Evaluation of indocyanine green tracheobronchial fluorescence (ICG-TBF) via nebulization during minimally invasive esophagectomy.

Surgical manipulation of the tracheobronchial complex is a contributing factor in pulmonary morbidity of esophagectomy. Accurate dissection between membranous trachea and bronchi with esophagus is essential. This study tests the feasibility of delivering indocyanine green (ICG) in an aerosol form to achieve tracheobronchial fluorescence (ICG-TBF). Patients with esophageal and esophagogastric junction carcinoma (N = 37) undergoing minimally invasive esophagectomy (McKeown type) were included. ICG was aerosolized by nebulization in supine position before thoracoscopy. ICG-TBF was observed with real-time fluorescence-enabled camera. Intra- and postoperative complications related to ICG were the primary focus. ICG-TBF was identified in 94.6% (35/37) of patients with median time to fluorescence identification of 15 minutes (range 1-43). There were no airway injuries in the study. The ICU median stay was 2 (range 2-21) days. No intra- or postoperative complications attributable to ICG were observed. Grade 3 or 4 pulmonary complications were seen in total 8.1% patients. No 90-day postoperative mortality was seen. ICG delivered in aerosol form was found to be safe and effective in achieving ICG-TBF. It aided in accurate dissection of esophagus from the tracheobronchial complex. Further studies on effect of ICG-TBF in decreasing pulmonary complications of esophagectomy are needed.

Factors associated with pathologic complete response following neoadjuvant chemoradiation and esophagectomy for carcinoma of esophagus and gastroesophageal junction.

BACKGROUND AND OBJECTIVES: The aim of this study was to analyze factors associated with pathologic complete response (pCR) following neoadjuvant chemoradiation (NCRT) and esophagectomy for carcinoma of the esophagus (EC) and gastroesophageal junction (GEJ). METHODS: Patients with EC and GEJ tumors who received NCRT and underwent esophagectomy between January 2010 to March 2021 were included. Univariate and multivariate analyses were performed to evaluate the factors associated with pCR by comparing the patients who achieved pCR (pCR group) with those who did not achieve pCR (non-pCR group). RESULTS: A total of 321 patients were included in the study, with squamous cell carcinoma (SCC) accounting for the majority of cases (76%). One hundred and sixty (49.8%) patients had pCR. SCC histology and pretreatment radiographic node-negative status (cN0) were associated with pCR. Patients in the pCR group had significantly better overall and disease-free survival compared with patients in the non-pCR group. CONCLUSIONS: SCC histology and pretreatment radiographic node-negative status were associated with pCR. For patients with tumors of EC and GEJ who received NCRT and underwent esophagectomy, pCR was associated with improved prognosis compared with those not achieving pCR.

Impact of fluorescent thoracic duct lymphography via intranodal approach in minimal access esophageal cancer surgery.

PURPOSE: Chyle leak resulting from thoracic duct (TD) injury poses significant morbidity and mortality challenges. We assessed the feasibility of using near-infrared (NIR) indocyanine green (ICG) imaging for intraoperative fluorescence TD lymphography during minimal access esophagectomy (MAE) in a semiprone position with inguinal nodal injection of ICG dye. METHODS: Ninety-nine patients with esophageal or gastroesophageal junctional cancer undergoing MAE received inguinal node injections of 2.5 mg ICG dye (total 5 mg) under sonographic guidance during anesthesia induction. Stryker's 1688 AIM HD system was used in 76 cases, Karl Storz OPAL 1 S in 20, and in three cases the Karl Storz Rubina. RESULTS: In 93 patients (94%), the TD was clearly delineated along its entire length; it was not visualized in 6 patients (6%). Fluorescence guidance facilitated TD ligation in 16 cases, while 3 cases required clipping of duct tributaries for oncological considerations. Twenty-eight patients exhibited minor duct variations. Fluorescence was sustained throughout surgery (median observation time 60 min post-injection; range 30-330). No patient experienced any chyle leak within 30 days post-surgery and no adverse reactions to ICG was evident. CONCLUSIONS: Intraoperative fluorescence TD lymphography using ICG during MAE in a semiprone position with inguinal nodal injection proved safe, feasible, and effective, allowing clear visualization of the TD in almost all cases. This approach aids safe ligation and reduces chyle leak risk. It offers real-time imaging of TD anatomy and variations, providing valuable feedback to surgeons for managing TD injuries during MAE procedures and represents an excellent educational tool.

Fluorescence-guided cancer surgery-A new paradigm.

