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Radiation-induced esophageal cancer (RIEC) is a rare but severe late consequence of radiotherapy. The literature regarding this topic is predominately limited in describing the risk of this disease. Tumor behavior, treatment strategies, and prognosis of this cancer remain poorly defined.We collected data of patients who were referred to our unit between 2000 and 2020 for RIEC. After tumor board discussion, upfront surgery or neoadjuvant therapy and surgery were indicated as the main treatment. Preoperative characteristics, long-term and short-term postoperative outcomes of RIEC patients were compared with a 1:1 clustering-matched cohort of patients affected by primary esophageal cancer (PEC).At pre-matching, 54 RIEC and 936 PEC patients were enrolled. The median time between primary irradiation and diagnosis of RIEC was 13.5 years, and the median primary radiation dose was 60 Gy. Compared to the unmatched cohort of PECs, RIEC patients were more frequently female (p = 0.0007), had earlier detection of disease (p = 0.03) and presented more frequently with upper esophageal cancers (p 0.0001). Neoadjuvant treatment was used less frequently in RIEC patients (p 0.0001). After matching, the 51 RIEC and 50 PEC patients showed comparable results in terms of exposure to neoadjuvant treatment, surgical radicality and survival outcomes. RIEC patients had more severe postoperative complications (p = 0.04) and a higher proportion of pulmonary complications (p = 0.04).Curative treatments are feasible for RIEC. Neoadjuvant chemotherapy or chemoradiation can be used in this subgroup, treatment response and long-term outcomes are comparable to those of PEC. The risk of postoperative complications is probably related to the detrimental effect of primary irradiation on lung function.

Summary Pulmonary complications, and especially pneumonia, remain one of the most common complications after esophagectomy for esophageal cancer. These complications are reduced by minimally invasive techniques or by avoiding thoracic access through a transhiatal approach. However, a transhiatal approach does not allow for a full mediastinal lymphadenectomy. A transcervical mediastinal esophagectomy avoids thoracic access, which may contribute to a decrease in pulmonary complications after esophagectomy. In addition, this technique allows for a full mediastinal lymphadenectomy. A number of pioneering studies have been published on this topic. Here, the initial experience is presented as well as a review of the current literature concerning transcervical esophagectomy, with a focus on the robot-assisted cervical esophagectomy procedure.

To ensure safe implementation of robot-assisted minimally invasive esophagectomy (RAMIE), the learning process should be optimized. This study aimed to report the results of a surgeon who implemented RAMIE in a German high-volume center by following a tailored and structured training pathway that involved proctoring. Consecutive patients who underwent RAMIE during the course of the program were included from a prospective database. A single surgeon, who had prior experience in conventional MIE, performed all RAMIE procedures. Cumulative sum (CUSUM) learning curves were plotted for the thoracic operating time and intraoperative blood loss. Perioperative outcomes were compared between patients who underwent surgery before and after a learning curve plateau occurred. Between 2017 and 2018, the adopting center adhered to the structured training pathway, and a total of 70 patients were included in the analysis. The CUSUM learning curves showed plateaus after 22 cases. In consecutive cases 23 to 70, the operating time was shorter for both the thoracic phase (median 215 vs. 249 minutes, P = 0.001) and overall procedure (median 394 vs. 440 minutes, P = 0.005), intraoperative blood loss was less (median 210 vs. 400 milliliters, P = 0.029), and lymph node yield was higher (median 32 vs. 23 nodes, P = 0.001) when compared to cases 1 to 22. No significant differences were found in terms of conversion rates, postoperative complications, length of stay, completeness of resection, or mortality. In conclusion, the structured training pathway resulted in a short and safe learning curve for RAMIE in this single center’s experience. As the pathway seems effective in implementing RAMIE without compromising the early oncological outcomes and complication rates, it is advised for surgeons who are wanting to adopt this technique.

The full robotic-assisted minimally invasive esophagectomy (RAMIE) is an upcoming approach in the treatment of esophageal and junctional cancer. Potential benefits are seen in angulated precise maneuvers in the abdominal part as well as in the thoracic part, but due to the novelty of this approach the optimal setting of the trocars, the instruments and the operating setting is still under debate. Hereafter, we present a technical description of the ‘Mainz technique’ of the abdominal part of RAMIE carried out as Ivor Lewis procedure. Postoperative complication rate and duration of the abdominal part of 100 consecutive patients from University Medical Center in Mainz are illustrated. In addition, the abdominal phase of the full RAMIE is discussed in general.

Background and Aims: Nutritional support (NS) in patients with malignancies and malnutrition improves outcome and treatment tolerance. The underlying mechanisms are not completely understood. We aimed to investigate for the first time the influence of an early individualized NS in newly diagnosed patients with gastrointestinal/hepato-pancreatic malignancies and malnutrition on DNA damage, oxidative stress and subclinical inflammation. Methods: This prospective case-control study included 43 patients with newly diagnosed malignancies and malnutrition. At baseline (F0), we documented patients’ data, oncological diagnosis, comorbidities, alcohol/ nicotine consume. Nutritional parameters, DNA damage [histone-variant H2AX phosphorylated on the 139-serine residue (γ-H2AX) foci/cell], oxidative status, subclinical inflammation were measured. During diagnostic workup, patients received an individualized NS, and got a follow-up before the start of treatment (F1), (n=21). Healthy controls (n=21) were included for comparison of DNA damage at baseline. Results: γ-H2AX-values at baseline were higher than in controls (p

Background This is a preclinical cadaveric study to investigate the feasibility of a fully robotic McKeown esophagectomy in simultaneous rendezvous technique using the DaVinci X for transhiatal dissection and the DaVinci single port (SP) for transcervical dissection. Methods Two transcervical esophagectomies with the DaVinci SP surgical system were performed as training procedures. In the third transcervical cadaveric procedure, the DaVinci SP was installed for the transcervical approach and the DaVinci X surgical system for the abdominal transhiatal phase. Primary outcomes were operating time and lymphadenectomy. Results The mobilization of the esophagus was successfully completed in 118 minutes by using the DaVinci SP for the transcervical phase and the DaVinci X for the transhiatal abdominal phase simultaneously. In total 18 lymph nodes were dissected in the thorax; 3 were located paratracheal right, 3 paratracheal left, 4 subcarinal, 4 para-aortic, 2 paraesophageal upper mediastinal, and 2 paraesophageal middle mediastinal. Conclusion This preclinical study demonstrated that a fully robotic McKeown esophagectomy in simultaneous rendezvous technique using the DaVinci X for transhiatal dissection and the DaVinci SP for transcervical dissection was feasible with adequate lymphadenectomy in a cadaver model. Future research will elucidate the indications for the use of the fully robotic transhiatal and transcervical esophagectomy.

