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Background: Transcervical mediastinoscopic esophagectomy for esophageal and esophagogastric junction cancer is indicated in select institutions because of the complex surgical technique required and the unfamiliar surgical view compared with the standard transthoracic esophagectomy approach. This study was performed to compare the feasibility and efficacy of bilateral transcervical mediastinoscopic-assisted transhiatal laparoscopic esophagectomy (BTC-MATLE) with thoracolaparoscopic esophagectomy (TLE) for esophageal cancer., Methods: This study involved 392 consecutive patients with esophageal cancer who underwent curative minimally invasive esophagectomy with R0 resection (excluding salvage, conversion, and two-stage operations and open thoracotomy) at the National Cancer Center Hospital from 2017 to 2022. The patients underwent either BTC-MATLE or TE (32 and 360 consecutive patients, respectively). Propensity score-matching analysis was used to balance the baseline differences by covariates of age, performance status, and clinical stage., Results: There were statistically significant differences in age, performance status, cT factor, cN factor, cStage, preoperative treatment, and surgical history for respiratory disease. After propensity score-matching, these significant differences (excluding a surgical history of respiratory disease) were no longer statistically significant, and 27 patients were assigned to each group. The total operation time and the postoperative intensive care unit stay were significantly shorter in the BTC-MATLE than TLE group. There were no significant differences in overall postoperative complications or the three major postoperative complications of recurrent laryngeal nerve paralysis, anastomotic leakage, and pneumonia, even for patients whose preoperative pulmonary function indices (vital capacity and forced expiratory volume in 1 s) were significantly lower in the BTC-MATLE than TLE group. The numbers of total and thoracic harvested lymph nodes were significantly higher in the TLE than BTC-MATLE group; however, there was no significant difference in the recurrence rate between the two groups., Conclusion: BTC-MATLE may provide the same feasibility and oncological outcomes as TLE even for patients with significantly lower pulmonary function., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Minimally invasive esophagectomy (MIE) is a technically challenging procedure with a substantial learning curve. Composite volume of upper gastrointestinal (upper GI) procedures for cancer has been previously linked to postoperative outcomes. This study aimed to investigate an association between hospital experience in bariatric surgery and short-term outcomes in MIE., Method: Data on esophagectomy patients between 2016 and 2020 were collected from the Dutch Upper Gastrointestinal Cancer Audit, a mandatory nationwide registry. Hospitals were categorized as bariatric or non-bariatric. Multivariable logistic regression investigated short-term postoperative outcomes, adjusting for case mix., Results: Of 3371 patients undergoing esophagectomy in sixteen hospitals, 2450 (72.7%) underwent MIE. Bariatric hospitals (N = 6) accounted for 1057 (43.1%) MIE. Annual volume of bariatric procedures was median 523 and esophagectomies 42. In non-bariatric hospitals, volume of esophagectomies was median 52 (P = 0.145). Overall postoperative complication rate was lower in bariatric hospitals (59.2% vs. 65.9%, P < 0.001). Bariatric hospitals were associated with a reduced risk of overall complications (aOR 0.76 [95% CI 0.62-0.92]), length of hospital (aOR 0.79 [95% CI 0.65-0.95]), and ICU stay (aOR 0.81 [95% CI 0.67-0.98]) after MIE. Surgical radicality (R0) did not differ. Lymph node yield (≥ 15) was lower in bariatric hospitals (90.0% vs. 94.7%, P < 0.001). Over the years, several short-term outcomes improved in bariatric hospitals compared to non-bariatric hospitals., Conclusion: In this nationwide analysis, there was an association between bariatric hospitals and improved short-term outcomes after MIE. Characteristics of bariatric hospitals that could explain this phenomenon and whether this translates to other upper GI procedures may be warranted to identify., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Studies have shown minimally invasive esophagectomy (MIE) to be a feasible surgical technique in treating esophageal carcinoma. Postoperative complications have been extensively reviewed, but literature focusing on intraoperative complications is limited. The main objective of this study was to report major intraoperative complications and 90-day mortality during MIE for cancer., Methods: Data were collected retrospectively from 10 European esophageal surgery centers. All intention-to-treat, minimally invasive laparoscopic/thoracoscopic esophagectomies with gastric conduit reconstruction for esophageal and GE junction cancers operated on between 2003 and 2019 were reviewed. Major intraoperative complications were defined as loss of conduit, erroneous transection of vascular structures, significant injury to other organs including bowel, heart, liver or lung, splenectomy, or other major complications including intubation injuries, arrhythmia, pulmonary embolism, and myocardial infarction., Results: Amongst 2862 MIE cases we identified 98 patients with 101 intraoperative complications. Vascular injuries were the most prevalent, 41 during laparoscopy and 19 during thoracoscopy, with injuries to 18 different vessels. There were 24 splenic vascular or capsular injuries, 11 requiring splenectomies. Four losses of conduit due to gastroepiploic artery injury and six bowel injuries were reported. Eight tracheobronchial lesions needed repair, and 11 patients had significant lung parenchyma injuries. There were 2 on-table deaths. Ninety-day mortality was 9.2%., Conclusions: This study offers an overview of the range of different intraoperative complications during minimally invasive esophagectomy. Mortality, especially from intrathoracic vascular injuries, appears significant., (© 2023. The Author(s).)

