Esophagectomy from then to now

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.

Chest vs. neck anastomotic leak post esophagectomy for malignancy: rate, predictors, and outcomes

BACKGROUND

Anastomotic leak is a major contributor to comorbidity and mortality following esophagectomy. We sought to assess rate and predictors of leak after esophagectomy and compare outcomes of chest versus neck anastomotic leaks.

METHODS

A retrospective review was performed utilizing National-Surgical-Quality-Improvement-Program data from 2016-2019 for patients undergoing esophagectomy for malignancy. Preoperative characteristics and postoperative outcomes were compared. Patients were classified into two groups: Ivor Lewis esophagectomy [ILE, chest leak (CL)] and transhiatal esophagectomy (THE)/McKeown esophagectomy [ME, neck leak (NL)]. Multivariable regression models were constructed to determine predictors of each type of leak and postoperative complications.

RESULTS

A total of 1,665 patients underwent esophagectomy with 14.1% reported post-operative leak, 61% of patients underwent ILE while 39% underwent THE or ME. Of patients who underwent ILE, 13.8% had CL with complications including significantly higher length of stay and mortality compared to patients without leak. Independent predictors of CL included: diabetes, hypertension, advanced disease stage, chronic steroid use, and operative time. Ninety-five patients (14.6%) who underwent either THE or ME had NL with similar complications. Diabetes, pre-operative white blood cell (WBC), and operative time were independent predictors for NL. On multivariable regression, CL was associated with greater odds of requiring intervention compared with NL.

CONCLUSIONS

Post-esophagectomy CL and NL are associated with higher morbidity and mortality. Diabetes and operative time were independent predictors for both leaks while steroid use, hypertension, and advanced disease stage predicted CL. CL was associated with greater odds of needing an intervention, but contrary to conventional wisdom, was not associated with higher morbidity or mortality.

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Two-lung ventilation in video-assisted thoracoscopic esophagectomy in prone position: A systematic review

Esophageal cancer surgery is still carrying a high risk of morbidity and mortality. That is why some anesthesia strategies have tried to reduce those postoperative complications. In this systematic review performed in accordance with the PRISMA-S guidelines (PROSPERO (ID: CRD42022310385)), we aimed to investigate the safety and advantages of two-lung ventilation (TLV) over one-lung ventilation (OLV) in minimally invasive esophagectomy (MIE) in the prone position. Seven trials, with a total number of 1710 patients (765 patients with TLV versus 945 patients with OLV) were included. Postoperative mortality and morbidity rates were similar between TLV and OLV when realised for esophagectomy. Interestingly, we observed no difference in changes in intraoperative respiratory parameters, operative duration, thoraco-conversion rate, number of harvested lymph nodes, postoperative heart rate and respiratory rate between TLV and OLV. TLV brings better results in terms of intraoperative oxygen arterial pressure (PaO₂) during the thoracic time, postoperative oxygenation, PaO2 on inspired fraction of oxygen (FiO₂) ratio, duration of thoracic surgery, preoperative time, blood loss, temperature on postoperative day-1, and C-reactive protein dosage. Our study highlighted the safety of TLV for MIE in prone position when compared to OLV. Interestingly, we found better intra and postoperative ventilation parameters. The choice of ventilation modality did not influence clinical outcome after surgery and the quality of oncological resection. Large randomised controlled trials are needed to confirm these results.

The Role of Prehabilitation in Modern Esophagogastric Cancer Surgery: A Comprehensive Review

Simple Summary

Surgery is the only potentially curative treatment option for esophagogastric cancer. Although esophagectomy/gastrectomy remains associated with major surgical trauma and significant morbidity. Prehabilitation has emerged as a novel strategy to improve postoperative outcomes by preparing patients for a surgery-associated physiological challenge. We discuss current knowledge and the results of studies on the role of prehabilitation in esophagogastric cancer surgery.

