“Esophagectomy” has long been associated with negative connotations. Physicians’ natural instinct to protect their patients from difficult treatments may complicate the discussion of potentially curative surgery for esophageal disorders, especially in the setting of patient’s preconceived notions about recovery from surgery of this magnitude. However, a clear increase in the diagnosis of malignant and benign disorders of the esophagus continues to increase demand for esophageal surgery, and newer treatment approaches have evolved.
The most common disorder requiring esophagectomy is esophageal cancer. Major contributing factors to the rise of esophageal cancer incidence include obesity, lack of exercise, smoking and the rising incidence of symptomatic gastroesophageal reflux disease and Barrett’s esophagitis. In addition, increasing incidence of autoimmune diseases leading to esophageal and gastric motility disorders as well as increased intake of processed food may be factors contributing to the rising incidence of lower esophageal cancers. The national trend for demand for procedures on the esophagus has thus been on a steady increase over the last 10 years.
For decades, esophageal cancer surgery was approached using one of three surgical techniques that required multiple operative fields through the abdomen, chest and neck (discussed below). Less invasive approaches, such as purely endoscopic transoral procedures, have been developed for limited use in early-stage disorders, but their utility has realistically been limited likely due to lack of screening and more common presentation of patients with disease too advanced for endoscopic therapy. Thus the utility of endoscopic operations has largely been limited to benign motility disorders and early-stage endoscopic mucosal resections for very early cancer and precancerous lesions.
Other “newer” procedures such as cryotherapy (therapy involving freezing the lining of the esophagus to destroy early malignancies and premalignant cells) and photodynamic therapy (utilization of light for this purpose) have been used selectively for recurrent, limited localized disease or as palliative measures and have not been useful for the treatment of invasive esophageal cancers.
Esophagectomy Overview
The most common operative technique utilized to resect esophageal cancers in mid and distal esophagus is named after the surgeon who described the procedure: Dr. Ivor Lewis. The technique utilizes abdominal and thoracic incisions.
The operation begins in the abdomen to mobilize the stomach and preserve the gastroepiploic blood supply, tabularizing the stomach to be utilized as new esophagus and then performing a pylorus draining procedure and jejunal feeding tube placement. The abdomen is then closed and the patient is repositioned on their side with the right chest up for thoracotomy incision, spreading the ribs to allow the surgeon access to the esophagus and posterior mediastinum to resection the esophagus along with associated mediastinal lymph nodes. The already liberated stomach can then be pulled through the esophageal hiatus and anastomosed to the upper healthy esophagus to restore the ability to swallow.
Oncologic outcome for this approach through the abdomen and chest have generally been superior to other attempts to make the open surgical esophagectomy less invasive. Thus it is the Ivor Lewis esophagectomy that formulated the basis for evolution of state-of-the-art esophageal surgery toward the minimally invasive approach.
Robotic Esophagectomy
The major advancement in esophageal surgery for a range of benign and malignant disorders of the esophagus followed the introduction of the surgical robot. Robotic surgery and the advancements in the surgical robotic platform permits aggressive oncologic esophageal resection with a minimally invasive approach providing the opportunity for efficient patient recovery.
The advantages of the minimally invasive, highly versatile robotic technique were applied utilizing the advantages of the Ivor Lewis approach to prepare the stomach for esophageal replacement through abdominal incisions, then repositioning the patient and robot for the transthoracic portion of the procedure.
Thus, the basic steps of the robotic-assisted esophagectomy mirror the basic steps of the Ivor Lewis esophagectomy. (See Images 1-3.) The identical surgical steps are taken during the abdominal and thoracic portions of the procedure, however the large abdominal incision and thoracotomy incision are avoided. The data demonstrates similar oncologic results with lower mean length of stay for robotic esophagectomy vs. the gold standard Ivor Lewis esophagectomy.
In our series at the Northside Hospital Cancer Institute, we observed a decrease in the average length of stay from 14 days with standard esophagectomy to only 6 days with robotic esophagectomy among patients with similar disease and functional characteristics. Not only have our oncologic outcomes reached or surpassed historic benchmarks, but complications such as pneumonia have also decreased from 9% to less than 2% over the last 3 years, and even our intensive care unit admission rate dropped from an already low 8% to nearly 0% following the introduction of robotic esophagectomy.
Robotic-assisted operations of all types have risen exponentially since the beginning of this century. The adoption of robotic techniques by thoracic surgeons has contributed to this rise in robot utilization in parallel to surgeons in other fields.
