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Minimally Invasive Esophagectomy

Clinical Services

Memorial Regional Hospital surgeons are specialized in Minimally Invasive Thoracic Surgery and Thoracic Oncology.

Below is a list of commonly treated conditions. Click on each topic for more information.

 

Airway Stent Placement

Airway stents are placed in the airway through a bronchoscope. They are placed for airway fistulas from tumors, tracheomalacia, extrinsic compression from tumors, intrinsic obstruction from airway tumors, and intrinsic stenosis from radiation or scarring. The stents are either silicone or metal and coated or uncoated. Silicone stents can be removed later after placement while the metal stents are usually left in place since they adhere tightly to the airway. The stents can be placed in the trachea or bronchi. In addition, airway balloon dilation usually accompanies and proceeds stent placement. The procedure usually is done on an outpatient basis or the patient can be discharged the following day after observation.

Bronchoscopy

Bronchoscopy uses a flexible or rigid scope to visualize the airways, diagnose pathologic lesions, or perform interventions to relieve an airway obstruction. Interventions include biopsy of lesions, secretion removal, foreign body removal, balloon dilation, stent placement, or laser debridement. Flexible bronchoscopy can be performed on awake, sedated patients, while rigid bronchoscopy requires general anesthesia.

Chest Wall Tumors

Tumors of the chest wall are primary benign and malignant tumors of the soft tissue and bony structures, metastatic tumors to the chest wall, or lung tumors that invade locally into the chest wall. Patients typically present with a painful mass. The diagnosis is made with a CT scan and a core needle or incisional biopsy. Treatment is primarily surgical but radiation can play a role. Complete surgical resection is vital for cure and prevention of local recurrence. Complete resection may require removing ribs, underlying lung tissue, muscle, and associated soft tissues. Reconstruction with prosthetic material or rotational muscle flaps may be required if the resection is large.

Decortication

Pus in the chest or pleural cavity is called an empyema. The process starts with a bacterial pneumonia and associated parapneumonic effusion becoming secondarily infected. Parapneumonic effusions occur in 20-60% of patients hospitalized for bacterial pneumonia and 5-10% of patients will go on to develop empyema. Other causes for empyema include trauma, subphrenic abscess extension and post lung surgery bronchopleural fistula formation. The mortality rate associated with empyema can be as high as 25-75%.

Empyemas are classified into three stages: exudative, fibropurulent, and organized. Drainage by thoracentesis (needle) or thoracostomy (chest tube) is more successful for early or exudative stage empyemas. Surgical therapy with drainage of the effusion, removal of the pus and “peel” over the trapped lung is called decortication and is the most effective therapy usually required for fibropurulent and organized empyemas. Traditionally, surgery required a large thoracotomy with significant complication risks that was not tolerated by elderly debilitated patients. Currently, decortication for empyema can be performed successfully using a minimally invasive approach with video assisted thorascopic surgery (VATS). The VATS approach allows reduced hospital stay, faster recovery, and allows surgery for older sicker patients who would not otherwise be candidates for the more invasive traditional open surgery.

Diagphragm Plication

Eventration of the diaphragm is either congential or acquired, and is characterized by extreme elevation of the diaphragm. Acquired eventration is typically associated with phrenic nerve paralysis, leading to a flaccid and atrophic diaphragm. The eventration causes paradoxical movement of the diaphragm, leads to reduced lung function causing patients to describe shortness of breath or dyspnea. If the symptoms are severe, the treatment is diaphragmatic plication which returns the diaphragm to a position of full inspiration and helps to maintain chest wall stability. Plication can be performed with an open incision and, can also be approached minimally invasively using a video assisted approach.

Esophagoscopy

Esophagoscopy is the use of a flexible or rigid scope introduced into the esophagus to evaluate and treat different pathological conditions. Interventions include biopsy of lesions in the esophagus or stomach, foreign body removal, balloon or bougie dilation, stent placement, laser debridement of tumor, and photodynamic therapy. Flexible esophagoscopy can be performed on awake, sedated patients, while rigid esophagoscopy requires general anesthesia. Both procedures are typically done on an outpatient basis.

Esophageal Stent Placement

Esophageal stents are placed for several reasons: extrinsic compression from tumors, intrinsic obstruction from esophageal tumors, esophageal strictures, and tracheoesophageal fistulas. The esophageal stents are either silicone or metal with the metal stents coated or uncoated. Silicone stents can be removed later after placement while the metal stents are usually left in place. The stents are placed in the esophagus through an esophagoscope and the procedure usually is short and the patient can be discharged the following day.

