Minimally Invasive Versus Open Esophageal Resection: Three-year Follow-up of the Previously Reported Randomized Controlled Trial: the TIME Trial. Ann Surg. 2017;266:232-236. [PMID: 28187044 DOI: 10.1097/sla.0000000000002171]

Robot-assisted minimally invasive esophagectomy for esophageal cancer in the left lateral decubitus position

BACKGROUND

The use of robot-assisted minimally invasive esophagectomy (RAMIE) in the prone position for esophageal cancer has been currently increasing worldwide. In future, as surgical-assisted robots become more widespread, it is estimated that only two methods of transthoracic approach will remain: RAMIE and open thoracotomy for thoracic esophageal cancer. RAMIE in the left lateral decubitus position (RAMIE-LLDP) has the same field of view as open thoracotomy, is safe in emergency situations, and provides education on open thoracotomy.

METHODS

Between September 2020 and April 2024, RAMIE-LLDP was performed in 64 consecutive patients with esophageal cancer. RAMIE-LLDP was performed with the operating table rotated and tilted 45° to the ventral side under artificial pneumothorax. The hand-control setting of the surgical-assist robot system was reversed left to right when the Patient Cart was rolled from the same direction as the RAMIE in the prone position.

RESULTS

The mean total surgery and console times during the thoracic procedure were 254-min overall and 225 min in the last 24 cases and 195-min overall and 178- min in the last 24 cases, respectively. The mean amount of blood loss was 203.4 g overall and 28.3 g in the last 24 cases. Postoperative recurrent laryngeal nerve palsy with Clavien-Dindo classification (CD) was ≥ 2 in six patients (9.4%). Postoperative pneumonia with CD ≥ 2 was observed in 11 patients (17.2%). Conversion to open thoracotomy was observed in three patients (4.7%). In all three patients, an immediate conversion to thoracotomy without patients' position change was actually possible and no serious complications were noted. No mortality occurred within 30 days postoperatively.

CONCLUSION

RAMIE-LLDP which facilitates emergency thoracotomy has perioperative results comparable to those of conventional thoracoscopic esophagectomy and is educational for open surgery. RAMIE-LLDP is the safest and most optimal surgery for esophageal cancer.

Minimally Invasive Esophagectomy Provides Better Short- and Long-Term Outcomes Than Open Esophagectomy in Locally Advanced Esophageal Cancer

BACKGROUND

Minimally invasive esophagectomy (MIE) has been increasingly performed for locally advanced esophageal cancer in place of open transthoracic esophagectomy (OE). This study explored the significance of MIE for esophageal squamous cell carcinoma (ESCC), focusing mainly on the depth of primary esophageal tumors.

METHODS

This study retrospectively assessed short- and long-term outcomes of patients who underwent esophagectomy for ESCC from 2005 through 2021. The inverse probability of the treatment-weighting (IPTW) method was used to compare the outcomes between OE and MIE. The outcomes also were evaluated in the subgroups stratified by cT category.

RESULTS

Among 1117 patients, 447 (40%) underwent OE and 670 (60%) underwent MIE. After IPTW adjustment, the incidence of any postoperative complications was significantly higher in the OE group than in the MIE group (60.8% vs 53.7%; p = 0.032), whereas the R0 resection rate was significantly higher in the MIE group (98.6% vs 92.7%; p < 0.001). The MIE group showed better 3 year overall and cancer-specific survival than the OE group (p < 0.001). The incidence of locoregional recurrence within the surgical field was significantly more frequent in the OE group (p < 0.001). In the subgroup analysis stratified by cT category, the R0 resection rate was significantly higher and the incidence of locoregional recurrence was lower in the MIE group among the patients with cT3-4 tumors. In the patients with cT1-2 tumors, MIE showed no significant benefit over OE.

CONCLUSIONS

For the patients with cT3-4 tumors, MIE showed fewer postoperative complications, better locoregional control, and better prognosis than OE. Compared with OE, MIE is beneficial, especially for locally advanced ESCC.

Risk Factors Associated With Anastomotic Stricture in Patients Undergoing Minimally Invasive Esophagectomy: Experience From a High-Volume Center

BACKGROUND

Esophageal cancer is a prevalent cancer, with a high incidence in low socioeconomic category countries. Minimally invasive esophagectomy is increasingly being used to treat this malignant condition. However, anastomotic stricture is a serious complication post esophagectomy. The study aims to enhance diagnostic consistency, improve treatment methods, guide patient management, stratify outcomes, and offer evidence-based preventive interventions.

METHODS

A retrospective analysis of 550 patients who had minimally invasive esophagus surgery was carried out at Shaukat Khanum Memorial Cancer Hospital and Research Centre in Lahore between 2015 and 2020. All patients were treated with radical resection. For tumors of the lower esophagus and gastroesophageal junction, transhiatal esophagectomy was used; for tumors of the middle and upper thoracic esophagus, right video-assisted thoracoscopic surgery (VATS) was used in a three-stage procedure. Patients were routinely followed up two weeks after discharge, then every three, six, and 12 months.

RESULTS

The mean age and BMI were 46.7 years and 19.4 kg/m2, respectively. Anastomotic leaks were rare, with only 13 patients experiencing them. The grade of tumor differentiation was poor, moderate, and well-differentiated. The study found that older age, high Eastern Cooperative Oncology Group (ECOG) performance status, and malignancies located in the upper and middle one-third of the esophagus had significant associations with anastomotic stricture. However, some variables, like sex, did not show significant associations in either analysis.

CONCLUSION

The study reveals that factors such as older patient age, high ECOG performance status, single comorbidity, and malignancies located in the upper and middle one-third of the esophagus significantly influence anastomotic stricture. The study suggests that measures against anastomotic stricture such as endoscopic procedures and minimally invasive esophagectomy should be implemented to minimize the complications.

Recurrence and Survival After Minimally Invasive and Open Esophagectomy for Esophageal Cancer: A Post Hoc Analysis of the Ensure Study

OBJECTIVE

To determine the impact of operative approach [open (OE), hybrid minimally invasive (HMIE), and total minimally invasive (TMIE) esophagectomy] on operative and oncologic outcomes for patients treated with curative intent for esophageal and junctional cancer.

BACKGROUND

The optimum oncologic surgical approach to esophageal and junctional cancer is unclear.

METHODS

This secondary analysis of the European multicenter ENSURE study includes patients undergoing curative-intent esophagectomy for cancer between 2009 and 2015 across 20 high-volume centers. Primary endpoints were disease-free survival (DFS) and the incidence and location of disease recurrence. Secondary endpoints included among others R0 resection rate, lymph node yield, and overall survival (OS).

RESULTS

In total, 3199 patients were included. Of these, 55% underwent OE, 17% HMIE, and 29% TMIE. DFS was independently increased post-TMIE [hazard ratio (HR): 0.86 (95% CI: 0.76-0.98), P = 0.022] compared with OE. Multivariable regression demonstrated no difference in absolute locoregional recurrence risk according to the operative approach [HMIE vs OE, odds ratio (OR): 0.79, P = 0.257; TMIE vs OE, OR: 0.84, P = 0.243]. The probability of systemic recurrence was independently increased post-HMIE (OR: 2.07, P = 0.031), but not TMIE (OR: 0.86, P = 0.508). R0 resection rates ( P = 0.005) and nodal yield ( P < 0.001) were independently increased after TMIE, but not HMIE ( P = 0.424; P = 0.512) compared with OE. OS was independently improved following both HMIE (HR: 0.79, P = 0.009) and TMIE (HR: 0.82, P = 0.003) as compared with OE.

CONCLUSION

In this European multicenter study, TMIE was associated with improved surgical quality and DFS, whereas both TMIE and HMIE were associated with improved OS as compared with OE for esophageal cancer.

Management of Major Complications After Esophagectomy

Esophagectomy remains a procedure with one of the highest complication rates. Given the advances in medical and surgical management of patients and increased patient survival, the number of complications reported has increased. There are different grading systems for complications which vary based on severity or organ system, with the Esophageal Complications Consensus Group unifying them. Management involves conservative intervention and dietary modification to endoscopic interventions and surgical reintervention. Treatment is etiology specific but rehabilitation and patient optimization play a significant role in managing these complications by preventing them. Management is a step-up approach depending on the severity of symptoms.

