Minimally invasive esophagectomy

Advantages of McKeown minimally invasive oesophagectomy for the treatment of oesophageal cancer: propensity score matching analysis of 169 cases

BACKGROUND

Oesophagectomy, the gold standard for oesophageal cancer treatment, causes significantly high morbidity and mortality. McKeown minimally invasive oesophagectomy (MIE) is preferred for treating oesophageal malignancies; however, limited studies with large sample sizes focusing on the surgical and oncological outcomes of this procedure have been reported. We aimed to compare the clinical safety and efficacy of McKeown MIE with those of open oesophagectomy (OE).

PATIENTS AND METHODS

Overall, 338 oesophageal cancer patients matched by gender, age, location, size, and T and N stages (McKeown MIE: 169 vs OE: 169) were analysed. The clinicopathologic features, operational factors, postoperative complications, and prognoses were compared between the groups.

RESULTS

McKeown MIE resulted in less bleeding (200 mL vs 300 mL, p<0.01), longer operation time (335.0 h vs 240.0 h, p<0.01), and higher number of harvested lymph nodes (22 vs 9, p<0.01) than OE did. Although the rate of recurrent laryngeal nerve injury in the two groups was not significantly different, incidence of anastomotic leakage (8 vs 24, p=0.003) was significantly lower in the McKeown MIE group. In addition, patients who underwent McKeown MIE had higher 5-year overall survival than those who underwent OE (69.9% vs 40.4%, p<0.001).

CONCLUSION

McKeown MIE is proved to be feasible and safe to achieve better surgical and oncological outcomes for oesophageal cancer compared with OE.

Novel Transgastric Endoluminal Segmental Esophagectomy and Primary Anastomosis Technique: A Hybrid Transgastric Thoracoscopic Esophagectomy for the Treatment of High Grade Dysplasia and Early Esophageal Cancer in a Porcine Ex vivo Model

Multiple modalities are currently employed in the treatment of high grade dysplasia and early esophageal carcinoma. While they are the subject of ongoing investigation, surgery remains the definitive modality for oncological resection. Esophagectomy, however, is traditionally a challenging surgical procedure and carries a significant incidence of morbidity and mortality. Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are considerably less invasive alternatives to esophagectomy in the diagnosis and treatment of high grade dysplasia, early esophageal squamous cell carcinoma and adenocarcinoma. However, many early esophageal cancer patients, with favorable histology, who could benefit from endoscopic resection, are referred for formal esophagectomy due to lesion characteristics such as unfavorable lesion morphology or recurrence after previous endoscopic resection. In this study we present a novel, hybrid thoracoscopic transgastric endoluminal segmental esophagectomy with primary anastomosis for the potential treatment of high grade dysplasia and early esophageal cancer in a porcine ex vivo model as a proposed bridge between endoscopic resection and the relatively high mortality and morbidity formal esophagectomy procedure. The novel technique consists of thoracoscopic esophageal mobilization in addition to transgastric endoluminal segmental esophagectomy and anastomosis utilizing a standard circular stapler. The technique was found feasible in all experimental subjects. The minimally invasive nature of this novel procedure as well as the utility of basic surgical equipment and surgical skill is an important attribute of this method and can potentially make it a treatment option for many patients who would otherwise be referred for a formal esophagectomy.

Minimally invasive esophagectomy: Preservation of arch of Azygos vein in prone position

Minimally invasive esophagectomy (MIE) for oesophageal cancer has gained wide popularity in recent years due to its improved morbidity and mortality outcomes. We describe our modified technique of MIE in prone position with preservation of the arch of azygos vein. In our experience with 14 patients, the mean operative duration was 378 min (standard deviation [SD] 378 ± 59 min) and the mean blood loss was 390 ml (SD 390 ± 142 ml). The mean lymph node count was 28 (range 17–54). The Visick score was I in 12 (85.7%) patients and II in 2 (14.3%) patients at follow-up. The preservation of azygos vein arch is a technically feasible procedure and may be associated with a better quality of life outcome.

Does Timing of Robotic Esophagectomy Adoption Impact Short-Term Postoperative Outcomes?

BACKGROUND

Robotic esophagectomies are increasingly common and are reported to have superior outcomes compared with an open approach; however, it is unclear if all institutions can achieve such outcomes. We hypothesize that early adopters of robotic technique would have improved short-term outcomes.

METHODS

The National Cancer Database (2010-2016) was used to identify robotic esophagectomies. Early adopters were defined as programs which performed robotic esophagectomies in 2010-2011, late adopters in 2012-2013. Outcomes of esophagectomies performed between 2014 and 2016 were compared and included length of stay, number of lymph nodes evaluated, readmission, conversion rate, and 90-day mortality. Multivariable regressions, accounting for robotic esophagectomy volume, were used to control for confounding factors.

RESULTS

There were 37 early adopters and 35 late adopters. Between 2014 and 2016, 683 robotic esophagectomies were performed: 446 (65.3%) by early adopters and 237 (34.7%) by late adopters. Early adopters were more likely to be academic programs (96.2 versus 72.8%, P < 0.01). Other clinical and demographic variables were similar. Late adopters were found to have decreased a number of lymph nodes evaluated (coefficient -2.407, P = 0.004) compared with early adopters. There were no significant differences in length of stay, readmissions, rate of positive margins, conversion from robotic to open, or 90-day mortality.

CONCLUSIONS

When accounting for robotic esophagectomy volume, late adoption of robotic esophagectomy was associated with a reduced lymph node harvest, but other postoperative outcomes were similar. These data suggest that programs can safely start new robotic esophagectomy programs, but must ensure an adequate case load.

Modified reverse-puncture anastomotic technique vs. traditional technique for total minimally invasive Ivor-Lewis esophagectomy

Background

Total endoscopic Ivor-Lewis esophagectomy is a challenging, complex, and costly operation. These disadvantages restrict its wide application. The aim of this study was to compare the modified reverse-puncture anastomotic technique and traditional technique for total minimally invasive Ivor-Lewis esophagectomy.

Methods

In this cohort retrospective study, all patients with medial and lower squamous cell carcinoma of esophagus from February 2014 and June 2018 were divided into two groups according to the surgical method, which were modified reverse-puncture anastomotic technique group and traditional technique group. The operation time, intraoperative bleeding volume, complications, and cost of the two groups were compared.

Results

Forty-eight patients in the modified reverse-puncture anastomotic technique group while 54 patients in the traditional technique group were included. The operation time was 293.4 ± 57.2 min in the modified reverse-puncture anastomotic technique group, which was significantly shorter than that in the traditional technique group (353.4 ± 64.1 min) (P < 0.05). The intraoperative bleeding volume of modified reverse-puncture anastomotic technique group was 157.3 ± 107.4 ml, while it was 191.9 ± 123.6 ml in traditional technique group (P = 0.14). There were similar complications between the two groups. The cost of modified reverse-puncture anastomotic and traditional technique in our hospital were and 72 ± 13 and 83 ± 41 thousand Yuan, respectively (P = 0.08).

Conclusion

The good short-term outcomes that were achieved suggested that the use of modified reverse-puncture anastomotic technique is safe and feasible for total endoscopic Ivor-Lewis esophagectomy.

