Esophageal Resection Research Articles

Overall morbidity after total minimally invasive keyhole oesophagectomy versus hybrid oesophagectomy (the MICkey trial): study protocol for a multicentre randomized controlled trial

BackgroundOesophageal cancer (EC) is the sixth leading cause of cancer death worldwide. Oesophageal resection is the only curative treatment option for EC which is frequently performed via an abdominal and right thoracic approach (Ivor-Lewis operation). This 2-cavity operation is associated with a high risk of major complications. To reduce postoperative morbidity, several minimally invasive techniques have been developed that can be broadly classified into either hybrid oesophagectomy (HYBRID-E) via laparoscopic/robotic abdominal and open thoracic surgery or total minimally invasive oesophagectomy (MIN-E). Both, HYBIRD-E and MIN-E, compare favourable to open oesophagectomy. However, there is still an evidence gap comparing HYBRID-E with MIN-E with regard to postoperative morbidity.MethodsThe MICkey trial is a multicentre randomized controlled superiority trial with two parallel study groups. A total of 152 patients with oesophageal cancer scheduled for elective oesophagectomy will be randomly assigned 1:1 to the control group (HYBRID-E) or to the intervention group (MIN-E). The primary endpoint will be overall postoperative morbidity assessed via the comprehensive complication index (CCI) within 30 days after surgery. Specific perioperative parameters, as well as patient-reported and oncological outcomes, will be analysed as secondary outcomes.DiscussionThe MICkey trial will address the yet unanswered question whether the total minimally invasive oesophagectomy (MIN-E) is superior to the HYBRID-E procedure regarding overall postoperative morbidity.Trial registrationDRKS00027927 U1111-1277-0214. Registered on 4th July 2022

A quantitative assessment of perfusion of the gastric conduit after oesophagectomy using near-infrared fluorescence with indocyanine green

IntroductionAnastomotic leakage is a severe complication after oesophageal resection with gastric conduit reconstruction. Poor perfusion of the gastric conduit plays an important role in the development of anastomotic leakage. Quantitative near-infrared (NIR) fluorescence angiography with indocyanine green (ICG-FA) is an objective technique that can be used for perfusion assessment. This study aims to assess perfusion patterns of the gastric conduit with quantitative ICG-FA. MethodsIn this exploratory study, 20 patients undergoing oesophagectomy with gastric conduit reconstruction were included. A standardized NIR ICG-FA video of the gastric conduit was recorded. Postoperatively, the videos were quantified. Primary outcomes were the time-intensity curves and nine perfusion parameters from contiguous regions of interest on the gastric conduit. A secondary outcome was the inter-observer agreement of subjective interpretation of the ICG-FA videos between six surgeons. The inter-observer agreement was tested with an intraclass correlation coefficient (ICC). ResultsIn a total of 427 curves, three distinct perfusion patterns were recognized: pattern 1 (steep inflow, steep outflow); pattern 2 (steep inflow, minor outflow); and pattern 3 (slow inflow, no outflow). All perfusion parameters were significantly different between the perfusion patterns. The inter-observer agreement was poor – moderate (ICC:0.345,95%CI:0.164–0.584). DiscussionThis was the first study to describe perfusion patterns of the complete gastric conduit after oesophagectomy. Three distinct perfusion patterns were observed. The poor inter-observer agreement of the subjective assessment underlines the need for quantification of ICG-FA of the gastric conduit. Further studies should evaluate the predictive value of perfusion patterns and parameters on anastomotic leakage.

