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

Effects of pressure-controlled ventilation targeting end-inspiratory flow rate on pulmonary complications and inflammation levels in patients undergoing spinal surgery in the prone position: a randomized clinical trial

BACKGROUND

This study assessed the impact of pressure-controlled ventilation (PCV) focusing on end-inspiratory flow rate on the incidence of postoperative pulmonary complications (PPCs) and inflammation levels in patients undergoing spinal surgery in the prone position.

METHODS

A total of 187 patients who underwent posterior spinal surgery were enrolled and randomly divided into 3 groups: 61 in the volume-controlled ventilation (VCV) group (group V), 62 in the PCV-volume-guaranteed (VG) group (group P1), and 64 in the PCV-VG end-expiratory zero flow rate group (group P2). Indicators including tidal volume (VT), peak airway pressure (Ppeak), and dynamic lung compliance (Cdyn) were recorded. The Ppeak, Cdyn, PETCO2, and oxygenation index (PaO2/FiO2) after intubation (T0), after prone position (T1), 60 min after prone position (T2), and after supine position at the end of surgery (T3) of the three groups were collected.

RESULTS

In the within-group comparison, compared with T0, Ppeak increased at T1 - 2 in groups V and P1 (P < 0.01), whereas it decreased at T1 - 3 in group P2 (P < 0.01). Cdyn decreased at T1 - 2 and PaO2/FiO2 increased at T1 - 3 in all three groups (P < 0.01), and PaO2/FiO2 increased at T1 - 3 (P < 0.01). Compared with group V, Ppeak decreased at T0 - 3 in group P1 (P < 0.01) and at T1 - 3 in group P2 (P < 0.01), while Cdyn increased at T0 - 3 in groups P1 and P2 (P < 0.01). Compared with group P1, Ppeak was elevated at T0 (P < 0.01) and decreased at T1 - 3 (P < 0.05), and Cdyn was elevated at T0 - 3 in group P2 (P < 0.01). The total incidence of PPCs in group P2 was lower than that in group V (P < 0.01). Compared with the preoperative period, serum interleukin 6 (IL-6) and C-reactive protein (CRP) levels were increased at 24 and 72 h after surgery in group V (P < 0.01), whereas that was increased at 24 h after surgery in group P1 and group P2 (P < 0.01). Compared with group V, serum IL-6 and CRP levels were reduced at 24 h after surgery in groups P1 and P2 (P < 0.01 or < 0.05).

CONCLUSION

In patients undergoing spinal surgery in the prone position, PCV-VG targeting an end-inspiratory zero flow rate lowers the incidence of PPCs and inflammation levels.

A Case of Esophageal Cancer Treated by Thoracoscopic Esophagectomy after Bilateral Cadaveric Lung Transplantation

PURPOSE

With de novo cancer, esophagectomy after lung transplantation (LTx) can be challenging because of intrathoracic adhesions, delayed wound healing, and postoperative pulmonary complications, which might be lethal.

CASE PRESENTATION

A 52-year-old woman with esophageal cancer had undergone bilateral LTx for end-stage diffuse panbronchiolitis at 50 years of age. Thoracoscopic esophagectomy was performed. Bilateral bronchial arteries and subcarinal and bilateral bronchial lymph nodes were preserved to maintain blood supply to the transplanted bronchi. No ischemic changes were observed in either bronchi. The patient's postoperative course was uneventful. Although she underwent chemoradiation therapy for recurrence at the left cervical paraesophageal lymph node, she remains alive with good disease control and well-maintained respiratory function.

CONCLUSION

Minimally invasive surgery with careful attention to blood supply to the transplanted bronchi was useful for treating esophageal cancer after LTx.

Analysis of factors associated with operative difficulty in thoracoscopic esophageal cancer surgery in the left-decubitus position: a single-center retrospective study

BACKGROUND

The degree of difficulty in the overall procedure and forceps handling encountered by surgeons is greatly influenced by the positional relationship of intrathoracic organs in minimally invasive esophagectomy. This study aimed to identify the anatomical factors associated with the difficulty of minimally invasive esophagectomy assessed by intraoperative injuries and postoperative outcomes.

METHODS

Minimally invasive esophagectomy in the left-decubitus position was performed in 258 patients. We defined α (mm) as the anteroposterior distance between the front of the vertebral body and aorta, β (mm) as the distance between the center of the vertebral body and center of the aorta, and γ (degree) as the angle formed at surgeon's right-hand port site by insertion of lines from the front of aorta and from the front of vertebrae in the computed tomography slice at the operator's right-hand forceps hole level. We retrospectively analyzed the correlations among clinico-anatomical factors, surgeon- or assistant-caused intraoperative organ injuries, and postoperative complications.

