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Ann Thorac Surg 2000;70:911-912
© 2000 The Society of Thoracic Surgeons
Discussion
DR MARK B. ORRINGER (Ann Arbor, MI): Doctor Luketich, this was a well-delivered paper, and I enjoyed it very much. Your technique is an extension of the concept of esophagectomy without thoracotomy, which I think has now been shown to be achievable in the majority of people needing an esophagectomy.
I do have some concerns that I would like you to address. This is not just minimally invasive esophagectomy. It is "minimally invasive gastric mobilization" as well, and the gastric mobilization is a key part of this operation. We have learned over the years, as we stopped focusing upon the actual transhiatal esophagectomy, that mobilizing the stomach in as atraumatic a fashion as possible is extremely important, and when the stomach is delivered out onto the abdominal wall, as the stapler is progressively applied, the stomach is gradually stretched and an elongated gastric tube fashioned. You do not do this with your technique. You cannot stretch the stomach in the same way when confined by the abdominal cavity. Further, you cannot palpate the tumor to see how far away you are from an EG junction tumor in applying your stapler. You also describe taking sutures into the apex of the stomach, which we are now preaching has to be traumatized as little as possible—no sutures to drains, no "beating up" the stomach so that you wind up with a contused, ecchymotic fundus when you bring it up to the neck for the anastomosis. The fact that you pull the divided esophagus (with its contained tumor) sutured to the gastric tip through the mediastinum without progressively lengthening the stomach is worrisome. Is this part of the reason that you have a 10% leak rate? We have just reported an anastomotic leak rate of under 3% using an end-to-end stapled anastomotic technique and strictly minimizing intraoperative trauma to the stomach. And I wonder why your patients need to go to the ICU. Our patients do not have an ICU stay, and their average hospitalization is 6 to 7 days after our "open" transhiatal esophagectomy without thoracotomy. So I am not convinced that the availability of the video-assisted or laparoscopic technology necessarily justifies its use for this type of operation. I certainly can understand that your visualization of the mediastinal anatomy may be more comfortable with video-assisted technology. But I am very concerned that using this approach prevents optimal elongation of the stomach, results in excessive trauma to the stomach, and requires a pyloroplasty with its gastroduodenal suture-line in the abdomen that an open transhiatal esophagectomy avoids. I would like you to address some of these issues. I enjoyed your paper very much.
DR LUKETICH: Thank you, Dr Orringer. The gastric elongation; I think what has made us comfortable in that area is that we do a very significant amount of laparoscopic benign work, and so our view of the stomach, we are very comfortable with that. Now, in terms of the mobilization of the stomach, we go to great lengths to minimize trauma to the stomach. We use multiple firings of the endo-GIA to uncoil the stomach. Using atraumatic noncrushing graspers to hold the stomach fundus up just above the tip of the spleen. So we are actually trying to duplicate what you have taught us and others have taught us, to be careful with the gastric tube and to gain as much length as possible. We have not actually had to convert any case for lack of gastric tube length. I think you have to be extremely careful using atraumatic graspers and pay a lot of attention to minimizing trauma to the gastric tube.
In terms of the margins, we do an on-the-table esophagoscopy, and in some cases we leave the scope in place. We do frozen sections in the operating room. If a margin is close, we staple out a strip of stomach between the specimen and the tubulonginal stomach to allow additional frozen sections to be performed. In our experience, we had 77 negative frozen section margins and only three came back on permanent pathology to be positive. But that remains a definite concern of ours and that is one reason why we approach it as I mentioned.
Again, in terms of the ICU stay, I hesitate to say that we have demonstrated definite advantages over conventional surgery. Clearly, even our own experience with open surgery is moving towards shorter hospital stays. So I think some of this is related to DRGs, etc. We are avoiding ICU stays in some patients. So I appreciate your concern there. I am not sure that we have demonstrated an advantage, and I hope that was my message. I think it is a safe operation, but I am not at all sure that it is a better operation or that it is more cost-effective by any means at this point in time. That will require prospective multiinstitutional trials.
DR ANTOON LERUT (Leuven, Belgium): Doctor Luketich, I enjoyed your presentation very much. Twenty years ago, Dr Orringer standardized the technique of the transhiatal esophagectomy. For this, he was awarded yesterday in the election as the President elect of this Society. It seems now that you are standardizing the technique of minimal invasive esophagectomy. Perhaps 20 years from now you may become the President-elect as an award for this effort. This is to say that, I have great respect for the efforts that you have done in this field.
The key element is: are you doing the same oncologic operation as in open surgery? Does it allow you to do a lymphadenectomy in the apex of the chest where you will often find positive lymph nodes? Many of your patients have carcinomas of the distal esophagus. Does laparoscopy allow a dissection along the common hepatic artery, the celiac axis, and splenic artery! Doing an extensive lymphadenectomy at least in our experience will make a substantial difference in the 5-year survival and the cure rate. Can you achieve these sorts of lymphadenectomies with your actual technique?
DR LUKETICH: Thank you, Dr Lerut. Well, I think that it partly depends on the philosophy, open or laparoscopic, in terms of how many lymph nodes should be dissected out. We certainly do dissect out the celiac nodes. We certainly do fairly aggressive lower and midthoracic esophagus mobilization of all subcarinal nodes and periesophageal tissue. Above the carinal area for GE junction tumors, we have not been very aggressive dissecting out recurrent nerve nodes or neck nodes in our neck dissection. We do not do a neck dissection, as you know. So I think that these are issues that are not clear at this point in time. Whether we are approaching the operation open or laparoscopic, do we need to do a radical nodal dissection? I do appreciate your comments, and your data certainly are provocative. The standard in the United States has not been as aggressive a thoracic nodal dissection. The addition of thoracoscopy greatly improves our ability to dissect the periesophageal lymph nodes and subcarinal areas. We have not been aggressively dissecting upper thoracic or neck nodes.
DR LERUT: The overall nodes that you removed are rather low, 16. I think most of us will accept that 25 will be the minimum. Can you comment on that? It seems to be rather low.
DR LUKETICH: I think the nodal count, to be honest with you, is not necessarily dependent on the surgeon. We do a very good nodal dissection. It is how many times I want to call the pathologist and ask him to get that specimen back out of the bucket and do an exhaustive nodal search. Once a single node is positive, there is less concern over counting nodes because they have documented N1 and additional nodal counting will not change the stage.
Related Article
Ann. Thorac. Surg. 2000 70: 906-911.
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