Minimally invasive esophageal resection

Esophagus resection is the adequate treatment for some benign esophageal diseases, especially caustic and peptic stenosis and end-stage motility dysfunction. However, the most frequent indications for esophageal resection are the high-grade dysplasia of Barrett esophagus and nonmetastasized esophageal cancer. Different procedures have been developed to perform esophageal resection given the 5-year survival rate among operated patients of only 18%. The disadvantage of the conventional approach is the high morbidity rate, especially with pulmonary complications. Minimally invasive esophageal resections, which were first performed in 1991, may reduce this important morbidity and preserve the oncologic outcome. The first reports of morbidity and respiratory complications with this approach were discouraging and it seemed likely that the procedure would have to be abandoned. However, in the last 5 years, an important impetus for these techniques was given by Japanese groups and the group of Luketich in Pittsburgh. The outcomes of these new series are different than those of the beginning period, leading to an enormous expansion worldwide. Important factors for this change are the standardization of the operative technique, the experience of many surgeons with more advanced laparoscopic procedures, important improvements in instruments for dissection and division of tissues, a better anesthesia technique, and a better selection of patients for operation. Two minimally invasive techniques are being perfected: the three-stage operation by right thoracoscopy and laparoscopy, and the transhiatal laparoscopic approach. It seems that the first approach may be applied successfully for any tumor in the esophagus, whereas the transhiatal seems ideal for distal esophageal and esophagogastric junction tumors. This review paper discusses all these aspects, with special attention for indications and operative technique.     

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     

Esophageal perforation during laparoscopic adjustable gastric band: conversion to open sleeve gastrectomy and endoscopic stent placement

Laparoscopic adjustable gastric band (LAGB) is one of the most popular bariatric surgical procedures both in Europe and United States, because it is considered to be a safe and effective way of treating morbid obesity. This minimally invasive frequently employed bariatric procedure has many reported complications, but only a few cases of esophageal perforation have been reported. We present a case of iatrogenic esophageal perforation in an 18-year-old patient occurring during attempt to place an adjustable gastric band laparoscopically, which was diagnosed intraoperatively. Conversion to open sleeve gastrectomy with primary suturing of the perforation and drainage were performed. On the early postoperative period leak from the intra-abdominal part of the esophagus was diagnosed and treated with endoscopic placement of a self-expandable metal stent.After 2-years of follow-up the patient continues to have no sequelae from the perforation or symptoms of dysphagia, while Excess Weight Loss is 74%.     

Robotic-assisted transhiatal esophagectomy

Background Despite its reduced aggressiveness and excellent results obtained in certain diseases, minimally invasive surgery did not manage to significantly lower the risks of esophageal resections. Further advances in technology led to the creation of robotic systems with their unique maneuverability of the instruments and exceptional view on the operative field, thus setting the prerequisites for performance in complex surgical procedures and offering new possibilities to a disease notorious for its dismal prognosis.Materials and methods The robotic-assisted transhiatal esophagectomy technique was used in a patient with squamous cell carcinoma of the lower esophagus that had high medical risk for surgical therapy.Results Esophageal resection and reconstruction were possible through a robotic-assisted minimally invasive transhiatal approach. There were no intraoperative incidents, blood loss was minimal, and lymph node dissection and removal was possible during the procedure. Early ambulation and conservative treatment of the mild complications that occurred offered a favorable postoperative outcome.Conclusion The robotic-assisted transhiatal esophagectomy technique is feasible and safe. Complex procedures become less technically demanding with the help of the robotic system and, thus, the minimally invasive approach can be offered for the benefit of selected patients. Further studies are required to confirm these observations and to establish the role of this procedure in the future.     

电视胸腔镜与小切口开胸手术治疗食管良性疾病的比较

目的比较电视胸腔镜手术与小切口开胸手术治疗食管良性疾病的临床效果和适应证。方法1995年1月至2007年1月我院胸外科应用微创手术治疗食管良性疾病患者52例。其中贲门失弛缓17例,食管平滑肌瘤24例,食管憩室7例,食管脂肪瘤1例,食管囊肿1例,贲门失弛缓合并食管憩室1例,贲门失弛缓球囊扩张食管破裂1例。根据手术方式分为电视胸腔镜手术组25例,小切口开胸手术组27例。结果两组患者手术治疗效果均良好,无术后并发症,无手术死亡。电视胸腔镜手术组有2例因胸腔内广泛粘连和食管黏膜损伤中转开胸。两组患者手术时间、术后胸腔闭式引流时间、胃肠减压时间以及术后住院时间均无明显差异。结论电视胸腔镜手术和小切口开胸手术治疗食管良性疾病安全有效,术后恢复快。电视胸腔镜手术切口符合美观要求,可作为治疗食管良性疾病的常规术式。小切口开胸手术更适合于病情较复杂的患者。     

电视胸腔镜在食管疾病诊断与治疗中的应用

电视胸腔镜手术(VATS)作为一种微创技术应用于食管疾病的诊断和治疗已10年左右,其优点为减少术后早期和长期胸痛,减少术后呼吸道并发症,符合美学要求.VATS食管癌分期主要是评估食管癌外侵和转移情况,有助于选择合适的治疗方案.VATS治疗食管癌主要应用于早期食管癌切除,但由于手术部位多,操作较繁杂,应用受到一定的限制;而对食管良性疾病,如平滑肌瘤、贲门失弛缓症等在有条件的医疗中心已成为首选的手术方案.     