Drug Delivery Opportunities in Esophageal Cancer: Current Treatments and Future Prospects

With one of the highest mortality rates of all malignancies, the 5-year survival rate for esophageal cancer is under 20%. Depending on the stage and extent of the disease, the current standard of care treatment paradigm includes chemotherapy or chemoradiotherapy followed by surgical esophagogastrectomy, with consideration for adjuvant immunotherapy for residual disease. This regimen has high morbidity, due to anatomic changes inherent in surgery, the acuity of surgical complications, and off-target effects of systemic chemotherapy and immunotherapy. We begin with a review of current treatments, then discuss new and emerging targets for therapies and advanced drug delivery systems. Recent and ongoing preclinical and early clinical studies are evaluating traditional tumor targets (e.g., human epidermal growth factor receptor 2), as well as promising new targets such as Yes-associated protein 1 or mammalian target of rapamycin to develop new treatments for this disease. Due the function and location of the esophagus, opportunities also exist to pair these treatments with a drug delivery strategy to increase tumor targeting, bioavailability, and intratumor concentrations, with the two most common delivery platforms being stents and nanoparticles. Finally, early results with antibody drug conjugates and chimeric antigenic receptor T cells show promise as upcoming therapies. This review discusses these innovations in therapeutics and drug delivery in the context of their successes and failures, with the goal of identifying those solutions that demonstrate the most promise to shift the paradigm in treating this deadly disease.

Minimally Invasive Ivor Lewis Esophagectomy

Minimally invasive Ivor Lewis esophagectomy is a technically demanding operation that requires an experienced surgeon, assistant, and anesthesiologist. The preoperative workup should focus on the extent of disease and extent of resection required, as well as the cardiopulmonary fitness of the patient. Surgical outcomes show decreased postoperative pain, decreased morbidity largely due to a reduction in respiratory complications, and decreased length of stay. Quality metrics and 5-year overall survival are equivalent to traditional open esophagectomy.

Association of hospital volume and operative approach with clinical and financial outcomes of elective esophagectomy in the United States

INTRODUCTION

Literature regarding the impact of esophagectomy approach on hospitalizations costs and short-term outcomes is limited. Moreover, few have examined how institutional MIS experience affects costs. We thus examined utilization trends, costs, and short-term outcomes of open and minimally invasive (MIS) esophagectomy as well as assessing the relationship between institutional MIS volume and hospitalization costs.

METHODS

All adults undergoing elective esophagectomy were identified from the 2016-2020 Nationwide Readmissions Database. Multiple regression models were used to assess approach with costs, in-hospital mortality, and major complications. Additionally, annual hospital MIS esophagectomy volume was modeled as a restricted cubic spline against costs. Institutions performing > 16 cases/year corresponding with the inflection point were categorized as high-volume hospitals (HVH). We subsequently examined the association of HVH status with costs, in-hospital mortality, and major complications in patients undergoing minimally invasive esophagectomy.

RESULTS

Of an estimated 29,116 patients meeting inclusion, 10,876 (37.4%) underwent MIS esophagectomy. MIS approaches were associated with $10,600 in increased incremental costs (95% CI 8,800-12,500), but lower odds of in-hospital mortality (AOR 0.76; 95% CI 0.61-0.96) or major complications (AOR 0.68; 95% CI 0.60, 0.77). Moreover, HVH status was associated with decreased adjusted costs, as well as lower odds of postoperative complications for patients undergoing MIS operations.

CONCLUSION

In this nationwide study, MIS esophagectomy was associated with increased hospitalization costs, but improved short-term outcomes. In MIS operations, cost differences were mitigated by volume, as HVH status was linked with decreased costs in the setting of decreased odds of complications. Centralization of care to HVH centers should be considered as MIS approaches are increasingly utilized.

Advances in diagnosis and management of cancer of the esophagus

Esophageal cancer is the seventh most common malignancy worldwide, with over 470 000 new cases diagnosed each year. Two distinct histological subtypes predominate, and should be considered biologically separate disease entities.1 These subtypes are esophageal adenocarcinoma (EAC) and esophageal squamous cell carcinoma (ESCC). Outcomes remain poor regardless of subtype, with most patients presenting with late stage disease.2 Novel strategies to improve early detection of the respective precursor lesions, squamous dysplasia, and Barrett's esophagus offer the potential to improve outcomes. The introduction of a limited number of biologic agents, as well as immune checkpoint inhibitors, is resulting in improvements in the systemic treatment of locally advanced and metastatic esophageal cancer. These developments, coupled with improvements in minimally invasive surgical and endoscopic treatment approaches, as well as adaptive and precision radiotherapy technologies, offer the potential to improve outcomes still further. This review summarizes the latest advances in the diagnosis and management of esophageal cancer, and the developments in understanding of the biology of this disease.

Contemporary Role of Open Left Thoracoabdominal Approach in Esophageal Malignancy Treatment

INTRODUCTION

Despite the widespread use of minimally invasive techniques, open left thoracoabdominal esophagectomy (LTE) can offer excellent visualization and adaptability. The current study aimed to present and evaluate the outcomes related to an open LTE in esophageal malignancy treatment.

METHODS

A retrospective cohort analysis of data collected from two institutions was performed, including patients with distal esophageal or junctional tumors who underwent open LTE between November 2018 and December 2023.

RESULTS

Twenty-two patients were included (16 males; mean age 62.8 years). Postoperative complications occurred in eight patients (36%), with pulmonary complications being the most prevalent (seven patients; 32%). One patient experienced a clinical anastomotic leak. No reoperations or escalation to a higher level of care were required. In-hospital and 30-day mortality were zero. Tumor cells were found at the surgical margins in six patients (27%). The mean lymph node yield was 27. During the follow-up period, there were nine deaths and 11 cases of disease recurrence. Isolated locoregional recurrence was seen in five patients (23%). The one-year and two-year overall survival rates were 79% and 47%, respectively.

CONCLUSION

In selected cases, open LTE remains a valid and safe operation with acceptable morbidity and oncological efficacy.

Impact of pulmonary complications following esophagectomy on long-term survival: multivariate meta-analysis and restricted mean survival time assessment

Pulmonary complications (PC) are common after esophagectomy and their impact on long-term survival is not defined yet. The present study aimed to assess the effect of postoperative PCs on long-term survival after esophagectomy for cancer. Systematic review of the literature through February 1, 2023, was performed. The included studies evaluated the effect of PC on long-term survival. Primary outcome was long-term overall survival (OS). Cancer-specific survival (CSS) and disease-free survival (DFS) were secondary outcomes. Restricted mean survival time difference (RMSTD), hazard ratio (HR), and 95% confidence intervals (CI) were used as pooled effect size measures. Eleven studies were included (3423 patients). Overall, 674 (19.7%) patients developed PC. The RMSTD analysis shows that at 60-month follow-up, patients not experiencing PC live an average of 8.5 (95% CI 6.2-10.8; p < 0.001) months longer compared with those with PC. Similarly, patients not experiencing postoperative PC seem to have significantly longer CSS (8 months; 95% CI 3.7-12.3; p < 0.001) and DFS (5.4 months; 95% CI 1.6-9.1; p = 0.005). The time-dependent HRs analysis shows a reduced mortality hazard in patients without PC at 12 (HR 0.6, 95% CI 0.51-0.69), 24 (HR 0.64, 95% CI 0.55-0.73), 36 (HR 0.67, 95% CI 0.55-0.79), and 60 months (HR 0.69, 95% CI 0.51-0.89). This study suggests a moderate clinical impact of PC on long-term OS, CSS, and DFS after esophagectomy. Patients not experiencing PC seem to have a significantly reduced mortality hazard up to 5 years of follow-up.

Neoadjuvant chemoimmunotherapy followed by robot esophagectomy has no effect on short-term results compared with surgery alone

BACKGROUND

To determine the safety and efficacy of robot-assisted minimally invasive esophagectomy (RAMIE) for locally advanced esophageal squamous cell carcinoma (ESCC) after neoadjuvant chemoimmunotherapy (NCI).

METHODS

Data from patients who underwent RAMIE between January 2020 and June 2022 were retrospectively analyzed. The oncological and operative outcomes of the NCI and surgery-only (S) groups were compared by both unmatched and 1:1 propensity score-matched (PSM) analysis.