Fluorescence-guided surgery is an emerging and promising operative adjunct to assist the surgeon in various aspects of oncosurgery, ranging from assessing perfusion, identification, and characterization of tumors and peritoneal metastases, mapping of lymph nodes/leaks, and assistance for fluorescence-guided surgery (FGS). This study aims to provide an overview of principles, currently available dyes, platforms, and surgical applications and summarizes the available literature on the utility of FGS with a focus on abdomino-thoracic malignancies.

Influence of neoadjuvant therapy on outcomes in patients with resectable carcinoma of esophagus and gastro-esophageal junction from a tertiary cancer care center in India.

BACKGROUND AND OBJECTIVES: The aim of this study is to compare the outcomes of neoadjuvant chemotherapy (nCT), neoadjuvant chemoradiotherapy (nCRT) followed by surgery to upfront surgery (surgery alone) in patients with resectable carcinoma of the esophagus (esophageal cancer [EC]), and gastro-esophageal junction (GEJ) in a limited resource setting. METHODS: A retrospective analysis of a prospectively maintained database was performed to identify patients (from January 2010 through December 2016) who underwent surgery for EC and GEJ cancers. RESULTS: A total of 454 patients were included and categorized into the following groups: nCT (n = 65), nCRT (n = 152) and upfront surgery (n = 237). Squamous cell carcinoma and adenocarcinoma accounted for two-thirds and one-third of the cases, respectively. nCRT group patients were also noted to have smaller tumors, lower margin positivity and a higher R0 resection rates. With a median follow up of 76 months (35-118 months) improved 5-year overall survival was noted in nCRT group in comparison to nCT and upfront surgery groups (56.5% vs. 34% and 35%, respectively, p = .021). CONCLUSIONS: The results of our study demonstrate the beneficial effect of nCRT for patients with EC and GEJ in a limited resource setting. Further studies are required to analyze and promote the benefits of nCRT in limited-resource settings.

Challenges of cytoreduction in porta hepatis in surgery for advanced ovarian cancer.

Introduction: Advanced ovarian cancer often necessitates aggressive surgical intervention, including cytoreduction of the porta hepatis, which poses significant challenges due to the intricate anatomical structures involved. This surgical video aims to illustrate these challenges and demonstrate effective techniques for clearance of critical structures such as the portal vein (PV), common bile duct (CBD), accessory left hepatic artery (Acc. LHA), obliterated umbilical vein (OUV), inferior vena cava (IVC), and foramen of Winslow. Methods: The surgical procedure depicted in the video involved meticulous dissection and identification of anatomical landmarks to access the porta hepatis. Techniques for safe clearance of the PV, CBD, Acc. LHA, OUV, IVC, and foramen of Winslow were employed and are highlighted in detail. Emphasis was placed on preserving vascular integrity and minimizing intraoperative complications. Conclusions: The video demonstrates the complexities associated with cytoreduction of the porta hepatis in advanced ovarian cancer surgery and offers insights into overcoming these challenges. By utilizing precise surgical techniques and careful anatomical consideration, successful clearance of critical structures can be achieved, thereby optimizing patient outcomes and minimizing postoperative complications. This educational resource provides valuable guidance for surgeons encountering similar challenges in the management of advanced ovarian cancer.

Successful Salvage of Partial Gastric Conduit Necrosis by Primary Anastomosis in a Post-Esophagectomy Patient.

Gastric conduit necrosis is a rare but severe complication of esophageal surgery, often associated with mediastinal sepsis and high morbidity and mortality rates, as well as reduced efficacy of conservative treatments. In most cases, management involves salvage therapy, including fluid resuscitation, antibiotics, aggressive debridement, drainage of infected collections, and proximal esophageal diversion. Primary anastomosis is rarely performed. We describe a successful case wherein we salvaged a patient following a McKeown esophagectomy and gastric pull-up, who developed partial full-thickness necrosis of the gastric conduit postoperatively, along with pleural and mediastinal sepsis. We managed this situation through thoracic debridement, take-down of the anastomosis, resection of the devitalized segment of the conduit, and primary esophagogastric anastomosis. Conduit perfusion was demonstrated using ICG fluorescent angiography. This case illustrates that, once debridement and sepsis control are achieved, a primary anastomosis, if feasible, can be safely performed, potentially avoiding a two-step procedure and a second laparotomy/thoracotomy.

Microvascular reconstruction in salvaging the gastric conduit post-esophagectomy after iatrogenic right gastroepiploic vessel injury.

