Robotic Intraoperative Tracheobronchial Repair during Minimally Invasive 3-Stage Esophagectomy

Management of an intraoperative tracheal injury during a Mckeown oesophagectomy: A case report

INTRODUCTION AND IMPORTANCE

Tracheobronchial injuries are uncommon complications during oesophagectomies adopting blind dissection or thoracoscopy. Neoadjuvant chemo-radiotherapy is considered a risk factor while double-lumen endotracheal tube insertion and direct surgical damage are other related causalities.

PRESENTATION OF CASE

A 65-year-old male underwent a Mckeown oesophagectomy with a right thoracotomy for a mid-oesophageal carcinoma. During the latter stages of cervical dissection and oesophageal mobilization, a 2-cm tracheal injury was noted in the posterior membranous trachea. It was repaired with 2.0 prolene with interrupted sutures and local transposition muscle flap using prevertebral muscles. Post-operatively, he was ventilated in view of prolonged surgery and the probability of airway oedema with the double-lumen ET tube. A transient bubbling of the intercostal drain was managed conservatively and attributed to a secondary pneumothorax. He was extubated and made an uncomplicated recovery. At 2 years, he did not have any tracheal stenosis.

CLINICAL DISCUSSION

If diagnosed intraoperatively and for sizes >2 cm, tracheobronchial injuries should be repaired. Various techniques exist with differing evidence. Repair with non-absorbable sutures, use of synthetic grafts, innate tissue such as intercostal and pectoral muscle flaps, and pericardial and pleural flaps are all being used. Early extubation might be useful provided other criteria for extubation are met.

CONCLUSION

Tracheobronchial injuries during oesophagectomies present a surplus challenge to both the anaesthetist and the surgeon. Collective decision-making tailored to the patient and close monitoring during the postoperative phase would result in good outcomes.

Robot-assisted esophagectomy with robot-sewn intrathoracic anastomosis (Ivor Lewis): surgical technique and early results

Esophagectomy is the selected treatment for nonmetastatic esophageal and esophagogastric junction cancer, although high perioperative morbidity and mortality incur. Robot-assisted minimally invasive esophagectomy (RAMIE) effectively reduces cardiopulmonary complications compared to open esophagectomy and offers a technical advantage, especially for lymph node dissection and intrathoracic anastomosis. This article aims at describing our initial experience of Ivor Lewis RAMIE, focusing on the technique's main steps and robotic-sewn esophagogastrostomy. Prospectively collected data from all consecutive patients who underwent Ivor Lewis RAMIE for cancer was reviewed. Reconstruction was performed with a gastric conduit pull-up and a robotic-sewn intrathoracic anastomosis. Intraoperative and postoperative complications were recorded as prescribed by the Esophagectomy Complications Consensus Group (ECCG). Thirty patients underwent Ivor Lewis RAMIE with complete mediastinal lymph node dissection and robot-sewn anastomosis. No intraoperative complications nor conversion occurred. Pulmonary complications totaled 26.7%. Anastomotic leakage (ECCG, type III) and conduit necrosis (ECCG, type III) both occurred in one patient (3.3%). Chylothorax appeared in 2 patients (6.7%) (ECCG, Type IIA). Anastomotic stricture, successfully treated with endoscopic dilatations, occurred in 8 cases (26.7%). Median overall postoperative stay was 11 days (range, 6-51 days). 30 day and 90 day mortality was 0%. R0 resection was performed in 96.7% of patients with a median number of 47 retrieved lymph nodes. RAMIE with robot-sewn intrathoracic anastomosis appears to be feasible, safe and effective, with favorable perioperative results. Nevertheless, further high-quality studies are needed to define the best anastomotic technique for Ivor Lewis RAMIE.

Current Status of Lung Cancer and Surgery Based on Studies Using a Nationwide Database

Lung cancer is a fatal disease, highlighting the importance of research on related topics, including surgery for lung cancer. However, systematic research analyzing surgery on a national scale is limited. This study aimed to investigate the research on lung cancer using nationwide data in South Korea and to analyze trends in lung cancer surgery, including its clinical implications. Published articles and data from the Korean National Health Insurance database were used. Although the incidence and mortality of lung cancer have been improving, it is predicted to be the most common and fatal type of cancer in South Korea in 2021. The number of surgical procedures for lung cancer is increasing, especially among women, those ≥76 years of age, residents of non-metropolitan cities, and middle-income patients. Lobectomy and sublobectomy, including segmentectomy, are increasingly common. However, the proportion of pneumonectomy relative to other procedures is not increasing. Surgery has shown a reasonable survival rate, especially after lobectomy, but survival remains poor in patients ≥76 years of age who undergo pneumonectomy. The frequency of lung cancer surgery is increasing concomitantly with various socioeconomic changes. Lobectomy has become increasingly common, and the clinical results of surgery are satisfactory. Further research on the changing composition of surgical candidates is required.