Technical feasibility and oncological outcomes of robotic esophagectomy compared with conventional thoracoscopic esophagectomy for clinical T3 or T4 locally advanced esophageal cancer: a propensity-matched analysis.

BACKGROUND: Minimally invasive esophagectomy is the first-line approach for esophageal cancer; however, there has recently been a paradigm shift toward robotic esophagectomy (RE). We investigated the clinical outcomes of patients who underwent RE compared with those of patients who underwent conventional minimally invasive thoracoscopic esophagectomy (TE) for locally advanced cT3 or cT4 esophageal cancer using a propensity-matched analysis. METHODS: Overall, 342 patients with locally advanced cT3 or cT4 esophageal cancer underwent transthoracic esophagectomy with total mediastinal lymph node dissection between 2018 and 2022. The propensity-matched analysis was performed to assign the patients to either RE or TE by covariates of histological type, tumor location, and clinical N factor. RESULTS: Overall, 87 patients were recruited in each of the RE and TE groups according to the propensity-matched analysis. The total complication rate and the rates of the three major complications (recurrent laryngeal nerve paralysis, anastomotic leakage, and pneumonia) were not significantly different between the RE and TE groups. However, the peak C-reactive protein concentration on postoperative day 3, rate of surgical site infection, and intensive care unit length of stay after surgery were significantly shorter in the RE group than in the TE group. No significant differences were observed in the harvested total and mediastinal lymph nodes. The total operation time was significantly longer in the RE group, while the thoracic operation time was shorter in the RE group than in the TE group. There was no significant difference between the two groups in the recurrence rate of oncological outcomes after surgery. CONCLUSION: RE may facilitate early recovery after esophagectomy with total mediastinal lymph node dissection and has the same technical feasibility and oncological outcomes as TE.

Impact of pre-diabetes, well-controlled diabetes, and poorly controlled diabetes on anastomotic leakage after esophagectomy for esophageal cancer: a two-center retrospective cohort study of 1901 patients.

BACKGROUND: Diabetes is known to be associated with anastomotic leakage (AL) after esophagectomy. However, it is unknown whether well-controlled diabetes is also associated with AL. METHODS: We conducted a two-center retrospective cohort database study of patients who underwent oncological esophagectomy (2011-2019). Patients were divided into four groups: normoglycemia, pre-diabetes, well-controlled diabetes (hemoglobin A1c [HbA1c] < 7.0%), and poorly controlled diabetes (HbA1c ≥ 7.0%). The occurrence of AL and length of stay were compared between groups using multivariable analyses. The relationship between categorical HbA1c levels and AL was also investigated in patients stratified by diabetes medication before admission. RESULTS: Among 1901 patients, 1114 (58.6%) had normoglycemia, 480 (25.2%) had pre-diabetes, 180 (9.5%) had well-controlled diabetes, and 127 (6.7%) had poorly controlled diabetes. AL occurred in 279 (14.7%) patients. Compared with normoglycemia, AL was significantly associated with both well-controlled diabetes (odds ratio 1.83, 95% confidence interval [CI] 1.22-2.74) and poorly controlled diabetes (odds ratio 1.95, 95% CI 1.23-3.09), but not with pre-diabetes. Preoperative HbA1c levels showed a J-shaped association with AL in patients without diabetes medication, but no association in patients with diabetes medication. Compared with normoglycemia, only poorly controlled diabetes was significantly associated with longer hospital stay after surgery, especially in patients with operative morbidity (unstandardized coefficient 14.9 days, 95% CI 5.6-24.1). CONCLUSIONS: Diabetes was associated with AL after esophagectomy even in well-controlled patients, but pre-diabetes was not associated with AL. Operative morbidity, including AL, in poorly controlled diabetes resulted in prolonged hospital stays compared with normoglycemia.

Complete response to definitive chemoradiotherapy in unresectable locally advanced esophageal squamous cell carcinoma.

