Muscle sparing thoracotomy for esophageal cancer: a comparison with posterolateral thoracotomy

Early volume loss of skeletal muscle after esophagectomy: a risk for late-onset postoperative pneumonia

Late-onset postoperative pneumonia (LOPP) after esophagectomy is poorly understood. This study was designed to clarify the features and risk factors for this event. Patients who underwent esophagectomy for esophageal cancer between 2006 and 2016 were included. LOPP was defined as radiologically proven pneumonia that occurred over 3 months after surgery, and clinically relevant late-onset postoperative pneumonia (CR-LOPP) was defined as LOPP that required administration of oxygen and antibiotics in the hospital and/or more intensive treatment. The total psoas muscle area (TPA) was measured using preoperative and postoperative (at 3 months after surgery) computed tomography scan images. Potential risk factors for CR-LOPP were investigated. Among 175 study patients, 46 (26.3%) had LOPP, 29 (16.6%) of whom exhibited CR-LOPP with a cumulative incidence of 15.6% at 3 years and 22.4% at 5 years. Four (13.8%) of these patients died of LOPP. Univariable analysis showed that clinical stage ≥III (P = 0.005), preoperative prognostic nutritional index (PNI) <45 (P = 0.035), arrhythmia (P = 0.014), postoperative hospital stay ≥40 days (P = 0.003), and percent decrease of TPA more than 5% (P < 0.001) were associated with CR-LOPP but not early onset postoperative pneumonia. Multivariable analysis revealed that clinical stage ≥III (hazard ratio [HR] 3.01, P = 0.004), postoperative hospital stay ≥40 days (HR 2.51, P = 0.015), and percent decrease of TPA >5% (HR 9.93, P < 0.001) were independent risk factors for CR-LOPP. CR-LOPP occurred in over 20% of patients at 5 years, and early postoperative loss of TPA was a potential trigger for this delayed complication.

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.

Dexmedetomidine Added to Ropivacaine for Ultrasound-guided Erector Spinae Plane Block Prolongs Analgesia Duration and Reduces Perioperative Opioid Consumption After Thoracotomy: A Randomized, Controlled Clinical Study

OBJECTIVES

Single-injection erector spinae plane block (ESPB) provides good control of pain relief after open thoracotomy surgeries. However, the duration of pain relief does not last long. For this purpose, we hypothesized that adding α2-adrenoceptor agonist, dexmedetomidine, for interfascial nerve blockade may increase the duration of analgesia. There are only few studies using dexmedetomidine for interfasical nerve blocks in humans. In this study, our aim is to investigate whether addition of dexmedetomidine to ropivacaine for ESPB could effectively prolong the duration of postoperative analgesia and reduce opioid consumption after open thoracotomy.

MATERIALS AND METHODS

Sixty patients with esophageal cancer were randomized to receive ESPB using 28 mL of 0.5% ropivacaine, with 2 mL of normal saline (group R) or 0.5 µg/kg dexmedetomidine in 2 mL (group RD) administered interfascially. ESPB was performed at the fifth thoracic level under ultrasound guidance. The primary outcome was the duration of analgesia. The secondary outcomes were total postoperative sufentanil consumption, Numeric Rating Scale pain scores, Ramsay Sedation Scale scores and adverse effects.

RESULTS

The duration of analgesia in group RD (505.1±113.9) was longer than that in group R (323.2±75.4) (P<0.001). The total postoperative sufentanil consumption was lower in group RD (23.3±10.0) than in group R (33.8±13.8) (P=0.001). There was no significant difference in the incidence of adverse effects between the 2 groups.

CONCLUSION

After open thoracotomy, addition of dexmedetomidine to ropivacaine for ESPB effectively prolonged the duration of postoperative analgesia and reduced opioid consumption without increasing additional incidence of adverse effects.

[Hybrid esophagectomy with intraoperative hyperspectral imaging : Video article]

The technique of hybrid esophagectomy with systematic 2‑field lymphadenectomy for esophageal cancer showed a significant reduction in postoperative morbidity in a recently published prospective randomized study. This video publication presents the abdominothoracic hybrid procedure with (i) laparoscopic gastrolysis and ischemic conditioning of the stomach and (ii) 2-stage transthoracic esophagectomy with gastric pull-up, intrathoracic gastric tube formation and anastomosis. Intraoperative hyperspectral imaging (HSI) during the thoracic part of the operation is used for identification of the ideally perfused anastomotic region.

MUSCLE-SPARING VERSUS STANDARD POSTEROLATERAL THORACOTOMY IN NEONATES WITH ESOPHAGEAL ATRESIA

Background:

The muscle-sparing thoracotomy (MST) has not yet been thoroughly studied and assessed in comparison to the traditional thoracotomy method in newborns.

Aim:

To compare the outcomes of MST and standard posterolateral thoracotomy (PLT) in newborns.

Methods:

Randomized, controlled, double-blind trial on 40 neonates with esophageal atresia, comparing the time of beginning a surgery until seeing the pleura, the duration of hospitalization in the neonatal intensive care unit, the time in ventilator, the time of returning the shoulder function, the time of returning the Moro reflex, and the mortality between the two techniques.

