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.     

Cost-Effectiveness of Minimally Invasive Versus Open Esophagectomy for Esophageal Cancer

Background

A recent randomized trial comparing minimally invasive (MIE) and open esophagectomy for esophageal cancer reported improved short-term outcomes. However, MIE has increased operative costs, and it is unclear whether the short-term benefits of MIE outweigh the increased operative costs. Therefore, the objective of this study was to determine the cost-effectiveness of MIE compared to open esophagectomy for esophageal cancer.

Methods

A decision-analysis model was developed to estimate the expected costs and outcomes after MIE and open esophagectomy from a health care system perspective with a time horizon of 1 year. Costs were represented in 2012 Canadian dollars, and effectiveness was measured in quality-adjusted life-years (QALYs). Probabilistic sensitivity analysis assessed parameter uncertainty.

Results

MIE was estimated to cost $1641 (95 % confidence interval 1565, 1718) less than open esophagectomy, with an incremental gain of 0.022 QALYs (95 % confidence interval 0.021, 0.023). MIE was therefore dominant over open esophagectomy. On deterministic sensitivity analyses, the results were most sensitive to variations in length of stay. Probabilistic sensitivity analysis demonstrated the robustness of the base case result, with 66, 77, and 82 % probabilities of cost-effectiveness at willingness-to-pay thresholds of $0/QALY, $50,000/QALY, and $100,000/QALY, respectively.

Conclusions

MIE is cost-effective compared to open esophagectomy in patients with resectable esophageal cancer.     

Immunological Changes After Minimally Invasive or Conventional Esophageal Resection for Cancer: A Randomized Trial

Background

This study was performed as a substudy analysis of a randomized trial comparing conventional open esophagectomy [open surgical technique (OE)] by thoracotomy and laparotomy with minimally invasive esophagectomy [minimally invasive procedure (MIE)] by thoracoscopy and laparoscopy. This additional analysis focuses on the immunological changes and surgical stress response in these two randomized groups of a single center.

Methods

Patients with a resectable esophageal cancer were randomized to OE (n = 13) or MIE (n = 14). All patients received neoadjuvant chemoradiotherapy. The immunological response was measured by means of leukocyte counts, HLA-DR expression on monocytes, the acute-phase response by means of C-reactive protein (CRP), interleukin-6 (IL-6), and interleukin-8 (IL-8), and the stress response was measured by cortisol, growth hormone, and prolactin. All parameters were determined at baseline (preoperatively) and 24, 72, 96, and 168 h postoperatively.

Results

Significant differences between the two groups were seen in favor of the MIE group with regard to leukocyte counts, IL-8, and prolactin at 168 h (1 week) postoperatively. For HLA-DR expression, IL-6, and CRP levels, there were no significant differences between the two groups, although there was a clear rise in levels upon operation in both groups.

Conclusion

In this substudy of a randomized trial comparing minimally invasive and conventional open esophagectomies for cancer, significantly better preserved leukocyte counts and IL-8 levels were observed in the MIE group compared to the open group. Both findings can be related to fewer respiratory infections found postoperatively in the MIE group. Moreover, significant differences in the prolactin levels at 168 h after surgery imply that the stress response is better preserved in the MIE group. These findings indicate that less surgical trauma could lead to better preserved acute-phase and stress responses and fewer clinical manifestations of respiratory infections.     

Endoscopic pyloric balloon dilatation obviates the need for pyloroplasty at esophagectomy

Background

Because the rate of acquired pyloric stenosis (APS) from truncal vagotomy is 15%, many surgeons perform pyloroplasty or pyloromyotomy at the time of esophagectomy. Endoscopic pyloric balloon dilatation (EPBD) is another method to manage APS. This study evaluated a cohort treated with preoperative EPBD.

Methods

This is a retrospective review of all patients treated with preoperative EPBD and esophagectomy for cancer from 2002 to 2009 at Brigham and Women’s Hospital, a tertiary care center. Outcome measures included need for subsequent surgery for gastric outlet obstruction, rate of pyloric stenosis noted on postoperative endoscopy, and complications.

