Mediastinoscopy-assisted oesophagectomy in T1 oesophageal cancer patients with serious comorbidities: a 5-year long-term follow-up

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.

Transhiatal esophagectomy via mediastinoscopy versus sweet for T2 esophageal squamous cell carcinoma patients

BACKGROUND

The aim was to compare transhiatal esophagectomy via mediastinoscopy (TEM) with Sweet procedure for patients with T2 midpiece and distal esophageal squamous cell carcinoma (ESCC).

MATERIALS AND METHODS

By virtue of propensity score matching, 42 T2 ESCC patients who underwent TEM (n = 21) and Sweet procedure (n = 21) were included. Both the short-term and long-term outcomes of these patients were observed.

RESULTS

Compared with the Sweet procedure, the TEM procedure showed less operation time (133.8 ± 30.4 vs 171.2 ± 30.3 min, p = 0.038), reduced drainage volume in 24 h (83.8 ± 142.3 vs 665.2 ± 220.0 mL, p < 0.001), shorter reserving time of chest tube (26.2 ± 26.3 vs 82.8 ± 49.8 h, p < 0.001) and less dissected lymph nodes (12.4 ± 6.1 vs 17.0 ± 6.5, p = 0.041). The average survival period was 62.6 months for TEM group and 62.5 months for Sweet group (p = 0.753). The COX regression showed that the nodal staging could be regarded as an independent prognostic factor (p = 0.013), not the surgical method (p = 0. 754).

CONCLUSIONS

The TEM procedure could reduce operative trauma compared with the Sweet procedure. The long-term survival rate of TEM group was acceptable. The lymph node resection was a major disadvantage of TEM procedure. The TEM procedure might be an alternate choice for T2 midpiece and distal ESCC patients, especially for patients who cannot tolerate transthoracic esophagectomy.

Learning curve for inflatable mediastinoscopic and laparoscopic-assisted esophagectomy

OBJECTIVE

To identify the morbidity that is associated with the learning curve of inflatable mediastinoscopic and laparoscopic-assisted esophagectomy (IMLE), and investigate the strategies to ride out the early period.

METHODS

Our study included a retrospective series of 108 consecutive patients undergoing IMLE by a single surgeon with advanced training in minimally invasive esophageal surgery in independent practice at high-volume tertiary center from July 2017 to November 2020. The cumulative sum (CUSUM) method was used to analyze the learning curve. Patients were stratified into two groups in chronological order, defining the surgeon's early (Group 1: the first 27 cases) and late experience (Group 2: the next 81 cases). Intraoperative characteristics and short-term surgical outcomes were compared between the two groups.

RESULTS

A total of 108 patients were included. Three patients converted into thoracoscopic surgery. The number of patients with postoperative pulmonary infection was 16 (14.8%), and vocal cord palsy had occurred in 12 patients (11.1%). One patient died within 90 days after surgery. CUSUM plots revealed decreasing total operative time, thoracic procedure time, abdominal procedure time, assistant-adjustment time after patients 27, 17, 26, and 35, respectively.

CONCLUSION

IMLE is technically feasible, in terms of perioperative outcomes, for using as a radical surgery for thoracic esophageal cancer. For a surgeon experienced in minimally invasive esophageal surgery, experience of 27 cases is required to gain early proficiency of IMLE.

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.

Thoracolaparoscopic esophagectomy for esophageal cancer with a cervical incision to extract specimen

BACKGROUND

Surgical treatment is the most important and effective therapy for resectable esophageal cancer. Minimally invasive esophagectomy (MIE) can reduce surgical trauma. A neck incision can be performed for extraction of surgical specimen. This study was performed to investigate the safety and feasibility of neck incision to extract surgical specimen in thoracolaparoscopic esophagectomy for esophageal cancer.

MATERIALS AND METHODS

Thirty-four patients who experienced thoracolaparoscopic esophagectomy for esophageal cancer and a neck incision for extraction of surgical specimen were enrolled. The clinical, surgical and follow-up data were analyzed.

RESULTS

The procedure was successful in all patients (100%), with a neck incision to extract the surgical specimen. The median surgical time was 309 min, and the median blood loss was 186 ml, with the mean length of hospital stay of 11.5 days. Pulmonary complications occurred in 8 patients (23.5%). Anastomotic leakage occurred in 5 patients (14.7%), with one patient being treated conservatively to recover and four (11.8%) who received interventional drainage. One patient with interventional drainage died of severe infection, resulting in a 30-day surgical mortality of 2.9% (n = 1). Gastrointestinal complications happened in 5 patients (14.7%), including ileus in three patients and anastomotic stenosis in two patients. Follow-up was performed at a median time of 20 months (interquartile range, 14-32 months), with no death during this period. No recurrence was found in the first 12 months after radical resection.

