Surgical Insight: Minimally Invasive Esophagectomy

Podcast Transcript

Dale Shepard, MD, PhD: Cancer Advances, a Cleveland Clinic Podcast for medical professionals, exploring the latest innovative research and clinical advances in the field of oncology.

Thank you for joining us for another episode of Cancer Advances. I'm your host, Dr. Dale Shepard, a medical oncologist here at Cleveland Clinic overseeing our Taussig Phase one and Sarcoma programs. Today, I'm happy to be joined by Dr. Anthony Visioni, a surgical oncologist at Cleveland Clinic, Akron General. Dr. Visioni was here previously to talk about trends in the care of patients with melanoma. That episode is still available for you to listen to. Today, he's here to talk to us about minimally invasive esophagectomy. So welcome back, Anthony.

Anthony Visioni, MD: Oh, thank you so much. It is my pleasure to be welcomed back. Happy to talk to you again, Dr. Shepard.

Dale Shepard, MD, PhD: Excellent. So maybe just remind us, what is your role at Cleveland Clinic, Akron General? What do you do there?

Anthony Visioni, MD: Yeah. So as your introduction kind of alluded to, I'm a surgical oncologist and I kind of wear several hats. So I specialize in the surgical care of cancer patients obviously. And within that, my practice is fairly broad. So as you mentioned, I treat melanoma. I obviously do minimally invasive esophagectomy and treat patients with foregut cancers like gastric and esophageal cancers. And then I also kind of expand the spectrum for other disease sites as well. So I wear several different hats around here.

Dale Shepard, MD, PhD: Very good. Well, today, we're going to be talking about minimally invasive esophagectomy, but we may have a lot of different backgrounds of providers listening to us today. Give us an overview. Surgical treatment of the esophagus is not simple and it has gone through some variations. Give us a broad overview to start about surgical management of esophageal cancers.

Anthony Visioni, MD: Yeah, it's been in flux recently as we kind of are trying to extend minimally invasive esophagectomy, but going way, way back and esophagectomy has kind of been the standard curative treatment for esophageal cancer, of which there's several subtypes, but including them all as one grouping I think is a fair assessment for today.

So esophagectomy is and was a very high risk, complex procedure. And so we have gravitated decades ago toward a more comprehensive multi-modality treatment for most of our patients, whether that be neoadjuvant chemotherapy or chemo radiation for the vast majority of patients who have locally advanced treatment. So now it's not just surgery, although obviously that's important. And from my perspective, it's not just the surgery that makes it, it's really a team approach that makes this important.

And then the surgical care of these patients has evolved incredibly over the years too, even just from an open approach, how we manage those patients with fluid balances, with operative monitoring, with postoperative care has evolved over the decades. And now as we've evolved into hopefully a more extensive use of minimally invasive approaches, that's once again been a new iteration. So it's thankfully an area that's constantly been moving forward over the years, but it's still just a very challenging cancer to treat and a challenging procedure to perform.

Dale Shepard, MD, PhD: And I guess just to sort from an anatomic standpoint, oftentimes think of something in the abdomen or in the chest and kind of remind us why exactly were the technical challenges in the past and why was it so difficult?

Anthony Visioni, MD: Well, the esophagus, kind of like you say, it expands multiple cavities and it kind of goes all the way from your neck to your belly. So first and foremost, it's been kind of the home of a lot of thoracic surgeons to kind of treat esophageal cancer. General surgeons have approached it as well or surgical oncologists, but it requires you to have an expertise going from the back of the neck all the way down to the abdomen. You have to kind of specialize in the treatment of esophageal cancer. So having that comfort and expertise has been rare to find. Even thoracic surgeons don't necessarily want to specialize in that as well. So it's really something that requires a niche practice.

That being said, esophageal cancer, it can be a squamous cell cancer or an adenocarcinoma, and that can dictate a little bit where it is. So it can be in the mid or upper esophagus or it can be down low in the esophagus toward the GE junction of the stomach. And so that can require different approaches to how we treat it, whether we're taking out just the lower half of the esophagus or lower two-thirds of the esophagus versus more or less taking out almost the entire thing.

