Endoscopic-assisted intrathoracic oesophagogastrostomy without thoracotomy for tumours of the lower oesophagus and cardia

Robotic-assisted single-incision gastric mobilization for minimally invasive oesophagectomy for oesophageal cancer: preliminary results

OBJECTIVES

With the gradual acceptance of robotic-assisted surgery to treat oesophageal cancer and the application of a single-port approach in several abdominal procedures, we adopted a single-port technique in robotic-assisted minimally invasive oesophagectomy during the abdominal phase for gastric mobilization and abdominal lymph node dissection.

METHODS

Robotic-assisted oesophagectomy and mediastinal lymph node dissection in the chest were followed by robotic-assisted gastric mobilization and conduit creation with abdominal lymph node dissection, which were performed via a periumbilicus single incision. The oesophagogastrostomy was accomplished either in the chest (Ivor Lewis procedure) or neck (McKeown procedure) depending on the status of the proximal resection margin.

RESULTS

The procedure was successfully performed on 11 patients with oesophageal cancer from January 2017 to December 2018 in our institute. No surgical or in-hospital deaths occurred, though we had one case each of anastomotic leakage, pneumonia and hiatal hernia (9%).

CONCLUSIONS

Robotic single-incision gastric mobilization for minimally invasive oesophagectomy for treating oesophageal cancer seems feasible. Its value in terms of perioperative outcome and long-term survival results awaits future evaluation.

A standardized comparison of peri-operative complications after minimally invasive esophagectomy: Ivor Lewis versus McKeown

BACKGROUND

While our institutional approach to esophageal resection for cancer has traditionally favored a minimally invasive (MI) 3-hole, McKeown esophagectomy (MIE 3-hole) during the last five years several factors has determined a shift in our practice with an increasing number of minimally invasive Ivor Lewis (MIE IL) resections being performed. We compared peri-operative outcomes of the two procedures, hypothesizing that MIE IL would be less morbid in the peri-operative setting compared to MIE 3-hole.

METHODS

Our institution's IRB-approved esophageal database was queried to identify all patients who underwent totally MI esophagectomy (MIE IL vs. MIE 3-hole) from June 2011 to May 2016. Patient demographics, preoperative and peri-operative data, as well as post-operative complications were compared between the two groups. Post-operative complications were analyzed using the Clavien-Dindo classification system.

RESULTS

There were 110 patients who underwent totally MI esophagectomy (MIE IL n = 49 [45%], MIE 3-hole n = 61 [55%]). The majority of patients were men (n = 91, 83%) with a median age of 62.5 (range 31-83). Preoperative risk stratifiers such as ECOG score, ASA, and Charlson Comorbidity Index were not significantly different between groups. Anastomotic leak rate was 2.0% in the MIE IL group compared to 6.6% in the MIE 3-hole group (p = 0.379). The rate of serious (Clavien-Dindo 3, 4, or 5) post-operative complications was significantly less in the MIE IL group (34.7 vs. 59.0%, p = 0.013). Serious pulmonary complications were not significantly different (16.3 vs. 26.2%, p = 0.251) between the two groups.

CONCLUSIONS

In this cohort, totally MIE IL showed significantly less severe peri-operative morbidity than MIE 3-hole, but similar rates of serious pulmonary complications and anastomotic leaks. These findings confirm the safety of minimally invasive Ivor Lewis esophagectomies for esophageal cancer when oncologically and clinically appropriate. Minimally invasive McKeown esophagectomy remains a satisfactory and appropriate option when clinically indicated.

Comparison of single- and multi-incision minimally invasive esophagectomy (MIE) for treating esophageal cancer: a propensity-matched study

OBJECTIVE

To compare the perioperative outcome of minimally invasive (MIE) esophagectomy performed with a single- or a multi-incision in treating esophageal cancer.

METHOD

Patients with esophageal cancer who underwent MIE from 2006 to 2016 were evaluated. A 3-4-cm incision was created in both the thoracoscopic and the laparoscopic phases during the single-incision MIE procedures. A propensity-matched comparison was made between the two groups of patients.

