Better perioperative outcomes in thoracoscopic-esophagectomy with two-lung ventilation in semi-prone position

Clinical implementation of minimally invasive esophagectomy

BACKGROUND

Minimally invasive surgery is becoming the method of choice for the resection of esophageal cancer worldwide.

METHODS

Retrospective analysis of prospectively collected clinical data in a tertiary care center with a detailed description of the course of the program.

RESULTS

A total of 136 transthoracic esophageal resections were performed between 2010 and 2023. The study group included 116 operations, 69 of which were fully minimally invasive and 47 hybrid. 80.0% of the study group underwent surgery using a multimodality approach. The median operation time was 431 min (± 103). The R0 resection rate was 100%. Forty-two patients (36.2%) had no postoperative complications. The postoperative Clavien-Dindo > IIIb morbidity was 27%. The postoperative 90-d mortality rate was 1.7%. The average number of lymph nodes removed in the last quarter of cancer patients was 31. The anastomotic insufficiency rate for reoperation was 4% (Ivor-Lewis 4.2%, McKeown 5%).

CONCLUSIONS

With extensive expertise in high-end minimally invasive abdominal and thoracic surgery, implementation of a minimally invasive esophageal resection program with a clinical and oncologic outcome within generally accepted limits is feasible.

Two-lung ventilation with artificial pneumothorax on cerebral desaturation and early postoperative cognitive outcome: a randomized controlled trial

BACKGROUND

The effect of two lung ventilation (TLV) with carbon dioxide artificial pneumothorax on cerebral desaturation and postoperative neurocognitive changes in elderly patients undergoing elective minimally invasive esophagectomy (MIE) is unclear.

OBJECTIVES

The first aim of this study was to compare the effect of TLV and one lung ventilation (OLV) on cerebral desaturation. The second aim was to assess changes in early postoperative cognitive outcomes of two ventilation methods.

METHODS

This prospective, randomized, controlled trial enrolled patients 65 and older scheduled for MIE. Patients were randomly assigned (1:1) to TLV group or OLV group. The primary outcome was the incidence of cerebral desaturation events (CDE). Secondary outcomes were the cumulative area under the curve of desaturation for decreases in regional cerebral oxygen saturation (rSO2) values below 20% relative to the baseline value (AUC.20) and the incidence of delayed neurocognitive recovery.

RESULTS

Fifty-six patients were recruited between November 2019 and August 2020. TLV group had a lower incidence of CDE than OLV group [3 (10.71%) vs. 13 (48.14%), P = 0.002]. TLV group had a lower AUC.20 [0 (0-35.86) % min vs. 0 (0-0) % min, P = 0.007], and the incidence of delayed neurocognitive recovery [2 (7.4%) vs. 11 (40.7%), P = 0.009] than OLV group. Predictors of delayed neurocognitive recovery on postoperative day 7 were age (OR 1.676, 95% CI 1.122 to 2.505, P = 0.006) and AUC.20 (OR 1.059, 95% CI 1.025 to 1.094, P < 0.001).

CONCLUSION

Compared to OLV, TLV had a lower incidence of CDE and delayed neurocognitive recovery in elderly patients undergoing MIE. The method of TLV combined with carbon dioxide artificial pneumothorax may be an option for these elderly patients. Chinese Clinical Trial Registry (identifier: ChiCTR1900027454).

Comparison of early postoperative pulmonary complications between two-lung ventilation with artificial pneumothorax and one-lung ventilation with bronchial blockade in patients undergoing minimally invasive esophagectomy: a retrospective propensity score-matched cohort study

Background

Two-lung ventilation (TLV) with artificial carbon dioxide (CO2) pneumothorax is used during the thoracoscopic phase of minimally invasive esophagectomy (MIE). However, the impact of TLV with artificial pneumothorax on postoperative pulmonary complications (PPCs) after MIE is unclear. This study aimed to compare the incidence of early PPCs between TLV with CO2 pneumothorax and one-lung ventilation (OLV) with bronchial blockade in patients undergoing MIE.

