Original Article
Anastomosis in minimally invasive Ivor lewis esophagectomy via two ports provides equivalent perioperative outcomes to open Zhao Y, Jiao W, Zhao J, Wang X, Luo Y, Wang Y Department of Thoracic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China Correspondence to: Dr. Wenjie Jiao, E-mail: [email protected]
Abstract
OBJECTIVE: Minimally invasive esophagectomy (MIE) is becoming a selective treatment of esophageal cancer; however, it’s a complex and
technically demanding surgical operation. MIE can be performed in high volume centers in a variety of ways using different techniques. Transthoracic staplers have traditionally been used in open transthoracic Ivor Lewis Esophagectomy (ILE) with good success. An investigation of the safety and utility of transthoracic stapler via two ports on thorax for esophageal anastomosis in minimally invasive ILE is reviewed. METHODS: Patients of esophageal cancer were selected between November 2012 and July 2014. All the patients received minimally invasive (MIE) or open transthoracic ILE. Transthoracic stapler for MIE anastomosis was performed through the major port located at subaxillary region. Patients’ demographics, indications for esophagectomy, perioperative treatments, intraoperative data, postoperative complications, hospital length of stay, 7 and in-hospital mortality were evaluated. RESULTS: Totally, 63 consecutive patients underwent MIE or ILE. All the patients were Han with a mean age of 60 years (52–74). The indication of surgery is esophageal cancer, and squamous cell carcinoma was defined by pathologist before operation. None of the patients had neoadjuvant chemotherapy or radiation. All the MIE patients were no conversions to open thoracotomy or laparotomy. Mean operative time was 4.5 h. One patient (3.03%) suffered postoperative pneumonia, no leak from the gastric conduit staple line or esophageal anastomoses, no postoperative complication required surgical intervention was observed. The median hospital length of stay was 13 days (range 7–18). There were no in-hospital mortalities. CONCLUSIONS: In our study, transthoracic stapler through the major port at subaxillary seems technically feasible and safe for minimally invasive ILE with comparable morbidity and oncologic data to open. Key Words: Esophageal cancer, minimally invasive esophagectomy, intrathoracic anastomosis.
Introduction
Methods
Esophageal cancer is one of the most common causes of cancers worldwide. [1] Surgical resection of the esophagus remains the primary treatment for this disease. Esophagectomy is a complex and technically demanding operation that is often associated with high morbidity and mortality even performed at an experienced center. There were surgical evolutionary changes at esophagectomy in attempts to improve early postoperative outcomes. [2] In many studies, minimally invasive approaches seem to reduce postoperative complications while comparing with the open series with regard to morbidity, mortality, and oncologic outcomes.[3-7] Minimally invasive esophagectomy (MIE) has been introduced to surgeons and first reported by Cuschieri et al. in 1992, which has become an accepted approach in recent years. [8] The surgical procedure has a trend toward the minimally invasive techniques with the hope of lessening the morbidity and mortality. Ivor Lewis Esophagectomy (ILE) is a widely accepted approach for early or locally advanced esophageal carcinoma, which is combined with thoracic and abdominal approaches. laparoscopic-thoracoscopic ILE is one of the minimally invasive techniques different from the laparoscopic transhiatal, laparoscopic-thoracoscopic 3-hole (McKeown).[9,10] Owing to the technically demanding nature of this procedure, access to MIE has been limited to select specialized centers.[11,12] Although technically demanding and associated with a significant operator learning curve, totally MIE has been shown to be a viable option for esophageal resection while reducing blood loss, length of hospital stay.[13]
All consecutive patients underwent MIE or ILE for a preoperative diagnosis of esophagus cancer. We identified 33 patients who underwent an MIE Ivor Lewis and 30 who underwent open ILE at The Affiliated Hospital of Qingdao University between November 2012 and July 2014.
