Comparison of three-field esophagectomy for esophageal cancer incorporating open or thoracoscopic thoracotomy

The course of physical fitness and nutritional status in patients following prehabilitation before esophageal cancer surgery: Results from the PRIOR study

INTRODUCTION

This study evaluates the course of physical fitness and nutritional status during curative therapy for esophageal cancer, after implementation of a prehabilitation program. Additionally, the impact of baseline physical fitness level and severe postoperative complications on the course of individual patients were explored.

MATERIALS AND METHODS

This multicenter, observational cohort study included patients with esophageal cancer following curative treatment. Prehabilitation, consisting of supervised exercise training and nutritional counseling was offered as standard care to patients after neoadjuvant therapy, prior to surgery. Primary outcome measures included change of exercise capacity, hand grip strength, self-reported physical functioning, Body Mass Index, and malnutrition risk from diagnosis to 2-6 months postoperatively. Analyses over time were performed using linear mixed models, and linear mixed regression models to investigate the impact of baseline level and severe postoperative complications.

RESULTS

Hundred sixty-eight patients were included (mean age 65.9 ± 8.6 years; 78.0 % male). All parameters (except for malnutrition risk) showed a decline during neoadjuvant therapy (p < .05), an improvement during prehabilitation (p < .005) and a decline postoperatively (p < .001), with a high heterogeneity between patients. Change in the outcomes from baseline to postoperatively was not different for patients with or without a severe complication. Better baseline physical fitness and nutritional status were significantly associated with a greater decline postoperatively (p < .001).

CONCLUSION

This study demonstrates a notable decline during neoadjuvant therapy, that fully recovers during prehabilitation, and a subsequent long lasting decline postoperatively. The heterogeneity in the course of physical fitness and nutritional status underlines the importance of individualized monitoring.

Robot-assisted minimally invasive esophagectomy for esophageal cancer in the left lateral decubitus position

BACKGROUND

The use of robot-assisted minimally invasive esophagectomy (RAMIE) in the prone position for esophageal cancer has been currently increasing worldwide. In future, as surgical-assisted robots become more widespread, it is estimated that only two methods of transthoracic approach will remain: RAMIE and open thoracotomy for thoracic esophageal cancer. RAMIE in the left lateral decubitus position (RAMIE-LLDP) has the same field of view as open thoracotomy, is safe in emergency situations, and provides education on open thoracotomy.

METHODS

Between September 2020 and April 2024, RAMIE-LLDP was performed in 64 consecutive patients with esophageal cancer. RAMIE-LLDP was performed with the operating table rotated and tilted 45° to the ventral side under artificial pneumothorax. The hand-control setting of the surgical-assist robot system was reversed left to right when the Patient Cart was rolled from the same direction as the RAMIE in the prone position.

RESULTS

The mean total surgery and console times during the thoracic procedure were 254-min overall and 225 min in the last 24 cases and 195-min overall and 178- min in the last 24 cases, respectively. The mean amount of blood loss was 203.4 g overall and 28.3 g in the last 24 cases. Postoperative recurrent laryngeal nerve palsy with Clavien-Dindo classification (CD) was ≥ 2 in six patients (9.4%). Postoperative pneumonia with CD ≥ 2 was observed in 11 patients (17.2%). Conversion to open thoracotomy was observed in three patients (4.7%). In all three patients, an immediate conversion to thoracotomy without patients' position change was actually possible and no serious complications were noted. No mortality occurred within 30 days postoperatively.

CONCLUSION

RAMIE-LLDP which facilitates emergency thoracotomy has perioperative results comparable to those of conventional thoracoscopic esophagectomy and is educational for open surgery. RAMIE-LLDP is the safest and most optimal surgery for esophageal cancer.

The influence of minimally invasive esophagectomy versus open esophagectomy on postoperative pulmonary function in esophageal cancer patients: a meta-analysis

OBJECTIVE

To compare the influence of minimally invasive esophagectomy (MIE) and open esophagectomy (OE) on postoperative pulmonary function in patients with esophageal cancer.

METHODS

Studies about the influence of MIE and OE on postoperative pulmonary function in esophageal cancer patients were searched from PubMed, EMBASE, the Cochrane Library, CNKI, Chinese Science and Technology Journal Database, CBM, and Wanfang Data from inception to March 18, 2021. Meta-analysis was performed using the RevMan 5.3.

RESULTS

This analysis included eight studies, enrolling 264 patients who underwent MIE and 257 patients who underwent OE. The meta-analysis results showed that the MIE group had a higher outcome regarding the percent predicted vital capacity (%VC), forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), and maximum voluntary ventilation (MVV) 1 month after surgery than the OE group. In addition, those who underwent MIE had lower ΔVC%, ΔFVC, and ΔFEV1 between pre-operation and 1 month after surgery than those who underwent OE. There is no statistical difference between the two groups in ΔMVV.

CONCLUSION

Compared with OE, MIE has a more protective effect on postoperative pulmonary function. However, due to the small number of included literature and all cohort studies, this finding needs to be validated with larger samples and higher quality RCT studies.

Impact of curative treatment on the physical fitness of patients with esophageal cancer: A systematic review and meta-analysis

BACKGROUND

Esophageal cancer and curative treatment have a significant impact on the physical fitness of patients. Knowledge about the course of physical fitness during neoadjuvant therapy and esophagectomy is helpful to determine the needs for interventions during and after curative treatment. This study aims to review the current evidence on the impact of curative treatment on the physical fitness of patients with esophageal cancer.

METHODS

A systematic literature search of PubMed, Embase, Cinahl and the Cochrane Library was conducted up to March 29, 2021. We included observational studies investigating the change of physical fitness (including exercise capacity, muscle strength, physical activity and activities of daily living) from pre-to post-neoadjuvant therapy and/or from pre-to post-esophagectomy. Quality of the studies was assessed and a meta-analysis was performed using standardized mean differences.

RESULTS

Twenty-seven articles were included. After neoadjuvant therapy, physical fitness decreased significantly. In the first three months after surgery, physical fitness was also significantly decreased compared to preoperative values. Subgroup analysis showed a restore in exercise capacity three months after surgery in patients who followed an exercise program. Six months after surgery, there was limited evidence that exercise capacity restored to preoperative values.

CONCLUSION

Curative treatment seems to result in a decrease of physical fitness in patients with esophageal cancer, up to three months postoperatively. Six months postoperatively, results were conflicting. In patients who followed a pre- or postoperative exercise program, the postoperative impact of curative treatment seems to be less.

Changes in Physical Function and Effects on QOL in Patients after Pancreatic Cancer Surgery

This study examined the changes in physical function and quality of life (QOL) of postoperative patients with pancreatic cancer for 3 months after surgery and examined the factors affecting the QOL at the 3 months after surgery. Methods: This study comprised 32 pancreatic cancer patients who underwent surgery at our hospital. Among these patients, 20 patients for whom data was measured before surgery to 3 months after surgery were selected for statistical analyses: 8 males and 12 females, 69.8 ± 7.4 years. The preoperative and postoperative rehabilitation was given to patients under the guidance of a physiotherapist. Nutritional status, body composition, physical function, gait assessments, and QOL were investigated. Results: Body weight, body fat mass, body fat percentage, body mass index (BMI), and muscle mass significantly decreased 3 months after surgery compared with their respective preoperative values. The mean grip strength at the time of 3 months after the surgery had decreased significantly from 27.3 kg to 24.5 kg. The mean skeletal muscle mass index (SMI) had decreased significantly from 6.3 kg before surgery to 5.9 kg after the surgery. The QOL scores for global health status, physical, and role showed significant decreases 2 weeks after surgery compared with the respective preoperative scores. Significant improvements in these scores were observed 3 months after surgery compared with the respective scores 2 weeks after surgery. Physical function assessments after surgery were associated with QOL 3 months after surgery. Conclusion: Recovery of patients after pancreatic cancer surgery in body weight, BMI, body fat percentage, body fat percentage, muscle mass, SMI, and grip strength was not sufficient at the time of 3 months after surgery. It has been observed that physical function of patients has affected the improvement of QOL.

