Open Esophagectomy Research Articles

Comparison of the Effects of Ultrasound-guided Erector Spinae Plane Block and Wound Infiltration on Perioperative Opioid Consumption and Postoperative Pain in Thoracotomy.

To compare the effects of preoperative ultrasound-guided erector spinae plane block (ESPB) and preoperative wound infiltration on perioperative opioid consumption and postoperative pain in thoracotomy. Randomised controlled trial. Department of Anesthesiology, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, from October 2018 to April 2019. Sixty adult patients undergoing open esophagectomy were allocated randomly into two groups: experimental group (ultrasound-guided ESPB group, n = 30) and control group (wound infiltration group, n = 30). In ultrasound-guided ESPB group (group EB), ESPB with 20 ml of 0.5% ropivacaine was performed at the level of thoracic 5 transverse process. Whereas, in wound infiltration group (group WI), 20 ml of 0.5% ropivacaine was injected subcutaneously along the marked line of skin incision for surgery and chest tube placement. The perioperative opioid consumption, pain scores at rest and during coughing immediately after surgery, at postoperative day (POD) 1 and POD 2, consumption of rescue analgesic tramadol and postoperative opioid-related adverse events were all assessed. Compared with group WI, the intraoperative and postoperative opioid consumptions, postoperative tramadol consumption were significantly less in group EB (p <0.05). Moreover, the postoperative pain scores immediately after surgery, at POD 1 and POD 2, were all lower in group EB compared to group WI (p <0.05). Significantly, the postoperative incidence of nausea and vomiting was lower in group EB than that in group WI (p = 0.021). Compared to wound infiltration with local anesthetics, preoperative ultrasound-guided ESPB could significantly reduce perioperative opioid consumption, provide a better postoperative analgesia and reduce opioid-related adverse events in thoracotomy.

P29 COMPARISON BETWEEN MINIMALLY INVASIVE AND OPEN ESOPHAGECTOMY IN PATIENTS AGED ≥75 YEARS: A NATIONWIDE PROPENSITY-SCORE MATCHED COHORT STUDY

Abstract Aim To compare postoperative outcome in elderly undergoing either open or minimally invasive esophagectomy. Background &amp; Methods Randomized controlled trials have shown improved short term outcome in patients undergoing minimally invasive compared with open esophagectomy. However, all of them have excluded patients aged 75 years or older. Evidence regarding this patient group, therefore, remains scarce. A propensity score matched retrospective cohort study was performed in a Dutch nationwide cohort from the period of april 2011 to april 2016 of patients aged ≥75 years diagnosed with local and locally advanced esophageal cancer who underwent either minimally invasive or open esophagectomy. Primary outcomes consisted of anastomotic leakage and perioperative mortality. Secondary outcomes were the rate of other complications, reintervention and hospital/ICU readmission. Results After matching, 322 patients were included, 161 in the open esophagectomy and 161 in the minimally invasive esophagectomy group. In the minimally invasive group, a significantly higher incidence occurend of Clavien-Dindo ≥3 complications (RR 1.63, CI-95% 1.24—2.13), anastomotic leaks (RR 1.60, CI-95% 1.12—2.29) and reinterventions (RR 1.70, CI-95% 1.19—2.42). There were no significant differences regarding perioperative mortality, other complications and readmission rate. Conclusion Elderly patients diagnosed with locally advanced esophageal cancer should undergo minimally invasive esophagectomy in favor of open esophagectomy. Keywords Elderly, minimally invasive esophagectomy, open esophagectomy, esophageal cancer, clinical outcome, perioperative mortality.