Background Surgical esophagectomy plays a crucial role in the curative and palliative treatment of esophageal cancer. Thereby, minimally invasive esophagectomy (MIE) is increasingly applied all over the world. Combining minimal invasiveness with improved possibilities for meticulous dissection, robot-assisted minimal invasive esophagectomy (RAMIE) has been implemented in many centers. Purpose This review focuses on the development of MIE as well as RAMIE and their value based on evidence in current literature. Conclusion Although MIE and RAMIE are highly complex procedures, they can be performed safely with improved postoperative outcome and equal oncological results compared with open esophagectomy (OE). RAMIE offers additional advantages regarding surgical dissection, lymphadenectomy, and extended indications for advanced tumors.

Purpose The robot-assisted approach for Ivor Lewis esophagectomy offers an enlarged, three-dimensional overview of the intraoperative situs. The vagal nerve (VN) can easily be detected, preserved, and intentionally resected below the separation point of the recurrent laryngeal nerve (RLN). However, postoperative vocal cord paresis can result from vagal or RLN injury during radical lymph node dissection, presenting a challenge to the operating surgeon. Methods From May to August 2019, 10 cases of robot-assisted minimally invasive esophagectomy (RAMIE) with extended 2-field lymphadenectomy, performed at the University Medical Center Mainz, were included in a prospective cohort study. Bilateral intermittent intraoperative nerve monitoring (IONM) of the RLN and VN was performed, including pre- and postoperative laryngoscopy assessment. Results Reliable mean signals of the right VN (2.57 mV/4.50 ms) and the RLN (left 1.24 mV/3.71 ms, right 0.85 mV/3.56 ms) were obtained. IONM facilitated the identification of the exact height of separation of the right RLN from the VN. There were no cases of permanent postoperative vocal paresis. Median lymph node count from the paratracheal stations was 5 lymph nodes. Conclusion IONM was feasible during RAMIE. The intraoperative identification of the RLN location contributed to the accuracy of lymph node dissection of the paratracheal lymph node stations. RLN damage and subsequent postoperative vocal cord paresis can potentially be prevented by IONM.

Background For patients undergoing an Ivor Lewis esophagectomy with a circular stapled anastomosis, the optimal diameter of the used circular stapler to restore continuity is unknown. The aim of this study was to compare the 25 mm stapled versus the 28 mm stapled esophagogastric anastomosis after Ivor Lewis esophagectomy, focusing on anastomotic insufficiency and postoperative anastomotic strictures. Methods Between February 2008 and June 2019, 349 consecutive patients underwent Ivor Lewis esophagectomy with gastric conduit reconstruction and circular stapled anastomosis. Patient characteristics and postoperative results, such as anastomotic insufficiency rates, postoperative anastomotic stricture rates, time to anastomotic stricture rate, and the number of dilatations, were recorded in a prospective database and analyzed. Results In 222 patients (64%), the 25 mm circular stapler was used and in 127 patients (36%) the 28 mm circular stapler was used. There were no differences in baseline characteristics. Anastomotic insufficiency rates were comparable between the 25 mm (12%) and the 28 mm groups (11%) (p = 0.751). There were no differences between postoperative anastomotic strictures in the 25 mm (14%) and the 28 mm groups (14%) (p = 0.863). Within patients with postoperative anastomotic strictures, a median number of 2 dilatations were observed in each group (p = 0.573) without differences in the time to first diagnosis (p = 0.412). Conclusion There were no differences in anastomotic insufficiency and postoperative anastomotic stricture rates between the 25 mm and the 28 mm circular stapled esophagogastric anastomosis after Ivor Lewis esophagectomy. Both the 25 mm and 28 mm stapler can be safely used to create a circular stapled esophagogastric anastomosis to restore continuity after esophagectomy.

Gastroesophageal reflux disease (GERD), a prevalent problem among obese individuals, is strongly associated with obesity and weight loss. Hence, bariatric surgery effectively improves GERD for many patients. Depending on the type of bariatric procedure, however, surgery can also worsen or even cause a new onset of GERD. As a consequence, GERD remains a relevant problem for many bariatric patients, and especially those who have undergone sleeve gastrectomy (SG). Affected patients report not only a decrease in physical functioning but also suffer from mental and emotional problems, resulting in poorer social functioning. The pathomechanism of GERD after SG is most likely multifactorial and triggered by the interaction of anatomical, physiological, and physical factors. Contributing factors include the shape of the sleeve, the extent of injury to the lower esophageal sphincter, and the presence of hiatal hernia. In order to successfully treat post-sleeve gastrectomy GERD, the cause of the problem must first be identified. Therapeutic approaches include lifestyle changes, medication, interventional treatment, and/or revisional surgery.

ERK3 is a ubiquitously expressed member of the atypical mitogen activated protein kinases (MAPKs) and the physiological significance of its short half-life remains unclear. By employing gastrointestinal 3D organoids, we detect that ERK3 protein levels steadily decrease during epithelial differentiation. ERK3 is not required for 3D growth of human gastric epithelium. However, ERK3 is stabilized and activated in tumorigenic cells, but deteriorates over time in primary cells in response to lipopolysaccharide (LPS). ERK3 is necessary for production of several cellular factors including interleukin-8 (IL-8), in both, normal and tumorigenic cells. Particularly, ERK3 is critical for AP-1 signaling through its interaction and regulation of c-Jun protein. The secretome of ERK3-deficient cells is defective in chemotaxis of neutrophils and monocytes both in vitro and in vivo. Further, knockdown of ERK3 reduces metastatic potential of invasive breast cancer cells. We unveil an ERK3-mediated regulation of IL-8 and epithelial secretome for chemotaxis.

