Mediastinoscopy-assisted transhiatal esophagectomy versus thoraco-laparoscopic esophagectomy for esophageal cancer: a single-center initial experience

Efficacy and complications of endoscopic thoracoscopic versus laparoscopic radical esophagectomy in esophageal cancer treatment: A retrospective study

To evaluate the efficacy and postoperative complications of endoscopic thoracoscopic and laparoscopic radical esophagectomy compared to open surgery in esophageal cancer treatment. This retrospective study included 103 esophageal cancer patients admitted from August 2018 to March 2022, divided into observation (endoscopic surgery) and control (open surgery) groups. We compared intraoperative parameters, postoperative outcomes, immune function, and one-year overall survival (OS). Intraoperative bleeding volume, the retention time of chest tube, postoperative fasting time, and hospital stay in the observation group were smaller than those in the control group (P < .05). The differences were not statistically significant (P > .05) when comparing operative time, the number of intraoperative blood transfusion cases, and the rate of operating room extubation in these 2 groups. The differences were not statistically significant when comparing the amount of resected lymph nodes and the positive rate of incisal edge in these 2 groups (P > .05). There was no statistically significant difference in the complication rates such as pneumonia, pleural effusion, pneumothorax, pulmonary embolism, anastomotic fistula, the leakage of thoracic duct, the injury of RLN and arrhythmia in these 2 groups (P > .05). At 7 days postoperatively, the CD4+ and CD4+/CD8+ in the observation group and the control group were smaller than the preoperative ones in their same groups, and they were larger in the observation group than those in the control group (P < .05); There was no statistically significant difference on the CD8+ in the observation group and the control group at 7 days postoperatively compared with the preoperative ones in their same groups (P > .05). The 1-year postoperative OS rate was 81.63% (40/49) in the observation group and 72.22% (39/54) in the control group, and the difference was not statistically significant when comparing the OS rates of these 2 groups (P = .238, HR = 0.622, 95% CI = 0.279-1.385). Endoscopic thoracoscopic and laparoscopic esophagectomy offers less invasive treatment with significant short-term benefits and better preservation of immune function in esophageal cancer patients, making it a safe and effective surgical option.

Substitute or coexistence? Mediastinoscopy-assisted versus thoracoscope-assisted esophagectomy in esophageal cancer: a meta-analysis of perioperative outcomes and long-term survival

BACKGROUND

Currently, mediastinoscopy-assisted esophagectomy (MAE) and thoracoscope-assisted esophagectomy (TAE) represent two prevalent forms of minimally invasive esophagectomy extensively employed in the management of esophageal cancer (EC). The aim of this meta-analysis is to assess and compare these two surgical approaches concerning perioperative outcomes and long-term survival, offering valuable insights for refining surgical strategies and enhancing patient outcomes in this field.

METHODS

Adhering to PRISMA guidelines, the authors systematically searched PubMed, Web of Science, Cochrane Library, Embase, and CNKI databases until 1 March 2024, for studies comparing MAE and TAE. Outcomes of interest included perioperative outcomes (intraoperative outcomes, postoperative recovery, postoperative complications) and survival rates. Statistical analyses were performed using RevMan 5.4, with heterogeneity dictating the use of fixed or random-effects models.

RESULTS

A total of 21 relevant studies were finally included. MAE was associated with significantly shorter operation times [mean difference (MD)=-59.58 min, 95% CI: -82.90 to -36.26] and less intraoperative blood loss (MD=-68.34 ml, 95% CI: -130.45 to -6.23). However, MAE resulted in fewer lymph nodes being dissected (MD=-3.50, 95% CI: -6.23 to -0.78). Postoperative recovery was enhanced following MAE, as evidenced by reduced hospital stays and tube times. MAE significantly reduced pulmonary complications [odds ratio (OR)=0.59, 95% CI: 0.44, 0.81] but increased the incidence of recurrent laryngeal nerve injury (OR=1.84, 95% CI: 1.30, 2.60). No significant differences were observed in anastomotic leakage, chylothorax, cardiac complications, wound infections, and gastric retention between MAE and TAE. The long-term survival outcomes showed no statistical difference [hazard ratio (HR)=1.05, 95% CI: 0.71, 1.54].

