Minimally invasive esophagectomy

Esophageal resection is associated with a high morbidity and mortality rate. Minimally invasive esophagectomy (MIE) might theoretically decrease this rate. We reviewed the current literature on MIE, with a focus on the available techniques, outcomes and comparison with open surgery. This review shows that the available literature on MIE is still crowded with heterogeneous studies with different techniques. There are no controlled and randomized trials, and the few retrospective comparative cohort studies are limited by small numbers of patients and biased by historical controls of open surgery. Based on the available literature, there is no evidence that MIE brings clear benef its compared to conventional esophagectomy. Increasing experience and the report of larger series might change this scenario.     

Minimally invasive surgery for oesophageal cancer

Worldwide an increasing part of oncologic oesophagectomies is performed in a minimally invasive way. Over the past decades multiple reports have addressed the perioperative outcomes and oncologic safety of minimally invasive oesophageal surgery. Although many of these (retrospective) case–control studies identified minimally invasive oesophagectomy as a safe alternative to open techniques, the clear benefit remained subject to debate. Recently, this controversy has partially resolved due to the results of the first randomized controlled trial that compared both techniques. In this trial short-term benefits of minimally invasive oesophagectomy were demonstrated in terms of lower incidence of pulmonary infections, shorter hospital stay and better postoperative quality of life. However, the current lack of long-term data on recurrence rate and overall survival precludes a comprehensive comparison of minimally invasive and open oesophagectomy. Proclaiming minimally invasive oesophagectomy as the standard of care for patients with resectable oesophageal cancer would therefore be a premature decision.     

胸腹腔镜联合与常规三切口手术治疗食管癌的同期临床及远期预后对照研究

目的探讨和评价胸腹腔镜联合与常规三切口手术治疗食管癌的安全性、有效性以及远期临床疗效。方法回顾性分析2009年2月至2011年12月同期收治的行胸腹腔镜联合食管癌根治术（微创组,94例）与常规三切口开放食管癌根治术（开放组,89例）的食管癌患者的临床资料。结果两组患者年龄、性别、体质量等基本资料以及肿瘤位置及分期等临床资料具有可比性。两组总手术时间、淋巴结清扫数无明显差异,并发症如吻合口瘘、脓胸、乳糜胸、声带麻痹、胃排空障碍发生率以及二次手术率、病死率亦无统计学差异。但微创组术中出血量[（86．6±38．3）ml比（217．4±87．2）ml,P=0．000]及需输血人数（1．1％比6．7％,P=0．045）明显少于开放组,总并发症（23．4％比38．2％,P=0．030）、呼吸系统并发症（9．6％比27．0％,P=0．002）及心律失常（4．1％比12．4％,P=0．046）发生率也均有统计学差异。微创组术后住院时间较开放组时间明显缩短,差异有统计学意义[（13．9±7．5）d比（17．1±10．2）d,P：0．017）。术后中位随访时间（28．0±2．0）月（95％CI为24．2～31．8）,微创组和开放组患者生存率分别为44．2％和42．2％（P=0．954）,差异无统计学意义。结论胸腹腔镜联合手术治疗食管癌安全、有效,在完全切除肿瘤的同时具有明显微创优势,尽管远期生存期并无明显提高,但仍值得推广。     

Lymph node dissection in esophageal carcinoma: Minimally invasive esophagectomy vs open surgery

AIM: To compare lymph node dissection results of minimally invasive esophagectomy(MIE) and open surgery for esophageal squamous cell carcinoma.METHODS: We retrospectively reviewed data from patients who underwent MIE or open surgery for esophageal squamous cell carcinoma from January 2011 to September 2014. Number of lymph nodes resected, positive lymph node(p N+) rate, lymph node sampling(LNS) rate and lymph node metastatic(LNM) rate were evaluated. R E S U LT S : A m o n g 4 4 7 p a t i e n t s i n c l u d e d, 1 2 3 underwent MIE and 324 underwent open surgery. The number of lymph nodes resected did not significantly differ between the MIE and open surgery groups(21.1 ± 4.3 vs 20.4 ± 3.8, respectively, P = 0.0944). The p N+ rate of stage T3 esophageal squamous cell carcinoma in the open surgery group was higher than that in the MIE group(16.3% vs 11.4%, P = 0.031), but no differences was observed for stages T1 and T2 esophageal squamous cell carcinoma. The LNS rate at left para-recurrent laryngeal nerve(RLN) site was significantly higher for open surgery than for MIE(80.2% vs 43.9%, P 0.001), but no differences were noted at other sites. The LNM rate at left para-RLN site in the open surgery group was significantly higher than that in the MIE group, regardless of pathologic T stage. CONCLUSION: For stages T1 and T2 esophageal squamous cell carcinoma, the lymph node dissection result after MIE was comparable to that achieved by open surgery. However, the efficacy of MIE in lymphadenectomy for stage T3 esophageal squamous cell carcinoma, particularly at left para-RLN site, remains to be improved.     

