Page 83 - Read Online

Page 2 of 19 Ackerman et al. Mini-invasive Surg 2021;5:14 https://dx.doi.org/10.20517/2574-1225.2021.02

BACKGROUND
As a complex, multi-cavity procedure, Ivor Lewis esophagectomy requires a thorough understanding of
surgical anatomy, technical skill, and perioperative care to achieve acceptable outcomes. The first successful
transthoracic esophagectomy was performed in 1913 by Dr. Torek , which marked the beginning of the
[3]
open surgical era that was plagued by high morbidity. Even in this modern era, outcomes can vary widely,
[4]
with mortality ranging from 8%-23%, largely dependent upon hospital volume . However, in experienced
centers, an acceptable 30-day (and even 90-day) hospital and/or overall mortality below 5% is often achieved
and becoming the standard . The initial descriptions of a minimally invasive esophagectomy (MIE) in the
[5]
early 1990s by Drs. Cuschieri et al. , Dallemagne et al. , and DePaula et al. ushered in a new era of
[7]
[6]
[8]
esophageal surgery. The safety, feasibility, oncologic soundness, and reproducibility of MIE were validated
in Eastern Cooperative Oncology Group (ECOG) 2202, a large, multicenter, prospective, randomized trial
[9]
published in 2015 . As the MIE was gaining popularity, the first report of a RAMIE was published by Dr.
Horgan et al. in 2003. Since its introduction, RAMIE has been validated against the standard open and
[10]
minimally invasive approaches . When compared to open esophagectomy, RAMIE has demonstrated
[11]
intraoperative benefits including less blood loss and more complete lymphadenectomy, despite its longer
operative time. RAMIE showed faster convalescence with a shorter length of stay (LOS), decreased pain,
decreased intensive care unit (ICU) admissions, and fewer infectious and cardiopulmonary complications.
There were no consistent differences in overall major complications, anastomotic leak rate, and 90-day
mortality [11-13] . When directly compared to MIE, RAMIE resulted in longer operative time, but no significant
difference in blood loss, overall complication rate, length of stay, or the number of total dissected lymph
nodes .
[14]

PREOPERATIVE PREPARATION
Risk stratification
In efforts to define and reduce significant morbidity and mortality, multiple attempts have been made to
define the risk factors associated with the adverse outcomes of esophagectomy. A large, prospective analysis
of the Department of Veterans Affairs (VA) National Surgical Quality Improvement Program (NSQIP)
database identified both preoperative and intraoperative risk factors for morbidity and mortality.
Preoperative predictors impacting mortality included neoadjuvant therapy, decreased functional status,
increasing age, insulin-dependent diabetes mellitus, and signs of hepatic dysfunction (elevated blood urea
nitrogen, elevated alkaline phosphatase, alcohol abuse, and ascites), while the addition of dyspnea with mild
exertion, chronic obstructive pulmonary disease, decreased serum albumin concentration, and an increased
[15]
complexity score increased overall morbidity . Intraoperative risk factors for morbidity included the need
for blood transfusion and prolonged operative time, while only transfusion requirement impacted
[15]
mortality . A review of the Society of Thoracic Surgeons General Thoracic Surgery Database revealed age >
65, BMI ≥ 35, preoperative congestive heart failure, Zubrod score > 1, McKeown Esophagectomy, current or
former smoking status, and squamous cell histology to be significant predictors of combined major
[16]
morbidity or mortality .
A preoperative esophagectomy risk score, developed as a composite of the revised cardiac risk index, the
model for end-stage liver disease score, and the pulmonary function test, was found to be an independent
predictor of tumor recurrence and overall survival . At our institution, we routinely calculate the Risk
[17]
Analysis Index (RAI), which is a practical, prospective frailty assessment tool requiring only a median of 33
s to complete and demonstrates a dose-dependent relationship with mortality, overall LOS, ICU LOS, and
readmission. When comparing patients using an RAI cutoff of ≥ 37 with those < 37, there was a 60% higher
30-day and 90-day readmission rate, twice the rate of an extended LOS > 14 days, and almost twice the rates
of prolonged ICU stay. When comparing for 180-day mortality, an RAI of < 37 carried an NPV of 98.6%