Minimally invasive esophagectomy (MIE) is becoming more widespread with a documented improvement in postoperative morbidity based on level I evidence. However, there is a lack of consensus regarding the optimal MIE approach, conventional thoracoscopy/laparoscopy vs robotics as well as the ideal anastomotic technique. All patients who underwent MIE via an Ivor Lewis approach with a side-to-side stapled anastomosis were included. The thoracoscopy-laparoscopy (TL) group was compared to the robotic group with respect to perioperative outcomes using the entire cohorts and after 1:1 propensity score matching. Comparisons were made using the Mann-Whitney U and Fisher's exact tests. Between July 2013 and November 2020, 72 TL and 67 robotic Ivor Lewis MIE were performed. After comparing the two unadjusted cohorts and 51 propensity matched pairs, there was a decrease in Clavien-Dindo Grade 2 or above complications in the robotic vs TL group (59.7% vs 41.8% [P = 0.042], (62.7% vs 39.2% [P = 0.029]), respectively. In both analyses, there was a reduction in hospital length of stay (median of 8 vs 7 days, P < 0.001) and a trend toward less anastomotic leaks in the robotic group (Unadjusted: 12.5 vs 3% [P = 0.057], Propensity-matched analysis: 13.7% vs 3.9% [P = 0.16]), respectively. A clinically significant decrease in overall morbidity, cardiac complications and hospital length of stay was observed in the robotic Ivor Lewis cohort when compared with the TL group at a high volume MIE program. Side-to-side stapled thoracic anastomoses utilizing a robotic platform provides the best outcomes in this single institution experience., (© The Author(s) 2022. Published by Oxford University Press on behalf of International Society for Diseases of the Esophagus. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Traditionally, esophageal oncological resections have been performed via open approaches with well-documented levels of morbidity and mortality complicating the postoperative course. In contemporary terms, minimally invasive approaches have garnered sustained support in all areas of surgery, and there has been an exponential adaptation of this technology in upper GI surgery with the advent of laparoscopic and robotic techniques. The current literature, while growing, is inconsistent in reporting on the benefits of minimally invasive esophagectomies (MIEs) and this makes it difficult to ascertain best practice. The objective of this review was to critically appraise the current evidence addressing the safety, efficacy, and cost-effectiveness of MIEs versus open esophagectomies. A systematic review of the literature was performed by searching nine electronic databases to identify any systematic reviews published on this topic and recommended Joanna Briggs Institute approach to critical appraisal, study selection, data extraction and data synthesis was used to report the findings. A total of 13 systematic reviews of moderate to good quality encompassing 143 primary trials and 36,763 patients were included in the final synthesis. Eleven reviews examined safety parameters and found a generalized benefit of MIE. Efficacy was evaluated by eight systematic reviews and found each method to be equivalent. There were limited data to judiciously appraise cost-effectiveness as this was only evaluated in one review involving a single trial. There is improved safety and equivalent efficacy associated with MIE when compared with open esophagectomy. Cost-effectiveness of MIE cannot be sufficiently supported at this point in time. Further studies, especially those focused on cost-effectiveness are needed to strengthen the existing evidence to inform policy makers on feasibility of increased assimilation of this technology into clinical practice., (© The Author(s) 2022. Published by Oxford University Press on behalf of International Society for Diseases of the Esophagus. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Despite decreasing overall morbidity with minimally invasive esophagectomy (MIE), conduit functional outcomes related to delayed emptying remain challenging, especially in the immediate postoperative setting. Yet, this problem has not been described well in the literature. Utilizing a single institutional prospective database, 254 patients who underwent MIEs between 2012 and 2020 were identified. Gastric conduit dilation was defined as a conduit occupying >40% of the hemithorax on the postoperative chest X-ray. Sixty-seven patients (26.4%) demonstrated acute conduit dilation. There was a higher incidence of conduit dilation in the patients who underwent Ivor Lewis esophagectomy compared to those with a neck anastomosis (67.2% vs. 47.1%; P = 0.03). Patients with dilated conduits required more esophagogastroduodenoscopies (EGD) (P < 0.001), conduit-related reoperations within 180 days (P < 0.001), and 90-day readmissions (P = 0.01). Furthermore, in 37 patients (25.5%) undergoing Ivor Lewis esophagectomy, we returned to the abdomen after intrathoracic anastomosis to reduce redundant conduit and pexy the conduit to the crura. While conduit dilation rates were similar, those who had intraabdominal gastropexy required EGD significantly less and trended toward a lower incidence of conduit-related reoperations (5.6% vs. 2.7%). Multivariable analysis also demonstrated that conduit dilation was an independent predictor for delayed gastric conduit emptying symptoms, EGD within 90 days, conduit-related reoperation within 180 days, and 30-day as well as 90-day readmission. Patients undergoing MIE with acute gastric conduit dilation require more endoscopic interventions and reoperations., (© The Author(s) 2022. Published by Oxford University Press on behalf of International Society for Diseases of the Esophagus. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Minimally invasive esophagectomy for esophageal cancer decreases overall complication rate and leads to faster postoperative recovery. Robot-assisted minimally invasive esophagectomy is becoming more common. Its three-dimensional view and wristed instruments may provide advantages over traditional thoraco-laparoscopic techniques. There are limited studies comparing robotic and conventional thoraco-laparoscopic esophagectomy. This study aimed to evaluate short-term outcomes of robot-assisted McKeown esophagectomy (RAME) and video-assisted McKeown esophagectomy (VAME). All consecutive patients undergoing minimally invasive McKeown esophagectomy for middle and distal third esophageal cancer between January 2016 and December 2018 at our center were included in this study. Data on baseline characteristics, pathological data and short-term outcomes were collected in a dedicated database. Postoperative complications were defined as per recommendations of Esophagectomy Complications Consensus Group. Histopathologic assessment was performed as per College of American Pathologists guidelines. Propensity score matching was performed for comparison between RAME and VAME groups using age, gender, performance status, American Society of Anesthesiologists grade, body mass index, Charlson Index, tumor location, clinical tumor stage, and neoadjuvant treatment as covariates. A total of 74 patients were included, 25 of whom underwent RAME and 49 underwent VAME. Propensity score matching on 1:1 basis produced 25 pairs of patients, comparable in terms of baseline characteristics. Total operative time and estimated blood loss was similar between the two groups. Length of hospital stay was significantly lower in RAME group. Major postoperative complications (Clavien-Dindo grade ≥ 3A) were more common in VAME group, but not statistically significant. Median number of harvested lymph nodes and R0 resection rate did not differ in between the two groups. In our experience, robot-assisted McKeown esophagectomy was comparable to video-assisted McKeown esophagectomy in terms of safety, feasibility and oncologic adequacy. Use of the robot was associated with reduced hospital stay. Further randomized controlled studies with larger patient samples are needed to compare the two., (© 2022. The Author(s), under exclusive licence to Springer-Verlag London Ltd., part of Springer Nature.)

The optimal surgical procedure for Siewert II oesophagogastric junction cancer is still debated. The minimally invasive Ivor Lewis technique can be considered the most adequate intervention from the oncological perspective but it is still contested owing to its technical difficulties. To allow an easier thoracoscopic stage during the procedure, we performed it with laparoscopic trans-hiatal oesophageal transection and transabdominal extraction. An 80-year-old man with stage 3 Siewert II oesophagogastric junction adenocarcinoma not suitable for neoadjuvant therapy underwent minimally invasive Ivor Lewis oesophagectomy with two-field lymphadenectomy, using a laparoscopic and thoracoscopic approach in prone position. The trans-hiatal oesophageal resection permitted easy extraction of a transabdominal specimen and frozen section examination. The prone position, together with the absence of the specimen in the operative field, allowed easier mediastinal node dissection and oesophagogastric anastomosis with better visualisation. The postoperative course was uneventful. Pathology showed a G3-pT3, N2 adenocarcinoma with 6/30 metastatic lymph nodes.

Background: Even though minimally invasive esophageal surgery (MIE) is spreading, questions remain regarding its oncological outcomes. The aim of this study was to assess the quality of oncological resection criteria in MIE., Methods: All patients undergoing a two-way Ivor Lewis esophagectomy for esophageal or junctional cancer between 2010 and 2020 in a single tertiary upper gastrointestinal surgery ward were analyzed retrospectively. The following oncological criteria were analyzed: lymph node (LN) harvest and location, positive lymph node rate, margins, and R0 rates. They were compared between the MIE group (thoracoscopy + laparoscopy) and the hybrid group (H/O, thoracotomy + laparoscopy)., Results: Among the 240 patients included, 34 (14%) had MIE and 206 a hybrid esophagectomy. Main surgical indication was lower thoracic adenocarcinoma and the rate of neoadjuvant treatments administered (chemotherapy or chemoradiotherapy) was comparable between both groups (p = 1.0). LN harvest was significantly higher in the MIE group (31 ± 9 vs. 28 ± 9, p = 0.04) as well as thoracic LN harvest (14 ± 7 vs. 11 ± 5, p = 0.002). When analyzing patients according to T stage and response to neoadjuvant treatments, patients with T1 and T2 tumors and patients with a poor pathological response (TRG3, 4, 5) had a significantly higher LN harvest when undergoing a minimally invasive approach (p = 0.021 and p = 0.01, respectively). Positive LN rates (1.26 ± 3.63 in the MIE group vs. 1.60 ± 2.84 in the H/O group, p = 0.061), R0 rates (97% vs. 98.5%, p = 0.46) as well as proximal (p = 0.083), distal (p = 0.063), and lateral (p = 0.15) margins were comparable between both approaches., Conclusion: MIE seems oncologically safe and may even be better than the open approach in terms of LN harvest especially in patients with T1 and T2 tumors and in poor responders., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: A transthoracic esophagectomy is associated with high rates of morbidity. Minimally invasive esophagectomy has emerged to decrease such morbidity. The aim of this study was to accurately determine surgical outcomes after totally minimally invasive Ivor-Lewis Esophagectomy (TMIE)., Methods: A systematic literature search was performed to identify original articles analyzing patients who underwent TMIE. Main outcomes included overall morbidity, major morbidity, pneumonia, arrhythmia, anastomotic leak, chyle leak, and mortality. A meta-analysis was conducted to estimate the overall weighted proportion and its 95% confidence interval (CI) for each analyzed outcome., Results: A total of 5619 patients were included for analysis; 4781 (85.1%) underwent a laparoscopic/thoracoscopic esophagectomy and 838 (14.9%) a robotic-assisted esophagectomy. Mean age of patients was 63.5 (55-67) years and 75.8% were male. Overall morbidity and major morbidity rates were 39% (95% CI, 33%-45%) and 20% (95% CI, 13%-28%), respectively. Postoperative pneumonia and arrhythmia rates were 10% (95% CI, 8%-13%) and 12% (95% CI, 8%-17%), respectively. Anastomotic leak rate across studies was 8% (95% CI, 6%-10%). Chyle leak rate was 3% (95% CI, 2%-5%). Mortality rate was 2% (95% CI, 2%-2%). Median ICU stay and length of hospital stay were 2 (1-4) and 11.2 (7-20) days, respectively., Conclusions: Totally minimally invasive Ivor-Lewis esophagectomy is a challenging procedure with high morbidity rates. Strategies to enhance postoperative outcomes after this operation are still needed., (Copyright © 2021 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.)

