Video-assisted mediastinoscopic and laparoscopic transhiatal esophagectomy for esophageal cancer

Comparison of mediastinoscopy and thoracoscope minimally invasive esophagectomy in the treatment of esophageal cancer: a meta-analysis and system review

OBJECTIVE

The efficacy and safety of transcervical inflatable mediastinoscopic esophagectomy (TIME) in the treatment of esophageal cancer are unclear. The objective of this meta-analysis was to evaluate the efficacy and safety of TIME treatment for esophageal cancer and to compare it with thoracoscopic assisted minimally invasive esophagectomy (TAMIE) for the treatment of esophageal cancer.

METHODS

A literature search was performed using PubMed, Embase, and the Cochrane Library to retrieve articles published up to January 2024 to comparatively assess studies of TIME and TAMIE. Meta-analysis was performed using randomized/fixed-effects models and heterogeneity was assessed.

RESULTS

A total of 819 patients were included in the nine studies herein. Among them, 409 patients with esophageal cancer underwent mediastinoscopy-assisted esophagectomy, and 410 patients with esophageal cancer underwent thoracolaparoscopy-assisted esophagectomy. There was no statistical difference between the TIME and TAMIE groups in intraoperative bleeding, incidence of anastomotic fistula, chylothorax, postoperative bleeding, arrhythmia, postoperative complications and in-hospital mortality. In addition, the operative time in the TIME group, 3-day postoperative induced flux, postoperative hospitalization time, number of lymph node dissection, and incidence of pulmonary complications were smaller than those in the TAMIE group, and the differences were all statistically significant. However, in terms of the incidence of recurrent laryngeal nerve injury (including hoarseness), the TIME group was higher than the TAMIE group.

CONCLUSION

TIME is a safe and feasible alternative to TAMIE for the treatment of resectable esophageal cancer, but further randomized studies are needed to better assess the long-term benefits of TIME compared with TAMIE.

Laparoscopic and thoracoscopic whole-stomach esophagectomy with preoperative pyloric balloon dilatation for esophageal cancer: a prospective multicenter case-series outcome

INTRODUCTION

To mitigate gastroparesis as well as other post-operative complications, we undertook a prospective multicenter study to assess the feasibility, safety, and efficacy in the short-term outcomes of laparoscopic and thoracoscopic whole stomach esophagectomy with preoperative pyloric balloon dilatation.

METHODS

A prospective descriptive study on 37 patients with laparoscopic and thoracoscopic whole stomach esophagectomy with preoperative pyloric balloon dilatation from January 2019 to March 2023. The perioperative indications, clinical data, intra-operative index, pathological postoperative specimens, postoperative complications, and follow-up results were retrospectively evaluated.

RESULTS

In our study, all patients were male, with dysphagia as the predominant symptom (45.9%). Esophageal cancer incidence was similar between middle and lower thirds. Nodules were the primary finding on esophagoscopy (48.6%). Preoperative pyloric dilation averaged 31.2 min without complications. Surgical duration ranged from 225 to 400 min (mean 305). Gastric tube fluid volume averaged 148.9 ± 110.66 ml per day. Among 34 post-operative cases underwent gastric transit scans, most had non-dilated stomachs with efficient pyloric drug circulation. Three cases required prolonged ventilation, precluding pyloric circulation scans. Four patients developed chylous fistula, one requiring chest tube embolization. Recurrent laryngeal nerve damage occurred in 10.8% of cases.

CONCLUSION

After evaluating esophageal cancer patients undergoing laparoscopic whole-stomach esophagectomy with preoperative pyloric balloon dilatation, it was found that this procedure is safe, effective, and significantly reduces postoperative gastroparesis and related complications.

Delta-CT radiomics based model for predicting postoperative anastomotic leakage following radical resection of esophageal squamous cell carcinoma

Objective

To predict postoperative anastomotic leakage (AL) following radical resection of esophageal squamous cell carcinoma (ESCC) based on clinical data and preoperative enhanced Computed tomography(CT) radiomics of the esophagus.

Method

We retrospectively analyzed the clinicopathological and radiological data of 213 patients with ESCC who received radical resection at Xiangyang No.1 People's Hospital from July 2011 to February 2024. 3D slicer software was used in combination with Lasso extraction and 10-fold cross-validation to extract texture parameters from contrast-enhanced CT images and generate Delta-Radscores. Several models were built using logistic regression to predict postoperative AL in ESCC.