Minimal Invasive Esophagectomy-a New Dawn of EsophagealSurgery

Surgery is the mainstay of esophageal cancer. However, esophagectomy is a major surgical trauma on a patient with high morbidity and mortality. The intent of minimally invasive esophagectomy (MIE) is to decrease the degree of surgical trauma and perioperative morbidity associated with open surgery, and provide faster recovery and shorter hospital stay with the equivalent oncological outcome. It also allows for lesser pulmonary morbidity, less blood loss, less pain, and a better quality of life. MIE is safe and effective but has a steep learning curve with high technical expertise. Recently, it is increasingly accepted and adopted all over the globe. In this article, we discuss the safety, efficacy, short-term, and oncological outcomes of thoracoscopic- and laparoscopic-assisted minimally invasive esophagectomy and robotic surgery compared with open esophagectomy with a special focus on the Indian perspective.

Analysis of the learning curve for artificial pneumothorax during an endoscopic McKeown-type resection of oesophageal carcinoma

Background

Due to the large trauma caused by conventional open surgery, minimally invasive esophageal cancer surgery has been gradually carried out, and there is no report on the learning curve for artificial pneumothorax during an endoscopic McKeown-type resection of oesophageal carcinoma.

Methods

Forty cases of McKeown resection of oesophageal carcinoma with artificial pneumothorax that were completed by the same operator between December 2017 and August 2019 were analysed. The patients were divided into four groups (A, B, C, D) of 10 cases each according to the order of operation. The operation time, intraoperative blood loss, total lymph nodes and left recurrent laryngeal nerve lymph nodes resection, conversion rate, complication rate and hospitalization time were compared between the four groups.

Results

The operation time of the four groups were as follows: A, 243.2±44.1 min; B, 265.0±59.3 min; C, 255.8±41.7 min; D, 201.0±16.2 min, there were significant difference in terms of the operation time between group A, group B, group C and group D (P<0.05). Moreover, groups A and C all differed significantly from group D in the number of dissected left recurrent laryngeal nerve lymph nodes. However, no significant inter-group differences were observed in the number of trans-laparotomy and trans-thoracotomy, number of dissected total lymph nodes, intraoperative blood loss, incidence of postoperative complications and postoperative length of hospital stay (P>0.05).

Conclusions

Artificial pneumothorax during an endoscopic McKeown-type resection of oesophageal carcinoma required a learning curve of approximately 30 cases.

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.

Oncologic Resection in Laparoscopic Versus Robotic Transhiatal Esophagectomy

Background and Objectives:

As the use of robotic surgery continues to increase, little is known about robotic oncologic outcomes compared with traditional methods in esophagectomy. The aim of this study was to examine the perioperative oncologic outcomes of patients undergoing laparoscopic versus robot-assisted transhiatal esophagectomy (THE).

Methods:

Thirty-six consecutive patients who underwent laparoscopic and robot-assisted THE for malignant disease over a 3-year period were identified in a retrospective database. Eighteen patients underwent robotic-assisted THE with cervical anastomosis, and 18 patients underwent laparoscopic THE. All procedures were performed by a single foregut and thoracic surgeon.

Results:

Patient demographics were similar between the 2 groups with no significant differences. Lymph node yields for both laparoscopic and robot-assisted THE were similar at 13.9 and 14.3, respectively (P = .90). Ninety-four percent of each group underwent R0 margins, but only 1 patient from each modality had microscopic positive margins. All of the robot-assisted patients underwent neoadjuvant chemoradiation, whereas 83.3% underwent neoadjuvant therapy in the laparoscopy group (P = .23). Clinical and pathologic stagings were similar in each group. There was 1 death after laparoscopic surgery in a cirrhotic patient and no mortalities among the robot-assisted THE patients (P = .99). One patient from each group experienced an anastomotic leak, but neither patient required further intervention.

Conclusions:

Laparoscopic and robot-assisted THEs yield similar perioperative oncologic results including lymph node yield and margin status. In the transition from laparoscopic surgery, robotic surgery should be considered oncologically noninferior compared with laparoscopy.

A feasibility study of mediastinoscopic radical esophagectomy for thoracic esophageal cancer from the viewpoint of the dissected mediastinal lymph nodes validated with thoracoscopic procedure: a prospective clinical trial

PURPOSE

A prospective trial evaluated the feasibility and safety of "mediastinoscopic esophagectomy with lymph node dissection" (MELD).

METHODS

Eligible patients had thoracic esophageal squamous cell carcinoma, excluding T4, a bulky primary lesion or distant metastasis. Ten patients were enrolled and treated between September 2015 and March 2018. Additionally, to verify the integrity of the mediastinal lymph node dissection, thoracoscopic observation and lymph node dissection were followed. The primary end point was the integrity of mediastinal lymph node dissection. The secondary end points were the short-term outcomes, including mortality and morbidity.

RESULTS

The median number of dissected lymph nodes in the upper mediastinal to cervical region and middle to lower mediastinal region by mediastinoscopy/thoracoscopy was 27/0.5 and 11.5/0, respectively. The median total operation time was 615 min, the median bleeding amount was 476 ml, and the median postoperative hospital stay was 15.5 days. Regarding complications of more than grade III according to the Clavien-Dindo classification, four had sputum excretion difficulty, one had pneumothorax and one had bilateral recurrent nerve palsy, but none required conversion to thoracotomy, and no operative deaths occurred.

CONCLUSION

Although the rate of recurrent nerve palsy still should be reduced, our mediastinoscopic lymphadenectomy technique is closely similar to radical esophagectomy.

Matched-pair comparisons of minimally invasive esophagectomy versus open esophagectomy for resectable esophageal cancer: A systematic review and meta-analysis protocol

BACKGROUND

Open esophagectomy (OE) with radical lymphadenectomy is known as one of the most invasive digestive surgeries with the high rate of complications. Minimally invasive esophagectomy (MIE) has developed very rapidly and has formed several available technical approaches. This systematic review and meta-analysis is aiming at how beneficial, and to what extent MIE resection really will be.

METHODS

A systematic literature search will be performed through May 31, 2018 using MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and Google Scholar for relevant articles published in any language. Randomized controlled trials, prospective cohort studies, and propensity score matched comparative studies will be included. If data are sufficient, subgroup analyses will be conducted in different surgical procedures of MIE.

RESULTS

The results of this systematic review and meta-analysis will be published in a peer-reviewed journal.

CONCLUSION

This will be the first systematic review and meta-analysis using data of randomized controlled, prospective, and propensity score matched comparative studies to compare the outcomes between MIE and OE updating to May 31, 2018.

Robot-Assisted Hybrid Esophagectomy Is Associated with a Shorter Length of Stay Compared to Conventional Transthoracic Esophagectomy: A Retrospective Study

Aim

To compare the peri- and postoperative data between a hybrid minimally invasive esophagectomy (HMIE) and the conventional Ivor Lewis esophagectomy.

Methods

Retrospective comparison of perioperative characteristics, postoperative complications, and survival between HMIE and Ivor Lewis esophagectomy.

Results

216 patients were included, with 160 procedures performed with the conventional and 56 with the HMIE approach. Lower perioperative blood loss was found in the HMIE group (600 ml versus 200 ml, p < 0.001). Also, a higher median number of lymph nodes were harvested in the HMIE group (median 28) than in the conventional group (median 23) (p = 0.002). The median length of stay was longer in the conventional group compared to the HMIE group (11.5 days versus 10.0 days, p = 0.03). Patients in the HMIE group experienced fewer grade 2 or higher complications than the conventional group (39% versus 57%, p = 0.03). The rate of all pulmonary (51% versus 43%, p = 0.32) and severe pulmonary complications (38% versus 18%, p = 0.23) was not statistically different between the groups.