Results:

The data showed no differences between the two groups in basic information (weight, height, gender, numbers of prematurity neonates and caesarean). The results on the size of the scar in the MST group was significantly lower than in the PLT group. Also, the time of returning the shoulder function in MST group was earlier than in PLT group. There were no significant differences in the duration since the beginning the surgery to see the pleura, the time of being hospitalized in intensive unit, the time that the infant required ventilator, returning time of the Moro reflex in 1^st and 3^rd months after the operation, and the mortality rates between MST and PLT groups.

Conclusion:

It seems that the advantages of using MST over PLT procedure in neonates include the earlier shoulder function recovery and also superior cosmetic results.

Clinical value of a prophylactic minitracheostomy after esophagectomy: analysis in patients at high risk for postoperative pulmonary complications

BACKGROUND

The aim of this study is to evaluate the clinical value of a prophylactic minitracheostomy (PMT) in patients undergoing an esophagectomy for esophageal cancer and to clarify the indications for a PMT.

METHODS

Ninety-four patients who underwent right transthoracic esophagectomy for esophageal cancer between January 2009 and December 2013 were studied. Short surgical outcomes were retrospectively compared between 30 patients at high risk for postoperative pulmonary complications who underwent a PMT (PMT group) and 64 patients at standard risk without a PMT (non-PMT group). Furthermore, 12 patients who required a delayed minitracheostomy (DMT) due to postoperative sputum retention were reviewed in detail, and risk factors related to a DMT were also analyzed to assess the indications for a PMT.

RESULTS

Preoperative pulmonary function was lower in the PMT group than in the non-PMT group: FEV1.0 (2.41 vs. 2.68 L, p = 0.035), and the proportion of patients with FEV1.0% <60 (13.3% vs. 0%, p = 0.009). No between-group differences were observed in the proportion of patients who suffered from postoperative pneumonia, atelectasis, or re-intubation due to respiratory failure. Of the 12 patients with a DMT, 11 developed postoperative pneumonia, and three required re-intubation due to severe pneumonia. Multivariate analysis revealed FEV1.0% <70% and vocal cord palsy were independent risk factors related to a DMT.

CONCLUSION

A PMT for high-risk patients may prevent an increase in the incidence of postoperative pneumonia and re-intubation. The PMT indications should be expanded for patients with vocal cord palsy or mild obstructive respiratory disturbances.

Tracheoesophageal fistula after total resection of gastric conduit for gastro-aortic fistula due to gastric ulcer

Background

Tracheoesophageal fistula (TEF) is a rare but life-threatening complication after esophagectomy. It has a high mortality rate and often leads to severe aspiration pneumonia. Various types of surgical repair procedures have been reported, but the optimal management of TEF is challenging and controversial. Treatment should be individualized to each patient.

Case presentation

A 66-year-old female underwent transthoracic esophagectomy with gastric tube reconstruction and an intrathoracic anastomosis for esophageal cancer. Three years later, she had hematemesis and was diagnosed with a gastro-aortic fistula due to a gastric ulcer. She underwent endovascular aortic repair urgently at another hospital. Two days later, she underwent total resection of the gastric tube, during which time an injury to the trachea occurred; it was repaired by patching the stump of the esophagus to the injury site. Two months later, descending aortic replacement was performed due to infection of the stent graft. Six months after the first operation, a TEF developed. The patient was referred to our hospital for further treatment. The fistula was ligated and divided via a cervical approach, and a pectoralis major muscle flap was used to cover the defect. Esophageal reconstruction with the pedunculated jejunum was performed via a subcutaneous route. The postoperative course was uneventful. The patient was discharged after 6 months of physical and dysphagia rehabilitation.

Conclusion

A TEF located near the cervicothoracic border was successfully treated with a pectoralis major muscle flap through a cervical approach. Total resection of a gastric conduit in the posterior mediastinum carries a risk of tracheobronchial injury; however, if such an injury occurs, surgeons should be able to repair the injury using a suitable flap depending on the injury site.

[Oncologic esophageal resection and reconstruction : Open, hybrid, minimally invasive or robotic?]

Minimally invasive resections are increasingly employed in oncologic surgery for esophageal carcinoma. The new German S3 guideline states that esophagectomy, as well as reconstruction of the esophagus, can be performed minimally invasively or in combination with open techniques (hybrid). However, the current value of different techniques - ranging from complete minimally invasive esophagectomy over hybrid to robotic surgery - remains unregarded.This review provides a critical comparison of these techniques based on current evidence. Minimally invasive procedures of oncologic esophageal resection are safe in experienced hands and show numerous advantages with regard to postoperative reconvalescence. Laparoscopic gastrolysis with intra-abdominal lymphadenectomy and muscle sparing as well as anterolateral mini-thoracotomy (also via VATS as single-port technique) as a hybrid method also result in a relevant reduction of postoperative mortality and offer the possibility of extended mediastinal lymphadenectomy, which requires a high level of expertise when performed thoracoscopically. At present, robotic esophagectomy is applied in only a few clinics in Germany. A lack of evidence based on studies for esophageal surgery, as well as high acquisition and operating costs of the robotic system, have to be taken into account.