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Comparison of minimally invasive esophagectomy with transthoracic and transhiatal esophagectomy
Abstract
Minimally invasive esophagectomy can be performed as safely as conventional esophagectomy and has distinct perioperative outcome advantages.
A retrospective comparison of 3 methods of esophagectomy: minimally invasive, transthoracic, and blunt transhiatal.
University medical center.
Eighteen consecutive patients underwent combined thoracoscopic and laparoscopic esophagectomy from October 9, 1998, through January 19, 2000. These patients were compared with 16 patients who underwent transthoracic esophagectomy and 20 patients who underwent blunt transhiatal esophagectomy from June 1, 1993, through August 5, 1998.
Operative time, amount of blood loss, number of operative transfusions, length of intensive care and hospital stays, complications, and mortality.
Patients who had minimally invasive esophagectomy had shorter operative times, less blood loss, fewer transfusions, and shortened intensive care unit and hospital courses than patients who underwent transthoracic or blunt transhiatal esophagectomy. There was no significant difference in the incidence of anastomotic leak or respiratory complications among the 3 groups.
Minimally invasive esophagectomy is safe and provides clinical advantages compared with transthoracic and blunt transhiatal esophagectomy.
... There have been only a few studies comparing minimally invasive thoracoscopic mobilization of the esophagus with conventional THE [16,17]. The primary aim of this study was to compare the short-term surgical outcome of patients of esophageal carcinoma undergoing open THE with thoracoscopy-assisted esophagectomy (TAE) comprising thoracoscopic esophageal mobilization and laparotomy/laparoscopy. ...
... Though we observed significantly lower operative time with THE in comparison with TAE, it was expected due to additional time of posture change from prone to supine and thoracoscopic dissection in TAE. However, the mean operative time of TAE was similar to other studies [16,22,23]. The overall pulmonary complication is heterogenous in literature. ...
... However, there was no difference in the median number of lymph nodes harvested (5.5 vs 6.0, p = 0.81) between MIE and THE. The lymph node yield in our study was low compared with other studies (6.9 to 29) [7,13,16,31]. This low number of lymph nodes could be due to routine neoadjuvant chemoradiotherapy and standard two-field lymphadenectomy in our patients. ...
Introduction Transhiatal esophagectomy (THE) was popularized to reduce the morbidity of esophagectomy. Thoracoscopy-assisted esophagectomy (TAE) offers esophageal dissection under magnified vision. This study compares the short-term morbidity and oncological outcome following TAE and THE for esophageal carcinoma. Methodology This is a prospective comparative (January 2017-May 2018) study between TAE and THE for >cT1bN1 esophageal carcinoma. After neoadjuvant chemoradiotherapy (NACRT), responders and patients with stable diseases were subjected to surgery. Thoracoscopy in esophagectomy was performed in prone position. Follow-up duration was at least 4 weeks post-discharge. Results Thirty-three patients of esophageal carcinoma undergoing TAE (n = 18) or THE (n = 15) were included. Common locations of tumor were lower third of esophagus (72.7%) and esophagogastric junction (18.2%). Majority (73.3%) had squamous cell carcinoma. Median interval between NACRT and surgery was 13 weeks. The mean operating time was significantly more with TAE than THE (292.5 vs 207.33 min, p = 0.005). R0 resection rate in TAE was 83.3% compared with 66.7% in THE. There was no difference in the lymph node yield. There was non-significant trend towards lower incidence of major pulmonary complication (66.7% vs 80.0%), cardiac complications (27.8% vs 46.7%), anastomotic leak (27.8% vs 46.7%), recurrent laryngeal nerve palsy (16.7% vs 20.0%), and overall major morbidity (Clavien-Dindo ≥ III) (44.4% vs 66.7%) in TAE than THE. The chyle leak was observed more in TAE (16.7%) than THE (6.7%). Conclusions TAE achieved higher R0 resection rate and better short-term morbidity than THE. Enrollment of small number of cases in the study precluded statistical significance. Trial Registration This study was registered in Clinical Trial Registry-India (CTRI registration no: CTRI/2018/05/013880) in 14-05-2018.
... There have been only a few studies comparing minimally invasive thoracoscopic mobilization of the esophagus with conventional THE [16,17]. The primary aim of this study was to compare the short-term surgical outcome of patients of esophageal carcinoma undergoing open THE with thoracoscopy-assisted esophagectomy (TAE) comprising thoracoscopic esophageal mobilization and laparotomy/laparoscopy. ...
... Though we observed significantly lower operative time with THE in comparison with TAE, it was expected due to additional time of posture change from prone to supine and thoracoscopic dissection in TAE. However, the mean operative time of TAE was similar to other studies [16,22,23]. The overall pulmonary complication is heterogenous in literature. ...
... However, there was no difference in the median number of lymph nodes harvested (5.5 vs 6.0, p = 0.81) between MIE and THE. The lymph node yield in our study was low compared with other studies (6.9 to 29) [7,13,16,31]. This low number of lymph nodes could be due to routine neoadjuvant chemoradiotherapy and standard two-field lymphadenectomy in our patients. ...
Introduction Transhiatal esophagectomy (THE) was popularized to reduce the morbidity of esophagectomy. Thoracoscopy-assisted esophagectomy (TAE) offers esophageal dissection under magnified vision. This study compares the short-term morbidity and oncological outcome following TAE and THE for esophageal carcinoma. Methodology This is a prospective comparative (January 2017-May 2018) study between TAE and THE for >cT1bN1 esophageal carcinoma. After neoadjuvant chemoradiotherapy (NACRT), responders and patients with stable diseases were subjected to surgery. Thoracoscopy in esophagectomy was performed in prone position. Follow-up duration was at least 4 weeks post-discharge. Results Thirty-three patients of esophageal carcinoma undergoing TAE (n = 18) or THE (n = 15) were included. Common locations of tumor were lower third of esophagus (72.7%) and esophagogastric junction (18.2%). Majority (73.3%) had squamous cell carcinoma. Median interval between NACRT and surgery was 13 weeks. The mean operating time was significantly more with TAE than THE (292.5 vs 207.33 min, p = 0.005). R0 resection rate in TAE was 83.3% compared with 66.7% in THE. There was no difference in the lymph node yield. There was non-significant trend towards lower incidence of major pulmonary complication (66.7% vs 80.0%), cardiac complications (27.8% vs 46.7%), anastomotic leak (27.8% vs 46.7%), recurrent laryngeal nerve palsy (16.7% vs 20.0%), and overall major morbidity (Clavien-Dindo ≥ III) (44.4% vs 66.7%) in TAE than THE. The chyle leak was observed more in TAE (16.7%) than THE (6.7%). Conclusions TAE achieved higher R0 resection rate and better short-term morbidity than THE. Enrollment of small number of cases in the study precluded statistical significance. Trial Registration This study was registered in Clinical Trial Registry-India (CTRI registration no: CTRI/2018/05/013880) in 14-05-2018.
... Minimally invasive esophagectomy (MIE) in oesophageal cancer management has become the standard of care in the last decade. [1,2] Several authors have described their techniques in lateral, prone or lateral-prone position and usually describe the crucial step of securing and ligating the arch of the azygos vein. We here describe our MIE technique with thoracic mobilisation of the oesophagus in the prone position and a particular focus on preserving azygos vein arch. ...
... MIE is now considered the standard approach and is associated with a significant decrease in morbidity and mortality, faster recovery and shorter hospital stays. [2] Thoracoscopic phase of the procedure can be done in either left lateral or prone positions with similar postoperative outcomes. Prone position decreases lung injury chances due to retraction as the lung collapses and falls due to gravity. ...
... In contrast, it can compromise lymph nodal clearance and influence outcomes. In our series of 14 patients, the mean number of lymph nodes harvested was 28 which was comparable to the nodes harvested in series where the arch was divided, 10.3 by Nguyen et al., 20 by Luketich et al. and 18 by Palanivelu et al. [2][3][4] We used the Visick score [5] for quality of life assessment and 85.7% of patients reported a score of I. This was similar to the outcome, 89.23% with Visick score I, reported by Palanivelu et al. [4] In conclusion, we believe that preserving the azygos vein arch is a technically feasible procedure and may be associated with a better quality of life outcome without compromising the oncological outcome. ...
Minimally invasive esophagectomy (MIE) for oesophageal cancer has gained wide popularity in recent years due to its improved morbidity and mortality outcomes. We describe our modified technique of MIE in prone position with preservation of the arch of azygos vein. In our experience with 14 patients, the mean operative duration was 378 min (standard deviation [SD] 378 ± 59 min) and the mean blood loss was 390 ml (SD 390 ± 142 ml). The mean lymph node count was 28 (range 17-54). The Visick score was I in 12 (85.7%) patients and II in 2 (14.3%) patients at follow-up. The preservation of azygos vein arch is a technically feasible procedure and may be associated with a better quality of life outcome.
... There have been only a few studies comparing minimally invasive thoracoscopic mobilization of the esophagus with conventional THE [16,17]. The primary aim of this study was to compare the short-term surgical outcome of patients of esophageal carcinoma undergoing open THE with thoracoscopy-assisted esophagectomy (TAE) comprising thoracoscopic esophageal mobilization and laparotomy/laparoscopy. ...
... Though we observed significantly lower operative time with THE in comparison with TAE, it was expected due to additional time of posture change from prone to supine and thoracoscopic dissection in TAE. However, the mean operative time of TAE was similar to other studies [16,22,23]. The overall pulmonary complication is heterogenous in literature. ...
... However, there was no difference in the median number of lymph nodes harvested (5.5 vs 6.0, p = 0.81) between MIE and THE. The lymph node yield in our study was low compared with other studies (6.9 to 29) [7,13,16,31]. This low number of lymph nodes could be due to routine neoadjuvant chemoradiotherapy and standard two-field lymphadenectomy in our patients. ...
Introduction
Transhiatal esophagectomy (THE) was popularized to reduce the morbidity of esophagectomy. Thoracoscopy-assisted esophagectomy (TAE) offers esophageal dissection under magnified vision. This study compares the short-term morbidity and oncological outcome following TAE and THE for esophageal carcinoma.
Methodology
This is a prospective comparative (January 2017–May 2018) study between TAE and THE for >cT1bN1 esophageal carcinoma. After neoadjuvant chemoradiotherapy (NACRT), responders and patients with stable diseases were subjected to surgery. Thoracoscopy in esophagectomy was performed in prone position. Follow-up duration was at least 4 weeks post-discharge.
