Ivor Lewis Approach Research Articles

565. MOVING FROM OPEN ESOPHAGECTOMY TO MINIMALLY INVASIVE ESOPHAGECTOMY: A PARADIGM SHIFT IN AN UPPER GASTROINTESTINAL CENTER

Abstract Esophagectomy is a complex procedure that is traditionally associated with high morbidities. Minimally invasive esophagectomy (MIE) has the benefits of reduced post-op complications and improved quality of life in comparison to open esophagectomy (OE). This study aimed to compare the outcomes of MIE vs OE since the advocation of MIE as the standard approach in an upper gastrointestinal center. A retrospective review of prospectively collected data from the institutional online databank. OE was the main approach for esophageal cancer between year 2015 to 2017, while MIE was the standard approach in 2020 to 2021. Patient’s demography, tumour’s characteristics, operative approach, perioperative outcomes such as operation time, blood loss, post-op length of hospital stay, number of lymph node yield, post-op morbidities and mortality were compared between the OE (Jan 2015 – Dec 2017) and the MIE (Jan 2020 – Dec 2021) group. 28 patients were included in this study, 15 in the OE group while 13 in the MIE group. Mean age was similar in both groups (60.4vs59.4). 46.7% were of squamous cell carcinoma in the OE group vs 76.9% of adenocarcinoma in the MIE group. Ivor-Lewis approach was more common in the OE group (53.3%vs38.5%). MIE was associated with shorter mean operative time (489.38minutes vs 526minutes), less blood loss (110ml vs 250ml), shorter length of stay post-op (10.38days vs 24.67days) and higher number of lymph node yield (44vs31.67). Post-op morbidity was lower in MIE (30.7%vs73.3%) with Clavien-dindo grade-III and above complication rate of 7.69% vs 26.67%. 90-day mortality was 0 in the MIE vs 1 in the OE group. MIE was associated with shorter operative time, higher number of lymph node yield, reduced post-op morbidity, mortality and shorter post-operative hospital stay in patients with esophageal cancer. The encouraging results marked the paradigm shift from OE to MIE in our center.

Robotic versus thoraco-laparoscopic minimally invasive Ivor Lewis esophagectomy, a matched-pair single-center cohort analysis.

Minimally invasive esophagectomy (MIE) is becoming more widespread with a documented improvement in postoperative morbidity based on level I evidence. However, there is a lack of consensus regarding the optimal MIE approach, conventional thoracoscopy/laparoscopy vs robotics as well as the ideal anastomotic technique. All patients who underwent MIE via an Ivor Lewis approach with a side-to-side stapled anastomosis were included. The thoracoscopy-laparoscopy (TL) group was compared to the robotic group with respect to perioperative outcomes using the entire cohorts and after 1:1 propensity score matching. Comparisons were made using the Mann-Whitney U and Fisher's exact tests. Between July 2013 and November 2020, 72 TL and 67 robotic Ivor Lewis MIE were performed. After comparing the two unadjusted cohorts and 51 propensity matched pairs, there was a decrease in Clavien-Dindo Grade 2 or above complications in the robotic vs TL group (59.7% vs 41.8% [P = 0.042], (62.7% vs 39.2% [P = 0.029]), respectively. In both analyses, there was a reduction in hospital length of stay (median of 8 vs 7days, P< 0.001) and a trend toward less anastomotic leaks in the robotic group (Unadjusted: 12.5 vs 3% [P = 0.057], Propensity-matched analysis: 13.7% vs 3.9% [P = 0.16]), respectively. A clinically significant decrease in overall morbidity, cardiac complications and hospital length of stay was observed in the robotic Ivor Lewis cohort when compared with the TL group at a high volume MIE program. Side-to-side stapled thoracic anastomoses utilizing a robotic platform provides the best outcomes in this single institution experience.

Safety comparison of minimally invasive abdomen-only esophagectomy versus minimally invasive Ivor Lewis esophagectomy: a retrospective cohort study.

