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Using Robots to Remove the Esophagus

Last year in the United States, doctors diagnosed 18,000 new cases of cancer of the esophagus, the muscular tube that connects the throat to the stomach. While no one is sure exactly what causes it, age, gender, and a history of acid reflux are risk factors. Now, surgeons are using a new technique to remove the esophagus and help patients recover faster than ever before.

The key to John Adamek's happiness is getting behind the wheel of his truck, or cruising with his camper. But he had to put the brakes on with hardly any warning.

Adamek told Ivanhoe, "They found it by accident, in essence. I had no symptoms."

After routine bloodwork and lots of tests, John learned he had cancer of the esophagus. It needed to come out.

Sharona Ross, MD, FACS, Director of Surgical Endoscopy at Florida Hospital Tampa told Ivanhoe, "A lot of things can go wrong if you are an inexperienced surgeon, doing it alone."

Dr. Ross and Dr. Alex Rosemurgy, MD, teamed up for a delicate, robotic surgery.

"Robotic esophagectomy is unique," Dr. Ross said.

With one surgeon bedside, and a second at the controls of the robot, incisions are made in the neck and the abdomen and the esophagus is removed. Surgeons are able to avoid the chest area, meaning less chance of serious complications.

Dr. Ross explained, "We, in fact, were able to completely bypass the intensive care unit."

The robotic surgery also meant a faster recovery time.  John was out of the hospital in six days, and he's getting used to life without his esophagus.

 "My stomach is now up here.  It doesn't feel any different.  Internally I feel fine.  I feel like I have my original strength," Adamek said.  

Which meant he could get right back on the road.

Doctors say not every esophageal cancer patient is a candidate for minimally invasive, robotic surgery. Experts say it's important that the cancer has not spread. John Adamek says his health insurance covered most of the $134,000 cost of the surgery.

Contributors to this news report include: Cyndy McGrath, Supervising Producer; Emily Maza Gleason, Field Producer; Cortni Spearman, Assistant Producer; Travis Bell, Videographer and Jamison Koczan, Editor.

BACKGROUND: The esophagus is a hollow muscular tube that helps to move food from the mouth into the stomach to be digested. Smoking, heavy drinking, acid reflux and a poor diet can lead to a development of cancer of the esophagus. Esophageal cancer is the eighth most common type of cancer and causes 12-thousand deaths a year in the United States. Esophageal cancer occurs when a cancerous or malignant tumor forms within the esophagus. This cancer usually starts in the cells that line the inside of the esophagus and spreads. There are two main types of esophageal cancer which are adenocarcinomas and squamous cell carcinomas. Both men and women are at risk for both types of esophageal cancer, but men ages 65 and older are at a greater risk for the disease.

(Sources: http://www.medicinenet.com/esophageal_cancer/article.htm, http://www.mayoclinic.org/diseases-conditions/esophageal-cancer/basics/symptoms/con-20034316)

SIGNS AND SYMPTOMS: Early esophageal cancer typically causes no signs or symptoms, but if symptoms do appear, they may include:

  • Food getting stuck in the esophagus
  • Vomiting
  • Pain when swallowing and chest and/or back pain
  • Heartburn
  • Weight loss
  • A hoarse voice

(Source: http://www.medicinenet.com/esophageal_cancer/article.htm)

NEW TECHNOLOGY: Robotic esophagectomy surgery is a newer approach to removing the esophagus from a patient. This technology allows doctors to make a small incision in the neck and abdomen avoiding the chest cavity all together. The robot allows doctors to visualize their work and perform very fine dissections. With this technique, doctors are able to have 3D visualization while working, allowing for a more precise surgery and little damage. "You do all the dissection in a cancer operation for esophageal cancer nicely and elegantly utilizing the robot", says Sharona Ross, MD, FACS, Surgeon at Florida Hospital Tampa.  Also due to smaller incisions during surgery, the length of stay in the hospital for a patient's recovery is a lot shorter. "We in fact were able to completely bypass the intensive care unit so patients would be sitting in a chair, walking around on the floor, and recovering very quickly", says Dr. Ross.

(Source: http://www.medicinenet.com/esophageal_cancer/page7.htm#surgery)

FOR MORE INFORMATION ON THIS REPORT, PLEASE CONTACT:

Sharona Ross, MD, FACS

Florida Hospital Tampa

813-431-3045

Sharona.ross@yahoo.com

If this story or any other Ivanhoe story has impacted your life or prompted you or someone you know to seek or change treatments, please let us know by contacting Marjorie Bekaert Thomas at mthomas@ivanhoe.com

Sharona Ross, M.D., FACS, Surgeon at Florida Hospital Tampa, talks about a new robotic surgery that allows doctors to remove cancer of the esophagus with little damage.

