Thoracoscopic-laparoscopic Esophagectomy 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.

Chylopericardium following esophagectomy: a case report and systematic review

BackgroundChylopericardium is a rare condition characterized by the accumulation of chyle in the pericardial space. It is most commonly caused by thoracic duct injury. Chylopericardium following esophagectomy is extremely rare but can cause life-threatening complications. This report presents a case of chylopericardium post-esophagectomy, resulting in cardiac tamponade and cardiac arrest. A systematic literature review was also conducted to facilitate the understanding of this rare condition.Case presentationA 41-year-old male was admitted to our hospital with intermediate to highly differentiated squamous cell carcinoma of the mid-thoracic esophagus (clinical T4NxM0). He underwent thoracoscopic-laparoscopic esophagectomy with cervical anastomosis. On postoperative day 1, patient had a cardiac arrest secondary to cardiac tamponade, requiring emergency ultrasound-guided drainage. The drained fluid was initially serous but became chylous after the administration of enteral nutritional emulsion. As a result of significant daily pericardial drainage, patient subsequently underwent thoracic duct ligation. The amount of drainage was substantially reduced post-thoracic duct ligation. Over a period of 2 years and 7 months, patient recovered well and tolerated full oral diet. A comprehensive literature review was conducted and 4 reported cases were identified. Among these cases, three patients developed pericardial tamponade secondary to chylopericardium post-esophagectomy.ConclusionChylopericardium is a rare but serious complication post-esophagectomy. Prompt echocardiography and thorough pericardial fluid analysis are crucial for diagnosis. Thoracic duct ligation has been shown to be an effective management approach for this condition.

The Role of Ultrasound-Guided Multipoint Fascial Plane Block in ElderlyPatients Undergoing Combined Thoracoscopic-Laparoscopic Esophagectomy: A Prospective Randomized Study.

We estimated the safety and efficacy of ultrasound-guided multipoint fascial plane block, including serratus anterior plane block (SAPB) and bilateral transversus abdominis plane block (TAPB) in elderly patients who underwent combined thoracoscopic-laparoscopic esophagectomy (TLE). The authors enrolled 80 patients in this prospective study after patient selection using the inclusion and exclusion criteria who were scheduled for elective TLE from May 2020 to May 2021. Patients were randomly assigned to the treated group (group N) or the control group (group C) (n = 40 per group) using the sealed-envelope method. Multipoint fascial plane blocks, including serratus anterior plane block (SAPB) and bilateral TAPB, were performed on patients undergoing TLE using a solution of 60mL 0.375% ropivacaine plus 2.5mg dexamethasone by 3 injections of 20mL each (group N) or no interventions (group C). Systolic blood pressure (SBP), diastolic blood pressure (DBP), and heart rate (HR) at T incision and 30min after T incision were significantly higher in group C than in group N, and also significantly higher than at baseline (P < 0.01). Blood glucose at 60min, 2h after T incision, was significantly higher in group C than in group N and significantly higher than at baseline (P < 0.01). Compared to group N, the dosages of propofol and remifentanil used during surgery in group C were more than those in group N (P < 0.01). The time to first rescue analgesic in group C was earlier than in group N. The total postoperative use of sufentanil, and the number of patients requiring rescue analgesics in group C, were more than in group N (P < 0.01). This study showed that applying the multipoint fascia pane block technique in TLE for elderly patients could significantly reduce postoperative pain, decrease the dosages of drugs used in general anesthesia, improve the quality of the awakening, and have no obvious adverse reactions. Chinese Clinical Trial Registry (ChiCTR-2000033617).

