Thoracic Surgeon at the Northwestern Medicine Canning Thoracic Institute, Ankit Bharat, MD, talks about a new procedure that treats esophageal cancer.
Interview conducted by Ivanhoe Broadcast News in December 2023.
Tell us about esophageal cancer.
Bharat: Esophageal cancer is not the most common cancer in the United States, but it’s a very lethal cancer globally. In the U.S., it kills thousands of patients, and it’s a very aggressive and disabling cancer. A lot of times patients will get hospital cancer. They cannot eat, they lose a lot of weight and it’s a very uncomfortable cancer to get.
What are the symptoms?
Bharat: It’s interesting depending on which part of the world you live in, it has different manifestations. In Asia, it tends to be associated with spicy foods, and smoked foods, and it tends to be higher up in the food pipe. The esophagus is the food pipe, and it connects the back of your throat to the stomach, all the way from your neck to the stomach. It’s a long pipe that serves as the conduit to push the food down. In Southeast Asia, and Asia or Japan, it manifests in a completely different manner. It has a different histology, what we call a different type. But in the United States, it tends to be further down in the food pipe. It tends to be associated with acid reflux most commonly and because it’s further down in the food pipe it tends to frequently present an inability to eat food. The food gets stuck in your throat when you eat. It can cause pain in your chest. Frequently these patients also have had a longstanding history of heartburn. Then, once cancer develops, they tend to lose a lot of weight and lose appetite. Some patients can experience blood in the stool or dark-color stools, and that’s a result of bleeding from the cancer that goes into the stomach and gets mixed with the tool. Then patients have that discolored tool. Those are some of the broad symptoms that the patients may experience.
What is a patient’s life like realizing they’re having what you just described?
Bharat: This cancer tends to be a little bit more predominant in men than women. Not everybody experiences that though. Many patients have had a longstanding history of heartburn from the acid reflux. Then once these patients develop cancer, they’re not able to eat food. As a result of, the discomfort they experience in eating food, they try to eat less and then they start to lose weight. That’s probably one of the most common things that we encounter when patients come, they have been miserable for months with heartburn that then causes pain while eating or food getting stuck. Then they come to us for endoscopy and that’s when this is found out.
How has it commonly been treated?
Bharat: Typically, there are three arms or treatments for esophageal cancer. Surgery has always been the best treatment for early-stage cancers. Chemotherapy is the best thing we can do for the Stage four cancers. Then there is the in-between stages where we combine surgery, radiation, and chemo. Esophageal cancer is a very broad topic and sometimes we use different combinations of treatment for that. A patient who may not be able to withstand esophageal cancer surgery is a big deal. So sometimes we would treat those patients with a combination of chemotherapy and radiation. But to simplify, early-stage cancers in patients who otherwise can undergo surgery, they’re treated with surgery. Then in between stages, between stage two and stage three, we would combine chemotherapy, and radiation first, then do the surgery. That’s how we treat them in stage four is typically chemotherapy-guided.
Now, there’s premier, tells us about that.
Bharat: Esophageal cancer surgery, it’s quite a morbid procedure. Historically, it’s been done through big cuts in your belly and then a cut in your chest where you have to spread the ribs. Previously people would take out one or two ribs. You must cut all the chest wall muscles. Then the surgery is done, and the patients have many tubes in both chests, and they have a feeding tube. Most patients cannot eat for a couple of weeks. Historically, patients have spent three to four weeks in the hospital. It has worked, it has helped patients with cancer, but it has been a very morbid procedure. There have been efforts to reduce the invasiveness of the surgery, and people have developed certain minimally invasive techniques. But the minimally invasive techniques that have been used so far, are still quite invasive in the sense that they still require the conventional pathways. Patients have a lot of pain and they have feeding tubes because they cannot eat for weeks. It’s quite invasive, so we are excited to launch this program premier which has, in our view, dramatically reduced the invasiveness of this procedure. It’s transformative when it comes to esophageal surgery. A couple of important aspects of the premier are it’s completely minimally invasive. For the first time, this is a complete robotic approach. People have done robotic assisted, meaning they still make bigger incisions in the belly or in the chest. They just use the robot to do parts of the operation. Now what we’re saying is there are no big cuts at all. There is no cut in the belly, these are tiny little pores that we make the size of my fingertips, and we can deploy four or five pores in the belly and do the whole operation there. Then we make an incision in the left side of the neck and do the whole operation with that. That’s the first important thing. It’s a minimum invasive, no muscle cutting, no bone cutting, no rib cutting. The second aspect of it is we’ve developed a way of creating the attachments. When we take the food pipe out, we must replace it with something else. We use the stomach to make a tube out of the stomach to replace the food pipe, so we pull it behind the heart and then we connect it to the back of the throat. We developed a way of doing this connection back of the throat with the new stomach that allows us to feed the patient the very next day and not have any tubes. It’s so minimally invasive and the pain is so minimal that most patients can go home within two to three days, compared to two weeks with the conventional approach. If I were to summarize, it’s completely robotic or minimally invasive, and it has significantly lowered pain. It allows us to eliminate the need for two feeds or allows us to feed the patient the next day. Dramatically cut down the length of stay for the patients.
