McKeown Minimally Invasive Esophagectomy Research Articles

Perioperative Risk Factors for Postoperative Pulmonary Complications After Minimally Invasive Esophagectomy.

Postoperative pulmonary complications (PPCs) are the most prevalent complication after esophagectomy and are associated with a worse prognosis. This study aimed to investigate the perioperative risk factors for PPCs after minimally invasive esophagectomy (MIE). Seven hundred and sixty-seven consecutive patients who underwent McKeown MIE via thoracoscopy and laparoscopy were retrospectively studied. Patient characteristics, perioperative data, and postoperative complications were analyzed. The incidence of PPCs after MIE was 25.2% (193/767). Univariate analysis identified age (odds ratio [OR] 1.022, P = 0.044), male sex (OR 2.955, P < 0.001), pulmonary comorbidities (OR 1.746, P = 0.032), chronic obstructive pulmonary disease (COPD) (OR 2.821, P = 0.003), former smoking status (OR 1.880, P = 0.001), postoperative albumin concentration (OR 0.941, P = 0.007), postoperative creatinine concentration (OR 1.011, P = 0.019), and perioperative transfusion (OR 2.250, P = 0.001) as risk factors for PPCs. In multivariate analysis, the independent risk factors for PPCs were male sex (OR 3.135, P < 0.001), body mass index (BMI) (OR 1.088, P = 0.002), COPD (OR 2.480, P = 0.012), neoadjuvant chemoradiotherapy (OR 2.057, P = 0.035), postoperative albumin concentration (OR 0.929, P = 0.002), and perioperative transfusion (OR 1.939, P = 0.013). The area under the receiver operating characteristic curve for the predictive model generated by multivariate logistic regression analysis was 0.671 (95% confidence interval 0.628-0.713). Male sex, BMI, COPD, neoadjuvant chemoradiotherapy, postoperative albumin concentration, and perioperative transfusion were independent predictors of PPCs after MIE.

Comparison of substernal and posterior mediastinal route of reconstruction after minimally invasive esophagectomy for esophageal cancer

BackgroundSubsternal (ST) and posterior mediastinal (PM) routes are the two most common for reconstruction after esophagectomy with cervical anastomosis. Recent evidence showed similar outcomes between the routes; thus, the superior choice remained controversial. This study aimed to compare the short-term outcomes of the ST to the PM route for reconstruction after esophagectomy for esophageal cancer (EC).MethodThis retrospective cohort study included 132 patients who underwent McKeown minimally invasive esophagectomy (MIE) with gastric conduit for EC between March 2015 and December 2022. Among these, 89 and 43 patients received the ST route and PM route for reconstruction, respectively. Short-term outcomes including operative characteristics, postoperative morbidity, and mortality were evaluated.ResultThere was no conversion from ST to PM route. The ST group had longer operating time (375 min vs. 341 min). Oral feeding initiation, postoperative hospital stays, and overall complication rates were comparable in the two groups. The rate and severity of anastomotic leakage were similar between the groups. The ST group had a significantly lower incidence of postoperative ICU admission and pneumonia compared to the PM group (5.6% vs. 16.3% and 19.1% vs. 37.2%, respectively). Azygos vein bleeding, obstruction at feeding jejunostomy site, and conduit–trachea fistula were severe complications that only occurred in PM route.ConclusionST route was superior to PM route in term of postoperative ICU admission and pneumonia. This route may prevent severe complications that only occur in PM route. ST route can be favorable option for reconstruction after McKeown MIE for EC.

Transhiatal bilateral cervical approach for mediastinoscopy-assisted esophagectomy: A retrospective cohort study.

The McKeown minimally invasive esophagectomy (McMIE) procedure has various limitations, including surgical contraindications and a high rate of postoperative pulmonary complications. A novel mediastinoscopic esophagectomy procedure was described in this study by using esophageal invagination and a transhiatal and bilateral cervical approach (EITHBC). According to the mode of operation, a total of 259 patients were divided into two groups, among which 106 underwent EITHBC and 153 underwent McMIE. The number of lymph nodes dissected, intraoperative outcomes, and postoperative outcomes were compared between the two groups of patients. The results revealed that the average number of resected lymph node in the EITHBC group was significantly higher in the recL106 and TbL106 stations (recL106: 1.75 vs. 1.51, p=0.016, TbL106: 1.53 vs. 1.19, p=0.016) and significantly lower in the 107 stations (1. 74 vs. 2. 07, p < 0.001) than in the McMIE group. The intraoperative blood loss in the EITHBC group was significantly lower than that in the McMIE group (63.30 vs. 80.45mL, p<0.001). The incidence of postoperative pulmonary complications in the EITHBC group was lower than that in the McMIE group (14.15% vs. 27.45%, p=0.008). The incidence of recurrent laryngeal nerve paralysis in the EITHBC group was significantly higher than that in the McMIE group (26.41% vs. 10.46%, p=0.003). Compared with the McMIE procedure, the EITHBC procedure has advantages in terms of removing the upper mediastinal lymph nodes and reducing postoperative pulmonary complications.