We report mortality and post-operative complications from esophageal resection in the treatment of gastroesophageal adenocarcinoma or stricture, comparing a minimally invasive abdomen-only esophagectomy (MIAE) approach with a minimally invasive Ivor Lewis esophagectomy (MIILE) approach. A single-center retrospective cohort study of patients with esophageal adenocarcinoma or stricture treated by either MIAE or MIILE was conducted. MIAE was offered for strictures less than five centimeters or cancers that were American Joint Committee on Cancer (AJCC) Stage ≤ T2 without lymphadenopathy. Patients treated with these surgical techniques were analyzed to assess pre-operative risk, intra and post-operative variables, adverse events, and overall survival. This study included 17 patients undergoing MIAE and 32 patients treated with MIILE. There were a fewer median number of lymph nodes resected (p < 0.001) and shorter operative duration (p < 0.001) for MIAE compared to MIILE. MIAE patients also had significantly higher Charlson Comorbidity Index scores and ACS National Surgical Quality Improvement Program (NSQIP) surgical risk values than MIILE patients (p < 0.05). There was no difference in median estimated blood loss, length of stay, pulmonary or cardiac complications between groups. There was no significant difference in 90-day survival. A minimally invasive abdomen-only approach in a specific patient population is comparable in safety to a minimally invasive Ivor Lewis approach, with associated shorter median operative duration. MIAE patients had significantly greater pre-operative comorbidities and higher calculated peri-operative risk of complication but demonstrated similar post-operative outcomes. This suggests that MIAE may be a suitable surgical approach for treating gastroesophageal adenocarcinoma or stricture in patients deemed unsuitable for MIILE.

Robotic assisted minimally invasive esophagectomy: Ivor-Lewis approach

: Recent published data indicate robotic assisted minimally invasive esophagectomy (RAMIE) can achieve comparable, if not superior outcomes to minimally invasive esophagectomy (MIE). Several studies have demonstrated improved postoperative pain and decreased cardiopulmonary complications following RAMIE for resectable intrathoracic esophageal cancer compared to MIE. Superior three-dimensional visualization and increased instrument precision result in greater lymph node harvest and ensures R0 resection without an increase in intraoperative complications or anastomotic leaks. Herein the authors describe their recent adoption of RAMIE as the standard of care over MIE for patients with resectable esophageal cancer. The authors present a detailed approach to preoperative considerations, intraoperative technical nuances and technique and postoperative outcomes and follow-up following RAMIE. An up to date review of the literature is presented and congruently acknowledges RAMIE as a feasible and safe alternative to MIE with comparable oncologic outcomes.

From McKeown to Ivor Lewis, the learning curve for thoracic lymphadenectomy over the first 100 robotic esophagectomy cases: a retrospective study.

BackgroundLymphadenectomy is an essential but challenging part of the surgical treatment for esophageal cancer. However, the previously reported learning curve for robotic esophagectomy primarily focused on only one surgical approach (McKeown or Ivor Lewis). However, both approaches must be mastered by a mature robotic surgical team to deal with different clinical conditions and satisfy patients’ needs. This study aimed to show how an experienced esophageal surgical team became proficient in both McKeown and Ivor Lewis robotic esophagectomy.MethodsA retrospective review of the first 100 cases of robot-assisted minimally invasive esophagectomy (RAMIE) by a single surgical team was performed. The cumulative sum (CUSUM) analysis was used to distinguish the change point during the learning course. A subgroup analysis was performed according to a surgical approach (McKeown or Ivor Lewis) to determine the effect of experience from one surgical approach on learning the other RAMIE technique.ResultsAccording to the tendency of the CUSUM plot, the learning curve was divided into four phases. The subgroup analysis indicated the decline of the CUSUM plot in the 3rd phase originated from the start of the Ivor Lewis approach. The attending surgeon took 23 cases to achieve a significant improvement in the number of harvested thoracic lymph nodes using the McKeown approach. Regardless of the acquired experience of McKeown RAMIE, it took another 18 cases for the surgical team to achieve significant improvement in harvesting thoracic lymph nodes using the Ivor Lewis approach.ConclusionsTwenty-three cases were needed for an experienced surgical team to improve thoracic lymphadenectomy results using McKeown RAMIE. There was another learning phase during the transition from McKeown to Ivor Lewis esophagectomy. Importantly, the acquired experience from performing McKeown RAMIE could shorten how long it takes to learn Ivor Lewis RAMIE.

