Transhiatal Esophagectomy For Esophageal Cancer Research Articles

Management of intra-operative tracheal injuries during transhiatal esophagectomy

Background and objective: In transhiatal esophagectomy, iatrogenic injuries to trachea are very uncommon but when it happens it is potentially lethal and has high morbidity. This study aimed to investigate the incidence and outcome of tracheal injuries during transhiatal esophagectomy.
 Methods: The medical records of 608 patients who underwent transhiatal esophagectomy for esophageal cancer from January 2000 to January 2019 were analyzed.
 Results: Out of 608 transhiatal esophagectomy, four (0.66%) patients sustained injuries to major airway. Three injuries occurred during transhiatal and one injury during transcervical part of dissection. All the injuries occurred in trachea proximal to carina. All four injuries were closed primarily, re-enforced by muscle and fascial pledgets.
 Conclusion: Tracheobronchial injury is a rare complication of transhiatal esophagectomy, mostly seen in patients who receive neo-adjuvant therapy or have locally advanced growth with dense adhesions. Its immediate recognition and closure decreases the mortality and morbidity associated with this rare but fatal intra-operative complication. It can be managed effectively by primary closure, with or without muscle and fascial pledget reinforcement.
 Ibrahim Med. Coll. J. 2021; 15(1): 26-30

Long-Term Quality of Life Following Transthoracic and Transhiatal Esophagectomy for Esophageal Cancer

BackgroundThe impact of transthoracic (TTE) and transhiatal esophagectomy (THE) on long-term health-related quality of life (HR-QoL) in patients with distal esophageal or gastro-esophageal junction (GEJ) cancer has been studied with variable results. This study investigates long-term HR-QoL in patients having undergone TTE or THE. MethodsDisease-free patients after TTE or THE for distal esophageal or GEJ cancer with a follow-up > 2 years were included. Patients who visited the outpatient clinic of a tertiary referral center between 2014 and 2018 were asked to complete EORTC-QLQ-C30 and EORTC-QLQ-OG25 questionnaires. Uni- and multivariable linear regression analysis of HR-QoL was performed in all patients and in subgroups of minimally invasive esophagectomy and neoadjuvant therapy. ResultsA total of 132 patients after TTE and 56 after THE were included. When compared with the general population, all patients reported worse HR-QoL in ‘role functioning’ and ‘social functioning’ and in a range of disease- and/or treatment-specific symptoms. The only significant difference between TTE and THE was a better HR-QoL score for “hair loss” following TTE (ß = 29.4,95%CI = -49.108 – −9.671, p = 0.016). Subgroup analysis of minimally invasively operated patients showed better scores in “physical functioning” following TTE (ß = 13.8,95%CI = 2.755–24.933, p = 0.030). No significant differences in HR-QoL were found between TTE and THE after neoadjuvant therapy. ConclusionLong-term HR-QoL is largely comparable in disease-free patients following TTE or THE for distal esophageal or GEJ cancer. If there were differences between the surgical groups, they were in favor of TTE. These findings may aid in preoperative counseling of patients with esophageal or GEJ cancer.

Comparison of end-to-side hand-sewn and side-to-side stapled cervical esophagogastric anastomosis in patients with lower thoracic esophageal cancer undergoing transhiatal esophagectomy: an Iranian retrospective cohort study

