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Fang P, Zhou J, Liu Y, Liang Z, Yang Y, Luan S, Xiao X, Li X, Zhang H, Shang Q, Chen L, Zeng X, Yuan Y. Substitute or coexistence? Mediastinoscopy-assisted versus thoracoscope-assisted esophagectomy in esophageal cancer: a meta-analysis of perioperative outcomes and long-term survival. Int J Surg 2024; 110:5802-5817. [PMID: 38869981 PMCID: PMC11392080 DOI: 10.1097/js9.0000000000001777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Accepted: 05/29/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND Currently, mediastinoscopy-assisted esophagectomy (MAE) and thoracoscope-assisted esophagectomy (TAE) represent two prevalent forms of minimally invasive esophagectomy extensively employed in the management of esophageal cancer (EC). The aim of this meta-analysis is to assess and compare these two surgical approaches concerning perioperative outcomes and long-term survival, offering valuable insights for refining surgical strategies and enhancing patient outcomes in this field. METHODS Adhering to PRISMA guidelines, the authors systematically searched PubMed, Web of Science, Cochrane Library, Embase, and CNKI databases until 1 March 2024, for studies comparing MAE and TAE. Outcomes of interest included perioperative outcomes (intraoperative outcomes, postoperative recovery, postoperative complications) and survival rates. Statistical analyses were performed using RevMan 5.4, with heterogeneity dictating the use of fixed or random-effects models. RESULTS A total of 21 relevant studies were finally included. MAE was associated with significantly shorter operation times [mean difference (MD)=-59.58 min, 95% CI: -82.90 to -36.26] and less intraoperative blood loss (MD=-68.34 ml, 95% CI: -130.45 to -6.23). However, MAE resulted in fewer lymph nodes being dissected (MD=-3.50, 95% CI: -6.23 to -0.78). Postoperative recovery was enhanced following MAE, as evidenced by reduced hospital stays and tube times. MAE significantly reduced pulmonary complications [odds ratio (OR)=0.59, 95% CI: 0.44, 0.81] but increased the incidence of recurrent laryngeal nerve injury (OR=1.84, 95% CI: 1.30, 2.60). No significant differences were observed in anastomotic leakage, chylothorax, cardiac complications, wound infections, and gastric retention between MAE and TAE. The long-term survival outcomes showed no statistical difference [hazard ratio (HR)=1.05, 95% CI: 0.71, 1.54]. CONCLUSIONS MAE offers advantages in reducing operation time, blood loss, and specific postoperative complications, particularly pulmonary complications, with a shorter recovery period compared to TAE. However, it poses a higher risk of recurrent laryngeal nerve injury and results in fewer lymph nodes being dissected. No difference in long-term survival was observed, indicating that both techniques have distinct benefits and limitations. These findings underscore the need for personalized surgical approaches in EC treatment, considering individual patient characteristics and tumor specifics.
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Affiliation(s)
- Pinhao Fang
- Department of Thoracic Surgery, Med+X Center for Informatics, West China Hospital, Sichuan University
| | - Jianfeng Zhou
- Department of Thoracic Surgery, Med+X Center for Informatics, West China Hospital, Sichuan University
| | - Yixin Liu
- Department of Thoracic Surgery, Med+X Center for Informatics, West China Hospital, Sichuan University
| | - Zhiwen Liang
- Department of Thoracic Surgery, Med+X Center for Informatics, West China Hospital, Sichuan University
| | - Yushang Yang
- Department of Thoracic Surgery, Med+X Center for Informatics, West China Hospital, Sichuan University
| | - Siyuan Luan
- Department of Thoracic Surgery, Med+X Center for Informatics, West China Hospital, Sichuan University
| | - Xin Xiao
- Department of Thoracic Surgery, Med+X Center for Informatics, West China Hospital, Sichuan University
| | - Xiaokun Li
- Department of Thoracic Surgery, Med+X Center for Informatics, West China Hospital, Sichuan University
| | - Hanlu Zhang
- Department of Thoracic Surgery, Med+X Center for Informatics, West China Hospital, Sichuan University
| | - Qixin Shang
- Department of Thoracic Surgery, Med+X Center for Informatics, West China Hospital, Sichuan University
| | - Longqi Chen
- Department of Thoracic Surgery, Med+X Center for Informatics, West China Hospital, Sichuan University
| | - Xiaoxi Zeng
- West China Biomedical Big Data Center, Med+X Center for Informatics, West China Hospital, Sichuan University, Chengdu, China
| | - Yong Yuan