A 10-year ACS-NSQIP Analysis of Trends in Esophagectomy Practices

BackgroundEsophagectomy practices have evolved over time in response to new technologies and refinements in technique. Using the National Safety and Quality Improvement Program (NSQIP) database, we aimed to describe trends for esophagectomy in terms of approach, surgeon specialty, and associated outcomes. Materials and methodsAdult patients undergoing esophagectomy were identified within the 2007-2017 NSQIP database. The proportion of cases performed using different approaches was trended over time. Outcomes were compared with chi-squared and t-tests. Multivariate logistic regression was used to identify factors associated with outcomes and provide risk-adjusted measures. ResultsA total of 10,383 esophagectomies were included; 6347 (61.1%) were performed for cancer. The proportion of esophagectomies performed via the Ivor Lewis approach (ILE) increased between 2007 (37.0%) and 2017 (62.4%). Simultaneously, transhiatal esophagectomies (THEs) decreased from 41.1% to 21.5% (P < 0.001). THE was more frequently performed in patients with higher baseline probability of mortality (2.3% versus 2.0%, P < 0.001) and morbidity (32.2% versus. 28.7%, P < 0.001). The percentage performed with cardiothoracic surgeons increased from 0.8% in 2007 to 50.3% in 2017 (P < 0.001). The risk-adjusted complication rate was 45% for THE, 40% for ILE, and 50% for McKeown (MCK) esophagectomy (P < 0.001). The risk-adjusted rate of surgical site infection was 17.3% for THE, 13.1% for ILE, and 19% for MCK (P = 0.001). Within risk-adjusted analysis, surgical approach was not associated with complications. ConclusionsILE has emerged as the predominant approach for esophagectomy nationwide among NSQIP-participating institutions and may be associated with lower complication rates than THE. The use of MCK esophagectomy has remained stable but is associated with increased complications.

Technique of Antiperistaltic Left Colonic Conduit

We describe a case of total esophagogastrectomy with colonic pull-up, in a case which was initially planned for an Ivor Lewis approach. Reconstruction was done using antiperistaltic left colon conduit based on left branch of middle colic artery. What inspired us to write this report is that, this procedure finds place in many discussions of various studies but nowhere is its detailed technique described. Gastric conduit is the workhorse of esophageal cancer surgery, but sometimes an alternative is required when primary conduit has failed or the stomach is not available due to previous surgery or disease extension.

P101 THE IMPACT OF PARATRACHEAL LYMPHADENECTOMY ON LYMPH NODE YIELD AND SHORT-TERM OUTCOMES IN ESOPHAGECTOMY: A NATIONAL PROPENSITY SCORE MATCHED ANALYSIS

Abstract Aim This study aimed to investigate the impact of paratracheal lymphadenectomy on lymph node yield and short-term outcomes in patients undergoing esophagectomy for cancer. Background &amp; Methods Although the addition of paratracheal lymphadenectomy to a standard two-field lymphadenectomy possibly may provide survival benefits for patients undergoing esophagectomy for esophageal cancer, the required dissection along the recurrent laryngeal nerves might be associated with increased morbidity. To investigate the impact of paratracheal lymphadenectomy on short-term oncological outcomes and postoperative complications, this nation-wide population-based cohort study included esophageal cancer patients who underwent neoadjuvant chemoradiotherapy followed by elective transthoracic esophagectomy with at least subcarinal and para-esophageal lymphadenectomy from the Dutch Upper Gastrointestinal Cancer Audit (DUCA). After propensity score matching Ivor Lewis and McKeown approaches separately, the lymph node yield and clinical outcomes were compared between patients who underwent paratracheal lymphadenectomy versus patients who did not. Results Between 2011-2017, a total of 2128 patients were included. A total of 770 patients (n=385 vs. n=385) and 516 patients (n=258 vs. n=258) were matched for the Ivor Lewis and McKeown approaches, respectively. Paratracheal lymphadenectomy was associated with a higher total lymph node yield in both Ivor Lewis (23 vs. 19 nodes, P&lt;0.001) and McKeown (21 vs. 19 nodes, P=0.015) esophagectomy. In McKeown esophagectomy, paratracheal lymphadenectomy was associated with significantly more advanced pathological nodal staging (pN0; 57% vs. 69%, pN1; 25% vs. 16%, pN2; 12% vs. 11%, pN3; 6% vs. 3%, P=0.006). No significant differences were observed regarding recurrent laryngeal nerve injury, other postoperative complications, and mortality, although a higher re-intervention rate was found after paratracheal lymphadenectomy during McKeown esophagectomy (30% vs. 18%, P=0.002) In patients undergoing Ivor Lewis esophagectomy, paratracheal lymphadenectomy was associated with increased length of stay (12 vs. 11 days, P&lt;0.048). Conclusion In patients undergoing transthoracic esophagectomy for cancer, the addition of paratracheal lymphadenectomy results in a higher lymph node yield with comparable complication and mortality rates.