P28 AN OPEN TRANSTHORACIC ESOPHAGECTOMY RESULTS IN HIGHER POSTOPERATIVE C-REACTIVE PROTEIN LEVELS COMPARED TO MINIMALLY INVASIVE ESOPHAGECTOMY

Abstract Aim With the introduction of minimally invasive access in centers for esophageal surgery, complications as well as mortality rates decreased. Laboratory tests are used routinely to screen patients for postoperative complications as early as possible. Still, the course of several laboratory parameters after esophagectomy following different surgical approaches has not been described yet and thus, reference values do not exist. Nowadays, the interpretation of inflammatory markers depends on the expertise of the medical staff. The aim of this study is to evaluate the development of CRP and leukocytes after thoracoabdominal esophagectomy following four different surgical approaches. Background &amp; Methods 217 consecutive patients receiving a thoracoabdominal esophagectomy with either open, hybrid, totally minimally invasive or robot-assisted minimally invasive technique between 2008 and 2018 have been evaluated. Daily blood tests regarding C-reactive protein (CRP) and leukocytes have been performed daily in all patients. Data was collected prospectively and analyzed depending on the postoperative course and the surgical approach. Results There is a natural increase of leukocytes and CRP with peak values on the 2nd postoperative day (POD) after thoracoabdominal esophagectomy following all surgical approaches. The increase of inflammatory parameters is significantly higher after open esophagectomy on the first three postoperative days compared to the three minimally invasive procedures. Furthermore, postoperative CRP values &gt; 200 mg/l on the 2nd postoperative day as well as an open esohagectomy are independently associated with postoperative complications. Conclusion The development of postoperative inflammatory laboratory parameters after esophagectomy is significantly depending on the surgical approach. Open esophagectomy results in significantly higher CRP and leukocyte values compared to the hybrid esophagectomy, minimally invasive esophagectomy and robot assisted minimally invasive esophagectomy. Open esophagectomy and an increase of CRP on the 2nd postoperative day above 200 mg/l are an independent positive predictor for postoperative complications in multivariate analysis.

P175 TRANSLATION OF MINIMALLY INVASIVE ESOPHAGECTOMY FROM RANDOMIZED CONTROLLED TRIAL SETTING (TIME) TO NATIONAL PRACTICE (DUCA) IN NETHERLANDS

Abstract Aims The TIME trial showed reduced pulmonary complications from minimally invasive esophagectomy (MIE) over an open approach, and led to widespread adoption of MIE in the Netherlands. The aim of this study was to compare clinical outcomes from minimally invasive esophagectomy in the DUCA (national dataset) and the TIME trial (RCT) for transthoracic esophagectomy1. Methods Original patient data from the TIME trial1 was extracted along-with data from the Dutch National Cancer Audit (DUCA) (2011-2017). Initially univariate analysis was used to compare patient and tumor demographics and clinical and pathological outcomes from patients receiving MIE in the TIME trial and in the DUCA-dataset. Secondly multivariate analysis, with adjustment patient and tumor factors, was performed for the effect of MIE vs. Open esophagectomy on clinical outcomes in both datasets. Thirdly the datasets were combined and multivariate analysis, was performed for the effect of patient inclusion in TIME trial or DUCA-dataset. Results 115 patients from TIME (59 MIE vs. 56 open) and 4605 patients from the DUCA-dataset (2652 MIE vs. 1953 open) were included. Univariate analysis showed, in TIME trial, MIE reduced postoperative complications and length of hospital stay. However in the DUCA-dataset, MIE increased postoperative complications, re-intervention rate and length of hospital stay, however pathological benefits included increased proportion of R0 margin and lymph nodes harvested. Multivariate analysis confirmed the TIME data showed MIE reduced postoperative complications (OR=0.38, 95%CI 0.16–0.90). In the DUCA-dataset, MIE was associated with increased postoperative complications (OR=1.37, 95%CI 1.20–1.55), re-intervention (OR=1.84, 95%CI 1.57–2.14), and length of hospital stay (Coeff=1.57, 95%CI 0.06–3.08). Pathological benefits to MIE in the DUCA-dataset included a reduction in proportion of R1 margin, and increased lymph node harvest. Multivariate analysis of the combined dataset, showed inclusion in the TIME trial was associated with a reduction in postoperative complications (OR=0.23, 95%CI 0.15–0.36) and reoperation rate (OR=0.34, 95%CI 0.17–0.66). Conclusions MIE when adopted nationally outside the TIME-trial, was associated with an increase in postoperative complications and reoperation rate, which may reflect surgeons on a national level going through their proficiency-gain curve in the technique and outside of expert MIE centers.

