Robot-assisted transcervical esophagectomy with a bilateral cervical approach for thoracic esophagectomy.

BACKGROUND: Thoracic esophageal cancer resection through the neck approach has recently been reported as mediastinoscopic surgery. We present the first report of a new minimally invasive technique for thoracic esophageal cancer: robot-assisted transcervical esophagectomy with a bilateral cervical approach. METHODS: Ten cases of robot-assisted bilateral transcervical esophagectomy performed at the National Cancer Center Hospital East, Japan, from February 2023 to August 2023 were reviewed. The short-term surgical outcomes were presented, and the feasibility and efficacy of this procedure were discussed. RESULTS: The mean operation time for the cervical procedure was 184.2 ± 23.6 min. The total time for the whole procedure was 472.7 ± 28.4 min, and total intraoperative blood loss was 162.2 ± 40.0 ml. Among the 10 cases, one patient developed recurrent nerve paralysis, one patient developed pulmonary complications, and no patients developed postoperative pneumonia. The median postoperative hospital stay was 22 (range: 12-43) days. No patients developed severe postoperative surgical complications, which were graded as Clavien-Dindo ≥ III. The total number of surgically harvested mediastinal lymph nodes was 37.2 ± 11.2. CONCLUSIONS: Robot-assisted bilateral transcervical esophagectomy, a novel procedure for thoracic esophageal cancer, was safe and feasible. Using this procedure, the incidence of recurrent nerve palsy, which is a problem with transcervical esophagectomy and mediastinoscopic esophagectomy, is expected to decrease.

A systematic review and meta-analysis of mediastinoscopy-assisted transhiatal esophagectomy (MATHE).

BACKGROUND: Transhiatal esophagectomy (THE) avoids thoracotomy but sacrifices mediastinal lymphadenectomy. Mediastinoscopy-assisted transhiatal esophagectomy (MATHE) allows for visualisation and en-bloc dissection of mediastinal lymph nodes while retaining the benefits of THE. However, given its novel inception, there is a paucity of literature. This study aimed to conduct the first meta-analysis to explore the efficacy of MATHE and clarify its role in the future of esophagectomy. METHODS: Four databases (PubMed, EMBASE, Scopus, and Cochrane Library) were searched from inception to May 1, 2023. Studies were included if they reported outcomes for patients with esophageal cancer who underwent MATHE. Meta-analyses of proportions and pooled means were performed for the outcomes of intraoperative blood loss, lymph node (LN) harvest, mean hospital length of stay (LOS), mean operative time, R0 resection, conversion rates, 30-day mortality rate, 5-year OS, and surgical complications (anastomotic leak, cardiovascular [CVS] and pulmonary complications, chyle leak and recurrent laryngeal nerve palsy [RLN]). Sensitivity analyses were performed for outcomes with substantial statistical heterogeneity. RESULTS: The search yielded 223 articles; 28 studies and 1128 patients were included in our analysis. Meta-analyses of proportions yielded proportion rates: 30-day mortality (0 %, 95 %CI 0-0), 5-year OS (60.5 %, 95 %CI 47.6-72.7), R0 resection (100 %, 95 %CI 99.3-100), conversion rate (0.1 %, 95 %CI 0-1.2). Among surgical complications, RLN palsy (14.6 %, 95 %CI 9.5-20.4) were most observed, followed by pulmonary complications (11.3 %, 95 %CI 7-16.2), anastomotic leak (9.7 %, 95 %CI 6.8-12.8), CVS complications (2.3 %, 95 %CI 0.9-4.1) and chyle leak (0.02 %, 95 %CI 0-0.8). Meta-analysis of pooled means yielded means: LN harvest (18.6, 95 %CI 14.3-22.9), intraoperative blood loss (247.1 ml, 95 %CI 173.6-320.6), hospital LOS (18.1 days, 95 %CI 14.4-21.8), and operative time (301.5 min, 95 %CI 238.4-364.6). There was moderate-to-high statistical heterogeneity. Findings were robust to sensitivity analyses. CONCLUSION: MATHE is associated with encouraging post-operative mortality and complication rates, while allowing for radical mediastinal lymphadenectomy with reasonable lymph node harvest.

Safety and Feasibility of Mediastinoscopy-assisted Esophagectomy: A Meta-analysis.

