Totally minimally invasive Ivor‐Lewis esophagectomy with single‐utility incision video‐assisted thoracoscopic surgery for treatment of mid‐lower esophageal cancer

The study aims to evaluate the safety and availability of totally minimally invasive Ivor‐Lewis esophagectomy (MIIE) with single‐utility incision video‐assisted thoracoscopic surgery. Forty‐one patients with mid‐lower thoracic esophageal cancer were prospectively treated with totally MIIE. Two stages of laparoscopic‐thoracoscopic procedures were performed. The first 29 patients were treated with four‐port video‐assisted thoracoscopic surgery (Group 1); the others were treated with single‐utility incision video‐assisted thoracoscopic surgery (Group 2). Short‐term clinicopathological outcomes were examined. All patients had negative tumor margins and were pathologically staged from T1N0M0 to T3N2M0. Among Group 1, there was one conversion to open surgery. The mean duration of surgery was 268.4 ± 37.8 minutes, and mean blood loss was 207.2 ± 74.1 mL without significant differences between groups. The average thoracic or abdominal lymph node yield was 12.6 ± 7.1 or 6 ± 5.8, respectively. The median postoperative hospital stay was 7 days. No mortalities occurred. Minor morbidity complicated by late‐stage gastroparesis occurred in two patients (4.9%) after discharge. Major morbidities, including intestinal obstruction and anastomotic leakage, occurred in three patients (7.3%) after discharge. Among Group 2, the average operative duration was 275.4 ± 31.2 minutes, and the mean blood loss was 220 ± 94.9 mL. One patient developed late‐stage anastomotic leakage. The average thoracic or abdominal lymph node yield was 14.7 ± 8.8 and 6.3 ± 5.7, respectively. No statistically significant differences were identified between Group 1 and Group 2. MIIE with single‐utility incision video‐assisted thoracoscopic surgery is feasible in patients with mid‐lower thoracic esophageal cancer without compromising the extent of surgical resection and perioperative outcomes.     

Thoracoscopic and laparoscopic esophagectomy with cervical manual anastomosis for esophageal cancer

Evidence on the benefits of minimally invasive approach over traditional open procedure in gastrointestinal surgery is continuing to accumulate. This is also the case for esophageal surgery.Although laparoscopic esophageal surgery was initially reserved for benign pathology, the technical development, increasing experience with laparoscopic and thoracoscopic techniques and the theoretical advantages of minimally invasive surgery have widened the scope of minimally invasive approach to esophageal cancer. The surgical treatment of esophageal cancer often requires extensive procedures and is therefore, considered one of the most challenging and invasive procedure of gastrointestinal surgery. While transhiatal and transthoracic esophagectomy are common approaches for esophageal resection, data regarding the combined thoracoscopic and laparoscopic approach to esophagectomy are limited. The minimally invasive technique of esophagectomy to be described consists of three phases: thoracoscopic esophageal mobilization and mediastinal lymphadenectomy followed by laparoscopic gastric mobilization, abdominal lymphadenectomy and gastric conduit formation and finally retrieval of the resection specimen followed by an esophagogastric anastomosis via a left cervical incision.     

Application of a modified McKeown procedure (thoracoscopic esophageal mobilization three‐incision esophagectomy) in esophageal cancer surgery: Initial experience with 30 cases

Early efforts with minimally invasive esophagectomy (MIE) were hybrid approaches. No conclusive benefit was seen with this approach compared with the standard open procedure. Total MIE has demonstrated its advantages in single institution series. The drawbacks of total MIE include the steep learning curve and the high cost of the disposable instrumentation. We sought to determine the feasibility of modifying the surgical technique involved in the hybrid approach in an effort to decrease the cost of the surgery without compromising the outcome. From December 2007 to September 2008, the modified McKeown procedure (thoracoscopic esophageal mobilization three‐incision esophagectomy) was performed in 30 cases. The median operative time was 225 minutes (range, 195 ?290 minutes) and the median average time of VATS was 70 minutes (range, 50 ?130 minutes). Median lymph node retrieval was 25.6 ± 4.8 nodes (15.1 ± 3.4 intrathoracic) per patient. The median postoperative hospital stay was 17.1 ± 6.3 days. There was no in‐hospital (30 days) mortality. Postoperative complications occurred in 9 patients (30%), including 2 (6.7%) pneumonia, 1 (3.3%) chylothorax, 1 (3.3%) delayed gastric emptying ,1 (3.3%) vocal cord palsy, 2 (6.7%) neck anastomotic leaks, and 2 (6.7%) arrhythmias. This procedure is technically feasible and safe with lower mortality and mobility. The short‐term surgical outcomes are comparable with most of the total MIE reports. Performing the gastric mobilization and spontaneous neck anastomosis first greatly facilitate and simplifies the VATS maneuver.     

