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Cao K, Li K, Zhang G, Chen Z, Zhu J. Study on the learning curve for thoracoscopic and laparoscopic radical resection of esophageal cancer. BMC Surg 2025; 25:111. [PMID: 40119279 PMCID: PMC11927204 DOI: 10.1186/s12893-025-02800-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2024] [Accepted: 02/06/2025] [Indexed: 03/24/2025] Open
Abstract
BACKGROUND The procedure for thoracoscopic and laparoscopic radical resection of esophageal cancer is complicated, so the operation time is long, which can easily negatively affect the self-confidence of young thoracic surgeons. This retrospective cohort study aimed to improve young thoracic surgeons' understanding of this type of surgery by analyzing the learning curve. METHODS From October 2017 to August 2018, 64 patients who underwent thoracoscopic and laparoscopic radical resection of esophageal cancer by a single team were reviewed by a retrospective cohort study. These patients were divided into four groups according to the date of operation. The baseline data, operation time, the amount of bleeding during the operation, and the number of lymph nodes sampled were compared. Then, the quality of the different stages of the operation was analyzed and evaluated. RESULTS There were no significant differences in the general baseline data, chest tube duration, or number of samples collected from the right laryngeal nodes among the four groups (p > 0.05). With the accumulation of experience, several key measures of surgical benefit were significantly different among the four groups. Specifically, the operation time became shorter, the amount of bleeding gradually decreased, the number of lymph nodes sampled gradually increased, and the number of left para-recurrent laryngeal nerve lymph nodes sampled gradually increased (p < 0.05). CONCLUSION According to the learning curve, approximately 16 patients needed to complete this type of operation in 300 min, and 22 patients needed to be independently sampled from more than 20 lymph nodes.
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Affiliation(s)
- Kexin Cao
- Department of Thoracic Surgery, The First Affiliated Hospital of Xinxiang Medical University, Xinxiang, People's Republic of China
| | - Kun Li
- Department of Anesthesiology, General Hospital of Central Theater Command of the People's Liberation Army, Wuhan, People's Republic of China
| | - Geng Zhang
- Department of Thoracic Surgery, The First Affiliated Hospital of Xinxiang Medical University, Xinxiang, People's Republic of China
| | - Zhijun Chen
- Department of Thoracic Surgery, The First Affiliated Hospital of Xinxiang Medical University, Xinxiang, People's Republic of China.
| | - Jian Zhu
- Department of Thoracic Cardiovascular Surgery, General Hospital of Central Theater Command of the People's Liberation Army, Wuhan, People's Republic of China.
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2
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Urabe M, Ohkura Y, Haruta S, Ueno M, Udagawa H. Factors Affecting Blood Loss During Thoracoscopic Esophagectomy for Esophageal Carcinoma. J Chest Surg 2021; 54:466-472. [PMID: 34667136 PMCID: PMC8646075 DOI: 10.5090/jcs.21.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 07/17/2021] [Accepted: 08/05/2021] [Indexed: 11/23/2022] Open
Abstract
Background Major intraoperative hemorrhage reportedly predicts unfavorable survival outcomes following surgical resection for esophageal carcinoma (EC). However, the factors predicting the amount of blood lost during thoracoscopic esophagectomy have yet to be sufficiently studied. We sought to identify risk factors for excessive blood loss during video-assisted thoracoscopic surgery (VATS) for EC. Methods Using simple and multiple linear regression models, we performed retrospective analyses of the associations between clinicopathological/surgical factors and estimated hemorrhagic volume in 168 consecutive patients who underwent VATS-type esophagectomy for EC. Results The median blood loss amount was 225 mL (interquartile range, 126–380 mL). Abdominal laparotomy (p<0.001), thoracic duct resection (p=0.014), and division of the azygos arch (p<0.001) were significantly related to high volumes of blood loss. Body mass index and operative duration, as continuous variables, were also correlated positively with blood loss volume in simple linear regression. The multiple linear regression analysis identified prolonged operative duration (p<0.001), open laparotomy approach (p=0.003), azygos arch division (p=0.005), and high body mass index (p=0.014) as independent predictors of higher hemorrhage amounts during VATS esophagectomy. Conclusion As well as body mass index, operation-related factors such as operative duration, open laparotomy, and division of the azygos arch were independently predictive of estimated blood loss during VATS esophagectomy for EC. Laparoscopic abdominal procedures and azygos arch preservation might be minimally invasive options that would potentially reduce intraoperative hemorrhage, although oncological radicality remains an important consideration.
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Affiliation(s)
- Masayuki Urabe
- Department of Gastroenterological Surgery, Toranomon Hospital, Tokyo, Japan
| | - Yu Ohkura
- Department of Gastroenterological Surgery, Toranomon Hospital, Tokyo, Japan.,Okinaka Memorial Institute for Medical Research, Tokyo, Japan
| | - Shusuke Haruta
- Department of Gastroenterological Surgery, Toranomon Hospital, Tokyo, Japan
| | - Masaki Ueno
- Department of Gastroenterological Surgery, Toranomon Hospital, Tokyo, Japan.,Okinaka Memorial Institute for Medical Research, Tokyo, Japan
| | - Harushi Udagawa
- Department of Gastroenterological Surgery, Toranomon Hospital, Tokyo, Japan.,Okinaka Memorial Institute for Medical Research, Tokyo, Japan
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Tsunoda S, Obama K, Hisamori S, Hashimoto K, Nishigori T, Sakai Y. Simple technique of azygos arch division and retraction for minimally invasive esophagectomy. Esophagus 2021; 18:169-172. [PMID: 32613326 DOI: 10.1007/s10388-020-00760-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 06/24/2020] [Indexed: 02/03/2023]
Abstract
The azygos arch is usually divided during esophagectomy. To achieve thorough lymphadenectomy up to upper mediastinum, many surgeons prefer to retract the distal stump of the azygos arch by pulling out the thread which ligates the stump to the skin through the dorsal side of the intercostal space. However, the access to the dorsal chest wall near vertebrae for percutaneous puncture is difficult during robot-assisted minimally invasive esophagectomy in the prone position. This paper reports a new simple method of azygos arch division and retraction using a polymer locking ligation system Hem-o-lok (Teleflex, Morrisville, NC, USA) and a barbed suture device. This technique can be easily performed completely as a robotic procedure without extra puncture, and it is also applicable for conventional thoracoscopic procedures with the potential benefits of less trauma and bleeding.
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Affiliation(s)
- Shigeru Tsunoda
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan.
| | - Kazutaka Obama
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Shigeo Hisamori
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Kyoichi Hashimoto
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Tatsuto Nishigori
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Yoshiharu Sakai
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
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Ozawa S. Minimally Invasive Surgery for Esophageal Cancer in Japan. Ann Thorac Cardiovasc Surg 2020; 26:179-183. [PMID: 32741882 PMCID: PMC7435135 DOI: 10.5761/atcs.ed.20-00079] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 06/25/2020] [Indexed: 02/07/2023] Open
Affiliation(s)
- Soji Ozawa
- Department of Gastroenterological Surgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan
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5
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Akiyama Y, Iwaya T, Endo F, Nikai H, Baba S, Chiba T, Kimura T, Takahara T, Otsuka K, Nitta H, Mizuno M, Kimura Y, Koeda K, Sasaki A. Safety of thoracoscopic esophagectomy after induction chemotherapy for locally advanced unresectable esophageal squamous cell carcinoma. Asian J Endosc Surg 2020; 13:152-159. [PMID: 31313511 DOI: 10.1111/ases.12731] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 05/03/2019] [Accepted: 06/09/2019] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Recent studies have reported that induction chemotherapy with docetaxel plus cisplatin and 5-fluorouracil (DCF) is an effective treatment for unresectable, locally advanced esophageal cancer. The aim of this study was to investigate the safety and feasibility of thoracoscopic esophagectomy (TE) after DCF for initially unresectable esophageal squamous cell carcinoma (ESCC). METHODS Twenty-three patients with initially unresectable T4 thoracic ESCC underwent TE after induction DCF. RESULTS The neighboring organs with tumors were the tracheobronchus in nine patients, thoracic aorta in 13, and pericardium and diaphragm in three each (concurrent overlapping invasion occurred in five patients). The mean total operation time was 556.3 ± 107.2 minutes, and the mean time of the thoracic procedure was 258.9 ± 83.9 minutes. The mean total blood loss was 166.2 ± 117.8 mL, and the loss during the thoracic procedure was 33.5 ± 24.6 mL. All patients achieved complete R0 resection under TE. No conversions to open thoracotomy were performed. The postoperative morbidity rate was 34.8%. The postoperative hospital stay was 24.3 (range, 13-38) days. Five patients had recurrence: four had distant metastasis (lung, two; liver, three; and one with overlap), and one had mediastinal lymph node recurrence. No local recurrence was noted at the site of the primary T4 tumor. CONCLUSIONS TE was safely performed in 23 patients after DCF therapy for locally advanced unresectable ESCC. Induction DCF, followed by TE, could be an alternative treatment for unresectable T4 ESCC.