BACKGROUND: The objective of the current study was to investigate the safety and feasibility of mediastinoscopy-assisted esophagectomy (MAE). METHODS: A meta-analysis was conducted between MAE and traditional transthoracic esophagectomy (TTE). For a comparative analysis of MAE and TTE, we searched PubMed, the Cochrane Library, Embase, and Web of Science databases. We identified the relevant literature and extracted the relevant data. Finally, RevMan 5.3 software was applied to conduct a meta-analysis of the data. RESULTS: A total of 1256 people were enrolled in 16 studies, comprising 575 patients with MAE and 681 with TTE. The findings revealed that the pulmonary complications, cardiac complications, and postoperative hospital stay in the MAE group were significantly better than those in the TTE group. No significant differences were found between the 2 groups in postoperative chylothorax, anastomotic fistula, and postoperative mortality. But the incidence of recurrent laryngeal nerve injury in the MAE group was higher than that in the TTE group (odds ratio=1.64, 95% CI, 1.15 to 2.35, P =0.006). The MAE group had less lymph node dissection than the TTE group (mean difference=-4.62, 95% CI, -5.97 to 3.45, P <0.00001). CONCLUSIONS: This meta-analysis presented that MAE was safe and feasible, reduced postoperative pulmonary and cardiac complications, and shortened hospital stay, but lymph node dissection was less, recurrent laryngeal nerve injury was higher, and the impact of long-term survival prognosis required more randomized controlled trials.

Transhiatal esophagectomy via mediastinoscopy versus sweet for T2 esophageal squamous cell carcinoma patients.

BACKGROUND: The aim was to compare transhiatal esophagectomy via mediastinoscopy (TEM) with Sweet procedure for patients with T2 midpiece and distal esophageal squamous cell carcinoma (ESCC). MATERIALS AND METHODS: By virtue of propensity score matching, 42 T2 ESCC patients who underwent TEM (n = 21) and Sweet procedure (n = 21) were included. Both the short-term and long-term outcomes of these patients were observed. RESULTS: Compared with the Sweet procedure, the TEM procedure showed less operation time (133.8 ± 30.4 vs 171.2 ± 30.3 min, p = 0.038), reduced drainage volume in 24 h (83.8 ± 142.3 vs 665.2 ± 220.0 mL, p < 0.001), shorter reserving time of chest tube (26.2 ± 26.3 vs 82.8 ± 49.8 h, p < 0.001) and less dissected lymph nodes (12.4 ± 6.1 vs 17.0 ± 6.5, p = 0.041). The average survival period was 62.6 months for TEM group and 62.5 months for Sweet group (p = 0.753). The COX regression showed that the nodal staging could be regarded as an independent prognostic factor (p = 0.013), not the surgical method (p = 0. 754). CONCLUSIONS: The TEM procedure could reduce operative trauma compared with the Sweet procedure. The long-term survival rate of TEM group was acceptable. The lymph node resection was a major disadvantage of TEM procedure. The TEM procedure might be an alternate choice for T2 midpiece and distal ESCC patients, especially for patients who cannot tolerate transthoracic esophagectomy.

Long-term follow-up of voice changes after cervical mediastinoscopy.

BACKGROUND: Vocal cord palsy after cervical mediastinoscopy is usually reported at less than 1%. However, its incidence might be underestimated and no follow-up studies are available. Our study aimed to evaluate the incidence of voice changes after cervical mediastinoscopy and report on long-term outcomes, including quality of life, after at least one-year follow-up. METHODS: A retrospective cohort study was performed, considering all patients who underwent cervical mediastinoscopy in our center between January 2011 and April 2016. Patients with pre-existing voice changes, voice changes only after pulmonary resection and patients who underwent neoadjuvant chemo(radio)therapy were excluded. Voice changes with full recovery within 14 days were attributed to intubation-related causes. Follow-up questionnaires, including the standardized Voice Handicap Index, were sent to patients with documented voice changes. RESULTS: Of 270 patients who were included for final analysis, 17 (6.3%) experienced voice changes after cervical mediastinoscopy, which persisted > 2 years in 4 patients (1.5%), causing mild to moderate disabilities in daily living. Twelve patients (out of 17, 71%) were referred for otolaryngology consultation, and paresis of the left vocal cord suggesting recurrent laryngeal nerve injury was confirmed in 10 (3.7% of our total study group). Additionally, 83% of the patients who were referred for otolaryngology consultation received voice treatment. Recovery rate after vocal exercises therapy and injection laryngoplasty was respectively 71% and 33%. CONCLUSIONS: Voice changes after cervical mediastinoscopy is an underreported complication, with an incidence of at least 6.3% in our retrospective study, with persisting complaints in at least 1.5% of patients, leading to mild to moderate disabilities in daily living. These findings highlight the need for appropriate patient education for this underestimated complication, as well as the exploration of possible preventive measures.