Abstract

Esophagogastric cancer is among the most common malignancies worldwide. Surgery with or without neoadjuvant therapy is the only potentially curative treatment option. Although esophagogastric resections remain associated with major surgical trauma and significant postoperative morbidity. Prehabilitation has emerged as a novel strategy to improve clinical outcomes by optimizing physical and psychological status before major surgery through exercise and nutritional and psychological interventions. Current prehabilitation programs may be unimodal, including only one intervention, or multimodal, combining the benefits of different types of interventions. However, it still is an investigational treatment option mostly limited to clinical trials. In this comprehensive review, we summarize the current evidence for the role of prehabilitation in modern esophagogastric cancer surgery. The available studies are very heterogeneous in design, type of interventions, and measured outcomes. Yet, all of them confirm at least some positive effects of prehabilitation in terms of improved physical performance, nutritional status, quality of life, or even reduced postoperative morbidity. However, the optimal interventions for prehabilitation remain unclear; thus, they cannot be standardized and widely adopted. Future studies on multimodal prehabilitation are necessary to develop optimal programs for patients with esophagogastric cancer.

Peri-operative approach to esophagectomy: a narrative review from the anesthesiological standpoint

Objective

This review summarizes the peri-operative anesthesiological approaches to esophagectomy considering the best up-to-date, evidence-based medicine, discussed from the anesthesiologist’s standpoint.

Background

Esophagectomy is the only curative therapy for esophageal cancer. Despite the many advancements made in the surgical treatment of this tumour, esophagectomy still carries a morbidity rate reaching 60%. Patients undergoing esophagectomy should be referred to high volume centres where they can receive a multidisciplinary approach to treatment, associated with better outcomes. The anesthesiologist is the key figure who should guide the peri-operative phase, from diagnosis through to post-surgery rehabilitation. We performed an updated narrative review devoted to the study of anesthesia management for esophagectomy in cancer patients.

Methods

We searched MEDLINE, Scopus and Google Scholar databases from inception to May 2021. We used the following terms: “esophagectomy”, “esophagectomy AND pre-operative evaluation”, “esophagectomy AND protective lung ventilation”, “esophagectomy AND hemodynamic monitoring” and “esophagectomy AND analgesia”. We considered only articles with abstract written in English and available to the reader. We excluded single case-reports.

Conclusions

Pre-operative anesthesiological evaluation is mandatory in order to stratify and optimize any medical condition. During surgery, protective ventilation and judicious fluid management are the cornerstones of intraoperative “protective anesthesia”. Post-operative care should be provided by an intensive care unit or high-dependency unit depending on the patient’s condition, the type of surgery endured and the availability of local resources. The provision of adequate post-operative analgesia favours early mobilization and rapid recovery. Anesthesiologist has an important role during the peri-operative care for esophagectomy. However, there are still some topics that need to be further studied to improve the outcome of these patients.

Self-expanding Metal Stents for Anastomotic Leaks After Upper Gastrointestinal Cancer Surgery

BACKGROUND

Anastomotic leakage (AL) is a common and severe complication after upper gastrointestinal (UGI) surgery. Although evidence is scarce, endoscopic deployed self-expanding metal stents (SEMS) are well-established for the management of AL in UGI surgery. The present study aimed to evaluate the feasibility, effectiveness, and safety of SEMS in terms of success, mortality, and morbidity in patients with AL after UGI cancer surgery.

MATERIALS AND METHODS

Patients with AL after primary UGI cancer surgery were retrospectively analyzed with regard to demographics, disease, surgical and endoscopic procedures, and complications. Stent treatment success was divided into technical, primary (within 72 hours of stent deployment), sustained (after 72 hours of stent deployment), and sealing success.

RESULTS

In a total of 63 patients, 74 stents were used and 11 were deployed in endoscopic reinterventions. Stent deployment was successful in all patients. Primary and sustained success rates were 68.3% (n = 43) and 65.1% (n = 41), respectively. Of the primarily successfully treated patients, 87.8% remained successfully treated. If primary treatment was unsuccessful, it remained unsuccessful in 66.6% of the patients (P = 0.002). Final sealing of the leakage was observed in 65.1% of patients (n = 41). Longer stent shafts and wider stent end widths were correlated with successful stent treatment (P < 0.05).