Conclusions

The HMIE was associated with lower intraoperative blood loss, a higher lymph node harvest, and a shorter hospital stay. However, the inborn limitations with the retrospective design stress a need for prospective randomized studies. Registration number is DRKS00013023.

Minimally invasive esophagectomy versus open esophagectomy for esophageal cancer: a meta-analysis

Background and objectives

The safety and effectiveness of minimally invasive esophagectomy (MIE) in comparison with the open esophagectomy (OE) remain uncertain in esophageal cancer treatment. The purpose of this meta-analysis is to compare the outcomes of the two surgical modalities.

Methods

Searches were conducted in MEDLINE, EMBASE, and ClinicalTrials.gov with the following index words: “esophageal cancer”, “VATS”, “MIE”, “thoracoscopic esophagectomy”, and “open esophagectomy” for relative studies that compared the effects between MIE and OE. Random-effect models were used, and heterogeneity was assessed.

Results

A total of 20 studies were included in the analysis, consisting of four randomized controlled trials and 16 prospective studies. MIE has reduced operative blood loss (P=0.0009) but increased operation time (P=0.009) in comparison with OE. Patients get less respiratory complications (risk ratio =0.74, 95% CI =0.58–0.94, P=0.01) and better overall survival (hazard ratio =0.54, 95% CI =0.42–0.70, P<0.00001) in the MIE group than the OE group. No statistical difference was observed between the two groups in terms of lymph node harvest, R0 resection, and other major complications.

Conclusion

MIE is a better choice for esophageal cancer because patients undergoing MIE may benefit from reduced blood loss, less respiratory complications, and also improved overall survival condition compared with OE. However, more randomized controlled trials are still needed to verify these differences.

Non-surgical versus surgical treatment for oesophageal cancer

BACKGROUND

Oesophageal cancer is the sixth most common cause of cancer-related mortality in the world. Currently surgery is the recommended treatment modality when possible. However, it is unclear whether non-surgical treatment options is equivalent to oesophagectomy in terms of survival.

OBJECTIVES

To assess the benefits and harms of non-surgical treatment versus oesophagectomy for people with oesophageal cancer.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Science Citation Index, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) up to 4th March 2016. We also screened reference lists of included studies.

SELECTION CRITERIA

Two review authors independently screened all titles and abstracts of articles obtained from the literature searches and selected references for further assessment. For these selected references, we based trial inclusion on assessment of the full-text articles.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted study data. We calculated the risk ratio (RR) with 95% confidence interval (CI) for binary outcomes, the mean difference (MD) or the standardised mean difference (SMD) with 95% CI for continuous outcomes, and the hazard ratio (HR) for time-to-event outcomes. We performed meta-analyses where it was meaningful.

MAIN RESULTS

Eight trials, which included 1132 participants in total, met the inclusion criteria of this Cochrane review. These trials were at high risk of bias trials. One trial (which included five participants) did not contribute any data to this Cochrane review, and we excluded 13 participants in the remaining trials after randomisation; this left a total of 1114 participants, 510 randomised to non-surgical treatment and 604 to surgical treatment for analysis. The non-surgical treatment was definitive chemoradiotherapy in five trials and definitive radiotherapy in three trials. All participants were suitable for major surgery. Most of the data were from trials that compared chemoradiotherapy with surgery. There was no difference in long-term mortality between chemoradiotherapy and surgery (HR 0.88, 95% CI 0.76 to 1.03; 602 participants; four studies; low quality evidence). The long-term mortality was higher in radiotherapy than surgery (HR 1.39, 95% CI 1.18 to 1.64; 512 participants; three studies; very low quality evidence). There was no difference in long-term recurrence between non-surgical treatment and surgery (HR 0.96, 95% CI 0.80 to 1.16; 349 participants; two studies; low quality evidence). The difference between non-surgical and surgical treatments was imprecise for short-term mortality (RR 0.39, 95% CI 0.11 to 1.35; 689 participants; five studies; very low quality evidence), the proportion of participants with serious adverse in three months (RR 0.61, 95% CI 0.25 to 1.47; 80 participants; one study; very low quality evidence), and proportion of people with local recurrence at maximal follow-up (RR 0.89, 95% CI 0.70 to 1.12; 449 participants; three studies; very low quality evidence). The health-related quality of life was higher in non-surgical treatment between four weeks and three months after treatment (Spitzer Quality of Life Index; MD 0.93, 95% CI 0.24 to 1.62; 165 participants; one study; very low quality evidence). The difference between non-surgical and surgical treatments was imprecise for medium-term health-related quality of life (three months to two years after treatment) (Spitzer Quality of Life Index; MD -0.95, 95% CI -2.10 to 0.20; 62 participants; one study; very low quality of evidence). The proportion of people with dysphagia at the last follow-up visit prior to death was higher with definitive chemoradiotherapy compared to surgical treatment (RR 1.48, 95% CI 1.01 to 2.19; 139 participants; one study; very low quality evidence).

AUTHORS' CONCLUSIONS

Based on low quality evidence, chemoradiotherapy appears to be at least equivalent to surgery in terms of short-term and long-term survival in people with oesophageal cancer (squamous cell carcinoma type) who are fit for surgery and are responsive to induction chemoradiotherapy. However, there is uncertainty in the comparison of definitive chemoradiotherapy versus surgery for oesophageal cancer (adenocarcinoma type) and we cannot rule out significant benefits or harms of definitive chemoradiotherapy versus surgery. Based on very low quality evidence, the proportion of people with dysphagia at the last follow-up visit prior to death was higher with definitive chemoradiotherapy compared to surgery. Based on very low quality evidence, radiotherapy results in less long-term survival than surgery in people with oesophageal cancer who are fit for surgery. However, there is a risk of bias and random errors in these results, although the risk of bias in the studies included in this systematic review is likely to be lower than in non-randomised studies.Further trials at low risk of bias are necessary. Such trials need to compare endoscopic treatment with surgical treatment in early stage oesophageal cancer (carcinoma in situ and Stage Ia), and definitive chemoradiotherapy with surgical treatments in other stages of oesophageal cancer, and should measure and report patient-oriented outcomes. Early identification of responders to chemoradiotherapy and better second-line treatment for non-responders will also increase the need and acceptability of trials that compare definitive chemoradiotherapy with surgery.

Impact of artificial capnothorax on coagulation in patients during video-assisted thoracoscopic esophagectomy for squamous cell carcinoma

BACKGROUND

Compared with the lung isolation using double-lumen endobronchial tube intubation, the artificial capnothorax using single-lumen endotracheal tube intubation has shown to be a safe, more convenient, and cost-effective procedure for thoracoscopic esophagectomy. However, the impact of capnothorax on coagulation is not well defined. Herein, we evaluate the impact of a capnothorax on coagulation and fibrinolysis in patients who undergoing thoracoscopic esophagectomy.

METHODS

Between March 2014 and August 2014, 24 patients underwent thoracoscopic esophagectomies for esophageal cancer with the procedure of artificial capnothorax (group P); we also performed 24 thoracoscopic esophagectomy cases without using capnothorax (group N). The demographics and arterial blood gas, as well as the parameters of coagulation and fibrinolysis, of the two groups were analyzed.

