Learning of thoracoscopic radical esophagectomy: how can the learning curve be made short and flat?

Learning curve in relation to health-related quality of life in long-term, disease free survivors after McKeown minimally invasive esophagectomy

BACKGROUND

The potential impact of learning curve on long-term health-related quality of life (QoL) after esophagectomy for cancer has not been investigated. The aim of this article is to investigate the relationship between learning curve for McKeown minimally invasive esophagectomy (MIE) and health-related quality of life (QoL) in long-term, disease free survivors up to 10 years after esophageal cancer resection.

METHODS

Esophageal cancer patients who underwent McKeown MIE between 2009 and 2019 were identified in which 280 who were free of disease at the time of survey and completed health-related QoL and symptom questionnaires, including EORTC QLQ-C30, EORTC QLQ-OES18, and Digestive Symptom Questionnaire. Patients were assessed in 3 cohorts according to the learning phases of expertise reported by our previous study: initial phase; plateau phase, and; experienced phase.

RESULTS

Median time from operation to survey was 5.8 years (interquartile range 4.6-8.2). The QLQ-C30 mean scores of functional scales, and symptom scales of respiratory and digestive systems including dyspnea (P = 0.006), shortness of breath (P = 0.003), and dysphagia (P = 0.031) were significantly better in experienced phase group. Furthermore, in the subgroup analyses for patients without postoperative major complications, patients in the initial learning phase remained suffering from more symptoms of dyspnea (P = 0.040) and shortness of breath (P = 0.001).

CONCLUSION

Esophageal cancer patients undergoing McKeown MIE in initial learning phase tend to suffer from a deterioration in long-term health-related QoL and higher symptomatic burden as compared to experienced learning phase, which did not improved over time and warranted more attention.

Exploring the learning curve in minimally invasive esophagectomy: a systematic review

Minimally invasive esophagectomy (MIE) has been shown to be superior to open esophagectomy with reduced morbidity, mortality, and comparable lymph node (LN) harvest. However, MIE is technically challenging. This study aims to perform a pooled analysis on the number of cases required to surmount the learning curve (LC), i.e. NLC in MIE. PubMed, Embase, Scopus, and the Cochrane Library were systematically searched for articles from inception to June 2022. Inclusion criteria were articles that reported LC in video-assisted MIE (VAMIE) and/or robot-assisted MIE (RAMIE). Poisson means (95% confidence interval [CI]) was used to determine NLC. Negative binomial regression was used for comparative analysis. There were 41 articles with 45 data sets (n = 7755 patients). The majority of tumors were located in the lower esophagus or gastroesophageal junction (66.7%, n = 3962/5939). The majority of data sets on VAMIE (n = 16/26, 61.5%) used arbitrary analysis, while the majority of data sets (n = 14/19, 73.7%) on RAMIE used cumulative sum control chart analysis. The most common outcomes reported were overall operating time (n = 30/45) and anastomotic leak (n = 28/45). Twenty-four data sets (53.3%) reported on LN harvest. The overall NLC was 34.6 (95% CI: 30.4-39.2), 68.5 (95% CI: 64.9-72.4), 27.5 (95% CI: 24.3-30.9), and 35.9 (95% CI: 32.1-40.2) for hybrid VAMIE, total VAMIE, hybrid RAMIE, and total RAMIE, respectively. NLC was significantly lower for total RAMIE compared to total VAMIE (incidence rate ratio: 0.52, P = 0.032). Studies reporting NLC in MIE are heterogeneous. Further studies should clearly define prior surgical experiences and assess long-term oncological outcomes using non-arbitrary analysis.

Anterior mediastinal tumor surgery applying single-port thoracoscopy using the subxiphoid approach

Background

This study aims to investigate the effectiveness of application of single-port thoracoscopy using the subxiphoid approach in anterior mediastinal tumor surgery.

Methods

Between June 2014 and June 2016, a total of 108 patients (59 males, 49 females; mean age: 64.9±7.5 years; range, 45 to 79 years) with anterior mediastinal tumors were randomized into subxiphoid (experimental) or right chest (control) groups. Single-port thoracoscopy using the subxiphoid approach was performed in the subxiphoid group, while thoracoscopy using the right thoracic approach was performed in the control group. Preand postoperative pain stress indicators, Visual Analog Scale scores, quality of life scores, postoperative tumor recurrence, and five-year survival rates were compared between the groups.