Methods

Five hundred ninety-three patients with esophageal cancer who underwent elective MIE with two-field lymph node dissection were analyzed. Patients in the TLV group were intubated using a single-lumen endotracheal tube and underwent surgery using TLV with artificial CO2 pneumothorax. Patients in the OLV group underwent surgery using OLV with a bronchial blocker. Patient characteristics and intraoperative and PPC data were collected and analyzed. Propensity score matching (PSM) was performed to reduce confounding bias.

Results

The TLV and OLV group comprised 513 and 80 patients, respectively. PSM matched 197 TLV group and 73 OLV group patients. Incidence of pneumonia within the first 3 days of surgery was higher in the TLV group (11.7% vs. 4.1%) but the difference was not significant (P=0.06). The incidence of infiltrates on chest radiography was 36.0% in the TLV group and 28.8% in the OLV group (P=0.26). Incidence of other major PPCs requiring treatment and major non-pulmonary postoperative complications did not significantly differ between the groups. Length of hospital stay was significantly longer in the TLV group (13.0 vs. 11.0 days; P=0.03).

Conclusions

Compared with OLV with bronchial blockade, TLV with CO2 pneumothorax did not reduce the incidence of early PPCs after MIE.

Association of DLT versus SLT with postoperative pneumonia during esophagectomy in China: a retrospective comparison study

BACKGROUND

Double lumen tube (DLT) and single lumen tube (SLT) are two common endotracheal tube (ETT) types in esophageal cancer surgery. Evidence of the relationship between two ETT types and postoperative pneumonia (PP) remains unclear. We aimed to determine the association between two types of ETT (DLT and SLT) and PP and assess the perioperative risk-related parameters that affect PP.

METHODS

This study included 680 patients who underwent esophageal cancer surgery from January 01, 2010 through December 31, 2020. The primary outcome was PP, and the secondary outcome was perioperative risk-related parameters that affect PP. The independent variable was the type of ETT: DLT or SLT. The dependent variable was PP. To determine the relationship between variables and PP, univariate and multivariate analyses were performed. The covariables included baseline demographic characteristics, comorbidity disease, neoadjuvant chemotherapy, tumor location, laboratory parameters, intraoperative related variables.

RESULTS

In all patients, the incidence of postoperative pneumonia in esophagectomy was 32.77% (36.90% in DLT group and 26.38% in SLT group). After adjusting for potential risk factors, we found that using an SLT in esophagectomy was associated with lower risk of postoperative pneumonia compared to using a DLT (Odd ratio = 0.41, 95% confidence interval (CI): 0.22, 0.77, p = 0.0057). Besides DLT, smoking history, combined intravenous and inhalation anesthesia (CIIA) and vasoactive drug use were all significant and independent risk factors for postoperative pneumonia in esophagectomy. These results remained stable and reliable after subgroup analysis.

CONCLUSIONS

During esophagectomy, there is significant association between the type of ETT (DLT or SLT) and PP. Patients who were intubated with a single lumen tube may have a lower rate of postoperative pneumonia than those who were intubated with a double lumen tube. This finding requires verification in follow-up studies.

Minimally invasive laparo-thoracoscopic Ivor-Lewis esophagectomy with semi-mechanical triangular anastomosis: Short-term outcomes of 114 consecutive patients

INTRODUCTION

Several surgical teams have developed so-called minimally invasive esophagectomy techniques with the intention of decreasing post-operative complications. The goal of this report is to determine the feasibility, reproducibility, morbidity and mortality of esophagectomy and intrathoracic anastomosis via thoracoscopy.

METHODS

This retrospective series included 114 consecutive non-selected patients who underwent Lewis Santy type esophagectomy between 2016 and 2020. The procedure was performed via abdominal laparoscopy, thoracoscopy with the patient in a supine position, without selective intubation, with intra-thoracic semi-mechanical triangular esophagogastric anastomosis.

RESULTS

Mean patient age was 62.8years. Conversion from laparoscopy to laparotomy was required in three patients (2.6%); no patient required conversion from thoracoscopy to thoracotomy. A semi-mechanical triangular esophagogastric anastomosis was successfully performed in all patients. Median duration of hospital stay was 16 (8-116) days. Mortality was 2.6%; 34 patients (29.8%) had major complications, 55 (48%) had a respiratory complication. The leakage rate was 12.3%; most were type I. Only 5.2% required an additional procedure. There was no mortality.

