MONTREAL — Laparoscopically assisted transhiatal esophagectomy is safe and technically feasible in most patients, but attempting the operation entirely through the laparoscope can result in higher morbidity rates, according to Dr. Dalilah Fortin.
In a prospective study that she presented at the annual meeting of the Canadian Association of Thoracic Surgeons, Dr. Fortin and her colleagues at the London (Ontario) Health Sciences Center concluded that laparoscopic-assisted transhiatal esophagectomy (LTE)—although not the least invasive approach—is the safest and most feasible of the minimally invasive techniques for esophagectomy.
“If you want the least invasive approach, you have to do a right video-assisted thoracic esophageal mobilization through the chest and then a laparoscopy in the abdomen, and then you need only a small incision to get the specimen out. But this is a complex operation; there is a learning curve, and the morbidity is higher,” she said in an interview.
The study involved 48 patients scheduled for minimally invasive esophagectomy. At exploratory laparoscopy, five of the patients were found to be unresectable and were converted to minilaparotomy with feeding-tube placement. Another five patients were converted to laparotomy and underwent gastrectomy.
Of the remaining 38 patients, 26 underwent LTE, 4 had a right thoracotomy and laparoscopic-assisted esophagectomy (T-LE), and 8 had the least invasive right video-assisted thoracic esophageal mobilization and laparoscopic esophagectomy (V-LE).
A total of nine procedures (23%) were converted to laparotomy—four for local invasion, four for adhesions, and one for spleen injury. The operating time, length of hospital stay, and rate of major complications were all significantly increased in the V-LE group.
Median operating time was 475 minutes in the V-LE group compared with 330 minutes and 270 minutes in the T-LE and LTE groups, respectively. In addition, patients in the V-LE group spent a median of about 40 days in the hospital, compared with about 10 days in the other groups.
Major complications leading to reoperation occurred in two LTE patients (port-site hernia, colon herniation), one T-LE patient (chylothorax), and five V-LE patients (three chylothorax, one empyema, one bronchial injury). There was one postoperative death, and two patients died within 3 months of surgery from metastatic disease.
Initial laparoscopic staging was possible, with up to 29 lymph nodes per resected specimen identified and histologically examined, Dr. Fortin said.