Thoracoscopic enucleation of benign tumors of the esophagus under simultaneous flexible esophagoscopy

Background: Benign tumors of the esophagus are very rare, accounting for only 0.1–2% of all esophageal tumors. Conventional treatment consists of thoracotomy adapted to the location of the tumor, followed by enucleation of the lesion. This approach, however, involves major surgery. Minimally invasive surgery represents a viable therapeutic alternative, in particular for benign tumors. Methods: In four patients with a benign tumor of the esophagus, we carried out thoracoscopic enucleation under simultaneous esophagoscopy. Results: Using this combination of endoscopic procedures, the tumors were removed reliably and safely. Two of the lesions were intramural leiomyomas, and two were intramural myxoid cysts. Conclusion: This combination of endoscopic procedures represents a minimally invasive approach with correspondingly minor surgical trauma. Using simultaneous esophagoscopy and transillumination (diaphanoscopy) of the esophageal wall, the safety and accuracy of the dissection is increased, and the risk of mucosal perforation minimized. Received: 10 January 2000/Accepted: 30 March 2000/Online publication: 29 August 2000     

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.     

Spektrum der laparoskopischen Chirurgie bei Magentumoren

Minimally invasive operative procedures are increasingly being used for treating tumors of the upper gastrointestinal tract. While minimally invasive surgery (MIS) has become established as a standard procedure for benign tumors and gastrointestinal stromal tumors (GIST) based on current studies, the significance of MIS in the field of gastric cancer is the topic of heated debate. Until now the majority of studies and meta-analyses on gastric cancer have come from Asia and these indicate the advantages of MIS in terms of intraoperative blood loss, minor surgical complications and swifter convalescence although without any benefits in terms of long-term oncological results and quality of life. Unlike in Germany, gastric cancer in Asia with its unchanged high incidence rate, 50?% frequency of early carcinoma and predominantly distal tumor localization is treated at high-volume centres. Due to the proven marginal advantages of MIS over open resection described in the published studies no general recommendation for laparoscopic surgery of gastric cancer can currently be given.     

Thoracoscopic management of benign tumors of the mid-esophagus: a retrospective study

Benign esophageal tumors are rare conditions. Traditionally, thoracotomy was the preferred route to approach these lesions. Now, increasingly more surgeons are using minimally invasive techniques to treat these benign mid-esophageal lesions. We present our experiences from a specialised minimally invasive surgery unit. We have managed 12 patients with benign tumors of the mid-esophagus from 1995 to 2007 in our institute. The enucleation was achieved with the patient placed in the prone position and approached via a right thoracoscopy in all cases. Hospital stay was 3-5 days and there were minor postoperative complications in 2 patients. Mortality was nil. There were 10 patients with leiomyoma and 2 with GISTs, as proved by immunohistochemistry. Short and long-term follow up was satisfactory, with none of the patients having recurrences or other problems. Leiomyomas and GISTs, respectively, are the commonest benign tumors of the esophagus. Tumors more than 5 cm have to be enucleated, and thoracotomy has been the traditional approach to these lesions. Thoracoscopy has definite benefits regarding reduced morbidity. The combined modality of peroperative endoscopy is useful in locating the lesion as well as confirming its complete removal. Based on our experience, a right thorax approach and the prone patient position is the ideal for thoracoscopic procedures.     

食管疾病内镜手术远期疗效的研究进展

食管疾病包括食管恶性疾病及良性疾病,在我国发病率高.随着内镜技术的发展,许多既往需要药物治疗或外科手术的疾病,现在可以通过内镜手术进行根治.本文对常见食管疾病包括食管早期鳞状细胞癌、食管狭窄、贲门失弛缓症、食管黏膜下肿瘤内镜手术的远期随访做一综述.     