Results

In the training set, the univariate analysis confirmed that duration of surgery, surgical method, delta radscore 1, delta radscore 2, contrast enhancement patterns, peripheral lymph node metastasis, post thoracotomy pulmonary infection(PTPI), and hot pot were risk factors for ESCC-AL (P<0.05 for both). The multivariate analysis showed that delta radscore 1, delta radscore 2, PTPI, and hot pot were independent risk factors for AL (P<0.05 for all). These results were verified by the XGboost machine learning model. The combinational model based on all of the above risk factors [AUC 0.900, OR 0.0282, 95%CI 0.841-0.943] outperformed either the clinical model[AUC 0.759, OR 0.0392, 95%0.683-0.825,P<0.05] or the imaging model[AUC 0.869, OR 0.0335, 95%0.804-0.918,P=0.1277] alone in predictive efficacy. The decision curve proved that the combinational model had a higher clinical net benefit. The nomogram generated via the combinational model simplified the predictive process. The same predictions were verified in the testing set.

Conclusion

Delta radscore 1, delta radscore 2, PTPI, and hot pot were related to ESCC-AL. The novel nomogram created using enhanced CT radiomics informed perioperative management and improved the survival quality of ESCC patients.

Bilateral transcervical mediastinoscopic-assisted transhiatal laparoscopic esophagectomy compared with thoracolaparoscopic esophagectomy for esophageal cancer: a propensity score-matched analysis

BACKGROUND

Transcervical mediastinoscopic esophagectomy for esophageal and esophagogastric junction cancer is indicated in select institutions because of the complex surgical technique required and the unfamiliar surgical view compared with the standard transthoracic esophagectomy approach. This study was performed to compare the feasibility and efficacy of bilateral transcervical mediastinoscopic-assisted transhiatal laparoscopic esophagectomy (BTC-MATLE) with thoracolaparoscopic esophagectomy (TLE) for esophageal cancer.

METHODS

This study involved 392 consecutive patients with esophageal cancer who underwent curative minimally invasive esophagectomy with R0 resection (excluding salvage, conversion, and two-stage operations and open thoracotomy) at the National Cancer Center Hospital from 2017 to 2022. The patients underwent either BTC-MATLE or TE (32 and 360 consecutive patients, respectively). Propensity score-matching analysis was used to balance the baseline differences by covariates of age, performance status, and clinical stage.

RESULTS

There were statistically significant differences in age, performance status, cT factor, cN factor, cStage, preoperative treatment, and surgical history for respiratory disease. After propensity score-matching, these significant differences (excluding a surgical history of respiratory disease) were no longer statistically significant, and 27 patients were assigned to each group. The total operation time and the postoperative intensive care unit stay were significantly shorter in the BTC-MATLE than TLE group. There were no significant differences in overall postoperative complications or the three major postoperative complications of recurrent laryngeal nerve paralysis, anastomotic leakage, and pneumonia, even for patients whose preoperative pulmonary function indices (vital capacity and forced expiratory volume in 1 s) were significantly lower in the BTC-MATLE than TLE group. The numbers of total and thoracic harvested lymph nodes were significantly higher in the TLE than BTC-MATLE group; however, there was no significant difference in the recurrence rate between the two groups.

CONCLUSION

BTC-MATLE may provide the same feasibility and oncological outcomes as TLE even for patients with significantly lower pulmonary function.

Substitute or coexistence? Mediastinoscopy-assisted versus thoracoscope-assisted esophagectomy in esophageal cancer: a meta-analysis of perioperative outcomes and long-term survival

BACKGROUND

Currently, mediastinoscopy-assisted esophagectomy (MAE) and thoracoscope-assisted esophagectomy (TAE) represent two prevalent forms of minimally invasive esophagectomy extensively employed in the management of esophageal cancer (EC). The aim of this meta-analysis is to assess and compare these two surgical approaches concerning perioperative outcomes and long-term survival, offering valuable insights for refining surgical strategies and enhancing patient outcomes in this field.

METHODS

Adhering to PRISMA guidelines, the authors systematically searched PubMed, Web of Science, Cochrane Library, Embase, and CNKI databases until 1 March 2024, for studies comparing MAE and TAE. Outcomes of interest included perioperative outcomes (intraoperative outcomes, postoperative recovery, postoperative complications) and survival rates. Statistical analyses were performed using RevMan 5.4, with heterogeneity dictating the use of fixed or random-effects models.

