Minimally invasive oesophagectomy: consultation document
NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE
Interventional Procedure Consultation Document
Thoracoscopically assisted oesophagectomy
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Thoracoscopically assisted oesophagectomy can be used to remove part of the oesophagus (gullet), usually because of cancer. The procedure involves making small cuts or holes in the chest wall and inserting a camera and other instruments into the chest cavity in order to carry out the operation on the oesophagus. |
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The National Institute for Health and Clinical Excellence is examining thoracoscopically assisted oesophagectomy and will publish guidance on its safety and efficacy to the NHS in England, Wales and Scotland. The Institute’s Interventional Procedures Advisory Committee has considered the available evidence and the views of Specialist Advisors, who are consultants with knowledge of the procedure. The Advisory Committee has made provisional recommendations about thoracoscopically assisted oesophagectomy. This document summarises the procedure and sets out the provisional recommendations made by the Advisory Committee. It has been prepared for public consultation. The Advisory Committee particularly welcomes:
Note that this document is not the Institute's formal guidance on this procedure. The recommendations are provisional and may change after consultation. The process that the Institute will follow after the consultation period ends is as follows. The Advisory Committee will meet again to consider the original evidence and its provisional recommendations in the light of the comments received during consultation. The Advisory Committee will then prepare draft guidance which will be the basis for the Institute’s guidance on the use of the procedure in the NHS in England, Wales and Scotland.
Closing date for comments: 23 May 2006 Target date for publication of guidance: August 2006 |
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Note that this document is not the Institute's guidance on this procedure. The recommendations are provisional and may change after consultation. |
| 1 | Provisional recommendations |
| 1.1 |
Current evidence on the safety and efficacy of thoracoscopically assisted oesophagectomy appears adequate to support the use of this procedure, provided that normal arrangements are in place for consent, audit and clinical governance. |
| 1.2 | This procedure is technically demanding, and surgeons undertaking it should have special expertise in laparoscopic and thoracoscopic surgical techniques. |
| 1.3 |
Patient selection and management should be carried out in the context of a multidisciplinary team. |
| 2 | The procedure |
| 2.1 | Indications |
| 2.1.1 | The most common indication for thoracoscopically assisted oesophagectomy is oesophageal cancer. Occasionally, pre-malignant conditions (such as high-grade dysplasia in the context of Barrett’s oesophagus) or severe benign disease (such as oesophageal stricture) may also be treated with oesophagectomy. |
| 2.1.2 | Oesophagectomy by open surgery is the conventional treatment for patients with resectable cancer of the oesophagus. Depending on the type, location and extent of lesions, the procedure may involve total or partial resection of the oesophagus, with or without dissection of regional lymph nodes. The procedure is usually performed through two main incisions: one in the chest to mobilise the oesophagus and one in the abdomen to dissect and prepare the stomach (or sometimes intestine) for oesophageal reconstruction. The new oesophagus or gastric tube is then drawn up the chest and connected to the remaining healthy oesophagus, usually via an incision in the neck. |
| 2.1.3 |
Minimally invasive oesophagectomy techniques, using thoracoscopy and laparoscopy, have been introduced with the aim of reducing perioperative morbidity and improving quality of life compared with open surgery. |
| 2.2 | Outline of the procedure |
| 2.2.1 | Thoracoscopy-assisted oesophagectomy is a minimally invasive technique that is performed under general anaesthesia and single-lung ventilation. The procedure consists of a thoracic stage and an abdominal stage. |
| 2.2.2 | For the thoracic stage, the right lung is usually collapsed. Carbon dioxide is blown into the right pleural cavity to compress the lung. Four to six small incisions are made, usually on the right side of the chest, to create thoracoscopic ports (holes) through which a camera (connected to a video and monitor) and all necessary instruments are inserted in order to perform the thoracic phase of the operation. This kind of technique is also known as video-assisted thoracoscopic surgery (VATS). |
| 2.2.3 |
