Minimally Invasive Ivor Lewis Esophagectomy Research Articles

Implementation of minimally invasive Ivor Lewis esophagectomy: learning curve of a single high-volume center.

Open esophagectomy is considered to be the main surgical procedure in the world for esophageal cancer treatment. Implementing a new surgical technique is associated with learning curve morbidity. The objective of this study is to determine the learning curve based on anastomotic leakage (AL) after implementing minimally invasive Ivor Lewis esophagectomy (MI-ILE) in January 2015. All 257 patients who underwent MI-ILE in a single high-volume center between January 2015 and December 2020 were retrospectively included in this study. The learning curve was evaluated using the standard CUSUM analysis with an expected AL rate of 11%. Secondary outcome parameters were postoperative complications, textbook outcome, and lymph node yield divided by the year of operation. Hierarchical binary logistic regression analysis was used to check for potential confounding variables. The CUSUM analysis showed a learning curve of 179 cases. The mean AL rate decreased from 33.3% in 2015 to 9.5% in 2020 (P = 0.007). There was an increase in the mean lymph node yield from 21 in 2018 to 28 in 2019 (P < 0.001) and textbook outcome from 37.3% in 2015 to 66.7% in 2020 (P = 0.005). A newly implemented MI-ILE has a learning curve of 179 patients based on a reference AL rate of 11% using the CUSUM method. Whether future generation surgeons will show similar learning curve numbers, implicating continuous development of different introduction programs of new techniques, will have to be the focus of future research.

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.

55: COMPETENCY ASSESSMENT TOOL FOR MINIMALLY INVASIVE ESOPHAGECTOMY: DEVELOPMENT AND PRELIMINARY CONSTRUCT VALIDITY AND RELIABILITY RESULTS

Abstract Background and aim Performance of the surgical team is essential for patient outcome. Minimally invasive esophagectomy (MIE) is a complex and technically demanding procedure and implementation is associated with a substantial learning curve. A validated, procedure specific and scientifically robust competency assessment tool (CAT) could provide structured feedback and can be a tool to improve patient outcome. The aim is to develop a MIE-CAT and assess construct validity, intra-observer reliability and inter-observer reliability. Methods Based on defined key steps from a Delphi study and refinement with a core group of MIE experts to establish content validity and obtain user agreement, the MIE-CAT was developed. Eighteen independent and blinded international MIE experts (&amp;gt; 120 MIEs performed) followed an online workshop to train in using the MIE-CAT and assessed Ivor Lewis MIE videos that were performed from 2010–2020 by four MIE surgeons from the Esophageal Center East Netherlands. To analyze construct validity, 32 videos were divided into four groups (novice, intermediate, advanced and expert) based on the surgical team’s experience. For intra-rater and inter-rater reliability, the same video was scored twice by the same and different experts. Results The MIE-CAT consists of eight procedural phases, starting with the mobilization of the greater curvature and ending with creation of the intrathoracic anastomosis. Each phase contains four domains (exposure, execution, adverse events and end-product quality) and are scored with a 1–4 Likert scale. A total of 72 video assessments were used for analysis. Substantial performance variation between the MIE-CAT scores was seen (median 98 [IQR, 84–113.4]; range = 47–126). Median MIE-CAT scores were 79.5 [IQR 74–96.3], 91 [87.5–107], 101 [84.8–108] and 101 [95.5–108.3] for respectively the novice, intermediate, advanced and expert group (Figure 1). Significant differences between the average MIE-CAT scores of the experience groups were found with a Kruskal Wallis (P = 0.002). Good intra-rater reliability was observed (ICC, 0.71, 95% CI [0.35, 0.89) and moderate inter-rater reliability was observed (ICC, 0.54, 95% CI [0.10, 0.87). Conclusion A specific competency assessment tool to score the MIE performance, the MIE-CAT, was developed. It has the potential to be used for surgical training, safe implementation, performance improvement and research purposes.