CONCLUSION

The analysis of this consecutive series found that this operative technique was reproducible and reliable. These results need to be confirmed by other studies. Pulmonary morbidity was high and remains the main challenge in this type of surgery.

Semiprone thoracoscopic approach during totally minimally invasive Ivor-Lewis esophagectomy seems to be beneficial

Minimally invasive Ivor-Lewis Esophagectomy (MIE) is widely accepted as a surgical treatment of resectable esophageal cancer. Aim of this paper is to describe the surgical details of our standardized MIE technique and its safety. We also evaluate the esophageal mobilization in semiprone compared to the left lateral position. A retrospective analysis of 141 consecutive patients who underwent Ivor-Lewis esophagectomy for cancer, from February 2016 to September 2021, was conducted. All the procedures were performed by totally thoraco-laparoscopic with an intrathoracic end-to-side circular stapled anastomosis. Thoracic phase was performed in left lateral position (LLP-group, n=47) followed by a semiprone position (SP-group, n=94). The intraoperative and postoperative outcomes were prospectively collected and analyzed. The procedure was completed without intraoperative complication in 94.68% of cases in SP-group and in 93.62% of cases in LLP-group (P=0.99). The total operative time and thoracic operative time were significantly shorter in SP-group (P=0.0096; P=0.009). No statistically significant differences were detected in postoperative outcomes between the groups, except for anastomotic strictures (higher in LLP-group, P=0.02) and intensive care unit stay (longer in LLP-group, P=00.1). No reoperation was needed in any cases. Surgical radicality was comparable; the median of harvested lymph nodes was significantly higher in SP-group (P<0.0001). The present semiprone technique of thoraco-laparoscopic Ivor-Lewis esophagectomy is safe and feasible but may also provide some advantages in terms of lymph nodes harvested and total operation time.

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.

Is there a relationship between two different anesthetic methods and postoperative length of stay during radical resection of malignant esophageal tumors in China?: a retrospective cohort study

BACKGROUND

Data providing a relationship between the anesthetic method and postoperative length of stay (PLOS) is limited. We aimed to investigate whether general anesthesia alone or combined with epidural anesthesia might affect perioperative risk factors and PLOS for patients undergoing radical resection of malignant esophageal tumors.

METHODS

The study retrospectively analyzed the clinical data of 680 patients who underwent a radical esophageal malignant tumor resection in a Chinese hospital from January 01, 2010, to December 31, 2020. The primary outcome measure was PLOS, and the secondary outcome was perioperative risk-related parameters that affect PLOS. The independent variable was the type of anesthesia: general anesthesia (GA) or combined epidural-general anesthesia (E-GA). The dependent variable was PLOS. We conducted univariate and multivariate logistic regression and propensity score matching to compare the relationships of GA and E-GA with PLOS and identify the perioperative risk factors for PLOS. In this cohort study, the confounders included sociodemographic data, preoperative chemotherapy, coexisting diseases, laboratory parameters, intraoperative variables, and postoperative complications.

RESULTS

In all patients, the average PLOS was 19.85 ± 12.60 days. There was no significant difference in PLOS between the GA group and the E-GA group either before or after propensity score matching (20.01 days ± 14.90 days vs. 19.79 days ± 11.57 days, P = 0.094, 18.09 ± 9.71 days vs. 19.39 ± 10.75 days, P = 0.145). The significant risk factors for increased PLOS were lung infection (β = 3.35, 95% confidence interval (CI): 1.54-5.52), anastomotic leakage (β = 25.73, 95% CI: 22.11-29.34), and surgical site infection (β = 9.39, 95% CI: 4.10-14.68) by multivariate regression analysis. Subgroup analysis revealed a stronger association between PLOS and vasoactive drug use, blood transfusions, and open esophagectomy. The results remained essentially the same (stable and reliable) after subgroup analysis.

