Total Minimally Invasive Esophagectomy Research Articles

Efficacy of preoperative single-dose dexamethasone in preventing postoperative pulmonary complications following minimally invasive esophagectomy: a retrospective propensity score-matched study

BackgroundThe study was performed to investigate the efficacy and safety of preoperative dexamethasone (DXM) in preventing postoperative pulmonary complications (PPCs) after minimally invasive esophagectomy (MIE).MethodsPatients who underwent total MIE with two-field lymph node dissection from February 2018 to February 2023 were included in this study. Patients who were given either 5 mg or 10 mg DXM as preoperative prophylactic medication before induction of general anesthesia were assigned to the DXM group, while patients who did not receive DXM were assigned to the control group. Preoperative evaluations, intraoperative data, and occurrence of postoperative complications were analyzed. The primary outcome was the incidence of PPCs occurring by day 7 after surgery.ResultsIn total, 659 patients were included in the study; 453 patients received preoperative DXM, while 206 patients did not. Propensity score-matched analysis created a matched cohort of 366 patients, with 183 patients each in the DXM and control groups. A total of 24.6% of patients in the DXM group and 30.6% of patients in the control group had PPCs (P = 0.198). The incidence of respiratory failure was significantly lower in the DXM group than in the control group (1.1% vs 5.5%, P = 0.019). Fewer patients were re-intubated during their hospital stay in the DXM group than in the control group (1.1% vs 5.5%, P = 0.019).ConclusionsPreoperative DXM before induction of anesthesia did not reduce overall PPC development after MIE. Nevertheless, the occurrence of early respiratory failure and the incidence of re-intubation during hospitalization were decreased.Trial registrationChinese Clinical Trial Registry (No. ChiCTR2300071674; Date of registration, 22/05/2023)

Robotic-Assisted Ivor Lewis Esophagectomy Is Safe and Cost Equivalent Compared to Minimally Invasive Esophagectomy in a Tertiary Referral Center.

In recent decades, robotic-assisted minimally invasive esophagectomy (RAMIE) has been increasingly adopted for patients with esophageal cancer (EC) or cancer of the gastroesophageal junction (GEJ). However, concerns regarding its costs compared to conventional minimally invasive esophagectomy (MIE) have emerged. This study examined outcomes and costs of RAMIE versus total MIE in 128 patients who underwent Ivor Lewis esophagectomy for EC/GEJ at our department between 2017 and 2021. Surgical costs were higher for RAMIE (EUR 12,370 vs. EUR 10,059, p < 0.001). Yet, median daily (EUR 2023 vs. EUR 1818, p = 0.246) and total costs (EUR 30,510 vs. EUR 29,180, p = 0.460) were comparable. RAMIE showed a lower incidence of postoperative pneumonia (8% vs. 25%, p = 0.029) and a trend towards shorter hospital stays (15 vs. 17 days, p = 0.205), which may have equalized total costs. Factors independently associated with higher costs included readmission to the intensive care unit (hazard ratio [HR] = 7.0), length of stay (HR = 13.5), anastomotic leak (HR = 17.0), and postoperative pneumonia (HR = 5.4). In conclusion, RAMIE does not impose an additional financial burden. This suggests that RAMIE may be considered as a valid alternative approach for esophagectomy. Attention to typical cost factors can enhance postoperative care across surgical methods.

Short-term outcome of totally minimally invasive versus hybrid minimally invasive Ivor-Lewis esophagectomy.

For resectable esophageal cancer, the choice of total minimally invasive esophagectomy (TMIE) or hybrid minimally invasive esophagectomy (HMIE) remains controversial. The purpose of this study was to evaluate the short-term clinical outcomes of TMIE and HMIE under the Ivor-Lewis procedure. The data of 145 patients diagnosed with middle or lower esophageal cancer who underwent radical Ivor-Lewis esophagectomy in the Affiliated Hospital of Qingdao University between January 2018 and December 2019 were retrospectively analyzed. The short-term outcomes such as complications during surgery or within 30 days after surgery and postoperative pain were analyzed. All patients were divided into TMIE group (75 patients) and HMIE group (70 patients). No significant difference was observed in the baseline characteristics of the two groups. TMIE was associated with less blood loss than the HMIE group (p<0.05). A total of 54 (37.2%) patients had postoperative complications. Although the two groups were statistically similar in the incidence of major complications, patients in the HMIE group were more likely to have pneumonia compared with those in the TMIE group. The numeric rating scale for pain was significantly higher in the HMIE group (p=0.002) and more patients required an additional opioid analgesia after esophagectomy (p=0.282). In conclusion, according to perioperative outcomes, TMIE can benefit patients better than HMIE.

