Thoracoscopic and laparoscopic esophagectomy for benign and malignant disease: lessons learned from 46 consecutive procedures

BACKGROUND: Transhiatal and transthoracic esophagectomy are common approaches for esophageal resection. The literature is limited regarding the combined thoracoscopic and laparoscopic approach to esophagectomy. The aim of this study was to evaluate the outcomes of combined thoracoscopic and laparoscopic esophagectomy for the treatment of benign and malignant esophageal disease. STUDY DESIGN: We performed a retrospective chart review of 46 consecutive minimally invasive esophagectomies performed between August 1998 and September 2002. Indications for esophagectomy were carcinoma (n = 38), Barrett's esophagus with high-grade dysplasia (n = 3), and recalcitrant stricture (n = 5). Of 38 patients with carcinoma 23 (61%) had neoadjuvant therapy. The main outcome measures were operative time, blood loss, length of intensive care unit and hospital stay, conversion rate, morbidity, mortality, pathology, disease recurrence, and survival. RESULTS: Approaches to esophagectomy were thoracoscopic and laparoscopic esophagectomy (n = 41), thoracoscopic and laparoscopic Ivor Lewis resection (n = 3), abdominal only laparoscopic esophagogastrectomy (n = 1), and hand-assisted laparoscopic transhiatal esophagectomy (n = 1). Minimally invasive esophagectomy was successfully completed in 45 (97.8%) of 46 patients. The mean operative time was 350 +/- 75 minutes and the mean blood loss was 279 +/- 184 mL. The median length of intensive care unit stay was 2 days and median length of stay was 8 days. Major complications occurred in 17.4% of patients and minor complications occurred in 10.8%. Late complications were seen in 26.1% of patients. The overall mortality was 4.3%. Among the 38 patients who underwent esophagectomy for cancer the 3-year survival was 57%. In a mean followup of 26 months there was no trocar site or neck wound recurrences. CONCLUSIONS: A thoracoscopic and laparoscopic approach to esophagectomy is technically feasible and safe for the treatment of benign and malignant esophageal disease. With a mean followup of 26 months thoracoscopic and laparoscopic esophagectomy appears to be an oncologically acceptable surgical approach for the treatment of esophageal cancer.     

Minimally invasive esophagectomy for caustic esophageal stricture in children

Esophageal stricture after lye ingestion in children is the most frequent indication for esophagectomy in children, but this operation entails significant risks for complications. With continuing advances in minimally invasive technology, complex procedures such as esophagectomy can be performed using small incisions, with the aim of reducing morbidity and mortality. Experience with minimally invasive esophagectomy is limited and has involved thoracoscopic dissection with the addition of laparotomy for gastric mobilization. The authors report a case of intractable caustic esophageal stricture in a child treated by a totally minimally invasive esophagectomy through a combined thoracoscopic and laparoscopic approach. In adult patients, this procedure has been associated with decreased hospital stay and more rapid return to normal activities, and we believe similar benefits will be obtained in children. Until further studies are done to show the advantage over the standard open technique, this procedure should be performed only in centers with experience in open esophageal surgery in children as well as by surgeons with advanced thoracoscopic and laparoscopic skills.     

Experience with minimally invasive esophagectomy

Background Minimally invasive esophagectomy (MIE) is an evolving surgical alternative to traditional open esophagectomy. Despite considerable technical challenges, it was hypothesized that MIE could be performed effectively by surgeons experienced in open esophageal resection and advanced laparoscopic surgery. The authors report their experience with 25 patients who underwent MIE for esophageal disease. Methods A multidisciplinary esophageal cancer team evaluated all the patients enrolled in this institutional review board–approved retrospective review study. Over an 18-month period, 25 consecutive patients (22 men and 3 women; mean age, 62 years; range, 48–77 years) with resectable esophageal cancer underwent MIE. Six patients were treated with neoadjuvant chemoradiotherapy. The preoperative diagnoses were adenocarcinoma (64%, n = 16), high-grade dysplasia (20%, n = 5), and squamous cell cancer (16%, n = 4). The outcomes evaluated included operative course, hospital and intensive care unit lengths of stay, pathologic stage, morbidity, and mortality. Results Two patients required conversion to open esophagectomy. Operative mortality was 4% (n = 1). The mean operative time was 350 min (range, 300–480), and the average blood loss was 200 ml. The patients remained ventilated for a median of 12 h, and the median intensive care unit utilization was 1 day. The median hospital length of stay was 9 days (range, 6–33 days). Major complications occurred in 32% of the patients. The anastomotic leak rate was 12%. Minor pulmonary complications occurred in 32% and atrial fibrillation in 16% of the patients. An anastomotic stricture developed in 24% of all the patients. One patient showed a positive proximal margin in the final pathology results. Conclusions Minimally invasive esophagectomy is a technically challenging procedure that can be performed safely at the Virginia Piper Cancer Institute. Optimal results require appropriate patient selection and a multidisciplinary team experienced in the management of esophageal cancer.     

