Technical details of video-assisted transcervical mediastinal dissection for esophageal cancer and its perioperative outcome.
ABSTRACT: To reduce pulmonary complications after esophagectomy, the transthoracic procedure should be shortened or totally avoided. Transcervical approach assisted by mediastinoscope for the upper mediastinum may be advantageous for this purpose. We carried out video-assisted transcervical mediastinal dissection (VATCMD) as part of totally non-transthoracic radical esophagectomy. A single-port laparoscopy device was adopted to a small cervical incision and the mediastinum was inflated with a positive pressure of 6 to 10 mmHg. Without assistant's retractor, the upper mediastinum and partially the middle mediastinum were dissected mainly by mediastinoscopic-assisted surgery. Video of the operation is demonstrated with illustrations. We have carried out and reported 17 cases of esophagectomy including VATCMD and its perioperative outcome. Non-transthoracic esophagectomy was completed without conversion to transthoracic procedure in all 17 cases. Procedure-related adverse event was not observed and postoperative course was favorable with a zero occurrence (0%) of recurrent laryngeal nerve palsy, chyle leakage or pulmonary complications. Median number of harvested lymph nodes from the upper mediastinal stations was 10. VATCMD is suggested as a safe and feasible approach for the upper mediastinum in esophagectomy for malignancies. It enabled a totally non-transthoracic radical esophagectomy in combination with a transhiatal approach. Video-assisted transcervical mediastinal dissection is suggested as a safe and feasible approach for the upper mediastinum in esophagectomy for malignancies. It enabled a totally non-transthoracic radical esophagectomy in combination with a transhiatal approach.
Project description:Robotic-assisted esophagectomy has been introduced as a minimally invasive esophagectomy; however, transhiatal esophagectomy with extended lymphadenectomy in the middle retromediastinal field has never been reported so far. We have developed a totally transhiatal robotic manipulation which enables middle retromediastinal lymph dissection. With this method, transthoracic approach, which is associated with risk of lung injury and loss of ventilatory function, can be avoided in radical esophageal cancer surgery. The robotic arms and camera entered the mediastinum passing the hiatus, and the dissection was performed along the medial aspect of the mediastinal pleura, the pericardia, and the aorta. The devices were able to reach the middle mediastinum, and lymph nodes on the bilateral main bronchi and the carina were retrieved by robotic manipulation. We present here our first experience of laparoscopic transhiatal lymphadenectomy of the middle mediastinal field, including a video, which could not have been possible without robotic-assisted surgery.
Project description:<h4>Background</h4>The role of upper mediastinal lymphadenectomy for distal esophageal or gastroesophageal junction (GEJ) adenocarcinomas remains a matter of debate. This systematic review aims to provide a comprehensive overview of evidence on the incidence of nodal metastases in the upper mediastinum following transthoracic esophagectomy for distal esophageal or GEJ adenocarcinoma.<h4>Methods</h4>A literature search was performed using Medline, Embase and Cochrane databases up to November 2020 to include studies on patients who underwent transthoracic esophagectomy with upper mediastinal lymphadenectomy for distal esophageal and/or GEJ adenocarcinoma. The primary endpoint was the incidence of metastatic nodes in the upper mediastinum based on pathological examination. Secondary endpoints were the definition of upper mediastinal lymphadenectomy, recurrent laryngeal nerve (RLN) palsy rate and survival.<h4>Results</h4>A total of 17 studies were included and the sample sizes ranged from 10-634 patients. Overall, the median incidence of upper mediastinal lymph node metastases was 10.0% (IQR 4.7-16.7). The incidences of upper mediastinal lymph node metastases were 8.3% in the 7 studies that included patients undergoing primary resection (IQR 2.0-16.6), 4,4% in the 1 study that provided neoadjuvant therapy to the full cohort, and 10.6% in the 9 studies that included patients undergoing esophagectomy either with or without neoadjuvant therapy (IQR 8.9-15.8%). Data on survival and RLN palsy rates were scarce and inconclusive.<h4>Conclusions</h4>The incidence of upper mediastinal lymph node metastases in distal esophageal adenocarcinoma is up to 10%. Morbidity should be weighed against potential impact on survival.
