Thoracoscopic Esophageal Resection Research Articles

EXAMINING THE IMPACT OF PERMISSIBILITY HYPERCAPNIA ON POSTOPERATIVE DELIRIUM AMONG ELDERLY PATIENTS UNDERGOING THORACOSCOPIC-LAPAROSCOPIC ESOPHAGECTOMY: A SINGLE-CENTER INVESTIGATIVE STUDY.

Objective: This study explores how permissive hypercapnia, a key aspect of lung-protective ventilation, impacts postoperative delirium in elderly patients following thoracic surgery. Methods: A single-center trial at The Second Hospital of Anhui Medical University involved 136 elderly patients undergoing thoracoscopic esophageal cancer resection. Randomly assigned to maintain PaCO 2 35-45 mm Hg (group N) or 46-55 mm Hg (group H). Primary outcome: postoperative delirium (POD) incidence 1-3 days post-surgery. Secondary endpoints included monitoring rSO 2 , cardiovascular parameters (MAP, HR), pH, OI, and respiratory parameters (VT, RR, Cdyn, PIP) at specific time points. Perioperative tests assessed CRP/ALB ratio (CAR) and systemic inflammatory index (SII). VAS scores were documented for 3 postoperative days. Results: Postoperatively, group H showed significantly lower POD incidence than group N (7.4% vs. 19.1%, P = 0.043). Group H exhibited higher PaCO 2 and rSO 2 during surgery ( P < 0.05). Patients in group H maintained better cardiovascular stability with higher blood pressure and lower heart rate on T2-4 ( P < 0.05). Respiratory parameters were more stable in group H with lower TV, RR, and PIP, and higher Cdyn during OLV ( P < 0.05). Group H had lower pH and higher OI at T2-4 ( P < 0.05). CRP and CAR levels rose less in group H on the first day and 1 week later ( P < 0.05). Conclusions: Maintaining PaCO 2 at 46-55 mm Hg reduces POD incidence, possibly by enhancing rSO 2 levels and stabilizing intraoperative respiration/circulation.

A novel anatomical description of the esophagus: the supracarinal mesoesophagus.

During thoracoscopic esophageal resection, while performing the supracarinal lymphadenectomy along the left recurrent laryngeal nerve (LRLN) from the aortic arch to the thoracic apex, we observed a not previously described bilayered fascia-like structure, serving as prolongation of the already known mesoesophagus. We retrospectively evaluated 70 consecutively unedited videos of thoracoscopic interventions on esophageal resections for cancer, in order to determine the validity of this finding and to describe its utility for performing a systematic and more accurate dissection of the LRLN and its adequate lymphadenectomy. After mobilization of the upper esophagus from the trachea and tilting the esophagus by means of two ribbons, a bilayered fascia was observed between the esophagus and the left subclavian artery in 63 of the 70 patients included in this study. By opening the right layer, the left recurrent nerve became visualized and could be dissected free in its whole trajectory. Vessels and branches of the LRLN were divided between miniclips. Mobilizing the esophagus to the right, the base of this fascia could be found at the left subclavian artery. After dissecting and clipping the thoracic duct, complete lymphadenectomy of 2 and 4L stations could be performed. Mobilizing the esophagus in distal direction, the fascia continued at the level of the aortic arch, where it had to be divided in order to mobilize the esophagus from the left bronchus. Here, a lymphadenectomy of the aorta-pulmonary window lymph nodes (station 8) can be performed. It seems that from there the fascia continued without interruption with the previously described mesoesophagus between the thoracic aorta and the esophagus. Here we described the concept of the supracarinal mesoesophagus on the left side. Applying the description of the mesoesophagus will create a better understanding of the supracarinal anatomy, leading to a more adequate and reproducible surgery.

Evaluation of Immediate Inflammatory Response in Thoracoscopic Esophageal Resection versus Open Approach - A Prospective Study.