The adoption of robotic techniques in the chest cavity made sense; surgical exposure into the chest in the past required larger incisions and painful rib spreading to allow safe access to the vital structures in the chest. Video-assisted techniques solved the issue of sparing the ribs, but early instrumentation devices lacked rotational dexterity.
Robotic-assisted surgery addressed and solved these two main problems, allowing the surgeon access with small incisions without rib spreading yet provided superb visualization and the necessary “dexterity” to conduct the operation with extreme precision. As experience with robotic esophagectomy has grown, there has been a steady decline in open esophagectomy such that robotic esophagectomy is now the dominant surgical approach used in major thoracic surgery and cancer centers around United States.
Outcomes
The favorable surgical outcomes of robotic esophageal surgery became another driving force for its adoption when compared to open techniques. The initial studies refuted concerns about inferiority from an oncologic view point. Minimally invasive esophageal surgery provides identical oncologic benefits to open esophageal surgery. Several studies showed parity among critical factors including resection with clear margins and dissection of appropriate number and stations of lymph nodes. Once oncologic equivalency was established, more major centers began to adopt robotic techniques.
We and others have subsequently shown that robotic esophagectomy is superior to open technique in centers of excellence with experienced surgeons. Superior outcomes were demonstrated related to several factors, including shorter hospital length of stay, fewer postoperative pulmonary complications, less frequent ICU admissions, all lower reoperation rate and significantly more rapid return to normal life.
One study showed the length of stay decreased by half (13.7 days for open procedures vs. 6.8 days for robotic procedures). Pneumonia rates have also dropped significantly from 8% to 4%.
Important data demonstrated that minimally invasive esophagectomy is associated with less decrease in quality of life during recovery, which has positively impacted the inaccurate perception or stigma that esophageal surgery was too hard or too difficult and that the patient should be protected from what should be considered potentially curative surgery. Rapid return to a normal performance status and uncomplicated major surgery provides the opportunity a patient’s return to their normal lives, allows patients to receive additional oncologic therapies to smooth the transition from surgery back to their primary care and oncologist care.
Future Directions
In addition to the advances in surgical robotics, recent advances of robotic endoscopy for the lungs sparked hope for development of robotic endoscopic techniques for the esophagus. Current work is being done to utilize navigational and targeted artificial intelligence to enhance endoscopic procedures.
The current endoscopic techniques and their use have been limited to myotomies for motility disorders in the form of peroral endoscopic myotomy (POEM). Another possible utilization for more advanced robotic techniques would be for endomucosal resections for limited-depth, early esophageal cancers, potentially expanding the population of patients with less-aggressive problems who could undergo totally endoscopic treatments.
Adoption of any surgical innovation, such as robotic-assisted esophagectomy, has a great potential to provide better and better short-term and long-term outcomes with growing experience. The technology is not magical. The same operation is done whether it is performed with classical open technique or with robotic technique and requires careful patient preparation, selection and surgery by experienced surgical teams.
Importantly, minimally invasive surgery is not always feasible. Some patients require open surgery. Relative contraindications to minimally invasive techniques include potential hostile environment in the chest or abdomen, intervention and surgical emergency and in some cases patient performance status.
Esophagectomy techniques have offered improved outcomes, efficient recovery and significantly improved patient satisfaction. Wider adoption of robotic-assisted techniques could help more open surgeons to translate their practice to minimally invasive benefits for their patients.
The era of the robot it is here to stay, and progressive improvements in technology and technique will progressively decrease the invasiveness and improve the outcomes for surgical treatment of esophageal disorders.
References
- Khaitan, PG et. Al. Robotic Esophagectomy Trends and Early Surgical Outcomes: The US Experience. Annals of Thoracic Surgery 2023;115:701-9
- Espinoza-Mercado F et al. Does The Approach Matter? Comparing Survival in Robotic, Minimally Invasive, and Open Esophagectomies. Annals of Thoracic Surgery 2019; 107:378-385
Dr. Shady M. Eldaif
Dr. Eldaif is the Chief of Thoracic Surgery for the Northside Hospital Healthcare System. He has a special focus on cancer operations and has performed more robotic thoracic surgeries than any general thoracic surgeon in Georgia. Dr. Eldaif has a keen interest in incorporating minimally invasive treatment modalities in the care of benign and malignant thoracic diseases for his patients. He has authored and co-authored many publications discussing advanced treatments for achalasia, Barrett’s esophagus, esophageal and lung cancer, as well as tracheal and thoracic trauma.