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Affiliation(s)
- Yuji Akiyama
- Department of Surgery, Iwate Medical University School of Medicine, Morioka, Japan
| | - Takeshi Iwaya
- Department of Surgery, Iwate Medical University School of Medicine, Morioka, Japan
| | - Fumitaka Endo
- Department of Surgery, Iwate Medical University School of Medicine, Morioka, Japan
| | - Haruka Nikai
- Department of Surgery, Iwate Medical University School of Medicine, Morioka, Japan
| | - Shigeaki Baba
- Department of Surgery, Iwate Medical University School of Medicine, Morioka, Japan
| | - Takehiro Chiba
- Department of Surgery, Iwate Medical University School of Medicine, Morioka, Japan
| | - Toshimoto Kimura
- Department of Surgery, Iwate Medical University School of Medicine, Morioka, Japan
| | - Takeshi Takahara
- Department of Surgery, Iwate Medical University School of Medicine, Morioka, Japan
| | - Koki Otsuka
- Department of Surgery, Iwate Medical University School of Medicine, Morioka, Japan
| | - Hiroyuki Nitta
- Department of Surgery, Iwate Medical University School of Medicine, Morioka, Japan
| | - Masaru Mizuno
- Department of Surgery, Iwate Medical University School of Medicine, Morioka, Japan
| | - Yusuke Kimura
- Department of Palliative Medicine, Iwate Medical University School of Medicine, Morioka, Japan
| | - Keisuke Koeda
- Department of Medical Safety Science, Iwate Medical University School of Medicine, Morioka, Japan
| | - Akira Sasaki
- Department of Surgery, Iwate Medical University School of Medicine, Morioka, Japan
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Akiyama Y, Iwaya T, Endo F, Nikai H, Sato K, Baba S, Chiba T, Kimura T, Takahara T, Otsuka K, Nitta H, Mizuno M, Kimura Y, Koeda K, Sasaki A. Thoracoscopic esophagectomy with total meso-esophageal excision reduces regional lymph node recurrence. Langenbecks Arch Surg 2018; 403:967-975. [PMID: 30413880 DOI: 10.1007/s00423-018-1727-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 10/31/2018] [Indexed: 10/27/2022]
Abstract
PURPOSE We investigated the operative outcomes of thoracoscopic esophagectomy (TE) in the prone position, using the concept of total meso-esophageal excision for esophageal cancer. METHODS The medical records of 140 consecutive patients with esophageal cancer who underwent radical esophagectomy by TE were reviewed retrospectively, and operative outcomes were compared between patients treated before (non-meso-esophagus; non-ME group) and after (ME group) the introduction of total meso-esophageal excision (ME). RESULTS There were no significant differences between the groups in postoperative morbidity (non-ME group vs. ME group, 28.3% vs. 41.4%, p = 0.119), 30-day mortality (non-ME group vs. ME group, 0% vs. 1.1%; p = 0.433), and in-hospital mortality (non-ME group vs. ME group, 1.9% vs. 0%, p = 0.199). Although overall survival and relapse-free survival did not differ significantly between the groups, the overall recurrence rate was significantly lower in the ME group than the non-ME group (non-ME group vs. ME group, 43.4% vs. 23%, p = 0.011). In particular, the rate of regional lymph node recurrence in the mediastinum was lower in the ME group (non-ME group vs. ME group, 11.3% vs. 2.3%; p = 0.026). CONCLUSIONS Our results suggest that the ME procedure might be one of the procedures that reduce regional lymph node recurrence in the mediastinum without any deterioration in short-term outcomes.
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Affiliation(s)
- Yuji Akiyama
- Department of Surgery, Iwate Medical University School of Medicine, 19-1 Uchimaru MoriokaIwate, 020-8505, Iwate, Japan.
| | - Takeshi Iwaya
- Department of Surgery, Iwate Medical University School of Medicine, 19-1 Uchimaru MoriokaIwate, 020-8505, Iwate, Japan
| | - Fumitaka Endo
- Department of Surgery, Iwate Medical University School of Medicine, 19-1 Uchimaru MoriokaIwate, 020-8505, Iwate, Japan
| | - Haruka Nikai
- Department of Surgery, Iwate Medical University School of Medicine, 19-1 Uchimaru MoriokaIwate, 020-8505, Iwate, Japan
| | - Kei Sato
- Department of Surgery, Iwate Medical University School of Medicine, 19-1 Uchimaru MoriokaIwate, 020-8505, Iwate, Japan
| | - Shigeaki Baba
- Department of Surgery, Iwate Medical University School of Medicine, 19-1 Uchimaru MoriokaIwate, 020-8505, Iwate, Japan
| | - Takehiro Chiba
- Department of Surgery, Iwate Medical University School of Medicine, 19-1 Uchimaru MoriokaIwate, 020-8505, Iwate, Japan
| | - Toshimoto Kimura
- Department of Surgery, Iwate Medical University School of Medicine, 19-1 Uchimaru MoriokaIwate, 020-8505, Iwate, Japan
| | - Takeshi Takahara
- Department of Surgery, Iwate Medical University School of Medicine, 19-1 Uchimaru MoriokaIwate, 020-8505, Iwate, Japan
| | - Koki Otsuka
- Department of Surgery, Iwate Medical University School of Medicine, 19-1 Uchimaru MoriokaIwate, 020-8505, Iwate, Japan
| | - Hiroyuki Nitta
- Department of Surgery, Iwate Medical University School of Medicine, 19-1 Uchimaru MoriokaIwate, 020-8505, Iwate, Japan
| | - Masaru Mizuno
- Department of Surgery, Iwate Medical University School of Medicine, 19-1 Uchimaru MoriokaIwate, 020-8505, Iwate, Japan
| | - Yusuke Kimura
- Department of Palliative Medicine, Iwate Medical University School of Medicine, Iwate, Japan
| | - Keisuke Koeda
- Department of Medical Safety Science, Iwate Medical University School of Medicine, Iwate, Japan
| | - Akira Sasaki
- Department of Surgery, Iwate Medical University School of Medicine, 19-1 Uchimaru MoriokaIwate, 020-8505, Iwate, Japan
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7
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Akiyama Y, Sasaki A, Endo F, Nikai H, Amano S, Umemura A, Baba S, Chiba T, Kimura T, Takahara T, Nitta H, Otsuka K, Mizuno M, Kimura Y, Koeda K, Iwaya T. Outcomes of esophagectomy after chemotherapy with biweekly docetaxel plus cisplatin and fluorouracil for advanced esophageal cancer: a retrospective cohort analysis. World J Surg Oncol 2018; 16:122. [PMID: 29966526 PMCID: PMC6027574 DOI: 10.1186/s12957-018-1420-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 06/22/2018] [Indexed: 02/08/2023] Open
Abstract
Background Docetaxel, cisplatin, and 5-fluorouracil (DCF) therapy can cause severe adverse events, including neutropenia and febrile neutropenia. The feasibility of DCF therapy is a concern, particularly for elderly patients, patients with moderate organ disorders, and patients suffering from malnutrition caused by dysphagia or insufficient oral intake. We introduced a biweekly DCF therapy (bDCF) for the purpose of reducing severe adverse events for these fragile patients. This study investigated the feasibility and outcome of an esophagectomy after bDCF therapy for patients with advanced esophageal squamous cell carcinoma. Methods Fifty-nine patients with esophageal carcinoma underwent an esophagectomy after DCF or bDCF therapy as primary chemotherapy. DCF was administered to 37 patients in the DCF group, whereas bDCF was administered to 22 patients in the bDCF group. Results Patients in the bDCF group were significantly older than those in the DCF group (p = 0.016). Heart and pulmonary comorbidities were significantly more common in the bDCF than in the DCF group (p < 0.001 and p = 0.039, respectively). Grade 3 or 4 neutropenia was less frequent in the bDCF than in the DCF group (40.9 vs. 81.1%, p = 0.002). Anorexia was more frequent in the DCF group than in the bDCF group (18.9 vs. 0%, p = 0.030). The clinical response rate of the bDCF group was significantly higher than that of the DCF group (86.4 vs. 62.2%, p = 0.047). There was no significant between-group difference in the postoperative morbidity rate (bDCF 45.5% vs. DCF 32.4%) or in the histological therapeutic effect. Conclusion The results demonstrate that primary bDCF therapy for high-risk patients with advanced esophageal cancer is feasible and safe in both chemotherapeutic and perioperative periods without a reduction in the efficacy of DCF therapy.
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Affiliation(s)
- Yuji Akiyama
- Department of Surgery, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, Iwate, 020-8505, Japan.
| | - Akira Sasaki
- Department of Surgery, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, Iwate, 020-8505, Japan
| | - Fumitaka Endo
- Department of Surgery, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, Iwate, 020-8505, Japan
| | - Haruka Nikai
- Department of Surgery, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, Iwate, 020-8505, Japan
| | - Satoshi Amano
- Department of Surgery, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, Iwate, 020-8505, Japan
| | - Akira Umemura
- Department of Surgery, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, Iwate, 020-8505, Japan
| | - Shigeaki Baba
- Department of Surgery, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, Iwate, 020-8505, Japan
| | - Takehiro Chiba
- Department of Surgery, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, Iwate, 020-8505, Japan
| | - Toshimoto Kimura
- Department of Surgery, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, Iwate, 020-8505, Japan
| | - Takeshi Takahara
- Department of Surgery, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, Iwate, 020-8505, Japan
| | - Hiroyuki Nitta
- Department of Surgery, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, Iwate, 020-8505, Japan
| | - Koki Otsuka
- Department of Surgery, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, Iwate, 020-8505, Japan
| | - Masaru Mizuno
- Department of Surgery, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, Iwate, 020-8505, Japan
| | - Yusuke Kimura
- Department of Palliative Medicine, Iwate Medical University School of Medicine, Morioka, Iwate, Japan
| | - Keisuke Koeda
- Department of Medical Safety Science, Iwate Medical University School of Medicine, Morioka, Iwate, Japan
| | - Takeshi Iwaya
- Department of Surgery, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, Iwate, 020-8505, Japan
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Kuwabara S, Kobayashi K, Kubota A, Shioi I, Yamaguchi K, Katayanagi N. Comparison of perioperative and oncological outcome of thoracoscopic esophagectomy in left decubitus position and in prone position for esophageal cancer. Langenbecks Arch Surg 2018; 403:607-614. [PMID: 29656329 DOI: 10.1007/s00423-018-1674-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 04/04/2018] [Indexed: 11/29/2022]
Abstract
PURPOSE The aim of this study was to clarify the differences between thoracoscopic esophagectomy in the left decubitus position (LP) and in the prone position (PP) in terms of short-term perioperative outcomes and long-term oncological outcomes after more than 5 years of follow-up. METHODS Patients with esophageal cancer who underwent thoracoscopic esophagectomy and were followed up for more than 5 years were analyzed retrospectively. Of 142 patients, 72 underwent LP esophagectomy and 70 underwent PP esophagectomy. Operation time, blood loss, operative morbidity, mortality, length of hospital stay, and the number of dissected lymph nodes were compared to evaluate short-term outcomes. Cancer recurrence and overall survival were compared to examine long-term outcomes. RESULTS Patient and tumor characteristics were not different between the LP and PP groups except for the rate of neoadjuvant chemotherapy. Blood loss was significantly lower in the PP group than in the LP group. Incidence of Clavien-Dindo (C.D.) grade ≥ III complications was significantly lower in the PP group than in the LP group. Pulmonary complications were also significantly lower in the PP group than in the LP group. Operation type (LP versus PP) was identified as an independent risk factor for pulmonary complications (odds ratio 0.27, p = 0.03) by multivariate analysis. Cancer recurrence rate, initial recurrence site, and overall survival rate were not different between the two groups. CONCLUSIONS PP is regarded as a less invasive procedure than LP with the same oncological effect.