Access this article online Quick Response Code:
Website: www.indianjcancer.com DOI: 10.4103/0019-509X.151996
Indian Journal of Cancer | Volume 51 | Special Issue 1-2014
Patients demographics, included age, sex, history of smoking, completeness of resection, histologic diagnosis, pathologic stage, the operative data, length of hospital stay, and perioperative complications, perioperative chemotherapy and radiation, indications for surgery were assessed. Any patient who died in the hospital stay postoperatively or within 30 days was considered as perioperative mortality. Postoperative management included an intraoperatively placed thoracostomy tube and nasogastric tube; both remaining in place until a swallow study demonstrated no evidence of leak 7 days postoperation. The operative data such as length of surgery (intrathoracic and abdominal), blood loss, intraoperative complications and conversion to open surgery. Length of surgery was determined by the time of incision made to close. Pathologic data included the completeness of resection, final tumor stage by pathologic evaluation, and the number of lymph nodes identified in resection specimens. Thoracoscopic esophageal resection and mobilization with en bloc lymphadenectomy of paraesophageal, subcarinal lymph nodes were performed through the right side of the chest. Postoperative information included hospital length of stay, postoperative complications, anastomotic leak rate, in-hospital mortality. Anastomotic leak was defined as clearly identifiable contrast extravasation at the esophagogastric anastomosis on radiographic imaging. Surgical technique for minimally invasive esophagectomy Laparoscopic portion
The patient is positioned supine. The surgeon stands on the patient’s right, the assistant on the left. Five abdominal trocars (two 5 mm, two 10 mm and one 12 mm) are then e25
Zhao, et al.: MIE via two ports provides equivalent perioperative outcomes
placed. A transumbilical approach is used for insertion of the 10 mm trocar port for camera. The 10 and 12 mm ports are placed two sides of the flanks for operation and tissue grasped. The remaining 5 mm ports are placed in the right lateral subcostal position and midaxillary line position. Carbon dioxide insufflation is used for pneumoperitoneum to a pressure of 15 mm Hg. A thorough staging procedure is then performed to evaluate for occult metastatic disease. If satisfactory, we then proceed with the gastric mobilization. The greater curvature of the stomach is first mobilized by dividing the gastrocolic omentum while carefully preserving the right gastroepiploic arcade followed by division of the short gastric vessels. The stomach is completely mobilized down to the origin of the right gastroepiploic arterial system. Adequate mobilization is required for the pylorus can be gently lifted up to the level of the right crus in a tension-free manner. The lesser curve was then mobilized. The gastrohepatic ligament is divided, and the right crura of the diaphragm are identified. At this point, the left gastric artery was divided by hemolocks. The short gastrics are divided, and the phrenoesophageal ligament was incised. The right and left cruras of the diaphragm are dissected. Thoracoscopic portion
The patient was placed in the left lateral decubitus position with a flexion of the operating table at the chest level to allow maximal expansion. Two ports sites are arranged as followed: 4 cm in the 4th intercostal space on the median axillary line for utility, with a mastoid retractor, kept the incision open. 1 cm in the 7th intercostal space on posterior axillary line for observation. The main operating procedures followed are completed through the major port. The division of the azygos vein followed by the esophagus was dissected free circumferentially; the length of dissection was above the level of the azygos vein or more proximal to ensure all tumor tissue was resected even to the thoracic inlet. The esophagus was then carefully separated from the trachea, and the lymph nodes around the esophagus and subcarinal was dissected and brought with the specimen. Aortoesophageal branches are clipped, and the esophagus and periesophageal tissue were dissected away from the aorta. By extracting esophageal specimen from the main port, a silk suture running around the seromuscular