Introduction: There is an immune response after major surgery and inflammatory complications following complex surgery have a direct impact on morbidity and mortality. Currently, we do not have clinical tools to predict in which subset of patients a major complication will occur. The aim of this study was to evaluate the immediate dynamics of C-reactive protein (CRP), presepsin and procalcitonin in patients in which esophagectomy was performed either through video assisted thoracic surgery (VATS) or open approach. Methods: We conducted a prospective study on 27 patients with a mean age of 61.48 +-6.80 years, 13 patients with VATS and 14 with open approach, most of the patients were on stage III esophageal cancer (81%) and in all cases neoadjuvant treatment was performed. Results: There were increased levels of CRP, presepsin and procalcitonin after both arms of the study with significantly higher values for the open approach and with the same dynamic curves. In 3 cases there were extremely elevated levels of procalcitonin in the absence of a septic complication, in all cases a major complication occurred. Conclusion: Video assisted thoracoscopic esophageal mobilization induces a less immune response, even with the association of laparotomy. An elevated postoperative procalcitonin level can be an early indicator of a major postoperative complication.

Prevention of postoperative pneumonia by perioperative oral care in patients with esophageal cancer undergoing surgery: a multicenter retrospective study of 775 patients.

Postoperative pneumonia is one of the major complications after esophageal cancer surgery. The risk factors associated with postoperative pneumonia are poor general health, smoking, decreased pulmonary function, diabetes mellitus, surgical stress, old age, postoperative aspiration, and oral hygiene. In this study, we examined the effect of perioperative oral care on reducing postoperative pneumonia since the evidence to-date is not clear. A multicenter, retrospective investigation of the relationship between perioperative oral care and incidence of postoperative pneumonia in patients undergoing esophageal cancer surgery was conducted. A total of 775 patients who underwent thoracoscopic esophageal resection at 25 hospitals between 2016 and 2017 were enrolled in the study. Various factors were examined for correlation with development of postoperative pneumonia. Multivariate analysis showed that old age, smoking habit, lower hemoglobin, higher creatinine, postoperative dysphagia, and lack of oral care intervention were independent risk factors for pneumonia. Oral care was more effective in preventing pneumonia in hospitals in which the incidence of postoperative pneumonia was lower than 20%, while it was not effective in hospitals in which the incidence was higher than 20%. Results of the study suggest that it is recommended to carry out perioperative oral care in esophageal cancer surgery.

PS02.011: ESOPHAGECTOMY IN A LOW VOLUME SINGLE CENTER FAVORING A TOTAL MINIMALLY INVASIVE APPROACH: 55 PATIENTS IN 7 YEAR

Abstract Background In Austria esophageal cancer is not very common. The incidence is 8.8/100.000 per year, thus esophageal cancer is on rank 18 of the most common carcinomas. Multimodal treatment inclouding surgery is standard for locally advanced esophageal cancer with a 5-year survival rate of around 40% in patients treated with a curative intent. Methods Retrospective single institution study in a tertiary care center using prospectively collected data we discuss our surgical procedure with patient survival as primary endpoint and morbidity as secondary endpoint. Results From 2010–1017, 55 Patients received an esophageal resection. The mean age was 61.5 years, five patients (9%) were female. Squamous cell carcinoma appeared in 37%, adenocarcinoma in 59% and a verrucous carcinoma in 4% of our patients. 98% of patients received an esophagectomy with gastric tube pull up, in 2% the colon was used for reconstruction. For patients with carcinoma located in the lower and middle thoracic esophagus a thoracic anastomosis was targeted (78%), in carcinomas of the upper thoracic esophagus a left cervical anastomosis (22%) was performed. Depending on location and comorbidities patients received either a conventional operation (11%), a hybrid operation with laparotomy and thoracoscopic esophageal resection (59%) or a totally minimal invasive approach (30%). The 60 days mortality was &lt; 2%, the need for reoperation &lt; 10%. Major complications (Clavien-Dindo III-V) were observed in 30%. Conclusion Esophagectomy is a high-risk operation with serious mortality and morbidity. However, patients may profit from a tailored approach with intent for the minimally invasive approach even in a low volume center when expertise in high-end endoscopic surgery is available. Disclosure All authors have declared no conflicts of interest.