505. OUTCOMES AFTER ROBOT-ASSISTED MINIMALLY INVASIVE ESOPHAGECTOMY: REVIEW OF 1000 PATIENTS IN A SINGLE CENTER

Abstract Robot-assisted minimally invasive esophagectomy (RAMIE), an increasingly adopted surgical approach, has been demonstrated with higher surgical efficiency and better lymph node dissection than thoracoscopic minimally invasive esophagectomy (MIE) in the Phase III RAMIE trial. We present the safety and feasibility of RAMIE for the surgical treatment in a large group of patients. We reviewed 1000 consecutive patients undergoing RAMIE between November 2015 to March 2022 in our institution. Demographic data, intraoperative parameters, and postoperative outcomes including length of hospital stay, morbidity and mortality were assessed. The primary endpoint of the study was operative (30-day) mortality. Squamous cell carcinoma accounted for 93.8% of all diseases. Most tumors were located in the mid-thoracic esophagus (46.3%) and clinically staged as T2 and T3 (87.4%). The proportion of preoperative therapy was 33.4% All patients received total robot-assisted thoracoscopic-laparoscopic esophagectomy, except for 49 planned hybrid surgery (thoracoscopy or laparotomy). The rate of conversion to open surgery was 3.2% and R0 resection was 96.8%. Overall postoperative complications occurred in 45.2% of patients (C-D grade III: 10.3%) including pulmonary complications (8.6%), anastomotic leakage (8.2%), and vocal cord paralysis (22.4%). Median length of hospital stay was 11 days and 30-day mortality was 0.5%. RAMIE resulted in acceptable surgical results, postoperative outcomes and low mortality, which can be performed safely with good results in an experienced center.

Handgrip strength predicts early postoperative dysphagia after thoracoscopic-laparoscopic esophagectomy in male patients with esophageal cancer.

Dysphagia after esophagectomy, especially in the early postoperative period, remains a severe complication. The association between sarcopenia and dysphagia has received attention in geriatric non-cancer populations. This study aimed to determine the associations between sarcopenia parameters and early postoperative dysphagia after esophagectomy. This retrospective observational study included 201 consecutive male patients undergoing thoracoscopic-laparoscopic esophagectomy (TLE) for esophageal cancer between October 2018 and December 2020. We used three sarcopenia parameters: handgrip strength (HGS), skeletal muscle index, and gait speed. Postoperative swallowing function was assessed by videofluoroscopy using the penetration-aspiration scale (PAS; range 1-8). Logistic regression analyses were used to predict factors associated with postoperative aspiration (PAS 6-8). Furthermore, we compared values in patients with symptomatic aspiration (PAS 6-7) and with silent aspiration (PAS 8). Aspiration occurred in 38 of 201 patients (18.9%). On multivariate analysis, significant predictors of aspiration included age [odds ratio (OR) 1.11; 95% confidence interval (CI) 1.05-1.17; p < 0.001], low HGS (OR 3.05; 95% CI 1.06-8.78; p = 0.039), upper third esophageal cancer (OR 2.79; 95% CI 1.03-7.54; p = 0.044) and recurrent laryngeal nerve palsy (OR 2.98; 95% CI 1.26-7.06; p = 0.013). Furthermore, among patients with aspiration (PAS 6-8), low HGS was significantly associated with silent aspiration (OR 6.43; 95% CI 1.06-39.00; p = 0.043). Low HGS was significantly associated with early postoperative aspiration and impairment of airway protective reflexes after TLE.

Feasibility and effectiveness of multi-injection thoracic paravertebral block via the intrathoracic approach for analgesia after thoracoscopic-laparoscopic esophagectomy

BackgroundWe observed the feasibility and effectiveness of multi-injection thoracic paravertebral block (TPB) via the intrathoracic approach under thoracoscopic direct vision for analgesia after thoracoscopic-laparoscopic esophagectomy (TLE).MethodsSixty patients undergoing TLE were randomly divided into a control group and an observation group. All patients underwent TPB via the intrathoracic approach at the three levels of T2, 5, and 8 with a scalp needle before closing the chest. The patients in the observation group received 10 ml 0.375% ropivacaine at each level, and the patients in the control group received 10 ml of 0.9% saline at each level. A patient-controlled intravenous analgesic (PCIA) pump with sufentanil was attached to all patients after surgery. The sufentanil consumption, number of PCIA presses and use of rescue analgesia in the first 24 h after surgery were recorded. The visual analogue scale (VAS) scores (rest and coughing) were recorded at 2 h, 6 h, 12 h, 24 h, and 48 h after surgery. The duration of postoperative hospital stay, active cough rate, first ambulation, and the incidence of adverse reactions after surgery was recorded.ResultsThe sufentanil consumption in the observation group was significantly lower than that in the control group (34.7 ± 1.9 µg vs. 52.1 ± 2.1 µg; P < 0.001). The VAS score at each postoperative time point, number of PCIA presses, use of rescue analgesia, and the incidence of adverse reactions in the observation group were significantly lower than those in the control group. The postoperative active cough rate of patients in the observation group was significantly higher than those in the control group, and the times of the first ambulation after surgery and postoperative hospital stay in the observation group were significantly shorter than those in the control group (all P < 0.05).ConclusionsMulti-injection TPB via the intrathoracic approach under thoracoscopic direct vision is easy to perform and can effectively alleviate postoperative pain after TLE with fewer adverse reactions and contributing to improved postoperative recovery.

