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New onset atrial fibrillation (AF) is observed in up to 37% of patients after esophagectomy for esophageal and esophago-gastric junction (EGJ) cancer. Little is known about risk factors for AF in this cohort of patients. Current literature describes an association between postoperative AF and other complications, notably anastomotic leaks and infective or pulmonary complications. The aim of this paper is to determine which factors relate to an increased risk of new-onset AF after esophagectomy. Methods We retrospectively analyzed a prospectively collected database in a high-volume, tertiary referral center for esophageal disease. All consecutive patients who underwent hybrid Ivor-Lewis (IL) esophagectomy for esophageal or EGJ cancer at the Upper GI surgery unit in Humanitas Research Hospital from January 2018 to august 2019 were evaluated for inclusion. Patients with a history of paroxysmal or chronic AF were excluded from the analysis. Complications were reported according to the ECCG classification. Association between variables and onset of AF was studied with univariable and multivariable logistic regression analysis. Results 89 IL cases among 125 esophagectomies were included for analysis. Overall complication rate was 29.2%. AF accounted for 9 cases (10.1%) and was the only complication in these patients. Anastomotic leak occurred in 2 patients (2.25%) both ECCG type 1, 3 developed significant pleural effusion (3.37%), 6 other infective conditions (6.7%). No postoperative deaths occurred. Significantly increased risk of AF was found in patients who underwent chemoradiotherapy(CRT) compared to those who received chemotherapy(CT) or no treatment(OR = 8.4, p = 0.02). If we compare only patients who received neoadjuvant treatment, a higher risk for CRT versus CT alone was found(OR = 5.5), with a trending significance(p = 0.08). Conclusion In this study, we did not find any association between AF and other complications. New-onset AF always presented as the only complication and it was significantly associated to neoadjuvant chemoradiotherapy. On the basis of this findings, we are designing a protocol with the aim of studying potential preventive intervention for postoperative FA after esophagectomy.

Minimally Invasive esophagectomy has been introduced to reduce the trauma associated with open surgery while keeping the same oncological outcome. Robotic platforms could facilitate this. Even with the increasing availability of surgical robots and the standardization of the technique, it can be difficult to convince high volume centers to change their surgical approach. Our aim is to assess the impact of the learning curve for robotic surgery in a high-volume laparoscopic center. Methods We retrospectively analyzed a prospectively collected database in a tertiary referral center for esophagogastric surgery. We identified two groups composed by the patients who underwent Ivor-Lewis (IL) esophagectomy by a hybrid laparoscopic (HL) approach (standard laparoscopy + open thoracotomy) and those who underwent a hybrid robotic (HR) approach (robotic abdominal part + open thoracotomy) with the Davinci Xi surgical platform for lower esophageal or EGJ cancer from November 2018 to September 2019. Data regarding post-operative stay, complications, leaks, total number of lymph nodes and length of surgery were analyzed. Complications were reported according to the ECCG classification. Results We selected 50 consecutive IL cases among which there were our first 17 HR cases. There were no differences in terms of demographics, comorbidities and neoadjuvant treatments between the two groups. No statistical difference was observed in post-operative stay(median 12 vs 10 days in HL and HR respectively, p = 0.09), overall complication rate was 33% in HL and 35% in HR(p = 0.9), patients with leaks 1(3.03%) in HL and 1(5.88%) in HR(p = 0.6), total lymph nodes median of 38 in HL vs 30 in HR(p = 0.4). Only the total length of surgery was statistically longer in the HR group (median 446 vs 478 min, p = 0.01). Conclusion We showed that in the setting of a high-volume center with no previous robotic surgery expertise, robotically performing only the abdominal phase could represent an effective alternative to familiarize with the robotic system without compromising the clinical outcome and workflow. We understand that the main advantages would be seen when using the robot during the thoracic part. After these first cases we will proceed to adopt it during the most demanding part of the operation.