Background: Because of its capacity to reduce surgical trauma to the chest wall, thoracoscopic esophagectomy is considered paramount for decreasing the risk of pulmonary complications in the context of minimally invasive esophagectomy. Whether laparoscopy (LS) following thoracoscopic esophagectomy can further improve outcomes compared with open laparotomy (OL) is unknown., Materials and Methods: We retrospectively reviewed the clinical and imaging records of 428 patients who received McKeown esophagectomy with a thoracoscopic approach for cancer. Using propensity score matching based on eight parameters (age, sex, body mass index, Charlson comorbidity index, tumor location, type of preoperative therapy, reconstruction route, and occurrence/severity of postoperative vocal cord palsy), 60 pairs were identified and compared with regard to perioperative complications and overall survival (OS)., Result: Compared with OL, LS resulted in lower blood loss (mean: 171.21 versus 107.58 mL, respectively, p = 0.023) and a reduced incidence of pneumonia (13.3% versus 3.3%, respectively, p = 0.048), albeit at the expense of a longer operating time (mean: 399.37 versus 443.93 min, respectively, p = 0.003). Notably, lymph node yields and OS of patients who were treated with LS were similar to those observed in those who underwent OL., Conclusions: Patients who receive LS after thoracoscopic esophagectomy experience lower blood loss and have a reduced risk of pneumonia than those treated with OL., Competing Interests: Declaration of competing interest All authors have no conflicts of interest or financial ties to disclose., (Copyright © 2021. Published by Elsevier Taiwan LLC.)

Objective: To analyze the results of thoracoscopic esophagectomy for benign esophageal diseases., Material and Methods: The study included 78 patients who underwent thoracoscopic esophagectomy between 2011 and 2019. Peptic and burn strictures of the esophagus were diagnosed in 53 patients, achalasia - in 24 patients. Minimally invasive esophagectomy and esophagoplasty with isoperistaltic gastric tube and esophagogastrostomy on the neck was performed in 68 patients, Ivor Lewis esophagectomy - in 1 patient, coloesophagoplasty - in 9 patients. We used manual technique of anastomosis in 58 patients, stapling device - in 19 patients. In 1 case, surgery was finished with esophagostomy and gastrostomy., Results: Mean blood loss was 200 ml (10-1200), surgery time - 450 min (265-765 min). Early postoperative complications occurred in 37 patients including anastomotic leakage in 24 cases. In long-term period, anastomotic strictures developed in 9 patients. No mortality was observed., Conclusion: Minimally invasive esophagectomy for benign esophageal diseases ensures favorable clinical outcomes. However, no consensus in the choice of surgical approach and indications, as well as small number of these patients cause challenges in implementation of this technique. There are different opinions regarding technique of anastomosis on the neck and surgical access in thoracoscopic esophagectomy.

The long-term outcomes of robotic-assisted McKeown esophagectomy (RAME) compared to thoraco-laparoscopic McKeown esophagectomy (TLME) for the patients with esophageal squamous cell carcinoma (ESCC) remain unclear. The aim of this study was to compare the number of dissected lymph nodes and long-term survival between RAME and TLME using a propensity score-matched (PSM) analysis. A total of 721 patients undergoing minimally invasive McKeown esophagectomy at our department from February 2015 to October 2019 were analyzed, including 310 patients in RAME group and 411 in TLME group. The exact numbers of lymph nodes including those among thoracic and abdominal categories as well as those along the recurrent laryngeal nerve (RLN) were all recorded. PSM analysis was applied to generate matched pairs for further comparison. All patients with R0 resection were followed with a strict follow-up period which range from 1 to 56 months. The effect of lymphadenectomy was compared between all patients in unmatched and matched groups. Long-term outcomes consisting of overall survival (OS), disease-free survival (DFS) and recurrence rate (including regional recurrence rate, systemic recurrence rate and mediastinal lymph nodes recurrence rate) were compared in R0 resection patients. Finally, 292 patients were identified for each cohort after PSM. RAME was found to yield significantly more left RLN lymph nodes (mean: 2.27 ± 0.90 vs. 2.09 ± 0.79; P = 0.011) and more thoracic lymph nodes (mean: 12.60 ± 4.22 vs. 11.83 ± 3.12, P = 0.012) compared with TLME after PSM analysis. There was no significant difference in the OS and DFS between the RAME and TLME group. Besides, total recurrences were recognized in 33 (11.7%) patients in the RAME group and 36 (12.9%) in the TLME group (P = 0.676). The mediastinal lymph nodes recurrence rate in the RAME group was tended to be lower than that in the TLME group (2.5% vs. 5.4%, P = 0.079). Therefore, RAME might be an alternative approach for the treatment of ESCC with more lymph nodes dissected and similar long-term survival outcomes compared to TLME., (© The Author(s) 2020. Published by Oxford University Press on behalf of International Society for Diseases of the Esophagus. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

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., (© 2020. Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Post-esophagectomy hiatal hernia (PEHH) is a known, but relatively uncommon, complication after esophagectomies. The incidence of PEHH seems to be increasing since the introduction of minimally invasive esophagectomy. This systematic review and meta-analysis aimed to determine the pooled incidence of PEHH after esophagectomy, and to evaluate if minimally invasive technique is associated with increased risk for PEHH compared to open esophagectomy., Methods: A systematic search of PubMed, Medline via Ovid and Web of Science was performed. Retrospective and prospective studies in English language describing the incidence or risk factors for PEHH were included. Weighted incidence of PEHH after all types of esophagectomy, and after open or minimally invasive technique was calculated., Results: A total of 7943 esophagectomy patients were included in the analysis. In total, 310 patients (3.9%) were diagnosed with PEHH. The estimated weighted incidence rate for PEHH after open esophagectomy was 0.024 (95% confidence interval: 0.012-0.045) compared to 0.065 (95% confidence interval: 0.040-0.106) after minimally invasive esophagectomy. Odds ratio for PEHH after minimally invasive esophagectomy compared to open esophagectomy was 2.76 (95% confidence interval: 1.49-5.11)., Conclusion: The risk for post-esophagectomy hiatal hernia was significantly higher after minimally invasive esophagectomy compared to open technique. Heterogeneity and retrospective designs of the included studies were important limitations of the analysis. Future studies should investigate preventive measures to reduce PEHH after minimally invasive esophagectomy., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Purpose: This study evaluates surgical outcomes of Ivor Lewis esophagectomy (ILE) in our institution, with the transition from open ILE to hybrid or totally minimally invasive ILE (MI-ILE)., Methods: Selected patients who underwent ILE for esophageal cancer between 2013 and 2020 were included. We retrospectively investigated the patients' background characteristics and the short-term surgical outcomes., Results: In this period, among a total of 858 esophagectomies, selected seventy-one patients (8.3%) underwent ILE, consisted of 17 cases with completely open procedures, 27 with hybrid MI-ILE, and 27 with total MI-ILE. The major indications for ILE were adenocarcinoma of the distal esophagus or esophagogastric junction (33.8%) and patients with prior treatment of head and neck cancer (31.0%). Among these approaches, there were no significant differences in the characteristics including age, body mass index (BMI), tumor location, preoperative therapy, and clinical TNM stage, except for histology. Compared to the completely open and hybrid groups, incidences of both total and severe complications in the total MI-ILE group were significantly lower (total 70.6 vs. 66.6 vs. 37.0%, p=0.036; severe 35.3 vs. 44.4 vs. 11.1%, p=0.023), and also, those of pneumonia (41.2 vs. 29.6 vs. 7.4%, p=0.026) and postoperative stricture (11.8 vs. 18.5 vs. 0%, p=0.001) were significantly fewer in the total MI-ILE group., Conclusions: We have been able to achieve the transition from completely open to total MI-ILE with better short-term outcomes. Total MI-ILE with linear-stapled anastomosis can be a good alternative to open procedures for the selected patients with reducing the incidence of postoperative pneumonia and anastomotic stricture., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Esophageal resection is a key component of the multidisciplinary management of esophageal cancer. Robotic-assisted minimally invasive esophagectomy is gaining widespread approval amongst few centers with promising early data. There is significant variability in the operative approach utilized by different centers and this review describes, step-by-step, the operative technique at a high-volume tertiary center. The cornerstone of management is individualized surgical approach, based on patient, tumor and technical factors. Although our approach is based on aforementioned factors, our preferred approach is an Ivor Lewis esophagectomy and this review focuses on that. The procedure is broken down into three key parts, starting with an abdominal exploration and creation of the gastric conduit, placement of jejunostomy tube, moving to thoracic mobilization and creation of the side-side 6 cm stapled esophagogastric anastomosis with a final abdominal portion to assure proper positioning of the conduit and reducing redundancy. This approach is fully robotic and a side to side anastomosis facilitates the creation of a widely patent anastomosis therefore minimizing the risk of anastomotic leaks and strictures. Our experience with minimally invasive esophagectomy, as has been previously published, is associated with a 5.1% of anastomotic leak and 7.6% of anastomotic stricture. The robotic platform further optimizes this technique and helps us safely accomplish a side to side stapled anastomosis. Superior instrument dexterity in a restricted thoracic space is facilitated by intracorporeal suturing and robotic stapling. Thus, it obviates the need for a larger thoracotomy incision, which is typically needed for an EEA anastomosis, and that is traditionally associated with higher stricture rate.