P113 ESOPHAGECTOMY-SPECIFIC OBJECTIVE STRUCTURED ASSESSMENT OF TECHNICAL SKILL (E-OSATS): CONSENSUS ON ESSENTIAL IVOR-LEWIS AND MCKEOWN STEPS TROUGH DELPHI METHODOLOGY

Abstract Aim The objective of this study was to determine expert consensus on essential steps in MIE to develop an ‘Esophagectomy-specific Objective Structured Assessment of Technical Skills’ tool (E-OSATS). Background &amp; Methods Minimally invasive esophagectomy (MIE) is a complex and technically demanding procedure. Studies have shown that MIE has a long learning curve which is associated with increased morbidity and mortality. To master MIE training of procedural steps is crucial. Yet, no consensus regarding the essential steps nor a structured way of assessment of MIE are available. Essential steps were defined for both Ivor-Lewis (IL) and McKeown (MCK) approach, based on expert opinion and peer-reviewed literature. In round table discussions experts finalized the list, and an online Delphi questionnaire was sent to an international expert panel (7 European countries) of minimally invasive upper GI surgeons. Based on replies and comments steps were adjusted and rephrased and sent in iterative fashion until consensus was achieved. Results Two Delphi rounds were conducted, and response rates were 74% (23 out of 31 experts) for the first and 81% (27 out of 33 experts) for the second round. Consensus was achieved on 94 and 98 steps for the IL and MCK approach respectively. Cronbach’s alpha in the first round was 0,77 (IL) and 0,77 (MCK), and in the second round 0,91 (IL) and 0,87 (MCK). Conclusion International consensus on essential surgical steps for MIE with both intrathoracic- and cervical anastomosis was achieved. Validation of the assessment tool allows for specific and structured feedback and will potentially shorten the learning curve and decrease learning associated morbidity consequently.

P121 ESOPHAGECTOMY-SPECIFIC OBJECTIVE STRUCTURED ASSESSMENT OF TECHNICAL SKILL (E-OSATS): VALIDATION PROTOCOL

Abstract Aim The objective of this study is to develop the ‘Esophagectomy-specific Objective Structured Assessment of Technical Skills’ tool (E-OSATS) and determine its validity, reliability and feasibility of use. Background &amp; Methods Minimally invasive esophagectomy (MIE) is a complex and technically demanding procedure. Increased morbidity and mortality are associated with the long learning curve of the procedure. Specific and structured feedback may shorten the learning curve and decrease the associated morbidity and mortality. Consensus regarding the essential procedural steps has recently been achieved and allows for development and validation of a procedure specific assessment tool for MIE (E-OSATS). The E-OSATS was created by anchoring previously defined essential steps for both Ivor-Lewis (IL) and McKeown (McK) approach. Ten video recordings of novice surgeons (&lt;15 MIE performed) and 10 recordings of expert surgeons (&gt;100 MIE performed) should be rated by two independent, blinded and trained raters. Records of time needed for the assessment are created. Inter-rater and test-retest reliability will be determined. Validity will be determined by analyzing differences between novice and expert surgeons. Results All IL video recordings are collected, McK collection is still pending. First assessments of video recordings are expected to take place in August 2019. We aim to collect all assessments before December 2019. Conclusion We hypothesize that we will demonstrate the feasibility, reliability and validity of the E-OSATS in MIE specific assessment of technical skill. This tool will allow for specific and structured feedback and will potentially shorten the learning curve and decrease learning associated morbidity.