Updated experiences with minimally invasive McKeown esophagectomy for esophageal cancer

AIM: To update our experiences with minimally invasive McKeown esophagectomy for esophageal cancer.METHODS: We retrospectively reviewed the medical records of 445 consecutive patients who underwent minimally invasive McKeown esophagectomy between January 2009 and July 2015 at the Cancer Hospital of Chinese Academy of Medical Sciences and used 103 patients who underwent open McKeown esophagectomy in the same period as controls. Among 375 patients who underwent total minimally invasive McKeown esophagectomy, 180 in the early period were chosen for the study of learning curve of total minimally invasive McKeown esophagectomy. These 180 minimally invasive McKeown esophagectomies performed by five surgeons were divided into three groups according to time sequence as group 1 (n = 60), group 2 (n = 60) and group 3 (n = 60).RESULTS: Patients who underwent total minimally invasive McKeown esophagectomy had significantly less intraoperative blood loss than patients who underwent hybrid minimally invasive McKeown esophagectomy or open McKeown esophagectomy (100 mL vs 300 mL vs 200 mL, P = 0.001). However, there were no significant differences in operation time, number of harvested lymph nodes, or postoperative morbidity including incidence of pulmonary complication and anastomotic leak between total minimally invasive McKeown esophagectomy, hybrid minimally invasive McKeown esophagectomy and open McKeown esophagectomy groups. There were no significant differences in 5-year survival between these three groups (60.5% vs 47.9% vs 35.6%, P = 0.735). Patients in group 1 had significantly longer duration of operation than those in groups 2 and 3. There were no significant differences in intraoperative blood loss, number of harvested lymph nodes, or postoperative morbidity including incidence of pulmonary complication and anastomotic leak between groups 1, 2 and 3.CONCLUSION: Total minimally invasive McKeown esophagectomy was associated with reduced intraoperative blood loss and comparable short term and long term survival compared with hybrid minimally invasive McKeown esophagectomy or open Mckeown esophagectomy. At least 12 cases are needed to master total minimally invasive McKeown esophagectomy in a high volume center.     

Hand‐assisted laparoscopic transhiatal esophagectomy with a systematic procedure for en bloc infracarinal lymph node dissection

Laparoscopic transhiatal esophagectomy is a minimally invasive approach for esophageal cancer. However, a transhiatal procedure has not yet been established for en bloc mediastinal dissection. The purpose of this study was to present our novel procedure, hand‐assisted laparoscopic transhiatal esophagectomy, with a systematic procedure for en bloc mediastinal dissection. The perioperative outcomes of patients who underwent this procedure were retrospectively analyzed. Transhiatal subtotal mobilization of the thoracic esophagus with en bloc lymph node dissection distally from the carina was performed according to a standardized procedure using a hand‐assisted laparoscopic technique, in which the operator used a long sealing device under appropriate expansion of the operative field by hand assistance and long retractors. The thoracoscopic procedure was performed for upper mediastinal dissection following esophageal resection and retrosternal stomach roll reconstruction, and was avoided based on the nodal status and operative risk. A total of 57 patients underwent surgery between January 2012 and June 2013, and the transthoracic procedure was performed on 34 of these patients. In groups with and without the transthoracic procedure, total operation times were 370 and 216 minutes, blood losses were 238 and 139 mL, and the numbers of retrieved nodes were 39 and 24, respectively. R0 resection rates were similar between the groups. The incidence of recurrent laryngeal nerve palsy was significantly higher in the group with the transthoracic procedure, whereas no significant differences were observed in that of pneumonia between these groups. The hand‐assisted laparoscopic transhiatal method, which is characterized by a systematic procedure for en bloc mediastinal dissection supported by hand and long device use, was safe and feasible for minimally invasive esophagectomy.     