RESULTS

The pH value of group P after CO2 insufflation was significantly lower than in group N (P < 0.05), and the partial pressure of carbon dioxide (PaCO2) was significantly increased compared with group N (P < 0.05). The R and K values after CO2 insufflation were significantly longer than before anesthesia (P < 0.05), and both α angle and MA value after CO2 insufflation were significantly lower than those before anesthesia (P < 0.05). No significant differences in R value, K value, α angle, or MA value were observed between pre-anesthesia and termination of capnothorax. No significant difference in LY30 data was found between different groups (P > 0.05).

CONCLUSION

Artificial capnothorax in patients receiving endoscopic resection of esophageal carcinoma had a significant impact on coagulation. These patients showed significant impairments in coagulation not observed in patients without artificial capnothorax.

Impact of minimally invasive surgery in the treatment of esophageal cancer

BACKGROUND

Surgical treatment of esophageal cancer is associated to a high morbidity and mortality rate. The open transthoracic or transhiatal esophagectomy are considerably invasive procedures and have been associated to high rates of complications and operative mortality. In this way, minimally invasive esophageal surgery has been suggested as an alternative to the classic procedures because would produce improvement in clinical longterm postoperative outcomes.

AIM

To assess survival, mortality and morbidity results of esophagectomy due to esophageal cancer submitted to minimally invasive techniques and compare them to results published in international literature.

METHOD

An observational, prospective study. Between 2003 and 2012, 69 patients were submitted to a minimally invasive esophagectomy due to cancer. It was recorded postoperative morbidity and mortality according to the Clavien-Dindo classification. The survival rate was analyzed with the Kaplan-Meier method. The number of lymph nodes obtained during the lymph node dissection, as an index of the quality of the surgical technique, was analysed.

RESULTS

63.7% of patients had minor complications (type I-II Clavien Dindo), while nine (13%) required surgical re-exploration. The most common postoperative complication corresponded to leak of the cervical anastomosis seen in 44 (63.7%) patients but without clinical repercusion, only two of them required reoperation. The mortality rate was 4.34%, and reoperation was necessary in nine (13%) cases. The average survival time was 22.59 ± 25.38 months, with the probability of a 3-year survival rate estimated at 30%. The number of resected lymph nodes was 17.17 ± 9.62.

CONCLUSION

Minimally invasive techniques have lower morbidity and mortality rate, very satisfactory lymphnodes resection and similar long term outcomes in term of quality of life and survival compared to results observed after open surgery.

Minimally invasive esophagectomy: results of a prospective phase II multicenter trial-the eastern cooperative oncology group (E2202) study

OBJECTIVE

The primary aim of this trial was to assess the feasibility of minimally invasive esophagectomy (MIE) in a multi-institutional setting.

BACKGROUND

Esophagectomy is an important, potentially curative treatment for localized esophageal cancer, but is a complex operation. MIE may decrease the morbidity and mortality of resection, and single-institution studies have demonstrated successful outcomes with MIE.

METHODS

We conducted a multicenter, phase II, prospective, cooperative group study (coordinated by the Eastern Cooperative Oncology Group) to evaluate the feasibility of MIE. Patients with biopsy-proven high-grade dysplasia or esophageal cancer were enrolled at 17 credentialed sites. Protocol surgery consisted of either 3-stage MIE or Ivor Lewis MIE. The primary end point was 30-day mortality. Secondary end points included adverse events, duration of hospital-stay, and 3-year outcomes.

RESULTS

Protocol surgery was completed in 95 of the 104 patients eligible for the primary analysis (91.3%). The 30-day mortality in eligible patients who underwent MIE was 2.1%; perioperative mortality in all registered patients eligible for primary analysis was 2.9%. Median intensive care unit and hospital stay were 2 and 9 days, respectively. Grade 3 or higher adverse events included anastomotic leak (8.6%), acute respiratory distress syndrome (5.7%), pneumonitis (3.8%), and atrial fibrillation (2.9%). At a median follow-up of 35.8 months, the estimated 3-year overall survival was 58.4% (95% confidence interval: 47.7%-67.6%). Locoregional recurrence occurred in only 7 patients (6.7%).

CONCLUSIONS

This prospective multicenter study demonstrated that MIE is feasible and safe with low perioperative morbidity and mortality and good oncological results. This approach can be adopted by other centers with appropriate expertise in open esophagectomy and minimally invasive surgery.

Robotic transthoracic esophagectomy

BACKGROUND

We have initially published our experience with the robotic transthoracic esophagectomy in 32 patients from a single institute. The present paper is the extension of our experience with robotic system and to best of our knowledge this represents the largest series of robotic transthoracic esophagectomy worldwide. The objective of this study was to investigate the feasibility of the robotic transthoracic esophagectomy for esophageal cancer in a series of patients from a single institute.

METHODS

A retrospective review of medical records was conducted for 83 esophageal cancer patients who underwent robotic esophagectomy at our institute from December 2009 to December 2012. All patients underwent a thorough clinical examination and pre-operative investigations. All patients underwent robotic esophageal mobilization. En-bloc dissection with lymphadenectomy was performed in all cases with preservation of Azygous vein. Relevant data were gathered from medical records.

RESULTS

The study population comprised of 50 men and 33 women with mean age of 59.18 years. The mean operative time was 204.94 mins (range 180 to 300). The mean blood loss was 86.75 ml (range 50 to 200). The mean number of lymph node yield was 18. 36 (range 13 to 24). None of the patient required conversion. The mean ICU stay and hospital stay was 1 day (range 1 to 3) and 10.37 days (range 10 to 13), respectively. A total of 16 (19.28%) complication were reported in these patents. Commonly reported complication included dysphagia, pleural effusion and anastomotic leak. No treatment related mortality was observed. After a median follow-up period of 10 months, 66 patients (79.52%) survived with disease free stage.

CONCLUSIONS

We found robot-assisted thoracoscopic esophagectomy feasible in cases of esophageal cancer. The procedure allowed precise en-bloc dissection with lymphadenectomy in mediastinum with reduced operative time, blood loss and complications.

A risk model for esophagectomy using data of 5354 patients included in a Japanese nationwide web-based database

OBJECTIVE

This study aimed to create a risk model of mortality associated with esophagectomy using a Japanese nationwide database.

METHODS

A total of 5354 patients who underwent esophagectomy in 713 hospitals in 2011 were evaluated. Variables and definitions were virtually identical to those adopted by the American College of Surgeons National Surgical Quality Improvement Program.

RESULTS

The mean patient age was 65.9 years, and 84.3% patients were male. The overall morbidity rate was 41.9%. Thirty-day and operative mortality rates after esophagectomy were 1.2% and 3.4%, respectively. Overall morbidity was significantly higher in the minimally invasive esophagectomy group than in the open esophagectomy group (44.3% vs 40.8%, P = 0.016). The odds ratios for 30-day mortality in patients who required preoperative assistance in activities of daily living (ADL), those with a history of smoking within 1 year before surgery, and those with weight loss more than 10% within 6 months before surgery were 4.2, 2.6, and 2.4, respectively. The odds ratios for operative mortality in patients who required preoperative assistance in ADL, those with metastasis/relapse, male patients, and those with chronic obstructive pulmonary disease were 4.7, 4.5, 2.3, and 2.1, respectively.

