Minimally Invasive Ivor-Lewis Esophagectomy is performed to remove the distal esophagus and proximal stomach for treatment of malignant or benign disease of the distal esophagus. Six incisions each less then 1 cm are placed in the abdomen to begin the abdominal part of the operation. For malignant disease we visualize the abdominal cavity to ensure there is no metastatic disease. Next we place a liver retractor to lift up the left lobe of the liver to allow us to visualize the distal esophagus and the stomach. We then mobilize the stomach by dividing various ligaments, attachements and vessels (short gastric artery and left gastric artery). Next we created a gastric conduit (new esophagus) by dividing the stomach with a stapler. After the creation of gastric conduit we perform pyloromyotomy which divide the pylorus (a muscle that empties the stomach) and perform jejunostomy tube placement.
We then place the patient on the side with right side up. We make three 1 cm incisions and one 4 cm incision on the side to perform the rest of the operation. The esophagus is mobilized then divided at usually the carina. We then bring the gastric conduit and specimen up into the chest. Specimen is removed and sent to pathology. For patients with malignancy, mediastinal lymph node dissection is performed. Next a connection is made between the gastric conduit and the esophagus. A NGT (small tube going to the gastric conduit through the nose) is placed in the patient and a chest tube is place in the right chest cavity.
Minimally invasive Ivor Lewis Esophagectomy is a safe and effective treatment for malignant and benign disease of the distal esophagus. However, in the presence of adhesions or variation of anatomy, this method becomes dangerous and your surgeon may need to make the prudent decision to continue by making the traditional incision to safely complete the operation. This should not be seen as a failure, but as a wise decision by your surgeon to prevent dangerous complications. Most common complication of the surgery is development of pneumonia due to poor pulmonary toilet after the surgery. Other uncommon complications are bleeding, infection, atrial fibrillation, leak at the anastomosis, injury to the liver, stomach, bowel, lung and spleen. Other rare complications are development of clot in the leg, clot traveling to the lung, heart attack or stroke.
After the operation, patients in the hospital for 5 to 8 days. Typically NGT is removed on day 4-7 and the chest tube is removed the next day. Tube feeds typically starts on first day after the surgery and slowly advanced to goal rate. Patients get all of the nutrition through the jejunostomy tube for 2 weeks then start liquid diet. About three weeks from surgery patients resume a regular diet. The jejunostomy tube is removed in clinic once patient can maintain his weight without using the jejunostomy tube which typically happens about 6 weeks from surgery.
Long Term Outcome
Since this operation creates a new esophagus from the stomach which leaves much smaller stomach, the most significant change is the volume of food a patient can eat at one time. Typically, patients eat 5-6 small meals per day to maintain their weight. About 80% of the patients are able to have normal diet without having any difficulties. Some patients may develop diarrhea after this operation which can be managed with medication. Rarely patients develop trouble eating some solid food which often is development of narrowing at the anastomosis. This can be treated with esophageal balloon dilatation.