Transhiatal Resection Research Articles

Transhiatal esophagectomy after major thoracic surgery. Don’t give up too soon!

Transhiatal esophagectomy (THE) involves a partially blunt dissection in the posterior mediastinum with incomplete visualization. The technical feasibility and safety of THE following thoracic surgery is unclear. We retrospectively identified cases of patients(5) who underwent transhiatal esophagectomy following major thoracic procedures. All patients had successful Transhiatal resections of esophageal cancer with minimal intraoperative complications (Table 1). THE is a feasible and safe approach, in experienced hands, for patients with previous thoracic surgeries especially in patients who are not candidates for single lung ventilation.

Analysis of surgical outcomes and risk factors for anastomotic leakage following trans-hiatal resection of esophagogastric junction cancer.

The trans-hiatal lower esophagectomy is considered less invasive than the trans-thoracic esophagectomy for resection of esophagogastric junction (EGJ) cancer. However, the optimal procedure remains controversial and should be determined while considering both oncological and safety aspects. This retrospective study comprised 124 patients that underwent curative resection for EGJ cancer. The study analysis included 93 patients with tumor centers located within 2 cm of the EGJ. Clinicopathological findings and surgical outcomes were compared between patients treated using trans-hiatal and trans-thoracic approaches. Sixty-three patients underwent lower esophagectomy using the trans-hiatal approach (TH-G). The remaining 30 patients underwent esophagectomy using the trans-thoracic approach (TT-E). The TH-G group were older, had a lower prevalence of lymphatic spread, shorter length of esophageal invasion, and shorter operative duration compared to the TT-E group. Although no significant differences in the frequency of postoperative complications, a higher proportion of patients in the TH-G group developed anastomotic leakage (16% vs. 7%, p = 0.33). Univariate and multivariate analyses demonstrated that cardiac comorbidity was an independent risk factor for anastomotic leakage (odds ratio, 5.24; 95% CI, 1.06-25.9; P < 0.05) in TH-G group. Further examination revealed that preoperative cardiothoracic ratio (CTR) with 50% or greater could be surrogate marker as risk factor for anastomotic leakage in TH-G group (35% vs. 7.5%, p < 0.05). The trans-hiatal approach can be used for resection of EGJ cancer. However, special attention should be paid to the prevention of anastomotic leakage in patients with cardiac comorbidities or a large preoperative CTR.

Transhiatal versus transthoracic esophagectomy for esophageal SCC: outcomes and complications

BackgroundTranshiatal esophagectomy (THE) and transthoracic esophagectomy (TTE) are both accepted procedures for esophageal cancer but still the most effective surgical approach continues to be controversial. This study aimed to determine post-operative complications and outcomes of TTE compared with THE.MethodsA retrospective analysis was performed on data of 243 adult patients with resectable esophageal cancer who underwent THE or TTE between December 2016 and October 2018. Demographic data, consisting of preoperative co-morbidities, disease stage, and perioperative morbidity and mortality were collected.ResultsAmong the patients, 99 individuals (40.7%) had a transhiatal resection and 144 (59.3%) had a transthoracic resection. Most patients (83.1%) were above 50 years old with no significant difference between groups (p = 0.297). The frequency distribution of comorbidities was similar in both groups. The most common site of the tumor in TTE group was middle esophagus and in THE group was lower esophagus. The most common complication was recurrence of dysphagia which was more common in THE group without significant difference. The other complications including pulmonary and cardiac events, tracheal and recurrent laryngeal nerve injury, chylothorax and anastomosis stricture did not differ between the groups. The operative mortality within 30 days after the operation was 2.8% with significant difference favored the THE group (THE 0%, TTE 5.2%, p = 0.033).ConclusionBecause of the controversies, the decision on the type of surgical technique in esophageal cancer treatment hinges on patient’s co-morbidities, cancer stage, tumor location and surgeon’s experience.