Prevention of stricture after semi-circumferential and whole circumferential esophageal endoscopic resection

: Stricture formation after esophageal endoscopic resection (ER) worsens a patient’s quality of life because it causes dysphagia and requires multiple endoscopic dilations. Numerous methods are available to prevent esophageal stricture formation after ER. For noncircumferential resections, much evidence indicates local steroid injection is the best choice and is therefore widely used in clinical practice. However, local steroid injection alone is insufficient to prevent stricture of whole circumferential resections. Accordingly, we should select oral steroid administration or combination therapy (oral steroid administration + local steroid injection) for such extensive resections. However, the stricture rate is significantly higher compared with noncircumferential resections despite these prevention methods. Steroid therapies, including local injection and oral administration, have the advantages of high effectiveness and low cost. However, concerns include the risk of steroid-related complications such as immunosuppression, diabetes onset/exacerbation, and fragility of the esophageal wall. Also, favorable outcomes of modified steroid methods such as local triamcinolone acetonide (TA) injection together with a polyglycolic acid sheet (PGA), TA-soaked PGA sheet together with a fully covered metal stent, and TA filling method have been reported. Innovative methods include tissue engineering approaches such as cell sheet transplantation and autologous mucosal transplantation. Despite the promise of these methods, further studies are required to establish their efficacies before widespread use in clinical practice.

A clinical practice review of the surgical approach for distal esophageal tumors

: Esophageal cancer is an aggressive malignancy. Many patients are found to have metastatic, unresectable disease at the time of diagnosis. Surgery is generally necessary as part of a multimodal treatment approach to non-metastatic esophageal cancer, but is associated with significant potential morbidity. During the operation, the surgeon must achieve an adequate cancer resection and then perform concomitant reconstruction of the gastrointestinal tract, which contributes to the high complexity of esophageal cancer surgery. The operation typically requires access to multiple body cavities, including some combination of the thorax, the abdomen, and the neck. Several options to accomplish esophageal resection and reconstruction exist, including Ivor Lewis esophagectomy, McKeown (three field) esophagectomy, transhiatal esophagectomy, and thoracoabdominal esophagectomy. The optimal approach for a specific patient will be dependent on patient, cancer, surgeon, and institution characteristics. This clinical practice review will explore the general epidemiology, work-up, and overall treatment of esophageal cancer, as well as outline the factors that impact surgical approach selection. The review describes the details as well as the advantages and disadvantages of each possible approach, and gives an overview of the spectrum of possible postoperative complications. An improved understanding of this topic can allow non-surgical specialists to better support their patients.

Vacuum-stent: A combination of endoscopic vacuum therapy and an intraluminal stent for treatment of esophageal transmural defects.

Endoscopic vacuum therapy (EVT) has gained a greater role in management of transmural defects in the upper gastrointestinal (GI) tract, including anastomotic leakage and esophageal perforation (e.g. Boerhaave syndrome and iatrogenic causes). The vacuum-stent is a new treatment modality, combining the benefits of EVT and an intraluminal stent. This prospective case series describes the first ten cases of a transmural defect in the upper GI tract treated with a vacuum-stent in a tertiary referral center. All patients signed informed consent for prospective registration of relevant data on treatment and outcomes in a specially designed database. Outcome parameters were successful closure of the defect, number of endoscopies, duration of treatment and adverse events. In total, ten patients treated with a vacuum-stent were included. Eight patients had anastomotic leakage after esophageal resection, of whom six were treated with vacuum-sponge and vacuum-stent, and two with vacuum-stent only. One patient had Boerhaave syndrome, treated with vacuum-sponge and vacuum-stent, and one had an iatrogenic perforation during pneumodilation for achalasia, treated with vacuum-stent only. Success rate was 100%, requiring a median of 5 (IQR 3-12) EVT-related endoscopies with a treatment course of median 18 (IQR 12-59) days. One patient developed an esophageal stricture, but no other vacuum-stent related adverse events were observed. The vacuum-stent, which combines benefits of EVT and an intraluminal stent, shows great feasibility and efficacy in treatment of transmural defects in the upper GI tract. Future studies should point out whether this device can prevent major (re-)surgery in these patients.