Combined thoracoscopic and laparoscopic esophagectomy: experience,technique and cautions

We described a 59-year-old female, who came to our institute with the diagnosis of esophageal squamous cell carcinoma. The preoperative clinical diagnosis was stage II esophageal squamous cell carcinoma. The three-stage minimally invasive esophagectomy (MIE), combined thoracoscopic-laparoscopic esophagectomy with cervical anastomosis, was performed in this case. The lateral-prone decubitus position and Harmonic scalpel facilitate the operation.KEYWORDS : Minimally invasive esophagectomy (MIE), thoracoscopic, laparoscopic     

Combined thoracoscopic and laparoscopic minimally invasive esophagectomy

With the improvement in thoracoscopic and laparoscopic surgery, thoracoscopic and laparoscopic esophagectomy (TLE), a minimally invasive approach, has attracted increasing attention as an alternative to open three-field esophagectomy. From June 2012 to October 2013, 90 patients underwent laparoscopic and thoracoscopic resection of esophageal carcinoma in our department. The VATS esophagectomy technique described here is the approach currently employed in the department of thoracic surgery at Sichuan Provincial People’s Hospital of China.     

Minimally invasive esophageal resection and intrathoracic anastomosis for lower thoracic esophageal cancer with single position

There are various esophagectomy approaches for lower thoracic esophageal cancer, and the minimally invasive esophagectomy (MIE) approach shows the advantages of less discomfort, shorter length of stay and a faster recovery to baseline status than open approaches. The current study reports a case of lower thoracic esophageal cancer was treated using a single-position, minimally invasive surgical technique with laparoscopy and thoracoscopy. A 68-year-old man, whose gastroscopy identified the esophageal carcinoma, came to our medical center due to dysphagia for over 1 year. The patient underwent tumor radical resection and intrathoracic anastomosis by laparoscopy and thoracoscopy with single position. The patient has recovered well after the surgery.     

Robot-assisted minimally invasive esophagectomy is equivalent to thoracoscopic minimally invasive esophagectomy

The use of the surgical robot has been increasing in thoracic surgery. Its three-dimensional view and instruments with surgical wrists may provide advantages over traditional thoracoscopic techniques. Our initial experience with thoracoscopic robot-assisted minimally invasive esophagectomy (RAMIE) for esophageal cancer was compared with our traditional thoracoscopic minimally invasive esophagectomy (MIE) approach for esophageal cancer. A retrospective review of a prospective database was performed. From July 2008 to October 2009, 43 patients underwent MIE resection. Patients who had benign disease and intrathoracic anastomosis were excluded. Results are presented as mean ± SD. Significance was set as P < 0.05. Eleven patients who underwent RAMIE and 26 who underwent MIE were included in the cohort. No differences in age, sex, race, body mass index, or preoperative radiotherapy or chemotherapy between the groups were observed. No significant differences in operative time, blood loss, number of resected lymph nodes, postoperative complications, days of mechanical ventilation, length of intensive care unit stay, or length of hospital stay were also observed. In this short-term study, RAMIE was found to be equivalent to thoracoscopic MIE and did not offer clear advantages.     

Laparoscopic and thoracoscopic esophagectomy with intrathoracic anastomosis for middle or lower esophageal carcinoma

Thoracoscopic mobilization of esophagus and laparoscopic mobilization of stomach with cervical anastomosis is employed widely in minimally invasive esophagectomy (MIE) for esophageal carcinoma. However, it is associated with high incidence of complications, including recurrent laryngeal nerve injury and anastomotic leak. This paper summarizes the key techniques in total laparoscopic and thoracoscopic esophagectomy with intrathoracic anastomosis for MIE in 62 patients of middle or lower esophageal cancer between March 2012 and August 2013. Total laparoscopic and thoracoscopic esophagectomy with intrathoracic anastomosis was performed to treat the middle or lower esophageal cancer. Laparoscopic and thoracoscopic Ivor-Lewis esophagectomy was performed using a circular stapler (Johnson and Johnson) intrathoracically to staple esophagogastric anastomosis and reconstruct the digestive tract. In addition, we performed tension-relieving anastomotic suture and embedded with pedicled omental flap. Compared with the trans-orally inserted anvil (OrVil) approach, the technique reported here is safe, feasible and user-friendly. Total thoracoscopic intrathoracic anastomosis can be performed with a circular stapler (Johnson and Johnson).     