Surgical outcomes of primary lung cancers following esophagectomy for primary esophageal carcinoma

BACKGROUND

The aim of this retrospective study is to evaluate the perioperative complications and prognosis of patients with a history of resected esophageal carcinoma who subsequently underwent pulmonary resection of a primary lung cancer.

METHODS

The study cohort comprised 23 patients who had undergone curative resection of a primary lung cancer following esophagectomy for a primary esophageal carcinoma. Clinical characteristics and surgical outcomes were analyzed.

RESULTS

The initial treatment for esophageal carcinoma was esophagectomy by thoracotomy in 10 patients and video assisted thoracoscopic surgery in 13. The treatments for lung cancer comprised wedge resection in three patients, segmentectomy in seven and lobectomy in 13. The pulmonary resections were performed by thoracotomy in six and video assisted thoracoscopic surgery in 17. The average operating time for the lung cancer surgeries was 202 min and average blood loss 122 ml. There were no perioperative deaths or severe complications. Three- and Five-year overall survival rates were 78.0% and 68.2%. According to univariate survival analysis, age, restrictive ventilatory impairment and histology of lung cancer were significant predictors of poor prognosis (all P < 0.05). Significantly more of the patients with than without restrictive ventilatory impairment died of other diseases (P = 0.0036).

CONCLUSIONS

Pulmonary resection for primary lung cancers following esophagectomy for esophageal carcinoma is acceptable in selected patients. Such surgery requires caution concerning intrathoracic adhesions and postoperative prolonged air leakage. Patients with restrictive ventilatory impairment had a poorer prognosis, and the indication for surgery in these patients should be carefully considered.

Comparison of short-term outcomes between transthoracic and robot-assisted transmediastinal radical surgery for esophageal cancer: a prospective study

Background

The present study aimed to assess the lower invasiveness of robot-assisted transmediastinal radical esophagectomy by prospectively comparing this procedure with transthoracic esophagectomy in terms of perioperative outcomes, serum cytokine levels, and respiratory function after surgery for esophageal cancer.

Methods

Patients who underwent a robot-assisted transmediastinal esophagectomy or transthoracic esophagectomy between April 2015 and March 2017 were included. The perioperative outcomes, preoperative and postoperative serum IL-6, IL-8, and IL-10 levels, and respiratory function measured preoperatively and at 6 months postoperatively were compared in patients with a robot-assisted transmediastinal esophagectomy and those with a transthoracic esophagectomy.

Results

Sixty patients with esophageal cancer were enrolled. The transmediastinal esophagectomy group had a significantly lower incidence of postoperative pneumonia (p = 0.002) and a significantly shorter postoperative hospital stay (p < 0.0002). The serum IL-6 levels on postoperative days 1, 3, 5, and 7 were significantly lower in the transmediastinal esophagectomy group (p = 0.005, 0.0007, 0.022, 0.020, respectively). In the latter group, the serum IL-8 level was significantly lower immediately after surgery and on postoperative day 1 (p = 0.003, 0.001, respectively) while the serum IL-10 level was significantly lower immediately after surgery (p = 0.041). The reduction in vital capacity, percent vital capacity, forced vital capacity, and forced expiratory volume at 1.0 s 6 months after surgery was significantly greater in the transthoracic esophagectomy group (p < 0.0001 for all four measurements).

Conclusions

Although further, large-scale studies are needed to confirm our findings, robot-assisted transmediastinal esophagectomy may confer short-term benefits in radical surgery for esophageal cancer.

Trial registration

This trial was registered in the UMIN Clinical Trial Registry (UMIN000017565 14/05/2015).

Minimal Invasive Esophagectomy-a New Dawn of EsophagealSurgery

Surgery is the mainstay of esophageal cancer. However, esophagectomy is a major surgical trauma on a patient with high morbidity and mortality. The intent of minimally invasive esophagectomy (MIE) is to decrease the degree of surgical trauma and perioperative morbidity associated with open surgery, and provide faster recovery and shorter hospital stay with the equivalent oncological outcome. It also allows for lesser pulmonary morbidity, less blood loss, less pain, and a better quality of life. MIE is safe and effective but has a steep learning curve with high technical expertise. Recently, it is increasingly accepted and adopted all over the globe. In this article, we discuss the safety, efficacy, short-term, and oncological outcomes of thoracoscopic- and laparoscopic-assisted minimally invasive esophagectomy and robotic surgery compared with open esophagectomy with a special focus on the Indian perspective.

Thoracoscopy-thoracotomy approach for an aortoesophageal fistula: a case report

An aortoesophageal fistula is often fatal, and standard radical surgery is highly invasive because both bilateral thoracotomy and laparotomy are required. We successfully incorporated thoracoscopic esophagectomy into this procedure for a 43-year-old man with an aortoesophageal fistula. After detaching the esophagus from the adjacent tissue, and leaving just the fistula in the right thoracoscopic procedure, we performed an open aortic graft replacement. Subsequently, we created an omental pedicle graft and wrapped it over the graft. Through this thoracoscopy-thoracostomy approach, minimal destruction of the right thoracic wall was achieved and the successful dissection of the diseased esophagus could be carried out while reducing the amount of bleeding during anticoagulation for cardiopulmonary bypass, and the field of view for the aortic replacement was not disturbed during left thoracotomy. Four months later, we reconstructed the esophagus by a pedunculated small intestinal graft through the ante-thoracic route. A thoracoscopy-thoracotomy approach is therefore considered to be effective and useful for treating a patient with an aortoesophageal fistula.

Early voice therapy for unilateral vocal fold paralysis improves subglottal pressure and glottal closure

PURPOSE

In cases of unilateral vocal fold paralysis (UVFP), voice disorders caused by glottic insufficiency can lead to a considerable reduction in the patient's quality of life. Voice therapy (VT) is an effective treatment that must be started early after the onset of vocal fold paralysis. This study examined the effect of early VT for patients with UVFP occurring after esophagectomy.

MATERIALS AND METHODS

Patients who had residual UVFP at 1 month postoperatively after esophagectomy for esophageal cancer between November 2014 and March 2017 were evaluated. Seventeen patients were divided into the VT group (n = 6) and non-VT group (n = 11). We compared these two groups and retrospectively examined the effect of early VT. The study endpoints included aerodynamic tests, laryngeal endoscopy, laryngeal stroboscopy, and glottal closure. All of these evaluations were performed at preoperatively and at 1 and 3 months postoperatively.

RESULTS

Subglottal pressure reduced notably in the VT group, and both the mean flow rate and maximum phonation time tended to improve after VT. Conversely, there were no significant differences in MFR and MPT in the non-VT group. Furthermore, although UVFP remained after VT, we achieved glottal closure for all three patients. Conversely, only two of the six patients with glottic insufficiency in the non-VT group achieved glottal closure.

CONCLUSION

VT may be effective for improving impaired vocal function in patients with UVFP. It is reasonable to expect that VT can be initiated 1 month after the onset of vocal fold paralysis.

Minimally invasive techniques for transthoracic oesophagectomy for oesophageal cancer: systematic review and network meta-analysis

BACKGROUND

Oesophagectomy is a demanding operation that can be performed by different approaches including open surgery or a combination of minimal access techniques. This systematic review and network meta-analysis aimed to evaluate the clinical outcomes of open, minimally invasive and robotic oesophagectomy techniques for oesophageal cancer.