Safety and feasibility of three-dimensional McKeown minimally invasive esophagectomy.

To compare the perioperative outcomes from McKeown minimally invasive esophagectomy (MIE) when performed in three-dimensional versus two-dimensional visualization system, and investigate the learning curve of a single surgeon who implemented three-dimensional McKeown MIE. A total of 335 consecutive cases (three-dimensional or two-dimensional) were identified. Perioperative clinical parameters were compared and cumulative sum learning curve was plotted. Propensity score matching was used to reduce selection bias from confounding factors. Patients in three-dimensional group were associated with more chronic obstructive pulmonary disease (23.9% vs 3.0%, p < 0.01). After propensity score matching (108 matched patients in each groups), this finding was no longer statistically significant. Comparing to two-dimensional group, significant improvement in total retrieved lymph nodes (28 vs 33, p = 0.003) was observed in three-dimensional group. In addition, more lymph nodes around the right recurrent laryngeal nerve were harvested in three-dimensional group than that in two-dimensional group (p = 0.045). However, there were no significantly differences were found between the two groups in terms of other intraoperative parameters (e.g., operative time) and postoperative relevant outcomes (e.g., lung infection). Furthermore, the change point in the cumulative sum learning curves for intraoperative blood loss and thoracic procedure time was 33 procedures, respectively. Three-dimensional visualization system appears to be superior in performing lymphadenectomy during McKeown MIE to that of a two-dimensional technique. For surgeons proficient in performing two-dimensional McKeown MIE, the learning curve for a three-dimensional procedure appears to begin near proficiency after more than 33 cases.

The feasibility of a "no tube, no fasting" fast-track recovery protocol after esophagectomy for esophageal cancer patients aged 75 and over.

For elderly patients aged ≥75 with esophageal cancer, whether surgical treatment is safe and effective and whether it is feasible to use a relatively radical "no tube, no fasting" fast-track recovery protocol remain topics of debate. We conducted a retrospective analysis to shed light on these two questions. We retrospectively collected the data of patients who underwent McKeown minimally invasive esophagectomy (MIE) combined with early oral feeding (EOF) on postoperative day 1 between April 2015 and December 2017 at Medical Group 1, Ward 1, Department of Thoracic Surgery of our hospital. Preoperative characteristics, postoperative complications, operation time, intraoperative blood loss, duration of anastomotic leakage (day), hospital stay, and survival were evaluated. Twenty-three elderly patients with esophageal cancer underwent surgery with EOF. No significant difference was observed in intraoperative measures. The incidence of postoperative complications was 34.8% (8/23). Two patients (8.7%) were terminated early during the analysis of the feasibility of EOF. For all 23 patients, the mean hospital stay was 11.4 (5-42) days, and the median survival was 51 months. Patients aged ≥75 with resectable esophageal cancer can achieve long-term survival with active surgical treatment. Moreover, the "no tube, no fasting" fast-track recovery protocol is safe and feasible for elderly patients.

A comparison of two methods of lymph node dissection along the left recurrent laryngeal nerve in McKeown minimally invasive esophagectomy.

