Comparison of single- and multi-incision minimally invasive esophagectomy (MIE) for treating esophageal cancer: a propensity-matched study

Application of single-port laparoscopic retrograde gastric mobilization during McKeown esophagectomy for esophageal cancer

BACKGROUND

As a novel alternative to the conventional minimally invasive esophagectomy (MIE) to treat esophageal cancer, single-port laparoscopic retrograde three-step gastric mobilization (SLRM) for esophageal reconstruction during MIE to treat esophageal cancer was attempted in our department. The aim of the present study was to explore the preliminary clinical outcomes and feasibility of this innovative surgery.

METHODS

From March 2020 to November 2021, patients undergoing SLRM combined with four-port thoracoscopic McKeown esophagectomy for their esophageal cancers were reviewed. Gastric mobilization with abdominal lymph node dissection was performed through SLRM. The clinical characteristics and short-term outcomes were analyzed retrospectively.

RESULTS

A total of 120 patients underwent R0 resection without conversion to open surgery. The mean times needed for the thoracic part, abdominal part, and total operation were 43 ± 6 min, 60 ± 18 min, and 230 ± 20 min, respectively. The numbers of mediastinal and abdominal lymph nodes harvested were 13.2 ± 2.7 and 10.2 ± 2.5, respectively. Postoperative pneumonia was encountered in 10 (8.3%) patients. Anastomotic leakage occurred in 3 (2.5%) cases. Temporary vocal cord paralysis was reported in 20 (16.6%) cases. The mean length of hospital stay was 8.5 ± 4.6 days.

CONCLUSIONS

The SLRM is a technically feasible and safe treatment for patients with esophageal cancer. It can be considered an alternative method for patients, especially for the ones with obesity and gastric distension.

Uniportal-VATS vs. open McKeown esophagectomy: Surgical and long-term oncological outcomes

Background

Till now there are very few reports about surgical results of Uniportal-VATS esophagectomy and no one about long-term outcomes. This study is the first comparing surgical and oncological outcomes of Uniportal-VATS with open McKeown esophagectomy, with the largest reported series and longest oncological follow-up.

Methods

The prospectively collected clinical, surgical and oncological data of 75 patients, undergone McKeown esophagectomy at our Thoracic Surgery Department, from January 2012 to August 2022, were retrospectively analyzed. Nineteen patients underwent esophagectomy by thoracotomy and reconstruction according to McKeown technique while 56 by Uniportal-VATS approach. Gastric tubulization was performed totally laparoscopic or through a mini-laparatomic access and cervical anastomosis was made according to Orringer's technique.

Results

The mean operative thoracic time was similar in both accesses (102.34 ± 15.21 min in Uniportal-VATS vs. 115.56 ± 23.12 min in open, p: 0.646), with a comparable number of mediastinal nodes retrieved (Uniportal-VATS:13.40 ± 8.12 vs. open:15.00 ± 6.86, p: 0.275). No case needed conversion from VATS to open. The learning curve in Uniportal-VATS was completed after 34 cases, while the Mastery was reached after 40. Both approaches were comparable in terms of minor post-operative complications (like pneumonia, lung atelectasis, anemization, atrial fibrillation, anastomotic-leak, left vocal cord palsy, chylothorax), while the number of re-operation for major complications (bleeding or mediastinitis) was higher in open group (21.0% vs. 3.6%, p: 0.04). Both techniques were also effective in terms of surgical radicality and local recurrence but VATS approach allowed a significantly lower chest tube length (11.89 ± 9.55 vs. 25.82 ± 24.37 days, p: 0.003) and post-operative stay (15.63 ± 11.69 vs. 25.53 ± 23.33, p: 0.018). The 30-day mortality for complications related to surgery was higher in open group (p: 0.002). The 2-, 5- and 8-year survival of the whole series was 72%, 50% and 33%, respectively. Combined 2- and 5-year OS in Uniportal-VATS group was 76% and 47% vs. 62% and 62% in open group, respectively (Log-rank, p: 0.286; Breslow-Wilcoxon: p: 0.036). No difference in DFS was recorded between the two approaches (5 year-DFS in Uniportal-VATS: 86% vs. 72%, p: 0.298). At multivariate analysis, only pathological stage independently affected OS (p: 0.02), not the surgical approach (p: 0.276).