Population-Based Cohort Study from a Prospective National Registry: Better Long-Term Survival in Esophageal Cancer After Minimally Invasive Compared with Open Transthoracic Esophagectomy.

Recent research indicates long-term survival benefits of minimally invasive esophagectomy (MIE) compared with open esophagectomy (OE) for patients with esophageal and gastroesophageal junction (GEJ) cancers, but there is a need for more population-based studies. We conducted a prospective population-based nationwide cohort study including all patients in Sweden diagnosed with esophageal or junctional cancer who underwent a transthoracic esophagectomy with intrathoracic anastomosis. Data were collected from the Swedish National Register for Esophageal and Gastric Cancer in 2006-2019. Patients were grouped into OE and MIE including hybrid MIE (HMIE) and totally MIE (TMIE). Overall survival and short-term postoperative outcomes were compared using Cox regression and logistic regression models, respectively. All models were adjusted for age, sex, American Society of Anesthesiologists (ASA) score, clinical T and N stage, neoadjuvant therapy, year of surgery, and hospital volume. Among 1404 patients, 998 (71.1%) underwent OE and 406 (28.9%) underwent MIE. Compared with OE, overall survival was better following MIE (hazard ratio [HR] 0.72, 95% confidence interval [CI] 0.55-0.94), TMIE (HR 0.67, 95% CI 0.47-0.94), and possibly also after HMIE (HR 0.76, 95% CI 0.56-1.02). MIE was associated with shorter operation time, less intraoperative bleeding, higher number of resected lymph nodes, and shorter hospital stay compared with OE. MIE was also associated with fewer overall complications (odds ratio [OR] 0.70, 95% CI 0.47-1.03) as well as non-surgical complications (OR 0.64, 95% CI 0.40-1.00). MIE seems to offer better survival and similar or improved short-term postoperative outcomes in esophageal and GEJ cancers compared with OE in this unselected population-based cohort.

Age and Charlson Comorbidity Index score are not independent risk factors for severe complications after curative esophagectomy for esophageal cancer: a Dutch population-based cohort study

BackgroundThe number of older patients undergoing curative esophagectomy for esophageal cancer is increasing, and minimally invasive techniques are being increasingly used. The aim of this study is to compare postoperative outcomes after curative esophagectomy between older and younger patients. MethodsData was retrieved from the Dutch Upper Gastrointestinal Cancer Audit (DUCA), a national surgical outcome registry. The primary outcome was severe complications, defined as complications graded Clavien-Dindo ≥ 3. The secondary outcomes were postoperative complications, reintervention rates, length of hospital stays, and mortality. Outcomes were compared between patients aged ≥75 and < 75 years. We performed additional subgroup analyses between these age groups after totally minimally invasive esophagectomy (TMIE) and in patients with severe complications. We adjusted for the following parameters: gender, BMI, Charlson Comorbidity Index score (CCI), ASA score, histology, type of neoadjuvant therapy, and surgical technique. ResultsOf all 3775 included patients, 455 (12.1%) were aged ≥75 years and 3302 (87.9%) were aged <75 years. Overall, severe complications occurred in 184 (40.4%) older and in 1140 (34.5%) younger patients (CI = 1.009–1.080). After TMIE, severe complications occurred in 150 (42.1%) older and in 891 (35.8%) younger patients (CI = 1.007–1.088). In patients with severe complications, rates of complications, reinterventions, mortality, and ICU stays were comparable between older and younger patients. After adjustment for casemix, age and CCI score were not independent risk factors for (severe) complications and mortality. ConclusionsAge and Charlson Comorbidity Index are not adequate predictors of postoperative morbidity and mortality after curative esophagectomy for esophageal cancer.

Effect of Phased Implementation of Totally Minimally Invasive Ivor Lewis Esophagectomy for Esophageal Cancer after Previous Adoption of the Hybrid Minimally Invasive Technique: Results from a French Nationwide Population-Based Cohort Study