BACKGROUND: Although definitive chemoradiotherapy (CRT) is the standard therapy for patients with unresectable locally advanced esophageal squamous cell carcinoma (ESCC), poor survival has been reported. Although the complete response (CR) rate is strongly correlated with good prognosis, the predictive factors for CR have not been elucidated. METHODS: This registry study aimed to identify predictors of CR to definitive CRT in patients with unresectable locally advanced ESCC. "Unresectable" was defined as the primary lesion invading unresectable adjacent structures such as the aorta, vertebral body, and trachea (T4b), or the regional and/or supraclavicular lymph nodes invading unresectable adjacent structures (LNT4b). RESULTS: Overall, 175 patients who started definitive CRT between January 2013 and March 2020 were included. The confirmed CR (cCR) rate was 24% (42/175). The 2-year progression-free survival (PFS) and overall survival (OS) rates of cCR cases vs. non-cCR cases were 59% vs. 2% (log-rank p < 0.001) and 90% vs. 31% (log-rank p < 0.001), with a median follow-up period of 18.5 and 40.5 months, respectively. Multivariate analysis of clinicopathological factors revealed that tumor length ≥ 6 cm [odds ratio (OR) 0.446; 95% CI 0.220-0.905; p = 0.025] was a predictor of cCR. CONCLUSIONS: Favorable PFS and OS rates were observed in patients with cCR. Tumor length was a predictive factor for cCR.

Prognostic Impact of the Loss of Skeletal Muscle Mass During Neoadjuvant Chemotherapy on Older Patients with Esophageal Cancer.

BACKGROUND: In older adults, skeletal muscle mass is an important factor for health and prognosis. The loss of SMM during neoadjuvant therapy affects the prognosis of patients with locally advanced esophageal cancer. However, information is limited regarding this possibility in older patients. This study aimed to establish the prognostic impact of SMM loss during neoadjuvant chemotherapy on older patients with locally advanced esophageal cancer. METHODS: This was a single-center retrospective cohort study. Patients age 65 years or older had undergone R0 curative esophagectomy after NAC. The skeletal muscle mass index before and after NAC was calculated from computed tomography images. The percentage change in the SMI during NAC (SMI%) was calculated from the SMI before and after NAC. RESULTS: The study analyzed 150 patients with a mean age of 71.1 ± 3.7 years. The mean value of the SMI was 42.7 ± 7.2 cm2/m2 before NAC, and the SMI% was - 6.4% ± 5.9%. The cutoff of SMI% for overall survival was defined by the log-rank test as - 12%. The Cox proportional hazard model showed that major loss of the SMI (≥ 12%) significantly influenced OS (hazard ratio, 2.490; 95% confidence interval, 1.121-5.529; p = 0.025) independently of age, sex, pathologic T and N factors, or treatment regimen. CONCLUSIONS: Major SMI loss has an impact on OS after R0 curative esophagectomy for older patients with locally advanced esophageal cancer.

Prognostic Impact of Postoperative Loss of Skeletal Muscle Mass in Patients Aged 70 Years or Older with Esophageal Cancer.

BACKGROUND: The number of patients with esophageal cancer aged ≥ 70 years with a poor prognosis is increasing. In general patients with esophageal cancer, postoperative loss of skeletal muscle mass (SMM) is a prognostic factor. This study was designed to investigate the prognostic impact of postoperative loss of SMM in patients aged ≥ 70 years with esophageal cancer. METHODS: This study was a single-center, retrospective cohort study. Patients with esophageal cancer who underwent R0 esophagectomy between 2016 and 2020 were included. The percentage postoperative loss of skeletal muscle mass index (SMI%) was calculated using computed tomography images before and at 4 ± 2 months after surgery. RESULTS: The number of subjects in the ≥ 70-year and < 70-year age groups was 166 and 218, respectively. The median SMI% was 5% in all patients; thus, 5% was defined as the cutoff point to define major loss of SMI. Major loss of SMI impacted 3-year overall survival (OS) in the ≥ 70-year age group, independent of age, sex, clinical stage, pathological T and N factors, Charlson comorbidity index, and length of hospital stay (adjusted hazard ratio [HR]: 4.400; 95% confidence interval: 1.202-16.105; P = 0.025). The adjusted HR of major loss of SMI in the ≥ 70-year age group was higher than in the < 70-year age group (adjusted HR: 4.400 vs. 2.388, respectively). CONCLUSIONS: Postoperative loss of SMI in patients with esophageal cancer aged ≥ 70 years more strongly impacted 3-year OS than in patients aged < 70 years.