Esophageal Perforation

Esophageal perforation is a serious condition that if left untreated is usually fatal. The most common cause is related to esophageal instrumentation. Other causes include forceful vomiting, and obstructing esophageal tumors. The consequence of an esophageal perforation is the extravasation of oral secretions with bacteria into the mediastinal space leading to a severe inflammatory reaction, septic shock and then death. The most important factor in survival is the time from perforation to treatment – the sooner it is treated the better. Treatment includes intravenous antibiotics, drainage with chest tubes and nasogastric tubes, and operative intervention. Surgical options include operative drainage, repair of the perforation which is preferred if possible, esophageal resection, and esophageal diversion.

Esophagectomy

Esophageal cancer affects approximately 14,000 Americans each year with a dismal 5 year survival. The two major types or esophageal cancer are squamous cell carcinoma and adenocarcinoma. Squamous cell cancers are related to smoking and alcohol intake and adenocarcinoma is thought to be related to chronic acid reflux exposure.

Most patients present with dysphagia, or difficulty swallowing. Diagnosis is made with a barium swallow, endoscopy with biopsy, and a CT scan. Endoscopic ultrasound and PET scan are used to stage patients for lymph node involvement, depth of invasion, and metastatic disease.

Treatment depends on the stage of the cancer. For very early stage tumors, surgical resection is performed alone or followed by chemotherapy. For earlier stage tumors, chemotherapy and radiation is given followed by surgery. Therapy for advanced stage esophageal cancer is chemotherapy and/or radiation therapy.

Surgery is directed at removing the esophagus and then replacing it with either the stomach or colon to re-establish gastrointestinal continuity. Most surgeons prefer to use the stomach as the conduit if possible. Traditionally, surgery involved either a large chest or abdominal incision or both, but now this can be accomplished minimally invasively. Most patients after undergoing an esophagectomy will stay in the hospital 10-14 days. The minimally invasive approach allows less postoperative pain, shorter hospital stays, and faster recovery.

If you wish to be advised on the most appropriate treatment, please call (954) 987-2000 to schedule an appointment or click here to get online appointment.

Heller Myotomy

Achalasia is a primary esophageal motility disorder characterized by failure of the lower esophagus to empty normally. The cause is unknown and patients often describe debilitating lifestyles with inability to eat solids or liquids and significant weight loss.

Treatment is directed at relieving the outflow obstruction caused by failure of the lower esophageal sphincter to relax. Options include Botox injection, balloon dilation, and surgical or Heller myotomy. Botox injection effects are temporary and balloon dilation therapy also has shortened efficacy in younger patients and risks perforating the esophagus, which can be distrastrous. Heller myotomy or dividing the offending esophageal muscle is the gold standard treatment for Achalasia. Surgery used to be performed either through a large abdominal or thoracic incision. Now, Heller myotomy is done minimally invasively using laparoscopy and/or Robotic assisted technology. The results are excellent with average hospital stays of 1-2 days, minimal pain, immediate relief of obstruction, and fast recovery to daily activity and work.

Lobectomy

Lobectomy is the removal of a lobe of the lung. It is the gold standard operation used to treat lung cancer. Traditionally, a thoracotomy was used to accomplish this, but the incision was large, painful, led to postsurgical complications such as pneumonia, and patients had prolonged hospital stays (7-10 days) and prolonged recovery times (several months). Now, lobectomies are performed minimally invasively thru a video assisted or Robotic assisted approach. The advantages include smaller incision, no rib removal or spreading, less pain, less pneumonia, shorter hospital stay (4 days versus 9 days in open lobectomy), and earlier return to normal activity and work. Also, the minimally invasive technique allows surgery in higher risk and elderly patients who would otherwise not be candidates for traditional open surgery.

Lung Biopsy

Lung biopsy is performed to make a diagnosis in order to treat an underlying pulmonary condition. Typically, the diagnosis is unknown and obtaining a biopsy allows the pathologist sufficient lung tissue to perform tests and analysis to make a definitive diagnosis which aids the treating physician immensely. Historically, the lung biopsy was performed with an open incision. Today, this procedure is performed minimally invasively using a video assisted approach, allowing patients to be discharged one to two days after surgery.

Lung Volume Reduction Surgery

Emphysema causes lung destruction resulting in the loss of normal elastic recoil and progressive lung distention. The lung distention in affected areas of the lung can also compress normal areas of lung and the diaphragm. Patients experience shortness of breath and increased work of breathing.