Minimally invasive approach for cancer of the esophagogastric junction

The incidence of esophagogastric junction (EGJ) cancer is increasing in the world. EGJ cancer is traditionally classified by the Siewert classification, despite its limitations. The definition and classification of EGJ cancer is a controversial topic. Thus, the best available strategy for the surgical treatment of EGJ cancer remains controversial. This chapter reviews a minimally invasive approaches for EGJ cancer. Most operations for EGJ cancer that are performed by open surgery can be performed minimally invasively. A minimally invasive transthoracic approach (Ivor-Lewis or McKeown esophagectomy) is the optimal surgical approach for Siewert type I cancer. Mediastinoscope-assisted transhiatal esophagectomy, which was recently reported, may be a suitable surgical option, especially for frail patients with Siewert type I cancer. Generally, laparoscopic total or proximal gastrectomy is regarded as the standard for surgerical method for Siewert type III cancer, while both laparoscopic gastrectomy (with lower esophagectomy) or a minimally invasive Ivor-Lewis approach are recommended for Siewert type II cancer. Minimally invasive surgery (MIS) has the potential to shorten the length of hospitalization, reduce the risk of postoperative pulmonary complications, and improve quality of life with a similar margin status, nodal harvest, and survival rate to open techniques. However, as the existing literature is still limited, the choice of surgical method should be judged by the experienced surgeons, especially in MIS. This review reveals that further large clinical stuidies are need to deepen our understanding of MIS for EGJ cancer.

Robotic-assisted McKeown esophagectomy.

Over the last few decades, minimally invasive approaches have gained in popularity for the surgical treatment of esophageal cancer, with the hopes of reducing the morbidity and mortality of this formidable procedure. The traditional McKeown approach includes thoracic esophageal dissection, abdominal mobilization of the gastric conduit and a cervical anastomosis. It presents several advantages over the Ivor Lewis approach: it is suitable for proximal tumors, allows a 3-field lymph node dissection, and avoids the morbidity associated with an intra-thoracic anastomotic leak. Here, we discuss the technical aspects of robotic-assisted minimally invasive McKeown esophagectomy (McKeown RAMIE).

Comparison of Long-term Quality of Life in Patients with Esophageal Cancer after Ivor-Lewis, Mckeown, or Sweet Esophagectomy

BackgroundThe aim of this study was to compare the long-term quality of life (QoL) in patients after Sweet, Ivor-Lewis, or Mckeown esophagectomy. MethodsEsophageal cancer patients after Sweet, Ivor-Lewis, or Mckeown esophagectomy from 2010 to 2012 were included. QoL was assessed according to the European Organization for Research and Treatment of Cancer general questionnaire: QLQ-C30 and esophagus-specific questionnaire: QLQ-OES18. ResultsA total of 126 qualified patients who have been alive for more than 3 years without tumor recurrence were divided into three groups: the Sweet group (n = 40), Ivor-Lewis group (n = 38), and Mckeown group (n = 48). Among these three groups, the QLQ-C30 mean scores of global health status, functional and symptom scales, and general QoL were similar. The symptom scales of QLQ-OSE18 showed that patients who had a Mckeown operation experienced more problem of eating (P = 0.029), choking when swallowing (P = 0.010) and coughing (P = 0.016), while patients undergoing Sweet operation complained more symptom of reflux (P = 0.003) and pain (P = 0.000). ConclusionsAll three types of esophagectomy provided a generally good long-term QoL. However, patients in Sweet and Mckeown group tend to suffer from a higher symptomatic burden as compared to Ivor-Lewis approach.