CONCLUSIONS

This study was the first, as per our knowledge, to perform risk stratification for esophagectomy using a Japanese nationwide database. The 30-day and operative mortality rates were relatively lower than those in previous reports. The risk models developed in this study may contribute toward improvements in quality control of procedures and creation of a novel scoring system.

Comparison of outcomes of open and minimally invasive esophagectomy in 183 patients with cancer

BACKGROUND AND OBJECTIVES

Only few randomized trials or comparative studies with large number of patients have been reported on the outcomes of thoracoscopic and laparoscopic esophagectomy (TLE) with cervical anastomosis and open 3-field esophagectomy (OE) for patients with esophageal cancer. The objective of this study is to compare the safety, feasibility, and short-term outcomes between TLE and OE (via right throax, abdomen, and left neck) for esophageal cancer.

METHODS

Clinical and surgical data of patients with esophageal cancer who underwent either TLE or OE between February 2011 and December 2013 were retrospectively analyzed. Demographic characteristics, pathological data, operative procedures, and intraoperative and postoperative outcomes and survival in patients were compared between both groups.

RESULTS

Of the 183 patients included in this retrospective analysis, 94 underwent TLE and 89 underwent OE. Demographics, pathologic data, inpatient mortality, and overall surgical morbidity in both cohorts were almost identical. A significant difference was observed in blood loss (182.6±78.3 vs. 261.4±87.2 mL, P<0.001), hospital stay (13.9±7.5 vs. 17.1±10.2 days, P=0.017), overall surgical morbidity (25.5% vs. 46.1%, P=0.004), and rate of pulmonary and cardiac complication (9.6% vs. 27.0%, P=0.002; 4.1% vs. 12.4%, P=0.046) between TLE and OE groups; however, no difference in survival period was observed between the groups.

CONCLUSIONS

The procedure of TLE for esophageal cancer possesses advantages in intraoperative and postoperative outcomes compared with OE. The TLE procedure results in similar or potentially better outcomes.

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.

Use of a fast-track surgery protocol on patients undergoing minimally invasive oesophagectomy: preliminary results

OBJECTIVES

The aim of this study was to evaluate the safety and effectiveness of a fast-track surgery (FTS) protocol on patients undergoing minimally invasive oesophagectomy.

METHODS

We retrospectively analysed the clinical data of 80 eligible patients who underwent elective minimally invasive oesophagectomy in our department from January 2012 to April 2013 by the same surgical team. Two groups of these patients were compared. The control group comprised patients treated with traditional methods. Clinical parameters were compared. The study group was formed by patients treated with the fast-track concept, such as (i) a semi-liquid meal was administered up to 6 h before surgery and the patients were made to drink 200 ml of 10% glucose solution 3 h before surgery; (ii) no nasogastric tube, no abdominal drainage tube and no draining sinus in the neck; (iii) the chest tube and catheter were removed as early as possible; (iv) prevention of hypothermia therapy; (v) an attempt at bedside rehabilitation on postoperative day (POD) 2; and (vi) early postoperative enteral nutrition, restrictive intravenous fluids intraoperatively and postoperatively, and oral feeding initiated 48 h after surgery.

RESULTS

There were no significant differences between the two groups with regard to age, sex, pathologic tumor-node-metastasis stage, tumour location, pathology, American Society of Anesthesiologists score, preoperative albumin level, 30-day readmission or complications (P >0.05). Compared with the conventional group, the FTS group had earlier first flatus [(3 (3-4) vs 6 (6-7) days], less fluid transfusion [2.1 (2.06-2.2) vs 2.8 (2.7-2.9) l] and shorter postoperative hospital stay [7 (6-9) days vs 12 (10-16.5) days] (P <0.05). There was no difference between the two groups with regard to vomiting, but patients in the conventional group suffered from/experienced pharyngitis considerably more than the FTS group (P <0.001).

CONCLUSIONS

FTS on patients with oesophageal cancer receiving minimally invasive oesophagectomy is safe, feasible and efficient, and can accelerate postoperative rehabilitation. Compared with the conventional protocol, its advantages were limited to short-term follow-up.

Video-assisted radical thoracoscopic and laparoscopic surgery for esophageal carcinoma

Esophageal cancer is a common malignancy, for which surgery is the most effective treatment. Compared with traditional surgery, video-assisted thoracoscopic and laparoscopy minimally invasive surgery enables less trauma, better visibility, reduced bleeding and postoperative pain, and lower incidence of surgical complications through a minimally invasive, safe, and highly cost-effective approach in favor of early rehabilitation after surgery. Therefore, the promotion and application of this surgical approach will undoubtedly benefit the majority of patients with esophageal cancer. We have performed video-assisted thoracoscopic and laparoscopy minimally invasive surgery for more than 150 patients in our hospital to date, and have carried out a series of studies in this regard. As the video shows, this approach is safe and reliable with minimal injury and bleeding.

Fully thoracoscopic versus conventional open resection for esophageal carcinoma: A perioperative comparison

BACKGROUND

To compare the efficacy of patients undergoing esophagectomy for cancer in video-assisted thoracoscopic surgery (VATS) versus traditional open surgery (TOS) in the perioperative period, along with the advantages and disadvantages of each.

METHODS

A retrospective analysis of 108 patients, who underwent esophagectomy between September 2011 and February 2012 in our department, was performed. Patients were divided into two groups based on operative technique (VATS vs. TOS), with 50 patients in the VATS group and 58 patients in the TOS group. Operative duration, intraoperative blood loss, intraoperative blood transfusion, number of lymph nodes harvested, postoperative pain score, period of time requiring chest tube drainage, complications, hospital stay, and hospital costs, were all statistically analyzed between the two groups.

RESULTS

There was no statistical difference between the two groups with regard to operative duration or number of lymph nodes harvested. The VATS group had significantly less intraoperative blood loss, intraoperative blood transfusion, postoperative pain, earlier ambulation, shorter postoperative hospital stay, and a shorter period of time requiring chest tube drainage. The amount of drainage was significantly lower in the TOS group (P < 0.05). Pulmonary complication (pneumonia and pleural effusion) was less prevalent among the VATS group.

CONCLUSION

Compared with TOS, VATS-assisted esophagectomy is less traumatic with lower intraoperative blood loss, faster recovery, and a better overall outcome.

Minimally invasive surgery for esophageal cancer: review of the literature and institutional experience

BACKGROUND

Esophageal cancer represents a major public health problem in the world. Several minimally invasive esophagectomy (MIE) techniques have been described and represent a safe alternative for the surgical management of esophageal cancer in selected centers with high volume and surgeons experienced in minimally invasive procedures.

METHODS

The authors reviewed the most recent and largest studies published in the medical literature that reported the outcomes for MIE techniques.

RESULTS

In larger series, MIE has proven to be equivalent in postoperative morbidity and mortality to the open esophagectomy. However, MIE has been associated with less blood loss, reduced postoperative pain, decreased time in the intensive care unit, and shortened length of hospital stay compared with the conventional open approaches. Despite limited data, no significant difference in survival stage for stage has been observed between open esophagectomy and MIE.