Results

Upon review of the series, 25 patients (80% male; median age, 63 [range 47–81] years) had outpatient preoperative EPBD and esophagectomies 1–2?weeks later and were included in the study. None had pyloroplasties or pyloromyotomies at the time of esophagectomy. Selected patients had postoperative endoscopy. Of the 25 patients, 20 had transhiatal esophagectomies, 3 had thoracoabdominal esophagectomies, and 2 had VATS 3-hole esophagectomies. Median follow-up time was 22 (range, 1–84) months. There were no complications from EPBD. There were no postoperative deaths. No patient needed a second operation for gastric outlet obstruction. All patients had postoperative barium swallows (BaS) or endoscopy or both. Only one patient (4%) required one postoperative EPBD to dilate a 16-mm pylorus. Three others had delayed gastric emptying on BaS with endoscopy showing each pylorus was wide open. Their symptoms improved with time.

Conclusions

In this cohort, preoperative EPBD in all patients combined with postoperative EPBD in one patient obviated the need for pyloroplasty. This approach merits further study in a larger cohort, particularly to determine whether preoperative EPBD is necessary or if only selected postoperative EPBD is sufficient.     

Comparing outcomes after transthoracic and transhiatal esophagectomy: a 5-year prospective cohort of 17,395 patients

BACKGROUND: Debate continues over whether transhiatal esophagectomy (THE) offers decreased morbidity and mortality compared with transthoracic esophagectomy (TTE). To definitively answer this question, we used the Nationwide Inpatient Sample database to compare morbidity and mortality after THE and TTE. STUDY DESIGN: Using ICD-9 procedure codes, we queried the Nationwide Inpatient Sample database for patients undergoing THE and TTE. Multivariate statistical analysis was completed to compare morbidity, mortality, length of stay, and hospital volume analysis between the groups. RESULTS: Between 1999 and 2003, 17,395 patients included in the Nationwide Inpatient Sample underwent esophagectomy. Mean patient age was similar in those undergoing THE and TTE (61.9 versus 62.0 years, respectively). Overall morbidity and mortality after esophagectomy were 50.7% and 8.8%, respectively. In-hospital mortality after THE was 8.91% compared with 8.47% after TTE (p=0.642). Multivariate regression analysis showed no difference in the incidence of mediastinitis, wound, infectious, pulmonary, gastrointestinal, cardiovascular, systemic, procedure-related, or overall complications or hospital length of stay between the two groups. Controlling additionally for hospital volume showed high-volume centers (more than 10 esophagectomies per year) had significantly lower mortality rates than low-volume centers (10 or fewer esophagectomies per year, p=0.024). Additionally, low-volume centers have a higher incidence of gastrointestinal and systemic complications in the TTE group (p=0.048 and p=0.038, respectively). CONCLUSIONS: This large-volume, multicenter study constitutes the largest cohort in the literature to compare outcomes after THE and TTE. These findings indicate the outcomes after THE and TTE for esophageal disease are equivalent, although higher-volume centers will have lower morbidity and mortality.     

Minimally invasive esophagectomy for esophageal cancer: an updated review

Purpose

The surgical, postoperative and oncologic outcomes of minimally invasive esophagectomy (MIE) for esophageal cancer were reviewed to clarify the benefits of this surgical modality.

Methods

A systematic literature search was performed using synonyms for minimally invasive or thoracoscopic esophagectomy. There were 18 retrospective cohort studies and 3 meta-analyses retrieved in this review.

Results

There are several minimally invasive approaches for esophageal cancer. Total MIE using both the thoracoscopic and laparoscopic approach is increasingly performed. A longer operative time and less blood loss are observed with MIE in comparison to open esophagectomy (OE). Although the benefit of MIE for reducing morbidity and mortality rates is still under debate, a shorter hospital stay was common among the studies. The oncologic outcomes of MIE were not inferior to OE, while the number of retrieved lymph nodes was greater in MIE than OE in several studies.

Conclusion

Total MIE using a combined thoracoscopic and laparoscopic approach can be performed safely, although the benefits for short-term outcomes are still controversial. Oncologic outcomes are favorable and MIE may have an advantage in lymph node dissection over OE. The benefits of MIE should therefore be confirmed by randomized controlled trials.     

Significance of Thoracoscopy-Assisted Surgery with a Minithoracotomy and Hand-Assisted Laparoscopic Surgery for Esophageal Cancer: The Experience of a Single Surgeon

Background

This retrospective study evaluated the surgical learning curve and outcomes of thoracolaparoscopic esophagectomy.

Patients and Methods

The study group comprised a series of 92 patients with preoperatively diagnosed resectable thoracic esophageal cancer. Additionally, the surgical outcomes in 79 esophageal cancer patients receiving open esophagectomies were compared. All patients underwent thoracolaparoscopic esophagectomy in the lateral decubitus position. The short- and long-term outcomes were evaluated, and the surgical learning curve was assessed.