Results

There were no mortality or serious complications in either group. The mean Visual Analog Scale pain scores on postoperative Days 1 and 7 were 6.5±0.8 and 2.9±0.8 in the subxiphoid group, respectively, compared to 7.2±0.8 and 3.4±0.8 in the control group (p<0.05 for all), respectively. The mean quality of life scores on postoperative Days 1 and 7 were 81.5±5.0 and 79.3±7.7, respectively, in the subxiphoid group compared to 72.4±4.3 and 71.3±4.8 in the control group, respectively (p<0.05 for all). Postoperative pain and pain mediator indexes were lower in the subxiphoid group (p<0.05 for all). The postoperative tumor recurrence rates were 3.70% and 20.37% in the subxiphoid and control groups, respectively (p=0.008). The five-year survival rates were 85.2% and 63.0% in the subxiphoid and control groups, respectively (p=0.008).

Conclusion

Single-port thoracoscopy using the subxiphoid approach is technically feasible, safe, and effective in performing surgery for anterior mediastinal tumors with an intact capsule and a tumor diameter of ≤5 cm.

Learning curves in minimally invasive esophagectomy: A systematic review and evaluation of benchmarking parameters

BACKGROUND

Minimally invasive techniques are increasingly used in the treatment of esophageal cancer. The learning curve for minimally invasive esophagectomy is variable and can impact patient outcomes. The aim of this study was to review the current evidence on learning curves in minimally invasive esophagectomy and identify which parameters are used for benchmarking.

METHODS

A search of the major reference databases (PubMed, Medline, Cochrane) was performed with no time limits up to February 2020. Results were screened in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies were included if an assessment of the learning curve was reported on, regardless of which (if any) statistical method was used.

RESULTS

Twenty-nine studies comprising 3,741 patients were included. Twenty-two studies reported on a combination of thoracoscopic, hybrid, and total minimally invasive esophagectomy, 6 studies reported robotic-assisted minimally invasive esophagectomy alone, and 1 study evaluated both robotic-assisted minimally invasive esophagectomy and thoracoscopic esophagectomies. Operating time was the most frequently used parameter to determine learning curve progression (23/39 studies), with number of resected lymph nodes, morbidity, and blood loss also frequently used. Learning curves were found to plateau at 7 to 60 cases for thoracoscopic esophagectomy, 12 to 175 cases for total and thoracoscopic/hybrid esophagectomy, and 9 to 85 cases for robotic-assisted minimally invasive esophagectomy.

CONCLUSION

Multiple parameters are employed to gauge minimally invasive esophagectomy learning curve progression. However, there are no validated or approved sets of outcomes. Further work is required to determine the optimum parameters that should be used to ensure best patient outcomes and required length of proctoring.

Utility of thoracic cage width in assessing surgical difficulty of minimally invasive esophagectomy in left lateral decubitus position

BACKGROUND

This study aimed to assess the surgical difficulty of minimally invasive esophagectomy in the left lateral decubitus position for patients with esophageal cancer from the perspective of short-term outcomes, including operation time, blood loss, and morbidity.

MATERIALS AND METHODS

The initial 44 consecutive patients with esophageal cancer who underwent minimally invasive esophagectomy were statistically analyzed retrospectively. Thoracic cage area was measured from preoperative computed tomography as a factor affecting the surgical difficulty of minimally invasive esophagectomy, as well as other patient characteristics. Correlations with short-term outcomes including chest operation time, blood loss, and morbidity rate were then examined.

RESULTS

In univariate analyses, smaller area of the upper thoracic cage width correlated with prolonged thoracic procedure time (p = 0.0119) and greater blood loss during thoracic procedures (p = 0.0283), but area of the lower thoracic cage showed no correlations. History of respiratory disease was associated with thoracic procedure time (p < 0.0001), but not blood loss. In multivariate analysis, small area of the upper thoracic cage was independently associated with prolonged thoracic procedure time (p = 0.0253). Small upper thoracic cage area was not directly correlated with morbidity rate, but prolonged thoracic procedure time was associated with increased blood loss (p < 0.0001) and morbidity rate (p = 0.0204). Empirical time reduction (p = 0.0065), but not blood loss, was associated with thoracic procedure time. However, area of the upper thoracic cage did not correlate with empirical case number. In multivariate analysis, area of the upper thoracic cage (p = 0.0317) and empirical case number (p = 0.0193) correlated independently with thoracic procedure time.