So you're dealing with a long organ, multiple body spaces, and then a surgical approach that may need to be adapted based on where the disease is. So it's really led to a lot of challenges and approaches to it. That being said, we do have multiple approaches so we can address each of these issues as long as we have the right hammer to hit the right nail with.

Dale Shepard, MD, PhD: So if we think about minimally invasive esophagectomy, tell us a little bit about what the procedure is and maybe even a little bit about what led us to be able to do this mean. Was there technical innovations for instance, that led to this as being an approach that we're able to offer now?

Anthony Visioni, MD: As much as I love to be on the cutting edge of things and to really be pushing kind of our surgical care, minimally invasive esophagectomy has been around for a while actually. So in the nineties, in the early nineties is really when we started to, I would say, experiment with it or try and push those limits. And it was born out of the necessity that esophagectomy is a relatively morbid operation. It does come with a high complication rate, and that complication rate is often related to pulmonary complications.

So the mother of invention, so to speak on this situation, was trying to reduce those pulmonary complications. So the first iterations of minimally invasive esophagectomy were really a full laparotomy, a full abdominal operation, but then doing a athroscopic approach, a minimally invasive approach in the chest to try and reduce our pulmonary complications. And that actually worked. We did see reductions in pulmonary complications over this timeframe. And then that kind of led to the impetus as we've had increasing utilization of minimally invasive approaches for colon surgery and other surgeries and being more facile at it, extending that minimally invasive approach to both the abdomen and the chest.

So most esophagectomy, I would say, are performed using an abdominal and chest approach, what we call an Ivor Lewis esophagectomy, where we remove the lower kind of two-thirds or lower half of the esophagus, usually for these lower esophageal adenocarcinomas, which is the most common form of cancer.

So kind of focusing a little bit on that perspective, the procedure has evolved then from that thoracoscopic approach to a more full minimally invasive approach. And we've been trying to drive down the complication rates from the pulmonary standpoint, then to the anastomotic leakage standpoint, cardiac standpoint. All of these things have been actually improving as we get better and better with our minimally invasive approaches. And then hopefully the goal here is to then even advance that further with just better technique and potentially even robotic approaches.

Dale Shepard, MD, PhD: And then I guess, what sort of tumors, what sort of esophageal cancers are best suited for minimally invasive procedure compared with.... We've had on a previous episode of this podcast, a discussion about endoscopic procedures. So what are the pros and cons and what kind of tumors would fit into each category?

Anthony Visioni, MD: Yeah. So as we've kind of gone minimally invasive for these more advanced cancers and more significant esophageal cancers, you're right, we've advanced it the other way too, going endoscopically more advanced too. So this is where that kind of team approach is really important. Selecting the right disease for the right tool.

And so unfortunately in our country, esophageal cancer is a relatively uncommon cancer, but when it occurs, it is usually locally advanced. So we don't often find a lot of patients with a truly early stage esophageal cancer. And that just goes to the fact of they don't often present with symptoms at these early stages. And we don't necessarily have a very active screening for a lot of things. So the patients that are screened, maybe they have Barrett's esophagus or a known history of reflux and they get screened, they may actually have early detection of their esophageal cancers or precancerous lesions that are very amenable to endoscopic approaches. And those are in excellent utility at the Cleveland Clinic. And we really have a wide variety of ways to treat those, from ablations to endoscopic resections. So those are on those very early precancerous or very, very early cancer lesions.

We kind of have a subset of patients who maybe they have a little bit more of an invasive cancer, not very early amenable to endoscopic resections, but maybe they're not fully locally advanced that would require a multi-modality treatment approach. And they may benefit from just an upfront surgical approach. Then we can execute usually a minimally invasive approach for those patients.