A preliminary experience with minimally invasive Ivor Lewis esophagectomy

With several small series examining minimally invasive Ivor Lewis esophagectomies, we look to contribute to a growing experience. In reporting our initial results, safety, initial oncologic completeness, and preliminary outcomes with a minimally invasive Ivor Lewis esophagectomy were demonstrated. From 2007 to 2010, 40 minimally invasive Ivor Lewis esophagectomies were carried out. The approach was a laparoscopic mobilization of the stomach and a thoracoscopic esophageal mobilization and creation of a high intrathoracic anastomosis. Indications included esophageal cancer in 39 patients and esophageal gastrointestinal stromal tumor in one patient. Median age was 62 (range 39-77) with 31 (78%) male patients. Non-emergent conversion was required in two (5%) patients. Twenty-five (63%) patients underwent neoadjuvant therapy. Mean operative time was 364 minutes (range 285-455), and mean blood loss was 205 cc (range 100-400). All patients underwent an R0 resection including the removal of all Barrett's esophagus, and mean number of nodes harvested was 21 (range 11-41). Median intensive care unit stay was 1 day (range 1-3), and hospital stay was 7 days (range 6-19). There were no anastomotic leaks and no 30-day mortality. Postoperative complications included eight (21%) patients with atrial fibrillation and two (5%) chylothorax, one requiring ligation. At a mean follow-up of 16.5 months (range 1-39 months), five (13%) patients have had a distant recurrence; there have been no local recurrences. Minimally invasive Ivor Lewis esophagectomy, although technically challenging, can be carried out with reasonable operative times, a short length of stay, and minimal complication. Final oncologic validity is pending longer follow-up and a larger series.     

Systematic review and meta‐analysis on the significance of salvage esophagectomy for persistent or recurrent esophageal squamous cell carcinoma after definitive chemoradiotherapy

The therapeutic strategy to be recommended in case of recurrent or persistent squamous cell esophageal cancer after completed definitive chemoradiotherapy (dCRT) has to be documented. Salvage esophagectomy has traditionally been recognized as a viable option, but many clinicians oppose the use of surgery due to the associated excessive morbidity and mortality. ‘Second‐line’ chemoradiotherapy (CRT) without surgery may offer a treatment alternative in these difficult and demanding clinical situations. Until now, no comprehensive attempt has been carried out to compare the respective therapeutic options. A systematic literature search was performed focusing on studies comparing survival and treatment‐related mortality in patients submitted to salvage esophagectomy or second‐line CRT for recurrent or persistent esophageal squamous cell carcinoma after dCRT. Hazard ratios and risk ratios were calculated to compare the effect of these therapeutic strategies on overall survival and treatment‐related mortality, respectively. Four studies containing 219 patients, with persistent or recurrent esophageal squamous cell carcinoma after dCRT, were included in the meta‐analysis. The analysis revealed an overall survival benefit following salvage esophagectomy with a pooled hazard ratio for death of 0.42 (95% confidence interval 0.21–0.86, P = 0.017) compared with second‐line CRT. A treatment‐related mortality of 10.3% was recorded in the 36 patients who were submitted to salvage esophagectomy, while it was impossible to perform a meta‐analysis comparing treatment‐related mortality between the groups. Salvage esophagectomy offers significant gain in long‐term survival compared with second‐line CRT, although the surgery is potentially at a price of a high treatment‐related mortality.     

Thoracoscopic esophagectomy in the prone position

Thoracoscopic esophagectomy performed with the patient in the left lateral position has been occasionally reported since the 1990s, but it has not been established as a standard procedure. This may be because the success of this procedure largely depends on the technical competence of an assistant to secure an adequate field of view during the procedure. Thoracoscopic esophagectomy with the patient in the prone position has recently been introduced and has been consistently shown to be useful. Compared with left lateral thoracoscopic esophagectomy, prone thoracoscopic esophagectomy requires less assistance in exposing the operative field and it is relatively easy to obtain a satisfactory field of view. We performed prone thoracoscopic esophagectomy on 20 patients and were successful in achieving a wide field of view. The postoperative course was remarkably favorable in all patients and the procedure is considered promising for standard thoracoscopic esophagectomy. There are few detailed reports of this procedure; herein, we describe the procedure of prone thoracoscopic esophagectomy employed at our hospital.     