RESULTS

We analyzed a total of 48 pairs of patients with propensity-matched from the cohort of 360 patients undergoing MIE during 2006-2015. There is no statistical difference in terms of postoperative ICU and hospital stay, number of dissected lymph nodes and presence of major surgical complications (anastomotic leakage and pulmonary complications) between the two groups of patients. The pain score one week after surgery was significantly lower in the single-incision group (p < 0.05). There was no surgical mortality in the single-incision MIE group.

CONCLUSION

Minimally invasive esophagectomy performed with a single-incision approach is feasible for treating patients with esophageal cancer, with a comparable perioperative outcome with that of multi-incision approaches. The postoperative pain one week after surgery was significantly reduced in patients undergoing single-incision MIE.

Techniques and short-term outcomes for total minimally invasive Ivor Lewis esophageal resection in distal esophageal and gastroesophageal junction cancers: pooled data from six European centers

Introduction

Esophagectomy for cancer can be performed in a two-stage procedure with an intrathoracic anastomosis: the Ivor Lewis esophagectomy. A growing incidence of distal and gastroesophageal junction adenocarcinomas and increasing use of minimally invasive techniques have prompted interest in this procedure. The aim of this study was to assess short-term results of minimally invasive Ivor Lewis esophagectomy (MIE-IL).

Methods

A retrospective cohort study was performed from June 2007 until September 2014, including patients that underwent MIE-IL for distal esophageal and gastroesophageal junction cancer in six different hospitals in the Netherlands and Spain. Data were collected with regard to operative techniques, pathology and postoperative complications.

Results

In total, 282 patients underwent MIE-IL, of which 90.2 % received neoadjuvant therapy. Anastomotic leakage was observed in 43 patients (15.2 %), of whom 13 patients (4.6 %) had empyema, necessitating thoracotomy for decortication. With an aggressive treatment of complications, the 30-day and in-hospital mortality rate was 2.1 %. An R0-resection was obtained in 92.5 % of the patients. After neoadjuvant therapy, 20.1 % of patients had a complete response.

Conclusions

Minimally invasive Ivor Lewis esophagectomy for distal esophageal and gastroesophageal junction adenocarcinomas is an upcoming approach for reducing morbidity caused by laparotomy and thoracotomy. Anastomotic leakage rate is still high possibly due to technical diversity of anastomotic techniques, and a high percentage of patients treated by neoadjuvant chemoradiotherapy. An aggressive approach to complications leads to a low mortality of 2.1 %. Further improvement and standardization in the anastomotic technique are needed in order to perform a safe intrathoracic anastomosis.

Single-incision laparo-thoracoscopic minimally invasive oesophagectomy to treat oesophageal cancer†

OBJECTIVES

Single-incision thoracoscopic and laparoscopic procedures have been applied in treating various diseases. However, it is unknown whether such procedures are feasible in treating oesophageal cancer.

METHODS

Minimally invasive oesophagectomy (MIO) with a single-incision approach in the thoracoscopic and laparoscopic procedures was attempted in 16 patients with oesophageal cancer.

RESULTS

One patient was converted to laparotomy and a four-port thoracoscopic procedure due to bleeding. Of the patients successfully treated with a single-port MIO, 6 underwent a McKeown procedure and 9 an Ivor Lewis procedure, including 3 cases of total laryngopharyngo-oesophagectomy with cervical pharyngogastrostomy. The mean ventilator usage of the patients after surgery was 0.3 ± 0.6 days, the mean intensive care unit (ICU) stay was 3.8 ± 3.1 days and the mean number of dissected lymph nodes was 28.6 ± 14.6. One delayed anastomotic leakage occurred, and another patient developed a trachea-oesophageal fistula induced by surgical clip-related tissue erosion, both of which were successfully treated by the placement of an oesophageal stent. No pulmonary complications or surgical mortalities occurred in the study. Minor complications developed in 2 patients, 1 experiencing pneumothorax and 1 postoperative delirium. When compared with traditional MIO in our series (n = 315), no statistical difference was found among patients receiving single-port MIO in terms of ventilator usage, ICU stay and the number of dissected lymph nodes.