Results
Thirty-three patients of esophageal carcinoma undergoing TAE (n = 18) or THE (n = 15) were included. Common locations of tumor were lower third of esophagus (72.7%) and esophagogastric junction (18.2%). Majority (73.3%) had squamous cell carcinoma. Median interval between NACRT and surgery was 13 weeks. The mean operating time was significantly more with TAE than THE (292.5 vs 207.33 min, p = 0.005). R0 resection rate in TAE was 83.3% compared with 66.7% in THE. There was no difference in the lymph node yield. There was non-significant trend towards lower incidence of major pulmonary complication (66.7% vs 80.0%), cardiac complications (27.8% vs 46.7%), anastomotic leak (27.8% vs 46.7%), recurrent laryngeal nerve palsy (16.7% vs 20.0%), and overall major morbidity (Clavien-Dindo ≥ III) (44.4% vs 66.7%) in TAE than THE. The chyle leak was observed more in TAE (16.7%) than THE (6.7%).
Conclusions
TAE achieved higher R0 resection rate and better short-term morbidity than THE. Enrollment of small number of cases in the study precluded statistical significance.
Trial Registration
This study was registered in Clinical Trial Registry-India (CTRI registration no: CTRI/2018/05/013880) in 14-05-2018.
... Minimally invasive esophagectomy began in the late 1990s and its technique, outcome and perioperative management continues to evolve over the past two decades [1]. Our group began to perform MIE in 1998 and similarly, our technique and perioperative management has evolved [4,5]. The aim of this study was to describe changes in surgical technique, perioperative management for postoperative leaks, and outcome of 75 consecutive MIEs performed between 2011 and 2018 compared to on our initial series of 104 MIEs performed between 1998 and 2007 [5]. ...
... The two most common approaches being the thoracoscopic esophageal mobilization followed by laparoscopy with gastric pull-up and construction of a neck anastomosis and the laparoscopic/thoracoscopic Ivor Lewis esophagectomy with construction of a chest anastomosis. Originally when MIE was described, most surgeons favored the threefield MIE approach with construction of a cervical anastomosis as it is (1) technically easier to perform the anastomosis in the neck using open surgical technique compared to construction of a thoracoscopic chest anastomosis and (2) if there is a leak, it is easier to manage the leak if it is located in the neck compared to the chest [4,5]. However, with advances in surgical proficiency of the surgeons, many now are comfortable in performance of a minimally invasive chest anastomosis and also more comfortable in management of a chest anastomotic leak [6][7][8]. ...
... In the current series, our surgical approach to MIE has changed to primarily the laparoscopic/thoracoscopic Ivor Lewis esophagectomy operation (95% of cases) and reserve the thoracoscopic and laparoscopic esophagectomy with a cervical anastomosis for cases that require the need for additional proximal esophageal resection to ensure a negative margin. The disadvantages of a neck esophagogastrostomy include excessive tension on the anastomosis, higher likelihood for ischemia on the tip of the gastric conduit leading to a higher leak rate, risk for recurrent laryngeal nerve injury, and development of postoperative oropharyngeal dysfunction [4,5,9]. Advantages of a chest anastomosis include less tension on the anastomosis and the ability to resect the tip of the gastric conduit as that is often the most ischemic portion of the gastric conduit while the main disadvantage for construction of a chest anastomosis is the surgeon's technical ability and comfort in construction a safe chest anastomosis. ...
Background
Initial adoption of minimally invasive esophagectomy (MIE) began in the late 1990s but its surgical technique, perioperative management, and outcome continues to evolve.
Methods
The aim of this study was to examine the evolving changes in the technique, outcome, and new strategies in management of postoperative leaks after MIE was performed at a single institution over a two-decade period. A retrospective chart review of 75 MIE operations was performed between November 2011 and September 2018 and this was compared to the initial series of 104 MIE operations performed by the same group between 1998 and 2007. Operative technique, outcomes, and management strategies of leaks were compared.
Results
There were 65 males (86.7%) with an average age of 61 years. The laparoscopic/thoracoscopic Ivor Lewis esophagectomy became the preferred MIE approach (49% of cases in the initial vs. 95% in the current series). Compared to the initial case series, there was no significant difference in median length of stay (8 vs. 8 days), major complications (12.5% vs. 14.7%, p = 0.68), incidence of leak (9.6% vs. 10.6%, p = 0.82), anastomotic stricture (26% vs. 32.0%, p = 0.38), or in-hospital mortality (2.9% vs. 2.6%, p = 0.47). Management of esophageal leaks has changed from primarily thoracotomy ± diversion initially (50% of leak cases) to endoscopic stenting ± laparoscopy/thoracoscopy currently (87.5% of leak cases).
Conclusion
In a single-institutional series of MIE over two decades, there was a shift toward a preference for the laparoscopic/thoracoscopic Ivor Lewis approach with similar outcomes. The management of postoperative leaks drastically changed with predilection toward minimally invasive option with endoscopic drainage and stenting.
... As noted above, Cushiery already reported on five cases of endoscopic esophagectomy through a right thoracoscopic approach, followed by a paper on 26 procedures in 1994 [1,2]. Consequently, surgeons all over the world worked with empathy and dedication to develop minimally invasive techniques of the existing different variations of esophageal resections [3][4][5][6][7][8][9][10][11]. Namely transhiatal, transthoracic and three-field (abdominal-thoracic--cervical) approaches found their position and therefore a more common use for a minimally invasive approach [10,[12][13][14][15][16][17][18][19]. ...
... Consequently, surgeons all over the world worked with empathy and dedication to develop minimally invasive techniques of the existing different variations of esophageal resections [3][4][5][6][7][8][9][10][11]. Namely transhiatal, transthoracic and three-field (abdominal-thoracic--cervical) approaches found their position and therefore a more common use for a minimally invasive approach [10,[12][13][14][15][16][17][18][19]. In Austria, some specialized departments used their highly developed minimally invasive skills to perform minimally invasive esophageal resections with good outcomes even without publishing their experiences, e. g., Schmid T, Innsbruck and Szinicz G., Bregenz, Austria (personal communication). ...
Background
Minimally invasive techniques have replaced the conventional open approach in many operations. For esophagectomy, it took quite a long time to become routine even in centers. The aim of this review was to demonstrate history and current status of minimally invasive esophagectomy and also robotic-assisted esophagectomy with its associated techniques.
Methods
Selected literature on minimally invasive surgery for esophageal cancer was identified using a PubMed search for the period 1990–2018 with the search terms esophagectomy, minimal invasive, robotic, indocyanine fluorescein, enhanced recovery after surgery (ERAS), fast-track, nerve monitoring and its permutations.
Results
Within the last two decades minimally invasive esophagectomy has found its way into clinical practice. It reduces perioperative morbidity with equivalent oncological outcome. It allows for better pulmonary results, less blood loss, less pain, and better quality of life. If robotic assisted esophagectomy helps to further improve the results is currently under investigation. Fast-track protocols have proven their value. Intraoperative nerve monitoring and indocyanine green fluorescein imaging of the perfusion of the gastric tube can lower perioperative complications.
Conclusions
Minimally invasive surgery for esophageal malignancies offers advantages when performed in an environment with sufficient expertise and caseload. Whether robotic-assisted minimally invasive esophagectomy further improves the results has to be investigated in the future. Intraoperative nerve monitoring and visualization of the graft perfusion with indocyanine green fluorescein should be used where available. Enhanced recovery protocols after surgery have become standard.
... Blood loss was minimal in this group with median EBL of 196 ml (range 75-300 ml) which minimizes the risk of blood transfusion requirements. Surgical procurement of lymph nodes was 16 nodes and is consistent with that reported by other open and MIE groups [13,14]. Although no randomized trial to date has documented survival benefit from extended lymphadenectomy during esophagectomy there is growing awareness of the importance of nodal staging related to its prognosis [15]. ...
... Respiratory complications have been reported to be the most common cause of death following esophagectomy [16] therefore avoidance of these complications are of the utmost importance. Not surprisingly it has been shown that patients undergoing thoracoscopic esophageal mobilization have less postoperative pain and improved vital capacity than do those undergoing thoracotomy [13]. ...
... Furthermore, the loss of blood and the length of hospital stay are minimized, and the involvement of the intensive care unit is reduced. Some authors, however, think that the period of hospital stay is still too long [7,21,30]. ...
... The duration of the laparoscopic transhiatal esophagectomy procedure was shorter than that of corresponding surgeries and proportional to the level of expertise of the surgical team, as already mentioned in the literature [11,15,19,25,31,32]. Regarding the occurrence of anastomosis leaks and respiratory complications, Nguyen and co-workers [20,21] have reported that there are no significant differences between the transhiatal and the conventional transthoracic esophagectomy. It is important to note that the definition and precision of the mediastinal dissection was greatly improved by laparoscopic transhiatal esophagectomy and permitted the efficient lymphadenectomy of the celiac trunk [4,30]. ...
... Recently, sensors capable of resolving rotations across all three-dimensions simultaneously have been studied for precise measurement of the position and orientation of medical microbots [29][30][31][32] . Microbots loaded with diverse sensors are envisioned to provide simultaneous in-vivo detection, diagnosis, and drug delivery thus allowing for fast, minimally invasive treatments 33,34 . For such devices it is necessary to collect, transmit, and store a wide range of data as they traverse through the body. ...
... For the measurement, a single cube was attached to a piece of double-sided Scotch Tape (material transparent to THz wave) and was placed at the center of a circular aluminum aperture of diameter 3.8 mm (Fig. 6a). The presence of only the Au SRRs as the resonant material, as well as the entirely polymeric composition of the cube, also ensures that no interference or coupling exists that can distort the transmission spectrum 33 . A THz pulse generated from a commercial GaAs emitter passed through the aperture and cube and was received by a detector. ...
Split-ring resonators (SRRs) present an attractive avenue for the development of micro/nano scale inclinometers for applications like medical microbots, military hardware, and nanosatellite systems. However, the 180° isotropy of their two-dimensional structure presents a major hurdle. In this paper, we present the design of a three-dimensional (3D) anisotropic SRR functioning as a microscale inclinometer enabling it to remotely sense rotations from 0° to 360° along all three axes (X, Y, and Z), by employing the geometric property of a 3D structure. The completely polymeric composition of the cubic structure renders it transparent to the Terahertz (THz) light, providing a transmission response of the tilted SRRs patterned on its surface that is free of any distortion, coupling, and does not converge to a single point for two different angular positions. Fabrication, simulation, and measurement data have been presented to demonstrate the superior performance of the 3D micro devices.
... Collard et al. first described esophageal resection by thoracoscopy in 1993 (1). This minimally-invasive approach documented shorter operative times, less blood loss, and shorter stays in the ICU with no increase in morbidity compared with the open approach (2). After the FDA's approval of The Da Vinci robotic surgical system for use in laparoscopy in 2000, Melvin et al. became the first to report robotic esophagectomy in 2002 (3). ...