PS01.144: LYMPH NODE YIELDS AFTER ESOPHAGECTOMY: IMPACT OF APPROACH TO SURGERY AND USE OF NEOADJUVANT THERAPIES

Abstract Background Although the importance of lymph node (LN) harvest for the adequate staging of esophageal cancer has been well studied, lymph node yields in the literature remain highly variable. Moreover, the effect of modern treatments of esophageal cancer such as induction therapy and minimally invasive approaches on lymph node yield is incompletely understood. Methods A retrospective review of 307 patients who underwent esophagectomy for esophageal cancer between 2005–2013 at Toronto General Hospital was conducted. Early in this experience, thoracoabdominal, transhiatal, Ivor Lewis and Mckeown approaches were utilized with transition over time to fully minimally invasive Ivor Lewis and Mckeown operations. Induction chemoradiotherapy is now our standard for locally advanced esophageal cancer. Demographics, histology, type and approach to esophagectomy, use of induction therapy, lymph node yield, and number of positive lymph nodes were collected. Kruskal-Wallis test was utilized for significance between groups. Results Our population comprised of 239 (78%) males and 68 (22%) females. Adenocarcinoma was the predominant histology at 220 (72%) with 78 (25%) squamous cell carcinoma and 9 (3%) as other histology. 144 (47%) patients had surgery alone, 147 (48%) had induction chemoradiotherapy, and 16 (5%) had induction chemotherapy. The open approach was used in 178 (58%), hybrid minimally-invasive in 33 (11%), fully minimally-invasive in 58 (19%), and transhiatal in 38 (12%). Overall, a median of 24 [IQR17–33; min 3, max 92] nodes were obtained. Induction therapy did not lower our yield (no induction 23[16–32], induction chemotherapy 32.5[17–47], induction chemoradiotherapy 25[19–33], P = 0.07). Transition to a minimally invasive approach similarly did not lower our yield, with only the transhiatal approach showing lower lymph node yield (open 26[17–33], hybrid 33[23–39], fully minimally-invasive 25[19–36], transhiatal 16[11–22], P = 0.005). Conclusion Lymph node yields above 20 can be routinely achieved for adequate staging. Despite the increasing use of induction therapy and minimally-invasive approaches, similar lymph node yields can and should be achieved. Disclosure All authors have declared no conflicts of interest.

PS01.197: SURVIVAL COMPARISON BETWEEN IVOR-LEWIS AND MCKEOWN MINIMALLY INVASIVE ESOPHAGECTOMY FOR ESOPHAGEAL CANCER: A PROSPECTIVE RANDOMIZED STUDY

Abstract Background Both Ivor Lewis (anastomosis in the chest) and McKeown (anastomosis in the neck) esophagectomy has been used to treat patients with esophageal cancer. It is unclear in literature about the survival difference performed by these two methods. Methods A prospective randomized trial enrolling 100 patients with esophageal cancer in the middle or lower esophagus was done to compare the survival outcome treated with minimally invasive esophagectomy by Ivor Lewis and McKeown approaches. Analysis for the retrospective patient cohort (n = 253) including Ivor Lewis (n = 115) and McKeown (n = 138) MIE in the same hospital was also performed. Results There is no significant difference in the overall and disease progression-free survival duration between the two groups of patients (n = 50 for each group) (Figure 1 for overall survival). Similar results were found when the comparison was done for the retrospective and whole patients cohort. Multivariate analysis demonstrates the TNM staging of the tumor to be the single significant factor for prognosis in terms of overall and disease progression-free survival. There was no significant difference in overall and disease progression- free survival between the patients with Ivor Lewis and McKeown MIE both in prospective and retrospective study cohort. Conclusion Ivor Lewis and McKeown MIE provide a similar survival results for the patients with esophageal cancer in the middle and lower thoracic esophagus. Disclosure All authors have declared no conflicts of interest.

Complications After Esophagectomy Are Associated With Extremes of Body Mass Index