CONCLUSIONS

MAE offers advantages in reducing operation time, blood loss, and specific postoperative complications, particularly pulmonary complications, with a shorter recovery period compared to TAE. However, it poses a higher risk of recurrent laryngeal nerve injury and results in fewer lymph nodes being dissected. No difference in long-term survival was observed, indicating that both techniques have distinct benefits and limitations. These findings underscore the need for personalized surgical approaches in EC treatment, considering individual patient characteristics and tumor specifics.

A systematic review and meta-analysis of mediastinoscopy-assisted transhiatal esophagectomy (MATHE)

BACKGROUND

Transhiatal esophagectomy (THE) avoids thoracotomy but sacrifices mediastinal lymphadenectomy. Mediastinoscopy-assisted transhiatal esophagectomy (MATHE) allows for visualisation and en-bloc dissection of mediastinal lymph nodes while retaining the benefits of THE. However, given its novel inception, there is a paucity of literature. This study aimed to conduct the first meta-analysis to explore the efficacy of MATHE and clarify its role in the future of esophagectomy.

METHODS

Four databases (PubMed, EMBASE, Scopus, and Cochrane Library) were searched from inception to May 1, 2023. Studies were included if they reported outcomes for patients with esophageal cancer who underwent MATHE. Meta-analyses of proportions and pooled means were performed for the outcomes of intraoperative blood loss, lymph node (LN) harvest, mean hospital length of stay (LOS), mean operative time, R0 resection, conversion rates, 30-day mortality rate, 5-year OS, and surgical complications (anastomotic leak, cardiovascular [CVS] and pulmonary complications, chyle leak and recurrent laryngeal nerve palsy [RLN]). Sensitivity analyses were performed for outcomes with substantial statistical heterogeneity.

RESULTS

The search yielded 223 articles; 28 studies and 1128 patients were included in our analysis. Meta-analyses of proportions yielded proportion rates: 30-day mortality (0 %, 95 %CI 0-0), 5-year OS (60.5 %, 95 %CI 47.6-72.7), R0 resection (100 %, 95 %CI 99.3-100), conversion rate (0.1 %, 95 %CI 0-1.2). Among surgical complications, RLN palsy (14.6 %, 95 %CI 9.5-20.4) were most observed, followed by pulmonary complications (11.3 %, 95 %CI 7-16.2), anastomotic leak (9.7 %, 95 %CI 6.8-12.8), CVS complications (2.3 %, 95 %CI 0.9-4.1) and chyle leak (0.02 %, 95 %CI 0-0.8). Meta-analysis of pooled means yielded means: LN harvest (18.6, 95 %CI 14.3-22.9), intraoperative blood loss (247.1 ml, 95 %CI 173.6-320.6), hospital LOS (18.1 days, 95 %CI 14.4-21.8), and operative time (301.5 min, 95 %CI 238.4-364.6). There was moderate-to-high statistical heterogeneity. Findings were robust to sensitivity analyses.

CONCLUSION

MATHE is associated with encouraging post-operative mortality and complication rates, while allowing for radical mediastinal lymphadenectomy with reasonable lymph node harvest.

Application of Inflatable Video-Assisted Mediastinoscopic Transhiatal Esophagectomy in Individualized Treatment of Esophageal Cancer

Surgery is a crucial treatment option for patients with resectable esophageal cancer. The emergence of minimally invasive esophageal techniques has led to the popularity of video-assisted thoracoscopic esophagectomy, which has proven to be more advantageous than traditional thoracotomy. However, some patients with esophageal cancer may not benefit from this procedure. Individualized treatment plans may be necessary for patients with varying conditions and tolerances to anesthesia, making conventional surgical methods unsuitable. Inflatable video-assisted mediastinoscopic transhiatal esophagectomy (IVMTE) has emerged as a promising treatment option for esophageal cancer because it does not require one-lung ventilation, reduces postoperative complications, and expands surgical indications. This technique also provides surgical opportunities for patients with impaired pulmonary function or thoracic lesions. It is crucial to have a comprehensive understanding of the advancements and limitations of IVMTE to tailor treatment plans and improve outcomes in patients with esophageal cancer. Understanding the advantages and limitations of this surgical method will help specific patients with esophageal cancer. We conducted a thorough review of the relevant literature to examine the importance of IVMTE for individualized treatment of this disease.