BackgroundControversies in terms of efficacy and postoperative advantages surround stapled esophagogastric anastomosis compared with the hand-sewn technique as a treatment for patients with esophageal cancer. The purpose of this study was to compare the clinical outcomes of hand-sewn end-to-side esophago-gastrostomy and side-to-side stapled cervical esophagogastric anastomosis after esophagectomy for the aforementioned patients.MethodsThis retrospective cohort study involved examining the medical records of 433 patients who underwent transhiatal esophagectomy for esophageal cancer from March 2010 to March 2016. All the patients were operated using end-to-side hand-sewn esophago-gastrostomy and side-to-side stapled cervical esophagogastric anastomosis. 409 of the patients received a year’s worth of follow-up evaluations. All the cases were revisited in 2 weeks as well as in four, eight, and 12 months after surgery. The patients were assessed in terms of postoperative outcomes, including reflux symptoms, anastomotic leakage and stricture, and the need for anastomotic dilatation.ResultsHand-sewn anastomosis was carried out in 271 (62.5%) patients, whereas stapled anastomosis was performed in 162 (37.4%) patients. The mean operative times were 214.46 ± 84.33 min and 250.55 ± 43.31 min for the stapled and hand-sewn anastomosis groups, respectively (P = 0.028). The two groups showed no significant differences with respect to stays in intensive care units and hospitals. Postoperatively, 38 (14.67%) cases of anastomotic leakage were detected in the hand-sewn anastomosis group, with incidence being significantly higher than that in the stapled anastomosis group (8 cases or 5.33%; P = 0.002). Anastomotic stricture occurred less frequently in the patients who underwent stapled anastomosis (P = 0.004). Within the one-year follow-up period, the patients treated via hand-sewn anastomosis more frequently required anastomotic dilatation (P = 0.02).ConclusionSide-to-side stapled cervical esophagogastric anastomosis may reduce operation times and decrease the rates of anastomotic leakage, anastomotic stricture, and anastomotic dilatation in patients with lower thoracic esophageal cancer undergoing transhiatal esophagectomy.

Initial management of esophageal anastomotic strictures after transhiatal esophagectomy for esophageal cancer with dilations up to 18-20mm.

Esophageal anastomotic stricture is a well-known complication after transhiatal esophagectomy (THE), but there is limited data regarding the initial management and subsequent outcomes after stricture dilation. There is concern that dilating to larger diameters upon the initial encounter, specifically with high-grade strictures, will lead to increased risk for complications. We therefore reviewed one surgeon's experience with esophageal dilations after THE and provided data and treatment recommendations based upon these findings. A retrospective review of patients who underwent esophageal dilations ≥ 18mm up to 20mm after THE between 2006 and 2019 at our institution was performed. Patient demographics were n = 97, age = 70, 81 males. For all cases, the mean location, length, diameter of the stricture, and number of days from surgery and initial dilation were 20cm, 1.9cm, 6.7mm, and 106days, respectively. Most dilations (79%) occurred within 2weeks to 3months from surgery. 29.9% were dilated up to 18mm, 10.3% were dilated up to 19mm, and 59.8% were dilated up to 20mm upon initial dilation. Even 1-mm-diameter lesions could be safely dilated upon 18-20mm. In this study group there were no complications after endoscopic dilation that required hospitalization or further surgical or endoscopic interventions. These results suggest that early aggressive endoscopic management of esophageal anastomotic strictures after THE can be safely performed.

Esophagectomy for cancer in octogenarians: should we do it?

Inconsistent data exists regarding esophagectomy outcomes in octogenarians undergoing transhiatal esophagectomy for esophageal cancer. A retrospective review was performed for esophagectomy cancer patients between 2000 and 2012 at our tertiary referral center. Outcome data for octogenarians was compared to younger patients aged 20 to 79years. A case-matched group of patients younger than 80years old (n=33) was included based on the Charlson comorbidity index with the octogenarian group (n=33). Endpoints included operative morbidity and mortality as well as short- and long-term survival. Thirty-three octogenarians met inclusion criteria. The median age was 82years, and 79% were male; 76% had adenocarcinoma, 87% had distal esophageal, and 52% had poorly differentiated tumors. Stages 0 through III were observed in 6, 18, 27, and 48% of octogenarians, respectively. Neoadjuvant therapy was administered to 70% of patients, with 48% experiencing downstaging. Transhiatal esophagectomy was performed in 82% of patients, with R0 resection in 94%. The mean hospital stay was 18days, with morbidity and mortality rates 56 and 9%, respectively, not significantly different from 13-day hospital stay, 45% morbidity, and 9% mortality in younger patients. Cardiac, pulmonary, and surgical site complications occurred in 24, 27, and 6% of octogenarians, respectively. Anastomotic leak occurred in 18% and reoperations in 3%. The median, 3-year survival, and 5-year survival were 21months, 55.9%, and 37.1%, respectively. Overall survival was worse for octogenarians (p<0.001). Postoperative mortality, morbidity, and length of stay in octogenarians are comparable to younger patients, while the overall survival is worse. With appropriate patient selection, good outcomes can be accomplished in octogenarians undergoing esophagectomy for cancer.