... Port placement for the abdominal portion of procedure.[C] Camera port;[1] left robotic arm port;[2] right robotic arm port #1;[3] right robotic arm port #2; [L] liver retractor port; [A] assistant port. ...
Robotic esophagectomy is an increasingly used modality. Patients who are candidates for traditional, open esophagectomy are typically also candidates for robotic esophagectomy. Knowledge of and training on the robotic platform is critical for success. Patient and port positioning is described. Either a hand-sewn or stapled intrathoracic anastomosis may be performed. Minimally invasive esophagectomy (MIE) appears to be associated with decreased respiratory complications versus open esophagectomy. Robotic esophagectomy may be performed with excellent perioperative outcomes, though long-term oncologic data regarding the operation are not yet available.
... These procedures utilize combinations of standard thoracoscopy, laparoscopy, and more recently, robotic assistance. A few high-volume centers have published large cohort studies [5][6][7][8] reporting perioperative outcomes after minimally invasive esophagectomy (MIE). These studies have shown a decrease in perioperative complications among MIE patients, with seemingly comparable oncologic results. ...
... Another potentially morbid complication in the postoperative period is an anastomotic leak, which could lead to localized infection, sepsis, and even death. Overall anastomotic leak rates among MIE patients can range from 0 to 12 %, which has been shown to be comparable to OE patients [5,6,8,[26][27][28]. Results from the TIME trial [4] showed a trend toward higher rates of anastomotic leaks after mTTE compared to after oTTE, but this did not reach statistical significance (12 vs. 7 %, p = 0.39). ...
Since the introduction of minimally invasive esophagectomy 25 years ago, its use has been reported in several high volume centers. With only one published randomized control trial and five meta-analyses comparing its outcomes to open esophagectomy, available level I evidence is very limited. Available technical approaches include total minimally invasive transthoracic (Ivor Lewis or McKeown) or transhiatal esophagectomy; several hybrid options are available with one portion of the procedure completed via an open approach. A review of available level I evidence with focus on total minimally invasive esophagectomy is presented. The old debate regarding the superiority of a transthoracic versus transhiatal approach to esophagectomy may have been settled by minimally invasive esophagectomy as only few centers are reporting on the latter being utilized. The studies with the highest level of evidence available currently show that minimally invasive techniques via a transthoracic approach are associated with less overall morbidity, fewer pulmonary complications, and shorter hospital stays than open esophagectomy. There appears to be no detrimental effect on oncologic outcomes and possibly an added benefit derived by improved lymph node retrieval. Quality of life improvements may also translate into improved survival, but no conclusive evidence exists to support this claim. Robotic and hybrid techniques have also been implemented, but there currently is no evidence showing that these are superior to other minimally invasive techniques.
... Pneumonia developed in nine patients (6.5%) in this study, a rate that is substantially lower than previously reported. 13,[16][17][18][24][25][26] Our low rate of pneumonia can be attributed to optimization of the operative procedure (muscle-sparing thoracotomy and a minimal upper abdominal vertical incision); improvement in surgical technique (the omission of a cervical incision for middle and lower third esophageal cancers); and good perioperative management (adequate pain management for both thoracic and abdominal wounds enabled early ambulation, coughing, and expectoration of secretions). Only five patients (3.6%) in this study needed bedside bronchoscopy for tracheobronchial toilet. ...
... The length of hospital stay in this study was a little longer than previously reported. 13,14,17,18,[24][25][26][30][31][32] We consider that reduction in complications and adequate perioperative pain management shortened the ambulation time and hospital stay. We introduced thoracoscopic esophagectomy to improve the operative technique by magnifying the surgical view and to enable visualization of the operative field on monitors for the purpose of education. ...
In our department, we have attempted to reduce the incidence of complications of conventional esophagectomy. The objective of this retrospective study was to report the short-term outcomes of esophagectomy. We reviewed 138 consecutive patients who had undergone subtotal esophagectomy by combined laparotomy via a 12-cm upper abdominal vertical incision combined with right anterior muscle-sparing thoracotomy from August 2010 to August 2014. Most of the cervical para-esophageal lymph node dissection was completed within the thoracic cavity. We performed three-field dissection in patients with tumors in the upper or middle third of the esophagus with clinical lymph node metastases in the superior mediastinum; the others underwent two-field dissection. We performed neck anastomoses in patients undergoing three-field dissection and thoracic anastomoses in those undergoing two-field dissection. Effective postoperative pain management was achieved with a combination of epidural anesthesia and paravertebral block. Postoperative rehabilitation was instituted for early ambulation and recovery. Enteral nutrition via a duodenal feeding tube was administered from postoperative day 2. Median hospital stay after surgery was 15 days (range, 10-129). Rates for both 30-day and in-hospital mortality were 0%. Morbidity rate for all Clavien-Dindo grades was 41.3%, whereas the morbidity rate for Clavien-Dindo grades III and IV was 7.2%. Anastomotic leakage developed in two patients (1.4%), recurrent laryngeal nerve palsy in 11 (8.0%), and pneumonia in nine (6.5%). Good short-term outcomes, especially regarding anastomotic leaks, were achieved by consistent improvements in surgical techniques, optimization of several operative procedures, and appropriate perioperative management.
... The number of total lymph nodes removed was 13.57 ± 2.76 per patient in the optimized TLE group. Our perioperative outcomes were slightly better compared with the previous literatures [17][18][19][20][21]. With regard to the postoperative complications, the cervical anastomotic leakage was seen in one case (3.3 %) in our series. ...
... Thoracoscopic esophagectomy is currently accepted by more and more thoracic surgeon due to minimal trauma and rapid recovery [19]. With the recent advance in thoracoscopic surgery, endoscopic esophagectomy gradually modified from the endoscopic-assisted mini-incision to total thoracoscopic and laparoscopic esophagectomy. ...
Background
Total thoracoscopic and laparoscopic esophagectomy (TLE) has attracted attention with the advantage of better operative field and minimal wound for the esophageal cancer. However, various severe complications are also reported during the TLE such as cervical anastomotic leakage, chylothorax, and tracheal injury. The aim of this study was to introduce a new optimized TLE procedure for the esophageal cancer and assess its safety and clinical effects.
Methods
We retrospectively collected the clinical data of 30 patients with esophageal cancer who underwent optimized TLE procedures between January 2014 and December 2014. The optimized TLE procedures mainly include as follows: (1) 50 ml of sesame oil-milk mixture (1:1) is injected via gastric tube after endotracheal intubation; (2) patients are intubated with a single lumen endotracheal tube; (3) patients were positioned at 150° in the left prone position rather than lateral decubitus position; and (4) duodenal feeding tube was not placed intraoperatively and however triple lumen nasojejunal feeding tube was placed on the second postoperative day under imaging guidance. Operation time, amount of blood loss, number of dissected nodes, length of hospital stays, and complications were recorded.
Results
The mean operation time of the optimized TLE group was 202.13 ± 13.74 min. The mean visible blood loss of the optimized TLE group was 300.00 ± 120.12 ml. The postoperative hospital stays in the optimized TLE group were 16.27 ± 4.51 days. The number of dissected nodes in the optimized TLE group was 13.57 ± 2.76. The postoperative complications for the optimized TLE procedure were seen in one case (3.3 %).
Conclusions
The method of optimized TLE is an effective, reliable, and safe procedure for the treatment of esophageal cancer, which provide favorable outcomes in terms of operation time, blood loss, length of hospital stays, the number the dissected nodes, and reduced incidence of postoperative complications compared to previous literatures. Further studies with a large number of samples are warranted.
... These include shorter operative time, decreased blood loss and thus transfusion requirement, decreased pulmonary complications, less vocal cord palsy, and reduced intensive care and hospital stay. [1][2][3][4] The MIE can be performed by a single-stage laparoscopic transhiatal approach, or by a staged thoracoscopic and laparoscopic approach. Thoracoscopic oesophageal mobilisation is most commonly performed with the patient placed in the lateral decubitus position (LDP). ...
... The credit of pioneering MIE goes to Cuschieri [13] and DePaula et al. [14] Since then, there has been an increasing number of reports of MIE that have documented shorter operative time, decreased blood loss, fewer transfusions, decreased pulmonary complications, less vocal cord palsy, reduced intensive care and hospital stay, acceptable lymph node yield and low mortality. [1][2][3][4] A very recent, multicenter, randomised trial by Biere et al. showed significantly decreased pulmonary infection, hospital stay, intraoperative blood loss and vocal cord palsy in the minimally invasive transthoracic oesophagectomy group when compared to the open transthoracic oesophagectomy group. In addition, the quality-of-life scores were also significantly better in the minimally invasive group. ...
Background:
Thoracoscopic oesophageal mobilisation during a minimally invasive oesophagectomy (MIE) is most commonly performed with the patient placed in the lateral decubitus position (LDP). The prone position (PP) for thoracoscopic oesophageal mobilisation has been proposed as an alternative.
Materials and methods:
This was a retrospective, comparative study designed to compare early outcomes following a minimally invasive thoracolaparoscopic oesophagectomy for oesophageal cancer in LDP and in PP.
Results:
During the study period, between January 2011 and February 2014, 104 patients underwent an oesophagectomy for cancer. Of these, 42 were open procedures (transhiatal and transthoracic oesophagectomy) and 62 were minimally invasive. The study group included patients who underwent thoracolaparoscopic oesophagectomy in LDP (n = 23) and in PP (n = 25). The median age of the study population was 55 (24-71) years, and there were 25 males. Twenty-one (21) patients had tumours in the middle third of the oesophagus, 24 in the lower third, and 3 arising from the gastro-oesophageal junction. The most common histology was squamous cell cancer (85.4%). The median duration of surgery was similar in the two groups; however, the estimated median intraoperative blood loss was less in the PP group [200 (50-400) mL vs 300 (100-600) mL; P = 0.01)]. In the post-operative period, 26.1% patients in the LDP group and 8% in the PP group (8%) developed respiratory complications. The incidence of other post-operative complications, including cervical oesophagogastric anastomosis, hoarseness of voice and chylothorax, was not different in the two groups. The T stage of the tumour was similar in the two groups, with the majority (37) having T3 disease. A mean of 8 lymph nodes (range 2-33) were retrieved in the LDP group, and 17.5 (range 5-41) lymph nodes were retrieved in the PP group (P = 0.0004). The number of patients with node-positive disease was also higher in the PP group (19 vs 10, P = 0.037).
Conclusion:
MIE in the PP is an effective alternative to LDP. The exposure obtained is excellent even without the need for a complete lung collapse, thereby obviating the need for a double-lumen endotracheal tube. A more meticulous dissection can be performed resulting in a higher lymph nodal yield.
