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Background: The global shift from open esophagectomy (OE) to minimally invasive esophagectomy (MIE) for treating esophageal cancer is well-established. Recent data indicate that transitioning from hybrid minimally invasive esophagectomy (hMIE) to total minimally invasive esophagectomy (tMIE) can be challenging due to concerns about higher leakage rates and lower lymph node counts, especially at the beginning of the learning curve. This study aimed to demonstrate that a safe transition from OE to tMIE for cancer is possible using process management methodology. Methods: A step-change approach was adopted in process management planning, with hMIE serving as an intermediate step between OE and tMIE. This single-center, case–control study included 150 patients who underwent the Ivor Lewis procedure with curative intent for esophageal cancer. Among these patients, 50 underwent OE, 50 hMIE (laparoscopic procedure followed by conventional right thoracotomy), and 50 tMIE (laparoscopic and thoracoscopic approach). A preceptored training scheme was implemented during execution, and treatment results were monitored and controlled to ensure a safe transition. Results: During the transition, the tMIE group was not worse than the hMIE and OE groups regarding operation duration (p = 0.135), overall postoperative complications (p = 0.020), anastomotic leakage rates (p = 0.773), 30-day mortality (p = 1.0), and oncological outcomes (based on R status (p = 0.628) and 2-year survival (p = 0.967)). Additionally, the tMIE group showed superior results in terms of major postoperative pulmonary complications (p = 0.004) and ICU stay duration (p < 0.001). Conclusions: Utilizing managerial methodology and practice in surgery, as a bridge between interdisciplinary and transdisciplinary approaches, demonstrated that transitioning from OE to tMIE, with hMIE as an intermediate step, is safe and feasible without compromising outcomes. [ABSTRACT FROM AUTHOR]

Abstract Background The study was performed to investigate the efficacy and safety of preoperative dexamethasone (DXM) in preventing postoperative pulmonary complications (PPCs) after minimally invasive esophagectomy (MIE). Methods Patients who underwent total MIE with two-field lymph node dissection from February 2018 to February 2023 were included in this study. Patients who were given either 5 mg or 10 mg DXM as preoperative prophylactic medication before induction of general anesthesia were assigned to the DXM group, while patients who did not receive DXM were assigned to the control group. Preoperative evaluations, intraoperative data, and occurrence of postoperative complications were analyzed. The primary outcome was the incidence of PPCs occurring by day 7 after surgery. Results In total, 659 patients were included in the study; 453 patients received preoperative DXM, while 206 patients did not. Propensity score-matched analysis created a matched cohort of 366 patients, with 183 patients each in the DXM and control groups. A total of 24.6% of patients in the DXM group and 30.6% of patients in the control group had PPCs (P = 0.198). The incidence of respiratory failure was significantly lower in the DXM group than in the control group (1.1% vs 5.5%, P = 0.019). Fewer patients were re-intubated during their hospital stay in the DXM group than in the control group (1.1% vs 5.5%, P = 0.019). Conclusions Preoperative DXM before induction of anesthesia did not reduce overall PPC development after MIE. Nevertheless, the occurrence of early respiratory failure and the incidence of re-intubation during hospitalization were decreased. Trial registration Chinese Clinical Trial Registry (No. ChiCTR2300071674; Date of registration, 22/05/2023)

Robotic surgery systems, as emerging minimally invasive approaches, have been increasingly applied for the treatment of esophageal cancer because they provide a high-definition three-dimensional surgical view and mechanical rotating arms that surpass the limitations of human hands, greatly enhancing the accuracy and flexibility of surgical methods. Robot-assisted McKeown esophagectomy (RAME), a common type of robotic esophagectomy, has been gradually implemented with the aim of reducing postoperative complications, improving postoperative recovery and achieving better long-term survival. Multiple centers worldwide have reported and summarized their experiences with the RAME, and some have also discussed and analyzed its perioperative effects and survival prognosis compared with those of video-assisted minimally invasive esophagectomy. Compared to traditional surgery, the RAME has significant advantages in terms of lymph node dissection although there seems to be no difference in overall survival or disease-free survival. With the continuous advancement of technology and the development of robotic technology, further development and innovation are expected in the RAME field. This review elaborates on the prospects of the application and advancement of the RAME to provide a useful reference for clinical practice.

Background: Esophagectomy is the gold standard treatment for resectable esophageal cancer; however, there is insufficient evidence to indicate potential advantages over standard minimally invasive esophagectomy (MIE) in treating thoracic esophageal cancer. Robot-assisted minimally invasive esophagectomy (RAMIE) bridges the gap between open and minimally invasive surgery. In this single-center retrospective review, we compare the clinical outcomes of EC patients treated with MIE and RAMIE. Method: We retrospectively reviewed the clinical data of patients with esophageal cancer who underwent surgery at Qilu Hospital between August 2020 and August 2022, including 159 patients who underwent MIE and 35 patients who received RAMIE. The intraoperative, postoperative, and preoperative patient characteristics in both groups were evaluated. Results: Except for height, the MIE and RAMIE groups showed no significant differences in preoperative features (P>0.05). Further, there were no significant differences in intraoperative indices, including TNM stage of the resected tumor, tumor tissue type, or ASA score, between the two groups. However, statistically significant differences were found in some factors; the RAMIE group had a shorter operative time, less intraoperative bleeding, and more lymph nodes removed compared to the MIE group. Patients in the RAMIE group reported less discomfort and greater chest drainage on the first postoperative day than patients in the MIE group; however, there were no differences in other features between the two datasets. Conclusion: By comparing the clinical characteristics and outcomes of RAMIE with MIE, this study verified the feasibility and safety of RAMIE for esophageal cancer. Overall, RAMIE resulted in more complete lymph node clearance, shorter operating time, reduced surgical hemorrhage, reduced postoperative discomfort, and chest drainage alleviation in patients. To investigate the function of RAMIE in esophageal cancer, we propose undertaking a future clinical trial with long-term follow-up to analyze tumor clearance, recurrence, and survival after RAMIE. [ABSTRACT FROM AUTHOR]