Lymph nodes dissection in esophagectomy is an essential procedure for radical resection, which can not only provide more accurate staging but may also improve survival, while it is technically challenging and may lead to recurrent laryngeal nerve (RLN) paralysis. Numerous efforts have been directed to achieve the dissection of more LNs around the RLN and to lower the incidence of RLN palsy, including Bascule method and modified Bascule method. On this basis, we modified and applied a novel method which involves the en bloc dissection of lymph nodes dissection along the left RLN in McKeown minimally invasive esophagectomy (MIE). A total of 244 consecutive cases of lymphadenectomy along the left RLN during McKeown MIE at our institution between January 2018 and August 2021 were retrospectively analyzed. The cases were divided into two groups based on the methods of lymphadenectomy along the left RLN: 77 cases received the conventional method (CM group) and 167 cases received the novel method (NM group). The surgical outcomes, especially the impact of surgical proficiency on the outcomes of lymphadenectomy along the left RLN, were assessed and compared between the two groups. Demographic data of the two cohorts were similar. The number of harvested lymph nodes (LNs) (total/abdomen/left RLN) in the NM group was markedly higher than that in the CM group (32 vs. 27, P=0.006; 11 vs. 9, P=0.038; 3 vs. 2, P=0.044). However, the number of harvested LNs from the chest or right RLN was not significantly different in the two groups. The hoarseness rate was 1.8% in the NM group, which was slightly but not notably lower than that of the CM group (1.8% vs. 2.6%, P=0.681). The incidence of LN metastasis along the left RLN was 13.9%, 15.6%, and 13.2% in the whole cohort, CM group, and NM group, respectively. Our novel method not only increased the number of LN dissections along left RLN but also slightly reduced the incidence of hoarseness. Therefore, this novel method of lymphadenectomy along the left RLN during McKeown MIE is safe and reliable.

Effect of pleural adhesions on short- and long-term outcomes after minimally invasive esophagectomy: a propensity score matching analysis.

The extent to which the presence of pleural adhesions affects the surgical and oncological outcomes of patients undergoing McKeown minimally invasive esophagectomy (MIE) for esophageal cancer (EC) has not previously been studied. Data of consecutive EC patients undergoing McKeown MIE by a single surgeon in the Department of Thoracic Surgery at Daping Hospital from November 2015 to December 2020 were collected. Patients were grouped according to the presence or absence of pleural adhesions when entering the chest cavity. Propensity score matching (PSM) was used to reduce selection bias from confounding factors. Kaplan-Meier was used to assess the survival differences. A total of 617 consecutive EC patients underwent McKeown MIE were enrolled. There were 116 patients with pleural adhesions (Group A) and 501 patients without pleural adhesions (Group B). Patients in Group A were more likely to be older than those of patients in Group B: (66.26 vs. 63.27, P = 0.001). In addition, Group A had more patients with chronic obstructive pulmonary disease (COPD) (24.1% vs. 16.8%, P = 0.04). After propensity score matching (102 matched patients in Group A and 185 matched patients in Group B), these findings were no longer statistically significant. Postoperative pulmonary infection occurred in 57 patients in Group A and in 15 patients in Group B (53.9% vs. 13.0%, P < 0.001). In addition, the presence of pleural adhesions was significantly associated with the prolonged operation time (232min vs. 210min, P < .001), length of stay (12days vs. 10days, P = 0.001), and hydrothorax requiring drainage (12.7% vs. 5.4%, P = 0.04). However, the disease-specific survival and disease-free survival rates were comparable between the two groups (P = 0.40 and 0.13, respectively). The presence of pleural adhesions predicted an increased operation time, length of stay, postoperative pneumonia, and hydrothorax requiring drainage of EC patients undergoing McKeown MIE, but did not exert unfavourable effect on long-term survival.

408. RISK FACTORS FOR PERMANENT RECURRENT LARYNGEAL NERVE PALSY AFTER MCKEOWN MINIMAL INVASIVE ESOPHAGECTOMY

Abstract Recurrent laryngeal nerve (RLN) palsy, especially left side, is a common complication after 3-stage McKeown esophageal cancer surgery and is related to increased risk of respiratory complication. Although some risk factors have been identified on the development of RLN palsy, data on its long-term recovery and factors affecting the recovery was scarce. The present study aimed to assess these unresolved issues. Patients who experienced left RLN palsy after McKeown minimally invasive esophagectomy (MIE) for esophageal carcinoma between 2008 and 2021 were selected from a prospective database. RLN palsy was defined based on postoperative fiberoptic laryngoscopy and was classified as permanent if recovery was not seen within 6 months. MIE was further classified as robot-assisted or conventional thoracoscopic approach. Among the 85 patients who developed left RLN palsy after MIE, recovery was observed in 22 patients (i.e., permanent palsy rate: 75%). Multivariate logistic regression analysis revealed active smoker (unfavorable, OR [95%CI]:2.99 [1.06 ~ 8.41], p = 0.038) and the use of thoracoscopic approach (unfavorable, OR [95%CI]:3.52 [1.14 ~ 10.8], p = 0.028) as independent risk factors for permanent palsy. The permanent palsy rate was 33.3% in patients who were non- or ex-smoker and received robotic approach as opposed to 85.7% in those who were smokers and received conventional thoracoscopic appraoch (p &amp;lt; 0.001). Among the patients who developed left RLN palsy after McKeown MIE, only one-fourth could be fully recovered. RLN palsy occurred in patients who were smoker and received thoracoscopic approach were less likely to have spontaneous recover and might be candidates for early intervention.

