Traditional Open Esophagectomy Research Articles

Assessment of changes in chest wall mechanics in esophageal cancer survivors using a 3D-motion capture system.

TPS360 Background: Surgical resection remains the mainstay of treatment for loco-regional esophageal cancer. Traditional open esophagectomy is associated with considerable morbidity, with postoperative pulmonary complications (PPC) being the most frequently observed morbidity. There are several peri- and postoperative factors that are known to affect the respiratory mechanics, including an open surgical approach, administration of sedatives, rib spreading with subsequent fracture or nerve injury, presence of PPC and neuropathic pain leading to post-thoracotomy syndrome. Enhanced recovery programmes with early mobilization protocols and chest physiotherapy have been shown to reduce pulmonary complication rates. However, no data is currently available regarding the long-term respiratory function, quality of life and chest wall function in esophageal cancer survivors. Quantification of chest wall movements provides an objective measurement of function for the long term assessment of chest wall mechanics and could be used to develop tailored physiotherapy for patients undergoing esophagectomy. The aim of this study is to develop a method to objectively quantify changes in breathing mechanics in esophageal cancer survivors using a biomechanical approach. Methods: In the initial phase, an 89-marker protocol will be validated against a 3D-printed chest wall model that can produced simulate of normal and abnormal motions. Retroreflective markers will be placed non-invasively on the anterior, posterior, and lateral parts of the thorax and abdomen. A working protocol of breathing mechanics will be assessed in healthy control volunteers with the subject seated in upright position. Subjects will perform the respiratory function tests, the spirometer and the respiratory pressure meter. Further to this clinical assessment, the impact of thoracic movements and treadmill exercise will be assessed on the parameters obtained from changes in breathing movements. Following this, an optimization phase will refine markers placement and identify parameters that are most likely to be clinically relevant in the assessment of breathing mechanics. A finalized protocol will be trialled in esophageal cancer survivors, to identify changes in thoracoabdominal motion after surgery and to assess whether these changes are associated with impairment in health-related quality of life. This information will aid the development of evidenced based physiotherapy regimens tailored to the needs of this patient population. Clinical trial information: NCT03835273.

Long-term weight development after esophagectomy for cancer-comparison between open Ivor-Lewis and minimally invasive surgical approaches.

Esophagectomy is an extensive procedure with severe postoperative effects. It can be assumed that the greater the trauma, the longer the nutritional recovery. This retrospective observational single-center cohort study compared weight development after esophagectomy with open and minimally invasive techniques. Three groups were compared in this study, one representing the first 41 patients who underwent the minimally invasive McKeown esophagectomy (MIMK). The second group included the first 84 consecutive patients operated with the minimally invasive Ivor-Lewis esophagectomy (MIIL). The third group comprised 100 consecutive patients operated with open thoracoabdominal Ivor-Lewis esophagectomy (IL). Virtually all patients submitted to a minimally invasive esophagectomy (MIE) and the majority with an IL had a jejunal catheter inserted during operation for postoperative enteral feeding. All together 225 patients were included in this study. The mean weight loss during the first year was 13.1% (±4.1), 11.2% (±6.1), and 9.6% (±7.5) in the IL, MIIL, and MIMK group, respectively (P=0.85 and P=0.95, respectively). The median duration of postoperative enteral nutrition support varied substantially within the groups and was 23.5 days in the IL group (range: 0-2033 days), 54.5 days in those having an MIIL (range: 0-308 days; P≤0.001) and 57.0 days among patients in the MIMK group (range: 0-538 days; P≤0.022). There was no difference in the risk of losing at least 10% of the preoperative weight at 3 or 6 months postoperatively between the groups. However, in patients who suffered severe complications (Clavien-Dindo score≥IIIb) after MIIL, there was a nonsignificant trend toward a lower risk of a 10% or greater weight loss, 3 months postoperatively. In conclusion, the greater surgical trauma associated with the traditional open esophagectomy was not followed by more severe weight loss, or other signs of poorer nutritional recovery, when compared to minimal invasive surgical techniques.

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.

Comparison of the short-term clinical outcome between open and minimally invasive esophagectomy by comprehensive complication index.

Esophagectomies are associated with high mortality and various complications. Previous studies reported on the short-term outcomes were heterogeneous and inconsistent in comparing minimally invasive esophagectomy (MIE) with traditional open esophagectomy (OE). The objective of this study is to compare the short-term outcomes between MIE and OE calculated using Comprehensive Complication Index (CCI) which incorporates all complication severities. We did expertise-based randomized controlled trial from September 2014 to October 2015. A total of 144 patients with resectable cancer were randomly selected to be treated by OE or MIE. The CCI was calculated using the Clavien-Dindo classification grade of all postoperative complications collected. Demographic characteristics, preoperative clinical assessment, postoperative complications, and CCI of patients were compared between both groups. Among the 144 patients included in this study, 97 underwent OE and 47 underwent MIE. Demographics, preoperative clinical assessment, and inpatient mortality in both cohorts were almost identical. Eighty-four patients (86.6%) of OE group and 26 patients (55.3%) of MIE group suffered from complications. A significant difference was observed in blood transfusion (P = 0.04), moderate and severe pain (P < 0.01), and diarrhea (P = 0.03) between two groups. There was an obvious statistical significance of CCI between OE and MIE groups (P = 0.036). The CCI is a promising scoring system that could be used to assess the severity of complications after esophagectomy. MIE could improve the short-term outcomes by reducing some mild and moderate complications.

