Thoracoscopic Esophagectomy Research Articles

251. COMPARISON OF LAPAROSCOPIC SURGERIES WITH OR WITHOUT HAND-ASSISTED PROCEDURE IN THE ABDOMINAL PHASE OF THORACOSCOPIC ESOPHAGECTOMY IN THE PRONE POSITION

Abstract Laparoscopic surgery is less invasive than open surgery in the abdominal phase of thoracoscopic esophagectomy in the prone position (TEP). Laparoscopic surgery (LAP) and hand-assisted laparoscopic surgery (HALS) for mobilization of the stomach and abdominal lymph node dissection have been standard procedures. We aimed to compare the safety and feasibility of those procedures in patients undergone TEP. We evaluated 69 patients who underwent TEP and received gastric conduit reconstruction for esophageal cancer. The LAP group consisted of 42 patients, whereas the HALS group consisted of 27 patients. Surgical outcomes and postoperative complications (Clavien-Dindo classification, grade II or higher) were evaluated between the two groups. No significant differences were found in age, sex, clinical T stage, clinical N status, and neoadjuvant chemotherapy status between the two groups. According to surgical outcomes, there were no significant differences in overall operation time and reconstruction route. Abdominal operation time was significantly shorter in HALS group than in LAP group (LAP: 157 min (73–238), HALS: 96 min (35–157), P < 0.0001). No significant differences were observed in anastomotic leakage, recurrent laryngeal nerve palsy, pneumonia, and postoperative stay (LAP vs HALS: 19.0% vs 25.9%, P = 0.558; 2.4% vs 3.7%, P = 1.000; 16.7% vs 29.6%, P = 0.240; 31 days (16–83) vs 36 days (16–97), P = 0.301). There were no significant differences in postoperative complications between the two groups. HALS is a feasible procedure with short abdominal operative time for patients with esophageal cancer.

289. PRIMARY MONOPHASIC SYNOVIAL SARCOMA OF THE CERVICAL ESOPHAGUS CONFIRMED BY DETECTION OF THE SS18-SSX2 FUSION TRANSCRIPTS

Abstract Synovial sarcoma (SS) of the esophagus is extremely rare. Because of the microscopic features of SS, the monophasic type can easily be misdiagnosed as other spindle cell tumors. Here, we present the first case of a primary SS of the esophagus in the presence of SS18-SSX2 fusion transcripts. A 47-year-old Japanese woman was initially diagnosed with thyroid papillary carcinoma in the left lobe and leiomyoma of the cervical esophagus and subsequently underwent left thyroid lobectomy and enucleation of the esophageal tumor. Four years after the first surgery, the esophageal tumor recurred. Endoscopic biopsy of the tumor revealed atypical cell proliferation with spindle cell features and mitoses. Immunohistochemistry showed focal positivity for bcl-2 and HHF35. Furthermore, the presence of SS18-SSX2 fusion transcripts was confirmed by reverse transcription-polymerase chain reaction analysis, using a paraffin-embedded tumor specimen. Therefore, the tumor was diagnosed as monophasic SS of the cervical esophagus. We re evaluated the surgical specimen enucleated 3 years previously, which was initially diagnosed as leiomyoma, and the diagnosis of SS was confirmed. The patient underwent cervical esophagectomy with isolated jejunal interposition reconstruction. Three years after the second surgery, SS recurred in the distal anastomotic site between the jejunum and the esophagus, and the patient underwent thoracoscopic esophagectomy with gastric conduit reconstruction. The pathological grade of the lesion worsened with every recurrence. Monophasic SS can be difficult to discriminate from other spindle cell tumors based on microscopy alone, and molecular analysis could be useful for confirming the precise diagnosis of monophasic SS.