Laparoscopic transhiatal resection of the lower third of the esophagus for late recurrence of achalasia cardia after laparoscopic esophagocardiomyotomy: a 12-year follow-up

The choice of treatment for recurrence after esophagocardiomyotomy is individual. Repeated esophagocardiomyotomy is appropriate in patients without malignancy and significant deposition of food masses in distal esophagus followed by severe pulmonary complications. Esophagectomy is desirable in case of unadvisable or failed repeated esophagocardiomyotomy. The authors presents laparoscopic transhiatal resection of the lower third of the esophagus (2019) in a patient with recurrent achalasia of the cardia stage 3-4 and cicatricial peptic stricture of the lower third of the esophagus after previous laparoscopic esophagocardiomyotomy with fundoplication (2009). The immediate results of redo surgery and physical status of the patient after 3 years (12-year follow-up) are described.

Neoadjuvant chemoradiotherapy followed by resection for esophageal cancer: clinical outcomes with the 'CROSS-regimen' in daily practice.

SummaryBackground and objectivesSince the first results of the Dutch randomized CROSS-trial, neoadjuvant chemoradiotherapy (CRT) using carboplatin and paclitaxel followed by resection for primary resectable nonmetastatic esophageal cancer (EC) has been implemented as standard curative treatment in the Netherlands. The purpose of this retrospective study is to evaluate the clinical outcomes of this treatment in daily practice in a large academic hospital.MethodsMedical records of patients treated for primary resectable nonmetastatic EC between May 2010 and December 2015 at our institution were reviewed. Treatment consisted of five weekly courses of carboplatin (area under the curve 2) and paclitaxel (50 mg/m2) with concurrent external beam radiotherapy (23 fractions of 1.8 Gy), followed by transthoracic or transhiatal resection. Data on survival, progression, acute and late toxicity were recorded.ResultsA total of 145 patients were included. Median follow-up was 43 months. Median overall survival (OS) and progression-free survival (PFS) were 35 (95% confidence interval [CI] 29.8–40.2) and 30 (95% CI 19.7–40.3) months, respectively, with corresponding 3-year OS and PFS of 49.6% (95% CI 40.4–58.8) and 45.6% (95% CI 36.6–54.6). Acute toxicity grade ≥3 was observed in 25.5% of patients. Late adverse events grade ≥3 were seen in 24.8%, mostly esophageal stenosis.ConclusionNeoadjuvant CRT followed by resection for primary resectable nonmetastatic EC in daily practice results in a 3-year OS of 49.6% (95% CI 40.4–58.8) and PFS of 45.6% (95% CI 36.6–54.6), compared with 58% (51–65%) and 51% (43–58%) within the CROSS-trial. The slightly poorer survival in our daily practice group might be due to the presence of less favorable patient and tumor characteristics in daily practice, as is to be expected in daily practice. Toxicity was comparable with that in the CROSS-trial and considered acceptable.

Laparoscopic Repair of Acute Post-Esophagectomy Diaphragmatic Herniation Following Minimal Access Esophagectomy.

This study's objective was to assess the presentation, incidence, operative approach, and outcomes of acute symptomatic post-esophagectomy diaphragmatic hernia (PEDH), following minimal access esophagectomy (MAE) for esophageal and gastro-esophageal junctional cancer. Between January 2010 and December 2020, all consecutive patients undergoing esophagectomy were retrospectively analyzed. Acute symptomatic PEDH occurred in 4 patients out of 680 consecutive patients undergoing esophagectomy (0.58%) and 636 MAE (0.63%). All patients were men, with a median age of 56.5years, and underwent minimal access transhiatal resection. The presentation was varied; 2 had restlessness, agitation, and tachycardia; one acute respiratory distress; and the last was asymptomatic but had reduced air entry over left hemithorax with unexplained hypoxia. All had transverse colon herniation into the left hemithorax. Herniated viscera were reduced with closure of hiatal defect, 3 underwent laparoscopic repair, and one needed laparotomy. Meshplasty or bowel resection was not required. The median hospital stay was 9days with no perioperative mortality. The major complications (Clavien-Dindo grade ≥ IIIa) occurred in 2 patients. One patient was lost to follow-up, 2 died of disease after a year and 15months post-procedure, and one is doing well at 10months without any relapse of hernia. Acute symptomatic PEDH is a rare complication after transhiatal esophagectomy and mainly occurs in the left hemithorax. The incidence appears to be less than 1% after MAE. Laparoscopic repair is feasible in most cases. We recommend routine assessment of hiatus and tightening of hiatus to snuggly accommodate the gastric conduit.