RESULTS

A total of 21 relevant studies were finally included. MAE was associated with significantly shorter operation times [mean difference (MD)=-59.58 min, 95% CI: -82.90 to -36.26] and less intraoperative blood loss (MD=-68.34 ml, 95% CI: -130.45 to -6.23). However, MAE resulted in fewer lymph nodes being dissected (MD=-3.50, 95% CI: -6.23 to -0.78). Postoperative recovery was enhanced following MAE, as evidenced by reduced hospital stays and tube times. MAE significantly reduced pulmonary complications [odds ratio (OR)=0.59, 95% CI: 0.44, 0.81] but increased the incidence of recurrent laryngeal nerve injury (OR=1.84, 95% CI: 1.30, 2.60). No significant differences were observed in anastomotic leakage, chylothorax, cardiac complications, wound infections, and gastric retention between MAE and TAE. The long-term survival outcomes showed no statistical difference [hazard ratio (HR)=1.05, 95% CI: 0.71, 1.54].

CONCLUSIONS

MAE offers advantages in reducing operation time, blood loss, and specific postoperative complications, particularly pulmonary complications, with a shorter recovery period compared to TAE. However, it poses a higher risk of recurrent laryngeal nerve injury and results in fewer lymph nodes being dissected. No difference in long-term survival was observed, indicating that both techniques have distinct benefits and limitations. These findings underscore the need for personalized surgical approaches in EC treatment, considering individual patient characteristics and tumor specifics.

Comparative study of acute and chronic pain after inflatable videoasisted MediastinoscopicTranshiatal esophagectomy and minimally invasive McKeown Esophagectomy:A propensity score matching analysis

Objective

The short-term quality of life of patients can be enhanced by performing Inflatable Video-Assisted Mediastinoscopic Transhiatal Esophagectomy (IVMTE). Nevertheless, there is limited research on how it impacts postoperative acute and chronic pain in individuals diagnosed with esophageal cancer.Hence, this research aimed to examine the impact of IVMTE and minimally invasive Mckeown esophagectomy (MIME) on the occurrence of acute and chronic pain following surgery in individuals diagnosed with esophageal cancer.

Methods

A retrospective, propensity score matching analysis was adopted. In total, 133 patients with esophageal cancer who underwent IVMTE and MIME between January 2020 and December 2021 were part of the study. Among them, 38 patients underwent IVMTE and 95 patients underwent MIME. Following the propensity score matching analysis, 36 patients were included in each group. Patients' postoperative pain was evaluated using the numerical rating scale (NRS).

Results

The IVMTE group (Group A) had significantly reduced operation time and intraoperative blood loss compared to the MIME group (Group B) (P < 0.05). NRS scores on the 1st, 2nd, 3rd, and 7th days after surgery, as well as on the 3rd and 6th months post-surgery, were notably reduced in the IVMTE group (Group A) compared to the MIME group (Group B) (P < 0.05). Univariate and multivariate analysis showed that chronic pain occurred postoperative 3rd months was related to the operation methods (P < 0.05). Univariate analysis showed that chronic pain occurred postoperative 6th months was related to the operation time, postoperative 14th days NRS scores and operation methods (P < 0.05). Multivariate analysis showed that chronic pain occurred postoperative 6th months was related to the operation methods (P < 0.05).

Conclusion

The results showed that the operation methods were the main risk factors for postoperative chronic pain. The compared with MIME, IVMTE can further reduce the acute and chronic pain of patients with esophageal cancer.

A systematic review and meta-analysis of mediastinoscopy-assisted transhiatal esophagectomy (MATHE)

BACKGROUND

Transhiatal esophagectomy (THE) avoids thoracotomy but sacrifices mediastinal lymphadenectomy. Mediastinoscopy-assisted transhiatal esophagectomy (MATHE) allows for visualisation and en-bloc dissection of mediastinal lymph nodes while retaining the benefits of THE. However, given its novel inception, there is a paucity of literature. This study aimed to conduct the first meta-analysis to explore the efficacy of MATHE and clarify its role in the future of esophagectomy.