Aim We evaluated short-term outcomes of esophagectomy for esophageal and esophagogastric carcinoma without routine postoperative admission to Intensive Care Unit (ICU). Background & Methods esophagectomy is subject to high rates of complications and mortality even when performed in high-volume centers and conventional postoperative management often involves routine ICU admission according to recent guidelines and recommendations1 . From January 2018 to June 2019 a total of 112 esophagectomies were performed in the Upper GI Surgery division of Humanitas Research Hospital. We included the 83 patients that underwent transthoracic esophagectomy with a hybrid technique (laparoscopy + right thoracotomy) and high intrathoracic anastomosis for esophageal and esophagogastric junction cancer. Preoperative assessment included a prehabilitation program (nutritional evaluation, respiratory physiotherapy and adjustment of cardiologic therapy). Postoperatively, patients were managed by surgical team members. We retrospectively recorded data on necessity of ICU, operative times, complication rate (according to ECCG)2,3, length of hospital stay, in-hospital, 30-day and 90-day mortality. Results 68 patients were males and 15 females. Mean age was 65 years old (range 29-82). 67 patients underwent neoadjuvant therapy (49 chemo-radiotherapy, 18 chemotherapy alone). Postoperative ICU admission was necessary in 6 patients (9,5%), reasons for admission were necessity of ventilatory weaning in 2 patients, high lactate levels in one patient, glottic oedema following oro-tracheal intubation in one patient, while in the other cases ICU admission was planned for severe comorbidities. Mean duration of prehabilitation was 20.3 days (1-107). Mean surgery duration was 452.4 minutes (337-549). Overall complication rate was 33.8%, with the most common complications being atrial fibrillation (50% of all complications) and urinary retention (20%). There were two type I anastomotic leaks. Median length of hospital stay was 11 days (range 8-29). All patients were alive at 30 and 90 days after surgery. Conclusion routine ICU admission is not necessary after transthoracic esophagectomy for cancer in over 90% of patients. Careful patients’ evaluation, stratification of the surgical risk and systematic use of a prehabilitation program, along with adequate peri-operative management, can narrow the need for postoperative ICU admission in the setting of a high-volume centre without any impact on short-term outcomes.

SUMMARY Gastric conduit used for reconstruction after esophagectomy for cancer has the potential to develop a metachronous neoplasm known as gastric tube cancer (GTC). The aim of this study was to review literature and evaluate outcomes and possible treatment strategies for GTC. A comprehensive systematic literature search was conducted using PubMed, EMBASE, Scopus, and the Cochrane Library Central Register of Controlled Trials. No restriction was set for the type of publication, number, age, or sex of the patients. The search was limited to articles in English. Characteristics of esophageal cancer (EC) and its treatment and GTC and its treatment were analyzed. A total of 28 studies were analyzed, 12 retrospective analyses and 16 case reports, involving 229 patients with 250 GTCs in total. The majority of ECs (88.2%) were squamous cell carcinomas. In 120 patients (52.4%) a posterior mediastinal reconstructive route was used when esophagectomy was performed. The mean interval between esophagectomy and diagnosis of GTC was 55.8 months, with a median interval of 56.8 months (4–236 months). One hundred and twenty-four GTCs (49.6%) were located in the lower part of the gastric tube. One hundred and forty patients were endoscopically treated. Eighty-five patients underwent surgery. Thirty-six total gastrectomies with lymphadenectomy with colon or jejunal interposition were performed. Forty-three subtotal gastrectomies and 6 wedge resections were performed. The main reported postoperative complications were anastomotic leak, vocal cord palsy, and respiratory failure. Twenty-five patients were treated with palliative chemotherapy. Three-year survival rates were 69.3% for endoscopically treated patients, 58.8% for surgically resected patients, and 4% for patients who underwent palliative treatment. The feasibility of endoscopic resections in patients diagnosed with superficial GTC has been reported. Surgical treatment represented the preferred treatment method in operable patients with locally invasive tumor. Patients treated with conservative therapy have a scarce prognosis. The development of GTC should be taken into consideration during the extended follow-up of patients undergoing esophagectomy for cancer. Total gastrectomy plus lymphadenectomy should be considered the preferred treatment modality in operable patients with locally invasive tumor, when endoscopy is contraindicated. Long-term yearly endoscopic follow-up is recommended.