The impacts of minimally invasive esophagectomy (MIE) in comparison with open esophagectomy (OE) on postoperative complications, wound infections and hospital length of stay in patients with esophageal carcinoma (ESCA) using meta‐analysis to provide reliable evidence for clinical practice. A search strategy was developed and computer searches were performed on Embase, Web of Science, PubMed, Cochrane Library, Wanfang, China Biomedical Literature Database and China National Knowledge Infrastructure databases for clinical studies that reported the effects of MIE in comparison with OE in patients with ESCA. The retrieval time was from their inception to October 2023. Two authors independently performed literature screening, and data extraction and literature quality evaluation were performed separately for the included studies. Meta‐analysis was performed using Stata 17.0 software. Overall, 26 studies with 2427 ESCA patients were included in this study, of which 1203 were in the MIE group and 1224 were in the OE group. The results showed that, compared with OE, ESCA patients who underwent MIE were less likely to develop postoperative wound infections (odds ratio [OR] = 0.31, 95% confidence intervals [CIs]: 0.20–0.49, p < 0.001) and complications (OR = 0.23, 95% CI: 0.18–0.30, p < 0.001) and have a shorter hospital stay (standardized mean difference = −1.93, 95% CI: −2.38 to −1.48, p < 0.001). MIE has advantages over OE in terms of shorter hospital stay and reduced incidence of postoperative wound infections and complications. [ABSTRACT FROM AUTHOR]

Abstract Background The degree of difficulty in the overall procedure and forceps handling encountered by surgeons is greatly influenced by the positional relationship of intrathoracic organs in minimally invasive esophagectomy. This study aimed to identify the anatomical factors associated with the difficulty of minimally invasive esophagectomy assessed by intraoperative injuries and postoperative outcomes. Methods Minimally invasive esophagectomy in the left-decubitus position was performed in 258 patients. We defined α (mm) as the anteroposterior distance between the front of the vertebral body and aorta, β (mm) as the distance between the center of the vertebral body and center of the aorta, and γ (degree) as the angle formed at surgeon’s right-hand port site by insertion of lines from the front of aorta and from the front of vertebrae in the computed tomography slice at the operator’s right-hand forceps hole level. We retrospectively analyzed the correlations among clinico-anatomical factors, surgeon- or assistant-caused intraoperative organ injuries, and postoperative complications. Results Intraoperative injuries significantly correlated with shorter α (0.2 vs. 3.9), longer β (33.0 vs. 30.5), smaller γ (3.0 vs. 4.3), R1 resection (18.5% vs. 8.3%), and the presence of intrathoracic adhesion (46% vs. 26%) compared with the non-injured group. Division of the median values into two groups showed that shorter α and smaller γ were significantly associated with organ injury. Longer β was significantly associated with postoperative tachycardia onset, respiratory complications, and mediastinal recurrence. Furthermore, the occurrence of intraoperative injuries was significantly associated with the onset of postoperative pulmonary complications. Conclusions Intrathoracic anatomical features greatly affected the procedural difficulty of minimally invasive esophagectomy, suggesting that preoperative computed tomography simulation and appropriate port settings may improve surgical outcomes.

Abstract In this review, we focused on four topics, namely, minimally invasive esophagectomy (MIE), robot‐assisted minimally invasive esophagectomy (RAMIE), conversion and salvage surgery, and neoadjuvant and adjuvant therapy, based on notable reports published in the years 2020 and 2021. It seems that while the short‐term outcomes of minimally invasive Ivor Lewis esophagectomy (MIE‐IL) were better than those of open Ivor Lewis esophagectomy (OE‐IL), there were no significant differences in the long‐term outcomes between MIE‐IL and OE‐IL. Similarly, the short‐term outcomes of minimally invasive McKeown esophagectomy (MIE‐MK) were better than those of open McKeown esophagectomy (OE‐MK), while there were no significant differences in the long‐term outcomes between MIE‐MK and OE‐MK. Furthermore, the short‐term outcomes of robot‐assisted minimally invasive Ivor Lewis esophagectomy (RAMIE‐IL) were superior to those of completely minimally invasive Ivor Lewis esophagectomy (CMIE‐IL). On the other hand, there were advantages and disadvantages in relation to the short‐term outcomes of robot‐assisted minimally invasive McKeown esophagectomy (RAMIE‐MK) as compared with completely minimally invasive McKeown esophagectomy (CMIE‐MK). However, there were no significant differences in the long‐term outcomes between RAMIE‐MK and CMIE‐MK. Further research is needed to evaluate of short‐term and long‐term outcomes of transmediastinal esophagectomy with and without robotic assistance. Both induction chemotherapy and induction chemoradiotherapy appear to be promising to secure a higher rate of conversion surgery. Neoadjuvant chemoimmunotherapy and chemoimmunoradiotherapy have shown promising results and are expected as new powerful therapies.