326. REDUCTION OF ANASTOMOTIC LEAKAGE AFTER ESOPHAGECTOMY WITH RETROSTERNAL GASTRIC TUBE RECONSTRUCTION

Abstract Anastomotic leakage (AL) after esophagectomy is one of the major complications after esophagectomy. The aim of this study was to evaluate anastomotic procedure to reduce AL after esophagectomy with retrosternal gastric pull up. A total of 157 consecutive patients underwent thoracoscopic esophagectomy followed by retrosternal reconstruction with gastric tube in our hospital between January 2008 and December 2021. The anastomotic procedure was revised at January 2016. After cervical esophagogastric anastomosis using circular stapler, gastric tube was pulled down to linearize and place the anastomotic site below the suprasternal notch (SN). The sternum tracheal distance (STD) and the level of esophagogastric anastomosis (LEA) were measured using CT image. In comparison between the former (-December 2015, 65 cases) and later (January 2016-, 92 cases) group, AL was significantly reduced from 11/65 (16.9%) to 0/92 (0%) cases (p < 0.001). LEA was significantly lower in the later group than former group (2.7 mm below SN vs 25 mm above SN; p < 0.001). No difference was observed in the clinicopathological characteristics. In comparison between the cases with and without AL (11/146 cases), significant difference was seen in BMI (average 24.4/21.6, p<0.01) and LEA (average 23.5/8.0 mm, p = 0.02). Multivariate analysis revealed that BMI (21.5>, p = 0.02) and LEA (0>, p < 0.01) were the independent factors associated to AL. Surgical procedure which avoids excessive compression on the gastric tube at the thoracic inlet may take an important role in reduction of AL.

457. STANDARDIZATION AND SHORT-TERM RESULTS OF ROBOT-ASSISTED THORACOSCOPIC ESOPHAGECTOMY

Abstract Surgical cases of robot-assisted thoracoscopic esophagectomy (RAMIE) is increasing because of the advantages of robotic system. We introduced RAMIE in 2019 and standardized the surgical procedure. The usefulness of RAMIE was examined by classifying surgical cases into early and late periods and comparing the surgical results. Fifty-four patients who underwent RAMIE were enrolled in the study. All patients underwent D2 or higher lymph node (LN) dissection, gastric tube reconstruction, and R0 surgery. The patients were divided into two groups, 26 cases in the first half up to December 2020 and 28 cases in the second half after January 2021. The patient background, surgical technique, and short-term results were compared. The tumor staging was based on the UICC 8th version. Thoracic surgery time was 274 minutes, the chest bleeding volume was 30 mL, and the postoperative hospital stay was 19 days (median). In the late stage, patients with clinical thoracic LN metastasis (p = 0.01) and advanced stage (p = 0.006) were higher than those in the early period. There were significantly more cases of thoracic duct resection and D3 dissection in the late period (p = 0.02, p = 0.009). No differences in postoperative complications and intra-hospital death was observed, however the postoperative hospital stay was significantly shortened in the late period (p = 0.001). Thorough mediastinal LN dissection by RAMIE could be safely performed by standardizing and improving the surgical procedures. RAMIE has several issues such as higher cost associated with equipment and longer operative time, but it is possible to perform precise procedures with solo surgery, and it is expected that cost reduction effects will be expected in terms of the number of participants in surgery and the length of hospital stay after surgery.

235. NEAR-INFRARED FLUORESCENCE IMAGING OF THORACIC DUCT IN MINIMALLY INVASIVE ESOPHAGECTOMY

Abstract Chylothorax is a serious complication after esophagectomy and an important reason for reoperation and prolonged hospital stay. A clear localization of thoracic ducts (TDs) and the potential leakage site is an ideal strategy to prevent postoperative chylothorax. In order to explore the feasibility and safety of near-infrared fluorescence imaging (NIR-FI) with indocyanine green (ICG) to identify TDs and potential chyle leakage during video-assisted thoracoscopic esophagectomy, a prospective clinical trial was conducted. We recruited 41 patients who underwent thoraco-laparoscopic minimally invasive esophagectomy for esophageal cancer in this prospective, single-arm clinical study between December 2020 and December 2021. The primary endpoint was the performance of NIR-FI in identifying TDs and chyle leakage. The ICG was injected subcutaneously into the right inguinal region 30 minutes before the thoracic operation, and it becomes fluorescent when excited by the light with a special wavelength in the NIR system. According to the intraoperative demands, surgeons can observe the position of the TDs under the real-time guidance of NIR-FI. In 38 of 41 patients (92.7%) using NIR-FI, TDs were clearly visible in high contrast. The mean signal-to-background ratio (SBR) of all fluorescent TDs was 3.05 ± 1.56. Fluorescence imaging of TDs could be detected 0.5 hours after ICG injection and last up to 3 hours with an acceptable SBR value. The optimal observation time window is from about 1 to 2 hours after ICG injection. Under the guidance of real-time NIR-FI, three patients were found to have chylous leakage and the selective TD ligation were performed intraoperatively. No patient had postoperative chylothorax. NIR-FI with ICG can provide highly sensitive and real-time assessment of TDs, as well as determine the source of chyle leakage, to prevent TD injury and direct selective TD ligation. It’s an effective navigation tool to minimize the incidence of chylothorax after minimally invasive esophagectomy.

