Invasive Esophageal Surgery Research Articles

Benchmark analyses in minimally invasive esophagectomy-impact on surgical quality improvement.

Over the last decades, benchmarking has become an established management tool to improve quality in commercial economics. It is a rather new concept in the healthcare industry, and a confusingly wide range of approaches referring to "benchmarking" have been employed in the field of minimally invasive esophageal cancer surgery. It is our conviction that benchmarking will be an essential element of surgical research in the future. Therefore, defining and implementing standards is not only a desirable, but a vital step. Recently, we have introduced a standardized method of establishing valid benchmarks for surgical quality improvement including ideal outcome thresholds for total minimally invasive transthoracic esophagectomy (ttMIE). The present article aims at discussing the actual literature on benchmarking in minimally invasive esophagectomy (MIE) and at fueling the debate on how to further improve the current practice of surgical outcome research.

Minimally invasive esophagectomy

Certain advantages of minimally invasive esophagectomy compared with conventional approaches were observed. Optimal surgical access, technique and features of anastomoses formation are still unclear despite common tendency to minimally invasive esophageal surgery. Further researches are necessary to resolve these problems and improve the outcomes.

A survey on the current development of thoracic surgery in tertiary hospitals of China

Objective: To study the current development of thoracic surgery in China. Methods: Chinese Society for Thoracic and Cardiovascular Surgery and Chinese Association for Thoracic Surgeons jointly conducted a network survey to directors of thoracic surgery departments in the tertiary hospitals in China from November to December 2018. The contents of the survey included the basic information of the hospital and the status of thoracic surgery department in the hospital. Rank sum test was used to compare the data between different regional hospitals Results: A total of 636 tertiary hospitals participated in the survey. The total number of beds for thoracic surgery departments was 30 646, with M(Q(R)) of 40(20) (range: 3 to 393) for each hospital. The total number of thoracic surgeons was 6 747, with M(Q(R)) of 9(6) (range: 1 to 75) in each hospital. In 2015, a total of 312 425 operations were performed in the 636 hospitals, with M(Q(R)) of 268(484.5) (range: 4 to 8 320) for each hospital. The total number of lung cancer surgeries was 146 601 in 2015, with M(Q(R)) of 100(216) (range: 0 to 6 911) operations in each hospital. The total number of esophageal cancer operations was 67 076, with M(Q(R)) of 40(95) (range: 0 to 1 550) in each hospital. Minimal invasive thoracic surgery was performed in 94.3% (601/636) of the hospitals, with 86.6% (551/636) of hospitals carried out video-assisted thoracoscopic (VATS) lobectomy. Among the hospitals performing VATS lobectomy, 89.3% (492/551) of them started to perform the technique after 2006, and 93.1% (513/551) of them do single-direction thoracoscopic lobectomy. A total of 403 640 VATS lobectomies had been performed until 2015, including 163 682 cases of single-direction thoracoscopic lobectomy. In 2015, 73.74% (108 116/146 601) lung cancer operations and 37.44% (25 110/67 076) of esophageal cancer resections were performed by minimally invasive technique. The development level of hospitals among eastern, middle and Western China was different significantly on number of doctors, number of total operations, number of lung cancer surgeries, proportion of minimally invasive lung cancer surgery, number of esophageal cancer surgeries, and proportion of minimally invasive esophageal cancer surgery (χ(2)∶7.65 to 60.8, all P<0.05). Conclusions: The discipline of thoracic surgery, especially the minimally invasive thoracic surgery in China is now experiencing a rapid development. The proportion of minimally invasive lung cancer surgery is higher than that of in the developed countries. However, unbalanced development among different regions is still a great challenge in China.

