going to meet the surgeon tomorrow

unknown said:

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OncoSurge said:

Open is OK
Below is a selected quote:
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"...With an MIE hospital stays are shorter, operation times shorter, less time in ICU, morbidity rates less, blood loss less, less chance of infection that can occur from being so long "open" on the operating table, quicker recovery time, just to name a few advantages over the "open" procedure...

If you have a choice, an MIE cannot be improved upon. Statistics have been around long enough now that indicate a "MIE" is preferable unless there are mitigating circumstances that prevent it...."
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I wanted to comment. I have a significant amount of minimally invasive surgical training. I believe it has a place and a time. In numerous circumstances (i.e. gallbladder and appendix), I think it IS the standard of care. The patient and the physician must discuss options and ultimately make the best choice. That brings us to a fact... cancer surgery is not the same thing as taking out a benign gall bladder for gallstones. So, it is risk and benefit. You take out the gallbladder, you do NOT have any risk of the gallbladder "recurring". So, the cosmetic considerations are real.

In esophageal cancer, we have any number of approaches available. In Michigan, you can have a "transhiatal" approach. It is done numerous times and is fairly quick. In other states, you can have a minimally invasive... partially or completely. You can get an open Ivor-Lewis. So, what do we know? I have been to the conferences and listened to the world experts on totally minimall invasive (MIS) esophagectomy. They have great experience. Every patient case needs to be assessed on an individual basis. But in general, facts that need to be looked at are comparison with EXPERIENCED open surgical procedures. Listening to the reports at the conferences and reviewing their publications about MIS esophagectomy, operative times are markedly longer and ICU stays markedly longer and often their "leak rate" is greater.

In practice, I have generally seen open Ivor-Lewis operative times of approximately 3 hours total. The reports from Pensylvania speak of MIS esophagectomy times upwards of 6-8 hours. At 3 hour open operative times, patients are generally extubated (taken off the breathing machine) in the operating room at conclusion of case. Thus, more often then not, there is NO ICU time. Plenty of EXPERIENCED open operative technique centers often report a leak rate less then 2%. The MIS esophagectomy experience reported out of the most experienced and published centers has a significantly higher rate then that.

So, as stated, each patient must be taken individually. Esophageal cancer patients may be quite diminished. You have to consider the overall health of the patient. There can be significant pre-operative weight loss. The immune system can be impaired (by disease or chemo). Radiation & chemo can have an adverse impact on lung function and lung reserves. You have to consider the impact of a significant long operation. MIS operation is consistently reported with LONGER operative times as compared to higher volume experienced open surgeons.

My point is not to say MIS esophagectomy is wrong or to be avoided. I just would hate for folks to believe that some how MIS esophagectomy has in anyway been "proven" to be best or proven to be "standard of care" or proven to be with quicker operative and/or recovery times, etc... Minimally invasive approach absolutely has room for improvement. That is one thing expressed and agreed upon by all the experts in the MIS approach. All the publications speak to the fact (and problem) that often we are comparing apples to oranges. The MIS esophagectomy or MIE if one prefers may be performed in an earlier/lower stage cancer then say the open. One may be comparing a high volume MIE center to a low volume open surgeon.

A surgeon may perform numerous esophagectomies per year. He/she thus has that experience to draw from and recommend from when dealing with the individual patient. Each patient, like yourself, and God willing, will only have that cancer experience in their life. It is potentially the most significant experience in their life and so that single experience may affect their perspective. It is not uncommon to have a patient at a one year follow-up mention not understanding or not realizing important components of our discussion as to their operative care. In my experience, patients spend years gaining an understanding of their individual experience.


Best wishes