First Experience with Three-Dimensional Thoracolaparoscopy in Esophageal Cancer Surgery

Safety and feasibility of three-dimensional McKeown minimally invasive esophagectomy

BACKGROUND

To compare the perioperative outcomes from McKeown minimally invasive esophagectomy (MIE) when performed in three-dimensional versus two-dimensional visualization system, and investigate the learning curve of a single surgeon who implemented three-dimensional McKeown MIE.

METHODS

A total of 335 consecutive cases (three-dimensional or two-dimensional) were identified. Perioperative clinical parameters were compared and cumulative sum learning curve was plotted. Propensity score matching was used to reduce selection bias from confounding factors.

RESULTS

Patients in three-dimensional group were associated with more chronic obstructive pulmonary disease (23.9% vs 3.0%, p < 0.01). After propensity score matching (108 matched patients in each groups), this finding was no longer statistically significant. Comparing to two-dimensional group, significant improvement in total retrieved lymph nodes (28 vs 33, p = 0.003) was observed in three-dimensional group. In addition, more lymph nodes around the right recurrent laryngeal nerve were harvested in three-dimensional group than that in two-dimensional group (p = 0.045). However, there were no significantly differences were found between the two groups in terms of other intraoperative parameters (e.g., operative time) and postoperative relevant outcomes (e.g., lung infection). Furthermore, the change point in the cumulative sum learning curves for intraoperative blood loss and thoracic procedure time was 33 procedures, respectively.

CONCLUSION

Three-dimensional visualization system appears to be superior in performing lymphadenectomy during McKeown MIE to that of a two-dimensional technique. For surgeons proficient in performing two-dimensional McKeown MIE, the learning curve for a three-dimensional procedure appears to begin near proficiency after more than 33 cases.

Three-Dimensional vs Two-Dimensional Completely Minimally Invasive 2-Stage Esophagectomy With Intrathoracic Hand-Sewn Anastomosis for Esophageal Cancer: Comparison of Intra-and Postoperative Outcomes

Background. Completely minimally invasive esophagectomy (CMIE) has been associated with reduced morbidity compared to open esophagectomy in the treatment of esophageal cancer. Three-dimensional (3D) vision can enhance depth perception during minimally invasive surgery when compared to two-dimensional (2D) vision. We aimed to compare outcomes from 2-stage CMIEs when performed in 2D vs 3D. Method. All consecutive 2-stage CMIEs performed for esophageal or gastroesophageal junctional cancer at a single-centre between 2016 and 2018 were identified from a prospectively maintained database. All operations were completed in either 2D or 3D. All esophagogastric anastomoses were hand-sewn thoracoscopically. Intraoperative and postoperative clinical parameters were compared between 2D and 3D CMIE. Results. Overall, 98 patients underwent a 2-stage CMIE, of which 59 (60.2%) were in 2D and 39 (39.8%) in 3D. Median operative blood loss was less in the 3D group compared to the 2D group (283 mls vs 409 mls, P = .016). A higher number of lymph nodes were retrieved from 3D CMIE (30 vs 25, P = .010). The median duration of surgery was 407 minutes (interquartile ranges (IQR): 358-472 minutes) and 426 minutes (IQR: 369-509 minutes) when performed in 2D and 3D, respectively (P = .162). There were no significant intergroup differences in 30-day postoperative complications, short-term mortality, and hospital stay. Conclusion. We report reduced blood loss and higher lymph node yield when performing 3D CMIE than 2D CMIE. Other intraoperative and postoperative clinical outcomes were similar in both groups. A randomized controlled trial is needed to validate these findings of superior outcomes from CMIE performed in 3D over 2D.

Using textbook outcome as a measure of quality of care in oesophagogastric cancer surgery

BACKGROUND

Textbook outcome is a multidimensional measure representing an ideal course after oesophagogastric cancer surgery. It comprises ten perioperative quality-of-care parameters and has been developed recently using population-based data. Its association with long-term outcome is unknown. The objectives of this study were to validate the clinical relevance of textbook outcome at a hospital level, and to assess its relation with long-term survival after treatment for oesophagogastric cancer.

METHODS

All patients with oesophageal or gastric cancer scheduled for surgery with curative intent between January 2009 and June 2015 were selected from an institutional database. A Cox model was used to study the association between textbook outcome and survival.

RESULTS

A textbook outcome was achieved in 58 of 144 patients (40·3 per cent) with oesophageal cancer and in 48 of 105 (45·7 per cent) with gastric cancer. Factors associated with not achieving a textbook outcome were failure to achieve a lymph node yield of at least 15 (after oesophagectomy) and postoperative complications of grade II or more. After oesophagectomy, median overall survival was longer for patients with a textbook outcome than for patients without (median not reached versus 33 months; P = 0·012). After gastrectomy, median survival was 54 versus 33 months respectively (P = 0·018). In multivariable analysis, textbook outcome was associated with overall survival after oesophagectomy (hazard ratio 2·38, 95 per cent c.i. 1·29 to 4·42) and gastrectomy (hazard ratio 2·58, 1·25 to 5·32).

CONCLUSION

Textbook outcome is a clinically relevant measure in patients undergoing oesophagogastric cancer surgery as it can identify underperforming parameters in a hospital setting. Overall survival in patients with a textbook outcome is better than in patients without a textbook outcome.

First intraoperative experience with three-dimensional (3D) high-definition (HD) nasal endoscopy for lacrimal surgeries

The aim of this study is to report our preliminary experiences with regard to safety and feasibility of three-dimensional (3D) endoscopic lacrimal surgeries with a recently launched latest generation 3D endoscope. A 4-mm rigid three-dimensional (3D) endoscope (TIPCAM 1S 3D ORL^R, Karl Storz, Tuttlingen, Germany) was used. Fifteen patients who underwent various endoscopic lacrimal procedures by a single surgeon (MJA) were included. The procedures included probing with nasolacrimal intubation, cruciate marsupialization of intranasal cysts for congenital dacryoceles, powered endoscopic dacryocystorhinostomy, post-operative stent removal with ostium granuloma excision. The implementation, visualization, optical performance, ease of tissue handling and complications were noted. Ten surgical observers filled a questionnaire to rate their experiences. Enhanced depth perception was found to be very beneficial intraoperatively. Greater anatomical delineation facilitated improved hand-eye coordination and dexterity. Intraoperative assessment and handling of tissues and surgical manoeuvring were precise and did not require the additional spatial cues that the surgeon derives from a two-dimensional image. These benefits were more appreciated in the complex cases. The setup was easy on previous endoscopic platforms and did not consume any additional time. All the surgical procedures were completed successfully without any complications. The surgical observers unanimously noted enhanced anatomical understanding and surgical learning as compared to the routine 2D planes. Operating in 3D planes enhances depth perception, dexterity and precision. Although initial results are promising, further randomized studies with head-on comparisons between 3D and 2D would help formulate specific guidelines.