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Affiliation(s)
- Shirou Kuwabara
- Department of Digestive Surgery, Niigata City General Hospital, 463-7 Shumoku, Chuo-ku, Niigata City, Niigata Prefecture, 950-1197, Japan.
| | - Kazuaki Kobayashi
- Department of Digestive Surgery, Niigata City General Hospital, 463-7 Shumoku, Chuo-ku, Niigata City, Niigata Prefecture, 950-1197, Japan
| | - Akira Kubota
- Department of Digestive Surgery, Niigata City General Hospital, 463-7 Shumoku, Chuo-ku, Niigata City, Niigata Prefecture, 950-1197, Japan
| | - Ikuma Shioi
- Department of Digestive Surgery, Niigata City General Hospital, 463-7 Shumoku, Chuo-ku, Niigata City, Niigata Prefecture, 950-1197, Japan
| | - Kenji Yamaguchi
- Department of Digestive Surgery, Niigata City General Hospital, 463-7 Shumoku, Chuo-ku, Niigata City, Niigata Prefecture, 950-1197, Japan
| | - Norio Katayanagi
- Department of Digestive Surgery, Niigata City General Hospital, 463-7 Shumoku, Chuo-ku, Niigata City, Niigata Prefecture, 950-1197, Japan
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9
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Murakami M, Otsuka K, Goto S, Ariyoshi T, Yamashita T, Aoki T. Thoracoscopic and hand assisted laparoscopic esophagectomy with radical lymph node dissection for esophageal squamous cell carcinoma in the left lateral decubitus position: a single center retrospective analysis of 654 patients. BMC Cancer 2017; 17:748. [PMID: 29126387 PMCID: PMC5681806 DOI: 10.1186/s12885-017-3743-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 10/31/2017] [Indexed: 11/10/2022] Open
Abstract
Background The rates of thoracoscopic esophagectomy performed in the prone and left lateral decubitus positions are similar in Japan. We retrospectively reviewed short- and long-term outcomes of thoracoscopic esophagectomy for esophageal cancer performed in the left lateral decubitus position. Methods Between 1996 and 2015, 654 patients with esophageal cancer underwent thoracoscopic esophagectomy in the left lateral decubitus position. Patients were divided into early (1996–2008) and late groups (2009–2015, with standardization of the procedure and formalized training), and their clinical outcomes reviewed. Results The completion rate of thoracoscopic esophagectomy was 99.5%, and the procedure was converted to thoracotomy in three patients, due to hemorrhage. The mean intrathoracic operative time, intrathoracic blood loss, and number of dissected mediastinal lymph nodes were 205.0 min, 127.3 mL, and 24.7, respectively. Postoperative complications included pneumonia (8.5%), anastomotic leakage (7.5%), and recurrent nerve paralysis (3.5%). Postoperative (30d) mortality was 4/654 (0.61%) due to anastomotic leak and pneumonia. The five year overall survival rate was 70%. A comparison of the 289 early- and 365 late-study period cases revealed significant differences in mean intrathoracic blood loss (174.0 vs. 94.2 mL), number of mediastinal lymph nodes dissected (20.0 vs. 28.4), hospital length of stay (33.4 vs. 20.0 days, p < 0.001), and postoperative anastomotic leakage (14% vs. 1.6%, p < 0.0001). Conclusions Standardization of the procedure for thoracoscopic esophagectomy in the left lateral decubitus position, with a standardized clinical pathway for perioperative care led to significant improvements in surgical outcomes.
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Affiliation(s)
- Masahiko Murakami
- Department of Surgery, Division of Gastroenterological and General Surgery, School of Medicine, Showa University, 142-8666, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, Japan.
| | - Koji Otsuka
- Department of Surgery, Division of Gastroenterological and General Surgery, School of Medicine, Showa University, 142-8666, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, Japan
| | - Satoru Goto
- Department of Surgery, Division of Gastroenterological and General Surgery, School of Medicine, Showa University, 142-8666, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, Japan
| | - Tomotake Ariyoshi
- Department of Surgery, Division of Gastroenterological and General Surgery, School of Medicine, Showa University, 142-8666, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, Japan
| | - Takeshi Yamashita
- Department of Surgery, Division of Gastroenterological and General Surgery, School of Medicine, Showa University, 142-8666, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, Japan
| | - Takeshi Aoki
- Department of Surgery, Division of Gastroenterological and General Surgery, School of Medicine, Showa University, 142-8666, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, Japan
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Mori K, Aikou S, Yagi K, Nishida M, Mitsui T, Yamagata Y, Yamashita H, Nomura S, Seto Y. Technical details of video-assisted transcervical mediastinal dissection for esophageal cancer and its perioperative outcome. Ann Gastroenterol Surg 2017; 1:232-237. [PMID: 29863160 PMCID: PMC5881365 DOI: 10.1002/ags3.12022] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 06/01/2017] [Indexed: 11/17/2022] Open
Abstract
To reduce pulmonary complications after esophagectomy, the transthoracic procedure should be shortened or totally avoided. Transcervical approach assisted by mediastinoscope for the upper mediastinum may be advantageous for this purpose. We carried out video‐assisted transcervical mediastinal dissection (VATCMD) as part of totally non‐transthoracic radical esophagectomy. A single‐port laparoscopy device was adopted to a small cervical incision and the mediastinum was inflated with a positive pressure of 6 to 10 mmHg. Without assistant's retractor, the upper mediastinum and partially the middle mediastinum were dissected mainly by mediastinoscopic‐assisted surgery. Video of the operation is demonstrated with illustrations. We have carried out and reported 17 cases of esophagectomy including VATCMD and its perioperative outcome. Non‐transthoracic esophagectomy was completed without conversion to transthoracic procedure in all 17 cases. Procedure‐related adverse event was not observed and postoperative course was favorable with a zero occurrence (0%) of recurrent laryngeal nerve palsy, chyle leakage or pulmonary complications. Median number of harvested lymph nodes from the upper mediastinal stations was 10. VATCMD is suggested as a safe and feasible approach for the upper mediastinum in esophagectomy for malignancies. It enabled a totally non‐transthoracic radical esophagectomy in combination with a transhiatal approach. Video‐assisted transcervical mediastinal dissection is suggested as a safe and feasible approach for the upper mediastinum in esophagectomy for malignancies. It enabled a totally non‐transthoracic radical esophagectomy in combination with a transhiatal approach.
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Affiliation(s)
- Kazuhiko Mori
- Department of Gastrointestinal Surgery Graduate School of Medicine University of Tokyo Tokyo Japan.,Department of Gastrointestinal Surgery Mitsui Memorial Hospital Tokyo Japan
| | - Susumu Aikou
- Department of Gastrointestinal Surgery Graduate School of Medicine University of Tokyo Tokyo Japan
| | - Koichi Yagi
- Department of Gastrointestinal Surgery Graduate School of Medicine University of Tokyo Tokyo Japan
| | - Masato Nishida
- Department of Gastrointestinal Surgery Graduate School of Medicine University of Tokyo Tokyo Japan
| | - Takashi Mitsui
- Department of Gastrointestinal Surgery Graduate School of Medicine University of Tokyo Tokyo Japan
| | - Yukinori Yamagata
- Department of Surgery Dokkyo Medical University Koshigaya Hospital Koshigaya Japan
| | - Hiroharu Yamashita
- Department of Gastrointestinal Surgery Graduate School of Medicine University of Tokyo Tokyo Japan
| | - Sachiyo Nomura
- Department of Gastrointestinal Surgery Graduate School of Medicine University of Tokyo Tokyo Japan
| | - Yasuyuki Seto
- Department of Gastrointestinal Surgery Graduate School of Medicine University of Tokyo Tokyo Japan
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Osugi H, Narumiya K, Kudou K. Supracarinal dissection of the oesophagus and lymphadenectomy by MIE. J Thorac Dis 2017; 9:S741-S750. [PMID: 28815070 DOI: 10.21037/jtd.2017.05.25] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Since 1995, video-assisted thoracoscopic oesophagectomy (VATS), according the same surgical principles as the Japanese open surgery, has been completed in 700 patients with oesophageal cancer. Our indication for VATS is (I) no extensive pleural adhesion; (II) no contiguous tumor spread; (III) pulmonary function capable of sustaining single-lung ventilation, and (IV) non radiated patients. We use 4 ports around a 5 cm mini-thoracotomy on 5th intercostal space. We laid emphasis on utilizing magnifying effect of video (5 to 20 magnifications), obtained by positioning the camera at close vicinity to the dissection. Magnified view facilitates recognizing the fine layer structure of the mediastinum. The dissection should be performed following this layer structure just like open the page of a book. Tearing the layer makes the dissection irrational and cause unnecessary bleeding and invasiveness. The microanatomies we recognize during upper mediastinal dissection are (I) the most outer layer below the mediastinal pleura are branches from the vagus nerve and thoracic sympathetic trunk; (II) there is no vessel flow in the nerves or out, in the field of dissection; (III) the ideal layer of dissection along the nerve is exposing the epineurium; (IV) the strongest fixing structures in the mediastinum are the vagal nerves and nerves form thoracic sympathetic trunk; (V) the stump of thoracic duct shows particular appearance because of the intramural smooth muscle; (VI) the lymphonodes in the mediastinum are fixed strongly with nerves and gently with vessels; (VII) the aorta is covered with fine fibrous membrane consisting of branches form thoracic sympathetic trunk, etc. Magnified view shows the microstructure of the lymph node such as the afferent lymphatics penetrating the capsule and the hilum structure consisting the efferent lymphatics, artery, vein and nerve. The direction of the hilum of nodes is defined in each region. Therefore, understanding the hilum direction facilitates rational dissection. The hospital mortality was four patients (0.6%). The rate of regional control was 95%. The 5-year survival rates of the patients with pStage 0, 1, 2, 3, 4 were 92%, 88%, 69%, 52% and 24%, respectively, which were favorably compared with open surgery.