P191 MINIMALLY-INVASIVE ESOPHAGECTOMY IN TREATMENT FOR ESOPHAGEAL DISEASES

Abstract Aim to study the benefits of the mini-invasive approach. Background &amp; Methods 115 esophagectomies were performed for the period from 2015 to 2018. Gastric conduit in 84 patients, colon - 2 and small intestine - 29. The study included 65 patients after I.Lewis, McKeown or transhiatal esophagectomy, who was performed esophageal replacement with gastric conduit. The first group consisted of 44 patients after open esophagectomy; second group - 21 patients after MIE (minimally invasive esophagectomy): included 8 patients - thoraco-laparoscopic McKeown surgery, 1 patient - laparoscopic transhiatal esophagectomy with anastomosis on the neck, 9 patients – hybrid minimally invasive I.Lewis surgery (laparoscopy+thoracotomy), and 3 patients – minimally invasive thoraco-laparoscopic I.Lewis surgery. The average age of patients was 53 years (13-64). 55 patients (84.6%) with esophageal cancer and 10 patients (15.4%) with benign strictures of the esophagus. There were anastomosis on the neck in 28 patients (43%) and intrathoracic anastomosis in 37 patients (57%). Results In the first group the average operative time was 286 minutes (240-370 min.), the average volume of blood loss was 345 ml (100-600 ml), the length of in-hospital stay was 15 days (9-29), complications: anastomosis leakage - 1 patient on the 5th postoperative day - EndoVAC system was used with a defect closure after 18 days; 1 patient - adhesive intestinal obstruction (relaparotomy, separation of adhesions). In the second group the average operative time was 400 min (370-480 min.), blood loss - 100 ml (50-200 ml), the length of in-hospital stay - 10 days (8-16), complications in 1 patient - acute strangulation with intestinal obstruction. There was no mortality in both groups. Conclusions The application of MIE helps to reduce the severity of postoperative pain, the length of in-hospital stay and intraoperative blood loss. This procedure should be performed in specialized hospitals with experience in miniinvasive surgery and esophageal surgery.

P53 MINIMALLY INVASIVE TECHNIQUES FOR TRANSTHORACIC ESOPHAGECTOMY FOR ESOPHAGEAL CANCERS: A SYSTEMATIC REVIEW AND NETWORK META-ANALYSIS

Abstract Aim To evaluate the clinical outcomes for open, minimally invasive and robotic esophagectomy techniques for esophageal cancers. Background &amp; Methods Esophagectomy is a demanding operation which can be performed by employing different approaches including open surgery or a combination of minimal access techniques. Each approach has specific reported advantages and disadvantages. A systematic literature search was conducted for studies reporting open, laparoscopic hybrid esophagectomy (LHE), thoracoscopic hybrid esophagectomy (THE), totally minimally invasive esophagectomy (MIE) or robotic MIE (RoMIE) for esophagectomy. A network meta-analysis of intraoperative (operating time, blood loss), postoperative (overall complications, anastomotic leaks, chyle leak, length of hospital stay), oncological outcomes (R0 resection, lymphadenectomy) and survival were performed. Results Ninety-eight studies including 32,296 patients were included in the network meta-analysis, of which 55% (n=17824), 5% (n=1576), 7% (n=2421), 30% (n=9558) and 3% (n=917) were open, LHE, THE, MIE and RoMIE respectively. Both MIE and RoMIE were associated with less blood loss, significantly lower rates of pulmonary complications, shorter length of stay and higher lymph node yield. There were no significant differences between surgical techniques for surgical site infections, chyle leak, and 30-day and 90-day mortality. MIE and RoMIE had better 1-year and 5-year survival rates compared to open respectively. Conclusion Minimally invasive and robotic techniques for esophagectomy are associated with reduced perioperative morbidity and length of stay with no compromise on oncological outcomes but no improvement in perioperative mortality. There are suggestions of improved long-term survival with MIE and RoMIE but these associations are not consistent across 1-, 3- and 5-year survival.