Comparative analysis of long-term oncologic outcomes for minimally invasive and open Ivor Lewis esophagectomy after neoadjuvant chemoradiation: a propensity score matched observational study

BackgroundLocally advanced esophageal carcinoma is typically treated with neoadjuvant chemoradiation and esophagectomy (trimodality therapy). We compared the long-term oncologic outcomes of minimally invasive Ivor Lewis esophagectomy (M-ILE) cohort with a propensity score weighted cohort of open Ivor Lewis esophagectomy (O-ILE) cases after trimodality therapy.MethodsThis is a retrospective review of 223 patients diagnosed with esophageal carcinoma who underwent neoadjuvant chemoradiation followed by M-ILE or O-ILE from April 2009 to February 2019. Inverse probability of treatment weighting (IPTW) adjustment was used to balance the baseline characteristics between study groups. Kaplan–Meier survival curves were calculated for overall survival and recurrence-free survival comparing the two groups. Multivariate Cox proportional hazards regression models were used to determine predictive variables for overall and recurrence-free survival.ResultsThe IPTW cohort included patients with esophageal carcinoma who underwent M-ILE (n = 142) or O-ILE (n = 68). The overall rate of postoperative adverse events was not significantly different after IPTW adjustment between the O-ILE and M-ILE trimodality groups (53.4% vs. 39.2%, p = 0.089). The 3-year overall survival (OS) for the M-ILE group was 59.4% (95% CI: 49.8–67.8) compared to 55.7% (95% CI: 39.2–69.4) for the O-ILE group (p = 0.670). The 3-year recurrence-free survival for the M-ILE group was 59.9% (95% CI: 50.2–68.2) compared to 61.6% (95% CI: 41.9–76.3) for the O-ILE group (p = 0.357). A complete response to neoadjuvant chemoradiation was significantly predictive of improved OS and RFS.ConclusionThe overall and recurrence-free survival rates for M-ILE were not significantly different from O-ILE for esophageal carcinoma after trimodality therapy. Complete response to neoadjuvant chemoradiation was predictive of improved overall and recurrence- free survival.

Side-overlap esophagogastric tube (SO-EG) reconstruction after minimally invasive Ivor Lewis esophagectomy or laparoscopic proximal gastrectomy for cancer of the esophagogastric junction.

Both laparoscopic proximal gastrectomy with lower esophagectomy (extended LPG) and minimally invasive Ivor Lewis esophagectomy (MIILE) are acceptable treatments for adenocarcinoma of the esophagogastric junction (AEG), but the optimal reconstruction technique for mediastinal esophagogastrostomy (one that provides adequate reflux prevention) has not been established. We devised a novel side-overlap esophagogastric-tube (SO-EG) reconstruction. We performed a retrospective review of patient records after LPG or MIILE. In each patient, we created a 3-cm wide gastric tube, overlapping the esophagus by 5 cm. A linear stapler was inserted into the left side of the esophageal stump and the anterior gastric wall along the greater curvature. The entry hole was closed to make a slit-like anastomosis, and the right side of the esophageal wall was fixed to the anterior gastric wall. Ten consecutive patients underwent this procedure between June 2020 and July 2021. Five patients had Siewert type II AEG: 4 with lower thoracic esophageal cancer and 1 with benign lower esophageal stenosis. A total of 3 patients underwent extended LPG, and 7 underwent MIILE. The median operative time was 352 min (range, 221-556 min). The postoperative course was uneventful in 9 patients; a single patient developed pneumonia. Seven patients underwent follow-up endoscopy at 6 months. One patient with anastomotic stenosis and 2 with mild reflux esophagitis were treated conservatively. Our novel SO-EG reconstruction is simple and feasible, with acceptable results for preventing reflux esophagitis. This technique can be performed with either extended LPG or MIILE.

The comparisons of three stapler placement methods for intrathoracic mechanistic circular stapling in Ivor Lewis minimally invasive esophagectomy.