RESULTS

Intraoperative injuries significantly correlated with shorter α (0.2 vs. 3.9), longer β (33.0 vs. 30.5), smaller γ (3.0 vs. 4.3), R1 resection (18.5% vs. 8.3%), and the presence of intrathoracic adhesion (46% vs. 26%) compared with the non-injured group. Division of the median values into two groups showed that shorter α and smaller γ were significantly associated with organ injury. Longer β was significantly associated with postoperative tachycardia onset, respiratory complications, and mediastinal recurrence. Furthermore, the occurrence of intraoperative injuries was significantly associated with the onset of postoperative pulmonary complications.

CONCLUSIONS

Intrathoracic anatomical features greatly affected the procedural difficulty of minimally invasive esophagectomy, suggesting that preoperative computed tomography simulation and appropriate port settings may improve surgical outcomes.

Minimally invasive laparo-thoracoscopic Ivor-Lewis esophagectomy with semi-mechanical triangular anastomosis: Short-term outcomes of 114 consecutive patients

INTRODUCTION

Several surgical teams have developed so-called minimally invasive esophagectomy techniques with the intention of decreasing post-operative complications. The goal of this report is to determine the feasibility, reproducibility, morbidity and mortality of esophagectomy and intrathoracic anastomosis via thoracoscopy.

METHODS

This retrospective series included 114 consecutive non-selected patients who underwent Lewis Santy type esophagectomy between 2016 and 2020. The procedure was performed via abdominal laparoscopy, thoracoscopy with the patient in a supine position, without selective intubation, with intra-thoracic semi-mechanical triangular esophagogastric anastomosis.

RESULTS

Mean patient age was 62.8years. Conversion from laparoscopy to laparotomy was required in three patients (2.6%); no patient required conversion from thoracoscopy to thoracotomy. A semi-mechanical triangular esophagogastric anastomosis was successfully performed in all patients. Median duration of hospital stay was 16 (8-116) days. Mortality was 2.6%; 34 patients (29.8%) had major complications, 55 (48%) had a respiratory complication. The leakage rate was 12.3%; most were type I. Only 5.2% required an additional procedure. There was no mortality.

CONCLUSION

The analysis of this consecutive series found that this operative technique was reproducible and reliable. These results need to be confirmed by other studies. Pulmonary morbidity was high and remains the main challenge in this type of surgery.

Postoperative awake prone position in geriatric patients with hip fractures: a protocol for a randomized controlled trial on the efficacy of postoperative prone position in reducing pulmonary complications and improving oxygenation

INTRODUCTION

Postoperative pulmonary complications (PPCs) are prevalent in geriatric patients with hip fractures. Low oxygen level is one of the most important risk factors for PPCs. Prone position has been proven efficacy in improving oxygenation and delaying the progress of pulmonary diseases, especially in patients with acute respiratory distress syndrome induced by multiple etiologies. The application of awake prone position (APP) has also attracted widespread attention in recent years. A randomized controlled trial (RCT) will be carried out to measure the effect of postoperative APP in a population of geriatric patients undergoing hip fracture surgery.

METHODS

This is an RCT. Patients older than 65 years old admitted through the emergency department and diagnosed with an intertrochanteric or femoral neck fracture will be eligible for enrollment and assigned randomly to the control group with routine postoperative management of orthopedics or APP group with an additional prone position for the first three consecutive postoperative days (PODs). Patients receiving conservative treatment will not be eligible for enrollment. We will record the difference in the patient's room-air-breathing arterial partial pressure of oxygen (PaO2) values between the 4th POD (POD 4) and emergency visits, the morbidity of PPCs and other postoperative complications, and length of stay. The incidence of PPCs, readmission rates, and mortality rates will be followed up for 90 PODs.

DISCUSSION

We describe the protocol for a single-center RCT that will evaluate the efficacy of postoperative APP treatment in reducing pulmonary complications and improving oxygenation in geriatric patients with hip fractures.

ETHICS AND DISSEMINATION

This protocol was approved by the independent ethics committee (IEC) for Clinical Research of Zhongda Hospital, Affiliated to Southeast University, and is registered on the Chinese Clinical Trial Registry. The findings of the trial will be disseminated through peer-reviewed journals.

ETHICS APPROVAL NUMBER

2021ZDSYLL203-P01 TRIAL REGISTRATION: ChiCTR ChiCTR2100049311 . Registered on 29 July 2021.

TRIAL STATUS

Recruiting. Recruitment is expected to be completed in December 2024.

The Influence of Preoperative Smoking Status on Postoperative Complications and Long-Term Outcome Following Thoracoscopic Esophagectomy in Prone Position for Esophageal Carcinoma

BACKGROUND

Esophagectomy for esophageal carcinoma is associated with higher morbidity and mortality rates than other gastrointestinal surgeries. Smoking is an established risk factor for postoperative complications after esophagectomy. This study aimed retrospectively to investigate the impact of smoking status on short- and long-term outcomes for patients undergoing thoracoscopic esophagectomy in the prone position (TEP) for esophageal carcinoma.

