Thoracolaparoscopic Esophagectomy Research Articles

Short-Term Outcomes and Quality of Life Following Minimally Invasive Esophagectomy in a Tertiary Care Center in Southern India.

With the advent of multimodality therapy and minimally invasive surgical approaches, patients suffering from carcinoma esophagus are showing promising outcomes. Hence, the frontier needs to be widened to assess the postoperative quality of life (QoL) of those surviving carcinoma esophagus. The objective of the study was to determine the short-term outcomes of minimally invasive esophagectomy (MIE) /hybrid esophagectomies in carcinoma esophagus and the organ-specific QoL in survivors of MIE for carcinoma esophagus, and to compare health-related QoL in patients following MIE for carcinoma esophagus with the general population. A longitudinal study design was used to evaluate the short-term postoperative outcomes of patients undergoing MIE for carcinoma esophagus between July 1, 2021, to July 15, 2022, and analyze the QoL of those patients who survived at one year without tumor recurrence. QoL was assessed using the European Organization for the Research and Treatment of Cancer (EORTC) QoL Questionnaire (EORTC QLQ-C30) and the EORTC QoL Questionnaire - Oesophageal Cancer Module (EORTC QLQ-OES18). A total of 15 patients who underwent minimal invasive/hybrid esophagectomy for esophageal carcinomawere included. Of these, 13 patients underwent hybrid esophagectomy while two patients underwent thoraco-laparoscopic esophagectomy. Squamous cell carcinoma was observed as the most common histological variant (60%) while 33% were adenocarcinoma and 6.7% lymphoma. The most common site of the tumor was the lower one-third esophagus (60%). Nine out of 15 patients developed postoperative complications needing prolonged ICU stay. One major anastomotic leak as well as one conduit necrosis was observed among 15 cases operated. Median length of hospital stay was 16 (IQR 12-24). QoL was assessed among 12 patients at the one-year follow-up excluding mortality cases and patients with tumor recurrence. The patients following MIE for carcinoma esophagus were observed to have low scores in physical functioning, role functioning, and social functionwhen compared with the general population. Cognitive functioning and emotional function were not found to be significantly different. No statistically significant difference was observed in the global health status among the two groups. There was no significant difference found in the general symptoms score comparison of the MIE patients with the general population. When it comes to organ-specific symptom scales, reflux was observed as a major issue among the patients who survived carcinoma esophagus after undergoing MIE. Dysphagia and dry mouth received low scores suggestive of minor issues. Though analysis of global health QoL scores of those with postoperative complications and those who had uneventful recovery at one year revealed a higher score for the latter, it was not statistically significant. Postoperative complications can prolong hospital stay, delay resuming normal work, and affect the global QoL of patients compared with those who recovered uneventfully. Physical and role functions were observed to be deficient among survived patients when compared with the normal population. Nutritional prehabilitation, cutting-edge surgical practice including minimally invasive techniques, minimizing deviation from normal postoperative recovery by high-quality ICU care, and postoperative rehabilitation are the cornerstones to ensure better QoL.

Robot-assisted versus thoracolaparoscopic oesophagectomy for locally advanced oesophageal squamous cell carcinoma after neoadjuvant chemoradiotherapy

IntroductionRobot-assisted oesophagectomy (RAE) and thoracolaparoscopic oesophagectomy (TLE) are surgical techniques for the treatment of oesophageal cancer. This study aimed to compare the perioperative and mid-term outcomes of RAE versus TLE for patients with locally advanced oesophageal squamous cell carcinoma (ESCC) undergoing neoadjuvant chemoradiotherapy (nCRT). MethodsConsecutive patients receiving nCRT plus RAE or TLE were retrospectively included in this single-institution study from January 2016 to January 2021. Perioperative outcomes were compared and survival analysis was performed. ResultsThis study enrolled 251 patients, 80 (31.9%) in RAE and 171 (68.1%) in TLE. The conversion rate was equivalent in RAE versus TLE (3.8% vs 2.9%, P = 1). Median operative time in RAE was significantly shorter than that in TLE (254 vs 289 min, P < 0.001). Compared to TLE, RAE harvested more lymph nodes along the recurrent laryngeal nerve [4 (3–6) vs 3 (1–5), P < 0.001]. Overall complications were similar in RAE compared to TLE (38.8% vs 38.0%, P = 0.911). No statistically significant difference in disease-free survival (log-rank P = 0.721) or overall survival (log-rank P = 0.325) was found between groups. ConclusionsCompared to TLE, RAE could achieve shorter operative duration and better lymph nodes dissection along the bilateral RLN for locally advanced ESCC after nCRT, with comparable short-term outcomes. A long-term survival remains to be verified.