Abstract Objective To compare the influence of minimally invasive esophagectomy (MIE) and open esophagectomy (OE) on postoperative pulmonary function in patients with esophageal cancer. Methods Studies about the influence of MIE and OE on postoperative pulmonary function in esophageal cancer patients were searched from PubMed, EMBASE, the Cochrane Library, CNKI, Chinese Science and Technology Journal Database, CBM, and Wanfang Data from inception to March 18, 2021. Meta-analysis was performed using the RevMan 5.3. Results This analysis included eight studies, enrolling 264 patients who underwent MIE and 257 patients who underwent OE. The meta-analysis results showed that the MIE group had a higher outcome regarding the percent predicted vital capacity (%VC), forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), and maximum voluntary ventilation (MVV) 1 month after surgery than the OE group. In addition, those who underwent MIE had lower ΔVC%, ΔFVC, and ΔFEV1 between pre-operation and 1 month after surgery than those who underwent OE. There is no statistical difference between the two groups in ΔMVV. Conclusion Compared with OE, MIE has a more protective effect on postoperative pulmonary function. However, due to the small number of included literature and all cohort studies, this finding needs to be validated with larger samples and higher quality RCT studies.

Abstract Objective By analyzing the perioperative, postoperative complications and long-term overall survival time, we summarized the 8-year experience of minimally invasive McKeown esophagectomy for esophageal cancer in a single medical center. Methods This retrospective follow-up study included 1023 consecutive patients with esophageal cancer who underwent MIE-McKeown between Mar 2013 and Oct 2020. Relevant variables were collected and evaluated. Overall survival (OS) and disease-free survival (DFS) were analyzed by Kaplan–Meier method. Results For 1023 esophageal cancer undergoing MIE-McKeown, the main intraoperative complications were bleeding (3.0%, 31/1023) and tracheal injury (1.7%, 17/1023). There was no death occurred during operation. The conversion rate of thoracoscopy to thoracotomy was 2.2% (22/1023), and laparoscopy to laparotomy was 0.3% (3/1023). The postoperative morbidity of complications was 36.2% (370/1023), of which anastomotic leakage 7.7% (79/1023), pulmonary complication 13.4% (137/1023), chylothorax 2.3% (24/1023), and recurrent laryngeal nerve injury 8.8% (90/1023). The radical resection rate (R0) was 96.0% (982/1023), 30-day mortality was 0.3% (3/1023). For 1000 cases with squamous cell carcinoma, the estimated 3-year and 5-year overall survival was 37.2% and 17.8% respectively. In addition, neoadjuvant chemotherapy offered 3-year disease-free survival rate advantage in advanced stage patients (for stage IV: 7.2% vs. 1.8%). Conclusions This retrospective single center study demonstrates that MIE-McKeown procedure is feasible and safe with low perioperative and postoperative complications’ morbidity, and acceptable long-term oncologic results.

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.

ObjectiveMinimally invasive McKeown esophagectomy (McKeown MIE) is performed at many hospitals in esophageal cancer(EC) treatment. However, secure and quick methods for dissecting the esophagus and dissecting lymph nodes in this surgery are lacking. This study introduces a simple, secure and feasible esophagus dissecting technique named two-rope method. Two mobile traction ropes are placed around the esophagus and we tow these ropes to free the esophagus, dissect the lymph nodes, and decrease the operative trauma.Materials and MethodsRetrospective analysis was performed on 112 patients who underwent McKeown MIE in our center from January 2019 to September 2021. They were assigned into two groups based on the method of dissecting the esophagus: Group A (two-rope method, 45 cases) and Group B (regular method, 67 cases). Operation time, thoracic operation time, the number of dissected thoracic lymph nodes, and postoperative complications were compared between the two groups after propensity score matching.ResultsUsing 1:1 nearest neighbor matching, we successfully matched 41 pairs of patients. Operation time, thoracic operation time, and the duration (ac to as) was significantly shorter and the size of the abdominal incision was significantly smaller in the Group A than Group B (p 0.05).ConclusionsTwo-rope method to free the esophagus and dissect thoracic lymph nodes in McKeown MIE has significant advantages compared with the regular method. The technique is, therefore suitable for widespread adoption by surgeons.

ObjectiveTo compare the short-term outcomes and postoperative quality of life in patients with esophageal cancer between inflatable videoasisted mediastinoscopic transhiatal esophagectomy (IVMTE) and minimally invasive Mckeown esophagectomy (MIME), and to evaluate the value of IVMTE in the surgical treatment of esophageal cancer.MethodsA prospective, nonrandomized study was adopted. A total of 60 esophageal cancer patients after IVMTE and MIME December 2019 to January 2022 were included. Among them, 30 patients underwent IVMTE and 30 patients underwent MIME. Shortterm outcomes (including the operation time, intraoperative blood loss, postoperative drainage 3 days, total postoperative tube time, postoperative hospital stay, number and number of thoracic lymph node dissection stations, postoperative complications and so on), postoperative quality of life, [including Quality of Life Core Questionnaire (QLQ-C30) and the esophageal site-specific module (QLQ-OES18)] were compared between the 2 groups.ResultsThe operation time, intraoperative blood loss, postoperative drainage volume and total postoperative intubation time in IVMTE group were significantly lower than those in MIME group (P

