Technical and perioperative outcomes of minimally invasive esophagectomy in the prone position

When Gastroplasty Is Not Feasible in Ivor Lewis Esophagectomy: A Single-Center Study of Intrathoracic Esophagojejunostomy

Objective: The surgical management of tumors of the esophagogastric junction is increasingly performed by minimally invasive Ivor Lewis esophagectomy. However, gastroplasty is not always feasible. The creation of a long loop is an alternative for esophageal reconstruction. The aim of this study was to evaluate the technical feasibility of using a minimally invasive thoracoscopic approach in esophagojejunostomy and to describe the contraindications for gastroplasty. Methods: All patients who had intrathoracic esophagojejunostomy in our center were identified in our database. Since 2016, the preferred approach for intrathoracic esophagojejunostomy is minimally invasive laparoscopy and thoracoscopy, using a long Roux-en-Y jejunal loop with a semimechanical triangular anastomosis technique. Results: Between January 1, 2012 and January 1, 2022, 12 patients who had esophagojejunostomy in our center were included in the study. Among them, 6 had thoracotomy and 6 had total minimally invasive thoracoscopy, representing 3.5% of surgical procedures for esophagogastric junction tumors since 2016. The mean operative time was 416.9 ± 107.47 minutes. No anastomotic leakage was observed in the minimally invasive group versus 2 leakages in the thoracotomy group. The main complication was pneumonia in 3 patients (27.3%). Finally, the main indication for intrathoracic esophagojejunostomy was tumor size with a mean of 4.72 ± 2.35 cm and the patient's surgical history. Conclusion: A total minimally invasive approach using a long jejunal loop with triangular anastomosis could be a feasible and reproducible alternative to gastroplasty to restore continuity in Ivor Lewis esophagectomy when the stomach cannot be used.

Thoracoscopy-Assisted Esophagectomy vs Transhiatal Esophagectomy for Carcinoma Esophagus: a Prospective Comparison of Short-Term Outcomes

INTRODUCTION

Transhiatal esophagectomy (THE) was popularized to reduce the morbidity of esophagectomy. Thoracoscopy-assisted esophagectomy (TAE) offers esophageal dissection under magnified vision. This study compares the short-term morbidity and oncological outcome following TAE and THE for esophageal carcinoma.

METHODOLOGY

This is a prospective comparative (January 2017-May 2018) study between TAE and THE for >cT1bN1 esophageal carcinoma. After neoadjuvant chemoradiotherapy (NACRT), responders and patients with stable diseases were subjected to surgery. Thoracoscopy in esophagectomy was performed in prone position. Follow-up duration was at least 4 weeks post-discharge.

RESULTS

Thirty-three patients of esophageal carcinoma undergoing TAE (n = 18) or THE (n = 15) were included. Common locations of tumor were lower third of esophagus (72.7%) and esophagogastric junction (18.2%). Majority (73.3%) had squamous cell carcinoma. Median interval between NACRT and surgery was 13 weeks. The mean operating time was significantly more with TAE than THE (292.5 vs 207.33 min, p = 0.005). R0 resection rate in TAE was 83.3% compared with 66.7% in THE. There was no difference in the lymph node yield. There was non-significant trend towards lower incidence of major pulmonary complication (66.7% vs 80.0%), cardiac complications (27.8% vs 46.7%), anastomotic leak (27.8% vs 46.7%), recurrent laryngeal nerve palsy (16.7% vs 20.0%), and overall major morbidity (Clavien-Dindo ≥ III) (44.4% vs 66.7%) in TAE than THE. The chyle leak was observed more in TAE (16.7%) than THE (6.7%).

CONCLUSIONS

TAE achieved higher R0 resection rate and better short-term morbidity than THE. Enrollment of small number of cases in the study precluded statistical significance.

TRIAL REGISTRATION

This study was registered in Clinical Trial Registry-India (CTRI registration no: CTRI/2018/05/013880) in 14-05-2018.