Toripalimab combined with docetaxel and cisplatin neoadjuvant therapy for locally advanced esophageal squamous cell carcinoma: a single-center, single-arm clinical trial (ESONICT-2).

More and more evidence has confirmed the efficacy and safety of immunotherapy drugs, such as camrelizumab and pembrolizumab. There are several phase-I/II studies showing that toripalimab has an acceptable safety profile and promising clinical activity in patients with advanced solid tumors. To further confirm its efficacy and safety, the aim of the study was to evaluate toripalimab combined with docetaxel and cisplatin neoadjuvant therapy for locally advanced esophageal squamous cell carcinoma (ESCC). This study was an investigator-initiated, open-label, non-randomized, single-arm, single-center phase II trial (registration number: ChiCTR2100052784). The patients eligible for inclusion criteria at Fujian Medical University Union Hospital from October 2019 to October 2020 were included in this study. Patients who were suitable for surgery underwent minimally invasive esophagectomy (MIE) within 4-6 weeks after neoadjuvant therapy. Pathological complete response (pCR) and adverse events (AEs) were the primary end points. Secondary endpoints included R0 resection rate, major pathological response (MPR), interval to surgery, and 30-day complications. A total of 20 patients were enrolled from October 2019 to October 2020. All patients successfully completed 2 cycles of neoadjuvant therapy. Treatment-related AEs were common during neoadjuvant therapy, with leucopenia the most frequently occurring AE (4/20, 25%). With respect to immune-related AEs, immune dermatitis occurred in 2 patients, including 1 patient with grade I and 1 patient with grade III. Based on radiologic evaluation, the objective response rate (ORR) was 70% (14/20). Twelve patients underwent McKeown MIE. The pCR rate of the primary tumor was 16.7% (2/12), and the MPR rate of the primary tumor was 5/12 (41.7%). The mean interval to surgery was 33.2 days, and no patients experienced delayed surgery due to treatment-related AEs. Pneumonia was the most common 30-day postoperative complication (3/12, 25%). Anastomotic leakage (AL) only occurred in 1 patient during the hospital stay. There were no treatment- or surgery-related deaths. Based on our results, toripalimab combined with docetaxel and cisplatin as a novel neoadjuvant therapy was safe and effective in locally advanced ESCC.

Learning Curve and Associated Prognosis of Minimally Invasive McKeown Esophagectomy

BackgroundThe implementation of McKeown minimally invasive esophagectomy (MIE) is associated with a steep learning curve. However, there is no consensus on the number of cases required before effective and safe McKeown MIE can be achieved. MethodsData on consecutive patients with esophageal carcinoma who underwent esophagectomy performed by a single surgeon in the Department of Thoracic Surgery at Daping Hospital in Chongqing, China from September 2009 to June 2019 were collected. The cumulative sum learning curve was plotted on the basis of the learning associated parameters. Propensity score matching was used to reduce selection bias from confounding factors. The Kaplan-Meier method was used to assess the survival differences. ResultsThe learning curve was divided into the ascending period (cases 1-197), the plateau period (198-314), and the descending period (315-onward). After 197 cases, significant improvements in operative time (300 minutes vs 210minutes; P < .001), retrieved lymph nodes (17 vs 20; P = .004), hospital length of stay (18 days vs 13 days; P = .001), major postoperative complications (38.6% vs 32.5%; P < .001), vocal cord palsy (6.1% vs 0.9%; P = .04), and pulmonary complications (31.5% vs 17.1%; P = .005) were observed. In addition, after 314 cases, significant decreases in blood loss (200 mL vs 100 mL; P < .001), anastomotic leak (24.8% vs 14.8%; P = .02), and chylothorax (4.3% vs 0%; P = .001) were observed. After propensity score matching, the overall and disease-free survival rates were significantly improved during the experienced period (P = .02 and .03, respectively). ConclusionsThe initial learning phase of McKeown MIE consisted of 197 procedures in 51 months. Moreover, the surgeon’s experience did have a direct impact on the long-term outcomes in patients with esophageal carcinoma.

Neoadjuvant sintilimab plus chemotherapy for locally advanced esophageal squamous cell carcinoma: a single-arm, single-center, phase 2 trial (ESONICT-1).