METHODS

In this study, 234 patients with esophageal carcinoma who underwent TEP between 2012 and 2020 were divided into two groups based on smoking status (current or non-current smokers and the Brinkman index) by patients' declarations. Postoperative complications (Clavien-Dindo classification grade ≥2), overall survival (OS), and disease-free survival (DFS) were compared between smoking statuses.

RESULTS

The rates of postoperative complications did not differ significantly between the two groups (current smoker vs non-current smoker; Brinkman index ≥800 vs <800). The rate of postoperative pneumonia was higher in the combination group of current and higher Brinkman index (≥800) smokers than in the other group (25.0 % vs 11.8 %; P = 0.036). Multivariate analysis showed that smoking status was an independent risk factor for postoperative pneumonia (hazard ratio, 0.41; 95 % confidence interval, 0.18-0.93; P = 0.037). According to the long-term outcomes, no significant differences in OS and DFS were observed between the smoking statuses.

CONCLUSIONS

The combination of current smoking and heavy smoking history is a risk factor for postoperative pneumonia in patients who have esophageal carcinoma treated with TEP, although no correlation was observed between the long-term outcomes and smoking status.

Prone position thoracoscopic-assisted total mesoesophageal excision: initial experiences and benefits of lymph node dissection

OBJECTIVE

Total mesoesophageal excision (TME) is a promising procedure. Prone position thoracoscopic-assisted TME might be a good choice, even without robust evidence yet. Therefore, it is necessary to explore the safety and efficacy of this procedure.

METHODS

We retrospectively analyzed the short-term outcomes regarding intraoperative unplanned events, postoperative complications, and lymphadenectomy in 61 patients who underwent prone position thoracoscopic-assisted TME from June, 2020 to August, 2021. The learning curve was also defined.

RESULTS

Of these sixty-one patients, there were 10, 24 and 27 cases of tumor in the upper, middle, and lower thoracic, respectively. Although there were five cases of unplanned events during surgery, no conversion to thoracotomy occurred. The median thoracic operation time was 113(43-161) minutes, R0 resection rate was 93.4% (57/61), and negative circumferential resection margin rate was 96.7% (59/61). Median overall lymph node dissection was 21(9-47), with 13(5-41) thoracic lymph node dissection. Incidence of postoperative pulmonary complications, cardiovascular complications, and leakage were 9.8%, 3.3%, and 9.8%, respectively, with no death within 30 days after operation. The positive rate of middle and lower mediastinal lymph nodes was 1.1%, 3.5%, and 2.4% for upper, middle, and lower tumors, and 5.5%, 1.8%, and 1.3% for pT3-4, pT2, and pT1 patients. Learning curve showed that 36 cases are the best cut-off value for proficiency of prone position thoracoscopic-assisted TME.

CONCLUSIONS

The prone position thoracoscopic-assisted TME is a safe procedure that is more conducive to thoracic lymph node dissection, especially for middle and lower mediastinum.

Influence of patient position in thoracoscopic esophagectomy on postoperative pneumonia: a comparative analysis from the National Clinical Database in Japan

BACKGROUND

Two prominent patient positions during thoracoscopic esophagectomy are the left lateral decubitus position (LP) and the prone position (PP). However, whether the patient position during thoracoscopic esophagectomy influences short-term outcomes, especially postoperative pneumonia, remains unclear. We aimed to elucidate the impact of patient position on the occurrence of postoperative pneumonia.

METHODS

We analyzed 9850 patients who underwent oncologic thoracoscopic esophagectomies between 2016 and 2019 from the National Clinical Database. We compared the short-term outcomes between the LP and PP groups, and the primary outcome measure was the incidence of postoperative pneumonia.

RESULTS

This study included 2637 (26.8%) and 7213 (73.2%) patients in the LP and the PP groups, respectively. The baseline characteristics of the two groups were well-balanced. Compared with the LP group, the PP group had a longer operative time and less blood loss. There were no significant differences in the incidences of postoperative pneumonia, recurrent laryngeal nerve palsy, anastomotic leakage, severe complications, and reoperation between the groups. Meanwhile, prolonged ventilation and surgery-related mortality occurred more frequently in the LP than in the PP group (P < 0.001 and 0.046, respectively). After multivariable adjustment, the patient position did not significantly influence the incidence of postoperative pneumonia (odds ratio 0.91, 95% confidence interval 0.80-1.04).

CONCLUSIONS

Although prolonged ventilation and surgery-related mortality occurred more frequently in the LP group than in the PP group, the patient position did not significantly influence the occurrence of postoperative pneumonia.

