Ectomy decisions

[Guest guest]

Hello Group,

I would like to update you on my visits with Dr. Patti and Dr. Luketich.

I saw Dr. Patti in late June. I arrived early in the morning to have a

barium swallow. I found it interesting that each institution performs this

test slightly differently. The first U of Chicago radiologist I saw was not

even familiar with the term timed barium swallow (used by Cleveland Clinic).

This was not a timed swallow. The second radiologist (the one who performed

the study) was great. I was side-lying, prone, supine and at every angle

they could get me in. His comment was, " Wow, that barium is just not getting

down there is it? " That pretty much sums it up. My E looked like a little

fetus (sorry for the vivid description).

After the swallow, I went up to see Dr. Patti and his assistant Loretta.

They saw me right on time. Dr. Patti has a sweet, yet powerful presence. His

words were the same as Dr. Rice's - you need an ectomy. Now here is where it

gets quite interesting. Dr. Patti was adamant about doing the surgery open

and using a transthoracic (TTE) approach - remember Dr. Rice was just as

adamant about using a transhiatal (THE) approach and doing it open. Dr.

Patti emphatically stated that he would not use a THE for three main

reasons:

1. There was no way to visualize all the esophageal blood vessels, i.e. THE

is " blind " and the risk of bleeding was too great. He said that in an

enlarged E the blood vessels going to and from the E are the size of your

pinkie (normal would be the size of a pen tip). He said that in THE you

could not see all the vessels when removing the E.

2. There would be too much pulling on the cervical (neck) anastomosis site

with a THE and the risk of leak was too great.

3. There is too great a chance of injury to the recurrent laryngeal nerves -

vocal cord nerves - (http://www.ghorayeb.com/RecurrentLaryngealNerve.html)

Dr. Patti's recovery period was significantly different from Dr. Rice's

(10-14 days hospital, 6-8 weeks feeding tube). Dr. Patti said a 7-9 day

hospital stay was typical. A feeding tube would be used during the

hospitalization and then small amounts of clear then " full " fluids would be

introduced. If tolerated, a " mush " would be initiated within a few days of

fluid being tolerated. He said it would be better if I stayed in Chicago for

10 days post hospital release because that is when most complications occur.

All going well, I would then return to land. Several weeks later I would

be re-examined and then follow-up annually with a visit and quarterly with

emails directly to Dr. Patti (who is wonderful with email).

While in Chicago I came across this great video by Dr. Orringer (Michigan):

http://surgery.med.umich.edu/thoracic/clinical/what_we_do/esophagectomy_faq.shtm\

l.

I corresponded with him by email (great with email too!) and he uses THE and

claims to have the most experience doing THE laparoscopically. He had just

operated on a man with a 12 cm E and he said the surgery went well. Here is

an interesting page about THE: http://www.ctsnet.org/doc/106 (See #4, #5)

Now comes by visit with Dr. Luketich from which we just returned. I did not

have to do any additional studies for Dr. L as I sent him the results of all

prior studies (Clev Clinic, U Chicago and all prior studies). We waited a

while to see him and he was accompanied by his assistant, . Dr. L

stated that he would do the surgery TTE laparoscopically. He said he has

done 1000 open TTE and 1000 laparoscopic TTE and was adamant about being

able to see the vessels when removing the E. He would make the anastomosis

a little higher than Dr. Patti, but not as high as Dr. Rice. He also said

that the risk of recurrent laryngeal nerve damage was much less with TTE.

Additionally, he said, " why should I pull up the stomach and recreated a

large boggy tube when that is what you have now " . He would leave only a

small amount of E below the cricopharyngeus muscle so the E does not dilate

again after surgery. He would basically tubularize the stomach and perform a

pyloroplasty to prevent gastroparesis. Other complications he mentioned were

" stomach death " since the blood supply to the stomach after surgery is only

from 2 vessels (normally 5) and damage to the thoracic duct (chylothorax -

damage to the lymphatic drainage - chyle (lymphatic fluid and free fatty

acids). He also said that he wanted the patient to receive as many nutrients

and calories as possible to help with healing (I certainly liked to hear

that!). He said at the anastomosis site he leaves a drain in case of

infection.

His recovery process was:

1. ICU overnight after surgery

2. 5-7 days hospital

3. Day 3 post-surgery - barium swallow. If everything is normal, start 1 oz

of clear fluids per hour. (As for this issue of swallowing post-surgically -

I asked him about Dr. Rice and the 8 weeks of feeding tube. He said, " you

swallow 250cc - 500cc of saliva per day. Also, you want the swallowing

mechanism to start working as quickly as possible without overstressing it.

That is why there is a strict protocol. " He also said he knew Dr. Rice well

and does not understand why he would do the ectomy THE. *WOW - what is a

patient to make of this!*)

4. Day 4 - full fluids (i.e. protein type drink) @ 1 oz per hour. Continue

this adding a few ounces per hour for two weeks. The feeding tube would be

left in and used if more intake was needed.

5. He prefers out of towners to stay in Pittsburgh for 10 days post surgery

for the same reasons as Dr. Patti.

6. Two weeks post surgery is another follow up barium swallow.

7. Email follow-ups after this and an annual visit.

Dr. L seemed to just " get-it " - meaning everything - his experience, the

surgical method (TTE), risks, complications, recovery (he is certainly the

only one who understands fittness. A bummer for me is that he said my

powerlifting days would be over. He felt there would be too much stress on

the phrenoesophageal ligament - he is not worried about the anastomosis site

after full recovery interestingly - with potential for hiatal hernia with an

all out one time maximal lifting attempt. The silver lining is that I could

still lift vigorously AFTER a full recovery.) The fact that he pinpointed

the phrenoesophageal ligament as the risky area was impressive.

After visiting all these top docs, Dr. L is my choice. All the docs agreed

that in my case I am at risk for aspiration pneumonia if I wait too long and

all thought I was probably aspirating microscopically already. I have

noticed that my ability to train is just not what it once was - I still

workout hard but just don't recover as quickly - for those of you who know

what I mean. I was chalking it up to turning 50 (4 weeks away) and this

makes me hopeful that post surgery I can feel a little more giddyup in my

step. All agreed that with a full recovery (12 -18 months), this should be

the case.

Any comments and suggestions are most welcome as you are all a great source

of information and support. I have not scheduled the surgery as of yet, but

am thinking about doing it in the fall.

Thanks!

Steve (land)

P.S.- to make matters more confusing - here are some studies comparing THE

with TTE:

http://www.ncbi.nlm.nih.gov/pubmed/12771885

http://ats.ctsnetjournals.org/cgi/content/abstract/85/2/424

http://www.journalacs.org/article/S1072-7515(07)01161-1/abstract