Two-step method for creating a gastric tube during laparoscopic-thoracoscopic Ivor-Lewis esophagectomy

Development and validation of the Convalescence Symptom Assessment Scale for EsophageCtomy patients

AIM

A specific, valid and reliable measure is much needed to dynamically assess the recovery of symptoms in oesophagectomy patients. This study describes developing and validating the Convalescent Symptom Assessment Scale for oesophagectomy patients (CSAS_EC).

DESIGN

An instrument development and cross-sectional validation study was conducted.

METHODS

This study consists of two components: instrument development and psychometric tests. In instrument development, the literature review, qualitative interviews, Delphi method expert consultation and face validation were used to develop and refine scale content. In psychometric tests, the clinical test version scale was used to conduct a cross-sectional in the thoracic surgery department from 17 June to 20 November 2022. The Classical Test Theory and Multidimensional Item Response Theory (MIRT) analyses examined psychometric properties.

RESULTS

In instrument development, literature review (n = 20), qualitative interviews (n = 21), expert consultation (n = 12) and pre-survey (n = 15) led to the development of the clinical test version scale. In psychometric tests, a total of 331 participants were enrolled. Confirmatory factor analysis and MIRT analysis verified that a model with 28 items in four dimensions was good. The four dimensions were early recovery symptoms, late recovery symptoms, persistent present symptoms and psychosocial symptoms. The Cronbach's α is 0.827. The validity and reliability were demonstrated to be acceptable.

CONCLUSIONS

The CSAS_EC scale can be used as a tool to evaluate the recovery status of oesophagectomy patients.

Transthoracic Esophagectomy: Hand-sewn Versus Side-to-side Linear-stapled Versus Circular-stapled Anastomosis: A Systematic Review and Meta-analysis

BACKGROUND

Three anastomotic techniques are mostly used to create an esophagogastric anastomosis in a transthoracic esophagectomy: hand-sewn (HS), side-to-side linear-stapled (SSLS), and circular-stapled (CS). The aim of this study was to compare surgical outcomes after HS, SSLS, and CS intrathoracic esophagogastric anastomosis.

MATERIALS AND METHODS

A systematic review using the MEDLINE database was performed to identify original articles analyzing outcomes after HS, SSLS, and CS esophagogastric anastomosis. The main outcome was an anastomotic leakage rate. Secondary outcomes included overall morbidity, major morbidity, and mortality. A meta-analysis of proportions and linear regression models were used to assess the effect of each anastomotic technique on the different outcomes.

RESULTS

A total of 101 studies comprising 12,595 patients were included; 8835 (70.1%) with CS, 2532 (20.1%) with HS, and 1228 (9.8%) with SSLS anastomosis. Anastomotic leak occurred in 10% [95% confidence interval (CI), 6%-15%], 9% (95% CI, 6%-13%), and 6% (95% CI, 5%-7%) of patients after HS, SSLS, and CS anastomosis, respectively. Risk of anastomotic leakage was significantly higher with HS anastomosis (odds ratio=1.73, 95% CI: 1.47-2.03, P<0.0001) and SSLS (odds ratio=1.68, 95% CI: 1.36-2.08, P<0.0001), as compared with CS. Overall morbidity (HS: 52% vs. SLSS: 39% vs. CS: 35%) and major morbidity (HS: 33% vs. CS: 19%) rates were significantly lower with CS anastomosis. Mortality rate was 4% (95% CI, 3%-6%), 2% (95% CI, 2%-3%), and 3% (95% CI, 3%-4%) after HS, SSLS, and CS anastomosis, respectively.

CONCLUSION

HS and SSLS intrathoracic esophagogastric anastomoses are associated with significantly higher rates of an anastomotic leak than CS anastomosis.

Surgical outcomes after totally minimally invasive Ivor Lewis esophagectomy. A systematic review and meta-analysis

BACKGROUND

A transthoracic esophagectomy is associated with high rates of morbidity. Minimally invasive esophagectomy has emerged to decrease such morbidity. The aim of this study was to accurately determine surgical outcomes after totally minimally invasive Ivor-Lewis Esophagectomy (TMIE).

METHODS

A systematic literature search was performed to identify original articles analyzing patients who underwent TMIE. Main outcomes included overall morbidity, major morbidity, pneumonia, arrhythmia, anastomotic leak, chyle leak, and mortality. A meta-analysis was conducted to estimate the overall weighted proportion and its 95% confidence interval (CI) for each analyzed outcome.

RESULTS

A total of 5619 patients were included for analysis; 4781 (85.1%) underwent a laparoscopic/thoracoscopic esophagectomy and 838 (14.9%) a robotic-assisted esophagectomy. Mean age of patients was 63.5 (55-67) years and 75.8% were male. Overall morbidity and major morbidity rates were 39% (95% CI, 33%-45%) and 20% (95% CI, 13%-28%), respectively. Postoperative pneumonia and arrhythmia rates were 10% (95% CI, 8%-13%) and 12% (95% CI, 8%-17%), respectively. Anastomotic leak rate across studies was 8% (95% CI, 6%-10%). Chyle leak rate was 3% (95% CI, 2%-5%). Mortality rate was 2% (95% CI, 2%-2%). Median ICU stay and length of hospital stay were 2 (1-4) and 11.2 (7-20) days, respectively.