METHODS

A systematic literature search was conducted for studies reporting open oesophagectomy, laparoscopically assisted oesophagectomy (LAO), thoracoscopically assisted oesophagectomy (TAO), totally minimally invasive oesophagectomy (MIO) or robotic MIO (RAMIO) for oesophagectomy. A network meta-analysis of intraoperative (operating time, blood loss), postoperative (overall complications, anastomotic leaks, chyle leak, duration of hospital stay) and oncological (R0 resection, lymphadenectomy) outcomes, and survival was performed.

RESULTS

Ninety-eight studies involving 32 315 patients were included in the network meta-analysis (open 17 824, 55·2 per cent; LAO 1576, 4·9 per cent; TAO 2421 7·5 per cent; MIO 9558, 29·6 per cent; RAMIO 917, 2·8 per cent). Compared with open oesophagectomy, both MIO and RAMIO were associated with less blood loss, significantly lower rates of pulmonary complications, shorter duration of stay and higher lymph node yield. There were no significant differences between surgical techniques in surgical-site infections, chyle leak, and 30- and 90-day mortality. MIO and RAMIO had better 1- and 5-year survival rates respectively compared with open surgery.

CONCLUSION

Minimally invasive and robotic techniques for oesophagectomy are associated with reduced perioperative morbidity and duration of hospital stay, with no compromise of oncological outcomes but no improvement in perioperative mortality.

Novel universally applicable technique for performing bilateral transcervical mediastinoscopic-assisted transhiatal laparoscopic esophagectomy: a truly minimally invasive procedure

BACKGROUND

The procedure of mediastinoscopic-assisted transhiatal esophagectomy (MATE) is only performed in a few institutions, despite this being the ultimate form of minimally invasive surgery for performing esophagectomy for esophageal and esophagogastric cancer in that it entails no chest wall trauma. We have developed a novel, universally applicable, surgical procedure for performing bilateral transcervical mediastinoscopic-assisted transhiatal laparoscopic esophagectomy (BTC-MATLE) that is an improvement on standard MATE surgery for esophageal and esophagogastric cancer.

METHODS

The patient is placed in a supine position under general anesthesia with bilateral lung ventilation. BTC-MATLE combined with mediastinoscopic and transhiatal laparoscopic esophagectomy with total mediastinal lymph node dissection are performed synchronously. After lymph node dissection along both recurrent laryngeal nerves through bilateral cervical skin incisions, bilateral transcervical mediastinoscopic esophagectomy is performed to avoid collision outside the cervical region and ensure operability even in patients with narrow mediastimun. Laparoscopic gastric mobilization and subsequent lower esophageal mobilization meet the bilateral transcervical mediastinoscopic esophagectomy at the border of the middle and lower third of the esophagus. The gastric tube is pulled up into the cervical region via a posterior mediastinal route and anastomosed in the neck.

RESULTS

BTC-MATLE was performed on 16 high-risk patients (Charlson Comorbidity Index ≥ 3 in 14 patients and two octogenarians with complex comorbidities). Median operation time and postoperative hospital stay were 231 min and 15 days, respectively. R0 resection was achieved in 15 patients (94%), and there were no in-hospital deaths.

CONCLUSIONS

BTC-MATLE, a procedure for performing minimally invasive esophagectomy, is likely to become the applicable form of MATE surgery for esophageal and esophagogastric cancer, even in high-risk patients because it is truly minimally invasive and has excellent short-term outcomes.

Effects of high-intensity exercise training on physical fitness, quality of life and treatment outcomes after oesophagectomy for cancer of the gastro-oesophageal junction: PRESET pilot study

Background

Treatment for cancer of the gastro‐oesophageal junction (GOJ) can result in considerable and persistent impairment of physical fitness and health‐related quality of life (HRQoL). This controlled follow‐up study investigated the feasibility and safety of postoperative exercise training.

Methods

Patients with stage I–III GOJ cancer were allocated to 12 weeks of postoperative concurrent aerobic and resistance training (exercise group) or usual care (control group). Changes in cardiorespiratory fitness, muscle strength and HRQoL were evaluated. Adherence to adjuvant chemotherapy, hospitalizations and 1‐year overall survival were recorded to assess safety.

Results

Some 49 patients were studied. The exercise group attended a mean of 69 per cent of all prescribed sessions. After exercise, muscle strength and cardiorespiratory fitness were increased and returned to pretreatment levels. At 1‐year follow‐up, the exercise group had improved HRQoL (+13·5 points, 95 per cent c.i. 2·2 to 24·9), with no change in the control group (+3·7 points, −5·9 to 13·4), but there was no difference between the groups at this time point (+9·8 points, −5·1 to 24·8). Exercise was safe, with no differences in patients receiving adjuvant chemotherapy (14 of 16 versus 16 of 19; relative risk (RR) 1·04, 95 per cent c.i. 0·74 to 1·44), relative dose intensity of adjuvant chemotherapy (mean 57 versus 63 per cent; P = 0·479), hospitalization (7 of 19 versus 6 of 23; RR 1·41, 0·57 to 3·49) or 1‐year overall survival (80 versus 79 per cent; P = 0·839) for exercise and usual care respectively.

Conclusion

Exercise in the postoperative period is safe and may have the potential to improve physical fitness in patients with GOJ cancer. No differences in prognostic endpoints or HRQoL were observed. Registration number: NCT02722785 ( https://www.clinicaltrials.gov).

Feasibility and Preliminary Effectiveness of a Tele-Prehabilitation Program in Esophagogastric Cancer Patients

Tele-rehabilitation provides better access to healthcare services and optimizes exercise adherence. However, its feasibility and effectiveness are unknown in the preoperative period in esophagogastric cancer patients. We aimed to assess the feasibility and the preliminary effects of a “tele-prehabilitation” program in esophagogastric cancer patients requiring surgery. Enrolled participants performed an internet-based tele-prehabilitation including aerobic, resistance and inspiratory muscle training over 2–4 weeks. The primary outcome was feasibility, measured in terms of recruitment, retention and attendance rates, adverse events and patient satisfaction. Secondary outcomes (functional exercise capacity, fatigue, quality of life, anxiety and depression) were assessed at baseline, presurgery, and 4 and 12 weeks postsurgery. Among the 24 eligible subjects, 23 were enrolled, 22 performed the intervention and 15 completed the study. Recruitment and retention rates were both 96%. Attendances to aerobic and resistance sessions and inspiratory muscle training were 77% and 68%, respectively. No adverse events occurred, and the satisfaction was excellent. After prehabilitation, participants significantly improved fatigue (p = 0.039), quality of life (p = 0.009), physical well-being (p = 0.034), emotional well-being (p = 0.005) and anxiety (p = 0.044). This study demonstrated the feasibility of a tele-prehabilitation in esophagogastric cancer patients undergoing surgery, with a high recruitment rate, retention rate and satisfaction, a good attendance to exercise sessions and no exercise-related adverse events.

Learning curve associated with thoraco-laparoscopic esophagectomy for esophageal cancer patients in the prone position

Objective

To observe the surgical index at the different learning stages of thoraco-laparoscopic esophagectomy in the prone position for esophageal cancer and to investigate the learning curve of this surgical procedure.

Methods

Sixty thoraco-laparoscopic esophagectomies in the prone position for esophageal cancer conducted by the same group of surgeons between January 2014 and December 2015 were retrospectively analyzed. The surgeries were divided into 5 groups, A, B, C, D, and E, in chronological order. The duration of surgery, intraoperative blood loss, total number of lymph nodes removed, rate of the intraoperative conversion to open surgery, complication rate, and length of postoperative hospitalization were recorded and analyzed.