Minimally Invasive Approach to Esophagectomy

Background:

Recent advances in laparoscopic and thoracoscopic surgery have made it possible to perform esophagectomy using minimally invasive techniques. The aim of this report was to present our preliminary experience with minimally invasive esophagectomy.

Methods:

We reviewed our experience on eight patients who underwent minimally invasive esophagectomy using either laparoscopic and/or thoracoscopic techniques from June 1996 to May 1997. Indications for esophagectomy included stage I carcinoma (5), palliative resection (1), Barrett''s with high grade dysplasia (1) and end stage achalasia (1).

Results:

The average age was 68 years (54-82). The surgical approach to esophagectomy included laparoscopic transhiatal esophagectomy with cervical anastomosis (n=4), thoracoscopic and laparoscopic esophagectomy with cervical anastomosis (n=1), and laparoscopic mobilization with right mini-thoracotomy and intra-thoracic anastomosis (n=3). Conversion to mini-laparotomy was required in two patients (25%) to complete esophageal dissection and facilitate gastric pull-up. The mean operative time was 460 minutes. The mean intensive care stay was 1.9 days (range of 0-7 days) with a mean hospital stay of 13-8 days. Minor complications included atrial fibrillation (n=1), pleural effusion (n=2) and persistent air leak (n=1). Major complications included cervical anastomotic leak (n=1), and delayed gastric emptying requiring pyloroplasty (n=1). There was no perioperative mortality.

Conclusions:

This preliminary experience suggests that minimally invasive esophagectomy is safe and feasible in centers with experience in advanced minimally invasive surgical procedures. Further studies are necessary to determine advantages over open esophagectomy.     

Thoracoscopic and laparoscopic esophagectomy: initial experience and outcomes

Background: Although surgical resection currently is the preferred treatment for fit patients with resectable esophageal cancers, it is associated with a relatively high risk of morbidity and significant perioperative mortality. Currently, a range of open surgical approaches are used. More recently, minimally invasive approaches have become feasible, with the potential to reduce perioperative morbidity. This study investigated the outcomes from one such approach. Methods: Outcome data were collected prospectively for 36 consecutive patients who underwent a minimally invasive esophagectomy for esophageal cancer. A three-stage approach was used, with all the patients undergoing a thoracoscopic esophageal mobilization, combined with either open or hand-assisted laparoscopic abdominal gastric mobilization, and open cervical anastomosis. An open abdominal approach was used for 15 of the patients and a hand-assisted laparoscopic approach for 21. A total of 34 patients had invasive malignancy, whereas 2 had preinvasive disease. A group of 23 patients (68%) who had invasive malignancies also received neoadjuvant chemotherapy and radiotherapy. Results: The mean operating time ranged from 190 to 360 min (mean, 263 min). The median postoperative hospital stay was 16 days. In-hospital mortality was 5.5% (2/36), and perioperative morbidity was 41%. The perioperative outcomes for patients undergoing an open abdominal approach and those who had hand-assisted laparoscopic surgery were similar. For the patients who underwent a hand-assisted laparoscopic abdominal procedure, the total operating time was shorter (248 vs 281 min), and the blood loss was less (223 vs 440 ml). The median follow-up period was 30 months. The 4-year survival predicted by Kaplan–Meir for the 34 patients with invasive malignancy was 44%. Conclusion: The outcome for esophagectomy using thoracoscopic esophageal mobilization, with or without hand-assisted laparoscopic abdominal surgery, was comparable with data from conventional open surgical approaches. These approaches can be performed with an acceptable level of perioperative morbidity. Further application of these techniques, with close scrutiny of outcome data, is appropriate.     

