This year, Baystate Medical Center became the only hospital in Western Massachusetts to offer minimally invasive esophagectomy (MIE) for patients with esophageal cancer or high-grade dysplasia. This thoracoscopic and laparoscopic procedure serves as an alternative to the traditional esophagectomy – a major surgery that carries a number of risks for patients.

Esophageal Cancer

Esophageal cancer is one of the fastest rising cancers in the United States. Early detection is key – 80 percent of cancers found in the early stages are cured. That number drops to 30 percent if the cancer is found in a later stage.

In addition to radiation therapy or chemotherapy, traditional treatment for early-stage esophageal cancer that does not involve the stomach is an esophagectomy, in which a portion of the stomach, esophagus, and surrounding lymph nodes are removed and the remaining esophagus is reconnected to the stomach.

“The traditional esophagectomy procedure is extensive,” says Gary Hochheiser, MD, chief of Thoracic Surgery at Baystate Medical Center and director of Thoracic Oncology for the Baystate Regional Cancer Program. “The esophagus is a three-cavity organ extending from the neck to the chest through the abdomen. To remove it, we have to address all three cavities through two or three large incisions, and open chest incisions are probably the most painful incisions a person can have.”

In addition, this complex surgery carries high risks including infection, bleeding, and leakage from the point where the esophagus is reattached.

“The concept of the minimally invasive approach is to perform the same operation for the patient, but make it more tolerable by minimizing the pain and recovery time,” says Dr. Hochheiser.

Gary M. Hochheiser, MD

Minimally Invasive Esophagectomy

A minimally invasive esophagectomy employs the same techniques used for performing other minimally invasive surgeries. During the procedure, the surgeon makes several small incisions (no bigger than 1.5 centimeters) to access the abdomen and chest in order to view the area with a small camera. The fundus and a portion of the esophagus are removed, and the stomach is pulled upward and joined to the remaining portion of the esophagus.

“We are essentially performing the same procedure as in the past, but through smaller incisions,” says Dr. Hochheiser. “The complexity of this procedure is what sets it apart.”

The benefits to patients are clear. While there is no evidence that the minimally invasive approach results in better esophageal cancer survival rates, there is a decrease in operative mortality rates with the less invasive method. Patients remain in the hospital about the same amount of time (seven to ten days), but the level of pain and discomfort for patients is greatly reduced.

“Another real benefit we’re seeing is that two to three weeks postoperatively, people are back to their normal physical activity levels, as opposed to the six to eight weeks we saw with the open incision surgery,” says Dr. Hochheiser. “This procedure provides an opportunity for patients to get back on their feet faster and experience less pain.”

Lifestyle Changes

All patients who have an esophagectomy need to learn to adapt to the major lifestyle changes that result from the surgery, primarily around the way they eat. Part of the esophagus is essentially replaced with the stomach, so the stomach no longer expands in the same way. “Patients have to eat smaller meals, more frequently,” says Dr. Hochheiser. “They can’t eat late at night, and should remain upright for several hours after eating.” Most people lose about ten percent of their baseline weight following the surgery. To help patients adjust to the changes, Baystate offers formal preoperative teaching sessions in addition to the education that Dr. Hochheiser provides in his office (see sidebar). Despite the significant adjustments they must make following the procedure, Dr. Hochheiser says most patients adapt very well.

Highly Advanced Care

While Dr. Hochheiser says he approaches every patient as a possible candidate for MIE, patients who had prior operations in the abdomen or chest, or those with larger, more advanced tumors, are not eligible for the procedure. “At Baystate, our approach is that if a patient is able to have a minimally invasive operation, we will pursue that,” he continues. “If we can offer the same treatment in a less painful and debilitating way for the patient, with the same outcomes, then that is ideal.”

Currently, only ten percent of hospitals nationwide perform minimally invasive esophagectomies, and less than a handful of Massachusetts hospitals offer the procedure. “By offering this technique at Baystate,” says Dr. Hochheiser, “we are bringing a highly advanced level of care to patients in Western Massachusetts.”

Minimally invasive esophagectomies are covered by most major health insurance plans. To refer a patient, call Baystate Thoracic Surgery at 413-794-8050.