SUMMARY The circular mechanical and hand-sewn intrathoracic anastomosis are most often used in robot-assisted minimally invasive esophagectomy (RAMIE). The aim of this study was to describe the technical details of both techniques that were pioneered in two high volume centers for RAMIE. A prospectively maintained database was used to identify patients with esophageal cancer who underwent RAMIE with intrathoracic anastomosis. The primary outcome was anastomotic leakage, which was analyzed using a moving average curve. For the hand-sewn anastomosis, video recordings were reviewed to evaluate number of sutures and distances between the anastomosis and the longitudinal staple line or gastric conduit tip. Between 2016 and 2019, a total of 68 patients with a hand-sewn anastomosis and 60 patients with a circular-stapled anastomosis were included in the study. For the hand-sewn anastomosis, the moving average curve for anastomotic leakage (including grade 1–3) started at a rate of 40% (cases 1–10) and ended at 10% (cases 59–68). For the circular-stapled anastomosis, the moving average started at 10% (cases 1–10) and ended at 20% (cases 51–60). This study showed the technical details and refinements that were applied in developing two different anastomotic techniques for RAMIE. Results markedly improved during the period of development with specific changes in technique for the hand-sewn anastomosis. The circular-stapled anastomosis showed a more stable rate of performance.

Summary Laparoscopic fundoplication is considered the gold standard surgical procedure for the treatment of symptomatic hiatus hernia. Studies on surgical performance in minimally invasive hiatus hernia repair have neglected the role of the camera assistant so far. The current study was designed to assess the applicability of the structured assessment of laparoscopic assistance skills (SALAS) score to laparoscopic fundoplication as an advanced and commonly performed laparoscopic upper GI procedure. Randomly selected laparoscopic fundoplications (n = 20) at a single institute were evaluated. Four trained reviewers independently assigned SALAS scoring based on synchronized video and voice recordings. The SALAS score (5–25 points) consists of five key aspects of laparoscopic camera navigation as previously described. Experience in camera assistance was defined as at least 100 assistances in complex laparoscopic procedures. Nine different surgical teams, consisting of five surgical residents, three fellows, and two attending physicians, were included. Experienced and inexperienced camera assistants were equally distributed (10/10). Construct validity was proven with a significant discrimination between experienced and inexperienced camera assistants for all reviewers (P

Genetic associations between variants on chromosome 5p13 and 8q24 and gastric cancer (GC) have been previously reported in the Asian population. We aimed to replicate these findings and to characterize the associations at the genome and transcriptome level. We performed a fine-mapping association study in 1926 GC patients and 2012 controls of European descent using high dense SNP marker sets on both chromosomal regions. Next, we performed expression quantitative trait locus (eQTL) analyses using gastric transcriptome data from 143 individuals focusing on the GC associated variants. On chromosome 5p13 the strongest association was observed at rs6872282 (P = 2.53 x 10(-04)) and on chromosome 8q24 at rs2585176 (P = 1.09 x 10(-09)). On chromosome 5p13 we found cis-eQTL effects with an up-regulation of PTGER4 expression in GC risk allele carrier (P = 9.27 x 10(-11)). On chromosome 8q24 we observed cis-eQTL effects with an upregulation of PSCA expression in GC risk allele carrier (P = 2.17 x 10(-47)). In addition, we found trans-eQTL effects for the same variants on 8q24 with a downregulation of MBOAT7 expression in GC risk allele carrier (P = 3.11 x 10(-09)). In summary, we confirmed and refined the previously reported GC associations at both chromosomal regions. Our data point to shared etiological factors between Asians and Europeans. Furthermore, our data imply an upregulated expression of PTGER4 and PSCA as well as a downregulated expression of MBOAT7 in gastric tissue as risk-conferring GC pathomechanisms.

Despite improvements in operative strategies for esophageal resection, anastomotic leaks, fistula, postoperative pulmonary complications, and chylothorax can occur. Our review seeks to identify potential risk factors, modalities for early diagnosis, and novel interventions that may ameliorate the potential adverse effects of these surgical complications following esophagectomy. ispartof: Annals of the New York Academy of Sciences vol:1434 issue:1 pages:254-273 ispartof: location:United States status: Published online

Perforation of the esophagus is the most severe complication of transesophageal echocardiography (TEE) and can lead to mediastinitis, pleural empyema, or peritonitis. Currently, the majority of patients receive operative treatment with only 6% treated endoscopically. We report our experience with endoscopic and conservative approaches.We retrospectively reviewed all patients treated for esophageal perforation and included all patients with perforation caused by TEE. All patients with perforation of the esophagus by TEE probe underwent conservative or endoscopic treatment, drainage of pleural and mediastinal retentions, and adjusted to antibiotic therapy.From January 2004 to December 2014 a total of 109 patients were treated for esophageal perforation in our department. In 6 patients (5.5%) the perforation was caused by TEE. Location was cervical and midthoracic in 2 and 4 cases, respectively. All patients underwent successful endoscopic treatment and no further surgical procedure, such as esophageal suture or resection was necessary. The mean time between TEE and therapy of the perforation was 7.3 days. In all patients closure of the leakage could be achieved within 30 days. Mortality rate was 0%.Esophageal perforations caused by TEE are typically small, in the cervical and mid esophagus, and minimally contaminated. These are good prognostic factors for successful endoscopic treatment with preservation of the esophagus. Operative treatment should only be considered in cases of failed endoscopic treatment.

