McKeown Procedure Research Articles

514. ESOPHAGOGASTRIC ANASTOMOSIS STRICTURE AFTER A CERVICAL FISTULA: LONG TERM COMPLICATION AFTER THE MCKEOWN PROCEDURE STERNOTOMY APPROACH: ANASTOMOSIS RESECTION

Abstract Background Anastomotic stricture after anastomotic leakage is a common long term complication after mckeown procedure. It can be resolved by endoscopic dilations on most occasions. However, if endoscopic aproach fail, we have to solve the estenosis with a surgery procedure. This type of reintervention could be a really hard aproach due to an intense fibrosis and anatomical layer destructuring. In this video, we show a initial cervical approach to do a anastomosis resection and reanastomosis. However, due to the intense fibrosis and the difficulty in dissecting the gastric plasty from the sternal table, the incision had to be extended and a partial sternotomy was performed. With this approach, we can see the gastric plasty, making the dissection. The we can perform a new esophagus gastric anastomosis safety. In conclusion, partial sternotomy allows us to visualize the gastric plasty and perform the dissection safety making a tensión free anastomosis. https://we.tl/t-6MTce26lI1

Short-term Outcomes of Minimally Invasive McKeown Procedure Versus Open Ivor-Lewis Procedure for Lower and Middle Esophageal Cancer

Short-term Outcomes of Minimally Invasive McKeown Procedure Versus Open Ivor-Lewis Procedure for Lower and Middle Esophageal Cancer

COMPLICATIONS OF USING A DOUBLE-LUMEN ENDOTRACHEAL TUBE AND THEIR TREATMENT

A 46-year-old woman, withheight 161 cm and weight 75 kg, underwent endoscopic resection of the esophagus with reconstruction of the gastrointestinal tract with a gastric tube (McKeown procedure). During the surgery a tracheal injury with a rupture of the membranous part revealed, which was considered as a complication regarding a double-lumen endotracheal tube installation. Clinically, the rupture remained asymptomatic during two hours of single-lung ventilation of the left lung and was visualized during the thoracoscopic stage of the surgery. The tracheal rupture was promptly repaired. In the postoperative period, the patient required prolonged lung ventilation through a laryngeal mask. Frequentbronchial fibroscopy was performed to verify the condition of the tracheal suture, its continuity, and to provide tracheobronchial sanitation in the intensive care unit. The application of a multidisciplinary approach to diagnose and treat a life-threatening complication as tracheal rupture in a short time allowed us to stabilize the patient’s condition and avoid the development of further complications.

255. EARLY COST-EFFECTIVENESS MODELLING STUDY COMPARING MINIMALLY INVASIVE TRANSCERVICAL ESOPHAGECTOMY (MICE) AND TRANSTHORACIC MINIMALLY INVASIVE ESOPHAGECTOMY (TMIE) IN OESOPHAGEAL CANCER PATIENTS

Abstract Introduction Minimally Invasive transCervical Esophagectomy (MICE) is a novel transcervical approach to esophagectomy with the possible advantage of decreased pulmonary complications. MICE is in an early stage of introduction in patients which are treated with the McKeown procedure in regular practice. The aim of this study was to provide insight in the potential cost-effectiveness of MICE and its sensitivity to different complications. Methods A decision tree modelled the postoperative outcomes of recurrent laryngeal nerve paresis, anastomotic leakage, pulmonary complications and 30-day mortality. Subsequently, we developed a Markov state transition model to calculate the effects of these input parameters on health outcomes (QALYs) and costs. The results were analysed with a sensitivity analysis and a scenario analysis of a clinical trial of a similar procedure. Results Preventing complications seemed to be effective in reducing hospital costs, but resulted in a limited improvement of health outcomes. Improving 30-day survival demonstrated to have a larger effect on health outcomes. A scenario analysis of data from a clinical trial studying similar procedures resulted in a cost reduction of €2974 and an increase of 0.016 QALYs per patient. Conclusion Reduced healthcare costs and improved health outcomes from reducing complications and 30-day mortality could offset the increased cost of MICE and lead to a cost-effective innovation. We advise close monitoring of short and long term survival outcomes in future studies.