Lung volume reduction surgery removes diseased emphysema portions of lung to improve the elastic recoil of the remaining more healthy lung and return the diaphragm and other respiratory muscles to a more physiologic position. This improves the work of breathing and as a result improves the shortness of breath. Lung volume reduction surgery is usually performed thru a median sternotomy for bilateral procedures, or minimally invasively thru a video assisted approach for unilateral procedures.

Mediastinoscopy

Mediastinoscopy is placement of a scope into the mediastinum to sample lymph nodes or mediastinal masses. It is usually an outpatient procedure done to stage patients with lung cancer and is also useful to diagnose neoplastic, granulomatous, and inflammatory conditions causing enlarged mediastinal lymph nodes.

Nissen Repair

Gastroesphageal Reflux Disease (GERD) is a condition of acid in the stomach refluxing upwards into the esophagus to cause symptoms of heartburn. Chronic acid exposure can cause changes in the esophagus that over time can lead to precancerous conditions (Barrett’s esophagus) and eventually esophageal cancer. GERD occurs because of failure of the antireflux barrier. Treatment starts with lifestyle modification, then medical therapy with H2 blockers and proton pump inhibitors, and if necessary, surgical repair with a Nissen repair.

Nissen fundoplication traditionally involved an open large abdominal incision, but is now done minimally invasively using the laparoscopic approach. Laparoscopic Nissen repair for GERD involves 5 small incisions, use of a videoscope, and insufflations of CO2 gas. The repair involves reducing the distal esophagus back into the abdomen, tightening the diaphragmatic crura or muscles, and performing a 360 degree wrap of the stomach around the distal esophagus to prevent acid reflux. Most patients after surgery have no or minimal symptoms of reflux. They are discharged home in 1-2 days, and return to full activity several weeks after surgery.

Paraesophageal Hernia Repair

Paraesophageal hernias occur when the stomach, colon, small bowel, omentum or spleen protrude into the chest. Most patients are asymptomatic but the hernia can cause severe complications such as bleeding, obstruction, strangulation of the stomach’s blood supply, and perforation of the stomach which could be lethal.

Surgery is the treatment of choice and was historically approached with either a large chest or abdominal incision. Currently, paraesophageal hernias can be repaired using a minimally invasive laparoscopic approach, which reduces hospital stay, reduces complication rates, and shortens postoperative recovery time significantly. The repair involves reducing the stomach or other organs into the abdomen, removing the hernia sac, closing the defect with mesh if necessary, wrapping the stomach (fundoplication) and then fixing the stomach in the abdomen with a gastrostomy feeding tube.

Pericardial Window

Pericardial effusions are abnormal collections of fluid around the heart that if large enough, can cause tamponade, preventing the heart from filling properly and leading to death. They can be caused by a variety of conditions such as cardiac surgery or renal failure, but over half of patients requiring interventions have a history of cancer.

Treatment options include pericardiocentesis or placement of a needle to drain the fluid. This is only 25% effective in preventing recurrence. The traditional approach of a subxyphoid pericardial window is 70-75% effective. A minimally invasive video assisted approach of a pericardial window creates a hole in the pericardium to allow the fluid to drain into the chest cavity and is 95% effective in draining the pericardial effusion and preventing cardiac tamponade recurrence.

Pleural Biopsy

Pleural biopsy is performed to make a diagnosis in order to treat an underlying pulmonary or pleural condition. Typically, the diagnosis is unknown and obtaining a biopsy allows the pathologist sufficient lung tissue to perform tests and analysis to make a definitive diagnosis which aids the treating physician immensely. Historically, the pleural biopsy was performed with an open incision. Today, this procedure is performed minimally invasively using a video assisted approach, allowing patients to be discharged one to two days after surgery.

Pleural Effusion

Pleural effusion is the accumulation of fluid in the chest or pleural cavity causing progressive compression of the lung and leading to shortness of breath. Malignant effusions are those secondary to lung cancer or metastatic cancers such as breast for example. The pleural effusion can be drained with a needle (thoracentesis) or chest tube (thoracostomy) but usually recurs and repetitive drainage causes discomfort, and loses efficacy over time. A minimally invasive approach using video assisted technology can drain the fluid and instill talc powder to cause the lung to adhere to the chest wall (pleurodesis) and prevent re-accumulation of fluid. Video assisted talc pleurodesis is 90- 95% effective and patients usually leave the hospital in 2-3 days after surgery.