CONCLUSIONS

Although there is no significant association between the type of anesthesia(GA or E-GA) and PLOS for patients undergoing radical esophageal malignant tumor resection, an association between PLOS and lung infection, anastomotic leakage, and surgical site infection was determined by multivariate regression analysis. A larger sample future study design may verify our results.

Minimally invasive esophagectomy in the semi-prone position for corrosive esophagitis: a case report

Treatment strategies for corrosive esophagitis include conservative treatment, such as balloon dilatation at the stenosis site, and surgical treatment. Esophagectomy for corrosive esophagitis is usually performed through the transthoracic or transhiatal approaches. Herein, we report a case of corrosive esophagitis treated with thoracoscopic esophagectomy with the patient in the semi-prone position. The patient was a 48-year-old woman who developed corrosive esophagitis due to accidental ingestion of an alkaline agent. Surgical intervention was required for esophageal stenosis. Therefore, thoracoscopic esophagectomy was performed with the patient in the semi-prone position with bilateral pulmonary ventilation. In our hospital, good operative outcomes have been obtained using thoracoscopic esophagectomy for esophageal cancer with the patient in the semi-prone position with bilateral pulmonary ventilation. This technique is also considered effective for the treatment of corrosive esophagitis.

Double-lumen tube versus bronchial blocker in lymphadenectomy along the left recurrent laryngeal nerve for esophageal cancer: a propensity-matched analysis

BACKGROUND

Lymph node (LN) dissection along left recurrent laryngeal nerve (RLN) is challenging in esophagectomy for esophageal cancer, and double-lumen endotracheal tube (DLT) impedes the exposure of this area. The aim of this study was to determine whether bronchial blockers (BB) could be a better choice for this procedure.

METHODS

The clinical characteristics of patients who received McKeown esophagectomy with radical lymph node dissection in Wuhan Tongji Hospital between August 2017 and July 2019 were retrospectively analyzed. The 1:1 propensity score match analysis was performed to compare the short-term effectiveness, the numbers of lymph nodes dissected, and the patterns of recurrence and survival between the two groups.

RESULTS

A total of 294 patients (192 and 102 in the DLT and BB group, respectively) were enrolled in the study. After matching, 204 patients (102 pairs) who underwent one-lung ventilation with DLT or BB displayed no significant variance in baseline characteristics. The BB group had higher number of LNs resected along left RLN (1.8 ± 2.3 vs. 2.5 ± 2.5, P = 0.001). For patients with metastatic left RLN LN, the BB group had longer medium survival time (15 vs. 32 months, P = 0.045), and tended to have longer medium recurrence-free survival time (6 vs. 15 months, P = 0.079), and lower rate of upper mediastinal and cervical LN recurrence (30.00% vs. 66.67%, P = 0.198). The postoperative complications were similar in both groups.

CONCLUSIONS

Compared with DLT, using BB in esophagectomy may allow more radical lymphadenectomy along left RLN.

Two-lung ventilation or one-lung ventilation for esophagectomy: maybe the more is better from the evidence of meta-analysis

One-lung ventilation (OLV) is the most commonly used ventilation strategy during esophagectomy. However, two-lung ventilation (TLV) with artificial pneumothorax has been applied in recent years during esophagectomy. It is unclear whether TLV takes advantages over OLV for esophagectomy. Here, we conducted a meta-analysis to compare the effects of TLV and OLV for esophagectomy. We searched relevant studies from the Cochrane Central Register of Controlled Trials, Pubmed, and Embase in November 2020. We included studies that compared the effects of TLV with OLV in esophagectomy and provided sufficient perioperative and postoperative data. We extracted data of postoperative outcomes (postoperative pulmonary complications, anastomotic leak, hospital stay) and surgical variables (thoracic phrase time, blood loss, the number of total resected thoracic lymph nodes). We calculated the risk ratio (RR) for dichotomous data and the weighted mean differences (WMDs) for continuous data. Six studies with 1725 patients were included in this meta-analysis. TLV was associated with significantly lower incidence of postoperative pulmonary complications [RR = 0.714; 95% confidence interval (CI) = (0.534, 0.956); P = 0.023], shorter hospital stay [WMD =  - 0.148; 95% CI = (- 0.246, - 0.051); P = 0.003], less blood loss [WMD =  - 0.352; 95% CI = (- 0.528, - 0.176); P < 0.001] and more resected thoracic lymph nodes [WMD = 0.207; 95% CI = (0.003, 0.4120); P = 0.047] than OLV. Moreover, TLV consumed similar time for thoracic phrase [WMD =  - 0.289; 95% CI = (- 0.661, 0.083); P = 0.128], and yielded a comparable rate of anastomotic leak [RR = 1.086; 95% CI = (0.842, 1.400); P = 0.525] compared with OLV. TLV with artificial pneumothorax resulted in less trauma than OLV. TLV with artificial pneumothorax is safe and could be a choice of ventilation strategy for esophagectomy.