Minimally invasive esophagectomy

BACKGROUND: Open esophagectomy can be associated with significant morbidity and delay return to routine activities. Minimally invasive surgery may lower the morbidity of esophagectomy but only a few small series have been published. METHODS: From August 1996 to September 1999, 77 patients underwent minimally invasive esophagectomy. Initially, esophagectomy was approached totally laparoscopically or with mini-thoracotomy; thoracoscopy subsequently replaced thoracotomy. RESULTS: Indications included esophageal carcinoma (n = 54), Barrett's high-grade dysplasia or carcinoma in situ (n = 17), and benign miscellaneous (n = 6). There were 50 men and 27 women with an average age of 66 years (range 30 to 94 years). Median operative time was 7.5 hours (4.5 hours with > 20 case experience). Median intensive care unit stay was 1 day (range 0 to 60 days); median length of stay was 7 days (range 4 to 73 days) with no operative or hospital mortalities. There were four nonemergent conversions to open esophagectomy; major and minor complication rates were 27% and 55%, respectively. CONCLUSIONS: Minimally invasive esophagectomy is technically feasible and safe in our center, which has extensive minimally invasive and open esophageal experience. Open surgery should remain the standard until future studies conclusively demonstrate advantages of minimally invasive approaches.     

Open versus minimally invasive esophagectomy: a single-center case controlled study

Background  

Recent advances in laparoscopic and thoracoscopic surgery have made it possible to perform esophagectomy using minimally invasive techniques. Although technically complex, recent case studies showed that minimally invasive approaches to esophagectomy are feasible and have the potential to improve mortality, hospital stay, and functional outcome.     

Simplifying minimally invasive transhiatal esophagectomy with the inversion approach: Lessons learned from the first 20 cases

HYPOTHESIS: The laparoscopic transhiatal esophagectomy can be simplified and performed safely and effectively by using a novel esophageal inversion technique. DESIGN: Case series describing technique, initial experience, and learning curve with laparoscopic inversion esophagectomy. SETTING: Tertiary care university hospital and veteran's hospital. PATIENTS: Twenty consecutive patients with high-grade dysplasia (n = 16) and esophageal adenocarcinoma (n = 4). INTERVENTION: Laparoscopic inversion esophagectomy, a totally laparoscopic approach to transhiatal esophagectomy that incorporates distal to proximal inversion to improve mediastinal exposure and ease of dissection. MAIN OUTCOME MEASURES: Perioperative end points and complications, compared between the first and second groups of 10 patients. RESULTS: There were 19 men and 1 woman. Median operative time was 448 minutes. Median blood loss was 175 cm3. Median intensive care unit stay was 4 days, and median total hospital stay was 9 days. Overall anastomotic leak rate was 20%. Five patients developed an anastomotic stricture, all successfully managed with endoscopic dilation. There were 2 recurrent laryngeal nerve injuries, which resolved. There was no intraoperative or 30-day mortality. Between the first 10 consecutive cases and last 10 procedures, the incidence of anastomotic leak and stricture formation decreased from 30% to 10% and 40% to 10%, respectively. During this period, the number of lymph nodes harvested increased 9-fold, and duration of intensive care unit stay decreased from 8.00 to 2.50 days. CONCLUSIONS: Laparoscopic inversion esophagectomy is a safe procedure. The learning curve for the inversion approach is approximately 10 operations in the hands of esophageal surgeons with advanced laparoscopic expertise.     

Minimally invasive esophagectomy: the evolution and technique of minimally invasive surgery for esophageal cancer

Beginning with the widespread introduction of laparoscopic cholecystectomy in late 1989, minimally invasive surgical technique has been refined in conjunction with the development of advanced instrumentation and have subsequently been applied to increasingly complicated disease processes. Esophageal surgeons have increasingly incorporated minimally invasive surgery into their practice since the first laparoscopic fundoplication was described by Dallemagne et al. in 1991. Esophagectomy is associated with significant morbidity and mortality even in highly experienced centers. Many esophageal surgeons have had a great deal of interest in minimally invasive esophagectomy (MIE), which has the potential advantages of being a less traumatic procedure with a resultant improvement in postoperative convalescence and fewer wound and cardiopulmonary complications compared to the open approaches. Throughout the 1990s, as confidence with laparoscopic surgery of the esophagogastric junction grew, MIE was initially attempted with hybrid operations combining traditional open surgery with minimally invasive approaches. Subsequently, a totally laparoscopic transhiatal approach was described; however, this approach was perceived to be very challenging and has not gained widespread acceptance. Approaches used at present depend on cancer stage, cancer location, body habitus, and pulmonary function. For localized cancer (T1N0) or HGD, we prefer laparoscopic inversion esophagectomy (retrograde or antigrade). This approach may also be used for patients at high risk for thoracotomy. For locally advanced cancer in the middle third of the esophagus or for proximal third esophageal cancer, we prefer 3-field MIE (abdomen, and chest with neck anastomosis). For locally advanced cancer in the distal esophagus, especially in patients with a short thick neck, we prefer thoracoscopic-laparoscopic (2-field) esophagectomy (TLE).     