Short- and long-term outcomes of thoracoscopic esophagectomy in the prone position for esophageal squamous cell carcinoma in patients with obstructive ventilatory disorder: a propensity score-matched study

BACKGROUND

Many patients with esophageal squamous cell carcinoma (ESCC) have obstructive ventilatory disorder (OVD), which is considered a risk factor for postoperative pneumonia. It has been reported that thoracoscopic esophagectomy in the prone position (TEP) is less invasive and is associated with fewer postoperative respiratory complications compared with open esophagectomy. This matched-cohort study aimed to elucidate the safety and oncologic outcomes of ESCC patients with OVD who undergo TEP.

METHODS

In this matched-cohort study, 237 patients with ESCC who underwent TEP between 2010 and 2018 were divided into two groups based on forced expiratory volume in 1 s/forced vital capacity. Postoperative complications (Clavien-Dindo classification grade II or higher), overall survival (OS), and disease-free survival (DFS) were compared between the two groups.

RESULTS

Based on their propensity scores, 75 patients with normal respiratory function (NRF) and 75 with OVD were selected. The rates of postoperative pneumonia were not significantly different between the two groups (NRF group vs OVD group: 18.7% vs 18.7%; P = 1.000). The rates of recurrent laryngeal nerve palsy and anastomotic leakage were also not significantly different (NRF group vs OVD group: 12.0% vs 18.7%, P = 0.365; 18.7% vs 18.7%, P = 1.000). The 5-year OS and DFS rates in the NRF vs OVD groups were 66.2% vs 54.9% and 63.5% vs 52.9%, respectively, with no significant differences (P = 0.421, 0.197).

CONCLUSIONS

TEP can be safely performed on ESCC patients with OVD and can result in an oncological efficiency equal to that of the NRF group.

Adverse outcomes of artificial pneumothorax under right bronchial occlusion for patients with thoracoscopic-assisted oesophagectomy in the prone position versus the semiprone position

Background

There are few studies on the impact of body position on variations in circulation and breathing, and it has not been confirmed whether body position changes can reduce the pulmonary complications of thoracoscopic-assisted oesophagectomy.

Methods

A single-center retrospective study included patients undergoing thoracoscopic-assisted oesophagectomy in the prone position or semiprone position between 1 July 2020, and 30 June 2021, at the Shanghai Chest Hospital. There were 103 patients with thoracoscopic-assisted oesophagectomy in the final analysis, including 43 patients undergoing thoracoscopic-assisted oesophagectomy in the prone position. Postoperative pulmonary complication (PPC) incidence was the primary endpoint. The incidence of cardiovascular and other complications was the secondary endpoint. Chest tube duration, patient-controlled anaesthesia (PCA) pressing frequency within 24 h, ICU stay, and the postoperative hospital length of stay (LOS) were also collected.

Results

Compared with the semiprone position, the prone position decreased the incidence of atelectasis (12% vs. 30%, P = 0.032). Nevertheless, there were no considerable differences in the rates of cardiovascular and other complications, ICU stay, or LOS (P &gt;0.05). Multivariable logistic regression analysis showed that the prone position (OR = 0.196, P = 0.011), no smoking (OR = 0.103, P &lt;0.001), preoperative DLCO% ≥90% (OR = 0.230, P = 0.003), and an operative time &lt;180 min (OR = 0.268, P = 0.006) were associated with less atelectasis.

Conclusions

Our study shows that artificial pneumothorax under right bronchial occlusion one-lung ventilation for patients with thoracoscopic-assisted oesophagectomy in the prone position can decrease postoperative atelectasis compared with the semiprone position.

Minimally invasive oesophagectomy in the prone versus lateral decubitus position: a systematic review and meta-analysis

The thoracic phase of minimally invasive esophagectomy was initially performed in the lateral decubitus position (LDP); however, many experts have gradually transitioned to a prone position (PP) approach. The aim of the present systematic review and meta-analysis is to quantitatively compare the two approaches. A systematic literature search of the MEDLINE, Embase, Google Scholar, Web of Knowledge, China National Knowledge Infrastructure and ClinicalTrials.gov databases was undertaken for studies comparing outcomes between patients undergoing minimally invasive esophageal surgery in the PP versus the LDP. In total, 15 studies with 1454 patients (PP; n = 710 vs. LDP; n = 744) were included. Minimally invasive esophagectomy in the PP provides statistically significant reduction in postoperative respiratory complications (Risk ratios 0.5, 95% confidence intervals [CI] 0.34-0.76, P < 0.001), blood loss (weighted mean differences [WMD] -108.97, 95% CI -166.35 to -51.59 mL, P < 0.001), ICU stay (WMD -0.96, 95% CI -1.7 to -0.21 days, P = 0.01) and total hospital stay (WMD -2.96, 95% CI -5.14 to -0.78 days, P = 0.008). In addition, prone positioning increases the overall yield of chest lymph node dissection (WMD 2.94, 95% CI 1.54-4.34 lymph nodes, P < 0.001). No statistically significant difference in regards to anastomotic leak rate, mortality and 5-year overall survival was encountered. Subgroup analysis revealed that the protective effect of prone positioning against pulmonary complications was more pronounced for patients undergoing single-lumen tracheal intubation. A head to head comparison of minimally invasive esophagectomy in the prone versus the LDP reveals superiority of the former method, with emphasis on the reduction of postoperative respiratory complications and reduced length of hospitalization. Long-term oncologic outcomes appear equivalent, although validation through prospective studies and randomized controlled trials is still necessary.