... Firstly, the application of MIE approaches was associated with a marginal increase in the likelihood of achieving a textbook outcome. Previous studies have demonstrated that MIE is associated with reductions in blood loss, operative time, postoperative ICU admission, and a shorter LOS 11,28,29 increased odds of margin-negative resection, suggesting that these approaches may offer oncological advantages beyond the benefits of improved postoperative recovery 11 . However, the advantages with MIE may likely be due to patient selection bias, which may not be completely mitigated with multivariable modelling. ...
Abstract
Background
Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.
Methods
Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).
Results
Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter ‘no major postoperative complication’ had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P < 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P < 0.001) were independently associated with a significantly increased likelihood of textbook outcome.
Conclusion
Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.
... In a similar study by Ninh et al the mean age of study group was 64 years with SD of ±12. 23 Most of the patients were between 50 and 70 years with mean age between 62±8 years. Also majority of the study subjects in our study were male and male to female ratio was around 3:1. ...
Background: Esophageal cancer is considered to be a one of the most lethal malignancy. Indian population have seen a lot of changes in the epidemiology of this deadly cancer. However very few studies have been done from northern India regarding the epidemiology and etiopathogenesis of this disease. Majority of esophageal cancers (about 90%) are either squamous cell or Adenocarcinoma. Any factor that causes chronic irritation and inflammation of the esophageal mucosa appears to increase the incidence of the esophageal. The aim of the study was to perform an epidemiological study and determine the various factors that are implicated in the pathogenesis of carcinoma esophagus.Methods: This study was conducted in the department of general surgery, Government Medical College, Jammu, as an observational prospective study. It took into account the patients from 2015 to 2020. A total of 23 patients of carcinoma oesophagus who presented to Outdoor patient wing of department of surgery were included in the study. After detailed history, examination and investigations, the various variables were extracted and data was processed.Results: In this study, the majority of people were from rural areas in their seventh decade of life with males: female ratio of 3:1. The majority of people complained of dysphagia and weight loss. The site of tumor was Gastroesophageal junction.Conclusions: This study emphasised the need of health education in our population, especially in young adults to lessen the risk factors for carcinoma esophagus.
... 4 Complication rates are routinely above 50%. [5][6][7][8] The most dreaded complication following esophagectomy is anastomotic leak. A study comparing two groups of 654 patients found an intrathoracic versus cervical anastomotic leak rate of 17.0 and 21.9%, respectively. ...
... Collectively, these advantages translate to lower conversion rates, shorter operative time, fewer postoperative intensive care unit admissions, and a shorter hospital stay. 12,22,23 Furthermore, robotic surgery appears to be linked with increased odds of margin-negative resection and improved lymphadenectomy, suggesting that these approaches may offer oncologic advantages beyond the benefits of short-term improvements in postoperative recovery. 12 These marginal gains translate to improvement in long-term survival, as reported in the current study. ...
Background
Robotic esophagogastric cancer surgery is gaining widespread adoption. This population-based cohort study aimed to compare rates of textbook outcomes (TOs) and survival from robotic minimally invasive techniques for esophagogastric cancer.
Methods
Data from the United States National Cancer Database (NCDB) (2010–2017) were used to identify patients with non-metastatic esophageal or gastric cancer receiving open surgery (to the esophagus, n = 11,442; stomach, n = 22,183), laparoscopic surgery (to the esophagus [LAMIE], n = 4827; stomach [LAMIG], n = 6359), or robotic surgery (to the esophagus [RAMIE], n = 1657; stomach [RAMIG], n = 1718). The study defined TOs as 15 or more lymph nodes examined, margin-negative resections, hospital stay less than 21 days, no 30-day readmissions, and no 90-day mortalities. Multivariable logistic regression and Cox analyses were used to account for treatment selection bias.
Results
Patients receiving robotic surgery were more commonly treated in high-volume academic centers with advanced clinical T and N stage disease. From 2010 to 2017, TO rates increased for esophageal and gastric cancer treated via all surgical techniques. Compared with open surgery, significantly higher TO rates were associated with RAMIE (odds ratio [OR], 1.41; 95% confidence interval [CI], 1.27–1.58) and RAMIG (OR 1.30; 95% CI 1.17–1.45). For esophagectomy, long-term survival was associated with both TO (hazard ratio [HR 0.64, 95% CI 0.60–0.67) and RAMIE (HR 0.92; 95% CI 0.84–1.00). For gastrectomy, long-term survival was associated with TO (HR 0.58; 95% CI 0.56–0.60) and both LAMIG (HR 0.89; 95% CI 0.85–0.94) and RAMIG (HR 0.88; 95% CI 0.81–0.96). Subset analysis in high-volume centers confirmed similar findings.
Conclusion
Despite potentially adverse learning curve effects and more advanced tumor stages captured during the study period, both RAMIE and RAMIG performed in mostly high-volume centers were associated with improved TO and long-term survival. Therefore, consideration for wider adoption but a well-designed phase 3 randomized controlled trial (RCT) is required for a full evaluation of the benefits conferred by robotic techniques for esophageal and gastric cancers.
... There are multiple surgical approaches to esophagectomy, each with different strengths and challenges. Laparoscopic and thoracoscopic techniques have been shown to have decreased operative blood loss, fewer complications, and reduced length of stay compared to open transthoracic (Ivor-Lewis) and 3-hole (McKeown) esophagectomies [3][4][5][6]. However, these techniques can also be technically demanding, with functional limitations related to the trocar decreasing operative mobility, limited tactile feedback, and indirect visualization of the operative field via endoscope, camera, and 2-D monitor system [7]. ...
Esophagectomy is a high-risk operation, regardless of technique. Minimally invasive transthoracic esophagectomy could reduce length of stay and pulmonary complications compared to traditional open approaches, but the benefits of minimally invasive transhiatal esophagectomy are unclear. We performed a retrospective review of prospectively gathered data for open transhiatal esophagectomies (THEs) and transhiatal robot-assisted minimally invasive esophagectomies (TH-RAMIEs) performed at a high-volume academic center between 2013 and 2017. Multivariate logistic regression was used to calculate adjusted odds ratios (aORs) for outcomes. 465 patients met inclusion criteria (378 THE and 87 TH-RAMIE). THE patients more likely had an ASA score of 3 + (89.1% vs 77.0%, p = 0.012), whereas TH-RAMIE patients more likely had a pathologic staging of 3+ (43.7% vs. 31.2%, p = 0.026). TH-RAMIE patients were less likely to receive epidurals (aOR 0.06, 95% confidence interval [CI] 0.03–0.14, p < 0.001), but epidural use itself was not associated with differences in outcomes. TH-RAMIE patients experienced higher rates of pulmonary complications (adjusted odds ratio [OR] 1.82, 95% CI 1.03–3.22, p = 0.040), particularly pulmonary embolus (aOR 5.20, 95% CI 1.30–20.82, p = 0.020). There were no statistically significant differences in lymph node harvest, unexpected ICU admission, length of stay, in-hospital mortality, or 30-day readmission or mortality rates. The TH-RAMIE approach had higher rates of pulmonary complications. There were no statistically significant advantages to the TH-RAMIE approach. Further investigation is needed to understand the benefits of a minimally invasive approach to the open transhiatal esophagectomy.
... There is a relationship between such conventional open transthoracic and trans-hiatal esophagectomy and comparatively great morbidity reaching 80% and mortality rate of 5% when operated by qualified surgeons (2). Some studies showed that minimally invasive esophagectomy (MIE) could potentially diminish the morbidity of open operations and result in a faster return to normal activities (3,4). For example, Torek demonstrated the first case of a transthoracic esophagectomy in 1913 (5). ...
Background: Surgical resection with curative intention is still a central therapeutic option for resectable esophageal cancer. Thoracoscopic esophagectomy in prone position would give each benefit of the lateral position. The present research aimed to analyze the short-term outcomes of thoracoscopic esophagectomy in prone position.
Methods: This was a retrospective cross-sectional study. Patients who underwent thoracoscopic esophagectomy in prone position at Tehran University Cancer institute during January 2017 to December 2018 entered the study. Esophagus was mobilized through the thoracoscopic approach in a prone position. Stomach was released using a laparoscopic approach for gastric pull-up. Finally, an end-to-end hand-sewn cervical anastomosis was performed.
Results
Three, four, seven, one and one patients suffered from pneumonia, leakage, tracheal tearing, chylothorax and pneumothorax, respectively after the operation. In 91.5% of patients, more than 10 lymph nodes were resected. Sixty percent of patients were discharged from the hospital earlier than one week.
Conclusions
laparoscopic esophagectomy in prone position is a feasible alternative. Better exposure and fewer complications were reported.
Thoracoscopy; Esophagectomy; Prone Position
... Arrhythmia was reported in 27 articles. Eighteen studies reported pulmonary Eleven studies [20][21][22][23][24][25][26][27][28][29][30] were conducted in the United States, 15 were conducted in Japan, 31-45 10 were conducted in the United Kingdom, 46-55 10 were conducted in China, [56][57][58][59][60][61][62][63][64][65] four were conducted in the Netherlands, 6,66-68 three were conducted in Germany, [69][70][71] three were conducted in Australia, 72-74 two were conducted in Italy 75,76 and in France, 77,78 and the remaining studies were conducted in Serbia, 79 Austria, 80 Belgium, 81 Thailand, 82 and Chile. 83 Among the 63 studies, 24 were retrospective studies (the largest proportion of the included studies), 24 were prospective trials, five were RCTs, and the remaining 10 were unknown study types. ...
Background:
To evaluate the existing literature comparing cardiopulmonary complications after minimally invasive esophagectomy (MIE) with open esophagectomy (OE) and conduct a meta-analysis based on the relevant studies.
Methods:
A systematic search for articles was performed in Medline, Embase, Wiley Online Library, and the Cochrane Library. The relative risks or odds ratios (ORs) were calculated by using fixed or random-effects models. The I2 and X2 tests were used to test for statistical heterogeneity. We performed a metaregression for the pulmonary complications with the adenocarcinoma proportion and tumor stage. Publication bias and small-study effects were assessed using Egger's test and Begg's funnel plot.
Results:
A total of 30,850 participants were enrolled in the 63 studies evaluated in the meta-analysis. Arrhythmia, pulmonary embolism, pulmonary complications, gastric tip necrosis, anastomotic leakage, and vocal cord palsy were chosen as outcomes. The occurrence rate of arrhythmia was significantly lower in patients receiving MIE than in patients receiving OE (OR = 0.69; 95% CI = 0.53-0.89), with heterogeneity (I2 = 30.7%, P = 0.067). The incidence of pulmonary complications was significantly lower in patients receiving MIE (OR = 0.54, 95% CI = 0.45-0.63) but heterogeneity remained (I2 = 72.1%, P = 0.000). The risk of gastric tip necrosis (OR = 1.48, 95% CI = 1.07-2.05) after OE was lower than that after MIE. Anastomotic leakage, pulmonary embolism, and vocal cord palsy showed no significant differences between the two groups.