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Affiliation(s)
- Harushi Osugi
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Kawada-Cho, Shinjuku-ku, Japan
| | - Kousuke Narumiya
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Kawada-Cho, Shinjuku-ku, Japan
| | - Kenji Kudou
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Kawada-Cho, Shinjuku-ku, Japan
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Akiyama Y, Iwaya T, Endo F, Chiba T, Takahara T, Otsuka K, Nitta H, Koeda K, Mizuno M, Kimura Y, Sasaki A. Investigation of operative outcomes of thoracoscopic esophagectomy after triplet chemotherapy with docetaxel, cisplatin, and 5-fluorouracil for advanced esophageal squamous cell carcinoma. Surg Endosc 2017; 32:391-399. [PMID: 28664431 DOI: 10.1007/s00464-017-5688-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 06/19/2017] [Indexed: 01/03/2023]
Abstract
BACKGROUND Preoperative chemotherapy with cisplatin and 5-fluorouracil (CF) has become the standard treatment for resectable stage II/III thoracic esophageal carcinoma in Japan. Recently, preoperative triplet chemotherapy with docetaxel, cisplatin, and 5-fluorouracil (DCF) has been reported to be effective for locally advanced esophageal cancer. Thoracoscopic esophagectomy (TE) has been increasingly accepted worldwide for the treatment of esophageal cancer. We conducted a retrospective study to evaluate the safety and outcomes of TE after DCF therapy for patients with advanced esophageal cancer. METHODS The medical records of 63 consecutive patients with esophageal squamous cell carcinoma who underwent thoracoscopic surgery after chemotherapy were reviewed. Thirty-four patients received neoadjuvant chemotherapy with CF, and 29 received DCF as first-line chemotherapy. RESULTS The clinical T stage was significantly higher in the DCF group than in the CF group (p < 0.0001), including 17 patients with T4. Lymph node metastasis was more frequent in the DCF group (p = 0.0005), and the clinical stage of the tumor was significantly higher in the DCF group than in the CF group (p = 0.0001). No significant difference existed between the two groups in operation time for the thoracic procedure (DCF 277.2 min vs. CF 302 min). Blood loss during the thoracic procedure was less in the DCF group than in the CF group (DCF 46.9 mL vs. CF 88.8 mL; p = 0.0056). No significant differences existed between the two groups in postoperative morbidity (DCF 34.5% vs. CF 47%) or mortality (DCF 0% vs. CF 2.9%) rates. CONCLUSIONS Our study suggests that TE after DCF therapy for advanced esophageal cancer is as safe as TE after CF therapy.
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Affiliation(s)
- Yuji Akiyama
- Department of Surgery, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, 020-8505, Iwate, Japan.
| | - Takeshi Iwaya
- Department of Surgery, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, 020-8505, Iwate, Japan
| | - Fumitaka Endo
- Department of Surgery, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, 020-8505, Iwate, Japan
| | - Takehiro Chiba
- Department of Surgery, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, 020-8505, Iwate, Japan
| | - Takeshi Takahara
- Department of Surgery, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, 020-8505, Iwate, Japan
| | - Koki Otsuka
- Department of Surgery, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, 020-8505, Iwate, Japan
| | - Hiroyuki Nitta
- Department of Surgery, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, 020-8505, Iwate, Japan
| | - Keisuke Koeda
- Department of Surgery, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, 020-8505, Iwate, Japan
| | - Masaru Mizuno
- Department of Surgery, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, 020-8505, Iwate, Japan
| | - Yusuke Kimura
- Department of Palliative Medicine, Iwate Medical University School of Medicine, Morioka, Iwate, Japan
| | - Akira Sasaki
- Department of Surgery, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, 020-8505, Iwate, Japan
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Makino H, Yoshida H, Maruyama H, Yokoyama T, Hirakata A, Ueda J, Takada H, Matsutani T, Nomura T, Hagiwara N, Uchida E. An original technique for lymph node dissection along the left recurrent laryngeal nerve after stripping the residual esophagus during video-assisted thorocoscopic surgery of esophagus. J Vis Surg 2016; 2:166. [PMID: 29078551 DOI: 10.21037/jovs.2016.11.01] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 10/13/2016] [Indexed: 11/06/2022]
Abstract
BACKGROUND A clear operative view of the middle and lower mediastinum is possible in prone position during video-assisted thorocoscopic surgery of esophagus (VATS-E), but the working space in the upper mediastinum is limited and lymph node dissection along the left recurrent laryngeal nerve (RLN) is difficult in this position. METHODS Esophagectomy and lymph node dissection are performed for pneumothorax by maintaining CO2 insufflation in the prone position. Working space in the left upper mediastinal area for lymph node dissection around RLN is limited in this position. To create space, the residual esophagus is stripped in the reverse direction and retracted toward the neck after the stomach tube is removed through the nose. Lymph node dissection is performed after stripping the residual esophagus. RESULTS We could obtain a clear operative field in the upper left mediastinum by stripping the residual esophagus in the prone position, enabling safe and straightforward lymph node dissection along the left RLN. The rate of permanent RLN paralysis was 1.2%. CONCLUSIONS Lymph node dissection along the left RLN after esophageal stripping is possible in the prone position during VATS-E.
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Affiliation(s)
- Hiroshi Makino
- Department of Surgery, Nippon Medical School, Tama-Nagayama Hospital, Tokyo, Japan
| | - Hiroshi Yoshida
- Department of Surgery, Nippon Medical School, Tama-Nagayama Hospital, Tokyo, Japan
| | - Hiroshi Maruyama
- Department of Surgery, Nippon Medical School, Tama-Nagayama Hospital, Tokyo, Japan
| | - Tadashi Yokoyama
- Department of Surgery, Nippon Medical School, Tama-Nagayama Hospital, Tokyo, Japan
| | - Atsushi Hirakata
- Department of Surgery, Nippon Medical School, Tama-Nagayama Hospital, Tokyo, Japan
| | - Jyunji Ueda
- Department of Surgery, Nippon Medical School, Tama-Nagayama Hospital, Tokyo, Japan
| | - Hideyuki Takada
- Department of Surgery, Nippon Medical School, Tama-Nagayama Hospital, Tokyo, Japan
| | - Takeshi Matsutani
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Tsutomu Nomura
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Nobutoshi Hagiwara
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Eiji Uchida
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
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Mori K, Yamagata Y, Aikou S, Nishida M, Kiyokawa T, Yagi K, Yamashita H, Nomura S, Seto Y. Short-term outcomes of robotic radical esophagectomy for esophageal cancer by a nontransthoracic approach compared with conventional transthoracic surgery. Dis Esophagus 2016; 29:429-34. [PMID: 25809390 PMCID: PMC5132031 DOI: 10.1111/dote.12345] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Transthoracic esophagectomy (TTE) is believed to have advantages for mediastinal lymphadenectomy in the treatment of resectable esophageal cancer despite its association with a greater incidence of pulmonary complications and postoperative mortality. Transhiatal esophagectomy is regarded as less invasive, though insufficient in terms of lymph node dissection. With the aim of achieving lymph dissection equivalent to that of TTE, we have developed a nontransthoracic esophagectomy (NTTE) procedure combining a video-assisted cervical approach for the upper mediastinum and a robot-assisted transhiatal approach for the middle and lower mediastinum. We prospectively studied 22 accumulated cases of NTTE and verified feasibility by analyzing perioperative and histopathological outcomes. We compared this group's short-term outcomes with outcomes of 139 equivalent esophageal cancer cases operated on at our institution by conventional TTE (TTE group). In the NTTE group, there were no procedure-related events and no midway conversions to the conventional surgery; the mean operation time was longer (median, 524 vs. 428 minutes); estimated blood loss did not differ significantly between the two groups (median, 385 mL vs. 490 mL); in the NTTE group, the postoperative hospital stay was shorter (median, 18 days vs. 24 days). No postoperative pneumonia occurred in the NTTE group. The frequencies of other major postoperative complications did not differ significantly, nor were there differences in the numbers of harvested mediastinal lymph nodes (median, 30 vs. 29) or in other histopathology findings. NTTE offers a new radical procedure for resection of esophageal cancer combining a cervical video-assisted approach and a transhiatal robotic approach. Although further accumulation of surgical cases is needed to corroborate these results, NTTE promises better prevention of pulmonary complications in the management of esophageal cancer.
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Affiliation(s)
- K. Mori
- Department of Gastrointestinal SurgeryGraduate School of MedicineUniversity of TokyoTokyoJapan
| | - Y. Yamagata
- Department of Gastrointestinal SurgeryGraduate School of MedicineUniversity of TokyoTokyoJapan
| | - S. Aikou
- Department of Gastrointestinal SurgeryGraduate School of MedicineUniversity of TokyoTokyoJapan
| | - M. Nishida
- Department of Gastrointestinal SurgeryGraduate School of MedicineUniversity of TokyoTokyoJapan
| | - T. Kiyokawa
- Department of Gastrointestinal SurgeryGraduate School of MedicineUniversity of TokyoTokyoJapan
| | - K. Yagi
- Department of Gastrointestinal SurgeryGraduate School of MedicineUniversity of TokyoTokyoJapan
| | - H. Yamashita
- Department of Gastrointestinal SurgeryGraduate School of MedicineUniversity of TokyoTokyoJapan
| | - S. Nomura
- Department of Gastrointestinal SurgeryGraduate School of MedicineUniversity of TokyoTokyoJapan
| | - Y. Seto
- Department of Gastrointestinal SurgeryGraduate School of MedicineUniversity of TokyoTokyoJapan
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15
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Suda K, Nakauchi M, Inaba K, Ishida Y, Uyama I. Minimally invasive surgery for upper gastrointestinal cancer: Our experience and review of the literature. World J Gastroenterol 2016; 22:4626-4637. [PMID: 27217695 PMCID: PMC4870070 DOI: 10.3748/wjg.v22.i19.4626] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Revised: 04/03/2016] [Accepted: 04/20/2016] [Indexed: 02/06/2023] Open
Abstract
Minimally invasive surgery (MIS) for upper gastrointestinal (GI) cancer, characterized by minimal access, has been increasingly performed worldwide. It not only results in better cosmetic outcomes, but also reduces intraoperative blood loss and postoperative pain, leading to faster recovery; however, endoscopically enhanced anatomy and improved hemostasis via positive intracorporeal pressure generated by CO2 insufflation have not contributed to reduction in early postoperative complications or improvement in long-term outcomes. Since 1995, we have been actively using MIS for operable patients with resectable upper GI cancer and have developed stable and robust methodology in conducting totally laparoscopic gastrectomy for advanced gastric cancer and prone thoracoscopic esophagectomy for esophageal cancer using novel technology including da Vinci Surgical System (DVSS). We have recently demonstrated that use of DVSS might reduce postoperative local complications including pancreatic fistula after gastrectomy and recurrent laryngeal nerve palsy after esophagectomy. In this article, we present the current status and future perspectives on MIS for gastric and esophageal cancer based on our experience and a review of the literature.
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Randomized Phase II Study of the Anti-inflammatory Effect of Ghrelin During the Postoperative Period of Esophagectomy. Ann Surg 2015; 262:230-6. [PMID: 25361222 DOI: 10.1097/sla.0000000000000986] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE A prospective randomized phase II trial was conducted to evaluate the efficacy of ghrelin administration in reducing systemic inflammatory response syndrome (SIRS) duration after esophagectomy. BACKGROUND Esophagectomy for esophageal cancer is highly invasive and leads to prolonged SIRS duration and postoperative complications. Ghrelin has multiple effects, including anti-inflammatory effects. METHODS Forty patients undergoing esophagectomy were randomly assigned to either the ghrelin group (n = 20), which received continuous infusion of ghrelin (0.5 μg/kg/h) for 5 days, or the placebo group (n = 20), which received pure saline for 5 days. The primary endpoint was SIRS duration. The secondary endpoints were the incidence of postoperative complications, time of a negative nitrogen balance, changes in body weight and composition, and levels of inflammatory markers, including C-reactive protein (CRP) and interleukin-6 (IL-6). RESULTS The ghrelin group had a shorter SIRS duration and lower CRP and IL-6 levels than did the placebo group. The incidence of pulmonary complications was lower in the ghrelin group than in the placebo group, whereas other complications did not differ between the groups. Although time of the negative nitrogen balance was shorter in the ghrelin group than in the placebo group, changes in total body weight and lean body weight did not differ significantly. CONCLUSIONS Postoperative ghrelin administration was effective for inhibiting inflammatory mediators and improving the postoperative clinical course of patients with esophageal cancer.