The benefits and limitations of robotic assisted transhiatal esophagectomy for esophageal cancer.

Robotic-assisted transhiatal esophagectomy (RATE) is a minimally invasive approach to total esophagectomy with less morbidity but equivalent efficacy when compared with the traditional open approach. The robotic platform offers numerous technical advantages that assist with the esophageal dissection, which allows the procedure to be completed without entry into the thoracic cavity. The major criticism of the transhiatal approach is that it forfeits the ability of the surgeon to perform a formal lymphadenectomy, but this does not appear to affect long-term survival.

Transhiatal Esophagectomy for Esophageal Cancer.

Survival for esophageal cancer has improved over the past four decades, probably as a result of a combination of more accurate staging, improved surgical outcomes, advances in adjuvant and neoadjuvant therapies, and the increasing implementation of multimodality treatment. Surgical resection still remains the mainstay in the treatment of localized esophageal adenocarcinoma. Multiple techniques have been described for esophagectomy, which are based on either a transthoracic or transhiatal approach. Despite proponents of each technique touting potential advantages such as superior oncologic resection with more extensive transthoracic lymphadenectomy compared to the relatively limited morbidity and mortality with a transhiatal resection, the superiority of one technique over another is not clear and may be relegated to a topic of historical significance in the era of minimally invasive surgery. With the increased acceptance of neoadjuvant multimodality therapy, both approaches have been shown to have acceptable outcomes. And in the hands of experienced surgeons, both techniques can provide excellent short-term results. Moreover, surgeon and hospital volume have shown to be strongly associated with improved operative morbidity and oncologic outcomes, which may supersede the type of approach selected for an individual patient.

Gastric Tube Motility Patterns in Patients After Esophageal Resection with Gastric Pull-up.

Oral intake after esophagectomy is decreased in about a quarter of the patients, even in the absence of anastomotic or pyloric stenosis and in early-stage disease.1 Dysmotility of the vagotomized gastric tube may be a putative factor for dysphagia. The manometric motor activity of the gastric tube has been scarcely studied in the era of conventional manometry. Some studies showed that the fasting migrating motor complexes may occur late in follow-up in no more than half of the patients,2,3 but the gastric tube was virtually inert after swallowing.4,5 High-resolution manometry gives a detailed view that allows proper study of organs not conventionally studied by standard manometry in identifying the pressure impression of non-contractile anatomy structures, subtle peristalsis and flow obstructions. This technology is probably the most adequate to study the gastric tube after esophagectomy even though no previous studies focused on the topic. Our figure illustrates high-resolution manometry findings in patients eating an unrestricted diet, and without anastomotic stenosis detected at upper endoscopy, that underwent trans-hiatal esophagectomy, gastric pull-up, and pyloroplasty for esophageal cancer. Absence of peristalsis was noticed in all patients, including the cervical esophageal stump. Pressurization of the esophagus proximal to the anastomosis and flow resistance at the level of the anastomosis as well as the thoracic inlet were secondary findings. Figure High-resolution manometric findings of patients who underwent trans-hiatal esophagectomy for esophageal cancer showing: (A) aperistalsis, seen in 100% of the patients, (B) pressurization of the esophagus proximal to the anastomosis (arrow), (C) flow resistance ...

Gastrotracheal Fistula as a Result of Transhiatal Esophagectomy for Esophageal Cancer: An Unusual Complication.