P69 INTRAOPERATIVE ENDOSCOPY IS OF A GREAT IMPORTANCE IN COMPLEX REVISIONAL UPPER GI SURGERY. CASE PRESENTATION OF RECURRENT ACHALASIA PREVIOUSLY TREATED WITH 3 LAPAROSCOPIC HELLERS CARDIOMYOTOMIES.

Abstract Aim To demonstrate the ability to perform increasingly complex revisional surgery utilising minimally invasive techniques and synchronous endoscopy for recurrent achalasia. Background &amp; Methods We present a case of recurrent achalasia previously treated with 3 laparoscopic Hellers cardiomyotomies. Traditionally such a case would be considered for either open revisional surgery or oesophagectomy. In this case a fourth laparoscopic Hellers cardiomyotomy was succesfully performed using 3D laparoscopy combined with synchronous intraoperative endoscopy. The 3D video footage we present demonstrates the added safety provided by depth perception and high resolution imaging in revisional laparoscopic surgery. Synchronous endoscopy confirms altered anatomy, pathology and luminal change from extraluminal interventions resulting in prompt recognition of LES and subsequent efficient gastric myotomy. Results After a laborious adhesiolysis using the advantages of 3D imaging system we faced difficulties recognizing the exact LES location, in order to proceed with the gastric myotomy. In our opinion this could be the reason for previous treatment failures. At this point the use of synchronous flexible endoscopy enabled the recognition of cardia, so we could safely and efficiently complete a fourth laparoscopic Hellers cardiomyotomy including repair of a distal oesophageal diverticulum and a substantially lengthened gastric myotomy. This resulted in a substantial improvement in dysphagia symptoms with the patient resuming consumption of liquid and solid food as well. Conclusion Early adoption of technological advancements facilitates organ preserving revisional surgery and the avoidance of significant patient morbidity. These techniques radically increase the safety profile of minimally invasive surgery by facilitating anatomic recognition and provisioning for tailored intervention.

P54 INCIDENCE AND OUTCOME OF HIATAL HERNIA AFTER OESOPHAGECTOMY: COMPARISON OF TRADITIONAL OPEN AND MINIMALLY INVASIVE APPROACH

Abstract Aim The primary aim of this retrospective study is to evaluate the incidence of symptomatic and asymptomatic hiatal hernia (HH) in patients who have undergone intended curative open or minimally invasive oesophagectomy (MIO) for cancer of the oesophagus in a high-volume surgical centre. The secondary aim is to describe the treatment and outcome after HH treatment. Background &amp; Methods MIO for the treatment of oesophageal cancer has emerged as an alternative to traditional open oesophagectomy without compromising disease free or overall survival1. HH of abdominal viscera other than the gastric conduit is an infrequent but potentially life-threatening complication following oesophagectomy. HH may present with grievous complications, such as severe respiratory failure, intestinal ischemia with perforation, bowel obstruction, and strangulation leading to emergency surgery2,3. Surgical repair of these HHs is associated with a high morbidity rate and in the emergent setting even a high mortality4. In meta-analysis, the pooled incidence of symptomatic HH after MIO was 4.5 %, compared to a pooled incidence of 1.0 % after open oesophagectomy5. However, studies on the subject, often do not describe whether patients are asymptomatic or simply have not been examined for the existence of HH. The actual HH incidence may therefore be underestimated and may be more sufficiently reported when including patient material with comprehensive follow-up. This retrospective cohort study includes all patients (n≈455) who have undergone curative intended resection for malignant disease in the oesophagus at The Department of Surgery, Odense University Hospital, from 1th January 2012 – 31th December 2018. Patient demography, perioperative data including surgical approach and follow-up, including occurrence and treatment of hiatal hernia, mortality and recurrence of malignant disease will be extracted from complete electronic patient records. Follow-up ranges from 6-84 months. Primary outcome is occurrence of hiatal hernia after oesophagectomy determined by CT-scan or during surgery. Results As of abstract deadline for ESDE 2019, we have only just received permission for the study from The Danish Patient Safety Authority and can unfortunately not present our results yet. However, we expect that results are ready for presentation at ESDE 2019 and hope for your understanding.