CONCLUSION

A small area of the upper thoracic cage correlated significantly with prolonged thoracic procedure time and increased thoracic blood loss for minimally invasive esophagectomy in the left lateral decubitus position, suggesting the surgical difficulty of minimally invasive esophagectomy in the left lateral decubitus position.

Learning curve and postoperative outcomes of minimally invasive esophagectomy

Surgical innovation is necessary to increase surgical effectiveness and to decrease postoperative complications, but can be associated with learning curves. The significance of surgical learning curves is increasing and it is important to take surgical learning curves into account when interpreting outcome data that is acquired during an implementation period. This may especially be the case for a technically challenging procedure like minimally invasive esophagectomy (MIE). This review article provides an overview of the published literature that has described a learning curve for MIE, with particular interest in the relationship between the learning curve and postoperative complications. Twenty two studies reported learning curves of different types of MIE. These studies showed that the length of the learning curve of MIE can be significant, but most studies are single center studies of limited methodological quality. In addition, several learning curve analysis methods are used but a clear recommendation regarding the preferred method is lacking. Most studies use intraoperative parameters (e.g., operative time) to define the length of the learning curve. However, significant learning curve effects have been found for clinically more relevant parameters (e.g., anastomotic leak), especially for Ivor Lewis MIE. These studies suggest that patient safety can be substantially compromised during learning curves. To increase patient safety and shorten the learning curve, evidence based and effective safe implementation programs are necessary.

Quality Improvement in Minimally Invasive Esophagectomy: Outcome Improvement Through Data Review

BACKGROUND

Esophagectomy is a complex operation in which outcomes are profoundly influenced by operative experience and volume. We report the effects of experience and innovation on outcomes in minimally invasive esophagectomy.

METHODS

Esophageal resections for cancer from 2007 to 2016 at Levine Cancer Institute at Carolinas Medical Center (Charlotte, NC) were reviewed. During this time, three changes in technique were made to improve outcomes: vascular evaluation of the gastric conduit to improve anastomotic healing (beginning at case #63), one-stage approach to permit access to abdomen and chest through one draped surgical field (case #82), and adoption of a lung-protective anesthetic protocol (case #101). Mortality, operative time, complications, and length of stay were analyzed relative to these interventions using GLM regression.

RESULTS

200 patients underwent minimally invasive esophagectomy. There were no mortalities at 30 days, and no change in mortality rate at 60 and 90 days. Anastomotic leak decreased significantly after the introduction of intraoperative vascular evaluation of the gastric conduit (3.6 vs 19.4%). Operative time decreased with adoption of a one-stage approach (416 vs 536 min). Pulmonary complications decreased coincident with a change in anesthetic technique (pneumonia 6 vs 28%). Lymph node harvest increased over time. Length of stay was driven primarily by complications and decreased with operative experience.

CONCLUSIONS

Postoperative complications, operative time, and length of stay decreased with case experience and alterations in surgical and anesthetic technique. We believe that adoption of the techniques and technology described herein can reduce complications, reduce hospital stay, and improve patient outcomes.

Surgical team proficiency in minimally invasive esophagectomy is related to case volume and improves patient outcomes

BACKGROUND

Minimally invasive esophagectomy (MIE) is being increasingly performed; however, it is still associated with high morbidity and mortality. The correlation between surgical team proficiency and patient load lacks clarity. This study evaluates surgical outcomes during the first 3-year period after establishment of a new surgical team.

METHODS

A new surgical team was established in September 2013 by two expert surgeons having experience of performing more than 100 MIEs. We assessed 237 consecutive patients who underwent MIE for esophageal cancer and evaluated the impact of surgical team proficiency on postoperative outcomes, as well as the team learning curve.

RESULTS

In the cumulative sum analysis, a point of downward inflection for operative time and blood loss was observed in case 175. After 175 cases, both operative time and blood loss significantly decreased (P < 0.001 and P < 0.001, respectively), and postoperative incidence of pneumonia significantly decreased from 18.9 to 6.5% (P = 0.024). Median postoperative hospital stay also decreased from 20 to 18 days (P = 0.022). Additionally, serum CRP levels on postoperative day 1 showed a significant, but weak inverse association with the number of cases (P = 0.024).