Salvage minimally invasive esophagectomy after definitive chemoradiotherapy for esophageal cancer can improve postoperative complications compared with salvage open esophagectomy

BACKGROUND

Although the advantage of minimally invasive esophagectomy (MIE) over open esophagectomy (OE) in planned esophagectomy is being established, the utility of salvage MIE (S-MIE) remains unclear. We aimed to investigate the feasibility and advantage of S-MIE compared with salvage OE (S-OE).

METHODS

We retrospectively assessed 82 patients who underwent salvage esophagectomy after definitive chemoradiotherapy for thoracic esophageal cancer between January 2007 and April 2020. Perioperative factors and postoperative complications were compared between the S-OE group (n = 62) and the S-MIE group (n = 20). Logistic regression analysis was performed to analyze the factors associated with postoperative complications.

RESULTS

Regarding the patients' preoperative characteristics, the S-OE group had a significant number of grade ≥ cT3 patients vs the S-MIE group (69% vs 35%, respectively; p = 0.006), whereas ycT rates were comparable. Compared with S-OE, S-MIE had comparable operative time, number of harvested thoracic lymph nodes, and R0 resection, but significantly less estimated blood loss (150 ml and 395 ml, respectively; p = 0.003). Regarding postoperative complications, total complications (79% vs 50%; p = 0.01) and pneumonia (48.3% vs 20%; p = 0.02) rates were significantly lower with S-OE vs S-MIE, respectively. On multivariate analysis, S-MIE was an independent factor associated with postoperative pneumonia (odds ratio: 0.29, 95% confidence interval: 0.06-0.99; p = 0.04) and total complications (odds ratio: 0.26, 95% confidence interval: 0.07-0.86; p = 0.02).

CONCLUSION

S-MIE was feasible for salvage esophagectomy, with favorable short-term outcomes vs S-OE regarding postoperative pneumonia and total complications.

Incidence of Recurrent Laryngeal Nerve Palsy in Robot-Assisted Versus Conventional Minimally Invasive McKeown Esophagectomy in Prone Position: A Propensity Score-Matched Study

BACKGROUND

Esophagectomy with lymphadenectomy is the principal treatment for localized esophageal cancer. Conventional minimally invasive esophagectomy (C-MIE) in prone position has spread worldwide as it is less invasive. However, its efficacy remains controversial. Robot-assisted MIE (RAMIE) can have more advantages than C-MIE. Therefore, the current study aimed to validate whether RAMIE is associated with lower incidence of left recurrent laryngeal nerve (RLN) palsy compared with C-MIE in prone position.

PATIENTS AND METHODS

In total, 404 patients with esophageal carcinoma underwent MIE (353 C-MIEs and 51 RAMIEs) in prone position at Kobe University between 2010 and 2020. Then, propensity score matching was performed, and results showed that 51 patients should be included in each group. Thereafter, the perioperative outcomes between the two groups were compared.

RESULTS

The RAMIE group had a significantly longer operative time than the C-MIE group (P < 0.0001). However, the number of lymph nodes resected along the left RLN was similar in both groups. Moreover, the incidence of left RLN palsy was significantly lower in the RAMIE group than in the C-MIE [Clavien-Dindo classification grade II; 0 (0%) versus 32 (9%), P = 0.022 in entire cohort, and 0 (0%) versus 5 (10%), P = 0.022 in matched cohort. Esophagectomy Complications Consensus Group definitions type I; 8 (16%) versus 101 (29%), P = 0.041 in entire cohort and 8 (16%) versus 18 (35%) in matched cohort, P = 0.023].

CONCLUSION

RAMIE is superior to C-MIE in prone position in decreasing the incidence of left RLN palsy.

Case report on thoracoscopic esophagectomy for long segment resistant oesophageal stricture in HIV infected patient

INTRODUCTION

The incidence of Esophageal strictures following esophagitis in human immunodeficiency virus (HIV)-infected patients is profound in majority of cases. Although endoscopic dilatation remains the first line of treatment, surgery is needed for non-dilatable strictures. Sparse literature is available on clinical management for surgical intervention.