Safety and Feasibility of Mediastinoscopy-assisted Esophagectomy: A Meta-analysis

BACKGROUND

The objective of the current study was to investigate the safety and feasibility of mediastinoscopy-assisted esophagectomy (MAE).

METHODS

A meta-analysis was conducted between MAE and traditional transthoracic esophagectomy (TTE). For a comparative analysis of MAE and TTE, we searched PubMed, the Cochrane Library, Embase, and Web of Science databases. We identified the relevant literature and extracted the relevant data. Finally, RevMan 5.3 software was applied to conduct a meta-analysis of the data.

RESULTS

A total of 1256 people were enrolled in 16 studies, comprising 575 patients with MAE and 681 with TTE. The findings revealed that the pulmonary complications, cardiac complications, and postoperative hospital stay in the MAE group were significantly better than those in the TTE group. No significant differences were found between the 2 groups in postoperative chylothorax, anastomotic fistula, and postoperative mortality. But the incidence of recurrent laryngeal nerve injury in the MAE group was higher than that in the TTE group (odds ratio=1.64, 95% CI, 1.15 to 2.35, P =0.006). The MAE group had less lymph node dissection than the TTE group (mean difference=-4.62, 95% CI, -5.97 to 3.45, P <0.00001).

CONCLUSIONS

This meta-analysis presented that MAE was safe and feasible, reduced postoperative pulmonary and cardiac complications, and shortened hospital stay, but lymph node dissection was less, recurrent laryngeal nerve injury was higher, and the impact of long-term survival prognosis required more randomized controlled trials.

Clinical advantage of transmediastinal esophagectomy in terms of postoperative respiratory complications

BACKGROUND

Although the transmediastinal approach as a radical esophagectomy for esophageal carcinoma patients has attracted attention, its advantages over the transthoracic approach remain unclear. This study aimed to evaluate the efficacy of transmediastinal esophagectomy (TME) in terms of postoperative respiratory complications compared to that of open transthoracic esophagectomy (TTE).

METHODS

We reviewed patients with thoracic and abdominal esophageal carcinoma who underwent TME or TTE between February 2014 and November 2021. We compared postoperative respiratory complications as the primary outcome. The secondary outcomes included perioperative operation time, blood loss, postoperative complications, and the number of harvested mediastinal lymph nodes.

RESULTS

Overall, 60 and 54 patients underwent TME and TTE, respectively. The baseline characteristics were similar between the two groups, except for age and histological type. There were no intraoperative lethal complications in either group. The incidence of respiratory complications was significantly lower in the TME group than in the TTE group (6.7 vs. 22.2%, p = 0.03). The TME group had a shorter operation time (403 vs. 451 min, p < 0.01), less blood loss (107 vs. 253 mL, p < 0.01), and slightly higher anastomotic leakage (11.7 vs. 5.6%, p = 0.33). The number of harvested lymph nodes was similar in both groups (24 vs. 26, p = 0.10). Multivariate analysis revealed that TME is an independent factor in reducing respiratory complications (odds ratio = 0.27, p = 0.04).

CONCLUSIONS

TME for esophageal carcinoma was performed safely. TME was superior to TTE in terms of postoperative respiratory complications; however, the relatively higher frequency of anastomotic leakage should be considered and requires further evaluation.

Transhiatal esophagectomy via mediastinoscopy versus sweet for T2 esophageal squamous cell carcinoma patients

BACKGROUND

The aim was to compare transhiatal esophagectomy via mediastinoscopy (TEM) with Sweet procedure for patients with T2 midpiece and distal esophageal squamous cell carcinoma (ESCC).

MATERIALS AND METHODS

By virtue of propensity score matching, 42 T2 ESCC patients who underwent TEM (n = 21) and Sweet procedure (n = 21) were included. Both the short-term and long-term outcomes of these patients were observed.