Metachronous cancer of gastroplasty after esophagectomy

We reviewed two cases of adenocarcinoma of the gastric tube used for reconstruction after esophagectomy for cancer. The first case gastric cancer was detected during follow-up by endoscopic examination. Total resection of the gastric tube and reconstruction by Roux-en-Y was performed each time. The patient was alive and disease-free 1 year after surgery. In the second case the tumor was revealed via thoracic pain. Chemotherapy, using carboplatin-5-fluorouracil, was performed because of lung metastasis but the patient died 1 year later. The incidence of gastric tube cancer after esophagectomy has recently increased in conjunction with the lengthening of survival of esophageal cancer patients. The clinical symptoms related to tumors are associated with short-term survival, whereas the cancers detected by routine endoscopy screening have occasional long-term survival. Gastrectomy is proposed for surgical treatment but the operating procedure is complex with a high morbidity rate. Lesions detected at an early stage could be treated by minimally invasive surgery such as endoscopic mucosal resection.     

Video-assisted thoracolaparoscopic esophagectomy: the experience of Shanghai Chest Hospital

The traditional open esophagectomy is associated with higher morbidity, while minimally invasive procedures could be accompanied with a lower one. In this case, the patient is placed in the prone-decubitus position and the surgeon stands in front of the patient. The “four ports” approach is adopted in the thoracoscopic procedure with CO₂ insufflation, and the esophagus and lymph nodes are dissected. In the laparoscopic procedure, “hand assistant technique” is employed. The esophagogastric anastomosis is similar with McKeown procedure.KEYWORDS : Esophageal cancer, esophagectomy, thoracoscopy, laparoscopy     

Optimal surgical approach for esophageal cancer in the era of minimally invasive esophagectomy and neoadjuvant therapy

The optimal surgical technique for the potentially curative treatment of patients with esophageal cancer is still under debate. The transhiatal esophagectomy (THE) with limited lymphadenectomy mainly focuses on a decrease of postoperative morbidity and mortality by preventing a formal thoracotomy. The transthoracic esophagectomy (TTE) with extended two‐field lymphadenectomy attempts to improve the radicality of the resection and thus to increase locoregional tumor control, but is associated with increased postoperative morbidity. The recent introduction of different minimally invasive techniques probably decreases postoperative morbidity following TTE, with reduction of especially pulmonary complications, but high‐quality evidence is still limited. It is widely agreed that extended lymphadenectomy as performed during TTE provides the benefit of more accurate staging, but its effect on improvement of survival is still debated. The literature on this topic is contradictory and the choice of surgical approach is primarily driven by personal opinions and institutional preferences. Moreover, the available evidence is mainly based on patients who underwent surgery alone without neoadjuvant therapy. Results of recent studies suggest that neoadjuvant chemoradiotherapy abolishes any possibly positive effect of extended lymphadenectomy as performed during TTE on survival, but this effect should be confirmed in future research. This review gives an overview and reflects the authors' personal view on the role of TTE and THE in the treatment of potentially curative treatment of patients with locally advanced esophageal cancer in the era of minimally invasive esophagectomy and neoadjuvant treatment and outlines future research perspectives.     

Intestinal interposition for benign esophageal disease

Opinion statement Various options exist for intestinal interposition for benign, but debilitating, end-stage esophageal disorders. Principally, the stomach, colon, or jejunum is used for esophageal replacement. Much debate exists regarding the ideal esophageal replacement option. The conduit choice must be tailored to the individual patient. Unlike malignant processes, the conduit choice for benign disorders must be sufficiently durable and functional. Colonic interposition meets both criteria. However, this operative procedure’s technical difficulty increases the complexity of this already challenging clinical problem, as seemingly small errors in judgment and technique can significantly impact graft viability and long-term function. Using a gastric tube also provides durability and functionality, but with an operative procedure that is less technically demanding. A minimally invasive laparoscopic transhiatal esophagectomy offers the patient even more benefit in terms of shorter operative times and intensive care unit and recovery periods. However, the advent of surgical robotic technology augments these benefits even further. Robotic technology arms the surgeon with improved dexterity and three-dimensional visualization. These revolutionary improvements allow the surgeon to overcome many of the operative limitations that exist with the open and minimally invasive approaches to esophagectomy, thus potentially offering patients reduced morbidity and mortality rates.     