Conclusions

Uniportal-VATS seems to be a safe, feasible and effective technique for performing McKeown esophagectomy, with equivalent surgical and long-term oncological results to standard thoracotomy, but with a faster and unharmed recovery, and a quite short learning curve.

Selection of minimally invasive surgical approaches for treating esophageal cancer

Minimally invasive esophagectomy has gradually been accepted as an active treatment option for surgery of esophageal cancer. However, there is no consensus about how to perform the procedures in the thoracic and abdominal phase including anastomosis in the neck (McKeown) or chest (Ivor Lewis), VATS, robotic‐assisted or reduced port approaches or various endoscopic abrasion techniques. Further studies to investigate the roles of these novel techniques are required to treat the various patient populations.

Uniportal VATS Approach in Esophageal Cancer - How to Do It Update

The adoption of minimally invasive esophagectomy has been used for over a decade, and the chest part is evolving into a uniportal video-assisted thoracoscopic surgery (VATS) approach. Uniportal esophageal mobilization and anastomosis have many peculiar aspects, which include placement of the incision, alignment of instruments, and anastomosis. The incision is placed over the sixth intercostal space posterior axillary line. The esophagus is usually encircled at the level of the inferior pulmonary vein. The use of curved suction helps in the retraction of the esophagus and the exposure of the left main bronchus deep in the mediastinum. For intrathoracic anastomosis in Ivor Lewis esophagectomy, a completely side-to-side linear-stapled anastomosis is preferred. This anastomotic technique results in a long stapler line. The correct alignment of tissues and adequate anastomotic circumference are of utmost importance to prevent leaks or strictures. Perioperative and oncologic results in several series with uniportal VATS, esophageal mobilization, and anastomosis are comparable with open or other types of minimally invasive esophagectomy. Uniportal VATS for esophagectomy is feasible and fast with good results.

Comparative study on short-term efficacy of single incision plus one (SI+1) port and multiportal 3D laparoscopic minimally invasive esophagectomy

Background

To evaluate the safety and efficacy of single incision plus one (SI+1) port three-dimensional (3D) laparoscopic minimally invasive esophagectomy (MIE).

Methods

Clinical data of patients who underwent 3D thoracic laparoscopic MIE in our department from September 2020 to March 2021 were analyzed retrospectively. According to the different methods of laparoscopic surgery, the patients were divided into 2 groups: SI+1 port 3D laparoscopy group and multiportal 3D laparoscopy group. The operation time of the 3D laparoscopy component, amount of intraoperative blood loss, number of celiac lymph node dissections, postoperative abdominal drainage days, postoperative total abdominal drainage, postoperative complications, and length of hospital stay were analyzed.

Results

There was no significant difference between the 2 methods in laparoscopic operation time (30.11±5.86 vs. 28.45±4.72 min, P=0.49), intraoperative blood loss (34.44±9.82 vs. 35.91±6.25 mL, P=0.69), number of celiac lymph node dissections (8.44±3.13 vs. 7.09±2.12, P=0.27), postoperative abdominal drainage days (3.11±0.33 vs. 3.00±0.00 days, P=0.28), postoperative total abdominal drainage (95.00±23.33 vs. 92.27±11.26 mL, P=0.74), postoperative complications (22.2% vs. 27.3%, P=0.33), and hospital stay (9.67±0.71 vs. 10.18±0.87 days, P=0.17). None of the patients enrolled in the study had recurrence or death to date.

Conclusions

The application of SI+1 port 3D laparoscopy in minimally invasive resection of esophageal carcinoma is safe and feasible.

Robotic-assisted single-incision gastric mobilization for minimally invasive oesophagectomy for oesophageal cancer: preliminary results

OBJECTIVES

With the gradual acceptance of robotic-assisted surgery to treat oesophageal cancer and the application of a single-port approach in several abdominal procedures, we adopted a single-port technique in robotic-assisted minimally invasive oesophagectomy during the abdominal phase for gastric mobilization and abdominal lymph node dissection.

METHODS

Robotic-assisted oesophagectomy and mediastinal lymph node dissection in the chest were followed by robotic-assisted gastric mobilization and conduit creation with abdominal lymph node dissection, which were performed via a periumbilicus single incision. The oesophagogastrostomy was accomplished either in the chest (Ivor Lewis procedure) or neck (McKeown procedure) depending on the status of the proximal resection margin.

