Quality Improvement in Minimally Invasive Esophagectomy: Outcome Improvement Through Data Review
Esophagectomy is a complex operation in which outcomes are profoundly influenced by operative experience and volume. We report the effects of experience and innovation on outcomes in minimally invasive esophagectomy.
Esophageal resections for cancer from 2007 to 2016 at Levine Cancer Institute at Carolinas Medical Center (Charlotte, NC) were reviewed. During this time, three changes in technique were made to improve outcomes: vascular evaluation of the gastric conduit to improve anastomotic healing (beginning at case #63), one-stage approach to permit access to abdomen and chest through one draped surgical field (case #82), and adoption of a lung-protective anesthetic protocol (case #101). Mortality, operative time, complications, and length of stay were analyzed relative to these interventions using GLM regression.
200 patients underwent minimally invasive esophagectomy. There were no mortalities at 30 days, and no change in mortality rate at 60 and 90 days. Anastomotic leak decreased significantly after the introduction of intraoperative vascular evaluation of the gastric conduit (3.6 vs 19.4%). Operative time decreased with adoption of a one-stage approach (416 vs 536 min). Pulmonary complications decreased coincident with a change in anesthetic technique (pneumonia 6 vs 28%). Lymph node harvest increased over time. Length of stay was driven primarily by complications and decreased with operative experience.
Postoperative complications, operative time, and length of stay decreased with case experience and alterations in surgical and anesthetic technique. We believe that adoption of the techniques and technology described herein can reduce complications, reduce hospital stay, and improve patient outcomes.
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Portions of this body of work were presented in abstract form at the Digestive Disease Week in San Diego, CA in May 2016.
- 3.Osugi H, Takemura M, Lee S, et al. Thoracoscopic esophagectomy for intrathoracic esophageal cancer. Ann Thorac Cardiovasc Surg. 2005;11(4):221–7.Google Scholar
- 10.Motz BM, Lorimer PD, Boselli D, et al. One-stage minimally-invasive Ivor-Lewis esophagectomy without patient repositioning. Surg Endosc. 2017;Annual SAGES conference proceedings.Google Scholar
- 11.Lorimer PD, Pollard RJ, Salo JC, Buhrman WC. Use of a standard evidence-based ventilation protocol reduces the incidence of pulmonary complications in minimally invasive esophagectomy. Society of Cardiovascular Anesthesiology. 2017; Annual Symposium Proceedings.Google Scholar
- 16.Crenshaw GD, Shankar SS, Brown RE, Abbas AE, Bolton JS. Extracorporeal gastric stapling reduces the incidence of gastric conduit failure after minimally invasive esophagectomy. Am Surg. 2010;76(8):823–8.Google Scholar
- 20.Dhamija A, Rosen JE, Dhamija A, et al. Learning curve to lymph node resection in minimally invasive esophagectomy for cancer. Innovations (Phila). 2014;9(4):286–91.Google Scholar
- 33.Schoppmann SF, Prager G, Langer F, Riegler M, Fleischman E, Zacherl J. Fifty-five minimally invasive esophagectomies: a single centre experience. Anticancer Res. 2009;29(7):2719–25.Google Scholar