Interview conducted by Ivanhoe Broadcast News in December 2014.

Why is this procedure unique?

Dr. Ross: Robotic esophagectomy is the uniqueness of this approach. There are two main surgical approaches to remove the esophagus for esophageal cancer. One is called Ivor Lewis esophagectomy and the other is trans-hiatal esophagectomy. The Ivor Lewis approach involves the chest; it involves one big incision in the chest and another big incision in the abdomen. The trans-hiatal esophagectomy involves a big incision in the abdomen and a small incision in the neck avoiding the chest altogether. Now when robotics came into play,surgeons that are more comfortable with the Ivor Lewis approach tend to make small incisions in the abdomen and then small incisions in the chest and that's how they adopted robotic esophagectomy to follow the Ivor Lewis approach. Trans-hiatal esophagectomy, which would be what we do for our patients, both Dr. Rosemurgy and I make small incisions in the abdomen and a small incision in the neck avoiding the chest altogether. Now why is it important to avoid the chest? If you make an incision in the chest and enter into the pleura cavity where the lungs are, first of all, you have to leave chest tubes at the end of the operation. The chest tubes are placed in between the ribs therefore causes pain with every breath the patient takes. Also, for the Ivor Lewis approach the reconnection of the remnant of the esophagus with the stomach that was made into a tube because the esophagus was removed is done in the chest. If the patient develops a leak it can be lethal. However, If you have the reconnection in the neck you can handle it without deadly consequences. We place a small drain in the neck and the consequence of a leak involves keeping the drain a longer in the neck. For these reasons we do our robotic esophagectomy with the trans-hiatal approach. What's so unique with this robotic approach is that we make small incisions in the abdomen to mobilize free the entire stomach and then dissect into the mediastinum under direct visualization. It allows you to have 3D visualization and ergonomically you have the wrist work that allows you to do very fine dissection. The surgeon can see every layer of tissue, identify the pleura that cover the lungs and avoid entering into it. Therefore chest tubes are not necessary. The surgeon can dissect and mobilize the esophagus with the lymphatic basin nicely. This has tremendous   consequences regarding patient's recovery. This allows the surgeon to do a nice and elegant cancer operation for esophageal cancer. The stomach is then brought up into the neck through the mediastinum and is reconnected in the neck to the remnant of the esophagus.

How long does the procedure take with the robot?

Dr. Ross: The length of the operation is a great question to ask. The reason why my partner Dr. Rosemurgy and I avoided robotic surgery was because it takes longer. We always assumed that longer operations expose patients to longer time under anesthesia and it cannot possibly be good. If we could do this operation "open" in two hours and with the robot it takes four to five hours, it can't possibly be beneficial.  We soon realized that eliminating big incisions and only using small incisions while avoiding the chest and chest tubes, allowed patients to recover quicker. We in fact were able to completely bypass the intensive care unit and send patients directly to the surgical floor so they can stay out of bed sitting in a chair and walking around on postoperative day 1. The overall length of stay in the hospital was shorter with the robotic approach, hence beneficial.

It takes longer but the consequences aren't as drastic?

Dr. Ross: That is correct. The operation takes longer but recovery is so much quicker. We thought the length of anesthesia was something we should avoid. We're actually finding that that's not what affects recovery. It's walking around taking a deep breath without fear of pain. That's a significant part of recovery.

How is this going to improve patient outcome?

Dr. Ross: First, it improves patients' outcomes because it's a more minimally invasive approach. When we used the "open" big incisions approach to esophagectomy, the dissection up in the mediastinum was undertaken with one hand in the patient's abdomen and the other in the neck incision. With both hands we would then blindly do the dissection in the mediastinum. Many times the pleural cavity is violated during this blinded and blunt dissection so most times chest tubes need to be placed even with the trans-hiatal approach. With the robotic trans-hiatal esophagectomy, chest tubes are not necessary at all. The pleura can be seen and avoided. That's what makes recovery quicker.

Acid reflux is kind of where this all started from. Why is it's important to pay attention to acid reflux and not rely on the medicine as much?