RESULTS

Compared with the Sweet procedure, the TEM procedure showed less operation time (133.8 ± 30.4 vs 171.2 ± 30.3 min, p = 0.038), reduced drainage volume in 24 h (83.8 ± 142.3 vs 665.2 ± 220.0 mL, p < 0.001), shorter reserving time of chest tube (26.2 ± 26.3 vs 82.8 ± 49.8 h, p < 0.001) and less dissected lymph nodes (12.4 ± 6.1 vs 17.0 ± 6.5, p = 0.041). The average survival period was 62.6 months for TEM group and 62.5 months for Sweet group (p = 0.753). The COX regression showed that the nodal staging could be regarded as an independent prognostic factor (p = 0.013), not the surgical method (p = 0. 754).

CONCLUSIONS

The TEM procedure could reduce operative trauma compared with the Sweet procedure. The long-term survival rate of TEM group was acceptable. The lymph node resection was a major disadvantage of TEM procedure. The TEM procedure might be an alternate choice for T2 midpiece and distal ESCC patients, especially for patients who cannot tolerate transthoracic esophagectomy.

Clinical-pathological features and perioperative outcomes of mediastinoscopy vs. thoracoscopy esophagectomy in esophageal cancer: A meta-analysis

Objective

To compare the clinicopathological features and perioperative outcomes of video-assisted mediastinoscopy esophagectomy (VAME) compared to video-assisted thoracoscopy esophagectomy (VATE) in esophageal cancer.

Methods

We comprehensively searched online databases (PubMed, Embase, Web of Science and Wiley online library) to find available studies exploring the clinicopathological features and perioperative outcomes between VAME and VATE in esophageal cancer. Relative risk (RR) with 95% confidence interval (CI) and standardized mean difference (SMD) with 95% CI were used to evaluate the perioperative outcomes and clinicopathological features.

Results

A total of seven observational studies and one randomized controlled trial involving 733 patients were considered eligible for this meta-analysis, of which 350 patients underwent VAME in contrast to 383 patients underwent VATE. Patients in the VAME group had more pulmonary comorbidities (RR = 2.18, 95% CI 1.37-3.46, P = 0.001). The pooled results showed that VAME shortened the operation time (SMD = -1.53, 95% CI -2.308--0.76, P = 0.000), and retrieved less total lymph nodes (SMD = -0.70, 95% CI -0.90--0.50, P = 0.000). No differences were observed in other clinicopathological features, postoperative complications or mortality.

Conclusions

This meta-analysis revealed that patients in the VAME group had more pulmonary disease before surgery. The VAME approach significantly shortened the operation time and retrieved less total lymph nodes and did not increase intra- or postoperative complications.

Thoracolaparoscopic esophagectomy for esophageal cancer with a cervical incision to extract specimen

BACKGROUND

Surgical treatment is the most important and effective therapy for resectable esophageal cancer. Minimally invasive esophagectomy (MIE) can reduce surgical trauma. A neck incision can be performed for extraction of surgical specimen. This study was performed to investigate the safety and feasibility of neck incision to extract surgical specimen in thoracolaparoscopic esophagectomy for esophageal cancer.

MATERIALS AND METHODS

Thirty-four patients who experienced thoracolaparoscopic esophagectomy for esophageal cancer and a neck incision for extraction of surgical specimen were enrolled. The clinical, surgical and follow-up data were analyzed.

RESULTS

The procedure was successful in all patients (100%), with a neck incision to extract the surgical specimen. The median surgical time was 309 min, and the median blood loss was 186 ml, with the mean length of hospital stay of 11.5 days. Pulmonary complications occurred in 8 patients (23.5%). Anastomotic leakage occurred in 5 patients (14.7%), with one patient being treated conservatively to recover and four (11.8%) who received interventional drainage. One patient with interventional drainage died of severe infection, resulting in a 30-day surgical mortality of 2.9% (n = 1). Gastrointestinal complications happened in 5 patients (14.7%), including ileus in three patients and anastomotic stenosis in two patients. Follow-up was performed at a median time of 20 months (interquartile range, 14-32 months), with no death during this period. No recurrence was found in the first 12 months after radical resection.