152. SINTILIMAB PLUS CISPLATIN AND PACLITAXEL INDUCTION TREATMENT FOR BORDERLINE RESECTABLE ESOPHAGEAL SQUAMOUS CELL CARCINOMA: A PHASE II CLINICAL TRIAL

Abstract Background An increasing number of clinical studies focus on investigating the use of immunotherapy in the treatment of esophageal cancer. This phase II trial (NEOCRTEC-2001 clinical trial) aimed to assess the safety and efficacy of sintilimab in combination with cisplatin and paclitaxel induction immunochemotherapy followed by surgery for locally advanced borderline-resectable esophageal squamous cell carcinoma (BR-ESCC). Methods Patients with primary tumor or bulky lymph nodes that might invade nearby organs were eligible. Treatment started with 2–4 cycles of induction immunochemotherapy, followed by surgery if the tumor was assessed resectable, or by radical concurrent chemoradiotherapy if unresectable. The primary endpoint was pathologically proven complete resection (R0) rate. The secondary end points included pathological complete response (pCR) rate, overall survival (OS), progression-free survival (PFS), adverse events and postoperative complication. Results From September 2020 to now, a total of 34 patients were enrolled. After immunochemotherapy, 21 patients (61.8%) received surgery and 13 (38.2%) did not. All patients underwent McKeown procedure, and median operation time was 295 minutes (range 201–489 minutes). All patients received esophageal reconstruction using gastric tube, and underwent cervical anastomosis. An average of 46.6 lymph nodes were dissected, and positive lymph nodes were observed in 5 of the 21 patients. R0 resection was confirmed in 20 patients (58.8%). One patient underwent R2 resection because of tumor invasion of the aorta. Pathologic complete response was confirmed in 6 patients (6/34, 17.6%), while 5 patients (5/34, 14.7%) had few or no regressive changes (TRG3). Conclusion The treatment strategy of induction immunochemotherapy followed by surgery is promising for patients with locally advanced borderline-resectable esophageal squamous cell carcinoma. The whole results of pathologic response and prognostic value are awaited with interest.

ASO Visual Abstract: Efficacy and Quality of Life of Modified Versus Traditional Thoraco-Laparoscopic McKeown Procedure for Esophageal Cancer: A Multicenter Propensity Score-Matched Study.

ASO Visual Abstract: Efficacy and Quality of Life of Modified Versus Traditional Thoraco-Laparoscopic McKeown Procedure for Esophageal Cancer: A Multicenter Propensity Score-Matched Study.

Efficacy and Quality of Life with the Modified Versus the Traditional Thoraco-Laparoscopic McKeown Procedure for Esophageal Cancer: A Multicenter Propensity Score-Matched Study.

This study aimed to compare the efficacy and postoperative quality of life for patients with esophageal cancer treated by either the modified or the traditional thoracolaparoscopic McKeown procedure. This retrospective case-control study included 269 patients with esophageal cancer admitted to three medical centers in China from February 2020 to August 2022. The patients were divided according to surgical method into the layered hand-sewn end-to-end invagination anastomosis group (modified group) and the traditional hand anastomosis group (traditional group). Propensity score-matching (PSM) was used to maintain balance and comparability between the two groups. The differences in age and tumor location between the patients in the traditional and modified groups were statistically significant. After PSM, the aforementioned factors were statistically insignificant. After PSM, each group had 101 patients. The modified group showed the greater advantage in terms of postoperative hospital stay (P = 0.036), incidence of anastomotic leak (P = 0.009), and incidence of gastroesophageal reflux (P < 0.001), and the difference was statistically significant. The results of the Quality of Life Questionnaire Core 30 (QLQ-C30) and Quality of Life Questionnaire Oesophageal Cancer Module 18 (QLQ-OES18) scales showed that the modified group also had the advantage over the traditional group in terms of physical function, overall health status, loss of appetite, eating, reflux, obstruction, and loss of appetite scores at the first and third months after surgery. The modified thoraco-laparoscopic McKeown procedure is a safe and effective surgical approach that can significantly reduce the incidence of postoperative anastomotic leak and gastroesophageal reflux, shorten the postoperative hospital stay, and improve the postoperative quality of life for patients with esophageal cancer.