Application of Right Bronchial Occlusion under Artificial Pneumothorax in the Thoracic Phase of Minimally Invasive McKeown Esophagectomy

Purpose: To evaluate the feasibility and safety of single-lumen endotracheal intubation combined with right bronchial occlusion (SLET) under artificial pneumothorax in minimally invasive McKeown esophagectomy.

Methods: A total of 165 patients who underwent minimally invasive McKeown esophagectomy at Peking Union Medical College Hospital were retrospectively analyzed. In all, 48 patients received double-lumen endotracheal intubation (DLET group), and 117 patients received SLET-B (SLET-B group). Clinical data, intraoperative hemodynamics, surgical variables, and postoperative complications were analyzed and compared.

Results: Compared with the DLET group, a shorter intubation time and lower tube dislocation rate were found in the SLET-B group. In the thoracic phase, with the application of artificial pneumothorax, patients in the SLET-B group had lower partial pressure of carbon dioxide (PaCO₂) and end-tidal carbon dioxide pressure (PetCO₂) values and higher pH than those in the DLET group. Patients in the SLET-B group had shorter thoracic phase times and hospital stays and less intraoperative hemorrhage than those in the DLET group. The numbers of thoracic and bilateral recurrent laryngeal lymph nodes harvested were significantly higher in the SLET-B group.

Conclusion: SLET under artificial pneumothorax is feasible and safe in minimally invasive McKeown esophagectomy.

Extraluminal Placement of a Bronchial Blocker Compared with Carbon Dioxide Artificial Pneumothorax in Infants Undergoing Video-Assisted Thoracoscopic Surgery

Objective: To investigate the safety and effectiveness of extraluminal placement of a bronchial blocker compared with carbon dioxide (CO₂) artificial pneumothorax in infants undergoing video-assisted thoracoscopic surgery (VATS).

Methods: The study involved 33 infants (group A) who underwent one-lung ventilation (OLV) with extraluminal placement of a bronchial blocker and 35 other infants (group B) who underwent CO₂ artificial pneumothorax. Clinical characteristics, the degree of lung collapse, and complications were compared.

Results: The degree of lung collapse in group A was significantly higher than that in group B at T2 and T3. The mean arterial pressure (MAP) of group B was significantly lower than that of group A at 10 min and 30 min after OLV. The partial pressure of carbon dioxide (PaCO₂) of group B was significantly higher than that of group A at 30 min after OLV. The incidence of hypotension in group B was higher than that in group A.

Conclusion: Compared with CO₂ artificial pneumothorax, extraluminal placement of a bronchial blocker is associated with a better degree of lung collapse, fewer episodes of hypotension, and lower PaCO₂ accumulation during OLV in infants undergoing VATS.

Changes in respiratory mechanics of artificial pneumothorax two-lung ventilation in video-assisted thoracoscopic esophagectomy in prone position