Effects of Epidural Anesthesia on Quality of Life in Elderly Patients Undergoing Esophagectomy

Continuous epidural analgesia during surgery can effectively inhibit surgically induced stress and inflammatory response. It also spares opioid use and reduces postoperative pain. This study explored the effects of intraoperative epidural anesthesia on quality of life and central nervous system injury in elderly patients after esophagectomy. Elderly patients who were scheduled for thoracoscopic-laparoscopic esophagectomy were eligible for this randomized controlled study. The patients in the experimental group received general anesthesia combined with epidural anesthesia, while the patients in the control group received only general anesthesia. At the end of surgery, all patients received the same epidural analgesia program before extubation. Health-related quality of life (HRQoL) was assessed using the European Organization for Research and Treatment of Cancer (EORTC) Quality of life Questionnaires (QLQ)-C30 and QLQ-OES18 questionnaires. Two HRQoL questionnaires were filled out before surgery, on day 7 and after the third month postoperatively. The Montreal Cognitive Assessment and serum S100β level were also evaluated at baseline and on postoperative day 7. Compared with the group without intraoperative epidural anesthesia, the epidural anesthesia group had better quality of life scores particularly in the social, emotional, and global health domains. The symptoms of nausea, constipation, sleep disorders, dysphagia, reflux, pain, and cough difficulty were less severe. In addition, the S100β content of peripheral blood was also lower on postoperative day 7 (1199.8 pg/mL vs 1341.2 pg/mL, P < 0.001). There was no significant difference in Montreal Cognitive Assessment scores between the 2 groups. Intraoperative epidural anesthesia may improve the quality of life after esophagectomy in elderly patients, and reduce the neuroinflammatory response, compared with the patients receiving general anesthesia only.

Handgrip Strength Predicts Postoperative Pneumonia After Thoracoscopic-Laparoscopic Esophagectomy for Patients with Esophageal Cancer.

Despite advances in minimally invasive surgery, postoperative pneumonia after esophagectomy remains a frequent complication. Sarcopenia, defined as low muscle strength and quantity, has been associated with adverse surgical outcomes in numerous cancers. The recent definition and diagnostic criteria for sarcopenia have emphasized muscle strength rather than muscle quantity as the primary indicator of sarcopenia, although most studies have focused only on muscle quantity. This study aimed to determine the association of muscle strength and quantity with postoperative pneumonia after thoracoscopic-laparoscopic esophagectomy (TLE). This retrospective, single-center, observational study investigated 161 men undergoing TLE for esophageal cancer between May 2017 and October 2019. Handgrip strength (HGS) and skeletal muscle mass index (SMI) were used respectively as proxy for muscle strength and quantity. The SMI was assessed using preoperative computed tomography at the L3 vertebral level. Predictors of postoperative pneumonia were determined using multivariate analysis. The study subjects had TLE performed for squamous cell carcinoma (n = 131), adenocarcinoma (n = 24), and other cancers (n = 6). Postoperative pneumonia developed in 28 patients (17.4%). In the multivariate analysis, HGS was significantly associated with postoperative pneumonia (odds ratio [OR], 1.21; 95% confidence interval [CI], 1.08-1.35; p = 0.001]. No association was found between SMI and postoperative pneumonia (p = 0.964). Comparison of the areas under the receiver operating characteristic curves for postoperative pneumonia prediction showed that the value for HGS was significantly higher than for SMI (0.79 vs 0.65, respectively; p = 0.012). Low HGS was a significant predictor of postoperative pneumonia after TLE for esophageal cancer.

Dexmedetomidine with sufentanil in intravenous patient-controlled analgesia for relief from postoperative pain, inflammation and delirium after esophageal cancer surgery.