Minimal invasive esophageal resection with anastomosis on the neck [McKeown]. Our experiences after 20 cases

Esophageal resection is a traumatic intervention usually performed on patients with poor condition, resulting high mortality and morbidity. To improve the high incidence of complications, minimal invasive interventions were introduced. The results of the thoracoscopically and laparoscopically performed esophageal resection (McKeown) was investigated after 20 cases and the technical details of the surgical intervention are presented. 20 thoracoscopic esophageal resection with laparoscopic gastric tube formation (sec. Akiyama) preparing the esophago-gastric anastomosis on the neck were performed in our department in the last four years. 1 patient with stricture and the other 19 patients with esophageal cancer were operated on, among them11 had T4 stage. 17 patient received neoadjuvant chemo-radiotherapy because of advanced disease. Regular follow up examinations were performed in the oncological outpatient department. 8 patients are alive after a mean follow up period of 25 months, 2 of them are treated oncologically because of recurrent disease. 19 patients were extubated within 12 hours after the intervention and the time spent in the intensive care unit were reduced to 1 or 2 days. The mean duration of the intervention was 320 minutes. Thoracoscopic dissection was performed in 8 patients without ventilation of the right lung using double lumen tracheal tube, among them 3 patients developed pneumonia in the postoperative period. The remaining 12 patients were operated with ventilated right lung, among them one patient developed pneumonia. One patient was converted because of injury of the thoracic aorta, after urgent thoracotomy we managed to suture the aortic wall. 1 patient died in 30 days after the operation, caused by leakage of the anastomosis, resulting mediastinitis and esophago-tracheal fistula. In two patients re-thoracoscopy and ligation of the thoracic duct was performed because of chylothorax refractory for conservative treatment. According to our observation the minimal invasive esophageal resection resulted in comparable oncological results with relevant reduction of mortality and morbidity compared to the open procedure. After procedures performed with ventilated lung further reduction of pulmonary complication was found. In case of tumors infiltrating the tracheal or the aortic wall, thoracotomy should be considered to explore the thoracic cavity and to carry out the dissection, if it is possible. Our results should be reinforced because of low number of patients.

Clinical application of artificial pneumothorax in thoracoscopic esophageal carcinoma resection

目的 探讨人工气胸应用于胸腔镜下食管癌根治术的可行性。 方法 收集2015年1月至2016年2月收治的食管癌病例，采用动态随机化的方式分成试验组与对照组。试验组纳入30例，采用人工气胸单腔气管插管下行胸腔镜食管癌根治术；对照组30例，采用非人工气胸双腔气管插管下行胸腔镜食管癌根治术，两组均采用电视辅助胸腔镜手术（VATS）三切口食管癌切除术+淋巴结清扫术，对比分析两组患者的近期临床治疗效果。 结果 60例患者手术均获成功，未发生中转开胸。试验组胸部手术出血量为（117±49）ml，少于对照组的（154±60）ml，两组差异有统计学意义（χ2=2.561 ，P=0.013）。试验组清扫左右喉返神经旁淋巴结数目平均为（3.93±1.08）个，对照组平均为（1.47±1.04）个，两组差异有统计学意义（χ2=9.001, P=0.000）。试验组插管时间为（6.3±0.9）min，短于对照组的（9.5±2.8）min，两组差异有统计学意义（χ2=9.236，P=0.000）。试验组术后肺部感染发生率为20.34 %，低于对照组的33.31 %，两组差异有统计学意义（χ2=11.267, P=0.001）。两组在手术时间、术后第1天胸腔引流量、拔除胸管时间方面差异均无统计学意义（均P>0.05）。 结论 人工气胸单腔气管插管下行胸腔镜食管癌根治术，可以明显减少胸腔出血及肺部感染，有助于更为有效及彻底地清扫左右喉返神经旁淋巴结。

RM-058 Thoracolaproscopic esophagectomy for carcinoma esophagus: our early experience and outcome

