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.

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.

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.

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.

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.

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.

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.

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.

Gingival Angiosarcoma: A Case Report and Clinicopathologic Review of 32 Cases of Primary Gingival Angiosarcoma.

Angiosarcoma is a malignant neoplasm of mesenchymal origin arising from vascular endothelium and most commonly involves extremities. Gingival angiosarcoma is a rare sporadic occurring tumor. We report a case of primary angiosarcoma of gingiva along with a review of 31 cases of primary gingival angiosarcoma reported in literature till 2018. A 30-year-old lady presented with recurrent gingival swelling over central mandible. She had no palpable cervical lymphadenopathy. She underwent central marginal mandibulectomy. Final histological analysis with immunohistochemistry was suggestive of the angiosarcoma of the gingiva. She is 50 months postoperative and doing well.

Flickering diaphragm sign, an indicator of laparoscopy-associated pneumothorax secondary to pleural breach.

During laparoscopic mobilisation of the oesophagus around hiatus in transhiatal oesophagectomy; commonly the pleura is breached causing iatrogenic pneumothorax. Often small breaches in pleura goes unnoticed till the attention is drawn by anaesthetist when pressures drop with building up of end-tidal CO2(etCO2) and other haemodynamic changes occur. We describe the flickering movements of the diaphragm associated with the pleural breach, a useful sign to alert the surgeon and anaesthetist to detect pneumothorax earlier than it is clinically evident.

Uterine Sarcomas: Experience from a Tertiary Cancer Care Center from India.

Uterine sarcomas are uncommon and aggressive tumors comprising 3-7% of all uterine malignancies. The aim is to evaluate clinical presentation, histopathologic pattern, recurrence pattern, and outcome of patients with uterine sarcomas presenting to a tertiary care cancer center over an 8-year period. A total of 11 cases of uterine sarcoma were diagnosed. The median age of patients at presentation was 51 years (range 30-67 years). Six patients had leiomyosarcoma (54.5%), 4 had endometrial stromal sarcoma (36%), and 1 had adenosarcoma (9%). The main presenting symptoms were abnormal vaginal bleeding, low abdominal pain, and white discharge. Median follow-up was 11 months ranging from 3 to 200 months. Median survivals for leiomyosarcoma, endometrial stromal sarcoma, and adenosarcoma were 6.5, 18, and 56 months. The 3- and 5-year survival by Kaplan-Meier survival analysis of the entire cohort was 30 and 20%. The mitotic index, age, adjuvant therapy (chemotherapy, radiotherapy), and performance of pelvic nodal dissection did not impact survival significantly in the patient with leiomyosarcoma. Stage and histology had the strongest bearing on survival and leiomyosarcoma has the worst survival, whereas adenosarcoma had the best prognosis. Adequately powered prospective studies are required to define the role of radiation therapy and chemotherapy in this rare disease.

Short-term Outcomes in Patients with Carcinoma of the Esophagus and Gastroesophageal Junction Receiving Neoadjuvant Chemotherapy or Chemoradiation before Surgery. A Prospective Study.

BACKGROUND: Neoadjuvant chemotherapy (NACT) and neoadjuvant chemoradiotherapy (NACRT) have been demonstrated to improve survival compared to surgery alone in esophageal carcinoma, but the evidence is scarce on which of these therapies is more beneficial, particularly with regard to resectability rates, postoperative morbidity and mortality, and histological responses. OBJECTIVE: This study compares the resectability, pathological response rates, and short-term surgical outcomes in patients with carcinoma of the esophagus or gastroesophageal junction receiving NACT or NACRT prior to surgery. METHODS: Patients with resectable carcinoma of the esophagus or gastroesophageal junction adenocarcinoma, squamous cell carcinoma, and adenosquamous histologies were enrolled in this well-matched prospective non-randomized study. Thirty-five patients were given NACT, and 35 NACRT. In the NACT group, 25 patients received three cycles of three-weekly carboplatin and paclitaxel, and 10 received three cycles of cisplatin/5-fluorouracil, while all the patients in the NACRT group received 41.4 Gy of radiotherapy concomitant with five cycles of weekly paclitaxel and carboplatin-based chemotherapy. RESULTS: Twenty-two patients in the NACT group and 33 patients in NACRT group had resection (P value = 0.0027). The percentage of microscopically margin-negative resection (R0 resection) was similar in both the groups (86% versus 88%). The incidences of surgical and non-surgical complications were similar in both the groups (P=0.34). There was no 30-day mortality. There was a trend toward more pathological complete regression in the NACRT group (P=0.067). The percentage of patients achieving complete tumor regression at the primary site (pT0) was significantly higher in the NACRT group. The down-staging effect on nodal status was similar in both the groups (P=0.55). There was a statistically significant reduction in tumor size in the NACRT group. The median numbers of nodes harvested and positive nodes were similar in both the groups. CONCLUSION: Patients receiving NACRT had better resectability rates and pathological response rates, but similar postoperative morbidity compared to the NACT group.

Anorectal Malignant Melanoma-Defining the Optimal Surgical Treatment and Prognostic Factors.

Patients with anorectal malignant melanoma (ARMM) have a poor prognosis. Optimal surgical treatment is not defined. The aim of the study was to define the surgical treatment for ARMM, to compare the overall survival (OS) of abdomino-perineal resection (APR) and wide local excision (WLE) and to study various prognostic factors. Thirty patients of ARMM were managed, 20 with locoregional disease, 10 metastatic. Of the 20 patients with locoregional disease, 15 underwent APR and 5 WLE. The 1-, 2-, 3-, and 4-year overall survival rates (by Kaplan-Meier survival analysis) in the APR group were 67, 40, 40, and 32%, and in WLE group were 100, 100, 67, and 67% respectively. Median survival for APR and WLE groups were 13 and 36 months and were not significant (p 0.48). Node-negative patients had better survival than node positive in the APR group (56 vs. 13 months) (p 0.017). Patients with tumor size < 2cm, lymphovascular invasion and perineural invasion negative, and margin-negative and with superficial infiltration had a trend toward better survival than their counterparts. WLE gives an equivalent oncological outcome and can be offered for patients with smaller ARMM and APR for locally advanced, larger tumors or as a salvage following recurrence after WLE.