CONCLUSIONS

Single-port MIO seems to be a feasible option for treating patients with oesophageal cancer, which requires further evaluation and follow-up in the future.

Minimally invasive oesophagectomy: preliminary results after introduction of an intrathoracic anastomosis

BACKGROUND

Intrathoracic anastomosis after oesophagectomy has recently been associated with reduced functional morbidity compared to a cervical anastomosis.

METHODS

From January 2011 until August 2012, all operable patients were scheduled to undergo minimally invasive oesophagectomy (MIE) with intrathoracic anastomosis. Patient characteristics, complications, morbidity and mortality were prospectively registered and analysed.

RESULTS

Forty-five patients underwent MIE with intrathoracic stapled end-to-side anastomosis. Major changes in operative technique were made 2 times due to non-satisfactory results, dividing the patients into 3 groups. One patient in group 1 died. The anastomotic leakage rate decreased from 44% in group 1 to 0% in groups 2 and 3 (p = 0.007). The pulmonary complication rate decreased from 67% in group 1 to 44% in group 2 (not significant, NS) and 22% in group 3 (p = 0.04). The median hospital stay decreased from 17 days in group 1 to 14 days in group 2 (NS) and 8 days in group 3 (p < 0.001). There were no stenoses, no dilatations and no patients with recurrent laryngeal nerve palsy.

CONCLUSIONS

The introduction of the intrathoracic anastomosis led to favourable functional results but was initially associated with considerable morbidity. RESULTS improved after changing operative techniques, but the learning curve may also be responsible.

Minimally invasive intrathoracic anastomosis after Ivor Lewis esophagectomy for cancer: a review of transoral or transthoracic use of staplers

Background

Minimally invasive Ivor Lewis esophagectomy is one of the approaches used worldwide for treating esophageal cancer. Optimization of this approach and especially identifying the ideal intrathoracic anastomosis technique is needed. To date, different types of anastomosis have been described. A literature search on the current techniques and approaches for intrathoracic anastomosis was held. The studies were evaluated on leakage and stenosis rate of the anastomosis.

Methods

The PubMed electronic database was used for comprehensive literature search by two independent reviewers.

Results

Twelve studies were included in this review. The most frequent applied technique was the stapled anastomosis. Stapled anastomoses can be divided into a transthoracic or a transoral introduction. This stapled approach can be performed with a circular or linear stapler. The reported anastomotic leakage rate ranges from 0 to 10%. The reported anastomotic stenosis rate ranges from 0 to 27.5%.

Conclusions

This review has found no important differences between the two most frequently used stapled anastomoses: the transoral introduction of the anvil and the transthoracic. Clinical trials are needed to compare different methods to improve the quality of the intrathoracic anastomosis after esophagectomy.

Is there any benefit to incorporating a laparoscopic procedure into minimally invasive esophagectomy? The impact on perioperative results in patients with esophageal cancer

BACKGROUND

The benefit of using the laparoscopic approach in minimally invasive esophagectomy (MIE) has not been established. We therefore compared the outcome of esophagectomy for patients with esophageal cancer performed with open surgery, video-assisted thoracic surgery (VATS)/laparotomy (hybrid MIE), and VATS/ laparoscopy (total MIE).

METHODS

Patients with esophageal cancer undergoing tri-incisional esophagectomy with three different approaches between 2005 and 2009 were analyzed from a prospective database.

