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.     

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.     

Short‐term outcomes of robotic radical esophagectomy for esophageal cancer by a nontransthoracic approach compared with conventional transthoracic surgery

Transthoracic esophagectomy (TTE) is believed to have advantages for mediastinal lymphadenectomy in the treatment of resectable esophageal cancer despite its association with a greater incidence of pulmonary complications and postoperative mortality. Transhiatal esophagectomy is regarded as less invasive, though insufficient in terms of lymph node dissection. With the aim of achieving lymph dissection equivalent to that of TTE, we have developed a nontransthoracic esophagectomy (NTTE) procedure combining a video‐assisted cervical approach for the upper mediastinum and a robot‐assisted transhiatal approach for the middle and lower mediastinum. We prospectively studied 22 accumulated cases of NTTE and verified feasibility by analyzing perioperative and histopathological outcomes. We compared this group's short‐term outcomes with outcomes of 139 equivalent esophageal cancer cases operated on at our institution by conventional TTE (TTE group). In the NTTE group, there were no procedure‐related events and no midway conversions to the conventional surgery; the mean operation time was longer (median, 524 vs. 428 minutes); estimated blood loss did not differ significantly between the two groups (median, 385 mL vs. 490 mL); in the NTTE group, the postoperative hospital stay was shorter (median, 18 days vs. 24 days). No postoperative pneumonia occurred in the NTTE group. The frequencies of other major postoperative complications did not differ significantly, nor were there differences in the numbers of harvested mediastinal lymph nodes (median, 30 vs. 29) or in other histopathology findings. NTTE offers a new radical procedure for resection of esophageal cancer combining a cervical video‐assisted approach and a transhiatal robotic approach. Although further accumulation of surgical cases is needed to corroborate these results, NTTE promises better prevention of pulmonary complications in the management of esophageal cancer.     

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.     

Intraoperative esophagoscopy provides accuracy and safety in video‐assisted thoracoscopic enucleation of benign esophageal submucosal tumors

Benign esophageal tumors are rare; complete surgical resection is essential for the management of the submucosal tumors. Larger, symptomatic, or non‐diagnostic lesions should be resected for both diagnostic and therapeutic indications. Video‐assisted thoracic surgery has become a popular treatment in the field of thoracic surgery; however, thoracoscopic esophageal surgery may lead to an increase in operative complications. The effect and safety of thoracoscopic surgery for esophageal submucosal lesions were evaluated. A retrospective study evaluated patients undergoing thoracoscopic treatment of benign submucosal tumors. Between March 2011 and December 2013, 17 patients underwent thoracoscopic resection of benign submucocal tumors. Intraoperative esophagoscopy was performed for tumor localization by transillumination and confirmation of mucosal integrity after enucleation in every patient. Median patient age was 47 years (range 30–65). The median surgery time was 170 minutes (range 80–429). The median tumor size was 3.8 cm (range 1.3–9). The median hospital stay was 4 days (range 2–12). There were 16 leiomyoma and 1 neurogenic tumor. There was one case of conversion to thoracotomy because of residual tumor after enucleation. Mucosal injuries occurred in three patients, two accidentally and one intentionally; each patient was treated with primary repair and confirmed integrity with flexible esophagoscopy at operating room. The small sized tumor with intraoperative esophagoscopy could be localized. Esophagoscopic assistance was necessary in eight patients to have better idea where to make myotomy. There were no major morbidities such as postoperative leakage or mortality. Esophageal submucosal tumors can be treated safely with thoracoscopic surgery. However, intraoperative esophagoscopy allows accurate tumor localization, direction of esophageal access incision, and decreases complications during VATS enucleation of esophageal submucosal tumors.     

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.     

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.     

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.     

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).     

Hybrid minimally invasive esophagectomy for cancer: impact on postoperative inflammatory and nutritional status

The purpose of this case–control study was to evaluate the impact of hybrid minimally invasive esophagectomy for cancer on surgical stress response and nutritional status. All 34 consecutive patients undergoing hybrid minimally invasive esophagectomy for cancer at our surgical unit between 2008 and 2013 were retrospectively compared with 34 patients undergoing esophagectomy with open gastric tubulization (open), matched for neoadjuvant therapy, pathological stage, gender and age. Demographic data, tumor features and postoperative course (including quality of life and systemic inflammatory and nutritional status) were compared. Postoperative course was similar in terms of complication rate. Length of stay in intensive care unit was shorter in patients undergoing hybrid minimally invasive esophagectomy (P = 0.002). In the first postoperative day, patients undergoing hybrid minimally invasive esophagectomy had lower C‐reactive protein levels (P = 0.001) and white cell blood count (P = 0.05), and higher albumin serum level (P = 0.001). In this group, albumin remained higher also at third (P = 0.06) and seventh (P = 0.008) postoperative day, and C‐reactive protein resulted lower at third post day (P = 0.04). Hybrid minimally invasive esophagectomy significantly improved the systemic inflammatory and catabolic response to surgical trauma, contributing to a shorter length of stay in intensive care unit.     