Results

The total operation time was 477.8?±?102.2 min, the thoracoscopic time was 157.9?±?61.3 min, the total blood loss was 554.4?±?280.5 ml, and the number of retrieved lymph nodes was 34.3?±?14.3. Postoperative morbidity was observed in 23 patients. After the surgeon??s first 40 cases, the surgical technique and short-term outcomes were stable. The 5-year disease-specific survival was 66.6% and the 5-year overall survival was 64.6% in patients receiving R0 thoracolaparoscopic esophagectomy. Comparison of 5-year disease-specific survival rate according to tumor?Cnode?Cmetastasis stage between patients receiving R0 thoracolaparoscopic esophagectomy and conventional open esophagectomy showed that there were no significant differences in survival in any stage between the two groups. Loco-regional recurrence was observed in 6 patients, distant recurrence in seven, and combined recurrence in nine after R0 thoracolaparoscopic esophagectomy. There was no significant difference in the pattern of recurrence between the two groups.

Conclusions

Thoracolaparoscopic esophagectomy for esophageal cancer was technically feasible and oncologically satisfactory, according to the surgical learning curve.     

Clinical benefits of thoracoscopic esophagectomy in the prone position for esophageal cancer

Purposes

The clinical benefits of thoracoscopic radical esophagectomy in the prone position compared to conventional open esophagectomy have not been fully documented.

Methods

Forty-six patients with esophageal cancer who underwent MIE in the prone position (MIE-P group) were enrolled, and 46 case-matched controls that underwent open esophagectomy (OE group) were identified using propensity score methods to achieve a valid comparison of outcomes between MIE and open esophagectomy.

Results

The duration of systemic inflammatory response syndrome was shorter in the MIE-P group than in OE group (P = 0.005). The time to first walking was earlier in the MIE-P group (P < 0.001). Although the vital capacity ratio (%VC) declined after the operation in both groups, the change ratio of the %VC was 85.3 % in the MIE-P group and 69.6 % in the OE group (P < 0.001). No mortality occurred in either group. The postoperative morbidity rate was lower in the MIE-P group (13 %) than in the OE group (30.4 %) (P = 0.020). Two patients (4.3 %) in the OE group and one patient in the MIE-P group (2.2 %) had pneumonia.

Conclusions

MIE in the prone position was associated with less impairment of the pulmonary function, earlier recovery of activity and lower subsequent morbidity compared to open esophagectomy. Further investigation of the long-term outcomes is, therefore, needed.     

Assessment and Comparison of Recovery after Open and Minimally Invasive Esophagectomy for Cancer: An Exploratory Study in Two Centers

Background

Minimally invasive esophagectomy (MIE) may lead to early restoration of health-related quality of life, but few prospective comparative studies have been performed. This exploratory study compared recovery between totally minimally invasive esophagectomy (MIE), laparoscopically assisted esophagectomy (LAE) and open surgery (OE).

Methods

A prospective study in 2 specialist centers recruited consecutive patients undergoing OE, LAE, or MIE for high-grade dysplasia or cancer. Patients completed validated questionnaires, the Multi-Dimensional Fatigue Inventory (MFI-20), modified Katz Scale, and modified Lawton and Brody Scale (assessing activities of daily living) before and 6 weeks and 3 and 6 months after surgery.

Results

A total of 97 patients (26 women; median age 64 years) were scheduled for surgery that was abandoned in 11 due to occult low-volume metastatic disease. In the remaining 86 (OE = 19, LAE = 31, and MIE = 36), there were 4 in-hospital deaths (4 %), and 54 postoperative complications (OE = 12, LAE = 19, and MIE = 23). Overall questionnaire compliance was high (77 %) and baseline scores similar in all groups, although clinical differences between groups were observed with earlier tumors and more squamous cell cancers selected for MIE. Following surgery fatigue levels increased dramatically and activity levels reduced in all groups. These gradually recovered to baseline following MIE and LAE within 6 months, but the ability to perform activities of daily living and most parameters of fatigue had not returned to baseline levels in the OE group.

Conclusions

This exploratory prospective nonrandomized study of recovery after different types of surgery for esophageal cancer showed possible small benefits to MIE. A much larger study is needed to confirm these findings.     

Impact of comorbidity on outcomes and overall survival after open and minimally invasive esophagectomy for locally advanced esophageal cancer

Background

The aim of this study was to examine the impact of the Charlson Comorbidity Index-Grade (CCI-G) on predicting outcomes and overall survival after open and minimally invasive esophagectomy (MIE).