Laparoscopic reconstruction in McKeown esophagectomy is a risk factor for postoperative diaphragmatic hernia.

Diaphragmatic hernia is a very rare but high-risk complication after esophagectomy. Although there are many studies on the Ivor Lewis esophagectomy procedure for diaphragmatic hernia, there are fewer studies on the McKeown procedure. The present study aimed to estimate the incidence of diaphragmatic hernia after esophagectomy, describing its presentation and management with the McKeown procedure. We retrospectively evaluated the 622 patients who underwent radical esophagectomy between January 2002 and December 2020 at the Wakayama Medical University Hospital. Statistical analyses were performed to evaluate risk factors for diaphragmatic hernia. Emergency surgery for postoperative diaphragmatic hernia was performed in nine of 622 patients (1.45%). Of these nine patients, one developed prolapse of the small intestine into the mediastinum (11.1%). The other eight patients underwent posterior mediastinal route reconstructions (88.9%), one of whom developed prolapse of the gastric conduit, and seven of whom developed transverse colon via the diaphragmatic hiatus. Laparoscopic surgery was identified in multivariate analysis as the only independent risk factor for diaphragmatic hernia (odd's ratio [OR] = 9.802, p = 0.034). In all seven cases of transverse colon prolapse into the thoracic cavity, the prolapsed organ had herniated from the left anterior part of gastric conduit. Laparoscopic surgery for esophageal cancer is a risk factor for diaphragmatic hernia. The left anterior surface of gastric conduit and diaphragmatic hiatus should be fixed firmly without compromising blood flow to the gastric conduit.

What is the best reconstruction procedure after esophagectomy? A meta-analysis comparing posterior mediastinal and retrosternal approaches.

Thoracic esophagectomy is a particularly invasive and complicated surgical procedure, with a reconstruction of the gastrointestinal tract, such as the stomach, jejunum, or colon. The posterior mediastinal, retrosternal, and subcutaneous routes are the three possible esophageal reconstruction routes. Each route has advantages and disadvantages, and the optimal reconstruction route after esophagectomy remains controversial. Additionally, the best anastomotic techniques after esophagectomy in terms of location (Ivor Lewis or McKeown) and suturing (manual or mechanical) are debatable. Our meta-analysis investigating postoperative complications after esophagectomy between the posterior mediastinal and retrosternal routes revealed that the posterior mediastinal route was associated with a significantly lower anastomotic leakage rate than the retrosternal route (odds ratio = 0.78, 95% confidence interval: 0.70-0.87, p < 0.0001). Conversely, pulmonary complications (odds ratio = 0.80, 95% confidence interval: 0.58-1.11, p = 0.19) and mortality between the posterior mediastinal and retrosternal routes (odds ratio = 0.79, 95% confidence interval: 0.56-1.12, p = 0.19) were not significantly different. However, the incidence of pneumonia may be lower when using the retrosternal route rather than the posterior mediastinal route for performing minimally invasive esophagectomy. The McKeown procedure is oncologically necessary for tumors located above the carina to dissect upper mediastinal and cervical lymph nodes; however, the Ivor Lewis procedure offers perioperative and oncological safety for tumors located under the carina. An individualized treatment strategy for selecting the optimal reconstruction procedure can be proposed in future studies based on oncological and patient risk factors considering mid- to long-term quality of life.