Outcomes of Patients with Anastomotic Leakage After Transhiatal, McKeown or Ivor Lewis Esophagectomy: A Nationwide Cohort Study

BackgroundAnastomotic leakage has a great impact on clinical outcomes after esophagectomy. It has never been studied whether anastomotic leakage is of equal severity between different types of esophagectomy (i.e., transhiatal, McKeown and Ivor Lewis) in terms of postoperative mortality and morbidity.MethodsAll esophageal cancer patients with anastomotic leakage after transhiatal, McKeown or Ivor Lewis esophagectomy between 2011 and 2019 were selected from the Dutch Upper Gastrointestinal Cancer Audit (DUCA) registry. The primary outcome was 30-day/in-hospital mortality. Secondary outcomes included postoperative complications, re-operation and ICU readmission rate.ResultsData from 1030 patients with anastomotic leakage after transhiatal (n=287), McKeown (n=397) and Ivor Lewis esophagectomy (n=346) were evaluated. The 30-day/in-hospital mortality rate was 4.5% in patients with leakage after transhiatal esophagectomy, 8.1% after McKeown and 8.1% after Ivor Lewis esophagectomy (P=0.139). After correction for confounders, leakage after transhiatal resection was associated with lower mortality (OR 0.152–0.699, P=0.004), but mortality after McKeown and Ivor Lewis esophagectomy was similar. Re-operation rate was 24.0% after transhiatal, 40.6% after McKeown and 41.3% after Ivor Lewis esophagectomy (P<0.001). ICU readmission rate was 24.0% after transhiatal, 37.8% after McKeown and 43.4% after Ivor Lewis esophagectomy (P<0.001).ConclusionThis study in patients with anastomotic leakage confirms a strong association between severity of clinical consequences and different types of esophagectomy. It supports the hypothesis that cervical leakage is generally less severe than intrathoracic leakage. The clinical impact of anastomotic leakage should be taken into account, in addition to its incidence, when different types of esophagectomy are compared by clinicians or researchers.

Thirty years of esophageal cancer surgery in Oulu University Hospital.

BackgroundEsophagectomy is the mainstay of surgical treatment of esophageal cancer, but involves high operative risk. The aim of this study was to review the evolution surgical treatment of esophageal cancer in Northern Finland, with introduction of minimally invasive techniques.MethodsAll elective esophagectomies performed in Oulu University Hospital between years 1987 and 2020 were included. Treatment strategies were compared to current guidelines including staging and use of neoadjuvant therapy, and benchmark values including postoperative morbidity, hospital stay, readmissions and 90-day mortality. Long-term survival was compared to previous national studies.ResultsBetween years 1987 and 2020 a total of 341 underwent an esophagectomy. Transhiatal resection was performed to 167 (49.3%), Ivor Lewis to 129 (38.1%) and McKeown to 42 (12.4%) patients. MIE was performed to 49 (14.5%) patients. During the past four years 83.7% of locally advanced diseases received neoadjuvant treatment. Since 1987, gradual improvements have occurred especially in incidence of pleural effusion requiring additional drainage procedure (highest in 2011–2013 and in last four years 14.0%), recurrent nerve injuries (highest in 2008–2010 29.4% and lowest in 2017–2020 1.8%) and in 1-year survival rate (1987–1998 68.4% vs. 2017–2020 82.1%). No major changes in comorbidity, complication rate, anastomosis leaks, hospital stay or postoperative mortality were seen.ConclusionsEsophageal cancer surgery has gone through major changes over three decades. Current guideline-based treatment has resulted with progressive improvement in mid- and long-term survival. However, despite modern protocol, no major improvement has occurred for example in major complications, anastomosis leak rates or hospital stay.

Robotic esophagectomy: results from a tertiary care Italian center.