Project description:BACKGROUND:Adenocarcinoma of the gastroesophageal junction (GEJ) Siewert type II can be resected by transthoracic esophagectomy or transhiatal extended gastrectomy. Both allow for a complete tumor resection, yet there is an ongoing controversy about which surgical approach is superior with regards to quality of life, oncological outcomes and survival. While some studies suggest a better oncological outcome after transthoracic esophagectomy, others favor transhiatal extended gastrectomy for a better postoperative quality of life. To date, only retrospective studies are available, showing ambiguous results. METHODS:This study is a multinational, multicenter, randomized, clinical superiority trial. Patients (n = 262) with a GEJ type II tumor resectable by both transthoracic esophagectomy and transhiatal extended gastrectomy will be enrolled in the trial. Type II tumors are defined as tumors with their midpoint between ?1?cm proximal and ? 2?cm distal of the top of gastric folds on preoperative endoscopy. Patients will be included in one of the participating European sites and are randomized to either transthoracic esophagectomy or transhiatal extended gastrectomy. The trial is powered to show superiority for esophagectomy with regards to the primary efficacy endpoint overall survival. Key secondary endpoints are complete resection (R0), number and localization of tumor infiltrated lymph nodes at dissection, post-operative complications, disease-free survival, quality of life and cost-effectiveness. Postoperative survival and quality of life will be followed-up for 24?months after discharge. Further survival follow-up will be conducted as quarterly phone calls up to 60?months. DISCUSSION:To date, as level 1 evidence is lacking, there is no consensus on which surgery is superior and both surgeries are used to treat GEJ type II carcinoma worldwide. The CARDIA trial is the first randomized trial to compare transthoracic esophagectomy versus transhiatal extended gastrectomy in patients with GEJ type II tumors. Several quality control measures were implemented in the protocol to ensure data reliability and increase the trial's significance. It is hypothesized that esophagectomy allows for a higher rate of radical resections and a more complete mediastinal lymph node dissection, resulting in a longer overall survival, while still providing an acceptable quality of life and cost-effectiveness. TRIAL REGISTRATION:The trial was registered on August 2nd 2019 at the German Clinical Trials Register under the trial-ID DRKS00016923 .
Project description:<h4>Introduction</h4>Esophagectomy is a challenging procedure associated with considerable morbidity. Previous pulmonary diseases, such as histoplasmosis fungal infection, may interfere in operative and postoperative outcomes after esophagectomy. Anastomotic leakage is one of the most feared complications after esophagectomy. However, new therapies developed such as vacuum procedure and esophageal prosthesis have been provenly beneficial.<h4>Presentation of case</h4>We present a case with squamous cell carcinoma of the mid esophagus portion on a young patient with a pulmonary histoplasmosis history. After a multidisciplinary board, the patient underwent transhiatal esophagectomy with gastric-pull up and cervical anastomosis due to pulmonary disease. The patient later developed an anastomotic leak with mediastinal abscess. We describe this complication's management via an endoscopic vacuum system, esophageal prosthesis, and exhibit a video illustrating the technique.<h4>Discussion</h4>We illustrate the management of esophageal cancer associated with previous pulmonary disease. Histoplasmosis may misunderstand the esophageal cancer staging, and it can contribute to anastomotic leakage occurrence. An endoscopic vacuum system is an excellent tool for treating esophagogastric anastomosis fistula after esophagectomy, even when the drainage is accumulated in the mediastinum. The esophageal prosthesis may be used after mediastinal abscess resolution.<h4>Conclusion</h4>Treatment of the association of esophageal cancer and histoplasmosis is feasible. However, care should be taken to avoid highly potential postoperative complications.