Background: Despite the announcement of the 8th edition of TNM classification, the 7th edition (2010) is still being used for prognostic assessment in gastric cancer patients. A proposed new staging system (termed as the Kiel proposal) claims to offer a better prognostic stratification. Our objective was to retrospectively evaluate the Kiel proposal and compare it with the 6th and 7th TNM editions on a collected database. Methods: We retrospectively analyzed gastric cancer patients who had undergone surgical resection without any previous treatment from selected randomized trials and from a cohort of patients operated at the University Hospital of Mainz, Germany. All patients were restaged using the 3 staging systems and overall survival was estimated and compared. Results: A study population of 491 patients was identified. Relevant changes in stage distribution between the 6th and 7th TNM and the Kiel staging systems were observed. The 6th classification appears to display the best discriminatory measures. The Kiel staging system is slightly less prognostic than the TNM editions, but provides clearly separated strata as with the 6th edition. Conclusions: The Kiel staging system for gastric cancer appears promising in terms of simplicity, predictability and applicability and should be taken into consideration in future TNM revisions.

Total minimally invasive upper gastrointestinal resections are currently mainly performed in centers. The advantages include reduction of operative trauma, magnified enlargement of the operation field and the resulting improvement in operative precision. Robotic-assisted minimally invasive esophagectomy (RAMIE) and laparoscopic/thoracoscopic minimally invasive esophagectomy (MIE) are currently the most commonly performed strategies for esophageal cancer. Laparoscopic (MIG) and robotic-assisted gastrectomy (RAG) are the equivalent procedures for gastric cancer. Due to the relatively low number of reported cases, no definitive statement regarding superiority of these procedures compared to standard open or hybrid procedures can be made; however, there is mounting evidence from high-volume centers in which these procedures are routinely performed that there might be an advantage regarding perioperative morbidity. All of the four procedures described are provided at our high-volume centers in a standardized manner and we are convinced of the benefits of these minimally invasive techniques with respect to morbidity compared to open and hybrid techniques. The additional costs of this technology have to be off-set against a possible reduction of morbidity, reduced cost for personnel and new operative options, such as real-time fluoroscopy.

Intraoperative pelvic neuromapping with electrophysiological evaluation of autonomic nerve preservation during robotic total mesorectal excision (TME) for rectal cancer is conventionally performed by the bedside assistant with a hand-guided probe. Our goal was to return autonomy over the neuromonitoring process to the colorectal surgeon operating the robotic console. A recently described prototype microfork electrostimulation probe was evaluated intraoperatively during abdominal robotic-assisted transanal TME (taTME) surgery for low rectal cancer in three consecutive male patients. An intraoperative video demonstrates the good control and maneuverability of the prototype probe with electrophysiological confirmation of bilateral pelvic autonomic nerve preservation. This study presents the first in situ application of a new microfork probe for fully robot-guided neuromapping in three patients undergoing TME surgery for low rectal cancer.

Robotic surgery is gaining importance in complex thoracoscopic surgery, such as robotic-assisted minimally invasive esophagectomy (RAMIE). The RAMIE procedure was designed using the first generation of the robotic system. The latest da Vinci Xi system has substantially increased the dexterity, especially designed for multiquadrant surgery. The original three-arm RAMIE approach was modified including the robotic four-arm use for the thoracoscopic and laparoscopic part of the operation. This extended approach (four-arm RAMIE approach) provides more flexibility and raises the independence of the surgeon.

Aim To predict the outcome of the implantation of an electronic gastric stimulation device (Enterra®, Medtronic) we established a minimal invasive procedure to perform a temporary gastric test stimulation prior to a definite implantation (1). We achieved promising short time results. This study will demonstrate the long-term results after more than 1 year. Background & Methods Gastroparesis (GP) is a complex disorder of gastric motility. It is defined as a delayed gastric emptying without pyloric obstruction. Due to its etiology GP is divided into three groups: diabetic (GP), postoperative (PG) and idiopathic (IP). Although electronic stimulation of the stomach is a well-established and approved procedure since over 18 years for the therapy of symptomatic GP, the response to gastric stimulation remains unpredictable. 13 patients (11 female, 2 male) with a history of symptomatic gastroparesis (4 idiopathic, 7 postoperative, 2 diabetic) were included. Patients underwent laparoscopy and received 2 temporary electrodes (Medtronic Streamline 6492®) 10 cm proximal to the pylorus into the gastric wall. Threads were passed through the abdominal wall and connected to an external gastric stimulator (Enterra, Fa. Medtronic). The device was taped to the abdominal wall by a dressing. Symptom intensity was measured by a standardized questionnaire, Gastoparesis Cardinal Symptom Index (GCSI)(2). Therapeutic response was defined as a GCSI reduction of at least 50% under the preoperative score. Half time gastric emptying was also measure pre and postoperatively using a half-solid test meal. Results 10 of 13 patients reported a response to temporary gastric stimulation with an increase of the pre-therapeutic GCSI over 50 %. 10 patients received a permanent stimulation device. 7 patients reached the 1-year follow up. They all remained responders with a reduction of GCSI over more than 50 %. In comparison to results after 6 months gastric half time emptying continued to decrease. Conclusion Temporary gastric electronic stimulation can predict the long-term outcome of patients receiving a definite implantation of an electronic gastric stimulation device.

Aim The aim of this study was to describe postoperative complications and short-term oncologic outcomes for RAMIE4 with intrathoracic anastomosis for esophageal cancer within our case series of 100 consecutive patients. Background & Methods Robot assisted minimally-invasive esophagectomy (RAMIE) with intrathoracic anastomosis is gaining popularity as a treatment for esophageal cancer. In this study, we present the results of 100 RAMIE procedures using the da Vinci Xi robotic system (RAMIE4). The aim of this study was to describe postoperative complications and short-term oncologic outcomes for RAMIE4 within our case series of 100 consecutive patients. Between January 2017 and February 2019, data of 100 consecutive patients with esophageal carcinoma undergoing modified Ivor-Lewis esophagectomy were prospectively collected. All operations were performed by the same surgeon using an identical intrathoracic anastomotic reconstruction technique with the same perioperative management and pain control regimen. Intra-operatively and post operatively complications were graded according to definitions stated by the Esophagectomy Complications Consensus Group (ECCG). Results Mean duration of the surgical procedure was 416 min (± 80). In total, 70 patients (70%) had an uncomplicated operative procedure and postoperative recovery. Pulmonary complications were most common and were observed in 17 patients (17 %). Anastomotic leakage was observed in 8 patients (8%). Median ICU stay was 1 day and median overall postoperative hospital stay was 11 days. 30 day mortality was 1%. A R0 resection was reached in 92% of patients with a median number of 29 dissected lymph nodes. Conclusion RAMIE4 with intrathoracic anastomosis for esophageal cancer or cancer located in the esophagus was technically feasible and safe. Postoperative complications and short term oncologic results were comparable to the highest international standards nowadays. These results could only be obtained due to a structured RAMIE training pathway. The superiority of RAMIE compared to conventional minimally invasive esophagus is currently investigated in multiple randomized controlled trials. Results of these trials will define the role for RAMIE for patients with esophageal cancer in the future.