Thoracolaparoscopic esophagectomy for esophageal cancer with a cervical or abdominal incision to extract specimen.

Surgery is the only curative approach for resectable esophageal cancer. This retrospective study was to investigate the immediate effect and operative complications of conventional and modified thoracolaparoscopic esophagectomy with a cervical or abdominal incision to extract specimen for the treatment of patients with esophageal cancer. Eighty-one patients were enrolled, among which 55 patients underwent conventional McKeown thoracolaparoscopic esophagectomy (conventional MTE) and 26 patients underwent modified MTE with a cerivical incision (modified MTE). The clinical, surgical, and postoperative data were analyzed. No significant (P > .05) difference was detected in the clinical data between two groups. The surgical procedure was successful in all patients (100%). The surgical time was significantly (P = .018) shorter in the conventional MTE group than in the modified MTE group (280 min vs 317 min). However, no significant (P > .05) difference was found in blood loss (200 mL vs 180 mL), intensive care unit (ICU) stay (31.3 ± 11.3 vs 25.2 ± 6.4 hours), first flatus after surgery (2.9 ± 1.9 vs 3.3 ± 1.6 days), postoperative hospital stay (12.9 ± 5.6 vs 12.6 ± 3.3 days), total number of lymph nodes dissected (27.9 ± 4.1 vs 26.7 ± 5.7), types of carcinoma, and pathological classification. No significant (P > .05) differences were detected in postoperative complications between the two groups. Assessment of postoperative pain using the visual analogue scale (VAS) score showed a significant (P < .05) difference in the VAS score at day 2 (4.81 ± 1.70 vs 3.87 ± 1.14) and day 3 (5.10 ± 0.83 vs 4.61 ± 1.12) between the conventional and modified MTE groups. The modified McKeown thoracolaparoscopic esophagectomy with only one cervical incision is more minimally invasive, more cosmetic, and less painful than the conventional approach.

Assessment of results of thoraco - laparoscopic esophagectomy in patients receiving neoadjuvant chemoradiotherapy for esophageal cancers

Abstract Introduction: Laparoscopic esophagectomy plays an important role in esophageal cancer. In recent years, the treatment of esophageal cancer is multidisciplinary, especially in neoadjuvant chemoradiotherapy for stages from IIB-IV to downstage to increase the possibility of R0 resection and survival. Globally, there have many studies showing the feasibility, safety, and effectiveness of laparoscopic esophagectomy after neoadjuvant chemoradiotherapy in patients with esophageal cancers. In Vietnam, there has been a paucity of data and surgical results in this group of patients. Therefore, we conducted a study to evaluate the safety, feasibility, and effectiveness of laparoscopic esophagectomy in patients receiving neoadjuvant chemoradiotherapy for esophageal cancers at Viet Duc Hospital. Patients and methods: A retrospective study of patients who underwent the thoraco-laparoscopic esophagectomy receiving neoadjuvant chemoradiotherapy at Viet Duc hospital from T9/ 20217- T9/2021. Results: From September 2017 to September 2021, there were 30 patients with esophageal cancer receiving neoadjuvant chemoradiotherapy followed by thoraco-laparoscopic esophagectomy. 100% were male, the mean age was 55.2 years old. Tumor locations in the middle and lower third parts were 53.3% and 46.7% respectively. 96.7% was squamous cell carcinoma, adenocarcinoma accounted for 3.3%. Before chemoradiotherapy stage III, and IV was 80%; 16.7%, after chemoradiotherapy, stages II and III were 43.3% and 40%. The average operation duration was 283 minutes, the average blood loss during video assisted thoracotomy was 60ml, there were no intraoperative complications, and there were no cases requiring conversion to open thoracotomy. The duration of intubation was 2.1 days, the average hospital stay was 12.5 days. There were 13.3% respiratory complications and 6.7% had experienced anastomosis leak. There were no postoperative deaths. The average number of harvested lymph nodes was 19, the lymph node metastasis rate was 43%. R0 resection rate was 93,4%. The results were 40% consistent completely with the histopathological examination. The mean survival time after surgery was 27 ± 3.7 (months), and the survival rate after 2 years was 42%. Conclusions: Thoraco-laparoscopic esophagectomy after neoadjuvant chemoradiotherapy is a feasible, safe, and beneficial procedure for post-surgery recovery of patients. Keywords: Esophagael cancer, Thoraco-laparoscopic esophagectomy, neoadjuvant chemoradiotherapy.