Gastrotracheal fistula following open transhiatal esophagectomy (Orringer's technique) for esophageal cancer is an unusual but lethal complication. Surgical intervention with resection of the fistula tract and primary interrupted suturing of gastric and tracheal orifices using a muscle flap interposition has proved to be a successful method. We report the case of a 73-year-old male with an adenocarcinoma of the distal part of the esophagus, who underwent open transhiatal esophagectomy (Orringer's technique) with gastric tube reconstruction and cervical anastomosis. The patient did not receive induction chemoradiotherapy before the esophagectomy. Two attempts of surgical repair of fistula failed and the patient died. Being aware of warning signs such as dyspnea and respiratory distress accompanied by bilious content in the tracheal tube is helpful in the early detection and treatment of this type of fistula.

P6 Comparison of outcomes following minimally invasive versus transhiatal esophagectomy for esophageal cancer; a case control study

P6 Comparison of outcomes following minimally invasive versus transhiatal esophagectomy for esophageal cancer; a case control study

Outcomes following laparoscopic transhiatal esophagectomy for esophageal cancer

Most published minimally invasive esophagectomy techniques involve a multiple field approach, including laparoscopic and thoracoscopic esophageal mobilization. Laparoscopic transhiatal esophagectomy (LTE) should potentially reduce the complications associated with thoracotomy. This study aims to compare outcomes of LTE with open transhiatal esophagectomy (OTE) and en-bloc esophagectomy (EBE). Retrospective chart review was performed on all patients who had an LTE for cancer between July 2008 and July 2012 at our institution. Data was compared with an historic cohort of patients who underwent OTE and EBE at the same institution from July 2002 to July 2008. There were 33 patients with LTE, compared with 60 patients with OTE and 139 with EBE. The presence of minor operative complications was similar (p=0.36), but major complications were significantly less common in the LTE group (12, 23 and 33%, respectively; p=0.04). The median number of blood transfusions during hospitalization was significantly lower in the LTE group (0, 2.5 and 3, respectively; p=0.005). Median tumor size was significantly smaller (1.5, 2.2, and 3cm, respectively; p=0.03), but the LTE group had a significantly higher percentage of patients with neoadjuvant treatment (39, 14 and 29%, respectively; p=0.008). Median lymph node yield for LTE was lower (24, 36 and 48, respectively; p<0.0001), but the percentage of patients with positive nodes was similar (33, 33 and 39%, respectively; p=0.69). Mortality was equivalent among the groups (0, 2 and 4%, respectively; p=0.38). The median LOS for the LTE group was significantly lower (10, 13 and 15 days, respectively; p<0.0001). Overall survival was not different between the three groups (p=0.65), with median survival at 24 months of 70, 65 and 65%, respectively. LTE can be performed safely with less major complications and shorter hospital stay than open esophagectomy. The reduced lymph-node harvest did not impact overall survival.

Secure hemostasis in transhiatal esophagectomy for esophageal cancer with gauze packing

BackgroundTranshiatal esophagectomy for esophageal cancer implies blind manipulation of the intrathoracic esophagus. We report a secure hemostatic method with gauze packing in transhiatal esophagectomy.MethodsThe gauze-packing technique is utilized for hemostasis just after removal of the thoracic esophagus during transhiatal esophagectomy. After confirming cancer-free margins, the abdominal esophagus and cervical esophagus are transected. A vein stripper is inserted into the oral-side stump of the esophagus and led to exit from the abdominal-side stump of the esophagus. The vein stripper and the oral stump of the esophagus are affixed by silk thread. A polyester tape is then affixed to the vein stripper, as the polyester tape is left in the posterior mediastinum after removal of the esophagus toward the abdominal side. The polyester tape on the cervical side is ligated with gauze and the polyester tape is removed toward the abdominal side. The oral stump of gauze and new additional gauze are affixed. As the first gauze is pulled out from the abdominal side, the second gauze gets drawn from the cervical wound into the mediastinum. The posterior mediastinum is finally packed with gauze and possible bleeding at this site undergoes a complete astriction. The status of hemostasis with the gauze packing is checked by an observation of color and bloodstain on the gauze.ResultsBetween January 2005 and February 2012, 13 consecutive patients with esophageal cancer underwent a transhiatal esophagectomy with the gauze-packing hemostatic technique. Hemostasis at the posterior mediastinum was performed successfully and quickly in all cases with this method, requiring up to four pieces of gauze for a complete hemostasis. Median required time for hemostasis was 1219 (range 1896 to 1293) seconds and estimated blood loss was 20.4 (range 15 to 25) ml during gauze packing.ConclusionsOur technique could minimize bleeding after the removal of the thoracic esophagus. The gauze-packing method is a simple and easy technique for secure hemostasis when performing a transhiatal esophagectomy.