CONCLUSION

SEMS are a safe and sufficient tool in the treatment of AL after UGI cancer surgery. Treatment success is improved with longer stent shafts and wider stent end widths. Switching to alternative treatments is strongly suggested if signs of persistent leakage are present beyond 72 hours after stent placement, as this is highly indicative of sustained stent failure.

Postoperative complications after minimally invasive esophagectomy in the prone position: any anesthesia-related factor?

OBJECTIVE

To evaluate the incidence of postoperative complications arising within 30 days of minimally invasive esophagectomy in the prone position with total lung ventilation and their relationship with 30-day and 1-year mortality. Secondary outcomes included possible anesthesia-related factors linked to the development of complications.

METHODS

The study is a retrospective single-center observational study at the Anesthesia and Surgical Department of a tertiary care center in the northeast of Italy. Patients underwent cancer resection through esophagectomy in the prone position without one-lung ventilation.

RESULTS

We included 110 patients from January 2010 to December 2017. A total of 54% of patients developed postoperative complications that increased mortality risk at 1 year of follow-up. Complications postponed first oral intake and delayed patient discharge to home. Positive intraoperative fluid balance was related to increased mortality and the risk to develop postoperative complications. C-reactive protein at third postoperative day may help detect complication onset.

CONCLUSIONS

Complication onset has a great impact on mortality after esophagectomy. Some anesthesia-related factors, mainly fluid balance, may be associated with postoperative mortality and morbidity. These factors should be carefully taken into account to obtain better outcomes after esophagectomy in the prone position without one-lung ventilation.

Giant hiatus hernia presenting as a chronic cough masking a sinister diagnosis

We present a case of an 82-year-old gentleman with an 18-month history of productive cough. Urgent CT scan of the thorax revealed type 1 hiatus hernia (HH). The patient was managed conservatively with lifestyle modifications to help his reflux symptomology. The patient subsequently presented with acute shortness of breath and vomiting. Repeat CT scan reported a giant incarcerated HH (15 cm). Endoscopy revealed an incidental finding of a 3 cm polypoid lesion in the oesophagus at the level of the carina and histology of biopsies reported an invasive adenocarcinoma. During admission, the patient unfortunately had a hospital acquired infection and cardiac complications which prevented surgical intervention. Patients with suspected HH should be investigated thoroughly with imaging studies including chest X-ray, CT or MRI alongside oesophageal manometry and gastroscopy. Endoscopic evaluation is particularly important as these patients are at higher risk of Barrett's oesophagus and invasive malignancy.

Prognostic value of inflammatory markers for detecting anastomotic leakage after esophageal resection

BACKGROUND

Early diagnosis of anastomotic leakage (AL) after esophageal resection is crucial for the successful management of this complication. Inflammatory serological markers are indicators of complications during the postoperative course. The aim of the present study was to evaluate the prognostic value of routine inflammatory markers to predict anastomotic leakage after transthoracic esophageal resection.

METHODS

Data from all consecutive patients undergoing transthoracic esophageal resection between January 2010 and December 2016 were analyzed from a prospective database. Besides clinicodemographic parameters, C-reactive protein, white blood cell count and albumin were analyzed and the Noble/Underwood (NUn) score was calculated to evaluate their predictive value for postoperative anastomotic leakage. Diagnostic accuracy was measured by sensitivity, specificity, and negative and positive predictive values using area under the receiver operator characteristics curve.

RESULTS

Overall, 233 patients with transthoracic esophageal resection were analyzed, 30-day mortality in this group was 3.4%. 57 patients (24.5%) suffered from AL, 176 patients were in the AL negative group. We found significant differences in WBCC, CRP and NUn scores between patients with and without AL, but the analyzed markers did not show an independent relevant prognostic value. For CRP levels below 155 mg/dl from POD3 to POD 7 the negative predictive value for absence of AI was > 80%. Highest diagnostic accuracy was detected for CRP levels on 4^th POD with a cut-off value of 145 mg/l reaching negative predictive value of 87%.