Long-term clinical outcome after endoscopic resection of esophageal squamous cell carcinoma invading the muscularis mucosae without lymphovascular invasion.

BACKGROUND AND AIMS: Lymph node recurrence (LNR) after endoscopic resection (ER) in patients with esophageal squamous cell carcinoma (ESCC) pathologically invading the muscularis mucosae (pMM) without lymphovascular invasion (LVI) has been reported as non-negligible in the ER guidelines for esophageal cancer by the Japan Gastroenterological Endoscopy Society. However, these data were not regarded as high-level evidence because several retrospective case series were tabulated without sufficient long-term follow-up. Hence, this guideline stated that the administration of additional treatment after ER could not be determined for this population. This study aimed to clarify the long-term clinical outcomes after ER of pMM ESCC without LVI. METHODS: Between January 2009 and November 2017, we enrolled followed patients who underwent ER and were diagnosed with pMM ESCC without LVI with no additional treatments. We retrospectively investigated the cumulative recurrence rate and recurrence-free, overall, and disease-specific survival at 5 years after ER. RESULTS: Eighty-seven patients were enrolled. During the median follow-up period of 64 months (range, 12-117), 3 patients developed lymph node and/or distant recurrence, and 2 of these cases occurred more than 3 years after ER; all 3 patients died of the primary disease. The 5-year cumulative recurrence rate was 4.3%, and the 5-year recurrence-free, disease-specific, and overall survival rates were 88.8%, 98.2%, and 91.7%, respectively. CONCLUSIONS: The long-term outcome for patients with pMM ESCC without LVI was favorable after ER; however, this population had a risk of recurrence directly leading to death. Long-term follow-up is necessary, with attention to the timing of recurrence.

A novel imaging technology to assess oxygen saturation of the gastric conduit in thoracic esophagectomy.

BACKGROUND: Real-time evaluation of blood perfusion is important when selecting the site of anastomosis during thoracic esophagectomy. This study investigated a novel imaging technology that assesses tissue oxygen saturation (StO2) in the gastric conduit and examined its efficacy. METHODS: Fifty-one patients undergoing thoracic esophagectomy for esophageal cancer who underwent intraoperative StO2 endoscopic imaging to assess the gastric conduit for the optimal site of anastomosis were examined. Efficacy of oxygen saturation imaging and patient outcomes were analyzed. RESULTS: All 51 patients underwent esophagectomy without intraoperative problems. Mean StO2 in the gastric tube was highest at the pre-pylorus area and then gradually decreased proceeding toward the tip. StO2 was well preserved in areas supplied by the right gastroepiploic artery but low in other areas. Anastomotic sites were selected based on StO2 imaging and tension considerations; most were located within 3 cm of the end of the right gastroepiploic artery. Three patients developed postoperative anastomotic leakage (5.8%). Mean StO2 at the point of anastomosis was significantly lower in the patients who experienced leakage than in those who did not (P = 0.04). CONCLUSION: Intraoperative endoscopic StO2 imaging is useful in esophageal cancer patients undergoing thoracic esophagectomy to determine the optimal site for anastomosis to minimize the risk of anastomotic leakage.

Real-time detection of the recurrent laryngeal nerve in thoracoscopic esophagectomy using artificial intelligence.

BACKGROUND: Artificial intelligence (AI) has been largely investigated in the field of surgery, particularly in quality assurance. However, AI-guided navigation during surgery has not yet been put into practice because a sufficient level of performance has not been reached. We aimed to develop deep learning-based AI image processing software to identify the location of the recurrent laryngeal nerve during thoracoscopic esophagectomy and determine whether the incidence of recurrent laryngeal nerve paralysis is reduced using this software. METHODS: More than 3000 images extracted from 20 thoracoscopic esophagectomy videos and 40 images extracted from 8 thoracoscopic esophagectomy videos were annotated for identification of the recurrent laryngeal nerve. The Dice coefficient was used to assess the detection performance of the model and that of surgeons (specialized esophageal surgeons and certified general gastrointestinal surgeons). The performance was compared using a test set. RESULTS: The average Dice coefficient of the AI model was 0.58. This was not significantly different from the Dice coefficient of the group of specialized esophageal surgeons (P = 0.26); however, it was significantly higher than that of the group of certified general gastrointestinal surgeons (P = 0.019). CONCLUSIONS: Our software's performance in identification of the recurrent laryngeal nerve was superior to that of general surgeons and almost reached that of specialized surgeons. Our software provides real-time identification and will be useful for thoracoscopic esophagectomy after further developments.