Video-assisted mediastinoscopic and laparoscopic transhiatal esophagectomy for esophageal cancer.

BACKGROUND: Mediastinoscopy was originally applied for lymph node biopsy and mediastinal tumor resection. Improved video imaging with spreadable working channels enabled mediastinoscopy for inspection and tissue biopsy in the superior mediastinum but it is rarely used in minimally invasive esophageal cancer surgery. In this prospective trial, the practicability and security of spreadable video-assisted mediastinoscopic combined with laparoscopic transhiatal esophagectomy (VAME) with video-assisted thoracoscopic esophagectomy (VATE) were compared. METHODS: A total of 200 eligible patients with esophageal squamous cell carcinoma were randomly divided into VAME or VATE groups. Early postoperative outcomes and lymph node dissection between the two groups were compared. RESULTS: The operation time was significantly shorter (164.3 ± 47.0 min vs. 265.4 ± 47.2 min, P < 0.001), the number of dissected lymph nodes was less (15.8 ± 4.5 vs. 20.3 ± 6.5, P < 0.001), and the intraoperative blood loss was also significantly reduced (94.7 ± 56.7 mL vs. 184.4 ± 65.2 mL, P < 0.001) in the VAME compared to the VATE group, respectively. The incidence of pneumonia was lower (7% vs. 29%; P < 0.001) and the length of hospital stay was shorter in the VAME group compared to the VATE group (18.0 ± 7.6 days vs. 23.2 ± 7.2, P < 0.001, respectively). The chyle leak incidence appeared to be lower in the VAME group but statistical significance was not reached (1% vs. 4%; P = 0.369). There were no differences in the incidence of anastomotic leakages and recurrent laryngeal nerve paralysis between the groups. No 30-day mortality occurred in any of the cases. CONCLUSION: VAME appears to be a practicable and secure method for esophagectomy but needs further proof of concept. CLINICAL REGISTRATION NUMBER: Registered at Chinese Clinical Trial Registry, ChiCTR1900022797.

Innominate Artery Dissection Caused by Video-Mediastinoscopy.

Mediastinoscopy is considered a safe technique to biopsy mediastinal lesions. Among its complications, vascular ones are the most common. We present a rare case of intimal dissection of the innominate artery during the performance of a mediastinoscopy that caused an ischemic attack from which the patient recovered completely without long-term sequelae. We analyze the possible causes and risk factors of this complication.

Comparison of transhiatal esophagectomy using a mediastinoscope with transhiatal esophagectomy by the classic method.

BACKGROUND: This study aimed to evaluate the results of transhiatal esophagectomy using a mediastinoscope in comparison with conventional transhiatal esophagectomy. METHODS: Sixty-two esophageal cancer patients who were referred to our thoracic surgery clinic between April 2015 and March 2017, and met the inclusion criteria, were randomly divided into two groups of 31 each. In the first group, patients were operated on by conventional transhiatal esophagectomy. In the second group, only release of the thoracic esophagus through a neck incision (mediastinal esophagolysis) was performed using a mediastinoscope. The other surgical procedures were similar to those in the first group. RESULTS: The mean age of the patients was almost the same in both groups (57.7 years in the first group versus 56.7 years in the second group). There was no significant difference in sex ratio. The mean volume of blood loss during the operation, mean operative time, and intensive care unit stay as well as cardiopulmonary complications and early postoperative complications were lower in the group that had esophagectomy using a mediastinoscope, and the number of resected mediastinal lymph nodes was greater. CONCLUSION: Based on the results of this study, it can be expected that use of a video mediastinoscope for esophagolysis of the thoracic esophagus in a transhiatal esophagectomy procedure is safe and it will reduce the morbidity and mortality in these patients.