Complications of esophageal reconstruction

Esophageal cancer is the most common cause of esophageal resections. Esophageal replacement is still a significant challenge for surgeons, because complications can be expected in over 50% and death also occurs between 4-7%. Complications can be divided into early and late categories and into general and specific complications. From a surgical point of view, early and late specific complications are the most important aspects. Between 1993 and 2012, 540 esophageal resections were performed due to malignant tumors at the Department of Surgery, Medical Center of the University of Pécs. Stomach was used for replacement in 445 cases, colon in 38 cases, and jejunum in 57 cases. The anastomosis with stomach replacement was located to the neck in 275 cases and to the thorax in 170 cases. The colon was pulled up to the neck in each case. There were 29 cases of free jejunal replacements located to the neck, and 28 cases with a Roux-loop reconstruction located to the thorax. In the case of gastric replacement, anastomotic insufficiency developed in 55 cases, graft necrosis occurred in 8 cases, and early anastomosis stricture developed in 30 cases. These numbers are 3 conduit necrosis and 2 strictures in cases of colonic replacements. There was one anastomosis failure in the case of a thoracic jejunum replacement. Also one conduit necrosis was observed in the free jejunal neck transplantation group. Among late special complications, dysphagia is the most important, the causes of which were found in the order of frequency: anastomotic stricture, conduit obstruction, peptic and ischemic stricture, foreign body, local recurrence, functional causes, new malignant tumor in the esophageal remnant after resection and malignant tumor emerging in the replaced organ. Causes may overlap each other, and their treatment may be conservative, endoscopic or surgical. Surgical treatment is usually the last option to restore the ability to swallow and can present a significant challenge even to experienced centers. Orv Hetil. 2023; 164(7): 243-252.

The effect of a mesenteric traction syndrome on internal carotid artery blood flow

PurposeDuring abdominal surgery, manipulation of internal organs may induce a “mesenteric traction syndrome” (MTS) including a triad of flushing, hypotension, and tachycardia that lasts for approximately 30 min. We evaluated whether MTS affects internal carotid artery blood flow.MethodsThis prospective cohort study included 27 patients aged 65 ± 11 years (mean ± SD) undergoing stomach resection (n = 12), esophageal resection (n = 14), or gastro-entero anastomosis (n = 1) during propofol-remifentanil and thoracic epidural anesthesia. Duplex ultrasound determined internal carotid artery blood flow, laser Doppler flowmetry assessed forehead skin blood flow, and near-infrared spectroscopy determined cerebral oxygenation. Development of MTS was defined by flushing within 60 min after incision.ResultsSeven patients developed MTS 22 [20–26; median (IQR)] min after incision and at that time the change in heart rate (to 87 ± 13 vs. 70 ± 11 bpm; P = 0.0007) and skin blood flow (to 214 (134–269) vs. 84 (59-112 PU; P = 0.0044) was higher in the patients who developed MTS as compared to those who did not, while mean arterial pressure (63 ± 13 vs. 64 ± 14 mmHg; P = 0.1433), cerebral oxygenation (69 ± 9% vs. 63 ± 10%; P = 0.2485), and internal carotid artery flow (225 ± 53 vs. 203 ± 69 ml/min; P = 0.9529) were similar.ConclusionHemodynamic perturbations are observed in some patients in response to manipulation of the viscera, but the development of MTS appears not to influence internal carotid artery flow.Clinical trial registrationhttps://clinicaltrials.gov/ct2/show/NCT02951273?term=NCT02951273&rank=1, identifier: NCT02951273.

Esophagogastrostomy with fundoplication versus double-tract reconstruction after laparoscopic proximal gastrectomy for gastric cancer.

346 Background: Upper-third gastric cancer has been increasing in incidence worldwide and performance of laparoscopic proximal gastrectomy has become increasing common. Various reconstructive procedures after laparoscopic proximal gastrectomy have been reported, but the optimal reconstructive procedure is unclear. Methods: This single-center retrospective study included 53 consecutive patients with early gastric cancer in the upper third of the stomach who received laparoscopic proximal gastrectomy at our hospital between September 2013 and November 2019. Of these 53 patients, 39 underwent esophagogastrostomy with fundoplication. In the 14 patients requiring resection of the abdominal esophagus or where the size of the remnant stomach was 50% or less, we performed double-tract reconstruction. We compared the surgical and nutritional outcomes of patients who underwent esophagogastrostomy or double-tract reconstruction after laparoscopic proximal gastrectomy. Results: There was no significant difference between the two groups regarding blood loss, incidence of postoperative complications, occurrence of gastroesophageal reflux disease, food intake, reflux symptoms, or usage of proton pump inhibitors. There was no significant difference in the rate of body weight change at 6 or 12 months, or in biochemical markers (hemoglobin, total protein and albumin) at 12 months. However, eight patients (21%) in the esophagogastrostomy group had extreme body weight loss (≥20%) within 12 months. Conversely, in the double-tract reconstruction group, no patients had any extreme body weight loss ( P = 0.013). Conclusions: Double-tract reconstruction is useful after laparoscopic proximal gastrectomy, especially in terms of preventing extreme body weight loss.