Comprehensive registry of esophageal cancer in Japan, 2015

BackgroundThe registration committee for esophageal cancer in the Japan Esophageal Society (JES) has collected the patients' characteristics, treatment, and outcomes of patients who underwent any treatment during 2015 in Japan.MethodsWe analyzed patients' data who had visited the participating hospitals in 2015. We collected the data using the National Clinical Database with a web-based data collection system. We used the Japanese Classification of Esophageal Cancer 10th edition by JES and the TNM classification by the Union of International Cancer Control (UICC) for cancer staging.ResultsA total of 9368 cases were registered from 355 institutions in Japan. Squamous cell carcinoma and adenocarcinoma accounted for 86.7% and 7.4%, respectively. The 5-year survival rates of patients treated by endoscopic resection, concurrent chemoradiotherapy, radiotherapy alone, and esophagectomy were 87.2%, 33.5%, 24.2%, and 59.9%, respectively. Esophagectomy was performed in 5172 cases. Minimally invasive approaches were selected for 60.6%, and 54.4% underwent thoracoscopic esophagectomy. The operative mortality (within 30 days after surgery) was 0.79% and the hospital mortality was 2.3%. The survival curves showed an excellent discriminatory ability both in the clinical and pathologic stages by the JES system. The survival of pStage IV was better than IIIC in the UICC system because pStage IV included the patients with supraclavicular lymph node metastasis (M1 LYM).ConclusionWe hope this report improves all aspects of diagnosing and treating esophageal cancer in Japan.

Influence of patient position in thoracoscopic esophagectomy on postoperative pneumonia: a comparative analysis from the National Clinical Database in Japan.

Two prominent patient positions during thoracoscopic esophagectomy are the left lateral decubitus position (LP) and the prone position (PP). However, whether the patient position during thoracoscopic esophagectomy influences short-term outcomes, especially postoperative pneumonia, remains unclear. We aimed to elucidate the impact of patient position on the occurrence of postoperative pneumonia. We analyzed 9850 patients who underwent oncologic thoracoscopic esophagectomies between 2016 and 2019 from the National Clinical Database. We compared the short-term outcomes between the LP and PP groups, and the primary outcome measure was the incidence of postoperative pneumonia. This study included 2637 (26.8%) and 7213 (73.2%) patients in the LP and the PP groups, respectively. The baseline characteristics of the two groups were well-balanced. Compared with the LP group, the PP group had a longer operative time and less blood loss. There were no significant differences in the incidences of postoperative pneumonia, recurrent laryngeal nerve palsy, anastomotic leakage, severe complications, and reoperation between the groups. Meanwhile, prolonged ventilation and surgery-related mortality occurred more frequently in the LP than in the PP group (P < 0.001 and 0.046, respectively). After multivariable adjustment, the patient position did not significantly influence the incidence of postoperative pneumonia (odds ratio 0.91, 95% confidence interval 0.80-1.04). Although prolonged ventilation and surgery-related mortality occurred more frequently in the LP group than in the PP group, the patient position did not significantly influence the occurrence of postoperative pneumonia.

Clinical Outcome of Intraoperative Recurrent Laryngeal Nerve Monitoring during Thoracoscopic Esophagectomy and Mediastinal Lymph Node Dissection for Esophageal Cancer.