腹腔镜辅助食管癌根治术的临床体会

目的:探讨腹腔镜辅助食管癌根治术的安全性及可行性.方法:回顾分析159例食管癌患者行腹腔镜辅助食管癌根治术的临床资料.结果:159例手术均获成功,无中转开腹及围手术期死亡病例.手术时间131～420 min,平均(236.67±47.66) min,术后肛门排气时间及住院时间分别为(3.08±1.02)d和(23.49...     

Minimally invasive transhiatal and transthoracic esophagectomy

Background Standard esophagectomy requires either a laparotomy with transhiatal removal of the esophagus or a combination of laparotomy and thoracotomy. Currently, it still is associated with a high rate of morbidity and mortality. Complications leading to greater morbidity and mortality are rarely seen after minimally invasive surgery. The authors present their experience with 25 minimally invasive esophageal resections. Methods Between August 1st, 2003 and November 30th, 2005, the authors performed 25 minimally invasive esophageal resections for 4 woman and 21 men. Data were acquired prospectively. Results In this series, a laparoscopic transhiatal approach was performed in 9 cases, a combined laparoscopic-thoracoscopic procedure in 12 cases, and laparoscopic creation of a gastric tube combined with thoracotomy in 4 cases. No conversion became necessary. The mean operation time was 165 min (range, 150–180 min) for the laparoscopic transhiatal approach and 300 min (range, 240–360 min) for both combination approaches. Using the combined laparoscopic-thoracoscopic procedure, 23 lymph nodes (range, 19–26 lymph nodes) were removed, and using the laparoscopic transhiatal approach, 14 lymph nodes (range, 12–17 lymph nodes) were removed. The median stay in the intensive care unit was 1.5 days (range, 1–22 days), and the overall postoperative stay was 10 days (range, 7–153 days). Two intraoperative complications and two cervical anastomotic leakages were observed. The 30-day mortality rate was 0%. Conclusion The findings demonstrate that laparoscopic transhiatal and combined laparoscopic/thoracoscopic esophagectomy are feasible and can be performed with low rates of morbidity and mortality. Due to an equal extent of lymph node dissection, there should be no difference in long-term survival between minimally invasive surgery and open surgery.     

微创McKeown食管切除术治疗食管下段癌的临床价值

目的探讨微创McKeown食管切除术治疗下段食管癌的临床价值。方法选取2013-01-2017-06间在郑州大学第一附属医院接受食管切除术的下段食管癌患者。将行微创McKeown手术的患者作为微创组,将行开放Sweet手术的患者作为开放组,倾向得分匹配(PSM)用于降低2组一般资料的统计学差异。比较2组患者的疗效。结果全部患者均顺利完成手术。2组患者的病死率、肺部并发症和吻合口漏发生率差异无统计学意义(P>0.05)。微创组淋巴结清扫数、平均住院费用和手术时间均多于开放组,差异均有统计学意义(P<0.05)。结论微创McKeown食管切除术治疗下段食管癌,较传统开放手术淋巴结清扫数多,但手术时间和治疗费用较多。     

