Esophagectomy without thoracotomy: 25 years of experience over 750 patients

Single-Center Randomized Trial Comparing Feeding Jejunostomy with Nasojejunal Tube Placement in Patients Undergoing Transhiatal Esophagectomy Post-Neoadjuvant Therapy for Esophageal Cancer

BACKGROUND

Enteral nutrition is the preferred mode of nutrition following esophagectomy. However, the preferred mode of enteral nutrition (feeding jejunostomy (FJ) vs. nasojejunal (NJ) tube) remains contentious. In this randomized controlled trial (RCT), we compared FJ with NJ tube feeding in terms of safety, feasibility, efficacy, and quality-of-life (QOL) parameters in Indian patients undergoing trans-hiatal esophagectomy (THE) for carcinoma esophagus.

MATERIALS AND METHODS

This single-center, two-armed (FJ and NJ tube), non-inferiority RCT was conducted from March 2020 to January 2024. Forty-eight patients underwent THE with posterior-mediastinal-gastric pull-up and were randomized to NJ and FJ arms (24 in each group). The postoperative complications, catheter efficacy, and QOL parameters were compared between the two groups till the 6-week follow-up.

RESULTS

In this RCT, we found no significant difference in the occurrence of catheter-related complications, postoperative complication rate, catheter efficacy, and visual analog pain scores between patients with NJ tube and FJ, following THE for esophageal cancer. There was a significantly better self-reported physical domain QOL score noted in the NJ group, both at the time of discharge (44.7 ± 6.2 vs 39.8 + 5.6; p value, 0.005) and at the 6-week follow-up (55.4 ± 5.2 vs 48.6 ± 4.5; p value, < 0.001).

CONCLUSION

Based on the findings of our RCT, we conclude that both enteral access methods (NJ vs. FJ) exhibit comparable incidences of catheter-related complications. The use of NJ tube is a viable alternative to a surgical FJ, has the benefit of early removal, and saves the distress associated with a tube per abdomen.

Preoperative computed tomography predicts the risk of recurrent laryngeal nerve paralysis in patients with esophageal cancer undergoing thoracoscopic esophagectomy in the prone position

BACKGROUND

Recurrent laryngeal nerve paralysis (RLNP) after thoracoscopic esophagectomy for esophageal cancer (EC) is known to be a major complication leading to poor quality of life. RLNP is mainly associated with surgical procedures performed near the RLN. Therefore, with focus on the region of the RLN, we used preoperative computed tomography to investigate the risk factors of RLNP in patients with EC undergoing thoracoscopic esophagectomy.

METHODS

We retrospectively examined 77 EC patients who underwent thoracoscopic esophagectomy in the prone position at our department between January 2010 and December 2018. Bilateral cross-sectional areas (mm²) of the fatty tissue around the RLN at the level of the lower pole of the thyroid gland were measured on preoperative axial computed tomography (CT) images. Univariate and multivariate logistic regression analysis was used to evaluate the association between the incidence of RLNP and patient clinical factors, including the cross-sectional areas.

RESULTS

RLNP occurred in 24 of 77 patients (31.2%). The incidence of RLNP was significantly more frequent on the left side than on the right. (26% vs. 5.2%, respectively). Univariate analysis identified the following left RLNP risk factors: intrathoracic operative time (> 235 min), and area around the RLN (> 174.3 mm²). Multivariate analysis found that the area around the RLN was an independent risk factor of left RLNP.

CONCLUSION

An increased area around the RLN measured on an axial CT view at the level of the lower pole of the thyroid gland was a risk factor of RLNP in EC patients undergoing thoracoscopic esophagectomy in the prone position.

Case report of successful management of intraoperative tracheal rupture during thoracoscopic esophageal resection in patient with esophageal cancer

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Intraoperative ruptures of trachea during thoracoscopic esophageal resection are very serious complications.

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A 52-year-old woman had cancer of middle third of esophagus T3N1M0, stage IIIB.

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The woman underwent thoracoscopic esophageal resection with gastric tube plasty.

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Successful management of intraoperative tracheal and bronchial rupture with use of the intracorporeal suture.

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The patient had an uneventful, standard recovery and was discharged 12 days after the surgery.