Propensity-Matched Analysis of the Short-Term Outcome of Robot-Assisted Minimally Invasive Esophagectomy Versus Conventional Thoracoscopic Esophagectomy in Thoracic Esophageal Cancer.

BACKGROUND: In this matched-cohort study, we investigated the short-term outcome of robot-assisted minimally invasive esophagectomy (RAMIE) compared with conventional minimally invasive thoracoscopic esophagectomy (MIE) in esophageal cancer patients. METHODS: One hundred eighty-nine patients with thoracic esophageal cancer scheduled to undergo thoracic esophagectomy between 2020 and 2021 were assigned to either RAMIE or MIE. Then, we retrospectively evaluated the postoperative surgical complications between two groups in a propensity-matched analyzation. RESULTS: Based on the propensity-matched score, 50 patients who underwent RAMIE or MIE were selected. Thoracic surgery time in RAMIE/MIE group were 233.1/173.3 min (p < 0.01), respectively. No significant intergroup differences were observed regarding incisional anastomotic leakage (RAMIE group 4.0% vs. MIE group 6.0%) and pneumonia (RAMIE group 8.0% vs. MIE group 12.0%; p = 0.68). The respective incidences of recurrent laryngeal nerve paralysis were 34.0 and 8.0% in the MIE and RAMIE groups, respectively (p < 0.01). In the matched cohort, no differences were observed between the groups in the success accomplishment of the clinical management pathway (RAMIE group 94.0% vs. MIE group 88.0%). CONCLUSIONS: Although patients who underwent RAMIE had longer operation times, the incidence of recurrent laryngeal nerve paralysis was lower than with MIE. Further study in a prospective multi-institutional setting are required to confirm the superiority of RAMIE compared with MIE.

Definitive chemoradiotherapy has comparable survival outcomes to esophagectomy in patients with clinical T1N0M0 esophageal squamous cell carcinoma: real-world data.

BACKGROUND: Recently, the JCOG0502 has shown a comparable efficacy of chemoradiotherapy and esophagectomy in patients with clinical T1N0M0 esophageal squamous cell carcinoma. However, few studies have compared the clinical outcomes of these treatments in esophageal squamous cell carcinoma patients (including elderly patients) based on real-world data. METHODS: This retrospective study determined real-world outcomes in patients who underwent chemoradiotherapy or esophagectomy, including those with clinical T1N0M0 esophageal squamous cell carcinoma, between 2009 and 2017 at the National Cancer Center Hospital East. RESULTS: Among a total of 156 patients, 120 and 36 patients underwent esophagectomy and chemoradiotherapy, respectively; 138, 12 and 6 patients had Eastern Cooperative Oncology Group performance status 0, 1, and 2, respectively; and 33 and 123 patients had clinical tumor depth MM-SM1 and SM2-SM3, respectively. In a median follow-up of 72 months, 5-year progression-free survival and overall survival were respectively 77.0% and 81.5% in the esophagectomy group and 74.4% and 82.6% in the chemoradiotherapy group (P = 0.48 and, P = 0.89). Moreover, no treatment-related death was detected in both groups. In elderly patients (75 years or older), 5-year progression-free survival and overall survival were not significantly different between esophagectomy and chemoradiotherapy groups (5-year progression-free survival: 72.3% vs. 81.8%, P = 0.38; 5-year overall survival: 76.9% vs. 81.8%, P = 0.59). CONCLUSIONS: This real-world study confirms the results of a previous clinical trial, and the present findings support chemoradiotherapy as one of the standard treatment options in patients of all ages with clinical T1N0M0 esophageal squamous cell carcinoma.

Propensity-matched analysis of the efficacy of olanexidine gluconate versus chlorhexidine-alcohol as an antiseptic agent in thoracic esophagectomy.