Conclusions:
MIE has advantages over OE, especially in reducing the incidence of arrhythmia and pulmonary complications. Thus, MIE can be recommended as the preferred alternative surgery method for resectable esophageal cancer.
... 9 In recent years, the use of minimally invasive esophagectomy (MIE) using thoracoscopy has become more common due to its potential to limit surgical trauma, reduce respiratory complications, and promote earlier functional recovery. Various studies have shown the short-term benefits of MIE in terms of intraoperative blood loss, postoperative development of pneumonia, and hospital stay compared to OE. [10][11][12] Yamashita et al. performed a propensity score matching study comparing clinical outcomes of MIE and OE, demonstrating that the MIE group had significantly lower postoperative peak serum Creactive protein levels and better disease-free survival (DFS) and OS rates than the OE group (3-year DFS rate, 81.7% vs. 69.3%; 3-year OS rate, 89.9% vs. 79.2%). ...
The number of elderly patients with esophageal cancer has increased in recent years. The use of thoracoscopic esophagectomy has also increased, and its minimal invasiveness is believed to contribute to postoperative outcomes. However, the short- and long-term outcomes in elderly patients remain unclear. This study aimed to elucidate the safety and feasibility of minimally invasive esophagectomy in elderly patients. This retrospective study included 207 patients who underwent radical thoracoscopic esophagectomy for thoracic esophageal squamous cell carcinoma at Kobe University Hospital between 2005 and 2014. Patients were divided into non-elderly (<75 years) and elderly (≥75 years) groups. A propensity score matching analysis was performed for sex and clinical T and N stage, with a total of 29 matched pairs. General preoperative data, surgical procedures, intraoperative data, postoperative complications, in-hospital death, cancer-specific survival, and overall survival were compared between groups. The elderly group was characterized by lower preoperative serum albumin levels and higher American Society of Anesthesiologists grade. Intraoperative data and postoperative complications did not differ between the groups. The in-hospital death rate was 4% in the elderly group, which did not significantly differ from the non-elderly group. Cancer-specific survival was similar between the two groups. Although overall survival tended to be poor in the elderly group, it was not significantly worse than that of the non-elderly group. In conclusion, the short- and long-term outcomes of minimally invasive esophagectomy in elderly versus non-elderly patients were acceptable. Minimally invasive esophagectomy is a safe and feasible modality for elderly patients with appropriate indications.
... Patients underwent transhiatal or transthoracic open esophagectomy (n = 18) or MIE (n = 18). The outcomes in MIE cases were significant for decreased blood loss, less operative transfusions, shorter length of intensive care and hospitalization, with decreased complications, and mortality [25]. We concurrently found that MIE specifically RAIL and thoracoscopic/laparoscopic MIE was associated with lower blood loss, decreased complications compared to MIE via transhiatal approach. ...
Objective
Minimally invasive esophagectomy (MIE) has demonstrated superior outcomes compared to open approaches. The myriad of techniques has precluded the recommendation of a standard approach. The addition of robotics to esophageal resection has potential benefits. We sought to examine the outcomes with MIE to include robotics.
Methods
Utilizing a prospective esophagectomy database, we identified patients who underwent (MIE) Ivor Lewis via thoracoscopic/laparoscopic (TL), transhiatal (TH), or robotic-assisted Ivor Lewis (RAIL). Patient demographics, tumor characteristics, and complications were analyzed via ANOVA, χ², and Fisher exact where appropriate.
Results
We identified 302 patients who underwent MIE: TL 95 (31.5%), TH 63 (20.8%), and RAIL 144 (47.7%) with a mean age of 65 ± 9.6. The length of operation was longer in the RAIL: TL (299 ± 87), TH (231 ± 65), RAIL (409 ± 104 min), p < 0.001. However, the EBL was lower in the patients undergoing transthoracic approaches (RAIL + TL): TL (189 ± 188 ml), TH (242 ± 380 ml), RAIL (155 ± 107 ml), p = 0.03. Conversion to open was also lower in these patients: TL 7 (7.4%), TH 8 (12.7%), RAIL 0, p < 0.001. The R0 resection rate and lymph node (LN) harvest also favored the RAIL cohort: TL 86 (93.5%), TH 60 (96.8%), and RAIL 144 (100%), p = 0.01; LN: TL 14 ± 7, TH 9 ± 6, and RAIL 20 ± 9, p < 0.001. The overall morbidity was lower in MIE patients that underwent a transthoracic approach vs. transhiatal: TL 29 (30.5%), TH 39 (61.9%), RAIL 34 (23.6%), p < 0.001.
Conclusions
Patients undergoing MIE via thoracoscopic/laparoscopic and robotic transthoracic approaches demonstrated lower EBL, morbidity, and conversion to open compared to the transhiatal approach. Additionally the oncologic outcomes measured by R0 resections and LN harvest also favored the patients who underwent a transthoracic approach.
... To date, several single-institution studies have demonstrated acceptable short-term outcomes of VATS esophagectomy for thoracic esophageal cancer in terms of operating time, blood loss, and postoperative complications, which are comparable with those of conventional OE (Table 3) (11,63). Regarding operating time, most studies have reported that VATS esophagectomy has a longer operating time than OE, although some studies have reported that OE has a longer operating time (37,38,50). In all studies, VATS esophagectomy involved less blood loss than OE. ...
Technical advances and developments in endoscopic equipment and thoracoscopic surgery have increased the popularity of minimally invasive esophagectomy (MIE). However, there is currently no established scientific evidence supporting the use of MIE as an alternative to open esophagectomy (OE). To date, a number of single‐institution studies and several meta‐analyses have demonstrated acceptable short‐term outcomes of thoracoscopic esophagectomy for esophageal cancer, and we recently reported one of the largest propensity score‐matched comparison studies between MIE and OE for esophageal cancer, based on a nationwide Japanese database. We found that, in general, MIE had a longer operative time and less blood loss than OE. Moreover, compared to OE, MIE was associated with a lower rate of pulmonary complications such as pneumonia, and both methods had similar mortality rates. Although MIE may reduce the occurrence of postoperative respiratory complications, MIE and OE seem to have comparable short‐term outcomes. However, the oncological benefit to patients undergoing MIE remains to be scientifically proven, as no randomized controlled trials have been conducted to verify each method's impact on the long‐term survival of cancer patients. An ongoing randomized phase III study (JCOG1409) is expected to determine the impact of each method with regard to short‐ and long‐term outcomes.
... Most of the patients were between 50 and 70yrs with mean age between 62±8 years (Table 3), Nin T et al 19 in his study had also mean age of 64 with SD of ± 12 which is almost similar to our study. ...
... When analysing available literature there are few data comparing MIE to open oe-sophagectomy. Nguyen performed a retrospective comparison of patients subject to MIE, open surgery and transhiatal oesophagectomy, and reported shorter hospitalisation, lower blood loss and associated lower amount of blood products transfused in patients subject to MIE [10]. ...
Aim
The aim of this study was to compare the metabolic response in the early postoperative period after radical resection of stage I and II oesophageal cancer applying a minimally invasive procedure and an open procedure involving classical laparotomy and thoracotomy.
Material and methods
Serum concentrations of interleukin 6 (IL-6), procalcitonin (PCT), C-reactive protein (CRP), tumour necrosis factor-α (TNF-α), and total serum protein (TP) and leukocyte count (WBC) in blood collected on the day of surgery prior to the procedure (day 0) and on days 1, 2 and 7 after the surgery were measured in two groups of patients undergoing oesophageal resection due to cancer: applying a minimally invasive procedure involving laparoscopy and videothoracoscopy (group A) and applying a classical procedure involving full opening of the chest and abdominal cavity (group B). The study involved a total of 24 patients divided into two groups of 12 patients each.
Results
Tumour necrosis factor-α concentration was lower in group A compared to group B on day 0, PCT concentration was lower in group A compared to group B on day 2 after surgery, and on the remaining days TNF-α and PCT concentrations were not statistically different between groups.
Conclusions
Lower concentration of PCT on post-surgery day 2 in the group of patients undergoing minimally invasive oesophageal resection seems to be associated with a smaller perioperative injury. Lower TNF-α concentration in serum collected on day 0 in the group of patients undergoing minimally invasive resection is associated with a lower stage of oesophageal cancer in this group.
... 19,20 Nguyen et al. (2000) compared MIE, transthoracic (TT), and transhiatal (TH) esophagectomy and found that MIE results in shorter operative time, hospital stay, and less blood loss with no difference in respiratory complications. 21 Luketich et al. reported the first large series of MIE for EC in 2003. They published outcomes of 222 patients and showed that MIE conferred lower mortality and shorter hospital stay. ...
Several esophageal resection techniques have been reported in literature. The objective of this study is to assess postoperative and oncological outcomes of two-stage minimally invasive esophagectomy (MIE) in a prone position using thoracoscopic hand-sewn anastomosis. Consecutive patients who underwent two-stage MIE in 2016 performed by the senior author were included. This was compared with the preceding cohort of consecutive patients who underwent two-stage hybrid esophagectomy (HE). The primary outcome was 30-day morbidity and mortality. The secondary outcomes were operation duration, length of stay (LOS), total nodes examined (TNE), number of positive nodes (NPN), and resection margin. Overall, 15 patients underwent MIE and 11 patients underwent HE. Respiratory complications occurred in three (20.0%) patients in the MIE group and in five (45.5%) patients in the HE group (P = 0.218). Cardiac complications occurred in two (18.2%) patients, and two other patients (18.2%) experienced anastomotic leak in the HE group. Mean operative duration was 349 ± 41.6 min in MIE and 309 ± 47.8 min in HE (P = 0.040). Median LOS was 10 days (range: 7–70) in MIE and 13 days (range: 10–116) in HE (P = 0.045). Median TNE was 23 (range: 12–36) in MIE and 20 (range: 14–47) in HE (P = 0.775). Longitudinal margin was involved in one patient (9.1%) in HE and no longitudinal margin was involved in the MIE group. Circumferential resection margin was involved in seven patients (46.7%) in MIE and in four patients (36.4%) in HE (P = 0.391). Two-stage MIE using hand-sewn technique is safe and feasible without compromising surgical and oncological outcomes. A multicenter large trial is recommended to confirm these results.
... The pooled SMD from these nine studies was 0.31 (95% CI, [0.02, 0.59]). We performed a sensitivity analysis and excluded the studies of Pham, 2010;Gao, 2011;Nguyen, 2000;and Parameswaran, 2009. The I 2 estimate of the variance between the studies was 58% and P = 0.04, which showed mediate heterogeneity, so we used the RE model. ...