Transcervical Mediastinoscopic Closure of Left-Sided Postpneumonectomy Bronchial Stump Fistula.

INTRODUCTION: This article presents a series of patients on which the transcervical approach was used to close a left-sided postpneumonectomy fistula. MATERIALS AND METHODS: The series comprises nine patients with a left pneumonectomy performed for a tuberculosis-related suppurative disease in five cases and for lung cancer in the remaining four. This procedure can be performed under certain conditions, the most important one being the length of the bronchial stump, which should be at least 1 cm, ideally 1.5 cm. The transcervical stump closure was successfully achieved in all patients, having been more technically demanding in cancer cases with previous lymphadenectomy. The postpneumonectomy infected cavity was subsequently treated. RESULTS: The follow-up continued for at least 1 year; one individual from the cancer patients group died from an uncontrolled sepsis during the postoperative period, another one died 17 months later from metastatic cancer and two of them are alive, with no signs of neoplastic or infectious relapse 15 and 37 months, respectively, after the cervical procedure. One patient from the suppurative disease group had a relapse of the fistula 2 months after surgery, requiring additional surgical procedures to deal with this issue; all the other patients are alive, with no signs of recurrence. CONCLUSIONS: The transcervical approach is a very suitable maneuver in selected patients with a bronchial stump at least 1 cm long, ideally 1.5 cm.

Safety and Costs of Endobronchial Ultrasound-Guided Nodal Aspiration and Mediastinoscopy.

BACKGROUND: There remains debate over the best invasive diagnostic modality for mediastinal nodal evaluation. Prior studies have limited generalizability and insufficient power to detect differences in rare adverse events. We compared the risks and costs of endobronchial ultrasound (EBUS)-guided nodal aspiration and mediastinoscopy performed for any indication in a large national cohort. METHODS: We conducted a retrospective study (2007-2015) with MarketScan, a claims database of individuals with employer-provided insurance in the United States. Patients who underwent multimodality mediastinal evaluation (n = 1,396) or same-day pulmonary resection (n = 2,130) were excluded. Regression models were used to evaluate associations between diagnostic modalities and risks and costs while adjusting for patient characteristics, year, concomitant bronchoscopic procedures, and lung cancer diagnosis. RESULTS: Among 30,570 patients, 49% underwent EBUS. Severe adverse events-pneumothorax, hemothorax, airway/vascular injuries, or death-were rare and invariant between EBUS and mediastinoscopy (0.3% vs 0.4%; P = .189). The rate of vocal cord paralysis was lower for EBUS (1.4% vs 2.2%; P < .001). EBUS was associated with a lower adjusted risk of severe adverse events (OR, 0.42; 95% CI, 0.32-0.55) and vocal cord paralysis (OR, 0.57; 95% CI, 0.54-0.60). The mean cost of EBUS was $2,211 less than mediastinoscopy ($6,816 vs $9,023; P < .001). After adjustment this difference decreased to $1,650 (95% CI, $1,525-$1,776). CONCLUSIONS: When performed as isolated procedures, EBUS is associated with lower risks and costs compared with mediastinoscopy. Future studies comparing the effectiveness of EBUS vs mediastinoscopy in the community at large will help determine which procedure is superior or if trade-offs exist.

Robot-Assisted McKeown Procedure via a Cervical Mediastinoscopy Avoiding an Abdominal and Thoracic Incision.

Total esophagectomy for esophageal cancer is associated with high morbidity. The avoidance of a thoracic access could especially reduce the occurrence of pulmonary complications. Therefore, the combination of a high transhiatal dissection of the esophagus and a neck access with mediastinal dissection of the esophagus appears to be a possibility to reduce the pulmonary risks. However, the access to the posterior mediastinum is very limited with the conventional minimal invasive instruments. These limitations can be overcome by the use of a surgical robot.In this article, we present a novel operation technique for a complete robot-assisted (da Vinci Xi) McKeown procedure avoiding a thoracic approach and abdominal incision by using a rendezvous technique with an abdominal and cervical docking of the robot system.