Impact of obesity on postoperative outcomes in patients undergoing esophagectomy for resectable esophageal cancer.

327 Background: The prevalence of obesity (Body Mass Index>30kg/m^2) is rising in the western world and is a risk factor for gastrointestinal malignancy. It is considered a risk factor for poor surgical outcomes including impaired wound healing and venous thromboembolism. Dysphagia is a late sign of esophageal cancer and is associated with pre-operative malnutrition and weight loss. However, the true impact of obesity on outcomes after esophagectomy is controversial. This analysis investigates the impact of pre-operative obesity on outcomes following esophagectomy for esophageal cancer. Methods: All patients with recorded pre-treatment BMI, who underwent surgery from January 2005 to June 2022 at a single tertiary, specialist cancer centre in the United Kingdom (UK), were included in this study. Demographic details including BMI and tumour staging (TNM classification) were collected, as well as total length of inpatient and critical care admission (LOS), 30- and 90- day mortality. Statistical analyses were performed on the R platform. Results: A total of 401 patients (348 male, 53 female) underwent resectional surgery for esophageal cancer; 132 (32.9%) were of normal BMI (18.5-24.9kg/m^2), 162 (40.1%) were overweight (BMI of 25-29.9kg/m^2), and 108 (26.9%) were obese (BMI>30kg/m^2). The mean BMI for obese patients was 33.6kg/m^2 and mean age was 62.5 years in this cohort. Laparoscopic Ivor-Lewis esophagectomy was the commonest procedure performed on obese patients (57/108, 52.3%). When all patients were categorised into healthy BMI, overweight or obese cohorts, there was no statistically significant difference in post-operative complications at Clavien-Dindo grade II or lower, (p=0.500) or grade IIIa or higher (p=0.201). Furthermore, there was no statistically significant difference in total inpatient LOS (p=0.503), length of critical care admission (p=0.358), 30-day (p=0.836) or 90-day mortality (p=0.691). Conclusions: Obesity is not significantly associated with increased risk of postoperative complications, LOS, 30- or 90-day mortality in patients undergoing esophagectomy for cancer. The increasing uptake of minimally invasive surgery for esophageal cancer resections may also be associated with favourable surgical outcomes being achieved in patients with BMI>30kg/m^2.

Prediction of risk factors associated with readmission after robotic esophagectomy.

