Modified anastomotic technique for thoracolaparoscopic Ivor-Lewis esophagectomy: early outcomes and technical details

Efficacy of modified thoraco-laparoscopic Ivor-Lewis versus traditional thoraco-laparoscopic Ivor-Lewis for esophageal cancer: Propensity score-matched analysis

Objective

To compare the clinical results of the modified Ivor-Lewis procedure, which preserves the azygous vein, thoracic duct and surrounding tissues, with the traditional Ivor-Lewis procedure, which removes these tissues, for treating esophageal squamous cell carcinoma, and evaluating whether the azygous vein, thoracic duct and surrounding tissues are required to be removed for the surgery of esophageal cancer.

Methods

To retrospectively analyze the clinical data of patients suffering from esophageal cancer treated by thoracic-laparoscopic Ivor-Lewis procedure admitted to the Department of Thoracic Surgery of Gansu Provincial People's Hospital from September 2017 to September 2019. According to the surgical method, they were divided into the modified thoracolaparoscopic Ivor-Lewis (modified group) and the traditional thoracolaparoscopic Ivor-Lewis (traditional group). Propensity score matching analysis (PSM) was applied to reduce the selection bias of confounding factors.

Results

A total of 245 patients who suffered from esophageal cancer and underwent thoracic-laparoscopic Ivor-Lewis were enrolled in the study. There were 124 cases in the modified group and 121 cases in the traditional group. The discrepancies in the age and T-stage among patients in the traditional and modified groups were statistically significant. After PSM, the above-mentioned factors became statistically insignificant. There were 86 patients in each group after PSM. Compared with the traditional group, the modified group has shorter operative time (p=0.007), less intraoperative bleeding (p=0.003) and less postoperative 3 days chest drainage(p=0.001), with a statistically significant difference. No significant difference in local recurrence (p=0.721) and distant metastasis (p=0.742) after surgery were found in the two groups, and the difference was not statistically significant. There was also no statistically significant difference in the 3-year postoperative survival rate (44.2% vs. 41.9%, p=0.605) between the modified and traditional groups.

Conclusion

The modified Ivor-Lewis procedure, which preserves the azygous vein, thoracic duct, and surrounding tissue, reduces surgical trauma in esophageal cancer, has not increased postoperative recurrent metastases, while achieved the same long-term outcomes as expanded surgery.

The comparisons of three stapler placement methods for intrathoracic mechanistic circular stapling in Ivor Lewis minimally invasive esophagectomy

Background

To analyze the impact of the reversal penetrating technique (RPT) for intrathoracic gastroesophageal mechanical anastomosis on the development of anastomotic complications in Ivor Lewis minimally invasive esophagectomy (ILMIE), and to further identify the risk factors for the development of anastomotic leakage and stricture.

Methods

A retrospective observational study was conducted using the clinical data of 316 patients with esophageal carcinoma (EC) who underwent ILMIE from January 2012 to December 2019. The participants were divided into three groups, namely the RPT group, the transoral Orvil technique (TOT) group, and the purse-string technique (PST) group, according to the different stapler placement methods for intrathoracic mechanistic circular stapling. Multivariate analysis was performed to investigate the association of risk factors with anastomotic leakage and stricture.

Results

There were 154 patients in the RPT group, 78 in the TOT group, and 84 in the PST group for intrathoracic gastroesophageal circular stapling in ILMIE. There were no differences in intraoperative anastomosis-related conditions including conversion of open operations, and lymph nodes harvested between the three groups. However, the mean total operative time and gastroesophageal anastomosis time in the RPT group were significantly shorter than those in the other groups (both P<0.05). The rates of anastomotic leakage and stricture showed no statistical differences between the three groups (leakage: P=0.875; stricture: P=0.942). Multivariate analysis revealed that the RPT method of anvil placement did not increase the probability of anastomotic leakage [RPT: reference; TOT: odds ratio (OR) 0.422, P=0.341; PST: OR 1.436, P=0.645] and stricture (RPT: reference; TOT: OR 0.579, P=0.376; PST: OR 1.195, P=0.755).

Conclusions

The RPT method of anvil placement for intrathoracic gastroesophageal circular stapling does not increase the risk of anastomotic complications in ILMIE, but had significantly shorter surgical time and anastomosis time.

Modified reverse-puncture anastomotic technique vs. traditional technique for total minimally invasive Ivor-Lewis esophagectomy

Background

Total endoscopic Ivor-Lewis esophagectomy is a challenging, complex, and costly operation. These disadvantages restrict its wide application. The aim of this study was to compare the modified reverse-puncture anastomotic technique and traditional technique for total minimally invasive Ivor-Lewis esophagectomy.

Methods

In this cohort retrospective study, all patients with medial and lower squamous cell carcinoma of esophagus from February 2014 and June 2018 were divided into two groups according to the surgical method, which were modified reverse-puncture anastomotic technique group and traditional technique group. The operation time, intraoperative bleeding volume, complications, and cost of the two groups were compared.

Results

Forty-eight patients in the modified reverse-puncture anastomotic technique group while 54 patients in the traditional technique group were included. The operation time was 293.4 ± 57.2 min in the modified reverse-puncture anastomotic technique group, which was significantly shorter than that in the traditional technique group (353.4 ± 64.1 min) (P < 0.05). The intraoperative bleeding volume of modified reverse-puncture anastomotic technique group was 157.3 ± 107.4 ml, while it was 191.9 ± 123.6 ml in traditional technique group (P = 0.14). There were similar complications between the two groups. The cost of modified reverse-puncture anastomotic and traditional technique in our hospital were and 72 ± 13 and 83 ± 41 thousand Yuan, respectively (P = 0.08).

Conclusion

The good short-term outcomes that were achieved suggested that the use of modified reverse-puncture anastomotic technique is safe and feasible for total endoscopic Ivor-Lewis esophagectomy.