Thoracolaparoscopic esophagectomy for esophageal cancer with a cervical incision to extract specimen

BackgroundSurgical treatment is the most important and effective therapy for resectable esophageal cancer. Minimally invasive esophagectomy (MIE) can reduce surgical trauma. A neck incision can be performed for extraction of surgical specimen. This study was performed to investigate the safety and feasibility of neck incision to extract surgical specimen in thoracolaparoscopic esophagectomy for esophageal cancer. Materials and methodsThirty-four patients who experienced thoracolaparoscopic esophagectomy for esophageal cancer and a neck incision for extraction of surgical specimen were enrolled. The clinical, surgical and follow-up data were analyzed. ResultsThe procedure was successful in all patients (100%), with a neck incision to extract the surgical specimen. The median surgical time was 309 min, and the median blood loss was 186 ml, with the mean length of hospital stay of 11.5 days. Pulmonary complications occurred in 8 patients (23.5%). Anastomotic leakage occurred in 5 patients (14.7%), with one patient being treated conservatively to recover and four (11.8%) who received interventional drainage. One patient with interventional drainage died of severe infection, resulting in a 30-day surgical mortality of 2.9% (n = 1). Gastrointestinal complications happened in 5 patients (14.7%), including ileus in three patients and anastomotic stenosis in two patients. Follow-up was performed at a median time of 20 months (interquartile range, 14–32 months), with no death during this period. No recurrence was found in the first 12 months after radical resection. ConclusionThe cervical incision to extract surgical specimen is safe and feasible with improved cosmetic effect in thoracolaparoscopic esophagectomy for esophageal cancer.

En bloc mesoesophageal esophagectomy through thoracoscopy combined with laparoscopy based on the mesoesophageal theory.

To investigate the effectiveness and clinical significance of thoracolaparoscopic esophagectomy with mesoesophagus excision. Patients who underwent en bloc mesoesophageal esophagectomy through thoracoscopy combined with laparoscopy were retrospectively enrolled. Carbon nanoparticles were used in some patients to label the esophageal drainage lymph nodes. The clinical data were analyzed. En bloc mesoesophageal esophagectomy was successfully performed in 135 patients (100%). The carbon nanoparticles were used in 10 patients, among which the left gastric arterial lymph nodes were labeled in all patients and excised together with the left gastric mesentery, mesoesophagus, esophageal cancer, lymph nodes, vessels, nerves, and adipose tissues as one intact package. The mean operation time was 182.5 ± 26.4min, intraoperative blood loss 45.9 ± 17.6ml, mean number of lymph nodes dissected 20.9 ± 8.12, extubation time of drainage tubes 7.5 ± 3.8days, first oral feeding time 7.5 ± 1.8days, and postoperative hospital stay 13 ± 5.11days. Postoperatively, anastomotic leakage occurred in six patients (4.4%), anastomotic stenosis in eight (5.9%), hoarseness in seven (5.2%), and inflammation of the remnant stomach in four (3.0%), with a complication rate of 18.5%. Patients were followed up for 13-34months (median 23). Eighteen patients presented with organ metastasis. No local recurrence or death during follow-up. Based on the membrane anatomy or mesoesophagus theory, thoracolaparoscopic en bloc mesoesophageal esophagectomy is safe, with decreased blood loss, and it is necessary to resect the left gastric artery lymph nodes together with the left gastric mesentery and its contents to completely remove the cancer.

Robot-assisted versus video-assisted thoraco-laparoscopic McKeown's esophagectomy for esophageal cancer: a propensity score-matched analysis of minimally invasive approaches.

Minimally invasive esophagectomy for esophageal cancer decreases overall complication rate and leads to faster postoperative recovery. Robot-assisted minimally invasive esophagectomy is becoming more common. Its three-dimensional view and wristed instruments may provide advantages over traditional thoraco-laparoscopic techniques. There are limited studies comparing robotic and conventional thoraco-laparoscopic esophagectomy. This study aimed to evaluate short-term outcomes of robot-assisted McKeown esophagectomy (RAME) and video-assisted McKeown esophagectomy (VAME). All consecutive patients undergoing minimally invasive McKeown esophagectomy for middle and distal third esophageal cancer between January 2016 and December 2018 at our center were included in this study. Data on baseline characteristics, pathological data and short-term outcomes were collected in a dedicated database. Postoperative complications were defined as per recommendations of Esophagectomy Complications Consensus Group. Histopathologic assessment was performed as per College of American Pathologists guidelines. Propensity score matching was performed for comparison between RAME and VAME groups using age, gender, performance status, American Society of Anesthesiologists grade, body mass index, Charlson Index, tumor location, clinical tumor stage, and neoadjuvant treatment as covariates. A total of 74 patients were included, 25 of whom underwent RAME and 49 underwent VAME. Propensity score matching on 1:1 basis produced 25 pairs of patients, comparable in terms of baseline characteristics. Total operative time and estimated blood loss was similar between the two groups. Length of hospital stay was significantly lower in RAME group. Major postoperative complications (Clavien-Dindo grade ≥ 3A) were more common in VAME group, but not statistically significant. Median number of harvested lymph nodes and R0 resection rate did not differ in between the two groups. In our experience, robot-assisted McKeown esophagectomy was comparable to video-assisted McKeown esophagectomy in terms of safety, feasibility and oncologic adequacy. Use of the robot was associated with reduced hospital stay. Further randomized controlled studies with larger patient samples are needed to compare the two.