- Department of Thoracic Surgery, Med+X Center for Informatics, West China Hospital, Sichuan University
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Masuda Y, Leong EKF, So JBY, Shabbir A, Lam Jia Wei T, Chia DKA, Kim G. A systematic review and meta-analysis of mediastinoscopy-assisted transhiatal esophagectomy (MATHE). Surg Oncol 2024; 53:102042. [PMID: 38330804 DOI: 10.1016/j.suronc.2024.102042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 01/23/2024] [Accepted: 01/31/2024] [Indexed: 02/10/2024]
Abstract
BACKGROUND Transhiatal esophagectomy (THE) avoids thoracotomy but sacrifices mediastinal lymphadenectomy. Mediastinoscopy-assisted transhiatal esophagectomy (MATHE) allows for visualisation and en-bloc dissection of mediastinal lymph nodes while retaining the benefits of THE. However, given its novel inception, there is a paucity of literature. This study aimed to conduct the first meta-analysis to explore the efficacy of MATHE and clarify its role in the future of esophagectomy. METHODS Four databases (PubMed, EMBASE, Scopus, and Cochrane Library) were searched from inception to May 1, 2023. Studies were included if they reported outcomes for patients with esophageal cancer who underwent MATHE. Meta-analyses of proportions and pooled means were performed for the outcomes of intraoperative blood loss, lymph node (LN) harvest, mean hospital length of stay (LOS), mean operative time, R0 resection, conversion rates, 30-day mortality rate, 5-year OS, and surgical complications (anastomotic leak, cardiovascular [CVS] and pulmonary complications, chyle leak and recurrent laryngeal nerve palsy [RLN]). Sensitivity analyses were performed for outcomes with substantial statistical heterogeneity. RESULTS The search yielded 223 articles; 28 studies and 1128 patients were included in our analysis. Meta-analyses of proportions yielded proportion rates: 30-day mortality (0 %, 95 %CI 0-0), 5-year OS (60.5 %, 95 %CI 47.6-72.7), R0 resection (100 %, 95 %CI 99.3-100), conversion rate (0.1 %, 95 %CI 0-1.2). Among surgical complications, RLN palsy (14.6 %, 95 %CI 9.5-20.4) were most observed, followed by pulmonary complications (11.3 %, 95 %CI 7-16.2), anastomotic leak (9.7 %, 95 %CI 6.8-12.8), CVS complications (2.3 %, 95 %CI 0.9-4.1) and chyle leak (0.02 %, 95 %CI 0-0.8). Meta-analysis of pooled means yielded means: LN harvest (18.6, 95 %CI 14.3-22.9), intraoperative blood loss (247.1 ml, 95 %CI 173.6-320.6), hospital LOS (18.1 days, 95 %CI 14.4-21.8), and operative time (301.5 min, 95 %CI 238.4-364.6). There was moderate-to-high statistical heterogeneity. Findings were robust to sensitivity analyses. CONCLUSION MATHE is associated with encouraging post-operative mortality and complication rates, while allowing for radical mediastinal lymphadenectomy with reasonable lymph node harvest.
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Affiliation(s)
- Yoshio Masuda
- Ministry of Health Holdings Singapore, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Jimmy Bok Yan So
- Upper Gastrointestinal Surgery, National University Hospital, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Asim Shabbir
- Upper Gastrointestinal Surgery, National University Hospital, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Daryl Kai Ann Chia
- Upper Gastrointestinal Surgery, National University Hospital, Singapore.
| | - Guowei Kim
- Upper Gastrointestinal Surgery, National University Hospital, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Yuan P, Hu W, Liu Z, Wu N, Lin H, Li S, Hu Y. Left-primary & right-auxiliary operation mode in mediastinoscope-assisted radical esophagectomy. Surg Endosc 2023; 37:7884-7892. [PMID: 37644153 DOI: 10.1007/s00464-023-10341-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 07/30/2023] [Indexed: 08/31/2023]
Abstract
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.
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Affiliation(s)
- Peisong Yuan
- Department of Thoracic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, China
| | - Weipeng Hu
- Department of Thoracic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, China
| | - Zheng Liu
- Department of Thoracic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, China
| | - Na Wu
- Department of Thoracic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, China
| | - Haonan Lin
- Department of Thoracic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, China
| | - Shiyu Li
- Department of Surgical Division I, Traditional Chinese Medicine Hospital of Wusheng County, Guangan, 638400, China
| | - Yang Hu
- Department of Thoracic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, China.