Abstract Background Locally advanced esophageal carcinoma is typically treated with neoadjuvant chemoradiation and esophagectomy (trimodality therapy). We compared the long-term oncologic outcomes of minimally invasive Ivor Lewis esophagectomy (M-ILE) cohort with a propensity score weighted cohort of open Ivor Lewis esophagectomy (O-ILE) cases after trimodality therapy. Methods This is a retrospective review of 223 patients diagnosed with esophageal carcinoma who underwent neoadjuvant chemoradiation followed by M-ILE or O-ILE from April 2009 to February 2019. Inverse probability of treatment weighting (IPTW) adjustment was used to balance the baseline characteristics between study groups. Kaplan–Meier survival curves were calculated for overall survival and recurrence-free survival comparing the two groups. Multivariate Cox proportional hazards regression models were used to determine predictive variables for overall and recurrence-free survival. Results The IPTW cohort included patients with esophageal carcinoma who underwent M-ILE (n = 142) or O-ILE (n = 68). The overall rate of postoperative adverse events was not significantly different after IPTW adjustment between the O-ILE and M-ILE trimodality groups (53.4% vs. 39.2%, p = 0.089). The 3-year overall survival (OS) for the M-ILE group was 59.4% (95% CI: 49.8–67.8) compared to 55.7% (95% CI: 39.2–69.4) for the O-ILE group (p = 0.670). The 3-year recurrence-free survival for the M-ILE group was 59.9% (95% CI: 50.2–68.2) compared to 61.6% (95% CI: 41.9–76.3) for the O-ILE group (p = 0.357). A complete response to neoadjuvant chemoradiation was significantly predictive of improved OS and RFS. Conclusion The overall and recurrence-free survival rates for M-ILE were not significantly different from O-ILE for esophageal carcinoma after trimodality therapy. Complete response to neoadjuvant chemoradiation was predictive of improved overall and recurrence- free survival.

In the past 20 years, robotic system has gradually found a place in esophagectomy which is a demanding procedure in the deep and narrow thoracic cavity containing crucial functional structures. Ivor Lewis esophagectomy (ILE) is a mainstream surgery type for esophagectomy and is widely accepted for its capability in lymphadenectomy and relatively mitigated trauma. As a minimally invasive technique, robot-assisted Ivor Lewis esophagectomy (RAILE) has been frequently compared with the video-assisted procedure and the traditional open procedure. However, high-quality evidence elucidating the advantages and drawbacks of RAILE is still lacking. In this article, we will review the surgical techniques, both short and long-term outcomes, the learning curve, and explicate the current progress and clinical efficacy of RAILE.

Our non-tube no fasting (early oral feeding and no nasogastric tube) fast-track surgery (FTS) was safe and effective to combine with neoadjuvant chemotherapy for McKeown minimally invasive esophagectomy. In addition, the two groups were similar in terms of the recovery time, hospital discharge day, and early resumption of oral feeding. Objectives: To evaluate the safety of early oral feeding (EOF) combined with neoadjuvant chemotherapy (NAC) of esophagectomy. Summary Background Data: Our non-tube no fasting (early oral feeding and no nasogastric tube) fast-track surgery (FTS) was safe and effective for primary surgery esophageal cancer patients. Methods: We retrospectively evaluated consecutive patients who underwent non-tube no fasting and McKeown minimally invasive (MIE). They were divided into two groups: one received NAC, and the other received primary surgery. Complications after the operation, postoperative CRG complications, operative time, operative bleeding, and length of stay were evaluated. Results: Between 01/2014 and 12/2017, there hundred and eighty two consecutive patients underwent MIE with total two-field lymphadenectomy under the non-tube no fasting fast-track surgery program. A total of 137 patients received NAC, and 245 accepted primary surgery. Propensity score matching was used to compare NAC patients with 62 matched patients from each group. The NAC group had a similar number of total complications as the primary surgery group (32.26% in the primary surgery group vs. 25.81% in the NAC group; p=0.429) and had the same median postoperative hospitalization duration (8 days, p=0.723). Conclusions: After McKeown MIE, the patients receiving NAC combined with “non-tube no fasting” FTS had a similar incidence of postoperative complications outcomes as those without NAC. In addition, the two groups were similar in terms of the recovery time, hospital discharge day, and early resumption of oral feeding. [ABSTRACT FROM AUTHOR]

Objective: Minimally invasive esophagectomy (MIE) was first implemented in 1992 and various MIEs have been performed subsequently. The modified McKeown MIE that includes thoracoscopic and laparoscopic procedures with left neck anastomosis has been implemented in our institution since 2006. We herein report our first 5-year experience in 376 consecutive patients undergone the modified McKeown MIE for esophageal cancer to evaluate perioperative outcomes and survival. Methods: A total of 376 patients underwent a modified McKeown MIE from March 2016 to March 2021 at Sir Run Run Shaw Hospital, Zhejiang University School of Medicine. Patient demographics and perioperative outcomes were collected and assessed, and overall survival and disease-free survival were analyzed. Results: All procedures were completed successfully with no conversions to open surgery. The median operative time was 240 min, and the median blood loss was 100 mL. The median number of harvested lymph nodes was 29, the median number of harvested thoracic lymph nodes was 18, and of harvested abdominal nodes was 10. The 30-day mortality rate was 0.27% and complications occurred in 133 (35.4%) patients. The median follow-up period was 19 (1–60) months, and 244 patients completed more than 1 year of follow-up. The 1-year overall survival and disease-free survival were 79.5% and 73.8%, respectively. Conclusion: The modified McKeown MIE is safe and feasible for esophageal cancer, offering satisfactory perioperative outcomes and acceptable oncologic survival.