Mediastinal lymph dissection in esophagectomy for patients with esophageal cancer is important. The dissection of recurrent laryngeal nerve (RLN) lymph nodes could cause RLN injury, vocal cord palsy, pneumonia, and respiratory failure. This retrospective study aimed to evaluate the effects of intraoperative RLN monitoring in esophagectomy and mediastinal lymph node dissection in preventing RLN injury and vocal cord palsy. This study included 75 patients who underwent minimally invasive esophagectomy and mediastinal lymph node dissection for esophageal cancer with (38 patients) and without (37 patients) IONM at Changhua Christian Hospital from 2015 to 2020. The surgical and clinical outcomes were reviewed. Patients in the IONM group had more advanced clinical T status, shorter operation time (570 vs. 633 min, p = 0.007), and less blood loss (100 mL vs. 150 mL, p = 0.019). The IONM group had significantly less postoperative vocal palsy (10.5% vs. 37.8%, p = 0.006) and pneumonia (13.2% vs. 37.8%, p = 0.014) than that in the non-IONM group. IONM was an independent factor for less postoperative vocal cord palsy that was related to postoperative 2-year survival. This study demonstrated that IONM could reduce the incidence of postoperative vocal cord palsy and pneumonia.

Clinical comparative study of glasses-free 3D and 2D thoracoscopic surgery in minimally invasive esophagectomy.

ObjectiveTo investigate the safety and efficacy of glasses-free three-dimensional (3D) thoracoscopic surgery in minimally invasive esophagectomy (MIE).MethodsThe clinical data of 98 patients, including 81 men and 17 women aged 45–77 years, with esophageal squamous cell carcinoma who underwent minimally invasive thoracoscopic esophagectomy from January 2017 to December 2019 [3 years, with clinical follow-up time: 1 year~4 years (2017.01–2020.12)] were retrospectively analyzed. Patients were divided into two groups according to different surgical methods including a glasses-free 3D thoracoscopic group (G-3D group: 38 patients) and a two-dimesional (2D) thoracoscopic group (2D group: 60 patients). The clinical outcome of the two groups were compared.ResultsThe operation time of the thoracoscopic part in the G-3D group was significantly shorter than that in the 2D group (P<0.05). The total number of lymph node dissection in the G-3D group was more than that in the 2D group (P<0.05). The thoracic indwelling time, postoperative hospital stay, severe pulmonary infection, arrhythmia, anastomotic leakage, chylothorax, and recurrent laryngeal nerve injury were not significantly different between the two groups (P>0.05). There was also no significant difference between the two groups on the progression-free survival (P>0.05).ConclusionGlasses-free 3D thoracoscopic surgery for esophageal cancer is a safe and effective surgical procedure. Compared with 2D thoracoscopic MIE, glasses-free 3D thoracoscopic MIE for esophageal cancer has higher safety, more lymph node dissection, and higher operation efficiency through the optimized surgical operations. We believe that glasses-free 3D thoracoscopy for MIE is worthy of clinical promotion.

Low tidal volume ventilation alleviates ventilator-induced lung injury by regulating the NLRP3 inflammasome

Purpose Low tidal volume ventilation (LTVV) is a well-known ventilation mode which can improve ventilator-induced lung injury (VILI). However, the mechanism of LTVV ameliorating VILI has not yet been elucidated. In this study, we aimed to reveal LTVV protected against VILI by inhibiting the activation of the NLRP3 inflammasome in bronchoalveolar lavage fluid (BALF) from humans and lungs from mice. Materials and Methods Twenty-eight patients scheduled for video-assisted thoracoscopic esophagectomy were randomized to receive high-tidal-volume ventilation [Vt = 10 mL/kg without positive end-expiratory pressure (PEEP)] or LTVV (Vt = 5 mL/kg along with 5 cm of H2O PEEP) during one-lung ventilation. BALF was collected before and at the end of surgery. Male C57BL/6 mice received high-tidal-volume ventilation, LTVV or MCC950 (an inhibitor of NLRP3). The activation of the formation of NLRP3 inflammasome in BALF from patients and in lungs from mice were analyzed. Results LTTV decreased the peak airway pressure (P peak), plateau airway pressure (P plat) and driving pressure (ΔP) during one-lung ventilation. Additionally, LTVV not only inhibited pulmonary infiltration and inflammation caused by mechanical ventilation, but also suppressed the NLRP3 inflammasome activation in BALF from humans. In mice, ventilator-induced inflammatory response and pulmonary edema were suppressed by LTVV with an efficacy comparable to that of MCC950 treatment. Furthermore, LTVV, similar to MCC950, clearly decreased ventilator-induced NLRP3 inflammasome activation. Conclusion Our study showed that LTVV played a protective role in ventilator-induced lung injury by suppressing the activation of the NLRP3 inflammasome. Trial registration This study was registered in The Chinese Clinical Trial Registry, ChiCTR1900026190 on 25 September 2019.

