AATS Focus on Thoracic Surgery: Mastering Surgical Innovation

Las Vegas, NVOctober 28, 2017

Session VIII: Video Session

Minimally Invasive Esophagectomy: Are We Still Getting Better in 2017?

James D. Luketich MD, FACSHenry T. Bahnson Professor and Chairman,

Department of Cardiothoracic Surgery University of Pittsburgh Medical Center

Technique: Laparoscopic-Transhiatal versus thoracoscopic/laparoscopic

• Lap-THE:• PRO:• No repositioning pt• No single lung

ventilation• CON:• small working space• Limited access to

thoracic nodes• Gastric tip ischemia• RLN injury

• Lap/VATS:• PRO:• better exposure /dissection of

mediastinum• Better esophageal margins• ? Survival/local recurrence

benefit• CON:• repositioning required• double lumen tube required• Delayed abdominal assessment• Gastric tip ischemia• Gastric margins• RLN injury

• MIE Ivor Lewis:• PRO:• pros of lap/vats• No pharyngeal/RLN

issues• Less gastric tip ischemia• Larger diameter anastomosis,• less strictures• Better gastric margins• CON:• Esophageal margins (SCC, or

high Barrett’s• Technical challenge

of VATS anastomosis

N=15, initial approach N=>500 N=>1500 current approach

Laparoscopic Portion: Step by Step

• On the table EGD• Laparoscopic staging• Crural dissection, nodal dissection, gastric vessels• Conduit preparation and construction• Pyloroplasty, coverage• J-tube• Omental flap

Laparoscopic Port Placement

Self-retaining liver retractor

4 5-mm portsone 10-mm port

Left Gastric artery and vein and node dissection (Improved nodal dissection)

• More aggressive nodal dissection• Skeletonize the base of left gastric artery and vein• Sweep all fatty and nodal tissue upward with specimen• Continue this dissection plane into the retro crural and pre-

aortic areas• Old data 15-20 nodes• New: 40 Plus lymph nodes

Celiac Nodal Dissection and Gastric Vessel Division

1) More aggressive nodal dissection

2) Skeletonize the base of left gastric artery and vein

3) Sweep all fatty and nodal tissue upward with specimen

4) Continue this dissection plane into the retro crural and pre-aortic areas

5) Old data : 16-20 lymph nodes

6) New goals: greater than 40 LN

Mobilization of Stomach

• 1) Handle the stomach gently, “No touch technique”of the final conduit

• 2) Division of the omentum and omental branches of the gastroepiploic artery– Leave 2-3 cm of greater arcade omentsl fat to insulate the gastric conduit

with greater curve omentum and keep staple line away from the airway• 3) Add omental flap in patients who have received neoadjuvant

chemoradiation to completely wrap the anastomosis

Gastric Tubularization: Newer modifications

GE junction tumor1) More narrow tube, 2.5-3 cm

2) Begin staple line 5-6 cm above pylorus

3) Concept of antral reservoirliving below the hiatus

4) Staple line parallel to line of short gastrics

5) Stomach on slight “stretch” while applying stapler

6) No trauma to the actual new conduit“no touch” technique

Antral Reservoir

1) Division of the omental branches

of the gastroepiploic artery -2-3cm of greater arcade fat

to insulate the gastric conduit and staple line from the airway

2) Omental flap in patients who have received neoadjuvantchemoradiation

3) Strict avoidance of vasopressors

Short Gastrics “No Touch”

Construction of the Gastric Conduit

Other Steps

• Needle Catheter Jejunostomy (our standard)• Pyloroplasty (our standard, but may not be necessary with

narrow gastric tube)• Celiac LN dissection (our standard)

Pyloroplasty

1) Open perpendicular to muscle band

2) Close on “stretch”

3) Time Goal: under 10 minutes

4) Omental patch (graham)

5) Single institution randomized trial in progress

Laparoscopic J Tube

1) 10 French kit, no more “needle J’s”

2) Time goal: under 10 minutes

3) Witzel all tubes

4) Parachute stitch replaces 4 interrrupted

Tack Gastric Tube to Mobilized GE-Junction Tumor For Chest Retrieval

Marking stitch

Antral reservoir

Preparation of the Conduit and Final Inspection

1. Tack Tip to Stapled gastric line

2. Assess crural opening, widervs. narrow

3. Tuck specimen and tip Intomediastinum

4. Final exam of conduitorientation, suture mark,bleeding, tack omental flap

Conduit Preparation Marking Stitch

Ivor Lewis: VATS Portion of Operation

• Standard LN dissection• Open phrenoesophageal ligament and retrieve specimen and

deliver gastric tube into chest• Transect esophagus• Remove specimen• Insert anvil and perform intrathoracic EEA anastomosis

(preferably 28 mm, or 25 EEA)

Typical Location of Surgeon and Assistant Instruments During VATS part of Ivor Lewis or Mckeown Approaches

VATS Esophageal Lymph node Dissection(Video)

1) Diaphragm retracting stitch

2) Watch posterior membranous airway

3) We generally leave thoracic duct, if damaged, ligate

4) Aorta, use clips, avoid tearing small vessels

5) Do not pull up excess gastric conduit, it is important to have a nice straight, non-redundant lie

6) separate staple line from airway with fat if possible

7) Drain, ? Type, avoid excess suction? Chest tube and NG tube.

VATS Ivor- Lewis Anastomosis(Video)

Omental Flap Creation

Completed anastomosis with omental pedicle wrap

Completed Reconstruction With Cervical Anastomosis: Consider laparoscopic look at end of Ivor Lewis

1) High intrathoracic anastomosis

2) Avoid redundant conduitabove diaphragm

3) Marking stitch, facilitates leaving antral reservoir

4) Tack gastric tube to hiatus to minimize delayed hernias

5) Consider final laparoscopic look

Perioperative OutcomesMortality

• Mortality (30 day) for all patients (n=1011):1.68 %

• Ivor-Lewis MIE: 0.9 % 30 day1.9% 90 day

James Luketich et al Ann Surg 2012

Thank You

Ivor Lewis Approach• Less gastric tube needed, better margins for cardia involvement, less

ischemia• Avoid neck dissection and potential recurrent laryngeal nerve injury• Less aspiration• Downside: intrathoracic leak can be more difficult to manage, no

third field of LN dissection• Technique, Learning curve to the VATS intrathoracic anastomosis