O144 CALCIFICATION IN THE DESCENDING AORTA PREDICTS POSTOPERATIVE LEAKAGE OF INTRA-THORACIC ANASTOMOSIS AFTER OPEN ESOPHAGECTOMY FOR CANCER

Abstract Aim Postoperative anastomotic leakage is a major complication in the surgery of the esophagus. In this study, we aim to examine whether calcifications of the aortic segments can predict anastomotic leakage after open esophagectomy for cancer with intra-thoracic anastomosis of a gastric conduit. Background and methods All patients with esophageal cancer who underwent elective esophagectomy with an intra-thoracic anastomosis at Tampere University Hospital between 2007-2018 were evaluated. Preoperative data were associated to outcome. These included demographic, anamnestic, clinical, laboratory, and radiologic data. Preoperative staging thoraco-abdominal CT-scans were re-evaluated to document the presence of calcifications in the various aortic segments. Results A total of 97 patients (median age 64 (43-78) years, 20% female) were analysed, with anastomotic leakage occurring in 22 patients (23%). Median time from surgery to leakage was 10 (1-32) days, and follow-up time 28 (1-143) months. From all the factors that were evaluated in the univariate analysis, only the presence of calcification in the descending thoracic aorta was associated with a higher risk of anastomotic leakage (11% vs. 33%, HR 4.571; 95% CI 1.40-15.0; p=0.011). There was a trend for anastomotic leakage in the presence of calcification in the suprarenal abdominal aorta (13% vs. 29%, p=0.057). A higher leakage rate was documented when a calcification was present in the infrarenal abdominal aorta (8.3% vs. 25%, p=0.205), and in the ascending thoracic aorta (22% vs. 30%, p=0.559), without reaching statistical significance. Conclusion The presence of a calcification in the descending thoracic aorta is associated with higher risk of anastomotic leakage after open esophagectomy for cancer.

Efficacy of hybrid minimally invasive esophagectomy vs open esophagectomy for esophageal cancer: A meta-analysis.

BACKGROUNDThe first line treatment regimen for esophageal cancer is still surgical resection and the choice of surgical scheme depends on surgeon. Now the efficacy comparison of hybrid minimally invasive esophagectomy (HMIE) and open esophagectomy (OE) is still controversial.AIMTo compare the perioperative and postoperative outcomes of HMIE and OE in patients with esophageal cancer.METHODSPubMed, EMBASE, and Cochrane Library databases were searched for related articles. The odds ratio (OR) or standard mean difference (SMD) with a 95% confidence interval (CI) was used to evaluate the effectiveness of HMIE and OE.RESULTSSeventeen studies including a total of 2397 patients were selected. HMIE was significantly associated with less blood loss (SMD = -0.43, 95%CI: -0.66, -0.20; P = 0.0002) and lower incidence of pulmonary complications (OR = 0.72, 95%CI: 0.57, 0.90; P = 0.004). No significant differences were seen in the lymph node yield (SMD = 0.11, 95%CI: -0.08, 0.30; P = 0.26), operation time (SMD = 0.24, 95%CI: -0.14, 0.61; P = 0.22), total complications rate (OR = 0.68, 95%CI: 0.46, 0.99; P = 0.05), cardiac complication rate (OR = 0.91, 95%CI: 0.62, 1.34; P = 0.64), anastomotic leak rate (OR = 0.95, 95%CI: 0.67, 1.35; P = 0.78), duration of intensive care unit stay (SMD = -0.01, 95%CI: -0.21, 0.19; P = 0.93), duration of hospital stay (SMD = -0.13, 95%CI: -0.28, 0.01; P = 0.08), and total mortality rates (OR = 0.70, 95%CI: 0.47, 1.06; P = 0.09) between the two treatment groups.CONCLUSIONCompared with the OE, HMIE shows less blood loss and pulmonary complications. However, further studies are necessary to evaluate the long-term oncologic outcomes of HMIE.

