Minimally invasive esophagectomy

Improvement of surgical complications using single-lumen endotracheal tube intubation and artificial carbon dioxide pneumothorax in esophagectomy: a meta-analysis

Background

Esophageal cancer has a poor prognosis. Surgery is the main treatment but involves a high risk of complications. Some surgical strategies have tried to eliminate complications. Our meta-analysis tried to find the benefits of single-lumen endotracheal tube intubation with carbon dioxide (CO₂) inflation.

Methods

A systematic search of studies on esophagectomy and CO₂ inflation was conducted using PubMed, Medline, and Scopus. The odds ratio of post-operative pulmonary complications and anastomosis leakage were the primary outcomes. The standardized mean difference (SMD) in post-operative hospitalization duration was the secondary outcome.

Results

The meta-analysis included four case-control studies with a total of 1503 patients. The analysis showed a lower odds ratio of pulmonary complications in the single-lumen endotracheal tube intubation in the CO₂ inflation group (odds ratio: 0.756 [95% confidence interval, CI: 0.518 to 1.103]) compared to that in the double-lumen endotracheal tube intubation group, but anastomosis leakage did not improve (odds ratio: 1.056 [95% CI: 0.769 to 1.45])). The SMD in hospitalization duration did not show significant improvement. (SMD: -0.141[95% CI: − 0.248 to − 0.034]).

Conclusions

Single-lumen endotracheal tube intubation with CO₂ inflation improved pulmonary complications and shortened the hospitalization duration. However, no benefit in anastomosis leakage was observed.

[Initial experience of robot-assisted minimally invasive McKeown esophagectomy]

OBJECTIVE

To report our initial experience of robot-assisted McKeown esophagectomy with stapled cervical esophagogastrostomy.

MATERIAL AND METHODS

There were 5 robot-assisted McKeown esophagectomies in patients with benign end-staged and malignant diseases of the esophagus for the period from October 2019 to February 2020.

RESULTS

No conversions and intraoperative complications were observed. Mean surgery time was 406±48 min, total intraoperative blood loss - 108±45 ml. Four patients had minor complications (wound infection, atelectasis, pneumothorax) that required conservative treatment. We have controlled anastomosis in 2-3 postoperative days with water-soluble contrast, none patient had an anastomotic leakage. Mean hospital-stay was 5 days. Complete (R0) resection was accomplished in all patients with malignant neoplasms.

CONCLUSIONS

Our first experience showed that robot-assisted McKeown esophagectomy is a safe and feasible surgical option for esophageal diseases. Robot-assisted interventions require advanced endoscopic surgical experience.

Uniportal Video-Assisted Thoracic Surgery Esophagectomy

Several minimally invasive approaches for esophagectomy have been described, including robot-assisted esophagectomy and hybrid techniques, total transhiatal laparoscopic approach, esophagectomy using right thoracoscopy, combined laparoscopic and right thoracoscopic esophagectomy, and esophageal resection through mediastinoscopy. However, very few publications have focused on the uniportal video-assisted thoracic surgery (VATS) approach. The authors describe their technique of the minimally invasive esophagectomy using uniportal VATS as the thoracic step.

Updated experiences with minimally invasive McKeown esophagectomy for esophageal cancer

AIM: To update our experiences with minimally invasive McKeown esophagectomy for esophageal cancer.

METHODS: We retrospectively reviewed the medical records of 445 consecutive patients who underwent minimally invasive McKeown esophagectomy between January 2009 and July 2015 at the Cancer Hospital of Chinese Academy of Medical Sciences and used 103 patients who underwent open McKeown esophagectomy in the same period as controls. Among 375 patients who underwent total minimally invasive McKeown esophagectomy, 180 in the early period were chosen for the study of learning curve of total minimally invasive McKeown esophagectomy. These 180 minimally invasive McKeown esophagectomies performed by five surgeons were divided into three groups according to time sequence as group 1 (n = 60), group 2 (n = 60) and group 3 (n = 60).

RESULTS: Patients who underwent total minimally invasive McKeown esophagectomy had significantly less intraoperative blood loss than patients who underwent hybrid minimally invasive McKeown esophagectomy or open McKeown esophagectomy (100 mL vs 300 mL vs 200 mL, P = 0.001). However, there were no significant differences in operation time, number of harvested lymph nodes, or postoperative morbidity including incidence of pulmonary complication and anastomotic leak between total minimally invasive McKeown esophagectomy, hybrid minimally invasive McKeown esophagectomy and open McKeown esophagectomy groups. There were no significant differences in 5-year survival between these three groups (60.5% vs 47.9% vs 35.6%, P = 0.735). Patients in group 1 had significantly longer duration of operation than those in groups 2 and 3. There were no significant differences in intraoperative blood loss, number of harvested lymph nodes, or postoperative morbidity including incidence of pulmonary complication and anastomotic leak between groups 1, 2 and 3.