The preservation of the right gastroepiploic vessels is essential to ensure proper perfusion of the gastric conduit following esophagectomy. The loss of these vessels can lead to conduit ischemia or necrosis, resulting in significant postoperative complications. Traditional approaches such as colonic or jejunal interposition require extensive surgery and multiple anastomoses. In this report, we present our successful experience of salvaging the gastric tube through microvascular reconstruction following iatrogenic injury to the right gastroepiploic vessels in two cases. The first case involved re-anastomosis of the right gastroepiploic vein, while the second case required reconstruction of both the artery and vein during esophagectomy in a single setting. The procedures were performed by an experienced surgical team using microvascular techniques. Both patients had uneventful postoperative courses without any anastomotic leakage or major complications. Adequate perfusion of the salvaged gastric tube was confirmed intraoperatively using indocyanine green fluorescence perfusion imaging. In conclusion, immediate microvascular reconstruction offers a viable solution by restoring perfusion of the gastric tube in cases of right gastroepiploic vessel injury during esophagectomy.

Open total mesometrial resection for cervical cancer.

Introduction: Cervical cancer management often relies on surgical interventions, among which open total mesometrial resection (TMMR) has gained prominence. This abstract gives an insight into the technique of TMMR in the surgical treatment of cervical cancer. TMMR involves precise dissection of the mesometrium surrounding the cervix, aiming for optimal oncological outcomes while minimizing surgical morbidity. Methods or Technique: TMMR entails meticulous dissection of the mesometrium surrounding the cervix, following embryonic planes to ensure complete removal of the primary tumour and associated lymphadenectomy. Access to the abdomen is achieved through either a muscle-cutting transverse or midline abdominal incision. The procedure emphasizes meticulous dissection and removal of the tumour-containing area, with careful attention to preserving vital structures such as the ureters and pelvic autonomic nerves to minimize postoperative complications. Extensive lymphadenectomy, including first and second echelon nodal groups, and in selected cases, third echelon nodes such as lower paraaortic nodes, is performed. Conclusion: TMMR offers several advantages, including precise identification and preservation of vital structures, thorough lymphadenectomy, and favourable oncological outcomes with improved survival rates. Importantly, TMMR allows for the avoidance of radiation therapy in the majority of operable cervical cancer cases. In conclusion, TMMR represents a cornerstone in the surgical management of cervical cancer, striking a balance between oncological efficacy, radiation avoidance, and preservation of patients' quality of life.

Feasibility and efficacy of indocyanine green in monitoring systemic drug leakage during isolated limb perfusion for recurrent melanoma of extremity.

Melanoma is known for its high metastatic potential and aggressive growth. Recurrence is common post-surgery, sometimes leading to unresectable disease. Locally recurrent unresectable melanoma of extremity has been treated with high-dose anticancer chemotherapy via isolated limb perfusion (ILP) to improve local efficacy of drug and salvage limbs. Standard ILP monitoring uses radiolabeled dyes, requiring specialized personnel and involving radiation exposure. In this case, we used indocyanine green (ICG) to track systemic drug leakage during ILP. A 47-year-old gentleman with recurrent malignant melanoma of the left foot, operated twice earlier and treated with adjuvant pembrolizumab, presented with multiple in-transit metastases in the limb. ILP was planned, with 5 mg ICG administered in the perfusion solution along with high-dose melphalan. Stryker's SPI PHI handheld device was employed to visualize ICG during ILP. Absence of fluorescence beyond the involved extremity, such as fingers, ears, and the abdominal wall, indicated no systemic drug dispersion. For control, technetium radiocolloid dye was co-administered, monitored by a precordial gamma probe, confirming no systemic leakage, and validating effectiveness of ICG in leakage monitoring. ICG proves to be a safe, reliable, cost-effective, radiation-free approach for precise systemic drug leakage monitoring during ILP for recurrent melanoma of extremity.

Current status of indocyanine green fluorescent angiography in assessing perfusion of gastric conduit and oesophago-gastric anastomosis.

Anastomotic leak (AL) remains a significant complication after esophagectomy. Indocyanine green fluorescent angiography (ICG-FA) is a promising and safe technique for assessing gastric conduit (GC) perfusion intraoperatively. It provides detailed visualization of tissue perfusion and has demonstrated usefulness in oesophageal surgery. GC perfusion analysis by ICG-FA is crucial in constructing the conduit and selecting the anastomotic site and enables surgeons to make necessary adjustments during surgery to potentially reduce ALs. However, anastomotic integrity involves multiple factors, and ICG-FA must be combined with optimization of patient and procedural factors to decrease AL rates. This review summarizes ICG-FA's current applications in assessing esophago-gastric anastomosis perfusion, including qualitative and quantitative analysis and different imaging systems. It also explores how fluorescent imaging could decrease ALs and aid clinicians in utilizing ICG-FA to improve esophagectomy outcomes.