328 Background: Approximately, 20,640 new esophageal cancers (EC) will be diagnosed in 2022 and this will result in 16,410 deaths. Surgical resection remains the only potentially curative option, however significant morbidity and mortality ensues. Robotic approaches to esophageal resection have decreased overall length of hospitalizations. However, readmissions rates continue to be a significant concern. We sought to evaluate factors predicting readmission after robotic assisted trans-thoracic esophagectomy (RATE). Methods: Utilizing a prospectively maintained esophageal database, we identified patients with EC who underwent RATE between 2009-2022. We then stratified by readmissions, length of hospitalization and post-operative complications. Pre-operative, peri-operative and post-operative risk factors were identified as predictors of readmissions. Baseline univariate comparisons were made for continuous variables using both the Mann-Whitney U and Kruskal Wallis tests. Pearson’s Chi-square test was used to compare categorical variables. Multivariate analysis was performed identifying predictors of readmission. Results: We identified 312 patients, who underwent RATE with a median age of 68 (38-91). There were 29 (9.3%) patients who underwent readmission. There were no differences in age (p=0.10), gender (p=0.39) BMI (p=0.22), or histology (p=0.35) between patients that were readmitted and those that were not. ASA scores were higher in those that were readmitted p=0.01 compared to those who were not. The median length of hospitalization (LOH) was 8 (7-11) and did not differ between those that were re-admitted and those that were not p=0.79. The most common reasons for re-admissions were pulmonary 16 (5.1%), anastomotic leak 6 (1.9%), soft tissue infection 2 (0.6%), nutrition 3 (1%) and gastrointestinal 2 (0.6%). Pre-operative risk factors predictive of readmissions included cardiac disease p=0.002 and diabetes p=0.04. Operative risk factors: estimated blood loss p=0.9 and operative time p=0.24 did not predict readmission. Post-operative complications occurred in 93 (29.8%) of patients. Any post-operative complication p=0.32 did not predict re-admission with the exception of anastomotic leak p=0.04. Additionally, length of ICU did not differ between those re-admitted and those who were not, p=0.96. Ninety-day mortality was significantly higher in those that were re-admitted, 13.8% vs 4% in those that were not re-admitted, p=0.001. Multivariate analysis revealed that cardiac disease, diabetes, ASA score, and anastomotic leak were all predictors of readmission. Conclusions: Readmission after RATE remains low despite decreased LOH. Patients that are readmitted will have a significantly higher risk of mortality at 90-days. Pre-operative, peri-operative and post-operative factors can be used to accurately predict risk for readmission after robotic esophagectomy.

Required esophageal resection length beyond the tumor boundary to ensure a negative proximal margin for gastric cancer with gross esophageal invasion or esophagogastric junction cancer.

To obtain a pathologically negative proximal margin (PM) for gastric cancer with gross esophageal invasion (EI) or esophagogastric junction (EGJ) cancer, we should transect the esophagus beyond the proximal boundary of gross EI with a safety margin because of a discrepancy between the gross and pathological boundaries of cancer. However, recommendations regarding the esophageal resection length for these cancers have not been established. Patients who underwent proximal or total gastrectomy for gastric cancer with gross EI or EGJ cancer were enrolled. A parameter ΔPM, which corresponded to the length of a discrepancy between the gross and pathological proximal boundary of the tumor, was evaluated. The maximum ΔPM, which corresponded to the minimum length ensuring a pathologically negative PM, was first determined in all patients. Then subgroup analyses according to factors associated with ΔPM ≥ 10mm were performed to identify alternative maximum ΔPMs. A total of 289 patients with gastric cancer with gross EI or EGJ cancer were eligible and analyzed in this study. The maximum ΔPM was 25mm. Clinical tumor (cTumor) size and growth and pathological types were independently associated with ΔPM ≥ 10mm. In subgroup analyses, the maximum ΔPM was 15mm for cTumor size ≤ 40mm and superficial growth type. Furthermore, the maximum ΔPM was 20mm in the expansive growth type. Required esophageal resection lengths to ensure a pathologically negative PM for gastric cancer with gross EI or EGJ cancer are proposed.

Dysphagia After Esophageal Replacement and Its Treatment

Dysphagia occurs temporarily or permanently following esophageal replacement in at least half of the cases. Swallowing disorder, in addition to severe decline in the quality of life, can lead to a deterioration of the general condition, which may lead to death if left untreated. For this reason, their early detection and treatment are a matter of importance. Between 1993 and 2012, 540 esophageal resections were performed due to malignant tumors at the Department of Surgery, Medical Center of the University of Pécs. Stomach was used for replacement in 445 cases, colon in 38 cases, and jejunum in 57 cases. The anastomosis with a stomach replacement was located to the neck in 275 cases and to the thorax in 170 cases. The colon was pulled up to the neck in each case. There were 29 cases of free jejunal replacements located to the neck and 28 cases with a Roux loop reconstruction located to the thorax. Based on the literature data and own experience, the following were found to be the causes of dysphagia in the order of frequency: anastomotic stenosis, conduit obstruction, peptic and ischemic stricture, foreign body, local recurrence, functional causes, new malignant tumor in the esophageal remnant, and malignant tumor in the organ used for replacement. Causes may overlap each other, and their treatment may be conservative or surgical. The causes of many dysphagic complications might be prevented by improving the anastomosis technique, by better preservation the blood supply of the substitute organ, by consistently applying a functional approach, and by regular follow-up.