We aimed to clarify the changes in respiratory mechanics and factors associated with them in artificial pneumothorax two-lung ventilation in video-assisted thoracoscopic esophagectomy in the prone position (PP-VATS-E) for esophageal cancer. Data of patients with esophageal cancer, who underwent PP-VATs-E were retrospectively analyzed. Our primary outcome was the change in the respiratory mechanics after intubation (T1), in the prone position (T2), after initiation of the artificial pneumothorax two-lung ventilation (T3), at 1 and 2 h (T4 and T5), in the supine position (T6), and after laparoscopy (T7). The secondary outcome was identifying factors affecting the change in dynamic lung compliance (Cdyn). Sixty-seven patients were included. Cdyn values were significantly lower at T3, T4, and T5 than at T1 (p < 0.001). End-expiratory flow was significantly higher at T4 and T5 than at T1 (p < 0.05). Body mass index and preoperative FEV_1.0% were found to significantly influence Cdyn reduction during artificial pneumothorax and two-lung ventilation (OR [95% CI]: 1.29 [1.03–2.24] and 0.20 (0.05–0.44); p = 0.010 and p = 0.034, respectively]. Changes in driving pressure were nonsignificant, and hypoxemia requiring treatment was not noted. This study suggests that in PP-VATs-E, artificial pneumothorax two-lung ventilation is safer for the management of anesthesia than conventional one-lung ventilation (UMIN Registry: 000042174).

Case report on thoracoscopic esophagectomy for long segment resistant oesophageal stricture in HIV infected patient

INTRODUCTION

The incidence of Esophageal strictures following esophagitis in human immunodeficiency virus (HIV)-infected patients is profound in majority of cases. Although endoscopic dilatation remains the first line of treatment, surgery is needed for non-dilatable strictures. Sparse literature is available on clinical management for surgical intervention.

PRESNTATION OF THE CASE

A 30 years old HIV positive male, taking ART for 10 years, presented with grade V dysphagia over long standing non-specific ulcerative esophagitis. Upper GI endoscopy revealed a long stricture starting 18 cm from the incisors. The patient underwent multiple endoscopic dilatation along with twice endoscopic stent placements over period of 2 years. As CD4 count was low associated with poor nutritional status a feeding jejunostomy was constructed. With improvement in CD4 count and nutritional status within 3 months; thoracoscopic esophagectomy, laparotomy and formation of gastric conduit and cervical anastomosis was performed. There were no intraoperative or postoperative adverse events with complete improvement in dysphagia. During follow up, 24 months after surgery the patient was on full oral diet with a total weight gain of 15 kg.

DISCUSSION

Long term solution to dysphagia due to long esophageal stricture merits a surgery in form of a replacement conduit by either stomach tube or a segment of colon. Experience and literature guiding surgical decision making are limited. Retaining or excision of the native oesophagus is still a matter of discussion.

CONCLUSION

Thoracoscopic esophagectomy with gastric tube conduit for reconstruction is a feasible and safe surgical option for esophageal stricture in a HIV infected patient.

Efficacy of artificial pneumothorax under two-lung ventilation in video-assisted thoracoscopic surgery for esophageal cancer

BACKGROUND

One-lung ventilation (OLV) is the standard and widely applied ventilation approach used in video-assisted thoracoscopic surgery for esophageal cancer (VATS-e). To address the disadvantages of OLV with respect to difficulties in intubation and induction, as well as the risk of respiratory complications, two-lung ventilation (TLV) with artificial pneumothorax has been introduced for use in VATS-e. However, no studies have yet compared TLV and OLV with postoperative infection and inflammation in the prone position over time postoperatively. Here, we investigated the efficacy of TLV in patients undergoing VATS-e in the prone position.

METHODS

Between April 2010 and December 2016, 119 patients underwent VATS-e under OLV or TLV with carbon dioxide insufflation. Clinical characteristics, surgical outcomes, and postoperative outcomes, including oxygenation and systemic inflammatory responses, were compared between patients who underwent OLV and those who underwent TLV.

RESULTS

Clinical characteristics other than pT stage were comparable between groups. The TLV group had shorter thoracic operation time than the OLV group. No patients underwent conversion to open thoracotomy. The PaO₂/FiO₂ ratios of the TLV group on postoperative day (POD) 5 and on POD7 were significantly higher than those of the OLV group. C-reactive protein levels on POD7 were lower in the TLV group than in the OLV group. There were no significant differences with respect to postoperative complications between the OLV and TLV groups. In the TLV group, the white blood cell count on POD7 was significantly lower than that in the OLV group; body temperature showed a similar trend immediately after surgery and on POD1.

