Novel Transgastric Endoluminal Segmental Esophagectomy and Primary Anastomosis Technique: A Hybrid Transgastric Thoracoscopic Esophagectomy for the Treatment of High Grade Dysplasia and Early Esophageal Cancer in a Porcine Ex vivo Model.

Anton Kvasha,Muhammad Khalifa,Seema Biswas,Zakhar Bramnik,Igor Waksman,Moaad Farraj

doi:10.3389/fsurg.2021.676031

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Open Access

https://doi.org/10.3389/fsurg.2021.676031

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Abstract

Multiple modalities are currently employed in the treatment of high grade dysplasia and early esophageal carcinoma. While they are the subject of ongoing investigation, surgery remains the definitive modality for oncological resection. Esophagectomy, however, is traditionally a challenging surgical procedure and carries a significant incidence of morbidity and mortality. Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are considerably less invasive alternatives to esophagectomy in the diagnosis and treatment of high grade dysplasia, early esophageal squamous cell carcinoma and adenocarcinoma. However, many early esophageal cancer patients, with favorable histology, who could benefit from endoscopic resection, are referred for formal esophagectomy due to lesion characteristics such as unfavorable lesion morphology or recurrence after previous endoscopic resection. In this study we present a novel, hybrid thoracoscopic transgastric endoluminal segmental esophagectomy with primary anastomosis for the potential treatment of high grade dysplasia and early esophageal cancer in a porcine ex vivo model as a proposed bridge between endoscopic resection and the relatively high mortality and morbidity formal esophagectomy procedure. The novel technique consists of thoracoscopic esophageal mobilization in addition to transgastric endoluminal segmental esophagectomy and anastomosis utilizing a standard circular stapler. The technique was found feasible in all experimental subjects. The minimally invasive nature of this novel procedure as well as the utility of basic surgical equipment and surgical skill is an important attribute of this method and can potentially make it a treatment option for many patients who would otherwise be referred for a formal esophagectomy.

Highlights

MATERIALS AND METHODSMucosal ablation, resection and cryotherapy are currently employed in the treatment of high grade dysplasia and early esophageal carcinoma
Resection and cryotherapy are currently employed in the treatment of high grade dysplasia and early esophageal carcinoma
Safety and effectiveness are the subject of ongoing investigation and debate, surgery remains the definitive modality for oncological resection especially for intramucosal and submucosal lesions where the risk of nodal spread is a significant threat [1]

Summary

MATERIALS AND METHODS

Resection and cryotherapy are currently employed in the treatment of high grade dysplasia and early esophageal carcinoma. Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are considerably less invasive alternatives to esophagectomy in the diagnosis and treatment of high grade dysplasia (HGD), early esophageal squamous cell carcinoma (SCC), and adenocarcinoma. At present there are no procedures which bridge the endoscopic and surgical approaches combining the low morbidity of endoscopic treatment and the radical nature of formal, open or minimally invasive, esophagectomy. To address this problem, we present a novel, hybrid thoracoscopic, transgastric endoluminal segmental esophagectomy with primary anastomosis for the potential treatment of high grade dysplasia and early esophageal cancer in a porcine ex vivo model. The stapler was extracted through the gastrotomy and the resected esophagus examined (Figure 5)

RESULTS

DISCUSSION

ETHICS STATEMENT