BackgroundTo investigate the safety and feasibility of combining neoadjuvant sintilimab (Innovent Biologics, Suzhou, China) and chemotherapy for locally advanced esophageal squamous cell carcinoma (ESCC).MethodsThe study was an investigator-initiated, open-label, non-randomized, single-arm, single-center phase 2 trial. Patients aged between 18 to 75 years with locally advanced ESCC were eligible for neoadjuvant immunochemotherapy (nICT). The nICT included cisplatin (60 mg/m2) on day 1, albumin-bound paclitaxel (125 mg/m2) on days 1 and 8, and sintilimab (200 mg) on day 1 of each 21-day cycle. Clinical evaluation was conducted after 2 cycles of nICT. Within 4–6 weeks after nICT, patients underwent esophagectomy. The primary end points were pathological complete response (pCR) and adverse events (AEs). Secondary endpoints included major pathological response (MPR), R0 resection rate, interval to surgery, and 30-day complications. This trial was registered at chictr.org.cn, ChiCTR2100045659.ResultsFrom July 2020 to June 2021, 30 patients were enrolled. All patients successfully completed 2 cycles of nICT. AEs were common during nICT, and the most common AE was anorexia (20/30, 67%). However, only one patient with grade 3 ESCC had increased transaminase. According to radiologic evaluations, the objective response rate (ORR) was 67% (20/30) and the disease control rate 97% (29/30). Twenty-three patients underwent McKeown minimally invasive esophagectomy (MIE). The pCR rate of the primary tumor was 21.7%, and the MPR rate of the primary tumor was 52.2%. The median interval to surgery was 40 days, and no patients delayed surgery due to AEs. Pneumonia was the most common major 30-day postoperative complication (9/23, 39%). Anastomotic leakage (AL) occurred in two patients during the hospital stay, and one patient was readmitted due to AL. There was no treatment- or surgery-related deaths.ConclusionsNeoadjuvant sintilimab plus chemotherapy for locally advanced ESCC appears to be safe and feasible with limited AEs, high R0 resection rate, promising pCR rate, and manageable postoperative complications. Long-term follow-up is required. A multicenter, randomized, phase III clinical trial assessing the efficacy and safety of sintilimab versus placebo in combination with chemotherapy in locally advanced ESCC is warranted to confirm these results.

382 INTRATHORACIC VERSUS CERVICAL ANASTOMOSIS AFTER MINIMALLY INVASIVE ESOPHAGECTOMY FOR OESOPHAGEAL CANCER: A RANDOMIZED CONTROLLED TRIAL (ICAN TRIAL)

Abstract Robust evidence is lacking whether Ivor Lewis minimally invasive esophagectomy (MIE) or McKeown MIE should be preferred for patients with mid to distal esophageal or gastro-esophageal junction Siewert I-II (GEJ) cancer. Methods In this multicenter randomized controlled trial, patients with esophageal (below the level of the carina) or GEJ cancer planned for curative resection were recruited. Eligible patients were randomly assigned (1:1) to either Ivor Lewis MIE or McKeown MIE. The primary endpoint was anastomotic leakage (AL) requiring endoscopic, radiologic or surgical intervention. Secondary outcome parameters were overall AL rate, postoperative complications, length of stay and mortality. Results A total of 262 patients were randomly assigned to Ivor Lewis MIE (n = 130) or McKeown MIE (n = 132). Seventeen patients were excluded due to not meeting inclusion criteria (n = 2), physical unfitness for surgery (n = 3), patients’ choice (n = 3), interval metastases (n = 5) or peroperative metastases (n = 4). AL necessitating reintervention occurred in 15 (12.3%) of 122 patients after Ivor Lewis MIE and in 39 (31.7%) of 123 patients after McKeown MIE (RR 0.39, 95%CI 0.22–0.65). Severe complications (Clavien-Dindo ≥3b) were observed in 10.7% after Ivor Lewis MIE and in 22.0% after McKeown MIE (RR 0.49, 95%CI 0.25–0.88). Conclusion This study provides evidence for a lower rate of AL requiring reintervention after Ivor Lewis MIE compared to McKeown MIE for patients with mid to distal esophageal or GEJ cancer.

Learning Curve for Lymph Node Dissection Around the Recurrent Laryngeal Nerve in McKeown Minimally Invasive Esophagectomy.