Abstract Minimally invasive esophagectomy (MIE) has been reported to reduce postoperative complications especially pulmonary complications and have equivalent long‐term survival outcomes as compared to open esophagectomy. Robot‐assisted minimally invasive esophagectomy (RAMIE) using da Vinci surgical system (Intuitive Surgical, Sunnyvale, USA) is rapidly gaining attention because it helps surgeons to perform meticulous surgical procedures. McKeown RAMIE has been preferably performed in East Asia where squamous cell carcinoma which lies in more proximal esophagus than adenocarcinoma is a predominant histological type of esophageal cancer. On the other hand, Ivor Lewis RAMIE has been preferably performed in the Western countries where adenocarcinoma including Barrett esophageal cancer is the most frequent histology. Average rates of postoperative complications have been reported to be lower in Ivor Lewis RAMIE than those in McKeown RAMIE. Ivor Lewis RAMIE may get more attention for thoracic esophageal cancer. The studies comparing RAMIE and MIE where recurrent nerve lymphadenectomy was thoroughly performed reported that the rate of recurrent nerve injury is lower in RAMIE than in MIE. Recurrent nerve injury leads to serious complications such as aspiration pneumonia. It seems highly probable that RAMIE is beneficial in performing recurrent nerve lymphadenectomy. Surgery for esophageal cancer will probably be more centralized in hospitals with surgical robots, which enable accurate lymph node dissection with less complications, leading to improved outcomes for patients with esophageal cancer. RAMIE might occupy an important position in surgery for esophageal cancer.

Abstract Background As an extensive surgery, minimally invasive esophagectomy (MIE) has advantages in reducing morbidity and improving quality of life for patients suffering from esophageal cancer. This study aims to investigate differences between MIE and open esophagectomy (OE) for considerations of the safety of procedures, rate of tumor resection, postoperative complications, and quality of life. This paper also tends to provide some references for MIE on esophageal cancer therapy. Methods A retrospective data analysis was undertaken on 140 patients who either underwent MIE or OE for esophageal cancer with cervical anastomosis from March 2013 to May 2014 by our surgical team. Preoperative characteristics were analyzed for both groups. Differences in perioperative and oncologic outcomes were compared in operation time, intraoperative blood loss, lymph nodes retrieved, and R0-resection rate. Accordingly, a comparative analysis was conducted on complications namely anastomotic leakage, pulmonary infection, in-hospital mortality, and short-term (3 months) postoperative EORTC C30 Global health as well. Results A total of 140 patients (87 with MIE and 53 with OE) were enrolled and the two groups were homogeneous in terms of patient- and tumor-related data. There was no difference on postoperative ICU stay (21.15 ± 1.54 h vs 21.75 ± 1.68 h, p = 0.07) and R0-resection rate (100% vs 100%, p = 1.00). The operation time for MIE was significantly shorter (146.08 ± 17.35 min vs 200.34 ± 14.51 min, p

Abstract Key papers to treatment of esophageal cancer surgery and reduction of postoperative complications after esophagectomy published between 2018 and 2019 were reviewed. Within this review there was a focus on minimally invasive esophagectomy (MIE), robot‐assisted MIE (RAMIE), and centralization to high‐volume center. Advantages of MIE, irrespectively of hybrid or total MIE, to prevent postoperative complications, especially pneumonia, were shown in comparison to open procedure. However, whether total MIE has evident effects or not, as compared to hybrid MIEs, still remains unclear. Differences between RAMIE and MIE were reported to be marginal, though the advantage of lymphadenectomy, especially along recurrent laryngeal nerve, has been suggested. Centralization to high‐volume center evidently benefits esophageal cancer patients by improving short‐term outcomes. The definition of high‐volume center has not been established yet, though institutional structure and quality are thought to be important. Transmediastinal esophagectomy, currently developed, has a potential to be one radical option of MIE for esophageal cancer.

Abstract Background Port site recurrence has been observed after a variety of oncologic resection procedures. However, few have reported port site recurrence of esophageal cancer. Case presentation A 51-year-old man underwent minimally invasive esophagectomy for pT3(AD)N3M0 adenocarcinoma of the esophagus. One year after surgery, he presented with a rapidly growing tumor on the right thoracic wall. Contrast computed tomography demonstrated an enhancing tumor with uptake on positron emission tomography. We performed resection of the thoracic wall, including the skin and subcutis. The pathologic diagnosis was poorly differentiated adenocarcinoma, consistent with metastasis of esophageal origin. Conclusion This was the first report on thoracic port site recurrence of esophageal adenocarcinoma. We recommend elimination of leakage around the thoracoscopic ports to prevent such recurrence. We should provide prudent postoperative clinical surveillance.