Several randomized controlled trials (RCTs) have demonstrated improved short-term outcomes of totally minimally invasive esophagectomy (TMIE) compared with open esophagectomy (OE); however, to what extent these outcomes can be extrapolated to a national level remains debatable. The aim of this study was to evaluate, on a nationwide basis, the short-term outcomes of TMIE and to analyze these results within the context of previously implemented hybrid minimally invasive esophagectomy (HMIE). All consecutive patients who underwent a curative Ivor Lewis esophagectomy in France between 2017 and 2019 were included in this retrospective cohort study. The primary endpoint was to compare 90-day postoperative mortality (POM) between OE, HMIE, and TMIE, while secondary endpoints were defined as the rate of postoperative complications. A matched and multivariate analysis was adjusted for confounding factors. Overall, 2675 patients were included (1003 OE vs. 1498 HMIE vs. 174 TMIE). In every center where TMIE was performed, HMIE had been previously adopted. The matched 90-day POM rate in the TMIE group was significantly lower compared with the OE group (2.3% vs. 6.3%, p=0.046) but not compared with the HMIE group (2.3% vs. 4.9%, p=0.156). There was no significant difference between TMIE and OE, or TMIE and HMIE, regarding the 30-day fistula rate (21.8% vs. 17%, p=0.176; and 21.8% vs. 21.3%, p=0.88, respectively). TMIE was associated with a reduced rate of pulmonary complications compared with OE (33.9% vs. 44%, p=0.027) and HMIE (33.9% vs. 42.8%, p=0.05). Low-volume centers were identified as a negative predictive factor for 90-day POM (odds ratio 1.89, 95% confidence interval 1.3-2.75, p=0.001). TMIE is associated with a lower 90-day POM rate compared with OE and offers reduced rates of pulmonary complications compared with OE and HMIE. After previous adoption of the HMIE technique, TMIE can be safely implemented in high-volume centers nationwide.

551 INCREASED POSTOPERATIVE MORBIDITY AFTER TOTALLY MINIMALLY INVASIVE ESOPHAGECTOMY FOR CANCER IN ELDERLY PATIENTS

Abstract The incidence of elderly patients with esophageal cancer is increasing. The aim of this study is to compare postoperative outcomes after esophagectomy between elderly patients and younger patients and to compare outcomes after totally minimally invasive esophagectomy (TMIE) and open esophagectomy (OE) in these age groups. Methods Data was retrieved from the Dutch Upper Gastrointestinal Cancer Audit (DUCA), a national surgical outcome registry. The primary outcome parameter was severe complications, defined as Clavien Dindo ≥3. Secondary outcome parameters were postoperative complications, reintervention rate, length of hospital stay and mortality. Outcome parameters were compared between patients aged ≥75 years and &amp;lt; 75 years and between TMIE and OE in these age groups. We adjusted for the following casemix parameters: gender, Charlson Co-morbidity Index score ASA score and neoadjuvant therapy. A sensitivity analysis was performed with different age groups: &amp;lt;65, 65–69, 70–74, 75–79 and ≥ 80 years. Results Of all 5539 included patients 14.0% were aged ≥75 years and 86.0% were aged &amp;lt;75 years. Severe complications were observed more frequently in the elderly group compared to the younger group (RR = 1.15 [1.04–1.27], p = 0.007). Interestingly, there was an increased risk of severe complications after TMIE in both the elderly group (RR = 1.50 [1.19–1.90], p = 0.001) and the younger group (RR = 1.41 [1.28–1.56], p &amp;lt; 0.001). No difference in mortality between TMIE and OE was found. Sensitivity analyses of TMIE compared to OE across all age groups showed increased risk of severe complications. Adjustment for casemix for all analysis did not change the results. Conclusion Severe complications after esophagectomy occur more frequently in elderly compared to younger patients. TMIE in elderly patients did not result in less morbidity and was in fact associated with more severe complications compared to OE across all age groups, which may be due to a learning curve effect.

Short- and long-term outcomes in patients operated with total minimally invasive esophagectomy for esophageal cancer.

At our hospital, the main treatment for resectable esophageal cancer (EC) has since 2013 been total minimally invasive esophagectomy (TMIE). The aim of this study was to present the short- and long-term results in patients operated with TMIE. This cross-sectional study includes all patients scheduled for TMIE from June 2013 to January 2016 at Oslo University Hospital. Data on morbidity, mortality, and survival were retrospectively collected from the patient administration system and the Norwegian Cause of Death Registry. Long-term postoperative health-related quality of life (HRQL) and level of dysphagia were assessed by patients completing the following questionaries: EORTC QLQ-OG25, QLQ-C30, and the Ogilvie grading scale. A total of 123 patients were included in this study with a median follow-up time of 58months (1-88months). 85% had adenocarcinoma, 15% squamous cell carcinoma. Seventeen patients (14%) had T1N0M0, 68 (55%) T2-T3N0M0, or T1-T2N1M0 and 38 (31%) had either T3N1M0 or T4anyNM0. Ninety-eight patients (80%) received neoadjuvant (radio)chemotherapy and 104 (85%) had R0 resection. Anastomotic leak rate and 90-days mortality were 14% and 2%, respectively. The 5-year overall survival was 53%. Patients with tumor free resection margins of >1mm (R0) had a 5-year survival of 57%. Median 60months (range 49-80) postoperatively the main symptoms reducing HRQL were anxiety, chough, insomnia, and reflux. Median Ogilvie score was 0 (0-1). In this study, we report relatively low mortality and good overall survival after TMIE for EC. Moreover, key symptoms reducing long-term HRQL were identified.