CONCLUSIONS

In this study, we demonstrated that, compared with OLV, TLV in the prone position provides better oxygenation and reduced inflammation in the postoperative course. Accordingly, TLV might be more useful than OLV for ventilation during esophageal cancer surgery.

Video-assisted thoracoscopic total thymectomy: two-lung ventilation with artificial pneumothorax

Objectives: Double-lumen endotracheal tube (DLET) and one-lung ventilation (OLV) have been generally accepted as the classic anesthetic method in video-assisted thoracoscopic total thymectomy (VATT). However, there are still some disadvantages of DLET. Two-lung ventilation (TLV) with single-lumen endotracheal tube (SLET) is considered to be an alternative in VATT to avoid these disadvantages. This study evaluated the safety and feasibility of TLV in VATT by comparing it with OLV cases.Material and methods: We retrospectively screened 198 patients who received TLV unilateral thoracic incision VATT and 117 patients who received OLV unilateral thoracic incision VATT. Perioperative data were analyzed, including surgical variables, intraoperative hemodynamic parameters, and postoperative complications and hospital stay.Results: No significant differences with regard to operative time (p = .146), postoperative hospital stay (p = .553), complications (p = .254), hemodynamic parameters and pulse oxygen saturation (SpO₂) were found between TLV group and OLV group. However, end-tidal CO₂ (EtCO₂) was higher in TLV group at 15 min (39.95 ± 5.03 vs 38.70 ± 4.57, p = .021) and 30 min (41.91 ± 5.50 vs 38.91 ± 4.51, p < .001) after initiation of the operation.Conclusions: It is safe and feasible to adopt TLV using SLET with CO₂ insufflation artificial pneumothorax in unilateral thoracic incision VATT.

Is two lung ventilation with artificial pneumothorax a better choice than one lung ventilation in minimally invasive esophagectomy?

Two lung ventilation (TLV) with artificial pneumothorax has been introduced into MIE for several years. A few researches have reported its clinical application, and proved its safety and feasibility. However, it is still controversial whether TLV with artificial pneumothorax is a better choice than one lung ventilation (OLV). Obviously, single lumen endotracheal tube is easy for intubation and intraoperative maintenance. Potential problems during intervention include hemodynamic changes, oxygenation, and air embolism. In this paper, present literature is reviewed about two and one lung ventilation in thoracoscopy, looking for clear conclusions for future application.

Bronchogenic cyst removal via thoracoscopic surgery in the prone position: A case report and literature review

INTRODUCTION

Mediastinal bronchogenic cysts are encountered relatively often, but in many cases, diagnosis using imaging modalities, is difficult. Early surgical excision of bronchogenic cysts is recommended as a diagnostic and therapeutic measure. Here, we report the case of patient with a lower mediastinal bronchogenic cyst, who was treated using thoracoscopic surgery with prone positioning and include a review of literature on diagnosis and treatment of this condition.

PRESENTATION OF CASE

The patient was a 66-year-old woman with an asymptomatic cystic lesion in the posterior, lower mediastinum. The lesion was diagnosed as an esophageal cyst using preoperative imaging and was scheduled for thoracoscopic removal with the patient in the prone position. Intraoperatively, the lesion was found to have no continuity with the esophageal wall and was easily separated from it. Moreover, a cord extending to the lesion, appeared to arise from the crura of the diaphragm. On histopathological examination of the extracted mass, the lesion was diagnosed as a bronchogenic cyst. Postoperatively, the patient recovered uneventfully and was discharged after 7 days.

CONCLUSION

Thoracoscopic mediastinal cystectomy with the patient in the prone position may be an optimal surgical strategy for the treatment of bronchogenic cysts in the posterior, lower mediastinum.

Is closed thoracic drainage tube necessary for minimally invasive thoracoscopic-esophagectomy?

Background

Closed thoracic drainage tube (CTDT) is a conventional treatment after esophagectomy, even after minimally invasive esophagectomy. Here, we report a single-center, retrospective study to explore the safety and necessity of CTDT after thoracoscopic-esophagectomy.