To analyze the impact of the reversal penetrating technique (RPT) for intrathoracic gastroesophageal mechanical anastomosis on the development of anastomotic complications in Ivor Lewis minimally invasive esophagectomy (ILMIE), and to further identify the risk factors for the development of anastomotic leakage and stricture. A retrospective observational study was conducted using the clinical data of 316 patients with esophageal carcinoma (EC) who underwent ILMIE from January 2012 to December 2019. The participants were divided into three groups, namely the RPT group, the transoral Orvil technique (TOT) group, and the purse-string technique (PST) group, according to the different stapler placement methods for intrathoracic mechanistic circular stapling. Multivariate analysis was performed to investigate the association of risk factors with anastomotic leakage and stricture. There were 154 patients in the RPT group, 78 in the TOT group, and 84 in the PST group for intrathoracic gastroesophageal circular stapling in ILMIE. There were no differences in intraoperative anastomosis-related conditions including conversion of open operations, and lymph nodes harvested between the three groups. However, the mean total operative time and gastroesophageal anastomosis time in the RPT group were significantly shorter than those in the other groups (both P<0.05). The rates of anastomotic leakage and stricture showed no statistical differences between the three groups (leakage: P=0.875; stricture: P=0.942). Multivariate analysis revealed that the RPT method of anvil placement did not increase the probability of anastomotic leakage [RPT: reference; TOT: odds ratio (OR) 0.422, P=0.341; PST: OR 1.436, P=0.645] and stricture (RPT: reference; TOT: OR 0.579, P=0.376; PST: OR 1.195, P=0.755). The RPT method of anvil placement for intrathoracic gastroesophageal circular stapling does not increase the risk of anastomotic complications in ILMIE, but had significantly shorter surgical time and anastomosis time.

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.

Technical details for a robot-assisted hand-sewn esophago-gastric anastomosis during minimally invasive Ivor Lewis esophagectomy.

BackgroundMinimally invasive Ivor Lewis esophagectomy (MIILE) provides better outcomes than open techniques, particularly in terms of post-operative recovery and pulmonary complications. However, in addition to requiring advanced technical skills, thoracoscopic access makes it hard to perform esophagogastric anastomosis safely, and the reported rates of anastomotic leak vary from 5 to 16%. Several minimally invasive esophago-gastric anastomotic techniques have been described, but to date strong evidence to support one technique over the others is still lacking. We herein report the technical details and preliminary results of a new robot-assisted hand-sewn esophago-gastric anastomosis technique.MethodsFrom January 2018 to December 2020, 12 cases of laparoscopic/thoracoscopic Ivor Lewis esophagectomy with robot-assisted hand-sewn esophago-gastric anastomosis were performed. The gastric conduit was prepared and tailored taking care of vascularization with a complete resection of the gastric fundus. The anastomosis consisted of a robot-assisted, hand-sewn four layers of absorbable monofilament running barbed suture (V-lock). The posterior outer layer incorporated the gastric and esophageal staple lines.ResultsThe post-operative course was uneventful in nine cases. Two patients developed chyloperitoneum, one patient a Sars-Cov-2 infection, and one patient a late anastomotic stricture. In all cases, there were no anastomotic leaks or delayed gastric conduit emptying. The median post-operative stay was 13 days (min 7, max 37 days); the longest in-hospital stay was recorded in patients who developed chyloperitoneum.ConclusionDespite the small series, we believe that our technique looks to be promising, safe, and reproducible. Some key points may be useful to guarantee a low complications rate after MIILE, particularly regarding anastomotic leaks and delayed emptying: the resection of the gastric fundus, the use of robot assistance, the incorporation of the staple lines in the posterior aspect of the anastomosis, and the use of barbed suture. Further cases are needed to validate the preliminary, but very encouraging, results.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00464-021-08715-4.

A long-term follow-up study of minimally invasive Ivor Lewis esophagectomy with linear stapled anastomosis

Minimally invasive esophagectomy (MIE) is increasingly performed to expect lower complication rate compared to open esophagectomy. Studies of minimally invasive Ivor Lewis esophagectomy (MIILE) with circular staplers have reported better outcomes compared to MIE with cervical anastomosis, but frequent anastomotic complications have also been reported. MIILE with linear staplers is a promising alternative, but the long-term functional and oncological outcomes are uncertain. To evaluate the functional and oncological outcomes of MIILE with linear stapled anastomosis, a retrospective cohort study was performed in 104 patients who underwent MIILE with linear stapled anastomosis for esophageal malignant tumors. The primary endpoints were the overall complication and anastomotic leak rates. The secondary endpoints were late complications, overall and disease-free survival, and nutritional status at 6 and 12months after MIILE. Anastomotic leak occurred in 4 patients (3.8%). The short-term complication rate of grade IIIb or higher was 6.7%. During a median 57-month follow-up period, anastomotic stricture occurred in one patient, 7 required hiatal hernia repair, and 2 underwent conduit revision surgery. The 5-year overall survival and disease-free survival rates were 69.3% and 59.5%, respectively. Status of reflux esophagitis at the time of most recent evaluation was grade N/A/B/C/D in 52/10/10/13/8 among 93 patients who had follow-up endoscopy. The mean body weight loss at 6 and 12months after MIILE was 11.3 and 11.8% with maintenance of the serum albumin level. MIILE with linear stapled anastomosis is a safe procedure with a low anastomotic complication rate and favorable long-term functional and survival outcomes.