Minimally invasive surgery for esophageal achalasia

INTRODUCTIONIdiopathic achalasia is a primary motor disorder characterized by incomplete relaxation of the lower esophageal sphincter and aperistalsis of the esophageal body secondary to loss of inhibitory ganglion cells in the myenteric plexus. It is unc…     

Transhiatal versus transthoracic esophagectomy for esophageal cancer

Esophageal cancer continues to represent a formidable challenge for both patients and clinicians. Relative 5-year survival rates for patients have improved over the past three decades, probably linked to a combination of improved surgical outcomes, progress in systemic chemotherapy and radiotherapy, and the increasing acceptance of multimodality treatment. Surgical treatment remains a fundamental component of the treatment of localized esophageal adenocarcinoma. Multiple approaches have been described for esophagectomy, which can be thematically grouped under two major categories: either transthoracic or transhiatal. The main controversy rests on whether a more extended resection through thoracotomy provides superior oncological outcomes as opposed to resection with relatively limited morbidity and mortality through a transhiatal approach. After numerous trials have addressed these issues, neither approach has consistently proven to be superior to the other one, and both can provide excellent short-term results in the hands of experienced surgeons. Moreover, the available literature suggests that experience of the surgeonand hospital in the surgical management of esophageal cancer is an important factor for operative morbidity and mortality rates, which could supersede the type of approach selected. Oncological outcomes appear to be similar after both procedures.     

Minimally invasive esophagectomy: evaluation of mediastinal lymphadenectomy for T1b thoracic esophageal cancer

Background  

Patients undergoing minimally invasive esophagectomy (MIE) may benefit from lower respiratory complications and total morbidity compared with those undergoing open transthoracic esophagectomy (OTE) according to a recent meta-analysis. Local recurrence rates after MIE need to be determined for an assessment of complete resection. The aim of this study was to investigate whether MIE is effective for submucosal (T1b) esophageal cancer in terms of survival and morbidity.     

Minimally invasive pharyngo-laryngo-esophagectomy: a salvage procedure for recurrent postcricoid esophageal cancer

Hypopharyngeal and cervical esophageal tumors represent 5-10% of all esophageal neoplasms and are challenging for both surgeons and oncologists, because the choice of the adequate therapeutic strategy is not clearly defined and therefore difficult. In fact, although surgical treatment represents the gold standard of therapy, chemo-radiotherapy, previously used as adjuvant treatment, has been more recently adopted with curative intent, leaving to surgery a salvage role only. When surgery is required it is advisable to reduce patients' trauma. The present study reports on a personal technique for minimally invasive pharyngo-laryngo-esophagectomy and reconstruction with the whole stomach. We use a laparoscopic approach for mobilization of the stomach, transhiatal esophageal dissection and to follow transhiatal gastric transposition to the neck combined to a cervicotomy to perform pharyngo-laryngectomy, proximal esophageal mobilization, and pharyngo-gastric anastomosis. We performed this technique on four patients with recurrent disease after initially curative primary chemo-radiotherapy. Mean operative time was 345 min (range: 300-384). There were no intraoperative complications. All patients were extubated immediately after the operation and were managed in postoperative care unit for a mean time of 10 days (range: 7-12). Enteral nutrition was begun on post-operative day (POD) 1. The nasogastric tube and drainages were removed on POD 11, and patients immediately started oral nutrition. One patient had a TIA (transient ischemic attack) on POD 2. All patients were discharged within 20 days (18-20). Initial experience with this minimally invasive technique in selected patients is encouraging because it seems to minimize postoperative complications and allows early rehabilitation.     

Minimally invasive surgery for esophageal cancer]

Minimally invasive surgery is now rapidly developing and becoming a standard surgical option in some fields. In the past, many thoracic surgeons were reluctant to adopt minimally invasive techniques in esophageal cancer surgery due to concern over the oncologic perspectives and technical difficulties. However, over the last few years, thoracic surgeons have progressively embraced the technical advancements and now many experienced centers have adopt minimally invasive surgery as a primary option for non-advanced esophageal cancer operations. In esophageal cancer surgery, the volume of operation performed in some hospital is closely related to the outcome of patients, and the experiences of surgical team play an important role in minimally invasive surgery. Minimally invasive esophageal surgery (MIES) has steep learning curves, also. The merits of MIES are as follows. The conventional esophageal cancer operation has two or triple incisions, resulting in high postoperative morbidity and mortality. However, postoperative complication in MIES became less frequent than conventional surgery. The patient's satisfaction is high. Mid-term outcomes of MIES have been reported that it is safe and feasible in esophageal cancer and survival curves are similar to those of conventional surgery. Therefore, MIES is a valuable therapeutic modality for both esophageal cancer patients and thoracic surgeons.     