CONCLUSIONS

The myriad of MIE techniques complicates the debate for defining the optimal surgical approach for the treatment of esophageal cancer. Randomized controlled trials comparing MIE with conventional open esophagectomy are needed to clarify the ideal procedure with the lowest postoperative morbidity, best quality of life after surgery, and long-term survival.

Laparoscopic ischemic conditioning of the stomach prior to esophagectomy

Several complications after esophagectomy with gastric pull-up are associated with ischemia within the gastric conduit. The aim of this study is to assess the feasibility of laparoscopic ischemic preconditioning of the stomach prior to thoracotomy, esophagectomy, and gastric pull-up with an intrathoracic anastomosis. A retrospective review of 24 consecutive patients between October 2008 and July 2011 with esophageal adenocarcinoma (stage I-III) undergoing laparoscopic gastric ischemic conditioning prior to esophagectomy was conducted. Conditioning included laparoscopic ligation of the left and short gastric arteries, celiac node dissection, and jejunostomy tube placement. Formal resection and reconstruction was then performed 4-10 days later. Of the 24 patients, 88% received neoadjuvant chemotherapy/radiation therapy. Twenty-three of the 24 patients underwent successful laparoscopic ischemic conditioning and subsequent esophagectomy. Total mean number of lymph nodes harvested was 21.8 (±8.0), and a mean of 5.3 (±2.4) celiac lymph nodes identified. There were no conversions to an open procedure. Length of stay was 3.8 (±4.8) days with a median length of stay of 2 (1-24) days. Three patients experienced anastomotic leak, six patients experience delayed gastric emptying, and two patients developed anastomotic stricture. There were no surgical site infections. R0 resection was achieved in all patients who underwent laparoscopic ischemic conditioning followed by esophagectomy. Laparoscopic ischemic conditioning of the gastric conduit has been shown to be feasible and safe.

Current status of minimally invasive esophagectomy for patients with esophageal cancer

Technical advancements and development of endoscopic equipment in thoracoscopic surgery have resulted in increase in the popularity of minimally invasive esophagectomy (MIE). However, advantages with regard to short-term outcome and oncological feasibility of MIE have not been adequately established. To date, a number of single-institution studies and several meta-analyses have demonstrated acceptable short-term outcomes of thoracoscopic esophagectomy for esophageal cancer, and the outcomes are comparable to those of conventional open esophagectomy (OE). A study group recently reported the results of the first multicenter randomized controlled trial (RCT) that compared MIE and OE. The incidence of pulmonary infection after surgery was markedly lower in the MIE group than in the OE group. Additional benefits of MIE included less operative blood loss, better postoperative patients' quality of life, and shorter hospital stay. However, the oncological benefit to patients undergoing MIE has not been scientifically proven because there have been no RCTs to verify the equivalency in long-term survival of patients undergoing MIE compared with that of patients undergoing OE. If future prospective studies indicate oncological benefits, MIE could truly become the standard care for patients with esophageal cancer.

Minimally invasive surgery for esophageal cancer

Minimally invasive surgery has revolutionized the surgical management of benign foregut disease, as well as pulmonary and other gastrointestinal malignancies. With the potential to reduce operative morbidity and increase patient satisfaction, minimally invasive esophagectomy for the management of esophageal cancer is gaining in popularity. It is unclear, however, whether the minimally invasive approach to esophageal cancer resection has comparable long-term oncologic results. This article discusses the rationale for minimally invasive esophagectomy, describes the surgical technique, and reviews the published results.

Treatment strategies for esophageal cancer

The treatment of esophageal cancer has evolved considerably in the past decade and depends largely on the extent of disease at the time of presentation. For disease confined to the esophageal mucosa, endoscopic therapy is replacing esophagectomy as the standard of care. For locoregional disease, neoadjuvant chemoradiation followed by esophagectomy is the best strategy for optimizing long-term survival. In the minority of patents who present with metastatic disease, the prognosis is poor. Palliative therapies available for these patients include chemotherapy, radiation, endoscopic therapies to ameliorate obstruction or bleeding, and surgical intervention to optimize nutritional status or to relieve obstruction.

Minimally invasive transhiatal esophagectomy after thoracotomy

Patients with end-stage achalasia may not be candidates for a transhiatal minimally invasive esophageal resection because of anatomic challenges and adhesions from previous interventions, namely, thoracotomy. Given the tactile feedback provided through a GelPort laparoscopic system (Applied Medical, Rancho Margarita, CA) we proposed that a minimally invasive transhiatal esophagectomy would be feasible in this patient cohort. The procedure was successful in 4 patients; seven complications occurred in 3 of the patients. At follow-up all patients demonstrated that they were meeting their nutritional needs with an oral diet.

Minimally invasive esophagectomy

Minimally invasive esophagectomy (MIE) has become an established approach for the treatment of esophageal carcinoma. In comparison with open esophagectomy MIE reduces blood loss, respiratory complications, and length of hospital stay. At the University of Pittsburgh, the authors now predominantly perform a laparoscopic-thoracoscopic Ivor Lewis esophagectomy. This article details this technique, discusses the recently published series of more than 1000 esophagectomies performed by the authors during the last 15 years, and reviews the current literature on MIE.

Refinement of minimally invasive esophagectomy techniques after 15 years of experience

INTRODUCTION

[corrected] In an effort to reduce the morbidity and mortality associated with open esophagectomy, a minimally invasive approach to esophagectomy was introduced at the University of Pittsburgh Medical Center (UPMC) in 1996. The objective of this article is to discuss the optimization and refinement of minimally invasive esophagectomy (MIE) techniques over the 15-year experience at UPMC. We also reviewed the literature on technical improvements in MIE.

METHOD

Literature highlights for MIE and related meta-analyses comparing open esophagectomy and MIE were reviewed. The rationale and outcomes of techniques refinements were discussed in detail.

RESULTS

Most meta-analyses and systematic reviews confirm the feasibility and safety of MIE and suggest similar oncologic outcomes as compared with open esophagectomy. Since 1996, over 1,000 minimally invasive esophagectomies have been performed at UPMC. We have made several refinements to the MIE procedure that we believe significantly improved our surgical outcomes. It included adjustment of width of the gastric conduit, application of omental flap, and conversion from minimally invasive, three-hole esophagectomy to minimally invasive Ivor Lewis esophagectomy.

CONCLUSION

MIE became a mainstay in the surgical treatment of esophageal cancer at UPMC. The technical improvements detailed above make the UPMC approach to MIE a feasible, safe, and efficient procedure.

A preliminary experience with minimally invasive Ivor Lewis esophagectomy

With several small series examining minimally invasive Ivor Lewis esophagectomies, we look to contribute to a growing experience. In reporting our initial results, safety, initial oncologic completeness, and preliminary outcomes with a minimally invasive Ivor Lewis esophagectomy were demonstrated. From 2007 to 2010, 40 minimally invasive Ivor Lewis esophagectomies were carried out. The approach was a laparoscopic mobilization of the stomach and a thoracoscopic esophageal mobilization and creation of a high intrathoracic anastomosis. Indications included esophageal cancer in 39 patients and esophageal gastrointestinal stromal tumor in one patient. Median age was 62 (range 39-77) with 31 (78%) male patients. Non-emergent conversion was required in two (5%) patients. Twenty-five (63%) patients underwent neoadjuvant therapy. Mean operative time was 364 minutes (range 285-455), and mean blood loss was 205 cc (range 100-400). All patients underwent an R0 resection including the removal of all Barrett's esophagus, and mean number of nodes harvested was 21 (range 11-41). Median intensive care unit stay was 1 day (range 1-3), and hospital stay was 7 days (range 6-19). There were no anastomotic leaks and no 30-day mortality. Postoperative complications included eight (21%) patients with atrial fibrillation and two (5%) chylothorax, one requiring ligation. At a mean follow-up of 16.5 months (range 1-39 months), five (13%) patients have had a distant recurrence; there have been no local recurrences. Minimally invasive Ivor Lewis esophagectomy, although technically challenging, can be carried out with reasonable operative times, a short length of stay, and minimal complication. Final oncologic validity is pending longer follow-up and a larger series.