Evaluation and patient selection for minimally invasive esophagectomy

Minimally invasive esophagectomy (MIE) is an evolving surgical alternative to traditional open esophagectomy. Despite considerable technical challenges, it was considered that MIE could be performed effectively by surgeons experienced in open esophageal resection and advanced laparoscopic surgery. This chapter illustrates the preoperative evaluation and operative indications of MIE for esophageal cancer. Firstly, a complete history and physical exam is required for counseling on preoperative optimization. Then, the operation can be conducted after standard preoperative work-up includes several parts, such as positron-emission tomography (PET), endoscopic ultrasound (EUS), esophagography and computed tomography (CT). To our knowledge, the operative indications for MIE is now extended due to the rapid development of surgical technique and detailed preoperative evaluation. Limited node invasion and neoadjuvant chemoradiation are not rigorous contraindications for MIE any more. Optimal results require elaborate evaluation, appropriate patient selection and a multidisciplinary team experienced in the management of esophageal cancer.

Effects of minimally invasive esophagectomy vs. traditional open esophagectomy of esophageal carcinoma on the lung function, immune function and stress response

Objective To investigate the effect of minimally invasive esophagectomy (MIE) vs. traditional open esophagectomy on pulmonary function, immune function and stress response in patients with esophageal cancer. Methods Seventy patients with esophageal cancer were randomly divided into the experimental group (37 cases) and control group (33 cases) according to the different treatment methods. The experimental group received minimally invasive laparoscopic surgery, and the control group underwent traditional open surgery. The pulmonary function indexes of the two groups were measured at 1st month after surgery. The immune function and stress response indexes were compared at first and 5th day after surgery. Results There were significant differences in the operation time [(240.86±13.96) vs. (251.15±11.70) min], bleeding volume [(204.84±12.47) vs. (229.69±18.15) ml] and hospital stay [(10.62±1.42) vs. (13.00±1.52) days] between the experimental group and the control group (t=-3.318, -6.739, -6.763, P=0.000, 0.000, 0.001). The VC, FEV, FEV1 and FVC in the minimally invasive group were higher than those in the traditional group (t=3.857, 6.231, 3.608, 3.302, P=0.000, 0.000, 0.001, 0.003). The levels of TNF-α in the experimental group were (3.02±0.47) and (1.35±0.31) mg/ml respectively, which were significantly lower than those in the control group at 1st and 5th day after surgery (t=-3.251, -4.542, P=0.002, 0.000). The level of interleukin (IL)-6 in the experimental group was (216.51±49.19) pg/ml at 1st day after operation, which was lower than that in the control group (t=-2.251, P=0.028). The counts of white blood cells (WBC) and C-reactive protein (CRP) levels in the experimental group at 1st and 5th day after surgery were (12.16±2.00)×109/L and (10.42±1.75)×109/L, and (93.71±18.74) and (23.84±12.09) mg/L respectively. There was no significant difference between the two groups (t=-1.930, -0.278, P=0.058, 0.782; t=-1.841, -0.717, P=0.070, 0.476). The level of cortisol at 1st day after surgery was (862.60±195.83) nmol/L, which was statistically significantly different from that in the control group (t=-2.148, P=0.035). Conclusion As compared with the traditional surgery, the minimally invasive surgery has more advantages about the influence on the changes of pulmonary function and immune function, without obvious harmful effect on the stress response. Key words: Esophageal carcinoma; Minimally invasive; Pulmonary function; Immune function; Stress response

Video-assisted thoracic surgery for esophagectomy: evolution and prosperity

Esophageal cancer is the eighth most commonly diagnosed cancer worldwide and the sixth most common cause of cancer-related death. For esophageal cancer patients without contraindications, esophagectomy remains the vital remedy despite great achievement of adjuvant therapy and neoadjuvant therapy. However, esophagectomy involves two or three compartment dissection, leading to high morbidity and mortality as well as profound decrease in quality of life. Since Dr. Franz Torek successfully conducted the first transthoracic esophagectomy in 1913, various surgical approaches have been established to resect the esophagus and reconstruct the alimentary canal. Facing with the huge trauma caused by traditional open esophagectomy, thoracic surgeons have been making every effort to make esophagectomy minimally invasive. Among these attempts, the emergence and improvement of video-assisted thoracic surgery is the milestone event. Nowadays video-assisted esophagectomy has been performed worldwide and proved to induce less surgical trauma with uncompromised efficiency. This is a review of the pertinent literature regarding this technique.