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.     

Esophageal intramural pseudodiverticulosis of the residual esophagus after esophagectomy for esophageal cancer

A 91-year-old man was referred to our hospital with intermittent dysphagia. He had undergone esophagectomy for esophageal cancer(T3N2M0 Stage Ⅲ) 11 years earlier. Endoscopic examination revealed an anastomotic stricture; signs of inflammation,including redness,erosion,edema,bleeding,friability,and exudate with white plaques; and multiple depressions in the residual esophagus. Radiographical examination revealed numerous fine,gastrografinfilled projections and an anastomotic stricture. Biopsy specimens from the area of the anastomotic stricture revealed inflammatory changes without signs of malignancy. Candida glabrata was detected with a culture test of the biopsy specimens. The stricture was diagnosed as a benign stricture that was caused by esophageal intramural pseudodiverticulosis. Accordingly,endoscopic balloon dilatation was performed and antifungal therapy was started in the hospital. Seven weeks later,endoscopic examination revealed improvement in the mucosal inflammation; only the pseudodiverticulosis remained. Consequently,the patient was discharged. At the latest follow-up,the patient was symptomfree and the pseudodiverticulosis remained in the residual esophagus without any signs of stricture or inflammation.     

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.     

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.     

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.     

Mediastinoscopy-assisted esophagectomy for thoracic esophageal cancer after right thoracotomy for lung cancer: report of two cases

We herein report two cases of thoracic esophageal cancer operated on by mediastinoscopy-assisted esophagectomy (MAE) via the neck and the esophageal hiatus after right thoracotomy for primary lung cancer. Case 1 was a 78-year-old man who had undergone a lower lobectomy of the right lung 5 years earlier and had also undergone a pleuroparietopexy for postoperative chylothorax via right thoracotomy again. A squamous cell carcinoma of the middle thoracic esophagus was detected by endoscopy. Although radiotherapy was performed on the patient, the esophageal tumor was locally recurrent. Thus, MAE was performed because it would have been difficult to approach the esophageal tumor by right thoracotomy again, and the patient was successfully treated. Case 2 was a 71-year-old-man who had undergone an upper lobectomy of the right lung 5 years earlier. For a squamous cell carcinoma located between the middle and lower esophagus, MAE was performed. Metastatic lymph nodes surrounding the middle and lower thoracic esophagus were sufficiently dissected. Although esophageal cancer patients with metachronous lung cancer are rare, therapeutic issues for these patients remain. MAE via the neck and the esophageal hiatus for esophageal cancer patients who had previously undergone a lobectomy of the right lung may be considered a tool for surgical approach. Furthermore, MAE may be considered to be a salvage operation such as in case 1.     

Three-dimensional vs two-dimensional video assisted thoracoscopic esophagectomy for patients with esophageal cancer

AIM: To define the benefits of three-dimensional video-assisted thoracoscopic esophagectomy(3D-VATE)over 2D-VATE for esophageal cancer.METHODS: A total of 93 patients with esophageal cancer including 45 patients receiving 3D-VATE and48 receiving 2D-VATE were evaluated. Data related to patient and cancer characteristics, operating time,intraoperative bleeding, morbidity and mortality,postoperative inflammatory markers, Numerical Rating Scale for postoperative pain, Constant-Murley rating system for shoulder recovery and oxygenation index(OI) were collected. All medical records were retrieved from a prospectively maintained oncological database at our institution. A retrospective study was performed to compare the short-term surgical outcomes between the two groups.RESULTS: No significant differences were found between the two groups in either morbidity or mortality(P = 0.328). An enhanced surgical recovery was noted in the 3D group as indicated by shortened thoracoscopic operation time(3D vs 2D: 68 ± 13.79 min vs 83 ± 13min, P 0.01), minor intraoperative blood loss(3D vs 2D: 68.2 ± 10.7 ml vs 89.8 ± 10.4 ml, P 0.01),earlier chest tube removal(3D vs 2D: 2.67 ± 1.01 vs3.75 ± 1.15 d, P 0.01), shorter length of hospital stay(3D vs 2D: 9.07 ± 2.00 vs 10.85 ± 3.40 d, P 0.01), lower in-hospital expenses(3D vs 2D: 74968.4± 9637.8 vs 86211.1 ± 8519.7 RMB, P 0.01), lower pain intensity(P 0.01) and faster recovery of the left shoulder function(P 0.01). Better preservation of the pulmonary function was also found in the 3D group as the decline of the OI post operation was significantly lower than that of the 2D group(P 0.01). Changes of postoperative inflammatory markers, including procalcitonin [postoperative days(PODs) 4 and 7: P 0.01], peripheral granulocytes(PODs 1, 4 and 7: P 0.01) and hypersensitive C-reactive protein(POD 4: P 0.01) in 3D-VATE patients were less than those in the 2D group. Moreover, utilization of the 3D technique extended the dissection of the thoracic lymph nodes(P 0.01), with better exposure of nodes in the left recurrent laryngeal nerve(P = 0.031).CONCLUSION: 3D-VATE could be a more viable technique over 2D-VATE in terms of short-term outcomes for patients with esophageal cancer.     