Background and aims: Postoperative pain can cause serious adverse reactions that severely affect postoperative outcome. The present study evaluated the effect of dexmedetomidine (DEX) added to sufentanil in intravenous patient-controlled analgesia (PCA) on the relief of pain and inflammatory responses during postoperative recovery of patients undergoing a combined thoracoscopic-laparoscopic esophagectomy (TLE). Methods: Sixty patients undergoing TLE were randomly allocated to receive 1 μg/ml of sufentanil alone (Group S) or 1 μg/ml of sufentanil plus 2.5 μg/ml of DEX (Group D) for postoperative intravenous (IV) PCA. Postoperative pain relief, cumulative PCA requirements, inflammatory marker levels, delirium and recovery were assessed. Results: A joint DEX and sufentanil regimen significantly reduced the area under the curve of numerical rating scores for pain at rest (NRSR) and coughing (NRSC) at 1–48 h postoperatively (P = 0.000) that were associated with lower PCA-delivered cumulative sufentanil consumption and less PCA frequency until 48 h postoperatively (P < 0.05 and P < 0.0001, respectively). The simultaneous administration of DEX and sufentanil significantly reduced plasma IL-6 and TNF-α concentrations and increased IL-10 level (P < 0.0001, P = 0.0003 and P = 0.0345, respectively), accompanied by better postoperative delirium categories and health statuses of patients (P = 0.024 and P < 0.05, respectively). There was no hypotension, bradycardia, respiratory depression or oversedation in Group D. Conclusion: Patients receiving DEX in addition to IV PCA sufentanil for TLE exhibited better postoperative analgesia, fewer inflammatory responses and lower postoperative delirium categories and better health statuses.

Thoracoscopic-laparoscopic esophagectomy and two-field lymph node dissection.

Minimally invasive esophagectomy (MIE) has been performed with increasing frequency worldwide since Cuschieri et al. first reported a thoracoscopic mobilization of the esophagus (1). As one of the most common MIE procedures, thoracoscopic-laparoscopic esophagectomy (TLE) is performed on 38.3% of those patients with advanced cancer according to the latest report of the Japanese Association for Thoracic Surgery, and the number of surgeries performed for superficial or advanced cancer has recently been increasing (2). Indeed, having an experienced surgeon can be a predictive factor of better postoperative outcomes of esophagectomy, due to better lymph node retrieval, less blood loss, and shorter operation duration (3-5). The aim of this study was to contribute to the standardization of esophagectomy in esophageal cancer (EC) by showing the procedures of TLE and two-field lymph node dissection (EC).

Postoperative analgesia after combined thoracoscopic-laparoscopic esophagectomy: a randomized comparison of continuous infusion and intermittent bolus thoracic epidural regimens.

PurposeJudicious postoperative pain management after thoracoscopic–laparoscopic esophagectomy (TLE) facilitates enhanced rehabilitation. Thoracic epidural analgesia (TEA) offers many benefits in esophagectomy, while several complications are associated with the delivery mode by continuous epidural infusion. This study compared the efficiency and safety of intermittent epidural bolus to continuous epidural infusion for pain management after TLE.Patients and methodsSixty patients, aged 18–80 years, with American Society of Anesthesiologists classes I–III and scheduled for TLE with combined general anesthesia and TEA were randomly allocated to two groups. Patients received either a continuous epidural infusion with 0.3% ropivacaine and 1.5 µg/mL fentanyl at 6 mL/h plus a patient-controlled bolus of 3 mL (continuous group) or an intermittent bolus of 6 mL of the same solution on demand with lockout time of 30 minutes (intermittent group). If the patient complained of pain and the visual analog scale score was >4, an intravenous injection of tramadol or dezocine was administered as rescue treatment. The primary outcome variable was the consumption of epidural opioids and local anesthetics for TEA.ResultsTEA for pain management following TLE by intermittent epidural bolus was associated with significantly lower consumption of fentanyl and ropivacaine and lower incidences of breakthrough pain and hypotension than continuous epidural infusion. No significant differences were observed between the two groups in terms of pain score at rest or while coughing, patient satisfaction, or incidence of postoperative complications.ConclusionCompared with continuous epidural infusion, TEA by on-demand intermittent bolus greatly reduced the consumption of local anesthetics and opioids with comparable pain relief and little impairment in hemodynamics when used for pain management after TLE.