BackgroundCompared to open esophagectomy (OE), minimally invasive esophagectomy (MIE) is associated with lower morbidity and mortality. However, lymph node (LN) dissection around the recurrent laryngeal nerve (RLN) is still an important factor that affects the length of the learning curve of MIE. This study aims to evaluate the surgical outcomes of the first nearly 5-year period and explore the learning curve for LN dissection around the RLN in McKeown MIE by a new single surgical team.MethodsA total of 285 consecutive patients who underwent McKeown MIE between March 2016 and September 2020 were included at our institution. According to the cumulative sum (CUSUM) analysis of LN dissection around the RLN, the patients were divided into three groups: exploration period, adjustment period, and stable period. We assessed the impact of surgical proficiency on postoperative outcomes and explored the learning curve for LN dissection around the RLN in McKeown MIE.ResultsThe CUSUM graph showed that a point of upward inflection for LN dissection around the RLN was observed in 151 cases. After 151 cases, LNs around the right and left RLNs were dissected thoroughly compared to the exploration and adjustment period (P = 0.010 and P = 0.012, respectively), and the postoperative incidence of hoarseness significantly decreased from 11.1 to 1.5% (P<0.001).ConclusionsOur study results revealed that not only are the LN, around the RLN, sufficiently dissected but also the incidence of hoarseness significantly decreased in the stable phase. Consequently, the learning curve length was approximately 151 cases for LN dissection around the RLN in McKeown MIE.

Risk factors for lymph node metastasis of the left recurrent laryngeal nerve in patients with esophageal squamous cell carcinoma.

BackgroundThe factors for left recurrent laryngeal nerve (RLN) lymph node (LN) metastasis have important guiding significance for whether the left RLN LNs should be dissected in patients with esophageal squamous cell carcinoma (ESCC), but few studies are currently available. To analyze the risk factors of LN metastasis of the left RLN area and to assess which LNs should be dissected in ESCC.MethodsThis was a retrospective study of patients who underwent McKeown minimally invasive esophagectomy (MIE) (no neoadjuvant therapy) at Tianjin Medical University Cancer Institute and Hospital (from January 2016 to December 2019). The detection of left RLN LNs using enhanced computed tomography (CT) was compared with the pathological examination.ResultsOf the total 94 participants, 43 had LN metastasis. The metastatic LNs were mainly located next to left (18.1%) and right (14.9%) RLN, and the left gastric artery (13.8%). Tumor size, LN size, tumor invasion (T stage), N stage, and tumor node metastasis (TNM) stage were associated with left RLN LNs metastasis, while LN size was the only independently associated factor [odds ratio (OR) =1.569, 95% confidence interval (CI): 0.259–1.956, P=0.0012]. The area under receiver operating characteristic (ROC) curve (AUC) reached 0.877, with 64% sensitivity and 75% specificity using a cutoff of 5.5 mm LN size.ConclusionsThe size of left RLN LN is independently associated with metastasis. Left RLN LNs >5.5 mm at CT examination are more likely to be positive and should probably be dissected.

Efficacy of Indocyanine Green Fluorescence Angiography in Preventing Anastomotic Leakage After McKeown Minimally Invasive Esophagectomy.

BackgroundIndocyanine green (ICG) fluorescence angiography (FA) was introduced to provide real-time intraoperative evaluation of the vascular perfusion of the gastric conduit during esophagectomy. However, its efficacy has not yet been proven. The aim of this study was to assess the usefulness of ICG-FA in the reduction of the rates of anastomotic leakage (AL) in McKeown minimally invasive esophagectomy (MIE).MethodsFrom June 2017 to December 2019, patients aged between 18 and 80 years with esophageal carcinoma were enrolled in the study and each patient underwent McKeown MIE. Patients were divided into two groups, those with or without ICG-FA. The patient demographics and perioperative outcomes were comparable between the two groups. The primary outcome was the rate of AL.ResultsA total of 192 patients were included: 86 in the ICG-FA group and 106 in the non-ICG-FA group. Overall, 12 patients (6.3%) had AL; the rate of AL was 10.4% in the non-ICG-FA group, which was significantly higher than the 1.2% in the ICG-FA group.ConclusionsICG-FA has the potential to reduce the rate of AL in McKeown MIE.

Risk Factors of Cervical Anastomotic Leakage after McKeown Minimally Invasive Esophagectomy: Focus on Preoperative and Intraoperative Lung Function.