RESULTS

The procedure was successfully performed on 11 patients with oesophageal cancer from January 2017 to December 2018 in our institute. No surgical or in-hospital deaths occurred, though we had one case each of anastomotic leakage, pneumonia and hiatal hernia (9%).

CONCLUSIONS

Robotic single-incision gastric mobilization for minimally invasive oesophagectomy for treating oesophageal cancer seems feasible. Its value in terms of perioperative outcome and long-term survival results awaits future evaluation.

Trans-stomal single-port laparoscopic Hartmann's reversal is an efficacious and efficient procedure: a case-controlled study

BACKGROUND

Hartman's reversal remains challenging and is associated with a widely variable success rate. In a previous study, we reported that laparoscopy may lower the mortality and morbidity rates of the procedure. The aim of the current study was to assess the operative results of single-port laparoscopic Hartmann's reversal (SP-HR) as compared to the more standard, multi-port laparoscopic variant (MP-HR).

METHODS

We performed a retrospective, non-randomized, case-controlled study of 44 consecutive patients who had SP-HR (Group A) compared to 44 patients who had MP-HR (Group B). The study was conducted in a high-volume colorectal unit in a 1200-bed university affiliated hospital, The Poissy-Saint Germain Medical Complex, France.

RESULTS

Preoperative patients' characteristics (sex, body mass index, American Society of Anesthesiologists status, prior surgery, comorbidities, colonic disease) were comparable in both groups. The conversion rate was 13.6% and 4.5% in Group A and in Group B, respectively (p = 0.084) and consisted of placement of any additional ports. Conversion to open surgery did not occur in any patient in either group (p = 1). Mean operative time was shorter in Group A than in in Group B, (105 vs. 155 min; p = 0.0133). The mortality rate was 2.2% in Group A and 0% in Group B (p = 0.3145). The overall morbidity rate was 11.4% in Group A and 18.2% in Group B (p = 0.5344). The median length of hospital stay was significantly shorter in Group than in Group B (4.8 vs. 6.8 days; p = 0.0102).

CONCLUSIONS

The SP-HR technique was found to be safe and efficient. It compares favorably with MP-HR. Moreover, indirect cost savings could be induced by the reduction in the length of hospital stay.

Initial experience with uniportal video-assisted thoracic surgery esophagectomy

Background

Multiportal thoracoscopic approach is already a well standardized procedure for minimally invasive esophagectomy (MIE); conversely very few reports have been published about uniportal video-assisted thoracic surgery (VATS) technique till now. We present our preliminary experience with uniportal VATS esophagectomy, evaluating short-term outcomes as perioperative mortality, complications, oncological radicality, postoperative pain and cosmetic results.

Methods

From December 2016 to November 2017, the prospectively collected clinical data of 12 patients, who underwent uniportal VATS esophagectomy and reconstruction with a stomach conduit, according to McKeown technique, were reviewed and outcomes evaluated.

Results

The mean age of population was 60.67±8.61 years. Ten (83.3%) patients were males. The main histological type was a squamous cell carcinoma in six patients (50%). No patient had a local recurrence. After 4.33±3.31 months 10 patients (83.3%) were alive with no evidence of disease; 2 (16.7%) patients died of other causes. Two (16.7%) patients developed an anastomotic leak (treated conservatively) and one (8.3%) patient a chylothorax (which required a surgical treatment). The mean operative time of uniportal VATS esophagectomy was 104.67±20.66 min. Mean number of thoracic nodes removed was 10.44±3.94. Post-operative hospitalization was 15.73±14.29 days (median of 9 days). The mean level of pain was 1.92±0.90 in first postoperative day with a duration of 2.25±1.54 days. Cosmetic result was 2.42±0.79 on a 3-point scale.

Conclusions

Uniportal VATS esophagectomy seems to be a safe, feasible and effective alternative to multiportal VATS in terms of operative time, postoperative mortality, hospital stay and oncological outcomes. Less postoperative pain and better cosmetic results seem to be some advantages in favor of Uniportal VATS, however further studies with longer follow-up are claimed.