Laparoscopic gastric dissociation using a two-port approach in minimally invasive esophagectomy

BackgroundA new approach for laparoscopic gastric dissociation in minimally invasive esophagectomy (MIE) was attempted. This study aimed to evaluate the short-term outcomes, safety, and efficacy of two-port laparoscopy using the McKeown procedure.MethodsThis retrospective study included 206 consecutive patients with esophageal cancer who underwent a modified two-port laparoscopic or the traditional five-port McKeown procedure at our institution from August 2019 to August 2021. Surgical outcomes of the two methods were compared.ResultsOf the 206 patients, 106 (51.46%) underwent the modified two-port procedure, whereas 100 (48.54%) underwent the traditional five-port procedure. Subsequently, 182 propensity score-matched patients were compared. No significant differences were observed in laparoscopic operative time, blood loss during laparoscopic surgery, number of dissected lymph nodes, and pain score on postoperative day 1 between the two groups. The rate of complication and postoperative length of hospital stay did not differ significantly between the two groups. The total hospitalization cost also did not differ significantly between the two groups (p = 0.325). No postoperative deaths occurred in either group.ConclusionsOur findings demonstrate that laparoscopic gastric dissociation using the two-port approach in MIE is a safe and effective procedure, with short-term outcomes comparable to those of the traditional five-port procedure in patients with esophageal cancer. Larger studies with longer follow-up duration are warranted.

Short-term outcomes of Ivor Lewis vs. McKeown esophagectomy: A meta-analysis

The objective of this article is to assess the rate of anastomotic leak and other perioperative outcomes in patients undergoing esophagectomy with either thoracic or cervical anastomosis. This meta-analysis was conducted by searching relevant literature studies in Web of Science, Cochrane Library, PubMed, and Embase databases. Articles that included patients undergoing esophagectomy and compared perioperative outcomes of McKeown with Ivor Lewis procedures were included. The primary outcome parameter was anastomotic leak, and secondary outcome parameters were grade ≥2 anastomotic leak, chylothorax, recurrent laryngeal nerve injury, hospital length of stay, intensive care unit (ICU) length of stay, postoperative mortality rate, operative time, blood loss, R0 resection rate, and lymph nodes examined. A total of eight studies, with 3,291 patients (1,857 Ivor Lewis procedure and 1,434 McKeown procedure) were eligible for analysis. Meta-analysis showed that Ivor Lewis procedure was associated with lower rate of anastomosis leak of all grades [risk ratio (RR), 0.67; 95% confidence interval (CI), 0.55-0.82; P = 0.0001], lower rate of recurrent laryngeal nerve injury (RR, 0.14; 95% CI, 0.08-0.25), and shorter length of hospital stay (weighted mean difference, 0.13; 95% CI, 0.04-0.22). Grade ≥2 anastomotic leak, chylothorax, ICU length of stay, postoperative mortality rate, operative time, blood loss, R0 resection rate, and lymph nodes examined were similar between the two groups. Although all grades of anastomotic leak and recurrent laryngeal nerve injury are higher in the McKeown procedure, this meta-analysis supports similar short-term outcomes and oncological efficacy between Ivor Lewis and McKeown esophagectomy.

Pembrolizumab Combined With Neoadjuvant Chemotherapy Versus Neoadjuvant Chemoradiotherapy Followed by Surgery for Locally Advanced Oesophageal Squamous Cell Carcinoma: Protocol for a Multicentre, Prospective, Randomized-Controlled, Phase III Clinical Study (Keystone-002).