Body mass index (BMI) is not routinely taken into consideration for risk stratification prior to esophagectomy. Extremes of BMI are associated with adverse surgical outcomes in a variety of surgical specialties. We assessed the relationship of BMI to outcomes after esophagectomy for cancer. Patients in the Society of Thoracic Surgeons General Thoracic Surgery Database (2009 to 2016) who underwent elective esophagectomy for cancer were selected for analysis. Open and minimally invasive approaches were included. Complications were categorized based on the Esophagectomy Complications Consensus Group recommendations. Multivariable logistic regression was used to adjust for confounding variables. We evaluated 9,389 patients grouped by BMI: underweight (<18.5 kg/m2; 3%), normal (18.5 to 24.9 kg/m2; 32%), overweight (25 to 29.9 kg/m2; 36%), obese I (30 to 34.9 kg/m2; 19%), obese II (35 to 39.9 kg/m2; 7%), and obese III (≥40 kg/m2; 3%). Most patients underwent open Ivor Lewis (33%), open transhiatal (23%), or minimally invasive Ivor Lewis (22%) approaches. The operative mortality rate was 3.4%; the frequency of complications by category ranged from 4% to 28%. On multivariable analysis, overall differences were identified among BMI categories for 7 out of 9 complication types. Underweight and obese III categories were associated with increased risk. In contrast, overweight and obese I BMI were associated with decreased risk for most complication types. BMI is associated with postoperative complications after esophagectomy. Postoperative risk assessment and prehabilitation regimens should be adjusted accordingly when planning an esophagectomy for a patient with very low or very high BMI.

Pylorus drainage procedures in thoracoabdominal esophagectomy \u2013 a single-center experience and review of the literature

BackgroundPylorotomy and pyloroplasty in thoracoabdominal esophagectomy are routinely performed in many high-volume centers to prevent delayed gastric emptying (DGE) due to truncal vagotomy. Currently, controversy remains regarding the need for these practices. The present study aimed to determine the value and role of pyloric drainage procedures in esophagectomy with gastric replacement.MethodsA retrospective review of prospectively collected data was performed for all consecutive patients who underwent thoracoabdominal resection of the esophagus between January 2009 and December 2016 at the Katharinenhospital in Stuttgart, Germany. Clinicopathologic features and surgical outcomes were evaluated with a focus on postoperative nutrition and gastric emptying.ResultsThe study group included 170 patients who underwent thoracoabdominal esophageal resection with a gastric conduit using the Ivor Lewis approach. The median age of the patients was 64 years. Most patients were male (81%), and most suffered from adenocarcinoma of the esophagus (75%). The median hospital stay was 20 days, and the 30-day hospital death rate was 2.9%. According to the department standard, pylorotomy, pyloroplasty, or other pyloric drainage procedures were not performed in any of the patients. Overall, 28/170 patients showed clinical signs of DGE (16.5%).ConclusionsIn the literature, the rate of DGE after thoracoabdominal esophagectomy is reported to be approximately 15%, even with the use of pyloric drainage procedures. This rate is comparable to that reported in the present series in which no pyloric drainage procedures were performed. Therefore, we believe that pyloric drainage procedures may be unwarranted in thoracoabdominal esophagectomy. However, future randomized trials are needed to ultimately confirm this supposition.

Minimally invasive esophagectomy for esophageal cancer according tothe location of the tumor: Experience of 251 patients.

BackgroundMinimally invasive esophagectomy (MIE) is increasingly used for the treatment of esophageal cancer. However, the ideal approach of MIE is not yet standardized. We explore the ideal approach of MIE according to the location of the tumor and compare the clinical outcomes between patients with cancer arising in the upper third of the esophagus and those with tumors involving the middle and lower third of the esophagus.MethodsWe included patients with esophageal carcinoma and had clear indications for MIE. For cancer arising in the upper third of the esophagus, MIE McKeown approach was performed. For tumors involving the middle and lower third of the esophagus, MIE Ivor Lewis approach was adopted.ResultsOf the 251 patients included in this analysis, 200 patients underwent Ivor-Lewis MIE and 51 patients underwent McKeown MIE. The incidence of anastomotic leak, anastomotic stenosis and recurrent laryngeal nerve injury was significantly higher in the McKeown MIE group than that in the Ivor Lewis MIE group. The 30-day postoperative mortality rate was 1.2% (n = 1) in the McKeown MIE group. Lymph nodes harvested were significantly more in the MIE-McKeown group than in Ivor Lewis MIE group (P < 0.05). The median follow-up period was 15 months (1–25 months) and the overall survival rate at 1 year stratified by pathologic stage at esophagectomy was 95.9% (stage 1), 83.8% (stage II), 73.4% (stage III).ConclusionsMIE for esophageal cancer according to the location and clinical stage of the tumor will decrease all postoperative complications and may yield the greatest benefit from surgery.