CONCLUSION

The cervical incision to extract surgical specimen is safe and feasible with improved cosmetic effect in thoracolaparoscopic esophagectomy for esophageal cancer.

Comparison of Ivor Lewis and Sweet esophagectomy for middle and lower esophageal squamous cell carcinoma: A systematic review and pooled analysis

BACKGROUND

Lack of robust evidence highlights the important need to address the controversy on the clinical safety and effectiveness between Ivor Lewis versus Sweet procedure for middle and lower esophageal squamous cell carcinoma (ESCC).

METHODS

Search results were filtered according to certain criteria and were analyzed in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

FINDINGS

The inter-study heterogeneity was high. Ivor Lewis procedure might be associated with longer operation time (p < 0.01) and higher lymph node yield (p < 0.01) compared with Sweet procedure. There was no significant difference in the length of hospital stay and postoperative complications with similar reoperation rate between the two procedures (p > 0.05). As the combined analysis of survival data revealed, there was no statistical difference in the oncologic efficacy of them (p = 0.97).

INTERPRETATION

The present study based on retrospective data with high heterogeneity indicated that Ivor Lewis esophagectomy might be associated with increased lymph node yield but longer operation time than Sweet. Prospective studies are warranted to compare the long-term survival of Ivor Lewis esophagectomy versus Sweet for middle and lower ESCC.

Synchronous carcinoma of oesophageal and lung treated with laparoscopic-thoracoscopic cooperative surgery: A case report

Traditional open surgery has been used and was regarded as suitable alternatives to synchronous carcinoma of oesophageal and lung. However, few previous reports described laparoscopic-thoracoscopic cooperative surgery for it. In this present case, we report synchronous carcinoma of oesophageal and lung with laparoscopic-thoracoscopic cooperative surgery, showing new successfully approach treated with minimally invasive laparoscopic-thoracoscopic surgery.

Comparison of Ivor-Lewis versus Sweet procedure for middle and lower thoracic esophageal squamous cell carcinoma: A STROBE compliant study

Our study compared the Ivor-Lewis and Sweet procedures used for treating middle and lower thoracic esophageal squamous cell carcinoma and assessed the associated perioperative complications and long-term survival rates of the patients.This retrospective study involved 624 middle and lower thoracic esophageal squamous carcinoma patients who received either Ivor-Lewis (n = 325) or Sweet (n = 299) procedures at our hospital. Further, the perioperative conditions and long-term survival rates were analyzed for both groups.Relative to the Sweet group, the Ivor-Lewis group showed lower volume of drainage within 24 hours after operation (400 (300-500) ml vs 550 (400-658) ml, P = .031). Although we found no significant differences in major postoperative complications between the groups (72 (22.2) vs 65 (21.7), P = .90), there were significant differences observed in minor postoperative complications between the Ivor-Lewis and Sweet groups (59 (18.2) vs 32 (10.7), P = .008). Perioperative death rates remained comparable for the 2 groups (2 (0.6) vs 2 (0.7), P > .99). Further, comparison of the 2 groups revealed that the Ivor-Lewis group had increased number of dissected lymph nodes, (20 (4-42) vs 16 (3-31), P < .001), especially in the upper mediastinum (4 (0-5) vs 2 (0-2), P < .001). The long-term survival rates did not differ significantly between the 2 groups (Kaplan-Meier method, P = .95; Cox regression, P = .20).These findings suggest that perioperative complications and long-term survival rates were comparable for both patients groups. Patients receiving the Sweet procedure had reduced minor postoperative complications compared to those receiving the Ivor-Lewis procedure. Due to improved quality of lymph node dissection in the upper mediastinum, the Ivor-Lewis procedure may have advantages over the Sweet procedure for treating patients with esophageal cancer with enlarged lymph nodes in the upper mediastinum.

Mediastinoscopy-assisted esophagectomy for T2 middle and lower thoracic esophageal squamous cell carcinoma patients

BACKGROUND

We aimed to compare mediastinoscopy-assisted esophagectomy (MAE) with the Ivor Lewis procedure in T2 middle and lower thoracic esophageal carcinoma patients in fields of perioperative complications and overall survival (OS).

METHODS

The clinical data of 112 T2 esophageal cancer patients who received MAE (n = 31) or Ivor Lewis procedure (n = 81) from January 2010 to December 2015 were retrospectively analyzed in propensity score analysis. Thirty-eight T2 esophageal cancer patients who underwent MAE (n = 19) and Ivor Lewis procedure (n = 19) were included in this study. The perioperative conditions and OS were analyzed.