BackgroundTo compare the efficacy and safety of pembrolizumab combined with neoadjuvant chemotherapy (neoCT) versus neoadjuvant chemoradiotherapy (neoCRT) followed by surgery for locally advanced resectable oesophageal squamous cell carcinoma (ESCC).MethodsThis study is a multicentre, prospective, randomized-controlled, phase III clinical study. Eligible ESCC (staging: cT1N2M0 or cT2-3N0-2M0 (stage II/III, high-risk lesions in T2N0M0)) patients will be randomly assigned to either the experimental group (pembrolizumab with neoCT, n = 228) or the control group (neoCRT, n = 114) at a ratio of 2:1. Within 4–6 weeks after preoperative therapy, the McKeown procedure will be performed. Patients in the experimental group will also receive pembrolizumab alone as adjuvant therapy after surgery until 1 year or until the radiographically confirmed PD or other condition indicated for premature termination is observed. The primary endpoint is event-free survival (EFS). The secondary endpoints are 1-, 3-, and 5-year overall survival (OS) and disease-free survival (DFS), short-term outcomes, and quality of life.DiscussionThis is the first prospectively randomized controlled trial designed to compare pembrolizumab plus chemotherapy and chemoradiotherapy as neoadjuvant therapy for resectable ESCC. According to our hypothesis, preoperative pembrolizumab combined with chemotherapy will result in a better tumour response and prolong the survival of patients, with acceptable toxicity. This study started in December 2021, and the enrolment time is estimated to be 2 years.Trial RegistrationThis prospective study has been registered at ClinicalTrials.gov (NCT04807673), March 2021.

784 TRANSHIATAL HERNIA: AN UNDERDIAGNOSED BUT OVER-TREATED COMPLICATION AFTER MINIMALLY INVASIVE ESOPHAGECTOMY

Abstract Postoperative transhiatal hernia is a possible life-threatening complication following esophagectomy. The incidence and indications to treat remain open to debate with apparently an increase after minimally invasive esophagectomy (MIE). The aim of this study is to analyze a large series of patients after MIE in a single high-volume center with a transhiatal herniation after minimally invasive esophagectomy (THAMIE) and obtain new insights in this pathology. Methods We included all patients who underwent a MIE (Ivor Lewis and McKeown procedure) in our hospital between 2015 and 2020. Retrospective analysis of demographic, clinical and surgical data was performed. Outcomes of measure were incidence, initial clinical presentation, treatment of choice, postoperative complications and symptoms, herniation recurrence. Results In 341 MIE 25 (7.3%) patients were diagnosed with a THAMIE postoperatively. 4 patients (16.0%) were asymptomatic at the time of presentation. 5 patients (20%) were treated conservatively because of recurrent carcinoma. 20 patients received a laparoscopic reduction of the transhiatal hernia and cruraplasty (19 non-absorbable sutures, 1 mesh) regardless whether they were symptomatic or not. 25.0%(5/20) of the patients were operated in emergency settings and 5.0% (1/20) was converted to a laparotomy. Postoperatively 6 of the 18 symptomatic patients (33.3%) experienced no relief of symptoms and 40.0% (8/20) of the THAMIE recurred. 35% had serious postoperative complications (clavien-dindo IIIa or more) and mortality was 0.0%. Conclusion The incidence of 7.33% found in our data suggests that THAMIE is a common complication after MIE. We almost exclusively (95.0%) treated patients in a laparoscopic way. Due to the high percentage of morbidity (35.0% ≥ CD IIIa), recurrence (40.0%) and patients with unrelieved symptoms(33.3%) we recommend a conservative treatment for the asymptomatic patients, and further analysis of predictive symptoms associated with a THAMIE to evolve to a shared decision making algorithm for elective symptomatic patients.

718 DIFFERENCES BETWEEN INTRACORPOREAL AND EXTRACORPOREAL GASTRIC TUBE RECONSTRUCTION AFTER ESOPHAGECTOMY: IS THERE A BETTER WAY?

