A useful method to keep azygos arch in minimally invasive resection of esophageal leiomyoma

Factors Affecting Blood Loss During Thoracoscopic Esophagectomy for Esophageal Carcinoma

Background

Major intraoperative hemorrhage reportedly predicts unfavorable survival outcomes following surgical resection for esophageal carcinoma (EC). However, the factors predicting the amount of blood lost during thoracoscopic esophagectomy have yet to be sufficiently studied. We sought to identify risk factors for excessive blood loss during video-assisted thoracoscopic surgery (VATS) for EC.

Methods

Using simple and multiple linear regression models, we performed retrospective analyses of the associations between clinicopathological/surgical factors and estimated hemorrhagic volume in 168 consecutive patients who underwent VATS-type esophagectomy for EC.

Results

The median blood loss amount was 225 mL (interquartile range, 126–380 mL). Abdominal laparotomy (p<0.001), thoracic duct resection (p=0.014), and division of the azygos arch (p<0.001) were significantly related to high volumes of blood loss. Body mass index and operative duration, as continuous variables, were also correlated positively with blood loss volume in simple linear regression. The multiple linear regression analysis identified prolonged operative duration (p<0.001), open laparotomy approach (p=0.003), azygos arch division (p=0.005), and high body mass index (p=0.014) as independent predictors of higher hemorrhage amounts during VATS esophagectomy.

Conclusion

As well as body mass index, operation-related factors such as operative duration, open laparotomy, and division of the azygos arch were independently predictive of estimated blood loss during VATS esophagectomy for EC. Laparoscopic abdominal procedures and azygos arch preservation might be minimally invasive options that would potentially reduce intraoperative hemorrhage, although oncological radicality remains an important consideration.

Effect of azygos arch preservation during thoracoscopic esophagectomy on facilitation of postoperative refilling

PURPOSE

In esophageal cancer surgery, the significance of preserving the azygos arch during thoracoscopic esophagectomy remains unknown. To determine the significance, we examined the difference in postoperative courses between patients who underwent an azygos arch-preserving technique and patients whose azygos arch had been dissected.

METHODS

We retrospectively analyzed 119 patients with esophageal cancer who underwent thoracoscopic esophagectomy from January 2017 to December 2019. Statistical tests, including univariate or multivariate analyses and propensity score-matched analysis, were performed focusing on changes in fluid balance caused by the preservation of the azygos arch.

RESULTS

The azygos arch was preserved in 65 patients and dissected in 54 patients. Urine output on postoperative day 2 was higher, and the IN-OUT balance on postoperative day 2 or accumulated IN-OUT balance up to postoperative day 2 tended to be lower in the azygos arch-preserving group than in the dissected group. The azygos arch-preserving technique did not affect the number of dissected mediastinal lymph nodes.

CONCLUSION

The azygos arch-preserving technique during thoracoscopic esophagectomy facilitated postoperative refilling and avoided postoperative fluid excess. This technique might be a novel minimally invasive option for an otherwise highly invasive esophageal cancer surgery.