CONCLUSIONS

Totally minimally invasive Ivor-Lewis esophagectomy is a challenging procedure with high morbidity rates. Strategies to enhance postoperative outcomes after this operation are still needed.

Minimally invasive Ivor Lewis esophagectomy: Robot-assisted versus laparoscopic-thoracoscopic technique. Systematic review and meta-analysis

BACKGROUND

Evidence comparing conventional minimally invasive esophagectomy (CMIE) via laparoscopy and thoracoscopy with robot-assisted minimally invasive esophagectomy (RAMIE) is scarce. The aim of this meta-analysis was to compare surgical outcomes after CMIE and RAMIE with an intrathoracic anastomosis.

METHODS

A systematic literature search was performed to identify original articles analyzing outcomes after CMIE and RAMIE. Main surgical outcomes included operative time, intraoperative blood loss, anastomotic leak rates, pneumonia, overall morbidity, length of stay (LOS), and 30-day mortality. Oncologic outcomes included lymph node yield and R0 resections rates. A meta-analysis of proportions and linear regression models were used to assess the effect of each procedure on the different outcomes.

RESULTS

A total of 6,249 patients were included for analysis; 5,275 (84%) underwent CMIE and 974 (16%) RAMIE. Robotic esophagectomy had longer operative time and less intraoperative blood loss. Anastomotic leakage rates were similar with both approaches. Patients undergoing RAMIE had significantly lower rates of postoperative pneumonia (OR 0.46, 95% CI 0.35-0.61, P < .0001) and overall morbidity (OR 0.67, 95% CI 0.58-0.79, P < .0001). Median LOS was similar in both procedures (RAMIE: 12.1 versus CMIE: 11.9 days, P = .64). Similar mortality rates were found after RAMIE and CMIE (OR 0.69, 95% CI 0.34-1.38, P = .29). Lymph node yield was similar in both procedures, but RAMIE was associated with higher rates of R0 resection (OR 2.84, 95% CI 1.53-5.26, P < .001).

CONCLUSION

Patients undergoing robotic esophagectomy have less intraoperative blood loss, lower rates of postoperative pneumonia, reduced overall morbidity, and higher rates of R0 resections, as compared with those undergoing a laparoscopic-thoracoscopic esophageal resection.

Minimally Invasive Esophagectomy: A Consensus Statement

BACKGROUND

Minimally invasive esophagectomy (MIE) is increasingly performed in various ways. The lack of international definitions and nomenclature makes accurate comparison of outcomes difficult.

METHODS

An international, multispecialty consensus-writing committee constructed definitions and nomenclature for MIE. After a PubMed search, vetting, and review with all authors, a consensus was reached.

RESULTS

The proposed definition for MIE is an operation "that removes part or all of the esophagus, does not retract, lift, spread or remove any part of the chest or abdominal wall and the surgeon's and assistant's vision of the operative field is via a monitor, the patient's tissue is manipulated only by instruments that are controlled by the operating surgeon or team, except for during the neck portion if used." A flexible nomenclature is proposed that attempts to describe current and future operations and systems.

CONCLUSIONS

Definitions and nomenclature for MIE are needed to ensure that future studies accurately compare results and outcomes of similar operations. Nomenclatures allow surgeons, researchers, and patients from different cultures to use a common language to facilitate communication and compare. This process is required in order to improve patient outcomes globally to drive adoption of best of practice, yet is lacking for MIE.

Clinical observation of modified gastric tube in middle and lower thoracic esophageal carcinoma surgery

Background

A clinical case-control study was conducted to analyze the short-term efficacy of modified gastric tube in surgery for middle (mid)- and lower- thoracic esophageal carcinoma compared with the conventional gastric tube and its effect on postoperative pulmonary function.

Methods

A total of 70 patients with mid- and lower-thoracic esophageal cancer who underwent esophagectomy between October 2012 and September 2018 in our hospital were recruited in the study. They were randomly divided into a modified gastric tube group (n = 35) and a conventional gastric tube group (n = 35). The operation time, intraoperative blood loss, number of intraoperative lymph node dissection, gastrointestinal decompression time and postoperative hospital stay were recorded. The operation results and complications were recorded, and the pulmonary function was recorded at 3 days before surgery and 6 weeks after surgery.

Results

The operation time in the modified gastric tube group was significantly lower than that in the gastric tube group (P < 0.05). There were no anastomotic leakage or death occurred in the modified gastric tube group. There was 1 case of anastomotic leakage in the conventional gastric tube group. The pulmonary function in both groups was improved at 6 weeks after surgery, but there was no significant difference between both groups (P > 0.05).

Conclusion

Modified gastric tube has a good clinical application value compared with gastric tube for patients with mid- and lower-thoracic esophageal cancer. It is easy and safe, and can shorten the operation time without aggravation of pulmonary function after surgery.