Minimally invasive management of intrathoracic leaks after esophagogastrectomy

Enthusiasm for minimally invasive esophagectomy is increasing. When feasible, the laparoscopic and thoracoscopic Ivor Lewis esophagogastrectomy with construction of an intrathoracic anastomosis is favored. A potential catastrophic consequence of an intrathoracic anastomosis is a postoperative leak. In this review, the authors summarize the current understanding of the pathophysiology and the management of intrathoracic leak using minimally invasive surgical techniques.     

Endoscopic evaluation of gastric conduit perfusion in minimally invasive Ivor Lewis esophagectomy

IntroductionLaser-assisted indocyanine green (ICG) fluorescent dye angiography has been used in esophageal reconstructive surgery where it has been shown to significantly decrease the anastomotic leak rate. Recent advances in technology have made this possible in minimally invasive esophagectomy.Presentation of caseWe present a 69-year-old male with a cuT2N0M0 adenocarcinoma of the esophagus at the gastroesophageal junction who presented to our clinic after chemoradiation and underwent a minimally invasive Ivor Lewis esophagectomy. The perfusion of the gastric conduit was assessed intraoperatively using endoscopic ICG fluorescent imaging system. The anastomosis was created at the well-perfused site identified on the fluorescent imaging. The patient tolerated the procedure well, had an uneventful recovery going home on postoperative day 6 and tolerating a regular diet 2 weeks after the surgery.DiscussionCombination of minimally invasive surgery and endoscopic evaluation of perfusion of gastric conduit provide improved outcomes for surgical treatment for patients with esophageal cancer.ConclusionThe gastric conduit during minimally invasive Ivor Lewis esophagectomy can be evaluated using endoscopic ICG fluorescent imaging.     

Laparoscopic and thoracoscopic Ivor Lewis esophagectomy with colonic interposition

Minimally invasive esophagectomy is a feasible and safe alternative to open esophagectomy. The stomach is the preferred conduit for gastrointestinal reconstruction after esophagogastrectomy; however, if the stomach is not usable, the colon can be interposed as an alternative conduit. We describe the technique of minimally invasive Ivor Lewis esophagogastrectomy in a patient with a gastric cardia cancer involving the gastric body and distal esophagus. Laparoscopic colonic interposition using the right colon based on the middle colic vessels was used to restore gastrointestinal continuity.     

Minimally invasive surgical enucleation or esophagogastrectomy for benign tumor of the esophagus

Experience in surgical resection of benign tumor of the esophagus is limited. Authors performed a chart review of 5 patients who underwent minimally invasive surgical resection of benign esophageal tumor. Main outcome measures included operative approaches, tumor's location and size, and outcomes. Tumor location were middle esophagus (n = 1), distal esophagus (n = 2), and gastroesophageal junction (n = 2). There were 4 females with a mean age of 55 years. Surgical approaches included thoracoscopic enucleation (n = 1), laparoscopic enucleation (n = 1), and laparoscopic and thoracoscopic Ivor Lewis esophagogastrectomy (n = 3). There were no open conversions. Mean operative time for enucleation was 127 minutes and 240 minutes for Ivor Lewis esophagectomy. Mean hospital stay was 5.8 days. There were no major or minor complications. Three patients developed stomal stenosis. The 30-day mortality was zero. Surgical pathology showed leiomyoma in 3 patients and gastrointestinal stromal tumor in 2 patients. Tumor size ranged from 1.1 to 10.5 cm. There has been no tumor recurrence at a mean follow-up of 14 months. Minimally invasive surgical enucleation or esophagogastrectomy for benign esophageal tumor is feasible and safe. The optimal approaches should be tailored based on the location and size of the tumor.     

The success of Eso-SPONGE® therapy in the treatment of anastomotic dehiscence after Ivor-Lewis subtotal esophagectomy: A case report

IntroductionEso-SPONGE® has proved to be an excellent method for the treatment of persistent dehiscence of the intrathoracic esophagogastric anastomosis during the operation of subtotal esophagectomy sec. Ivor Lewis.Clinical case presentationThe case presented is of a 72-year-old patient with esophageal adenocarcinoma (ADK) who underwent sub-total esophagectomy and esophagoplasty sec. Ivor Lewis complicated by an esophageal leak. The Eso-SPONGE® therapy has been successful halving the index of inflammation after the first two sessions and generation of a neowall after seven sessions.DiscussionEso-SPONGE® therapy has proven to be a valuable resource as a treatment for esophageal anastomotic dehiscences because it is easily repeatable in suburban centers, provided that they have a digestive endoscopy specialized in the positioning process.ConclusionsEso-SPONGE® is a minimally invasive method that delivers excellent results in the treatment of fragile patients, such as those who have post-esophageal anastomotic dehiscence.     