Results

The general information of the patients did not significantly differ among the 5 groups (P > 0.05). The duration of surgery, intraoperative blood loss, number of lymph node removed, rate of intraoperative conversion to open surgery, and number of injuries to the recurrent laryngeal nerve all significantly differed (P < 0.05). The rates of postoperative pulmonary infection, anastomotic fistula, pneumothorax, and hospitalization did not significantly differ (P > 0.05).

Conclusion

Thoracic physicians with some endoscopic experience can meet the requirements of the thoraco-laparoscopic esophagectomy in the prone position for esophageal cancer after completing 24–30 surgeries.

Effectiveness of Transthoracic Hybrid Minimally Invasive Esophagectomy: A Meta-Analysis

BACKGROUND

Transthoracic hybrid minimally invasive esophagectomy (HMIE) is frequently performed in patients with esophageal cancer. However, no conclusive benefit has been defined for HMIE compared with open esophagectomy (OE) or totally MIE (TMIE). The aim of this meta-analysis is to evaluate the effectiveness of HMIE compared with OE and TMIE.

METHODS

PubMed, Embase (via OVID) and Cochrane databases were comprehensively searched for relevant studies up to January 2019. Studies comparing the efficacy of transthoracic HMIE with OE or TMIE were included in this meta-analysis.

RESULTS

Twenty-nine relevant studies comprising 3994 patients were identified and included in the analysis of HMIE vs OE. HMIE decreased the incidence of postoperative total morbidity (OR = 0.66, 95% CI 0.55 to 0.80, p = 0.00), pneumonia (OR = 0.55, 95% CI 0.45 to 0.66, p = 0.00), in-hospital mortality (OR = 0.54, 95% CI 0.36 to 0.83, p = 0.01), duration of hospitalization (SMD=-1.03, 95% CI -1.73 to -0.33, p = 0.00) and the estimated intraoperative blood loss (SMD=-1.01, 95% CI -1.62 to -0.40, p = 0.00) compared with OE. Twenty-one relevant studies comprising 3007 patients were identified and included in the analysis of HMIE vs TMIE. HMIE increased estimated intraoperative blood loss [standardized mean difference (SMD) = 1.02, 95% CI 0.45 to 1.58, p = 0.00] and the incidence of postoperative pneumonia (OR = 1.69, 95% CI 1.26 to 2.26, p = 0.00) compared with TMIE. No statistical differences were observed for other surgical outcomes.

CONCLUSIONS

In our opinion, HMIE is a promising surgical technique. But further RCTs are still needed to confirm the advantages and disadvantages of HMIE mentioned above.

Physical recovery in the first six months following oesophago-gastric cancer surgery. Identifying rehabilitative needs: a qualitative interview study

PURPOSE

To investigate patients' perspectives of their physical recovery in the first six months post oesophago-gastric cancer surgery.

MATERIALS AND METHODS

Semi-structured interviews were held at St James's Hospital, Dublin, with participants who were 4 weeks to 6 months post-oesophagectomy/gastrectomy. Interviews were an average of 14 min and included questions pertaining to physical recovery post-oesophagectomy/gastrectomy. Interviews were audio-taped, transcribed verbatim, and analyzed by thematic analysis.

RESULTS

Twenty participants (mean age 63.35(7.50) years) were recruited. Four themes were identified: i) challenges of recovery and impact on physical activity, ii) facilitators of, and barriers to, returning to physical activity, iii) physical challenges of returning to pre-operative societal roles, iv) recommendations for health services on measures which may enhance the return to physical activity. Post-operative barriers to physical activity included dietary issues, continuing treatments, pain, breathlessness, muscle weakness, fatigue, and anxiety. Participants identified that strategies such as a gradual return to activities, rest, and family support facilitated return to physical activity. Participants highlighted the need for i) greater physiotherapy input, ii) psycho-social support, and iii) fatigue management may aid physical recovery.

CONCLUSIONS

Following oesophago-gastric cancer surgery, patients experience physical and psychosocial difficulties which can hamper recovery, but many of which are amenable to rehabilitative intervention. Accordingly, rehabilitative measures throughout the early stages of recovery require investigation.Implications for RehabilitationCurative treatment for oesophageal and gastric cancer is associated with significant risk of post-operative morbidity, resulting in a myriad of physical and nutritional challenges which may impact on post-operative physical recovery.Greater provision of physiotherapy services to counteract physical impairments post oesophago-gastric cancer surgery is required.Physical recovery may also be aided through the enhanced provision of other supportive care services such as fatigue management and psychological support.

Long-Term Trends in Respiratory Function After Esophagectomy for Esophageal Cancer

BACKGROUND

Esophagectomy for esophageal cancer is known to lead to deterioration in respiratory function (RF). The aim of this study was to assess long-term trends in RF after esophagectomy and the impact of different operative procedures.

METHODS

A total of 52 patients with thoracic esophageal cancer who were scheduled for esophagectomy from 2003 to 2012 were enrolled. We prospectively evaluated patients for vital capacity (VC), forced expiratory volume in 1 s (FEV1.0), and 6-min walk distance (6MWD) before and after esophagectomy at 3, 6, 12, 24, and 60 mo.

RESULTS

Patients had mostly recovered their VC and FEV1.0 after 12 mo. After that point, VC and FEV1.0 declined again, reaching levels lower than baseline at 60 mo, with a median change ratio of 0.85 and 0.86, respectively. Although the 6MWD after open esophagectomy declined, patients treated with transhiatal esophagectomy and minimally invasive esophagectomy maintained above baseline levels throughout the follow-up period. Furthermore, we identified transhiatal esophagectomy (odds ratio [OR] = 0.03, 95% confidence interval [CI] 0.002-0.43, P = 0.01) and minimally invasive esophagectomy (OR = 0.14, 95% CI 0.02-0.94, P = 0.04) as favorable factors and postoperative pulmonary complication (OR = 9.14, 95% CI 1.22-68.6, P = 0.03) as an unfavorable factor for RF after 12 mo. Operative procedures had no significant impact on RF after 60 mo.

CONCLUSIONS

Our results support the notion that RF does not recover to the baseline level, and operative procedures have no significant impact on RF at late phase after esophagectomy.

Measuring the impact of oesophagectomy on physical functioning and physical activity participation: a prospective study

BACKGROUND

Oesophagectomy remains the only curative intervention for oesophageal cancer, with defined nutritional and health-related quality of life (HR-QOL) consequences. It follows therefore that there is a significant risk of decline in physical wellbeing with oesophagectomy however this has been inadequately quantified. This study prospectively examines change in physical functioning and habitual physical activity participation, from pre-surgery through 6-months post-oesophagectomy.

METHODS

Patients scheduled for oesophagectomy with curative intent were recruited. Key domains of physical functioning including exercise tolerance (six-minute walk test (6MWT)) and muscle strength (hand-grip strength), and habitual physical activity participation, including sedentary behaviour (accelerometry) were measured pre-surgery (T0) and repeated at 1-month (T1) and 6-months (T2) post-surgery. HR-QOL was measured using the EORTC-QOL C30.

RESULTS

Thirty-six participants were studied (mean age 62.4 (8.8) years, n = 26 male, n = 26 transthoracic oesophagectomy). Mean 6MWT distance decreased significantly from T0 to T1 (p = 0.006) and returned to T0 levels between T1 and T2 (p < 0.001). Percentage time spent sedentary increased throughout recovery (p < 0.001) and remained significantly higher at T2 in comparison to T0 (p = 0.003). In contrast, percentage time spent engaged in either light or moderate-to-vigorous intensity activity, all reduced significantly (p < 0.001 for both) and remained significantly lower at T2 in comparison to T0 (p = 0.009 and p = 0.01 respectively). Patients reported deficits in multiple domains of HR-QOL during recovery including global health status (p = 0.04), physical functioning (p < 0.001) and role functioning (p < 0.001). Role functioning remained a clinically important 33-points lower than pre-operative values at T2.