Evidenzlage zur minimalinvasiven Chirurgie beim Ösophaguskarzinom

Surgery remains the mainstay of potentially curative treatment of esophageal cancer; however, esophageal resection is still associated with a relevant morbidity and mortality. Furthermore, patients frequently suffer from concomitant comorbidities and present in a reduced nutritional status. The rationale of minimally invasive surgery is the reduction of surgical trauma with subsequent minimization of (pulmonary) complications and mortality without compromising oncological quality. Minimally invasive esophageal resection was established nearly two decades ago and since then some centers worldwide have adopted this approach as the preferred option for surgical treatment of esophageal cancer. Minimally invasive esophageal resection can be safely performed and provides excellent results in experienced hands. Currently, there is only one randomized trial available comparing open and minimally invasive resection. It was demonstrated that the latter significantly reduced pulmonary complications with comparable mortality and oncological outcome. However, in the majority of studies these convincing results could not be confirmed. Reduced blood loss and a shortened hospital stay were shown to be the main advantages of the minimally invasive approach. Due to technical modifications, patient selection and a remarkable heterogeneity of current studies, a final conclusion on the value of minimally invasive esophagectomy is difficult to be drawn. Based on the current evidence, a noncritical use of minimally invasive resection for esophageal cancer cannot be recommended; however, in selected patients and with appropriate expertise this approach is at least comparable to open esophagectomy.     

Laparoscopic versus open gastroplasty in esophagectomy for esophageal cancer: a comparative study

How best to approach esophagectomy is a controversial issue. In the last decade, the opportunity to use minimally invasive surgical methods for esophagectomy has been documented, but their real advantages over conventional surgery have yet to be clearly established. The aim of this study was to compare a series of patients who underwent laparoscopic esophagectomy with those who underwent open surgery to ascertain the feasibility, safety, and clinical advantages of the former surgical techniques. Between January 2002 and May 2004, 14 patients with cancer of the esophagus underwent laparoscopic esophagectomy and another 14 had conventional open esophagectomy. Their demographic features, and intraoperative and postoperative data were compared. The 2 groups were comparable in terms of age, American Society of Anesthesiologists score, and site of the neoplasm. The operating times were the same for transhiatal laparoscopic esophagectomy and conventional surgery, although using the thoraco-laparoscopic access took longer than the thoraco-laparotomic procedure (P<0.05). The hospital stay was shorter after laparoscopy (P<0.05). No differences emerged in terms of morbidity, mortality, number of transfusions, and time in the intensive care. The numbers of lymph nodes removed were comparable. In conclusion, it is feasible and safe to use a laparoscopic approach instead of open surgery for esophagectomy, but the former does not offer very significant clinical advantages in the postoperative stage. A shorter hospital stay seems to be the most significant finding. The minimally invasive procedure would seem to assure oncological radicality because it enables lymphadenectomy to be as thorough as in the conventional surgical approach.     

Minimally invasive esophagectomy: thoracoscopic mobilization of the esophagus and mediastinal lymphadenectomy in prone position--experience of 130 patients

BACKGROUND: To evaluate outcomes after minimally invasive or thoracolaparoscopic esophagectomy (TLE) with thoracoscopic mobilization of the esophagus and mediastinal esophagectomy in prone position. Esophagectomies are being performed increasingly by a minimally invasive route with decreased morbidity and shorter hospital stay compared with conventional esophagectomy. Most series report thoracoscopic mobilization of the esophagus and mediastinal lymphadenectomy in the left lateral position with respiratory complications up to 8% and prolonged operative time, probably because of inadequate stance of the surgeon during the thoracoscopic part. This study shows the potential of the thoracoscopic part of the procedure in prone position to ease these difficulties. STUDY DESIGN: From January 1997 through April 2005, TLE was performed in 130 patients. All patients had histologically proved squamous cell carcinoma of the middle third of the esophagus. Only one (0.77%) patient received neoadjuvant chemotherapy. The thoracoscopic part of the procedure was performed in prone position with excellent ergonomics, translating into less operative time and better respiratory results. We performed a minilaparotomy to retrieve the specimen owing to bulky tumors. Feeding jejunostomy and pyloromyotomy were performed in all patients. RESULTS: There were 102 men and 28 women. Median age was 67.5 years (range 38 to 78 years). There was no conversion to open method. Median ICU stay was 1 day (range 1 to 32 days) and median hospital stay was 8 days (range 4 to 68 days). Perioperative mortality was 1.54% (n = 2). Anastomotic leak rate was 2.31% (n = 3). There was no incidence of tracheal or lung injury and a very low incidence of postoperative pneumonia. At mean followup of 20 months (range 2 to 70 months), stage-specific survival was similar to open and other minimally invasive series. CONCLUSIONS: TLE with thoracoscopic part in prone position is technically feasible, with a low incidence of respiratory complications and less operative time required. It provides comparable outcomes with other techniques of minimally invasive esophagectomy and most open series. In our experience, we observed a low mortality rate (1.54%), hospital stay of 8 days, and low incidence of postoperative pneumonia. It has the potential to replace conventional and other techniques of minimally invasive esophagectomy.     