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...     

Construct Validation: Simulation of Thoracoscopic Intrathoracic Anastomosis

Background and Objectives:

We sought to develop a simulation model that accurately replicates the challenges of the thoracoscopic intrathoracic anastomosis. This model is intended to serve as a teaching tool during the introduction to, and development of, the skills required to perform a thoracoscopic intrathoracic anastomosis during an Ivor Lewis minimally invasive esophagectomy.

Methods:

The simulation model uses porcine tissue placed within an artificial hemithorax and covered with a synthetic skin. The model is draped to simulate a realistic operative setting, and ports are placed in standard surgical fashion. Dissection of the esophagus from the mediastinum is then performed, followed by the creation of an esophagogastric anastomosis. The effectiveness of the training model was evaluated using volunteer general and thoracic surgery residents at varying stages of surgical training. The quality of the anastomoses created were evaluated using both objective and subjective criteria, and successful anastomoses were tested for leaks using hydrostatic pressure.

Results:

Objective evaluation showed that successful completion of the anastomosis task increased with the number of attempts, with 100% of participants successfully completing an anastomosis by the final attempt. The time to completion of a successful anastomosis also improved across successive attempts. Moreover, objective measures also showed improvement over time based on the graded quality of the completed anastomosis.

Conclusion:

As surgical techniques continue to evolve, so must the means by which they are taught. This simulation model shows effectiveness in the training of general and thoracic surgery residents performing thoracoscopic intrathoracic anastomosis during the Ivor Lewis minimally invasive esophagectomy.     

Ivor Lewis esophagectomy with manual esogastric anastomosis by thoracoscopy in prone position and laparoscopy

Introduction  

Only a few authors have reported the technique of Ivor Lewis esophagectomy by minimally invasive means, and anastomosis was usually performed by a circular stapler. We report an Ivor Lewis esophagogastrectomy with manual esogastric anastomosis performed by thoracoscopy in the prone position.     

Laparoscopic and thoracoscopic Ivor Lewis esophagectomy after Roux-en-Y gastric bypass

Roux-en-Y gastric bypass is a commonly performed procedure for the treatment of morbid obesity. Esophagectomy in patients with a history of Roux-en-Y gastric bypass presents a difficult technical challenge for the surgeon. In this report we describe a technique of minimally invasive Ivor Lewis esophagogastrectomy in a patient who had had an open Roux-en-Y gastric bypass. Minimally invasive esophagectomy was performed with resection of the Roux limb using the gastric remnant as the conduit for gastrointestinal reconstruction.     

经口置入钉砧头技术用于全腔镜食管癌切除胸腔内胃食管吻合

目的 介绍一种通过经口置入钉砧头进行全腔镜食管切除胸腔内胃食管吻合的新技术.方法 2010年4月至6月,6例食管癌患者经口置入钉砧头进行全腔镜食管切除胸腔内胃食管吻合术.患者男性5例,女性1例;年龄38～69岁,平均55岁.病变位于贲门1例,食管下段4例,食管中段1例.病变平均长度4 cm.6例患者均采用腹腔镜胸腔镜联合食管癌切除胃食管胸腔内吻合术.手术分为两大步骤,首先采用腹腔镜游离胃和腹段食管,而后采用胸腔镜游离胸段食管并切除病变食管,应用经口置入钉砧头的方法进行胸腔内胃食管吻合术.结果 本组6例患者手术顺利,未发生术中并发症、中转开腹或开胸等情况.平均手术时间380 min,平均术中出血量300 ml,平均恢复进食时间为术后9 d.术后病理学检查示:食管鳞状细胞癌5例,食管小细胞癌1例,切缘和吻合口圈均阴性.pTNM分期:T2N0M0期3例,T2N1M0期1例,T3N0M0期2例.术后无吻合口和其他重大并发症.结论 本方法创伤小、恢复快,是一种较为安全可靠、操作简便的腔镜下胸腔内胃食管吻合方法.     

The rationale for esophagectomy as the optimal therapy for Barrett''s esophagus with high-grade dysplasia.