Project description:<h4>Background</h4>Esophagectomy for esophageal cancer carries high morbidity and mortality, particularly in older patients. Transthoracic esophagectomy allows formal lymphadenectomy, but leads to greater perioperative morbidity and pain than transhiatal esophagectomy. Epidural analgesia may attenuate the stress response and be less immunosuppressive than opioids, potentially affecting long-term outcomes. These potential benefits may be more pronounced for transthoracic esophagectomy due to its greater physiologic impact. We evaluated the impact of epidural analgesia on survival and recurrence after transthoracic versus transhiatal esophagectomy.<h4>Methods</h4>A retrospective cohort study was performed using the linked Surveillance, Epidemiology and End Results (SEER)-Medicare database. Patients aged ?66 years with locoregional esophageal cancer diagnosed 1994-2009 who underwent esophagectomy were identified, with follow-up through December 31, 2013. Epidural receipt and surgical approach were identified from Medicare claims. Survival analyses adjusting for hospital esophagectomy volume, surgical approach, and epidural use were performed. A subgroup analysis restricted to esophageal adenocarcinoma patients was performed.<h4>Results</h4>Among 1,921 patients, 38% underwent transhiatal esophagectomy (n = 730) and 62% underwent transthoracic esophagectomy (n = 1,191). 61% (n = 1,169) received epidurals and 39% (n = 752) did not. Epidural analgesia was associated with transthoracic approach and higher volume hospitals. Patients with epidural analgesia had better 90-day survival. Five-year survival was higher with transhiatal esophagectomy (37.2%) than transthoracic esophagectomy (31.0%, p = 0.006). Among transthoracic esophagectomy patients, epidural analgesia was associated with improved 5-year survival (33.5% epidural versus 26.5% non-epidural, p = 0.012; hazard ratio 0.81, 95% confidence interval [0.70, 0.93]). Among the subgroup of esophageal adenocarcinoma patients undergoing transthoracic esophagectomy, epidural analgesia remained associated with improved 5-year survival (hazard ratio 0.81, 95% confidence interval [0.67, 0.96]); this survival benefit persisted in sensitivity analyses adjusting for propensity to receive an epidural.<h4>Conclusion</h4>Among patients undergoing transthoracic esophagectomy, including a subgroup restricted to esophageal adenocarcinoma, epidural analgesia was associated with improved survival even after adjusting for other factors.
Project description:Preoperative mediastinal staging is crucial in the management of patients with non-small cell lung cancer (NSCLC), especially to define prognosis and the most proper treatment. To obtain the highest certainty level before lung resection, the current American and European guidelines for preoperative mediastinal nodal staging for NSCLC recommend getting tissue confirmation of regional nodal spread in all cases except in patients with small (?3 cm) peripheral carcinomas with no evidence of nodal involvement on computed tomography (CT) and positron emission tomography (PET). We have a wide variety of surgical methods for mediastinal staging that are well integrated in the current preoperative algorithms. Their main indication is the validation of negative results obtained by minimally invasive endoscopic techniques. However, recent studies have reported the superiority of mediastinoscopy over endosonography methods in terms of accuracy for those tumours classified as clinical (c) N0-1 by CT and PET or with intermediate risk of N2 disease (cN1 and central tumours). Apart from the exploration of the mediastinum, other surgical procedures [parasternal mediastinotomy, extended cervical mediastinoscopy (ECM) and video-assisted thoracoscopic surgery (VATS)] allow the completion of the staging process with the assessment of the primary tumour and metastasis, exploring the lung, pleural cavity, and pericardium when it is required. Transcervical lymphadenectomies represent the evolution of mediastinoscopy and they are already considered the most reliable method for mediastinal staging, mainly in the subgroup of patients in whom endosonography methods have a low sensitivity: tumours with normal mediastinum by CT and PET. In addition to their indication for staging, these procedures have also demonstrated to be feasible as preresectional lymphadenectomy in VATS lobectomy, improving the radicality of the number of lymph nodes and lymph node stations explored, mostly for left-sided tumours for which a complete mediastinal nodal dissection is not always possible by VATS approach.
Project description:INTRODUCTION:The treatment of choice for mediastinal tumours is surgical, with the standard approach being sternotomy. Because of the invasive nature of this procedure, the management of these masses through mini-invasive surgery has become an alternative method. PRESENTATION OF CASE:We report the case of a woman with a mediastinum tumour and a new technique used for resection, through an inframammary left incision, using a Thoratrak rib spreader and Rultract Skyhook retractor assisted by a video. DISCUSSION/CONCLUSION:This approach allows a complete visualization of the mediastinum and total dissection of the tumour safely around vascular and nervous structures. The pain is minimal because there is no real rib spread but instead an anterior displacement of the upper rib. This is the first reported case of resection of a mediastinum tumour by inframammary approach using a Thoratrak rib spreader and Rultract Skyhook.