CONCLUSIONS

After 175 cases, both operative time and blood loss significantly decreased. In addition, the incidence of pneumonia decreased significantly. Additionally, surgical team proficiency may decrease serum CRP levels immediately after MIE. Surgical team proficiency based on team experience had beneficial effects on patients undergoing MIE.

Learning curve for robotic esophagectomy and dissection of bilateral recurrent laryngeal nerve nodes for esophageal cancer

Dissection of bilateral recurrent laryngeal nerve (RLN) nodes is a technically demanding procedure, but robotic systems have been useful for RLN node dissection. This retrospective study investigated the learning curve for bilateral RLN node dissection in esophageal-cancer patients using a robotic system for esophageal cancer. We retrospectively reviewed 33 consecutive patients who received a robotic esophagectomy and total lymphadenectomy by single surgeon. The patients were divided into either group 1 (initial 20 cases) or group 2 (later 13 cases). The mean patient age was 61.88 ± 9.03 years and 28 (84.8%) patients were male. Most cases were pathologically diagnosed as squamous cell carcinoma. The lesion locations included 3 (9.1%) in the upper esophagus, 12 (63.6%) in the mid esophagus, and 9 (27.3%) in the lower esophagus. Eleven (33.3%) cases were stage I, 7 (21.2%) were stage II, and 15 (45.5%) were stage III. One case in group 2 (3%) suffered operative mortality. Operation time, robot console time, and blood loss were similar between the two groups. The timing of right and left RLN node dissection, the number of total dissected lymph nodes, and the percentage of dissected right and left RLN nodes were also comparable. However, the incidence of vocal cord palsy was significantly lower in group 2 (55% vs. 0%, p= 0.02). The incidence of other operative complications did not vary between the two groups. Even though operative outcomes and incidence of other complications were comparable between the two groups, the incidence of vocal cord palsy decreased significantly after 20 cases. Thus, we conclude that a minimum of 20 cases is required before a surgeon is experienced enough to perform safe dissection of bilateral RLN nodes.

Minimally Invasive Techniques and Hybrid Operations for Esophageal Cancer

Background

Minimally invasive esophagectomy (MIE) is slowly gaining acceptance due to advantages in short-term outcome. While evidence is slowly increasing, the discussion about MIE is still controversial.

Methods

A literature review was performed to compare MIE with open esophagectomy (OE). Current studies are summarized in view of short- and long-term outcome as well as oncological accuracy.

Results

The majority of studies show that MIE is associated with a significant reduction of pulmonary complications, blood loss, and shorter length of stay on the intensive care unit. Pulmonary complications are reduced by 14-65%. MIE shows an improved quality of life 6 weeks after surgery. There is some evidence that the endoscopic reintervention rate may be higher after MIE than after OE. Mortality rates do not differ. Regarding oncological results, the rate of R0 resections is comparable between MIE and OE, as is the number of retrieved lymph nodes. Long-term survival seems to be comparable. A few single center trials suggest oncological advantages of MIE over OE concerning the number of lymph nodes, R0 resection rate, and 1-year survival.

Conclusion

Current evidence supports that MIE has advantages over OE in the short-term outcome. Oncological results are comparable to those achieved by OE. As a result, MIE has already been included in current guidelines for the treatment of esophageal cancer.

Minimally invasive Ivor Lewis esophagectomy: description of a learning curve

BACKGROUND

Minimally invasive Ivor Lewis esophagectomy (MIE) is gaining popularity for the treatment of esophageal cancer. However, as it is a technically demanding operation, a learning curve should be defined to guide training and allow implementation at institutions not currently using this technique.

STUDY DESIGN

Our study included a retrospective series of the first 80 consecutive patients undergoing MIE by a single surgeon with advanced training in minimally invasive esophageal surgery in independent practice at a high-volume tertiary center. Patients were stratified into 2 groups of 40 patients, with chronological order defining early and late experiences. Primary end points included conversion to open procedure, surgical time, blood loss, chest drainage duration, time to oral intake, hospital stay, postoperative morbidity, and mortality. The cumulative sum methodology was used and analyzed by visually inspecting the plots.