RESULTS

A total of 201 patients with ESCC who underwent three-incision RAMIE were included in this study (143 patients in the S group and 58 patients in the NCI group). Of the 58 patients who underwent NCI, a pathologically complete response (pCR) (ypT0N0) was identified in 14 (24.1%) patients. The patients in the NCI group were younger than those in the S group (p = 0.017), and had more advanced cT (p < 0.001) and cN stage diseases (p = 0.002). After 1:1 PSM of the confounders, 55 patients were allocated to each of the NCI and S groups. No significant differences were found in oncological and operative results, including surgical blood loss, operative time, and lymph node harvest (all p > 0.05). However, the NCI group exhibited a lower rate of pulmonary complications than the S group (3.6% vs. 14.5%, p = 0.047). No significant difference between the groups was found for other complications (all p > 0.05).

CONCLUSION

These findings indicate that NCI could result in a high pCR rate without increased complications in locally advanced ESCC. RAMIE is safe and feasible in patients with ESCC after NCI.

Predictors of anastomotic leak and conduit necrosis after oesophagectomy: Results from the oesophago-gastric anastomosis audit (OGAA)

BACKGROUND

Both anastomotic leak (AL) and conduit necrosis (CN) after oesophagectomy are associated with high morbidity and mortality. Therefore, the identification of preoperative, modifiable risk factors is desirable. The aim of this study was to generate a risk scoring model for AL and CN after oesophagectomy.

METHODS

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018-December 2018. Definitions for AL and CN were those set out by the Oesophageal Complications Consensus Group. Univariate and multivariate analyses were performed to identify risk factors for both AL and CN. A risk score was then produced for both AL and CN using the derivation set, then internally validated using the validation set.

RESULTS

This study included 2247 oesophagectomies across 137 hospitals in 41 countries. The AL rate was 14.2% and CN rate was 2.7%. Preoperative factors that were independent predictors of AL were cardiovascular comorbidity and chronic obstructive pulmonary disease. The risk scoring model showed insufficient predictive ability in internal validation (area under the receiver-operating-characteristic curve [AUROC] = 0.618). Preoperative factors that were independent predictors of CN were: body mass index, Eastern Cooperative Oncology Group performance status, previous myocardial infarction and smoking history. These were converted into a risk-scoring model and internally validated using the validation set with an AUROC of 0.775.

CONCLUSION

Despite a large dataset, AL proves difficult to predict using preoperative factors. The risk-scoring model for CN provides an internally validated tool to estimate a patient's risk preoperatively.

History and evidence for state of the art of lymphadenectomy in esophageal cancer surgery

The current curative multimodal treatment of advanced esophageal cancers consists of neoadjuvant or perioperative chemo(radio)therapy followed by a radical surgical resection of the primary tumor and a 2- or 3-field lymphadenectomy. One of the most important predictors of long-term survival of esophageal cancer patients is lymph node involvement. The distribution pattern of lymph node metastases in esophageal cancer is unpredictable and depends on the primary tumor location, histology, T-stage and application of neoadjuvant or perioperative treatment. The optimal extent of the lymphadenectomy remains controversial; there is no global consensus on this topic yet. Some surgeons advocate an aggressive and extended lymph node dissection to remove occult metastatic disease, to optimize oncological outcomes. Others promote a more restricted lymphadenectomy, since the benefit of an extended lymphadenectomy, especially after neoadjuvant chemoradiotherapy, has not been clearly demonstrated, and morbidity may be reduced. In this review, we describe the development of lymphadenectomy, followed by a summary of current evidence for lymphadenectomy in esophageal cancer treatment.

Updated German guideline on diagnosis and treatment of squamous cell carcinoma and adenocarcinoma of the esophagus

Diagnosis and therapy of esophageal carcinoma is challenging and requires a multidisciplinary approach. The purpose of the updated German guideline "Diagnosis and Treatment of Squamous Cell Carcinoma and Adenocarcinoma of the Esophagus-version 3.1" is to provide practical and evidence-based advice for the management of patients with esophageal cancer. Recommendations were developed by a multidisciplinary expert panel based on an extensive and systematic evaluation of the published medical literature and the application of well-established methodologies (e.g. Oxford evidence grading scheme, grading of recommendations). Accurate diagnostic evaluation of the primary tumor as well as lymph node and distant metastases is required in order to guide patients to a stage-appropriate therapy after the initial diagnosis of esophageal cancer. In high-grade intraepithelial neoplasia or mucosal carcinoma endoscopic resection shall be performed. Whether endoscopic resection is the definitive therapeutic measure depends on the histopathological evaluation of the resection specimen. Esophagectomy should be performed minimally invasive or in combination with open procedures (hybrid technique). Because the prognosis in locally advanced esophageal carcinoma is poor with surgery alone, multimodality therapy is recommended. In locally advanced adenocarcinomas of the esophagus or esophagogastric junction, perioperative chemotherapy or preoperative radiochemotherapy should be administered. In locally advanced squamous cell carcinomas of the esophagus, preoperative radiochemotherapy followed by complete resection or definitive radiochemotherapy without surgery should be performed. In the case of residual tumor in the resection specimen after neoadjuvant radiochemotherapy and R0 resection of squamous cell carcinoma or adenocarcinoma, adjuvant immunotherapy with nivolumab should be given. Systemic palliative treatment options (chemotherapy, chemotherapy plus immunotherapy, immunotherapy alone) in unresectable or metastastic esophageal cancer depend on histology and are stratified according to PD-L1 and/or Her2 expression.

[Evidence for Minimal Invasive Oesophageal Resection]

In the course of the last 20 years, minimally invasive therapy has become much more important in all areas. In particular, surgical procedures have been established in oncological surgery, even without generating the necessary evidence to assure that the quality is equal to that achieved with open procedures. For this purpose, it has only been in recent years that appropriate randomised controlled studies followed by meta-analyses have been carried out. In this article, we summarise the evidence for minimally invasive resection of the oesophagus and review current literature for each procedure.

Application of overlap anastomosis in digestive tract reconstruction during minimally invasive Ivor-Lewis esophagectomy

This study aims to assess the feasibility of the Overlap anastomosis technique in minimally invasive Ivor-Lewis esophagectomy. An accompanying video presentation elucidates our surgical procedures. A retrospective review of 46 patients diagnosed with middle and lower esophageal cancer was conducted. These patients underwent minimally invasive Ivor-Lewis esophagectomy with Overlap anastomosis between January 2019 and December 2020. A consistent team of surgeons performed all procedures. The initial phase involved laparoscopic stomach mobilization, intra-abdominal lymphadenectomies, and preparation of the tubular stomach. Subsequently, with the patient in the left decubitus position, thoracoscopy was used to dissect the esophagus, excise the diseased segment, and conduct mediastinal lymph node dissection. The final stage encompassed the intrathoracic gastroesophageal anastomosis using the Overlap method. All surgeries were completed without converting to an open approach, achieving complete resection. There were no operative fatalities, with an average surgery duration of 259.4 min. Average statistics included intraoperative blood loss of 92.3 ml, 16.2 lymph nodes dissected, and a postoperative hospital stay of 10.3 days. Postoperative complications comprised three instances of hoarseness due to recurrent laryngeal nerve palsy, two cases of aspiration pneumonia, one occurrence of chylothorax, and one gastric emptying disorder. Anastomotic technique-related complications were minimal, with only one patient experiencing an anastomotic leak that resolved spontaneously and two patients facing anastomotic stenosis, which was subsequently alleviated. Our findings posit that the Overlap anastomosis method is safe and efficient for minimally invasive Ivor-Lewis esophagectomy, marked by a notably low rate of anastomosis-related complications. Further evaluation of its long-term implications remains necessary.

Fashioning esophagogastric anastomosis in robotic Ivor-Lewis esophagectomy: a multicenter experience

BACKGROUND

The aim of the present study is to compare outcomes of the robotic hand-sewn, linear- and circular-stapled techniques performed to create an intrathoracic esophagogastric anastomosis in patients who underwent Ivor-Lewis esophagectomy.