Propensity-Matched Analysis Comparing Survival After Hybrid Thoracoscopic-Laparotomy Esophagectomy and Complete Thoracoscopic-Laparoscopic Esophagectomy.

Hybrid thoracoscopic-laparotomy esophagectomy (hTE) and complete thoracoscopic-laparoscopic esophagectomy (cTLE) are the two most frequently used minimally invasive esophagectomy (MIE) procedures and are broadly utilized for esophageal cancer. We evaluated differences in short- and long-term outcomes between hTE and cTLE in patients with esophageal squamous cell carcinoma (ESCC). Patients who underwent MIE for ESCC between September 2009 and February 2016 were included in this retrospective study. Propensity score matching (PSM) was utilized to contrast the postoperative results of hTE and cTLE according to the obtained and analyzed pertinent patient features and postoperative variables. Univariate and multivariate Cox proportional hazard regression analysis was used on possible predictors of survival. Eighty-six well-balanced pairs of patients were available for outcome comparison after PSM. Compared to Group 1 (hTE), the patients in Group 2 (cTLE) had significantly shorter operative times and less intraoperative blood loss, but a higher number of retrieved nodes (p = 0.000, p = 0.003, and p = 0.000, respectively). The incidence of postoperative complications was 40.7% (70/172) and did not significantly differ between the two groups. The patients in Group 2 exhibited higher disease-free survival and disease-specific survival (DSS) than those in Group 1 (p = 0.048 and p = 0.041, respectively). Univariate and multivariate Cox proportional hazard regression analyses showed that pT stage, pN stage, differentiation grade, and the surgical procedure had significant HRs, which suggested that cTLE is associated with better DSS. cTLE possibly shows better postoperative and oncologic outcomes than hTE.

PS01.135: PROGNOSTIC ANALYSIS OF TLE-CHEST SURGERY IN ESOPHAGEAL CANCER

Abstract Background Esophageal cancer was the ninth most common malignant tumor and ranked sixth for death globally, especially in developing country[1]. Standardized esophagectomy followed by chemotherapy or chemoradiotherapy remains the curative treatment for esophageal cancer[2]. Ivor Lewis esophageal resection, including two-stage approach for carcinoma of the middle third of the esophagus, was proposed in 1946[3]. Meanwhile, to avoid the risk of anastomotic leakage in Ivor Lewis surgery, three-stage approach with cervical anastomosis was introduced by McKeown[4]. However, considering the less complications of minimally invasive Ivor Lewis esophagectomy and the increased incidence of distal esophageal and gastroesophageal junction adenocarcinoma, two-stage approach with intrathoracic anastomosis was gaining more attention. Recent years, thoracoscopic laparoscopic esophagectomy with intrathoracic anastomosis (TLE-chest) has gradually become the mainstream approach of minimally invasive Ivor Lewis esophagectomy for the treatment of middle and lower esophageal cancers. In the previous study, we described the technique strategies of TLE-chest, which was featured with improved anastomosis layer by layer and embedding of the anastomosis with preserved mediastinal pleura[5]. In this study, we presented the perioperative data, complications and long-term survivals of TLE-chest in esophageal cancers. Methods The clinical data of 201 patients, who underwent TLE-chest for primary esophageal cancer in the First Affiliated Hospital of Anhui Medical University (FAHAMU) from November 2011 to December 2015, was analyzed retrospectively. Postoperative patients’ life quality by the European Organization into Research and Treatment of Cancer (EORTC) quality of life questionnaire for esophageal cancer and overall survivals were analyzed using Kaplan–Meier curve. The normal distribution of the measured data is expressed in terms of x ± s. Cox's hazard regression model was used for single factor and multi-factor analysis. Results Overall, 168 (83.6%) patients were males and 33 (16.4%) were females. The mean age of patients was 62.7 years old (range from 40 to 88). 150 (74.6%) patients’ tumors were located in the middle of esophagus, whereas 50 (24.9%) and 1 (0.5%) tumors were in the low and up. 194 (96.5%) esophageal tumors were confirmed as squamous carcinoma expect 7 (3.5%) adenocarcinomas. The mean of tumor size was 3.7 cm and the numbers of postoperative pathological TNM classification I, II, III and IV were 38 (18.9%), 72 (35.8%), 73 (36.3%) and 18 (9%) respectively. The average of total operation time was 293.9 min. Among them, the means of VATS and LS time were 156.9 min and 116.5 min respectively. The mean of intraoperative blood loss was 77.5 ml. The number of resected lymph nodes was 22.9 ± 9.7 (maximum: 58).7 (3.5%) patients suffered from anastomotic fistula, 5 (2.5%) patients occurred RRLN injury in lymph nodes dissection and 5 (2.5%) suffered chylothorax. Pulmonary complications were observed in 21 (10.4%) patients. Meanwhile, the rates of other complications containing anastomotic stenosis, bleeding and delayed gastric empty were 0.5% (1/201), 1.5% (3/201) and 0.5% (1/201) respectively. The score of quality of patients’ life was 85 ± 6.5. And at the 12 months, quality of life was improved by 4.1%. Until up to the 24 months, patients’ quality of life was recovered to 90 ± 7.5. The 1, 2 and 3 years overall survival of 100 patients was 94%, 79% and 74% respectively. Univariate analysis showed that the pT stage (P = 0.040), pN stage (P = 0.001), pTNM stage(P = 0.001) and Total operative time(P = 0.000) were associated with 3-year overall survival (3-OS). Further, multivariate analysis affirmed that the operative time (≥ 311 min), tumor size (≥ 3.5 cm) and pTNM stage were independent prognostic factors for 3-OS (P &lt; 0.05). Conclusion TLE-chest surgery in esophageal cancer was safe and effective. And the total operative time, tumor size and TNM stage could be used as independent prognostic indicators in esophageal cancer patients after the TLE-chest. Disclosure All authors have declared no conflicts of interest.