A case of refractory pneumothorax and contralateral atelectasis after thoracoscopic subtotal esophagectomy treated with independent lung ventilation

BackgroundIndependent lung ventilation (ILV) allows separate positive end-expiratory pressures (PEEP) and inspiratory pressures for each lung. However, only a few articles have reported ILV management for lungs affected by different pathologies.Case presentationA 56-year-old man underwent video-assisted thoracic surgery for esophageal cancer. The right lung was injured during surgery, causing a bronchopleural fistula and necessitating chest drainage. On the third day in the intensive care unit, the patient’s oxygenation worsened during pressure support with continuous positive airway pressure ventilation. ILV was initiated for right-sided severe pneumothorax and left-sided atelectasis and pneumonia. ILV was continued for 2 days, and the patient’s trachea was successfully extubated the following day.ConclusionApplying high-level PEEP to the one lung and minimizing the airway pressure on the other lung could be achieved using ILV, which might contribute to successful tracheal extubation.

Intraoperative visualization of morphological patterns of the thoracic duct by subcutaneous inguinal injection of indocyanine green in esophagectomy for esophageal cancer.

To prevent chylothorax after esophageal cancer surgery, it is important to recognize morphological patterns of the thoracic duct intraoperatively. The present study aimed to evaluate the safety and usefulness of near-infrared (NIR) fluorescence imaging with subcutaneous inguinal injection of indocyanine green (SII-ICG) to detect the thoracic duct during thoracoscopic esophagectomy for esophageal cancer. Patients (n=16) who underwent thoracoscopic esophagectomy in the prone position with SII-ICG at Shinshu University Hospital between June 2020 and January 2022 were enrolled in the present study and retrospectively reviewed. Immediately prior to thoracoscopic esophagectomy, we injected 0.2-0.5mg/kg ICG into the subcutaneous tissue in the bilateral inguinal region. The identification rate of the thoracic duct was 93.8% (n=15), and the success rate of fluorescence using SII-ICG was 87.5% (n=14). The visible thoracic ducts had four patterns: a typical pattern in 50% (n=8), duplication pattern in 18.8% (n=3), branching pattern in 12.5% (n=2), and plexiform pattern in 12.5% (n=2). In all cases, ICG fluorescence did not disappear and was visible during the thoracic surgery. No SII-ICG-related complications were observed. Intraoperative NIR fluorescence imaging of the thoracic duct using SII-ICG is a simple and safe method with very high detection sensitivity. This method can be a powerful tool for avoiding thoracic duct injuries during esophageal cancer surgery.

Outcomes of the Modified Thoracoscopic En-bloc Esophagectomy in Patients with Esophageal Cancer

