Surgical Approaches to Remove the Esophagus: Robotic

Indications

Most candidates for esophagectomy are also candidates for attempted MIE and therefore also candidates for robotic esophagectomy. There are few specific contraindications for the use of robotic technology. The need to perform an en bloc resection of aorta or intrathoracic trachea or carina along with the esophagectomy, which has been safely applied to selected patients, would generally be considered a contraindication to robotic esophagectomy. Prior thoracic or abdominal surgery can make a robotic approach more challenging due to the presence of adhesions, but lysis of adhesions can be performed to permit its use. Comorbidities or poor functional status that would otherwise make patients suboptimal candidates for esophagectomy generally would also apply to offering robotic esophagectomy, although robotic esophagectomy may permit surgeons to offer esophagectomy to somewhat older and sicker patients by decreasing the perioperative complication rate (especially respiratory complications). However, caution in patient selection should be applied, as the physiologic effects of complications such as anastomotic leak and chylothorax remain significant regardless of whether they occur in a robotic or open esophagectomy.

Early-stage (T1a and early T1b) esophageal cancers can be managed with endoscopic mucosal resection (EMR). Generally, if a lesion is not amenable to EMR or is T1b or deeper on final pathologic analysis, esophagectomy may be considered. If EMR for early-stage esophageal cancer is performed in the context of Barrett esophagus, radiofrequency ablation (RFA) to promote regression of Barrett should also be considered. Patients with persistent high-grade dysplasia following attempted RFA are also candidates for esophagectomy. Benign indications for esophagectomy include end-stage achalasia or mega-esophagus, refractory stricture, intractable reflux resistant to surgical interventions, and multiple failed hiatal hernia operations.

Equipment

The Da Vinci Surgical System is currently the only US Food and Drug Administration (FDA)-approved robotic system for surgery. The surgeon sits at a console some distance from the patient, who is positioned on an operating table close to the robotic unit with its four robotic arms. The robotic arms incorporate remote center technology, in which a fixed point in space is defined,and about it the surgical arms move so as to minimizestress on the thoracic or abdominal wall during manipulations. The small proprietary Endowrist instruments attachedto the arms are capable of a wide range of high-precision movements. These are controlled by the surgeon's hand movements via “master” instruments at the console. The “master” instruments sense the surgeon's hand movements and translate them electronically into scaled-down micro-movements to manipulate the small surgical instruments. Hand tremor is filtered out by a 6-Hz motion filter. The surgeon observes the operating field through console binoculars. The image comes from a maneuverable high-definition stereoscopic camera (endoscope) attached to one of the robot arms. The console also has foot pedals that allow the surgeon to engage and disengage different instrument arms, reposition the console “master” controls without the instruments themselves moving, and activate electric cautery. A second optional console allows tandem surgery and training. Da Vinci currently offers both the Xi and Si systems. The Xi system is newer and features an overhead beam that permits rotation of the instrument arms, allowing for greater flexibility in terms of direction of approach of the robot to the patient. Compared with the Si, the Xi also has thinner instrument arms, longer instruments themselves, and the option to switch the camera to any arm/port.

Preoperative Evaluation

A thorough history and physical should be performed, focusing on key points such as Barrett esophagus, gastroesophageal reflux disease, motility disorders such as achalasia, prior surgeries, functional status, and cardiac and respiratory comorbidities. Smoking cessation should be encouraged and alcohol use should be noted to screen for cirrhosis and warn of possible withdrawal issues in the perioperative period. Patients undergoing esophagectomy for neoplasm should receive a whole-body positron emission tomography (PET)-computed tomography (CT) scan to evaluate for possible metastatic disease, unless this is obvious from chest/abdominal CT scans alone. If fairly convincing combined radiologic and clinical evidence exists for metastatic disease (e.g., weight loss, widespread adenopathy or liver/lung nodules), biopsy confirmation of metastatic disease may not be necessary. However, single-site M1 disease should likely be confirmed with tissue diagnosis. Location of tumor, synchronous lesions, and presence/extent of Barrett esophagus should be noted on the preoperative endoscopy. Tumors extending into the proximal stomach may require a partial gastrectomy and different reconstructive approach; tumors in the mid-esophagus should generally be approached via a McKeown type operation rather than Ivor Lewis. An adequate margin may be difficult to achieve for tumors in the proximal one-third of the esophagus; these patients are better suited for definitive chemoradiation, although in some centers, laryngoesophagectomy may be an option. Some investigators have suggested that patients with preoperative dysphagia may not need an endoscopic ultrasound (EUS) given that 90% of them had T3 to T4 disease, a finding that has been corroborated by others. However, although the presence of symptoms such as dysphagia is a very specific finding for the presence of a T3 or greater lesion, the absence of symptoms does not necessarily indicate that the patient does not have a T3 or greater lesion. Given that being T3 or deeper and/or the presence of N1 or greater disease dictates the performance of induction chemoradiation at our institution, we also consider EUS a critical part of the preoperative evaluation. Performance of induction chemoradiation for T2N0 lesions is variable. We prefer preoperative therapy since a significant percentage will have nodal disease, although there is a controversy regarding patients who are older than 75 years. Brain imaging is performed if the patient has neurologic symptoms or headaches that are concerning for intracranial metastases. Bronchoscopy is done if the patient has an esophageal cancer of the proximal or middle esophagus to rule out airway invasion. Patients who remain candidates for esophagectomy after the aforementioned testing generally also receive pulmonary function testing and stress testing. No specific diagnostic procedures are performed for robotic esophagectomy per se.

After the completion of induction chemoradiation, restaging PET-CT should be performed. Patients who develop progression of disease or metastases are offered palliative management strategies. Patients who have persistent disease or show a response (complete or partial resolution of fluorodeoxyglucose (FDG) avidity of the lesion on PET-CT scan) are scheduled for esophagectomy from 8 to 12 weeks after the conclusion of chemoradiation, once they have recovered reasonably well from the side effects of induction therapy. Data on the optimal interval between completion of chemoradiation and surgery are mixed. Kim et al. showed no difference in terms of perioperative risk, pathologic response, or overall survival between patients who were resected more than 8 weeks after chemoradiation versus those resected less than 8 weeks after. Lee et al. demonstrated that prolonging the interval after chemoradiation for esophageal adenocarcinoma increased the pathologic complete response rate to induction therapy; however, this did not translate to survival. Chiu et al., though, found that delayed surgery (defined as >8 weeks after chemoradiation) was associated with decreased 5-year survival for patients with squamous cell carcinoma that demonstrated a complete clinical response.

Choice of Operation

The abdominal and/or thoracic phase of the esophagectomy can be performed with robotic assistance. Choice of type of esophagectomy (Ivor Lewis, McKeown, ortranshiatal) can be surgeon-dependent, with some preferring a neck anastomosis due to the decreased incidence of mediastinal leaks, and others preferring a chest anastomosis due to the risk of recurrent laryngeal nerve injury. Location of the tumor may dictate this decision; for instance, a midthoracic tumor is best suited for resection of the entire intrathoracic esophagus with a neck anastomosis.