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By Jonathan Salo, MD

Esophagectomies are complex, with high rates of postoperative complications. Our team at Atrium Health Levine Cancer Institute (LCI) is changing that, with innovations that are transforming how esophagectomies are performed and significantly improving outcomes.

Our push to transform care started in 2007, when our esophagectomy operative mortality was 9%, our leak rate was 20% and we were considered a low-volume institution, treating less than 13 patients per year. Since then, our multidisciplinary team revamped the esophagectomy procedure, and established a new model to evaluate high-risk surgical patients and personalize treatment plans.

Today, our operative mortality and leak rate are down to less than 4% and we’re a high-volume center for esophagectomy, treating about 40 patients per year.

Identifying Opportunities for Innovation

We began revamping the esophagectomy procedure by launching a cross-disciplinary partnership led by myself as a GI surgeon, and a thoracic surgeon. We believed we could improve outcomes by applying techniques and technology to thoracic surgery that had been successfully used in general surgery and other surgical disciplines.

Together, our teams analyzed esophagectomy outcome metrics and collaborated with colleagues to identify opportunities for innovation. Following this investigation, we narrowed our focus to key advances that would allow us to:

1. Create a better, well-vascularized neo-esophagus and reduce leak rate
2. Upgrade thoracoscopy to improve surgical and postoperative outcomes
3. Enhance treatment planning for high-risk surgical patients

Creating a Better Neo-Esophagus

In GI surgery, blood supply is a critical consideration for anastomotic healing. With that in mind, we thought that if we could evaluate the blood supply in the stomach, we could create a better neo-esophagus.

That’s when we collaborated with our plastic surgery colleagues. For them, evaluating blood supply leads to improved outcomes for breast reconstruction using autogenous material. We learned that the plastic surgery team was using fluoroscopic angiography with indocyanine green to map blood vessels in the area they’re operating on. They use that information to construct well-vascularized flaps and improve outcomes.

We applied similar blood vessel mapping to 30 esophagectomy cases. Our rate of anastomotic leak dropped immediately. This enabled us to learn how to make a better, well-vascularized neo-esophagus that improves anastomotic healing and reduces leak rate.

Today, we use that knowledge in every esophagectomy. But instead of using fluoroscopic angiography, we’re now able to use a Doppler probe with the same outcome results.

Upgrading Thoracoscopy with Abdominal Laparoscopic Techniques

For the second innovation, we saw an opportunity to leverage technology we had successfully used for years in GI surgery to develop a new esophagectomy approach.

In GI laparoscopic surgery, we expand the abdomen with carbon dioxide in a closed system. We saw an opportunity to apply this to esophagectomies. But instead of using carbon dioxide to expand, we use it to compress and protect the operative lung and the diaphragm during the procedure.

Adopting these abdominal laparoscopic techniques has improved surgical outcomes, including operative mortality, and reduced common postoperative pulmonary complications, such as pneumonia.

Enhancing Treatment Planning for High-Risk Surgical Patients

We also innovated beyond the procedure. In 2014, we began researching muscle mass and grip strength as predictors of esophagectomy outcomes to define high-risk surgical patients and personalize treatment plans to include therapies other than surgery, when appropriate.

Initially, our staff dietitian used a dynamometer to measure grip strength as a part of a thorough nutritional assessment. Later, our study expanded to also estimate muscle mass in the abdominal wall using a CT scan.

Over time, our data has shown that muscle mass and strength are strong predictors of esophagectomy patient outcomes. We’re now able to categorize patient risk into quartiles. For patients who have muscle mass and strength measurements in the bottom quartile, we will occasionally postpone surgery to allow time for “prehabilitation” prior to surgery to work to rebuild muscle mass. This enables some patients to get strong enough to have a better chance at a good surgical outcome. In other cases, we will treat patients with chemotherapy and radiation therapy and forgo surgery in patients who appear to be high risk.

This research, which we recently submitted for publication, allows us to effectively design a personalized treatment plan with the right combination of chemotherapy, radiation therapy and/or surgery to improve cancer outcomes and preserve quality of life.

Raising the Bar on Esophageal Cancer Care

Today, with a 3% esophagectomy leak rate and 3.5% operative mortality, we’re a national leader in esophageal cancer patient outcomes, as reflected in data reported to the Society of Thoracic Surgeons.

These innovations were possible because of extensive multidisciplinary collaboration and a commitment to constantly evaluating our data. And we will continue to innovate, conduct research and publish our findings. This will help us not only improve patients’ lives here in the Southeast, but also change the standard of care for esophageal cancer nationwide.

To learn more about our esophageal cancer program at Atrium Health Levine Cancer Institute or refer a patient, call 980-442-6410.

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