BACKGROUND: In the present matched-cohort study, we investigated the efficacy of olanexidine gluconate in comparison with chlorhexidine-alcohol as an antiseptic agent in thoracic esophagectomy. METHODS: A total of 372 patients with esophageal cancer who were scheduled to undergo thoracic esophagectomy between 2016 and 2018 were assigned to one of two groups based on the preoperative antiseptic agent used in thoracic esophagectomy. We investigated the incidence of surgical site infectious complications in the propensity-matched cohort. RESULTS: Based on the propensity score, 116 patients prepared with 1.5% olanexidine gluconate and 114 patients prepared with 1.0% chlorhexidine-alcohol as surgical skin antisepsis were selected. No significant intergroup differences were observed with respect to incisional surgical site infection (0.8% in the olanexidine group versus 0.8% in the chlorhexidine group) and deep fascial/organ space surgical site infection (1.7%/10.3% in the olanexidine group versus 3.5%/15.7% in the chlorhexidine group, p = 0.39/p = 0.03). Notably, the respective incidences of surgical site infection except anastomotic leakage were 1.7% and 7.0% in the olanexidine and chlorhexidine groups (p = 0.04). CONCLUSIONS: Olanexidine gluconate was well tolerated and significantly reduced incidence of surgical site infection except anastomotic leakage in comparison with chlorhexidine-alcohol as an antiseptic agent in thoracic esophagectomy with three-field lymph node dissection.

Significance of chemotherapy-free interval and tumor regression grade in patients with recurrent esophageal squamous cell carcinoma receiving chemotherapy with fluorouracil and platinum after esophagectomy following preoperative chemotherapy.

BACKGROUND: In Japan, standard treatment for locally advanced esophageal squamous cell carcinoma (ESCC) includes preoperative chemotherapy with fluorouracil plus cisplatin followed by esophagectomy. However, its efficacy is unclear in patients with recurrent disease with < 6 months of chemotherapy-free interval (CFI) after preoperative chemotherapy followed by esophagectomy and in those with ≥ 6 months of CFI and poor pathological response to prior preoperative chemotherapy. METHOD: We retrospectively evaluated the efficacy of fluorouracil plus platinum in patients with recurrent ESCC who received preoperative chemotherapy followed by curative esophagectomy. RESULTS: Among 105 patients with recurrent ESCC after preoperative chemotherapy followed by esophagectomy, a total of 55 patients received fluorouracil plus platinum for recurrent disease. Patients with a CFI < 6 months (n = 20) had significantly shorter overall survival (OS) (median, 7.1 vs 14.5 months, P = 0.008) compared with those with a CFI ≥ 6 months (n = 35). Multivariate analysis showed that OS was worse in patients with a CFI < 6 months or a tumor regression grade (TRG) ≤ 1a. Furthermore, in patients with a CFI ≥ 6 months, TRG ≤ 1a was associated with significantly shorter OS (11.1 months vs. not reached, P = 0.001). CONCLUSION: Fluorouracil plus platinum was ineffective for recurrent ESCC in patients with a CFI < 6 months and in those with a CFI ≥ 6 months and a TRG ≤ 1a. Alternate regimens including nivolumab or pembrolizumab might be considered for the treatment for recurrence in these patients.

Tumor response and survival outcomes of salvage concurrent chemoradiotherapy with three-dimensional conformal radiotherapy and 5-fluorouracil/platinum-based chemotherapy for postoperative locoregional recurrence of esophageal squamous cell carcinoma.

BACKGROUND: Salvage concurrent chemoradiotherapy is effective against locoregional recurrence after curative resection of esophageal squamous cell carcinoma. However, there is no consensus on its application. We investigated the outcomes of salvage concurrent chemoradiotherapy (60 Gy in 30 fractions) with three-dimensional conformal radiotherapy and 5-fluorouracil/platinum-based chemotherapy. METHODS: We retrospectively investigated the outcomes and prognostic factors in 51 patients with esophageal squamous cell carcinoma treated with salvage concurrent chemoradiotherapy. RESULTS: The median follow-up was 17.5 (range, 2.8-116.1) months. The overall response, complete response, and partial response rates were 74.5%, 49.0%, and 25.5%, respectively. The median progression-free survival was 8.2 months; the 3-year progression-free survival rate was 22.9%. The median overall survival was 23.1 months; the 3-year overall survival rate was 40.7%. Overall survival was significantly longer in patients with a complete response than in those without (median overall survival: not reached vs. 15.3 months); 3-year overall survival rate: 62.5% vs. 20.3% (hazard ratio: 0.222; P < 0.001). Multivariate analysis showed that the independent prognostic factor for overall survival was < 25 mm longest diameter of metastatic lymph nodes (hazard ratio: 3.71). CONCLUSIONS: Salvage concurrent chemoradiotherapy (60 Gy in 30 fractions) with three-dimensional conformal radiotherapy and 5-fluorouracil/platinum-based chemotherapy was an effective and safe treatment for locoregional recurrence after curative resection of esophageal squamous cell carcinoma, especially in those approaching a complete response. Additionally, a shorter longest diameter of metastatic lymph nodes may be associated with better long-term survival.