layer. The proximal esophagus could be cut in a half circumference for placement of a single circular stapler endo-GIA anvil. Then, the remaining part of proximal esophagus was cut for total separation. The string was then tensed to fix the anvil [Figure 1]. The specimen was free to pull up into the chest, and the end of esophagus would be closed to reduce any pollution by the leakage. During this step, care was taken to maintain alignment so that subsequent retrieval of the specimen through the hiatus into the chest does not lead to any rotation. One instrument was used to grasp the lower esophagus, and another was used to stabilize the cardia. A port was made to allow the stapler that passed through the major port site e26
into the thorax and inserted into the stomach. The anvil at the esophageal stump was stabilized while the anastomoses were completing [Figure 2]. Transthoracic anastomoses were done followed by the gastric conduit constructed using multiple fires of the stapler (60 mm–4.8 mm) through the observation port, from the lesser curve antral area, heading toward the cardia. Statistical analysis
All collected data were tested for normality and presented as mean (standard deviation) or median. Univariate analysis of continuous variables was done using the two-tailed, unpaired t-test. Statistical analysis was performed using IBM SPSS (version 19.0, 2010, IBM corp, USA) Statistics 19.0. Results Between November 2012 and July 2014. Totally, 63 patients in this series had tumors in middle one-third or distal of the esophagus. Presented as high as 26 cm. Totally, 33 patients had MIE, and intrathoracic anastomoses were able to be performed in all cases through the subaxillary major port. While, 30 underwent ILE [Table 1]. All the patients were Han with a mean age of 60 years (52–74). The indication of surgery was esophageal cancer and squamous cell carcinoma defined by pathologist before operation. None of the patients had neoadjuvant
a
b
Figure 1: The anvil is placed through the half cut of esophagus (a) and then the string is tensed (b)
Table 1: Patient demographics and preoperative characteristics N Age, mean±SD, year Male, n (%) History of smoking, n (%) Hypertension, n (%) Diabetes mellitus, n (%) Coronary artery disease, n (%) Chest surgery history, n (%) COPD, n (%) Pathologic stage, n (%) Stage 0 Stage I Stage II Stage III Neoadjuvant therapy, n (%)
MIE
ILE
P
33 57.85±8.14 29 (87.879) 28 (84.848) 9 (27.273) 3 (9.091) 3 (9.091) 1 (3.030) 7 (21.212)
30 60.03±6.03 28 (93.33) 23 (76.667) 9 (30) 3 (10) 3 (10) 1 (3.333) 7 (23.333)
0.222 0.465 0.413 0.812 0.903 0.903 0.946 0.841
0 (0) 11 (33.333) 19 (57.576) 3 (9.091)
0 (0) 9 (30) 18 (60) 3 (10)
0 (0)
0 (0)
0.777
MIE=Minimally invasive esophagectomy; ILE=Ivor Lewis esophagectomy; SD=Standard deviation; COPD=Chronic obstructive pulmonary disease
Indian Journal of Cancer | Volume 51 | Special Issue 1-2014
Zhao, et al.: MIE via two ports provides equivalent perioperative outcomes
Table 2: The operative data
c
d
Figure 2: A port is made around cardia to allow the stapler insert into stomach (c), and transthoracic anastomoses are done (d)
chemotherapy and radiation. There were no conversions to open thoracotomy or laparotomy for MIE. Patients who underwent MIE had less blood loss than the ILE group. Intrathoracic operative time and anastomosis time were longer for patients who underwent MIE compared with those undergoing ILE respectively (P < 0.001). Median lymph node harvest was higher in the MIE group compared with the ILE group (P = 0.001) [Table 2]. The overall hospital stay did not differ between the 2 groups. The pain degree in both groups were evaluated in the postoperative period. The MIE group had apparently advantage in pain degree score. One patient in the MIE group had postoperative pneumonia while 6 in the ILE group. Clinical staging was not statistically different between the two groups. There were no in-hospital mortalities in MIE group, and the MIE group had lower morbidity and mortality rates than the ILE group [Table 3]. Discussion Minimally invasive esophagectomy has become increasingly prevalent with numerous reports after its first description in 1992, and the experience for minimally invasive approach to esophageal resection was growing in the past decades.