Bronchial bleeding caused by recurrent pneumonia after radical esophagectomy for esophageal cancer

We herein report a case of bronchial bleeding afterradical esophagectomy that was treated with lobectomy.A 65-year-old male who underwent subtotal esophagectomy with three-field lymph node dissection for esophageal carcinoma was referred to our hospital because of sudden hemoptysis.After the esophagectomy,bilateral vocal cord paralysis was observed,and the patient suffered from repeated episodes of aspiration pneumonia.Bronchoscopy revealed hemosputum in the right middle lobe bronchus,and contrast-enhanced computed tomography showed tortuous arteries arising from the right inferior phrenic artery and left subclavian artery toward the right middle lobe bronchus.Although bronchial arterial embolization was performed twice to control the recurrent hemoptysis,the procedures were unsuccessful.Right middle lobectomy was therefore performed via video-assisted thoracic surgery.Engorged bronchial arterys with medial hypertrophy and overgrowth of the small branches were noted near the bronchus in the resected specimen.The patient recovered uneventfully and was discharged on postoperative day 14.     

Delayed aortic rupture after radiochemotherapy and esophagectomy for esophageal cancer

SUMMARY Spontaneous rupture of major vessels is a known though rare complication in treatment of patients with esophageal cancer, but its pathophysiology is not very well understood. We herein report about the sudden death of a 42‐year‐old man due to spontaneous aortic rupture, 11 days after transthoracic esophagectomy. Because of a locally advanced squamous cell carcinoma of the distal esophagus, which was considered irresectable at the time of presentation, the patient had received one course of chemotherapy followed by synchronous chemoradiation (60 Gy, 5‐fluorouracil and cisplatin) prior to surgery. We discuss the patho‐anatomic findings of the postmortem examination concerning alterations of the aortic wall and the potential correlations with aggressive radiochemotherapy protocols.     

Minimally invasive esophagectomy versus open esophagectomy,a symptom assessment study

Minimally invasive esophagectomy (MIE) is used with hope to decrease the morbidity associated with an open esophagectomy. Reflux and dumping syndromes are the most important functional complaints in patients after esophagectomy. This study compares the functional benefits of MIE with open esophagectomy. The study enrolled patients who underwent either minimally invasive or open esophagectomy for cancer between 2004 and 2009. No patients in the MIE group had a pyloroplasty or myotomy. Each patient in the MIE group was paired to a patient in the open esophagectomy group via propensity matching. Matching variables included age, race, gender, preoperative treatment, history of prior cancer, American Society of Anesthesiologists Risk Scale, performance status, clinical stage, body mass index, histology, level of anastomosis, and time elapsed since surgery. The patients were asked to answer 26 questions about their reflux and dumping using validated questionnaires. A total of 181 patients were included in the study. From this group, 44 pairs of patients were created and used for the analysis. The median follow‐up was 12.1 months for the MIE group and 18.3 months for the open group. The reflux score was slightly worse in the MIE group (5.5 versus 3.5, P= 0.021). There was no difference in the dumping symptoms between the two groups. The most common complaints seen in the dumping questionnaire in almost one‐third of all patients were early satiety, abdominal discomfort, nausea, and diarrhea. Of the patients, 77% were satisfied or very satisfied with their condition in the MIE group compared with 93% in the open group (P= 0.287). Reflux, dumping, and overall satisfaction after MIE without pyloroplasty are comparable with those obtained after open esophagectomy with a pyloric drainage procedure.