Lymph node dissection for Siewert II esophagogastric junction adenocarcinoma: A retrospective study of 3 surgical procedures.

The present study was aimed to investigate the application of right thansthoracic Ivor–Lewis (IL), left transthoracic (LTT), and left thoracoabdominal (LTA) approach in Siewert type II adenocarcinoma of esophagogastric junction (AEG).The data of 196 patients with Siewert type II AEG received surgical resection in our cancer center between January 2014 and April 2016 was retrospectively analyzed. Finally, 136 patients met the inclusion criteria were enrolled in the study and divided into the IL (47 cases), LTT (51 cases), and LTA group (38 cases). Clinical and short-term treatment effects were compared among the 3 groups.The patients with weight loss, diabetes, and heart disease increased in the LTT group (P = 0.054, P = 0.075, and P = 0.063, respectively). Operation time was significantly longest in the IL group (P < 0.001), but the amount of bleeding and tumor size did not significantly differ among the 3 groups (P = 0.176 and P = 0.228, respectively). The IL group had the significantly longest proximal surgical margin (P < 0.001) and most number of total (P < 0.001) and thoracic lymph nodes (P < 0.001) dissected. Both the IL and LTA groups had more abdominal lymph nodes dissected than the LTT group (P < 0.001). In general, the IL and LTT groups had the highest dissection rates of every station of thoracic (P < 0.05) and lower mediastinal lymph nodes (P < 0.05), respectively. The dissection rate of the paracardial, left gastric artery, and gastric lesser curvature lymph nodes did not differ significantly among the 3 groups (P > 0.05), but the dissection rate of the hepatic artery, splenic artery, and celiac trunk lymph nodes was significantly highest in the IL group (P < 0.05). Postoperative hospital stay, perioperative complications, and mortality did not differ significantly among the 3 groups (P > 0.05).Compared with the traditional left transthoracic approach, the Ivor–Lewis approach did not increase the perioperative mortality and complication rates in Siewert type II AEG, but obtained satisfactory length of the proximal surgical margin, and was better than the left transthoracic approach in thoracic and abdominal lymph node dissection. However, the advantages of Ivor–Lewis procedure requires further follow-up and validation through prospective randomized controlled trials.

The impact of operative approaches on outcomes of middle and lower third esophageal squamous cell carcinoma.

The aim of this study was to investigate the perioperative outcomes and 3-year overall survival (OS) of 2 approaches including Sweet and open Ivor Lewis esophagectomy in the surgical treatment of middle and lower third esophageal squamous cell carcinoma. The medical records of 1,746 consecutive patients who underwent esophagectomy for middle and lower esophageal cancer between January 2009 and September 2015 at the First Department of Thoracic Oncologic Surgery of Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College were retrospectively reviewed. The clinical variables and 3-year survival were compared between Sweet (n=1,701) and open Ivor Lewis (n=45) approaches in unmatched and propensity score matching analysis. Patients who received esophagectomy by Sweet approach had shorter duration of surgery (mean 212 vs. 390 min; P<0.001), more lymph nodes removed (mean 24 vs. 19; P=0.005), lower overall complications rate (24.4% vs. 11.7%; P=0.009), lower total hospital cost (¥77,200 vs. 106,000; P=0.045) compared with patients who received open Ivor Lewis approach. After propensity score matching analysis, Sweet approach was still associated with decreased duration of surgery (mean 210 vs. 390 min; P<0.001), more lymph nodes removed (mean 24 vs. 19; P=0.050), and lower total hospital cost (¥86,800 vs. 106,000; P=0.045) compared with Ivor Lewis approach. However, there were no significant differences in overall complication rates (24.4% vs. 24.4%; P=1.000) between two approaches. There was no significant difference in 3-year OS between Sweet and open Ivor Lewis approaches (59.9% vs. 61.4%; P=0.637) in unmatched analysis and in matched analysis (77.8% vs. 61.4%; P=0.264). In this cohort, for middle and lower third esophageal squamous cell carcinoma patients, both Sweet and open Ivor Lewis approaches are feasible in terms of perioperative outcomes and 3-year OS.