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17
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Wang ZQ, Chen LQ, Yuan Y, Wang WP, Niu ZX, Yang YS, Cai J. Effects of neutrophil elastase inhibitor in patients undergoing esophagectomy: A systematic review and meta-analysis. World J Gastroenterol 2015; 21:3720-3730. [PMID: 25834341 PMCID: PMC4375598 DOI: 10.3748/wjg.v21.i12.3720] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2014] [Revised: 06/23/2014] [Accepted: 07/30/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the benefit and safety of sivelestat (a neutrophil elastase inhibitor) administration in patients undergoing esophagectomy.
METHODS: Online databases including PubMed, EMBASE, the Cochrane Library, Web of Knowledge, and Chinese databases (Wanfang database, VIP and CNKI) were searched systematically up to November 2013. Randomized controlled trials and high-quality comparative studies were considered eligible for inclusion. Three reviewers evaluated the methodological quality of the included studies, and Stata 12.0 software was used to analyze the extracted data. The risk ratio (RR) was used to express the effect size of dichotomous outcomes, and mean difference (MD) or standardized mean difference was used to express the effect size of continuous outcomes.
RESULTS: Thirteen studies were included in this systematic review and nine studies were included in the meta-analysis. The duration of mechanical ventilation was significantly decreased in the sivelestat group on postoperative day 5 [I2 = 76.3%, SMD = -1.41, 95%CI: -2.63-(-0.19)]. Sivelestat greatly lowered the incidence of acute lung injury in patients after surgery (I2 = 0%, RR = 0.27, 95%CI: 0.08-0.93). However, it did not decrease the incidence of pneumonia, intensive care unit stay or postoperative hospital stay, and did not increase the incidence of complications such as anastomotic leakage, recurrent nerve palsy, wound infection, sepsis and catheter-related fever.
CONCLUSION: A neutrophil elastase inhibitor is beneficial in patients undergoing esophagectomy. More high quality, large sample, multi-center and randomized controlled trials are needed to validate this effect.
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Takemura M, Kaibe N, Takii M, Sasako M. Operative Benefits of Artificial Pneumothorax in Thoracoscopic Esophagectomy in the Left Lateral Decubitus Position for Esophageal Cancer. ACTA ACUST UNITED AC 2015. [DOI: 10.4236/ijcm.2015.612127] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Clinical utility of a novel hybrid position combining the left lateral decubitus and prone positions during thoracoscopic esophagectomy. World J Surg 2014; 38:410-8. [PMID: 24101023 DOI: 10.1007/s00268-013-2258-4] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND We developed a hybrid of the prone and left lateral decubitus positions for thoracoscopic esophagectomy (TE) in 2009. This study aimed to evaluate the feasibility of applying this novel TE position. METHODS We retrospectively analyzed 78 patients who underwent TE at our institution between 2005 and 2010. Altogether, 33 patients underwent TE in the left lateral decubitus position (LD-TE) from 2005 to 2008, and 45 underwent TE in the hybrid position (hybrid-TE) from 2009 to 2010. Radical lymphadenectomy along the bilateral recurrent laryngeal nerves was performed in both groups. The thoracic duct was preserved in the LD-TE group and resected in the hybrid-TE group. In the LD-TE group, all thoracic procedures were performed with the patient in the left lateral decubitus position. In the hybrid-TE group, the upper mediastinal procedure was performed with the patient in the left lateral decubitus position, and procedures at the middle and lower mediastinum were performed with the patient in the prone position under CO2 pneumothorax. RESULTS Hybrid-TE was associated with increased operating time. The number of harvested mediastinal nodes and the PaO2/FiO2 ratio on postoperative day 1 were both greater in this position. Although vocal cord palsy was observed more frequently in the hybrid-TE group, there was no significant difference in the rate of other complications or in-hospital mortality between the two groups. CONCLUSIONS The novel hybrid position is believed feasible for use during TE. We believe that this position facilitates a more radical mediastinal lymphadenectomy with minimal intraoperative pulmonary damage.
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Retrospective study using the propensity score to clarify the oncologic feasibility of thoracoscopic esophagectomy in patients with esophageal cancer. World J Surg 2014; 37:1673-80. [PMID: 23539192 DOI: 10.1007/s00268-013-2008-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The present study aimed to clarify the long-term prognostic impact and oncologic feasibility of thoracoscopic esophagectomy (TSE) in patients with esophageal cancer in comparison with open thoracic esophagectomy (OTE). METHODS Patients with esophageal cancer underwent surgically curative esophagectomy without neoadjuvant therapy from January 1991 to December 2008 and were analyzed retrospectively. Of 257 patients, 91 underwent TSE and 166 had OTE. Relations between the long-term prognosis after surgery, the surgical procedure, and clinicopathologic parameters were analyzed statistically. The propensity scores were calculated for all patients through a multiple logistic regression model that was optimized with Akaike's Information Criterion. Using Cox's proportional hazard model with prognostic variables and the propensity scores, we implemented a multivariate analysis for comparing the performance of two surgical methods. RESULTS Patient characteristics and the incidence of perioperative morbidity or hospital death were similar for the TSE and OTE groups. Significantly more lymph nodes were dissected in the TSE group than in the OTE group (total p = 0.013; thoracic p = 0.0094; recurrent laryngeal p < 0.0001). The TSE group exhibited a more favorable prognosis after surgery than the OTE group in terms of overall survival (p = 0.011) and disease-specific survival (DSS) (p = 0.0040). Particularly in subgroup analysis of DSS, the TSE group had a favorable prognosis in upper thoracic esophageal cancer (p = 0.0053), invasive cancer (p = 0.046), node-positive cancer (p = 0.020), progressive cancer (p = 0.0052), cancer with lymphatic vessel invasion (p = 0.0019), and cancer without blood vessel invasion (p = 0.0081). In terms of DSS, the TSE group exhibited a more favorable prognosis than the OTE group regardless of the presence or absence of metastasis to lymph nodes around the thoracic (p < 0.0001) or recurrent laryngeal (p < 0.0001) nerves. TSE (p = 0.0430), lymph node metastasis (p = 0.0382), lymphatic invasion (p = 0.0418), and p stage (p = 0.0047) were independent prognostic parameters in the Cox's proportional hazard model with the propensity scores. CONCLUSIONS TSE can contribute to prolonged survival after surgery in patients with esophageal cancer by enabling precise thoracic lymph node dissection based on a magnified surgical field. TSE might have maximum oncologic benefit and minimum invasiveness for patients with esophageal cancer.
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Ninomiya I, Osugi H, Fujimura T, Fushida S, Okamoto K, Maruzen S, Oyama K, Kinoshita J, Tsukada T, Kitagawa H, Takamura H, Nakagawara H, Tajima H, Hayashi H, Makino I, Ohta T. Thoracoscopic esophagectomy with extended lymph node dissection in the left lateral position: technical feasibility and oncologic outcomes. Dis Esophagus 2014; 27:159-167. [PMID: 23551804 DOI: 10.1111/dote.12071] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The aim of this study was to estimate the technical and oncologic feasibility of video-assisted thoracoscopic radical esophagectomy (VATS) in the left lateral position. From January 2003 to December 2011, 132 patients with esophageal cancer underwent VATS. The mean duration of the thoracic procedure and the entire procedure was 294 ± 88 and 623 ± 123 minutes, respectively. Mean blood loss during the thoracic procedure and the entire procedure was 313 ± 577 and 657 ± 719 g, respectively. The mean number of dissected thoracic lymph nodes was 32.6 ± 12.9. There were four in-hospital deaths (3.0%); two patients (1.5%) died of acute respiratory distress syndrome and two patients (1.5%) died of tumor progression. Postoperative unilateral or bilateral recurrent laryngeal nerve (RLN) palsy, or pneumonia was found in 33 (25.0%), 21 (15.9%), and 27(20.5%) patients, respectively. The patients were divided into the first 66 patients who underwent VATS (Group 1) and the subsequent 66 patients (Group 2). The numbers of cases who underwent neoadjuvant or induction chemotherapy for T4 tumor and intrathoracic anastomosis were higher in Group 2 than in Group 1. The duration of the procedure, amount of blood loss, and the number of dissected thoracic lymph nodes were not different between the two groups. The total number of dissected lymph nodes was higher in Group 2 than in Group 1 (72.6 ± 27.8 vs. 62.6 ± 21.6, P = 0.023). The rate of bilateral RLN palsy was less in Group 2 than in Group 1 (7.6% vs. 24.2%, P = 0.042). The mean follow-up period was 38.7 months. Primary recurrence consisted of hematogenous, lymphatic, peritoneal dissemination, pleural dissemination, and locoregional in 15 (11.3%), 20 (15.1%), 3 (2.3%), 4 (3.0%), and 5 patients (3.8%), respectively. The rate of regional lymph node recurrence within the dissection field was only 4.5%. The prognosis of patients with lymph node metastasis was significantly poorer than that of patients without lymph node metastasis. However, the prognosis of the 11 cases that had metastasis only around RLNs was similar to that of node-negative cases. Thirteen patients with pathological remnant tumor (R1 or R2) did not survive longer than 5 years at present. The overall 5-year survival rate of stage I, II, and III disease after curative VATS was 82.2%, 77.0%, and 52.3%, respectively. Expansion of VATS criteria for patients after induction chemotherapy for T4 tumor or thoracoscopic anastomosis did not adversely affect the surgical results by experience. Although the VATS procedure is accompanied by a certain degree of morbidity including RLN palsy and pulmonary complications, VATS has an excellent locoregional control effect. In addition, the favorable survival after VATS shows that the procedure is oncologically feasible.