An air-containing mediastinal mass in a patient with a primary adenocarcinoma of the right lung.

Objective: The following case report elicits the treatment of a 55-year-old male who was diagnosed with a surinfected mediastinal chyloma as a complication of mediastinoscopy and radiotherapy for a primary adenocarcinoma of the right lung (cT2aN2M0). Methods: The patient was admitted to the hospital after radiographical imaging showed a surinfected mediastinal chyloma. CT-guided percutaneous drainage was performed and via gastroscopy a fistula was diagnosed for which a full covered stent was placed. Then, a right thoracotomy was performed to wash out the chylous cavity, to seal the thoracic duct and to cover the other end of the fistula with an intercostal muscle flap. Results: Postoperative imaging showed a clear reduction of the mediastinal mass with no residual air-fluid level. Realimention was possible three days after placement of the stent. The patient was discharged after 11 days. There was no recurrence of the chyloma. Fistulisation did recur after removal of the stent. Conclusion: Surinfected mediastinal chyloma due to oesopagho-mediastinal fistula is an extremely rare complication after cervical mediastinoscopy and radiotherapy. Open drainage of the chyloma and total coverage of the fistula can control infection and prevent recurrence on short term.

Robot-assisted mediastinoscopic esophagectomy for esophageal cancer: the first clinical series.

BACKGROUND: Radical esophagectomy for esophageal cancer is associated with high morbidity, especially with pulmonary complications. Mediastinoscopic esophagectomy via a small left neck incision combined with the esophageal hiatus, without using transthoracic approach, has been reported to reduce pulmonary complication; however, from technical point of view, this approach using non-articulating, straight, long forceps is extremely challenging, especially in the middle mediastinal area. Its technical difficulties may be attenuated using da Vinci Surgical System. The aim of this study was to evaluate the feasibility and safety of robot-assisted mediastinoscopic esophagectomy. METHODS: Robot-assisted mediastinoscopic esophagectomy was performed in six patients between October 2016 and May 2017. Robotic esophageal mobilization with upper and middle mediastinal lymphadenectomy was performed via the three da Vinci Xi (Intuitive Surgical, Inc. Sunnyvale, CA) trocars placed on the 5-cm left cervical incision. Thereafter, the remaining part of radical esophagectomy was completed via a transhiatal approach. RESULTS: Upper and middle mediastinal lymphadenectomy was robotically completed via the transcervical approach in all cases without conversion to transthoracic approach. No postoperative complications (Clavien-Dindo classification grade ≥ III) were observed. CONCLUSIONS: Robot-assisted mediastinoscopic esophagectomy was technically feasible and safe. Use of da Vinci Surgical System may help attenuate technical difficulties in transcervical middle mediastinal lymph node dissection.

Management of Pleural Effusion After Mediastinoscopic Radical Esophagectomy.

BACKGROUND/AIM: Trans-hiatal and -cervical approach mediastinoscopic radical esophagectomy (TMrE) for esophageal cancers is a less-invasive procedure and does not require for trans-thoracic approach management. However, some patients suffer from pleural effusion after TMrE. In the present study, we investigated the clinicopathological factors of patients needing drainage of pleural effusion (DPE) after TMrE. PATIENTS AND METHODS: This study included 118 patients who underwent TMrE between 2010 and 2016. RESULTS: There were 43, 34 and 41 patients that underwent none, a single, and two or more DPEs respectively. Left-side DPE was significantly more frequent compared to right-side DPE. Change in the C-reactive protein (CRP) levels after surgery was significantly higher in patients with multiple DPEs than patients with none or a single DPE. The hospitalization days were significantly longer for patients with multiple DPEs. CONCLUSION: Pleural effusion accumulates due to continuous inflammation. Although a temporary DPE is sometimes performed, post-operative chest drainage tubes are not necessarily needed.

Fundamental and Practical Aspects of Airway Anatomy: From Glottis to Segmental Bronchus.

The surgical anatomy of the airways from the glottis to segmental bronchi is reviewed with a focused review on pertinent anatomic findings surrounding common surgical procedures. The knowledge of the anatomy of the trachea while performing tracheostomy, tracheal and sleeve carinal resection, and bronchoplastic procedures is addressed. Pertinent anatomic relationships as evident on common computed tomographic imagery are emphasized.

