February 2009

Minimally Invasive Esophagectomy for Cancer, Pre-Malignant Disorders

Pierre Theodore, M.D.
Thoracic Surgeon
UCSF Center for Esophageal Disorders

Esophageal cancer has been on the rise in the United States and other Western countries for the past three decades, with a particular increase in adenoid carcinomas. The causes are unclear but it may be related to increases in obesity and reflux disease, and environmental factors. Early detection in endoscopy is helping identify patients who are curable via surgical intervention.

Conventional esophagectomy for esophageal cancer and severe pre-malignant esophageal disorders is associated with significant morbidity. In comparison, research shows that minimally invasive esophagectomy (MIE) reduces trauma and results in a lower morbidity rate and no increase in mortality. Other advantages include reduced blood loss, reduced need for transfusion, less pain, faster recovery and shorter hospitalization.

Patients who undergo MIE typically spend six to eight days in the hospital, compared to 10 or more after conventional esophagectomy. MIE also avoids the disfiguring incisions associated with open surgery, while allowing surgeons to perform a thorough excision of a patient's cancer. In addition, having a lower degree of inflammatory insult may reduce the chance of tumor recurrence.

The minimally invasive approach avoids painful incisions associated with open surgery while permitting a complete oncologic resection of the tumor. Having a lower degree of inflammatory insult may reduce the chance of tumor recurrence.

The Procedure

MIE is a technically demanding operation, requiring advanced laparoscopic and thoracoscopic surgical skills. The procedure is performed using small incisions measuring 2 to 5 centimeters. The entire operation is performed using laparoscopic and thorascopic instruments.

The operation involves:

  • Removal of the esophagus and associated lymph nodes
  • Creation of a gastric conduit
  • Anastromosis performed in the chest

Research shows that centers performing a large number of esophagectomies by surgeons specializing in the procedure have significantly lower surgical mortality rates compared to centers that perform few esophagetomies. The surgical mortality rate for high-volume centers is 3 to 5 percent compared to 16 to 20 percent at low-volume centers.

Clinical Criteria

MIE is recommended for patients with esophageal cancer and pre-malignant conditions, such as high-grade dysplasia caused by Barrett's esophagus. Without treatment, the risk of developing esophageal cancer in patients with high-grade dysplasia increases forty-fold.

Some patients are reluctant to undergo an esophagectomy because of its highly invasive nature and its associated mortality and morbidity. MIE now provides these patients with a less invasive option, while eliminating the risk for esophageal cancer.

UCSF Center for Esophageal Disorders

UCSF recently formed the UCSF Center for Esophageal Disorders to offer the latest diagnostic and treatment options for benign and malignant conditions. Our team includes experts from general surgery, gastroenterology, cardiology, pulmonology, oncology and radiology.

UCSF is considered a high-volume surgery center for esophageal disorders. To date, the center's surgical mortality for esophageal disorders is negligible.

The center specializes in conditions, including:

  • Achalasia
  • Barrett's esophagus
  • Diffuse esophageal spasm
  • Esophageal cancer
  • Gastric tumors
  • Gastroesophageal reflux disease (GERD)
  • Hypertensive lower esophageal sphincter
  • Nutcracker esophagus

For more information, contact the Physician Referral Service at UCSF Medical Center:

Phone (888) 689-UCSF or (888) 689-8273
Email referral.center@ucsfmedctr.org

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