METHODS

Patients who underwent a planned Ivor-Lewis esophagectomy were retrospectively analysed from prospectively maintained databases. Only patients who underwent a robotic thoracic approach with the creation of an intrathoracic esophagogastric anastomosis were included in the study. Patients were divided into three groups: hand-sewn-, circular stapled-, and linear-stapled anastomosis group. Demographic information and surgery-related data were extracted. The primary outcome was the rate of anastomotic leakages (AL) in the three groups. Moreover, the rate of grade A, B and C anastomotic leakage were evaluated. In addition, patients of each group were divided in subgroups according to the characteristics of anastomotic fashioning technique.

RESULTS

Two hundred and thirty patients were enrolled in the study. No significant differences were found between the three groups about AL rate (p = 0.137). Considering the management of the AL for each of the three groups, no significant differences were found. Evaluating the correlation between AL rate and the characteristics of anastomotic fashioning technique, no significant differences were found.

CONCLUSIONS

No standardized anastomotic fashioning technique has yet been generally accepted. This study could be considered a call to perform ad hoc high-quality studies involving high-volume centers for upper gastrointestinal surgery to evaluate what is the most advantageous anastomotic technique.

Carbon dioxide gas-induced pneumothorax versus one-lung ventilation in minimally invasive esophagectomy: a multicenter propensity score matching cohort study

BACKGROUND

Carbon dioxide gas-induced pneumoperitoneum might be the reason for the shorter postoperative survival of patients with malignant tumors. Whether CO 2 gas-induced pneumothorax has unfavorable impacts on the surgical and oncological outcomes of minimally invasive esophagectomy remains unclear.

METHODS

Between 2010 and 2016, a total of 998 patients with squamous cell carcinoma of the esophagus who received video-assisted surgery were registered from three large-volume medical centers. The overall survival (OS) and disease-free survival (DFS) were compared after using propensity score-matched and inverse probability-weighted methods. In addition, the tumor-relapse state was evaluated, and the relapse pattern was compared.

RESULTS

A total of 422 and 576 minimally invasive esophagectomies with intraoperative one-lung ventilation and CO 2 -induced pneumothorax were enrolled, respectively. The 5-year OS and DFS were similar between the CO 2 -induced pneumothorax (64.2% and 64.7%) and one-lung ventilation (65.3% and 62.4%) groups following propensity matching. The inverse probability weighting revealed similarly equal survival results in the two groups. The 5-year relapse rates were 35.1% and 30.6% in the one-lung ventilation and CO 2 -induced pneumothorax groups, respectively. Moreover, the relapse patterns were not significantly different between the two groups.

CONCLUSION

The results of this study suggested that the use of intraoperative one-lung ventilation and CO 2 -induced pneumothorax have similar oncological outcomes; therefore, the two methods are both viable options in esophagectomy.

The impact of minimally-invasive esophagectomy operative duration on post-operative outcomes

Background

Esophagectomy, an esophageal cancer treatment mainstay, is a highly morbid procedure. Prolonged operative time, only partially predetermined by case complexity, may be uniquely harmful to minimally-invasive esophagectomy (MIE) patients for numerous reasons, including anastomotic leak, tenuous conduit perfusion and protracted single-lung ventilation, but the impact is unknown. This multi-center retrospective cohort study sought to characterize the relationship between MIE operative time and post-operative outcomes.

Methods

We abstracted multi-center data on esophageal cancer patients who underwent MIE from 2010 to 2021. Predictor variables included age, sex, comorbidities, body mass index, prior cardiothoracic surgery, stage, and neoadjuvant therapy. Outcomes included complications, readmissions, and mortality. Association analysis evaluated the relationship between predictor variables and operative time. Multivariate logistic regression characterized the influence of potential predictor variables and operative time on post-operative outcomes. Subgroup analysis evaluated the association between MIE >4 h vs. ≤4 h and complications, readmissions and survival.

Results

For the 297 esophageal cancer patients who underwent MIE between 2010 and 2021, the median operative duration was 4.8 h [IQR: 3.7-6.3]. For patients with anastomotic leak (5.1%) and 1-year mortality, operative duration was elevated above the median at 6.3 h [IQR: 4.8-8.6], p = 0.008) and 5.3 h [IQR: 4.4-6.8], p = 0.04), respectively. In multivariate logistic regression, each additional hour of operative time increased the odds of anastomotic leak and 1-year mortality by 39% and 19%, respectively.

Conclusions

Esophageal cancer is a poor prognosis disease, even with optimal treatment. Operative efficiency, a modifiable surgical variable, may be an important target to improve MIE patient outcomes.

Robotic assisted minimally invasive esophagectomy versus minimally invasive esophagectomy

Background

Esophagectomy is the gold standard treatment for resectable esophageal cancer; however, there is insufficient evidence to indicate potential advantages over standard minimally invasive esophagectomy (MIE) in treating thoracic esophageal cancer. Robot-assisted minimally invasive esophagectomy (RAMIE) bridges the gap between open and minimally invasive surgery. In this single-center retrospective review, we compare the clinical outcomes of EC patients treated with MIE and RAMIE.

Method

We retrospectively reviewed the clinical data of patients with esophageal cancer who underwent surgery at Qilu Hospital between August 2020 and August 2022, including 159 patients who underwent MIE and 35 patients who received RAMIE. The intraoperative, postoperative, and preoperative patient characteristics in both groups were evaluated.

Results

Except for height, the MIE and RAMIE groups showed no significant differences in preoperative features (P>0.05). Further, there were no significant differences in intraoperative indices, including TNM stage of the resected tumor, tumor tissue type, or ASA score, between the two groups. However, statistically significant differences were found in some factors; the RAMIE group had a shorter operative time, less intraoperative bleeding, and more lymph nodes removed compared to the MIE group. Patients in the RAMIE group reported less discomfort and greater chest drainage on the first postoperative day than patients in the MIE group; however, there were no differences in other features between the two datasets.

Conclusion

By comparing the clinical characteristics and outcomes of RAMIE with MIE, this study verified the feasibility and safety of RAMIE for esophageal cancer. Overall, RAMIE resulted in more complete lymph node clearance, shorter operating time, reduced surgical hemorrhage, reduced postoperative discomfort, and chest drainage alleviation in patients. To investigate the function of RAMIE in esophageal cancer, we propose undertaking a future clinical trial with long-term follow-up to analyze tumor clearance, recurrence, and survival after RAMIE.

No difference in the incidence of postoperative pulmonary complications between abdominal laparoscopy and laparotomy for minimally invasive thoracoscopic esophagectomy: a retrospective cohort study using a nationwide Japanese database

INTRODUCTION

There remains a lack of evidence regarding the optimal abdominal approach, including laparoscopy, hand-assisted, and open laparotomy for minimally invasive thoracoscopic esophagectomy. We aimed to compare the incidence of postoperative complications, particularly pulmonary complications, between laparoscopy and open laparotomy for minimally invasive thoracoscopic esophagectomy using nationwide Japanese databases.

METHODS

Data from patients in the National Clinical Database (NCD) who underwent thoracoscopic esophagectomy for esophageal cancer were analyzed. The incidence of pulmonary complications was compared between abdominal laparoscopy and laparotomy after matching the propensity scores (PS) from preoperative factors to account for confounding bias. Laparoscopic-assisted surgery (LAS) was also compared to hand-assisted laparoscopic surgery (HALS).

RESULTS

Of the 24,790 patients who underwent esophagectomy between 2018 and 2021, data from 12,633 underwent thoracoscopic procedure. The proportion of patients who experienced pulmonary complications did not significantly differ between the laparoscopy group and the laparotomy group after matching (664/3195 patients, 20.8% versus 702/3195 patients, 22.0%; P = 0.25). No difference in the incidence of pulmonary complications was observed among patients treated using the laparoscopic approach (508/2439 patients, 20.8% in the LAS group versus 498/2439 patients, 20.4% in the HALS group; P = 0.72).

CONCLUSIONS

We observed no significant difference in the incidence of postoperative pulmonary complications between laparoscopy and laparotomy for thoracoscopic esophagectomy. Short-term outcomes were similar between the laparoscopic-assisted approach and the hand-assisted approach. This study provides valuable insights into the optimal abdominal approach for thoracoscopic esophagectomy using data from a nationwide database that reflect real-world clinical practice.