A prospective comparison of totally minimally invasive versus open Ivor Lewis esophagectomy

The majority of esophagectomies in Western parts of the world are performed by a transthoracic approach reflecting the prevalence of adenocarcinoma of the lower esophagus or esophagogastric junction. Minimally invasive esophagectomy (MIE) has been reported in a variety of formats, but there are no series that directly compare totally minimally invasive thoracolaparoscopic 2 stage esophagectomy (MIE‐2) with open Ivor Lewis (IVL). A prospective single‐center cohort study of patients undergoing elective MIE‐2 or IVL between January 2005 and November 2010 was performed. Short‐term clinicopathologic outcomes were recorded using validated systems. One hundred and six patients (median age 66, range 36–85, 88 M : 18 F) underwent two‐stage esophagectomy (53 MIE‐2 and 53 IVL). Patient demographics (age, sex, body mass index, American Society of Anesthesiologists grade, tumor characteristics, neoadjuvant chemotherapy, and TNM stage) were comparable between the two groups. Outcomes for MIE‐2 and IVL were comparable for anastomotic leak rates (5 [9%] vs. 2 [4%], P= 0.241), resection margin clearance (R0) (43 [81%] vs. 38 [72%], P= 0.253), median lymph node yield (19 vs. 18, P= 0.584), and median length of stay (12 [range 7–91] vs. 12 [range 7–101] days), respectively. Blood loss was significantly less for MIE‐2 compared with IVL (median 300 [range 0–1250] mL vs. 400 [range 0–3000] mL, respectively, P= 0.021). MIE‐2 in this series of selected patients supports its efficacy, when performed by an experienced minimally invasive surgical team. A well‐designed multicenter trial addressing clinical effectiveness is now required.     

Mediastinoscopic esophagectomy for patients with early esophageal cancer

Objective

The purpose of this study was to detect the feasibility, safety, and effectiveness of mediastinoscopic esophagectomy for early esophageal cancer.

Methods

The clinical data of 194 patients who underwent mediastinoscopic esophagectomy for early esophageal cancer in our center from December 2005 to October 2014 were retrospectively analyzed.

Results

All the surgery was performed successfully. The average duration of thoracic surgery was 48.2±7.8 min and the average intra-operative blood loss was 128.1±34.5 mL. An average of 3.1±1.6 lymph node stations were dissected, with an average number of dissected lymph nodes being 9.38±6.2, among which 4.2±5.4 were mediastinal lymph nodes. No peri-operative mortality was noted, and the rate of peri-operative morbidity was 13.4%. The median duration of follow-up was 39 [3-108] months, and the overall survival was 72.73%. The overall survival rates significantly differed among different T stages; more specifically, the 5-year survival was 95.23% in patients with stage T_1a esophageal cancer, 70.15% for T_1b, and 55.56% for T₂ (P<0.001). The overall survival was significantly better in patients with negative lymph nodes than those with lymph nodes metastasis (P=0.003); more specifically, the 5-year survival rate was 84.9% for N₀, 62.5% for N₁, and 50.0% for N₂ + N₃.

Conclusions

The mediastinoscopic esophagectomy can achieve a similar effectiveness as the conventional thoracoscopic surgery for patients with early stage esophageal cancer.     

Outcomes of laparoscopic‐assisted transhiatal esophagectomy for adenocarcinoma of the esophagus and esophago‐gastric junction