Background Iatrogenic bronchial injury during an esophageal surgery is a severe complication. Hence, immediate treatment is necessary to avoid further pulmonary complications and death. We present a case of an intraoperative bronchial injury caused by a bronchial tube cuff during a full robotic-assisted Ivor-Lewis esophagectomy (RAMIE). Case report A 64-year old patient with adenocarcinoma of the distal esophagus was planned for a RAMIE after completing neoadjuvant radiochemotherapy. Before beginning the thoracic phase, the anesthesist reported an airway leakage during the ventilation. During the transthoracic robotic assisted esophagectomy a perforation of the left main bronchus caused by the cuff of the double-lumen tube was found. Due to the diameter of the defect (1/2 inch) direct suturing was not possible. Therefore, we used a stalked pericardial patch to robotically oversew the perforation. The precise agility using the robotic DaVinci system was very useful treating this perforation minimally- invasively during the RAMIE without conversion. The rest of the surgery including the gastric pull-up and intrathoracic anastomosis was carried out without further complication. The patient had a normal postoperative course and showed no signs of any pulmonary restrictions or any other morbidity. The patient was discharged fully enteralised and in good conditions at the 9th postoperative day. The histopathological stage was ypT3, N2(4/21), L0, V0, Pn0, R0 (stage IIIB in 7th UICC). Conclusion This case report points out the great possibilities of robotic surgery dealing with unexpected complications during complex operations. Robot-assisted complex suturing is a great advantage in robot-assisted minimally invasive surgery, especially during sewing a pericardium-flap onto the left bronchus perforation during an esophagectomy.

Background Total minimally-invasive transthoracic esophagectomy (ttMIE) faces increasing application in surgical treatment of esophageal cancer. For esophago-gastric reconstruction, different anastomotic techniques are currently used, but their impact on postoperative anastomotic leakage and morbidity has not been investigated. The aim of this retrospective multicenter analysis was to describe anastomotic techniques used for ttMIE and to analyze the associated morbidity. Patients and Methods Patients were selected from a basic dataset, collected over a 5-year period from 13 international surgical high-volume centers. Endpoints were anastomotic leakage rate and postoperative morbidity in correlation to anastomotic techniques, measured by the CD classification and the Comprehensive Complication Index® (CCI). Results Five anastomotic techniques were identified in 966 patients after ttMIE: Intrathoracic end-to-side circular-stapled technique in 427 patients (double-stapling n=90, purse-string n=337), intrathoracic (n=109) or cervical (n=255) side-to-side linear-stapled, and cervical end-to-side hand-sewn (n=175). Leakage rates were similar in intrathoracic and cervical anastomoses (15.9% vs. 17.2%, P=0.601), but overall complications (56.7%% vs. 63.7%, P=0.029) and median 90-day CCI (21 (IQR 0-36) vs. 29 (IQR 0-40), P=0.019) favored intrathoracic reconstructions. Leakage rates after intrathoracic end-to-side double-stapling (23.3%) and cervical end-to-side hand-sewn (25.1%) techniques were significantly higher compared with intrathoracic side-to-side linear (15.6%), end-to-side purse-string (13.9%) and cervical side-to-side linear-stapled esophago-gastrostomies (11.8%) (P Conclusion Results of this analysis present the current status of the technical evolution of ttMIE with anastomotic leakage as predominant surgical complication. However, technique-related morbidity requires cautious interpretation considering the long learning curve of this complex surgical procedure.

Aim The aim of this study was to gain insight in the techniques and outcomes of RAMIE worldwide. Background & Methods Although robot-assisted minimally invasive esophagectomy (RAMIE) is increasingly adopted. The current literature on RAMIE mainly consists of single-center case series with considerable variation in reported techniques and outcomes. To gain an overview of the worldwide practice in RAMIE, an online registry was established by the Upper GI International Robotic Association (UGIRA). The collected data involve patient- and treatment characteristics, as well as postoperative outcomes that include complications as defined by the Esophageal Complications Consensus Group, length of stay, re-admissions (i.e. Results A total of 434 patients who underwent RAMIE for esophageal cancer between 2016-2019 were included in this interim analysis. The mean age was 63 years (SD ±9.7), the majority was male (n=359, 83%), and nearly all patients had an ASA score ≥2 (n=398, 92%). Adenocarcinoma (n=253, 58%) and squamous cell carcinoma (n=162, 37%) were most prevalent. The usual surgical approach was transthoracic (n=428, 99%) with the patient in semiprone position (n=393, 91%). Gastric conduit reconstruction was performed in all except one patient, who received a colonic interposition. The anastomosis was created by hand-sewing (n=207, 48%), circular stapling (n=142, 32%), or linear stapling (n=85, 20%). The median intraoperative blood loss was 120 milliliters (IQR 70-280) and the median operating time was 392 minutes (IQR 353-455). Postoperative complications occurred in 251 patients (59%) and mainly involved pulmonary complications (n=138, 32%), anastomotic leakage (n=80, 18%), and cardiac complications (n=55, 13%). Mortality occurred in 9 patients (2%) and re-admission because of complications was required in 57 patients (14%). A median of 28 lymph nodes (IQR 21-35) were removed and a radical resection was achieved in 400 patients (92%). Conclusion The presented results are the first to provide an overview of the techniques that are commonly used in RAMIE. By demonstrating results that are in line with recent benchmarking literature, this study demonstrates the safety and feasibility of RAMIE.