Pneumonectomy

Pneumonectomy is the removal of an entire lung, almost always performed for lung cancer. Select patients with adequate pulmonary function can survive and function on only one lung if needed. Pneumonectomy is considered an aggressive surgical approach and does have significant risks – mortality rates have been historically quoted at 8-12% compared to 1-2% for lobectomy. Based upon anatomical considerations, a pneumonectomy usually requires a traditional thoracotomy approach but some surgeons are attempting to perform this minimally invasively using a video assisted approach.

Sleeve Resection

Sleeve resection is an operation used for tumors or diseases that are not amenable to simple lobectomy, because the tumor involves the origin of a lobar bronchus. The goal of a sleeve resection is to avoid a pneumonectomy and its risks. To accomplish this, the involved lobe is removed and the ends of the bronchus are rejoined and any remaining lobes are reattached to the bronchus. The sleeve resection therefore, spares uninvolved lung and maintains more respiratory function. Sleeve resections based upon their complexity require a traditional open thoracotomy approach.

Spontaneous Pneumothorax

Spontaneous pneumothorax is collapse of a lung leading to an accumulation of air in the chest cavity. It occurs in two main groups of patients. The first group has no known lung disease and is attributed to rupture of small blebs on the surface of the lung. It usually occurs in thin, young males with cigarette smoking increasing its risk by 20 fold. The second group of patients are older chronic smokers with emphysema who experience a rupture of a bleb. Both groups of patients present with shortness of breath or pain on taking a deep breath (pleurisy).

Treatment varies from observation for a small pneumothorax, to chest tube placement for a larger pneumothorax. After the first episode there is a 30% chance of recurrence and after the second episode the recurrence rate is 70%. For this reason, surgery is recommended for recurrent spontaneous pneumothorax.

Surgery is done minimally invasively with a video assisted approach and involves stapled resection of the blebs if present and pleurodesis (abrasion of the chest lining) to facilitate adhesion of the lung to the chest wall to prevent recurrences. Most patients are in the hospital for 2-3 days and return to full activity in a few weeks after surgery.

Thymectomy

Thymectomy refers to removal of the thymus gland. Indications for the procedure include thymomas (tumors of the thymus gland), thymic cysts, and myasthenia gravis.

Thymomas are one of the most common tumors in the anterior mediastinum. About 50% of patients with thymomas have myasthenia gravis, while of all patients with myasthenia gravis only about 20% have a thymoma. Myasthenia gravis is an autoimmune disease causing voluntary muscle weakness. It is caused by antibodies to the acetycholince receptor of the motor end plate. Thymectomy improves the symptoms in 80-90% of patients with myasthenia gravis.

Thymectomy can be performed minimally invasively using a video assisted or Robotic assisted approach. These approaches significantly reduce the hospital stay to 1-2 days, and allow faster recovery and return to work. A median sternotomy approach is recommended for patients with tumors of the thymus gland and patients usually have a 4-5 day hospital stay.

Wedge Resection

Wedge resection refers to a non-anatomic resection of a portion of the lung. This is usually done to make a diagnosis with respect to a lung nodule, and can be used to treat lung cancer in patients whose lung function does not permit a more extensive cancer operation such as lobectomy. Traditionally, an open thoracotomy was used to accomplish a wedge resection, but the incision was large, painful, led to postsurgical complications, and led to long hospital stays and prolonged recovery times.

Currently, wedge resections are performed minimally invasively thru a video assisted approach. The advantages include smaller incisions, no rib removal or breaking by spreading, less pain, shorter hospital stay, and earlier return to normal activity and work. Furthermore, the minimally invasive video assisted approach permits an opportunity for surgery in higher risk patients who would otherwise not be candidates for traditional open surgery.

Zenker’s Diverticulum

Zenker’s diverticulum refers to an outpouching of the esophagus as a result of dysfunction of the pharyngoesophageal muscle. This dysfunction leads to increased pressure which causes the outpouching, usually on the left side. The diverticulum leads to food or pills getting stuck, causes bad breath, causes difficulty with swallowing, and can lead to aspiration pneumonia.

Surgery is recommended once it is diagnosed. The operation involves a left neck incision to divide the pharyngoesophageal muscle and then to either remove or suspend the diverticulum to prevent further complications. Most patients have complete resolution of their symptoms after surgery and are discharged home in 2-3 days time.