Comparative analysis of safety and effect of minimally invasive esophageal cancer radical resection and conventional thoracotomy for esophageal cancer

【Abstract】Objective: To compare the clinical effects of minimally invasive esophageal cancer radical resection and traditional esophageal cancer radical resection.Methods: 200 cases of esophageal cancer radical resection were performed from July 2014 to July 2017 in our hospital.The cases were divided into experimental group and control group, 82 cases in the experimental group and 118 cases in the control group.The experimental group was treated with minimally invasive esophageal cancer radical surgery, and the control group was treated with conventional thoracotomy.Record the comparison between the two groups (1) surgical conditions, including the time of surgery, intraoperative blood loss, hospitalization time; (2) the number of lymph nodes cleaned; (3) the postoperative control group used conventional thoracotomy, including lung lesions, anastomotic fistula / narrow.RESULTS: The parameters of operation time, intraoperative blood loss, hospitalization time, and number of lymph nodes cleaned in the experimental group were lower than those in the control group, and the difference was statistically significant (p&lt;0.05). In addition to pulmonary infection (p&lt;0.05), There was no significant difference in the incidence of other complications between the experimental group and the control group (p&gt;0.05).Conclusion: Minimally invasive esophageal cancer radical resection and conventional thoracotomy have good clinical effects in the treatment of esophageal cancer. Minimally invasive esophageal cancer radical surgery can effectively reduce intraoperative trauma and postoperative reaction, which is worthy of popularization and application.

Autologous Activated Fibrin Sealant for the Esophageal Anastomosis: A Feasibility Study

BackgroundEsophageal cancer is surgically treated by means of an esophagectomy. However, esophagectomies are associated with high morbidity rates with dehiscence of the anastomosis occurring in 19% of these procedures in the Netherlands. Application of a fibrin sealant may improve mechanical strength of the anastomosis. The aim of this study was to determine the technical feasibility of the application of an autologous fibrin sealant by aerosolized spraying on esophageal anastomoses. MethodsThis study was designed as a single-center feasibility study. Patients undergoing elective minimal invasive esophageal surgery with the creation of a thoracic or a cervical anastomosis were eligible. Fibrin sealant (Vivostat) was applied to the anastomosis intraoperatively. Feasibility was measured using a nine-item checklist, designed for intraoperative application. ResultsIn total, fifteen patients, between the ages of 43-79 y, were included in this study. One procedure scored eight out of nine points on the feasibility checklist, so application was considered as unsuccessful. The other fourteen procedures obtained a 100% score and were documented as successful procedures. Together, this led to a success rate of 93%. Grade III anastomotic leakage occurred in one of the fifteen patients (6.7%). ConclusionsThis study showed that application of fibrin sealant on esophageal anastomoses is technically feasible and safe. Future studies may investigate the possible protective effects of fibrin sealant application on the development of anastomotic leakage. NCT03251040.

Application of different intrathoracic esophagogastric anastomosis in surgery for esophageal cancer

Intrathoracic esophagogastric anastomosis is the mainstay of esophageal reconstruction after esophagectomy for the middle and lower esophageal cancer, which is the majority of esophageal cancer. In spite of the constant development of techniques and instruments for esophageal reconstruction, incidence of anastomotic complications stays high, including anastomotic leak and stricture. The current common esophagogastric anastomosis primarily consists of hand-sewn anastomosis and stapled anastomosis. This review presented different ways of intrathoracic esophagogastric anastomosis in reference to the literatures in China and abroad, and comparisons and analyses were made according to operative techniques, anastomotic complication rates, postoperative mortality rates, etc. The results demonstrated that various anastomotic methods had individual, advantages and disadvantages. Duration of stapled anastomosis is short, and linear-stapled anastomosis has a low incidence of anastomotic stricture. Traditional hand-sewn anastomosis, as a necessary skill for thoracic surgeons, shows great manipulative flexibility and reliability. Moreover, the advances in minimally invasive esophageal surgery, such as robot-assisted esophagectomy, increases the operability and efficiency of hand-sewn anastomosis with a promising perspective. In general, among diverse anastomotic methods, mortality does not differ, and the comparison of anastomotic leak rates requires further large clinical trials. Thoracic surgeons have to decide on the anastomotic method of every single case based on patient characteristics and technical proficiency, with the final aim of minimizing anastomotic complications and maximizing patient benefits.