Project description:BACKGROUND:Considering the poor survival rate of patients with esophageal cancers, mainly due to the disease effects and surgical co morbidities, we have aimed to introduce a new method of Transhiatal Esophagectomy (THE) without mediastinal manipulation for lower third esophageal and cardial cancers. It has suggested that using this technique would decrease mentioned complications. METHODS:In this prospective study, patients with esophageal cancer who referred for surgical treatment have enrolled and undergone to new method of THE, without mediastinal manipulation. Pre and post-operative morbidities as well as the duration of procedure, duration of hospital and ICU stay have recorded. All patients have followed up or 4-40 months. RESULTS:In this study 53 patients with mean age of 55.2+/-10.3 years have undergone esophagectomy, and then in 50 of them the new method has performed. Median operative time and volume of blood loss was 120 minutes and 130 ml, respectively. Median duration of hospital and ICU stay was 7 and 1 day, respectively. There were no Pre-operative mortalities, arrhythmia, hemodynamic instability and mediastinal vessels injury. The most common co morbidities have related to our new method were mediastinal pleura injury, anastomotic leaks and anastomotic narrowing with 20%, 16% and 10% reported rate, respectively. CONCLUSION:The findings of current study have indicated that transhiatal esophagectomy without mediastinal manipulation, has represented a safe and effective method for treatment of lower third esophageal and cardial cancers due to its potential advantages of decreased blood loss, being a less traumatic procedure, minimal cardiopulmonary complications and low rate of hospital mortality.
Project description:Although technical advances in non-invasive and minimally invasive approaches to lung and pleural cancer diagnosis and staging have become more widely available and accurate, surgical techniques remain the gold standard in assessing the extent of loco-regional involvement. Precise surgical staging of lung or pleural tumours is pivotal in the selection of surgical candidates and for predicting survival. In some patients, both mediastinal and pleural exploration may be needed for many different reasons. Transcervical videomediastino-thoracoscopy (VMT) combines simultaneously the exploration of both the mediastinum and the pleural cavities through a single cervical incision, allowing for biopsies or sampling of the mediastinal lymph nodes, lymphadenectomy and pleuropulmonary assessment (mainly pleural effusions, tumour involvement of the visceral and parietal pleura and pulmonary nodules). Thoracic surgeons should be aware of this combined surgical approach and completely familiar with classical indications and technical details of the transcervical approach to the mediastinum and thoracoscopic exploration of the pleural cavities.
Project description:Background: In China, open surgical approaches for esophageal cancer (EC) can be divided into two techniques, the right- and left- transthoracic esophagectomy. Although there is an increasing number of instances that use the right side, the optimal surgical technique remains unclear. Based in a large cancer center with rich experience of both transthoracic side approaches, this study compared the long-term survival of patients treated by these two surgical techniques. Methods: The patients included in this study underwent a right transthoracic esophagectomy (Right, McKeown) or left transthoracic esophagectomy (Left, Sweet, or chest neck dual-incision) for esophageal squamous cell carcinoma (ESCC) between January 2015 and October 2018. The overall survival(OS) rate and perioperative data between the two groups were then retrospectively analyzed. Results: We included 437 patients who underwent Right (n = 202) and Left (n = 235) approaches for ESCC. There was a significantly longer median operative time (250 vs. 190 min, P < 0.001) and longer median postoperative hospital stay (17 vs. 14 days, P < 0.001) in the Right side group. The OS at 5-years was 49.9% in the Right group and 52.45% in the Left group; hazard ratio (HR) (95% CI): 1.002 (0.752-1.337), p = 0.987. Conclusions: For middle thoracic ESCC without suspected lymph node metastasis in the upper mediastinum, the esophagectomy through the Left thoracic approach could achieve the same OS as the Right side, with better short-term outcomes.