Patients with cancer of the esophagus benefit from new technique developed by OHSU surgeons

Surgeons at the Oregon Health & Science University Digestive Health Center have developed a new technique that makes feasible and safe a potentially lifesaving and noninvasive surgical procedure known as laparoscopic esophagectomy.

Until now, the procedure was considered too technically demanding for most surgeons to perform. A paper on their findings recently was presented at the European Association of Endoscopic Surgery in Venice, Italy.

For more than a decade, the original procedure has been used in a few specialized centers around the world to remove cancer as well as other diseased tissue of the esophagus laparoscopically, that is by inserting fiber-optic instruments into a small, quarter-sized incision in the abdomen and maneuvering them to the affected portion of the esophagus while observing with a camera.

When first introduced, the less invasive laparoscopic esophagectomy was embraced by surgeons eager to forgo traditional open surgery, which requires cutting through the patient's chest. But it proved so difficult and time-consuming that most surgeons abandoned it, according to John G. Hunter, M.D., co-director of the OHSU Digestive Health Center, chairman of surgery in the OHSU School of Medicine, and co-author of the paper.

Hunter, a pioneer in minimally invasive surgery, however, did not abandon it. He knew from experience that laparoscopic surgery is inherently better for patients. "They recover faster with less pain, fewer complications and smaller scars," he explained.

He and colleagues worked in earnest to develop a means by which they could more easily and safely perform laparoscopic esophagectomies. The fruit of that labor is the laparoscopic inversion esophagectomy, or LIE. The LIE eliminates some of the technical obstacles that plagued the original procedure, the researchers report.

"With the original laparoscopic esophagectomy, the entire esophagus is in the way as you try to take it out, and all access is from behind, making it difficult to see surrounding structures and blood vessels. Space is tight," said Blair Jobe, M.D., first author of the paper and assistant professor of surgery (general surgery), OHSU School of Medicine, Portland Veterans Affairs Medical Center (PVAMC), and a member of the OHSU Cancer Institute.

"With LIE, we roll up the esophagus from the bottom, section by section, into the neck. The technique is similar to taking off a sock, rolling it down from the outside in. This opens the surrounding space, making it easier and safer to cut attachments and tissue as you go."

In their paper, the researchers state that LIE has proved effective in removing precancerous tissue as well as other noncancerous esophageal disease with fewer complications than the original laparoscopic esophagectomy. In addition, they explain, the survival rate with LIE may be greater than that of traditional open surgery. Charles Kim, M.D., resident in surgery (general surgery), OHSU, PVAMC, also participated in the research.

"We have now accumulated a large experience with this procedure and believe that as we have designed it, the technique will become very popular among esophageal surgeons," said Hunter.

Two gentlemen from Vernonia, Ore., who were among the first to undergo LIE, are already among big fans of the procedure.

Burdette Robb and Warren Curington met when Robb's Hillsboro physician referred him to Hunter to discuss LIE. Curington had already undergone the procedure nine months earlier to remove some growths on his esophagus and happened to be in for a follow-up visit the same day as Robb's initial appointment. Donna Markey, R.N., M.N, A.C.N.P., patient care coordinator for the OHSU Digestive Health Center, asked him if he would share his experience with Robb.

"It was very reassuring to see how good Warren looked and know that he was doing well. It was good to know I didn't need to have my chest cracked open. This was less radical and less threatening. I'm a single parent with three children, so I didn't want to have a lot of concerns and worries about the procedure or the results."

Curington echoed those words. "I decided I liked life too much not to have the surgery. And those people did a really good job. They knew everything before they went in there."

The National Cancer Institute estimates 13,200 Americans will be diagnosed with esophageal cancer this year and 12,500 will die of the malignancy. Of the new cases, 9,200 will occur in men and 3,100 will occur in women.

An estimated 25 million Americans have some form of esophageal disease, the most common of which is gastroesophageal reflux disease (GERD). Patients with severe GERD have a 40 times greater risk of developing esophageal cancer than those without GERD symptoms, similar to the risk of developing lung cancer for a cigarette smoker. However, for any one particular individual with GERD, the risk of esophageal cancers is quite low.

There are two main types of esophageal cancer: squamous cell cancer and adenocarcinoma of the esophagus. Adenocaricinoma is the most common and is increasing in frequency. It is associated with GERD, which affects some 61 million Americans, according to the American Gastroenterological Association. If left untreated, over time, GERD can change the cells in the esophageal lining, a condition called Barrett's esophagus, which can lead to adenocarcinoma. Squamous cell cancer of the esophagus is linked to cigarette smoking and excessive alcohol consumption. Its incidence is not increasing in frequency.