METHODS

Four databases (PubMed, EMBASE, Scopus, and Cochrane Library) were searched from inception to May 1, 2023. Studies were included if they reported outcomes for patients with esophageal cancer who underwent MATHE. Meta-analyses of proportions and pooled means were performed for the outcomes of intraoperative blood loss, lymph node (LN) harvest, mean hospital length of stay (LOS), mean operative time, R0 resection, conversion rates, 30-day mortality rate, 5-year OS, and surgical complications (anastomotic leak, cardiovascular [CVS] and pulmonary complications, chyle leak and recurrent laryngeal nerve palsy [RLN]). Sensitivity analyses were performed for outcomes with substantial statistical heterogeneity.

RESULTS

The search yielded 223 articles; 28 studies and 1128 patients were included in our analysis. Meta-analyses of proportions yielded proportion rates: 30-day mortality (0 %, 95 %CI 0-0), 5-year OS (60.5 %, 95 %CI 47.6-72.7), R0 resection (100 %, 95 %CI 99.3-100), conversion rate (0.1 %, 95 %CI 0-1.2). Among surgical complications, RLN palsy (14.6 %, 95 %CI 9.5-20.4) were most observed, followed by pulmonary complications (11.3 %, 95 %CI 7-16.2), anastomotic leak (9.7 %, 95 %CI 6.8-12.8), CVS complications (2.3 %, 95 %CI 0.9-4.1) and chyle leak (0.02 %, 95 %CI 0-0.8). Meta-analysis of pooled means yielded means: LN harvest (18.6, 95 %CI 14.3-22.9), intraoperative blood loss (247.1 ml, 95 %CI 173.6-320.6), hospital LOS (18.1 days, 95 %CI 14.4-21.8), and operative time (301.5 min, 95 %CI 238.4-364.6). There was moderate-to-high statistical heterogeneity. Findings were robust to sensitivity analyses.

CONCLUSION

MATHE is associated with encouraging post-operative mortality and complication rates, while allowing for radical mediastinal lymphadenectomy with reasonable lymph node harvest.

Relationship between the severity of emphysematous change in the lung and morbidity after esophagectomy for esophageal cancer: A retrospective study on a novel strategy for risk prediction

BACKGROUND

Chronic obstructive pulmonary disease (COPD) prevalence increases post-esophagectomy morbidity. However, the association between COPD severity and post-esophagectomy morbidity remains unclear because of the lack of an objective method to classify COPD severity. Low attenuation volume ratio (LAVR) estimated using Ziostation2 may reflect the extent of emphysematous changes in the lungs and COPD severity, thereby predicting post-esophagectomy morbidity.

METHODS

A total of 776 patients who underwent curative McKeown esophagectomy for esophageal cancer between April 2005 and June 2021 were included. The patients were divided into high and low preoperative LAVR groups. Short-term outcomes between the groups were compared for patients who underwent open esophagectomy (OE) and minimally invasive esophagectomy (MIE).

RESULTS

A total of 219 (28%) patients were classified into the high LAVR group. High LAVR was significantly associated with disadvantageous patient characteristics such as advanced age, heavy smoking, and impaired respiratory function. Patients with high LAVR had a significantly higher incidence of severe morbidity and pneumonia after OE. High LAVR was an independent risk factor for severe morbidity (odds ratio [OR], 2.52; 95% confidence interval [CI]: 1.237-5.143; p = 0.011) and pneumonia (OR, 2.12; 95% CI: 1.003-4.493; p = 0.049) after OE. Meanwhile, LAVR was not correlated with the incidence of post-MIE morbidity.

CONCLUSIONS

LAVR may reflect COPD severity and predict severe morbidity and pneumonia after OE, but not after MIE. Less invasiveness of MIE may alleviate the effects of various disadvantageous backgrounds associated with high LAVR on worse short-term outcomes.

Application of Inflatable Video-Assisted Mediastinoscopic Transhiatal Esophagectomy in Individualized Treatment of Esophageal Cancer

Surgery is a crucial treatment option for patients with resectable esophageal cancer. The emergence of minimally invasive esophageal techniques has led to the popularity of video-assisted thoracoscopic esophagectomy, which has proven to be more advantageous than traditional thoracotomy. However, some patients with esophageal cancer may not benefit from this procedure. Individualized treatment plans may be necessary for patients with varying conditions and tolerances to anesthesia, making conventional surgical methods unsuitable. Inflatable video-assisted mediastinoscopic transhiatal esophagectomy (IVMTE) has emerged as a promising treatment option for esophageal cancer because it does not require one-lung ventilation, reduces postoperative complications, and expands surgical indications. This technique also provides surgical opportunities for patients with impaired pulmonary function or thoracic lesions. It is crucial to have a comprehensive understanding of the advancements and limitations of IVMTE to tailor treatment plans and improve outcomes in patients with esophageal cancer. Understanding the advantages and limitations of this surgical method will help specific patients with esophageal cancer. We conducted a thorough review of the relevant literature to examine the importance of IVMTE for individualized treatment of this disease.