Enhanced Recovery Pathways for Minimally Invasive Esophageal Surgery

The outcomes for enhanced recovery after surgery (ERAS) have yet to be thoroughly studied in minimally invasive esophageal surgery. In this review, we examine the literature to provide an overview of the current state of ERAS in minimally invasive esophageal surgery. We searched the PubMed database up to January 2018 for relevant literature. We reviewed two randomized controlled trials, one Cochrane Review, two meta-analyses, three systematic reviews, three prospective cohort studies, three retrospective case-control studies, one consecutive series, and several other studies pertaining to ERAS in minimally invasive esophageal surgery. Compared with conventional perioperative care, ERAS pathways after minimally invasive esophageal procedures reduce postoperative hospital length of stay, encourage earlier return of bowel function, increase cost savings, and do not significantly change perioperative complication rates. We recommend that patients undergoing minimally invasive esophageal surgery enter a postoperative ERAS pathway to maximize recovery. ERAS pathways offer the best opportunity for successful postoperative recovery without negatively impacting patient safety.

Robotic-assisted Ivor Lewis esophagectomy: technique and early outcomes.

Esophagectomy is pivotal for the long-term survival in patients with early stage and advanced esophageal cancer, and improved perioperative care and advanced surgical techniques have contributed to reduced postoperative morbidity. However, despite these advances, esophagectomy continues to be associated with significant morbidity and mortality. Minimally invasive esophageal surgery (MIE) has been increasingly used in patients undergoing surgery for esophageal cancer. Potential advantages of MIE include the decreased postoperative pain; lower postoperative wound infection, decreased pulmonary complications, and decreased length of hospitalization. Robotic esophageal surgery has the ability to overcome some of the limitations of laparoscopic and thoracoscopic approaches to esophagectomy while maintaining the benefits of the minimally invasive approach. In this article, we will review the clinical efficacy and outcomes associated with robotic-assisted Ivor Lewis esophagectomy (RAIL).

Preface for focused issue on minimally invasive esophageal surgery.

Esophageal cancer is one of high morbidity and mortality disease in China. Radical resection is still the dominant method in the early stage esophageal cancer. Esophageal resections have experienced from open to minimally invasive, which reduced the postoperative complications and early rehabilitation has a great significance. Minimally invasive techniques are popular around the world.

615. Initial experience in robot assisted minimally invasive esophagectomy (ramie)

Background: Emerging techniques in minimally invasive esophageal surgery include robot assisted approach. The aim of this review is to analyze our initial experience in Hospital Clinic of Barcelona after the first year working with the Da Vinci Xi system. We here present our initial results of RAMIE approach in terms of quality of oncological resection, morbidity and mortality.

Minimally invasive surgery for esophageal achalasia.

Esophageal achalasia is due to the esophagus of neuromuscular dysfunction caused by esophageal functional disease. Its main feature is the lack of esophageal peristalsis, the lower esophageal sphincter pressure and to reduce the swallow's relaxation response. Lower esophageal muscular dissection is one of the main ways to treat esophageal achalasia. At present, the period of muscular layer under the thoracoscope esophagus dissection is one of the treatment of esophageal achalasia. Combined with our experience in minimally invasive esophageal surgery, to improved incision and operation procedure, and adopts the model of the complete period of muscular layer under the thoracoscope esophagus dissection in the treatment of esophageal achalasia.

RM-058 Thoracolaproscopic esophagectomy for carcinoma esophagus: our early experience and outcome

Introduction: Background: Advances in technology have allowed us to explore the possibility of performing Esophagectomy using minimal invasive surgical technique. Minimal invasive esophageal surgery has the potential to improve morbidity, mortality, hospital stay and functional outcomes when compared with open method. Although technically complex, combined laparoscopic and thoracoscopic esophageal resection is feasible. Most studies shows thoracoscopic mobilization of the esophagus in left lateral position with single lung ventilation with respiratory complication up to 8–9% where our series show potential of the thoracoscopic part of the procedure in prone position to overcome the difficulty. Methods: From March 2009 through December 2015, TLE was performed in 50 patients. All patients had histologically proved squamous cell carcinoma of the middle and lower third of the esophagus. Only one (0.77%) patient received neoadjuvant chemotherapy. The Thoracoscopic part of the procedure was performed in prone position with double lung ventilation and comfortable port placement for better view and ergonomics which significantly decreased the operative time and better post operative respiratory result. Laparoscopy done for gastric mobilization and conduit formation, minilaparotomy done to retrieved the specimen. Feeding jejunostomy was done in selective patients. Results: There were 38 men and 18 women. Median age was 64.5 years (range 34 to 72 years). There was no conversion to open method. Median ICU stay was 1 day (range 1 to 15 days) and median hospital stay was 7 days (range 4 to 22days). Perioperative mortality was 0.5% (n = 1). Anastomotic leak rate was 0.5% (n = 1). There was no incidence of tracheal or lung injury and a very low incidence of postoperative pneumonia. At mean follow up of 24month (range 2 to 7- month), stage–specific survival was similar to open and other minimally invasive series. Conclusion: Thoracolaparoscopic Esophagectomy is complex and technically difficult, but its safe in experience hand. Due to its comfortable view and excellent ergonomics in the prone position for thoracoscopy, patient do well and benefit from a shorted stay and more rapid recovery compared with open esophagectomy. It provides comparable outcomes with other techniques of minimally invasive esophagectomy and most open series. In our experience, we observed a low mortality rate (0.5%), hospital stay of 7 days, and low incidence of postoperative pneumonia. It has the potential to replace conventional and other techniques of minimally invasive esophagectomy.

