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Lessons Learned From the First 20 Cases

Blair A. Jobe, MD; Charles Y. Kim, MD; Renee C. Minjarez, MD; Robert O’Rourke, MD; Eugene Y. Chang, MD; John G. Hunter, MD

Arch Surg. 2006;141:857-866.

Hypothesis  The laparoscopic transhiatal esophagectomy can be simplified and performed safely and effectively by using a novel esophageal inversion technique.

Design  Case series describing technique, initial experience, and learning curve with laparoscopic inversion esophagectomy.

Setting  Tertiary care university hospital and veteran's hospital.

Patients  Twenty consecutive patients with high-grade dysplasia (n = 16) and esophageal adenocarcinoma (n = 4).

Intervention  Laparoscopic inversion esophagectomy, a totally laparoscopic approach to transhiatal esophagectomy that incorporates distal to proximal inversion to improve mediastinal exposure and ease of dissection.

Main Outcome Measures  Perioperative end points and complications, compared between the first and second groups of 10 patients.

Results  There were 19 men and 1 woman. Median operative time was 448 minutes. Median blood loss was 175 cm³. Median intensive care unit stay was 4 days, and median total hospital stay was 9 days. Overall anastomotic leak rate was 20%. Five patients developed an anastomotic stricture, all successfully managed with endoscopic dilation. There were 2 recurrent laryngeal nerve injuries, which resolved. There was no intraoperative or 30-day mortality. Between the first 10 consecutive cases and last 10 procedures, the incidence of anastomotic leak and stricture formation decreased from 30% to 10% and 40% to 10%, respectively. During this period, the number of lymph nodes harvested increased 9-fold, and duration of intensive care unit stay decreased from 8.00 to 2.50 days.

Conclusions  Laparoscopic inversion esophagectomy is a safe procedure. The learning curve for the inversion approach is approximately 10 operations in the hands of esophageal surgeons with advanced laparoscopic expertise.

Author Affiliations: Department of Surgery, Oregon Health & Science University (Drs Jobe, Kim, Minjarez, O’Rourke, Chang, and Hunter), and Surgical Services, Portland VA Medical Center (Dr Jobe), Portland.