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Outcomes after Minimally Invasive Esophagectomy
James D Luketich, MD, Omar Awais, DO*, Manisha Shende, MD*, Neil A Christie, MD*, Benny Weksler, MD*, Rodney J Landreneau, MD, Blair A Jobe, MD*, Ghulam Abbas, MD*, Arjun Pennathur, MD*, Matthew J Schuchert, MD*, Katie S Nason, MD, MPH*
University of Pittsburgh, Pittsburgh, PA


Objectives:

Esophagectomy continues to be associated with high morbidity and mortality. In an attempt to lower morbidity, we have developed a minimally invasive approach to esophagectomy (MIE). This study describes our outcomes after elective MIE. We compare our modified McKeown approach, [videothoracoscopic esophageal mobilization, laparoscopic conduit preparation, neck anastomosis (MIE-neck)] versus our current approach, a modified Ivor Lewis [laparoscopic conduit preparation, videothoracoscopic esophageal mobilization, chest anastomosis (MIE-chest)].
Methods:
We reviewed 1000 consecutive patients undergoing MIE. Patients were stratified by surgical approach and perioperative outcomes analyzed.
Results:
Elective MIE was performed on 973 patients, 27 urgent cases were excluded. A MIE-neck was performed in 478 (49%) and a MIE-chest in 494 (51%). Patients undergoing MIE-chest were operated in the current era. Median length of stay (8 days), ICU stay (2 days), and median lymph node (LN) count (n=20) were similar between the two approaches. Higher rate of complications were seen in the MIE-neck group versus the MIE-chest, including vocal fold paresis (9% MIE-neck versus 1 % MIE-chest; p<0.001), sepsis (11% versus 7%; p=0.024), anastomotic leak requiring surgery (8% versus 4%; p=0.013) and gastric tube necrosis (3% versus <1%; p=0.018). There was a trend toward a lower 30-day in-house mortality in the MIE-chest group (2%) versus MIE-neck (4%; p=0.09).
Conclusions:
MIE in our center resulted in acceptable lymph node resections, postoperative outcomes and low mortality using either a MIE-neck or MIE-chest approach. The modified Ivor Lewis approach (MIE with intrathoracic anastomosis) reduced conduit complications and mortality, and is now our preferred approach.


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