Long-term clinical outcomes of patients diagnosed with pT1a-muscularis mucosae with lymphovascular invasion or pT1b after endoscopic resection for cT1N0M0 esophageal squamous cell carcinoma.

BACKGROUND: Endoscopic resection (ER) is performed for early esophageal squamous cell carcinoma (ESCC) cases. Additional esophagectomy or chemoradiotherapy is recommended for non-curative resection (NCR) even with pathologically negative vertical margins (pVM0); however, their clinical outcomes remain unknown. We examined the long-term clinical outcomes of NCR for ESCCs according to additional treatments. METHODS: We retrospectively analyzed the data of patients who underwent ER for cT1N0M0 ESCC between 2009 and 2017 judged to have NCR, which defined when pathologically diagnosed as invading the submucosa (SM) or muscularis mucosae (MM) involving lymphovascular invasion (LVI), pVM0, and endoscopically judged as negative horizontal margin. Additional esophagectomy (involving three-field lymphadenectomy), chemoradiotherapy [mainly cisplatin and 5-fluorouracil with concurrent radiotherapy (41.4 Gy)], or observation was undertaken. Thereafter, computed tomography was performed every 6-12 months. The cumulative recurrence (CRR) and recurrence-free survival (RFS) rates were evaluated. RESULTS: Eighty-nine patients were included. Among them, 14 had pathologically diagnosed pMM with LVI; 9 and 6, and 32 and 28 patients had pSM1 and pSM2 without and with LVI. Twenty-one patients underwent observation, whereas 18 and 50 underwent esophagectomy and chemoradiotherapy. During the 60.6-month median follow-up period, nine patients had recurrence; among them, six patients had occurrence at > 4 years after ER. The 5-year CRR/RFS rates were 35.7%/48.1%, 13.4%/80.4%, and 0.0%/98.0% in the observation, esophagectomy, and chemoradiotherapy groups, respectively (observation vs. chemoradiotherapy; P < 0.001). CONCLUSIONS: Additional treatments showed better long-term outcomes than observation for patients with NCR. As recurrence may occur at > 4 years after ER, careful long-term follow-up examinations are needed.

Does staged surgical training for minimally invasive esophagectomy have an impact on short-term outcomes?

BACKGROUND: sophageal cancer has a low incidence, and the anatomy is difficult to understand during esophagectomy. This necessitates a precise and lengthy operation. Therefore, the establishment of a training system in esophageal surgery is of critical importance. In this study, we compared the short-term outcomes of minimally invasive esophagectomy (MIE) performed by consultants versus trainees and explored the factors that impacted the thoracic operation time for each group. METHODS: We have introduced standardized MIE surgical techniques to our trainees in 2016. Our procedure consists of a laparoscopic phase and a thoracoscopic phase and is systematically designed to be learned in a step-by-step manner in each phase. We retrospectively identified 308 patients who underwent MIE from April 2016 to April 2018. The patients were divided into those who underwent MIE by consultants and those who underwent MIE by trainees. The preoperative background factors, operation-related factors, and postoperative complications were compared between the two groups. We also assessed the association between a prolonged thoracic operation time and tumor-and patient-related factors in each of the consults and trainees. RESULTS: Significantly more patients had stage ≥ III cancer in the consultant than trainee group. However, the postoperative complications were comparable, specifically pneumonia (11% vs. 18%), anastomotic leakage (11% vs. 13%), and mortality (0.6% vs. 1.3%). There was no significant difference in the lymph node yield (20 vs. 17) or R0 resection rate (94% vs. 91%) between the two groups. However, the trainees had a significantly longer thoracic operation time (143 ± 34 vs. 190 ± 28 min) and significantly greater blood loss (93 vs. 183 ml). Oncological factors were correlated with a prolonged thoracic operation time in the consultants, but not in the trainees. CONCLUSIONS: Under standardized surgical management using a stepwise educational program, performance of MIE by trainees has no impact on short-term outcomes.