Incidence and impact of new-onset postoperative arrhythmia after surgery of the lower gastrointestinal tract

Postoperative arrhythmias (PAs) are common events and have been widely investigated in cardiothoracic surgery. Within visceral surgery, a recent study revealed a significant occurrence of PA in esophageal resections. In contrast, PA in lower gastrointestinal surgery is rarely investigated and has been rudimentary described in the medical literature. The present work is a retrospective cohort study of 1171 patients who underwent surgery of lower gastrointestinal tract between 2012 and 2018. All included patients were treated and monitored in the intensive care unit (ICU) or intermediate care unit (IMC) after surgery. Follow-up, performed between January and May 2021, was obtained for the patients with PA investigating the possible persistence of PA and complications such as permanent arrhythmia or thromboembolic events after discharge. In total, n = 1171 patients (559 female, 612 male) without any history of prior arrhythmia were analyzed. Overall, PA occurred in n = 56 (4.8%) patients after surgery of the lower GI. The highest incidence of PA was seen in patients undergoing bowel surgery after mesenteric ischaemia (26.92%), followed by cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC; 16.67%). PA was significantly associated with higher age (72 years (IQR 63–78 years) vs. 64 years (IQR 55–73.5 years), p < 0.001) and longer length of stay in the ICU (median 15 days (IQR 5–25 days) vs. median 2 days (IQR 1–5 days), p < 0.001). PA was independently associated with organ failure (OR = 4.62, 95% CI 2.11–10.11, p < 0.001) and higher in-house mortality (OR = 3.37, 95% CI 1.23–9.28, p < 0.001). In median, PA occurred 66.5 h after surgery. In follow-up, 31% of all the patients with PA showed development of permanent arrhythmia. The incidence of PA after lower GI surgery is comparatively low. Its occurrence, however, seems to have severe implications since it is significantly associated with higher rates of organ failure and in-house mortality. Also, compared to the general population, the development of permanent arrhythmia is significantly higher in patients who developed new-onset PA.

ESDE-MIE fellowship: a descriptive analysis of the first experiences.

Esophageal resection is a high-risk and technically demanding procedure, with a long proficiency-gain curve. The European Society Diseases of the Esophagus (ESDE)-Minimally Invasive Esophagectomy (MIE) training program was launched in 2018 for European surgeons willing to train and to begin a career undertaking MIE. The aim of this study was to evaluate the first experience of the ESDE-MIE fellowship and relate this to the initially predetermined core principles and objectives of the program. Between October 2021 and May 2022, the participating fellows, in collaboration with the ESDE Educational Committee, initiated a survey to assess the outcome and experience of these fellowships. Data from each individual fellowship were analysed and reported in a descriptive manner. Between 2018 and 2022, in total, five fellows have completed the ESDE-MIE fellowship program. Despite the COVID-19 outbreak just the year after its launch, predetermined clinical and research goals were achieved in all cases. Each of the fellows were able to assist in a median of 40 (IQR 27-69) MIE and/or Robot assisted (RA)MIE procedures, of a total median of 115 (IQR 83-123) attended Upper GI cases. After the fellowship, MIE has been fully adopted by the fellows who returned to their home institutions as Upper GI surgeons. The fellowship was concluded by the European Union of Medical Specialists (UEMS) Multidisciplinary Joint Committee (MJC) certification in Upper GI Surgery, which was successfully obtained by all who took part. Based on the experience of the first five fellows, the ESDE-MIE training fellowship meets with the expected needs even despite the COVID-19 outbreak in 2019. Furthermore, these fellows have returned home and integrated MIE into their independent surgical practice, affirming the ability of this program to train the next generation of MIE surgeons, even in the most challenging of circumstances.

Advances in conduits and anastomotic techniques employed in esophageal cancer resections: A review.

