Implementation of minimally invasive esophagectomy in a tertiary referral center for esophageal cancer

Abstract

years, high morbidity rates are still recorded (5,6). In an effort to reduce the postoperative morbidity associated with open esophagectomy various minimally invasive esophagectomy (MIE) techniques have been introduced and developed during the recent years. MIE is believed to minimize the surgical trauma and subsequently the postoperative pain resulting in a faster mobilization and recovery with reduced postoperative complication rates and shorter hospital stay compared to the open procedure. During the last 20 years several studies have been published within the field demonstrating that MIE is a safe technique with an oncological outcome at least equal to open esophagectomy with regard to complete resection rate, number of lymph nodes harvested and postoperative survival (7-9). Moreover, there is an indication of shortterm benefits after MIE especially with regards to reduced pulmonary complications and improved health related quality of life compared to the open procedure (10,11).The aim of the current study was to present our 4.5-year experience of the gradual implementation of various MIE techniques in our tertiary referral center with special focus on the evolution of adaptive changes and refinements of our practice of the procedure over this period. Methods Our unitCenter of digestive diseases (CDD) at Karolinska University Hospital, Stockholm is one of the largest and most highly specialized centers in the Nordic countries. It is a tertiary referral center in Stockholm County with a catchment area of approximately 2,500,000 inhabitants. Furthermore, CDD receives referrals for patients with newly diagnosed esophageal and cardia cancer from neighboring counties with an additional population of 650,000. This results in an annual case volume of 40-60 esophageal and resections in the most recent years.The Unit engages three consultant surgeons (MN, ML, IR), with long laparoscopic experience within benign upper gastrointestinal (UGI) surgery as well as long previous experience in open esophageal cancer surgery. Karolinska, Stockholm. From 2009, one of the current consultant surgeons, IR, spent 3 years in a fellowship in UGI cancer surgery at Bristol Royal Infirmary, Bristol, UK with special focus in MIE. During these years he became confident in both the hybrid laparoscopic assisted esophagectomy (HLAE) technique including laparoscopic gastric mobilization and abdominal lymph node dissection followed by thoracotomy and intrathoracic anastomosis as well as with the minimal invasive McKeown (MIMK) technique, i.e., thoracolaparoscopy followed by cervical anastomosis by performing more than 70 cases. In the meantime, two other consultant surgeons (MN & ML) had the chance to visit another center with extensive In May 2012 and as a first test of transition to MIE, the first HLAE was performed safely with all consultants present. This was followed shortly by an additional procedure with satisfactory results and without any technical problems to be encountered. HLAE was chosen as the most feasible MIE in the beginning...

Safe Introduction of Minimally Invasive Esophagectomy at a Medium Volume Center

“…Reports propose the learning curve of MIE to be around 30–40 operations (15, 16) to overcome the technical difficulties and even suggested as high as 119 surgeries to surpass the learning curve regarding anastomotic insufficiency (17). The present study of 51 MIE patients operated in a medium volume center proposes similar results to Nilsson et al reporting on the successful implementation of MIE at a Swedish high-volume center in 173 patients over 5 years (18). In the present study, the duration of surgery was unaffected by the transition to MIE, possibly reflecting the present surgeons’ extensive experience in other advanced laparoscopic procedures.…”

Benchmark values for transthoracic esophagectomy are not set as the defined °∞best possible°±°™a validation study

“…Previous studies have shown higher postoperative mortality associated with neck anastomosis (25,27). Also, part of the benchmark centers, as addressed by the authors, were still in the middle of their learning curve, and also changing the approach used during the study period (28). The results can be further improved with omental reinforcement flaps, also used routinely at our center, which were shown to decrease overall leak rates (29).…”

Prospective Randomized Controlled Study on Treatment of Stage T1-3N0M0 Middle-Lower Section Esophageal Cancer by Two Minimally Invasive Radical Surgeries

“…This indicates that, Ivor-Lewis surgery has higher safety. This may be because the living quality of patients in this group is higher after the operation [6][7][8][9] . Clinical literatures and reports indicate that, Ivor-Lewis surgery is relatively simple during the treatment of middle-lower section esophageal cancer, while McKeown surgery is relatively complex and increases the risk of recurrent laryngeal nerve injury, thus reducing patients' living quality.…”