Introduction: Background: Advances in technology have allowed us to explore the possibility of performing Esophagectomy using minimal invasive surgical technique. Minimal invasive esophageal surgery has the potential to improve morbidity, mortality, hospital stay and functional outcomes when compared with open method. Although technically complex, combined laparoscopic and thoracoscopic esophageal resection is feasible. Most studies shows thoracoscopic mobilization of the esophagus in left lateral position with single lung ventilation with respiratory complication up to 8–9% where our series show potential of the thoracoscopic part of the procedure in prone position to overcome the difficulty. Methods: From March 2009 through December 2015, TLE was performed in 50 patients. All patients had histologically proved squamous cell carcinoma of the middle and lower third of the esophagus. Only one (0.77%) patient received neoadjuvant chemotherapy. The Thoracoscopic part of the procedure was performed in prone position with double lung ventilation and comfortable port placement for better view and ergonomics which significantly decreased the operative time and better post operative respiratory result. Laparoscopy done for gastric mobilization and conduit formation, minilaparotomy done to retrieved the specimen. Feeding jejunostomy was done in selective patients. Results: There were 38 men and 18 women. Median age was 64.5 years (range 34 to 72 years). There was no conversion to open method. Median ICU stay was 1 day (range 1 to 15 days) and median hospital stay was 7 days (range 4 to 22days). Perioperative mortality was 0.5% (n = 1). Anastomotic leak rate was 0.5% (n = 1). There was no incidence of tracheal or lung injury and a very low incidence of postoperative pneumonia. At mean follow up of 24month (range 2 to 7- month), stage–specific survival was similar to open and other minimally invasive series. Conclusion: Thoracolaparoscopic Esophagectomy is complex and technically difficult, but its safe in experience hand. Due to its comfortable view and excellent ergonomics in the prone position for thoracoscopy, patient do well and benefit from a shorted stay and more rapid recovery compared with open esophagectomy. It provides comparable outcomes with other techniques of minimally invasive esophagectomy and most open series. In our experience, we observed a low mortality rate (0.5%), hospital stay of 7 days, and low incidence of postoperative pneumonia. It has the potential to replace conventional and other techniques of minimally invasive esophagectomy.

High Intrathoracic Anastomosis with Thoracoscopy Is Safe and Feasible for Treatment of Esophageal Squamous Cell Carcinoma.

BackgroundMinimally invasive esophagectomy (MIE) has the potential to reduce the morbidity and mortality of esophageal cancer surgery. Esophageal squamous cell carcinoma (ESCC) has a high incidence of earlier lymphatic spread and is usually located more proximal to the incisor than esophageal adenocarcinoma; consequently, the anastomosis should be made more proximal in the thorax or in the neck. We adopted the proximal intrathoracic anastomotic technique using thoracoscopy for mid-to-lower ESCC.MethodsFrom October 2010 to August 2014, fifty-eight consecutive patients underwent MIE for ESCC. After laparoscopic gastric tubing, thoracoscopic esophageal resection and reconstruction were performed using a 28-mm circular stapler following radical mediastinal lymph node dissection. We tried to make an anastomosis at the apex of the chest. Postoperative outcomes, including overall survival and recurrence, were assessed.ResultsThe mean patient age was 64.3±9 years. The mean operative time was 371.8±51.6 minutes, and the duration of the thorax procedure was 254.8±38.3 minutes. The mean number of lymph nodes dissected was 31±11.7. The mean intensive care unit (ICU) stay and hospital stay were 3.5±8.2 hours and 13.6±7.4 days, respectively. The level of anastomosis was 22.3±1.8cm from the incisor. One patient died of uncontrolled sepsis due to necrosis of the gastric graft. Two patients developed small contained leakage. Nine patients exhibited distant metastasis during the follow-up period.ConclusionThoracoscopic intrathoracic anastomosis at the proximal esophagus is feasible and safe.

Thoracoscopic Enucleation of Esophageal Submucosal Tumor by Prone Position Under Artificial Pneumothorax by CO2 Insufflation

Recently, the usefulness of the prone position for thoracoscopic esophagectomy has been demonstrated. Thoracoscopic resection of an esophageal submucosal tumor using a prone position also offers advantages over a lateral decubitus position. We describe 2 cases operated on using the prone position for the resection of esophageal submucosal tumor. Case 1 was a 35-year-old man, who was diagnosed with a 50×20 mm leiomyoma in the middle thoracic esophagus, and underwent right thoracoscopic tumor enucleation. Case 2 was a 61-year-old female, who had 45×30 mm esophageal schwannoma in the lower thoracic esophagus with symptoms of dysphagia, and underwent left thoracoscopic tumor enucleation. No complication was observed in both cases. Thoracoscopic esophageal submucosal resection with prone position may add the merits to conventional decubitus position, such as superior visualization, and less bleeding. The side of incision should be determined according to the location of the tumor and anatomic rationality.

