MIE or Ivor-Lewis. Which method should we choose?

timp

Dianna was diagnosed with Stage III esophageal cancer on March 8, 2010. She is currently mid-way through a chemo/radiation series, to be followed by surgery later this summer. There appear to be two major options with respect to the surgery, the traditional open chest approaches (Ivor-Lewis, Transhiatal (THE), Transthoracic (TTE)) and the newer Minimally Invasive (MIE) approach. We are looking for information about these approaches.

I know William Marshall of this network will offer a strong case for MIE. I have read many of his posts and have found them very informative. But I have not seen much comment from others who have had this procedure. I have seen a few reports of complications due to constriction of the surgically joined areas. The open chest approaches appear to be much more common. From the reports I have read, this type of surgery is quite arduous for the patient and is associated with a lengthy and generally uncomfortable recovery period. It is also unclear what the effects on quality of life are after surgery.

I understand that all of these surgeries are unique to individuals and depend on many things, including location of the tumor, health/age of the patient, etc. Thus experiences of others must be viewed with caution. My wife’s tumor is at or near the stomach-esophageal junction. She is 67 years old and is otherwise in good general health.

We need to know more about these surgical options, the risks, benefits and most importantly, what have been the experiences of members of this network with these surgeries?

Please share those experiences, and your recommendations, with us. If you had it to do over again, what would you choose? What cancer centers would you recommend, or not recommend?

Thanks for your help as we face this most important decision.

Tim

tb7

Which method should we choose?
Hi Tim!

My husband had the same staging (T3N1M0) as Dianna. We had the full surgery at University Hospitals, Cleveland, OH, in March 2008. We were advised at the time, due to the N1 staging, that the bigger surgery was preferred, so more of the lymph nodes could be examined and/or removed, the theory being that the chance for a "cure" or prevention of a recurrence would be greater. We felt at the time of his surgery that going the route of the full surgery would give him the best shot at a possible cure, but when the surrounding lymph nodes were removed there were still some active cancer cells, even though he had been through both chemo and radiation prior to surgery.

My husband did, unfortunately, have a recurrence 21 months out from surgery, for which we have been involved in a clinical trial (at Case Comprehensive Cancer Center, University Hospitals, Ireland Cancer Center) since January 2010. Results have been great, and he is currently NED.

The recovery from surgery cannot be sugar-coated. It is challenging. But, my husband was only out of commission for about 2 1/2 months following surgery, then returned to work full-time. Actually, he was doing work from home even before returning to the office. Following the full surgery, life is challenging, but I think that would be the case even with the MIE surgery. It just takes time to adjust to a different life style with respect to eating & drinking.

I am sure others will post comments for you as well. Looks like you have had diaglogue with William who often posts. I don't know what his staging was, but it would be relevant to have that info. Then, pose a lot of questions to Dianna's oncologist and surgeon.

Best to Dianna and you on this journey . . .

Trisha

paul61

Ivor Lewis Surgery
Tim,

I hope Dianna is improving from her recent infection.

I had Ivor Lewis surgery in December of last year. I was diagnosed with a tumor at the Gastroesophageal Junction. T3N0M0. Subsequent to pathology analysis of the removed surgical material my staging was changed to T2N1M0 as one active lymph node was discovered in the 30 that were removed. I am currently completing adjuvant chemotherapy.

My surgery was done my Dr. Carolyn Reed at Medical University of South Carolina in Charleston, South Carolina. I was in the hospital for 12 days. I was in intensive care for 3 days subsequent to the surgery; then in a step down unit for the remaining period.

The Ivor Lewis technique involves the placement of two large incisions. One in the abdomen from approximately the belly button to the top of the navel, and one in the back from mid back just under the right shoulder blade to the right side. They use the front incision to re sect and reposition the stomach and they used the back incision to re sect and remove the esophagus and associated lymph nodes. The procedure also requires collapsing the right lung and moving the ribs on the right side around a bit.

The primary surgical risks are:
1. Reaction to anesthesia (It is about a 7 hour procedure)
2. Respiratory complications
3. Infection

I was in the hospital for an extra two days because in my second day in the step down unit they discovered I had developed an infection in both surgical incisions that required the incisions be re-opened and administration of IV antibiotics. This added significantly to my recovery because the large incision on my back required the use of a wound vacuum device to
accelerate the healing process.