Objective:
The objective of this study was to perform a meta-analysis to evaluate the effects of thoracoscopic-laparoscopic esophagectomy (TLE) and open esophagectomy (OE) in the treatment of esophageal cancer.
Methods:
A literature search was performed using PubMed, Embase, and Google Scholar databases for relevant keywords and the medical subject headings. After we had screened further, 13 clinical trials were included in the final meta-analysis. Specific odds ratios (ORs), standardized mean differences (SMDs), mean differences (MDs), and confidence intervals (CIs) were calculated.
Results:
The outcomes of treatment effects included anastomotic leakage, blood loss, number of lymph nodes harvested, and operating time. Comparing OE for esophageal cancer patients, the pooled OR of anastomotic leakage was 0.89 (95% CI = [0.47, 1.68]), the pooled SMD of blood loss was - 0.56 (95% CI = [-0.77, -0.35]), the pooled MD of lymph nodes harvested was - 0.93 (95% CI = [-2.35, 0.50]), and the pooled SMD of operating time was 0.31 (95% CI = [0.02, 0.59]).
Conclusion:
TLE was found to significantly decrease patients' blood loss. There is no difference of anastomotic leakage and the number of lymph nodes harvested between TLE and OE.
... Several randomized trials compared transhiatal esophagectomy and standard transthoracic esophagectomy, showing no significant differences between them. The differences between transthoracic and transhiatal esophagectomy were examined in three randomized trials [17][18][19][20][21]. The results of these clinical trials showed no significant differences between the two approaches in what concerns patient survival. ...
... These limitations are less prominent with the implementation of robot-assisted esophagectomy, which allows threedimensional view and improved articulation of instruments with seven degrees of freedom [10]. Still, data on the clinical effects of robot-assisted esophagectomy are scarce with only few studies published [11,12]. ...
Aim:
To compare the peri- and postoperative data between a hybrid minimally invasive esophagectomy (HMIE) and the conventional Ivor Lewis esophagectomy.
Methods:
Retrospective comparison of perioperative characteristics, postoperative complications, and survival between HMIE and Ivor Lewis esophagectomy.
Results:
216 patients were included, with 160 procedures performed with the conventional and 56 with the HMIE approach. Lower perioperative blood loss was found in the HMIE group (600 ml versus 200 ml, p < 0.001). Also, a higher median number of lymph nodes were harvested in the HMIE group (median 28) than in the conventional group (median 23) (p = 0.002). The median length of stay was longer in the conventional group compared to the HMIE group (11.5 days versus 10.0 days, p = 0.03). Patients in the HMIE group experienced fewer grade 2 or higher complications than the conventional group (39% versus 57%, p = 0.03). The rate of all pulmonary (51% versus 43%, p = 0.32) and severe pulmonary complications (38% versus 18%, p = 0.23) was not statistically different between the groups.
Conclusions:
The HMIE was associated with lower intraoperative blood loss, a higher lymph node harvest, and a shorter hospital stay. However, the inborn limitations with the retrospective design stress a need for prospective randomized studies. Registration number is DRKS00013023.
... Although the shorter LOS in the MIE group might partly be attributed to the advances in postoperative pathways developed over the last decade that have shorten postoperative LOS. The median follow-up in this study is longer than some of the previously published research [11,33,34] with a median follow-up of 26 months for MIE and 37 months for OE (compared to previous reports ranging from 6 to 18 months). Overall, there is no difference in survival between the two groups. ...
Background:
Surgical resection remains a critical component of esophageal cancer treatment with curative-intent. The aim of this study was to compare open (OE) to minimally invasive Ivor Lewis esophagectomy (MIE) with respect to perioperative and oncologic outcomes.
Methods:
Retrospective single-institution review of MIE and OE patients operated between 2001 and 2015 was conducted. Univariable and multivariable models were created using Cox regression. The Kaplan-Meier method was used to compare oncologic outcomes. Propensity score matching was used to compare oncological outcomes in MIE and OE patients.
Results:
Of 210 esophageal resection patients, 47% had OE (137/291) and 25% had MIE (73/291). The MIE and OE groups were comparable with respect to patient factors and operative details. Fewer OE patients received neoadjuvant chemoradiation. MIE was associated with improved lymph node yield, (MIE = 30 [IQR:22-39]; OE = 14 [IQR:7-19], p < 0.001), less intraoperative blood loss (MIE = 312 mL [100-400]; OE = 657 mL [350-700], p < 0.001), and shorter median length of stay (MIE = 10 days [IQR = 8-14]; OE = 14 days [IQR = 11-22] p < 0.01). The OE group had significantly more adverse events resulting in reoperation or intensive care unit admission (MIE = 21%; OE = 34%; p < 0.01). On multivariable analysis, age and positive resection margins were associated with decreased odds of survival. The number of lymph nodes retrieved, positive resection margins, and pathologic stage were significant predictors of disease-free survival. Analysis of 69 matched pairs showed equivalent median overall survival (MIE = 49 months [18-67]; OE = 29 months [17-69]; p = 0.26) and disease-free survival (MIE = 9 [6-22]; OE = 13 [6-22]; p = 0.45) between the two groups.
Conclusions:
Although long-term oncologic outcomes appear to be similar, MIE is associated with significantly less intraoperative blood loss, improved lymph node yield, less risk of severe postoperative adverse events, and shorter length of stay.
... Since then, there has been several studies that have documented the advantages of the minimally invasive approach over the standard transthoracic and transhiatal esophagectomy. These include comparable operative time, decreased blood loss, decreased pulmonary complications, less vocal cord palsy, and reduced intensive care and hospital stay [4,5,6,7,8]. Also the advantages of MIE include a magnified view of the operative field. ...
We present the technique of triple approach minimally invasive subtotal esophagectomy: thoracoscopy, laparoscopy and left cervicotomy with gastric pull-up and cervical esogastric anastomosis in a 59 y.o patient. He was diagnosed with a middle thoracic esophageal tumor. The histologic report, thoracic CT and echoendoscopy confirmed the presence of scuamos esophageal carcinoma.
... At Moffitt Cancer Center, we prefer an Ivor Lewis esophagectomy using a robotic approach, with a right intrathoracic anastomosis. A minimally-invasive approach, as illustrated in our video, has been proven to be associated with a shorter recovery and less morbidity as compared to an open approach (7). Furthermore, the intrathoracic anastomosis avoids creating an anastomosis at the left neck, which has been found to be associated with a higher rate of dysphagia, recurrent laryngeal nerve injury and anastomotic leak (8). ...
... Thoracoscopic esophagectomy is currently accepted as the procedure of choice by a large number of surgeons due to minimal trauma and rapid recovery (3). However, esophagectomy still is a technically challenging operation with considerable potential for various postoperative complications. ...
Post-esophagectomy chylothorax is a rare yet serious complication. Herein we report the case of a patient with intractable post-esophagectomy chylothorax despite medical treatment with total parenteral nutrition and octreotide, as well as prophylactic and repeated thoracic duct mass ligation. The patient was eventually treated with localization of thoracic duct using T2-weighted magnetic resonance imaging (T2W MRI), followed by video-assisted thoracoscopic thoracic duct ligation.
... Of the 48 studies, only 1 was a randomized controlled trial (RCT) [4]. Eight studies [54,56,58,59,72,76,79,80,85] were done in the United Kingdom (UN), 8 in the USA [21,44,52,55,64,73,74,88],11 in Japan [6,45,46,50,66,68,70,75,77,78,81], 7 in China [43,63,65,82,84,86,87], 4 in Australia [3,57,60,67],3 in Netherlands [4,47,71], and 2 in Italy [49,51], and the remaining studies were conducted in Germany [61], France [69], Chile [48], and Finland [83]. Key methodological characteristics are shown in Table 1. ...
Background:
Compared with open oesophagectomy (OE), minimally invasive oesophagectomy (MIO) proves to have benefits in reducing the risk of pulmonary complications for patients with resectable oesophageal cancer. However, it is unknown whether MIO has superiority in reducing the occurrence of in-hospital mortality (IHM).
Objective:
The objective of this meta-analysis was to explore the effect of MIO vs. OE on the occurrence of in-hospital mortality (IHM).
Data sources:
Sources such as Medline (through December 31, 2014), Embase (through December 31, 2014), Wiley Online Library (through December 31, 2014), and the Cochrane Library (through December 31, 2014) were searched.
Study selection:
Data of randomized and non-randomized clinical trials related to MIO versus OE were included.
Interventions:
Eligible studies were those that reported patients who underwent MIO procedure. The control group included patients undergoing conventional OE.
Study appraisal and synthesis methods:
Fixed or random -effects models were used to calculate summary odds ratios (ORs) or relative risks (RRs) for quantification of associations. Heterogeneity among studies was evaluated by using Cochran's Q and I2 statistics.
Results:
A total of 48 studies involving 14,311 cases of resectable oesophageal cancer were included in the meta-analysis. Compared to patients undergoing OE, patients undergoing MIO had statistically reduced occurrence of IHM (OR=0.69, 95%CI =0.55 -0.86). Patients undergoing MIO also had significantly reduced incidence of pulmonary complications (PCs) (RR=0.73, 95%CI = 0.63-0.86), pulmonary embolism (PE) (OR=0.71, 95%CI= 0.51-0.99) and arrhythmia (OR=0.79, 95%CI = 0.68-0.92). Non-significant reductions were observed among the included studies in the occurrence of anastomotic leak (AL) (OR=0.93, 95%CI =0.78-1.11), or Gastric Tip Necrosis (GTN) (OR=0.89, 95%CI =0.54-1.49).
Limitation:
Most of the included studies were non-randomized case-control studies, with a diversity of study designs, demographics of participants and surgical intervention.
Conclusions:
Minimally invasive oesophagectomy (MIO) has superiority over open oesophagectomy (OE) in terms of the occurrence of in-hospital mortality (IHM) and should be the first-choice surgical procedure in esophageal surgery.
... The selected trials included a total of 43 studies and 5537 patients (Table 1). Among the included 43 studies, 19 were retrospective studies [15,[24][25][26][27][28][29][30][31][32][33][34][35][36][37][38][39][40][41], 13 were prospective ones [14,[42][43][44][45][46][47][48][49][50][51][52][53], and only 1 was randomized controlled trial (RCT) [13]. Ten studies were done in Japan [25,28,29,35,43,44,50,52,54,55] [45,64], and the remaining were conducted in Germany [30], Chile [26], Belgium [32], and Finland [37]. ...
Background:
Compared with open esophagectomy (OE), minimally invasive esophagectomy (MIE) proves to have clear benefits in reducing the risk of pulmonary complications for patients with resectable esophageal cancer. The objectives of our study were to explore the superiority of MIE in reducing the occurrence of anastomotic leakages (ALs) when compared to OE.