Then we have patients who have a little bit more of an advanced esophageal cancer, maybe they have some surrounding lymphopathy. And in those patients we would recommend multi-modality treatment with either chemotherapy and/or chemo radiation. And then followed by an esophagectomy, usually to good effect and still for curative intent.

And then we have patients who have a more truly locally advanced tumor that's maybe invading into surrounding organs. And those are patients that then really carefully selecting them for their surgical approach is that much more important because not every tumor is amenable to a good minimally invasive approach.

Dale Shepard, MD, PhD: Excellent. When we think about these procedures from a patient perspective, looking at sort of endoscopic minimally invasive or a more extensive surgery that's not a minimally invasive procedure, what does that look like in terms of hospitalizations and recovery times?

Anthony Visioni, MD: Yeah. I mean these are, like I said, complex surgeries that do require what would be considered a little bit of a longer hospitalization. I would say on the average, if we do a straightforward, minimally invasive esophagectomy that has an uncomplicated course, six days in the hospital is not unusual. And that's kind of, I think a fairly brisk course, quite frankly, if you look at some of these national averages about a length of stay. When you started to get in any kind of complications, obviously that'll prolong things. And then an open approach, that can also prolong things a little bit too. So five to seven days in a hospital after this is not an unusual timeframe for a routine recovery.

And then to fully have a patient kind of completely recovered from their surgery can take a couple months just to get to a new baseline. A new normal for eating takes a little while. They're kind of been rerouted to a new lifestyle. And that can take a little bit, just the recovery from getting their wind back, so to speak, and getting their energy levels up can also take a little while. So these are big impactful operations even in a minimally invasive approach. And that then dictates how we select our patients. They have to be able to be healthy enough to undergo the surgery.

Dale Shepard, MD, PhD: And I guess, what are some of the primary things that would sort exclude a patient from being able to have these procedures? You mentioned pulmonary complications with our earlier surgeries. I guess what are the more common complications we see now and what are the sort of risk factors for patients that might make them a poor operative candidate?

Anthony Visioni, MD: Yeah. And as I said, even as we've improved pulmonary complications, that still is a large driver of our concerns. So it's not unusual that an esophageal surgeon will routinely get pulmonary function tests on patients to make sure that it's safe enough to kind of enter their chest or to do an operation in the chest. So poor lung function, COPD, a lot of our esophageal cancer patients are also smokers. They may have some poor lung function. That may be a driver to say that maybe they're not a great candidate for surgery. Obviously we have patients who have other comorbidities like heart disease or liver disease that can contribute to their overall health picture as well.

And so when you have these kind of higher risk comorbid diseases that does put your surgery at higher risk. Those are surgeries that if they're coming in with maybe a 33% complication rate, when you then start elevating those rates for a higher risk patient, it may actually mean that maybe doing surgery is not the best approach for them. And maybe we want to do things like definitive chemotherapy or definitive radiation for those patients to get the best overall health for them. There is a relatively low but real rate of complete responses with chemo radiation. So it is a backup plan that we can have for them. So those drivers, particularly cardiopulmonary comorbidities, are really what drive us to make the decisions of, I think, who is a good candidate.

Then tumor specific factors also come into play as well. If a tumor is invaded into certain surrounding structures like the aorta or the trachea, then maybe a tumor that really is not amenable to resection versus minimal invasion into maybe the pericardium is then a candidate. So those obviously play a large factor as well.

Dale Shepard, MD, PhD: So it seems that surgical oncologists are often a pretty innovative group, and I must imagine during long surgeries, you're always thinking, what if, what are those gaps, as you do a procedure. What are sort the barriers to the next step in and new innovations and techniques?