Oncologic outcomes in minimally invasive esophagectomy for esophageal carcinoma

: Esophagectomy, with clear surgical margins and appropriate lymph node dissection, is the mainstay of curative intent treatment in esophageal cancer. Minimally invasive esophagectomy (MIE) including total MIE, hybrid and robotic approaches has become more frequent. Whether or not MIE offers the same oncologic outcomes as open esophagectomy (OE) is an unanswered question to be addressed in this review. A literature review was conducted using the search terms esophageal cancer, esophagectomy, outcomes, minimally invasive surgery, survival, lymph node assessment. Relevant studies were identified by two of the authors (NAD and GED). Studies reporting short terms outcomes consistently report decreased frequency of pneumonia, decreased blood loss and shorter length of stay. Margin status, appears to be similar while lymph node harvest is similar or better compared to open surgery. Overall survival (OS) is at least similar to open surgery but in several recent reports, survival after MIE is superior. Health-related quality of life (HRQOL) appears to be improved with MIE within the first 6 months but similar thereafter. MIE offers at least equivalent outcomes in terms of resection margins and lymph node harvest and long-term survival data. MIE offers earlier recovery from surgery with improved HRQOL within the first 6 months postoperatively.

Learning Curves of Ivor Lewis Totally Minimally Invasive Esophagectomy by Hospital and Surgeon Characteristics: A Retrospective Multinational Cohort Study.

To describe the pooled learning curves of Ivor Lewis totally minimally invasive esophagectomy (TMIE) in hospitals stratified by predefined hospital- and surgeon-related factors. Ivor Lewis (TMIE is known to have a long learning curve which is associated with considerable learning associated morbidity. It is unknown whether hospital and surgeon characteristics are associated with more efficient learning. A retrospective analysis of prospectively collected data of consecutive Ivor Lewis TMIE patients in 14 European hospitals was performed. Outcome parameters used as proxy for efficient learning were learning curve length, learning associated morbidity, and the plateau level regarding anastomotic leakage and textbook outcome. Pooled incidences were plotted for the factor-based subgroups using generalized additive models and 2-phase models. Casemix predicted outcomes were plotted and compared with observed outcomes. The investigated factors included annual volume, TMIE experience, clinic visits, courses and fellowships followed, and proctor supervision. This study included 2121 patients. The length of the learning curve was shorter for centers with an annual volume >50 compared to centers with an annual volume <50. Analysis with an annual volume cut-off of 30 cases showed similar but less pronounced results. No outcomes suggesting more efficient learning were found for longer experience as consultant, visiting an expert clinic, completing a minimally invasive esophagectomy fellowship or implementation under proctor supervision. More efficient learning was observed in centers with higher annual volume. Visiting an expert clinic, completing a fellowship, or implementation under a proctor's supervision were not associated with more efficient learning.

Laparoscopic versus open esophagectomy for patients with esophageal cancer: Systematic review and meta-analyses of randomized controlled trials.

