Laparoscopic total esophagectomy
L. L. Swanstrom and P. Hansen
Department of Surgery, Oregon Health Sciences University, Portland, USA.
OBJECTIVE: To evaluate early results with laparoscopic total esophagectomy
for benign and malignant disease of the esophagus. DESIGN: Case series
involving 9 patients with mean follow-up of 13 months. SETTING: An advanced
endoscopic surgery unit at a tertiary referral teaching hospital. PATIENTS:
Between December 12, 1993, and December 1, 1996, 9 patients with a mean age
of 61 years underwent laparoscopic esophagectomy. Indications were
adenocarcinoma in 5, squamous cell carcinoma in 1, dysplastic Barrett
esophagus in 2, and refractory stricture with severe shortening in 1.
INTERVENTIONS: Gastroduodenal mobilization, transhiatal wide esophageal
dissection, gastric tube formation (8 cases), pyloromyotomy (2 cases),
cervical anastomosis (8 cases), and laparoscopic jejunal feeding tube
placement (8 cases). OUTCOME MEASURES: Operative time, amount of blood
loss, operative complications, length of hospital stay, postoperative
complications, dysphagia rates, and survival. RESULTS: All procedures were
completed endoscopically. Operative time was 6.5 hours (range, 4 3/4 to 9
1/4). Average blood loss was 290 mL. One patient required a right
thoracoscopy for an intrathoracic anastomosis because of questionable
viability of the gastric tube. Mean hospital stay was 6.4 days (range, 4-9
days). Hospital complications included subclavian vein thrombosis (1
patient), dysphonia (6 patients), and atelectasis (5 patients). There were
no anastomotic leaks. Three patients subsequently died: 2 of distant
metastatic cancer (at 13 months and 33 months) and 1 of cardiac failure at
10 months. The 6 surviving patients were cancer free at a mean follow-up of
13 months. One patient had left vocal cord paralysis. All patients were
doing well and had Visick scores of I or II. CONCLUSIONS: Laparoscopic
esophagectomy is a technically feasible but difficult procedure. Despite
the long operative times, patients do well and benefit from a shorter
hospital stay and more rapid recovery compared with open esophagectomy. Its
role as a curative cancer procedure remains unknown, but it may have a
place on the basis of its palliative superiority.