CONCLUSIONS

In contrast to their prognostic value in other surgical procedures, CRP, WBCC and NUn score cannot be recommended as independent markers for the prediction of anastomotic leakage after transthoracic esophageal resection. CRP is an accurate negative predictive marker and discrimination of AL and no-AL may be helpful for postoperative clinical management. Trial registration The study was approved by the local ethical committee (S635-2013).

Prognostic risk factors for respiratory failure after esophagectomy

Background

Esophagectomy is a high-risk surgical procedure with significant postoperative morbidity and mortality. Respiratory failure is one of the most common complications after esophageal cancer surgery. The purpose of this study was to explore risk factors that affect the recovery of respiratory failure in this kind of patients.

Methods

Totally 2,360 patients underwent esophagectomies with cervical anastomosis or intrathoracic anastomosis in our center from January 2012 to December 2017. Among them, 130 patients with respiratory failure requiring mechanical ventilation were included in the study. The Spearman’s rank correlation test and Mann-Whitney U test were performed to identify the influential factors for the duration of mechanical ventilation.

Results

Most patients (81.5%) in this study recovered in the first two weeks of mechanical ventilation, the average duration of mechanical ventilation was 10.1 days. Statistical analysis indicated that lung function test parameters such as FEV₁/FVC ratio and RV/TLC ratio could have significant influence on the duration of mechanical ventilation. The abnormally increased FEV₁/FVC ratio and RV/TLC ratio could obviously prolong the ventilation duration. Old age, thrombocytopenia, the elevated creatinine, C-reactive protein (CRP) and lactate could also significantly lengthen the duration of mechanical ventilation.

Conclusions

Abnormally increased FEV₁/FVC ratio and RV/TLC ratio as well as old age, thrombocytopenia, elevated creatinine, CRP and blood lactate were found to be risk factors for the recovery of patients with respiratory failure after esophagectomies.

Predicting Successful Laparoendoscopic Transhiatal Esophagectomy (THE) by Mediastinal Height Measurement

BACKGROUND

Laparoendoscopic transhiatal esophagectomy (THE) provides advantages over traditional THE by not only avoiding laparotomy but by also allowing more precise esophageal mobilization. Occasionally, the length of the gastric conduit is insufficient to allow delivery into the neck after laparoscopic mobilization and requires laparotomy to complete the procedure. We hypothesize that the need for laparotomy will correlate with the measurement of mediastinal height (distance from thoracic vertebrae T1-T12) on chest CT.

METHODS

Medical records of all patients who underwent attempted laparoendoscopic-assisted THE at a tertiary referral center between March 1, 2003 and January 31, 2019 were reviewed. Patients' mediastinal height was measured using computed tomography (CT) imaging of the chest by investigators and analyzed for correlation between mediastinal height and successful completion of a totally laparoendoscopic procedure.

RESULTS

A total of 21 cases met inclusion criteria: 9 successful laparoendoscopic THE procedures and 12 failed laparoendoscopic THE procedures (those requiring addition of a mini-laparotomy or thoracotomy). The mean mediastinal length for successful laparoendoscopic surgery was 23.5 cm, whereas the mean mediastinal length for failed laparoscopic surgeries was 24.8 cm (P = .03). Patient's overall height was not found to correlate with the need for conversion.

CONCLUSIONS

Shorter mediastinal length is associated with successful laparoendoscopic or laparoscopic THE. This information is readily available to clinicians from routine preoperative staging studies (chest CT) and may be used to potentially predict the success rate of a totally laparoendoscopic approach and aid in patient selection. Further prospective evaluation of these findings is warranted.