194 Background: There has been an increase in the use of minimally invasive approaches for complex cancer operations. However, its benefit has not been clearly demonstrated for esophageal cancers when compared to open procedures. The purpose of this meta-analysis was to compare operative and postoperative outcomes for partial minimally invasive esophagectomy (MIE) versus open esophagectomy (OE) for patients with esophageal carcinoma. Methods: We conducted a systematic review using CENTRAL, PubMed, Global Index Medicus, ClinicalTrials.gov, EU Clinical Trials Register, and WHO ICTRP until August 30, 2020 without restrictions on publication date, language, or publication status. We included randomized controlled trials evaluating MIEs and partial MIEs including laparoscopic approach with OE for esophageal cancer. All trials including any one of our primary outcome measures -mortality and morbidity- were included. Two authors assessed trials for inclusion. Meta-analyses were conducted for categorical outcomes when heterogeneity was low ( I2&lt; 50%). We reported risk ratios with 95% confidence intervals and GRADE quality of evidence based on our risk of bias assessment. Results: Of 5638 retrieved studies, 10 studies representing 6 trials consisting of 951 patients were included. 347 underwent partial MIE, 106 total MIE, and 498 OE. These were categorized into four cohorts:Co-A: Partial MIE versus OE (4 trials); Co-B: Partial MIE with thoracotomy versus OE (2 trials); Co-C: Partial MIE with cervical incision versus OE (2 trials); Co-D: Complete MIE versus OE (2 trials). Co-A revealed that partial MIE was associated with lower risk of serious adverse events (0.54[0.36-0.83]; 3 trials; 471 participants; I2= 48%), with specifically lower rates of delayed gastric emptying (0.32[0.13-0.80]; 3 trials; 666 participants; I2= 0%), pulmonary complications (0.49[0.29-0.84]; 3 trials; 471 participants; I2= 27%), and mortality (0.67[0.54-0.83]; 4 trials; 692 participants; I2= 0%). Co-B revealed that partial MIE with thoracotomy was associated with lower risk of pulmonary complications (0.61[0.38-0.99]; 2 trials; 231 participants; I2= 0%) and mortality (0.66[0.50-0.87]; 2 trials; 231 participants; I2= 0%). Co-C revealed that partial MIE with cervical incisions were associated with lower risk of serious adverse events (0.38[0.22-0.64]; 1 trial; 240 participants), including pulmonary complications (0.29[0.13-0.65]); 1 trial; 240 participants) and mortality (0.68[0.50-0.94]; 2 trials; 461 participants). Co-D revealed no significant differences between MIE and OE. All significant findings reported originated from high-quality evidence. Conclusions: When compared with completely open esophagectomy, partial MIE is associated with lower risk of mortality and serious adverse events, especially delayed gastric emptying and pulmonary complications.

Minimally Invasive Versus open AbdominoThoracic Esophagectomy for esophageal carcinoma (MIVATE)\xa0\u2014\xa0study protocol for a randomized controlled trial DRKS00016773

BackgroundThe only curative treatment for most esophageal cancers is radical esophagectomy. Minimally invasive esophagectomy (MIE) aims to reduce postoperative morbidity, but is not yet widely established. Linear stapled anastomosis is a promising technique for MIE because it is quite feasible even without robotic assistance. The aim of the present study is to compare total MIE with linear stapled anastomosis to open esophagectomy (OE) with circular stapled anastomosis with special regard to postoperative morbidity in an expertise-based randomized controlled trial (RCT).Methods/designThis superiority RCT compares MIE with linear stapled anastomosis (intervention) to OE with circular stapled anastomosis (control) for Ivor-Lewis esophagectomy. It was initiated in February 2019, and recruitment is expected to last for 3 years. For inclusion, patients must be 18 years of age or more with a resectable primary malignancy in the distal esophagus. Participants with tumor localizations above the azygos vein, metastasis, or infiltration into adjacent tissue will be excluded. In an expertise-based approach, the allocated treatment will only be carried out by the single most experienced surgeon of the surgical center for each respective technique. The sample size was calculated with 20 participants per group for the primary endpoint postoperative morbidity according to comprehensive complication index (CCI) within 30 postoperative days. Secondary endpoints include anastomotic insufficiency, pulmonary complications, other intra- and postoperative outcome parameters such as estimated blood loss, operative time, length of stay, short-term oncologic endpoints, adherence to a standardized fast-track protocol, postoperative pain, and postoperative recovery (QoR-15). Quality of life (SF-36, CAT EORTC QLQ-C30, CAT EORTC QLQ-OES18) and oncological outcomes are evaluated with 60 months follow-up.DiscussionMIVATE is the first RCT to compare OE with circular stapled anastomosis to total MIE with linear stapled anastomosis exclusively for intrathoracic anastomosis. The expertise-based approach limits bias due to heterogeneity of surgical expertise. The use of a dedicated fast-track protocol in both OE and MIE will shed light on the role of the access strategy alone in this setting. The findings of this study will serve to define which approach has the best perioperative outcome for patients requiring esophagectomy.Trial registrationGerman Clinical Trials Register DRKS00016773. Registered on 18 February 2019.