Background: To evaluate the incidence, treatment and postoperative outcomes of an acute hiatal hernia (HH) after totally minimally invasive esophagectomy (tMIE) for oesophageal cancer., Methods: The incidence and treatment of acute HH were analysed from our prospective database including all patients that were surgically treated for oesophageal cancer in the period between January 2011 and December 2018., Results: Within the study period, the database contained 307 patients that underwent minimally invasive oesophagectomy. Patients' characteristics were in line with the literature of Western data. The incidence of acute HH was 2.6% (N = 8). All patients presented with gastro-intestinal obstruction symptoms, that required acute operation, repositioning of the intrathoracic organs in combination with a crural repair. Mesh reinforcement was used in 38% (N = 3). In two patients, the intestines were partially resected due to ischemia. Postoperative complications, as atrial fibrillation, respiratory failure and anastomotic leakage, were seen in 63% (N = 5). Recurrence-rate was 38% (N = 3)., Conclusions: This present study demonstrates that an acute HH after tMIE is a serious complication with an incidence of 2.6%. When symptomatic and acute, HH requires surgical intervention and has high postoperative morbidity and recurrence-rate. Therefore, this requires treatment in a centre specialised in oesophageal surgery.

Objectives: To compare the short-, mid-, and long-term outcomes in patients with esophageal cancer between minimally invasive esophagectomy via Sweet approach in combination with cervical mediastinoscopy (MIE-SM) and minimally invasive esophagectomy via McKeown approach (MIE-MC), and to evaluate the value of MIE-SM in the surgical treatment of esophageal cancer., Methods: A prospective, nonrandomized study was adopted. A total of 65 esophageal cancer patients after MIE-SM and MIE-MC from June 2014 to May 2016 were included. Among them, 33 patients underwent MIE-SM and 32 patients underwent MIE-MC. Short-term outcomes (including the duration of surgery, intraoperative blood loss volume, ICU stay time, postoperative complications, postoperative hospital stay, reoperation, open surgery, number of dissected lymph nodes, and 30-day mortality), mid-term outcomes, [including Quality of Life Core Questionnaire (QLQ-C30) and the esophageal site-specific module (QLQ-OES18)], long-term outcomes [including overall survival and disease-free survival] were compared between the 2 groups., Results: Radical resection (R0) were achieved in all patients. There were no significant differences in the duration of surgery, intraoperative blood loss volume, ICU stay time, postoperative complications, and postoperative hospital stay between the 2 groups (all P >0.05). More lymph nodes were dissected in the MIE-SM group (24.1±7.3) than those in the MIE-MC group (17.8±5.0, P <0.001). The emotional function, global health status scale scores in QLQ-C30 scale in the MIE-SM group were significantly higher than those in the MIE-MC group ( P =0.025, P <0.001, respectively), and the pain score in the MIE-SM group was significantly lower than that in the MIE-MC group ( P =0.013). QLQ-OES18 results showed that the pain score in the MIE-SM group was significantly lower than that in the MIE-MC group ( P =0.021). Survival analysis showed that the overall survival and disease-free survival were similar between the 2 groups., Conclusions: MIE-SM appears to be a safe surgical approach, which may get better quality of life, suffer less pain, and can achieve the same therapeutic effect as MIE-MC. Therefore, MIE-SM should be considered as a valuable approach for the treatment of middle and lower esophageal cancer.

Background: The only curative treatment for most esophageal cancers is radical esophagectomy. Minimally invasive esophagectomy (MIE) aims to reduce postoperative morbidity, but is not yet widely established. Linear stapled anastomosis is a promising technique for MIE because it is quite feasible even without robotic assistance. The aim of the present study is to compare total MIE with linear stapled anastomosis to open esophagectomy (OE) with circular stapled anastomosis with special regard to postoperative morbidity in an expertise-based randomized controlled trial (RCT)., Methods/design: This superiority RCT compares MIE with linear stapled anastomosis (intervention) to OE with circular stapled anastomosis (control) for Ivor-Lewis esophagectomy. It was initiated in February 2019, and recruitment is expected to last for 3 years. For inclusion, patients must be 18 years of age or more with a resectable primary malignancy in the distal esophagus. Participants with tumor localizations above the azygos vein, metastasis, or infiltration into adjacent tissue will be excluded. In an expertise-based approach, the allocated treatment will only be carried out by the single most experienced surgeon of the surgical center for each respective technique. The sample size was calculated with 20 participants per group for the primary endpoint postoperative morbidity according to comprehensive complication index (CCI) within 30 postoperative days. Secondary endpoints include anastomotic insufficiency, pulmonary complications, other intra- and postoperative outcome parameters such as estimated blood loss, operative time, length of stay, short-term oncologic endpoints, adherence to a standardized fast-track protocol, postoperative pain, and postoperative recovery (QoR-15). Quality of life (SF-36, CAT EORTC QLQ-C30, CAT EORTC QLQ-OES18) and oncological outcomes are evaluated with 60 months follow-up., Discussion: MIVATE is the first RCT to compare OE with circular stapled anastomosis to total MIE with linear stapled anastomosis exclusively for intrathoracic anastomosis. The expertise-based approach limits bias due to heterogeneity of surgical expertise. The use of a dedicated fast-track protocol in both OE and MIE will shed light on the role of the access strategy alone in this setting. The findings of this study will serve to define which approach has the best perioperative outcome for patients requiring esophagectomy., Trial Registration: German Clinical Trials Register DRKS00016773 . Registered on 18 February 2019.

Background: Esophagectomy is a fundamental step to achieve long-term disease-free survival in esophageal cancer. While various approaches have been described, there is no consensus on the single best technique to optimize operative and oncologic outcomes. We aim to report the modern experience with laparoscopic transhiatal esophagectomy (LTHE) for invasive adenocarcinoma., Methods: We reviewed all patients who underwent LTHE with extended lymph node dissection for distal esophageal adenocarcinoma (EAC) at our institution between 2007 and 2016. Pre-operative characteristics, operative details, postoperative complications, and long-term outcomes were tracked by review of the electronic medical record and patient surveys. Survival rates were calculated with Kaplan-Meier curves., Results: Eighty-two EAC patients underwent LTHE during the study period (84% male, mean age 65, mean BMI 27.8, large). Most patients were clinical stage III (42.7%) and 68.3% had received neoadjuvant chemoradiation (nCRT). Laparoscopy was successful in 93.9%, with five cases requiring conversion to open (6.1%). The median lymph node harvest was 19. Overall complication rate (major and minor) was 45.5% and ninety-day mortality was 4%. Overall 5-year survival was 52% (77% for stage 1, 57% for stage 2, 37% for stage 3)., Conclusions: Laparoscopic transhiatal esophagectomy has an important role in current esophageal cancer treatment and can be performed with curative intent in patients with distal esophageal tumors. In addition to the well-known advantages of laparoscopy, the increased mediastinal visibility and a modern focus on oncologic principles seem to have a positive impact on cancer survival compared to the open transhiatal approach.