Progress in the application of robot assisted minimally invasive esophagectomy

Robotic assisted surgery system is the most advanced minimally invasive surgical platform in the world, and this system has been widely used in cardiac surgery, urology surgery, gynecology surgery and general surgery. Although the application of this system was relative late in esophageal surgery, it has been developing vigorously. According to the research progress and practical experience in the world, robot assisted minimally invasive esophagectomy (RAMIE) has the same safety and effectiveness as traditional open esophagectomy (OE) and thoracoscopic laparoscopic esophagectomy (TLE). In this paper, several aspects on this novel operation were demonstrated, including the origin, safety evaluation, lymph node dissection, learning curve, prognosis of RAMIE, comparison among RAMIE, OE and TLE and the role of RAMIE in multidisciplinary treatment of esophageal cancer, in order to promote the rational application of RAMIE in esophagectomy.

Is thoracoscopic-laparoscopic esophagectomy a better alternative to thoracoscopic esophagectomy?

Minimally invasive esophagectomy (MIE) is gaining rapid popularity as an alternative to conventional open esophagectomy. However, whether incorporating laparoscopy into MIE can further help the patients with esophageal cancer has rarely been studied. The aim of this study was to evaluate the short-term clinical efficacy of thoracoscopic-laparoscopic esophagectomy (TLE) compared with thoracoscopic esophagectomy (TE) in treating esophageal cancer. From September 2014 to December 2016, a total of 131 patients with esophageal cancer who had consecutively undergone MIE were included in the analysis; of them, TLE was performed in 71 patients and TE in 60 patients. Characteristics and perioperative outcomes of all patients were collected and compared to determine differences between the 2 groups. Operation time (p=0.172), chest drainage volume (p=0.656), and pathologic staging (p=0.671) were similar in the 2 groups. Compared with the TE approach, the TLE approach was associated with less blood loss during the operation (median, 100 vs 150ml, p<0.001), shorter chest drainage time (median, 2 vs 3 days, p<0.001), a larger number of harvested lymph nodes (median, 24 vs 20, p<0.001), and shorter postoperative hospital stay (median, 10 vs 11 days, p=0.008). There was no significant difference between groups with regard to the major (grade≥III) and minor (grade<III) complications. TLE is a safe and effective alternative to TE. Patients undergoing TLE may benefit from less blood loss, a larger number of harvested lymph nodes and faster postoperative recovery. Additional randomized controlled trial with longer follow-up is needed.