RESULTS

The MAE group showed shorter operation time (143.2 ± 20.6 vs 176.8 ± 31.1 min, P = 0.001), less drainage in 24 h (119.2 ± 235.1 vs 626.3 ± 396.3 mL, P < 0.001), less retention time of thoracic tube (27.8 ± 24.0 vs 101.2 ± 54.6 h, P < 0.001), and less hemorrhage during operation (255.4 ± 159.8 vs 367.4 ± 150.9 mL, P = 0.059) compared with the Ivor Lewis group. Less dissected lymph nodes were detected in the MAE group (12.2 ± 5.4 vs 16.8 ± 5.8, P = 0.044) than in the Ivor Lewis group, especially in the upper mediastinum (1.8 ± 2.1 vs 3.5 ± 2.3, P < 0.001) and middle mediastinum (2.5 ± 2.0 vs 5.3 ± 3.2, P = 0.027). The mean survival time was 59.1 and 53.3 months for the MAE group and Ivor Lewis group, respectively (P = 0.635). The results of Cox regression indicated that the nodal stage (P = 0.016) was an independent prognostic factor and the surgical method was not an independent prognostic factor for these patients (P = 0.290).

CONCLUSIONS

MAE procedure showed less surgical trauma compared with the Ivor Lewis procedure. The mediastinal lymphadenectomy of T2 esophageal carcinoma patients who underwent MAE was inferior to those who underwent Ivor Lewis procedure. The perioperative complications and OS of the MAE group were no worse than that of the Ivor Lewis group.

Left minimally invasive esophagectomy in a patient with synchronous esophageal and lung cancers: Case report

RATIONALE

Minimally invasive esophagectomy (MIE) have been increasingly used and are regarded as suitable alternatives to open esophagectomy. However, few previous reports described minimally invasive esophagectomy using a left-sided approach.

PATIENT CONCERNS AND DIAGNOSES

A 71-year-old man was admitted to our hospital because of progressive dysphagia. Synchronous double primary thoracic esophageal and left lung cancers were considered before the operation.

INTERVENTIONS AND OUTCOMES

A lobectomy and MIE, via a left video-assisted thoracoscopic approach, was performed. Preparation of a gastric conduit and an intra-abdominal lymphadenectomy were completed by laparoscopy and a cervical anastomosis was made. In addition, a cervical mediastinoscopy was performed to dissect the lymph nodes along the bilateral recurrent laryngeal nerves. No postoperative complications were observed. The patient achieved a favorable short-term outcome.

LESSONS

This is the first report of a patient with synchronous esophageal and left lung cancers treated with minimally invasive resection via left thoracoscopy, laparoscopy, and cervical mediastinoscopy. Our results showed that the left MIE approach in combination with cervical mediastinoscopy is potentially most appropriate for some esophageal cancer patients, when the right MIE approach is not applicable in certain conditions.

Mediastinoscopic esophagectomy for patients with early esophageal cancer

OBJECTIVE

The purpose of this study was to detect the feasibility, safety, and effectiveness of mediastinoscopic esophagectomy for early esophageal cancer.

METHODS

The clinical data of 194 patients who underwent mediastinoscopic esophagectomy for early esophageal cancer in our center from December 2005 to October 2014 were retrospectively analyzed.

RESULTS

All the surgery was performed successfully. The average duration of thoracic surgery was 48.2±7.8 min and the average intra-operative blood loss was 128.1±34.5 mL. An average of 3.1±1.6 lymph node stations were dissected, with an average number of dissected lymph nodes being 9.38±6.2, among which 4.2±5.4 were mediastinal lymph nodes. No peri-operative mortality was noted, and the rate of peri-operative morbidity was 13.4%. The median duration of follow-up was 39 [3-108] months, and the overall survival was 72.73%. The overall survival rates significantly differed among different T stages; more specifically, the 5-year survival was 95.23% in patients with stage T1a esophageal cancer, 70.15% for T1b, and 55.56% for T2 (P<0.001). The overall survival was significantly better in patients with negative lymph nodes than those with lymph nodes metastasis (P=0.003); more specifically, the 5-year survival rate was 84.9% for N0, 62.5% for N1, and 50.0% for N2 + N3.

CONCLUSIONS

The mediastinoscopic esophagectomy can achieve a similar effectiveness as the conventional thoracoscopic surgery for patients with early stage esophageal cancer.