Despite excellent short-term outcomes of minimally invasive esophagectomy (MIE), there is minimal data on long-term outcomes compared to open esophagectomy. MIE's superior visualization may have improved lymphadenectomy and complete resection rate and therefore improved long-term outcomes. We hypothesized that MIE would have superior long-term survival. Patients undergoing an esophagectomy for cancer between 2010 and 2016 were identified in the National Cancer Database. MIE included laparoscopic/robotic approach, and conversions were categorized as open. A 1:1 propensity match was performed. Lymphadenectomy and margin status were compared between MIE and open using Stuart Maxwell marginal homogeneity and Wilcoxon matched-pair signed-rank test. Survival was compared using log-rank test. 13,083 patients were identified: 8,906 (68%) open and 4,177 (32%) MIE. Propensity matching identified 3,659 'pairs' of MIE and open esophagectomy patients. Among them, MIE was associated with higher number lymph nodes examined (16 vs. 14, P < 0.001) and similar number of positive lymph nodes (0 vs. 0, P = 0.33). MIE had higher rate of negative pathologic margin (95 vs. 93.5%, P < 0.001). MIE was also associated with shorter hospitalization (9 vs. 10 days, P < 0.001). Survival was improved among MIE patients (46.6 vs. 41.4 months for open, P = 0.003) and among pathologic node-negative patients (71.4 vs. 61.5 months, P = 0.005). These data suggest that MIE has improved short-term outcomes (improved lymphadenectomy, pathologic margins, and length of stay) and also associated improved overall survival. The etiology of superior overall survival is likely secondary to many factors related and unrelated to surgical approach., (© The Author(s) 2020. Published by Oxford University Press on behalf of International Society for Diseases of the Esophagus. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Minimally invasive foregut surgery is increasingly performed for both benign and malignant diseases. We present a retrospective series of patients who underwent minimally invasive Ivor Lewis esophagectomy (MIE) with linear stapled anastomosis performed at two centers in the USA, with a focus on evaluating leak and stricture rates., Methods: Patients treated from 2007 to 2018 were included, and data on demographics, oncologic treatment, pathology, and outcomes were analyzed. The surgical technique utilized laparoscopic and thoracoscopic access, with an intrathoracic esophagogastric anastomosis using a 6-cm linear stapled side-to-side technique., Results: A total of 124 patients were included and 114 resections (91.9%) were completed in a minimally invasive fashion with a 6-cm linear stapled side-to-side anastomosis. Patients were predominantly male (90.7%) with a median age of 66.0 years and body mass index of 28.8 kg/m 2 . Of 121 patients with malignancy, negative margins were obtained in 94.3% and median lymph node yield was 15 (IQR 12-22). In the intention to treat analysis, median operative time was 463 min (IQR 403-515), blood loss was 150 mL (IQR 100-200), and length of stay was 8 days (IQR 7-11). Postoperative complications were experienced by 64 patients (51.6%) including respiratory failure in 14 (11.3%) and pneumonia in 12 (9.7%). In patients who successfully underwent a 6-cm stapled side-to-side anastomosis, anastomotic leaks occurred in 6 patients (5.1%) without need for operative intervention, and anastomotic strictures occurred in 6 patients (5.1%) requiring endoscopic management., Conclusions: Ivor Lewis MIE with a 6-cm linear stapled anastomosis can be completed with a high technical success rate, and low rates of anastomotic leak and stricture.

Minimally invasive oesophagectomy has become popular, but studies showed a higher rate of postoperative hiatus hernia compared with open oesophagectomy. Our video presents the laparoscopic biosynthetic mesh repair of a symptomatic giant hiatus hernia in a 71-year-old man who had undergone minimally invasive oesophagectomy one year earlier for distal adenocarcinoma of the oesophagus. The operative time was 120 minutes. The patient started oral intake on postoperative day one and was discharged on postoperative day three. Postoperative computed tomography at six months showed no signs of recurrence. In the setting of a symptomatic hiatus hernia post-minimally invasive oesophagectomy, we suggest an initial laparoscopic approach, because of its countless advantages.

Controversy exists on the advantages of robotic McKeown esophagectomy (RME) versus thoraco-laparoscopic McKeown esophagectomy (TLME). The aim was to evaluate the short- and mid-term outcomes of RME and TLME in the treatment of patients with esophageal squamous cell carcinoma (ESCC). A consecutive series of 652 patients, 280 in RME and 372 in TLME, who underwent minimally invasive McKeown esophagectomy for ESCC at our department from November 2015 to June 2018 was analyzed. A propensity score-matched comparison with clinicopathological covariates was performed between the two groups. Complications were categorized based on the Esophagectomy Complications Consensus Group (ECCG) recommendation. To identify the recurrence, all patients with R0 resection were followed with a median follow-up period of 20.2 months (range 1-33 months). After propensity score matching, 271 patients were identified for each cohort. In the matched cohorts, two patients died within 90 days in TLME, whereas no patients died in RME. RME was associated with similar intraoperative blood loss (P = 0.895), but with shorter surgical duration (244.5 vs. 276.0 min, P < 0.001), shorter thoracic duration (85.0 vs. 102.9 min, P < 0.001) and lower thoracic conversions (0.7% vs. 5.9%, P = 0.001). In spite of the similar results on total and thoracic lymph nodes dissection, RME yielded more lymph nodes along recurrent laryngeal nerve (4.8 vs. 4.1, P = 0.012), as well as the higher incidence of recurrent nerve injury (29.2% vs. 15.1%, P < 0.001) when compared to TLME. Tumor recurrence occurred in 30 patients and was locoregional only in 9 (3.5%) patients, systemic only in 17 (6.7%) patients, and combined in 4 (1.6%) patients in RME, while in 26 patients and was locoregional only in 10 (10.6%) patients, systemic only in 7 (2.8%) patients, and combined in 9 (3.6%) patients in TLME. RME was associated with a lower rate of mediastinal lymph nodes recurrence (2.0% vs. 5.3%, P = 0.044). Overall and disease-free survival was not different between the two cohorts (P = 0.097 and P = 0.248, respectively). RME was shown to be a safe and oncologically effective approach with favorable short- and mid-term outcomes in the treatment of patients with ESCC., (© The Author(s) 2019. Published by Oxford University Press on behalf of International Society for Diseases of the Esophagus. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Initial adoption of minimally invasive esophagectomy (MIE) began in the late 1990s but its surgical technique, perioperative management, and outcome continues to evolve., Methods: The aim of this study was to examine the evolving changes in the technique, outcome, and new strategies in management of postoperative leaks after MIE was performed at a single institution over a two-decade period. A retrospective chart review of 75 MIE operations was performed between November 2011 and September 2018 and this was compared to the initial series of 104 MIE operations performed by the same group between 1998 and 2007. Operative technique, outcomes, and management strategies of leaks were compared., Results: There were 65 males (86.7%) with an average age of 61 years. The laparoscopic/thoracoscopic Ivor Lewis esophagectomy became the preferred MIE approach (49% of cases in the initial vs. 95% in the current series). Compared to the initial case series, there was no significant difference in median length of stay (8 vs. 8 days), major complications (12.5% vs. 14.7%, p = 0.68), incidence of leak (9.6% vs. 10.6%, p = 0.82), anastomotic stricture (26% vs. 32.0%, p = 0.38), or in-hospital mortality (2.9% vs. 2.6%, p = 0.47). Management of esophageal leaks has changed from primarily thoracotomy ± diversion initially (50% of leak cases) to endoscopic stenting ± laparoscopy/thoracoscopy currently (87.5% of leak cases)., Conclusion: In a single-institutional series of MIE over two decades, there was a shift toward a preference for the laparoscopic/thoracoscopic Ivor Lewis approach with similar outcomes. The management of postoperative leaks drastically changed with predilection toward minimally invasive option with endoscopic drainage and stenting.

Background: Minimally invasive esophagectomy is associated with significant morbidity, which can substantially influence the hospital length of stay for patients. Anastomotic leak is the most devastating complication. Minimizing major postoperative complications can facilitate adherence to a clinical pathway protocol and can decrease hospital length of stay., Methods: This is a retrospective study of 130 patients who underwent an elective laparoscopic and thoracoscopic Ivor Lewis esophagectomy for esophageal carcinoma between August 2014 and June 2018. A total of 112 patients (86%) underwent neoadjuvant chemoradiation. All of the 130 patients underwent a laparoscopic gastric devascularization procedure a median of 15 days prior to the esophagectomy. The target discharge date was postoperative day number 8., Results: Thirty patients (23.08%) had postoperative complications. Atrial fibrillation (20 patients) [15.38%] was the most frequent complication. Four patients (3.1%) developed an anastomotic leak. There was one postoperative death (0.77%) in the cohort of patients. The median length of stay was 8 days. The mean length of stay for patients without complications was 8 days ± 1.2 days and 12.4 days ± 7.1 days for patients with one or more complications (p = 0.002)., Conclusion: The development of postoperative complications after minimally invasive Ivor Lewis esophagectomy significantly increases hospital length of stay. Performing the operation with a specialized tandem surgical team and including preoperative ischemic preconditioning of the stomach minimizes overall and anastomotic complications and facilitates on time hospital discharge as defined by a perioperative clinical pathway protocol.

Minimally invasive esophagectomy (MIE) was introduced in the 1990s with the aim to decrease the rate of respiratory complications associated with thoracotomy, along with the benefits of reduced morbidity and a quicker return to normal activities provided by minimally invasive techniques. However, MIE is not routinely applied as a standard approach for esophageal cancer worldwide, due to the high technical complexity of this minimally invasive procedure. Therefore, the open transthoracic esophagectomy is considered to be the gold standard for resectable esophageal cancer worldwide nowadays. In this article, the current status of conventional MIE and robot-assisted minimally invasive thoraco-laparoscopic esophagectomy will be reviewed., (© 2019 The Author(s) Published by S. Karger AG, Basel.)