The abdominal phase of the operation usually involves dissection of the stomach to construct the new oesophagus and can be performed either laparoscopically or with an open technique. This is followed by a cervical anastomosis, or sometimes by an intrathoracic endoscopic anastomosis. |
| 2.3 | Efficacy |
| 2.3.1 |
There was heterogeneity between the studies in terms of clinical indications, tumour type, anatomic location and staging, use of adjunctive treatments (such as chemotherapy or radiotherapy), oesophagectomy techniques and experience of surgeons. |
| 2.3.2 | In a retrospective comparative study of 149 patients (77 VATS, 72 open surgery), estimated survival rates were similar for the two groups at 3 years (VATS 70%, open surgery 60%) and 5 years (VATS 55%, open surgery 57%). In a case series of 75 patients, which included the patients in the comparative study, the estimated 5-year survival of 37 patients with no nodal involvement was 80%, whereas 5-year survival for the entire series, including patients with nodal involvement, was 57%. |
| 2.3.3 | In another case series, 2-year survival in 38 patients with oesophageal cancer who underwent minimally invasive oesophagectomy was 100% in patients with stage 0 or stage I disease, 58% in patients with stage II disease, 48% in patients with stage III disease and 0% in patients with stage IV disease. |
| 2.3.4 | In a case series of 222 patients who underwent minimally invasive oesophagectomy, quality of life after the operation, as assessed by the short-form-36 questionnaire, was similar to pre-operative values and to the general population norm. |
| 2.3.5 | In a study of 77 patients who underwent VATS and 72 patients who underwent open surgery, the number of resected mediastinal lymph nodes (used as a surrogate marker for completeness of tumour excision) was similar for VATS (33.9 ± 12 nodes) and open surgery (32.8 ± 14 nodes). For more details, refer to the Sources of evidence (see appendix). |
| 2.3.6 |
The Specialist Advisors stated that the probability of complete resection of tumours may be lower with this procedure than with open surgery. Other uncertainties about the efficacy of the procedure include whether the extended operating time for the procedure is justified in terms of improved outcomes, and whether morbidity and mortality are reduced compared with open surgical approaches. |
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| 2.4 | Safety |
| 2.4.1 |
In three case series, conversion to open surgery (either by thoracotomy or laparotomy) was 2% (1/46), 7% (11/162) and 7% (16/222) of patients. It was noted that these figures were obtained from centres with extensive experience in oesophageal surgery. |
| 2.4.2 | In five case series, 30-day mortality varied from 0% (0/54) to 3% (5/151) of patients. In-hospital mortality was 0% (0/39) and 5% (8/151) in two case series. |
| 2.4.3 | In a retrospective comparative study, the reported incidence of complications was similar for VATS (38% of patients, 27/77) and open surgery (32% of patients, 25/72). However, pulmonary complications were less common with open surgery than with VATS (p = 0.047) and reduction in lung vital capacity 3–4 months after the procedure was significantly less with VATS (15%) than with open surgery (22%) (p = 0.016). |
| 2.4.4 | In the largest case series of 222 patients, reported complications included anastomotic leak (12%), pneumonia (8%), vocal cord palsy (4%), chylothorax (3%), gastric tip necrosis (3%), minor tracheal perforation (1%) and tracheal tear (1%). Other complications reported in the same case series were atrial fibrillation (12%), pleural effusion (6%), lung atelectasis (5%), myocardial infarction (2%), delayed gastric emptying (2%), acute respiratory disease (2%), wound infection (1%), pancreatitis (1%), deep vein thrombosis (1%), pulmonary embolism (1%), renal failure (1%), Clostridium difficile colitis and jejunostomy-tube infection (0.5%). For more details, refer to the Sources of evidence (see appendix). |
| 2.4.5 | The Specialist Advisors stated that the theoretical adverse events include major vascular injury and bleeding, major airway damage, damage to adjacent structures, thoracic duct injury/chyle leakage, recurrent laryngeal nerve damage and post-thoracoscopy pain. |
| 3 | Further information |
| 3.1 |
The Institute has published Interventional Procedures guidance on photodynamic therapy for high-grade dysplasia in Barrett's oesophagus (www.nice.org.uk/IPG082). The Institute has also published a clinical guideline on managing dyspepsia in adults in primary care ( www.nice.org.uk/CG017). |
Bruce Campbell
Chairman, Interventional Procedures Advisory Committee
May 2006
| Appendix: | Sources of evidence |
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The following document, which summarises the evidence, was considered by the Interventional Procedures Advisory Committee when making its provisional recommendations.
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This page was last updated: 07 October 2011