Open transthoracic or transhiatal esophagectomy versus minimally invasive esophagectomy in terms of morbidity, mortality and survival

Background Surgical treatment of esophageal cancer is associated with a high rate of morbidity and mortality even in specialized centers. Minimally invasive surgery has been proposed to decrease these complications. Methods The authors present their results regarding postoperative complications and the survival rate at 3 years, comparing the classic open procedures (transthoracic or transhiatal esophagectomy) with minimally invasive surgery. Surgical procedures were performed according to procedures published elsewhere. Results The study enrolled 166 patients who underwent surgery between 1990 and 2003. Open transthoracic surgery was performed for 60 patients. In this group of patients, postoperative mortality was observed in 11% of the cases. Major, minor, and late complications were observed in 61.6% of the patients, and the 3-year survival rate was 30% for this group. Open transhiatal surgery was performed for 59 patients. The morbidity, mortality, and 3-year rate were almost the same as for the transthoracic surgery group. For the 47 patients submitted to minimally invasive procedures (thoracoscopic and laparoscopic), the complications and mortality rates were significantly reduced (38.2% and 6.4%, respectively). For the patients submitted to minimally invasive surgery, the 3-year survival rate was 45.4%. It is important to clarify that the patients submitted to minimally invasive surgery manifested early stages of the diseases, and that this the reason why the morbimortality and survival rates were better. Conclusions The transthoracic and transhiatal open approaches have similar early and late results. Minimally invasive surgery is an option for patients with esophageal carcinoma, with reported results similar to those for open surgery. This approach is indicated mainly for selected patients with early stages of the disease. Presented as a “free paper” during the 9th World Congress of Endoscopic Surgery, Cancun, Mexico, 4-7 February, 2004     

Laparoscopic Nissen fundoplication is an effective treatment for gastroesophageal reflux disease.

OBJECTIVE: The open Nissen fundoplication is effective therapy for gastroesophageal reflux disease. In this study, the outcomes in 198 patients treated with the laparoscopic Nissen fundoplication was evaluated for up to 32 months after surgery to ascertain whether similar positive results could be obtained. SUMMARY BACKGROUND DATA: To ensure surgical success, patients were required to have mechanically defective sphincters on manometry and increased esophageal acid exposure on 24-hour pH monitoring. The patients either had severe complications of gastroesophageal reflux disease or had failed medical therapy. These requirements have been found to be necessary to ensure a successful surgical outcome. METHODS: The disease was complicated by ulceration (46), stricture (25) and Barrett's esophagus (33). Patients underwent standard Nissen fundoplications identical in every detail to open procedures except that the procedures were carried out by the laparoscopic route. RESULTS: Perioperative complications included gastric or esophageal perforation (3), pneumothorax (2), bleeding (2), breakdown of crural repair (2) and periesophageal abscess (1). The only mortality occurred from a duodenal perforation. Six patients required conversion to the open procedure. The median hospital stay was 3 days. One hundred patients were observed for follow-up for 6 to 32 months (median 12 months), with outcomes similar to the open Nissen fundoplication. Further surgery was required for two patients who had recurrent gastroesophageal reflux and one who developed an esophageal stricture. Ninety-seven percent are satisfied with their decision to have the operation. CONCLUSIONS: The laparoscopic Nissen fundoplication can be carried out safely and effectively with similar positive results to the open procedure and with all of the advantages of the minimally invasive approach.     

Perioperative outcomes of laparoscopic transhiatal inversion esophagectomy compare favorably with those of combined thoracoscopic–laparoscopic esophagectomy