Comparison of the short‐term quality of life in patients with esophageal cancer after subtotal esophagectomy via video‐assisted thoracoscopic or open surgery

For patients with esophageal cancer, radical surgical resection of the esophagus and surrounding lymph nodes is the only curative treatment option. The conventional open esophagectomy has the disadvantage of extensive trauma and slow recovery. Recently, video‐assisted thoracoscopic surgery (VATS) has been applied in esophagectomy, and it appears to have better outcome preliminarily. In this study, we compared the short‐term quality of life (QOL) in patients with esophageal cancer after subtotal esophagectomy via VATS or open surgery. A total of 56 patients who underwent three‐incision esophagectomy by the same surgical group from January 2007 to February 2008 were enrolled in this retrospective study. Twenty‐seven patients followed VATS (VATS group) and 29 patients followed open surgery (open group). The EORTC core questionnaire (QLQ C‐30) together with esophageal‐specific module (OES‐18) were applied to assess the short‐term QOL of the patients before and 2, 4, 16, 24 weeks after operation. In result, all of the global quality scale, functioning scale, general symptom scales (or items) did not show differences before operation between the two groups. Further, the scores of global quality and physical functioning were higher in VATS group than in open group overall after operation, however, the scores of fatigue, pain, dyspnea were lower inversely. In conclusion, VATS shows an overall benefit on QOL for the patients with esophageal cancer during the follow‐up of six month after esophagectomy, compared with open surgery.     

Salvage esophagectomy after exclusive chemoradiotherapy: results at the Brazilian National Cancer Institute (INCA)

Surgical resection is considered the gold standard treatment for esophageal cancer, with global cure rates ranging from 15 to 40%. Exclusive chemoradiotherapy has been used for patients with locally advanced esophageal carcinoma or without clinical conditions for esophagectomy, reaching a 5‐year survival rate of up to 30%. However, locoregional control is poor, with local recurrence of 40–60%, being reported in the literature. Maybe, these patients can benefit from salvage surgery. In this study, 15 patients with esophageal cancer submitted to salvage esophagectomy after exclusive chemoradiotherapy treatment were retrospectively analyzed. Salvage esophagectomy was demonstrated to be technically feasible. However, it presents with high surgical morbidity. Currently, salvage esophagectomy is considered the best available treatment to attempt cure in cases of tumor recurrence or persistence after exclusive chemoradiotherapy. All the other types of treatments are regarded as palliative with discouraging survival results.     

Esophageal verrucous carcinoma arising from hyperkeratotic plaques associated with human papilloma virus type 51

Esophageal verrucous carcinoma is a rare variant of esophageal squamous cell carcinoma. We report a case of esophageal verrucous carcinoma associated with human papilloma virus (HPV) type 51. The patient had long‐standing dysphagia and odynophagia, and white esophageal plaques showing hyperkeratosis on biopsy. At repeat endoscopy, the esophagus was covered with verrucous white plaques and areas of nodular mucosa with white fronds, with a distal 10‐cm smooth mass protruding into the lumen. Biopsies demonstrated an atypical squamoproliferative lesion but no frank malignancy. HPV type 51 DNA was detected in endoscopic biopsy specimens by polymerase chain reaction. Because the size of the lesion favored an underlying verrucous carcinoma, our patient underwent minimally invasive esophagectomy with gastric pull‐up and cervical anastomosis. The pathologic diagnosis was a well‐differentiated esophageal verrucous carcinoma. One year after esophagectomy, the patient feels well and is free of disease. Although HPV DNA was not detected in the cancer tissue obtained at surgery, our case suggests an association between HPV type 51 and esophageal verrucous carcinoma. The clinical evolution in this case highlights the importance of endoscopic surveillance in patients with exuberant esophageal hyperkeratosis, and of definitive surgical resection when malignancy is suspected even if frank malignancy is not demonstrated on superficial biopsies.