Blumer's Shelf on Laparoscopy.

Blumer's shelf indicates metastatic tumor deposit in rectouterine, or rectovesical pouch on digital rectal or vaginal examination, frequently from stomach, pancreatic, colon, or lung cancer. It underscores the need to carry out  a thorough clinical examination. Though it is much discussed and described in the literature, there are hardly any article or image about its appearance  on laparoscopy. We describe a case  of gastric cancer with Blumer's shelf and its appearance on laparoscopy with clinical and radiological correlation.

Thoracic Duct Lymphography by Near-Infrared Indocyanine Green Fluorescence imaging in Thoracic Surgery. A Review.

Near-infrared (NIR) fluorescence imaging with indocyanine green dye (ICG) is an emerging technology in detecting the anatomy of the thoracic duct; hence, it can be useful for the identification of the thoracic duct in real time and prevention of its injury during thoracic surgery. It helps to localize thoracic duct injury, identifying chyle leaks in difficult, recurrent, and refractory cases. This review paper provides insights regarding the current applications, advantages, and potential developments of NIR fluorescence imaging with ICG in recognizing thoracic duct during thoracic surgery.

Pneumomediastinum: A Rare Complication of Epidural Analgesia.

Pneumomediastinum is a rare complication following epidural block using the loss of resistance (LOR) technique with air. It is speculated to result from the opening of potential space connecting the epidural space and the posterior mediastinum via intervertebral foramina through fascial planes. To date, only two cases of pneumomediastinum after epidural block have been reported. An incidental finding of pneumomediastinum two days after the procedure has not been reported before. Epidural block as a cause should be considered among multiple causes while interpreting the imaging of this life-threatening complication in the postoperative period.

Minimally Invasive Esophagectomy the Standard of Care: Experience from a Tertiary Care Cancer Center from India.

For localized esophageal cancer, esophageal resection remains the prime form of treatment but is a highly invasive procedure associated with prohibitive morbidity. Minimally invasive esophagectomy (MIE) by laparoscopic or thoracoscopic approach was therefore introduced to reduce surgical trauma and its associated morbidity. We thereby review our minimally invasive esophagectomy results with short- and long-term outcomes. From January 2010 through December 2016, 459 patients with carcinoma esophagus and gastro-esophageal junction undergoing minimally invasive esophagectomy were retrospectively reviewed. The morbidity, mortality data with short- and long-term results of the procedure were studied. Patients were stratified into two arms based on the approach into minimally invasive transhiatal esophagectomy (MI-THE) and minimal invasive transthoracic esophagectomy TTE (MI-THE). Thirty days mortality in the whole cohort was 3.5% (2.5% in MI-THE vs. 5% in MI-TTE arm). Anastomotic leak rates (5 vs. 4.9%), median intensive care unit (ICU) stay (4 days), hospital stay (9 days), were similar between both the approaches. Major pulmonary complications were significantly higher in MI-TTE arm (18.9% vs 12.5%) (p 0.047). Cardiac, renal, conduit-related complication rates, vocal cord palsy, chyle leak, re-exploration, and late stricture rates were similar between the groups. The median number of nodes resected was higher in the MI-TTE arm (14 vs. 12) (p 0.002). R0 resection rate in the entire cohort was 89% (87.4% in MI-THE, 92% in MI-TTE arm p 0.12). The median overall survival and disease-free survival were also not different between MI-THE and MI-TTE arms (34 vs. 38 months, p 0.64) (24 vs. 36 months, p 0.67). Minimally invasive esophagectomy either by transhiatal or transthoracic approach is feasible and can be safely accomplished with a low morbidity and mortality and with satisfactory R0 resection rates, good nodal harvest, and acceptable long-term oncological outcomes.

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 56.5 years, 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 9 days 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 15 months post-procedure, and one is doing well at 10 months 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.

Minimal Invasive Esophagectomy-a New Dawn of EsophagealSurgery.