Learning curve associated with thoraco-laparoscopic esophagectomy for esophageal cancer patients in the prone position

Objective

To observe the surgical index at the different learning stages of thoraco-laparoscopic esophagectomy in the prone position for esophageal cancer and to investigate the learning curve of this surgical procedure.

Methods

Sixty thoraco-laparoscopic esophagectomies in the prone position for esophageal cancer conducted by the same group of surgeons between January 2014 and December 2015 were retrospectively analyzed. The surgeries were divided into 5 groups, A, B, C, D, and E, in chronological order. The duration of surgery, intraoperative blood loss, total number of lymph nodes removed, rate of the intraoperative conversion to open surgery, complication rate, and length of postoperative hospitalization were recorded and analyzed.

Results

The general information of the patients did not significantly differ among the 5 groups (P > 0.05). The duration of surgery, intraoperative blood loss, number of lymph node removed, rate of intraoperative conversion to open surgery, and number of injuries to the recurrent laryngeal nerve all significantly differed (P < 0.05). The rates of postoperative pulmonary infection, anastomotic fistula, pneumothorax, and hospitalization did not significantly differ (P > 0.05).

Conclusion

Thoracic physicians with some endoscopic experience can meet the requirements of the thoraco-laparoscopic esophagectomy in the prone position for esophageal cancer after completing 24–30 surgeries.

Palliative fenestration for a symptomatic subcarinal bronchogenic cyst by the prone position approach

A complete excision is the most reliable therapy for bronchogenic cysts (BC) but is often accompanied by technical difficulties due to severe adhesions. An 83-year-old-woman with poorly controlled diabetes noted worsening upper abdominal pain after meals and paroxysmal atrial fibrillation. Magnetic resonance imaging revealed a cystic mass in the subcarinal region, and she underwent a thoracoscopic prone position surgery. The cyst wall was found to have strictly adhered to the adjacent organs, and the lesion was not amenable to a complete excision. We performed a fenestration of the cyst wall with the aspiration of an yellowish mucus content. After opening the cavity wide enough, the remnant luminal epithelium was ablated by electrocautery. Her clinical symptoms disappeared immediately after the surgery without any surgical morbidity. A prone-position thoracoscopic palliative fenestration is a feasible option for a symptomatic subcarinal BC.

Comparative study of three types of lymphadenectomy along the left recurrent laryngeal nerve by minimally invasive esophagectomy

Background

The objective of this study was to compare three kinds of lymphadenectomy methods along the recurrent laryngeal nerve (RLN) and assess the safety and effectiveness of the new method.

Methods

A total of 194 patients with esophageal cancer who underwent minimally invasive esophagectomy (MIE) at our institution from May 2013 to May 2017 were analyzed retrospectively. According to the method of lymphadenectomy along the left RLN, the patients were divided into three groups: 75 cases underwent the conventional method (A group), 80 cases the skeletonized method (B group) and 39 cases the modified Bascule method (C group). The number of dissected lymph nodes and surgical outcomes were recorded and compared to identify differences among the three groups.

Results

The frequency of metastasis to the LRLN lymph node was 18.6% among all patients, and 12%, 20% and 28% in groups A, B and C, respectively. The number of harvested lymph nodes (total/chest/LRLN/LRLN+) in group B and group C were significantly greater than that of group A, but not significant between group B and group C. The hoarseness rate in group C was 15.4%, which was lower than the rate in group B (21.3%) and higher than the rate in group A (13.3%), but there was no statistical significance.

Conclusions

The new method for lymphadenectomy along the left RLN during MIE in the semi‐prone position is safe and reliable. It provides sufficient lymph node dissection along the left RLN.