Introduction

A rupture of the membranous part of trachea during thoracoscopic and transhiatal resection of esophagus is a rare complication that occurs in 0.4% of cases. This complication often requires thoracotomy and is associated with prolonged pulmonary ventilation, long-term pleural draining due to persistent air leakage and development of a tracheopleural fistula, prolonged hospitalization, and high risk of septic and secondary cardiorespiratory complications.

Presentation of case

A 52-year-old woman complained of difficulty eating solid food, impaired swallowing, persistent pain behind the sternum, nausea, sickness and weight loss. EGD revealed tumor almost completely obturating the lumen in the middle third of the esophagus. The histopathological examination showed esophageal SCC. CT scan confirmed 33 × 29 × 55 mm tumor. The patient underwent thoracoscopic esophageal resection during which two defects of the tracheobronchial tree with sizes of 15 mm and 30 mm were detected and then successfully sewn using intracorporeal continuous Stratafix 3.0 suture. The patient was diagnosed with cancer of middle third of esophagus pT3N1M0, stage IIIB.

Discussion

Thorough selection of patients undergoing thoracoscopic esophageal resection together with gentle manipulations with the esophagus in the area adjacent to the trachea can prevent intraoperative tracheobronchial damages. Timely diagnosis of such serious complications makes it possible to successfully manage them using thoracoscopic techniques.

Conclusion

Intraoperative tracheal and bronchial ruptures can be successfully managed with thoracoscopic intracorporeal suture.

MINIMALLY INVASIVE LAPAROSCOPIC ESOPHAGECTOMY VS. TRANSHIATAL OPEN ESOPHAGECTOMY IN ACHALASIA: A RANDOMIZED STUDY

BACKGROUND

Open and laparoscopic trans-hiatal esophagectomy has been successfully performed in the treatment of megaesophagus. However, there are no randomized studies to differentiate them in their results.

AIM

To compare the results of minimally invasive laparoscopic esophagectomy (EMIL) vs. open trans-hiatal esophagectomy (ETHA) in advanced megaesophagus.

METHOD

A total of 30 patients were randomized, 15 of them in each group - EMIL and ETHA. The studied variables were dysphagia score before and after the operation at 24-months follow-up; pain score in the immediate postoperative period and at hospital discharge; complications of the procedure, comparing each group. Were also studied: surgical time in minutes, transfusion of blood products, length of hospital stay, mortality and follow-up time.

RESULTS

ETHA group comprised eight men and seven women; in the EMIL group, four women and 11 men. The median age in the ETHA group was 47.2 (29-68) years, and in the EMIL group of 44.13 (20-67) years. Mean follow-up time was 33 months, with one death in each group, both by fatal aspiration. There was no statistically significant difference between the EMIL vs. ETHA scores for dysphagia, pain and in-hospital complications. The same was true for surgical time, transfusion of blood products and hospital stay.

CONCLUSION

There was no difference between EMIL and ETHA in all the studied variables, thus allowing them to be considered equivalent.

Current status of laparoscopic transhiatal esophagectomy for esophageal cancer patients: a systematic review of the literature

Minimally invasive techniques in transhiatal esophagectomy (THE) were introduced to reduce morbidity and enhance postoperative recovery. Aim of this study was to systematically review the current status and possible beneficial effects of the minimally invasive approach in THE. A systematic search was performed in PubMed, the Cochrane Library, and Embase to identify English articles published on laparoscopic THE. Comparative cohort studies were included for critical appraisal. Data describing perioperative and oncological outcomes were analyzed. A total of four comparative cohort studies that compared laparoscopic THE (n = 122) with open THE (n = 144) and four noncomparative cohort studies reporting on laparoscopic THE (n = 212) were included in this review. Median blood loss was significantly lower in the laparoscopic group in all studies (100-500 vs. 526-900 mL). Length of hospital stay was also significantly shorter for the laparoscopic approach in all studies (9-13 vs. 12-16 days). One study reported less major postoperative complications after laparoscopic THE (12 vs. 23%), in the other studies no differences were found. Also no differences were found with regard to operating time, postoperative morbidity, radicality, and lymph node retrieval. Based on these pioneer studies, laparoscopic THE was demonstrated to be safe and feasible with evidence of reduced blood loss and shorter hospital stays. However, level 1 evidence is lacking and further research is warranted to confirm these findings and also to evaluate long-term oncologic outcomes.