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Zhang Z, He H, Lu S, Yang M, Luo J. Safety and Feasibility of Mediastinoscopy-assisted Esophagectomy: A Meta-analysis. Surg Laparosc Endosc Percutan Tech 2023; 33:420-427. [PMID: 37505923 DOI: 10.1097/sle.0000000000001182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 01/31/2023] [Indexed: 07/30/2023]
Abstract
BACKGROUND The objective of the current study was to investigate the safety and feasibility of mediastinoscopy-assisted esophagectomy (MAE). METHODS A meta-analysis was conducted between MAE and traditional transthoracic esophagectomy (TTE). For a comparative analysis of MAE and TTE, we searched PubMed, the Cochrane Library, Embase, and Web of Science databases. We identified the relevant literature and extracted the relevant data. Finally, RevMan 5.3 software was applied to conduct a meta-analysis of the data. RESULTS A total of 1256 people were enrolled in 16 studies, comprising 575 patients with MAE and 681 with TTE. The findings revealed that the pulmonary complications, cardiac complications, and postoperative hospital stay in the MAE group were significantly better than those in the TTE group. No significant differences were found between the 2 groups in postoperative chylothorax, anastomotic fistula, and postoperative mortality. But the incidence of recurrent laryngeal nerve injury in the MAE group was higher than that in the TTE group (odds ratio=1.64, 95% CI, 1.15 to 2.35, P =0.006). The MAE group had less lymph node dissection than the TTE group (mean difference=-4.62, 95% CI, -5.97 to 3.45, P <0.00001). CONCLUSIONS This meta-analysis presented that MAE was safe and feasible, reduced postoperative pulmonary and cardiac complications, and shortened hospital stay, but lymph node dissection was less, recurrent laryngeal nerve injury was higher, and the impact of long-term survival prognosis required more randomized controlled trials.
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Affiliation(s)
- Zhan Zhang
- Department of Thoracic Surgery, 989th Hospital of PLA, Luoyang, China
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Dabsha A, Elkharbotly IAMH, Yaghmour M, Badr A, Badie F, Khairallah S, Esmail YM, Shmushkevich S, Hossny M, Rizk A, Ishak A, Wright J, Mohamed A, Rahouma M. Novel Mediastinoscope-Assisted Minimally Invasive Esophagectomy for Esophageal Cancer: A Systematic Review and Meta-analysis. Ann Surg Oncol 2023; 30:4030-4039. [PMID: 36820939 DOI: 10.1245/s10434-023-13264-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 02/01/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND Minimally invasive surgery is an expanding field of surgery that has replaced many open surgical techniques. Surgery remains a cornerstone in the treatment of esophageal cancer, yet it is still associated with significant morbidity and technical difficulties. Mediastinoscope-assisted esophagectomy is a promising technique that aims to decrease the surgical burden and enhance recovery. METHODS PubMed, MEDLINE, and EMBASE databases were searched for publications on mediastinoscope-assisted esophagectomies for esophageal cancer. The primary endpoint was a postoperative anastomotic leak, while secondary endpoints were assessment of harvested lymph nodes (LNs), blood loss, chyle leak, hospital length of stay (LOS), operative (OR) time, pneumonia, wound infection, mortality, and microscopic positive margin (R1). The pooled event rate (PER) and pooled mean were calculated for binary and continuous outcomes respectively. RESULTS Twenty-six out of the 2274 searched studies were included. The pooled event rate (PER) for anastomotic leak was 0.145 (0.1144; 0.1828). The PERs for chyle leak, recurrent laryngeal nerve injury/hoarseness, postoperative pneumonia, wound infection, early mortality, postoperative morbidity, and microscopically positive (R1) resection margins were 0.027, 0.185, 0.09, 0.083, 0.020, 0.378, and 0.037 respectively. The pooled means for blood loss, hospital stay, operative time, number of total harvested LNs, and number of harvested thoracic LNs were 159.209, 15.187, 311.116, 23.379, and 15.458 respectively. CONCLUSIONS Mediastinoscopic esophagectomy is a promising minimally invasive technique, avoiding thoracotomy, patient repositioning, and lung manipulation; thus allowing for shorter surgery, decreased blood loss, and decreased postoperative morbidity. It can also be reliable in terms of oncological safety and LN dissection.