Novel universally applicable technique for performing bilateral transcervical mediastinoscopic-assisted transhiatal laparoscopic esophagectomy: a truly minimally invasive procedure.

BACKGROUND: The procedure of mediastinoscopic-assisted transhiatal esophagectomy (MATE) is only performed in a few institutions, despite this being the ultimate form of minimally invasive surgery for performing esophagectomy for esophageal and esophagogastric cancer in that it entails no chest wall trauma. We have developed a novel, universally applicable, surgical procedure for performing bilateral transcervical mediastinoscopic-assisted transhiatal laparoscopic esophagectomy (BTC-MATLE) that is an improvement on standard MATE surgery for esophageal and esophagogastric cancer. METHODS: The patient is placed in a supine position under general anesthesia with bilateral lung ventilation. BTC-MATLE combined with mediastinoscopic and transhiatal laparoscopic esophagectomy with total mediastinal lymph node dissection are performed synchronously. After lymph node dissection along both recurrent laryngeal nerves through bilateral cervical skin incisions, bilateral transcervical mediastinoscopic esophagectomy is performed to avoid collision outside the cervical region and ensure operability even in patients with narrow mediastimun. Laparoscopic gastric mobilization and subsequent lower esophageal mobilization meet the bilateral transcervical mediastinoscopic esophagectomy at the border of the middle and lower third of the esophagus. The gastric tube is pulled up into the cervical region via a posterior mediastinal route and anastomosed in the neck. RESULTS: BTC-MATLE was performed on 16 high-risk patients (Charlson Comorbidity Index ≥ 3 in 14 patients and two octogenarians with complex comorbidities). Median operation time and postoperative hospital stay were 231 min and 15 days, respectively. R0 resection was achieved in 15 patients (94%), and there were no in-hospital deaths. CONCLUSIONS: BTC-MATLE, a procedure for performing minimally invasive esophagectomy, is likely to become the applicable form of MATE surgery for esophageal and esophagogastric cancer, even in high-risk patients because it is truly minimally invasive and has excellent short-term outcomes.

Robotic esophagectomy with total mediastinal lymphadenectomy using four robotic arms alone in esophageal and esophagogastric cancer (RETML-4): a prospective feasibility study.

BACKGROUND: Robotic-assisted esophagectomy is still in the implementation phase. Robotic surgical systems refine visualization via robotically-enhanced surgical anatomy (RESA), and the stable articulated robotic arms provide precise movements. This prospective feasibility study was conducted to evaluate robotic esophagectomy with total mediastinal lymphadenectomy using four robotic arms exclusively (RETML-4). METHODS: The inclusion criterion was clinical stage I-IIIB esophageal cancer with stable general condition. Patients were positioned hemi-prone with single-lung ventilation, and the operation table was tilted until the patient was prone. The first, second, third, and fourth robotic ports were inserted into the ninth intercostal space (ICS) on the angulus inferior scapulae line, seventh ICS on the posterior axillary line, and the fifth and third ICS on the mid-axillary line, respectively. RETML-4 was performed by precise sharp dissection in wide stable operation fields, with countertraction created by a tip-up fenestrated grasper with gauze. Esophagectomy was performed separately for the middle to lower, and upper esophagus. After mobilizing the middle to lower esophagus and performing lymph node dissection, the upper esophagus was mobilized, with bilateral lymph node dissection along the recurrent laryngeal nerves. The assistant surgeon was involved only during removing gauze and collecting harvested lymph nodes in the thorax. RESULTS: RETML-4 was performed in all ten patients enrolled in 2018. The median postoperative hospital stay was 15 days, and the complication rate was 60%. Nine cases achieved R0 resection. Recurrence occurred in two cases. CONCLUSIONS: RETML-4 is feasible, and may facilitate minimally invasive esophagectomy by providing precise instrument movements and RESA.