Abstract Minimally invasive esophagectomy (MIE) has been performed increasingly more frequently for the treatment of esophageal cancer, ever since it was first described in 1992. However, the incidence of postoperative complications of MIE has not yet been well‐characterized, because (a) there are few reports of studies with a sufficient sample size, (b) a variety of minimally invasive surgical techniques are used, and (c) there are few reports in which an established system for classifying the severity of complications is examined. According to an analysis performed by the Esophageal Complications Consensus Group, the most common complications of MIE are pneumonia, arrhythmia, anastomotic leakage, conduit necrosis, chylothorax, and recurrent laryngeal nerve palsy. Therefore, we decided to focus on these complications. We selected 48 out of 1245 reports of studies (a) that included more than 50 patients each, (b) in which the esophagectomy technique used was clearly described, and (c) in which the complications were adequately described. The overall incidences of the postoperative complications of MIE for esophageal cancer were analyzed according to the MIE technique adopted, that is, McKeown MIE, Ivor Lewis MIE, robotic‐assisted McKeown MIE, robotic‐assisted Ivor Lewis MIE, or mediastinoscopic transmediastinal esophagectomy. Pneumonia, arrhythmia, anastomotic leakage, and recurrent laryngeal nerve palsy occurred at an incidence rate of about 10% each; Ivor Lewis MIE was associated with a relatively low incidence of recurrent laryngeal nerve palsy. It is important to recognize that the incidences of complications of MIE are influenced by the MIE technique adopted and the extent of lymph node dissection.

Study Objective: This study aimed to investigate whether stroke volume variation (SVV)-guided goal-directed therapy (GDT) can improve postoperative outcomes in elderly patients undergoing minimally invasive esophagectomy (MIE) compared with conventional care.Design: A prospective, randomized, controlled study.Setting: A single tertiary care center with a study period from November 2017 to December 2018.Patients: Patients over 65 years old who were scheduled for elective MIE.Interventions: The GDT protocol included a baseline fluid supplement of 7 ml/kg/h Ringer's lactate solution and SVV optimization using colloid boluses assessed by pulse-contour analysis (PiCCO™). When SVV exceeded 11%, colloid was infused at a rate of 50 ml per minute; if SVV returned below 9% for at least 2 minutes, then colloid was stopped.Measurements: The primary outcome was the incidence of postoperative complications before discharge, as assessed using a predefined list, including postoperative anastomotic leakage, postoperative hoarseness, postoperative pulmonary complications, chylothorax, myocardial injury, and all-cause mortality.Main Results: Sixty-five patients were included in the analysis. The incidence of postoperative complications between groups was similar (GDT 36.4% vs. control 37.5%, P = 0.92). The total fluid volume was not significantly different between the two groups (2,192 ± 469 vs. 2,201 ± 337 ml, P = 0.92). Compared with those in the control group (n = 32), patients in the GDT group (n = 33) received more colloids intraoperatively (874 ± 369 vs. 270 ± 67 ml, P

Abstract 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.

Abstract Background Minimally invasive esophagectomy is considered a beneficial approach to esophageal cancer, although a hiatal hernia occurs more frequently in this approach than in open esophagectomy with reconstruction via the mediastinal route. Development of an internal hernia to the retrosternal space is not a recognized complication of reconstruction via the retrosternal route after esophagectomy. We herein report three cases of the development of an internal hernia to the retrosternal space after minimally invasive esophagectomy. Case presentation Thoracolaparoscopic esophagectomy with cervical anastomosis by retrosternal route reconstruction was performed in all three cases. All patients were men ranging in age from 60 to 80 years. Two patients had abdominal pain, and one had experienced syncope. All patients were diagnosed by computed tomography with an internal hernia to the retrosternal space and thoracic cavity (retrosternal hernia) without ischemic change to the incarcerated intestine. Two patients received medical therapy to relieve their intra-abdominal pressure, which allowed for a successful reduction of the intestine into the abdomen. Open laparotomy was performed to repair the hernia in the third patient. After reducing the intestine into the abdomen, reefing of the retrosternal orifice was performed, and the gastric conduit was anchored to the abdominal wall. No relapse occurred in three cases throughout follow-up. Conclusion Hiatal hernia is a well-recognized complication after minimally invasive esophagectomy; however, retrosternal hernia is a rare complication following this procedure. Based on the present report, if no ischemic change is present in the herniated intestine, two types of potentially curative treatments are available: medical or surgical. As minimally invasive esophagectomy is performed more frequently, retrosternal hernia may become an increasingly more common complication in the near future.

Background: Malignant rhabdoid tumor is a kidney childhood tumor with aggressive clinical behavior and a wide spectrum of histologic, immunophenotypic, and cytogenetic findings. Extra-renal rhabdoid tumors have been reported in the brain, breast, liver, pancreas, bladder, vulva, prostate, and colon. To date, only nine cases of esophageal rhabdoid tumors have been described, all in patients over 50-year old. We add to the current literature the case of an esophageal, poorly differentiated rhabdoid tumor occurring in a young man.Case Report: A 24-year-old man was referred for progressive dysphagia, retrosternal pain, nausea, and food regurgitation. Esophagogastroduodenoscopy showed an obstructing neoplastic lesion of the distal esophagus associated with Barrett's esophagus. Biopsies revealed undifferentiated esophageal cancer with epithelial morphology and immunohistochemistry positive for CK pan, CK 7 e CK 8-18. Minimally invasive esophagectomy and extended lymphadenectomy was performed. Histopathology showed a poorly differentiated tumor, with morphologic characteristics of rhabdoid tumor, central necrosis and transmural infiltration of the esophageal wall. Definitive immunohistochemistry was positive for vimentin, CD34, synaptophysin, and INI1.Conclusion: Esophageal rhabdoid tumor is extremely rare and highly aggressive, with only few patients alive at 1 year follow-up, according to our review. Immunohistochemistry characterization is critical for diagnosis. Minimally invasive esophagectomy is an appealing and possibly less morbid option compared to open surgery. However, further research is needed to investigate the potential role of targeted immunotherapy.