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Affiliation(s)
- Anas Dabsha
- Cardiothoracic Surgery Department, Weill Cornell Medicine, New York, NY, USA
- Surgical Oncology Department, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Ismail A M H Elkharbotly
- Surgical Oncology Department, National Cancer Institute, Cairo University, Cairo, Egypt
- General Surgery Department, Newham University Hospital, London, UK
| | - Mohammad Yaghmour
- Cardiothoracic Surgery Department, Weill Cornell Medicine, New York, NY, USA
| | - Amr Badr
- El Ruwaisat Family Medical Center, Sharm Elsheikh, Egypt
| | - Fady Badie
- General Surgery Department, Kasr Al-ainy School of Medicine, Cairo University, Cairo, Egypt
| | - Sherif Khairallah
- Cardiothoracic Surgery Department, Weill Cornell Medicine, New York, NY, USA
- Surgical Oncology Department, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Yomna M Esmail
- Cardiothoracic Surgery Department, Weill Cornell Medicine, New York, NY, USA
| | - Shon Shmushkevich
- Cardiothoracic Surgery Department, Weill Cornell Medicine, New York, NY, USA
| | - Mohamed Hossny
- Cardiothoracic Surgery Department, Weill Cornell Medicine, New York, NY, USA
| | - Amr Rizk
- Cardiothoracic Surgery Department, Weill Cornell Medicine, New York, NY, USA
- Surgical Oncology Department, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Amgad Ishak
- Cardiothoracic Surgery Department, Weill Cornell Medicine, New York, NY, USA
| | - Jessica Wright
- Cardiothoracic Surgery Department, Weill Cornell Medicine, New York, NY, USA
| | - Abdelrahman Mohamed
- Surgical Oncology Department, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Mohamed Rahouma
- Cardiothoracic Surgery Department, Weill Cornell Medicine, New York, NY, USA.
- Surgical Oncology Department, National Cancer Institute, Cairo University, Cairo, Egypt.
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Gong S, Rao X, Yuan Y, Yao X, Li G, Wang N, Li D, Jiang L. Clinical-pathological features and perioperative outcomes of mediastinoscopy vs. thoracoscopy esophagectomy in esophageal cancer: A meta-analysis. Front Surg 2023; 10:1039615. [PMID: 36865627 PMCID: PMC9971490 DOI: 10.3389/fsurg.2023.1039615] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 01/10/2023] [Indexed: 02/16/2023] Open
Abstract
Objective To compare the clinicopathological features and perioperative outcomes of video-assisted mediastinoscopy esophagectomy (VAME) compared to video-assisted thoracoscopy esophagectomy (VATE) in esophageal cancer. Methods We comprehensively searched online databases (PubMed, Embase, Web of Science and Wiley online library) to find available studies exploring the clinicopathological features and perioperative outcomes between VAME and VATE in esophageal cancer. Relative risk (RR) with 95% confidence interval (CI) and standardized mean difference (SMD) with 95% CI were used to evaluate the perioperative outcomes and clinicopathological features. Results A total of seven observational studies and one randomized controlled trial involving 733 patients were considered eligible for this meta-analysis, of which 350 patients underwent VAME in contrast to 383 patients underwent VATE. Patients in the VAME group had more pulmonary comorbidities (RR = 2.18, 95% CI 1.37-3.46, P = 0.001). The pooled results showed that VAME shortened the operation time (SMD = -1.53, 95% CI -2.308--0.76, P = 0.000), and retrieved less total lymph nodes (SMD = -0.70, 95% CI -0.90--0.50, P = 0.000). No differences were observed in other clinicopathological features, postoperative complications or mortality. Conclusions This meta-analysis revealed that patients in the VAME group had more pulmonary disease before surgery. The VAME approach significantly shortened the operation time and retrieved less total lymph nodes and did not increase intra- or postoperative complications.
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Affiliation(s)
- Sheng Gong
- Department of Thoracic Surgery, The Public Health Clinical Center of Chengdu, Chengdu, China
| | - Xin Rao
- Department of Thoracic Surgery, The Public Health Clinical Center of Chengdu, Chengdu, China
| | - Ye Yuan
- Department of Thoracic Surgery, The Public Health Clinical Center of Chengdu, Chengdu, China
| | - Xiaojun Yao
- Department of Thoracic Surgery, The Public Health Clinical Center of Chengdu, Chengdu, China
| | - Gang Li
- Department of Thoracic Surgery, The Public Health Clinical Center of Chengdu, Chengdu, China
| | - Ning Wang
- Department of Public Health, Chengdu Medicine College, Chengdu, China
| | - Dan Li
- Department of Thoracic Surgery, The Public Health Clinical Center of Chengdu, Chengdu, China
| | - Liangshuang Jiang
- Department of Thoracic Surgery, The Public Health Clinical Center of Chengdu, Chengdu, China,Correspondence: Liangshuang Jiang
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