Background: The published rates of morbidity and mortality remain relatively high for patients who undergo laparoscopic and thoracoscopic Ivor Lewis esophagectomy. We report the postoperative and oncologic outcomes of a large cohort of patients with esophageal carcinoma who were uniformly treated with laparoscopic and thoracoscopic Ivor Lewis esophagectomy following neoadjuvant chemoradiation., Methods: This is a retrospective observational study of 112 patients diagnosed with esophageal carcinoma who underwent total laparoscopic and thoracoscopic Ivor Lewis esophagectomy from May 2014 to May 2018. All of the patients received neoadjuvant chemoradiation consisting of 45 to 50.4 Gray of radiation and 3-5 cycles of carboplatin and paclitaxel chemotherapy. Perioperative morbidity and 90-day mortality were recorded. The overall and disease-free survival rates were estimated by Kaplan Meier techniques., Results: A total of 112 patients completed induction chemoradiation followed by a total laparoscopic and thoracoscopic Ivor Lewis esophagectomy. There were 87 (77.68%) males and 25 (22.32%) females with a mean age of 61.6 years ± 10.4. A total of 28 (25%) patients had one or more complications. A total of 4 patients (3.57%) had an anastomotic leak. The 90-day mortality rate was 0.89%. The 3-year overall survival rate was 64.7% and the 3-year disease-free survival rate was 70.2%., Conclusion: The current outcomes suggest that laparoscopic and thoracoscopic Ivor Lewis esophagectomy can be performed with minimal overall and anastomotic complications following neoadjuvant chemoradiation.

Background: The effectiveness of minimally invasive oesophagectomy (MIO) compared to open oesophagectomy (OO) remains controversial. Various techniques for performing MIO are currently used, but the evidence for them is lacking. The objective of this meta-analysis was to compare the safety, efficacy and oncological outcomes of McKeown's minimally invasive oesophagectomy (McKeown's-MIO) to OO., Methods: PubMed, Embase and Cochrane Library databases were searched up to December 2016 for relevant articles comparing McKeown's-MIO to OO. As no randomised control trials (RCTs) currently exist, only cohort and case control studies were included. Fixed or random-effects models were used to calculate summary odds ratios (ORs) or relative risks (RRs) for binary outcomes, and hazard ratios (HRs) for time-to-event outcomes. Heterogeneity among studies were evaluated using I 2 statistics., Results: Four studies, which consisted a total of 573 patients, were included in the meta-analysis. In comparison to patients undergoing OO, those who were treated with McKeown's-MIO had a reduced incidence of pneumonia and total respiratory complications, however, there were no statistically significant differences for other measures of safety such as RLN palsy and anastomotic leak. In terms of efficacy data, MIO had significantly less blood loss and a shorter duration of hospital stay but a longer operating time. Lymph node retrieval trended towards favouring McKeown's-MIO, but was not statistically significant. There was insufficient data to report on other oncological outcomes., Conclusions: McKeown's-MIO is a safe and effective procedure that has comparable outcomes to OO. However, RCTs with large sample sizes are needed to confirm these results., (Copyright © 2018 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.)

Totally minimally invasive Ivor-Lewis esophagectomy (Ivor Lewis TMIE) is a technically challenging procedure and is associated with a learning curve. Refinement of surgical technique is an important part of this learning curve. However, detailed descriptions of these refinements according to the idea, development, exploration, assessment, and long-term follow-up (IDEAL) framework are lacking and this study was undertaken to fill this knowledge gap. From 2010 until 2016, all consecutive patients (n = 164) were included from the first patient undergoing Ivor Lewis TMIE. Surgical reports were analyzed and surgeons were interviewed to determine surgical refinements. These data were used to describe the transition of the surgical technique from IDEAL stage IIB to stage III. The main findings were that four refinements were made to the surgical procedure in IDEAL stage IIB: (1) At case 9, the use of the 25 mm OrVil was abandoned, exchanged for a 28 mm EEA stapler and a large omental wrap around the anastomosis was introduced; (2) at case 27, the omental wrap was reduced in volume; (3) at case 60, the omental wrap was refined to cover the full 360° of the anastomosis and (4) at case 77, the fixation of the anvil with the Endostitch was replaced by fixation with two Endoloops®. During the transition from IDEAL stage IIB to stage III, the incidence of anastomotic leakage decreased from 26.0% to 4.6% (P < 0.001) and the incidence of textbook outcome increased from 31.2% to 47.1% (P = 0.039). In conclusion, this study describes the surgical refinements that were made during the progression of Ivor Lewis TMIE from IDEAL stage IIB to IDEAL stage III. During IDEAL stage IIB, postoperative outcome improved as surgical proficiency was gained and the technique was refined., (© The Author(s) 2018. Published by Oxford University Press on behalf of International Society for Diseases of the Esophagus.)

Background: The impact of total minimally invasive esophagectomy (MIE) on early postoperative outcome and patient's survival is a matter of recent discussion., Methods: We performed a 1:2 propensity score-matched comparison of 20 patients who underwent 3D-MIE and high intrathoracic esophagogastrostomy with 40 patients who underwent hybrid esophagectomy (HYBRID) with laparoscopic gastric mobilization and open transthoracic esophagectomy and the same anastomosis for esophageal adenocarcinoma in 2014 and 2015. Matching criteria were tumor localization, age, gender, and neoadjuvant treatment., Results: Both groups did not differ regarding overall postoperative complications (MIE 55% vs. HYBRID 50%, p = 0.715) and anastomotic leakage (MIE 15% vs. HYBRID 5%, p = 0.186). A significant difference was seen regarding the rate of postoperative pneumonia (MIE 5% vs. HYBRID 27.5%; p = 0.040) and the postoperative ICU stay (MIE median 1 day vs. HYBRID median 2 days, p < 0.001). The R0-resection rate was 100% in both groups and median number of dissected lymph nodes was 32 for MIE and 35 for HYBRID (p = 0.236). Significant differences between both groups were noticed for postoperative number of patients with use of opiate demand medication and numeric rating scale for pain (NRSP maximum pain, median) both in favor of the MIE group (MIE 25%, NRSP 2 vs. HYBRID 60%, NRSP 4; p = 0.011, p < 0.001). Overall 2-year survival rate was 85% in both groups., Conclusion: Total minimally invasive esophagectomy is superior to hybrid esophagectomy in regard of postoperative pain and rate of pneumonia. No differences exist for postoperative surgical complications or short-term prognosis.

Background: The aim of this study is to summarize the causes and implications of intraoperative conversion from minimally invasive esophagectomy (MIE) to open thoracotomy, and to evaluate the effect on long-term survival., Methods: There were 293 thoracoscopic esophagectomies for esophageal squamous cell carcinoma (ESCC) of the thoracic esophagus performed by the authors from September 2009 to August 2015. Totally, 257 patients were enrolled in this study. These patients were divided into two groups (those underwent complete MIE and those converted to open thoracotomy) and then compared. A standardized preoperative evaluation, as well as a postoperative method of following at a regular frequency were adopted for all of these patients. The clinicopathologic characteristics and the perioperative variables were retrospectively analyzed. Univariate and multivariate analyses were performed to identify prognostic factors. And the Kaplan-Meier method was used to compare survival differences., Results: There were 231 patients (89.9%) underwent successful thoracoscopic esophagectomy (Group 1), and 26 cases (10.1%) required conversion to open procedure (Group 2). The majority of conversion (73.1%, 19/26) occurred in the initial 100 cases. No significant difference in background or clinicopathologic factors between the two groups was observed, but patients in Group 2 had significantly longer operative time and more operative blood loss. Among the 26 patients of Group 2, there were nine cases that need emergent conversion for various reasons. And the most common cause for emergent conversion was intraoperative bleeding. Univariate and multivariate analyses all demonstrated that intraoperative conversion did not significantly influence the overall or recurrence-free survival of these patients., Conclusions: Univariate analysis and multivariate Cox proportional hazard regression analysis indicated that intraoperative conversion did not significantly influence the OS and RFS rate of these patients. Our results demonstrated that the intraoperative conversion did not affect the long-term survival of patients underwent MIE for ESCC.

Background: Minimally invasive esophagectomy (MIE) for patients with esophageal cancer has recently spread worldwide. However, whether MIE is less invasive has not yet been fully evaluated., Methods: We retrospectively analyzed data from 551 patients who underwent curative esophagectomy for esophageal cancer from 2005 to 2014: 145 patients underwent minimally invasive esophagectomy (MIE) and 406 patients underwent open transthoracic esophagectomy (OE). We compared postoperative CRP levels with propensity score matching. In addition, long-term outcomes were also compared between the groups., Results: Operative time was significantly longer, and intraoperative blood loss was significantly less in the MIE group compared with the OE group. Although the incidence of postoperative complications was similar between the 2 groups, postoperative serum CRP levels during the first 3 and 5 postoperative days and peak postoperative CRP levels were significantly lower after MIE versus OE (MIE vs. OE, median, 15.21 vs. 19.50 mg/dl; P < 0.001). The MIE group had significantly more favorable disease-free survival (DFS) and overall survival (OS) rates than the OE group (3-year DFS rate, 81.7 vs. 69.3%, log-rank P = 0.021; 3-year OS rate, 89.9 vs. 79.2%, log-rank P = 0.007). MIE was an independent prognostic factor for patients with esophageal cancer. The incidence of regional lymph node recurrence was lower in the MIE group., Conclusions: MIE significantly attenuated postoperative serum CRP levels compared with OE. MIE could contribute to improved survival.