The Society of Thoracic Surgeons/American Society for Radiation Oncology Updated Clinical Practice Guidelines on Multimodality Therapy for Locally Advanced Cancer of the Esophagus or Gastroesophageal Junction

Outcomes for patients with esophageal cancer have improved over the last decade with the implementation of multimodality therapy. There are currently no comprehensive guidelines addressing multidisciplinary management of esophageal cancer that have incorporated the input of surgeons, radiation oncologists, and medical oncologists. To address the need for multidisciplinary input in the management of esophageal cancer and to meet current best practices for clinical practice guidelines, the current guidelines were created as a collaboration between The Society of Thoracic Surgeons (STS), American Society for Radiation Oncology (ASTRO), and the American Society of Clinical Oncology (ASCO). Physician representatives chose 8 key clinical questions pertinent to the care of patients with locally advanced, resectable thoracic esophageal cancer (excluding cervical location). A comprehensive literature review was performed identifying 227 articles that met the inclusion criteria covering the use of induction chemotherapy, chemotherapy vs chemoradiotherapy before surgery, optimal radiation dose, the value of esophagectomy, timing of esophagectomy, the approach and extent of lymphadenectomy, the use of minimally invasive esophagectomy, and the value of adjuvant therapy after resection. The relevant data were reviewed and voted on by the panel with 80% of the authors, with 75% agreement on class and level of evidence. These data were then complied into the guidelines document.

The Society of Thoracic Surgeons/American Society for Radiation Oncology Updated Clinical Practice Guidelines on Multimodality Therapy for Locally Advanced Cancer of the Esophagus or Gastroesophageal Junction

Outcomes for patients with esophageal cancer have improved over the last decade with the implementation of multimodality therapy. There are currently no comprehensive guidelines addressing multidisciplinary management of esophageal cancer that have incorporated the input of surgeons, radiation oncologists, and medical oncologists. To address the need for multidisciplinary input in the management of esophageal cancer and to meet current best practices for clinical practice guidelines, the current guidelines were created as a collaboration between The Society of Thoracic Surgeons (STS), American Society for Radiation Oncology (ASTRO), and the American Society of Clinical Oncology (ASCO). Physician representatives chose 8 key clinical questions pertinent to the care of patients with locally advanced, resectable thoracic esophageal cancer (excluding cervical location). A comprehensive literature review was performed identifying 227 articles that met the inclusion criteria covering the use of induction chemotherapy, chemotherapy vs chemoradiotherapy before surgery, optimal radiation dose, the value of esophagectomy, timing of esophagectomy, the approach and extent of lymphadenectomy, the use of minimally invasive esophagectomy, and the value of adjuvant therapy after resection. The relevant data were reviewed and voted on by the panel with 80% of the authors, with 75% agreement on class and level of evidence. These data were then complied into the guidelines document.

Prince and princesses: The current status of robotic surgery in surgical oncology

Robotic surgery has experienced a dramatic increase in utilization across general surgery over the last two decades, including in surgical oncology. Although urologists and gynecologists were the first to show that this technology could be utilized in cancer surgery, the robot is now a powerful tool in the treatment of gastrointestinal, hepato-pancreatico-biliary, colorectal, endocrine, and soft tissue malignancies. While long-term outcomes are still pending, short-term outcomes have showed promise for this technologic advancement of cancer surgery.

Surgical and Perioperative Treatments for Esophagogastric Junction Cancer

Esophagogastric junction cancer (EGJC) is a rare malignant disease that occurs in the gastroesophageal transition zone. In recent years, its incidence has been rapidly increasing not only in Western countries but also in East Asia, and it has been attracting the attention of both clinicians and researchers. EGJC has a worse prognosis than gastric cancer (GC) and is characterized by complex lymphatic drainage pathways in the mediastinal and abdominal regions. EGJC was previously treated in the same way as GC or esophageal cancer, but, in recent years, it has been treated as an independent malignant disease, and treatment focusing only on EGJC has been developed. A recent multicenter prospective study revealed the frequency of lymph node metastasis by station and established the optimal extent of lymph node dissection. In perioperative treatment, the combination of multi-drug chemotherapy, radiation therapy, molecular targeted therapy, and immunotherapy is expected to improve the prognosis. In this review, we summarize previous clinical trials and their important evidence on surgical and perioperative treatments for EGJC.

Treatment options for neoadjuvant strategies of esophageal squamous cell carcinoma (Review)

Compared with postoperative adjuvant therapy, neoadjuvant therapy has more potential advantages, such as decreasing tumor stage, killing micrometastatic cells. Because of these advantages, neoadjuvant therapy is recommended for numerous types of tumor, such as breast, lung and rectal cancer. To determine the role of neoadjuvant therapy on overall survival and adverse for patients with resectable esophageal carcinoma. we summarized clinical studies on 7 types of neoadjuvant therapies in this review. Currently, patients with esophageal cancer (EC) in China mainly receive postoperative treatment with <30% of patients receiving neoadjuvant therapy. One reason for the limited use of neoadjuvant therapy in China is inaccurate staging based on imaging and neoadjuvant treatment may increase difficulties in surgery. After neoadjuvant therapy, there may be tissue edema, blurry surgical field of view and unclear tissue gaps, resulting in greater difficulty in surgical procedures. However, oncologists are interested in neoadjuvant treatment, especially neoadjuvant immunotherapy to treat EC. Concurrent chemoradiotherapy for esophageal squamous cell carcinoma (ESCC) is the most common neoadjuvant treatment regimen and increases the pathological complete response (pCR) and 5- and 10-year survival rates. Preoperative induction chemotherapy and sequential concurrent chemoradiotherapy are currently the most widely treatments used in clinical practice in China. However, this treatment strategy does not yield long-term survival. The pCR rate of neoadjuvant immunotherapy is greater than that of concurrent chemoradiotherapy but, to the best of our knowledge, no evidence of long-term survival benefit has been found in phase I and II clinical trials. Neoadjuvant treatment should be considered for patients with locally advanced ESCC.

Robotic-Assisted Ivor Lewis Esophagectomy Is Safe and Cost Equivalent Compared to Minimally Invasive Esophagectomy in a Tertiary Referral Center

In recent decades, robotic-assisted minimally invasive esophagectomy (RAMIE) has been increasingly adopted for patients with esophageal cancer (EC) or cancer of the gastroesophageal junction (GEJ). However, concerns regarding its costs compared to conventional minimally invasive esophagectomy (MIE) have emerged. This study examined outcomes and costs of RAMIE versus total MIE in 128 patients who underwent Ivor Lewis esophagectomy for EC/GEJ at our department between 2017 and 2021. Surgical costs were higher for RAMIE (EUR 12,370 vs. EUR 10,059, p < 0.001). Yet, median daily (EUR 2023 vs. EUR 1818, p = 0.246) and total costs (EUR 30,510 vs. EUR 29,180, p = 0.460) were comparable. RAMIE showed a lower incidence of postoperative pneumonia (8% vs. 25%, p = 0.029) and a trend towards shorter hospital stays (15 vs. 17 days, p = 0.205), which may have equalized total costs. Factors independently associated with higher costs included readmission to the intensive care unit (hazard ratio [HR] = 7.0), length of stay (HR = 13.5), anastomotic leak (HR = 17.0), and postoperative pneumonia (HR = 5.4). In conclusion, RAMIE does not impose an additional financial burden. This suggests that RAMIE may be considered as a valid alternative approach for esophagectomy. Attention to typical cost factors can enhance postoperative care across surgical methods.

Evolving Perspectives on Esophagectomy Care: Clinical Update

Recent changes in perioperative care have led to new perspectives and important advances that have helped to improve outcomes among patients treated with esophagectomy for esophageal cancer.

Quality Performance Indicators for the Surgical Management of Oesophageal Cancer: A Systematic Literature Review

BACKGROUND

The objective of this systematic review was to identify pre-existing quality performance indicators (QPIs) for the surgical management of oesophageal cancer (OC). These QPIs can be used to objectively measure and compare the performance of individual units and capture key elements of patient care to improve patient outcomes.

METHODS

A systematic literature search of PubMed, MEDLINE, Scopus and Embase was conducted. Articles reporting on the quality of healthcare in relation to oesophageal neoplasm or cancer and the surgical treatment of OC available until the 1st of March 2022 were included.