Background: Cervical anastomotic leakage (CAL) is one of the most common complications that occur minimally invasive esophagectomy (MIE). It is associated with high postoperative mortality. Some risk factors still remained controversial and so accurate prediction of risk groups for CAL remained very difficult. This study aimed to identify the risk factors of CAL after McKeown MIE to predict the accuracy of the technique as early as possible.Material and Methods: A total of 129 patients with esophageal cancer who underwent McKeown MIE at the Department of Thoracic Surgery, the Fourth Hospital of Hebei Medical University, between January 2018 and June 2019 were retrospectively reviewed. Multivariate logistic regression analysis was used to identify the risk factors for CAL and receiver operating characteristic (ROC) curve analysis was used to predict the accuracy for each quantitative data variable and determine the cutoff value.Results: There were statistically significant differences between Group CAL and Group NCAL in FEV1 (p = 0.031), neoadjuvant chemotherapy (p = 0.001), intraoperative minimum PaCO2 (p = 0.002), and hospital stays (p <0.001). In multivariate logistic regression, FEV1 (OR = 0.440, p = 0.047), neoadjuvant chemotherapy (OR = 4.425, p = 0.003), and intraoperative minimum PaCO2 (OR = 1.14, p <0.001) were identified to be three risk factors of CAL. The ROC curve analysis showed that FEV1 <2.18L (p = 0.029) and intraoperative minimum PaCO2 >45.5 mmHg (p = 0.002) demonstrated good accuracy.Conclusion: FEV1, neoadjuvant chemotherapy, and intraoperative minimum PaCO2 in arterial blood gas (ABG) were considered as risk factors of CAL after McKeown MIE for esophageal cancer. Preoperative FEV1 <2.18L and intraoperative minimum PaCO2 >45.5 mmHg in ABG showed good accuracy in predicting risk factors for CAL.

Intrathoracic versus cervical anastomosis after minimally invasive esophagectomy for esophageal cancer: A randomized controlled trial.

4509 Background: Robust evidence is lacking whether Ivor Lewis minimally invasive esophagectomy (MIE) or McKeown MIE should be preferred for patients with mid to distal esophageal or gastro-esophageal junction Siewert I-II (GEJ) cancer. Methods: In this multicenter randomized controlled trial, patients with esophageal (below the level of the carina) or GEJ cancer planned for curative resection were recruited. Eligible patients were randomly assigned (1:1) to either Ivor Lewis MIE or McKeown MIE. The primary endpoint was anastomotic leakage (AL) requiring endoscopic, radiologic or surgical intervention. Secondary outcome parameters were overall AL rate, postoperative complications, length of stay and mortality. Results: A total of 262 patients were randomly assigned to Ivor Lewis MIE (n = 130) or McKeown MIE (n = 132). Seventeen patients were excluded from the trial due to not meeting inclusion criteria (n = 2), physical unfitness for surgery (n = 3), patients’ choice (n = 3), interval metastases (n = 5) or peroperative metastases (n = 4). AL necessitating reintervention occurred in 15 (12.3%) of 122 patients after Ivor Lewis MIE and in 39 (31.7%) of 123 patients after McKeown MIE (relative risk 0.39, 95% CI 0.22-0.65; risk difference 19.4%, 95% CI 7.9%-31.8%). Overall AL rate was 12.3% after Ivor Lewis MIE and 34.1% after McKeown MIE. Severe complications (Clavien-Dindo ≥ 3b) were observed in 10.7% after Ivor Lewis MIE and in 22.0% after McKeown MIE. Pleural effusion requiring drainage occurred in 9.8% of patients after Ivor Lewis MIE and 21.1% of patients after McKeown MIE. RLN palsy rate was 0% after Ivor Lewis MIE and 7.3% after McKeown MIE. Median length of hospital stay was 10 days (IQR 8 – 15 days) after Ivor Lewis MIE and 12 days (IQR 9 – 18 days) after McKeown MIE. ICU length of stay and mortality rates were comparable between groups. Conclusions: These findings provide evidence for a lower rate of AL requiring reintervention after Ivor Lewis MIE compared to McKeown MIE for patients with mid to distal esophageal or GEJ cancer. Clinical trial information: NTR4333 .

Postoperative complications of minimally invasive esophagectomy for esophageal cancer.

Minimally invasive esophagectomy (MIE) has been performed increasingly more frequently for the treatment of esophageal cancer, ever since it was first described in 1992. However, the incidence of postoperative complications of MIE has not yet been well‐characterized, because (a) there are few reports of studies with a sufficient sample size, (b) a variety of minimally invasive surgical techniques are used, and (c) there are few reports in which an established system for classifying the severity of complications is examined. According to an analysis performed by the Esophageal Complications Consensus Group, the most common complications of MIE are pneumonia, arrhythmia, anastomotic leakage, conduit necrosis, chylothorax, and recurrent laryngeal nerve palsy. Therefore, we decided to focus on these complications. We selected 48 out of 1245 reports of studies (a) that included more than 50 patients each, (b) in which the esophagectomy technique used was clearly described, and (c) in which the complications were adequately described. The overall incidences of the postoperative complications of MIE for esophageal cancer were analyzed according to the MIE technique adopted, that is, McKeown MIE, Ivor Lewis MIE, robotic‐assisted McKeown MIE, robotic‐assisted Ivor Lewis MIE, or mediastinoscopic transmediastinal esophagectomy. Pneumonia, arrhythmia, anastomotic leakage, and recurrent laryngeal nerve palsy occurred at an incidence rate of about 10% each; Ivor Lewis MIE was associated with a relatively low incidence of recurrent laryngeal nerve palsy. It is important to recognize that the incidences of complications of MIE are influenced by the MIE technique adopted and the extent of lymph node dissection.