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Affiliation(s)
- I Ninomiya
- Gastroenterologic Surgery, Department of Oncology, Division of Cancer Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa
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Ninomiya I, Okamoto K, Fujimura T, Fushida S, Osugi H, Ohta T. Oncologic Outcomes of Thoracoscopic Esophagectomy with Extended Lymph Node Dissection: 10‐year Experience from a Single Center. World J Surg 2014; 38:120-130. [DOI: 10.1007/s00268-013-2238-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
AbstractBackgroundThe oncologic feasibility of video‐assisted thoracoscopic (VATS) radical esophagectomy for esophageal cancer has yet to be proven. We evaluated the oncologic outcome of VATS‐esophagectomy by reviewing our 10‐year experience, with particular emphasis on the effect of lymph node dissection.MethodsFrom January 2003 to December 2012, 146 patients with esophageal cancer underwent completion of VATS‐esophagectomy in the left lateral position.ResultsThe mean follow‐up period was 37.1 months. Forty‐six patients (31.5 %) had recurrence of cancer. Primary recurrence was hematogenous, lymphatic, peritoneal dissemination, pleural dissemination, locoregional, or port site in 20 (13.7 %), 23 (15.8 %), 2 (1.4 %), 5 (3.4 %), 4 (2.7 %), and 1 (0.67 %) patients, respectively. Pleural dissemination occurred more frequently after noncurative operation than curative operation (p = 0.010). The frequency of lymphatic metastasis within the mediastinal regional lymph nodes in the dissection field was only 5.5 %. The overall 5‐year survival rate of stage I, II, and III disease after curative VATS‐esophagectomy was 79.1, 77.9, and 56.7 %, respectively. T4 tumor, lymph node metastasis, R1 or 2, and concomitant lymph node metastasis in the cervical, mediastinal, and abdominal fields were indicators of unfavorable outcome. The lymph nodes in the abdominal region and those around the bilateral recurrent laryngeal nerves (RLNs) were frequent metastasis sites. Patients who had metastasis only around RLNs had favorable survival comparable to node‐negative cases after curative VATS‐esophagectomy.ConclusionsVideo‐assisted thorascopic‐esophagectomy has an excellent locoregional control effect with favorable oncologic outcome. The lymph node dissection procedure by VATS‐esophagectomy has survival benefit for the patients having lymph node metastasis around bilateral RLNs.
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Affiliation(s)
- Itasu Ninomiya
- Division of Cancer Medicine, Gastroenterologic Surgery, Department of Oncology, Graduate School of Medical Science Kanazawa University Takaramachi 13‐1 920‐8641 Kanazawa Ishikawa Japan
| | - Kouichi Okamoto
- Division of Cancer Medicine, Gastroenterologic Surgery, Department of Oncology, Graduate School of Medical Science Kanazawa University Takaramachi 13‐1 920‐8641 Kanazawa Ishikawa Japan
| | - Takashi Fujimura
- Division of Cancer Medicine, Gastroenterologic Surgery, Department of Oncology, Graduate School of Medical Science Kanazawa University Takaramachi 13‐1 920‐8641 Kanazawa Ishikawa Japan
| | - Sachio Fushida
- Division of Cancer Medicine, Gastroenterologic Surgery, Department of Oncology, Graduate School of Medical Science Kanazawa University Takaramachi 13‐1 920‐8641 Kanazawa Ishikawa Japan
| | - Harushi Osugi
- Department of Gastroenterological Surgery, Graduate School of Medicine Osaka City University Osaka Osaka Japan
| | - Tetsuo Ohta
- Division of Cancer Medicine, Gastroenterologic Surgery, Department of Oncology, Graduate School of Medical Science Kanazawa University Takaramachi 13‐1 920‐8641 Kanazawa Ishikawa Japan
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Chen B, Zhang B, Zhu C, Ye Z, Wang C, Ma D, Ye M, Kong M, Jin J, Lin J, Wu C, Wang Z, Ye J, Zhang J, Hu Q. Modified McKeown minimally invasive esophagectomy for esophageal cancer: a 5-year retrospective study of 142 patients in a single institution. PLoS One 2013; 8:e82428. [PMID: 24376537 PMCID: PMC3869695 DOI: 10.1371/journal.pone.0082428] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2013] [Accepted: 10/22/2013] [Indexed: 11/28/2022] Open
Abstract
Background To achieve decreased invasiveness and lower morbidity, minimally invasive esophagectomy (MIE) was introduced in 1997 for localized esophageal cancer. The combined thoracoscopic-laparoscopic esophagectomy (left neck anastomosis, defined as the McKeown MIE procedure) has been performed since 2007 at our institution. From 2007 to 2011, our institution subsequently evolved as a high-volume MIE center in China. We aim to share our experience with MIE, and have evaluated the outcomes of 142 patients. Methods We retrospectively reviewed 142 consecutive patients who had presented with esophageal cancer undergoing McKeown MIE from July 2007 to December 2011. The procedure, surgical outcomes, disease-free and overall survival of these cases were assessed. Results The average total procedure time was 270.5±28.1 min. The median operation time for thoracoscopy was 81.5±14.6 min and for laparoscopy was 63.8±9.1 min. The average blood loss associated with thoracoscopy was 123.8±39.2 ml, and for laparoscopic procedures was 49.9±14.3 ml. The median number of lymph nodes retrieved was 22.8. The 30 day mortality rate was 0.7%. Major surgical complications occurred in 24.6% and major non-surgical complications occurred in 18.3% of these patients. The median DFS and OS were 36.0±2.6 months and 43.0±3.4 months respectively. Conclusions Surgical and oncological outcomes following McKeown MIE for esophageal cancer were acceptable and comparable with those of open-McKeown esophagectomy. The procedure was both feasible and safe – properties that can be consolidated by experience.
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Affiliation(s)
- Baofu Chen
- Department of Thoracic Surgery, Taizhou Hospital, Wenzhou Medical College, Linhai, Zhejiang, China
| | - Bo Zhang
- Department of Thoracic Surgery, Taizhou Hospital, Wenzhou Medical College, Linhai, Zhejiang, China
| | - Chengchu Zhu
- Department of Thoracic Surgery, Taizhou Hospital, Wenzhou Medical College, Linhai, Zhejiang, China
- * E-mail:
| | - Zhongrui Ye
- Department of Thoracic Surgery, Taizhou Hospital, Wenzhou Medical College, Linhai, Zhejiang, China
| | - Chunguo Wang
- Department of Thoracic Surgery, Taizhou Hospital, Wenzhou Medical College, Linhai, Zhejiang, China
| | - Dehua Ma
- Department of Thoracic Surgery, Taizhou Hospital, Wenzhou Medical College, Linhai, Zhejiang, China
| | - Minhua Ye
- Department of Thoracic Surgery, Taizhou Hospital, Wenzhou Medical College, Linhai, Zhejiang, China
| | - Min Kong
- Department of Thoracic Surgery, Taizhou Hospital, Wenzhou Medical College, Linhai, Zhejiang, China
| | - Jiang Jin
- Department of Thoracic Surgery, Taizhou Hospital, Wenzhou Medical College, Linhai, Zhejiang, China
| | - Jiang Lin
- Department of Thoracic Surgery, Taizhou Hospital, Wenzhou Medical College, Linhai, Zhejiang, China
| | - Chunlei Wu
- Department of Thoracic Surgery, Taizhou Hospital, Wenzhou Medical College, Linhai, Zhejiang, China
| | - Zheng Wang
- Department of Thoracic Surgery, Taizhou Hospital, Wenzhou Medical College, Linhai, Zhejiang, China
| | - Jiahong Ye
- Department of Thoracic Surgery, Taizhou Hospital, Wenzhou Medical College, Linhai, Zhejiang, China
| | - Jian Zhang
- Department of Thoracic Surgery, Taizhou Hospital, Wenzhou Medical College, Linhai, Zhejiang, China
| | - Quanteng Hu
- Department of Thoracic Surgery, Taizhou Hospital, Wenzhou Medical College, Linhai, Zhejiang, China
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Guo W, Zou YB, Ma Z, Niu HJ, Jiang YG, Zhao YP, Gong TQ, Wang RW. One surgeon's learning curve for video-assisted thoracoscopic esophagectomy for esophageal cancer with the patient in lateral position: how many cases are needed to reach competence? Surg Endosc 2012; 27:1346-52. [PMID: 23093242 DOI: 10.1007/s00464-012-2614-8] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2012] [Accepted: 09/09/2012] [Indexed: 02/06/2023]
Abstract
BACKGROUND Minimally invasive esophagectomy is a feasible technique shown to be safe and oncologically adequate for the treatment of esophageal cancer. This study aimed to describe one surgeon's learning curve for video-assisted thoracoscopic esophagectomy with the patient in lateral position. METHODS From May 2010 to June 2012, 89 thoracoscopic esophagectomies for esophageal cancer were performed by one surgeon. The patients were divided into three groups. Group A included the first 30 cases. Group B comprised cases 31 to 60, and group C included the final 29 cases. The demographic characteristics and the intra- and postoperative variables were collected retrospectively and analyzed. RESULTS One postoperative death occurred. Eight patients required conversion. No significant difference in background or clinicopathologic factors among the three groups was observed. Compared with group A, a significant decrease in intrathoracic operative time (107.7 ± 16.2 min; P = 0.0000), total operative time (326.3 ± 40.7 min; P = 0.0002), and blood loss (290.8 ± 114.3 ml; P = 0.0129) was observed in group B, whereas more retrieved nodes were harvested (20.1 ± 9.5; P = 0.0002). The last 29 patients (group C) involved significantly less intrathoracic operative time (82.8 ± 18.4 min; P = 0.0386), total operative time (294.7 ± 37.4 min; P = 0.0009), and blood loss (234.7 ± 87.8 ml; P = 0.0125) as well as a shorter postoperative hospital stay (12.4 ± 3.7 days; P = 0.0125) compared with group B. A significant decline in the overall morbidity from group A to group C (P = 0.0005) also was observed. CONCLUSIONS The results of this study suggest that at least 30 cases were needed to reach the plateau of thoracoscopic esophagectomy. After more than 60 cases of thoracoscopic esophagectomies had been managed, lower morbidity could be obtained.