Background: Esophageal cancer is one of the most prevalent types of cancer and causes of death worldwide. As the mainstream treatment, surgical resection is technically demanding and time-consuming. Therefore, the scope of its application is limited in the clinical setting. A new surgical approach is thus needed for an improved surgical effect and the prognosis of esophageal cancer. Objectives: This study aimed to investigate the effect of a modified thoracoscopic en-bloc esophagectomy on the removal of patients’ esophageal cancers and its outcomes. Methods: In this study, a modified en-bloc esophagectomy was developed to remove esophageal cancer. Patients who underwent the modified en-bloc esophagectomy by right thoracoscopic approach or thoracoscope-assisted small incisional approach to have their esophageal cancers removed in Peking University First Hospital (Beijing, China) between January 2014 and January 2017, were screened and retrospectively studied. Cancer recurrence, overall survival, mortality, as well as intraoperative and postoperative outcomes, were reported. Results: A total of 31 patients (22 male and 9 female, mean age: 62.9 years) were included in the study. Out of 30 patients with R0 resection, eight patients had cancer recurrences in the neck, lung, liver, and bone; however, none of the recurrences was identified in the mediastinum. Six patients died during the follow-up period. By the end of December 2020, the five-year survival rate of all patients was 58.3%. The median survival time of N0 patients was 52 months, which was significantly longer than that in N1+2 patients (23 months). Additionally, there was no statistically significant difference between the median survival time of N1 and N2 patients. Moreover, perioperative complications included pneumonia, arrhythmia, hoarseness, and chylous ascites, which were consistent with those reported previously. Conclusion: The modified en-bloc esophagectomy to remove esophageal cancer by right thoracoscopic approach or thoracoscope-assisted small incisional approach was found safe and reliable due to decreased cancer recurrence, increased overall survival rate, and prolonged survival time.

Novel surgical technique of robot-assisted thoracoscopic esophagectomy in the lateral decubitus position

We performed robot-assisted thoracoscopic esophagectomy in lateral decubitus position (LDP) with camera rotation and manual hand control assignment to reproduce the visualization and manipulation of open esophagectomy or thoracoscopic esophagectomy in LDP. Four robotic ports and two 12 mm assistant ports were placed. The camera image for the operator was vertically and horizontally inverted by camera rotation to create an operative view similar to that achieved under open thoracotomy. We used a forward-oblique viewing endoscope with a 30° down-facing orientation. The mediastinal view was obtained by single lung ventilation, artificial pneumothorax by carbon dioxide insufflation, and trachea retraction by the assistant. The right and left hands were assigned to any combination of two out of the three arms depending on the situation. The remaining arm was used as an assistant to create an adequate surgical view. The robotic platform is useful to manage aortic injury by direct suturing.

Right top pulmonary vein is a venous anomaly of which surgeons should be aware in subcarinal dissection for thoracoscopic esophagectomy: a case report and literature review

BackgroundA right top pulmonary vein (RTPV) that crosses behind the right main or intermediate bronchus is a variation of the superior posterior pulmonary vein in the right upper lobe. Damage or ligation of this abnormal vessel can lead to massive intraoperative bleeding and serious complications, such as congestion of the posterior segment of the right upper lobe and cardiac tamponade. Subcarinal lymph node dissection is mandatory in radical thoracoscopic esophagectomy for esophageal cancer, and the RTPV is an anomalous vessel of which thoracic surgeons should be aware.Case presentationA 70-year-old man underwent thoracoscopic esophagectomy for esophageal cancer (T3N1M0). An anomaly of the superior posterior pulmonary vein in the right lobe was recognized on preoperative computed tomography imaging. With simulation and intraoperative navigation using three-dimensional imaging of the same view as that observed during the operation, radical subcarinal dissection could be performed with preservation of the RTPV.ConclusionIn our review of the relevant literature, the incidence of RTPV ranged from 0.28 to 9.3%, and its mean vascular diameter was 7.0 mm at the maximum and 2.2 ± 0.72 mm at the minimum, with the right superior pulmonary vein being a relatively common inflow site. Our case in which the RTPV ran dorsal to the right main bronchus is very rare. In radical subcarinal dissection of thoracoscopic esophagectomy, it is important to recognize the posterior pericardial plane and release the ventral fixation of these lymph nodes to free space for the back side. This is also true in the case of RTPV, which should be noted to avoid injury. In cases involving an RTPV larger than 4.5 mm, ligation should be avoided, and preoperative recognition of the exact run of this abnormal vessel using three-dimensional imaging can be very useful.

A comparison of the surgical invasiveness and short-term outcomes between thoracoscopic and pneumatic mediastinoscopic esophagectomy for esophageal cancer.