Thoracoscopic pericardial patch repair of iatrogenic major bronchial injury during oesophagectomy.

Tracheobronchial injuries are rare but dreaded and potentially lethal complications of oesophagectomy. The reported literature on tracheobronchial injuries in thoraco-laparoscopic oesophagectomy is sparse. They may be detected either intraoperatively or in the post-operative period. Those tracheobronchial injuries detected intraoperatively usually need conversion to an open procedure for appropriate management. The surgical approaches and the methods employed for closure depend on the size and location of the rent. The methods of surgical repair include primary closure, gastric patch closure, pericardial patch, pleural patch, pedicled intercostal muscle flap, dural graft and synthetic polytetrafluoroethylene grafts. Herein, we report a thoracoscopic repair of a major bronchial injury encountered in a patient during thoracoscopic oesophagectomy using a pericardial patch. To the best of our knowledge, this is the first report of a thoracoscopic repair of a bronchial injury using a pericardial patch.

Robot-assisted minimally invasive thoraco-laparoscopic esophagectomy versus minimally invasive esophagectomy for resectable esophageal adenocarcinoma, a randomized controlled trial (ROBOT-2 trial)

BackgroundFor patients with esophageal adenocarcinoma or cancer of the gastroesophageal junction, radical esophagectomy with 2-field lymphadenectomy is the cornerstone of the multimodality treatment with curative intent. Both conventional minimally invasive esophagectomy (MIE) and robot assisted minimally invasive esophagectomy (RAMIE) were shown to be superior compared to open transthoracic esophagectomy considering postoperative complications. However, no randomized comparison exists between MIE and RAMIE in the Western World for patients with esophageal adenocarcinoma.MethodsThis is an investigator-initiated and investigator-driven multicenter randomized controlled parallel-group superiority trial. All adult patients (age ≥ 18 and ≤ 90 years) with histologically proven, surgically resectable (cT1-4a, N0–3, M0) esophageal adenocarcinoma of the intrathoracic esophagus or adenocarcinoma of the gastroesophageal junction and with European Clinical Oncology Group performance status 0, 1 or 2 will be assessed for eligibility and included after obtaining informed consent. Patients (n = 218) with resectable esophageal adenocarcinoma of the intrathoracic esophagus or adenocarcinoma of the gastroesophageal junction are randomized to either RAMIE (n = 109) or MIE (n = 109). The primary outcome of this study is the total number of resected abdominal and mediastinal lymph nodes specified per lymph node station.ConclusionThis is the first randomized controlled trial designed to compare RAMIE to MIE as surgical treatment for resectable esophageal adenocarcinoma or adenocarcinoma of the gastroesophageal junction in the Western World. The hypothesis of the proposed study is that RAMIE will result in a higher abdominal and mediastinal lymph node yield specified per station compared to conventional MIE.Short-term results and the primary endpoint (total number of resected abdominal and mediastinal lymph nodes per lymph node station) will be analyzed and published after discharge of the last randomized patient within this trial.Trial registrationClinicalTrials.gov Identifier: NCT04306458. Registered 13th March 2020, https://clinicaltrials.gov/ct2/show/NCT04306458; Date of first enrolment 18.01.2021; Target sample size 218; Recruitment status: Recruiting; Protocol version 2; Issue date 10.03.2020; Rev. 02.02.2021; Authors ET, PCvdS, PPG.

469 ASSESSMENT OF PERFUSION OF GASTRIC CONDUIT AND PROXIMAL ESOPHAGEAL STUMP BY INDOCYANINE GREEN FLUORESCENCE IMAGING IN PATIENTS UNDERGOING ESOPHAGECTOMY