RESULTS

Conversion to open procedure occurred in 2 (5%) patients in the early group and none in the late group (p = 0.49). Comparing early vs late experience, mean surgical time was 364 vs 316 minutes (p < 0.01), estimated blood loss was 205 vs 176 mL (p = 0.14), median hospital stay was 7 vs 6 days (p < 0.01), and morbidity was observed in 16 (40%) and 14 (35%) patients (p = 0.82), respectively. There were no anastomotic leaks or 30-day mortality. Cumulative sum plots showed decreasing surgical time after patient 54 (plateau after patient 31), decreasing chest tube duration after patients 38 and 33, sooner oral intake after patient 35, and decreased hospital stay after patient 33.

CONCLUSIONS

Improved operative and perioperative parameters for MIE were observed in the last 40 patients when compared with the first 40 patients. A reasonable learning curve for MIE would require the operation and perioperative care of 35 to 40 patients.

Modified McKeown minimally invasive esophagectomy for esophageal cancer: a 5-year retrospective study of 142 patients in a single institution

Background

To achieve decreased invasiveness and lower morbidity, minimally invasive esophagectomy (MIE) was introduced in 1997 for localized esophageal cancer. The combined thoracoscopic-laparoscopic esophagectomy (left neck anastomosis, defined as the McKeown MIE procedure) has been performed since 2007 at our institution. From 2007 to 2011, our institution subsequently evolved as a high-volume MIE center in China. We aim to share our experience with MIE, and have evaluated the outcomes of 142 patients.

Methods

We retrospectively reviewed 142 consecutive patients who had presented with esophageal cancer undergoing McKeown MIE from July 2007 to December 2011. The procedure, surgical outcomes, disease-free and overall survival of these cases were assessed.

Results

The average total procedure time was 270.5±28.1 min. The median operation time for thoracoscopy was 81.5±14.6 min and for laparoscopy was 63.8±9.1 min. The average blood loss associated with thoracoscopy was 123.8±39.2 ml, and for laparoscopic procedures was 49.9±14.3 ml. The median number of lymph nodes retrieved was 22.8. The 30 day mortality rate was 0.7%. Major surgical complications occurred in 24.6% and major non-surgical complications occurred in 18.3% of these patients. The median DFS and OS were 36.0±2.6 months and 43.0±3.4 months respectively.

Conclusions

Surgical and oncological outcomes following McKeown MIE for esophageal cancer were acceptable and comparable with those of open-McKeown esophagectomy. The procedure was both feasible and safe – properties that can be consolidated by experience.

Laparoscopic ischemic conditioning of the stomach prior to esophagectomy

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

Variation in the standard of minimally invasive esophagectomy for cancer--systematic review

Minimally invasive esophagectomy (MIE) has been increasingly performed to treat esophageal cancer. Studies published between 1990 and 2012 that described the use of MIE for cancer in at least 50 patients were included for systematic review. The literature search retrieved 34 publications comprising 18 case series, 15 comparative studies, and 1 randomized control trial. Results revealed a wide variability in surgical techniques and perioperative outcomes with a lack of standardized definitions of postoperative complications. In most studies, radical formal lymphadenectomy was not performed and the lymph node harvest fell below the minimum number recommended to achieve survival benefits. There is a need to reach a consensus regarding surgical approaches in MIE, the definition of postoperative complications and the extent of lymphadenectomy before embarking on further randomized controlled trials comparing MIE vs. open approach.

Thoracoscopic esophagectomy with extended lymph node dissection in the left lateral position: technical feasibility and oncologic outcomes

