The lateral decubitus position improves transoral endoscopic access to the posterior aspects of the thorax

The application of rigid and flexible mediastinoscopy in esophagectomy: our experience and a new technology

Background

To avoid the inconvenience of triangulation among various rigid operating instruments in mediastinoscopy-assisted esophagectomy, we invented a new technique: used a flexible endoscope to mobilize thoracic esophagus and dissected mediastinal lymph nodes through the left cervical incision. This technology has not been reported so far. In this study, we introduce our long-term experience and demonstrate this new technique.

Methods

Twenty-nine patients with early esophageal cancer underwent mediastinoscopy-assisted esophagectomy in our hospital from June 2018 to September 2020. Among them, 12 patients used flexible mediastinoscopy, and 17 patients used conventional rigid mediastinoscopy and instruments to observe their therapeutic effect.

Results

There were no significant differences between the two groups in gender, average age, body mass index, incidence of adverse reactions, bleeding volume, and postoperative hospital stay. The operation time of flexible mediastinoscopy group was significantly shorter than that of rigid mediastinoscopy group (192.9 ± 13.0 vs 246.8 ± 6.9 min, p < 0.01). The number of lymph nodes removed by flexible endoscopy was significantly more than that of rigid endoscopy (8.5 ± 0.6 vs 6.0 ± 0.3, P < 0.01). Postoperative follow-up was completed for all patients, and the average follow-up time was 11.6 ± 7.2 months. During the follow-up period, no recurrence or death was observed.

Conclusions

Mediastinoscopy-assisted esophagectomy is an effective way to treat early esophageal cancer. The application of flexible mediastinoscopy provides more convenience and better stability. It can facilitate the operation of the surgeon and lymph node dissection, which proved to be a feasible technology.

Transoral endoscopic mediastinal surgery (TOEMS)-results of a first clinical study for scarless mediastinal lymph node biopsies

BACKGROUND

Video-assisted mediastinoscopy (VAM) represents the standard procedure for mediastinal lymph node biopsies. This operation results in a scar at prominent position at the anterior neck. Since there is a trend to less invasive procedures, natural orifice transluminal endoscopic surgery (NOTES) was introduced to different fields of surgery. Based on NOTES we developed a new approach for mediastinoscopy: transoral endoscopic mediastinal surgery (TOEMS). In previous studies using human cadavers and living pigs the feasibility of TOEMS was shown. It was unclear whether TOEMS could be safely applied in patients requiring mediastinal lymph node biopsies.

METHODS

We conducted a clinical phase I study recruiting ten patients with unclear mediastinal lymphadenopathy not resolved by prior bronchoscopy. All patients underwent TOEMS for mediastinal lymph node biopsy. The duration of the procedure and complications were monitored. In addition, all patients were examined for pain, swallowing dysfunction and sensation disturbance.

RESULTS

TOEMS was accomplished in eight patients. In two patients operation was converted to VAM due to technical problems. Mediastinal lymph nodes were dissected in all patients who finished with TOEMS. On average, two separate lymph stations were reached by TOEMS. Duration of the procedure was 159±22 min. Permanent palsy of the right recurrent laryngeal nerve was noticed in one patient postoperatively.

CONCLUSIONS

This is the first report for a human application of NOTES in thoracic surgery. In fact, transoral endoscopic surgery seems to be a feasible approach for mediastinal lymph node biopsies. Further studies are needed to show whether this procedure has an advantage over VAM in terms of pain, complications and accessibility of mediastinal lymph node stations.

Feasibility of endoscopic transumbilical thoracic sympathectomy in a porcine model

OBJECTIVES

Thoracoscopic sympathectomy is an effective treatment for palmar hyperhidrosis. Current methods are associated with risks of chronic neuropathic pain and a visible chest scar. We developed a novel surgical technique for the performance of sympathectomy by embryonic natural orifice transumbilical endoscopic surgery with a flexible endoscope in a porcine model.

METHODS

Transumbilical flexible endoscopic thoracic sympathectomies were performed in seven farm pigs (three acute and four 4-week survivals). Under general anaesthesia, animals were intubated and mechanically ventilated with a dual lumen endotracheal tube through tracheostomy. A newly developed long transabdominal trocar was placed through the umbilicus. After insertion of a gastroscope through this trocar, a small incision was created on both sides of the diaphragm by a needle-knife. Then the gastroscope was inserted into the thoracic cavity, and the sympathetic chain was identified at the desired thoracic level and ablated. Operation time, safety and feasibility were recorded in all animals.

RESULTS

The transumbilical thoracic sympathectomies were successfully completed in all pigs with a mean operation time of 66.7 ± 9.4 min. Intraoperative bleeding occurred in one pig during the electrosurgical incision of diaphragm tissue, which was successfully controlled by hot biopsy forceps. No other acute intraoperative complications were observed in any cases. In the acute group, the length of the diaphragm incision ranged from 4 to 5 mm in three pigs. In the survival group, the animals recovered promptly from surgery. In three pigs, a small pneumothorax was found in the postoperative chest X-ray, but all of them were completely resolved with conservative treatment. Autopsy showed all bilateral T3 sympathetic chains were successfully ablated and no evidence of vital structure injury or diaphragmatic hernia.

CONCLUSIONS

Transumbilical flexible endoscopic thoracic sympathectomy is technically feasible, simple and safe in a porcine model. This technique can be used as a novel experimental platform for studies of natural orifice transluminal endoscopic surgery (NOTES) for intrathoracic surgery.