Laparoscopically assisted versus open oesophagectomy for patients with oesophageal cancer—the Randomised Oesophagectomy: Minimally Invasive or Open (ROMIO) study: protocol for a randomised controlled trial (RCT)

IntroductionSurgery (oesophagectomy), with neoadjuvant chemo(radio)therapy, is the main curative treatment for patients with oesophageal cancer. Several surgical approaches can be used to remove an oesophageal tumour. The Ivor Lewis (two-phase...

Comparative outcomes of robot-assisted minimally invasive versus open esophagectomy in patients with esophageal squamous cell carcinoma: a propensity score-weighted analysis.

Robots are increasingly used in minimally invasive surgery. We evaluated the clinical benefits of robot-assisted minimally invasive esophagectomy (RAMIE) in comparison with the conventional open esophageal surgery. From 2012 to 2016, 371 patients with esophageal squamous cell carcinoma underwent an Ivor Lewis or McKeown procedure at our institution. Of these, 130 patients underwent laparoscopic gastric conduit formation followed by RAMIE, whereas 241 patients underwent conventional esophageal surgery, including laparotomy and open esophagectomy (OE). We compared the short- and long-term clinical outcomes of these patients using the propensity score-based inverse probability of treatment weighting technique (IPTW). Among the early outcomes, the OE group showed a higher incidence of pneumonia (P = 0.035) and a higher requirement for vasopressors (P = 0.001). Regarding the long-term outcomes, all-cause mortality was significantly higher (P = 0.001) and disease-free survival was lower (P = 0.006) in the OE group. Wound-related problems also occurred more frequently in the OE group (P = 0.020) during the long-term follow-up. There was no statistical intergroup difference in the recurrence rates (P = 0.191). The Cox proportional-hazard analysis demonstrated that wound problems (HR 0.16, 95% CI 0.02-0.57; P = 0.017), pneumonia (HR 0.23, 95% CI 0.06-0.68; P = 0.019), and use of vasopressors (HR 0.14, 95% CI 0.08-0.25; P = 0.001) were independent predictors of mortality. RAMIE could be a better surgical option for selected patients with esophageal squamous cell carcinoma.

Oncological Outcomes After Radical Esophagectomy from a Tertiary Cancer Center.

Although esophageal cancers have poor survival outcomes, evidence suggests that preoperative chemoradiation followed by surgery have improved survival outcomes. Minimally invasive surgery has equivalent oncological outcomes with less complication compared with open surgery, but there is insufficient data available in South Indian population. Our aim was to analyze the perioperative outcome and survival between minimally invasive and open transhiatal esophagectomy group. Data from patients operated for esophageal cancer in our department from the year 2015 to 2018 were collected retrospectively using medical records. Among 55 carcinoma esophagus patients, squamous histology (67%) and lower third location (57%) being predominant. Twenty-six patients underwent video-assisted thoracoscopic surgery (VATS)-assisted esophagectomy and 18 patients underwent open transhiatal esophagectomy. Eleven patients were inoperable. Sixteen patients in VATS arm and three patients in transhiatal arm received preoperative chemoradiation. VATS arm has lesser intraoperative blood loss, early pulmonary recovery with early intercostal drain removal, and lesser hospital stay but longer mean operating time of 171 min versus 140 min (P < 0.01). It has higher mean nodal harvest of 15 versus 7 nodes (P 0.01) and higher overall median survival of 36 months (95% CI, 29.3 to 42.7) as against 23 months (95% CI, 17.8 to 29.2) for transhiatal arm (P < 0.01). VATS-assisted esophagectomy is less morbid procedure with early postoperative recovery, better oncological outcomes, and improved survival compared with transhiatal arm which is equivalent to apex centers in India.

The Impact of Hospital Size on National Trends and Outcomes Following Open Esophagectomy.