484. Clinicopathologic Features, Treatment Patterns and Outcome of Marjolin's Ulcer in a Tertiary Care Cancer Centre

Background: The introduction of neoadjuvant chemoradiation therapy, centralization and minimal invasive esophagectomy has reduced peri-operative mortality and morbidity to an acceptable level. However, functional results after esophageal resection remain poor, with reported rates of esophageal stenosis and dilatation of 40% and frequent recurrent laryngeal nerve damage. Aim: To describe the functional results after laparoscopic esophageal resection with intrathoracic anastomosis. Methods: From January 2011 until March 2012, 27 consecutive patients underwent laparoscopic and thoracoscopic esophageal resection with gastric tube reconstruction and a stapled, intrathoracic end-to-side anastomosis in a large teaching hospital. Demographic, clinical and functional parameters were collected prospectively. Results: Mean age was 65 and 85% of patients were male. Ninety-six percent received neoadjuvant chemoradiation therapy. None of the 27 patients developed an esophageal stenosis, there were no dilatations and no recurrent laryngeal nerve damage was observed. In all patients, a radical resection was achieved. In the first 3 months, 4 out of 9 patients developed an anastomotic leakage, all requiring re-operation. One patient died. After revising the technique of anastomosis from double stapling using the Orvil into single stapling using a 28mm EEA stapler with an omental wrap in March 2011, no further patients developed an anastomotic leakage, the re-operation rate was 11%, and there was no in hospital mortality. Conclusions: Laparo-thoracoscopic esophageal resection with gastric tube reconstruction and stapled intrathoracic end-to-side anastomosis with omental wrap is a safe technique that improves functional outcome.

Ausdehnung der Lymphknotendissektion nach minimalinvasiver Ösophagusresektion?

Esophageal resection is still today associated with a high morbidity and mortality. Minimally invasive procedures show a significantly lower rate of such complications and therefore might also be associated with a lower surgical risk. However, publications till date contain little or no data on the extent of lymph node dissection. The aim of our study was to evaluate the morbidity and mortality rate of minimally invasive esophageal resection. In the last two years, we carried out 25 minimally invasive esophageal resections on five women and 20 men with a median age of 63 years (range 41-74 years). All data were accrued prospectively. Nine patients were operated upon transhiatally and 12 combined laparocopic-thoracoscopic. On four patients, a thoracotomy was necessary. The average surgical time for the transhiatal approach was calculated at 164 minutes (range 150-180 min) and for the combined laparoscopic-thoracoscopic procedure 285 minutes (240-360 min). The thoracoscopic esophageal resection itself lasted 105 minutes on average; the last five resections each lasting 70 minutes. A median of 24,5 lymph nodes (19-26) was calculated in the laparoscopic-thoracoscopic technique. The transhiatal procedure revealed a median of 14 lymph nodes (12-17). Postoperatively, we had three cases of anastomotic and two cases of bronchial leakages, most probably associated with the use of monopolar current; complications no longer seen since usage of the HARMONIC ACE for surgical preparation. There was no 30 day letality. Our experience with 25 successful minimally invasive esophageal resections shows that with increasing experience and better surgical equipment, the extent of lymph node dissection does not differ from open procedure.