CONCLUSION

Habitual physical activity participation remains significantly impaired at 6-months post-oesophagectomy. Physical activity is a measurable and modifiable target for physical rehabilitation, which is closely aligned with patient-reported deficits in role functioning. Rehabilitation aimed at optimising physical health in oesophageal cancer survivorship is warranted.

Survival benefit of multimodal local therapy for repeat recurrence of thoracic esophageal squamous cell carcinoma after esophagectomy

BACKGROUND

This study was performed to clarify the optimal therapeutic strategy for recurrent disease after esophagectomy.

METHODS

We investigated the prognosis of 37 patients who developed recurrence among 128 patients who underwent curative thoracoscopic esophagectomy (TE) at Kanazawa University Hospital. The prognostic factors after recurrence were examined by univariate and multivariate analyses.

RESULTS

Of these 37 recurrences, 29 patients underwent local therapy (surgery, 10 patients; surgery followed by radiation, 2 patients; radiation, 17 patients). Radiation includes intensity-modulated radiation therapy, chemoradiation, and simple radiation therapy. Seventeen patients (58.6%) were considered to have undergone successful therapy by disappearance or diminishment of the targeted region without regrowth. Eleven of 17 patients (64.7%) showed repeat recurrence at another site. Multiple local therapy was performed for repeat recurrence or uncontrollable first therapy. Finally, 57 local therapies were performed. Using multimodal local therapy, 37 (64.9%) of 57 recurrences were successfully managed. The 12 patients treated by surgery as the initial therapy showed the most favorable survival. Seventeen patients who underwent successful initial therapy showed better survival than others. Multiple or miscellaneous organ metastasis, abdominal lymphatic recurrence and best supportive care at recurrence were statistically significant negative variables for survival after recurrence. Performance of surgery and successful therapy as the initial recurrence were statistically significant positive variables for survival after recurrence. Multivariate analysis showed that successful therapy at the initial recurrence was the only independent variable for survival after recurrence.

CONCLUSIONS

Multimodal local therapy for repeat recurrence after TE contributes to the improvement of survival after recurrence.

Effect of early mobilization on postoperative pulmonary complications in patients undergoing video-assisted thoracoscopic surgery on the esophagus

BACKGROUND

Esophagectomy performed via thoracotomy is associated with a high rate of postoperative pulmonary complications. Video-assisted thoracoscopic surgery at the esophagus (VATS-E) can reduce the rate of postoperative pulmonary complications. VATS-E is being increasingly implemented owing to its benefits. This procedure makes early patient mobilization possible, because there is minimal thoracic wall invasion, and thus, less postoperative pain. This study aimed to identify the efficacy of early mobilization in patients undergoing VATS-E.

METHODS

We retrospectively reviewed the patients who underwent VATS-E between November 2008 and October 2016. All the patients underwent preoperative physiotherapy and postoperative early mobilization for standard perioperative management. We examined the relation between early mobilization and the factors affecting postoperative pulmonary complications and the duration of physiotherapy with regard to the surgical outcome of VATS-E.

RESULTS

A total of 118 patients who underwent VATS-E were assessed. The incidence of postoperative pulmonary atelectasis decreased with early mobilization, and earlier mobilization was associated with a better decrease (P < 0.001). Multiple logistic regression analysis identified the percentage of volume capacity [odds ratio (OR) 0.96; 95% confidence interval (CI) 0.93-0.99] and initial walking (OR 1.82; 95% CI 1.40-2.48) as independent risk factors for postoperative pulmonary atelectasis. In addition, the presence or absence of atelectasis was found to reduce the necessary period of physiotherapy (P < 0.001).

CONCLUSION

Our results indicated that early mobilization reduces the incidence of postoperative pulmonary atelectasis, which may also contribute to early recovery in patients who undergo VATS-E.

Comparison of the outcomes between thoracoscopic and laparoscopic esophagectomy via retrosternal and prevertebral lifting paths by the same surgeon

BACKGROUND

The objective of the study is to explore the effects of retrosternal and prevertebral lifting paths of the tubular stomach on postoperative complications of patients undergoing cervical anastomosis in thoracoscopic and laparoscopic esophagectomy.

METHODS

Sixty-three patients were retrospectively analyzed. The patients received thoracoscopic and laparoscopic esophagectomy by the same surgeon. According to the path by which the stomach was lifted upward, the patients were divided into two groups: the retrosternal path group (32 patients) and the prevertebral path group (31 patients). Operative indications and complications of postoperative patients in these two groups were observed.

RESULTS

There was no statistically significant difference in the time duration of surgery, amount of bleeding, number of dissected lymph node, and postoperative hospitalization time between the retrosternal and prevertebral lifting paths (P > 0.05). Furthermore, the two groups did not show significant difference in the incidence rate of postoperative anastomosis fistula complications (P = 0.702). Instead, the amount of postoperative gastric drainage and the incidence rates of the pulmonary infection were significantly lower in the retrosternal path group than in the prevertebral path group, respectively (P = 0.001, P = 0.012, respectively).

CONCLUSION

The esophagogastrostomic cervical anastomoses performed via the retrosternal and prevertebral paths are both feasible methods of digestive tract reconstruction. The amount of postoperative gastric drainage volume and the pulmonary infection incidence rate in the retrosternal path group were lower than those in the prevertebral path group. Therefore, gastroesophageal anastomosis via the retrosternal lifting path may be preferably considered for thoracoscopic and laparoscopic surgery for esophageal carcinoma patients.

Technical details of video-assisted transcervical mediastinal dissection for esophageal cancer and its perioperative outcome

To reduce pulmonary complications after esophagectomy, the transthoracic procedure should be shortened or totally avoided. Transcervical approach assisted by mediastinoscope for the upper mediastinum may be advantageous for this purpose. We carried out video‐assisted transcervical mediastinal dissection (VATCMD) as part of totally non‐transthoracic radical esophagectomy. A single‐port laparoscopy device was adopted to a small cervical incision and the mediastinum was inflated with a positive pressure of 6 to 10 mmHg. Without assistant's retractor, the upper mediastinum and partially the middle mediastinum were dissected mainly by mediastinoscopic‐assisted surgery. Video of the operation is demonstrated with illustrations. We have carried out and reported 17 cases of esophagectomy including VATCMD and its perioperative outcome. Non‐transthoracic esophagectomy was completed without conversion to transthoracic procedure in all 17 cases. Procedure‐related adverse event was not observed and postoperative course was favorable with a zero occurrence (0%) of recurrent laryngeal nerve palsy, chyle leakage or pulmonary complications. Median number of harvested lymph nodes from the upper mediastinal stations was 10. VATCMD is suggested as a safe and feasible approach for the upper mediastinum in esophagectomy for malignancies. It enabled a totally non‐transthoracic radical esophagectomy in combination with a transhiatal approach.

Video‐assisted transcervical mediastinal dissection is suggested as a safe and feasible approach for the upper mediastinum in esophagectomy for malignancies. It enabled a totally non‐transthoracic radical esophagectomy in combination with a transhiatal approach.

Prone position in thoracoscopic esophagectomy improves postoperative oxygenation and reduces pulmonary complications

BACKGROUND

While thoracoscopic esophagectomy is a widely performed surgical procedure, only few studies regarding the influence of body position on changes in circulation and breathing, after the surgery, have been reported. This study aimed at evaluating the effect of body position, during surgery, on the postoperative breathing functions of the chest.