Background and Objectives: Previous studies have demonstrated superior patient outcomes for thoracic oncology patients treated at high-volume surgery centers compared to low-volume centers. However, the specific role of overall hospital size in open esophagectomy morbidity and mortality remains unclear. Materials and Methods: Patients aged >18 years who underwent open esophagectomy for primary malignant neoplasia of the esophagus between 2002 and 2014 were identified using the National Inpatient Sample. Minimally invasive procedures were excluded. Discharges were stratified by hospital size (large, medium, and small) and analyzed using trend and multivariable regression analyses. Results: Over a 13-year period, a total of 69,840 open esophagectomy procedures were performed nationally. While the proportion of total esophagectomies performed did not vary by hospital size, in-hospital mortality trends decreased for all hospitals (large (7.2% to 3.7%), medium (12.8% vs. 4.9%), and small (12.8% vs. 4.9%)), although this was only significant for large hospitals (P < 0.01). After controlling for patient demographics, comorbidities, admission, and hospital-level factors, hospital length of stay (LOS), total inflation-adjusted costs, in-hospital mortality, and complications (cardiac, respiratory, vascular, and bleeding) did not vary by hospital size (all P > 0.05). Conclusions: After risk adjustment, patient morbidity and in-hospital mortality appear to be comparable across all institutions, including small hospitals. While there appears to be an increased push for referring patients to large hospitals, our findings suggest that there may be other factors (such as surgeon type, hospital volume, or board status) that are more likely to impact the results; these need to be further explored in the current era of episode-based care.

Conversion from Minimally Invasive to Open Esophagectomy Was Not Associated with Radiation Dose or Interval from Radiation to Surgery

Khil, Alina BS; Worrell, Stephanie G. MD; Bachman, Katelynn MD; Perry, Yaron MD, FACS; Linden, Philip A. MD, FACS; Towe, Christopher W. MD Author Information

Using Benchmarking Standards to Evaluate Transition to Minimally Invasive Esophagectomy

Minimally invasive esophagectomy (MIE) is performed in nearly 50% of patients worldwide. The effectiveness of the technique arises from a single randomized control trial and multiple single series cohorts. Consistent reporting of complications is varied. We describe our experience of transitioning to MIE compared with open esophagectomy (OE) with the use of Esophageal Complications Consensus Group (ECCG) standardized complication benchmark definitions. Between 2007 and 2017, all patients undergoing esophagectomy were identified with the use of a prospectively curated database. Complications were defined by the ECCG and graded with the Clavien-Dindo (most severe complication) and comprehensive complication index (complexity of complications during hospital stay). Of 383 patients, 299 (76%) were men with a median age of 64.5 years (range, 56-72 years). MIE was performed in 49.6%. No differences were found in age, histologic finding (P= .222), pT stage (P= .136), or nodal positivity (P= .918). Stage 3 cancers accounted for 42.0% of OEs and 47.9% of MIEs. A thoracic anastomosis was more frequent in MIEs (156 of 190; 82.1%) than in OEs (113 of 193; 58.5%; P= .001). Frequency, severity (Clavien-Dindo), and complexity (comprehensive complication index) of complications were better in the MIE group, without compromising operative outcomes. No differences were identified in individual complication groupings or grade in MIEs compared with OEs (pneumonia: 19.5% versus 26.9% ([P= .09]; intensive care unit readmission: 7.4% versus 9.3% [P= .519]; atrial fibrillation: 11.1% versus 6.7% [P= .082], or grade of leak [P= .99]). These results compare favorably to those reported by ECCG. MIE can be the standard approach for surgical management of esophageal cancer. Introduction of the approach in each surgeon's practice should be benchmarked to international standards.

Ivor Lewis robotic assisted minimally invasive esophagectomy: different approaches

The best surgical approach for esophageal cancer remains controversial. Minimally invasive esophagectomy has gained popularity over the last two decades, and has shown some advantages over open esophagectomy (OE) without compromising oncologic outcomes. Surgical robotics has expanded on that approach with the development of the robotic assisted minimally invasive esophagectomy (RAMIE). A growing experience has been described from highly specialized centers, however, long-term data remains sparse. We describe our operative approach in detail herein, and provide a summarization of different technical considerations published in the literature to date.