Methods:
A systematic review and meta-analysis was performed to assess the superiority of MIE on the occurrence of ALs over OE, by searching many sources (through December, 2014) such as Medline, Embase, Wiley Online Library, and Cochrane Library. Fixed-effects model was used to calculate summary odds ratios (ORs) to quantify associations between OE and MIE groups. Cochran's Q and I (2) statistics were used to evaluate heterogeneity among studies.
Results:
Among a total of 43 studies involving 5537 patients included in the meta-analysis, 2527 (45.6 %) cases underwent MIE and 3010 (54.4 %) cases underwent OE. Compared to patients undergoing OE, patients undergoing MIE did not have statistical significance in reduced occurrence of ALs (OR = 0.97, 95 % CI = 0.80-1.17). Insignificant reduced occurrence of ALs was not associated with anastomotic location (OR = 0.90, 95 % CI = 0.71-1.13) or anastomotic procedure (OR = 1.02, 95 % CI = 0.79-1.30).
Conclusions:
More proofs are needed to clarify the strengths or weaknesses of MIE in preventing anastomotic leakages after esophagectomy for cancer. A largely randomized, controlled trial should be undertaken to resolve this contentious issue urgently.
... To reduce the morbidity as a result of surgical trauma from open procedures, minimal invasive procedures were introduced in the recent past. There are published reports that favored the use of MIE due to advantages of shorter operative time; reduced blood loss and shorter hospital stay [7,12,[15][16][17]. Nevertheless, the conventional MIE methods are limited by the technical difficulties. ...
We have initially published our experience with the robotic transthoracic esophagectomy in 32 patients from a single institute. The present paper is the extension of our experience with robotic system and to best of our knowledge this represents the largest series of robotic transthoracic esophagectomy worldwide. The objective of this study was to investigate the feasibility of the robotic transthoracic esophagectomy for esophageal cancer in a series of patients from a single institute.
A retrospective review of medical records was conducted for 83 esophageal cancer patients who underwent robotic esophagectomy at our institute from December 2009 to December 2012. All patients underwent a thorough clinical examination and pre-operative investigations. All patients underwent robotic esophageal mobilization. En-bloc dissection with lymphadenectomy was performed in all cases with preservation of Azygous vein. Relevant data were gathered from medical records.
The study population comprised of 50 men and 33 women with mean age of 59.18 years. The mean operative time was 204.94 mins (range 180 to 300). The mean blood loss was 86.75 ml (range 50 to 200). The mean number of lymph node yield was 18. 36 (range 13 to 24). None of the patient required conversion. The mean ICU stay and hospital stay was 1 day (range 1 to 3) and 10.37 days (range 10 to 13), respectively. A total of 16 (19.28%) complication were reported in these patents. Commonly reported complication included dysphagia, pleural effusion and anastomotic leak. No treatment related mortality was observed. After a median follow-up period of 10 months, 66 patients (79.52%) survived with disease free stage.
We found robot-assisted thoracoscopic esophagectomy feasible in cases of esophageal cancer. The procedure allowed precise en-bloc dissection with lymphadenectomy in mediastinum with reduced operative time, blood loss and complications.
... However, conventional transthoracic esophagectomy and transhiatal esophagectomy have high rates of morbidity (50%) and mortality (10%) [17]. Therefore, minimally invasive techniques, such as the combination of open surgery with either thoracoscopy or laparoscopy, are being used to reduce these complications [18,19]. ...
We report on a case of synchronous carcinomas of the esophagus and stomach. A 68-year-old man was referred to our hospital for an abnormality found during his medical examination. Further evaluation revealed squamous cell carcinoma in the thoracic lower esophagus and gastric adenocarcinoma located in the middle third of the stomach. Thoracoscopic esophagectomy in the prone position (TSEP), laparoscopic total gastrectomy (LTG) with three-field lymph node dissection, and laparoscopically assisted colon reconstruction (LACR) were performed. The patient did not have any major postoperative complications. His pathological examination revealed no metastases in 56 harvested lymph nodes and no residual tumor. He was followed up for 30 months without recurrence. To our knowledge, this is the first report of esophageal and gastric synchronous carcinomas that were successfully treated with a combination of TSEP, LTG, and LACR. These operations may be a feasible and appropriate treatment for this disease.
Background
Esophagectomy is a complex oncologic operation associated with high rates of postoperative complications. While respiratory and septic complications have been well-defined, the implications of acute kidney injury (AKI) remain unclear. Using a nationally representative database, we aimed to characterize the association of AKI with mortality, resource use, and 30-day readmission.
Methods
All adults undergoing elective esophagectomy with a diagnosis of esophageal or gastric cancer were identified in the 2010–2019 Nationwide Readmissions Database. Study cohorts were stratified based on presence of AKI. Multivariable regressions and Royston-Parmar survival analysis were used to evaluate the independent association between AKI and outcomes of interest.
Results
Of an estimated 40,438 patients, 3,210 (7.9%) developed AKI. Over the 10-year study period, the incidence of AKI increased from 6.4% to 9.7%. Prior radiation/chemotherapy and minimally invasive operations were associated with reduced odds of AKI, whereas public insurance coverage and concurrent infectious and respiratory complications had greater risk of AKI. After risk adjustment, AKI remained independently associated with greater odds of in-hospital mortality (AOR: 4.59, 95% CI: 3.62–5.83) and had significantly increased attributable costs ($112,000 vs $54,000) and length of stay (25.7 vs 13.3 days) compared to patients without AKI. Furthermore, AKI demonstrated significantly increased hazard of 30-day readmission (hazard ratio: 1.16, 95% CI: 1.01–1.32).
Conclusions
AKI after esophagectomy is associated with greater risk of mortality, hospitalization costs, and 30-day readmission. Given the significant adverse consequences of AKI, careful perioperative management to mitigate this complication may improve quality of esophageal surgical care at the national level.
Background
Mediastinoscope-assisted transhiatal esophagectomy (MATHE) is the most minimally invasive esophagectomy procedure. It is a more challenging procedure and more difficult to be popularized than thoracoscopic surgery. We developed a new MATHE operation mode that provides a clearer visual field and makes the procedures simpler.
Methods
A total of 80 patients with esophageal cancer were divided into a control group (n = 29) and a study group (n = 51). The control group underwent classic MATHE, while the study group received modified MATHE. We compared the two groups on operation time; intraoperative blood loss; blood transfusion amount; incidence rate of lung infection, recurrent laryngeal nerves (RLNs) injury, chylothorax, and anastomotic leakage; and upper mediastinal lymph node dissection.
Results
The study group was significantly better than the control group in operation time (271.78 min vs. 322.90 min, p < 0.05), intraoperative blood loss (48.63 mL vs. 68.97 mL, p < 0.05), and left paratracheal lymph node (No. 4L) dissection rate (88.24% vs. 24.14%, p < 0.01). No significant differences were identified in the incidence rate of anastomotic leakage, lung complications, or RLNs injury between the two groups.
Conclusion
The modified MATHE is easier to perform. Modified MATHE is significantly superior to classic MATHE in operation time, intraoperative blood loss, and upper mediastinal lymph node dissection rate.
It has been said that “thoracoscopy suppresses the occurrence of pneumonia in comparison to thoracotomy”, but does it reflect real clinical practice? To resolve this clinical question, we compared the results of randomized controlled trials (RCTs) and retrospective cohort studies from limited institutes (CLIs) in which a large number of high-volume centers were the main participants to those of retrospective cohort studies based on nationwide databases (CNDs) in which both high-volume centers and low-volume hospitals participated. A systematic review and meta-analysis were conducted to compare the short-term outcomes of thoracoscopic to open esophagectomy for esophageal cancer in the three above-mentioned research formats. In total, 43 studies with 21,057 patients, which included 1 RCT with 115 patients, 38 CLIs with 6,126 patients and 4 CNDs with 14,816 patients, were selected. Pneumonia was one of the most important complications. Although significant superiority in thoracoscopic esophagectomy was observed in RCTs (p = 0.005) and CLIs (p = 0.003), no such difference was seen in findings using nationwide databases (p = 0.69). In conclusion, unlike RCTs and CLIs, CNDs did not show the superiority of thoracoscopic surgery in terms of post-operative pneumonia. RCTs and CLIs were predominantly performed by high-volume hospitals, while CNDs were often performed by low-volume hospitals. In actual clinical practice including various types of hospitals, the superiority of thoracoscopic over open esophagectomy regarding the incidence of pneumonia may, therefore, decrease.
Background
Robotic esophagectomies are increasingly common and are reported to have superior outcomes compared with an open approach; however, it is unclear if all institutions can achieve such outcomes. We hypothesize that early adopters of robotic technique would have improved short-term outcomes.
Methods
The National Cancer Database (2010-2016) was used to identify robotic esophagectomies. Early adopters were defined as programs which performed robotic esophagectomies in 2010-2011, late adopters in 2012-2013. Outcomes of esophagectomies performed between 2014 and 2016 were compared and included length of stay, number of lymph nodes evaluated, readmission, conversion rate, and 90-day mortality. Multivariable regressions, accounting for robotic esophagectomy volume, were used to control for confounding factors.
Results
There were 37 early adopters and 35 late adopters. Between 2014 and 2016, 683 robotic esophagectomies were performed: 446 (65.3%) by early adopters and 237 (34.7%) by late adopters. Early adopters were more likely to be academic programs (96.2 versus 72.8%, P < 0.01). Other clinical and demographic variables were similar. Late adopters were found to have decreased a number of lymph nodes evaluated (coefficient −2.407, P = 0.004) compared with early adopters. There were no significant differences in length of stay, readmissions, rate of positive margins, conversion from robotic to open, or 90-day mortality.
Conclusions
When accounting for robotic esophagectomy volume, late adoption of robotic esophagectomy was associated with a reduced lymph node harvest, but other postoperative outcomes were similar. These data suggest that programs can safely start new robotic esophagectomy programs, but must ensure an adequate case load.
Background
Assessment of quality in oncologic operations traditionally involves use of discrete metrics reported individually. Such metrics have limited value to payers and patients making broad comparisons of clinical programs. We define a composite textbook oncologic outcome for esophagectomy.
Methods
The National Cancer Database was queried to identify patients presenting with clinically resectable esophageal cancer between 2004 and 2015. Textbook oncologic outcome was defined as stage-appropriate use of neoadjuvant chemoradiation followed by margin negative esophagectomy with formal lymph node assessment and having no prolonged hospitalization, readmission, or 30-day mortality.