Three-field minimally invasive esophagectomy: current results and technique

The adoption of minimally invasive esophagectomy has increased worldwide since its first description more than 15 years ago. The technique has evolved from a transhiatal to a 3-hole McKeowan approach and, more recently, to a minimally invasive Ivor Lewis approach. We reviewed the technique and results of 3-hole minimally invasive esophagectomy. We favor thoracoscopic esophageal mobilization with the patient in a lateral decubitus position, although other groups have reported this with a prone or robotic approach. Several series have demonstrated low perioperative mortality with minimally invasive esophagectomy. A major advantage compared with esophagectomy with thoracotomy is a lower incidence of respiratory complications, which have been shown to be a significant predictor of mortality in other studies.

Prognostic implications of lymphadenectomy in esophageal cancer after neo-adjuvant therapy: a single center experience

INTRODUCTION

The objective of this study is to explore the prognostic implications of lymphadenectomy in esophageal cancer patients after neo-adjuvant therapy.

METHODS

Retrospective review of a prospectively maintained database identified esophageal cancer patients with locoregional disease who received neo-adjuvant therapy and surgery. Patients were grouped based on the number of nodes resected, pathological lymph node status, and percentage of positive nodes. Kaplan-Meier curves were used to analyze overall survival (OS) and disease-free survival (DFS). Log-rank test was used to compare survival between groups.

RESULTS

Eighty-four patients formed the study group. Patients with ≥ 18 nodes resected had a significantly longer median OS than those with <18 nodes resected (68.6 vs. 29.6 months; p = 0.014). Lymph node-negative patients had significantly longer median OS (51.4 vs. 27.4 months; p = 0.025) and DFS (45.3 vs. 12.9 months; p = 0.03) when compared to lymph node-positive patients. Patients with a percentage of positive nodes <0.25 had a significantly longer median OS (31.1 vs. 17.8 months; p = 0.015) and DFS (21.7 vs. 8.9 months; p = 0.021) than patients with ≥ 0.25% positive.

CONCLUSION

Extent of lymphadenectomy, percentage of positive nodes, and pathological lymph node status are significant prognostic markers in patients who undergo esophagectomy after neo-adjuvant therapy.

Video. Surgical optimisation of the gastric conduit for minimally invasive oesophagectomy

BACKGROUND

Total minimally invasive oesophagectomy (MIO) is a valid alternative to open surgery for the management of oesophagogastric cancer and may lead to a more rapid restoration of health-related quality of life post surgery. However, a high incidence of gastric conduit failure (GCF) has also been observed which could be detrimental to any potential benefits of this approach. Technical modifications have been introduced in an attempt to reduce conduit morbidity, and the aim of this study was to evaluate their efficacy.

METHODS

Minimally invasive oesophagectomy has been the procedure of choice in our unit since April 2004. Data on patient and surgical variables are entered onto a prospective database. Laparoscopic ischaemic conditioning (LIC) by ligation of the left gastric vessels 2 weeks prior to MIO was introduced in April 2006. Extracorporeal formation of the gastric conduit through a minilaparotomy was offered to patients since January 2008. Where present, GCF was characterised as one of three types: I, simple anastomotic leak; II, conduit tip necrosis; and III, whole conduit necrosis.

RESULTS

As of January 2010, 131 patients had undergone an MIO and GCF was observed in 21 patients (16.0%). Sixty-seven patients had LIC and 9 of them (13.4%) developed GCF (I, 10.4%; II, 0%; III, 3.0%) compared to 12 (18.8%) of 64 patients who did not have LIC (I, 6.3%; II, 7.8%; III, 4.7%). A total of 43 patients had an extracorporeally fashioned conduit and 6 (14.0%) developed GCF (I, 11.6%; II, 0%; III, 2.3%), whilst 88 had an intracorporeal conduit with 15 (17.0%) developing GCF (I, 6.8%; II, 5.7%; III, 4.5%). GCF can be reduced with the incorporation of LIC and an extracorporeally fashioned conduit, with possible elimination of type II conduit tip necrosis.

CONCLUSIONS

Surgical modification of a three-stage minimally invasive oesophagectomy technique, with the further incorporation of laparoscopic ischaemic conditioning and extracorporeal conduit formation, reduces gastric conduit morbidity, allowing the potential benefits of this approach to be realised.

Outcomes of laparoscopic-assisted transhiatal esophagectomy for adenocarcinoma of the esophagus and esophago-gastric junction

Esophagectomy is associated with substantial morbidity and mortality, yet it is the only modality that offers the possibility of cure for esophageal and gastroesophageal junction (E-GEJ) adenocarcinoma. Several minimally invasive techniques have been developed to decrease the morbidity of the operation, but to date, the results have not led to its wide adoption in part due to their complexity. We developed a technique of laparoscopic-assisted transhiatal esophagectomy (LA-THE) with the idea of preserving some of the advantages of the minimally invasive approach while eliminating the degree of complexity and the time required to complete the operation solely using laparoscopy. The course of all patients who underwent LA-THE for E-GEJ adenocarcinoma at the University of Washington Medical Center was determined by analysis of all hospital records to determine perioperative variables, complications, and survival. Patients were also given a follow-up survey in order to assess long-term health-related quality of life (Gastrointestinal Quality of Life Index or GIQLI). Seventy-two patients underwent LA-THE between 1995 and 2007. Median age was 64 years (range, 42-83 years), and the median body mass index was 28 (range 17-35). Twenty-eight tumors (39%) were categorized as Siewert I, 41 (57%) as Siewert II, and 3 (4%) as Siewert III. Median operative time was 299min (range, 212-700min). All the resections were R-0. The median number of lymph nodes harvested was 11 (range, 2-32). Using the Dindo-Clavien classification of surgical complication, we had a total of 48 postoperative complications in 37 patients: 26 (53%) grade I, 20 (41%) grade II, 1 (2%) grade IIIb, 1 (2%) grade IVb, and 1 (2%) grade V complications. Median length of hospital stay was 9 days (range, 7-58 days). One patient (1.4%) died within 30 days. Overall, 3- and 5-year survival (calculated Kaplan-Meier) was 68% and 63%, respectively. Forty-nine patients (90% of those still alive) answered the GIQLI survey. Median follow-up was 26 months (range, 6-144 months). The mean GIQLI score was 108 (range, 74-138) from a maximum possible value of 144. Our study shows that LA-THE is feasible, safe, and effective in the treatment of adenocarcinoma of the esophagus and GEJ and should probably be considered an alternative to open esophagectomy and other minimally invasive techniques in the treatment of this disease.