Comparison of the short-term outcomes of robot-assisted minimally invasive, video-assisted minimally invasive, and open esophagectomy

Background

The development of minimally invasive surgery has initiated many changes in the surgical treatment of esophageal cancer (EC) patients. The aim of this study was to compare the short-term outcomes of robotic-assisted minimally invasive esophagectomy (RAMIE), video-assisted minimally invasive esophagectomy (VAMIE), and open esophagectomy (OE).

Methods

Our study included patients who had undergone McKeown esophagectomy at Tianjin Medical University Cancer Institute and Hospital between January 2016 and December 2018. We analyzed clinical baseline data, as well as perioperative and pathological outcomes.

Results

A total of 312 cases met the inclusion criteria (OE: 77, VAMIE: 144, RAMIE: 91). The OE group had a greater number of late-stage patients as well as those who received the neo-adjuvant therapy, compared with the other two groups (P=0.001). The procedure time in the OE group was also shorter by approximately 20 minutes (P=0.021). Total blood loss was significantly lower in the two MIE groups (P=0.004) than in the OE group. There were no differences in the total number of dissected lymph nodes between the three groups (OE: 24.09±10.77, VAMIE: 23.07±10.18, RAMIE: 22.84±8.37, P=0.680). Both the lymph node number (P=0.155) and achievement rate (P=0.190) in the right recurrent laryngeal nerve (RLN) area were comparable between the three groups. However, in the left RLN area, minimally invasive approaches resulted in a higher number of harvested lymph nodes (P=0.032) and greater achievement rate (P=0.018). Neither MIE procedure increased the incidence of postoperative complications.

Conclusions

Minimally invasive surgery could guarantee the quality of bilateral RLN lymphadenectomy without increasing postoperative complications, especially in RAMIE patients. The rational choice of different surgical approaches would improve both safety and oncological outcomes for patients.

McKeown or Ivor Lewis minimally invasive esophagectomy: a systematic review and meta-analysis

BACKGROUND

Minimally invasive esophagectomy (MIE) is increasingly accepted in many countries. McKeown esophagectomy and Ivor Lewis esophagectomy are two protocols commonly used for MIE, but which one provides more benefit to the patients remains matter of controversy.

METHODS

All records in PubMed, Embase, Medline, The Cochrane Library, Wanfang Database, China National Knowledge Infrastructure (CNKI) and Chinese VIP Information till May 2019 were systematically retrieved to compare the cohort studies of McKeown esophagectomy and Ivor Lewis esophagectomy. A meta-analysis of the extracted data was performed using the Review Manager 5.3 and Stata 15 software.

RESULTS

The meta-analysis included 23 cohort studies in which a total of 4,933 patients were enrolled. The results revealed that minimally invasive McKeown esophagectomy (MIME) was superior to minimally invasive Ivor Lewis esophagectomy (MILE) in hospital cost, but inferior to it in operating time, length of hospital stay, in-hospital mortality, 30-day mortality, 90-day mortality, anastomotic leakage, anastomotic leakage requiring surgery, anastomotic stenosis, recurrent laryngeal nerve (RLN) injury, chylothorax, pulmonary complications and total complications. There were no statistical differences between MIME and MILE in blood loss, detected number of lymph nodes, blood transfusion rate, R0 resection rate, re-operation rate, drainage duration, length of the stay in intensive care unit (ICU), 1-year mortality, lung infection, cardiac arrhythmia and delayed gastric emptying.

CONCLUSIONS

Except for the cost, MILE is superior to MIME in several aspects, and may represent a better choice for MIE. The results of the present study should be interpreted with caution since the meta-analysis is based on nonrandom cohort studies which may have a selection bias.

Comparison of the therapeutic effects of endoscopic submucosal dissection and minimally invasive esophagectomy for T1 stage esophageal carcinoma

BACKGROUND

In recent years, diagnosis of early squamous cell carcinoma of the esophagus has been increasingly emphasized. The application of endoscopic submucosal dissection (ESD) has enabled safe resection of esophageal lesions. Minimally invasive esophagectomy (MIE) is also safe and feasible for early stages of the cancer. This study aimed to compare the therapeutic effects of early esophageal carcinoma treatment, and find the best predictive factor for the selection of treatment for T1a patients.