Abstract Background Minimally invasive esophagectomy (MIE) was shown to be effective in reducing the morbidity and was adopted increasingly. The robot-assisted minimally invasive esophagectomy (RAMIE) remains in the initial stage of application. This study evaluated its safety and feasibility by comparing short-term outcomes of RAMIE and video-assisted minimally invasive esophagectomy (VAMIE). Methods Between March 2016 and December 2017, 115 consecutive patients underwent RAMIE or VAMIE at our institute. The baseline characteristics, pathological data and short-term outcomes of these two group patients were collected and compared. RAMIE patients were propensity score matched with VAMIE patients for a more accurate comparison. Results Matching based on propensity scores produced 27 patients in each group. After propensity score matching (PSM), the baseline characteristics between the two groups were comparable. The operation time in RAMIE group was significantly longer than that in VAMIE group (349 and 294 min, respectively; P

An investigation included 33 patients with cancer of thoracal section of the esophagus at the age from 42 to 74 years old. A surgical method of treatment was applied as only one in 13 patients and methods of nonadjuvant chemoradiation therapy were used for 20 patients. A hybrid minimally invasive esophagectomy (laparoscopic mobilization of the stomach and right-side thoracotomy) was performed on 16 patients. The rate of postoperative complications consisted of 31%. The minimally invasive esophagectomy (performed by totally endovideosurgical approach) was carried out in 15 cases. Postoperative complications developed in 53% of follow-up patients. There weren’t cases of lethality. The experience of minimally invasive methods indicated the satisfactory results of application of given methods in patient treatment of esophageal cancer. The use of endovideosurgical approaches allowed performing oncologically adequate volume of operative interventions.

Background: The objective of this study was to compare three kinds of lymphadenectomy methods along the recurrent laryngeal nerve (RLN) and assess the safety and effectiveness of the new method. Methods: A total of 194 patients with esophageal cancer who underwent minimally invasive esophagectomy (MIE) at our institution from May 2013 to May 2017 were analyzed retrospectively. According to the method of lymphadenectomy along the left RLN, the patients were divided into three groups: 75 cases underwent the conventional method (A group), 80 cases the skeletonized method (B group) and 39 cases the modified Bascule method (C group). The number of dissected lymph nodes and surgical outcomes were recorded and compared to identify differences among the three groups. Results: The frequency of metastasis to the LRLN lymph node was 18.6% among all patients, and 12%, 20% and 28% in groups A, B and C, respectively. The number of harvested lymph nodes (total/chest/LRLN/LRLN+) in group B and group C were significantly greater than that of group A, but not significant between group B and group C. The hoarseness rate in group C was 15.4%, which was lower than the rate in group B (21.3%) and higher than the rate in group A (13.3%), but there was no statistical significance. Conclusions: The new method for lymphadenectomy along the left RLN during MIE in the semi‐prone position is safe and reliable. It provides sufficient lymph node dissection along the left RLN. [ABSTRACT FROM AUTHOR]

Background: There has been an increasing inclination towards minimally invasive esophagectomies (MIEs) at our institute recently for resectable oesophageal cancer. Objectives: The purpose of the present study is to report peri-operative and long-term procedure specific outcomes of the two groups and analyse their changing pattern at our institute. Methods: All adult patients with a diagnosis of oesophageal cancer managed at our institute from 2005 to 2015 were included in this retrospective study. Patients' demographic and clinical characteristics were recorded through our hospital information system. The cohort of esophagectomies was allocated into two groups, conventional open esophagectomy (OE) or total laparoscopic MIE; hybrid esophagectomies were taken as a separate group. The short-term outcome measures are an operative time in minutes, length of hospital and Intensive Care Unit (ICU) stay in days, post-operative complications and 30 days in-hospital mortality. Complications are graded according to the Clavien-Dindo classification system. Long-term outcomes are long-term procedure related complications over a minimum follow-up of 1 year. Trends were analysed by visually inspecting the graphic plots for mean number of events in each group each year. Results: Our results showed no difference in mortality, length of hospital and ICU stays and incidence of major complications between three groups on uni- and multi-variate analysis (P > 0.05). The operative time was significantly longer in MIE group (odds ratio [OR]: 1.66, confidence interval [CI]: 2.4–11.5). The incidence of long-term complication was low for MIE (OR: 1.0, CI: 133–1.017). However, all post-operative surgical outcomes trended to improve in both groups over the course of this study and stayed better for MIE group except for the operative time. Conclusion: MIE has overall comparable surgical outcomes to its conventional counterpart. Furthermore, the peri-operative outcomes tend to improve in our centre with the maturation of program and experience.

Esophageal leiomyosarcoma is the commonest of all esophageal sarcomas but yet has a very low incidence. These tumors have been resected by the open approach so far. We describe the steps and challenges involved in the thoracoscopic excision of a huge leiomyosarcoma of the esophagus.