Abstract Introduction Esophagectomy remains good option to curative intent for esophageal carcinoma. However, quality of life for post-operative symptoms such as reflux, gastric emptying delayed and dysphagia is on debate. Some studies advocate relations between those symptoms to gastric tube conformation and discrepancies between intra and extracorporeal gastric tube construction. We aimed to analyze differences between both methods. Methods During 2014–2020, patients underwent to esophagectomy by thoracoscopic approach with cervical anastomosis (McKeown procedure). The abdominal part was performed by totally laparoscopic (group A) or hybrid (group B) hand-assisted gastric tubulization. Clinical parameters, symptoms of reflux, gastric tube evaluated by tomography, post-operative endoscopic findings were assessed and compared between groups. Multivariable analysis was performed. Results 36 group A and 56 group B, 55 (59.7%) were squamous cell carcinoma and 60 (66.6%) did neoadjuvant chemoradiotherapy. Mean follow-up was 32 months. Group A had more gastric tube diameter (p &amp;lt; 0.001), alimentary stasis (p &amp;lt; 0.001), redundant conformation (p &amp;lt; 0.05) and distant from axial central point of the thorax (p &amp;lt; 0.05); all evaluated by tomography. And also, more symptoms of reflux and gastric empty delay by reflux symptoms index (RSI) (p &amp;lt; 0.001); and numbers of esophagitis grade B and C by upper endoscopy (p &amp;lt; 0.01). After multivariable analysis, intracorporeal (p &amp;lt; 0.001) and diameter more than 4.2 cm (p &amp;lt; 0.01) was related to worst RSI. Conclusion The intracorporeal gastric tube reconstruction may lead wider gastric tube conformation, which might be related to gastric empty delay, resulting in intense reflux symptoms confirmed by upper endoscopy.

351 SINGLE-PORT MINIMALLY INVASIVE ESOPHAGECTOMY TO TREAT ESOPHAGEAL CANCER: EXPERIENCE OF 144 CASES

Abstract Single-incision thoracoscopic and laparoscopic procedures has have been applied in treating various diseases. However, it is limited in literature for such procedures used in treating esophageal cancer. Methods Minimally invasive esophagectomy (MIE) with a single-incision approach in the thoracoscopic and laparoscopic procedures was attempted in 144 patients with esophageal cancer. Results There was 96 patients underwent a McKeown procedure and 48 an Ivor Lewis procedure repectively. The mean ventilator usage of the patients after surgery was 0.3 ± 0.6 days, the mean ICU stay was 7.42 ± 17.15 days, and the mean number of dissected lymph nodes was 43.5 ± 21.8. There 11 patients suffered from postoperative complications, including 3 pulmonary complications, 4 anastomotic leakage and 4 vocal cord palsy. There are no 30-day mortality, however, there were one patient died from ARDS 40 days after surgery. Conclusion Single-port MIE seems to be a feasible option for treating patients with esophageal cancer, which offers an acceptable perioperative surgical outcome. However, the long-term survival results of the patients requires to be follow-up in the future.

Robot-assisted thoracoscopic esophagectomy for gastrointestinal stromal tumor of the esophagus: A case report

IntroductionA gastrointestinal stromal tumor (GIST) often arises in the stomach and small intestine, while esophageal GIST is rare. The first-choice treatment is surgical resection, but there is no standard technique. Herein, we describe our experience in the treatment of esophageal GIST and discuss the usefulness of robotic esophagectomy.Presentation of caseThe patient was a 60-year-old woman, who was diagnosed with a 30 mm GIST in the middle thoracic esophagus. We underwent robot-assisted thoracoscopic esophagectomy in the prone position. The duration of the thoracoscopic part was 69 min and the total operation time was 319 min. Total blood loss was 135 ml. The patient's postoperative course was uneventful after surgery and the patient was discharged home in good condition on the 18th postoperative day.DiscussionThe prognosis of esophageal GIST was less favorable compared with gastric GIST, and due to the anatomical peculiarities of the esophagus, which surgical procedure should be performed is still under debate. Robotic surgery has several technological advantages as it provides a three-dimensional view, ten times magnification, tremor control, and ambidexterity. Therefore, Robotic-assisted minimally invasive esophagectomy (RAMIE) allows achieving for safe R0 resection of esophageal GIST.ConclusionRAMIE may be useful for esophageal GIST because it facilitates safe and minimally invasive surgery in a limited space of the thoracic cavity.