Esophageal surgery has evolved significantly since the first esophagectomy, with advancements in diagnosis allowing medicine to keep pace with the disease's increasing incidence. Multimodal treatment improves outcomes, but surgical resection remains imperative for local control, with various techniques in existence but none demonstrating clear superiority. More recently, minimally invasive and robotic surgery have further reduced perioperative morbidity. This review discusses techniques for esophageal resection, with attention to the options available for anastomosis and reconstructive conduits.

Treatment of esophageal leakages with the Microtech®-VAC-Stent: a monocentric early experience of three cases.

Endoscopic approaches in the treatment of transmural esophageal defects, either after esophageal resection or due to perforation, have demonstrated convincing feasibility. Surgical options are limited and associated with high morbidity and mortality rates. Currently, internal endoscopic drainage with pigtail stents, self-expanding metal stent (SEMS), or endoscopic vacuum therapy (EVT) are options for first-line treatment. Here, we report the outcome of the recently developed combination of SEMS and EVT using the endoscopic Microtech®-VAC-Stent (EVS). Between June and July 2022, three consecutive patients (one female and two males) with esophageal transmural defects were treated with the Microtech®-VAC-Stent. Two patients suffered from an anastomotic leak after oncologic gastroesophageal surgery, and one patient presented with esophageal perforation due to Boerhaave syndrome. Three consecutive patients were successfully treated with EVS. In one patient, one EVS treatment was sufficient, whereas the other two patients needed two and six EVS exchanges. Exchanges were scheduled every 7 days and no procedural adverse events were observed. In line with the former case series, EVS therapy is a promising new approach for the treatment of esophageal leaks. Exchange of the EVS seems feasible every 7 days reducing interventions for the individual patient. Prospective studies comparing EVS with other endoscopic therapies are needed to define the best therapeutic approach.

Clinical analysis of inflatable video-assisted mediastinoscopic transhiatal esophagectomy combined with laparoscopy

Objective: To examine the safety and effectiveness of inflatable video-assisted mediastinoscopic transhiatal esophagectomy (IVMTE). Methods: Totally 269 patients admitted to the Anhui Provincial Hospital of Anhui Medical University who underwent IVMTE (IVMTE group, n=47) or thoracoscopy combined with minimally invasive Mckeown esophageal cancer resection (MIME group, n=222) from September 2017 to December 2021 were analyzed retrospectively. There were 31 males and 16 females in IVMTE group, aged (68.6±7.5) years (range: 54 to 87 years). There were 159 males and 63 females in MIME group, aged (66.8±8.8) years (range: 42 to 93 years). A 1∶1 match was performed on both groups by propensity score matching, with 38 cases in each group. The intraoperative conditions and postoperative complication rates of the two groups were compared by t test, Wilcoxon rank, χ2 test, or Fisher exact probability method. Results: Patients in IVMTE group had less intraoperative bleeding ((96.0±39.2) ml vs. (123.8±49.3) ml, t=-2.627, P=0.011), shorter operation time ((239.1±47.3) minutes vs. (264.2±57.2) minutes, t=-2.086, P=0.040), and less drainage 3 days after surgery (85(89) ml vs. 675(573) ml, Z=-7.575, P<0.01) compared with that of MIME group. There were no statistically significant differences between the two groups in terms of drainage tube-belt time, postoperative hospital stay, and lymph node dissection stations and numbers (all P>0.05). The incidence of Clavien-Dindo grade 1 to 2 pulmonary infection (7.9%(3/38) vs. 31.6%(12/38), χ²=6.728, P=0.009), total complications (21.1%(8/38) vs. 47.4%(18/38), χ²=5.846, P=0.016) and total lung complications (13.2%(5/38) vs. 42.1%(16/38), χ²=7.962, P=0.005) in the IVMTE group were significantly lower. Conclusion: Inflatable video-assisted mediastinoscopic transhiatal esophagectomy combined with laparoscopic esophagectomy is safe and feasible, which can reach the same range of oncology as thoracoscopic surgery.