Esophagectomy is associated with substantial morbidity and mortality, yet it is the only modality that offers the possibility of cure for esophageal and gastroesophageal junction (E‐GEJ) adenocarcinoma. Several minimally invasive techniques have been developed to decrease the morbidity of the operation, but to date, the results have not led to its wide adoption in part due to their complexity. We developed a technique of laparoscopic‐assisted transhiatal esophagectomy (LA‐THE) with the idea of preserving some of the advantages of the minimally invasive approach while eliminating the degree of complexity and the time required to complete the operation solely using laparoscopy. The course of all patients who underwent LA‐THE for E‐GEJ adenocarcinoma at the University of Washington Medical Center was determined by analysis of all hospital records to determine perioperative variables, complications, and survival. Patients were also given a follow‐up survey in order to assess long‐term health‐related quality of life (Gastrointestinal Quality of Life Index or GIQLI). Seventy‐two patients underwent LA‐THE between 1995 and 2007. Median age was 64 years (range, 42–83 years), and the median body mass index was 28 (range 17–35). Twenty‐eight tumors (39%) were categorized as Siewert I, 41 (57%) as Siewert II, and 3 (4%) as Siewert III. Median operative time was 299 min (range, 212–700 min). All the resections were R‐0. The median number of lymph nodes harvested was 11 (range, 2–32). Using the Dindo‐Clavien classification of surgical complication, we had a total of 48 postoperative complications in 37 patients: 26 (53%) grade I, 20 (41%) grade II, 1 (2%) grade IIIb, 1 (2%) grade IVb, and 1 (2%) grade V complications. Median length of hospital stay was 9 days (range, 7–58 days). One patient (1.4%) died within 30 days. Overall, 3‐ and 5‐year survival (calculated Kaplan–Meier) was 68% and 63%, respectively. Forty‐nine patients (90% of those still alive) answered the GIQLI survey. Median follow‐up was 26 months (range, 6–144 months). The mean GIQLI score was 108 (range, 74–138) from a maximum possible value of 144. Our study shows that LA‐THE is feasible, safe, and effective in the treatment of adenocarcinoma of the esophagus and GEJ and should probably be considered an alternative to open esophagectomy and other minimally invasive techniques in the treatment of this disease.     

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.     

Radical minimally invasive esophagectomy for esophageal cancer via transcervical and transhiatal approaches: a narrative review

ObjectiveMinimally invasive esophagectomy (MIE) has been widely applied for the treatment of esophageal carcinoma. It is much less invasive, as it avoids employing a transthoracic procedure.BackgroundMIE via transcervical and transhiatal approaches has been adopted in our center. In this approach, with the assistance of single-port techniques or robotic-assisted surgical systems, the esophagus is mobilized under visualization, which is followed by the removal of esophageal and mediastinal lymph nodes.MethodsIncreasing the surgical space by mediastinal insufflation or by elevation of the sternum with a hook may improve intraoperative identification of tissues and facilitate intraoperative mobilizations. The procedure can be performed simultaneously via both cervical and abdominal approaches without the need for intraoperative turning of the patient, which shortens the operative time. Also, there is no need for thoracotomy or single-lung ventilation, which avoids disturbance to the respiratory and circulation systems.ConclusionsSuitable instruments, especially state-of-the-art energy instruments, facilitate surgical separation and hemostasis. This surgical procedure has become increasingly sophisticated over the past decade, and its modular operation has been widely recognized. The feasible place of the neck-esophageal hiatus rendezvous is on the left main bronchus around the subcarinal region. Here we describe the technical features, key steps, and necessary precautions of this minimally invasive surgery for esophageal carcinoma.     

Robot‐assisted thoracoscopic esophagectomy with extensive mediastinal lymphadenectomy: experience with 114 consecutive patients with intrathoracic esophageal cancer

The study aims to report the operative outcomes of robot‐assisted thoracoscopic esophagectomy (RATE) with extensive mediastinal lymphadenectomy (ML) for intrathoracic esophageal cancer. We analyzed a prospective database of 114 consecutive patients who underwent RATE with lymph node dissection along recurrent laryngeal nerve (RLN) followed by cervical esophagogastrostomy. The study included 104 men with a mean age of 63.1 ± 0.8 years. Of these, 110 (96.5%) had squamous cell carcinoma, and the location of the tumor was upper esophagus in 7 (6.1%), middle in 62 (54.4%), and lower in 45 (39.5%). Preoperative concurrent chemoradiation was performed in 15 patients (13.2%). All but one patient underwent successful RATE, and R0 resection was achieved in 111 patients (97.4%). Extended ML and total ML were performed in 24 (21.1%) and 90 (78.9%) patients, respectively. Total operation time was 419.6 ± 7.9 minutes, and robot console time was 206.6 ± 5.2 minutes. The mean number of total, mediastinal, and RLN nodes was 43.5 ± 1.4, 24.5 ± 1.0, and 9.7 ± 0.7, respectively. The most common complication was RLN palsy (30, 26.3%), followed by anastomotic leakage (17, 14.9%) and pulmonary complications (11, 9.6%). Median hospital stay was 16 days, and 90‐day mortality was observed in three patients (2.5%). On multivariate analysis, preoperative concurrent chemoradiation was a risk factor for pulmonary complications (odds ratio 7.42, 95% confidence interval 1.91–28.8, P = 0.004). RATE with extensive ML could be performed safely with acceptable postoperative outcomes. Long‐term survival data should be followed in the future to verify the oncological outcome of the procedure.