RESULTS

Three groups of patients underwent esophagectomy by open surgery (n = 64), hybrid MIE (n = 44), and total MIE (n = 30). The total MIE group had significantly longer operative times but had shorter postoperative ventilator usage times postoperative hospital stay, and they began jejunostomy feeding sooner (P < 0.05, compared with the other groups). There was a significant trend toward a decrease in postoperative pulmonary complications and anastomotic leakage in parallel to the proportion of minimally invasive procedures for esophagectomy (P < 0.05 for the trend test), with a significant difference between the open surgery and total MIE groups (30% vs. 6.7%, and 28% vs. 6.7%, respectively; P < 0.05).

CONCLUSIONS

Use of a laparoscopic procedure in MIE for patients with esophageal cancer might provide benefit by facilitating postoperative recovery and reducing the rates of post-esophagectomy pulmonary complications and anastomotic leakage.

Minimally invasive oesophagectomy: current status and future direction

BACKGROUND

Oesophagectomy is one of the most challenging surgeries. Potential for morbidity and mortality is high. Minimally invasive techniques have been introduced in an attempt to reduce postoperative complications and recovery times. Debate continues over whether these techniques are beneficial to morbidity and whether oncological resection is compromised. This review article will analyse the different techniques employed in minimally invasive oesophagectomy (MIO) and critically evaluate commonly reported outcome measures from the available literature.

METHODS

Medline, Embase, Science Citation Index, Current Contents, and PubMed databases were used to search English language articles published on MIO. Thirty-one articles underwent thorough analysis and the data were tabulated where appropriate. To date, only level III evidence exists. Where appropriate, comparisons are made with a meta-analysis on open oesophagectomy.

RESULTS

Positive aspects of MIO include at least comparable postoperative recovery data and oncological resection measures to open surgery. Intensive care unit requirements are lower, as is duration of inpatient stay. Respiratory morbidity varies. Negative aspects include increased technical skill of the surgeon and increased equipment requirements, increased operative time and limitation with respect to local advancement of cancer. With increasing individual experience, improvements in outcome measures and the amenability of this approach to increasing neoplastic advancement has been shown.

CONCLUSION

MIO has outcome measures at least as comparable to open oesophagectomy in the setting of benign and nonlocally advanced cancer. Transthoracic oesophagectomy provides superior exposure to the thoracic oesophagus compared to the transhiatal approach and is currently preferred. No multicentre randomised controlled trials exist or are likely to come into fruition. As with all surgery, careful patient selection is required for optimal results from MIO.

Assisted laparoscopic transhiatal esophagectomy for the treatment of esophageal cancer

BACKGROUND

Esophageal resection for the treatment of esophageal cancer is usually associated with high morbido-mortality risks, that can be reduced using laparoscopy. Laparoscopic transhiatal esophagectomy (LTE) has the potential to improve these results but, to-date, only a few limited series of cases have been reported. This report summarizes our experience in 24 cases.

OBJECTIVE

To assess the outcomes following LTE.

METHODS AND MATERIALS

Between 1998 and 2005, LTE was performed in 24 patients; 18 men and 6 women with an overall mean age of 63 years (range: 36-85). Indication for surgery was lower third esophageal cancer; 11 squamous cell carcinoma and 13 adenocarcinoma. Neoadjuvant chemotherapy and radiotherapy were used in 18 patients (75%). A laparoscopic transhiatal approach was used to perform an esophagectomy with curative intent. A cervical esophagogastric anastomosis was created.

RESULTS

No reversion to conventional open surgery was required. Mean anesthesia time was 293.8 min (range: 255-360). Major complications occurred in 7 patients (29.2%). Two patients (8.3%) had leakage from the cervical anastomosis. Surgical mortality was 8.3%. The median stay in Intensive Care Unit was 5 days (range: 1-29). Median hospital stay was 11.5 days (range: 7-54). At a mean follow-up of 24.9 months, 8 patients (36.4%) had disease recurrence (36.4%), global survival rate was 62.5%, and diseasefree survival rate was 50%.

CONCLUSIONS

Assisted laparoscopic transhiatal esophagectomy for lower third esophageal cancer is a potentially safe and effective method when performed by surgeons with expertise in the field. Benefits from this approach need to be confirmed by further randomized studies.