Aim With the introduction of minimally invasive access in centers for esophageal surgery, complications as well as mortality rates decreased. Laboratory tests are used routinely to screen patients for postoperative complications as early as possible. Still, the course of several laboratory parameters after esophagectomy following different surgical approaches has not been described yet and thus, reference values do not exist. Nowadays, the interpretation of inflammatory markers depends on the expertise of the medical staff. The aim of this study is to evaluate the development of CRP and leukocytes after thoracoabdominal esophagectomy following four different surgical approaches. Background & Methods 217 consecutive patients receiving a thoracoabdominal esophagectomy with either open, hybrid, totally minimally invasive or robot-assisted minimally invasive technique between 2008 and 2018 have been evaluated. Daily blood tests regarding C-reactive protein (CRP) and leukocytes have been performed daily in all patients. Data was collected prospectively and analyzed depending on the postoperative course and the surgical approach. Results There is a natural increase of leukocytes and CRP with peak values on the 2nd postoperative day (POD) after thoracoabdominal esophagectomy following all surgical approaches. The increase of inflammatory parameters is significantly higher after open esophagectomy on the first three postoperative days compared to the three minimally invasive procedures. Furthermore, postoperative CRP values > 200 mg/l on the 2nd postoperative day as well as an open esohagectomy are independently associated with postoperative complications. Conclusion The development of postoperative inflammatory laboratory parameters after esophagectomy is significantly depending on the surgical approach. Open esophagectomy results in significantly higher CRP and leukocyte values compared to the hybrid esophagectomy, minimally invasive esophagectomy and robot assisted minimally invasive esophagectomy. Open esophagectomy and an increase of CRP on the 2nd postoperative day above 200 mg/l are an independent positive predictor for postoperative complications in multivariate analysis.

Aim We present a case of a 71 year old female with a combined anastomotic leakage after ivor-lewis resection and esophagotracheal perforation. Background & Methods Anastomotic leakage after esophageal resection is still associated with high morbidity and mortality throughout hospitalization. Nowadays there are several methods to accomplish sufficient closure of the anastomotic leakage such as clipping and using fibrin sealant in smaller leakages. Severe insufficiencies are commonly treated using esophageal stents. In our case the use of such a stent (10cm covered) placed to an anastomotic leak following esophagectomy with high intrathoracic anastomosis lead to an esophagotracheal fistula that was treated in a two-step approach. Firstly a tracheotomy was performed and the cuff of the tracheal cannula was blocked below the esophagotracheal fistula to prevent respiratory insufficiency. The stent was removed and an endosponge therapy was induced in order to manage the anastomotic leak. Finally, the semicircular wound could be covered by a fibrin sealant for final closure. In a second step, via open cervical surgery, the esophagotracheal fistula was resected, followed by overstitching of the pars membranacea and the esophagus and interposition of a muscle flap of the left pectoralis major muscle between trachea and esophagus. Results Postoperatively the patient was extubated with spontaneous breathing and the tracheal tube could be removed five days after surgery. After four days, the patient started drinking and enteral nutrition could be increased with a constant sufficiency of the gastric interponate. A postoperative contrast swallow at day 11 showed no leak and a good emptying of the gastric conduit. The control of the recurrent laryngeal nerves showed no abnormalities. Conclusion Our experience with endosponge treatment suggests that this is the first choice for successful healing of anastomotic leakage after ivor-lewis resection, especially in patients with a low BMI, to prevent esophageal stent perforations. Furthermore, the combination of an esophagotracheal fistula and an anastomotic leak does not have to result in a cervical outlet and removal of the gastric conduit. Patients should be delivered to specialized upper GI surgical centers, which have a high standard of complex esophageal surgery and endoscopic intervention possibilities.

In recent years, the evolution of advanced robotic medical systems has increased rapidly. These technical developments have led to advanced robotic systems, such as the da Vinci Xi, which allows superior controlled complex procedures and innovative surgical strategies. In esophageal surgery, the robotic-assisted minimally invasive esophagectomy (RAMIE) procedure is being developed and carried out with increasing frequency at centers worldwide. Recently, a new single port robotic system was introduced (da Vinci Single Port (SP)), which may allow for the exploration of new routes, such as transcervical robotic assisted minimally invasive esophagectomy (TC-RAMIE). This approach avoids opening the pleura by entering the mediastinum through the jugular window. In this report, we describe the technical steps of the TC-RAMIE using the new da Vinci SP system and compare it to the da Vinci Xi system.

Contains fulltext : 215779.pdf (Publisher’s version ) (Open Access) BACKGROUND: An important parameter for survival in patients with esophageal carcinoma is lymph node status. The distribution of lymph node metastases depends on tumor characteristics such as tumor location, histology, invasion depth, and on neoadjuvant treatment. The exact distribution is unknown. Neoadjuvant treatment and surgical strategy depends on the distribution pattern of nodal metastases but consensus on the extent of lymphadenectomy has not been reached. The aim of this study is to determine the distribution of lymph node metastases in patients with resectable esophageal or gastro-esophageal junction carcinoma in whom a transthoracic esophagectomy with a 2- or 3-field lymphadenectomy is performed. This can be the foundation for a uniform worldwide staging system and establishment of the optimal surgical strategy for esophageal cancer patients. METHODS: The TIGER study is an international observational cohort study with 50 participating centers. Patients with a resectable esophageal or gastro-esophageal junction carcinoma in whom a transthoracic esophagectomy with a 2- or 3-field lymphadenectomy is performed in participating centers will be included. All lymph node stations will be excised and separately individually analyzed by pathological examination. The aim is to include 5000 patients. The primary endpoint is the distribution of lymph node metastases in esophageal and esophago-gastric junction carcinoma specimens following transthoracic esophagectomy with at least 2-field lymphadenectomy in relation to tumor histology, tumor location, invasion depth, number of lymph nodes and lymph node metastases, pre-operative diagnostics, neo-adjuvant therapy and (disease free) survival. DISCUSSION: The TIGER study will provide a roadmap of the location of lymph node metastases in relation to tumor histology, tumor location, invasion depth, number of lymph nodes and lymph node metastases, pre-operative diagnostics, neo-adjuvant therapy and survival. Patient-tailored treatment can be developed based on these results, such as the optimal radiation field and extent of lymphadenectomy based on the primary tumor characteristics. TRIAL REGISTRATION: NCT03222895 , date of registration: July 19th, 2017.