[12,14] And for many investigations, the safety of this kind of technique has been proved. In some series, the in hospital and oncologic outcomes are both equivalent to that of the open operation. [15-17] This operation could be taken in different ways, as laparoscopic-thoracoscopic ILE, laparoscopic transhiatal and laparoscopic-thoracoscopic 3-hole (McKeown).[16,18] The Ivor Lewis technique was commonly adopted in our center. The major advantages of this technique are tensionfree anastomosis between the remnant esophagus and the gastric conduit. The MIE has evolved considerably as it allows for improved visualization of mediastinal structures, decreased frequency of recurrent laryngeal nerve injuries. However, there are technical challenges of transthoracic anvil placement.[19] Transoral anvil placement in Ivor Lewis technique is one of the major procedures in some centers. But the head of the patient should be repositioned, and the endotracheal tube may need to be deflated to achieve passage into the stump.[20] We chose a 25-mm stapler for utility of placement through the subaxillary major port. And the stump of esophagus was not cut out of the entire circumference before the placement. The stapler used in our study was in a normal length which was adequate for anastomosis through the major port located at the 4th intercostal space. Indian Journal of Cancer | Volume 51 | Special Issue 1-2014
MIE
ILE
P
Operating time Abdomen portion, median, min Chest portion, median, min Anastomosis, median, min Estimated blood loss, median, ml Intraoperative transfusions, n (%) Lymph nodes harvested, median Positive lymph nodes, median
45 56 45 270 1 (3.03) 12 4
47 60.5 38 275 2 (6.67) 10 5
0.201 0.001 0.000 0.961 0.602 0.001 0.387
R0 resection, n (%)
33 (100)
30 (100)
0.294
MIE=Minimally invasive esophagectomy; ILE=Ivor Lewis esophagectomy
Table 3: Perioperative parameters and complications ICU length of stay, median, day Hospital length of stay, median, day Mortality, n (%) Atrial fibrillation, n (%) Respiratory failure or ARDS, n (%) Pneumonia, n (%) Chylothorax, n (%) Anastomotic leak, n (%) Pulmonary embolus, n (%)
MIE
ILE
P
0.000 13 0 (0) 2 (6.06) 0 (0) 1 (3.03) 0 (0) 0 (0)
0.000 13 0 (0) 3 (10) 1 (3.3) 6 (20) 1 (3.3) 1 (3.3)
0.577 0.768 1.000 1.000 1.000 0.034 0.294 0.294
0 (0)
0 (0)
1.000
All cardiac and pulmonary complications were calculated as the number of patients that experienced any type of cardiac or pulmonary complication divided by the total number of patients. MIE=Minimally invasive esophagectomy; ILE=Ivor Lewis esophagectomy; ARDS=Acute respiratory distress syndrome; ICU=Intensive care unit
The morbidity of this kind of procedure was acceptable and similar to or better than most published series of open esophagectomy. [21-24] In our series, MIE and ILE, patients who underwent MIE represents a trend to have a fast recovery with a shorten median hospital stay and a lower complication rates. Several recent reports of MIE have demonstrated the trend to decrease the rates of pulmonary complications, and our report supports the finding. [14,16,21,22,25,26] A MIE may lead to fewer early perioperative complications, when compared with an ILE. As fewer reports of complications with MIE method because of the relative novelty of this technique, we need more evidence to support the advantage. Conclusion The staplers for esophagogastric anastomosis in MIE could be used in viable ways. The anastomosis using the transthoracic stapler through the subaxillary port in MIE with comparable morbidity and oncologic data with that of open. Two ports minimal invasive surgery could be utilized in esophagectomy with acceptable safety and feasibility. References 1. Connors RC, Reuben BC, Neumayer LA, Bull DA. Comparing outcomes after transthoracic and transhiatal esophagectomy: A 5-year prospective cohort of 17,395 patients. J Am Coll Surg 2007;205:735-40. 2. Mardin WA, Palmes D, Bruewer M. Current concepts in the management of leakages after esophagectomy. Thorac Cancer 2012;3:117-24. 3. Safranek PM, Cubitt J, Booth MI, Dehn TC. Review of open and minimal access approaches to oesophagectomy for cancer. Br J Surg 2010;97:1845-53. 4. Atkins BZ, Shah AS, Hutcheson KA, Mangum JH, Pappas TN, Harpole DH Jr, e27
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5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18.