The comparison of thoracoscopic-laparoscopic esophagectomy and open esophagectomy: A meta-analysis.

The objective of this study was to perform a meta-analysis to evaluate the effects of thoracoscopic-laparoscopic esophagectomy (TLE) and open esophagectomy (OE) in the treatment of esophageal cancer. A literature search was performed using PubMed, Embase, and Google Scholar databases for relevant keywords and the medical subject headings. After we had screened further, 13 clinical trials were included in the final meta-analysis. Specific odds ratios (ORs), standardized mean differences (SMDs), mean differences (MDs), and confidence intervals (CIs) were calculated. The outcomes of treatment effects included anastomotic leakage, blood loss, number of lymph nodes harvested, and operating time. Comparing OE for esophageal cancer patients, the pooled OR of anastomotic leakage was 0.89 (95% CI = [0.47, 1.68]), the pooled SMD of blood loss was - 0.56 (95% CI = [-0.77, -0.35]), the pooled MD of lymph nodes harvested was - 0.93 (95% CI = [-2.35, 0.50]), and the pooled SMD of operating time was 0.31 (95% CI = [0.02, 0.59]). TLE was found to significantly decrease patients' blood loss. There is no difference of anastomotic leakage and the number of lymph nodes harvested between TLE and OE.

The effect of postoperative complications on survival of patients after minimally invasive esophagectomy for esophageal cancer.

Minimally invasive esophagectomy (MIE) has been shown to be a feasible technique for the treatment of esophageal cancer; however, its postoperative morbidity remains high. This retrospective study aimed to evaluate the effect of postoperative complications on long-term outcomes in patients who have undergone MIE for esophageal squamous cell carcinoma (ESCC). This retrospective study enrolled patients who had undergone MIE for ESCC between September 2009 and November 2014; all procedures were performed by a single surgical team. Relevant patient characteristics and postoperative variables were collected and evaluated. The disease-free survival (DFS) and disease-specific survival (DSS) were determined by the Kaplan-Meier method, and compared by log-rank tests. Possible predictors of survival were subjected to univariate analysis and multivariate Cox proportional hazard regression analysis. In all, data on 214 patients with ESCC were analyzed, including 170 men and 44 women. All study subjects had undergone thoracoscopic or thoracoscopic-laparoscopic esophagectomy and cervical esophagogastric anastomosis. One hundred and thirty patients (60.7%) had postoperative complications (Grades 1-4). The overall DFS and DSS rates were 80.0 and 88.9% at 1year, 48.6 and 54.2% at 3years, and 43.2 and 43.5% at 5years, respectively. Univariate analysis and multivariate Cox proportional hazard regression analysis showed that T stage, N stage, and tumor grade were independent prognostic factors for long-term survival; however, postoperative complications had no significant effect on the DFS or DSS of this patient cohort (log-rank test, p=0.354 and 0.160, respectively). Postoperative complications have no significant effect on long-term survival in patients who have undergone MIE for ESCC.

Thoracoscopic and laparoscopic radical esophagectomy with left neck anastomosis.

We described a 50-year-old female, who came to our institute with the diagnosis of esophageal squamous cell carcinoma. The preoperative clinical diagnosis was stage II esophageal squamous cell carcinoma. The minimally invasive esophagectomy (MIE), combined thoracoscopic-laparoscopic esophagectomy with cervical anastomosis, was performed in this case. Total surgery time was 190 min and blood loss was 100 mL. Postoperative pathological exam suggested squamous cell carcinoma, without evidence of lymph node metastasis in any station (T2N0M0 IIb stage). The patient was discharged home on the 12(th) postoperative day.

Thoracoscopic-laparoscopic esophagectomy and enhanced recovery after surgery

Thoracoscopic-laparoscopic esophagectomy and enhanced recovery after surgery

Thoracoscopic-Laparoscopic Esophagectomy for Carcinoma of the Esophagus: Preliminary Reports of Seven Cases from the High-Volume Institution

Thoracoscopic-Laparoscopic Esophagectomy for Carcinoma of the Esophagus: Preliminary Reports of Seven Cases from the High-Volume Institution