Aims  Wide acceptance of laparoscopic esophagectomy has been hampered by the technical difficulty of the procedure and inconsistent improvements in morbidity and mortality. Most case series have utilized a combined thoracoscopic–laparoscopic approach (TLE), but laparoscopic inversion esophagectomy (LIE), a method of transhiatal esophagectomy, has been proposed as an alternative. Inversion esophagectomy simplifies retraction and improves exposure during the mediastinal dissection; however, no previous studies have directly compared LIE outcomes with those of the combined approach. Methods  Between July 2003 and March 2008, 70 consecutive patients underwent minimally invasive esophagectomy by LIE (N = 40) or TLE (N = 30). Data for all patients were collected prospectively and stored in a relational database. Recorded outcome measures included operative time, blood loss, length of hospital stay, intensive care unit stay, and perioperative complications. Results  There were no significant differences in patient age, gender, body mass index (BMI), or American Society of Anesthesiologists (ASA) class between the groups, but LIE patients had lower stage of esophageal cancer, and were less likely to have received induction chemoradiotherapy than TLE patients. Patients undergoing LIE had significantly lower operative time (398 vs. 537 min, p < 0.001), intraoperative blood loss (100 vs. 200 ml, p < 0.001), and overall length of stay (9 vs. 14 days, p = 0.003) compared with TLE patients. LIE yielded a median of 10 lymph nodes removed compared with 13 for TLE (p = 0.016). Atrial arrhythmia and postoperative pneumonia were less common in LIE patients than in TLE patients, occurring in 17.5% vs. 27.1% (p = 0.036), and in 7.5% vs. 15.7% of cases (p = 0.029), respectively. Conclusion  LIE provides safe and effective approach to minimally invasive esophagectomy for patients with early esophageal cancer and high-grade dysplasia. Compared with TLE, inversion esophagectomy requires less operative time and has lower operative blood loss and length of hospital stay. LIE may also result in fewer perioperative cardiac and pulmonary complications compared with TLE. Based on these results, we reserve TLE for more advanced esophageal cancer and those undergoing preoperative radiochemotherapy. Presented at EAES, June 13, 2008, Stockholm, Sweden.     

Minimally invasive esophagectomy is safe in patients with previous gastric bypass

BackgroundThe prevalence of morbid obesity in the United States has been steadily increasing, and there is an established relationship between obesity and the risk of developing certain cancers. Patients who have undergone prior gastric bypass (GB) and present with newly diagnosed esophageal cancer represent a new and challenging cohort for surgical resection of their disease. We present our case series of consecutive patients with previous GB who underwent minimally invasive esophagectomy (MIE).MethodsRetrospective review of consecutive patients with a history of GB who underwent a MIE for esophageal cancer between July 2010 and August 2012.ResultsFive patients were identified with a mean age of 57 years. Mean follow-up was 9.1 months. Four patients had undergone laparoscopic GB, and 1 patient had an open GB. Two patients received neoadjuvant chemoradiation therapy for locally advanced disease. Minimally invasive procedures were thoracoscopic/laparoscopic esophagectomy with cervical anastomosis in 4 patients and colonic interposition in 1 patient. Mean operative time was 6 hours and 52 minutes. Median length of stay was 7 days. There was no mortality. Postoperative complications occurred in 3 patients and included pneumonia/respiratory failure, recurrent laryngeal nerve injury, and pyloric stenosis. All patients are alive and disease free at last follow-up.ConclusionsMinimally invasive esophagectomy after prior GB is well tolerated, is technically feasible, and has acceptable oncologic and perioperative outcomes. We conclude that precise endoscopic evaluation before bariatric surgery in patients with gastroesophageal reflux disease is essential, as is the necessity for continuing postsurgical surveillance in patients with known Barrett’s esophagitis and for early evaluation in patients who develop new symptoms of gastroesophageal reflux disease after bariatric surgery.     

全腔镜食管癌三野根治术颈部机械吻合与手工吻合的应用比较

目的：评估全腔镜食管癌三野根治术食管胃颈部吻合方式（机械或手工）对术后吻合口相关并发症发生的影响。方法回顾性分析2010年1月至2013年11月间在福建省肿瘤医院胸外科接受全腔镜食管癌三野根治术治疗的203例食管癌患者的临床资料。根据颈部吻合方式的不同,分为机械吻合组（104例）和手工吻合组（99例）。比较两组患者术后吻合口相关并发症发生率。结果机械吻合组术中吻合时间较手工吻合组明显缩短[（15．5±5．0） min比（28．0±4．5） min,P＜0．01]。两组术后吻合口瘘发生率分别为5．8％（6/104）和3．0％（3/99）,差异无统计学意义（P＞0．05）;吻合口狭窄发生率分别为9．6％（10/104）和2．0％（2/99）,差异有统计学意义（P＜0．05）。结论与手工吻合相比,全腔镜食管癌三野根治术食管胃颈部机械吻合操作简单、吻合确切,但吻合口狭窄的风险增加,因此,在临床实践中,应结合患者的具体情况合理选择吻合方式。