Methods

From October 2015 and August 2016, 50 patients were enrolled and underwent thoracoscopic-esophagectomy in semi-prone position by same surgical team. Perioperative demographic and surgical parameters, and patients' satisfaction with or without CTDT after thoracoscopic-esophagectomy were collected and analyzed.

Results

All eligible patients (18 patients without CTDT and 32 patients with CTDT) were successfully underwent thoracoscopic procedures without conversion to open approach or major intraoperative complications and perioperative death. The two groups, with similar demographic parameters, had no statistically difference in thoracic operation time, blood loss, ICU stay, postoperative mobilization and oral feeding, and hospital stay. Also, the incidence of postoperative complications was similar with or without CTDT after esophagectomy. But, no-CTDT group had better post-operative satisfaction, including less pain scale scoring and better Norton scoring.

Conclusions

This study demonstrated that the treatment of no-CTDT after the minimally invasive thoracoscopic-esophagectomy is safe and feasible, might reduce the work intensity of medical stuff and lead to a better patients' experience.

A comparison between two lung ventilation with CO2 artificial pneumothorax and one lung ventilation during thoracic phase of minimally invasive esophagectomy

Background

To investigate the feasibility and safety of two lung ventilation with artificial pneumothorax in minimally invasive esophagectomy (MIE) through a comparison with conventional one lung ventilation.

Methods

Eleven hundred and sixty-six patients with esophageal cancer, who underwent McKeown MIE in our center from February 2006 to December 2016, were studied retrospectively. Seven hundred and five patients who underwent one lung ventilation with double lumen endotracheal tube (DLET) were assigned to DLET group. Other 461 patients who underwent two lung ventilation with single lumen endotracheal tube (SLET) were assigned to SLET group. Clinical characteristics, surgical variables and complications were compared between two groups.

Results

There were comparable patient characteristics in two groups. Surgical variables and complications were discussed between two groups. SLET group seemed to have shorter operative time, shorter postoperative hospital stay, and more harvested recurrent laryngeal nerve (RLN) lymph nodes than DLET group, which might be attributed to experienced surgeons. However, there were no significant differences of complications between two groups. Intraoperative clinical parameters were further studied. Before intubation and artificial pneumothorax, there were no significant differences between two groups, except diastolic blood pressure (DBP). With the application of artificial pneumothorax, patients in SLET group have obviously higher PO₂, PCO₂, and PetCO₂ value, and slightly lower pH value and blood pressure during thoracic phase. After the thoracic phase, the changes induced by artificial pneumothorax in SLET group were gradually reversed and clinical parameters gradually return to normal level.

Conclusions

Two lung ventilation with artificial pneumothorax is a safe and feasible choice during MIE.

Minimally invasive esophagectomy: a propensity score-matched analysis of semiprone versus prone position

Background

The preferred surgical approach for esophageal cancer is a minimally invasive transthoracic esophagectomy with a two-field lymph node dissection. The thoracoscopic phase may be performed either in prone- or in left lateral decubitus (LLD) position. Prone positioning has been associated with better pulmonary outcomes compared to LLD positioning; however, conversion to a classic thoracotomy is more difficult. The semiprone position has been proposed as an alternative approach.

Methods

A retrospective review of a prospectively maintained database (2008–2014) was performed to compare postoperative complications, surgical radicality, and lymph node yield between patients who underwent three-stage minimally invasive transthoracic esophagectomy in either the prone or semiprone position. Comparative analyses were conducted before and after propensity score matching.

Results

One hundred and twenty-one patients were included. In total, 82 patients underwent minimally invasive esophagectomy (MIE) in semiprone position and 39 patients in prone position. After propensity score matching, both groups consisted of 39 patients. The operative time in the semiprone group was longer (368 vs. 225 min, P < 0.001) and in this group the lymph node yield was significantly higher (16 (range 6–80) vs. 13 (range 3–33), P = 0.019). There were no statistically significant differences regarding radical resections, postoperative complications, and hospital stay.

Conclusion

The use of semiprone positioning in MIE is safe, feasible, and at least comparable to MIE in prone position in terms of oncological clearance and postoperative complications.