Wayne Hofstetter, MD
- Surgery - Thoracic
Wayne L. Hofstetter, M.D., is currently Associate Professor in the Department of Thoracic and Cardiovascular Surgery and serves as Director of the Esophageal Surgery Program at The University of Texas MD Anderson Cancer Center.
A graduate of the University of Southern California Medical School, Dr. Hofstetter focused on thoracic surgical disease, completing fellowships in esophageal and foregut surgeries at the University of Southern California, and then thoracic oncology at M. D. Anderson Cancer Center. Broadly trained as a cardiothoracic surgeon and thoracic oncologist at the Texas Heart Institute, he now devotes a great deal of his work to esophageal cancer and lung cancer. At M. D. Anderson, he formed a strong network of clinicians with specific interests in esophageal diseases. A multidisciplinary group emerged under his able leadership, and together, physicians from other specialties like Gastrointestinal Medical Oncology, Radiation Oncology, and Gastroenterology collaborate closely to treat esophageal cancer patients.
Dr. Hofstetter is a leading proponent of surgical and multidisciplinary approaches to esophageal cancer and minimally invasive approaches to lung cancer, bringing to the institution his unique clinical skills in MIS approaches to thoracic surgery.
Board certified both by the American Board of Surgery and the American Board of Thoracic Surgery, Dr. Hofstetter is nationally and internationally involved in a host of clinical and scientific endeavors with membership in several organizations, including the American Society of Clinical Oncology, the Society of Thoracic Surgeons, and the International Association for the Study of Lung Cancer. His research, which forms a vital part of his academic role, has led to numerous peer-reviewed publications, notably in such journals as the Journal of Thoracic and Cardiovascular Surgery, Annals of Surgery, and Cancer.
Surgery - Thoracic
University of Southern California Medical School
LAC+USC Medical Center/USC University Hospital
University of Southern California (LAC+USC) Medical Center
USC University Hospital; Texas Heart Institute; The University of Texas MD Anderson Cancer Center
MD Anderson Cancer Center
1515 Holcombe Blvd., Unit 445
Practice phone number:
When the esophagus is removed it must be replaced by a functional replacement. Most often this is the stomach, but occasionally the small bowel or even the large bowel can be used. The reconstruction requires a splice (anastomosis) between the esophageal remnant and the replacement organ. The most significant complications of the procedure are leak or rarely, complete loss of the tissue used to reconstruct the esophagus. Fortunately, at experienced centers these are relatively rare events (5-10% and <1% respectively). This is a major surgical procedure, so consideration of potential tolerance to the procedure should be discussed extensively with your surgeon. Risk of loss of life within 90 days of the operation should be low (<10%). These rates can vary, so a conversation with your surgeon about an individual hospital and surgeon’s personal experience is critical.
There are several surgical techniques that have been developed to remove the esophagus and surrounding lymph nodes. An experienced esophageal surgeon will be facile in many different approaches. Often the choice of incisions is influenced by the location of the tumor within the esophagus and surgeon preference. Tumors that are in the lower esophagus or gastroesophageal junction (GEJ) are often approached through the abdomen and chest or abdomen and neck (two-field or transhiatal approach). Tumors in the mid to upper esophagus may require dissection in three cavities, abdomen, chest, and neck (three-field or McKoewn approach). The most important consideration is the appropriate removal of the tumor with an adequate number of lymph nodes, generally between 20-30.
Margins are determined by the location of the tumor and the ability to resect the surrounding structures. Ultimately we strive for negative margins, indicating that all of the margins; proximal, distal and radial (above, below and around) are clear of tumor. These are reported by our pathologists either at the time of surgery if requested by the surgeon or on the pathology report generated after the removed tissue has been prepared and evaluated. Several centimeters of negative margin above and below the tumor is considered optimal but is not always possible depending on location of the tumor. If tumor is very close to a vital structure the luxury of several cm of margin may not be possible. Overall, it is critically important to make every effort to clear the margins, as subsequent non-surgical therapy is very often unsuccessful compensation for a negative margin.
Minimally invasive esophagectomy (MIE) is an alternative to standard incision approaches in any situation where surgery is being recommended. There are advantages in the level of post-operative discomfort, decreased hospital stays and potentially faster recovery to regular activity. It is extremely important, however, to assess the experience and comfort level of the surgeon who is going to perform the operation. The main purpose of an esophageal cancer operation is to effectively remove the tumor and surrounding lymph node bearing tissue. If limitations of surgical technique result in a compromised resection then risk of recurrence could be increased. Further, the other primary endpoint of surgery is to avoid post-operative events that can complicate recovery. There is a steep learning curve to MIE with potentially serious ramifications to post-operative complications. If your surgeon is comfortable with the techniques and experienced enough to have complication rates that are equivalent to highly experienced surgeons performing open techniques at centers of excellence then it is reasonable to consider the minimally invasive technique.
Other than the tests outlined in this question:http://www.talkabouthealth.com/if-esophageal-cancer-is-suspected-what-are-the-next-steps
, your surgeon will want to know that you are healthy enough to withstand a surgical resection and reconstruction of the esophagus. Laboratory analyses of blood to measure solid organ function, lung function studies, EKG, and possibly a cardiac evaluation are typically recommended. Patients who use tobacco products need to discontinue them completely to minimize risks of therapy related untoward events.
Stage of disease, as determined by the diagnostic work-up determines the recommended course of therapy. In general, the higher the chance that there is spread of disease outside of the esophagus, the more likely that chemotherapy with or without radiation will be prescribed. Patients with stage II and III disease are now very commonly treated with concurrent chemoradiation followed by surgical resection. This is called neoadjuvant therapy. Alternatively, patients who present with early disease (Stage 0-1) can often be treated without chemotherapy or radiation if endoscopic or surgical therapy is successful. Finally, if a patient was suspected to have early disease but was discovered to harbor diseased lymph nodes at the time of surgery (a sign of potential future recurrence) chemotherapy with radiation is frequently considered after recovery from surgery.
Anyone who is diagnosed with esophageal cancer that has not spread to distant sites (other organs or lymph nodes outside of the tumor region) is a candidate, and should see a surgeon. A consult with a surgeon prior to beginning any therapy is an essential component of esophageal cancer care, even in a setting where multimodality therapy (chemotherapy and radiation) is being recommended. If, however, the diagnostic work-up indicates the presence of advanced disease (stage IV), surgical therapy is generally not beneficial. There are occasions where impending obstruction of the esophagus coupled with excessive weight loss prior to the diagnosis will prompt a consultation for surgical placement of a feeding tube.
The first step is to identify a center of excellence where esophageal disease is a specialty practice. Next is to undergo consultation with an esophageal specialist, this can be a clinician based in surgical or gastroenterology practice. A detailed history will guide a work-up; a series of tests that your doctor will recommend to you. Endoscopy is often the first study performed. This will allow your doctor to directly view the esophagus and to document, describe and biopsy any esophageal abnormalities. If a tumor is encountered, ultrasound performed at the time of the endoscopy will detail the depth of penetration of the tumor into the esophageal wall and the presence of any lymph nodes with potential spread of disease. These important characteristics of the tumor determine the recommended treatment for a newly diagnosed cancer. A CT scan of the chest and abdomen and PET scan are recommended for tumors that are of significant size or penetrating the wall of the esophagus. Both of these tests aid to establish the extent of the tumor spread, otherwise known as stage.