METHODS

A total of 266 patients who underwent right-sided transthoracic esophagectomy for esophageal cancer from 2004 to 2012 were included in this study. Fifty-four of them underwent open thoracotomies in the left lateral decubitus position (Group O), 108 underwent thoracoscopic esophagectomy in the left lateral decubitus position (Group L) and 104 patients were treated by thoracoscopic esophagectomy in the prone position (Group P). Two patients in Group P, who presented with intra-operative bleeding and underwent thoracotomy, were subsequently excluded from the pulmonary function analysis.

RESULTS

Two patients in Group P had to be changed from the prone position to the lateral decubitus position and underwent thoracotomy in order to control intra-operative bleeding. Despite the significantly longer chest operation period in Group P, total blood loss was significantly lower in this group when compared to Groups O and L. Furthermore, patients in Group P presented with significantly lower water balance during the perioperative period and markedly higher SpO₂/FiO₂ ratio after the surgery. The incidence of respiratory complications was significantly higher in Group O when compared to the other two groups; however, no significant differences were observed between the Groups L and P.

CONCLUSION

The findings of this study demonstrate that thoracoscopic esophagectomy in the prone position improves postoperative oxygenation and is therefore a potentially superior surgical approach.

Video-assisted thoracoscopic esophagectomy: keynote lecture

Minimally invasive esophagectomy (MIE) by thoracoscopy after neoadjuvant therapy results in significant short-term advantages such as a lower incidence of pulmonary infections and a better quality of life (QoL) with the same completeness of resection. After 1 year, a better QoL is still observed for MIE in comparison with the open approach, while having the same survival. Seven issues about implementation of MIE for cancer require discussion: (1) choice of the extension of esophageal resection and use of neoadjuvant therapy; (2) reasons to approach the esophageal cancer by MIE; (3) determining the best minimally invasive approach for gastro-esophageal junction cancers; (4) implementation of evidence-based MIE; (5) standardization of the surgical anatomy of the esophagus based on MIE; (6) future lines of research of MIE; and (7) learning process. In the time of imaging-integrated surgery it is clear that the MIE approach should be increasingly implemented in all centers worldwide having an adequate volume of patients and expertise.

Superiority of Minimally Invasive Oesophagectomy in Reducing In-Hospital Mortality of Patients with Resectable Oesophageal Cancer: A Meta-Analysis

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.

Laparoscopic assisted versus open gastric pull-up following thoracoscopic esophagectomy: A cohort study

BACKGROUND

Thoracolaparoscopic esophagectomy (TLE) is a type of minimally invasive esophagectomy (MIE) for esophageal cancer which consists of thoracoscopic resection and laparoscopic reconstruction. The aim of the present study was to evaluate the technical and oncological feasibility of alimentary tract reconstruction with laparoscopically assisted gastric pull-up (LAG) following thoracoscopic esophagectomy in the prone position (TSEP) in comparison with reconstruction with open laparotomy gastric pull-up (OLG) following TSEP, to establish TLE with extended lymph node dissection as a standard operation for esophageal cancer.

METHODS

Sixty-four patients with esophageal cancer underwent TSEP with 3-field lymphadenectomy from 2008 through 2010: for reconstruction after TSEP, 31 patients underwent LAG, and 33 patients underwent OLG. We retrospectively evaluated the technical and oncological feasibility of TLE with 3-field lymphadenectomy and compared surgical outcomes after reconstruction with OLG and that with LAG.

RESULTS

TLE with 3-field lymphadenectomy was successfully completed in 30 of 31 (97%) patients, and no surgery-related postoperative deaths occurred. No significant difference was found between LAG and OLG in the mean number of dissected abdominal lymph nodes, amount of blood loss, incidence of postoperative complications, mean postoperative hospital stay, restoration rate of respiratory function, or rate of complete resection or locoregional control, but the mean duration of abdominal procedures was significantly longer with LAG than with OLG.

CONCLUSION

This study demonstrates that the quality and safety of surgery and the oncological effectiveness of LAG for esophageal cancer. TLE consisting of LAG following TSEP with extended lymph-node dissection is a feasible surgical technique for thoracic esophageal carcinoma.

Recurrent laryngeal nerve monitoring during thoracoscopic esophagectomy

INTRODUCTION

There have been several reports on the feasibility and curability of thoracoscopic esophagectomy, which may reduce injury to the thoracic cage and decrease the invasiveness of surgery. Although the recurrent laryngeal nerve (RLN) is identified and kept intact during operations, RLN palsy sometimes occurs. Currently, surgical aides, including intraoperative neurological monitoring, are being utilized to avoid RLN injury during thyroid surgery. This system is utilized during thoracoscopic esophagectomy in the prone position.

PATIENTS AND METHODS

Seven consecutive patients (six men, one woman; age range 62-74 years; mean 68 years) were included. Patients underwent general anesthesia and were intubated using the NIM TriVantage™ electromyography (EMG) tube. One-lung ventilation was performed with an endobronchial blocker. Thoracoscopic esophagectomy was performed in the prone position. The nerve stimulator was calibrated to 0.5 mA, and after the RLN was visually identified it was subsequently stimulated, which also confirmed normal machine functioning. In some situations, in the absence of a response, stimuli were increased to 1.0 mA and then 2.0 mA.

RESULTS

Intraoperatively, all seven patients had their nerve signals monitored. In one case, a nerve signal disappeared after complete lymph node dissection along the left RLN. This system could identify the site of injury, and the thoracoscopic magnified view allowed the disrupted point to be located precisely. When we checked VTR after surgery, the source of injury was one point tension of the nerve pulled by fiber during lymph node dissection.

CONCLUSIONS

Intraoperative RLN monitoring during thoracoscopic esophagectomy in the prone position, with one-lung ventilation performed using the TriVantage™ EMG tube and a bronchial blocker, is technically feasible, easy, and reliable.

Minimally invasive esophagectomy for esophageal cancer: the first experience from Pakistan

Background. Two common procedures for esophageal resection are Ivor Lewis esophagectomy and transhiatal esophagectomy. Both procedures have high morbidity rates of 20–46%. Minimally invasive esophagectomy has been introduced to decrease morbidity. We report initial experience of MIE to determine the morbidity and mortality associated with this procedure during learning phase. Material and Methods. Patients undergoing MIE at our institute from January 2011 to May 2013 were reviewed. Record was kept for any morbidity and mortality. Descriptive statistics were presented as frequencies and continuous variables were presented as median. Survival analysis was performed using Kaplan Meier curves. Results. We performed 51 minimally invasive esophagectomies. Perioperative morbidity was in 16 (31.37%) patients. There were 3 (5.88%) anastomotic leaks. We encountered 1 respiratory complication. Reexploration was required in 3 (5.88%) patients. Median operative time was 375 minutes. Median hospital stay was 10 days. The most frequent long-term morbidity was anastomotic narrowing observed in 5 (9.88%) patients. There were no perioperative mortalities. Our mean overall survival was 37.66 months (95% confidence interval 33.75 to 41.56 months). Mean disease-free survival was 24.43 months (95% CI 21.26 to 27.60 months). Conclusion. Minimally invasive esophagectomy, when performed in the learning phase, has acceptable morbidity and mortality.

Retrospective study using the propensity score to clarify the oncologic feasibility of thoracoscopic esophagectomy in patients with esophageal cancer

BACKGROUND

The present study aimed to clarify the long-term prognostic impact and oncologic feasibility of thoracoscopic esophagectomy (TSE) in patients with esophageal cancer in comparison with open thoracic esophagectomy (OTE).

METHODS

Patients with esophageal cancer underwent surgically curative esophagectomy without neoadjuvant therapy from January 1991 to December 2008 and were analyzed retrospectively. Of 257 patients, 91 underwent TSE and 166 had OTE. Relations between the long-term prognosis after surgery, the surgical procedure, and clinicopathologic parameters were analyzed statistically. The propensity scores were calculated for all patients through a multiple logistic regression model that was optimized with Akaike's Information Criterion. Using Cox's proportional hazard model with prognostic variables and the propensity scores, we implemented a multivariate analysis for comparing the performance of two surgical methods.