Different gastric tubes in esophageal reconstruction during esophagectomy

Esophagectomy is currently the mainstay of treatment for resectable esophageal carcinoma. Gastric grafts are the first substitutes in esophageal reconstruction. According to the different tailoring methods applied to the stomach, gastric grafts can be classified as whole stomach, subtotal stomach and gastric tube. Gastric-tube placement has been proven to be the preferred method, with advantages in terms of postoperative complications and long-term survival. In recent years, several novel methods involving special-shaped gastric tubes have been proposed, which have further decreased the incidence of perioperative complications. This article will review the progress and clinical application status of different types of gastric grafts from the perspectives of preparation methods, studies of anatomy and perioperative outcomes, existing problems and future outlook.

Safety and Feasibility of Mediastinoscopy-assisted Esophagectomy: A Meta-analysis

BACKGROUND

The objective of the current study was to investigate the safety and feasibility of mediastinoscopy-assisted esophagectomy (MAE).

METHODS

A meta-analysis was conducted between MAE and traditional transthoracic esophagectomy (TTE). For a comparative analysis of MAE and TTE, we searched PubMed, the Cochrane Library, Embase, and Web of Science databases. We identified the relevant literature and extracted the relevant data. Finally, RevMan 5.3 software was applied to conduct a meta-analysis of the data.

RESULTS

A total of 1256 people were enrolled in 16 studies, comprising 575 patients with MAE and 681 with TTE. The findings revealed that the pulmonary complications, cardiac complications, and postoperative hospital stay in the MAE group were significantly better than those in the TTE group. No significant differences were found between the 2 groups in postoperative chylothorax, anastomotic fistula, and postoperative mortality. But the incidence of recurrent laryngeal nerve injury in the MAE group was higher than that in the TTE group (odds ratio=1.64, 95% CI, 1.15 to 2.35, P =0.006). The MAE group had less lymph node dissection than the TTE group (mean difference=-4.62, 95% CI, -5.97 to 3.45, P <0.00001).

CONCLUSIONS

This meta-analysis presented that MAE was safe and feasible, reduced postoperative pulmonary and cardiac complications, and shortened hospital stay, but lymph node dissection was less, recurrent laryngeal nerve injury was higher, and the impact of long-term survival prognosis required more randomized controlled trials.

Novel Mediastinoscope-Assisted Minimally Invasive Esophagectomy for Esophageal Cancer: A Systematic Review and Meta-analysis

BACKGROUND

Minimally invasive surgery is an expanding field of surgery that has replaced many open surgical techniques. Surgery remains a cornerstone in the treatment of esophageal cancer, yet it is still associated with significant morbidity and technical difficulties. Mediastinoscope-assisted esophagectomy is a promising technique that aims to decrease the surgical burden and enhance recovery.

METHODS

PubMed, MEDLINE, and EMBASE databases were searched for publications on mediastinoscope-assisted esophagectomies for esophageal cancer. The primary endpoint was a postoperative anastomotic leak, while secondary endpoints were assessment of harvested lymph nodes (LNs), blood loss, chyle leak, hospital length of stay (LOS), operative (OR) time, pneumonia, wound infection, mortality, and microscopic positive margin (R1). The pooled event rate (PER) and pooled mean were calculated for binary and continuous outcomes respectively.

RESULTS

Twenty-six out of the 2274 searched studies were included. The pooled event rate (PER) for anastomotic leak was 0.145 (0.1144; 0.1828). The PERs for chyle leak, recurrent laryngeal nerve injury/hoarseness, postoperative pneumonia, wound infection, early mortality, postoperative morbidity, and microscopically positive (R1) resection margins were 0.027, 0.185, 0.09, 0.083, 0.020, 0.378, and 0.037 respectively. The pooled means for blood loss, hospital stay, operative time, number of total harvested LNs, and number of harvested thoracic LNs were 159.209, 15.187, 311.116, 23.379, and 15.458 respectively.

