Ivor Lewis Esophagectomy: Experience at Jinnah Hospital, Lahore

Abstract

Although different approaches have been used for surgical resection of esophageal cancer, the Ivor Lewis approach is the standard technique at most centers for resection of the diseased middle and lower third esophagus. This procedure has historically been associated with significant morbidity and mortality. However, modern literature suggests that Ivor Lewis esophagectomy can be performed with an acceptable complication rate and mortality. Patients and methods: We conducted a case series of thirteen consecutive patients who underwent an Ivor Lewis esophagectomy at Jinnah Hospital Lahore from January, 2001 to December, 2002. The objective was to examine the morbidity, mortality and short-term outcome of this surgical procedure. Results: The mean age of the patients was 45.9 years +/- 18.3 years (median: 44.5 years; range: 22 to 78 years). 7 patients were men and 6 patients were women. 6 patients (46.2%) were operated for benign corrosive esophageal strictures whereas seven patients (63.8%) had esophageal cancer. The median age of the patients with benign strictures was 28 years (range: 20 - 35 years). The median age of the cancer patients was 58 years (range: 54-70 years). Of these patients, one had Stage I cancer (9.29%), two had Stage II a (28.57%), two had Stage II b (28.57%), and two had Stage III disease (28.57%). Five patients (71.42%) had adenocarcinoma and two (28.57%) had squamous cell carcinoma. Seven patients (53.8%) had one or more co-morbid conditions, including diabetes, hypertension, cardiovascular disease and chronic obstructive pulmonary disease. Four patients (30.77%) had history of smoking. The mean operative time was 270 minutes +/- 31 minutes. The mean operative blood loss was 1500 ml +/- 102 ml. The median ICU stay was one day (range: I to 7 days). The median hospital stay was 19 days (range: 15 to 38 days). Eight patients (61.54%) developed post-operative complications. Most of these complications were medical (60%) rather than surgical (40%). Respiratory complications were the commonest (30.77%). Of the surgical complications, the most common was the development of an anastomotic leak (23.08%). All of these were managed conservatively and none proved fatal. There were two mortalities on post operative days 7 and 8, due to ARDS and multi-organ failure respectively. The operative mortality was 15.39%.Conclusion: Ivor Lewis esophagectomy represents a major physiological and surgical insult. However, careful patient selection, perioperative monitoring and early aggressive treatment of complications can significantly reduce morbidity and mortality.