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.

Successful transition from open to minimally invasive approach in Ivor Lewis esophagectomy: a single-center experience in Japan.

This study evaluates surgical outcomes of Ivor Lewis esophagectomy (ILE) in our institution, with the transition from open ILE to hybrid or totally minimally invasive ILE (MI-ILE). Selected patients who underwent ILE for esophageal cancer between 2013 and 2020 were included. We retrospectively investigated the patients' background characteristics and the short-term surgical outcomes. In this period, among a total of 858 esophagectomies, selected seventy-one patients (8.3%) underwent ILE, consisted of 17 cases with completely open procedures, 27 with hybrid MI-ILE, and 27 with total MI-ILE. The major indications for ILE were adenocarcinoma of the distal esophagus or esophagogastric junction (33.8%) and patients with prior treatment of head and neck cancer (31.0%). Among these approaches, there were no significant differences in the characteristics including age, body mass index (BMI), tumor location, preoperative therapy, and clinical TNM stage, except for histology. Compared to the completely open and hybrid groups, incidences of both total and severe complications in the total MI-ILE group were significantly lower (total 70.6 vs. 66.6 vs. 37.0%, p=0.036; severe 35.3 vs. 44.4 vs. 11.1%, p=0.023), and also, those of pneumonia (41.2 vs. 29.6 vs. 7.4%, p=0.026) and postoperative stricture (11.8 vs. 18.5 vs. 0%, p=0.001) were significantly fewer in the total MI-ILE group. We have been able to achieve the transition from completely open to total MI-ILE with better short-term outcomes. Total MI-ILE with linear-stapled anastomosis can be a good alternative to open procedures for the selected patients with reducing the incidence of postoperative pneumonia and anastomotic stricture.

Indocyanine green perfusion assessment of the gastric conduit in minimally invasive Ivor Lewis esophagectomy.

Anastomotic leak is a serious complication following esophagectomy. The aim of the study was to report our experience with indocyanine green fluorescence angiography (ICG-FA)-PINPOINT® assisted minimally invasive Ivor Lewis esophagectomy (MILE) and assess factors associated with anastomotic leak. We reviewed consecutive patients undergoing MILE from 2013 to 2018. Intraoperative real-time assessment of gastric conduit was performed using ICG-FA with PINPOINT®. Perfusion was categorized as good perfusion (brisk ICG visualization to conduit tip) or non-perfusion (any demarcation along the conduit). 100 patients (81 males, median age 68 [60-72]) underwent MILE for malignancy in 96 patients and benign disease in 4 patients. There were six anastomotic leaks all managed with endoscopic stent placement. There was no intraoperative mortality and no 30-day mortality in leak patients. Patients with a leak were more likely to be overweight with BMI > 25 (100% versus 53%, p = 0.03), have pre-existing diabetes (50% versus 13%, p = 0.04), and have higher intraoperative estimated blood loss (260mL [95-463] versus 75mL [48-150], p = 0.03). Anastomotic leaks occurred more frequently in the non-perfusion (67%) versus the good perfusion category (33%, p = 0.03). By multivariable analysis, diabetes (odds ratio [OR] 6.42; p = 0.04) and non-perfusion (OR 6.60; p = 0.04) were independently associated with leak. Intraoperative use of ICG-FA may be a useful adjunct to assess perfusion of the gastric conduit with non-perfusion being independently associated with a leak. While perfusion plays an important role in anastomotic integrity, development of a leak is multifactorial, and ICG-FA should be used in conjunction with the optimization of patient and procedural components to minimize leak rates. Prospective, randomized studies are required to validate the interpretation, efficacy, and application of this novel technology in minimally invasive esophagectomies.