PRESNTATION OF THE CASE

A 30 years old HIV positive male, taking ART for 10 years, presented with grade V dysphagia over long standing non-specific ulcerative esophagitis. Upper GI endoscopy revealed a long stricture starting 18 cm from the incisors. The patient underwent multiple endoscopic dilatation along with twice endoscopic stent placements over period of 2 years. As CD4 count was low associated with poor nutritional status a feeding jejunostomy was constructed. With improvement in CD4 count and nutritional status within 3 months; thoracoscopic esophagectomy, laparotomy and formation of gastric conduit and cervical anastomosis was performed. There were no intraoperative or postoperative adverse events with complete improvement in dysphagia. During follow up, 24 months after surgery the patient was on full oral diet with a total weight gain of 15 kg.

DISCUSSION

Long term solution to dysphagia due to long esophageal stricture merits a surgery in form of a replacement conduit by either stomach tube or a segment of colon. Experience and literature guiding surgical decision making are limited. Retaining or excision of the native oesophagus is still a matter of discussion.

CONCLUSION

Thoracoscopic esophagectomy with gastric tube conduit for reconstruction is a feasible and safe surgical option for esophageal stricture in a HIV infected patient.

Does staged surgical training for minimally invasive esophagectomy have an impact on short-term outcomes?

BACKGROUND

sophageal cancer has a low incidence, and the anatomy is difficult to understand during esophagectomy. This necessitates a precise and lengthy operation. Therefore, the establishment of a training system in esophageal surgery is of critical importance. In this study, we compared the short-term outcomes of minimally invasive esophagectomy (MIE) performed by consultants versus trainees and explored the factors that impacted the thoracic operation time for each group.

METHODS

We have introduced standardized MIE surgical techniques to our trainees in 2016. Our procedure consists of a laparoscopic phase and a thoracoscopic phase and is systematically designed to be learned in a step-by-step manner in each phase. We retrospectively identified 308 patients who underwent MIE from April 2016 to April 2018. The patients were divided into those who underwent MIE by consultants and those who underwent MIE by trainees. The preoperative background factors, operation-related factors, and postoperative complications were compared between the two groups. We also assessed the association between a prolonged thoracic operation time and tumor-and patient-related factors in each of the consults and trainees.

RESULTS

Significantly more patients had stage ≥ III cancer in the consultant than trainee group. However, the postoperative complications were comparable, specifically pneumonia (11% vs. 18%), anastomotic leakage (11% vs. 13%), and mortality (0.6% vs. 1.3%). There was no significant difference in the lymph node yield (20 vs. 17) or R0 resection rate (94% vs. 91%) between the two groups. However, the trainees had a significantly longer thoracic operation time (143 ± 34 vs. 190 ± 28 min) and significantly greater blood loss (93 vs. 183 ml). Oncological factors were correlated with a prolonged thoracic operation time in the consultants, but not in the trainees.

CONCLUSIONS

Under standardized surgical management using a stepwise educational program, performance of MIE by trainees has no impact on short-term outcomes.

Completely Minimally Invasive Esophagectomy Versus Hybrid Esophagectomy for Esophageal and Gastroesophageal Junctional Cancer: Clinical and Short-Term Oncological Outcomes

BACKGROUND

Minimally invasive surgery for resectable esophageal and gastroesophageal junctional (GEJ) cancer significantly reduces morbidity when compared with open surgery, as is evident from published landmark trials. Comparison of outcomes between hybrid esophagectomy (HE) and completely minimally invasive esophagectomy (CMIE) remains unclear.

OBJECTIVE

We aimed to ascertain whether CMIE is associated with less postoperative complications compared with HE without oncological compromise.

METHODS

All consecutive two-stage HEs and CMIEs performed between 2016 and 2018 were included. All procedures were performed with an intrathoracic anastomosis. Primary clinical outcomes were pulmonary infective and overall complications within 30 days of surgery, while primary oncological outcomes included overall survival (OS) and disease-free survival (DFS) at both 6 months and to date. Secondary outcomes included intraoperative variables and postoperative clinical parameters.

RESULTS

Overall, 98 patients had CMIEs and 49 patients had HEs. There were no baseline differences between the two groups. Thirty-day postoperative pulmonary infection rates were lower in the CMIE group compared with the HE group (12.2% vs. 28.6%; p = 0.014), and 30-day overall postoperative complication rates were also lower following CMIE (35.7% vs. 59.2%; p = 0.007). OS and DFS were similar between the two groups at 6 months (p = 0.201 and p = 0.109, respectively).

CONCLUSIONS

CMIE is associated with less pulmonary infective and overall postoperative complications compared with HE for resectable esophageal and GEJ cancer. No intergroup difference was observed regarding short-term survival and cancer recurrence in patients undergoing CMIE and HE. A randomized controlled trial comparing the two operative approaches is required to validate these findings.

Current status of minimally invasive esophagectomy for esophageal cancer: Is it truly less invasive?

