Mediastinoscopic esophagectomy for patients with early esophageal cancer

Clinical-pathological features and perioperative outcomes of mediastinoscopy vs. thoracoscopy esophagectomy in esophageal cancer: A meta-analysis

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.

Video-assisted mediastinoscopic and laparoscopic transhiatal esophagectomy for esophageal cancer

BACKGROUND

Mediastinoscopy was originally applied for lymph node biopsy and mediastinal tumor resection. Improved video imaging with spreadable working channels enabled mediastinoscopy for inspection and tissue biopsy in the superior mediastinum but it is rarely used in minimally invasive esophageal cancer surgery. In this prospective trial, the practicability and security of spreadable video-assisted mediastinoscopic combined with laparoscopic transhiatal esophagectomy (VAME) with video-assisted thoracoscopic esophagectomy (VATE) were compared.

METHODS

A total of 200 eligible patients with esophageal squamous cell carcinoma were randomly divided into VAME or VATE groups. Early postoperative outcomes and lymph node dissection between the two groups were compared.

RESULTS

The operation time was significantly shorter (164.3 ± 47.0 min vs. 265.4 ± 47.2 min, P < 0.001), the number of dissected lymph nodes was less (15.8 ± 4.5 vs. 20.3 ± 6.5, P < 0.001), and the intraoperative blood loss was also significantly reduced (94.7 ± 56.7 mL vs. 184.4 ± 65.2 mL, P < 0.001) in the VAME compared to the VATE group, respectively. The incidence of pneumonia was lower (7% vs. 29%; P < 0.001) and the length of hospital stay was shorter in the VAME group compared to the VATE group (18.0 ± 7.6 days vs. 23.2 ± 7.2, P < 0.001, respectively). The chyle leak incidence appeared to be lower in the VAME group but statistical significance was not reached (1% vs. 4%; P = 0.369). There were no differences in the incidence of anastomotic leakages and recurrent laryngeal nerve paralysis between the groups. No 30-day mortality occurred in any of the cases.

CONCLUSION

VAME appears to be a practicable and secure method for esophagectomy but needs further proof of concept. Clinical registration number: Registered at Chinese Clinical Trial Registry, ChiCTR1900022797.

Postoperative complications of minimally invasive esophagectomy for esophageal cancer

Minimally invasive esophagectomy (MIE) has been performed increasingly more frequently for the treatment of esophageal cancer, ever since it was first described in 1992. However, the incidence of postoperative complications of MIE has not yet been well-characterized, because (a) there are few reports of studies with a sufficient sample size, (b) a variety of minimally invasive surgical techniques are used, and (c) there are few reports in which an established system for classifying the severity of complications is examined. According to an analysis performed by the Esophageal Complications Consensus Group, the most common complications of MIE are pneumonia, arrhythmia, anastomotic leakage, conduit necrosis, chylothorax, and recurrent laryngeal nerve palsy. Therefore, we decided to focus on these complications. We selected 48 out of 1245 reports of studies (a) that included more than 50 patients each, (b) in which the esophagectomy technique used was clearly described, and (c) in which the complications were adequately described. The overall incidences of the postoperative complications of MIE for esophageal cancer were analyzed according to the MIE technique adopted, that is, McKeown MIE, Ivor Lewis MIE, robotic-assisted McKeown MIE, robotic-assisted Ivor Lewis MIE, or mediastinoscopic transmediastinal esophagectomy. Pneumonia, arrhythmia, anastomotic leakage, and recurrent laryngeal nerve palsy occurred at an incidence rate of about 10% each; Ivor Lewis MIE was associated with a relatively low incidence of recurrent laryngeal nerve palsy. It is important to recognize that the incidences of complications of MIE are influenced by the MIE technique adopted and the extent of lymph node dissection.