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et al. Reducing hospital morbidity and mortality following esophagectomy. Ann Thorac Surg 2004;78:1170-6. Bailey SH, Bull DA, Harpole DH, Rentz JJ, Neumayer LA, Pappas TN, et al. Outcomes after esophagectomy: A ten-year prospective cohort. Ann Thorac Surg 2003;75:217-22. Jianjun Q, Yin L, Wenqun X, Ming Y, Qingfeng J. Fast track program for esophagectomy patients. Thorac Cancer 2012;3:55-9. Wu X, He J, Jiang H, Song X, Tang X, Shen J, et al. Fully thoracoscopic versus conventional open resection for esophageal carcinoma: A perioperative comparison. Thorac Cancer 2013;4:369-72. Cuschieri A, Shimi S, Banting S. Endoscopic oesophagectomy through a right thoracoscopic approach. J R Coll Surg Edinb 1992;37:7-11. Guven H, Karahan SR, Koc B, Erdogu V, Ozsoy A, Adas GT, et al. Minimally invasive 3-field esophagectomy with cervical single-port access. Surg Laparosc Endosc Percutan Tech 2014;24:e151-4. Nguyen NT, Follette DM, Lemoine PH, Roberts PF, Goodnight JE Jr. Minimally invasive Ivor Lewis esophagectomy. Ann Thorac Surg 2001;72:593-6. Tapias LF, Morse CR. Minimally invasive Ivor Lewis esophagectomy: Description of a learning curve. J Am Coll Surg 2014;218:1130-40. Pennathur A, Awais O, Luketich JD. Technique of minimally invasive Ivor Lewis esophagectomy. Ann Thorac Surg 2010;89:S2159-62. Xie MR, Liu CQ, Guo MF, Mei XY, Sun XH, Xu MQ. Short-term outcomes of minimally invasive Ivor-Lewis esophagectomy for esophageal cancer. Ann Thorac Surg 2014;97:1721-7. Shah R, Jobe BA. Open versus minimally invasive esophagectomy: What is the best approach? Minimally invasive esophagectomy. J Gastrointest Surg 2011;15:1503-5. Levy RM, Wizorek J, Shende M, Luketich JD. Laparoscopic and thoracoscopic esophagectomy. Adv Surg 2010;44:101-16. Hoppo T, Jobe BA, Hunter JG. Minimally invasive esophagectomy: The evolution and technique of minimally invasive surgery for esophageal cancer. World J Surg 2011;35:1454-63. Biere SS, van der Peet DL, Cuesta MA. Minimally invasive esophagectomy. Ann Surg 2010;251:178-9. Maas K, Biere S, Van der Peet D, Cuesta M. Minimally invasive
19.
20.
21. 22. 23. 24. 25. 26.
esophagectomy: Current status and future direction. Surg Endosc 2012;26:1794. Maas KW, Biere SS, Scheepers JJ, Gisbertz SS, Turrado Rodriguez VT, van der Peet DL, et al. Minimally invasive intrathoracic anastomosis after Ivor Lewis esophagectomy for cancer: A review of transoral or transthoracic use of staplers. Surg Endosc 2012;26:1795-802. Ichikawa H, Miyata G, Miyazaki S, Onodera K, Kamei T, Hoshida T, et al. Esophagectomy using a thoracoscopic approach with an open laparotomic or hand-assisted laparoscopic abdominal stage for esophageal cancer: Analysis of survival and prognostic factors in 315 patients. Ann Surg 2013;257:873-85. Zingg U, McQuinn A, DiValentino D, Esterman AJ, Bessell JR, Thompson SK, et al. Minimally invasive versus open esophagectomy for patients with esophageal cancer. Ann Thorac Surg 2009;87:911-9. Predina JD, Morse CR. Minimally invasive esophagectomy and its current role in esophageal cancer. Minerva Chir 2014;69:363-70. Luketich JD, Pennathur A, Awais O, Levy RM, Keeley S, Shende M, et al. Outcomes after minimally invasive esophagectomy: Review of over 1000 patients. Ann Surg 2012;256:95-103. Martin DJ, Bessell JR, Chew A, Watson DI. Thoracoscopic and laparoscopic esophagectomy: Initial experience and outcomes. Surg Endosc 2005;19:1597-601. Ai B, Zhang Z, Liao Y. Laparoscopic and thoracoscopic esophagectomy with intrathoracic anastomosis for middle or lower esophageal carcinoma. J Thorac Dis 2014;6:1354-7. Watanabe M, Baba Y, Nagai Y, Baba H. Minimally invasive esophagectomy for esophageal cancer: An updated review. Surg Today 2013;43:237-44.
How to cite this article: Zhao Y, Jiao W, Zhao J, Wang X, Luo Y, Wang Y. Anastomosis in minimally invasive Ivor lewis esophagectomy via two ports provides equivalent perioperative outcomes to open. Indian J Cancer 2014;51:25-8 Source of Support: Nil. Conflict of Interest: None declared.