RESULTS

The final list of articles included retrospective reviews (n = 13), prospective reviews (n = 8), expert guidelines (n = 1) and consensus (n = 1). The final list of QPIs was categorized as process, outcome or structural measures. Process measures included multidisciplinary involvement, availability of multimodality diagnostic and treatment pathways and surgical metrics. Outcome measures included reoperation and readmission rates, the achievement of RO resection and length of hospital stay. Structural measures include multidisciplinary meetings.

CONCLUSIONS

This systematic review summarizes QPIs for the surgical treatment of OC. The data will serve as an introduction to establishing a quality initiative project for OC resections.

Major Intraoperative Complications During Minimally Invasive Esophagectomy

BACKGROUND

Studies have shown minimally invasive esophagectomy (MIE) to be a feasible surgical technique in treating esophageal carcinoma. Postoperative complications have been extensively reviewed, but literature focusing on intraoperative complications is limited. The main objective of this study was to report major intraoperative complications and 90-day mortality during MIE for cancer.

METHODS

Data were collected retrospectively from 10 European esophageal surgery centers. All intention-to-treat, minimally invasive laparoscopic/thoracoscopic esophagectomies with gastric conduit reconstruction for esophageal and GE junction cancers operated on between 2003 and 2019 were reviewed. Major intraoperative complications were defined as loss of conduit, erroneous transection of vascular structures, significant injury to other organs including bowel, heart, liver or lung, splenectomy, or other major complications including intubation injuries, arrhythmia, pulmonary embolism, and myocardial infarction.

RESULTS

Amongst 2862 MIE cases we identified 98 patients with 101 intraoperative complications. Vascular injuries were the most prevalent, 41 during laparoscopy and 19 during thoracoscopy, with injuries to 18 different vessels. There were 24 splenic vascular or capsular injuries, 11 requiring splenectomies. Four losses of conduit due to gastroepiploic artery injury and six bowel injuries were reported. Eight tracheobronchial lesions needed repair, and 11 patients had significant lung parenchyma injuries. There were 2 on-table deaths. Ninety-day mortality was 9.2%.

CONCLUSIONS

This study offers an overview of the range of different intraoperative complications during minimally invasive esophagectomy. Mortality, especially from intrathoracic vascular injuries, appears significant.

Commentary: The Prognostic Value of Oligo-Recurrence Following Esophagectomy for Esophageal Cancer

See Article page 403.

Delayed Surgical Intervention After Chemoradiotherapy in Esophageal Cancer: (DICE) Study

OBJECTIVE

To determine the impact of delayed surgical intervention following chemoradiotherapy (CRT) on survival from esophageal cancer.

BACKGROUND

CRT is a core component of multimodality treatment for locally advanced esophageal cancer. The timing of surgery following CRT may influence the probability of performing an oncological resection and the associated operative morbidity.

METHODS

This was an international, multicenter, cohort study, including patients from 17 centers who received CRT followed by surgery between 2010 and 2020. In the main analysis, patients were divided into 4 groups based upon the interval between CRT and surgery (0-50, 51-100, 101-200, and >200 days) to assess the impact upon 90-day mortality and 5-year overall survival. Multivariable logistic and Cox regression provided hazard ratios (HRs) with 95% CIs adjusted for relevant patient, oncological, and pathologic confounding factors.

RESULTS

A total of 2867 patients who underwent esophagectomy after CRT were included. After adjustment for relevant confounders, prolonged interval following CRT was associated with an increased 90-day mortality compared with 0 to 50 days (reference): 51 to 100 days (HR=1.54, 95% CI: 1.04-2.29), 101 to 200 days (HR=2.14, 95% CI: 1.37-3.35), and >200 days (HR=3.06, 95% CI: 1.64-5.69). Similarly, a poorer 5-year overall survival was also observed with prolonged interval following CRT compared with 0 to 50 days (reference): 101 to 200 days (HR=1.41, 95% CI: 1.17-1.70), and >200 days (HR=1.64, 95% CI: 1.24-2.17).

CONCLUSIONS

Prolonged interval following CRT before esophagectomy is associated with increased 90-day mortality and poorer long-term survival. Further investigation is needed to understand the mechanism that underpins these adverse outcomes observed with a prolonged interval to surgery.

Machine learning to predict curative multidisciplinary team treatment decisions in oesophageal cancer

BACKGROUND

Rising workflow pressures within the oesophageal cancer (OC) multidisciplinary team (MDT) can lead to variability in decision-making, and health inequality. Machine learning (ML) offers a potential automated data-driven approach to address inconsistency and standardize care. The aim of this experimental pilot study was to develop ML models able to predict curative OC MDT treatment decisions and determine the relative importance of underlying decision-critical variables.

METHODS

Retrospective complete-case analysis of oesophagectomy patients ± neoadjuvant chemotherapy (NACT) or chemoradiotherapy (NACRT) between 2010 and 2020. Established ML algorithms (Multinomial Logistic regression (MLR), Random Forests (RF), Extreme Gradient Boosting (XGB)) and Decision Tree (DT) were used to train models predicting OC MDT treatment decisions: surgery (S), NACT + S or NACRT + S. Performance metrics included Area Under the Curve (AUC), Accuracy, Kappa, LogLoss, F1 and Precision -Recall AUC. Variable importance was calculated for each model.

RESULTS

We identified 399 cases with a male-to-female ratio of 3.6:1 and median age of 66.1yrs (range 32-83). MLR outperformed RF, XGB and DT across performance metrics (mean AUC of 0.793 [±0.045] vs 0.757 [±0.068], 0.740 [±0.042], and 0.709 [±0.021] respectively). Variable importance analysis identified age as a major factor in the decision to offer surgery alone or NACT + S across models (p < 0.05).

CONCLUSIONS

ML techniques can use limited feature-sets to predict curative UGI MDT treatment decisions. Explainable Artificial Intelligence methods provide insight into decision-critical variables, highlighting underlying subconscious biases in cancer care decision-making. Such models may allow prioritization of caseload, improve efficiency, and offer data-driven decision-assistance to MDTs in the future.

Reducing Conduit Ischemia and Anastomotic Leaks in Transhiatal Esophagectomy: Six Principles

BACKGROUND

Transhiatal esophagectomy (THE) is an accepted approach for distal esophageal (DE) and gastroesophageal junction (GEJ) cancers. Its reported weaknesses are limited loco-regional resection and high anastomotic leak rates. We have used laparoscopic assistance to perform a THE (LapTHE) as our preferred method of resection for GEJ and DE cancers for over 20 years. Our unique approach and experience may provide technical insights and perhaps superior outcomes.

METHODS

We reviewed all patients who underwent LapTHE for DE and GEJ malignancy over 10 years (2011-2020). We included 6 principles in our approach: (1) minimize dissection trauma using laparoscopy; (2) routine Kocher maneuver; (3) division of lesser sac adhesions exposing the entire gastroepiploic arcade; (4) gaining excess conduit mobility, allowing resection of proximal stomach, and performing the anastomosis with a well perfused stomach; (5) stapled side-to-side anastomosis; and (6) routine feeding jejunostomy and early oral diet.

RESULTS

One hundred and forty-seven patients were included in the analysis. The median number of lymph nodes procured was 19 (range 5-49). Negative margins were achieved in all cases (95% confidence interval [CI] 98-100%). Median hospital stay was 7 days. Overall major complication rate was 24% (17-32%), 90-day mortality was 2.0% (0.4-5.8%), and reoperation was 5.4% (2.4-10%). Three patients (2.0%, 0.4-5.8%) developed anastomotic leaks. Median follow-up was 901 days (range 52-5240). Nine patients (6.1%, 2.8-11%) developed anastomotic strictures.

CONCLUSIONS

Routine use of LapTHE for DE and GEJ cancers and inclusion of these six operative principles allow for a low rate of anastomotic complications relative to national benchmarks.

Effective Postoperative Surveillance Protocol after Thoracoscopic Esophagectomy Focusing on Symptoms in Patients with Esophageal Cancer

BACKGROUND

The optimal postoperative surveillance protocol after esophagectomy for patients with esophageal cancer has still not been established. We investigated the risk factors for recurrence of esophageal cancer to devise an appropriate surveillance protocol. We focused on the appearance and worsening of symptoms to determine if additional imaging examinations should be performed.