The aim of this study was to estimate the technical and oncologic feasibility of video-assisted thoracoscopic radical esophagectomy (VATS) in the left lateral position. From January 2003 to December 2011, 132 patients with esophageal cancer underwent VATS. The mean duration of the thoracic procedure and the entire procedure was 294 ± 88 and 623 ± 123 minutes, respectively. Mean blood loss during the thoracic procedure and the entire procedure was 313 ± 577 and 657 ± 719 g, respectively. The mean number of dissected thoracic lymph nodes was 32.6 ± 12.9. There were four in-hospital deaths (3.0%); two patients (1.5%) died of acute respiratory distress syndrome and two patients (1.5%) died of tumor progression. Postoperative unilateral or bilateral recurrent laryngeal nerve (RLN) palsy, or pneumonia was found in 33 (25.0%), 21 (15.9%), and 27(20.5%) patients, respectively. The patients were divided into the first 66 patients who underwent VATS (Group 1) and the subsequent 66 patients (Group 2). The numbers of cases who underwent neoadjuvant or induction chemotherapy for T4 tumor and intrathoracic anastomosis were higher in Group 2 than in Group 1. The duration of the procedure, amount of blood loss, and the number of dissected thoracic lymph nodes were not different between the two groups. The total number of dissected lymph nodes was higher in Group 2 than in Group 1 (72.6 ± 27.8 vs. 62.6 ± 21.6, P = 0.023). The rate of bilateral RLN palsy was less in Group 2 than in Group 1 (7.6% vs. 24.2%, P = 0.042). The mean follow-up period was 38.7 months. Primary recurrence consisted of hematogenous, lymphatic, peritoneal dissemination, pleural dissemination, and locoregional in 15 (11.3%), 20 (15.1%), 3 (2.3%), 4 (3.0%), and 5 patients (3.8%), respectively. The rate of regional lymph node recurrence within the dissection field was only 4.5%. The prognosis of patients with lymph node metastasis was significantly poorer than that of patients without lymph node metastasis. However, the prognosis of the 11 cases that had metastasis only around RLNs was similar to that of node-negative cases. Thirteen patients with pathological remnant tumor (R1 or R2) did not survive longer than 5 years at present. The overall 5-year survival rate of stage I, II, and III disease after curative VATS was 82.2%, 77.0%, and 52.3%, respectively. Expansion of VATS criteria for patients after induction chemotherapy for T4 tumor or thoracoscopic anastomosis did not adversely affect the surgical results by experience. Although the VATS procedure is accompanied by a certain degree of morbidity including RLN palsy and pulmonary complications, VATS has an excellent locoregional control effect. In addition, the favorable survival after VATS shows that the procedure is oncologically feasible.

A preliminary experience with minimally invasive Ivor Lewis esophagectomy

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

Extensive mediastinal lymphadenectomy during minimally invasive esophagectomy: optimal results from a single center

INTRODUCTION

Recent advances in thoracoscopic surgery have made it possible to perform esophagectomy with conventional lymphadenectomy (paraesophageal and subcarinal lymph node dissection) using minimally invasive techniques. However, minimally invasive esophagectomy (MIE) combined with extensive lymphadenectomy along the recurrent laryngeal nerves (RLN) has remained technically challenging for thoracic surgeons. The aim of this study was to examine the safety and efficacy of extensive lymphadenectomy when compared to conventional lymphadenectomy during MIE.

METHODS

We retrospectively reviewed data from a cohort of 147 consecutive patients who underwent MIE for esophageal cancer (EC) over a 3-year period at our institution. During thoracoscopic esophagectomy, extensive lymphadenectomy along the RLN was performed on 76 patients from June 2009 to December 2010 (group A), while 71 patients underwent conventional lymphadenectomy from June 2008 to May 2009 (group B) and were enrolled as historical controls. Clinical characteristics including patient demographics, operation features, and the rate and type of complications were recorded for both groups. The number of dissected lymph nodes and the number of patients with nodes positive for cancer on histological examination were determined for both groups. Statistical analysis was used to identify differences between the two groups.

RESULTS

All patients underwent thoracoscopic esophagectomy without conversion to open thoracotomy. Patient demographics and operation features were similar between the two groups. Of the 76 patients that underwent extensive lymphadenectomy there were 13 patients (17.11%) who were RLN positive, which resulted in upstaging of TNM in 5 patients (6.58%). The overall incidence of postoperative complications (42.10% versus 39.47%, p = 0.742) and permanent recurrent laryngeal nerve palsy (1.32% versus 0%, p = 0.517) was similar between the two groups.

CONCLUSIONS

Extensive mediastinal lymphadenectomy during minimally invasive esophagectomy is a feasible procedure for EC patients. It is technically safe and oncologically adequate in experienced hands, and improves the accuracy of tumor staging. Further study is required to discuss its long-term prognostic value for esophagus cancer patients.