There is growing evidence supporting the use of minimally invasive resection in esophageal surgery, mainly due to reduced postoperative morbidity and faster recovery after surgery. In recent years, robot-assisted surgery has shown some potential benefits over conventional laparo-thoracoscopic esophagectomy. The purpose of this study is to report our experience with different esophageal resections with a full-robotic approach for malignant disease. All consecutive patients with resectable esophageal malignancy undergoing robotic esophagectomy over a 6-year time frame by a single surgical team were included in this analysis. Perioperative and clinicopathological outcomes were assessed. A total of 76 patients received robotic esophagectomy. Surgeries included 45 Lewis procedures, 25 McKeown procedures, and six transhiatal resections. There were no intraoperative complications and no conversions occurred. The rate of postoperative morbidity was 41%, while the rate of anastomotic leak was 13%. Overall, eight patients required reintervention. All patients received R0 resection, with a median of harvested lymph nodes of 35. 30-day and 90-day mortality was 3.9 and 7.9%, respectively. Our findings support the safety and oncological efficiency of full-robotic esophagectomy. All procedures of esophageal resection were associated with the expected perioperative morbidity while providing excellent pathological outcomes for patients with malignancy.

Trans-thoracic versus trans-hiatal resection for oesophageal carcinoma: a retrospective comparative study of a single-centre case series

BackgroundOesophageal carcinoma (EC) is the eighth most common cancer. Surgery is the cornerstone of management for resectable EC. Trans-thoracic oesophagectomy (TTE) and trans-hiatal oesophagectomy (THE) are the two most widely practised procedures. Most of the related controversies are centred on both early and late post-operative complications and mortality (in terms of overall survival and cancer-free survival).This was a single-centre, retrospective, comparative study analysing the outcomes of two EC resection methods. All 87 patients underwent surgery by the same surgical team over 13 years. Consequently, 87 oesophagectomies with curative intent were performed and divided into the TTE group (group A = 47) and the THE group (group B = 40).ResultsThe mean patient age was 65.60 ± 6.30 years in the TTE group and 63.48 ± 9.34 years in the THE group. No significant difference was found in operative time, blood loss or duration of stay in the intensive care unit. The duration of hospital stay was significantly different between the THE and TTE groups (17.25 ± 5.92 vs. 12.93 ± 3.44, respectively; P ≤ 0.001). In-hospital mortality was higher in the TTE group (9/47, 19.14%) than in the THE group (5/40, 12.5%) (P = 0.400). The mean survival rate from our series showed the superiority of group A (TTE) (65.56 months) over group B (THE) (45.01 months), with P = 0.146.ConclusionNo high level of evidence suggests the superiority of one surgical procedure over another. The THE procedure is less time-consuming concerning care and follow-up, and most patients were more satisfied and experienced less pain than with the TTE procedure. Both THE and TTE have comparable post-operative anastomotic complications, and they have no significant long-term survival differences.

Current surgical treatment standards for esophageal and esophagogastric junction cancer.

A number of different surgical techniques for the treatment of cancer of the esophagus and the esophagogastric junction have been proposed. Guidelines generally recommend a transthoracic approach for esophageal cancer, including Siewert type I tumors. In tumors of the proximal esophageal third, transthoracic esophagectomy may be extended to a three-field approach, including resection of cervical lymph nodes. However, the choice between transthoracic esophagectomy with intrathoracic anastomosis (Ivor Lewis esophagectomy) and the three-incision approach with cervical esophago-gastrostomy (McKeown esophagectomy) remains controversial, with guidelines varying among different countries. Furthermore, it is commonly accepted that Siewert type III tumors should be treated by extended total gastrectomy with transhiatal resection of the lower esophagus, whereas currently no consensus exists regarding the optimal surgical approach for the treatment of Siewert type II adenocarcinoma. Likewise, there is a major controversy regarding palliative and potentially curative treatment modalities in oligometastatic disease. This review deals with current surgical treatment standards for cancer of the esophagus and the eosphagogastric junction, including discussion of ongoing trials.