STUDY DESIGN

We enrolled 416 patients with esophageal and esophagogastric junctional cancer who had undergone thoracoscopic esophagectomy at Tokai University Hospital. Outpatient visits for the patients are usually scheduled at least 4 times per year with CT imaging and blood biochemical examination. We evaluated the time to recurrence after esophagectomy, especially the correlation of this parameter with the appearance and worsening of symptoms during the postoperative outpatient follow-up.

RESULTS

Of the 416 patients, recurrence occurred in 127 patients (30.5%). The median time to recurrence was 6 months after esophagectomy; recurrence occurred within 24 months in 112 patients (88%), and 51 of these patients (40%) developed some new symptom(s) (symptomatic group) before the diagnosis of recurrence. The number of patients who developed recurrence within 6 months was significantly higher in the symptomatic group compared with that in the asymptomatic group (66.7% vs 46.0%, p = 0.02). The overall survival in the symptomatic group was significantly shorter than that in the asymptomatic group (p < 0.001).

CONCLUSIONS

We advocate an effective surveillance protocol depending on the appearance and worsening of symptoms to diagnose recurrence of esophageal cancer; we recommend routine imaging examinations every 6 months and clinical outpatient follow-up at even shorter intervals for the first 24 months after esophagectomy.

Long-Term Survival Associated with Direct Oral Feeding Following Minimally Invasive Esophagectomy: Results from a Randomized Controlled Trial (NUTRIENT II)

Advancements in perioperative care have improved postoperative morbidity and recovery after esophagectomy. The direct start of oral intake can also enhance short-term outcomes following minimally invasive Ivor Lewis esophagectomy (MIE-IL). Subsequently, short-term outcomes may affect long-term survival. This planned sub-study of the NUTRIENT II trial, a multicenter randomized controlled trial, investigated the long-term survival of direct versus delayed oral feeding following MIE-IL. The outcomes included 3- and 5-year overall survival (OS) and disease-free survival (DFS), and the influence of complications and caloric intake on OS. After excluding cases of 90-day mortality, 145 participants were analyzed. Of these, 63 patients (43.4%) received direct oral feeding. At 3 years, OS was significantly better in the direct oral feeding group (p = 0.027), but not at 5 years (p = 0.115). Moreover, 5-year DFS was significantly better in the direct oral feeding group (p = 0.047) and a trend towards improved DFS was shown at 3 years (p = 0.079). Postoperative complications and caloric intake on day 5 did not impact OS. The results of this study show a tendency of improved 3-year OS and 5-year DFS, suggesting a potential long-term survival benefit in patients receiving direct oral feeding after esophagectomy. However, the findings should be further explored in larger future trials.

Relevance of Subcarinal Lymph Node Dissection for Gastroesophageal Junction Adenocarcinoma

INTRODUCTION

Reported rates of subcarinal lymph node (LN) metastases for esophageal carcinoma vary from 20% to 25% and the relevance of subcarinal lymph node dissection (LND) for gastroesophageal junction (GEJ) adenocarcinoma is poorly defined. This study aimed to evaluate rates of subcarinal LN metastasis in GEJ carcinoma and determine their prognostic significance.

METHODS

Patients with GEJ adenocarcinoma undergoing robotic minimally invasive esophagectomy from 2019 to 2021 were retrospectively assessed within a prospectively maintained database. Baseline characteristics and outcomes were examined with attention to subcarinal LND and LN metastases.

RESULTS

Among 53 consecutive patients, the median age was 62, 83.0% were male, and all had Siewert type I/II tumors (49.1% and 50.9%, respectively). Most patients (79.2%) received neoadjuvant therapy. Three patients had subcarinal LN metastases (5.7%) and all had Siewert type I tumors. Two had clinical evidence of LN metastases preoperatively and all three additionally had non-subcarinal nodal disease. A greater proportion of patients with subcarinal LN disease had more advanced (T3) tumors compared to patients without subcarinal metastases (100.0% versus 26.0%; P = 0.025). No patient with subcarinal nodal metastases remained disease free at 3 y after surgery.

CONCLUSIONS

In this consecutive series of patients with GEJ adenocarcinoma undergoing minimally invasive esophagectomy, subcarinal LN metastases were found only in patients with type I tumors and were noted in just 5.7% of patients, which is lower than historical controls. Subcarinal nodal disease was associated with more advanced primary tumors. Further study is warranted to determine the relevance of routine subcarinal LND, especially for type 2 tumors.

Left-primary & right-auxiliary operation mode in mediastinoscope-assisted radical esophagectomy

BACKGROUND

Mediastinoscope-assisted transhiatal esophagectomy (MATHE) is the most minimally invasive esophagectomy procedure. It is a more challenging procedure and more difficult to be popularized than thoracoscopic surgery. We developed a new MATHE operation mode that provides a clearer visual field and makes the procedures simpler.

METHODS

A total of 80 patients with esophageal cancer were divided into a control group (n = 29) and a study group (n = 51). The control group underwent classic MATHE, while the study group received modified MATHE. We compared the two groups on operation time; intraoperative blood loss; blood transfusion amount; incidence rate of lung infection, recurrent laryngeal nerves (RLNs) injury, chylothorax, and anastomotic leakage; and upper mediastinal lymph node dissection.

RESULTS

The study group was significantly better than the control group in operation time (271.78 min vs. 322.90 min, p < 0.05), intraoperative blood loss (48.63 mL vs. 68.97 mL, p < 0.05), and left paratracheal lymph node (No. 4L) dissection rate (88.24% vs. 24.14%, p < 0.01). No significant differences were identified in the incidence rate of anastomotic leakage, lung complications, or RLNs injury between the two groups.

CONCLUSION

The modified MATHE is easier to perform. Modified MATHE is significantly superior to classic MATHE in operation time, intraoperative blood loss, and upper mediastinal lymph node dissection rate.

Short-term outcomes of robot-assisted versus thoracoscopic-assisted Mckeown esophagectomy

BACKGROUND

Thoracoscopic-assisted and robot-assisted Mckeown esophagectomy are currently two common surgical methods, but there is no clear statement on the advantages and disadvantages of the two.

METHODS

This study conducted a single-centre retrospective analysis of esophageal cancer patients diagnosed and treated at Lanzhou University Second Hospital from 1 February 2020 to 31 July 2022. According to the inclusion and exclusion criteria, 126 patients were finally included in the RAM group and 169 patients in the TAM group.

RESULTS

There was no significant difference between the RAM and TAM groups in the number of lymph node dissections, operative time, the length of stay in the intensive care unit after surgery, the incidence of hoarseness, postoperative pulmonary complications, surgery-related complications, use of opioids after surgery, the length of postoperative hospital stay, and 30-day mortality.

CONCLUSIONS

RAM is a minimally invasive alternative to TAM and has similar short-term oncological efficacy.

Proctored adoption of robotic hiatus hernia surgery: outcomes and learning curves in a high-volume UK centre

BACKGROUND

The adoption of new surgical technologies is inevitably accompanied by a learning curve. With the increasing adoption of robotic techniques in benign foregut surgery, it is imperative to define optimal learning pathways, to ensure a clinically safe introduction of such a technique. The aim of this study was to assess the learning curve for robotic hiatal hernia repair with a pre-defined adoption process and proctoring.

METHODS

The learning curve was assessed in four surgeons in a high-volume tertiary referral centre, performing over a 100 hiatal hernia repairs annually. The robotic adoption process included simulation-based training and a multi-day wet lab-based course, followed by robotic operations proctored by robotic upper GI experts. CUSUM analysis was performed to assess changes in operating time in sequential cases.

RESULTS

Each surgeon (A, B, C and D) performed between 22 and 32 cases, including a total of 109 patients. Overall, 40 cases were identified as 'complex' (36.7%), including 16 revisional cases (16/109, 14.7%). With CUSUM analysis inflection points for operating time were seen after 7 (surgeon B) to 15 cases (surgeon B).

CONCLUSION

The learning curve for robotic laparoscopic fundoplication may be as little as 7-15 cases in the setting of a clearly organized learning pathway with proctoring. By integrating these organized learning pathways learning curves may be shortened, ensuring patient safety, preventing detrimental outcomes due to longer learning curves, and accelerating adoption and integration of novel surgical techniques.