Esophagectomy with extended lymphadenectomy remains the mainstay of treatment for localized esophageal cancer. However, it is one of the most invasive procedures with high morbidity. To reduce invasiveness, minimally invasive esophagectomy (MIE), which includes thoracoscopic, laparoscopic, mediastinoscopic, and robotic surgery, is becoming popular worldwide. Thoracoscopic esophagectomy in the prone position is ergonomic for the surgeon and has better perioperative arterial oxygen pressure/fraction of inspired oxygen (P/F) ratio. Thoracoscopic esophagectomy in the left decubitus position is easy to introduce because it is similar to standard right posterolateral open esophagectomy (OE) in position. It has a relatively short operative time. Laparoscopic approach could potentially have a substantial effect on pneumonia prevention under the condition of thoracotomy. Mediastinoscopic surgery has the potential to reduce pulmonary complications because it can avoid a transthoracic procedure. In robotic surgery, in the future, less recurrent laryngeal nerve palsy will be expected as a result of polyarticular fine maneuvering without human tremors. In studies comparing MIE with OE, mediastinoscopic surgery and robotic surgery are usually not included; these studies show that MIE has a longer operative time and less blood loss than OE. MIE is particularly beneficial in reducing postoperative respiratory complications such as atelectasis, despite no dramatic decrease in pneumonia. Reoperation might occur more frequently with MIE. There is no significant difference in mortality rate between MIE and OE. It is important to recognize that the advantages of MIE, particularly "less invasiveness", can be of benefit at facilities with experienced medical personnel.

Thoracoscopic esophagectomy with total meso-esophageal excision reduces regional lymph node recurrence

PURPOSE

We investigated the operative outcomes of thoracoscopic esophagectomy (TE) in the prone position, using the concept of total meso-esophageal excision for esophageal cancer.

METHODS

The medical records of 140 consecutive patients with esophageal cancer who underwent radical esophagectomy by TE were reviewed retrospectively, and operative outcomes were compared between patients treated before (non-meso-esophagus; non-ME group) and after (ME group) the introduction of total meso-esophageal excision (ME).

RESULTS

There were no significant differences between the groups in postoperative morbidity (non-ME group vs. ME group, 28.3% vs. 41.4%, p = 0.119), 30-day mortality (non-ME group vs. ME group, 0% vs. 1.1%; p = 0.433), and in-hospital mortality (non-ME group vs. ME group, 1.9% vs. 0%, p = 0.199). Although overall survival and relapse-free survival did not differ significantly between the groups, the overall recurrence rate was significantly lower in the ME group than the non-ME group (non-ME group vs. ME group, 43.4% vs. 23%, p = 0.011). In particular, the rate of regional lymph node recurrence in the mediastinum was lower in the ME group (non-ME group vs. ME group, 11.3% vs. 2.3%; p = 0.026).

CONCLUSIONS

Our results suggest that the ME procedure might be one of the procedures that reduce regional lymph node recurrence in the mediastinum without any deterioration in short-term outcomes.

Comparison of perioperative and oncological outcome of thoracoscopic esophagectomy in left decubitus position and in prone position for esophageal cancer

PURPOSE

The aim of this study was to clarify the differences between thoracoscopic esophagectomy in the left decubitus position (LP) and in the prone position (PP) in terms of short-term perioperative outcomes and long-term oncological outcomes after more than 5 years of follow-up.

METHODS

Patients with esophageal cancer who underwent thoracoscopic esophagectomy and were followed up for more than 5 years were analyzed retrospectively. Of 142 patients, 72 underwent LP esophagectomy and 70 underwent PP esophagectomy. Operation time, blood loss, operative morbidity, mortality, length of hospital stay, and the number of dissected lymph nodes were compared to evaluate short-term outcomes. Cancer recurrence and overall survival were compared to examine long-term outcomes.

RESULTS

Patient and tumor characteristics were not different between the LP and PP groups except for the rate of neoadjuvant chemotherapy. Blood loss was significantly lower in the PP group than in the LP group. Incidence of Clavien-Dindo (C.D.) grade ≥ III complications was significantly lower in the PP group than in the LP group. Pulmonary complications were also significantly lower in the PP group than in the LP group. Operation type (LP versus PP) was identified as an independent risk factor for pulmonary complications (odds ratio 0.27, p = 0.03) by multivariate analysis. Cancer recurrence rate, initial recurrence site, and overall survival rate were not different between the two groups.

CONCLUSIONS

PP is regarded as a less invasive procedure than LP with the same oncological effect.

Is thoracoscopic-laparoscopic esophagectomy a better alternative to thoracoscopic esophagectomy?