Bronchogenic cyst removal via thoracoscopic surgery in the prone position: A case report and literature review

INTRODUCTION

Mediastinal bronchogenic cysts are encountered relatively often, but in many cases, diagnosis using imaging modalities, is difficult. Early surgical excision of bronchogenic cysts is recommended as a diagnostic and therapeutic measure. Here, we report the case of patient with a lower mediastinal bronchogenic cyst, who was treated using thoracoscopic surgery with prone positioning and include a review of literature on diagnosis and treatment of this condition.

PRESENTATION OF CASE

The patient was a 66-year-old woman with an asymptomatic cystic lesion in the posterior, lower mediastinum. The lesion was diagnosed as an esophageal cyst using preoperative imaging and was scheduled for thoracoscopic removal with the patient in the prone position. Intraoperatively, the lesion was found to have no continuity with the esophageal wall and was easily separated from it. Moreover, a cord extending to the lesion, appeared to arise from the crura of the diaphragm. On histopathological examination of the extracted mass, the lesion was diagnosed as a bronchogenic cyst. Postoperatively, the patient recovered uneventfully and was discharged after 7 days.

CONCLUSION

Thoracoscopic mediastinal cystectomy with the patient in the prone position may be an optimal surgical strategy for the treatment of bronchogenic cysts in the posterior, lower mediastinum.

Robot-assisted minimally invasive thoraco-laparoscopic esophagectomy for esophageal cancer in the upper mediastinum

BACKGROUND

Patients with upper third esophageal cancer or esophageal cancer with upper mediastinal paratracheal lymph node metastases are often precluded from surgery because of technical difficulties. With the aid of robotic surgery, an excellent overview and reach of the thoracic inlet can be accomplished. In this way, patients with upper mediastinal esophageal cancer are eligible for esophageal resection with curative intent. The aim of this study was to review the results of a consecutive series of patients who underwent robot-assisted minimally invasive esophagectomy (RAMIE) for tumors of the upper 1/3 of the esophagus or positive lymph nodes in the upper mediastinum.

METHODS

Between 2007-2016, 31 patients who underwent RAMIE in the UMC Utrecht for proximal esophageal cancer or proximal thoracic lymphadenopathy were identified from a prospective surgical database. Perioperative characteristics and oncologic outcomes were collected.

RESULTS

The majority of patients had a squamous cell carcinoma. Clinical tumor stage was cT3 or higher in 25 (81%) of patients. Clinically positive lymph nodes (cN1-3) were observed in 29 (94%) patients. Neoadjuvant treatment was administered in 27 (87%) patients. Median duration of the surgical procedure was 435 min (range 299-874 min). Pulmonary complications were most frequent and occurred in 13 (42%) patients. Median intensive care (ICU stay) was 1 day (range 1-65 days) and median overall postoperative hospital stay was 15 days (range 10-118 days). In hospital mortality was 10%. Causes of mortality were tracheo-neo-esophageal fistula, sepsis after abdominal wall drainage due to leakage of the jejunal fistula resulting in respiratory and kidney failure, after which refraining further treatment resulting in death, and irreversible ARDS in a patient with COPD Gold III needing extracorporeal life support. Radical resection was achieved in 30 (97%) of the patients. Median number of retrieved lymph nodes was 22 (range 9-57). Median time of follow up was 18 months (range 3-81 months). Median disease-free survival was 13 months (range 0-81 months) and median overall survival was 16 months (range 0-81 months). Tumor recurrence occurred in 15 patients (48%) and was locoregional only in 3 patients, systemic only in 5 patients and combined locoregional and systemic in 7 patients.

CONCLUSIONS

Robot assisted thoraco-laparoscopic esophagectomy with curative intent in patients with upper mediastinal esophageal cancer is feasible, but associated with increased in hospital mortality. Short-term oncologic results are encouraging.

Immediate Postoperative Oral Nutrition Following Esophagectomy: A Multicenter Clinical Trial

BACKGROUND

Immediate start of oral intake is beneficial following colorectal surgery. However, following esophagectomy the safety and feasibility of immediate oral intake is unclear, thus these patients are still kept nil by mouth. This study therefore aimed to determine the feasibility and safety of oral nutrition immediately after esophagectomy.