Abstract Post esophagectomy anastomotic leakage and stricture are crucial factors in determining morbidity and mortality. Good vascularity of the gastric conduit is essential to avoid this complications. This prospective study assesses the utility of intraoperative indocyanine green (ICG) fluorescence imaging to determine gastric conduit vascularity in patients undergoing esophagectomy. Methods Thirteen consecutive patients who were undergoing esophagectomy for carcinoma middle, lower third esophagus or gastro-esophageal junction from August 2019 to September 2019, were included. Three patients underwent laparoscopic-assisted transhiatal esophagectomy, ten thoraco-laparoscopic assisted esophagectomy. Reconstruction was done by gastric pull up via posterior mediastinal route. Vascularity of gastric conduit was assessed by the near-infrared camera using ICG. Results On visual assessment of perfusion at the tip of gastric conduit, it was dusky in 11 patients, pink in two. Fuorescence imaging showed inadequate perfusion at the tip of conduit in 12 patients, needing revision. In one patient visual inspection showed adequate perfusion, but ICG disclosed poor vascularity requiring revision of the conduit’s tip. Resection of the devitalized portion of the proximal esophageal stump was needed in 5 patients both by visual and ICG assessment. The median time to appearance of blush from the time of injection of dye was 15 seconds (10 to 23 seconds). Conclusion Visual inspection of the gastric conduit vascularity can underestimate perfusion and hence can compromise resection of the devitalized part. ICG fluorescence imaging is more objective and promising means to ascertain the vascularity of gastric conduit during an esophagectomy. It could complement the visual inspection to decide the site of anastomosis.

647 THE LEFT AND RIGHT RECURRENT LARYNGEAL NERVE LYMPH NODES POSSESS DIFFERENT ANATOMICAL CHARACTERISTICS AND RISK STRATIFICATIONS OF METASTASIS

Abstract The left and right recurrent laryngeal nerve(RLN) are asymmetrical, and the precise differences and metastasis risk stratifications based on preoperative CT scan between the left and right RLN lymph nodes have not yet been analyzed. In this study, we compared the anatomical characteristics and generated prediction models to predict the probability of left and right RLN lymph node metastasis using preoperative clinical data in patients undergoing thoracolaparoscopic esophagectomy with cervical anastomosis to guide clinical treatment. Methods We retrospectively reviewed the clinical data of 1660 consecutive patients with thoracic esophageal cancer who underwent esophagectomy with cervical anastomosis at the Department of Thoracic Surgery at our center between January 2015 and December 2020 and investigated the anatomical characteristics and risks of bilateral RLN lymph nodes according to preoperative CT scan and pathological examination findings. Results A total of 299 and 343 patients who underwent left(right) RLN lymph node dissection were included in the final analysis. By plotting ROC curves, we concluded that the cutoff values of the long and short axis to predict metastasis of the left (right) RLN lymph nodes were 10 (8 mm) and 7.5 (6.5 mm), respectively. The short axis rather than the long axis was significantly associated with left RLN lymph node metastasis. Correspondingly, the long axis was much more important than the short axis in regard to the right RLN lymph nodes. Conclusion There were different anatomical characteristics and precise metastasis risk stratifications between the left and right RLN lymph node metastases.

Development of a prediction model for the risk of recurrent laryngeal nerve lymph node metastasis in thoracolaparoscopic esophagectomy with cervical anastomosis.

BackgroundThere are no effective preoperative diagnostic measures to predict the probability of left and right recurrent laryngeal nerve (RLN) lymph node (LN) metastasis using preoperative clinical data in patients undergoing thoracolaparoscopic esophagectomy with cervical anastomosis.MethodsWe retrospectively reviewed the clinical data of 1,660 consecutive patients with thoracic esophageal cancer who underwent esophagectomy with cervical anastomosis at the Department of Thoracic Surgery at the First Affiliated Hospital of Zhengzhou University between January 2015 and December 2020.ResultsA total of 299 and 343 patients who underwent left (Cohort 1) and right (Cohort 2) RLN LN dissection were included in the final analyses. The analyses were conducted within each cohort. Among the 299 patients in Cohort 1, left RLN LN involvement was found in 41 patients (13.7%). A multivariable analysis showed that age, tumor location, and short axis were significantly associated with RLN LN metastasis (all P<0.05). Among the 343 patients in Cohort 2, right RLN LN involvement was found in 65 patients (19.0%). A multivariable analysis showed that computed tomography (CT) appearance, tumor location, long axis, and short axis were significantly associated with RLN LN metastasis (all P<0.05). Based on the results of the multivariable analyses, we constructed nomograms that could estimate the probability of RLN LN metastasis. Finally, we stratified the 2 cohorts into risk subgroups using a recursive partitioning analysis (RPA). The risk of left and right RLN LN metastasis was found to be 9.3% and 7.5%, 27.3% and 21.4%, and 52.4% and 47.3% for the low-risk, intermediate-risk, and high-risk groups, respectively.ConclusionsOur nomograms and RPAs appear to be suitable for the risk stratification of left and right RLN LN metastasis in patients undergoing thoracolaparoscopic esophagectomy with cervical anastomosis. This tool could be used to help clinicians to select more effective locoregional treatments, such as surgical protocols and radiation area selection.

