P1.243. Bi-Cavity Esophagectomy With Supra-Aortic Reconstruction (BEAR): A Novel Approach to Esophagectomy

Abstract

Abstract Topic Esophageal Cancer: Surgical Treatment of Esophageal Cancer – technique Background Due to its reduced incisional burden minimally-invasive Ivor Lewis esophagectomy (MIE) is an emerging standard of care, though it remains a long operation with high morbidity. Left thoraco-abdominal esophagectomy can achieve comparable oncological radicality and improve perioperative outcomes, yet its adoption has been limited by the lack of a minimally-invasive radical approach. Methods We introduce Bi-cavity Esophagectomy with supra-Aortic Reconstruction (BEAR): an innovative approach to esophagectomy. BEAR is a fully minimally-invasive esophagectomy, combining laparoscopy and left thoracoscopy performed entirely with the patient in a left-lateral position. A two-field lymphadenectomy is performed, and the anastomosis placed above the aortic arch. The technique capitalises on the benefits of both left thoraco-abdominal esophagectomy and minimally-invasive surgery and provides an efficient, single-phase approach, without compromising on oncological radicality. Using the IDEAL framework, the BEAR technique was developed in the pre-clinical stage (IDEAL stage 0) with consensus expert thoracic surgeon development of surgical protocol, following institutional ethics approval. Subsequently cadaveric simulation with video review was performed, to assess feasibility and refine surgical steps. Patient selection and conversion rules were defined prior to the idea stage (IDEAL stage 1): first-in-man BEAR. Indications were distal third and junctional adeno- or squamous-carcinoma without right para-tracheal lymphadenopathy or distant metastases. Results A 61-year-old male smoker with stage two distal esophageal adenocarcinoma following neoadjuvant FLOT chemotherapy underwent BEAR. Surgery was completed using a minimally-invasive portal technique permitting insufflation in both cavities. Four ports were utilized (2x12mm and 2x5mm) with a Nathanson liver retractor for the abdomen, and 5 ports were utilized for the chest (2x12mm, 2x5mm, and a 2 cm axillary extraction site). Post-operatively, the patient developed pneumonia requiring antibiotics (Clavien-Dindo II). He was discharged home on day six tolerating a post-esophagectomy diet. Pathology was ypT3N1 (1/38 lymph nodes positive) moderately differentiated adenocarcinoma with negative surgical margins. The IDEAL stage 2A study is currently underway, with data collected prospectively to establish BEAR safety, efficacy, and technique optimisation. Reporting late 2026, these data will inform surgical protocol standardisation with development of a structured training and quality assurance programme as stage 2B multicentre cohort and stage 3 trial are undertaken, comparing BEAR with MIE. Conclusion BEAR provides numerous potential benefits over MIE. Panoramic bi-cavity access throughout the procedure offers unparalleled efficiency: flexibility in conduit selection, early resectability assessment within the abdomen and chest, real-time bi-cavity review of conduit orientation and perfusion, and reduced operative time. Siting the anastomosis away from the airway, and hiatal closure following conduit delivery, mitigate airway fistula and para-conduit hernia risk, respectively. BEAR has the potential to improve efficiency and operative outcomes for esophagectomy.