CONCLUSION

The cervical incision to extract surgical specimen is safe and feasible with improved cosmetic effect in thoracolaparoscopic esophagectomy for esophageal cancer.

Implementation of the Esophagectomy Complication Consensus Group definitions: the benefits of speaking the same language

In 2015 the Esophagectomy Complication Consensus Group (ECCG) reported consensus definitions for complications after esophagectomy. This aimed to reduce variation in complication reporting, attributed to heterogeneous definitions. This systematic review aimed to describe the implementation of this definition set, including the effect on complication frequency and variation. A systematic literature review was performed, identifying all observational and randomized studies reporting complication frequencies after esophagectomy since the ECCG publication. Recruitment periods before and subsequent to the index ECCG publication date were included. Coefficients of variance were calculated to assess outcome heterogeneity. Of 144 studies which met inclusion criteria, 70 (48.6%) used ECCG definitions. The median number of separately reported complication types was five per study; only one study reported all ECCG complications. The coefficients of variance of the reported frequencies of eight of the 10 most common complications were reduced in studies which used the ECCG definitions compared with those that did not (P = 0.036). Among ECCG studies, the frequencies of postoperative pneumothorax, reintubation, and pulmonary emboli were significantly reduced in 2020-2021, compared with 2015-2019 (P = 0.006, 0.034, and 0.037 respectively). The ECCG definition set has reduced variation in esophagectomy morbidity reporting. This adds greater confidence to the observed gradual improvement in outcomes with time, and its ongoing use and wider dissemination should be encouraged. However, only a handful of outcomes are widely reported, and only rarely is it used in its entirety.

The surgical anatomy of a (robot-assisted) minimally invasive transcervical esophagectomy

BACKGROUND

Transcervical esophagectomy allows for esophagectomy through transcervical access and bypasses the thoracic cavity, thereby eliminating single lung ventilation. A challenging surgical approach demands thorough understanding of the encountered anatomy. This study aims to provide a comprehensive overview of surgical anatomy encountered during the (robot-assisted) minimally invasive transcervical esophagectomy (RACE and MICE).

METHODS

To assess the surgical anatomy of the lower neck and mediastinum, MR images were made of a body donor after, which it was sliced at 24-μm intervals with a cryomacrotome. Images were made every 3 slices resulting in 3.200 images of which a digital 3D multiplanar reconstruction was made. For macroscopic verification, microscopic slices were made and stained every 5 mm (Mallory-Cason). Schematic drawings were made of the 3D reconstruction to demonstrate the course of essential anatomical structures in the operation field and identify anatomical landmarks.

RESULTS

Surgical anatomy 'boxes' of three levels (superior thoracic aperture, upper mediastinum, subcarinal) were created. Four landmarks were identified: (i) the course of the thoracic duct in the mediastinum; (ii) the course of the left recurrent laryngeal nerve; (iii) the crossing of the azygos vein right and dorsal of the esophagus; and (iv) the position of the aortic arch, the pulmonary arteries, and veins.

CONCLUSIONS

The presented 3D reconstruction of unmanipulated human anatomy and schematic 3D 'boxes' provide a comprehensive overview of the surgical anatomy during the RACE or MICE. Our findings provide a useful tool to aid surgeons in learning the complex anatomy of the mediastinum and the exploration of new surgical approaches such as the RACE or MICE.

Huge esophageal gastrointestinal stromal tumor successfully resected under mediastino-laparoscopic transhiatal esophagectomy: a case report

BACKGROUND

Esophageal gastrointestinal stromal tumors (E-GISTs) are often diagnosed early due to complaints such as dysphagia and are rarely found to be huge in size. Here, we report the treatment of a case of huge E-GIST successfully resected by minimally invasive surgery after neoadjuvant imatinib therapy.