Introduction: Anastomotic leak and conduit necrosis are devastating complications following Ivor Lewis esophagectomy. Near infrared imaging (NIR) using IndoCyanine Green allows for real time tissue perfusion assessment which may reduce anastomotic leak during minimally invasive Ivor Lewis esophagectomy (MIE)., Methods: Forty consecutive MIE were performed by a single surgeon at a tertiary referral center. The first 20 were assessed for gastric conduit perfusion by clinical criteria (Group 1). The second 20 were also assessed using NIR laparoscopic system (Group 2)., Results: Comparing Group 1 to Group 2, no significant differences were found in overall complication rate, readmission or reoperation rate. NIR resulted in resection of the non perfused proximal portion of the conduit in 30% (6/20). Two patients in group 2 group developed anastomotic leak (2/20) compared to 0 in Group 1 (p = 0.49). Graft necrosis led to one mortality in Group 1, while there were 0 mortalities in Group 2. (p = 1.0)., Conclusion: Although NIR plays a role in assessment of tissue perfusion, in our study its use did not result in reduction of anastomotic leak rate., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Minimally invasive esophagectomy has several benefits as an effective alternative treatment for esophageal cancer. The three-phase esophageal resection may be the most popular approach to esophagectomy. Numerous thoracoport designs are available for the thoracoscopic procedure. The present study aims to contribute a distinctive three-port technique that is designed to minimize surgical trauma and facilitate operation during the thoracoscopic procedure. In this paper, we describe and demonstrate the details of the port design and each operation step. Based on our practical experience, the rational combination of the port design and instrument usage of the three-port technique makes the thorascopic procedure more convenient., (© 2018 Wiley Periodicals, Inc.)

Background and Objectives: The short-term benefits of minimally invasive esophagectomy (MIE) Ivor Lewis were proved, but 6-year outcomes in esophageal squamous cell carcinoma (ESCC) patients remain unclear. We sought to investigate perioperative outcomes, quality of life (QOL), survival and impact of adjuvant therapy in ESCC patients who underwent MIE Ivor Lewis., Methods: We conducted a retrospective review of 530 ESCC patients treated with MIE Ivor Lewis from 2011 to 2016. Relevant variables were collected and assessed. Overall survival (OS) and disease-free survival (DFS) was analyzed by Kaplan-Meier or Cox proportional hazards modeling., Results: Median operation duration was 266 min. The median number of lymph nodes was 28. The 30-day postoperative mortality was 1.7%. At a median follow-up of 41 months, the 6-year OS and DFS were 44.7% and 46.1%. Adjuvant chemoradiotherapy offered survival advantages in advanced stage patients. Pathological tumor-node-metastasis stage, postoperative complications, and recurrent laryngeal nerve lymphadenectomy were independent prognostic factors based on multivariate analysis. Generalized estimating equation analysis showed a rapid postoperative QOL improvement., Conclusions: MIE Ivor Lewis is a safe and feasible procedure in ESCC patients. It offers satisfactory perioperative outcomes, rapid QOL improvement, and acceptable long-term oncologic survival. Adjuvant chemoradiotherapy may improve OS and DFS in advanced stage patients., (© 2018 Wiley Periodicals, Inc.)

Background: Postoperative pulmonary complications (PPCs) are the most common causes of serious morbidity after esophagectomy, which involves both thoracic and abdominal incisions. Although the thoracoscopic approach decreases PPC frequency after esophagectomy, it remains unclear whether the frequency is further decreased by combining it with laparoscopic gastric mobilization. This study aimed to determine the impact of laparoscopy on the prevention of PPCs after thoracoscopic esophagectomy using data from the Japan Clinical Oncology Group Study 0502 (JCOG0502)., Methods: JCOG0502 is a four-arm prospective study comparing esophagectomy with definitive chemo-radiotherapy. The use of thoracoscopy and/or laparoscopy was decided at the surgeon's discretion. PPCs were defined as one or more of the following postoperative morbidities grade ≥2 (as per Common Terminology Criteria for Adverse Events v3.0): pneumonia, atelectasis, and acute respiratory distress syndrome., Results: A total of 379 patients were enrolled in JCOG0502. Of these, 210 patients underwent esophagectomy via thoracotomy with laparotomy (n = 102), thoracotomy with laparoscopy (n = 7), thoracoscopy with laparotomy (n = 43), and thoracoscopy with laparoscopy (n = 58). PPC frequency was reduced to a greater extent by thoracoscopy than by thoracotomy (thoracoscopy 15.8%, thoracotomy 30.3%; p = 0.015). However, following thoracoscopic esophagectomy, laparoscopy failed to further decrease the PPC frequency compared with laparotomy (laparoscopy 15.5%, laparotomy 16.3%; p = 1.00). Univariable analysis showed that thoracoscopy (shown above) and less blood loss (<350 mL 16.3%, ≥350 mL 30.2%; p = 0.022) were associated with PPC prevention, whereas laparoscopy showed a borderline significant association (laparoscopy 15.4%, laparotomy 26.9%; p = 0.079). Multivariable analysis also showed that thoracoscopy and less blood loss were associated with PPC prevention., Conclusion: Thoracoscopic approach to esophagectomy significantly reduced PPC frequency with minimal additional effect from laparoscopic gastric mobilization.

Background: Minimally invasive esophagectomy (MIE) has been shown to be a feasible technique for the treatment of esophageal cancer; however, its postoperative morbidity remains high. This retrospective study aimed to evaluate the effect of postoperative complications on long-term outcomes in patients who have undergone MIE for esophageal squamous cell carcinoma (ESCC)., Methods: This retrospective study enrolled patients who had undergone MIE for ESCC between September 2009 and November 2014; all procedures were performed by a single surgical team. Relevant patient characteristics and postoperative variables were collected and evaluated. The disease-free survival (DFS) and disease-specific survival (DSS) were determined by the Kaplan-Meier method, and compared by log-rank tests. Possible predictors of survival were subjected to univariate analysis and multivariate Cox proportional hazard regression analysis., Results: In all, data on 214 patients with ESCC were analyzed, including 170 men and 44 women. All study subjects had undergone thoracoscopic or thoracoscopic-laparoscopic esophagectomy and cervical esophagogastric anastomosis. One hundred and thirty patients (60.7%) had postoperative complications (Grades 1-4). The overall DFS and DSS rates were 80.0 and 88.9% at 1 year, 48.6 and 54.2% at 3 years, and 43.2 and 43.5% at 5 years, respectively. Univariate analysis and multivariate Cox proportional hazard regression analysis showed that T stage, N stage, and tumor grade were independent prognostic factors for long-term survival; however, postoperative complications had no significant effect on the DFS or DSS of this patient cohort (log-rank test, p = 0.354 and 0.160, respectively)., Conclusions: Postoperative complications have no significant effect on long-term survival in patients who have undergone MIE for ESCC.

Objective: To compare the perioperative outcome of minimally invasive (MIE) esophagectomy performed with a single- or a multi-incision in treating esophageal cancer., Method: Patients with esophageal cancer who underwent MIE from 2006 to 2016 were evaluated. A 3-4-cm incision was created in both the thoracoscopic and the laparoscopic phases during the single-incision MIE procedures. A propensity-matched comparison was made between the two groups of patients., Results: We analyzed a total of 48 pairs of patients with propensity-matched from the cohort of 360 patients undergoing MIE during 2006-2015. There is no statistical difference in terms of postoperative ICU and hospital stay, number of dissected lymph nodes and presence of major surgical complications (anastomotic leakage and pulmonary complications) between the two groups of patients. The pain score one week after surgery was significantly lower in the single-incision group (p < 0.05). There was no surgical mortality in the single-incision MIE group., Conclusion: Minimally invasive esophagectomy performed with a single-incision approach is feasible for treating patients with esophageal cancer, with a comparable perioperative outcome with that of multi-incision approaches. The postoperative pain one week after surgery was significantly reduced in patients undergoing single-incision MIE.