CONCLUSION: Total minimally invasive McKeown esophagectomy was associated with reduced intraoperative blood loss and comparable short term and long term survival compared with hybrid minimally invasive McKeown esophagectomy or open Mckeown esophagectomy. At least 12 cases are needed to master total minimally invasive McKeown esophagectomy in a high volume center.

Impact of artificial capnothorax on coagulation in patients during video-assisted thoracoscopic esophagectomy for squamous cell carcinoma

BACKGROUND

Compared with the lung isolation using double-lumen endobronchial tube intubation, the artificial capnothorax using single-lumen endotracheal tube intubation has shown to be a safe, more convenient, and cost-effective procedure for thoracoscopic esophagectomy. However, the impact of capnothorax on coagulation is not well defined. Herein, we evaluate the impact of a capnothorax on coagulation and fibrinolysis in patients who undergoing thoracoscopic esophagectomy.

METHODS

Between March 2014 and August 2014, 24 patients underwent thoracoscopic esophagectomies for esophageal cancer with the procedure of artificial capnothorax (group P); we also performed 24 thoracoscopic esophagectomy cases without using capnothorax (group N). The demographics and arterial blood gas, as well as the parameters of coagulation and fibrinolysis, of the two groups were analyzed.

RESULTS

The pH value of group P after CO2 insufflation was significantly lower than in group N (P < 0.05), and the partial pressure of carbon dioxide (PaCO2) was significantly increased compared with group N (P < 0.05). The R and K values after CO2 insufflation were significantly longer than before anesthesia (P < 0.05), and both α angle and MA value after CO2 insufflation were significantly lower than those before anesthesia (P < 0.05). No significant differences in R value, K value, α angle, or MA value were observed between pre-anesthesia and termination of capnothorax. No significant difference in LY30 data was found between different groups (P > 0.05).

CONCLUSION

Artificial capnothorax in patients receiving endoscopic resection of esophageal carcinoma had a significant impact on coagulation. These patients showed significant impairments in coagulation not observed in patients without artificial capnothorax.

The 3-Hole Minimally Invasive Esophagectomy: A Safe Procedure Following Neoadjuvant Chemotherapy and Radiation

Induction therapy followed by esophagectomy has become standard for treatment of intermediate-stage esophageal cancer in many centers. Herein we evaluate the feasibility and safety of the 3-hole minimally invasive esophagectomy (3HMIE) approach in patients who received induction radiation and chemotherapy. Between 2003 and 2012, the records of 119 consecutive patients with esophageal cancer who underwent 3HMIE were reviewed for perioperative complications and long-term outcomes. Comparison was made between procedures performed for patients receiving neoadjuvant chemoradiation and patients who were treated with only surgery. Of them, 78 patients received neoadjuvant chemoradiation and 41 patients were treated with only surgery. Tumor locations were upper (2), middle (16), distal (64), and gastroesophageal junction (37). In all, 76 patients were at clinical stage IIA or above at presentation. Increased requirement for blood replacement in the induction therapy group was significant compared with the surgery-only group. Operative time, estimated blood loss, proximal and distal margin lengths, and length of stay were not significantly different between the cohorts. There was a 30-day perioperative death (0.8%), and this patient was from the surgery-only group. No conduit necrosis or need for diversion was recorded. Overall, 5-year survival was 62% among the 107 patients with early-stage esophageal cancer. 3HMIE is feasible with low mortality and acceptable morbidity even in patients with locally advanced esophageal cancer who received neoadjuvant radiochemotherapy. Overall perioperative and survival outcomes are similar to or better than those reported in the published literature on esophagectomy after induction therapy.

Transhiatal Esophagectomy without Mediastinal Manipulation for Lower Third Esophageal and Cardial Cancers: The First Experience of a New Technique

BACKGROUND

Considering the poor survival rate of patients with esophageal cancers, mainly due to the disease effects and surgical co morbidities, we have aimed to introduce a new method of Transhiatal Esophagectomy (THE) without mediastinal manipulation for lower third esophageal and cardial cancers. It has suggested that using this technique would decrease mentioned complications.

METHODS

In this prospective study, patients with esophageal cancer who referred for surgical treatment have enrolled and undergone to new method of THE, without mediastinal manipulation. Pre and post-operative morbidities as well as the duration of procedure, duration of hospital and ICU stay have recorded. All patients have followed up or 4-40 months.

RESULTS

In this study 53 patients with mean age of 55.2+/-10.3 years have undergone esophagectomy, and then in 50 of them the new method has performed. Median operative time and volume of blood loss was 120 minutes and 130 ml, respectively. Median duration of hospital and ICU stay was 7 and 1 day, respectively. There were no Pre-operative mortalities, arrhythmia, hemodynamic instability and mediastinal vessels injury. The most common co morbidities have related to our new method were mediastinal pleura injury, anastomotic leaks and anastomotic narrowing with 20%, 16% and 10% reported rate, respectively.