Anthony Visioni, MD: But I'd like to think I thought of these, but I didn't. So ultimately when it comes down to it's really those things that can drive access to care too. So a truly athroscopic and laparoscopic, minimally evasive esophagectomy is a highly technical procedure, and it's applicability to a broad range of surgeons is probably more limited. And it's also, it's a challenge. When I do one of these procedures, it does take several hours. It is kind of a little bit of a physical tour to force even for the surgeon. So this is where I see robotic surgery actually being a good tool for us as surgeons and patients to maybe broaden the access of a minimally invasive approach, a little bit of an easier approach on the surgeon to allow more of a uniform of procedure, kind of increase the consistency across patients as well. So from my perspective, increasing robotic approaches I think is going to be something we see a lot more of from our practice, here as well as across the country.

Dale Shepard, MD, PhD: Is there anything that's sort of taking place within this area in terms of consideration of novel neoadjuvant approaches or things that might sort make the operation different?

Anthony Visioni, MD: Yeah. So even though I'm a surgeon, that's probably a little bit more of an exciting topic too, is that we are classically relying on chemo radiation for a lot of our esophageal cancer patients. But we may be seeing trends toward increasing the utilization of just neoadjuvant chemotherapy, which allows, I think, for good responses, while maybe decreasing some of the complications from radiation that we could see or some of the long term consequences we can see. So that's one area that I think is in active use and in active study.

And then the interventions with biologics. So Herceptin can also be used, as well as some of our immunotherapies to bear on some of these patients. It requires a little bit more nuanced than some things like melanoma where we may be able to use it more broadly. We actually have to be guided more by markers within the tumor to use immunotherapy. But currently we are able to do that in an adjuvant or rescue setting too. And using that more broadly, even in a neoadjuvant setting, I think is going to be an exciting time to see how we approach those patients as well.

Dale Shepard, MD, PhD: As we think about systemic therapies and as part of this multidisciplinary approach, with the current surgical management, what's the bigger concern in most patients? Local recurrence or distance spread?

Anthony Visioni, MD: Yeah. Unfortunately, I think we've done a fair job controlling local recurrence. It's still a problem and it's still something that creeps up, but this is a cancer that will often recur distantly. So I think this is where we have been seeing the integration of a multi-modality approach be very important. Those very early stage cancers, I think they are treated well by surgery alone, but they're just very rare to find those patients. So in that case, that multi-modality approach, that systemic therapy to reduce that risk of distant disease is I think really an important driver of overall care.

Dale Shepard, MD, PhD: Doubling back to something you mentioned earlier, I guess the easiest cancer to treat's the one that patient doesn't have. And so we think about screening, we think about catching things at an early stage. So do you think there's, screening is tough, because something that's rare, you have to pick the right patients. Do you think there's a role for increased screening, increased education of who needs to go through screening? What are your thoughts in that area?

Anthony Visioni, MD: Yeah, absolutely. This is something I definitely agree with you about. These are cancers that we do know the risk factors for them, and we do have the ability to intervene. Maybe with colonoscopy, a broad screening program, more or less that's applicable to everybody, isn't as necessary for esophageal cancer. But I think we can pick out those patients who may benefit and we do have screening protocols for those patients.

So we do know that reflux disease is a driver of esophageal cancer. It's a driver of the precursors of those, and we can intervene on those precursors to then prevent the cancer. So something as simple as if you have heartburn and reflux, seeing your doctors, getting onto appropriate medical therapy, even surgical therapy for a reflux disease can actually lead to the prevention of these cancers down the road. And then if you have a diagnosis of Barrett's esophagus, which can be a precursor as well, to be adequately screened for that, which can involve upper endoscopy, which is fairly straightforward and tolerated very well.

So there's, I think, good guidelines for us to follow. It's really getting the patients on board with them and to kind of adhere to them. And also to take a very large pool of patients who have reflux and heartburn and to bring to bear our screening appropriately, right? Because we don't necessarily need to screen everybody who takes an over the counter PPI for occasional heartburns.

Dale Shepard, MD, PhD: Well, you've offered some great advice and some excellent insight and thank you for being with us today.

Anthony Visioni, MD: It is always my pleasure, always happy to talk about these things. It kind of gets me excited to see our next patients.

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