In general, while I was in the hospital pain was well managed. And other than the infection I had no other complications. I should add that I am 61 years old and was in excellent health prior to surgery.

In terms of quality of life changes after surgery I would have to say I am not completely sure because I am still completing chemotherapy and that it's own set of side effects and issues.

However, in general I would say the most significant lifestyle changes I have had to make are:

1. I must eat six or seven times a day since my stomach fills quickly
2. I have found certain things cause "dumping syndrome" like sugar, drinking to much liquid with meals, and eating too much at one time. (This seems to be improving over time)
3. Six months after surgery I still have some tenderness in my right ribcage area where they went in through my back to access my esophagus and lymph nodes.

My surgeon did not discuss MIE as an option. I asked her if there was a laparoscopic approach available and she said not one that would allow her to remove all the lymph node material she wished to remove.

In retrospect I probably should have pursued that question more aggressively because given William's description of his recovery experience, he had a much quicker and easier recovery than I did.

So I would suggest, given what Dianna has already been through, if an MIE would get to all the material that has to be removed and the surgical risks are comparable, I would opt for he MIE.

Hope this helps and that Dianna will be feeling better soon.

Best Regards,

Paul Adams
AKA: "paul61"
McCormick, South Carolina

cjmac49

MIE
I was diagnosed T2N0M0 in April 2008. Did chemo and radiation and had the minimally invasive procedure, in Boston @ Beth Israel Deaconess Medical Center, August 2008. William has presented all the reasons why the MIE is considered better and the name of the surgeon who pioneered the procedure.

I will tell you that the MIE was easier on my body and made surgical recovery much better. I was told that the Drs. took a significant number of lymph nodes to be sure. Pathology on all was negative. All I have are 6 little scars < 1.5" on my stomach, 5 or 6 little ones on my back and a barely noticeable incision along my left collar bone.

So far, 21 months, I have not had significant problems and all the new knitting and piping is working as advertised.

If I were to do it again I would still go the same path.

Good luck.
Jim

MOE58

IVOR LEWIS-We did fine
Hi

My sign on name is MOE but my real name is Lori, my husband had the IVOR LEWIS, last July of 09, he did fine, his was stage 2 and had Chemo before surgery. Jeff, was in surgery about 6 hours, and recovery about 2 hours, he was in ICU for several days BUT NOT AGAIN I STRESS NOT DUE TO THE SURGERY, he had complications with his lungs, he was a heavy smoker, and his lungs were sick so that made him in ICU longer, the normal stay is 2-3 days, once you are breathing on your own, they usually transfer you to a regular floor, now I will tell you they do cut you from chest to belly button to remove the cancer, and then around the back to insert a drain tube, and she will have to have what they call a NG tube so that her stomach continue to get drained. Your wife will probably have a J-tube for feedings, which is normal you have that with the other surgery too. Once they have the surgery you have a swallowing test, which is to make sure there is no leaks, once they discover no leaks she will be put on food as tolerated.

The recovery period depends on the person, if she is willing to fight she will do fine, because jeff had other complications his took a little longer to recouperate, was on pain meds longer than anticipated but about October, was off those. In November he was pretty much on his own, he tired out easy but doing well. It will be one year in July since the surgery and he is doing anything he wants,inside and out. Of course if he overdoes he knows it.

Your loved one will have to watch what she eats with either surgery instead of 3 big meals you eat several little meals a day, Stay away from the milk or dairy products as she will visit the bathroom often in other words she will have a book in there.

You see either surgery they have to take part of your stomach to make a new esophogus so your new one just doesn't know how to take all the intake of the new stuff going down. Eventually it does get better as time goes on. Once we realized what was causing some problems we cut out alot of things, no peelings on potatoes, no wheat bread no corn, things that are high in fiber are not good items according to his specialist.

I know Jeff is not sorry about having it done, realizing the journey he had to walk was tough, but making it to the end of the journey was great.

Every body's body acts different and the IVOR Lewis is not bad, but you have to go with your heart, and your gut, don't let anyone persude you one way or the other. If you trust your doctors, and you have did your research then you have nothing to worry about. If you have confidence in the doctors, and they have discussed all the options of both surgeries, and you know what to expect, then its nobodys decision but yours and your loved one.