Improved Quality of Care and Efficiency Do Not Always Mean Cost Recovery After Minimally Invasive Ivor Lewis Esophagectomy

PurposeThe aim of this study is to determine the financial impact of clinical complications and outcomes after minimally invasive Ivor Lewis esophagectomy (MILE) at a safety-net hospital. MethodsThis was a single-center retrospective analysis of consecutive patients undergoing MILE from 2013 to 2018. Postoperative complications were classified by Clavien-Dindo grade and associated total and direct recovered costs were assessed. Direct cost and LOS index were defined as the ratio of observed to expected values (>1 denotes above nationwide expectations). Annual outcomes were based on Medicare fiscal years. ResultsOne hundred twenty-four patients (99 males, mean age 65.7 ± 9.3) were surgically treated for esophageal malignancy (n = 118) and benign disease (n = 6) by MILE between 2014 and 2018. Mean ICU LOS (5.8±6.6 versus 4.3±6.3 days) and LOS index (1.16 versus 0.76) improved from 2014 to 2018. Both direct cost index (1.03 versus 0.99) and indirect costs (43.4% versus 41.4%) decreased over time. However, direct costs recovered (213.6 to 159.0%) and total costs recovered (119.1 to 92.5%) declined during this period. Clinical complications grade was not associated with total costs recovered (p = 0.69). Extent of recovered expenditure was significantly higher from commercial/private payers as compared to government-sponsored payers (p < 0.05). ConclusionImprovement in clinical outcomes and efficiency of care are not reflected by annual recovered expenditure. Furthermore, clinical complications do not correlate with the ability to recover hospital spending. Financial recovery was primary payer dependent. Enhanced collaboration with hospital administration may be needed in an effort to maximize financial fidelity in the presence of good quality of care after highly complex procedures.

An Analysis of Outcomes After Transition From Open to Minimally Invasive Ivor Lewis Esophagectomy

The morbidity and mortality remain relatively high for transthoracic esophagectomy with open thoracotomy. We compared a total laparoscopic and thoracoscopic minimally invasive Ivor Lewis esophagectomy (M-ILE) cohort with a propensity score-weighted cohort of open Ivor Lewis esophagectomy (O-ILE) cases. This is a retrospective review of 259 patients diagnosed with esophageal carcinoma who underwent M-ILE (n= 173) or O-ILE (n= 86) from April 2009 to March 2019. The postoperative morbidity and mortality were reported for each group. Inverse probability of treatment weighting (IPTW) adjustment was used to balance the baseline characteristics between study groups. Recurrence-free and overall survival rates were compared on an intention-to-treat basis. The IPTW cohort included 249 patients with esophageal carcinoma who underwent M-ILE (n= 163) or O-ILE (n= 86). The overall rate of postoperative adverse events was significantly higher after IPTW adjustment in the O-ILE group (54.2% vs 39.02%; P= .039). The median hospital length of stay was 8.0 (interquartile range, 7.0-9.0) days for the M-ILE group compared with 10.0 (interquartile range, 8.0-14.0) days for the O-ILE group (P < .001). The 3-year overall survival for the M-ILE group was 64.63% (95% confidence interval, 54.7%-72.9%) compared with 54.76% (95% confidence interval, 39.9%-67.4%) for the O-ILE group (P= .447). The 3-year recurrence-free survival rate did not differ significantly between the groups (P= .461). The M-ILE approach demonstrated short-term clinical outcomes that were superior to O-ILE at our institution. The survival rate and recurrence-free survival rate for M-ILE were not significantly different from O-ILE for esophageal carcinoma.

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 .

Hiatal repair in Ivor Lewis minimally invasive esophagectomy: a case report

Hiatal hernia after minimally invasive esophagectomy (MIE) is an important postoperative complication that can cause severe morbidity or even mortality among patients with esophageal cancer. Usually repair of the hiatus immediately after esophageal reconstruction is suggested to prevent such complication. However, during the Ivor Lewis MIE procedure, hiatal repair is difficult to perform due to the deep-seated location of the hiatus after the final step of esophageal reconstruction in the right chest. The current study demonstrates a method of repairing the hiatus in the Ivor Lewis MIE. This is especially useful in the resection of a massive tumor near the esophagogastric (E-G) junction, which harbors a high risk of hiatal hernia when the hiatus is left unrepaired after extensive hiatal dissection.

McKeown or Ivor Lewis minimally invasive esophagectomy: a systematic review and meta-analysis.