Novel minimally invasive approach to lymph node dissection around the left renal vein in patients with esophagogastric junction cancer.

The left renal vein lymph node (LRVLN) may be the extended locoregional node in esophagogastric junction cancer; however, only open-surgical methods of dissection have been reported. We therefore developed a novel minimally invasive laparoscopic method for LRVLN dissection. Following esophagectomy, the stomach was mobilized and LRVLN dissection was started by taping the pancreatic body using two silicone drains. The transverse mesocolon was then retracted through the superior duodenal fossa to expose the horizontal duodenum and permit LRVLN dissection. We carried out the procedure successfully in 17 patients with advanced esophagogastric cancer. The median total and laparoscopic operative times were 415 and 161 min, respectively. Postoperative esophagectomy-related complications occurred in six patients. The median estimated blood loss was 120 ml and hospital stay was 15 days. This minimally invasive laparoscopic LRVLN dissection method was safe and effective, and may support faster recovery and earlier postoperative adjuvant therapy in patients with esophagogastric junction cancer.

Totally Mechanical Collard Technique for Cervical Esophagogastric Anastomosis Reduces Stricture Formation Compared with Circular Stapled Anastomosis.

BACKGROUND: The optimal technique for cervical esophagogastric anastomosis in esophagectomy has not yet been established. Using circular stapled (CS) technique effectively reduces the incidence of anastomotic leakage and shortens the operating time; however, anastomotic stricture has been reported to be more common. The present study was performed to compare the clinical outcomes of the recently developed totally mechanical Collard (TMC) and CS anastomosis. METHODS: We retrospectively reviewed consecutive esophageal cancer cases who are undergoing transthoracic extended esophagectomy with gastric conduit reconstruction using cervical CS or TMC anastomosis from December 2013 to December 2016. Propensity score matching and multivariate regression were used to adjust for differences in baseline characteristics. RESULTS: Among 313 patients, 93 underwent CS anastomosis and 220 underwent TMC anastomosis. Stricture formation occurred in 59 patients (18.8%), significantly more often with the CS than TMC anastomosis (30.1% vs. 14.1%, p = 0.001). No significant differences were observed in the refractory stricture rate (9.7% vs. 5.0%, p = 0.134) or the anastomotic leakage rate (11.8% vs. 10.9%, p = 0.845) between the two groups. The propensity score matching cohort study including 86 pairs of patients confirmed a significantly lower stricture formation rate with the TMC than CS technique (27.9% vs. 14.0%, p = 0.038). In the multivariable analysis, anastomotic leakage, the CS technique, and a body mass index of ≥25 mg/m2 were independently associated with a risk of stricture formation. CONCLUSION: TMC technique contributed to a reduced rate of stricture formation compared with CS technique in cervical esophagogastric anastomosis.

Efficacy of prewarming prophylaxis method for intraoperative hypothermia during thoracoscopic esophagectomy.

BACKGROUND: This study was performed to elucidate the clinical efficacy of the prewarming prophylaxis method for intraoperative hypothermia during thoracoscopic esophagectomy for esophageal cancer. METHODS: We enrolled 100 consecutive patients with esophageal cancer. Two patients in the prewarming group could not undergo thoracoscopic esophagectomy because of conversion to thoracotomy. The intraoperative core temperature was measured in 50 and 48 patients classified into the control and prewarming groups, respectively. Patients in the prewarming group wore a Bair Hugger warming gown (3 M, Maplewood, MN, USA) in the ward for 30 min before entering the operation room. The primary outcome measure was the difference in the intraoperative body core temperature between the control and prewarming groups, and the secondary outcome measure was the difference in postoperative infectious complications between the control and prewarming groups. RESULTS: The intraoperative core temperature was significantly different between the two groups at each 30-min time point from the starting of operation to the ending of the thoracic procedure (P < 0.001). The incidence of infectious surgical complications was not significantly different between the control and prewarming groups (30.0% vs. 14.6%, respectively; P = 0.11). CONCLUSION: The prewarming prophylaxis method was effective for maintaining normothermia during thoracoscopic esophagectomy.