Methods

One hundred and forty-six patients who underwent esophagectomy between 1995 and 2011 for stage II and III cancer were selected and separated into open esophagectomy (Open) and MIE groups. Risk adjustment was performed using the CCI-G. The outcomes of interest were operative time, estimated blood loss (EBL), lymph node harvest, length of hospital stay (LOS), major complications, 30-day mortality, and overall survival.

Results

Sixty-four patients (44 %) underwent Open while 71 (49 %) had MIE. An additional (7 %) were converted and classified with MIE. There was no significant difference between MIE and Open in terms of operative time. MIE had less EBL (mean difference = 234 mL, p < 0.001), higher lymph node harvest (mean = 7.4 nodes, p < 0.001), and shorter LOS (median = 1.5 days, p = 0.02). Atrial arrhythmias were the most frequent complication, occurring in 33 % of patients in both the MIE and the Open group (p = 0.988). Thirty-day mortality was 2 % for MIE and 5 % for Open (p = 0.459). Five-year survival was 41 % for MIE and 33 % for Open (p = 0.513). Operative approach, age, gender, BMI, clinical stage, and neoadjuvant therapy did not have any significant effect on the outcomes or overall survival. CCI-G influenced outcomes with operative time, LOS, cardiovascular complication, and anastomotic leak rate, favoring CCI-G 0 compared to CCI-G 3. Overall survival was worse for CCI-G 1 in comparison with CCI-G 0 [hazard ratio (HR) 1.99, p = 0.027].

Conclusions

MIE is a safe alternative to open esophagectomy for the treatment of locally advanced esophageal cancer. The presence of comorbidities increased operative time, length of hospital stay, and postoperative complications while worsening overall survival.     

Evidence-Based Selective Application of Transhiatal Esophagectomy in a High-Volume Esophageal Center

Background  

Transthoracic esophagectomy (TTE) with lymphadenectomy represents the gold standard of operative approaches to esophageal cancer. The TTE procedure carries significant operative risk, particularly in patients with co-morbidities, and the possible oncologic benefit of a mediastinal lymph node dissection in certain subgroups of patients with esophageal cancer is controversial. Transhiatal esophagectomy (THE), which avoids a thoracotomy, may reduce morbidity and mortality below levels seen with TTE, and there is no proof from randomized studies of any oncologic inferiority to TTE in patients with early tumors. Accordingly, the selective use of THE has increased in our high-volume center in recent years, and this study audits that experience over the last decade     

Is there any benefit to incorporating a laparoscopic procedure into minimally invasive esophagectomy? The impact on perioperative results in patients with esophageal cancer

Background  

The benefit of using the laparoscopic approach in minimally invasive esophagectomy (MIE) has not been established. We therefore compared the outcome of esophagectomy for patients with esophageal cancer performed with open surgery, video-assisted thoracic surgery (VATS)/laparotomy (hybrid MIE), and VATS/ laparoscopy (total MIE).     

Minimally invasive esophagectomy for esophageal squamous cell carcinoma: a case–control study of thoracoscope versus mediastinoscope assistance

Objective

Minimally invasive esophagectomy (MIE) has been widely applied for esophageal carcinoma treatment. Thoracoscope-assisted transthoracic esophagectomy (TATTE) and mediastinoscope-assisted transhiatal esophagectomy (MATHE) are two kinds of MIE. The objective of this study is to compare these two methods with respect to surgical safety and survival.

Methods

Single-institution experience with MATHE and TATTE was analyzed to assess morbidity, adequacy of tumor clearance, and survival. A pair-matched case–control study was performed to compare 54 patients who underwent either MATHE or TATTE between July 2000 and December 2009. Patients were matched by age, sex, comorbidity, forced expiratory volume in 1?s (FEV1), tumor location, and stage.

Results

Statistically significant differences between the MATHE group and the TATTE group were: shorter operative time for MATHE (194.4?min) versus TATTE (228.1?min), less blood loss during operation in the TATTE group (142.6?ml) versus the MATHE group (214.6?ml), and more lymph nodes retrieved in the TATTE group (19.1 nodes) versus the MATHE group (11.4 nodes). There was no difference in survival between the groups.

Conclusions

MATHE and TATTE are both technically feasible. TATTE can provide better visibility. TATTE has less blood loss compared with MATHE. More adequate tumor clearance in terms of lymph node dissection can be achieved with TATTE.     