Efficacy and complications of single-port thoracoscopic minimally invasive esophagectomy in esophageal squamous cell carcinoma: a single-center experience

The traditional surgical technique for esophageal cancer is mainly open esophagectomy. With the innovation of surgical instruments, it is necessary to re-optimize the minimally invasive surgery. Therefore, single-port thoracoscopic minimally invasive esophagectomy (SPTE) is an important direction of development. This study retrospectively analyzed 202 patients with esophageal squamous cell carcinoma undergoing SPTE. Surgical variables and postoperative complications were further evaluated. All procedures were performed using SPTE. The number of patients who received R0 resection was 201 (99.5%). The total number of resected lymph nodes during the whole operation was on average 32.01 ± 12.15, and the mean number of positive lymph nodes was 1.56 ± 2.51. In 170 cases (84.2%), intraoperative blood loss did not exceed 100 ml (ml), while 1 case had postoperative bleeding. Only 1 patient (0.5%) required reoperation after surgery. Postoperative complications included 42 cases of pneumonia (20.8%), 9 cases of anastomotic leak (4.5%), 7 cases of pleural effusion (3.8%), and 1 case (0.5%) of both pleural hemorrhage and acute gastrointestinal hemorrhagic ulcer. Besides, we also recorded the time to remove the drain tube, which averaged 9.13 ± 5.31 days. In our study, we confirmed that the application of SPTE in clinical practice is feasible, and that the postoperative complications are at a low level.

Reducing the Risks of Esophagectomies: A Retrospective Comparison of Hybrid versus Full-Robotic-Assisted Minimally Invasive Esophagectomy (RAMIE) Approaches

This retrospective analysis aimed to assess and compare the short-term perioperative outcomes and morbidity of hybrid and full-Robotic-Assisted Minimally Invasive Esophagectomy (RAMIE) surgical techniques. A total of 168 robotic-assisted Ivor Lewis esophagectomy procedures performed at Muenster University Hospital were included in the study, with 63 cases in the hybrid group and 105 cases in the full-robotic group. Demographic factors, comorbidities, and tumor stages showed no significant differences between the two groups. However, the full-RAMIE technique demonstrated superiority in terms of overall operative time, postoperative pain levels, and patient morphine consumption. Additionally, the full-RAMIE group exhibited better perioperative outcomes, with significantly shorter ICU stays and fewer occurrences of pneumonias and severe complications. While there was a trend favoring the full-RAMIE technique in terms of severe postoperative complications and anastomotic insufficiencies, further research is required to establish it as the gold standard surgical technique for Ivor Lewis esophagectomy.

Intraoperative Nerve Monitoring during Minimally Invasive Esophagectomy and 3-Field Lymphadenectomy: Safety, Efficacy, and Feasibility

Background

The objective of this study was to demonstrate the safety, efficacy, and feasibility of intraoperative monitoring of the recurrent laryngeal nerves during thoracoscopic and robotic 3-field esophagectomy.

Methods

This retrospective analysis details our initial experience using intraoperative nerve monitoring (IONM) during minimally invasive 3-field esophagectomy. Data were obtained from a prospectively maintained database and electronic medical records. The study included all patients who underwent minimally invasive (video-assisted thoracic surgery/robotic) transthoracic esophagectomy with neck anastomosis. The patients were divided into those who underwent IONM during the study period and a historical cohort who underwent 3-field esophagectomy without IONM at the same institution. Appropriate statistical tests were used to compare the 2 groups.

Results

Twenty-four patients underwent nerve monitoring during minimally invasive 3-field esophagectomy. Of these, 15 patients underwent thoraco-laparoscopic operation, while 9 received a robot-assisted procedure. In the immediate postoperative period, 8 of 24 patients (33.3%) experienced vocal cord paralysis. Relative to a historical cohort from the same institution, who were treated with surgery without nerve monitoring in the preceding 5 years, a 26% reduction was observed in the nerve paralysis rate (p=0.08). On follow-up, 6 of the 8 patients with vocal cord paralysis reported a return to normal vocal function. Additionally, patients who underwent IONM exhibited a higher nodal yield and a decreased frequency of tracheostomy and bronchoscopy.

Conclusion

The use of IONM during minimally invasive 3-field esophagectomy is safe and feasible. This technique has the potential to decrease the incidence of recurrent nerve palsy and increase nodal yield.

Effect of Anastomotic Leak on Long-Term Survival After Esophagectomy: Multivariate Meta-analysis and Restricted Mean Survival Times Examination

BACKGROUND

Anastomotic leak (AL) is a serious complication after esophagectomy. It is associated with prolonged hospital stay, increased costs, and increased risk for 90-day mortality. Controversy exists concerning the impact of AL on survival. This study was designed to investigate the effect of AL on long-term survival after esophagectomy for esophageal cancer.

METHODS

PubMed, MEDLINE, Scopus, and Web of Science were searched through October 30, 2022. The included studies evaluated the effect of AL on long-term survival. Primary outcome was long-term overall survival. Restricted mean survival time difference (RMSTD), hazard ratio (HR), and 95% confidence intervals (CI) were used as pooled effect size measures.

RESULTS

Thirteen studies (7118 patients) were included. Overall, 727 (10.2%) patients experienced AL. The RMSTD analysis shows that at 12, 24, 36, 48, and 60 months, patients not experiencing AL live an average of 0.7 (95% CI 0.2-1.2; p < 0.001), 1.9 (95% CI 1.1-2.6; p < 0.001), 2.6 (95% CI 1.6-3.7; p < 0.001), 3.4 (95% CI 1.9-4.9; p < 0.001), and 4.2 (95% CI 2.1-6.4; p < 0.001) months longer compared with those with AL, respectively. The time-dependent HRs analysis for AL versus no AL shows a higher mortality hazard in patients with AL at 3 (HR 1.94, 95% CI 1.54-2.34), 6 (HR 1.56, 95% CI 1.39-1.75), 12 (HR 1.47, 95% CI 1.24-1.54), and 24 months (HR 1.19, 95% CI 1.02-1.31).

CONCLUSIONS

This study seems to suggest a modest clinical impact of AL on long-term OS after esophagectomy. Patients who experience AL seem to have a higher mortality hazard during the first 2 years of follow-up.

[Robotic esophageal surgery]

Robot-assisted minimally invasive esophagectomy (RAMIE) is increasingly becoming established as a standard procedure in surgical centers for esophagectomy in cases of cancer. To date, RAMIE has been shown to have fewer postoperative complications and at least equivalent oncological outcomes compared with open resection. Compared with classical minimally invasive resection, there seem to be fewer cases of postoperative pneumonia after RAMIE. In addition, a higher number of harvested lymph nodes could lead to better oncological long-term outcomes. The learning curve for this complex surgical procedure is relatively shallow but can be greatly reduced at high-volume centers through special training and proctoring programs. Robotic surgical approaches have also been described for other esophageal diseases; however, no clear superiority compared to laparoscopic surgery has so far been shown.

Essential updates 2021/2022: Perioperative and surgical treatments for gastric and esophagogastric junction cancer

In recent years, important clinical trials for gastric cancer (GC) and esophagogastric junction cancer (EGJC) have been reported, changing the strategies of surgical and perioperative treatment. Although laparoscopic gastrectomy has already been shown to be effective for early-stage cancer, recent evidence from both Asia (JLSSG0901, CLASS-01 and KLASS-02) and Europe (LOGICA and STOMACH trials) has demonstrated that it is useful for advanced GC. Robotic surgery has been rapidly gaining popularity in recent years, and randomized controlled trials are ongoing to evaluate its efficacy. A prospective nationwide multicenter study mapped sites with frequent metastasis and revealed lymphatic flow specific to EGJC, thus establishing the optimal lymph node dissection area and surgical approach based on esophageal involvement. Perioperative chemotherapy, the mainstay of treatment in Europe, also has been established in Asia by the PRODIGY and RESOLVE studies. New clinical trials have been conducted to evaluate the efficacy of combining immunotherapy or molecular-targeted therapy with perioperative chemotherapy or chemoradiotherapy. In this review, we present important recent clinical trials regarding the treatment of GC and EGJC published in 2021 or 2022.