METHODS

A multicenter, prospective trial was conducted in 3 referral centers between August 2013 and May 2014, including 50 patients undergoing a minimally invasive esophagectomy. Oral nutrition was started postoperatively immediately (clear liquids on postoperative day [POD] 0, liquid nutrition on POD 1 to 6, solid food from POD 7). Nonoral enteral nutrition was started when <50% of caloric need was met on postoperative day POD 5 or when oral intake was impossible. A comparison was made with a retrospective cohort (n = 50) with a per-protocol delayed start of oral intake until POD 4 to 7.

RESULTS

The median caloric intake at POD 5 was 58% of required. In 38% of the patients nonoral nutrition was started, mainly due to complications (36%). The pneumonia rate was 28% following immediate oral intake and 40% following delayed oral intake (p = 0.202). The aspiration pneumonia rate was 4% in both groups. The anastomotic leakage rate was 14% after immediate oral intake versus 24% following delayed oral intake (p = 0.202). The 90-day mortality rate was 2% in both groups. Hospital stay and intensive care unit stay were significantly shorter following immediate oral intake.

CONCLUSIONS

Immediate start of oral nutrition following esophagectomy seems to be feasible and does not increase complications compared to a retrospective cohort and literature. However, if complications arise an alternative nutritional route is required. This explorative study shows that a randomized controlled trial is needed.

Internal and External Validation of a multivariable Model to Define Hospital-Acquired Pneumonia After Esophagectomy

BACKGROUND

Pneumonia is an important complication following esophagectomy; however, a wide range of pneumonia incidence is reported. The lack of one generally accepted definition prevents valid inter-study comparisons. We aimed to simplify and validate an existing scoring model to define pneumonia following esophagectomy.

PATIENTS AND METHODS

The Utrecht Pneumonia Score, comprising of pulmonary radiography findings, leucocyte count, and temperature, was simplified and internally validated using bootstrapping in the dataset (n = 185) in which it was developed. Subsequently, the intercept and (shrunk) coefficients of the developed multivariable logistic regression model were applied to an external dataset (n = 201) RESULTS: In the revised Uniform Pneumonia Score, points are assigned based on the temperature, the leucocyte, and the findings of pulmonary radiography. The model discrimination was excellent in the internal validation set and in the external validation set (C-statistics 0.93 and 0.91, respectively); furthermore, the model calibrated well in both cohorts.

CONCLUSION

The revised Uniform Pneumonia Score (rUPS) can serve as a means to define post-esophagectomy pneumonia. Utilization of a uniform definition for pneumonia will improve inter-study comparability and improve the evaluations of new therapeutic strategies to reduce the pneumonia incidence.

Esophageal strictures and diverticula

Esophageal disease and dysfunction of the lower esophageal sphincter (LES) manifesting as gastroesophageal reflux disease (GERD) particularly, is the most common of all gastrointestinal conditions impacting patients on a day-to-day basis. LES dysfunction can lead to anatomic changes to the distal esophagus, with GERD-mediated changes being benign stricture or progression of GERD to Barrett's esophagus and even esophageal cancer, and LES hypertension impairing esophageal emptying with subsequent development of pulsion esophageal diverticulum. This article details the causes, clinical presentation, workup, and treatment of esophageal stricture and epiphrenic esophageal diverticulum. Other types of esophageal diverticula (Zenker's and midesophageal) are also covered.

Minimally invasive surgery for esophageal cancer - benefits and controversies

Open esophagectomy (OE) requires extensive surgery and is associated with significant morbidity and mortality. Furthermore, the long-term results of esophageal cancer surgery are not satisfactory; hence, the best surgical approach is constantly under debate. During the last twenty years, minimally invasive esophagectomy (MIE) employing laparoscopy and/or thoracoscopy has been introduced in a growing number of centers worldwide. To date, several studies have demonstrated that MIE has better outcomes than OE, as it results in shorter hospital stay and decreased overall morbidity. However, the length of operating time in MIE is increased in comparison to OE. The survival benefit has been demonstrated to be similar in OE and MIE. Highly advanced laparo-thoracoscopic skills are required to perform MIE; along with the relatively long learning curve, this makes MIE feasible only in high-volume, experienced university surgical centers. There is a need for further large-scale comparative studies to prove the superiority of MIE over open surgery.