Comparison of GLIM and PG-SGA for predicting clinical outcomes of patients with esophageal squamous carcinoma resection.

to determine the validity of the Global Leadership Initiative on Malnutrition (GLIM) against the Patient Generated-Subjective Global Assessment (PG-SGA) as a gold standard tool in malnutrition diagnosis, and to assess the impact of malnutrition diagnosed using GLIM and PG-SGA on the clinical outcomes of patients with esophageal squamous carcinoma (ESCC) resection. we prospectively analyzed 182 patients with ESCC who underwent radical esophagectomy. Preoperative malnutrition was diagnosed using GLIM and PG-SGA, and the postoperative clinical outcomes, including postoperative complications, postoperative chest tube indwelling time, length of stay and total hospitalization cost, were recorded. The association between the prevalence of malnutrition defined by the two tools and postoperative clinical outcomes was evaluated. among the 182 ESCC patients, the incidence of malnutrition before surgery was 58.2 % and 48.4 % defined by PG-SGA and GLIM, respectively. GLIM and PG-SGA had good consistency in nutritional assessment of ESCC patients (k = 0.628, p < 0.001). Malnourished patients had higher TNM stages and older ages (all p < 0.05). Patients with malnutrition as assessed by PG-SGA and GLIM had a higher incidence of postoperative complications, a longer indwelling time of chest tube after esophagectomy, longer hospital length of stay, and higher hospitalization costs than patients with good nutrition (p < 0.001). Comparing the predictive efficiency of postoperative complications, the sensitivity of PG-SGA- and GLIM-defined malnutrition were 81.6 % and 79.6 %, the specificity were 50.4 % and 63.2 %, the Youden index were 0.320 and 0.428, and the Kappa value were 0.110 and 0.130, respectively. The areas under ROC curve of PG-SGA- and GLIM-defined malnutrition and postoperative complications were 0.660 and 0.714, respectively. this study indicates the effectiveness of malnutrition diagnosed according to GLIM and PG-SGA in predicting postoperative clinical outcomes among patients with ESCC. Compared with PG-SGA, GLIM criteria can better predict postoperative complications of ESCC. Follow-up analysis of postoperative long-term survival is needed to explore the association between different assessment tools and postoperative long-term clinical outcomes.

Surgical treatment of thoracic esophageal diverticula.

Thoracic esophageal diverticulum (TED) is a rare benign disease associated with motility disorders of the esophagus. Surgical management is usually the definitive treatment, with traditional excision of the diverticulum via thoracotomy and minimally invasive techniques being comparable and associated with a mortality rate of between 0 and 10%. To present the results of surgical treatment of patients with thoracic diverticula of the esophagus in a 20-year period. The study presents a retrospective analysis of the results of surgical management of patients with the thoracic esophageal diverticulum. All patients underwent open transthoracic diverticulum resection with myotomy. Patients were evaluated for the degree of dysphagia before and after surgery, associated complications and overall comfort after surgical treatment. Twenty-six patients due to diverticula of the thoracic part of the esophagus underwent surgical treatment. Resection of the diverticulum with esophagomyotomy was performed in 23 (88.5%) patients, anti-reflux surgery was performed in 7 (26.9%) and in 3 (11.5%) patients with achalasia, the diverticulum was left unresected. Among the patients operated on, 2 (7.7%) patients developed a fistula, and both required mechanical ventilation. In 1 patient the fistula closed spontaneously, and the other patient required esophageal resection and colon reconstruction. Two patients required emergency treatment due to mediastinitis. There was no mortality in the perioperative period of hospital stay. Treatment of thoracic diverticula is a difficult clinical problem. Postoperative complications pose a direct threat to the patient's life. Esophageal diverticula is characterized by good long-term functional results.

Novel techniques for the management of esophageal anastomotic leaks

Anastomotic leaks (ALs) after esophageal resection remain a dreaded complication and are associated with high morbidity and mortality, along with an increased cost of care and prolonged hospitalization. Management strategies include confirming conduit viability, controlling sepsis with drainage/antibiotics, and maintaining nutrition. Traditional treatment of ALs has given way to nonoperative management including endoscopic and radiological techniques, which are associated with decreased morbidity. This article aims to review novel technologies and techniques for the management of esophageal ALs, including self-expandable metal stents, endoluminal vacuum therapy, leak content drainage, and radiology-guided drain placement.