RESULTS

Patient characteristics and the incidence of perioperative morbidity or hospital death were similar for the TSE and OTE groups. Significantly more lymph nodes were dissected in the TSE group than in the OTE group (total p = 0.013; thoracic p = 0.0094; recurrent laryngeal p < 0.0001). The TSE group exhibited a more favorable prognosis after surgery than the OTE group in terms of overall survival (p = 0.011) and disease-specific survival (DSS) (p = 0.0040). Particularly in subgroup analysis of DSS, the TSE group had a favorable prognosis in upper thoracic esophageal cancer (p = 0.0053), invasive cancer (p = 0.046), node-positive cancer (p = 0.020), progressive cancer (p = 0.0052), cancer with lymphatic vessel invasion (p = 0.0019), and cancer without blood vessel invasion (p = 0.0081). In terms of DSS, the TSE group exhibited a more favorable prognosis than the OTE group regardless of the presence or absence of metastasis to lymph nodes around the thoracic (p < 0.0001) or recurrent laryngeal (p < 0.0001) nerves. TSE (p = 0.0430), lymph node metastasis (p = 0.0382), lymphatic invasion (p = 0.0418), and p stage (p = 0.0047) were independent prognostic parameters in the Cox's proportional hazard model with the propensity scores.

CONCLUSIONS

TSE can contribute to prolonged survival after surgery in patients with esophageal cancer by enabling precise thoracic lymph node dissection based on a magnified surgical field. TSE might have maximum oncologic benefit and minimum invasiveness for patients with esophageal cancer.

Clinical evaluation of the feasibility of minimally invasive surgery in esophageal cancer

INTRODUCTION

Open thoracotomy laparotomy with extended dissection for esophageal cancer is associated with problems such as delayed postoperative recovery and decreased quality of life. In contrast, in minimally invasive surgery, these problems can be improved. In the present study, we investigated the feasibility of minimally invasive surgery in esophageal cancer.

METHODS

In this retrospective study, we evaluated esophagectomy performed by the same surgeon in 98 patients with thoracic esophageal cancer. Open surgery was performed in 30 patients (open group), and minimally invasive surgery was performed in 68 patients (MIS group). We compared the invasiveness and radical cure of cancer by minimally invasive surgery with that of open surgery.

RESULTS

Comparison between the open and MIS groups showed that intraoperative blood loss, intraoperative and postoperative transfused blood volume, and surgical site infection rates were significantly lower in the MIS group. The duration of postoperative endotracheal intubation and hospital stay were significantly shorter in the MIS group. The histopathologic type was squamous cell carcinoma in 93.3% in the open group and 92.6% in the MIS group. The respective 3-year survival rates were 36.7% and 71.5%, and the respective 5-year survival rates were 26.7% and 61.5%.

CONCLUSION

Based on a historical control study at a single institution, we are unable to conclude that minimally invasive surgery is superior to open surgery. However, our results indicate that minimally invasive surgery is feasible as a surgical procedure in esophageal cancer.

Secure hemostasis in transhiatal esophagectomy for esophageal cancer with gauze packing

BACKGROUND

Transhiatal esophagectomy for esophageal cancer implies blind manipulation of the intrathoracic esophagus. We report a secure hemostatic method with gauze packing in transhiatal esophagectomy.

METHODS

The gauze-packing technique is utilized for hemostasis just after removal of the thoracic esophagus during transhiatal esophagectomy. After confirming cancer-free margins, the abdominal esophagus and cervical esophagus are transected. A vein stripper is inserted into the oral-side stump of the esophagus and led to exit from the abdominal-side stump of the esophagus. The vein stripper and the oral stump of the esophagus are affixed by silk thread. A polyester tape is then affixed to the vein stripper, as the polyester tape is left in the posterior mediastinum after removal of the esophagus toward the abdominal side. The polyester tape on the cervical side is ligated with gauze and the polyester tape is removed toward the abdominal side. The oral stump of gauze and new additional gauze are affixed. As the first gauze is pulled out from the abdominal side, the second gauze gets drawn from the cervical wound into the mediastinum. The posterior mediastinum is finally packed with gauze and possible bleeding at this site undergoes a complete astriction. The status of hemostasis with the gauze packing is checked by an observation of color and bloodstain on the gauze.

RESULTS

Between January 2005 and February 2012, 13 consecutive patients with esophageal cancer underwent a transhiatal esophagectomy with the gauze-packing hemostatic technique. Hemostasis at the posterior mediastinum was performed successfully and quickly in all cases with this method, requiring up to four pieces of gauze for a complete hemostasis. Median required time for hemostasis was 1219 (range 1896 to 1293) seconds and estimated blood loss was 20.4 (range 15 to 25) ml during gauze packing.

CONCLUSIONS

Our technique could minimize bleeding after the removal of the thoracic esophagus. The gauze-packing method is a simple and easy technique for secure hemostasis when performing a transhiatal esophagectomy.

One surgeon's learning curve for video-assisted thoracoscopic esophagectomy for esophageal cancer with the patient in lateral position: how many cases are needed to reach competence?

BACKGROUND

Minimally invasive esophagectomy is a feasible technique shown to be safe and oncologically adequate for the treatment of esophageal cancer. This study aimed to describe one surgeon's learning curve for video-assisted thoracoscopic esophagectomy with the patient in lateral position.

METHODS

From May 2010 to June 2012, 89 thoracoscopic esophagectomies for esophageal cancer were performed by one surgeon. The patients were divided into three groups. Group A included the first 30 cases. Group B comprised cases 31 to 60, and group C included the final 29 cases. The demographic characteristics and the intra- and postoperative variables were collected retrospectively and analyzed.

RESULTS

One postoperative death occurred. Eight patients required conversion. No significant difference in background or clinicopathologic factors among the three groups was observed. Compared with group A, a significant decrease in intrathoracic operative time (107.7 ± 16.2 min; P = 0.0000), total operative time (326.3 ± 40.7 min; P = 0.0002), and blood loss (290.8 ± 114.3 ml; P = 0.0129) was observed in group B, whereas more retrieved nodes were harvested (20.1 ± 9.5; P = 0.0002). The last 29 patients (group C) involved significantly less intrathoracic operative time (82.8 ± 18.4 min; P = 0.0386), total operative time (294.7 ± 37.4 min; P = 0.0009), and blood loss (234.7 ± 87.8 ml; P = 0.0125) as well as a shorter postoperative hospital stay (12.4 ± 3.7 days; P = 0.0125) compared with group B. A significant decline in the overall morbidity from group A to group C (P = 0.0005) also was observed.

CONCLUSIONS

The results of this study suggest that at least 30 cases were needed to reach the plateau of thoracoscopic esophagectomy. After more than 60 cases of thoracoscopic esophagectomies had been managed, lower morbidity could be obtained.

Quality of life after three kinds of esophagectomy for cancer

AIM: To evaluate quality of life (QOL) following Ivor Lewis, left transthoracic, and combined thoracoscopic/laparoscopic esophagectomy in patients with esophageal cancer.

METHODS: Ninety patients with esophageal cancer were assigned to Ivor Lewis (n = 30), combined thoracoscopic/laparoscopic (n = 30), and left transthoracic (n = 30) esophagectomy groups. The QOL-core 30 questionnaire and the supplemental QOL-esophageal module 18 questionnaire for patients with esophageal cancer, both developed by the European Organization for Research and Treatment of Cancer, were used to evaluate patients’ QOL from 1 wk before to 24 wk after surgery.