Risk Factors and Prognostic Impact of Mediastinal Lymph Node Metastases in Patients with Esophagogastric Junction Cancer.

We retrospectively investigated the risk factors for mediastinal lymph node (MLN) metastasis in esophagogastric junction (EGJ) cancer with an epicenter within 2cm above and below the anatomical cardia, including both adenocarcinoma (AC) and squamous cell carcinoma (SCC). Fifty patients who underwent initial surgery for EGJ cancer from January 2002 to December 2013 were included in this study. We defined metastatic lymph nodes as pathological metastases in resected specimens and recurrence within 2years postoperatively. Thirty-four patients had AC and 16 had SCC; 24 patients underwent transhiatal resection and 26 underwent transthoracic resection. MLN metastasis was observed in 13 patients (26%) regardless of the histological type, 9 of whom had metastasis in the upper and middle mediastinum. Metastasis occurred when the esophageal invasion length (EIL) exceeded 20mm. In addition, 10/13 patients had stage pN2-3 cancer. Multivariable analysis identified EIL ≥ 20mm and stage pN2-3 as significant risk factors for MLN metastasis. The 5-year overall survival was 38% and 65% in the MLN-positive and -negative groups, respectively (p = 0.12). Multivariable Cox regression analysis showed that only stage pN2-3, and not the presence of MLN metastasis, was a significantly poor prognostic factor. MLN metastasis in EGJ cancer may have a close association with the EIL of the tumor, but the presence of MLN metastasis itself was not a poor prognostic factor. The significance and indications for MLN dissection should be clarified in prospective clinical trials.

Long-term oncological outcomes of laparoscopic versus open transhiatal resection for patients with Siewert type II adenocarcinoma of the esophagogastric junction.

Insufficient information is available about the long-term outcomes of patients with Siewert type II adenocarcinoma of the esophagogastric junction (AEG) who undergo laparoscopic transhiatal approach (LTH). Here we evaluated the oncological safety of LTH for patients with Siewert type II AEG compared with the open transhiatal approach (OTH). Subjects included 79 patients with Siewert type II AEG who underwent gastrectomy combined with lower esophagectomy from 2008 to 2018 at our institution. Overall survival (OS), recurrence-free survival (RFS), status of adjuvant chemotherapy, late-phase complications, and recurrence patterns werecompared between the OTH (n = 29) and LTH groups (n = 43). The median observation periods were 60months (6-120months) and 36months (1-88) for the OTH and LTH groups, respectively. The 5-year OS rates were significantly different: 74% (95% CI 71-77%) and 98% (95% CI 97-99) in the OTH and LTH groups (HR 0.10, 95% CI 0.01-0.83), respectively, though the OTH group included more patients with advanced disease. After stratification, according to pathological stage to adjust for selection bias, the 5-year OS and RFS rates were longer, but not significantly different among patients in the LTH group with pStage III (HR 0.42, 95% CI 0.05-3.47; HR 0.47, 95% CI 0.10-2.12, respectively). Recurrence patterns were similar in the both groups. Long-term outcomes of the LTH group were not inferior to those of the OTH group, suggesting the possibility of LTH as a treatment option for selected patients with Siewert type II AEG.

Effect of Radical Surgery for Advanced Adenocarcinoma of Esophagogastric Junction on Perioperative Cellular Cell Immunity

Background: To investigate the perioperative peripheral blood levels of CD4+CD25+ regulatory T cells, programed cell death 1 (PD-1), and lymphocyte activation gene 3 (LAG-3) in patients with advanced Siewert type II adenocarcinoma of esophagogastric junction (AEG). Methods: Patients (n = 102) with advanced Siewert type II AEG underwent open total gastrectomy/proximal gastrectomy with a transhiatal resection of the distal esophagus and lymphadenectomy of the lower mediastinum and the abdominal D2 compartment. Flow cytometry was used to detect CD4+CD25+ T cells, PD-1 and LAG-3 expression on both CD4+ and CD8+ T cells in the peripheral blood of the Siewert type II AEG patients prior to surgery and on postoperative day (POD) 1, 3, 7, and 9. Results: The proportion of CD4+CD25+ T cells rapidly decreased on POD 1, then gradually increased and peaked at POD 7. The proportion of CD4+PD-1+ T cells significantly increased after surgery, reaching a maximum on POD 1, and remained significantly elevated on POD 3 compared to the preoperative day. The proportion of CD8+ PD-1+ and CD4+LAG-3+ T cells gradually increased after surgery and reached a peak at POD 7. The change in proportion of CD8+LAG-3+ T cells in the peripheral venous blood lymphocytes after surgery was not statistically significant. Conclusion: The change in the CD4+PD-1+ T lymphocyte ratio may likely reflect the cellular immunity status of the perioperative period.