CONCLUSION

The findings of current study have indicated that transhiatal esophagectomy without mediastinal manipulation, has represented a safe and effective method for treatment of lower third esophageal and cardial cancers due to its potential advantages of decreased blood loss, being a less traumatic procedure, minimal cardiopulmonary complications and low rate of hospital mortality.

Minimally invasive surgery for esophageal cancer - benefits and controversies

Open esophagectomy (OE) requires extensive surgery and is associated with significant morbidity and mortality. Furthermore, the long-term results of esophageal cancer surgery are not satisfactory; hence, the best surgical approach is constantly under debate. During the last twenty years, minimally invasive esophagectomy (MIE) employing laparoscopy and/or thoracoscopy has been introduced in a growing number of centers worldwide. To date, several studies have demonstrated that MIE has better outcomes than OE, as it results in shorter hospital stay and decreased overall morbidity. However, the length of operating time in MIE is increased in comparison to OE. The survival benefit has been demonstrated to be similar in OE and MIE. Highly advanced laparo-thoracoscopic skills are required to perform MIE; along with the relatively long learning curve, this makes MIE feasible only in high-volume, experienced university surgical centers. There is a need for further large-scale comparative studies to prove the superiority of MIE over open surgery.

Multidisciplinary approach for patients with esophageal cancer

Patients with esophageal cancer have a poor prognosis because they often have no symptoms until their disease is advanced. There are no screening recommendations for patients unless they have Barrett's esophagitis or a significant family history of this disease. Often, esophageal cancer is not diagnosed until patients present with dysphagia, odynophagia, anemia or weight loss. When symptoms occur, the stage is often stage III or greater. Treatment of patients with very early stage disease is fairly straight forward using only local treatment with surgical resection or endoscopic mucosal resection. The treatment of patients who have locally advanced esophageal cancer is more complex and controversial. Despite multiple trials, treatment recommendations are still unclear due to conflicting data. Sadly, much of our data is difficult to interpret due to many of the trials done have included very heterogeneous groups of patients both histologically as well as anatomically. Additionally, studies have been underpowered or stopped early due to poor accrual. In the United States, concurrent chemoradiotherapy prior to surgical resection has been accepted by many as standard of care in the locally advanced patient. Patients who have metastatic disease are treated palliatively. The aim of this article is to describe the multidisciplinary approach used by an established team at a single high volume center for esophageal cancer, and to review the literature which guides our treatment recommendations.

Review of minimally invasive esophagectomy and current controversies

Esophagectomy is a complex operation with significant morbidity and mortality. Minimally invasive esophagectomy (MIE) was described in the 1990s in an effort to reduce operative morbidity. Since then many institutions have adopted and described their series with this technique. This paper reviews the literature on the variety of MIE techniques, clinical and quality of life outcomes with open versus MIE, and controversies surrounding MIE-such as prone positioning, stapling techniques, size of the gastric conduit, and robotic techniques.

Feasibility and effectiveness of pre-operative inspiratory muscle training in patients undergoing oesophagectomy: a pilot study

BACKGROUND

Patients undergoing oesophageal surgery have a high risk for post-operative complications including pulmonary infections. Recently, physical therapy has shifted from the post-operative to the pre-operative phase to diminish post-operative complications and to shorten hospital stay. The purpose of this pilot study was to investigate the feasibility and initial effectiveness of pre-operative inspiratory muscle training (IMT) on the incidence of pneumonia in patients undergoing oesophagectomy.

METHODS

A pragmatic non-randomized controlled trial was conducted among all patients who underwent an oesophagectomy between January 2009 and February 2010. Patients in the intervention group received IMT prior to surgery. Feasibility was assessed on the basis of the occurrence of adverse effects during testing or training and patient satisfaction. Initial effectiveness on respiratory function was evaluated by maximal inspiratory pressure (MIP) and endurance, the incidence of post-operative pneumonia and length of hospital stay.

RESULTS

Eighty-three patients were included, of which 44 received pre-operative IMT. No adverse effects were observed. IMT was well tolerated and appreciated. In the intervention group, the median MIP and endurance improved significantly after IMT by 32% and 41%, respectively (p < 0.001). The incidence of post-operative pneumonia and the length of hospital stay were comparable for the intervention and the conventional care groups (pneumonia, 25% vs. 23% [p = 0.84]; hospitalization, 13.5 vs. 12 days [p = 0.08]).

CONCLUSIONS

Pre-operative IMT is feasible in patients with oesophageal carcinoma and significantly improves respiratory muscle function. This, however, did not result in a reduction of post-operative pneumonia in patients undergoing oesophagectomy.

Gastroesophageal reflux disease: From heartburn to cancer

About 10%-15% of patients with gastroesophageal reflux disease develop Barrett’s esophagus. This is considered a premalignant condition because it can progress from metaplasia to high-grade dysplasia, and eventually to adenocarcinoma. Recently, major advances have been made in the endoscopic treatment of Barrett’s esophagus, therefore limiting the role of surgery in the treatment of this disease.