CONCLUSIONS

Mediastinoscopic esophagectomy is a promising minimally invasive technique, avoiding thoracotomy, patient repositioning, and lung manipulation; thus allowing for shorter surgery, decreased blood loss, and decreased postoperative morbidity. It can also be reliable in terms of oncological safety and LN dissection.

Clinical-pathological features and perioperative outcomes of mediastinoscopy vs. thoracoscopy esophagectomy in esophageal cancer: A meta-analysis

Objective

To compare the clinicopathological features and perioperative outcomes of video-assisted mediastinoscopy esophagectomy (VAME) compared to video-assisted thoracoscopy esophagectomy (VATE) in esophageal cancer.

Methods

We comprehensively searched online databases (PubMed, Embase, Web of Science and Wiley online library) to find available studies exploring the clinicopathological features and perioperative outcomes between VAME and VATE in esophageal cancer. Relative risk (RR) with 95% confidence interval (CI) and standardized mean difference (SMD) with 95% CI were used to evaluate the perioperative outcomes and clinicopathological features.

Results

A total of seven observational studies and one randomized controlled trial involving 733 patients were considered eligible for this meta-analysis, of which 350 patients underwent VAME in contrast to 383 patients underwent VATE. Patients in the VAME group had more pulmonary comorbidities (RR = 2.18, 95% CI 1.37-3.46, P = 0.001). The pooled results showed that VAME shortened the operation time (SMD = -1.53, 95% CI -2.308--0.76, P = 0.000), and retrieved less total lymph nodes (SMD = -0.70, 95% CI -0.90--0.50, P = 0.000). No differences were observed in other clinicopathological features, postoperative complications or mortality.

Conclusions

This meta-analysis revealed that patients in the VAME group had more pulmonary disease before surgery. The VAME approach significantly shortened the operation time and retrieved less total lymph nodes and did not increase intra- or postoperative complications.

Study of the short-term quality of life of patients with esophageal cancer after inflatable videoassisted mediastinoscopic transhiatal esophagectomy

Objective

To compare the short-term outcomes and postoperative quality of life in patients with esophageal cancer between inflatable videoasisted mediastinoscopic transhiatal esophagectomy (IVMTE) and minimally invasive Mckeown esophagectomy (MIME), and to evaluate the value of IVMTE in the surgical treatment of esophageal cancer.

Methods

A prospective, nonrandomized study was adopted. A total of 60 esophageal cancer patients after IVMTE and MIME December 2019 to January 2022 were included. Among them, 30 patients underwent IVMTE and 30 patients underwent MIME. Shortterm outcomes (including the operation time, intraoperative blood loss, postoperative drainage 3 days, total postoperative tube time, postoperative hospital stay, number and number of thoracic lymph node dissection stations, postoperative complications and so on), postoperative quality of life, [including Quality of Life Core Questionnaire (QLQ-C30) and the esophageal site-specific module (QLQ-OES18)] were compared between the 2 groups.

Results

The operation time, intraoperative blood loss, postoperative drainage volume and total postoperative intubation time in IVMTE group were significantly lower than those in MIME group (P < 0.05). A total of 22 patients had postoperative complications, including 7 patients in IVMTE group (23.3%) and 15 patients in MIME group (50.0%). There was significant difference between the two groups (P = 0.032). The physical function, role function, cognitive function, emotional function and social function and the overall health status in the IVMTE group were higher than those in the MIME group at all time points after operation, while the areas of fatigue, nausea, vomiting and pain symptoms in the MIME group were lower than those in the MIME group at all time points after operation.

Conclusion

IVMTE is a feasible and safe alternative to MIME. Therefore, when the case is appropriate, IVMTE should be given priority, which is conducive to postoperative recovery and improve the quality of life of patients after operation.

Feasibility and safety of expandable mediastinoscopic and laparoscopic radical esophagectomy

Background

At present, minimally invasive radical esophagectomy is the main surgical method for esophageal cancer treatment, but it has inherent limitations. We have developed a novel method of radical esophagectomy without thoracotomy to improve this situation, namely, by using EMLE. We evaluated the feasibility and safety of expandable mediastinoscopic and laparoscopic radical esophagectomy (EMLE) through a retrospective analysis.