PS02.234: POSTOPERATIVE PNEUMONIA AFTER ESOPHAGEAL RESECTION: DO WE NEED PROPHYLCATIC ANTIBIOTICS FOR PREVENTION?

Abstract Background Postoperative pulmonary complications are a common course of serious morbidity after esophageal resection. In literature rates of pneumonia are quoted up to 38%. Recent studies showed that minimally invasive esophagectomy could reduce this to 9 to 15%, but is this the only approach to lower the incidence of postoperative pneumonia? Methods We analysed our data from esophagectomies performed in our department between 2014 to 2017. Only procedures with thoracotomy due to malignancies were included. All patients received a single shot dose of piperacillin/tazobactam repeated after 4 hours during operation. Bronchoscopy was performed intraoperatively with bronchial toilet. Patients at risk (COPD or viscous secretion) recieved antibiotics for further 7 days. If postoperatively elevation of CRP or leucocytes ocurred, thorax CT scan was performed. Only when pulmonary infiltrates were visible pneumonia was diagnosed. Results 151 operations due to esophageal cancer were performed. Extended gastrectomies, minimal invasive esophagectomies with thoracoscopy and transhiatal resections were excluded. Only Ivor-Lewis resectios (108), McKeown resections (8) and colon interpositions (2) were analysed. The all over pneumonia rate was 13,6% (16 patients). The 30 day mortality was 2,5%. None of the patients died due to pneumonia. Conclusion To reduce postoperative pneumonia rates is an important aim in esophageal surgery. Latest data showed that minimally invasive surgery is adequate to achieve this. But not every patient is suitable for this procedure. From our single center experience we could show that also intraopereative bronchial toilet together with prophylactic antibiotic therapy could achieve good results. Disclosure All authors have declared no conflicts of interest.

Laparoscopic transhiatal resection of a large mid-esophageal diverticulum: a case report

This is a description of transhiatal laparoscopic approach for mid-esophageal diverticulum. Traditionally mid-esophageal diverticula are approached by thoracotomy or thoracoscopy, with the laparoscopic technique being reserved for epiphrenic diverticula. A 78-year-old Caucasian female with a secondary dilatative ischemic cardiomyopathy presented with dysphagia, tenderness in the epigastrium and a considerable weight loss. A large mid-esophageal diverticulum was found on barium swallow and confirmed by CT scan. Underlying achalasia was recorded on manometry. The patient underwent diverticulectomy via transhiatal approach, followed by Heller myotomy and Dor fundoplication. Throughout the procedure auxiliary, esophagoscopic image was provided by interventional gastroenterologist due to a very narrow operating field and lack of orientation points. Based on our experience with this case, we propose transhiatal approach as a feasible alternative to thoracoscopy, in particular with patients who suffer from cardiac or pulmonary co-morbidities which make traditional techniques of high risk.

Short-term outcomes after laparoscopic versus open transhiatal resection of Siewert type II adenocarcinoma of the esophagogastric junction.