What’s the recovery for the patients?
Bharat: The recovery so far in all the patients that we’ve done has been quite transformative. These patients I said are home in two to three days, they’re eating and functional. Most patients require minimal to no pain medicines when they go home because we don’t put any chest tubes in them, that pain has gone. We’ve seen almost no problems with infections which has historically been a big problem with conventional approaches like pneumonias. We’ve had minimal to no leaks in the attachments that we’ve done. Because of all of these things being reduced and improved, the recovery is really fast. We see patients back to their baseline in three to four weeks.
Are they able to eat and swallow normally?
Bharat: The next day they’re able to eat. We start with a liquid diet, and on day 2, if they’re doing better, we put them on a soft diet. But by two to three weeks, they’re eating normally. The pattern of eating changes because now they don’t have stomachs, we’ve made the tube out of the stomach. Instead of eating large meals previously, now they must take smaller, more frequent meals which is healthier for you anyway.
I interviewed Rudy the other day. I got a video of him eating one of his meals. We were calling it a snack, and I was calling it a meal. But tell us about Rudy.
Bharat: He is one of our favorite patients, He was such a compliant patient. Very motivated and had great family support to get him through. We’re very proud to have helped him and how much of an ambassador he’s become for this. He’s a classic example of how well this technique works.
As far as his cancer, was it average, worse than average?
Bharat: I would say average. He had a very common presentation of this obital cancer, which was a little bit further down in the throat. He had all the standard features. Not the worst we’ve seen, but not the easiest we’ve seen also.
He’s learning to eat again. We talked to him about what he’s looking forward to and he’s obviously being compliant with you and the small meals and knowing that he has a certain amount of recovery. He’s looking forward to a steak. How long in his future do you think that is?
Bharat: We are very protective of Rudy so we are going a little bit slower, but I think he can eat steak now. We think that with this technique by about three to four weeks, patients can pretty much eat anything. Now what happens, is because we are rerouting everything in the body, the stomach is not there, and what used to be the esophagus, is now a two-bottled stomach so the body takes a little bit of adjusting. Patients must be a little bit thoughtful about what foods the body is happy with and what foods the body doesn’t like. We tell patients to keep a diary. There are certain foods some patients can become allergic to. In Rudy’s case, we haven’t observed anything. I think he’ll be able to eat anything if he chooses it well and eats small frequent meals. Steak should be no problem.
How in his future will he be able to eat normally again? Is it just a matter of taking time?
Bharat: Taking time. What happens to patients is stomach is a big sac. When we eat a lot of food, all of it goes into the stomach. That sac then collects all the food and is able to digest it by producing acid and so forth. Now when we do this esophagectomy, the food pipe or esophagus has been taken out because it has cancer. What we’re doing is taking the stomach, the big sac, and rolling it into a tube that now must be pulled up and functions as a replacement for this esophagus. Some patients get very uncomfortable if they eat a very large meal too quickly. It’s a matter of training it, and it’s not just with the premier, this happens with every conventional esophagectomy.
Is this going to be the way all esophageal cancer patients are going to be treated moving forward?
Bharat: I think we hope that once we teach other people and we show our techniques, it could be used much more commonly for patients who have early-stage cancers and even some more advanced-stage cancers. I don’t know if it can be applied because there are certain cancers, that are on different sides. They have anatomic considerations where this technique may not be feasible, or components of our technique can be applied to different scenarios. I think the overall principles of this could be applied to every scenario. Now for early-stage cancer, this has become pretty much universal because of how excellent the outcomes are. I think this would become quite well utilized. But there’ll certainly be certain types of esophageal cancers that have to use other techniques.
What is the most exciting thing about ER?
Bharat: To be able to get the patients to eat the next day. The happiness that they experience, is being able to eat the next day after having gone through a very difficult period of not being able to eat and having lost a lot of weight. Then most of these patients have had chemotherapy and radiation, to the smile they have and the happiness they experience in eating the very next day after such a major operation is perhaps the most exciting thing for us.
What do you want people in other areas to know about this medical story?
Bharat: They should ask their providers if this is an option and if their local providers can offer this to them. We are always happy to work with their local team. We’ll do our best to share our technique and our experiences with anybody who wants to adopt this. Ultimately, we want the patients, wherever they are, to get the best possible care.
Is there anything I missed?Bharat: If anybody wants to explore that and talk to us, they can go to our website. They can go to any web search and look up Premier and Northwestern or Savagal Surgery in Northwestern. They have all the contacts. We are happy to talk to them about this and we’re happy to work with their care teams if we could be of help in these patients getting this procedure when feasible.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
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Jenny Nowatzke Megan McCann
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