous exposure of the chest, abdomen and neck. It’s essentially combining three surgeries into one, and any one of these surgeries would cause a significant amount of trauma on its own.
What is the mortality rate for esophagectomy?
As with any major sugery, esophagectomy (whether traditional or MIE) has a mortality rate of 2% to 5%, meaning that 2% to 5% of patients die from the surgery, because major surgery raises the risk of complications such as pneumonia or pulmonary distress.
One out of five patients has complications in surgery, so patients need to be in a hospital where these procedures are more routinely performed and are equipped to handle complications.
What can patients expect in recovery?
Every patient initially does poorly physically. Patients who undergo MIE may do slightly less poorly. In general, there is quite a significant adjustment in lifestyle. Most patients are able to resume the lifestyle they had prior to surgery, but it takes six months to a year.
What are the most common problems after surgery?
The most common problem is learning how to eat again. When we remove the esophagus, we create a tube out of the stomach to replace the esophagus, so the patient has no more stomach. This means the type of food they eat and the amount they eat is decreased. Raw sugar and volume of food may not be tolerated, so they might vomit.
Patients need to eat smaller amounts and more frequently, six to eight meals a day. Eventually they will go to a normal diet because the tube eventually stretches, but it takes six months to a year to get there.
Patients will have a feeding tube for up to three months while they’re learning to eat, so they’re not at risk of developing more disease.
Patients also can develop dumping disease (nausea, vomiting, cramps, flushing and diarrhea), which also takes time to resolve.
What can patients do to aid their recovery?
Patients have to have a positive attitude. They have to know that there’s hope. Despite the fact that it’s esophageal cancer, one of the worst types of cancer one can get, there’s still a chance for a successful recovery.
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