Surgery is the mainstay of esophageal cancer. However, esophagectomy is a major surgical trauma on a patient with high morbidity and mortality. The intent of minimally invasive esophagectomy (MIE) is to decrease the degree of surgical trauma and perioperative morbidity associated with open surgery, and provide faster recovery and shorter hospital stay with the equivalent oncological outcome. It also allows for lesser pulmonary morbidity, less blood loss, less pain, and a better quality of life. MIE is safe and effective but has a steep learning curve with high technical expertise. Recently, it is increasingly accepted and adopted all over the globe. In this article, we discuss the safety, efficacy, short-term, and oncological outcomes of thoracoscopic- and laparoscopic-assisted minimally invasive esophagectomy and robotic surgery compared with open esophagectomy with a special focus on the Indian perspective.

The Utility of Indocyanine Green Angiography in the Assessment of Perfusion of Gastric Conduit and Proximal Esophageal Stump Against Visual Assessment in Patients Undergoing Esophagectomy: a Prospective Study.

Post esophagectomy anastomotic leakage is a crucial factor in determining morbidity and mortality. Good vascularity of the gastric conduit is essential to avoid this complication. This prospective study compares the utility of intraoperative indocyanine green (ICG) fluorescence angiography and visual assessment in assessing the vascularity of gastric conduit and proximal esophageal stump in patients undergoing esophagectomy. Thirteen consecutive patients who underwent esophagectomy for carcinoma middle, lower third esophagus or gastro-esophageal junction from August 2019 to September 2019 were included. Three patients underwent laparoscopic-assisted transhiatal esophagectomy, ten thoraco-laparoscopic-assisted esophagectomy. Reconstruction was done by gastric pull-up via posterior mediastinal route. All patients underwent assessment of perfusion of gastric conduit and proximal esophageal stump by ICG angiography and by visual assessment based on inspection of the color, the palpation of warmth, pulse, and bleeding from the edges. Visual assessment revealed the tip of the gastric conduit was dusky and ischemic in 11 patients, pink and well perfused in two. ICG fluorescence imaging showed inadequate perfusion at the tip of conduit in 12 patients, adequate in one, overall requiring revision in 12 cases. There was a discrepancy in one patient where visual inspection showed adequate perfusion, but ICG disclosed poor vascularity requiring revision of the conduit's tip. Resection of the devitalized portion of the proximal esophageal stump was needed in 5 patients both by visual and by ICG assessment. The median time to appearance of blush from the time of injection of dye was 15 s (10 to 23 s). In all the cases, the pattern of blush was simultaneous, with the concurrent appearance of ICG blush in the gastric conduit and gastro-epiploic arcade. No anastomotic leaks were noted. Visual inspection of the gastric conduit vascularity can underestimate perfusion and hence can compromise resection of the devitalized part. ICG fluorescence imaging is an accurate and promising means to ascertain the vascularity of gastric conduit during an esophagectomy. But its utility needs to be validated in randomized trials.

The Value of Lymphadenectomy Post-Neoadjuvant Therapy in Carcinoma Esophagus: a Review.

Lymph nodal metastasis is one of the most important prognostic factors determining survival in patients with carcinoma esophagus. Radical esophagectomy, with the resection of surrounding lymph nodes, is considered the prime treatment of carcinoma esophagus. An extensive lymphadenectomy improves the accuracy of staging and betters locoregional control, but its effect on survival is still not apparent and carries the disadvantage of increased morbidity. The extent of lymphadenectomy during esophagectomy also remains debatable, with many studies revealing contradictory results, especially in the era of neoadjuvant therapy. The pattern of distribution and the number of nodal metastasis are modified by neoadjuvant therapy. The paper reviews the existing evidence to determine whether increased lymph node yield improves oncological outcomes in patients undergoing esophagectomy with particular attention to those patients receiving neoadjuvant therapy.

Operative Challenges with Minimally Invasive McKeown Esophagostomy with Two-Field Lymphadenectomy in a Case of Situs Inversus Totalis with Carcinoma Esophagus: A Case Report with Review of the Literature.

Situs inversus totalis is an uncommon anatomical congenital anomaly characterized by complete transposition of viscera with right-to-left reversal across the sagittal plane. Consequently, surgery in such cases is more technically challenging and requires a complete reorientation of visual-motor coordination skills. We describe a case of a 50-year-old gentleman with locally advanced lower esophagus carcinoma post-neoadjuvant chemoradiotherapy with situs inversus totalis and treated with minimally invasive McKeown esophagectomy using a left thoracoscopic, laparoscopic-assisted and right cervical approach. The operative procedure and difficulties during surgery are highlighted. Minimal invasive esophagectomy is safe and feasible in situs inversus totalis. Recognition of the anatomy with a meticulous preoperative planning is advocated for an uneventful operative intervention.