Long-Term Trends in Respiratory Function After Esophagectomy for Esophageal Cancer

BackgroundEsophagectomy for esophageal cancer is known to lead to deterioration in respiratory function (RF). The aim of this study was to assess long-term trends in RF after esophagectomy and the impact of different operative procedures. MethodsA total of 52 patients with thoracic esophageal cancer who were scheduled for esophagectomy from 2003 to 2012 were enrolled. We prospectively evaluated patients for vital capacity (VC), forced expiratory volume in 1 s (FEV1.0), and 6-min walk distance (6MWD) before and after esophagectomy at 3, 6, 12, 24, and 60 mo. ResultsPatients had mostly recovered their VC and FEV1.0 after 12 mo. After that point, VC and FEV1.0 declined again, reaching levels lower than baseline at 60 mo, with a median change ratio of 0.85 and 0.86, respectively. Although the 6MWD after open esophagectomy declined, patients treated with transhiatal esophagectomy and minimally invasive esophagectomy maintained above baseline levels throughout the follow-up period. Furthermore, we identified transhiatal esophagectomy (odds ratio [OR] = 0.03, 95% confidence interval [CI] 0.002-0.43, P = 0.01) and minimally invasive esophagectomy (OR = 0.14, 95% CI 0.02-0.94, P = 0.04) as favorable factors and postoperative pulmonary complication (OR = 9.14, 95% CI 1.22-68.6, P = 0.03) as an unfavorable factor for RF after 12 mo. Operative procedures had no significant impact on RF after 60 mo. ConclusionsOur results support the notion that RF does not recover to the baseline level, and operative procedures have no significant impact on RF at late phase after esophagectomy.

Health-related Quality of Life Following Hybrid Minimally Invasive Versus Open Esophagectomy for Patients With Esophageal Cancer, Analysis of a Multicenter, Open-label, Randomized Phase III Controlled Trial

Hybrid minimally invasive esophagectomy (HMIE) has been shown to reduce major postoperative complications compared with open esophagectomy (OE) for esophageal cancer. The aim of this study was to compare short- and long-term health-related quality of life (HRQOL) following HMIE and OE within a randomized controlled trial. We performed a multicenter, open-label, randomized controlled trial at 13 study centers between 2009 and 2012. Patients aged 18 to 75 years with resectable cancers of the middle or lower third of the esophagus were randomized to undergo either transthoracic OE or HMIE. Patients were followed-up every 6 months for 3 years postoperatively and global health assessed with EORTC-QLQC30 and esophageal symptoms assessed with EORTC-OES18. The short-term reduction in global HRQOL at 30 days specifically role functioning [-33.33 (HMIE) vs -46.3 (OE); P = 0.0407] and social functioning [-16.88 (HMIE) vs -35.74 (OE); P = 0.0003] was less substantial in the HMIE group. At 2 years, social functioning had improved following HMIE to beyond baseline (+5.37) but remained reduced in the OE group (-8.33) (P = 0.0303). At 2 years, increases in pain were similarly reduced in the HMIE compared with the OE group [+6.94 (HMIE) vs +14.05 (OE); P = 0.018]. Postoperative complications in multivariate analysis were associated with role functioning, pain, and dysphagia. Esophagectomy has substantial effects upon short-term HRQOL. These effects for some specific parameters are, however, reduced with HMIE, with persistent differences up to 2 years, and maybe mediated by a reduction in postoperative complications.

Robotic-assisted Ivor-Lewis esophagectomy

Esophagectomy is the core treatment modality for operable esophageal cancer. For middle and lower third esophageal carcinoma, Ivor Lewis two stage esophagectomy is increasingly performed worldwide. In recent years, minimally invasive esophagectomy (MIE) has been widely applied, which has the superiority over open esophagectomy in terms of postoperative morbidity and mortality. The robotic surgical system provides a three-dimensional, high definition view, and improved stability and flexibility for operation, which unveiled a new era of MIE. Robot-assisted Ivor-Lewis esophagectomy (RAILE) has been suggested as a safe and feasible procedure for the treatment of operable middle and distal esophageal cancer. This review focuses on the perioperative and oncological outcomes of RAILE based on available evidence.