CASE PRESENTATION

An 86-year-old male patient with a 3-month history of dysphagia was referred to our hospital because of a suspected mediastinal tumor on chest X-ray. The chest computed tomography scan revealed a huge solid tumor, of about 100 mm in diameter, protruding into the left thoracic cavity. Histopathological examination results of fine-needle aspiration biopsy under endoscopic ultrasonography revealed a c-kit and CD34-positive esophageal gastrointestinal stromal tumor. The patient received neoadjuvant therapy with imatinib (400 mg/day) to reduce the size of the tumor and prevent rupture during resection. After 28 days of oral administration of imatinib, the tumor size decreased. However, the patient refused to continue treatment with imatinib and therefore underwent mediastino-laparoscopic transhiatal esophagectomy. We successfully resected the tumor completely with mediastino-laparoscopic surgical techniques. Esophageal reconstruction was performed using a gastric tube in the posterior sternal route. After an uneventful postoperative course, the patient was discharged postoperative day 14. Immunohistochemical findings of the resected specimen showed that the tumor cells were positive for c-kit, DOG-1 and CD34 and negative for smooth muscle actin and S100.

CONCLUSIONS

Hybrid surgical procedure utilizing mediastino-laparoscopy might be useful for high-risk patient with esophageal tumors.

Transcervical inflatable mediastinoscopic esophagectomy versus thoracoscopic esophagectomy for local early‐ and intermediate‐stage esophageal squamous cell carcinoma: A propensity score‐matched analysis

Background and objective

Transcervical inflatable mediastinoscopic esophagectomy (TIME) is a novel method of minimally invasive esophagectomy (MIE) for esophageal cancer. However, whether TIME is effective and feasible as conventional MIE remains unclear. This study aimed to evaluate the efficacy of TIME by comparing it with thoracoscopic esophagectomy (TE).

Methods

Surgical outcomes and relapse‐free survival (RFS) rates of patients with local early‐ or intermediate‐stage thoracic esophageal squamous cell carcinoma that underwent TIME or TE from January 2017 to December 2019 were analyzed in this retrospective study. Propensity score matching was used to control the confounding factors.

Results

The mean operation time in TIME was shorter than that in TE (p < 0.05). Patients in the TIME group achieved postoperative ambulation earlier than those in the TE group (p < 0.05). The rate of pulmonary complications was lower in TIME than in TE (p < 0.05). The number of lymph nodes harvested during surgery and the RFS rates of two groups did not have significant differences.

Conclusion

TIME may be a feasible and safe method to treat local early‐ and intermediate‐stage thoracic esophageal squamous cell carcinoma effectively and it could be a supplementary surgical method of TE for patients with poor pulmonary function or cannot undergo TE.

Sternal lifting increases the operating space in esophagectomy via mediastinoscopy: a prospective cohort study

Background

Esophagectomy with combined single-port inflatable mediastinoscopy and laparoscopy reduces the risk of postoperative respiratory complications as it obviates the need to pass through the pleural space. However, it has strict indications owing to the narrow space for operation. Therefore, we adopted a sternal lifting method using a retractor that enables the expansion of the operating space, a technique which has not been previously reported. We describe our experience and report the results of an evaluation of this new approach.

Methods

Thirty-nine patients with esophageal squamous cell carcinomas underwent esophagectomy using combined single-port inflatable mediastinoscopy and laparoscopy from March 2019 to August 2021. Among them, 20 cases received sternal suspension [sternal suspension group (SS group)], and 19 cases did not receive sternal suspension [non-sternal suspension group (NSS group)]. The short-term efficacy of the two groups was observed.

Results

Patients in the SS group had a shorter intramediastinal operation time (82.50 vs. 110.00 minutes; P<0.001), more dissected chest lymph nodes (14 vs. 12; P=0.036), and a lower incidence of postoperative hoarseness (2 vs. 6; P=0.235) than did those in the NSS group. There were no significant differences between the SS group and NSS group in terms of intraoperative blood loss, postoperative hospital stay, post-surgical pathologic TNM classification (pTNM), post-surgical pathologic tumor classification (pT), post-surgical pathologic extent of lymph node involvement (pN), and total number of dissected lymph nodes. There were no statistical differences in the incidence of anastomotic fistula, respiratory complications, arrhythmia, or chylothorax between the two groups. There was no mortality during hospitalization in the two groups.

Conclusions

Sternal lifting increases the working space in esophagectomy via mediastinoscopy. It can make video-assisted radical esophagectomy by a transmediastinal approach with total pneumomediastinum assistance (VARETT) easier to perform, and sternal suspension in VARETT is safe and effective.