With the introduction of minimally invasive esophagectomy, postoperative complications rates have decreased. Daily laboratory tests are used to screen patients for postoperative complications. The course of inflammatory indicators after esophagectomy after different surgical approaches has not been described yet. The aim of the study was to describe the postoperative C-reactive protein (CRP) and leukocyte levels after different surgical approaches for esophagectomy and relate it to postoperative complications.Between 2010 and 2018, 217 consecutive patients underwent thoracoabdominal esophagectomy with gastric conduit reconstruction. Blood tests to assess CRP and leukocytes were performed daily in all patients. Differences between treatment groups were analyzed with a linear mixed model. All postoperative complications were recorded in a prospective database. Prognostic factors were analyzed using multivariate logistic regression modeling.The study evaluated 4 different esophagectomy techniques: open (n = 57), hybrid (n = 53), totally minimally invasive (n = 52), and robot-assisted minimally invasive (n = 55). The increase of inflammatory indicators was significantly higher after open esophagectomy on the first 2 postoperative days compared with the 3 minimally invasive procedures (P.001). Postoperative CRP values exceeding 200 mg/L on the second postoperative day and open esophagectomy were independently associated with postoperative complications.Open esophagectomy results in significantly higher CRP and leukocyte values compared with hybrid, minimally invasive, and robot-assisted minimally invasive esophagectomy. Open esophagectomy and a CRP increase on the second postoperative day above 200 mg/L are independent positive predictors for postoperative complications in multivariate analysis.

Nowadays robotic surgery is established for abdominal and thoracic surgery. It has been shown that complex procedures are feasible using robotic systems, e.g., da Vinci Xi, with a huge benefit in precision. Different techniques for esophageal cancer surgery are reported; however, only a few robotic and partial robotic procedures are described. Therefore, a fully robotic (abdominal and thoracic) Ivor Lewis esophageal resection using four robotic arms-RAMIE4-the standard technique used for lower esophageal cancer, is presented in this paper. The technique shown in the video was performed successfully in 100 cases in 24 months. The reconstruction is performed with a gastric conduit pull-up and intrathoracic manually inserted 28-mm circular end-to-side stapled anastomosis. This video demonstrates the feasibility of RAMIE4 in the abdomen and thorax and reveals advantages of the robotic assistance.

SUMMARY Robot-assisted minimally invasive esophagectomy (RAMIE) is increasingly being applied as treatment for esophageal cancer. In this study, the results of 50 RAMIE procedures were compared with 50 conventional minimally invasive esophagectomy (MIE) operations, which had been the standard treatment for esophageal cancer prior to the robotic era. Between April 2016 and March 2018, data of 100 consecutive patients with esophageal carcinoma undergoing modified Ivor Lewis esophagectomy were prospectively collected. All operations were performed by the same surgeon using an identical intrathoracic anastomotic reconstruction technique with the same perioperative management and pain control regimen. Intra-operative and postoperative complications were graded according to definitions stated by the Esophagectomy Complications Consensus Group. Data analysis was carried out with and without propensity score matching. Baseline characteristics did not show significant differences between the RAMIE and MIE group. Propensity score matching of the initial group of 100 patients resulted in two equal groups of 40 patients for each surgical approach. In the RAMIE group, the median total lymph node yield was 27 (range 13–84) compared to 23 in the MIE group (range 11–48), P = 0.053. Median intensive care unit (ICU) stay was 1 day (range 1–43) in the RAMIE group compared to 2 days (range 1–17) in the MIE group (P = 0.029). The incidence of postoperative complications was not significantly different between the two groups (P = 0.581). In this propensity-matched study comparing RAMIE to MIE, ICU stay was significantly shorter in the RAMIE group. There was a trend in improved lymphadenectomy in RAMIE.

Delayed gastric emptying (DGE) after Ivor-Lewis esophagectomy occurs postoperatively in up to 50% of the patients. This pyloric dysfunction can lead to severe secondary complications postoperatively such as early aspiration, pneumonia or may even have an impact on anastomotic healing and therefore leakage. Early detection of DGE is essential to prevent further complications. The common treatment postoperatively is endoscopic pyloric balloon dilatation (EPBD) after symptoms already occurred. In our work, we analyzed patients who received a preoperative EPBD during the routine restaging endoscopy and compared those patients to a control group to analyze if preoperative EPBD may prevent postoperative DGE and secondary additional complications. We performed a single-center retrospective analysis of 115 patients who received an Ivor-Lewis esophagectomy by the same surgeon between June 2015 and October 2017. Out of these 115 patients, 91 (79.1%) patients received EPBD preoperatively during the staging/restaging endoscopy (PDG, pyloric dilatation group). In 24 (20.9%) patients, preoperative EPBD was not performed due to stenotic esophageal tumors or logistic reasons (NDG, non-pyloric dilatation group). Data of the PDG and NDG group were compared regarding the rate of postoperative DGE as well as DGE and EPBD related complications. In total, 21 (18.3%) patients developed pyloric dysfunction requiring a total of 27 EPBD during follow-up. There were 12 (13.2%) patients in the PDG and 9 (37.5%) patients in the NDG (p = 0.014), respectively. DGE-related complications such as anastomotic leaks (p = 0.466), pulmonary complications (p = 0.466) and longer median hospital stay (p = 0.685) were more frequent in the NDG group; however this difference did not reach statistical significance. The success rate for postoperative EPBD with 20-mm balloons was lower (58.5%) compared to the usage of 30-mm balloons (93.3%). All pre- and postoperative EPBD were performed without any complications. Preoperative EPBD is feasible, safe and can be combined with restating endoscopy. It seems that preoperative EPBD reduces the incidence of DGE and can prevent the need for early postoperative endoscopic interventions. Our recommendation is therefore to perform an EPBD preoperatively when possible to reduce postoperative complications to a minimum. For postoperative EPBD, we recommend the use of the 30-mm balloon due to lower redilatation rates.