Thoracoscopic intrathoracic esophagogastrostomy is a technically demanding operation; these technical requirements restrict the extensive application of minimally invasive Ivor-Lewis esophagectomy. In an attempt to reduce the difficulty of this surgical procedure, this study developed a modified anastomotic technique for thoracolaparoscopic Ivor-Lewis esophagectomy. During the entirety of this modified approach, neither technically challenging operations such as intrathoracic suturing or knotting, nor special instruments such as an OrVil system or a reverse-puncture head are required. Between October 2015 and January 2016, 15 consecutive patients with cancer in the distal third of the esophagus or the gastric cardia underwent this modified surgical procedure. The good short-term outcomes that were achieved suggest that the modified anastomotic technique is safe and feasible for thoracolaparoscopic Ivor-Lewis esophagectomy., (© International Society for Diseases of the Esophagus 2017. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Laparoscopic gastric devascularization (LGD) is an innovative method to improve gastric conduit perfusion and improve anastomotic healing following esophagectomy. This study reports our early experience with LGD performed two weeks prior to minimally invasive esophagectomy (MIE) with intrathoracic anastomosis., Methods: We performed a retrospective review of all patients who underwent LGD prior to minimally invasive Ivor Lewis esophagectomy between August 2014 and July 2015 at a large academic medical center. LGD included staging laparoscopy with division of the short gastric vessels, left gastric artery and coronary vein, and posterior gastric attachments. Patient demographics, comorbid conditions, clinical stage, use of neoadjuvant chemoradiation, perioperative events, length of hospital stay, 60-day readmission, and complications were collected and analyzed., Results: Thirty patients underwent LGD prior to minimally invasive Ivor Lewis esophagectomy, and 21 (70 %) received neoadjuvant chemoradiation. LGD was performed a median of 14.5 (9-42) days prior to esophagectomy. Median operative time was 39 (18-56) minutes, and median length of stay was 0 (0-1) days. There were no complications or readmissions following LGD. MIE was completed laparoscopically in 93 % of patients; two patients required conversion to an open procedure due to mediastinal inflammation following neoadjuvant chemoradiation. Five patients (17 %) were readmitted within 60 days of surgery: one (3 %) patient with an anastomotic leak, two (7 %) with pneumonia, and two (7 %) with post-operative nausea and vomiting. One patient (3 %) expired following an anastomotic leak that required reoperation, and no patients developed an anastomotic stricture during the study period., Conclusions: LGD with delayed esophageal resection and reconstruction can be safely performed two weeks prior to MIE with minimal morbidity. The low rate of anastomotic leak (3 %) and absence of anastomotic strictures in this series suggest that this approach may successfully improve gastroesophageal anastomotic healing and reduce the rate of anastomotic complications reported with single-stage approaches.

Esophageal cancer has a poor prognosis, with little improvement in outcomes in recent years. Surgery maintains its pivotal role in cure, but this involves two or three compartment dissection with associated high risks. Chiefly, pulmonary complications following surgery are most common, and can be life-threatening. As a consequence, minimally invasive and robotic esophagectomy have been performed with improving efficacy and equivalent oncological outcomes. This is a review of the pertinent literature regarding these techniques. J. Surg. Oncol. 2016;114:731-735. © 2016 Wiley Periodicals, Inc., (© 2016 Wiley Periodicals, Inc.)

The last 25 years have witnessed a steady increase in the use of minimally invasive esophagectomy for the treatment of esophageal cancer. However, it is unclear which the optimal minimally invasive approach is: totally minimally invasive or hybrid (laparoscopic assisted or thoracoscopic assisted)? The current evidence from nonrandomized control trials suggests that hybrid laparoscopic-assisted esophagectomy couples the benefits of laparoscopy and the advantages of thoracotomy, leading to reduced surgical trauma without jeopardizing survival compared with open esophagectomy. Compromised blood supply and tension on the anastomosis are two of the main factors that lead to anastomotic leakage. Recent studies have shown that a side-to-side mechanical intrathoracic esophagogastric anastomosis is associated with low anastomotic complications. This article discusses surgical aspects and outcomes of hybrid laparoscopic-assisted esophagectomy for esophageal cancer.

Background: The prevalence of morbid obesity in the United States has been steadily increasing, and there is an established relationship between obesity and the risk of developing certain cancers. Patients who have undergone prior gastric bypass (GB) and present with newly diagnosed esophageal cancer represent a new and challenging cohort for surgical resection of their disease. We present our case series of consecutive patients with previous GB who underwent minimally invasive esophagectomy (MIE)., Methods: Retrospective review of consecutive patients with a history of GB who underwent a MIE for esophageal cancer between July 2010 and August 2012., Results: Five patients were identified with a mean age of 57 years. Mean follow-up was 9.1 months. Four patients had undergone laparoscopic GB, and 1 patient had an open GB. Two patients received neoadjuvant chemoradiation therapy for locally advanced disease. Minimally invasive procedures were thoracoscopic/laparoscopic esophagectomy with cervical anastomosis in 4 patients and colonic interposition in 1 patient. Mean operative time was 6 hours and 52 minutes. Median length of stay was 7 days. There was no mortality. Postoperative complications occurred in 3 patients and included pneumonia/respiratory failure, recurrent laryngeal nerve injury, and pyloric stenosis. All patients are alive and disease free at last follow-up., Conclusions: Minimally invasive esophagectomy after prior GB is well tolerated, is technically feasible, and has acceptable oncologic and perioperative outcomes. We conclude that precise endoscopic evaluation before bariatric surgery in patients with gastroesophageal reflux disease is essential, as is the necessity for continuing postsurgical surveillance in patients with known Barrett's esophagitis and for early evaluation in patients who develop new symptoms of gastroesophageal reflux disease after bariatric surgery., (Copyright © 2014 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Because of its capacity to reduce surgical trauma to the chest wall, thoracoscopic esophagectomy is considered paramount for decreasing the risk of pulmonary complications in the context of minimally invasive esophagectomy. Whether laparoscopy (LS) following thoracoscopic esophagectomy can further improve outcomes compared with open laparotomy (OL) is unknown. Materials and methods: We retrospectively reviewed the clinical and imaging records of 428 patients who received McKeown esophagectomy with a thoracoscopic approach for cancer. Using propensity score matching based on eight parameters (age, sex, body mass index, Charlson comorbidity index, tumor location, type of preoperative therapy, reconstruction route, and occurrence/severity of postoperative vocal cord palsy), 60 pairs were identified and compared with regard to perioperative complications and overall survival (OS). Result: Compared with OL, LS resulted in lower blood loss (mean: 171.21 versus 107.58 mL, respectively, p = 0.023) and a reduced incidence of pneumonia (13.3% versus 3.3%, respectively, p = 0.048), albeit at the expense of a longer operating time (mean: 399.37 versus 443.93 min, respectively, p = 0.003). Notably, lymph node yields and OS of patients who were treated with LS were similar to those observed in those who underwent OL. Conclusions: Patients who receive LS after thoracoscopic esophagectomy experience lower blood loss and have a reduced risk of pneumonia than those treated with OL.

Background: Thoracoscopic esophagectomy (TE) is considered the standard surgery for esophageal cancer because of its superiority over open esophagectomy (OE) in terms of short-term outcomes. However, few prospective multicenter studies have evaluated its long-term survival after TE. This study aimed to investigate whether the prognosis for patients with T1bN0M0 esophageal cancer after TE is not inferior to OE using data from the Japan Clinical Oncology Group Study (JCOG0502), a prospective multicenter trial comparing esophagectomy with chemoradiotherapy. Methods: Data of patients in JCOG0502 after esophagectomy were used to compare the overall survival (OS) and relapse-free survival (RFS) after OE versus TE. OE or TE was selected at the surgeon's discretion. A hazard ratio and 95% confidence interval (CI) were calculated via Cox proportional-hazards model. Results: Of the 210 patients who underwent esophagectomy, 109 underwent OE, whereas 101 underwent TE. The 5-year OS was 88.9% after OE and 85.0% after TE. The hazard ratio of TE for OS was 1.53 (95% CI, 0.84–2.78; p = 0.16) and 1.10 (95% CI, 0.52–2.35; p = 0.80) in the univariable and multivariable analyses, respectively. The 5-year RFS was 85.3% after OE and 79.1% after TE. The hazard ratio of TE for RFS was 1.39 (95% CI, 0.81–2.38; p = 0.23) and 0.88 (95% CI, 0.44–1.74; p = 0.70) in the univariable and multivariable analyses, respectively. Conclusion: The prognosis for patients with T1bN0M0 esophageal cancer after TE was not inferior to OE. [ABSTRACT FROM AUTHOR]