Thoracoscopic esophagectomy using prone positioning

Thoracotomic esophagectomy followed by cervical and abdominal procedures has been conventionally performed as the best curable operative procedure for treating invasive thoracic esophageal carcinoma. Despite improvements in the survival rate, the procedure is associated with significant operative morbidity and mortality rates due to the extreme invasiveness of an extensive dissection of the lymph nodes. Minimally invasive esophagectomy (MIE) was developed to reduce surgical invasiveness. Recently, the use of thoracoscopic esophagectomy performed in the prone position has stimulated new interest in minimally invasive approaches. However, the advantages and disadvantages of this technique are not well known. In this review, the literature to date, including series and comparative studies of minimally invasive esophagectomy performed in the prone position, is summarized, and the various lessons learned and controversies surrounding this technique are addressed.

The impact of tidal volume on pulmonary complications following minimally invasive esophagectomy: a randomized and controlled study

BACKGROUND

Minimally invasive esophagectomy (MIE) has been advantageous for lowering pulmonary complications compared with open approaches.(1) However, pulmonary complications remain the most common morbidity after surgical resection of esophageal cancer.(2,3) The aim of this prospective, randomized, controlled, clinical trial was designed to see whether low tidal volume (VT) could further minimize pulmonary complications after MIE.

METHODS

Between June 2011 and July 2012, a total of 101 patients who underwent MIE received left-lung ventilation during thoracoscopic esophagectomy. All patients received left-lung ventilation during thoracoscopic esophagectomy. Patients were randomly assigned to a low VT (5 mL/kg + 5 cm H2O positive end-expiratory pressure) preserved ventilation (PV) group (n = 53) and a conventional VT (8 mL/kg) controlled ventilation (CV) group (n = 48) in the thoracic stage. Alveolar lavage fluid was harvested from the ventilated lung at intubation and at 18 hours after surgery for analysis of interleukin (IL)-1ß, IL-6, and IL-8 levels. Clinical characteristics, including patient demographics, operation features, and changes in oxygenation index, were recorded and analyzed. Pulmonary complications were identified and statistically compared between the 2 groups.

RESULTS

The clinical characteristics and operation features were comparable between the 2 groups. IL-1ß, IL-6, and IL-8 expressions in preoperative alveolar lavage fluid were similar between the 2 groups. Significantly lower IL expressions were observed in the PV group than those in the CV group at 18 hours after MIE (IL-1ß, 25.42 ± 31.01 vs 94.96 ± 118.24 pg/mL; IL-6, 30.86 ± 75.78 vs 92.99 ± 72.90 pg/mL; IL-8, 258.75 ± 188.24 vs 403.95 ± 151.44 pg/mL; all P < .05). The 18-hour postoperative oxygenation index was lower in the CV group than that in the PV group (292.85 ± 28.74 vs 326.35 ± 34.43; P = .046). Pulmonary complications were observed in 18 cases of our series, occurring more frequently on the ventilation side (right, 6 cases; and left, 12 cases). All patients were cured by conservative therapy without severe sequelae. The occurrence of pulmonary complications in the PV group was lower than that in the CV group (9.43% vs 27.08%; P = .021).

CONCLUSIONS

Lung injury due to intraoperative single-lung ventilation may contribute to pulmonary complications after MIE. Low VT ventilation could decrease ventilation-associated lung inflammation, thus minimizing pulmonary complications after MIE. Further studies, based on a larger volume of populations, are required to confirm these findings.