411 LEARNING CURVES IN MINIMALLY INVASIVE ESOPHAGECTOMY: A SYSTEMATIC REVIEW

Abstract Minimally invasive techniques are being increasingly used in the treatment of esophageal cancer. The learning curve for minimally invasive esophagectomy (MIE) is variable and can have an impact upon training delivered within residency and fellowship programmes. The aims of this review are to critically appraise current literature on the learning curve for MIE, identify what parameter(s) is used to quantify achieving competence and determine if there is evidence of resultant impact on surgical training. Methods A search of the major reference databases (MEDLINE, EMBASE, Cochrane) was performed with no time limits up to the date of the search (February 2020). Results were screened in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and study quality assessed using the Newcastle-Ottawa Scale for cohort studies. Results Twenty-one studies comprising 2720 patients were included- 17 studies reported on a combination of thoracoscopic, hybrid and total MIE, 3 studies reported robotic assisted alone and 1 study evaluated robotic assisted and thoracoscopic esophagectomy. 3 studies used a cumulative sum (CUSUM) analysis to define learning, 1 study used CUSUM and another parameter and 17 studies used one or more parameters. Quantification of surgical competence was variable and ranged from 12–80 cases for robotic surgery and 12–60 cases for other modes of MIE. One study reported trainees achieving MIE skills quicker if mentoring surgeons had attained proficiency on the learning curve. Conclusion Learning curves in MIE remain ill-defined with limited evidence on impact upon training received by residents and fellows. Additionally, the parameters used to define achievement of surgical competency is heterogenous. As minimally invasive techniques are increasingly adopted, specific standards to help define competence need to be identified and agreed on. This could help in designing training programmes and improve the rate of achieving competency.

Totally minimally invasive esophagectomy versus hybrid minimally invasive esophagectomy: systematic review and meta-analysis.

SummaryMinimally invasive esophagectomy is increasingly performed for the treatment of esophageal cancer, but it is unclear whether hybrid minimally invasive esophagectomy (HMIE) or totally minimally invasive esophagectomy (TMIE) should be preferred. The objective of this study was to perform a meta-analysis of studies comparing HMIE with TMIE. A systematic literature search was performed in MEDLINE, Embase, and the Cochrane Library. Articles comparing HMIE and TMIE were included. The Newcastle–Ottawa scale was used for critical appraisal of methodological quality. The primary outcome was pneumonia. Sensitivity analysis was performed by analyzing outcome for open chest hybrid MIE versus total TMIE and open abdomen MIE versus TMIE separately. Therefore, subgroup analysis was performed for laparoscopy-assisted HMIE versus TMIE, thoracoscopy-assisted HMIE versus TMIE, Ivor Lewis HMIE versus Ivor Lewis TMIE, and McKeown HMIE versus McKeown TMIE. There were no randomized controlled trials. Twenty-nine studies with a total of 3732 patients were included. Studies had a low to moderate risk of bias. In the main analysis, the pooled incidence of pneumonia was 19.0% after HMIE and 9.8% after TMIE which was not significantly different between the groups (RR: 1.46, 95% CI: 0.97–2.20). TMIE was associated with a lower incidence of wound infections (RR: 1.81, 95% CI: 1.13–2.90) and less blood loss (SMD: 0.78, 95% CI: 0.34–1.22) but with longer operative time (SMD:-0.33, 95% CI: −0.59—-0.08). In subgroup analysis, laparoscopy-assisted HMIE was associated with a higher lymph node count than TMIE, and Ivor Lewis HMIE was associated with a lower anastomotic leakage rate than Ivor Lewis TMIE. In general, TMIE was associated with moderately lower morbidity compared to HMIE, but randomized controlled evidence is lacking. The higher leakage rate and lower lymph node count that was found after TMIE in sensitivity analysis indicate that TMIE can also have disadvantages. The findings of this meta-analysis should be considered carefully by surgeons when moving from HMIE to TMIE.