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Affiliation(s)
- Wei Guo
- Department of Thoracic Surgery, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Changjiang Route 10#, Daping, Chongqing, 400042, People's Republic of China
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25
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Watanabe M, Baba Y, Nagai Y, Baba H. Minimally invasive esophagectomy for esophageal cancer: an updated review. Surg Today 2012; 43:237-44. [PMID: 22926551 DOI: 10.1007/s00595-012-0300-z] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2012] [Accepted: 04/09/2012] [Indexed: 12/14/2022]
Abstract
PURPOSE The surgical, postoperative and oncologic outcomes of minimally invasive esophagectomy (MIE) for esophageal cancer were reviewed to clarify the benefits of this surgical modality. METHODS A systematic literature search was performed using synonyms for minimally invasive or thoracoscopic esophagectomy. There were 18 retrospective cohort studies and 3 meta-analyses retrieved in this review. RESULTS There are several minimally invasive approaches for esophageal cancer. Total MIE using both the thoracoscopic and laparoscopic approach is increasingly performed. A longer operative time and less blood loss are observed with MIE in comparison to open esophagectomy (OE). Although the benefit of MIE for reducing morbidity and mortality rates is still under debate, a shorter hospital stay was common among the studies. The oncologic outcomes of MIE were not inferior to OE, while the number of retrieved lymph nodes was greater in MIE than OE in several studies. CONCLUSION Total MIE using a combined thoracoscopic and laparoscopic approach can be performed safely, although the benefits for short-term outcomes are still controversial. Oncologic outcomes are favorable and MIE may have an advantage in lymph node dissection over OE. The benefits of MIE should therefore be confirmed by randomized controlled trials.
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Affiliation(s)
- Masayuki Watanabe
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Kumamoto, 860-8556, Japan
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Makino H, Nomura T, Miyashita M, Okawa K, Hagiwara N, Uchida E. Esophageal stripping creates a clear operative field for lymph node dissection along the left recurrent laryngeal nerve in prone video-assisted thoracoscopic surgery. J NIPPON MED SCH 2012; 78:199-204. [PMID: 21720096 DOI: 10.1272/jnms.78.199] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
We describe a 54-year-old man in whom esophageal carcinoma was diagnosed and who underwent video-assisted thoracoscopic surgery of the esophagus (VATS-E) in the prone position. Initially, the patient was fixed in a semiprone position, from which he could be rotated to a prone or left lateral position. Four ports were inserted, and then the patient was rotated to the prone position. Once the patient was prone, gravity caused the lung to move downwards. Next, the chest cavity was inflated with a CO(2) insufflation pressure of 6 mm Hg. Esophagectomy was then performed, and the lymph nodes in the middle and lower mediastinum and along the right recurrent laryngeal nerve were dissected. In the left upper mediastinum, lymph node dissection was performed after the residual esophagus was stripped. Stripping of the residual esophagus created sufficient working space and a clear operative field for lymph node dissection. VATS-E in the prone position has achieved remarkable results in Japan. It allows a clear operative view of the middle and lower mediastinum, but the working space in the upper mediastinum is limited. Our results indicate that esophageal stripping in prone VATS-E allows for safe and straightforward lymph node dissection along the left recurrent laryngeal nerve. Our technique overcame the difficulties usually encountered with this type of lymph node dissection.
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Affiliation(s)
- Hiroshi Makino
- Surgery for Organ Function and Biological Regulation, Graduate School of Medicine, Nippon Medical School, Japan.
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Significance of thoracoscopy-assisted surgery with a minithoracotomy and hand-assisted laparoscopic surgery for esophageal cancer: the experience of a single surgeon. J Gastrointest Surg 2011; 15:1939-51. [PMID: 21909843 DOI: 10.1007/s11605-011-1664-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2010] [Accepted: 08/09/2011] [Indexed: 01/31/2023]
Abstract
BACKGROUND This retrospective study evaluated the surgical learning curve and outcomes of thoracolaparoscopic esophagectomy. PATIENTS AND METHODS The study group comprised a series of 92 patients with preoperatively diagnosed resectable thoracic esophageal cancer. Additionally, the surgical outcomes in 79 esophageal cancer patients receiving open esophagectomies were compared. All patients underwent thoracolaparoscopic esophagectomy in the lateral decubitus position. The short- and long-term outcomes were evaluated, and the surgical learning curve was assessed. RESULTS The total operation time was 477.8 ± 102.2 min, the thoracoscopic time was 157.9 ± 61.3 min, the total blood loss was 554.4 ± 280.5 ml, and the number of retrieved lymph nodes was 34.3 ± 14.3. Postoperative morbidity was observed in 23 patients. After the surgeon's first 40 cases, the surgical technique and short-term outcomes were stable. The 5-year disease-specific survival was 66.6% and the 5-year overall survival was 64.6% in patients receiving R0 thoracolaparoscopic esophagectomy. Comparison of 5-year disease-specific survival rate according to tumor-node-metastasis stage between patients receiving R0 thoracolaparoscopic esophagectomy and conventional open esophagectomy showed that there were no significant differences in survival in any stage between the two groups. Loco-regional recurrence was observed in 6 patients, distant recurrence in seven, and combined recurrence in nine after R0 thoracolaparoscopic esophagectomy. There was no significant difference in the pattern of recurrence between the two groups. CONCLUSIONS Thoracolaparoscopic esophagectomy for esophageal cancer was technically feasible and oncologically satisfactory, according to the surgical learning curve.
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Kothari KC, Nair CK, George PS, Patel MH, Gatti RC, Gurjar GC. Comparison of esophagectomy with and without thoracotomy in a low-resource tertiary care center in a developing country. Dis Esophagus 2011; 24:583-9. [PMID: 21489043 DOI: 10.1111/j.1442-2050.2011.01194.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Esophageal cancer surgery is traditionally performed by a number of open surgical approaches. Open approaches require thoracotomy and laparotomy. Developments in instrumentation and optics have allowed the use of minimally invasive approaches to esophageal cancer, which had been traditionally managed by open operation. Minimally invasive surgery (MIS) avoids thoracotomy and laparotomy and results in quicker return to normal functions and less morbidity. In this prospective study, we compared the immediate surgical and oncologic outcomes of patients who have undergone MIS with those who have had open surgery. From November 1, 2003 to March 30, 2006, 62 cases of carcinoma esophagus were operated in Surgical unit 3 (MIS unit) in the institute. Out of the 62 patients, 34 (54.8%) underwent minimally invasive esophagectomy (MIE), and the remaining 28 patients (45.2%) underwent open surgery. Both operations were done by the same team of surgeons. The groups were compared in terms of perioperative outcomes, morbidity, mortality, and adequacy of oncologic excision. The average duration for MIS was 312.35 min (60-480 min), which was more than that of open group surgery whose average duration was 261.96 min (60-360 min). This difference was found to be not significant (P < 0.110). The average blood loss was 275.74 mL (200-500 mL) in minimally invasive group compared with 312.50 (200-500 mL) in open group (P-value 0.33). Four patients (11.76%) in MIS group had been converted to open surgery. Average duration of hospitalization was 11.9 (4-24) days in MIS group compared with 12.19 (5-24) days in open group (P-value 0.282). Nine (26.47%) patients in MIS group had developed major or minor morbidity. Similarly, eight (28.57%) patients in open group had morbidity. One patient each expired in each group. The morbidity and mortality rates were not statistically significant. There were four leaks (11.76%) in MIS group and three leaks (10.71%) in open group (P-value 0.85). Regarding the extent of nodal clearance, an average number of 9.5 (0-19) nodes were removed in MIS group compared with an average of 7.26 (0-12) nodes in open group (P-value 0.05). Better visibility and magnification enabled more number of lymph nodes to be removed in MIS group. MIE is oncologically safe compared with open surgery. It has almost similar postoperative course, morbidity pattern, and duration of hospital stay as open surgery. Increased duration of procedure compared with open surgery is a disadvantage of MIS, especially in the early part of learning curve.
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Affiliation(s)
- K C Kothari
- Department of Surgical Oncology, Gujarat Cancer and Research Institute, Ahmedabad, Gujarat
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Yamasaki M, Miyata H, Fujiwara Y, Takiguchi S, Nakajima K, Kurokawa Y, Mori M, Doki Y. Minimally invasive esophagectomy for esophageal cancer: Comparative analysis of open and hand-assisted laparoscopic abdominal lymphadenectomy with gastric conduit reconstruction. J Surg Oncol 2011; 104:623-8. [DOI: 10.1002/jso.21991] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2011] [Accepted: 05/19/2011] [Indexed: 11/08/2022]
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Ninomiya I, Osugi H, Tomizawa N, Fujimura T, Kayahara M, Takamura H, Fushida S, Oyama K, Nakagawara H, Makino I, Ohta T. Learning of thoracoscopic radical esophagectomy: how can the learning curve be made short and flat? Dis Esophagus 2010; 23:618-26. [PMID: 20545973 DOI: 10.1111/j.1442-2050.2010.01075.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Attainment of proficiency in video-assisted thoracoscopic radical esophagectomy (VATS) for thoracic esophageal cancer requires much experience. We have mastered this procedure safely under the direction of an experienced surgeon. After adoption of the procedure, the educated surgeon directed induction of this surgical procedure at another institution. We evaluated the efficacy of instruction during the induction period by comparing the results at the two institutions in which VATS had been newly induced. We defined the induction period as the time from the beginning of VATS to the time when the last instruction was carried out. From January 2003 to December 2007, 53 patients were candidates for VATS at Kanazawa University (institution 1). Of these, 46 patients underwent curative VATS by a single operator. We divided this period into three parts: the induction period of VATS, post-induction period, and proficient period when the educated surgeon of institution 1 directed the procedure at Maebashi Red Cross Hospital (institution 2). At institution 1, 12 VATS were scheduled, and nine procedures (75%) (group A) including eight instructions were completed during the induction period (from January 2003 to August 2004). Thereafter, VATS was performed without instruction. In the post-induction period, nine VATS were scheduled, and eight procedures (88.8%) (group B) were completed from September 2004 to August 2005. Subsequently, 32 VATS were scheduled, and 29 procedures (90.6%) (group C) were completed during the proficient period (from September 2005 to December 2007). The surgeon at Maebashi Red Cross Hospital (institution 2) started to perform VATS under the direction of the surgeon who had been educated at institution 1 from September 2005. VATS was completed in 13 (76.4%) (group D) of 17 cases by a single surgeon including seven instructions during the induction period at institution 2 from September 2005 to December 2007. No lethal complication occurred during the induction period at both institutions. We compared the results of VATS among four groups from the two institutions. There were no differences in the background and clinicopathological features among the four groups. The number of dissected lymph nodes and amount of thoracic blood loss were similar in the four groups (35 [22-52] vs 41 [26-53] vs 32 [17-69] vs 29 [17-42] nodes, P = 0.139, and 170 [90-380] vs 275 [130-550] vs 220 [10-660] vs 210 [75-543] g, P = 0.373, respectively). There was no difference in the duration of the thoracic procedure during the induction period at the two institutions. However, the duration of the procedure was significantly shorter in the proficient period of institution 1 (group C: 266 [195-555] minutes) than in the induction period of both institutions (group A: 350 [280-448] minutes [P = 0.005] and group D: 345 [270-420] mL [P = 0.002]). There were no surgery-related deaths in any of the groups. The incidence of postoperative complications did not differ among the four groups. Thoracoscopic radical esophagectomy can be mastered quickly and safely with a flat learning curve under the direction of an experienced surgeon. The educated surgeon can instruct surgeons at another institution on how to perform thoracoscopic esophagectomy. The operation time of thoracoscopic surgery is shortened by experience.