BACKGROUND

Minimally invasive esophagectomy (MIE) is gaining rapid popularity as an alternative to conventional open esophagectomy. However, whether incorporating laparoscopy into MIE can further help the patients with esophageal cancer has rarely been studied. The aim of this study was to evaluate the short-term clinical efficacy of thoracoscopic-laparoscopic esophagectomy (TLE) compared with thoracoscopic esophagectomy (TE) in treating esophageal cancer.

METHODS

From September 2014 to December 2016, a total of 131 patients with esophageal cancer who had consecutively undergone MIE were included in the analysis; of them, TLE was performed in 71 patients and TE in 60 patients. Characteristics and perioperative outcomes of all patients were collected and compared to determine differences between the 2 groups.

RESULTS

Operation time (p = 0.172), chest drainage volume (p = 0.656), and pathologic staging (p = 0.671) were similar in the 2 groups. Compared with the TE approach, the TLE approach was associated with less blood loss during the operation (median, 100 vs 150 ml, p < 0.001), shorter chest drainage time (median, 2 vs 3 days, p < 0.001), a larger number of harvested lymph nodes (median, 24 vs 20, p < 0.001), and shorter postoperative hospital stay (median, 10 vs 11 days, p = 0.008). There was no significant difference between groups with regard to the major (grade ≥ III) and minor (grade < III) complications.

CONCLUSIONS

TLE is a safe and effective alternative to TE. Patients undergoing TLE may benefit from less blood loss, a larger number of harvested lymph nodes and faster postoperative recovery. Additional randomized controlled trial with longer follow-up is needed.

Efficacy of CO2 insufflation during thoracoscopic esophagectomy in the left lateral position

OBJECTIVE

Thoracoscopic esophagectomy (TE) is widely performed as a minimally invasive technique in the management of esophageal cancer. The aim of this study was to estimate the efficacy of intrathoracic carbon dioxide (CO2) insufflation during TE in the left lateral position.

METHODS

From January 2010 to April 2016, 58 patients with esophageal cancer underwent TE without intrathoracic CO2 insufflation (Group N) and 37 patients with esophageal cancer underwent TE with intrathoracic CO2 insufflation (Group C). The operation results and respiratory parameters during the thoracic procedure were compared in both groups.

RESULTS

A satisfactory surgical field was obtained by CO2 insufflation. There was no difference in the duration of the thoracic procedure or number of dissected mediastinal lymph nodes between the two groups. The amount of thoracic blood loss in Group C was significantly less than that in Group N (P < 0.05). Intrathoracic CO2 insufflation did not affect oxygenation during single-lung ventilation. However, both end-tidal CO2 (ETCO2) 1 h after single-lung ventilation and maximum ETCO2 in Group C were significantly higher than those in Group N. Intraoperative hypercapnia in Group C was permissive. The rate of extubation in the operation room, mortality and morbidity were not different between the two groups.

CONCLUSIONS

Intrathoracic CO2 insufflation is beneficial to make satisfactory surgical field and to reduce thoracic blood loss in TE. Application of intrathoracic CO2 insufflation may contribute to the widespread adoption of TE in the left lateral position.

Investigation of operative outcomes of thoracoscopic esophagectomy after triplet chemotherapy with docetaxel, cisplatin, and 5-fluorouracil for advanced esophageal squamous cell carcinoma

BACKGROUND

Preoperative chemotherapy with cisplatin and 5-fluorouracil (CF) has become the standard treatment for resectable stage II/III thoracic esophageal carcinoma in Japan. Recently, preoperative triplet chemotherapy with docetaxel, cisplatin, and 5-fluorouracil (DCF) has been reported to be effective for locally advanced esophageal cancer. Thoracoscopic esophagectomy (TE) has been increasingly accepted worldwide for the treatment of esophageal cancer. We conducted a retrospective study to evaluate the safety and outcomes of TE after DCF therapy for patients with advanced esophageal cancer.

METHODS

The medical records of 63 consecutive patients with esophageal squamous cell carcinoma who underwent thoracoscopic surgery after chemotherapy were reviewed. Thirty-four patients received neoadjuvant chemotherapy with CF, and 29 received DCF as first-line chemotherapy.

RESULTS

The clinical T stage was significantly higher in the DCF group than in the CF group (p < 0.0001), including 17 patients with T4. Lymph node metastasis was more frequent in the DCF group (p = 0.0005), and the clinical stage of the tumor was significantly higher in the DCF group than in the CF group (p = 0.0001). No significant difference existed between the two groups in operation time for the thoracic procedure (DCF 277.2 min vs. CF 302 min). Blood loss during the thoracic procedure was less in the DCF group than in the CF group (DCF 46.9 mL vs. CF 88.8 mL; p = 0.0056). No significant differences existed between the two groups in postoperative morbidity (DCF 34.5% vs. CF 47%) or mortality (DCF 0% vs. CF 2.9%) rates.

CONCLUSIONS

Our study suggests that TE after DCF therapy for advanced esophageal cancer is as safe as TE after CF therapy.