Combined thoracoscopic-laparoscopic esophagectomy versus open esophagectomy: a meta-analysis of outcomes.

At present there is controversy regarding the optimal surgical method for esophageal cancer. Specifically, whether combined thoracoscopic-laparoscopic esophagectomy is superior to open esophagectomy with respect to the surgical wound, perioperative morbidities and mortality, and the overall survival rate is of great concern. This article aimed to compare thoracoscopic-laparoscopic esophagectomy versus open esophagectomy on the perioperative morbidities and long-term survival. PubMed, Embase, and Google Scholar databases were searched for relevant studies comparing combined thoracoscopic-laparoscopic esophagectomy with open esophagectomy using the Preferred Reporting Items for Systemic Reviews and Meta-Analyses standards. Odds ratios were extracted to give pooled estimates of the perioperative effect of the two surgical procedures. Hazard ratios were extracted to compare overall survival between the two surgical procedures. Thirteen studies involving 1549 patients were included in this meta-analysis. We found that patients that underwent combined thoracoscopic-laparoscopic esophagectomy had lower total complication rates (relative risk 1.20; 95% CI 1.08-1.34; p=0.0009), wound infection rates, pulmonary complications, and less intraoperative blood loss. Moreover, our study also showed combined thoracoscopic-laparoscopic esophagectomy did not compromise the 5-year survival rate (hazard risk 0.920; 95% CI 0.720-1.176; p=0.505) and even improved 2-year survival rate. The 30-day mortality and other common morbidities, including anastomotic leakage, anastomotic stricture, pulmonary infection, chylothorax, arrhythmia, or recurrent laryngeal nerve injury, were not significantly different between combined thoracoscopic-laparoscopic esophagectomy and traditional open esophagectomy (p>0.05). Combined thoracoscopic-laparoscopic esophagectomy is a feasible and reliable surgical procedure that can achieve uncompromising long-term survival rates and reduce perioperative complications.

Minimally invasive esophagectomy

The application of minimally invasive esophagectomy in the treatment of esophageal carcinoma has drawn much attention. At present, results of quite a number of clinical researches show that minimally invasive esophagectomy is helpful to reduce trauma and complications of esophageal surgery, especially cardiopulmonary complications with shorter length of hospital stay. However, there are still controversies on resection extent, lymph node dissection and survival as compared to traditional open esophagectomy. This paper discusses the minimally invasive esophagectomy on the telescopic esophagectomy of primary lesion, lymph node dissection and survival based on the worldwide reports of telescopic esophagectomy researches.

Video-assisted thoracolaparoscopic esophagectomy: the experience of Shanghai Chest Hospital.

The traditional open esophagectomy is associated with higher morbidity, while minimally invasive procedures could be accompanied with a lower one. In this case, the patient is placed in the prone-decubitus position and the surgeon stands in front of the patient. The "four ports" approach is adopted in the thoracoscopic procedure with CO2 insufflation, and the esophagus and lymph nodes are dissected. In the laparoscopic procedure, "hand assistant technique" is employed. The esophagogastric anastomosis is similar with McKeown procedure.

Experience with minimally invasive esophagectomy

Minimally invasive esophagectomy (MIE) is an evolving surgical alternative to traditional open esophagectomy. Despite considerable technical challenges, it was hypothesized that MIE could be performed effectively by surgeons experienced in open esophageal resection and advanced laparoscopic surgery. The authors report their experience with 25 patients who underwent MIE for esophageal disease. A multidisciplinary esophageal cancer team evaluated all the patients enrolled in this institutional review board-approved retrospective review study. Over an 18-month period, 25 consecutive patients (22 men and 3 women; mean age, 62 years; range, 48-77 years) with resectable esophageal cancer underwent MIE. Six patients were treated with neoadjuvant chemoradiotherapy. The preoperative diagnoses were adenocarcinoma (64%, n = 16), high-grade dysplasia (20%, n = 5), and squamous cell cancer (16%, n = 4). The outcomes evaluated included operative course, hospital and intensive care unit lengths of stay, pathologic stage, morbidity, and mortality. Two patients required conversion to open esophagectomy. Operative mortality was 4% (n = 1). The mean operative time was 350 min (range, 300-480), and the average blood loss was 200 ml. The patients remained ventilated for a median of 12 h, and the median intensive care unit utilization was 1 day. The median hospital length of stay was 9 days (range, 6-33 days). Major complications occurred in 32% of the patients. The anastomotic leak rate was 12%. Minor pulmonary complications occurred in 32% and atrial fibrillation in 16% of the patients. An anastomotic stricture developed in 24% of all the patients. One patient showed a positive proximal margin in the final pathology results. Minimally invasive esophagectomy is a technically challenging procedure that can be performed safely at the Virginia Piper Cancer Institute. Optimal results require appropriate patient selection and a multidisciplinary team experienced in the management of esophageal cancer.