Clinical value of lymph node dissection for stage T1b mid-thoracic esophageal squamous cell carcinoma

Surgery remains the mainstay of treatment for esophageal squamous cell carcinoma (ESCC), during which lymph node (LN) dissection, especially recurrent laryngeal nerve (RLN) LN dissection, is particularly important and challenging. This study aimed to investigate the LN metastasis of stage T1b mid-thoracic ESCC and explore the clinical value of RLN LN dissection. The clinicopathological data of 254 patients with stage T1b mid-thoracic ESCC who underwent the McKeown procedure ("tri-incisional esophagectomy") and three-field LN dissection (3FD) at Fujian Cancer Hospital from January 2010 to December 2015 were retrospectively analyzed. The value of LN dissection (especially RLN LNs) was evaluated by calculating the metastasis rate of each LN station. The efficacy index (EI) of the dissection was calculated by multiplying the frequency (%) of metastases to a station and the 5-year survival rate (%) of patients with metastases to that station, and then dividing by 100. The stage T1b mid-thoracic ESCC had the highest rate of metastasis in the paracardiac LNs (4.3%), followed by RLN LNs (2.8%) and the left gastric artery LNs (2.8%). The 5-year survival rate was highest in patients who received lesser gastric curvature LN dissection (100%), followed by patients who underwent right RLN LN dissection (80%), and was 50% in patients who had undergone dissection of the left RLN LNs, upper paraesophageal LNs, subcarinal LNs, and left gastric artery LNs, respectively. In addition, dissection of the right RLN LNs had the highest EI value (2.2), followed by the dissection of LNs along the lesser curvature of the stomach (1.6) and left gastric artery LNs (1.4). Right RLN LNs have a metastasis rate only lower than that of the paracardiac LNs, but could be the most valuable location for performing dissection.

Neoadjuvant camrelizumab combined with chemotherapy and apatinib for locally advanced thoracic esophageal squamous cell carcinoma (ESCC): A single-arm, open-label, phase Ib study.

4047 Background: Neoadjuvant therapy with PD-1 blockade plus chemotherapy has been found to be effective in the first-line treatment of advanced esophageal cancer. However, evidence of PD-1 blockade combined with chemotherapy as neoadjuvant treatment is limited. This study was designed to investigate the safety and efficacy of camrelizumab, a PD-1 blockade combined with chemotherapy and apatinib as neoadjuvant therapy for locally advanced esophageal squamous cell carcinoma (ESCC). Methods: A regiment of 2–4 cycles of neoadjuvant camrelizumab (200 mg, intravenous, day 1), nab-paclitaxel (150 mg/m2, intravenous, day 1), nedaplatin (50 mg/m2, intravenous, day 1), and apatinib (250 mg, orally, day 2–4) was given to the treatment-naive patients with resectable locally advanced ESCC. The treatments were repeated every 14 days. In this study, six patients were planned to receive two cycles of neoadjuvant therapy as safety assessment, and then 24 patients received four cycles of neoadjuvant therapy, followed by esophagectomy after 4–8 weeks. The primary end points were safety and feasibility. The secondary end points were the rate of major pathologic response (MPR) and pathologic complete response rate (pCR). Results: A total of 30 patients were enrolled, among them, five patients received two planned cycles of neoadjuvant therapy, and one patient missed the second cycle of therapy due to grade 3 ALT elevations. Further, all other 24 patients received four planned cycles of neoadjuvant therapy. A total of 11 patients (11/30, 36.7%) experienced grade 3 neoadjuvant treatment-related adverse events (TRAEs). No grade 4 and grade 5 TRAEs were reported. The most frequent grade 3 TRAEs was neutropenia (7/30, 23.3%). Twenty-nine patients underwent minimally invasive esophagectomy (McKeown procedure) after neoadjuvant therapy. The reason for not undergoing surgery was due to bone metastasis. There were five treatment-related surgical delays that were caused by adverse reactions (hyperglycemia, arthritis, anemia, leukopenia, capillary endothelial proliferation in oral mucosa). Among the 29 patients undergoing esophagectomy, 15 patients (15/29, 51.7%) achieved MPR, including 7 patients with pCR (7/29, 24.1%). Among the 24 patients who received four cycles of neoadjuvant treatment, there were 7 patients with pCR (7/24, 29.2%), and 14 patients with MPR (14/24, 58.3%). No surgery related mortality was documented. Conclusions: Neoadjuvant camrelizumab combined with chemotherapy plus apatinib is a safe and tolerable treatment for patients with locally advanced ESCC, and the MPR and pCR rate are promising. Clinical trial information: ChiCTR1900023880.