Impact of minimally invasive surgery in the treatment of esophageal cancer.

BackgroundSurgical treatment of esophageal cancer is associated to a high morbidity and mortality rate. The open transthoracic or transhiatal esophagectomy are considerably invasive procedures and have been associated to high rates of complications and operative mortality. In this way, minimally invasive esophageal surgery has been suggested as an alternative to the classic procedures because would produce improvement in clinical longterm postoperative outcomes.AimTo assess survival, mortality and morbidity results of esophagectomy due to esophageal cancer submitted to minimally invasive techniques and compare them to results published in international literature.MethodAn observational, prospective study. Between 2003 and 2012, 69 patients were submitted to a minimally invasive esophagectomy due to cancer. It was recorded postoperative morbidity and mortality according to the Clavien-Dindo classification. The survival rate was analyzed with the Kaplan-Meier method. The number of lymph nodes obtained during the lymph node dissection, as an index of the quality of the surgical technique, was analysed.Results63.7% of patients had minor complications (type I-II Clavien Dindo), while nine (13%) required surgical re-exploration. The most common postoperative complication corresponded to leak of the cervical anastomosis seen in 44 (63.7%) patients but without clinical repercusion, only two of them required reoperation. The mortality rate was 4.34%, and reoperation was necessary in nine (13%) cases. The average survival time was 22.59±25.38 months, with the probability of a 3-year survival rate estimated at 30%. The number of resected lymph nodes was 17.17±9.62.ConclusionMinimally invasive techniques have lower morbidity and mortality rate, very satisfactory lymphnodes resection and similar long term outcomes in term of quality of life and survival compared to results observed after open surgery.

Hyperglycemia 3 Days After Esophageal Cancer Surgery Is Associated with an Increased Risk of Postoperative Infection

PurposePostoperative hyperglycemia is associated with infectious complications after various types of surgery. Our objective was to determine whether postoperative blood glucose levels up to 1 week after highly invasive esophageal cancer surgery are associated with the incidence of postoperative infections (POIs). MethodsWe conducted a retrospective chart review of 109 consecutive thoracic esophageal squamous cell cancer patients who underwent invasive esophagectomy with thoracotomy and laparotomy. The incidence of postoperative POIs and risk factors for POIs, including postoperative blood glucose levels, were evaluated. ResultsOf the 109 patients, 37 (34.0 %) developed POIs. Clinically, 73.0 % of the POIs became evident on or after postoperative day 4 (median, 5.25 days; interquartile range, 3.00–9.25 days). On and after postoperative day 3, chronological changes in blood glucose levels were significantly different between two groups of patients with or without POIs, as indicated by repeated measures ANOVA (P = 0.006). Multivariate logistic regression analysis results showed that an increased blood glucose concentration on postoperative day 3 was a significant risk factor for POIs. ConclusionsOur findings suggested that postoperative hyperglycemia on postoperative day 3 was a predictive factor of POIs after highly invasive esophageal cancer surgery.