Results
Fourteen thousand nine hundred and sixty-nine patients underwent esophagectomy. Of those, 5,561 (37.2%) had textbook oncologic outcome. The overall survival of patients having textbook oncologic outcome was significantly longer than those who did not (52.1 (95% confidence interval [49.0–58.8]) vs 29.1 months (95% confidence interval [29.1–32.3]). On multivariable modeling adjusted for age, comorbid conditions, demographics, treatment characteristics, and esophagectomy volume, volume (odds ratio 1.38, 95% confidence interval [1.16–1.65]) and minimally invasive approach were independently associated with textbook oncologic outcome (odds ratio 1.15, 95% confidence interval [1.02–1.30]), and textbook oncologic outcome was independently associated with improved overall survival (hazard ratio 0.74, 95% confidence interval [0.68–0.80]).
Conclusion
Textbook oncologic outcome is achieved in a minority of patients undergoing esophagectomy. Textbook oncologic outcome is independently associated with improved overall survival.
Esophagectomy remains a surgical operation with the potential for significant morbidity and mortality. Minimally invasive techniques have been introduced in an attempt to reduce postoperative complications and enhance patient recovery. Whether minimally invasive techniques decrease morbidity while maintaining the quality of the oncological resection remains a topic of debate. Globally, minimally invasive esophagectomy (MIE) has been shown to be feasible and safe, with outcomes similar to open esophagectomy. Assessments of the current role of MIO have largely been made based on retrospective comparative studies and many single institution series. These generally have reported that MIO reduces blood loss, shortens time in high-dependency care, and decreases length of hospital stay. Lymph node yields appear to be similar with a minimally invasive resection compared to open extended lymphadenectomy, and MIO cancer outcomes are comparable. MIO will be a major component of the future esophageal surgeons’ armamentarium, but should continue to be carefully assessed. Randomized trials comparing MIO versus open resection in esophageal cancer are urgently needed, with only one phase III (TIME) trial having been published with the final results from a further phase III trial (MIRO trial) being keenly awaited.
Background
Open esophagectomy (OE) is associated with significant morbidity and mortality. Minimally invasive oesophagectomy (MIO) reduces complications in resectable esophageal cancer. The aim of this study is to explore the superiority of MIO in reducing complications and in-hospital mortality than OE. MethodsMEDLINE, Embase, Science Citation Index, Wanfang, and Wiley Online Library were thoroughly searched. Odds ratio (OR)/weighted mean difference (WMD) with a 95% confidence interval (CI) was used to assess the strength of association. ResultsFifty-seven studies containing 15,790 cases of resectable esophageal cancer were included. MIO had less intraoperative blood loss, short hospital stay, and high operative time (P < 0.05) than OE. MIO also had reduced incidence of total complications; (OR = 0.700, 95% CI = 0.626 ~ 0.781, PV < 0.05), pulmonary complications (OR = 0.527, 95% CI = 0431 ~ 0.645, PV < 0.05), cardiovascular complications (OR = 0.770, 95% CI = 0.681 ~ 0.872, PV < 0.05), and surgical technology related (STR) complications (OR = 0.639, 95% CI = 0.522 ~ 0.781, PV < 0.05), as well as lower in-hospital mortality (OR = 0.668, 95% CI = 0.539 ~ 0.827, PV < 0.05). However, the number of harvested lymph nodes, intensive care unit (ICU) stay, gastrointestinal complications, anastomotic leak (AL), and recurrent laryngeal nerve palsy (RLNP) had no significant difference. ConclusionsMIO is superior to OE in terms of perioperative complications and in-hospital mortality.
With the development of minimally invasive procedures, minimally invasive Ivor-Lewis esophagectomy (MIILE) has been proposed as a safe and feasible surgical choice for the treatment of esophageal cancer. This retrospective study evaluated MIILE results from a single medical center. A total of 619 patients were selected as candidates for Ivor-Lewis esophagectomy from December 2011 to May 2015, in which 334 patients accepted MIILE and 285 patients accepted open Ivor-Lewis esophagectomy (OILE). General characteristics, surgical data, complication rates, and survival were analyzed. Differences in general characteristics between groups were not significant. Intraoperative blood loss (P < 0.01), postoperative volume of drainage for the first day (P < 0.01), time to drain removal (P ≤ 0.01), wound infection rate (P = 0.04), and length of hospital stay (P < 0.01) were significantly reduced in the MIILE group. There were no statistically significant differences in general morbidity (P = 0.56), the total swept lymph nodes (P = 0.47), mortality (P = 0.34), and survival rate at 3 years (P = 0.63). MIILE is a safe and feasible method for the treatment of esophageal cancer, in which good outcomes were reported and some advantages were found over the open procedure.
Introduction:
Endoscopic techniques are rapidly gaining interest in esophageal cancer surgery due to lower pulmonary complication rates and faster postoperative recovery. Conventional two-dimensional endoscopic surgery has two main limitations: lack of depth perception and limited dexterity due to the use of rigid instruments. Theoretically, three-dimensional (3D) endoscopy can overcome these limitations, but to date, its use has not been reported in the context of esophageal cancer surgery. We studied our first series of 3D thoracolaparoscopic esophagectomies to document the safety and feasibility of implementing this technique.
Methods:
Patients who underwent a thoracolaparoscopic esophagectomy using a glasses-based 3D system with a 100° angulating camera tip were included. Continuity of the digestive tract was restored with gastric tube reconstruction and a cervical anastomosis.
Results:
All 13 resections were completed thoracolaparoscopically. Median duration of surgery was 360 minutes (range: 245-590 minutes), and median blood loss was 170 mL (range: 50-230 mL). A median of 20 lymph nodes was resected, and all resections were microscopically radical. Median hospital stay was 9 days. Two patients developed pneumonia (15%), and three patients experienced an anastomotic leakage (23%). All postoperative complications were managed on the ward.
Conclusion:
In this series, the newest generation glasses-based 3D systems proved safe and useful for the thoracolaparoscopic resection of esophageal cancer. Besides better visualization, dexterity seemed to be improved using the 100° flexible 3D camera. Implementation was without significant problems, and the first results are promising.
From the first laparoscopic cholecystectomy performed in 1985 to the introduction of robotic surgical telemanipulators in general surgery in the early 2000s, the field of general surgery has changed tremendously, to the point that isn’t general anymore; indeed this concept barely exists as a surgical discipline outside rural areas. It has however evolved into the last subspecialty of what was once known as general surgery, and it called Gastrointestinal or Alimentary Tract surgery. The factor the influenced the most on this change was the adoption of Minimally Invasive Surgery in the late 1980s, which selected the General Surgeons that were interested on the abdominal cavity and the gastrointestinal tract. Furthermore, the success and wide spread acceptance of the Laparoscopic Cholecystectomy, brought this field to the spotlight. Nowadays laparoscopic anti-reflux surgical procedures, esophagectomies, colectomies and bariatric surgery are done routinely in major centers across the United States, Europe and many parts of the world.
Background: Esophageal cancer is one of the major public health problems worldwide. Different methods of minimally invasive esophagectomy (MIE) have been described, and they represent a safe alternative for the surgical management of esophageal cancer in selected centres with high volume and expertise in them. The procedural goal is to decrease the high overall morbidity of a traditional open esophageal resection. Aims: This article reviews the most recent and largest series evaluation of MIE techniques. Methods: A literature search performed using search engines Google, HighWire press, SpringerLink, and Yahoo. Selected papers are screened for other related reports. Results: Though MIE requires greater expertise and a long learning curve, once technique has been mastered it greatly reduces the postoperative morbidity and mortality to a significant extent. There was not much difference in average operating time compared to open surgery but bleeding was less in MIE. Mean hospital stay was similar to open surgery. There was no significant difference in number and location of lymph nodes harvested. Conclusion: The current review shows that MIE with its decreased blood loss, minimal cardiopulmonary complications and decreased morbidity and oncological adequacy, represents a safe and effective alternative for the treatment of esophageal carcinoma.
The study aims to report the operative outcomes of robot-assisted thoracoscopic esophagectomy (RATE) with extensive mediastinal lymphadenectomy (ML) for intrathoracic esophageal cancer. We analyzed a prospective database of 114 consecutive patients who underwent RATE with lymph node dissection along recurrent laryngeal nerve (RLN) followed by cervical esophagogastrostomy. The study included 104 men with a mean age of 63.1 ± 0.8 years. Of these, 110 (96.5%) had squamous cell carcinoma, and the location of the tumor was upper esophagus in 7 (6.1%), middle in 62 (54.4%), and lower in 45 (39.5%). Preoperative concurrent chemoradiation was performed in 15 patients (13.2%). All but one patient underwent successful RATE, and R0 resection was achieved in 111 patients (97.4%). Extended ML and total ML were performed in 24 (21.1%) and 90 (78.9%) patients, respectively. Total operation time was 419.6 ± 7.9 minutes, and robot console time was 206.6 ± 5.2 minutes. The mean number of total, mediastinal, and RLN nodes was 43.5 ± 1.4, 24.5 ± 1.0, and 9.7 ± 0.7, respectively. The most common complication was RLN palsy (30, 26.3%), followed by anastomotic leakage (17, 14.9%) and pulmonary complications (11, 9.6%). Median hospital stay was 16 days, and 90-day mortality was observed in three patients (2.5%). On multivariate analysis, preoperative concurrent chemoradiation was a risk factor for pulmonary complications (odds ratio 7.42, 95% confidence interval 1.91-28.8, P = 0.004). RATE with extensive ML could be performed safely with acceptable postoperative outcomes. Long-term survival data should be followed in the future to verify the oncological outcome of the procedure.
© 2015 International Society for Diseases of the Esophagus.
Since 1982, Ivor Lewis esophagectomy has been performed on 264 patients with epidermoid esophageal carcinoma in our series. The mean age was 59. There were 243 men and 21 women; 91 patients had respiratory or cardiovascular problems. Two-hundred forty-eight tumors were located in the lower two thirds of the esophagus. Sixty-eight patients had preoperative radiochemotherapy with cisplatinum and 5-flourouracil. One half of the resected specimens showed no residual tumor after radiochemotherapy. Tumor infiltration was T3 or deeper in 162 specimens, and 142 were N0. The main complications were respiratory (16%) and leaks (7%). Respiratory insufficiency was always fatal, but only 16% of the leaks led to death. The overall postoperative mortality was 4.5%, and the overall 5-year survival is 33.3%. Only T1 tumors have a significantly better prognosis (53.2% 5-year survival) as compared to T2 (30.6%) and T3 (27.2%), both at 5-year survival. Negative lymph node patients have a significantly improved 5-year survival rate of 44.8% vs. 15.2% for node-positive patients. For T3 tumors, preoperative radiochemotherapy seems to improve survival. Comparison of Ivor Lewis esophagectomy with other procedures shows no radical differences in complications. The 5-year survival rate seems unaffected by the procedure chosen; radiochemotherapy and extended lymphadenectomy still need further assessment.