Methods

From January 2019 to June 2022, we successfully performed 106 cases of radical resection of esophageal cancer with this new surgical technique, gradually improved the surgical path, and recorded the perioperative data and postoperative complications of all patients.

Results

The operation was successfully performed in all patients except for two patients who required a switch to open surgery. The mean operation time was 171.11 ± 33.29 min and the mean intraoperative blood loss was 93.53 ± 56.32 ml. The mean number of removed lymph nodes was 23.59 ± 5.42. The postoperative complications included pneumonia (3.77%), recurrent laryngeal nerve palsy (1.89%), anastomotic leak (14.15%), pleural effusion (5.66%), chylothorax (2.83%), and reoperation (4.72%). All complications were graded I-III per the Clavien-Dindo classification. No perioperative death was recorded.

Conclusion

Expandable mediastinoscopic and laparoscopic radical esophagectomy is feasible for radical resection of esophageal cancer, with good therapeutic effect and safety. Because of its minimal impact on patients and convenient operation, it is a novel surgical option for patients with esophageal cancer and is expected to become a standard surgical method for radical esophagectomy in the future.

A descriptive comparison of postoperative outcomes between hybrid mediastino-thoracoscopic approach and conventional thoracoscopic esophagectomy for esophageal cancer

BACKGROUND

The purpose of this study was to compare the results of the hybrid mediastino-thoracoscopic approach with that of the conventional thoracoscopic approach and to identify the advantages and disadvantages of the hybrid approach.

METHODS

We retrospectively analyzed 172 patients who underwent thoracoscopic esophagectomy for esophageal cancer from July 2009 to June 2021, excluding salvage surgery. In the mediastinoscopic approach, the lymph nodes were dissected from a small incision in the left aspect of the neck to the aortic arch with supine double-lung ventilation. Thereafter, the middle-to-lower mediastinum and right superior mediastinum were dissected thoracoscopically in the prone position. The patients' demographics, surgical outcomes, postoperative complications, and postoperative recurrence patterns were compared between 51 patients in the hybrid approach and 121 patients in the conventional approach.

RESULTS

The hybrid group had more elderly patients (71 years vs. 67 years; P = 0.010), more cardiovascular disease (33.3% vs. 16.7%; P = 0.021), lower rates of preoperative chemotherapy (49.0% vs. 69.4%; P = 0.015), and shorter right lung collapse time (196 min vs. 264 min; P < 0.001). Postoperative hoarseness was not different between the two groups (31.4% vs. 27.3%; P = 0.584), and there was a significant difference in the sternal-vertebral distance at the level of the sternal notch (41 mm in the hybrid group vs. 48 mm in the conventional group; P = 0.029). The sternal-vertebral distance of less than 45 mm was an independent risk factor for postoperative hoarseness in the logistic analysis (odds ratio 3.636, 95% confidence interval 1.054-12.546; P = 0.041).

CONCLUSION

The hybrid mediastino-thoracoscopic approach could be safely adapted to elderly or cardiopulmonary diseased patients; however, short sternal-vertebral distance might be a risk factor of postoperative recurrent laryngeal nerve palsy.

Outcomes of Minimally Invasive and Robot-Assisted Esophagectomy for Esophageal Cancer

Simple Summary

This is an invited review for the special edition, “Minimally Invasive Surgery for Cancer: Indications and Outcomes.” Indications to perform minimally invasive techniques for esophagectomy rather than the classic open technique do not exist. This review outlines the current research by comparing outcomes among minimally invasive esophagectomy, robot-assisted esophagectomy, and open esophagectomy. After determining the benefits of each technique in terms of each outcome, the discussion focuses on how surgeons may use the presented information to determine which approach is most appropriate. We hope this study provides a comprehensive review of the current state of the literature regarding minimally invasive esophagectomy, as well as a guide for surgeons who treat patients with esophageal cancer.

Abstract

With the evolution of minimally invasive esophagectomy (MIE) and robot-assisted minimally invasive esophagectomy (RAMIE), questions remain regarding the benefits and indications of these methods. Given that set indications do not exist, this article aims first to review the reported outcomes of MIE, RAMIE, and open esophagectomy. Then, considerations based on the reported outcomes are discussed to guide surgeons in selecting the best approach. MIE and RAMIE offer the potential to improve outcomes for esophagectomy patients; however, surgeon experience as well as individual patient factors play important roles when deciding upon the surgical approach.