Minimally invasive esophagectomy for esophageal leiomyomatosis

Abstract Background Esophageal leiomyomatosis (EL) is a rare benign tumor defined as a diffuse form of marked hypertrophy in the muscular layer of the esophagus. Relapses have been reported as a result of misdiagnoses of other tumors or achalasia, followed by inappropriate surgical intervention. The endoscopic approach is preferred because of its lesser degree of invasiveness and better cosmesis; however, its effectiveness for treatment of EL is unclear because these tumors are bulkier and more extensive than those in other esophageal diseases. Case presentation We treated an 11-year-old girl who had been experiencing progressive dysphagia, vomiting, and coughing during sleep since the age of 4 years and was correctly diagnosed with EL using computed tomography and endoscopic ultrasonography. She was successfully treated with total minimally invasive esophagectomy (MIE), combining thoracoscopy and laparoscopy, in the prone position, without any complications or recurrence of symptoms. To our knowledge, this is the first case report of MIE for EL. A review of 84 EL cases (including the present case) revealed a rate of accurate preoperative diagnosis of only 23.8%. Esophagectomy should be employed because the recurrence rate of the non-esophagectomy cases, involving myotomy and tumorectomy, was significantly higher than that of the esophagectomy cases (57.9% vs. 7.7%, p = 0.002). Among 11 relapse cases in the non-esophagectomy cases, esophagectomy was performed in eight. Among the four relapse cases in the esophagectomy group, additional esophagectomy was necessary in three because of insufficient resection of the tumors at the primary esophagectomy. Conclusions Multimodal imaging contributes to accurate diagnosis and assessment of the extent of the tumors, thus leading to the selection of the appropriate surgical intervention, i.e., radical esophagectomy. Total MIE in the prone position provides excellent exposure of the operative fields; our experience suggests that total MIE is beneficial for EL, as it is for other esophageal tumors.

Essential Updates 2018/2019: Essential Updates for esophageal cancer surgery.

Key papers to treatment of esophageal cancer surgery and reduction of postoperative complications after esophagectomy published between 2018 and 2019 were reviewed. Within this review there was a focus on minimally invasive esophagectomy (MIE), robot‐assisted MIE (RAMIE), and centralization to high‐volume center. Advantages of MIE, irrespectively of hybrid or total MIE, to prevent postoperative complications, especially pneumonia, were shown in comparison to open procedure. However, whether total MIE has evident effects or not, as compared to hybrid MIEs, still remains unclear. Differences between RAMIE and MIE were reported to be marginal, though the advantage of lymphadenectomy, especially along recurrent laryngeal nerve, has been suggested. Centralization to high‐volume center evidently benefits esophageal cancer patients by improving short‐term outcomes. The definition of high‐volume center has not been established yet, though institutional structure and quality are thought to be important. Transmediastinal esophagectomy, currently developed, has a potential to be one radical option of MIE for esophageal cancer.

T-shaped linear-stapled cervical esophagogastric anastomosis for minimally invasive esophagectomy: a pilot study.

Minimally invasive esophagectomy (MIE) has become a good option in the surgical treatment of esophageal cancer. Cervical esophagogastric anastomoses (CEGA) are widely used during esophagectomy. However, CEGA are related with a higher incidence of anastomotic complications. In the present study, a new procedure of T-shaped linear-stapled cervical esophagogastric anastomosis was used during MIE and the short-term outcomes are presented. From May 2014 to December 2018, 32 consecutive patients with esophageal cancer who underwent total MIE followed by T-shaped linear-stapled cervical esophagogastric anastomosis were included. Postoperative outcomes were analyzed. Fifteen men and 17 women were included this pilot study. The histology of all cases was squamous cell carcinoma. Mean operation time of T-shaped linear-stapled cervical esophagogastric anastomosis was 17.6 minutes. There were no early or late mortalities. A minor cervical anastomotic leakage occurred in 1 patient. No complications of anastomotic stenosis occurred in this study. The T-shaped linear-stapled cervical esophagogastric anastomosis is efficient, reliable, easy to perform, and associated with lower postoperative complication rate.

Propensity Score-Matched Analysis Comparing Minimally Invasive Ivor Lewis Versus Minimally Invasive Mckeown Esophagectomy.

Totally minimally invasive esophagectomy (TMIE) is increasingly used in treatment of patients with esophageal carcinoma. However, it is currently unknown if McKeown TMIE or Ivor Lewis TMIE should be preferred for patients in whom both procedures are oncologically feasible. The study was performed in 4 high-volume Dutch esophageal cancer centers between November 2009 and April 2017. Prospectively collected data from consecutive patients with esophageal cancer localized in the distal esophagus or gastroesophageal junction undergoing McKeown TMIE or Ivor Lewis TMIE were included. Patients were propensity score matched for age, body mass index, sex, American Society of Anesthesiologists classification, Charlson Comorbidity Index, tumor type, tumor location, clinical stage, neoadjuvant treatment, and the hospital of surgery. The primary outcome parameter was anastomotic leakage requiring reintervention or reoperation. Secondary outcome parameters were operation characteristics, pathology results, complications, reinterventions, reoperations, length of stay, and mortality. Of all 787 included patients, 420 remained after matching. The incidence of anastomotic leakage requiring reintervention or reoperation was 23.3% after McKeown TMIE versus 12.4% after Ivor Lewis TMIE (P = 0.003). Ivor Lewis TMIE was significantly associated with a lower incidence of pulmonary complications (46.7% vs 31.9%), recurrent laryngeal nerve palsy (9.5% vs 0.5%), reoperations (18.6% vs 11.0%), 90-day mortality (7.1% vs 2.9%), shorter median intensive care unit length of stay (2 days vs 1 day) and shorter median hospital length of stay (12 vs 11 days) (all P < 0.05). R0 resection rate was similar between the groups. The median number of examined lymph nodes was 21 after McKeown TMIE and 25 after Ivor Lewis TMIE (P < 0.001). Ivor Lewis TMIE is associated with a lower incidence of anastomotic leakage, 90-day mortality and other postoperative morbidity compared to McKeown TMIE in patients in whom both procedures are oncologically feasible.