Modified Thoracoscopic versus Minimally Invasive Oesophagectomy in Curative Resection of Oesophageal Cancer

Conventional thoracoscopic oesophagectomy is time-consuming and requires sophisticated endoscopic skills. To reduce these problems we have modified the operating procedure, first by anastomosis of the oesophagus with the tubular stomach pulled up via the retrosternal route, followed by thoracoscopic oesophagectomy (modified thoracoscopic oesophagectomy). Outcomes were compared between the modified procedure and minimally invasive oesophagectomy. There were no significant differences in general preoperative clinical characteristics between the two patient groups. The modified thoracoscopic oesophagectomy group had significantly lower hospitalization expenses, significantly shorter operation times and significantly more lymph nodes removed compared with the minimally invasive oesophagectomy group, but there were no significant group differences in lengths of hospital and intensive care unit stays, morbidity and mortality. These results indicate that modified thoracoscopic oesophagectomy is feasible, simplifies operating procedures and reduces hospitalization expenses with acceptable morbidity.

Minimally invasive oesophagectomy: current status and future direction

BACKGROUND

Oesophagectomy is one of the most challenging surgeries. Potential for morbidity and mortality is high. Minimally invasive techniques have been introduced in an attempt to reduce postoperative complications and recovery times. Debate continues over whether these techniques are beneficial to morbidity and whether oncological resection is compromised. This review article will analyse the different techniques employed in minimally invasive oesophagectomy (MIO) and critically evaluate commonly reported outcome measures from the available literature.

METHODS

Medline, Embase, Science Citation Index, Current Contents, and PubMed databases were used to search English language articles published on MIO. Thirty-one articles underwent thorough analysis and the data were tabulated where appropriate. To date, only level III evidence exists. Where appropriate, comparisons are made with a meta-analysis on open oesophagectomy.

RESULTS

Positive aspects of MIO include at least comparable postoperative recovery data and oncological resection measures to open surgery. Intensive care unit requirements are lower, as is duration of inpatient stay. Respiratory morbidity varies. Negative aspects include increased technical skill of the surgeon and increased equipment requirements, increased operative time and limitation with respect to local advancement of cancer. With increasing individual experience, improvements in outcome measures and the amenability of this approach to increasing neoplastic advancement has been shown.

CONCLUSION

MIO has outcome measures at least as comparable to open oesophagectomy in the setting of benign and nonlocally advanced cancer. Transthoracic oesophagectomy provides superior exposure to the thoracic oesophagus compared to the transhiatal approach and is currently preferred. No multicentre randomised controlled trials exist or are likely to come into fruition. As with all surgery, careful patient selection is required for optimal results from MIO.

Minimally-invasive subtotal oesophagectomy: three-stage thoracoscopic, laparoscopic subtotal oesophagectomy with cervical anastomosis

This contribution describes a minimally-invasive approach to subtotal oesophagectomy. Indications, pre-emptive ischaemic conditioning and feeding jejunostomy are discussed. In the lateral position, the oesophagus is mobilized thoracoscopically in a specific order, formally identifying 'at risk' structures. A radical en bloc dissection is performed with formal lymphadenectomy. Slings are placed around proximal and distal oesophagus and a paravertebral catheter is inserted for postoperative analgesia. In the supine position, the stomach is mobilized laparoscopically, preserving the gastroepiploic arcade and the right gastric artery. Kocher's manoeuvre is undertaken. Lymphadenectomy is performed around the coeliac axis, common hepatic, left gastric and splenic arteries. The proximal oesophagus is delivered through a cervical approach and transected, suturing the distal end to a delivery system to facilitate passage of the conduit through the mediastinum. The mobilized stomach is delivered through a 6-cm right paramedian minilaparotomy and a wide gastric conduit formed, preserving collateral supply and venous drainage from the distal lesser curve. The conduit is passed to the neck using a vacuum/camera sleeve technique and anastomosed to the transected cervical oesophagus with a semi-mechanical technique. The paramedian minilaparotomy is closed with a local anaesthetic catheter in the posterior sheath and the conduit brought back into an anatomical position laparoscopically. Postoperative care is described.

Open versus minimally invasive esophagectomy: a single-center case controlled study

BACKGROUND

Recent advances in laparoscopic and thoracoscopic surgery have made it possible to perform esophagectomy using minimally invasive techniques. Although technically complex, recent case studies showed that minimally invasive approaches to esophagectomy are feasible and have the potential to improve mortality, hospital stay, and functional outcome.

METHODS

We have performed a case controlled pair-matched study comparing 62 patients who had undergone either minimally invasive (MIE) or open esophagectomy (OE) between 2004 and 2007. Patients were matched by tumor stage and localization, sex, age, and preoperative ASA score. Pathologic stage, operative time, blood loss, transfusion requirements, hospital length of stay, postoperative morbidity, and mortality were recorded.

RESULTS

Statistically significant differences were seen in the overall number of patients with surgical morbidity (MIE: 25% vs. OE: 74%, p = 0.014), the transfusion rate (MIE: 12.9% vs. OE: 41.9%, p = 0.001), and the rate of postoperative respiratory complications (MIE: 9.7% vs. OE: 38.7%, p = 0.008). There was no difference with respect to the duration of surgery. The number of resected lymph nodes and rate of pathologic complete resection were comparable. ICU stay [MIE: 3 days (range = 0-15) vs. OE: 6 days (range = 1-40), p = 0.03] and hospital stay [MIE: 12 days (range = 8-46) vs. OE: 24 days (range = 10-79), p = 0.001] were significantly shorter in the MIE group.

CONCLUSION

The results of this case-controlled study provide further evidence for the feasibility and possible improvements in the postoperative morbidity of minimally invasive esophagectomy. Our data are comparable to those from other centers and lead us to initiate the first prospectively randomized study comparing the morbidity of total minimally invasive esophagectomy with the open technique.

Is minimally invasive surgery beneficial in the management of esophageal cancer? A meta-analysis

INTRODUCTION

Open esophagectomy for cancer is a major oncological procedure, associated with significant morbidity and mortality. Recently, thoracoscopic procedures have offered a potentially advantageous alternative because of less operative trauma compared with thoracotomy. The aim of this study was to utilize meta-analysis to compare outcomes of open esophagectomy with those of minimally invasive esophagectomy (MIE) and hybrid minimally invasive esophagectomy (HMIE).

METHODS

Literature search was performed using Medline, Embase, Cochrane Library, and Google Scholar databases for comparative studies assessing different techniques of esophagectomy. A random-effects model was used for meta-analysis, and heterogeneity was assessed. Primary outcomes of interest were 30-day mortality and anastomotic leak. Secondary outcomes included operative outcomes, other postoperative outcomes, and oncological outcomes in terms of lymph nodes retrieved.

RESULTS

A total of 12 studies were included in the analysis. Studies included a total of 672 patients for MIE and HMIE, and 612 for open esophagectomy. There was no significant difference in 30-day mortality; however, MIE had lower blood loss, shorter hospital stay, and reduced total morbidity and respiratory complications. For all other outcomes, there was no significant difference between the two groups.

CONCLUSION

Minimally invasive esophagectomy is a safe alternative to the open technique. Patients undergoing MIE may benefit from shorter hospital stay, and lower respiratory complications and total morbidity compared with open esophagectomy. Multicenter, prospective large randomized controlled trials are required to confirm these findings in order to base practice on sound clinical evidence.