Propensity matched analysis of short term oncological and perioperative outcomes following robotic and thoracolaparoscopic esophagectomy for carcinoma esophagus- the first Indian experience.

Thoracolaparoscopic esophagectomy (TLE) for carcinoma esophagus has better short-term outcomes compared to open esophagectomy. The precise role of robot-assisted laparoscopic esophagectomy (RALE) is still evolving. Single center retrospective analysis of TLE and RALE performed for carcinoma esophagus between January 2015 and September 2018. Propensity score matching was done between the groups for age, gender, BMI, ASA grade, tumor location, neoadjuvant therapy, the extent of surgical resection (Ivor Lewis or McKeown’s), histopathological type (squamous cell carcinoma or adenocarcinoma), clinical T and N stages. The primary outcome parameter was lymph node yield. Secondary outcome parameters were resection margin status, duration of surgery, blood loss, conversion to open procedure, length of hospital stay, length of ICU stay, complications, 90-day mortality and cost. There were 90 patients in TLE and 25 patients in RALE group. After propensity matching, there were 22 patients in each group. The lymph node yield was similar in both the groups (23.95 ± 8.23 vs 22.73 ± 11.63; p = 0.688). There were no conversions or positive resection margins in either group. RALE was associated with longer operating duration (513.18 ± 91.23 min vs 444.77 ± 64.91 min; p = 0.006) and higher cost ($5271.75 ± 456.46 vs $4243.01 ± 474.64; p < 0.001) than TLE. Both were comparable in terms of blood loss (138.86 ± 31.20 ml vs 133.18 ± 34.80 ml; p = 0.572), Clavien-Dindo grade IIIa and above complications (13.64% vs 9.09%; p = 0.634), hospital stay (12.18 ± 6.35 days vs 12.73 ± 7.83 days; p = 0.801), ICU stay (4.91 ± 5.22 days vs 4.77 ± 4.81 days; p = 0.929) and mortality (0 vs 4.55%; p = 0.235). RALE is comparable to TLE in terms of short-term oncological and perioperative outcomes except for longer operating duration when performed for carcinoma esophagus. RALE is costlier than TLE.

Effect of thoraco-laparoscopic esophagectomy on postoperative immune function of patients with esophageal carcinoma

To investigate the effect of thoraco-laparoscopic esophagectomy on postoperative immune function of patients with esophageal carcinoma. Eighty-one patients undergoing radical esophagectomy in our hospital between January, 2017 and December, 2019 were enrolled in this study.According to the surgical approach, the patients were divided into endoscopic group (41 cases) and open surgery (3 incisions) group (40 cases).The immunological indicators (CD3+, CD4+, CD8+, and CD4+/CD8+ratio) of the patients were analyzed using double antibody sandwich enzyme-linked immunosorbent assay at 1 day before the surgery and on days 1, 4 and 7 after the surgery.The plasma levels of interleukin 6(IL-6) and cortisol, β-endorphin (β-EP) level, white blood cell count (WBC) and C-reactive protein (CRP) levels of the patients were measured before and on days 1 and 7 after the operation. No death occurred in either of the group after the operation.On days 4 and 7 after the operation, CD3+, CD4+, CD8+, and CD4+/CD8+ratio were significantly higher in patients undergoing thoracolaparoscopic surgery than in those receiving open surgery (P < 0.05).In both groups, the levels of cortisol, β-EP, WBC, CRP and IL-6 measured on days 1 and 7 postoperatively were significantly different from those before the operation (P < 0.05).At all the indicated postoperative time points, all the measured indicators, with the exception of IL-6 levels on postoperative day 7, which were comparable between the two groups, were significantly higher in the open surgery group than in the endoscopic group (P < 0.05). Thoraco-laparoscopic resection of esophageal cancer can reduce postoperative secretion of proinflammatory factors, alleviate inflammatory responses, and promote the recovery of immune functions to accelerate postoperative recovery of the patients.

Outcome for esophageal cancer following thoraco-laparoscopic esophagectomy: A single institution experience