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Affiliation(s)
- I Ninomiya
- Gastroenterologic Surgery, Department of Oncology, Division of Cancer Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa, Japan.
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The azygos vein: to resect or not? J Gastrointest Surg 2008; 12:2246-7; author reply 2248. [PMID: 18677537 DOI: 10.1007/s11605-008-0608-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2008] [Accepted: 07/08/2008] [Indexed: 01/31/2023]
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Qureshi I, Nason KS, Luketich JD. Is minimally invasive esophagectomy indicated for cancer? Expert Rev Anticancer Ther 2008; 8:1449-1460. [PMID: 18759696 DOI: 10.1586/14737140.8.9.1449] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Esophagectomy is an important component in the comprehensive treatment of esophageal cancer. The 5-year survival in patients who are treated with esophagectomy is approximately 35% compared with approximately 16% for all patients. However, esophagectomy is a complex operation with high (40-60%) morbidity and 5-20% mortality rates reported by many centers. Minimally invasive approaches to esophagectomy have been developed over the past decade; potential advantages of minimally invasive esophagectomy (MIE) include a reduced risk of perioperative morbidity and mortality with equivalent oncologic outcomes, including extent of lymphadectomy and survival. However, significant debate still exists regarding the role of MIE in the treatment of esophageal cancer, particularly given the limitations in the widespread implementation of this technically challenging operation. This review summarizes the current status of the use of minimally invasive surgery in treating esophageal cancer and seeks to answer the question of whether MIE is indicated in the treatment of esophageal cancer.
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Boone J, Schipper MEI, Bleys RLAW, Borel Rinkes IHM, van Hillegersberg R. The effect of azygos vein preservation on mediastinal lymph node harvesting in thoracic esophagolymphadenectomy. Dis Esophagus 2008; 21:226-9. [PMID: 18430103 DOI: 10.1111/j.1442-2050.2007.00760.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The standard surgical procedure for esophageal cancer is transthoracic esophagectomy with en bloc resection of the azygos vein, thoracic duct and mediastinal lymph nodes. To reduce morbidity of esophago-lymphadenectomy, minimally invasive techniques are increasingly being applied. In (robot-assisted) thoracoscopic esophagolymphadenectomy, the azygos vein is generally left in place, as the scopic ligation of the numerous intercostal veins is technically difficult and time-consuming. This could affect the extent of mediastinal lymph node dissection. Therefore, in this study, the effect of azygos vein preservation during thoracic esophagectomy on mediastinal lymph node harvesting was assessed. In 15 human cadavers, a right-sided thoracotomy was performed, followed by esophagectomy with mediastinal lymph node dissection after ligation of the azygos arch (representing the situation in robot-assisted thoracoscopic esophagolymphadenectomy). Subsequently, the remaining azygos vein with surrounding tissue was resected. The number of lymph nodes in both specimens was determined. A mean of 17.3 (95% Poisson CI 15.3-19.6) lymph nodes was dissected en bloc with the esophagus, and 0.67 (95% Poisson CI 0.32-1.23) around the separately resected azygos vein. The additional azygos vein resection did not add to the number of lymph nodes dissected in 60% (9/15) of cadavers. In conclusion, the extent of mediastinal lymph node dissection was not substantially affected by leaving the azygos vein in situ . Time-sparing azygos vein preservation in (robot-assisted) thoracoscopic esophagolymphadenectomy may therefore be considered justified.
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Affiliation(s)
- J Boone
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
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Results of video-assisted thoracoscopic surgery for esophageal cancer during the induction period. Gen Thorac Cardiovasc Surg 2008; 56:119-25. [PMID: 18340511 DOI: 10.1007/s11748-007-0196-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2006] [Accepted: 10/23/2007] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The attainment of proficiency in thoracoscopic radical esophagectomy for thoracic esophageal cancer requires much experience. We aimed to master this procedure safely with our regular surgical team members under the direction of an experienced surgeon. We evaluated the efficacy of instruction during the induction period and the significance of our results. METHODS We compared the results of 12 thoracic esophageal cancer patients who underwent thoracoscopic radical esophagectomy in our institution (group A) to those of the initial 17 patients who underwent the same operation at the director's institution (group B). RESULTS We were able to perform complete thoracoscopic radical esophagectomies without any direction after experiencing 10 cases that were performed under adequate direction. The number of dissected lymph nodes and the duration of the procedure were similar in the two groups: 34 (22-53) vs. 26 (9-55) nodes, P = 0.23; and 327.5 (230-455) vs. 315 (190-515) min, P = 0.947, respectively. The amount of thoracic blood loss was significantly less in group A than in group B: 185 (110-380) g vs. 440 (110-2360) g, P = 0.0035. Postoperative pneumonia and atelectasis were observed in 25.0% of group A patients and in 17.6% of group B patients. The incidence of recurrent nerve palsy was 30.7% in group A and 11.7% in group B, but there was no statistically significant difference (P = 0.19). The morbidity rates in group A and group B were 41.6% and 29.4%, respectively (P = 0.694). CONCLUSION Thoracoscopic radical esophagectomy can be mastered relatively quickly and safely under the direction of an experienced surgeon and a regular surgical team.
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Masuda M, Wakasaki T, Tamae A, Komune N, Hara T, Uchiyama A. [Mediastinal dissection for patients with differentiated thyroid carcinoma: sternotomy vs VATS (video-assisted thoracoscopic surgery)]. NIHON JIBIINKOKA GAKKAI KAIHO 2007; 110:758-761. [PMID: 18186293 DOI: 10.3950/jibiinkoka.110.758] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
We here present two cases of differentiated thyroid carcinoma with mediastinal lymph nodes metastases below level 106 according to the classification of the Guidelines for the Clinical and Pathologic Studies for Carcinoma of the Esophagus (9 th edition) edited by the Japanese Society for Esophageal Diseases. For Case 1, we adopted a conventional anterior approach with resection of the right half of the manubrium and sternum to the level of the second intercostal space and medial half of the right clavicule. Case 2 underwent a combined cervical approach and video-assisted thoracoscopic surgery (VATS). In Case 1, the lymph nodes around the subclavian vein, 105R, 106pre and 106recR were successfully dissected under clear view. However, through this case, the difficulty in the dissection of 106tbR was recognized, because it is quite challenging to gain an adequate surgical view in this small compartment by this approach. Conversely, in Case 2, in which mediastinal lymph nodes extended to level 107, the lymph nodes were relatively easily dissected by VATS under excellent surgical views of 106tbR and 107. Although VATS is associated with difficulty in en bloc resection, requirements of a thoracotomy, changes of body position and an intubation tube during the surgery, this approach is of great use for the dissection of 106tbR and 107.
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Affiliation(s)
- Muneyuki Masuda
- Department of Otolaryngology and Head and Neck Surgery, Kyushu Koseinennkin Hospital, Kitakyusyu
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Yoshida T, Usui S, Inoue H, Kudo SE. The management of esophageal cancer with situs inversus totalis by simultaneous hand-assisted laparoscopic gastric mobilization and thoracoscopic esophagectomy. J Laparoendosc Adv Surg Tech A 2005; 14:384-9. [PMID: 15684787 DOI: 10.1089/lap.2004.14.384] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Situs inversus is a rare disorder. We present a case of esophageal cancer with situs inversus totalis, which was successfully managed by laparoscopic gastric mobilization and thoracoscopic esophagectomy. A 57-year-old man presented to our hospital with intermittent epigastric and retrosternal pains. X-ray and computed tomography demonstrated situs inversus totalis. Upper gastrointestinal endoscopy and barium swallow showed esophageal cancer of the lower thoracic esophagus. After neoadjuvant chemotherapy, he underwent surgical intervention. Under general anesthesia, laparoscopic gastric mobilization using hand-assisted laparoscopic surgery technique was performed. The locations of the port sites were all the mirror image of the regular fashion, and the right hand of the surgeon was inserted into the peritoneal cavity. Reconstruction of the digestive tract using a gastric tube via the retrosternal route was then achieved. Finally, thoracoscopic esophagectomy with the patient in the right decubitus position was successfully completed. Postoperative recovery was uneventful.
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Affiliation(s)
- Tatsuya Yoshida
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan.
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Abstract
Transthoracic surgery for oesophageal cancer is associated with a high incidence of respiratory complications. Recent development of minimally invasive oesophagectomy by the use of video-assisted thoracoscopic approach may have a potential to minimize morbidity and mortality. While results from earlier series were equivocal, recent reports have shown an encouraging trend. This article serves to review the recent literature evidence in relation to the surgical approach, safety, efficacy and potential problems of such a highly complex minimally invasive operation.
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Affiliation(s)
- Enders K W Ng
- Upper Gastrointestinal Surgical Division, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, SAR, China.
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Taguchi S, Osugi H, Higashino M, Tokuhara T, Takada N, Takemura M, Lee S, Kinoshita H. Comparison of three-field esophagectomy for esophageal cancer incorporating open or thoracoscopic thoracotomy. Surg Endosc 2003; 17:1445-50. [PMID: 12811660 DOI: 10.1007/s00464-002-9232-9] [Citation(s) in RCA: 79] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2002] [Accepted: 01/20/2003] [Indexed: 12/13/2022]
Abstract
BACKGROUND Thoracoscopic esophagectomy for esophageal cancer has been performed as an alternative to open surgery to reduce surgical trauma. However, its effect on pulmonary function, exercise tolerability, and quality of life is unknown. METHODS Fifty-one patients with esophageal cancer underwent thoracic esophagectomy with radical lymphadenectomy by posterolateral thoracotomy (29 cases) or thoracoscopic surgery (22 cases). Patients performed spirometry and exercise tolerance testing and completed a quality-of-life questionnaire before and 3 months after surgery. RESULTS Pre-to-postoperative change in vital capacity was 74.3 +/- 10.6% in the thoracotomy group and 84.9 +/- 10.4% in the thoracoscopy group (p = 0.021). Maximum oxygen uptake was similar, but dyspnea was the more common factor limiting exercise tolerance postoperatively in the thoracotomy group. Change in pre-to-postoperative performance status was 1.20 +/- 0.62 in the thoracotomy group and 0.55 +/- 0.51 in the thoracoscopy group (p = 0.0003). CONCLUSIONS Thoracoscopic esophagectomy for esophageal cancer has better preservation of pulmonary function and quality-of-life.
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Affiliation(s)
- S Taguchi
- Department of Gastroenterological Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan.
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