Management of persistent gastroesophageal anastomotic strictures with removable self-expandable polyester silicon-covered (Polyflex) stents: an alternative to serial dilation

A benign gastroesophageal anastomotic stricture occurs in up to 42% of patients after transhiatal esophagectomy for esophageal cancer. Management of anastomotic strictures may require extended periods of serial endoscopic dilation, with significant risk, cost, and inconvenience for the patient. To determine if placement of removable self-expandable polyester silicon-covered (Polyflex) stents (SEPSs) prolonged the interval between endoscopic interventions in the management of persistent anastomotic stricture. Retrospective cohort study. National Cancer Institute designated comprehensive cancer center. Eight patients after a transhiatal esophagectomy referred for management of benign persistent anastomotic strictures. Serial balloon and bougie dilations and SEPS placement. The interval between endoscopic interventions and the number of endoscopic interventions before and after SEPS placement. Over a 365-day period, 13 SEPS were placed in 8 patients with benign persistent anastomotic strictures after a transhiatal esophagectomy. A SEPS placement delayed the interval between endoscopic interventions from a mean of 7 days before stent insertion to 62 days after insertion (P < .008). The median number of preinsertion interventions was 4 and was reduced to 1 after insertion (P < .005). The small number of patients. A SEPS placement did not result in stricture resolution or stabilization after SEPS removal. The SEPS migration rate was much higher in our patients with postesophagectomy anastomotic strictures than previously reported for other types of strictures. However, a SEPS placement did significantly delay the interval between endoscopic interventions in patients with persistent gastroesophageal anastomotic strictures after transhiatal esophagectomy. SEPS placement should be considered as an alternative to continued serial dilation in patients with persistent anastomotic strictures after transhiatal esophagectomy.

Complications following Video-Assisted Transhiatal Esophagectomy for Esophageal Cancer

Background: The aim of the study was to evaluate theclinical safety and usefulness of esophageal dissectionunder laparoscopic monitoring during transhiatal esophagectomyfor esophageal cancer. Patients and Methods:The study group of 115 patients included 102 menand 13 women. The mean age was 57 (range 32-79)years. Tumor histology showed a squamous cell carcinomain 75% and an adenocarcinoma in 25% of cases. Accordingto the American Joint Committee on Cancerclassification, 3 patients were classified as stage I, 19 asstage IIA, 24 as stage IIB, 64 as stage III, and 5 as stageIVA. Mean operating time was 4.5 ± 1 h. Results: Tensignificant intraoperative complications were observed(9 hemorrhages, 1 death). The mean blood loss was 900(range 300-2,100) ml. Postoperative complications occurredin 61% of the patients; the most frequent werepulmonary complications (27%), recurrent laryngealnerve injury (17.4%), anastomotic stricture (14%), andanastomotic leak (10.4%). Early re-laparotomy was performedin 6% of the patients. Hospital mortality rate was9%. Mean hospital stay was 34 (range 5-64) days. Conclusion:Video-assisted transhiatal esophagectomy is auseful method, but does not allow a vision-guided removalof the upper esophagus. The method does notprevent or diminish the number of intra- and postoperativecomplications of esophageal resection.