Minimally invasive esophagectomy (MIE) has been widely accepted as a treatment for esophageal cancer. This retrospective study compared the short-term outcomes and surgical invasiveness between thoracoscopic esophagectomy (TE) and mediastinoscopic esophagectomy with pneumomediastinum (pneumatic mediastinoscopic esophagectomy [PME]). A total of 72 patients who underwent TE or PME were included and assessed for their surgical findings, postoperative complications, and inflammatory responses on postoperative day (POD) 1, 3, 5, and 7. The PME group exhibited a significantly shorter operative time and fewer lymph nodes retrieved than the TE group. Furthermore, the PME group tended to have greater incidences of recurrent laryngeal nerve palsy and lower incidences of atelectasis than the TE group. The PME group had significantly lower white blood cell counts on POD 5, serum C-reactive protein (CRP) levels on POD 3 than the TE group. PME seems to be less invasive than TE and can be considered the preferred option for patients with lower-stage esophageal cancer expected to have severe pleural adhesion or who cannot tolerate TE.

Short- and long-term outcomes of thoracoscopic esophagectomy in the prone position for esophageal squamous cell carcinoma in patients with obstructive ventilatory disorder: a propensity score-matched study.

Many patients with esophageal squamous cell carcinoma (ESCC) have obstructive ventilatory disorder (OVD), which is considered a risk factor for postoperative pneumonia. It has been reported that thoracoscopic esophagectomy in the prone position (TEP) is less invasive and is associated with fewer postoperative respiratory complications compared with open esophagectomy. This matched-cohort study aimed to elucidate the safety and oncologic outcomes of ESCC patients with OVD who undergo TEP. In this matched-cohort study, 237 patients with ESCC who underwent TEP between 2010 and 2018 were divided into two groups based on forced expiratory volume in 1s/forced vital capacity. Postoperative complications (Clavien-Dindo classification grade II or higher), overall survival (OS), and disease-free survival (DFS) were compared between the two groups. Based on their propensity scores, 75 patients with normal respiratory function (NRF) and 75 with OVD were selected. The rates of postoperative pneumonia were not significantly different between the two groups (NRF group vs OVD group: 18.7% vs 18.7%; P = 1.000). The rates of recurrent laryngeal nerve palsy and anastomotic leakage were also not significantly different (NRF group vs OVD group: 12.0% vs 18.7%, P = 0.365; 18.7% vs 18.7%, P = 1.000). The 5-year OS and DFS rates in the NRF vs OVD groups were 66.2% vs 54.9% and 63.5% vs 52.9%, respectively, with no significant differences (P = 0.421, 0.197). TEP can be safely performed on ESCC patients with OVD and can result in an oncological efficiency equal to that of the NRF group.

Left thoracoscopic approach in the supine position for torsion of the residual esophagus after esophagectomy: a case report

BackgroundAnastomotic stenosis can occur after esophagectomy and gastric tube reconstruction. The effective surgical treatment for refractory anastomotic stenosis, which seems difficult to resolve with endoscopic treatment, has not been established. We report a case of refractory stenosis due to esophageal torsion in which reconstructive surgery was possible using a left thoracoscopic approach in the supine position.Case presentationA 72-year-old man who underwent thoracoscopic subtotal esophagectomy and retrosternal gastric tube reconstruction for esophageal cancer 6 months previously presented to us. Postoperative endoscopy revealed that the residual esophagus was twisted approximately 360°, just above the anastomotic site. Conservative endoscopic treatment failed to improve the condition due to severe passage obstruction, and reconstructive surgery was repeated. Surgery was performed in the supine position using a left thoracoscopic approach. The entire circumferences of the gastric tube and residual esophagus were dissected from the inferior mediastinum to the top of the sternum, with focus on preserving the right gastroepiploic vein and gastric-tube wall. Subsequently, laparoscopic surgery was performed to remove the gastric tube from the thoracoabdominal junction. After separating the esophagus on the oral side of the torsion from the left cervical wound, the abdomen was opened, the gastric tube was pulled out through the abdominal wound, and adhesions in the abdominal cavity were peeled off to raise the gastric tube cranially via the retrosternal route. An end-to-side anastomosis was performed using a circular stapler, and the esophageal torsion and previous anastomosis were resected. Oral intake was resumed on the 7th postoperative day, and the patient was discharged on the 38th day.ConclusionsAfter subtotal esophagectomy and retrosternal gastric tube reconstruction, the left thoracoscopic approach is one of the most minimally invasive approaches and is especially useful for preserving the right gastroepiploic artery and veins and for mobilizing the gastric tube wall.