METHODS

We performed a retrospective study of early-stage patients admitted to Tianjin Medical University Cancer Institute and Hospital between January 2015 and December 2018. A total of 128 patients underwent MIE, while 78 patients underwent ESD. The depth of the tumor invasion, lymph node metastasis, and complications were compared between the two groups.

RESULTS

In the ESD group, 76.92% of the patients were stage T1a, while 34.38% in the MIE group were stage T1a. The lymph node metastasis rate was 16.41% in the MIE group (6.98% in T1a stage), which related to tumor differentiation, tumor length (≥37.5 mm), depth of invasion, and angiolymphatic invasion. However, the R0 resection rate was only 73.08% in the ESD group. Comprehensive analysis of all T1 patients in the two groups revealed that the positive margin was related to tumor differentiation, tumor width (≥13.5 mm), and depth of invasion (≥3.25 mm).

CONCLUSION

For early-stage cases, lymph node metastasis and positive margins are risk factors affecting long-term survival. Efficient predictive factors mentioned in our study would provide a proper indication for treatment strategy selection.

Risk factors for anastomotic leak after esophagectomy for cancer: A NSQIP procedure-targeted analysis

BACKGROUND

Anastomotic leak is the most common major complication after esophagectomy. We investigated the 2016 American College of Surgeons National Surgical Quality Improvement Program esophagectomy targeted database to identify risk factors for anastomotic leak.

METHODS

Patients who underwent esophagectomy for cancer were included. Patients experiencing an anstomotic leak were identified, and univariate and multivariable logistic regression was performed to identify variables independently associated with anastomotic leak.

RESULTS

Of 915 patients included, 83% were male and the median age was 64 years. Patients with anastomotic leak more frequently had additional complications (87% vs 36%, P < .001). Rates of reoperation (64% vs 11%, P < .001) and mortality (8% vs 2%, P = .001) were higher in patients with anastomotic leak. After adjusting for patient and procedure characteristics, prolonged operative time (for each additional 30-minutes; adjusted odds ratios (AOR) 1.068, 95% CI, 1.022-1.115, P = .003), increased preoperative WBC count (for each 3000/µL increase; AOR 1.323, 95% CI, 1.048-1.670, P = .019), pre-existing diabetes (AOR 1.601, 95% CI, 1.012-2.534, P = .045), and perioperative transfusion (AOR 1.777, 95% CI, 1.064-2.965, P = .028) were independently associated with anastomotic leak.

CONCLUSION

Both patient and procedure-related factors are associated with anastomotic leak. Though frequently non-modifiable, these findings could facilitate risk stratification and early detection of anastomotic leak to reduce associated morbidity.

The procedure of single-port inflatable mediastinoscopy and laparoscopic surgery for radical esophagectomy

It has been described as a new non-transthoracic esophagectomy that the single-port inflatable mediastinoscopy and laparoscopic surgery is safe and effective for the radical esophagectomy of esophageal cancer. This report describes the whole procedure in detail. The patient lies in the supine position with the legs apart. The procedure is performed under general anesthesia with a single lumen endotracheal tube. For upper mediastinal operation, a lateral incision of the clavicle was made about 3 cm; for laparoscopic operation, the incisions of 5 ports for the laparoscopic operation. CO₂ insufflation is performed into the mediastinum with 10 mmHg to make artificial mediastinal emphysema. The Maryland forceps is used to perform separation before dissection. In the non-transthoracic esophagectomy, it is essential to expose the recurrent laryngeal nerve and the azygos vein. The lymph nodes around the esophagus were removed in en bloc. Maintaining double lung ventilation during surgery can significantly reduce carbon dioxide accumulation, especially for those with reduced lung function or severe pleural adhesion. Furthermore, it saves much time that upper mediastinal operation and laparoscopic operation are undergone simultaneously. It is a perfect surgical technique that is worth to promote.