OBJECTIVE: The authors determined the incidence of invasive adenocarcinoma after esophagectomy in patients endoscopically diagnosed as having Barrett's esophagus with high-grade dysplasia. SUMMARY BACKGROUND DATA: Barrett's esophagus is a well-recognized premalignant condition. There is controversy with regard to the optimal treatment of high-grade dysplasia in Barrett's esophagus. Recognizing the morbidity and mortality associated with esophagectomy, some recommend a selective approach, reserving esophagectomy only for evidence of invasive cancer identified through endoscopic surveillance. Other advocate esophagectomy for all suitable operative candidates. METHODS: The authors reviewed their experience between 1985 and 1995 with 11 patients with high-grade dysplasia arising in Barrett's esophagus diagnosed by endoscopic biopsy and treated by esophagectomy. RESULTS: All patients were white men ranging in age from 47 to 70 years. Ten patients underwent esophagectomy by the Ivor Lewis technique; one had a transhiatal resection. Eight patients (73%) had invasive adenocarcinoma identified after esophagectomy; two (18%) had positive lymph nodes; one required a prolonged hospital stay for an anastomotic leak; two (18%) temporarily suffered delayed gastric emptying. The authors' review identified 85 additional patients previously reported during the same period. Including the current series, 39 patients (41%) had invasive adenocarcinoma identified in the resected specimen. A preponderance of early, potentially curable carcinomas are characteristically found in these patients. CONCLUSION: A high incidence of endoscopically undetected invasive carcinoma strongly supports esophagectomy as the preferred approach for suitable operative candidates with high-grade dysplasia in Barrett's esophagus.     

Techniques and short-term outcomes for total minimally invasive Ivor Lewis esophageal resection in distal esophageal and gastroesophageal junction cancers: pooled data from six European centers

Introduction

Esophagectomy for cancer can be performed in a two-stage procedure with an intrathoracic anastomosis: the Ivor Lewis esophagectomy. A growing incidence of distal and gastroesophageal junction adenocarcinomas and increasing use of minimally invasive techniques have prompted interest in this procedure. The aim of this study was to assess short-term results of minimally invasive Ivor Lewis esophagectomy (MIE-IL).

Methods

A retrospective cohort study was performed from June 2007 until September 2014, including patients that underwent MIE-IL for distal esophageal and gastroesophageal junction cancer in six different hospitals in the Netherlands and Spain. Data were collected with regard to operative techniques, pathology and postoperative complications.

Results

In total, 282 patients underwent MIE-IL, of which 90.2 % received neoadjuvant therapy. Anastomotic leakage was observed in 43 patients (15.2 %), of whom 13 patients (4.6 %) had empyema, necessitating thoracotomy for decortication. With an aggressive treatment of complications, the 30-day and in-hospital mortality rate was 2.1 %. An R0-resection was obtained in 92.5 % of the patients. After neoadjuvant therapy, 20.1 % of patients had a complete response.

Conclusions

Minimally invasive Ivor Lewis esophagectomy for distal esophageal and gastroesophageal junction adenocarcinomas is an upcoming approach for reducing morbidity caused by laparotomy and thoracotomy. Anastomotic leakage rate is still high possibly due to technical diversity of anastomotic techniques, and a high percentage of patients treated by neoadjuvant chemoradiotherapy. An aggressive approach to complications leads to a low mortality of 2.1 %. Further improvement and standardization in the anastomotic technique are needed in order to perform a safe intrathoracic anastomosis.

     

Incidence of diaphragmatic hernias following minimally invasive versus open transthoracic Ivor Lewis McKeown esophagectomy

Objectives  

To compare the incidence of post-operative hiatal herniation after open and minimally invasive Ivor Lewis McKeown esophagectomy for malignant disease.     

微创手术治疗食管癌160例临床分析

目的探讨微创手术治疗食管癌的可行性、安全性及临床应用价值。方法回顾性分析2008年2月至2011年12月四川大学华西医院采用微创手术完成的160例食管癌病例的临床资料。结果160例病例中男140例,女20例．平均年龄59．6岁。行胸腔镜腹腔镜联合食管切除术139例．腹腔镜纵隔镜联合食管切除术3例,腹腔镜辅助lvor—Lewis术15例．胸腹腔镜联合Ivor．Lewis3例。手术时间230～780（平均364．0）min,术中出血量20～4000（平均286．2）ml;获得R0切除152例（95．0％）,清扫淋巴结6。39（平均19．4）枚。中转开放手术11例（6．9％）,其中开胸9例。开腹2例：术中并发症发生率为11．3％（18／160）。重症监护室监护时间0。430h（平均22．1）h。术后住院时间7-93（平均13．1）d：术后并发症发生率34．4％（55／160）,术后30d内死亡率1．2％（2／160）。住院死亡率2．5％（4／160）。结论微创手术治疗食管癌在技术上安全可行,可取得相当于甚至优于传统手术的治疗效果。     