Risk Factors and Clinical Outcomes of Recurrent Laryngeal Nerve Paralysis After Esophagectomy for Thoracic Esophageal Carcinoma

BACKGROUND

The objectives of this study were to assess the incidence of recurrent laryngeal nerve paralysis (RLNP) using laryngoscopy after esophagectomy for thoracic esophageal carcinoma and to clarify the risk factors influencing postoperative RLNP.

METHODS

A total of 299 patients who underwent laryngoscopic examination after esophagectomy were retrospectively reviewed. Patients who were found to have postoperative RLNP were followed up every 1–3 months, with a median follow-up period of 3 months. Recovery from paralysis was also evaluated on the basis of each affected nerve. Multivariate analyses using logistic regression were used to identify independent risk factors for RLNP. Cumulative recovery rate was calculated using Kaplan–Meier method.

RESULTS

A total of 178 (59.5%) patients were diagnosed with RLNP by first laryngoscopy [bilateral in 59 (33.1%) patients, right in 15 (8.4%), and left in 104 (58.4%)]. In 206 patients who underwent transthoracic and thoracoscopic esophagectomy, independent risk factors for RLNP were lymph node dissection along the right RLN (odds ratio [OR] 3.01, 95% confidence interval [CI] 1.06–8.54, P = 0.04) and cervical anastomosis (OR 5.94, 95% CI 1.78–19.80, P < 0.01). Cumulative recovery rate from RLNP was 61.7% at 12 months after esophagectomy with 91 nerves eventually recovering from paralysis. Median recovery time was 6 months.

CONCLUSIONS

RLNP developed in 60 % of patients after esophagectomy and may be associated with lymphadenectomy around the right RLN and cervical esophageal mobilization. Although 62% of affected nerves recovered within 12 months, great attention should be given when performing these procedures.

Long-term outcomes of extended proximal gastrectomy for oesophagogastric junctional tumours

BACKGROUND

There is no consensus on the optimum approach for resection of oesophagogastric junctional (OGJ) tumours. We prospectively evaluated the efficacy of transabdominal radical extended proximal gastrectomy with oesophagogastric anastomosis (EPGOG) for selected tumours of the OGJ.

METHODS

Between 1998 and 2007, 66 selected consecutive patients with tumours of the OGJ underwent successful EPGOG. Selection was limited to tumours where the maximal proximal extent was 36 cm ab oral. Pre-, peri-, and postoperative outcomes together with long-term survival data for these patients were prospectively collected.

RESULTS

Median theatre time was 242 min (range = 120-480), with a median blood loss of 300 ml (range = 50-1720). Eighty-nine percent of patients were extubated in theatre; major complications occurred in 9 (14%) patients, with an overall in-hospital mortality rate of 8%. Thirty-five (53%) patients had nodal disease and the median lymph node yield was 13 (range = 4-36), with an R0 resection rate of 80%. In terms of long-term outcomes, the 2- and 5-year actuarial survival rates were 54 ± 6% and 41 ± 6%.

CONCLUSION

Extended radical proximal gastrectomy with oesophagogastric anastomosis for selected junctional tumours is a feasible technique which does not compromise oncological principles as evidenced by an excellent long-term survival rate.

National trends in esophageal surgery--are outcomes as good as we believe?

INTRODUCTION

Positive volume-outcome relationships in esophagectomy have prompted support for regionalization of care; however, outcomes have not recently been analyzed. This study examines national trends in provision of esophagectomy and reassesses the volume-outcome relationship in light of changing practice patterns and training paradigms.

METHODS

The Nationwide Inpatient Sample was queried from 1998 to 2006. Quantification of patients' comorbidities was made using the Charlson Index. Using logistic regression modeling, institutions' annual case volumes were correlated with risk-adjusted outcomes over time, as well as presence or absence of fellowship and residency training programs.

RESULTS

A nationwide total of 57,676 esophagectomies were recorded. In-hospital unadjusted mortality fell from 12% to 7%. Adjusting for comorbidities, greater esophagectomy volume was associated with improvements in the incidence of most measured complications, though mortality increased once greater than 100 cases were performed. Hospitals supporting fellowship training or a surgical residency program did not have higher rates of mortality or total complications.

CONCLUSIONS

The current national mortality rate of 7% following esophagectomy is higher than is reported in most contemporary case series. A greater annual esophagectomy volume improves outcomes, but only up to a point. Current training paradigms are safe.