ing those patients from a very selected population . This avoids morbidity and mortality of esophagectomy and unlike ablative therapies , it mimics surgery and allows pathological evaluation of the specimen .
For T1-2 , N0 , we typically take people straight to surgical resection as those patients don ’ t receive as much benefit from neoadjuvant therapy . For T3-4 , N0 lesions or T1-2 , N +, the best data points in the direction of neoadjuvant chemotherapy and radiation .
Esophagectomy approaches
• MCKEOWN
» Chest mobilization first , followed by combined left neck and abdomen .
» Open versus minimally invasive abdomen and chest .
» Cervical esophageal gastric anastomosis .
• IVOR LEWIS
» Right chest and abdomen with intrathoracic esophagogastric anastomosis .
» Open versus minimally invasive .
• TRANSHIATAL
» Abdomen and neck , no chest incisions .
» Cervical esophagogastric anastomosis .
• OTHERS
» Left thoracicoabdominal .
In looking at surgical esophagectomy options , it ’ s important to re-stage prior to surgery with a PET scan looking for distal , metastasis and tumor response . This should be done five to eight weeks after completion of neoadjuvant therapy with a goal of surgery within the window of six to eight weeks . A CT scan of the abdomen and chest with contrast is recommended and EGD and biopsy are optional .
Historically , mortality after esophagectomy ranges from 8 to 23 %, dependent on the hospital volume and if there is significant
associated morbidity .
A minimally invasive approach adopted to lessen morbidity and mortality while providing an adequate cancer operation is in order . Robotic assisted minimally invasive esophagectomy ( RAMIE ), has been adopted recently and so far results in fewer post-op respiratory complications and fewer vocal cord injuries , despite an often longer operative time .
Future treatments
• Improved , better tolerated chemotherapy regimens
» 5-FU , leucovorin , oxaliplatin ( FOLFAX )
» 5-FU , leucovorin , oxaliplatin , docetaxel ( FLOT )
• Immunotherapy with programmed death-ligand 1 ( PD-L1 inhibitors ), HER2
» Currently used for locally advanced and unresectable metastatic disease
» Being used as adjuvant therapy in many patients
Dr . Black ’ s lecture was informative , educational and up-todate . We thank Dr . Black for his contribution to the GLMS lecture series .
References
Black MC , Hess NR , Okusanya OT , Luketich JD , Sarkaria IS . Robotic Assisted Minimally Invasive Esophagectomy for Esophageal Cancer . Ivor Lewis Robotic Assisted Minimally Invasive Esophagectomy : Different Approaches . Focused Issue on “ Robotic Surgery for Esophageal Cancer ”. Journal of Visualized Surgery , Vol 5 , 2019 .
Black MC , Sarkaria IS , Luketich JD . Robotic Esophagectomy , Current Status and Ongoing Trials . Annals of Translational Medicine-Focused Issue on Esophageal Cancer . Pending publication
Black MC , Luketich JD , Sarkaria IS . Robotic Assisted Minimally Invasive Esophagectomy for Esophageal Cancer . Robotic Surgery : Clinical Perceptions , Approaches , and Challenges . Nova Science Publishers , Inc . January 2019 .
Dr . Yared is a retired cardiovascular and thoracic surgeon and Chair of the Senior Physicians Committee .
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