RESULTS: A total of 324 questionnaires were collected from 90 patients; 36 postoperative questionnaires were not completed because patients could not be contacted for follow-up visits. QOL declined markedly in all patients at 1 wk postoperatively: preoperative and 1-wk postoperative global QOL scores in the Ivor Lewis, combined thoracoscopic/laparoscopic, and left transthoracic groups were 80.8 ± 9.3 vs 32.0 ± 16.1 (P < 0.001), 81.1 ± 9.0 vs 53.3 ± 11.5 (P < 0.001), and 83.6 ± 11.2 vs 46.4 ± 11.3 (P < 0.001), respectively. Thereafter, QOL recovered gradually in all patients. Patients who underwent Ivor Lewis esophagectomy showed the most pronounced decline in QOL; global scores were lower in this group than in the combined thoracoscopic/laparoscopic (P < 0.001) and left transthoracic (P < 0.001) groups at 1 wk postoperatively and was not restored to the preoperative level at 24 wk postoperatively. QOL declined least in patients undergoing combined thoracoscopic/laparoscopic esophagectomy, and most indices had recovered to preoperative levels at 24 wk postoperatively. In the Ivor Lewis and combined thoracoscopic/laparoscopic groups, pain and physical function scores were 78.9 ± 18.5 vs 57.8 ± 19.9 (P < 0.001) and 59.3 ± 16.1 vs 70.2 ± 19.2 (P = 0.02), respectively, at 1 wk postoperatively and 26.1 ± 28.6 vs 9.5 ± 15.6 (P = 0.007) and 88.4 ± 10.5 vs 95.8 ± 7.3 (P = 0.003), respectively, at 24 wk postoperatively. Scores in the left transthoracic esophagectomy group fell between those of the other two groups.

CONCLUSION: Compared with Ivor Lewis and left transthoracic esophagectomies, combined thoracoscopic/laparoscopic esophagectomy enables higher postoperative QOL, making it a preferable surgical approach for esophageal cancer.

Minimally invasive esophagectomy for esophageal cancer: an updated review

PURPOSE

The surgical, postoperative and oncologic outcomes of minimally invasive esophagectomy (MIE) for esophageal cancer were reviewed to clarify the benefits of this surgical modality.

METHODS

A systematic literature search was performed using synonyms for minimally invasive or thoracoscopic esophagectomy. There were 18 retrospective cohort studies and 3 meta-analyses retrieved in this review.

RESULTS

There are several minimally invasive approaches for esophageal cancer. Total MIE using both the thoracoscopic and laparoscopic approach is increasingly performed. A longer operative time and less blood loss are observed with MIE in comparison to open esophagectomy (OE). Although the benefit of MIE for reducing morbidity and mortality rates is still under debate, a shorter hospital stay was common among the studies. The oncologic outcomes of MIE were not inferior to OE, while the number of retrieved lymph nodes was greater in MIE than OE in several studies.

CONCLUSION

Total MIE using a combined thoracoscopic and laparoscopic approach can be performed safely, although the benefits for short-term outcomes are still controversial. Oncologic outcomes are favorable and MIE may have an advantage in lymph node dissection over OE. The benefits of MIE should therefore be confirmed by randomized controlled trials.

Does minimally invasive esophagectomy (MIE) provide for comparable oncologic outcomes to open techniques? A systematic review

PURPOSE

The aim of this study is to compare minimally invasive esophagectomy (MIE) and open techniques with respect to oncologic outcomes through analysis of the extent of lymph node clearance, number of lymph nodes retrieved, oncologic stage, and 5-year mortality.

METHODOLOGY

A systematic review of the literature review was conducted using MEDLINE, PubMed, EMBASE, and the Cochrane databases (1950-2011), and evaluated all comparative studies. Comparison between the open and MIE/hybrid MIE (HMIE) groups was possible with data being available for direct comparison.

RESULTS

After careful review, 17 case-control studies with 1,586 patients having an esophagectomy were included in this systematic review. The median (range) number of lymph nodes found in the MIE, open and HMIE groups were 16 (5.7-33.90), 10 (3-32.80) and 17 (17-17.15), of which there was significance between the MIE and open groups (p=0.03) but not significant between MIE versus HMIE (p=0.25). There was no statistical significance in pathologic stage between open, MIE and HMIE groups. Generally, there were good short-term (30 day) survival rates between all three groups. The open group had 5-year survival rates between 16% and 57% compared to the MIE group 12.5%-63% (p=0.33). Overall 5-year survival was found to be not significant between open group and MIE (p=0.93). MIE does not appear on statistical evidence to present any survival advantage.

CONCLUSION

The evidence of this study suggests that MIE is equivalent to standard open esophagectomy in achieving similar oncological outcomes. Further randomised controlled trials are required to provide for a higher level of evidence.

Prevention of postoperative chylothorax with thoracic duct ligation during video-assisted thoracoscopic esophagectomy for cancer

BACKGROUND

Minimally invasive esophagectomy (MIE) is a feasible technique that has been shown to be safe for the treatment of esophageal cancer. Chylothorax remains a challenging and potentially life-threatening postoperative complication of MIE. In this retrospective series, we evaluated the results of preventive intraoperative thoracic duct ligation in patients who underwent video-assisted thoracoscopic esophagectomy for cancer.

METHODS

From May 2009 to June 2010, 70 video-assisted thoracoscopic esophagectomies for cancer of the esophagus (group A) were performed without prophylactic thoracic duct ligation. Since June 2010, 65 patients (group B) with esophageal cancer underwent video-assisted thoracoscopic esophagectomy with routine ligation of the thoracic duct during the operation.

RESULTS

No intraoperative or postoperative complications directly related to thoracic duct ligation were recorded. Postoperative chylothorax occurred in seven patients in group A and in one patient in group B (P = 0.0375).

CONCLUSIONS

The results of this study suggest that thoracic duct ligation during video-assisted thoracoscopic esophagectomy for cancer is an effective and safe method for prevention of postoperative chylothorax.

Thoracoscopic resection for esophageal cancer: A review of literature

Esophageal resection remains the only curative option in high grade dysplasia of the Barrett esophagus and non metastasized esophageal cancer. In addition, it may also be an adequate treatment in selected cases of benign disease. A wide variety of minimally invasive procedures have become available in esophageal surgery. Aim of the present review article is to evaluate minimally invasive procedures for esophageal resection, especially the approach performed through right thoracoscopy.

Curative treatment of oesophageal carcinoma: current options and future developments

Since the 1980s major advances in surgery, radiotherapy and chemotherapy have established multimodal approaches as curative treatment options for oesophageal cancer. In addition the introduction of functional imaging modalities such as PET-CT created new opportunities for a more adequate patient selection and therapy response assessment.

The majority of oesophageal carcinomas are represented by two histologies: squamous cell carcinoma and adenocarcinoma. In recent years an epidemiological shift towards the latter was observed. From a surgical point of view, adenocarcinomas, which are usually located in the distal third of the oesophagus, may be treated with a transhiatal resection, whereas squamous cell carcinomas, which are typically found in the middle and the upper third, require a transthoracic approach. Since overall survival after surgery alone is poor, multimodality approaches have been developed. At least for patients with locally advanced tumors, surgery alone can no longer be advocated as routine treatment. Nowadays, scientific interest is focused on tumor response to induction radiochemotherapy. A neoadjuvant approach includes the early and accurate assessment of clinical response, optimally performed by repeated PET-CT imaging and endoscopic ultrasound, which may permit early adaption of the therapeutic concept. Patients with SCC that show clinical response by PET CT are considered to have a better prognosis, regardless of whether surgery will be performed or not. In non-responding patients salvage surgery improves survival, especially if complete resection is achieved.