Minimally invasive esophagectomy: Direction of the art

Conduit Ischemia After Esophagectomy: A Spectrum of Clinical Manifestations, Prevention, and Management

This article outlines the anatomic and physiologic basis for gastric conduit ischemia and the range of its possible manifestations, from superficial mucosal ischemia to gross conduit necrosis. Methods by which these complications are suspected and ultimately diagnosed are discussed, focusing on clinical and laboratory signs as the harbingers and the use of imaging and endoscopy for confirmation. From there, management options are detailed based on the Esophagectomy Complications Consensus Group classification of esophageal leak and gastric necrosis. Finally, the short- and long-term implications of these complications are reviewed.

The anastomotic leak triad: preoperative patient characteristics, intraoperative risk factors, and postoperative outcomes

BACKGROUND

The aim of this study was to determine perioperative risk factors associated with anastomotic leak (AL) after minimally invasive esophagectomy (MIE) and its association with cancer recurrence and overall survival.

METHODS

This retrospective observational study of electronic health record data included patients who underwent MIE for esophageal cancer between September 2013 and July 2023 at a tertiary center. The primary outcome was AL after esophagectomy, whereas the secondary outcomes included time to cancer recurrence and overall survival. Perioperative patient factors were evaluated to determine their associations with the primary and the secondary outcomes. Propensity score-matched logistic regression assessed the associations between perioperative factors and AL. Kaplan-Meier survival curves compared cancer recurrence and overall survival by AL.

RESULTS

A total of 251 consecutive patients with esophageal cancer were included in the analysis; 15 (6%) developed AL. Anemia, hospital complications, hospital length of stay, and 30-day readmissions significantly differed from those with and without AL (P = .037, <.001, <.001, and.016, respectively). Moreover, 30- and 90-day mortality were not statistically affected by the presence of AL (P = .417 and 0.456, respectively). Logistic regression modeling showed drug history and anemia were significantly associated with AL (P = .022 and.011, respectively). The presence of AL did not significantly impact cancer recurrence or overall survival (P = .439 and.301, respectively).

CONCLUSION

The etiology of AL is multifactorial. Moreover, AL is significantly associated with drug history, preoperative anemia, hospital length of stay, and 30-day readmissions, but it was not significantly associated with 30- or 90-day mortality, cancer recurrence, or overall survival. Patients should be optimized before undergoing MIE with special consideration for correcting anemia. Ongoing research is needed to identify more modifiable risk factors to minimize AL development and its associated morbidity.

Impact of minimally invasive total mesoesophageal excision and minimally invasive esophagectomy on failure patterns of locally advanced esophageal squamous cell carcinoma: a matched cohort study with long-term follow-up

BACKGROUND

The effects of minimally invasive total mesoesophageal excision (MITME) on the long-term prognosis of locally advanced esophageal squamous cell carcinoma (ESCC) remain unknown. The objective of this study was to compare the static and dynamic failure patterns of MITME and minimally invasive esophagectomy (MIE) for locally advanced ESCC.

METHODS

We use propensity score matching (PSM) method to analyze the postoperative failure patterns of the two groups. Cumulative event curves were analyzed for cumulative incidence of failure between different groups, and independent prognostic factors were assessed using time-dependent multivariate analyses. The risk of dynamic failure calculated at 12-month intervals was compared between the two groups using the lifetime table.

RESULTS

A total of 366 ESCC patients were studied by 1:1 PSM for T stage and TNM stage (MITME group, n = 183; MIE group, n = 183). In the matched cohort, there was significant differences between the MITME and MIE groups in the failure pattern of regional lymph node recurrence (0.5 vs 3.8%, P = 0.032) and non-tumor death (10.9 vs 31.7%, P < 0.001). The cumulative event curve found that the 5-year cumulative failure rate was lower in the MITME group than in the MIE group (3.3 vs 17.1%, P = 0.026) after 5 years of survival. In addition, multivariate Cox regression analysis showed that MIE was an independent poor prognostic factor for a high cumulative failure rate in locally advanced ESCC patients at 5 years after surgery (HR:4.110; 95% CI 1.047-16.135; P = 0.043). The dynamic risk curve showed that the MITME group had a lower risk of failure within 5 years after surgery than the MIE group.

CONCLUSION

Considering that MITME can significantly improve the postoperative failure pattern and the benefit lasts for at least 5 years, it is feasible to use MITME as a treatment for locally advanced ESCC.

Two-rope method for dissecting esophagus in McKeown MIE

Objective

Minimally invasive McKeown esophagectomy (McKeown MIE) is performed at many hospitals in esophageal cancer(EC) treatment. However, secure and quick methods for dissecting the esophagus and dissecting lymph nodes in this surgery are lacking. This study introduces a simple, secure and feasible esophagus dissecting technique named two-rope method. Two mobile traction ropes are placed around the esophagus and we tow these ropes to free the esophagus, dissect the lymph nodes, and decrease the operative trauma.

Materials and Methods

Retrospective analysis was performed on 112 patients who underwent McKeown MIE in our center from January 2019 to September 2021. They were assigned into two groups based on the method of dissecting the esophagus: Group A (two-rope method, 45 cases) and Group B (regular method, 67 cases). Operation time, thoracic operation time, the number of dissected thoracic lymph nodes, and postoperative complications were compared between the two groups after propensity score matching.

Results

Using 1:1 nearest neighbor matching, we successfully matched 41 pairs of patients. Operation time, thoracic operation time, and the duration (ac to as) was significantly shorter and the size of the abdominal incision was significantly smaller in the Group A than Group B (p < 0.05). There was no statistically significant difference in the number of dissected thoracic lymph nodes, pulmonary infection, anastomotic leak, recurrent laryngeal (RLN) injury, and chylothorax between the two groups (p > 0.05).

Conclusions

Two-rope method to free the esophagus and dissect thoracic lymph nodes in McKeown MIE has significant advantages compared with the regular method. The technique is, therefore suitable for widespread adoption by surgeons.

Update on Management of Squamous Cell Esophageal Cancer

PURPOSE OF THE REVIEW

Esophageal cancer is the sixth most common cause of cancer death globally. Squamous cell carcinoma of the esophagus (ESCC) is the predominant histologic type in the world. Treatment strategies have evolved in the last decade and new paradigms are replacing traditional approaches at all stages of cancer. This review will summarize the epidemiology, diagnosis, staging, and treatment of esophageal squamous cell carcinoma.

RECENT FINDINGS

Novel approaches to screening may be cost-effective in regions with a high incidence of ESCC. Multi-disciplinary evaluation and treatment has become the standard of care. Endoscopic resection may be an option for early stage ESCC. Minimally invasive esophagectomy can be performed safely as a primary therapy or after-induction chemoradiation. Several recent studies have found a survival benefit to immunotherapy for patients with metastatic or persistent disease. Multi-disciplinary evaluation and multi-modal therapy including cytotoxic chemotherapy, radiation, surgery, and immunotherapy have improved survival compared to surgery alone.