Propensity-Matched Analysis of the Short-Term Outcome of Robot-Assisted Minimally Invasive Esophagectomy Versus Conventional Thoracoscopic Esophagectomy in Thoracic Esophageal Cancer.

In this matched-cohort study, we investigated the short-term outcome of robot-assisted minimally invasive esophagectomy (RAMIE) compared with conventional minimally invasive thoracoscopic esophagectomy (MIE) in esophageal cancer patients. One hundred eighty-nine patients with thoracic esophageal cancer scheduled to undergo thoracic esophagectomy between 2020 and 2021 were assigned to either RAMIE or MIE. Then, we retrospectively evaluated the postoperative surgical complications between two groups in a propensity-matched analyzation. Based on the propensity-matched score, 50 patients who underwent RAMIE or MIE were selected. Thoracic surgery time in RAMIE/MIE group were 233.1/173.3min (p < 0.01), respectively. No significant intergroup differences were observed regarding incisional anastomotic leakage (RAMIE group 4.0% vs. MIE group 6.0%) and pneumonia (RAMIE group 8.0% vs. MIE group 12.0%; p = 0.68). The respective incidences of recurrent laryngeal nerve paralysis were 34.0 and 8.0% in the MIE and RAMIE groups, respectively (p < 0.01). In the matched cohort, no differences were observed between the groups in the success accomplishment of the clinical management pathway (RAMIE group 94.0% vs. MIE group 88.0%). Although patients who underwent RAMIE had longer operation times, the incidence of recurrent laryngeal nerve paralysis was lower than with MIE. Further study in a prospective multi-institutional setting are required to confirm the superiority of RAMIE compared with MIE.

Circular stapling anastomosis with indocyanine green fluorescence imaging for cervical esophagogastric anastomosis after thoracoscopic esophagectomy: a propensity score-matched analysis

BackgroundThoracoscopic esophagectomy has been extensively used worldwide as a curative surgery for patients with esophageal cancer; however, complications such as anastomotic leakage and stenosis remain a major concern. Therefore, the objective of this study was to evaluate the efficacy of circular stapling anastomosis with indocyanine green (ICG) fluorescence imaging, which was standardized for cervical esophagogastric anastomosis after thoracoscopic esophagectomy.MethodsAltogether, 121 patients with esophageal cancer who underwent thoracoscopic esophagectomy with radical lymph node dissection and cervical esophagogastric anastomosis from November 2009 to December 2020 at Tottori University Hospital were enrolled in this study. Patients who underwent surgery before the anastomotic method was standardized were included in the classical group (n = 82) and patients who underwent surgery after the anastomotic method was standardized were included in the ICG circular group (n = 39). The short-term postoperative outcomes, including anastomotic complications, were compared between the two groups using propensity-matched analysis and the risk factors for anastomotic leakage were evaluated using logistic regression analyses.ResultsOf the 121 patients, 33 were included in each group after propensity score matching. The clinicopathological characteristics of patients did not differ between the two groups after propensity score matching. In terms of perioperative outcomes, a significantly higher proportion of patients who underwent surgery using the laparoscopic approach (P < 0.001) and narrow gastric tube (P = 0.003), as well as those who had a lower volume of blood loss (P = 0.009) in the ICG circular group were observed after matching. Moreover, the ICG circular group had a significantly lower incidence of anastomotic leakage (39% vs. 9%, P = 0.004) and anastomotic stenosis (46% vs. 21%, P = 0.037) and a shorter postoperative hospital stay (30 vs. 20 days, P < 0.001) than the classical group. According to the multivariate analysis, the anastomotic method was an independent risk factor for anastomotic leakage after thoracoscopic esophagectomy (P = 0.013).ConclusionsCircular stapling anastomosis with ICG fluorescence imaging is effective in reducing complications such as anastomotic leakage and stenosis.