Full Esophogectomy or not??

Dear Randy,

So much to say—so little space to try to condense it.  Needless to say, our heart aches for you and your mom even though we’ve never met.  Once you are diagnosed with Esophageal Cancer, you become a member of an “elite rare group”—a minority of the US populace for sure.  But there is hope for your Mom.

Randy, first let me agree with Paul61 and say that the decision as to how much of the Esophagus and Stomach to be removed depends upon the extent of the infiltration of the cancer.  Now you didn’t state why the first surgeon said he would be pleased to perform the “open” surgery and suggested removing part of the stomach and the Esophagus.  Most of the cases of Esophageal cancer are “Adenocarcinoma at the GastroEsophageal  (GE) junction”.  This was the case with my husband William.  So if no part of the stomach was infiltrated with the cancer, one wonders why the first surgeon would want to “take part of it”.  You see, the stomach is divided into 2 parts and made into a new “gastric tube” to replace the diseased Esophagus.  In my husband’s case he had his entire Esophagus removed, but no part of his stomach was “taken” because it contained no cancer.

            I would differ slightly with the UCLA surgeon’s remarks about the “side effects” would be about the same.  Perhaps he should have clarified those remarks a bit more.  The side effects from the surgery itself are remarkably different.  With the MIE there are no massive incisions to heal, thereby causing less possibility of infection.  I read of one lady’s story recently, and she said that one side of her back was “numb” still and it had been several years since her “open” surgery. 

            Now “recovery” is quicker as well because there is quite a difference between a massive incision and a one-inch Band-Aid cut.  However, there are certain after effects from this surgery which all will have to work their way through.  This will differ from patient to patient, and I won’t even begin to enumerate them here.  That will be for a later date.  Right now you are endeavoring to find the best surgeon for your mother.  However, all our EC friends know the “new normal” they are living with, and are happy to be alive I might add.

However, initially at the time of my husband’s MIE surgery on May 17, 2003, there was one small incision (estimated no larger than 2 or 2 ½ inches) where the diseased Esophagus was removed.  There was a potential danger of damage to sensitive nerves, however, my husband experienced no damage or voice change.   Therefore, I would want to see your mother have her surgery where the least possible complications present themselves.  So it seems that this UCLA surgeon is familiar with the MIE procedure, but perhaps was trained to perform the surgery where the removal of the Esophagus was removed at a “neck incision” as was the practice originally.  There is a Thoracic surgeon at UC-Irvine by the name of Dr. Ninh Nguyen.  He practiced with Dr. Luketich in the mid 90s when the MIE was in its infancy.  He is extremely gifted.  He makes the incision in the chest rather than in the neck.  Incidentally, one way to tell a good surgeon is by the number of medical documents he has authored that have been accepted by the medical society.  Both Dr. Luketich and Dr. Nguyen have written “hundreds” of articles relative to their findings.  They are truly “gifted” thoracic surgeons.

Hopefully this information will be of help in letting you make an “informed decision.”  Our prayers will certainly be with you and your mom during this trying time.  We all understand.

In this report Dr. Luketich is discussing a study of 980 patients who either had the McKeown MIE-Neck Approach …or the modified Ivor-Lewis minimally invasive esophagectomy chest (MIE-chest) approach   The enlarged fonts, italics, and underlines are mine to try to illustrate the contrast between the two types of Minimally Invasive Laparoscopic Esophagectomies. 

*1. http://oncologystat.com/news/Minimally_Invasive_Esophagectomy_Leads_to_Low_Mortality_US.html

Published in Oncology

News · May 04, 2011

“Minimally Invasive Esophagectomy Leads to Low Mortality - Frontline Medical News

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BOCA RATON, FLA. (EGMN) — Minimally invasive esophagectomy has advanced to the point where it offers significant advantages over open esophagectomy in terms of operative morbidity and mortality, judging by results of a single-center review of 980 cases.

Published series indicate that the operative mortality of open esophagectomy is 8%-21%, although a very few high-volume medical centers have reported rates as low as 3%.

"There is a perception among patients and physicians that open esophagectomy is to be avoided at all costs because of it substantial morbidity," Dr. James D. Luketich said at the annual meeting of the American Surgical Association.

In his review of 980 consecutive, elective, nonurgent, minimally invasive esophagectomies, the 30-day mortality was just 1.8%. Median operative time was 6.7 hours, which dropped to 4 hours in cases that were not done by residents. The median ICU stay was 2.0 days, with a median hospital length of stay of 8 days. A median 21 lymph nodes were dissected, and 98% of cases had negative surgical margins.

"A less invasive surgical approach for esophageal cancer would improve the standard of care by reducing morbidity and shortening hospital stays and time to return to daily activities.

 If successful, surgeons might see more early-stage referrals from Barrett's patients now in surveillance," added Dr. Luketich, professor of surgery and chief of the Heart, Lung and Esophageal Surgery Institute at the University of Pittsburgh Medical Center.

A modified Ivor-Lewis approach involving laparoscopic conduit preparation, videothoracoscopic esophageal mobilization, and intrathoracic anastomosis is preferable to the McKeown approach when the minimally invasive route is chosen. It entails fewer conduit complications and lower mortality, according to Dr. Luketich.

In this series, 49% of patients underwent a modified McKeown approach involving videothoracoscopic esophageal mobilization, laparoscopic conduit preparation, and neck anastomosis, whereas 51% were treated via the modified Ivor-Lewis approach.