We all have had the walk down memory lane and some still going, and we are all here for each other, to help anyone that asks, but we can give all the advice and help out there but you have to make the decision.

There is one other person on this board that had it shortly after Jeff and her name is Donna70, and she is also doing good.

We live in Oklahoma and we had a wonderful cancer doctor, surgeon, and specialist, and had full confidence in them all.

You also have to look at your insurance if your insurance is good and will pay then go with heart not with anyone tells you.

I wish you luck and if you have any further quesitons i will be glad to help.

also you can go back as far on my post as May of last year and see all my posts, it is definately scary but you will get through this journey.

Good Luck
moe/lori

cindyhils

i was diagnosed stage II in
i was diagnosed stage II in august of 09. I had chemo and radiation and then surgery in december. i had the open chest incision and also the incision on my left collar bone. i had mine done at the mayo clinic in rochester,mn. i was on day 3 out from my surgery and was doing fine when i had complications of a vein wrapped around my new stomach. needless to say i ended up in the hospital for 3 weeks instead of 8 days like they thought it would be. i was in intensive care for almost 2 weeks. it was a tough time but i am great now. i even went back to work full time exactly 2 months after getting out of the hospital. i have to eat a lot less food at one time. i cannot drink when i eat or i get too full from the drink. i also have to eat slow and certain foods make me feel sick sometimes. I have been home now 5 months since surgery and everything for me is going great. you have to have a good attitude and more than anything you have to have faith. good luck with everything. cindy

timp

cindyhils said:

i was diagnosed stage II in
i was diagnosed stage II in august of 09. I had chemo and radiation and then surgery in december. i had the open chest incision and also the incision on my left collar bone. i had mine done at the mayo clinic in rochester,mn. i was on day 3 out from my surgery and was doing fine when i had complications of a vein wrapped around my new stomach. needless to say i ended up in the hospital for 3 weeks instead of 8 days like they thought it would be. i was in intensive care for almost 2 weeks. it was a tough time but i am great now. i even went back to work full time exactly 2 months after getting out of the hospital. i have to eat a lot less food at one time. i cannot drink when i eat or i get too full from the drink. i also have to eat slow and certain foods make me feel sick sometimes. I have been home now 5 months since surgery and everything for me is going great. you have to have a good attitude and more than anything you have to have faith. good luck with everything. cindy

Thanks to all for the
Thanks to all for the responses so far. This is an incredible treasure of information from those who have already taken this journey.

Dianna just spent a week in the hospital with a C. Difficile infection, and now has severe colitis and will have to be on TPN nutrition for the immediate future. She will restart radiation next week, but chemo has been set back because it is so hard on the intestine. So surgery will also be set back a bit, but that will give me more time to pursue information on the surgeries, and to read through past postings on this site as some of you have suggested.

Tim

Tina Blondek

cindyhils said:

i was diagnosed stage II in
i was diagnosed stage II in august of 09. I had chemo and radiation and then surgery in december. i had the open chest incision and also the incision on my left collar bone. i had mine done at the mayo clinic in rochester,mn. i was on day 3 out from my surgery and was doing fine when i had complications of a vein wrapped around my new stomach. needless to say i ended up in the hospital for 3 weeks instead of 8 days like they thought it would be. i was in intensive care for almost 2 weeks. it was a tough time but i am great now. i even went back to work full time exactly 2 months after getting out of the hospital. i have to eat a lot less food at one time. i cannot drink when i eat or i get too full from the drink. i also have to eat slow and certain foods make me feel sick sometimes. I have been home now 5 months since surgery and everything for me is going great. you have to have a good attitude and more than anything you have to have faith. good luck with everything. cindy

Hi Tim and Dianna,
Hope
Hi Tim and Dianna,
Hope Dianna is recovering well from her recent infection. Looks like you have gotten a lot of replies concerning the type of surgery. I do not have any experience in this area, my dad was not a candidate for surgery. I just wanted to wish you the best of luck in your decision. Hoping you are getting wonderful care from UVA. I will be thinking and praying for both of you. Peace.
Tina