Introduction. At the Department of Minimally Invasive Upper Digestive Surgery of the Hospital for Digestive Surgery in Belgrade, hybrid minimally invasive esophagectomy (hMIE) has been a standard of care for patients with resectable esophageal cancer since 2009. As a next and final step in the change management, from January 2015 we utilized total minimally invasive esophagectomy (tMIE) as a standard of care. Objective. The aim of the study was to report initial experiences in hMIE (laparoscopic approach) for cancer and analyze surgical technique, major morbidity and 30-day mortality. Methods. A retrospective cohort study included 44 patients who underwent elective hMIE for esophageal cancer at the Department for Minimally Invasive Upper Digestive Surgery, Hospital for Digestive Surgery, Clinical Center of Serbia in Belgrade from April 2009 to December 2014. Results. There were 16 (36%) middle thoracic esophagus tumors and 28 (64%) tumors of distal thoracic esophagus. Mean duration of the operation was 319 minutes (approximately five hours and 20 minutes). The average blood loss was 173.6 ml. A total of 12 (27%) of patients had postoperative complications and mean intensive care unit stay was 2.8 days. Mean hospital stay after surgery was 16 days. The average number of harvested lymph nodes during surgery was 31.9. The overall 30-day mortality rate within 30 days after surgery was 2%. Conclusion. As long as MIE is an oncological equivalent to open esophagectomy (OE), better relation between cost savings and potentially increased effectiveness will make MIE the preferred approach in high-volume esophageal centers that are experienced in minimally invasive procedures.

Background: Pulmonary morbidities after esophagectomy are still common and are a major cause of surgery-related mortality. The relationship between minimally invasive esophagectomy (MIE) and pulmonary morbidities is not clear. The current study aimed to examine the incidence of pulmonary morbidities after MIE and to clarify the associated risk factors.Methods: Between May 2011 and December 2016, 184 patients underwent MIE for esophageal cancer. Clinical data were prospectively collected and analyzed. Patient- and surgery-related factors, relating to pulmonary complications, were compared between the complicated and uncomplicated cases.Results: The incidence of any pulmonary morbidity following MIE was 17.9%. Univariate analysis showed that past heavy smoking [Brinkman index (BI) ≥ 1000], presence of neoadjuvant therapy, advanced clinical stage (stage III, IV), and intraoperative bleeding ≥ 600 g were candidates for being postoperative pulmonary morbidity risk factors. Multivariate analysis suggested that BI ≥ 1000 and advanced clinical stage were independent risk factors for causing pulmonary morbidities.Conclusions: Past heavy smoking and advanced stage are independent risk factors for pulmonary morbidities after MIE. When performing MIE for such cases, various preoperative precautions and careful postoperative monitoring are necessary. [ABSTRACT FROM AUTHOR]

Purpose: Anastomotic leakage is the most feared postoperative complication after esophagectomy. Omentoplasty, wrapping the omentum around the alimentary tract anastomosis, is thought to decrease the anastomotic leakage rate. The purpose of this clinical study is to investigate the use of omentoplasty to reinforce cervical esophagogastrostomy after minimally invasive esophagectomy (MIE). Patients and methods: In this retrospective study, the data of 160 consecutive patients who underwent cervical esophagogastrostomy after MIE between September 2012 and May 2015 were analyzed, 87 who underwent omentoplasty (group A) and 73 who did not undergo omentoplasty (group B). The primary outcome was the incidence of anastomotic leakage and anastomotic strictures after the operation. Secondary outcomes were other complications and mortality rate. Univariate and multivariate analysis of variables associated with an increased risk for anastomotic leak was performed. Results: The median age was 61 years (range, 37-82 years). The anastomotic leakage rates were 4.6% (4/87) in group A and 15.1% (11/73) in group B (P = 0.023). There was no statistical significance in anastomotic stricture rates between group A (6.9%) and group B (9.6%; P = 0.535). No difference was noted in other complications between the groups. There was a trend toward lower leak-associated mortality rates for group A (0%) compared with that for group B (4.1%). Conclusion: Cervical esophagogastrostomy with omentoplasty is more effective than esophagogastrostomy without omentoplasty for the prevention of anastomotic leakage in MIE with cervical anastomosis. Omentoplasty could be used as an adjunct technique to reduce the incidence of anastomotic leakage in cervical esophagogastrostomy following MIE. [ABSTRACT FROM AUTHOR]

Aim To assess the effectiveness of hybrid minimally invasive esophagectomy (hMIE) in comparison with open esophagectomy (OE) in esophageal cancer treatment. Methods The single center prospective nonrandom cohort study included a total of 88 patients in convenience sample, who underwent the Ivor-Lewis procedure with a curative intention for the middle- and lower-third esophageal cancer between January 2009 and February 2015. All patients were operated by the one surgical team. Out of 88 patients, 44 underwent OE and 44 hMIE laparoscopic approach (laparoscopic gastric mobilization). Primary endpoints were significant early postoperative complications, including major postoperative pulmonary complications (MPPCs). Secondary endpoints were perioperative characteristics, 30-day mortality and oncological outcomes. Results The total number of complications was 21 in the OE group vs. 13 in the hMIE group (p > 0.05). Higher prevalence of major postoperative pulmonary complications (MPPCs) was observed in the OE group compared to the hMIE group. Mean intensive care unit (ICU) stay was 3.8 (1–21) days; there was a statistically significant difference in favor of the hMIE group. Mean number of harvested lymph nodes was 26.3 in the OE group compared to 31.9 in the hMIE group (p < 0.05). There was no statistically significant difference regarding 30-day mortality between the groups. Overall median survival rate was 807 days; 824 days in the OE group vs. 778 days in the hMIE group (p > 0.05). Conclusion Perioperative and oncologic results after hMIE are not inferior but are even better in some aspects of treatment when compared to OE. [ABSTRACT FROM AUTHOR]