Die laparoskopische Antirefluxchirurgie (LARC) ist eine etablierte Therapie fur die Behandlung der gastrosophagealen Refluxkrankheit (GERD). Die weltweit haufigsten Verfahren sind die Fundoplicatio nach Nissen, nach Toupet oder seltener nach Dor. Fur eine operative Behandlung der GERD kommen ausschlieslich Patienten in Betracht, bei denen eine ausgepragte Symptomatik mit langfristiger Behandlungsnotwendigkeit besteht. Vorrausetzungen fur die LARC sind eine grundliche Evaluation der Beschwerden, eine standardisierte Diagnostik mittels pH-Metrie, oberer Endoskopie, Manometrie und Bariumbreischluck sowie eine kritische Indikationsstellung. Ideale Kandidaten leiden an typischen Refluxsymptomen und sprechen auf die Behandlung mit Protonenpumpeninhibitoren (PPI) an. In der aktuellen LOTUS-Studie wurde gezeigt, dass bei dieser Patientengruppe die Ergebnisse der LARC und der symptomadaptierten medikamentosen Behandlung mit PPI hinsichtlich der Kontrolle des Sodbrennens gleichwertig sind. Patienten mit symptomatischem Volumenreflux unter PPI-Behandlung stellen eine weitere potenzielle Behandlungsgruppe dar. Grose Vorsicht ist bei allen Patienten geboten, die nicht auf eine PPI-Behandlung ansprechen. Die LARC hat bei kritischer Indikationsstellung und ausreichender Erfahrung des Operateurs eine niedrige Morbiditat und Mortalitat mit sehr guten Langzeitergebnissen. Reoperationen bei fehlgeschlagener Antirefluxchirurgie sind selten und sollten nur von erfahrenen Chirurgen durchgefuhrt werden. Neuere Verfahren, wie die laparoskopische Applikation eines Magnetrings um den unteren Osophagussphinkter (LINX®), die transorale inzisionslose Fundoplicatio (EsophyX™) oder die Elektrostimulation des unteren Osophagussphinkters (EndoStim™) sind derzeit noch in klinischer Erprobung.

Robotic-assisted surgery is rapidly increasing, especially in general surgery. It has been shown for years that the minimal invasive esophagectomy (MIE) is possible using a robotic system, for example, da Vinci Xi, Intuitive Surgical. In the past, most robotic esophageal resections have been performed thoracoscopically, and the anastomosis was mostly sutured at the neck. Due to the increase of usable instruments and technical progress, it is possible to perform the total abdominothoracic esophagectomy with an intrathoracic sutured anastomosis robotically. In this article, we would like to present the standardized operation technique and tricks for the robotic-assisted (da Vinci Xi) Ivor Lewis MIE (RAMIE), especially the robotic technique in combination with a standardized intrathoracic circular end-to-side stapled esophagogastric anastomosis.

Background The incidence of esophageal carcinoma is increasing in the western world, and esophageal resection is the essential therapy. Several studies report advantages of minimally invasive esophagectomies (MIEs) versus conventional open procedures (OPs). The benefits of the use of fully MIE or robot-assisted MIE (RAMIE) compared with the hybrid approaches (laparoscopic gastric preparation and open transthoracic esophagectomy) remain unclear. Methods Between July 2015 and August 2017, the data of 75 patients with esophageal carcinoma were prospectively registered. Of the 75 patients, 25 treated with a hybrid MIE (hybrid), 25 with total MIE (MIE), and 25 with RAMIE. All patients were operated by the same specialized surgeon in our center with an identical anastomotic technique (circular stapler). Results The overall 30- and 90-day mortality rates were 0 and 1.33% (1/75), respectively. Total hospital stay (p = 0.262), intensive care unit stay (p = 0.079), number of resected lymph nodes (p = 0.863), and R status (p = 0.132) did not differ statistically between the groups. However, pneumonia and wound infections occurred significantly and more frequently in the hybrid group compared with the minimally invasive groups (MIE and RAMIE) (p = 0.046 and p = 0.003, respectively). Conclusion Comparable results regarding morbidity and short-term outcome could be achieved in the MIE and RAMIE groups compared with the hybrid group. The data indicate that the learning curve is low in surgeons changing the technique form hybrid esophagectomy to fully MIE. Additionally, the total minimally invasive approaches seem to be associated with a low incidence of complications such as pneumonia and wound infections.

Background Esophagectomy has a high incidence of postoperative morbidity. Complications lead to a decreased short-term survival, however the influence of those complications on long-term survival is still unclear. Most of the performed studies are small, single center cohort series with inconclusive or conflicting results. Minimally invasive esophagectomy (MIE) has been shown to be associated with a reduced postoperative morbidity. In this study, the influence of complications on long-term survival for patients with esophageal cancer undergoing a MIE were investigated. Methods Data was collected from the EsoBenchmark database, a collaboration of 13 high-volume centers routinely performing MIE. Patients were included in this database from June 1, 2011 until May 31, 2016. Complications were scored according to the Clavien-Dindo (CD) classification for surgical complications. Major complications were defined as a CD grade ≥ 3. The data were corrected for 90-day mortality to correct for the short-term effect of postoperative complications on mortality. Overall survival was analyzed using the Kaplan Meier, log rank- and (uni- and multivariable) Cox-regression analyses. Results A total of 926 patients were eligible for analysis. Mean follow-up time was 30.8 months (SD 17.9). Complications occurred in 543 patients (59.2%) of which 39.3% had a major complication. Anastomotic leakage (AL) occurred in 135 patients (14.5%) of which 9.2% needed an intervention (CD grade ≥ 3). A significant worse long-term survival was observed in patients with any AL (HR 1.73, 95% CI 1.29–2.32, P Conclusion The occurrence and severity of anastomotic leakage and cardiac complications after MIE negatively affect long-term survival of esophageal cancer patients. Disclosure All authors have declared no conflicts of interest.