Minimally Invasive Ivor Lewis Esophagectomy: Description of a Learning Curve

Minimally invasive Ivor Lewis esophagectomy (MIE) is gaining popularity for the treatment of esophageal cancer. However, as it is a technically demanding operation, a learning curve should be defined to guide training and allow implementation at institutions not currently using this technique. Our study included a retrospective series of the first 80 consecutive patients undergoing MIE by a single surgeon with advanced training in minimally invasive esophageal surgery in independent practice at a high-volume tertiary center. Patients were stratified into 2 groups of 40 patients, with chronological order defining early and late experiences. Primary end points included conversion to open procedure, surgical time, blood loss, chest drainage duration, time to oral intake, hospital stay, postoperative morbidity, and mortality. The cumulative sum methodology was used and analyzed by visually inspecting the plots. Conversion to open procedure occurred in 2 (5%) patients in the early group and none in the late group (p= 0.49). Comparing early vs late experience, mean surgical time was 364 vs 316 minutes (p < 0.01), estimated blood loss was 205 vs 176 mL (p= 0.14), median hospital stay was 7 vs 6 days (p < 0.01), and morbidity was observed in 16 (40%) and 14 (35%) patients (p= 0.82), respectively. There were no anastomotic leaks or 30-day mortality. Cumulative sum plots showed decreasing surgical time after patient 54 (plateau after patient 31), decreasing chest tube duration after patients 38 and 33, sooner oral intake after patient 35, and decreased hospital stay after patient33. Improved operative and perioperative parameters for MIE were observed in the last 40 patients when compared with the first 40 patients. A reasonable learning curve for MIE would require the operation and perioperative care of 35 to 40 patients.

Laparoscopic management of totally intra-thoracic stomach with chronic volvulus

To evaluate the outcomes of patients who underwent laparoscopic repair of intra-thoracic gastric volvulus (IGV) and to assess the preoperative work-up. A retrospective review of a prospectively collected database of patient medical records identified 14 patients who underwent a laparoscopic repair of IGV. The procedure included reduction of the stomach into the abdomen, total sac excision, reinforced hiatoplasty with mesh and construction of a partial fundoplication. All perioperative data, operative details and complications were recorded. All patients had at least 6 mo of follow-up. There were 4 male and 10 female patients. The mean age and the mean body mass index were 66 years and 28.7 kg/m(2), respectively. All patients presented with epigastric discomfort and early satiety. There was no mortality, and none of the cases were converted to an open procedure. The mean operative time was 235 min, and the mean length of hospitalization was 2 d. There were no intraoperative complications. Four minor complications occurred in 3 patients including pleural effusion, subcutaneous emphysema, dysphagia and delayed gastric emptying. All minor complications resolved spontaneously without any intervention. During the mean follow-up of 29 mo, one patient had a radiological wrap herniation without volvulus. She remains symptom free with daily medication. The laparoscopic management of IGV is a safe but technically demanding procedure. The best outcomes can be achieved in centers with extensive experience in minimally invasive esophageal surgery.

Results of the introduction of a minimally invasive esophagectomy program in a tertiary referral center.

Esophagectomy is accompanied by a high postoperative complication rate. Minimally invasive esophageal surgery appears to be a promising technique that might be associated with a lower pulmonary morbidity rate. The objective of this study was to describe the implementation of minimally invasive esophageal surgery in a tertiary referral center and to compare the results of our first series of minimally invasive esophagectomies (MIE) to conventional open esophagectomies. MIE was implemented after several procedures had been proctored by a surgeon with extensive experience with MIE. Preoperative characteristics and the postoperative course of patients who underwent a transthoracic esophagectomy were prospectively registered. Morbidity and overall hospital stay were compared between minimally invasive and open resections performed in the same period. A total of 90 consecutive esophageal cancer patients underwent a transthoracic resection, 41 patients by means of a minimally invasive approach. Preoperative characteristics were comparable for both groups. The duration of surgery was longer in the MIE group (6.0 vs. 5.2 hours, P<0.001) and median blood loss was lower [100 vs. 500 mL (P<0.001)]. There was only a trend towards a shorter hospital stay in the MIE group (11 vs. 13 days, P=0.072), pulmonary complications occurred in 20% of patients in the MIE group vs. 31% in the open group (P=0.229). The overall complication rate was 51% in the MIE group vs. 63% in the open group, P=0.249. Implementation of MIE in our center was successful and it appears to be a safe technique for patients with potentially curable esophageal carcinoma.