The potential advantages of laparoscopic surgery (LS) compared with open surgery (OS) for Siewert type II adenocarcinoma of the esophagogastric junction (AEG) have not been fully clarified. This study aimed to assess the feasibility and safety of the laparoscopic transhiatal approach for Siewert type II AEG, and compare the short-term outcomes of LS versus OS for Siewert type II AEG. We retrospectively analyzed 87 consecutive patients with Siewert type II AEG who underwent curative surgery from January 2008 to November 2016. Surgery-related short-term variables were analyzed in LS versus OS. Forty-five patients underwent LS, and 42 underwent OS. Compared with OS, LS was associated with significantly less intraoperative blood loss (11 vs. 408ml, p<0.001) and extended operation time (256 vs. 226min, p=0.001). There was no significant difference between LS and OS in postoperative hospitalization duration (9 vs. 10days, p=0.193) or rate of surgical morbidity (≥grade 3) for complications such as anastomotic leakage (4.4 vs. 4.8%, p=1.000), or pancreatic leakage (4.4 vs. 9.5%, p=0.423), and there were no pulmonary-associated complications in either group. There was no difference between groups in total number of harvested lymph nodes (24 vs. 29, p=0.502), but the number of harvested mediastinum LNs was larger in LS (2 vs. 1, p=0.002). There was no difference between groups in the length of the proximal margin (9 vs. 10mm, p=0.246), and the margins were negative in all cases in both groups. Laparoscopic transhiatal resection for Siewert type II AEG is technically challenging, but appears feasible and safe in technical or short-term oncological aspects when performed by an experienced surgical team. A large-scale prospective study is needed to evaluate long-term outcomes.

Risk Factors for Anastomotic Stricture Post-esophagectomy with a Standardized Sutured Anastomosis.

Benign anastomotic strictures occur frequently after esophagectomy, and impact on postoperative recovery, nutritional status, and quality of life. This large cohort study explored the incidence of stricture after transthoracic (2- and 3-stage) and transhiatal resections with uniform single-layer sutured anastomotic technique, and aimed to identify independent risk factors. Patients undergoing esophagectomy with gastric conduit reconstruction between February 2001 and October 2014 were studied prospectively. Symptomatic anastomotic stricture was defined as dysphagia requiring endoscopic dilatation, and refractory strictures as those requiring >5 dilatations. Multivariable logistic regression was performed to determine factors independently associated with stricture development. Five-hundred and twenty-four patients, 77% with adenocarcinoma, underwent esophagectomy [2-stage, n=328 (62.6%); 3-stage, n=129 (23.3%); transhiatal, n=74 (14.1%)], with an overall inhospital mortality rate of 2.7%. 58.5% of patients received neoadjuvant therapy [chemotherapy only, n=119 (22.7%); chemoradiation, n=188 (35.9%)]. Anastomotic stricture developed in 125 patients (24.5%), was refractory in 20 (3.9%) and required a median of 2 dilatations (range 1-18). On multivariable analysis, ASA grade (P<0.05), cervical anastomosis (P<0.001), and a significant postoperative cardiac event (P<0.05) were independently associated with stricture risk. Refractory strictures were independently associated with anastomotic leak (P=0.01) and transhiatal resections (P<0.001). Benign anastomotic strictures are common, particularly with cervical reconstruction, and after transhiatal resection. Refractory strictures are rare. Where fitness and oncologic equivalence apply, a thoracic anastomosis provides significant advantages compared with a cervical anastomosis in terms of anastomotic stricture risk.

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.

Robotic Transhiatal Esophagectomy in a Community Hospital: Evolution of Technique

Esophageal cancer is an uncommon but highly lethal disease. Surgical resection is the gold standard of treatment for early-stage disease. Traditional surgical approach entailed significant convalescence, hospital stay, and morbidity and mortality. Transhiatal esophagectomy (THE) involves blind dissection of the esophagus with minimal mediastinal lymphadenectomy. Integration of robotic surgery is an alternate platform for minimally invasive approach while maintaining safety and following oncologic principles. We review our technique for minimally invasive THE using robotic technology, demonstrating the safety and efficacy of robotic technology surgery. We present a retrospective review of a single surgeon's data of patients treated with robotic-assisted THE, with a chart review to evaluate pathology, adequacy of surgical resection, nodal harvest, and perioperative course. Robotic THE (rTHE) shows promise as a valid option for esophageal resection, including premalignant and advanced stages of cancer. Adequate transhiatal mediastinal nodal resection can be performed with the robot.