Indian Journal of Cancer | Volume 51 | Special Issue 1-2014
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Anastomosis in minimally invasive Ivor lewis esophagectomy via two ports provides equivalent perioperative outcomes to open Zhao Y, Jiao W, Zhao J, Wang X, Luo Y, Wang Y Department of Thoracic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China Correspondence to: Dr. Wenjie Jiao, E-mail: [email protected]
Abstract
OBJECTIVE: Minimally invasive esophagectomy (MIE) is becoming a selective treatment of esophageal cancer; however, it’s a complex and
technically demanding surgical operation. MIE can be performed in high volume centers in a variety of ways using different techniques. Transthoracic staplers have traditionally been used in open transthoracic Ivor Lewis Esophagectomy (ILE) with good success. An investigation of the safety and utility of transthoracic stapler via two ports on thorax for esophageal anastomosis in minimally invasive ILE is reviewed. METHODS: Patients of esophageal cancer were selected between November 2012 and July 2014. All the patients received minimally invasive (MIE) or open transthoracic ILE. Transthoracic stapler for MIE anastomosis was performed through the major port located at subaxillary region. Patients’ demographics, indications for esophagectomy, perioperative treatments, intraoperative data, postoperative complications, hospital length of stay, 7 and in-hospital mortality were evaluated. RESULTS: Totally, 63 consecutive patients underwent MIE or ILE. All the patients were Han with a mean age of 60 years (52–74). The indication of surgery is esophageal cancer, and squamous cell carcinoma was defined by pathologist before operation. None of the patients had neoadjuvant chemotherapy or radiation. All the MIE patients were no conversions to open thoracotomy or laparotomy. Mean operative time was 4.5 h. One patient (3.03%) suffered postoperative pneumonia, no leak from the gastric conduit staple line or esophageal anastomoses, no postoperative complication required surgical intervention was observed. The median hospital length of stay was 13 days (range 7–18). There were no in-hospital mortalities. CONCLUSIONS: In our study, transthoracic stapler through the major port at subaxillary seems technically feasible and safe for minimally invasive ILE with comparable morbidity and oncologic data to open. Key Words: Esophageal cancer, minimally invasive esophagectomy, intrathoracic anastomosis.
Introduction
Methods
Esophageal cancer is one of the most common causes of cancers worldwide. [1] Surgical resection of the esophagus remains the primary treatment for this disease. Esophagectomy is a complex and technically demanding operation that is often associated with high morbidity and mortality even performed at an experienced center. There were surgical evolutionary changes at esophagectomy in attempts to improve early postoperative outcomes. [2] In many studies, minimally invasive approaches seem to reduce postoperative complications while comparing with the open series with regard to morbidity, mortality, and oncologic outcomes.[3-7] Minimally invasive esophagectomy (MIE) has been introduced to surgeons and first reported by Cuschieri et al. in 1992, which has become an accepted approach in recent years. [8] The surgical procedure has a trend toward the minimally invasive techniques with the hope of lessening the morbidity and mortality. Ivor Lewis Esophagectomy (ILE) is a widely accepted approach for early or locally advanced esophageal carcinoma, which is combined with thoracic and abdominal approaches. laparoscopic-thoracoscopic ILE is one of the minimally invasive techniques different from the laparoscopic transhiatal, laparoscopic-thoracoscopic 3-hole (McKeown).[9,10] Owing to the technically demanding nature of this procedure, access to MIE has been limited to select specialized centers.[11,12] Although technically demanding and associated with a significant operator learning curve, totally MIE has been shown to be a viable option for esophageal resection while reducing blood loss, length of hospital stay.[13]
All consecutive patients underwent MIE or ILE for a preoperative diagnosis of esophagus cancer. We identified 33 patients who underwent an MIE Ivor Lewis and 30 who underwent open ILE at The Affiliated Hospital of Qingdao University between November 2012 and July 2014.