Comparative Experience of Open and Minimally Invasive Esophagogastric Resection

Background  A minimally invasive approach to esophagogastric cancer resection offers an attractive alternative to traditional open surgery; however, concerns regarding feasibility, safety, cost, and outcomes have restricted widespread acceptance of these procedures. This study outlines our comparative experiences of both open and minimally invasive esophagectomy over a 4-year period. Methods  Surgical outcomes were analyzed and compared between 30 consecutive patients who underwent open (Ivor Lewis) transthoracic esophagectomy (TTO) between January 2002 and December 2003 and 50 consecutive patients who underwent minimally invasive esophagectomy (MIO) from January 2004 to July 2006. Results  Inpatient mortality and overall surgical morbidity were identical for each cohort (TTO versus MIO: mortality 3% versus 2%; morbidity 50% versus 48%). Pulmonary-related complications were higher in the open series (23% versus 8%; p = 0.05). The incidence of gastric-conduit-related complications was similar between the two cohorts (13% versus 18%; p = 0.52). Survival at 1 and 2 years was 86% and 58% in the TTO group and 94% and 74% in the MIO group. No significant difference in calculated cost was observed (￡7,017 versus ￡7,885). Conclusions  Transition from open to minimally invasive techniques of esophagogastric resection for cancer is possible without compromising patient safety or incurring excessive financial expenses, and the minimally invasive procedure results in similar or potentially better outcomes.     

Refinement of Minimally Invasive Esophagectomy Techniques After 15?Years of Experience

Intoduction

In an effort to reduce the morbidity and mortality associated with open esophagectomy, a minimally invasive approach to esophagectomy was introduced at the University of Pittsburgh Medical Center (UPMC) in 1996. The objective of this article is to discuss the optimization and refinement of minimally invasive esophagectomy (MIE) techniques over the 15-year experience at UPMC. We also reviewed the literature on technical improvements in MIE.

Method

Literature highlights for MIE and related meta-analyses comparing open esophagectomy and MIE were reviewed. The rationale and outcomes of techniques refinements were discussed in detail.

Results

Most meta-analyses and systematic reviews confirm the feasibility and safety of MIE and suggest similar oncologic outcomes as compared with open esophagectomy. Since 1996, over 1,000 minimally invasive esophagectomies have been performed at UPMC. We have made several refinements to the MIE procedure that we believe significantly improved our surgical outcomes. It included adjustment of width of the gastric conduit, application of omental flap, and conversion from minimally invasive, three-hole esophagectomy to minimally invasive Ivor Lewis esophagectomy.

Conclusion

MIE became a mainstay in the surgical treatment of esophageal cancer at UPMC. The technical improvements detailed above make the UPMC approach to MIE a feasible, safe, and efficient procedure.     

Minimally invasive Ivor–Lewis esophagogastrectomy for gastric cardia cancer

Introduction  

Gastric cardia cancer with involvement of the esophagus may require an esophagogastrectomy to obtain negative tumor margins. Multiple studies have shown that minimally invasive esophagectomy is a safe approach for the treatment of esophageal cancer [1–3]. We describe the technique of a minimally invasive Ivor–Lewis esophagectomy in a 55-year-old patient with a gastric cardia tumor.     

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.     

Ivor Lewis' operation for epidermoid cancer of the esophagus. Immediate and late results. Apropos of 168 cases]

168 Ivor Lewis operations for squamous carcinoma of the lower esophagus are reviewed. 155 men and 13 women with a mean age of 59 years were operated on. 46 tumors were stage I and II, and 122 were stage III. Operations were considered to be curative for 120 patients and only palliative for 48. An esophagectomy associated with lymphadenectomy was performed through laparotomy and right thoracotomy. Feeding jejunostomy and pyloroplasty were routine. EEA or ILS 25 staplers were used to perform esophagogastric anastomosis and the gastroplasty tube was fashioned by TA 90 stapler. In every case an extended esophagectomy was performed with anastomosis between 3 ans 7 cm below the pharyngo-esophageal junction. Postoperative mortality was 4.7%. There were 10 leaks (6%) and 28 pulmonary complications. Median actuarial survival is 17 months. Actuarial survival at 2 years is significantly greater for stages I and II (68.4%) than for stage III (23.2%) (p < 0.01). Ivor Lewis esophagectomy is a reliable procedure to treat squamous carcinoma of the lower two thirds of the esophagus ensuring a good quality of life.