Background: The feasibility and the safety of the thoraco-laparoscopic esophagectomy (TLE) was proved by several prominent academic institutions. This technique is technically challenging and requires advanced laparoscopic and thora-coscopic skills. With experience gained from open esophagectomy as well as laparoscopic surgery, thoraco-laparoscopic esophagectomy was introduced in our hospital in 2016. We report our experience in performing TLE. Materials and Methods: We conducted a prospective, nonrandomized, observational study in Hue central hospital, which is one of the biggest hospitals in Vietnam, from January 2016 to January 2021. This study included the esophageal cancers that were diagnosed by endoscopy and confirmed by pathology. Esophageal cancer with cT1b-3N0M0 using chest CT, ultrasound-endoscopy, abdominal CT was indicated for resection initially, while esophageal cancer with cT4N0M0 or T3N(+)M0 was indicated for resection after neoadjuvant therapy. The patients had the ASA I-III. All the data were analyzed statistically using SPSS software (SPSS, Inc, Chicago, IL). Results: We used the TLE technique to operate for 52 consecutive patients. All patients were in a semi-prone position. The male/female ratio was 47/5. The mean age was 57.3±6.3 years, and the mean BMI was 20.5±3.3 kg/m2. The preoperative location of the esophageal cancer was the upper one-third in two (3.8%), the middle one-third in 24 (46.1%), and the lower one-third in 26 (50.0%). The majority of our patients had cTNM stage II (30, 57.7%). Only seven patients (13.7%) had cTNM stage I, whereas 15 patients (31.4%) had cTNM stage III. Of the 45 patients (stage II and III) who needed the neoadjuvant therapy, 30 (57.7%) received short-courses, 15 (28.8%) received long-course of chemotherapy. For 24 patients (46.1%), the histopathology was squamous cell carcinoma. The remaining 28 patients (53.8%) had adenocarcinomas. The operative time was 311.2±45.9 minutes. We did not record either conversion or intraoperative events. The mortality and morbidity rates were 1.9% and 23%, respectively. The hospital stay was 15.6±7.2 days. The median follow-up time was 22±1.5 months, and the overall survival rate at one year was 84.7%. Conclusion: Thoraco-laparoscopic esophagectomy for esophageal cancer with the patient in a semi-prone position is safe and effective, including the lower morbidity rate and the shorter operative time while preserving the long-term outcomes. © 2021, PJD Publications Ltd. All rights reserved.

Phẫu thuật nội soi ngực bụng trong điều trị ung thư thực quản

Objectives: Evaluating the results of thoraco-laparoscopic esophagectomy to treat esophageal cancer, prospective studies of 35 patients esophageal cancer were conducted from January 2016 to December 2019 at Hue Central Hospital. Results: Average age 57.6±6.3years (44-69), male/female 16.5/1. Clinical symptoms: 82.9% swallowing difficulty, weight loss 34.3%, increased preoperative CEA 31.4%, mean tumor size 2.6±1.2cm(3-6). Stage: I 31.4%; II 45.7%; III of 22.9%. Time of surgery 315.2±49.9minutes(240-420), mean hospital stay 15.6±7.2days(7-25). Postoperative complications: pneumonia 11.4% , leakage of neck anastomosis 8.6%, hoarseness 11.4% and mortality 2.9%. Follow-up time 2-35months, anastomotic recurrence 2.9%, local recurrence 5.9% and metastasis 8.8%. The overal survival time 28.4±1.9months, the survival time after 12 months 84.7% and after 2 years 73.9%. Conclusion: Thoraco-laparoscopic esophagectomy to treat esophageal cancer has many advantages, avoiding to the long thoracotomy-laparotomy, reducing postoperative pain, reducing respiratory complications during the postoperative period. However, a larger number of patients should be studied to accurately evaluate long-term results, especially in oncology results.

Robot-assisted minimally invasive thoracolaparoscopic esophagectomy versus open esophagectomy: long-term follow-up of a randomized clinical trial.

Initial results of the ROBOT, which randomized between robot-assisted minimally invasive esophagectomy (RAMIE) and open transthoracic esophagectomy (OTE), showed significantly better short-term postoperative outcomes in favor of RAMIE. However, it is not yet clarified if RAMIE is equivalent to OTE regarding long-term outcomes. The aim of this study was to report the long-term oncological results of the ROBOT trial in terms of survival and disease-free survival. This study is a follow-up study of the ROBOT trial, which was a randomized controlled trial comparing RAMIE to OTE in 112 patients with intrathoracic esophageal cancer. Both the trial protocol and short-term results were previously published. The primary outcome of the current study was 5-year overall survival. Secondary outcomes were disease-free survival and recurrence patterns. Analysis was by intention to treat. During the recruitment period, 109 patients were included in the survival analysis (RAMIE n = 54, OTE n = 55). Majority of patients had clinical stage III or IV (RAMIE 63%, OTE 55%) and received neoadjuvant chemoradiotherapy (80%). Median follow-up was 60months (range 31-60). The combined 5-year overall survival rates for RAMIE and OTE were 41% (95% CI 27-55) and 40% (95% CI 26-53), respectively (log rank test P = 0.827). The 5-year disease-free survival rate was 42% (95% CI 28-55) in the RAMIE group and 43% (95% CI 29-57) in the OTE group (log rank test P = 0.749). Out of 104 patients, 57 (55%) developed recurrent disease detected at a median of 10months (range 0-56) after surgery. No statistically difference in recurrence rate nor recurrence pattern was observed between both groups. Overall survival and disease-free survival of RAMIE are comparable to OTE. These results continue to support the use of robotic surgery for esophageal cancer.