Dr. Ross: Twenty or 30 years ago the most common type of esophageal cancer was squamous cell carcinoma. Currently its adenocarcinoma, which we rarely saw 20 years ago. So why do we see more adenocarcinoma, where is it coming from? If you notice, many Americans walk around complaining of heartburn. If you have two or three episodes of heartburn per week you have what we call GERD or gastro esophageal reflux disease. What that means is that you need to have it treated; you need to be further evaluated by a gastroenterologist and then referred for definitive curative treatment to a surgeon. Most Americans are prescribed anti-reflux medications to improve their symptoms. However, because acid reflux is a mechanical problem, it should be treated mechanically. Medications are not going to affect the valve mechanism at the end of the esophagus to prevent acid to reflux. Only an operation can fix the problem by tightening the lower esophageal sphincter/valve. How do we know that to be true? We see many patients in our clinic who have been chronically taking PPIs, the most effective anti-acid medication like Protonix, and still develop esophageal cancer.  Some people are taking these medications twice a day and yet eventually develop esophageal cancer. Taking medications doesn't prevent the development of esophageal cancer. 

People who require anti-acid medications for longer than six weeks should be evaluated for an operation. There are several surgical options that are minimally invasive which didn't exist in the past.  Some of the procedures can be done through the mouth without any skin incision. There are other laparoscopic options that include a 1.2cm single incision inside the belle button that allow surgeons to repair hiatal hernias and construct an effective fundoplication/wrap around the esophagus. Patients do well with these procedures and go home same day or the next day after the procedure. Twenty or 30 years ago when PPIs came out, anti-reflux operations included a big incision and long hospitalization. But nowadays it's really minimally invasive. The FDA approved PPIs for six weeks use, not for lifelong use and unfortunately people are using it for many, many years.

For people who have done that have you seen that they develop cancer?

Dr. Ross: Yes, patients who have chronic exposure of acid to the lining of their esophagus develop changes that may lead to cancer. The changes progress from esophagitis which is inflammation of the lining of the esophagus, to Barrett's esophagus to dysplasia which starts as mild, moderate and severe, to then cancer, adenocarcinoma of the esophagus. The problem is that patients are not informed that there are minimally invasive curative surgical options that they need to consider in order to stop the progression of these changes to esophageal cancer.

Is there anything else?

Dr. Ross: Who is a candidate for robotic esophagectomy? It's whoever would be a candidate for laparoscopic operations.  Patients with high BMI, obese or overweight, may not be good candidates for the robotic approach. Abundant amount of intraperitoneal fat inside the abdomen makes it very difficult to get good exposure for safe dissection. It's not impossible but it makes the operation more complex. If a patient had previous "open" abdominal operations, the robotic approach might be impossible due to scar tissue. The scar tissue causes organs to stick together which increases the rate of complications. Patients with certain comorbidities like liver cirrhosis with portal hypertension are at high risk for bleeding which potentially make the operation more challenging yet not impossible. 

Who should offer the robotic esophagectomy surgery? 

In my opinion, surgeons need to be proficient with foregut laparoscopy before they decide to adopt foregut robotic surgery. When robotic surgery was introduced to the market it was mostly used by urologists and gynecologists. General surgeons really adopted this very late in the game. I went to a conference 2 months ago and there were commercials on TV encouraging patients who had a robotic operation and developed complications to call their law firm. This is because there were many complications when robotic surgery was first introduced. The problem with robotic surgery is that you're working on a very small focused area. If you're a laparoscopic surgeon you're constantly thinking about the rest of the body and all the areas that are not in your visual field. You're worrying about the other robotic arms that are not in your visual field. If you're not used to thinking that way, injuries can happen. That's why it's important to have laparoscopic skills. Finally, I believe that complex HPB operations should be done by two HPB surgeons, one at the bedside and another at the console to ensure safety. At FHT Dr. Rosemurgry and myself undertake robotic HPB operations together. If we experience bleeding which can't be controlled robotically, the person at the bedside is the one that needs to apply pressure while the other surgeon undocks the robot. Complications are always possible but surgeons can minimize and eliminate bad consequences. 

How often have you had to the robot out of the scenario during a surgery?

Dr. Ross: Rarely. However, we review our cases at the beginning of each day and we debrief during the cases. The team includes my partner Dr. Rosemurgy and myself, the anesthesiologists, our two fellows as well as our OR staff. We also meet weekly to go over the cases. We formulate a plan of how to approach each pathology. Surgery is a team sport. Everybody is expected to bring their A game to the operating room. The team approach is the secret to our good outcomes.

This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.

If you would like more information, please contact
Sharona Ross, MD, FACS

813-431-3045

Florida Hospital Tampa

Sharona.ross@yahoo.com

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