Comparison of the surgical outcomes of McKeown minimally invasive esophagectomy and Ivor-Lewis esophagectomy for the treatment of middle esophageal cancer: A single-center retrospective study

BackgroundIn China, the esophageal cancer is the most common tumor type, and the main treatment is still surgical treatment. Over the past decade, thoracic laparoscopy combined with esophageal cancer resection and neck anastomosis---McKeown minimally invasive esophagectomy (MIE) has gained interest and known as a minimally invasive surgery for the middle esophageal cancer. However, the safety and operability of McKeown MIE remains to be confirmed clinically. The purpose of this article is to examine the clinical safety and operability of McKeown MIE, and compare the security and outcomes of McKeown MIE and Ivor-Lewis esophagectomy. Materials and methodsThe clinical data of 312 patients with middle esophageal cancer in Sir Run Run Shaw Hospital from January 2013 to December 2018 were retrospectively analyzed. Among them, 176 patients underwent Ivor-Lewis esophagectomy and 136 patients underwent McKeown MIE. Patients' demographics and perioperative outcomes were comparable between the two groups. ResultsThere were no significant differences in terms of operative time, postoperative hospital stay, restore fluid diet time, pathology, tumor node metastasis staging between the two groups. In the McKeown MIE group, the intraoperative blood loss was less than that in the Ivor-Lewis group (116.54 ± 80.99 ml vs 152.78 ± 115.35 ml, p = 0.001). The total number of lymph nodes and the number of lymph nodes dissection in bilateral recurrent laryngeal nerves were more than those in the Ivor-Lewis group (30.04 ± 14.08 vs 27.51 ± 11.34, p = 0.039; 5.74 ± 4.27 vs 1.80 ± 2.68, p < 0.001). There were no significant differences in the incidence of complications. The overall survival for the McKeown MIE group was higher than the Ivor-Lewis group (p = 0.013) and no significant difference was found on disease-free survival. ConclusionMcKeown MIE is safe and operational for middle esophageal cancer, which is consistent with the principle of tumor radicalization.

Ergonomic thoracic port design for video-assisted thoracoscopic minimally invasive esophagectomy and lymphadenectomy: a preliminary pilot study.

Video-assisted minimally invasive esophagectomy (MIE) has been widely applied in clinical practice. However, the optimal port design for thoracoscopic esophagectomy and lymphadenectomy has not been well established. Here we introduced our novel ergonomic thoracic port design as well as our novel procedures of lymphadenectomy via tissue interactive retraction and compared its effects with that of conventional port design in this pilot study. Patients undergoing McKeown MIE from January 2018 to December 2018 in one surgical team were randomly assigned into the ergonomic port design group and conventional port design group. Data of baseline characteristics, perioperative outcomes, and ergonomic assessment were collected and compared between the two groups. A total of 70 patients undergoing curative McKeown MIE were randomly assigned and there were 35 patients in each group. The baseline characteristics between the two groups were comparable and well-matched. Moreover, there was no significant difference of number of total dissected lymph nodes, positive lymph nodes and total dissected mediastinal lymph nodes between the two groups. As for perioperative outcomes, there was also no significant difference of in-operating time and blood loss in the thoracic part between the two groups. However, there were significantly less times of forced pause of the surgeon by fatigue during thoracic part in the ergonomic group compared to conventional group (mean time: 1.1 vs. 7.4, respectively; P<0.001) and the symptom score referable to the musculoskeletal system by the surgeon was significantly lower in the ergonomic group than in the conventional group (2.3 vs. 7.6; P<0.001). Postoperatively, there was no significant difference of hospital stay duration and rate of complication and 30-day mortality between the two groups. Our novel thoracoscopic port design and procedures of lymphadenectomy was proved to be feasible and ergonomic, which could be easily mastered by most of the thoracic surgeons.