Outcomes following laparoscopic transhiatal esophagectomy for esophageal cancer

Background

Most published minimally invasive esophagectomy techniques involve a multiple field approach, including laparoscopic and thoracoscopic esophageal mobilization. Laparoscopic transhiatal esophagectomy (LTE) should potentially reduce the complications associated with thoracotomy. This study aims to compare outcomes of LTE with open transhiatal esophagectomy (OTE) and en-bloc esophagectomy (EBE).

Methods

Retrospective chart review was performed on all patients who had an LTE for cancer between July 2008 and July 2012 at our institution. Data was compared with an historic cohort of patients who underwent OTE and EBE at the same institution from July 2002 to July 2008.

Results

There were 33 patients with LTE, compared with 60 patients with OTE and 139 with EBE. The presence of minor operative complications was similar (p = 0.36), but major complications were significantly less common in the LTE group (12, 23 and 33 %, respectively; p = 0.04). The median number of blood transfusions during hospitalization was significantly lower in the LTE group (0, 2.5 and 3, respectively; p = 0.005). Median tumor size was significantly smaller (1.5, 2.2, and 3 cm, respectively; p = 0.03), but the LTE group had a significantly higher percentage of patients with neoadjuvant treatment (39, 14 and 29 %, respectively; p = 0.008). Median lymph node yield for LTE was lower (24, 36 and 48, respectively; p < 0.0001), but the percentage of patients with positive nodes was similar (33, 33 and 39 %, respectively; p = 0.69). Mortality was equivalent among the groups (0, 2 and 4 %, respectively; p = 0.38). The median LOS for the LTE group was significantly lower (10, 13 and 15 days, respectively; p < 0.0001). Overall survival was not different between the three groups (p = 0.65), with median survival at 24 months of 70, 65 and 65 %, respectively.

Conclusion

LTE can be performed safely with less major complications and shorter hospital stay than open esophagectomy. The reduced lymph-node harvest did not impact overall survival.     

Zero Leaks With Minimally Invasive Esophagectomy: a Team-Based Approach

Introduction:

Minimally invasive surgery has been applied in several ways to esophagectomy. Newer techniques have improved patient outcomes while maintaining oncological principles; however, mortality still exists. Most series have reported mortality rates ranging from 2% to 25%. The aim of this study was to determine the efficacy of minimally invasive esophagectomies (MIE) in a non-university tertiary care center.

Methods:

MIE in the form of a combined thoracoscopic and laparoscopic technique was performed cooperatively by 2 surgeons. Records of patients who underwent MIE between September 2005 and August 2008 were retrospectively reviewed.

Results:

Thirty-four patients underwent MIE over a 3-year period. There was a male predominance. Mean age at presentation was 62.6 years. Comorbidities were documented in 79% of the patients. Most patients (68%) presented with dysphagia. Two patients had end-stage achalasia, 1 had corrosive esophageal stricture, and 31 had esophageal malignancies. No mortalities were reported. No anastomotic leaks were observed. Eighteen (58%) patients with malignancy received preoperative chemoradiotherapy. Six (33%) patients had a pathological response (CR) on final histopathology. The mean operating time was 294 minutes. The mean blood loss was 302 mL.

Conclusions:

Minimally invasive esophagectomy can be performed with results that meet and exceed reported benchmarks. A team-based approach greatly impacts the outcome of the surgery. This surgical technique must be standardized to achieve this outcome.     

Open Versus Thoracoscopic Esophagectomy in Patients with Esophageal Squamous Cell Carcinoma

Background

The impact of minimally invasive esophagectomy on patient prognosis, particularly disease-free survival (DFS), has not been well addressed. We compared the clinical outcomes of open and thoracoscopic esophagectomy in patients with esophageal squamous cell carcinoma (ESCC).

Methods

Sixty-three and 66 patients, nonrandomized, underwent open and thoracoscopic esophagectomies for ESCC between 2008 and 2011 were included. The clinicopathological data were reviewed retrospectively. Perioperative outcome, overall survival (OS), DFS, and the recurrence sites after open and thoracoscopic esophagectomy were compared.

Results

The open and thoracoscopic groups were comparable with regard to the total number of harvested lymph nodes and the percentage patients undergoing R0 resection. Fewer patients in the thoracoscopic group had pneumonia and wound complications. Intensive care unit (ICU) stay also was shorter in the thoracoscopic group. The recurrence pattern was similar in the two groups. In the open and thoracoscopic groups, the 3-year OS rates were 47.6 and 70.9 % (p = 0.031), respectively, and the 3-year DFS rates were 35 and 62.4 % (p = 0.007), respectively. However, the trends in better OS and DFS in the thoracoscopic group were not significant after stratification according to pathologic stage.