Comparison of QoL Between Substernal and Posterior Mediastinal Routes in Esophagogastrostomy

BackgroundAfter esophagectomy, various reconstruction routes can be considered for technical and oncologic objectives. The substernal route is believed to cause more dysphagia or delayed gastric emptying symptoms than the posterior mediastinal route. We evaluated and compared the quality of life (QoL) after reconstruction by either the substernal or posterior mediastinal routes in the McKeown procedure. MethodsBetween 2011 and 2018, 378 patients who received an esophagectomy and cervical esophagogastrostomy for esophageal cancer were followed up. Among these patients, 278 received reconstruction via the substernal route and 100 via the posterior mediastinal route. Patients completed the validated questionnaires, EORTC QLQ-C30 and QLQ-OES18, before surgery and at 1, 2, 3, 6, 12, and 24 months after surgery. Linear mixed-effects models were used to examine changes in questionnaire scores over time. ResultsOne month after surgery, patients QoL deteriorated and more symptoms were observed than at baseline. Global health status, nausea and vomiting, and esophageal pain gradually recovered from 2 months and recovered to initial levels at 2 years. However, the other functional and symptom scales of the QLQ-C30 and OES18 were not normalized at 2 years after the operation. When comparing the substernal and posterior mediastinal routes, QLQ-OES18 symptom scales, such as eating, dysphagia, trouble with swallowing saliva trouble with taste and reflux, were no different between the two groups, even after adjusting confounding factors at 2 years after the operation. ConclusionThe cervical esophagogastrostomy with a substernal route showed comparable QoL to reconstruction with a posterior mediastinal route.

Robotic-assisted single-incision gastric mobilization for minimally invasive oesophagectomy for oesophageal cancer: preliminary results.

OBJECTIVESWith the gradual acceptance of robotic-assisted surgery to treat oesophageal cancer and the application of a single-port approach in several abdominal procedures, we adopted a single-port technique in robotic-assisted minimally invasive oesophagectomy during the abdominal phase for gastric mobilization and abdominal lymph node dissection.METHODSRobotic-assisted oesophagectomy and mediastinal lymph node dissection in the chest were followed by robotic-assisted gastric mobilization and conduit creation with abdominal lymph node dissection, which were performed via a periumbilicus single incision. The oesophagogastrostomy was accomplished either in the chest (Ivor Lewis procedure) or neck (McKeown procedure) depending on the status of the proximal resection margin.RESULTSThe procedure was successfully performed on 11 patients with oesophageal cancer from January 2017 to December 2018 in our institute. No surgical or in-hospital deaths occurred, though we had one case each of anastomotic leakage, pneumonia and hiatal hernia (9%).CONCLUSIONSRobotic single-incision gastric mobilization for minimally invasive oesophagectomy for treating oesophageal cancer seems feasible. Its value in terms of perioperative outcome and long-term survival results awaits future evaluation.