Concomitant Mediastinoscopy Increases the Risk of Postoperative Pneumonia After Pulmonary Lobectomy.

BACKGROUND: Mediastinoscopy is considered the gold standard for preresectional staging of lung cancer. We sought to examine the effect of concomitant mediastinoscopy on postoperative pneumonia (POP) in patients undergoing lobectomy. METHODS: All patients in our institutional database (2008-2015) undergoing lobectomy who did not receive neoadjuvant therapy were included in our study. The relationship between mediastinoscopy and POP was examined using univariate (Chi square) and multivariate analyses (binary logistic regression). In order to validate our institutional findings, lobectomy data in the National Surgical Quality Improvement Program (NSQIP) from 2005 to 2014 were analyzed for these associations. RESULTS: Of 810 patients who underwent a lobectomy at our institution, 741 (91.5%) surgeries were performed by video-assisted thoracic surgery (VATS) and 487 (60.1%) patients underwent concomitant mediastinoscopy. Univariate analysis demonstrated an association between mediastinoscopy and POP in patients undergoing VATS [odds ratio (OR) 1.80; p = 0.003], but not open lobectomy. Multivariate analysis retained mediastinoscopy as a variable, although the relationship showed only a trend (OR 1.64; p = 0.1). In the NSQIP cohort (N = 12,562), concomitant mediastinoscopy was performed in 9.0% of patients, with 44.5% of all the lobectomies performed by VATS. Mediastinoscopy was associated with POP in patients having both open (OR1.69; p < 0.001) and VATS lobectomy (OR 1.72; p = 0.002). This effect remained in multivariate analysis in both the open and VATS lobectomy groups (OR 1.46, p = 0.003; and 1.53, p = 0.02, respectively). CONCLUSIONS: Mediastinoscopy may be associated with an increased risk of POP after pulmonary lobectomy. This observation should be examined in other datasets as it potentially impacts preresectional staging algorithms for patients with lung cancer.

Evolution in the Surgical Care of Patients With Non-Small Cell Lung Cancer in the Mid-South Quality of Surgical Resection Cohort.

Surgery is the most important curative treatment modality for patients with early-stage non-small cell lung cancer (NSCLC). We examined the pattern of surgical resection for NSCLC in a high incidence and mortality region of the United States over a 10-year period (2004-2013) in the context of a regional surgical quality improvement initiative. We abstracted patient-level data on all resections at 11 hospitals in 4 contiguous Dartmouth Hospital Referral Regions in North Mississippi, East Arkansas, and West Tennessee. Surgical quality measures focused on intraoperative practice, with emphasis on pathologic nodal staging. We used descriptive statistics and trend analyses to assess changes in practice over time. To measure the effect of an ongoing regional quality improvement intervention with a lymph node specimen collection kit, we used period effect analysis to compare trends between the preintervention and postintervention periods. Of 2566 patients, 18% had no preoperative biopsy, only 15% had a preoperative invasive staging test, and 11% underwent mediastinoscopy. The rate of resections with no mediastinal lymph nodes examined decreased from 48%-32% (P < 0.0001), whereas the rate of resections examining 3 or more mediastinal stations increased from 5%-49% (P < 0.0001). There was a significant period effect in the increase in the number of N1, mediastinal, and total lymph nodes examined (all P < 0.0001). A quality improvement intervention including a lymph node specimen collection kit shows early signs of having a significant positive effect on pathologic nodal examination in this population-based cohort. However, gaps in surgical quality remain.

Transient Aphonia After Mediastinoscopy.

The most common adverse event after cervical mediastinoscopy is recurrent laryngeal nerve (RLN) injury, which has an incidence of 0.6% [1]. We report the case of a 68-year-old man with non-small cell lung cancer (NSCLC) who experienced transient bilateral vocal cord paralysis after mediastinoscopy, which manifested in complete aphonia. This patient's ability to maintain his airway was carefully followed up, but neither endotracheal intubation nor tracheostomy was required. The vocal cord paralysis resolved without intervention after 5 hours. To our knowledge, this is the first reported case in which bupivicaine used at the end of a cervical mediastinoscopy diffused through the freshly dissected planes to paralyze both RLNs along the tracheoesophageal grooves.