Conclusions

The perioperative benefit of thoracoscopic esophagectomy included fewer postoperative complications and shorter ICU stays. Mid-term OS and DFS associated with thoracoscopic techniques are at least equivalent to those associated with open procedures.     

Centralization of Esophagectomy: How Far Should We Go?

Background

This study was designed to define a statistically sound and clinically meaningful cutoff point for annual hospital volume for esophagectomy. Higher hospital volumes are associated with improved outcomes after esophagectomy. However, reported optimal volumes in literature vary, and minimal volume standards in different countries show considerable variation. So far, there has been no research on the noncategorical, nonlinear, volume-outcome relationship in esophagectomy.

Methods

Data were derived from the Netherlands Cancer Registry. Restricted cubic splines were used to investigate the nonlinear effects of annual hospital volume on 6 month and 2 year mortality rates. Outcomes were adjusted for year of diagnosis, case-mix, and (neo)adjuvant treatment.

Results

Between 1989 and 2009, 10,025 patients underwent esophagectomy for cancer in the Netherlands. Annual hospital volumes varied between 1 and 83 year, increasing over time. Increasing annual hospital volume showed a continuous, nonlinear decrease in hazard ratio (HR) for mortality along the curve. Increasing hospital volume from 20 year (baseline, HR = 1.00) to 40 and 60 year was associated with decreasing 6 month mortality, with a HR of 0.73 (95 % confidence interval (0.65–0.83) and 0.67 (0.58–0.77) respectively. Beyond 60 year, no further decrease was detected. Higher hospital volume also was associated with decreasing 2 year mortality until 50 esophagectomies year with a HR of 0.86 (0.79–0.93).

Conclusions

Centralization of esophagectomy to a minimum of 20 resections/year has been effectively introduced in the Netherlands. Increasing annual hospital volume was associated with a nonlinear decrease in mortality up to 40–60 esophagectomies/year, after which a plateau was reached. This finding may guide quality improvement efforts worldwide.     

Transcervical videoscopic esophageal dissection in minimally invasive esophagectomy

Background  

Minimally invasive esophagectomy (MIE) may involve video-assisted thoracoscopic surgery (VATS) for mediastinal esophageal dissection. Usually, VATS requires single-lung ventilation and has associated cardiopulmonary morbidity [1–3]. Alternatively, transhiatal dissection can be performed, although its complications include vocal cord palsy [4], cardiac arrythmias [5], and increased bleeding [5, 6], the latter associated with mortality after esophagectomy [2]. Therefore, the feasibility of MIE using transcervical videoscopic esophageal dissection (TVED) in swine was investigated. A simultaneous laparoscopic and TVED approach may decrease operative time and blood loss while improving visualization and avoiding single-lung ventilation.     

The Incidence of Hiatal Hernia After Minimally Invasive Esophagectomy

Introduction

Minimally invasive esophagectomy (MIE) has evolved as a means to minimize the morbidity of an operation which is traditionally associated with a significant risk. However, this approach may have its own unique postoperative complications. In this study, we describe the incidence and outcomes of hiatal hernia in a cohort of MIE patients.

Methods

Clinical follow-up data on 114 patients who had undergone minimally invasive esophagectomy between 2003 and 2011 were retrospectively reviewed. Clinical presentation and computed tomography (CT) scans of the chest and abdomen were used to establish the diagnosis of hiatal herniation after minimally invasive esophagectomy. Age, gender, presenting complaint, comorbid conditions, clinical tumor stage, surgical specimen size, length and cost of hospital admissions, operation performed for hiatal herniation, and mortality were all recorded for analysis.

Results

Nine (8 %) of the 114 patients who underwent MIE had postoperative hiatal herniation. Five of these patients were asymptomatic. All patients except two who presented emergently were repaired laparoscopically on an elective basis. The average length of stay after hiatal hernia repair was 5.5 days (range 2–12) at an average charge of $40,785 (range $25,264–$83,953). At follow-up, one patient complained of symptoms associated with reflux.

Conclusion

Hiatal herniation is not a rare event after MIE. It is also associated with significant health-care cost and may be lethal. Most occurrences appear to be asymptomatic and, if detected, can be repaired with good resolution of symptoms, minimal associated morbidity, and no mortality.