Description Giant esophageal leiomyomas (GEL) are challenging benign conditions to treat in a total minimally invasive way. Here we show the management of a complete thoracoscopic enucleation (TE) of three giant esophageal masses in three different patients. Not only the size of these masses but mostly the position of them made the indication for TE borderline. Methods Every patient underwent a full diagnostic pre-op workup with CT scan, PET and EUS guided biopsies to rule out any malignancy. In this video, we show a full thoracoscopic approach with the patient on the left flank in a semi-prone/prone position and under general anesthesia without lung exclusion. We use a 3 trocars approach and low pressure(8mmHg) CO2 insufflation during the whole procedure. The dissection of the mass is carefully performed to keep the whole mucosal layer undamaged and minimizing the incision in the muscular layer. Careful reconstruction of the muscular layer is a mandatory step at the end of the procedure. Azygos vein resection is performed depending on the mass location. We extract the mass in a bag by enlarging the incision of the inferior scapular trocar. The integrity of the mucosal layer was constantly checked during the procedure either by direct endoscopic vision or by insufflation of air through a nasogastric tube. Results All the patients had an uneventful post-operative course, upper-GI series showed no leak, no stricture nor dilatation of the esophagus. On POD 4 a soft diet was administered. Conclusions Esophageal leiomyomas are a rare condition; the ones larger than 10cm are defined as GEL and they represent the 17% of the total. While, in advanced centers, Total TE for small leiomyomas is a standard of care, GELs are usually managed by open surgery, and in many cases, esophagectomy has to be performed. In our series of five consecutive GELs, located in the upper esophagus, TE proved to be safe and effective in all the patients. Disclosure All authors have declared no conflicts of interest.

Background Gastric conduit used for reconstruction after esophagectomy for esophageal cancer (EC) has the potential to develop a metachronous cancer known as gastric tube cancer (GTC). The aim of our study was to review literature and evaluate outcomes and possible treatment strategies for GTC. Methods A comprehensive systematic literature search was conducted using PubMed. No restriction was set for type of publication, number, age and sex of patients. Study language was limited to English. Characteristics of EC and its treatment and GTC and its treatment were analyzed. Results A total of 26 studies were analyzed, 10 retrospective analysis and 16 case reports, involving 170 patients, 17 patients (10%) were affected by multifocal GTC. 143 ECs (84,1%) were squamous cell carcinomas. In 95 patients (55,9%) a posterior-mediastinal reconstructive route was used at the time of esophagectomy for EC. Mean interval between esophagectomy and diagnosis of GTC was 67,18 months (4–236 months). 184 GTCs were metachronous lesions (98,4%). 164 GTCs were adenocarcinomas (98,2%). 84 GTCs were located in the lower part of the gastric tube. 88 patients were endoscopically treated. 63 patients underwent surgery. 30 total gastrectomies + limphoadenectomy with colon or jejunal interposition were performed. 27 subtotal gastrectomies and 6 wedge resections were performed. Main reported post-operative complications were: anastomotic leak, vocal cord palsy and respiratory failure. 19 patients were treated with chemoradiotherapy and palliative care. 68,2% of endoscopically treated patients, 63,5% of surgically resected patients and 5,2% of patients who underwent chemoradiotherapy were alive at a mean follow-up of 25,5 months. Feasibility of endoscopic resections in patients diagnosed with superficial GTC has been established. Surgical treatment represents the preferred treatment modality in operable patients with locally invasive tumor. Patients treated with conservative therapy have a scarce prognosis. Conclusion Yearly endoscopic follow-up is of paramount importance in patients who underwent esophagectomy for EC with gastric tube reconstruction. At least, a 10-year endoscopic surveillance is recommended. Disclosure All authors have declared no conflicts of interest.

Collis gastroplasty was originally designed to deal with the increasing incidence of short esophagus (SE) associated with the new epidemic of gastroesophageal reflux disease (GERD) and hiatal hernias. In following years, a fundoplication was added to the procedure in an attempt to correct the underlying cause of the disease. Nowadays Collis gastroplasty with fundoplication is the standard treatment for patients in whom, even after an extensive surgical dissection of the distal esophagus, the gastroesophageal junction (GEJ) cannot be brought at least 2.5 cm below the diaphragmatic hiatus without tension. The real incidence of SE is controversial in the era of laparoscopic fundoplication, with some groups proposing that all short esophagi can be solved with adequate mediastinal dissection of the esophagus prior to fundoplication, and others advocating frequent use of the Collis. Still others have tried to identify predictive factors linked to the presence of a true SE. However, studies suggest that a significant percentage of failures of primary antireflux surgery might be due to axial tension on the repair from intrinsic shortening of the esophagus that was not properly addressed. With the advent of the laparoscopic era new tools and new approaches were described to asses and to treat this condition. We describe both thoracoscopic/laparoscopic and totally laparoscopic techniques for minimally invasive Collis gastroplasty. While symptomatic results are good, the procedure is non-physiologic and many patients have esophagitis from ectopic gastric mucosa. While the true incidence of SE is unknown, what is undeniable is that chronic reflux disease can lead to foreshortening of the esophagus and, although in the proton pump inhibitor (PPI) era the presence of a SE is a relatively rare finding, the foregut surgeon must be prepared to identify and treat this condition.