BackgroundMinimally invasive esophagectomy (MIE) is increasingly accepted in many countries. McKeown esophagectomy and Ivor Lewis esophagectomy are two protocols commonly used for MIE, but which one provides more benefit to the patients remains matter of controversy.MethodsAll records in PubMed, Embase, Medline, The Cochrane Library, Wanfang Database, China National Knowledge Infrastructure (CNKI) and Chinese VIP Information till May 2019 were systematically retrieved to compare the cohort studies of McKeown esophagectomy and Ivor Lewis esophagectomy. A meta-analysis of the extracted data was performed using the Review Manager 5.3 and Stata 15 software.ResultsThe meta-analysis included 23 cohort studies in which a total of 4,933 patients were enrolled. The results revealed that minimally invasive McKeown esophagectomy (MIME) was superior to minimally invasive Ivor Lewis esophagectomy (MILE) in hospital cost, but inferior to it in operating time, length of hospital stay, in-hospital mortality, 30-day mortality, 90-day mortality, anastomotic leakage, anastomotic leakage requiring surgery, anastomotic stenosis, recurrent laryngeal nerve (RLN) injury, chylothorax, pulmonary complications and total complications. There were no statistical differences between MIME and MILE in blood loss, detected number of lymph nodes, blood transfusion rate, R0 resection rate, re-operation rate, drainage duration, length of the stay in intensive care unit (ICU), 1-year mortality, lung infection, cardiac arrhythmia and delayed gastric emptying.ConclusionsExcept for the cost, MILE is superior to MIME in several aspects, and may represent a better choice for MIE. The results of the present study should be interpreted with caution since the meta-analysis is based on nonrandom cohort studies which may have a selection bias.

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.

Laparoscopic needle catheter jejunostomy by using a double semipurse string suture method in minimally invasive Ivor Lewis esophagectomy

BackgroundTo investigate the safety and effectiveness of a double semipurse string suture method for jejunum fixation in laparoscopic needle catheter jejunostomy in minimally invasive Ivor Lewis esophagectomy (MIILE).MethodsTwo hundred and six esophageal cancer patients continuously receiving MIILE from March 2014 to February 2018 were enrolled. In all patients, the double semipurse string suture method was applied for jejunum fixation in laparoscopic needle catheter jejunostomy. The methods and details of this technique are introduced herein. General information, clinical data, postoperative complications and follow-up results were retrospectively analyzed, and the complication causes and treatment methods are discussed.ResultsLaparoscopic needle catheter jejunostomy-using the double semipurse string suture method was successfully performed in 206 patients. The operative time of laparoscopic needle catheter jejunostomy was 10.56±2.04 min. No conversion to laparotomy or postoperative death or serious infection associated with the jejunostomy tube occurred. The incidence of complications associated with the jejunostomy tube was 16.50% (34/206), and most of the complications were mild. Severe complications occurred in 2 cases (0.97%), which were cured after reoperation, without serious consequence.ConclusionsThe double semipurse string suture method is safe, simple and feasible for the jejunum fixation in laparoscopic needle catheter jejunostomy in MIILE. It is worth popularization and clinical application.

MA20.10 Long-Term Prognostic Factors After Minimally Invasive Esophagectomy (MIE) for Esophageal Cancer

MIE has been demonstrated to associate a better peri-operative outcome to treat esophageal cancer as compared to that done by open surgery. However, the long-term clinical impact of MIE and its prognostic factors still requires further clarification. In current study, we evaluated the survival results and the factors influencing the prognosis of patients with esophageal cancer who received total minimally invasive esophagectomy using thoracoscopic and laparoscopic esophagectomy and esophageal reconstruction. A total of 483 patients were included in the study with 179 and 304 receiving Ivor Lewis and McKeown MIE respectively. Neoadjuvant chemoradiation was administered to 379 (78 %) of the patients. The overall and disease progression-free survival curves of all the patients were constructed with five-year survival rates of 48.3% and 40.3% respectively. Multivariate analysis revealed that pathological tumor stage was a significant factor for prognosis after surgery both in the patients treated with and without neoadjuvant CCRT (P< 0.05). Of the patients with patholoigical stage I or ypStage I esopahgeal cancer after CCRT, overall survival was significantly improved with the increased number of dissected lymph nodes (P=0.022). The survival of patients with esophageal cancer undergoing MIE was influenced by their tumor staging, irrespective the use of neoadjuvant CCRT. Of these patients with stage I and ypStage I disease, improved survival can be facilitated with increased number of dissected lymph nodes during MIE.