Minimally Invasive Esophagectomy: Early Experience and Outcomes

Minimally invasive esophageal surgery has the potential to improve mortality, hospital stay, and functional outcomes when compared with open methods. Although technically complex, combined laparoscopic and thoracoscopic esophageal resection is feasible. A case series of 20 patients who underwent minimally invasive total esophagectomy is presented. This study was a review of a prospective database. The purpose was to evaluate early results with laparoscopic total esophagectomy for benign and malignant disease. Between January 2003 and November 2005, 20 patients underwent minimally invasive esophageal surgery. All operations were performed by the same two surgeons. Age, gender, indications for surgery, pathologic stage, operative time, blood loss, transfusion requirements, intensive care unit length of stay, hospital length of stay, postoperative complications, and mortality were recorded. Diet progression, dysphagia, and need for stricture management were also recorded. Of the 20 minimally invasive total esophagectomies performed, 18 (90%) were completed successfully. The average age of the patients was 53 years. Indications for surgery were malignancy (n = 13), carcinoma in situ in the setting of Barrett's esophagus (n = 2), and benign stricture (n = 3). The average operating time was 467 minutes (range 346-580 min). Median blood loss was 350 mL (range 150-500 mL). The median intensive care unit stay was 2 days, and the median hospital length of stay was 12 days. Pathology revealed that 7 per cent of patients had stage I disease, 27 per cent of patients had stage II disease, and 53 per cent of patients had stage III disease. There was a single mortality (5%), a cervical leak in two patients (10%), a gastric tip necrosis in one patient (5%), and tracheoesophageal fistula in one patient (5%). Major complications occurred in eight patients (40%) and minor complications in nine (50%). Thirteen (72%) patients were discharged on enteral tube feeds to supplement caloric intake. The application of minimally invasive techniques in the arena of esophageal surgery continues to evolve. This approach has the potential to improve mortality, hospital stay, and other outcomes when compared with open methods. Although technically complex, laparoscopic total esophagectomy is feasible.

Die Technik der laparoskopisch-thorakoskopischen Ösophagusresektion beim Ösophaguskarzinom - Erste Erfahrungen

Esophageal resection for carcinoma is still associated with high mortality and morbidity. Minimally invasive techniques are regarded to reduce operative trauma. However, to date only few studies on minimally invasive esophageal resection have been published. We describe in detail the technique of combined laparoscopic and thoracoscopic esophageal resection with gastric-pull-up and conventional open cervical anastomosis for esophageal squamous carcinoma. Prone positioning of the patient with bilateral lung ventilation was used during the thoracoscopic part of the operation. Our first experiences in 5 patients confirm the feasibility of the technique. We did not observe any surgical related adverse incidences and found the typically advantages of minimally invasive surgery, such as early mobility, less pain and a comfortable cosmetic result in our patients. Although the number of procedures is to low to decide the value of minimally invasive surgery for esophageal cancer, we think it could be a promising technology to reduce mortality and morbidity for esophageal resection.

Laparoscopic and Endoscopic Surgery in Esophageal Malignancy

Surgery remains the mainstay of treatment of esophageal cancer, although the optimal type and extent of resection continue to be debated. Minimally invasive techniques, including laparoscopic and thoracoscopic esophageal resection and endoscopic ablative and resectional therapies, have emerged recently as possible alternatives.

Thoracoscopic esophagectomy for esophageal cancer

Background. Minimal access surgery is an alternative to open surgery in esophageal surgery. Its role in cancer resection is controversial. Methods. Thoracoscopic esophageal resection was attempted in 22 patients who had increased operative risk. Postoperative outcomes of these patients were compared with the outcomes of 63 patients who underwent open thoracotomy resection during the same period. Results. Thoracoscopy was completed in 18 patients. Conversion to thoracotomy was necessary because of locally advanced tumor in three patients, and a bypass procedure was performed in another patient because of poor ventilation during thoracoscopy and the finding of metastatic disease. The median thoracoscopy time was 110 minutes (range, 55 to 165 minutes). The total operating times were 240 minutes (range, 165 to 360 minutes) and 250 minutes (range, 190 to 420 minutes) for thoracoscopy and thoracotomy, respectively, p = 0.5. Blood loss was significantly less than that of open resection; medians were 450 ml (range, 200 to 800 ml) and 700 ml (range, 300 to 2500 ml) for thoracoscopy and thoracotomy, respectively, p < 0.01. The median number of lymph nodes removed at thoracoscopy was 7 (range, 2 to 13) compared with 13 (range, 5 to 34) in the thoracotomy group. Bronchopneumonia affected 17% of both groups of patients. Only one patient who was converted to open thoracotomy died. Port site recurrence developed in one patient. Overall survival rates were not significantly different. Conclusions. Thoracoscopic esophageal resection was a feasible option. Clear advantages over open thoracotomy were not demonstrated, although patients who were selected for thoracoscopy had worse performance status. This technique deserves further investigation in dedicated centers.