McKeown esophagectomy is a surgical procedure to remove the esophagus and the upper portion of the stomach. It is used to treat patients with benign and malignant disease of the esophagus or esophageal cancer.
We use the most advanced robotic system called Da Vinci Xi to perform McKeown esophagectomy. The procedure is called “Robot-assisted minimally invasive McKeown Esophagectomy.” Another term for the operation is minimally invasive three-hole esophagectomy. We perform the procedure through five small incisions in the right chest. The esophagus is separated from the surrounding structures. We remove lymph nodes in the middle of the chest next to the esophagus.
We continue the operation by creating six small incisions in the abdomen. We then mobilize the stomach by dividing various ligaments, attachments and vessels. Next, we create a gastric conduit or new esophagus by dividing the stomach with a stapler. After the creation of a gastric conduit, we ensure good perfusion of the new esophagus by performing ICG angiography. This is completed by injecting ICG in the blood stream, which turns green when it is viewed with the FIREFLY function on the robot. Next, we place BOTOX into the pylorus or the valve between the stomach and the small bowel to allow the food to pass from the gastric conduit to the small bowel. Finally, a jejunostomy tube is placed in the small bowel so that patients can get nutrition while the connection between the gastric conduit and the esophagus heals.
We then bring the gastric conduit and specimen up into the left side of the neck. The specimen is removed and sent to pathology. Next, we connect the gastric conduit to the esophagus. At the end of the surgery, a small tube called an NG tube or nasalgastric tube goes into the gastric conduit through the nose, a chest tube is placed in the right chest cavity and a drain called “Penrose” is placed in the left side of the neck.
Minimally invasive McKeown Esophagectomy is a safe and effective treatment for malignant disease of the distal esophagus. In the presence of adhesions or variation of anatomy, however, this method becomes dangerous and your surgeon may need to make the prudent decision to continue by making a traditional incision to safely complete the operation. The most common complication of the surgery is the development of pneumonia due to poor pulmonary care after the surgery. Other uncommon complications are bleeding, infection, atrial fibrillation, leak at the anastomosis, or injury to the liver, stomach, bowel, lung and spleen. Rare complications include the development of a blood clot in the leg, a blood clot traveling to the lung, heart attack or stroke.
Hospital Stay: 5-7 days
After the operation, the patient is admitted to the Intensive Care Unit (ICU) typically for 1 day. Once the patient recovers, he or she is transferred to the surgical floor. Over the next couple of days, the foley and central lines are removed. The NGT is typically removed 2 or 3 days after surgery. The chest tube is typically removed 4 or 5 days after surgery. The “Penrose” is removed 5 or 6 days after surgery. We start the nutrition through the jejunostomy tube 1 day after surgery. Patients have pre-emptive pain control around the clock. Patients are not allowed to take anything by mouth or NPO to allow the new connection to heal. Once the patient can tolerate the tube feeds and the chest tube is removed, he or she is ready to continue recovery at home.
Patients get all of their nutrition through the jejunostomy tube for 2 weeks. After two weeks, patients undergo an esophagram, which is a test in which the patient drinks contrast under an X-ray to determine if there are any concerns about the new connection between the esophagus and the gastric conduit. If there are no concerns, the patient starts a liquid diet and resumes a regular diet. The jejunostomy tube is removed in the clinic once the patient can maintain his weight without using the jejunostomy tube. This process typically happens about 6 weeks after surgery.
Once the patient is cleared to resume a regular diet, most important aspect of eating is to eat small portions frequently. Patients are advised to eat six small meals a day. When patients eat more than the amount that can be processed by the gastric conduit, patients often feel discomfort that lasts until the food passes down into the small bowel. In order to prevent these episodes, patients are advised to take small frequent meals.
We also advise our patients to stay ahead of the pain with pre-emptive pain control. Instead of taking pain medication after having pain, we ask patients to take pain medication in regular intervals. The typical regimen for post-operative pain medication is:
5 days of Tylenol (Acetaminophen) 1 g three times a day
7 days of Neurontin (Gabapentin) 300 mg three times a day
After 7 days, take Tylenol as needed. If this regimen is not adequate to control pain, we ask patients to call our office.
In order to further help with recovery from surgery, we advise patients to walk at least three times a day, work on the incentive spirometer, and sit in a chair for at least 6 hours a day for about a week after the surgery. We advise patients to avoid heavy lifting for 6 weeks. As long as the patient is not on narcotic pain medication, it is safe to drive.
Sleeping in incline
After the operation, it is very important to sleep in an incline of at least 45 degrees. This prevents aspiration of gastric materials into the airway.