Hybrid approaches to minimally invasive esophagectomy

Esophageal cancer resection usually requires a two-field or three-field surgical approach to perform the resection and the reconstruction. With the progress of anaesthesiology and surgical skills, the possibility to reduce the surgical trauma has grown up and minimally invasive esophagectomy (MIE) has widespread worldwide. The hybrid approaches to MIE are the combination of minimally invasive approaches mixed to open approaches by applying the minimally invasive techniques at one level of the two stages (abdomen or thorax) of the procedure. The hybrid techniques can be decided prior to surgery in the surgical decision-making strategy to focus and to keep open approach for one the two stages, either because of expected surgical issues or to obtain a better exposure for confection of the intrathoracic anastomosis. Sometimes, the decision to opt for hybrid techniques can also results from the necessity to convert intraoperatively at both stages during total MIE. The most described hybrid techniques are represented by the laparoscopic hybrid Ivor Lewis esophagectomy where the gastric mobilization is performed laparoscopically whereas the confection of the intrathoracic anastomosis is performed with an open approach. This technique appears safe, reproducible, and easy to teach. The recent MIRO trial has provided evidences that the unique use of laparoscopy for the abdominal part of the esophagectomy resulted in a strong benefit on postoperative respiratory outcomes, with the same magnitude to those observed with total MIE. The MIRO trial suggests that the maximum benefits of minimally invasive techniques are more provided by laparoscopy rather than thoracoscopy. Moreover the laparoscopic approach results in better short, mid and long-term outcomes compared to open approach, without any compromise regarding oncological outcomes. At last, laparoscopy seems to improve health-related quality of life. The laparoscopic approach has to be seen as a new standard approach and should be incorporated to all esophageal cancer resections whenever possible.

O102 FINDING FACTORS ASSOCIATED WITH SAFE IMPLEMENTATION OF IVOR LEWIS TOTALLY MINIMALLY INVASIVE ESOPHAGECTOMY

Abstract Aim To define factors associated with more efficient learning after implementation of Ivor Lewis totally minimally invasive esophagectomy (TMIE). Background and Methods It is unknown which factors are associated with more efficient learning after implementation of Ivor Lewis TMIE. Prospectively collected data of 15 European expert centers are retrospectively analyzed. Consecutive patients undergoing Ivor Lewis TMIE are included. The primary outcome is anastomotic leakage and the secondary outcome is textbook outcome (TBO). The pre-defined level of acceptance for anastomotic leakage is set at 8% with a 5% margin. Trends in outcome parameters are plotted using weighted moving average to define when the pre-defined level of acceptance is reached. Outcome trends are compared between groups of hospitals for the following factors: hospital volume, surgeon experience, overall TMIE experience, expert clinic visit, Ivor Lewis TMIE course followed and Ivor Lewis TMIE proctor supervision during implementation. Results This study included 1718 patients. Hospitals with a volume &gt;50 cases per year reached the pre-defined level of acceptance for anastomotic leakage at case 114, hospitals with a volume &lt;50 cases did not reach the pre-defined level of acceptance. Hospitals with surgeon experience &gt;10 years and &lt;10 years reached the pre-defined level of acceptance at case 112 and 135, respectively. Hospitals with overall TMIE experience &gt;50 cases and &lt;50 cases reached the pre-defined level of acceptance at case 45 and 112, respectively. Visiting an expert clinic, followed a TMIE course, or implementation under a proctor’s supervision did not contribute to reaching the level of acceptance earlier. Conclusion Learning curves are shorter and the level of acceptance is reached earlier if Ivor Lewis TMIE is implemented in a high-volume hospital, if the procedure is implemented in a hospital with a surgeon with &gt;10 years of experience, or if the surgeon has experience in other types of TMIE of &gt;50 cases. These findings can inform surgeons and can contribute to formulate evidence-based training programs.