胸腹腔镜辅助微创McKeown食管切除的近期疗效分析

目的 探讨联合胸腔镜和腹腔镜辅助微创McKeown食管癌手术的临床应用价值。 方法 回顾性分析四川大学华西医院2008年2月至2012年8月期间196例经胸腹腔镜辅助微创McKeown食管癌手术患者的临床资料,观察患者手术效果及术后并发症。其中男145例、女51例,年龄40～76 （58.8±6.6） 岁。其中食管上段癌43例,食管中段癌115例,食管下段癌38例。 结果 手术总时间215～780 （305.0±40.7） min,胸腔镜手术时间50～580 （105.0±38.4） min,腹腔镜手术时间28～105 （54.0±8.6） min。术中出血量20～440 （285.4±38.5） ml,淋巴结清扫6～39 （20.4±1.6） 枚,术后住院时间7～93 （12.8±5.2） d。术后60例 （30.6%） 患者出现并发症,其中包括肺部并发症28例（14.3%）,乳糜胸5例（2.5%）,心律失常5例（2.5%）,吻合口瘘15例（7.6%）,喉返神经损伤10例（5.1%）,其他2例。 结论 胸腹腔镜辅助微创McKeown食管癌手术是一种安全、可行的术式。     

Bifocal esophageal and rectal cancer palliatively treated with argon plasma coagulation

Primary multiple neoplasms make a serious diagnostic and therapeutic problem. They occur infrequently; however, they must be considered in the diagnosis as the detection of simultaneous neoplastic foci requires change of therapeutic approach. We present a case of a patient with synchronous esophageal and rectal cancer treated at the Department of Surgery. Because of the advanced neoplastic process and concomitant diseases, the patient was qualified for minimally invasive procedures with recanalization using argon plasma coagulation to avoid injuring palliative procedures and to improve quality of life. The patient died of the primary disease without symptoms of gastrointestinal tract obstruction.     

Patient selection for minimally invasive spine surgery

Minimally invasive approaches to treat lumbar spine disease may carry many benefits over traditional open surgery with comparable patient outcomes. However, this advantage is conferred through appropriate patient selection. Not only do patient-specific anatomic factors influence the use of these techniques, but also surgeon familiarity with approaches. Adult spinal deformity surgery represents an area where minimally invasive spine (MIS) techniques have demonstrated significant impact in appropriately selected patients. Conversely, applying MIS techniques in patients inappropriate for minimally invasive surgery can result in complications, reoperations, and adverse outcomes. This chapter will highlight algorithms to guide patient and technique selection for MIS deformity surgery.     

Minimally invasive surgical staging for esophageal cancer

Background: The incidence of esophageal adenocarcinoma is increasing in the United States, and the 5-year survival rate is dismal. Preliminary data suggest that conventional imaging is inaccurate in staging esophageal cancer and could limit accurate assessment of new treatments. The objective of this study was to compare minimally invasive surgical staging (MIS) with conventional imaging for staging esophageal cancer. Methods: Patients with potentially resectable esophageal cancer were eligible. Staging by conventional methods used computed tomography (CT) scan of the chest and abdomen, and endoscopic ultrasound (EUS), whereas MIS used laparoscopy and videothoracoscopy. Conventional staging results were compared to those from MIS. Results: In 53 patients, the following stages were assigned by CT scan and EUS: carcinoma in situ (CIS; n= 1), I (n= 1), II (n= 23), III (n= 20), IV (n= 8). In 17 patients (32.1%), MIS demonstrated inaccuracies in the conventional imaging, reassigning a lower stage in 10 patients and a more advanced stage in 7 patients. Conclusions: In 32.1% of patients with esophageal cancer, MIS changed the stage originally assigned by CT scan and EUS. Therefore, MIS should be applied to evaluate the accuracy of new noninvasive imaging methods and to assess new therapies for esophageal cancer. Received: 5 April 1999/Accepted: 15 March 2000/Online publication: 12 July 2000     

微创食管切除术治疗食管癌的研究进展

食管癌是全世界8大常见恶性肿瘤之一,外科手术仍为最主要的治疗方案。传统开放食管切除术术后并发症发生率高,患者生活质量较差。为减少手术并发症、提高患者的生活质量,微创食管切除术逐渐被胸外科医师接受并应用于食管癌的治疗当中。目前,多数研究认为微创食管切除术是安全、可行的,同时术后并发症发生率等短期效果优于开放食管切除术,而总生存率等远期效果并不低于开放食管切除术。随着研究的不断细化深入,食管癌的精准微创治疗将得到进一步的发展和推广。     

Endoscopic treatment of benign esophageal tumors: case report of three patients

Benign esophageal tumors are rare. Enucleation of the tumor is considered when the patient reports problems. The traditional approach is to use thoracotomy or laparotomy if the tumor is located in the distal esophagus. The use of minimally invasive techniques permits enucleation with all the concomitant advantages. Our experience with the minimally invasive management of three benign esophageal tumors is described. The methods and results of preoperative studies are reported. The surgical technique is described. Two patients could be managed using thoracoscopy, and one patient required conversion to laparoscopy. All the patients had complete and quick recoveries.