Evaluating early results of minimally invasive esophagectomy in abdominal surgery department II at National K Hospital

Abstract Introduction: To evaluate early results of minimally invasive esophagectomy for esophageal cancer in Abdominal Surgery Department II at National K Hospital. Materials and methods: 130 patients with esophageal cancer underwent thoraco-laparoscopic esophagectomy - also was known as minimally invasive esophagectomy (MIE) - and gastric - tube reconstruction in Abdominal Surgery Department II at National K Hospital from 10/2017 to 7/2020. Descriptive study, patients were observed during hospitalization. Results: Mean age 56,8 ± 6,77 (min 35 - max 72), lymph node metastasis was 17,8%, T1 was 35,6%, T2 was 48,9% and T3 was 15,5%, squamous cell carcinoma accounted for 97,7%. Mean operative time was 226 ± 6 minutes, mean hospital stay was 15,2 ± 4,6 days, anastomosis leakage accounted for 6,1%, anastomosis stenosis was 15,3%, vocal cord palsy was 4,6% and pneumonia happened in 13,8%. Conclusions: Esophagectomy is a major surgery procedure that could be perform by thoraco-laparoscopy with good result.

52 SHORT-TERM OUTCOMES OF RAMIE VERSUS TLE FOR LOCALLY ADVANCED ESOPHAGEAL CANCER AFTER NEOADJUVANT CHEMORADIOTHERAPY: A PROPENSITY SCORE-MATCHED ANALYSIS

Abstract This study aimed to compare the short-term outcomes of esophagectomy (RAMIE) versus thoracolaparoscopic esophagectomy (TLE) for patients undergoing neoadjuvant chemoradiotherapy (nCRT) for locally advanced esophageal cancer in a propensity matched cohort. Methods Data for consecutive patients receiving nCRT plus RAMIE or TLE were collected prospectively from February 2016 to December 2019. Baseline characteristics and perioperative outcomes of the RAMIE and TLE groups were retrospectively compared. Results After propensity matching, 48 pairs were identified. The conversion rate to open thoracotomy was comparable in RAMIE and TLE (4.2% vs 6.3%, P = 1). Median operative time in RAMIE was significantly shorter than TLE (237 vs 271 min, P &amp;lt; 0.001). Compared with TLE group, the median number of dissected lymph nodes was higher in RAMIE group at the left recurrent laryngeal nerve (RLN) area [2 (1–3) vs 1 (0–2), P = 0.014], total RLN area [4.5 (2.0–7.0) vs 2.5 (1.0–5.0), P = 0.008], and thoracic area [10.5(7.0–16.0) vs 8.5(5.0–14.5), P = 0.049]. There was no significant difference in pneumonia, leakage, and vocal cord paralysis. Conclusion Compared to traditional TLE, RAMIE can achieve more lymph nodes yield at the RLN region and shorter operative time for the patients undergoing nCRT with comparable postoperative outcomes.

Mediastinoscopy-assisted transhiatal esophagectomy versus thoraco-laparoscopic esophagectomy for esophageal cancer: a single-center initial experience

BackgroundWe aimed to compare mediastinoscopy-assisted transhiatal esophagectomy (MATHE) with thoraco-laparoscopic esophagectomy (TLE) for patients with esophageal cancer in terms of the clinical effectiveness and perioperative complications.MethodsIn total, 98 patients who underwent esophagectomy consecutively for esophageal squamous cell carcinoma in our center from Jan. 2018 to Dec. 2019 were included in this study. Thirty patients underwent mediastinoscopy-assisted and laparoscopic transhiatal esophagectomy with cervical anastomosis (the MATHE group). The other sixty-eight patients received TLE (the TLE group). Each patient’s general conditions and perioperative complications were recorded.ResultsPatients in the MATHE group were observed to have a higher incidence of postoperative hoarseness than those in the TLE group. There were no significant differences between the MATHE group and the TLE group in regards to the operation time, intraoperative blood loss, number of lymph nodes dissected or postoperative hospital stay. Similarly, no statistically significant differences were observed in the incidence of anastomotic fistula, respiratory complications, or chylothorax or in the conversion rate or in-hospital mortality rate between the two groups.ConclusionsThe short-term efficacy in the MATHE group was similar to that in the TLE group, although patients in the MATHE group may have had a higher incidence of postoperative hoarseness. Therefore, MATHE may be a feasible and safe surgical procedure for appropriate patients with esophageal cancer.