Thoracoscopic esophagectomy in the prone position

Minimally invasive esophageal surgery has arisen in an attempt to reduce the significant complications associated with esophagectomy. Despite proposed technical and physiological advantages, the prone position technique has not been widely adopted. This article reviews the current status of prone thoracoscopic esophagectomy. A systematic literature search was performed to identify all published clinical studies related to prone esophagectomy. Medline, EMBASE and Google Scholar were searched using the keywords "prone," "thoracoscopic," and "esophagectomy" to identify articles published between January 1994 and September 2010. A critical review of these studies is given, and where appropriate the technique is compared to the more traditional minimally invasive technique utilising the left lateral decubitus position. Twelve articles reporting the outcomes following prone thoracoscopic oesophagectomy were tabulated. These studies were all non-randomised single-centre prospective or retrospective studies of which four compared the technique to traditional minimally invasive surgery. Although prone esophagectomy is demonstrated as being both feasible and safe, there is no convincing evidence that it is superior to other forms of esophageal surgery. Most authors comment that the prone position is associated with superior surgical ergonomics and theoretically offers a number of physiological benefits. The ideal approach within minimally invasive esophageal surgery continues to be a subject of debate since no single method has produced outstanding results. Further clinical studies are required to see whether ergonomic advantages of the prone position can be translated into improved patient outcomes.

Results of the Introduction of a Minimally Invasive Esophagectomy Program in a Tertiary Referral Center

Background: Esophagectomy is accompanied by a high postoperative complication rate. Minimally invasive esophageal surgery appears to be a promising technique that might be associated with a lower pulmonary morbidity rate. The objective of this study was to describe the implementation of minimally invasive esophageal surgery in a tertiary referral center and to compare the results of our first series of minimally invasive esophagectomies (MIE) to conventional open esophagectomies. Methods: MIE was implemented after several procedures had been proctored by a surgeon with extensive experience with MIE. Preoperative characteristics and the postoperative course of patients who under went a transthoracic esophagectomy were prospectively registered. Morbidity and overall hospital stay were compared between minimally invasive and open resections performed in the same period. Results: A total of 90 consecutive esophageal cancer patients underwent a transthoracic resection, 41 patients by means of a minimally invasive approach. Preoperative characteristics were comparable for both groups. The duration of surgery was longer in the MIE group (6.0 vs. 5.2 hours, P<0.001) and median blood loss was lower (100 vs. 500 mL (P<0.001)). There was only a trend towards a shorter hospital stay in the MIE group (11 vs. 13 days, P=0.072), pulmonary complications occurred in 20% of patients in the MIE group vs. 31% in the open group (P=0.229). The overall complication rate was 51% in the MIE group vs. 63% in the open group, P=0.249. Conclusions: Implementation of MIE in our center was successful and it appears to be a safe technique for patients with potentially curable esophageal carcinoma.

Learning curves of minimally invasive esophageal cancer surgery☆

Minimally invasive esophageal cancer surgery (MIES) has been performed at some experienced health centers. MIES has shown to be feasible and safe in esophageal cancer surgery. However, there are a few reports concerning the learning curve of MIES. From 2004 to 2007, MIES was performed in 28 patients by a single surgeon. This amount includes total MIES that contained thoracoscopic esophagectomy, laparoscopic gastric preparation, cervical anastomosis and hybrid MIES that contained only one scope surgery. Surgical outcomes and clinical factors in the first 14 patients (group A) and the other 14 patients (group B) were compared. There were no differences in clinical factors between the two groups. Total MIES was completed in 14 patients, while 13 patients underwent hybrid MIES. There were 6 cases of emergent conversion to open procedures; one case was a thoracotomy and 5 cases were a laparotomy. Chest, abdominal, and total operation time were shorter in group B (p<0.05). The amount of red cell transfusions and intensive care unit stay times were less in the total MIES group (p<0.05). There was one hospital mortality due to acute respiratory distress syndrome. Postoperative complication rate was 43%. As cases increase, surgical outcomes have improved. We think that this report showed a substantial learning curve for a complex surgery such as MIES.