This was a nonrandomized study, but patients in the two study arms were essentially the same in terms of baseline characteristics. In all, 95% were operated on for malignant disease, 80% were men, and 31% received preoperative chemotherapy and/or radiotherapy.

 Patients who were operated on in the most recent years of the series underwent the Ivor-Lewis approach because Dr. Luketich has come to prefer it. He noted that most trainees are more comfortable with it; they have far more experience with operating in the chest than the neck.

Furthermore, outcomes are better than results with the McKeown approach. Indeed, the 30-day mortality rate was just 1.2% with the Ivor-Lewis minimally invasive esophagectomy chest (MIE-chest) approach vs. 2.5% with the McKeown MIE-neck approach.

 The major morbidity rate was 31% in the MIE-chest group, significantly less than the 36% with the MIE-neck group.

This difference was driven by the increased risk of laryngeal nerve injury with the McKeown approach.

The incidence of vocal cord paresis or paralysis was 8% in the MIE-neck patients, compared with 1% in the MIE-chest group.

Rates of other complications were closely similar in the two groups: 6% for empyema, 5% for acute respiratory distress syndrome, 5% for pulmonary embolism, 2% for acute MI, 3% for heart failure, and 5% for anastomotic leak requiring surgery.

Quality of life assessments using the Short Form-36 indicate that by 90 days, post-MIE patients scored in the age-adjusted normal range.

"I think by 90 days the patients have bounced back," he concluded. "Laparoscopy-VATS [video-assisted thoracic surgery]-chest anastomosis is now our preferred approach to most esophageal cancers."

Discussant Dr. David J. Sugarbaker called Dr. Luketich's study "a landmark paper."

"Dr. Luketich has been a pioneer in esophageal resection, and I think has developed a procedure that is rapidly becoming a standard of care worldwide.

This is the largest experience reported to date," noted Dr. Sugarbaker, professor of surgical oncology and chief of the division of thoracic surgery at Brigham and Women's Hospital and Harvard Medical School, Boston.

"He's set the standard, both in quantity and quality, for this operation," agreed Dr. John G. Hunter, professor and chairman of the department of surgery at Oregon Health and Science University, Portland.

This is Dr. Ninh Nguyen in an actual Minimally Invasive Esophagectomy surgery.  He operates out of UCIrvine in California.  These are excerpts from the MIE surgery.  It lasts approximately 46 minutes.  I realize it may be more than you can comprehend at this point, but it is a great video to educate one on the totally laparoscopic MIE. 

This is Dr. Nguyen giving a quick synopsis of how he performs the MIE. He now uses the MIE-Chest incision which is the latest improvement for an Ivor Lewis Minimally Invasive Esophagectomy.  In this video at point 7.49 or so, he will show the placement in the right chest where the MIE-Chest incision will be made.  You might want to ask your UCLA surgeon if he uses the MIE-Neck or the MIE-Chest incision.  As you have read, in the link #12, the MIE-Chest is far superior to the older method of making the incision in the neck.

3.  https://www.youtube.com/watch?v=u3o30epRTiM

Hi All. I am wondering if anyone has had Cancer in the upper (cerival portion) of the esophagus?

My mom was recently diagnosed with Cervical Esophageal Cancer. She is T2 or T3, N0 or N1, M0. They are not sure about the lymph because they cannot biopsy it due to location. did not light up like normal cancer would on PET. There were no other METS. Her tumor is 3.8 CM.

The Dr. is saying that surgery is not an option due to where the tumor is.

They are going to do 7 weeks of radiation 1 hour per day Mon-Fri (35 total) and 1 chemo (Charbo/Taxol) each of those 7 weeks. Then she will have a break for 4-5 weeks and then they want to do more chemo only a stronger dose.

She has had and beaten cancer twice befor... She had Hodgkins Lymphoma when she was 19 years young. had remission for 27 years until she got Breast Cancer at 27. She had remission from that for 15 years and now she is dealing with this. 

Please help with any advice and I would really like to hear from anyone who had had EC in this portion of the esophagus.

Thank you in Advance for any help you can give me. I feel so darn helpless!

Deathorglory said:

Wow, That's a Lot

Hello Tressa,

That sure is a lot your mother has been hit with.  She must have some sort of superhuman strength.  I'm sorry that I know very little about EC in the upper esophagus.  I had adenocarcinoma which is usually at the gastric junction or thereabouts.  Squamous cell is what usually shows up higher in the esophagus.  One thing that I do know is that they are two seperate animals and need to be treated as such.  The plan they have your mom on is similar to the plan I was on my 1st time with EC (when I was stage III).  I did chemo/radiation (also Carbo/Taxol) and the initial chemo was a reduced "activating" dose to make the radiation more successful.  Unlike your mom, I then had surgery.  Then I had another course of chemo that was the same, but full strength.  The chemo/radiation side effects were primarily from radiation (fried my esophagus shut).  The second round of chemo was worse.  I lost ALL of my hair (leg, chest & goatee are probably less of an issue for your mom).  I was also frequently nauseous.  I was weaker the second time b/c I was recovering from a pretty significant surgery, though.  Hopefully your mom is stronger for her 2nd course of chemo than I was.  

The one thing you can seem to count on with your mother is that she's some sort of freakish superwoman.  She's 2-0 against cancer and I'd put my money on her this time around, too.

Best Wishes,

Ed

Thank you for your encouraging words, and also for sharing a bit with me. I finally figured out how to creat a new forum discussion, so I will copy and paste ,y original post from here in hopes of finding someone with cancer around the same spot as my mom... Have a great day.