McKeown Approach Research Articles

Use of the Stomach in Esophageal Reconstructive Surgery in Era of Minimally Invasive Approach.

Esophagectomy is standard indication for surgical treatment of resectable esophageal cancer, but it can also be performed for the management of benign conditions. Esophagectomy is followed by esophageal reconstruction using other parts of the digestive tract and is associated with increased postoperative morbidity and mortality. Gastric interposition with intrathoracic or cervical esophago- gastric anastomosis is currently the preferred technique for reconstruction after esophagectomy. The incidence of esophagectomy performed by the minimal invasive approach has increased in recent years due to the advanced technology of endoscopic surgery and image enhancement that provides a better estimate of anatomical plans, facilitates access to narrow spaces and more precise dissection with less tissue trauma. Randomized clinical trials have found a significant reduction in postoperative respiratory complications, decreased hospital stay and equivalent oncological results to open esophagectomy. We present the operative technique of minimally invasive esophagectomy performed in our clinic by three-stage modified McKeown approach thoracoscopic, laparoscopic and cervical with esophageal reconstruction with stomach.

Minimally invasive esophagectomy via Sweet approach in combination with cervical mediastinoscopy for esophageal squamous cell carcinoma: a case series.

Objective:Minimally invasive esophagectomy (MIE) is increasingly used for the treatment of esophageal cancer. However, MIE via the Sweet approach has seldom been reported owing to the challenging procedure for a mediastinal lymph node. Thus, the approach of MIE via left-sided thoracoscopy coupled with video-assisted cervical mediastinoscopy (MIE-SM) was explored for eradicating the mediastinal lymph nodes and recurrent laryngeal nerve; the incidence of perioperative complications, mortality, and surgical radicality were analyzed.Materials and Methods:Thirty patients with esophageal carcinoma underwent MIE-SM between June 2014 and February 2016. The primary outcome was postoperative morbidity within 2 weeks postsurgery. The secondary outcome was surgical radicality, including the circumferential margins, and the number of lymph nodes dissected.Results:The MIE-SM was completed in all patients within 367.6±68.7 minutes. The incidences of postoperative morbidities including pulmonary complications, anastomotic leakage, chylothorax, or recurrent nerve injury were 43.3%.Conclusion:The MIE-SM was utilized for the first time to reduce the disadvantage of purely Sweet and McKeown approach, with favorable efficacy in the mediastinal and laryngeal recurrent nerve lymph node eradication. Thus, MIE-SM might be a promising alternative approach in treating esophageal cancer in selected patients.

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.

Minimally Invasive Esophagectomy Utilizing a Stapled Side-to-Side Anastomosis is Safe in the Western Patient Population.

There has been an increased utilization of minimally invasive esophagectomy (MIE) in an effort to reduce morbidity, decrease length of stay, and improve quality of life. However, there are limited large series of patients undergoing MIE from the United States and no standardized approach. We reviewed our experience with MIE utilizing a stapled side-to-side anastomosis during a 7.5-year period. A retrospective review of prospectively maintained databases for patients undergoing planned esophagectomy were reviewed from 2007 to 2015. Esophagogastric anastomoses were performed via a 6-cm linear stapled side-to-side method. Demographics, comorbidities, surgical approach, pathology data, and postoperative morbidities were recorded and reviewed. A MIE was attempted in 303 of 315 (96%) patients, and a total minimally invasive approach was completed in 293 of 315 (93%) patients. Location of anastomosis was predominantly in the neck, with 244 patients (77.5%) undergoing a total minimally invasive McKeown approach (n=231). A total, minimally invasive Ivor-Lewis was completed in 60 patients (19.1%). Anastomotic leak was identified in 24 patients (7.6%). Rates of anastomotic leak were 4.4% for Ivor-Lewis and 8.5% for McKeown resection. Median length of stay was 8days, and in-hospital mortality occurred in only three patients (n=1%). Ninety-day follow-up demonstrated a 4.1% stricture rate requiring dilatation. In the Western patient population, MIE utilizing a 6-cm stapled side-to-side anastomosis is associated with low rates of anastomotic leak, stricture, and mortality.

Comparative study of minimally invasive versus open esophagectomy for esophageal cancer in a single cancer center

Background In order to minimize the injury reaction during the surgery and reduce the morbidity rate, hence reducing the mortality rate of esophagectomy, minimally invasive esophagectomy (MIE) was introduced. The aim of this study was to compare the postoperative outcomes in patients with esophageal squamous cell carcinoma undergoing minimally invasive or open esophagectomy (OE). Methods The medical records of 176 consecutive patients, who underwent minimally invasive esophagectomy (MIE) between January 2009 and August 2013 in Cancer Institute &amp; Hospital, Chinese Academy of Medical Sciences, were retrospectively reviewed. In the same period, 142 patients who underwent OE, either Ivor Lewis or McKeown approach, were selected randomly as controls. The clinical variables of paired groups were compared, including age, sex, Charlson score, tumor location, duration of surgery, number of harvested lymph nodes, morbidity rate, the rate of leak, pulmonary morbidity rate, mortality rate, and hospital length of stay (LOS). Results The number of harvested lymph nodes was not significantly different between MIE group and OE group (median 20 vs. 16, P=0.740). However, patients who underwent MIE had longer operation time than the OE group (375 vs. 300 minutes, P &lt;0.001). Overall morbidity, pulmonary morbidity, the rate of leak, in-hospital death, and hospital LOS were not significantly different between MIE and OE groups. Morbidities including anastomotic leak and pulmonary morbidity, in-hospital death, hospital LOS, and hospital expenses were not significantly different between MIE and OE groups as well. Conclusions MIE and OE appear equivalent with regard to early oncological outcomes. There is a trend that hospital LOS and hospital expenses are reduced in the MIE group than the OE group.