Access this article online Quick Response Code:
Website: www.indianjcancer.com DOI: 10.4103/0019-509X.151996
Indian Journal of Cancer | Volume 51 | Special Issue 1-2014
Patients demographics, included age, sex, history of smoking, completeness of resection, histologic diagnosis, pathologic stage, the operative data, length of hospital stay, and perioperative complications, perioperative chemotherapy and radiation, indications for surgery were assessed. Any patient who died in the hospital stay postoperatively or within 30 days was considered as perioperative mortality. Postoperative management included an intraoperatively placed thoracostomy tube and nasogastric tube; both remaining in place until a swallow study demonstrated no evidence of leak 7 days postoperation. The operative data such as length of surgery (intrathoracic and abdominal), blood loss, intraoperative complications and conversion to open surgery. Length of surgery was determined by the time of incision made to close. Pathologic data included the completeness of resection, final tumor stage by pathologic evaluation, and the number of lymph nodes identified in resection specimens. Thoracoscopic esophageal resection and mobilization with en bloc lymphadenectomy of paraesophageal, subcarinal lymph nodes were performed through the right side of the chest. Postoperative information included hospital length of stay, postoperative complications, anastomotic leak rate, in-hospital mortality. Anastomotic leak was defined as clearly identifiable contrast extravasation at the esophagogastric anastomosis on radiographic imaging. Surgical technique for minimally invasive esophagectomy Laparoscopic portion
The patient is positioned supine. The surgeon stands on the patient’s right, the assistant on the left. Five abdominal trocars (two 5 mm, two 10 mm and one 12 mm) are then e25
Zhao, et al.: MIE via two ports provides equivalent perioperative outcomes
placed. A transumbilical approach is used for insertion of the 10 mm trocar port for camera. The 10 and 12 mm ports are placed two sides of the flanks for operation and tissue grasped. The remaining 5 mm ports are placed in the right lateral subcostal position and midaxillary line position. Carbon dioxide insufflation is used for pneumoperitoneum to a pressure of 15 mm Hg. A thorough staging procedure is then performed to evaluate for occult metastatic disease. If satisfactory, we then proceed with the gastric mobilization. The greater curvature of the stomach is first mobilized by dividing the gastrocolic omentum while carefully preserving the right gastroepiploic arcade followed by division of the short gastric vessels. The stomach is completely mobilized down to the origin of the right gastroepiploic arterial system. Adequate mobilization is required for the pylorus can be gently lifted up to the level of the right crus in a tension-free manner. The lesser curve was then mobilized. The gastrohepatic ligament is divided, and the right crura of the diaphragm are identified. At this point, the left gastric artery was divided by hemolocks. The short gastrics are divided, and the phrenoesophageal ligament was incised. The right and left cruras of the diaphragm are dissected. Thoracoscopic portion
The patient was placed in the left lateral decubitus position with a flexion of the operating table at the chest level to allow maximal expansion. Two ports sites are arranged as followed: 4 cm in the 4th intercostal space on the median axillary line for utility, with a mastoid retractor, kept the incision open. 1 cm in the 7th intercostal space on posterior axillary line for observation. The main operating procedures followed are completed through the major port. The division of the azygos vein followed by the esophagus was dissected free circumferentially; the length of dissection was above the level of the azygos vein or more proximal to ensure all tumor tissue was resected even to the thoracic inlet. The esophagus was then carefully separated from the trachea, and the lymph nodes around the esophagus and subcarinal was dissected and brought with the specimen. Aortoesophageal branches are clipped, and the esophagus and periesophageal tissue were dissected away from the aorta. By extracting esophageal specimen from the main port, a silk suture running around the seromuscular layer. The proximal esophagus could be cut in a half circumference for placement of a single circular stapler endo-GIA anvil. Then, the remaining part of proximal esophagus was cut for total separation. The string was then tensed to fix the anvil [Figure 1]. The specimen was free to pull up into the chest, and the end of esophagus would be closed to reduce any pollution by the leakage. During this step, care was taken to maintain alignment so that subsequent retrieval of the specimen through the hiatus into the chest does not lead to any rotation. One instrument was used to grasp the lower esophagus, and another was used to stabilize the cardia. A port was made to allow the stapler that passed through the major port site e26
into the thorax and inserted into the stomach. The anvil at the esophageal stump was stabilized while the anastomoses were completing [Figure 2]. Transthoracic anastomoses were done followed by the gastric conduit constructed using multiple fires of the stapler (60 mm–4.8 mm) through the observation port, from the lesser curve antral area, heading toward the cardia. Statistical analysis
All collected data were tested for normality and presented as mean (standard deviation) or median. Univariate analysis of continuous variables was done using the two-tailed, unpaired t-test. Statistical analysis was performed using IBM SPSS (version 19.0, 2010, IBM corp, USA) Statistics 19.0. Results Between November 2012 and July 2014. Totally, 63 patients in this series had tumors in middle one-third or distal of the esophagus. Presented as high as 26 cm. Totally, 33 patients had MIE, and intrathoracic anastomoses were able to be performed in all cases through the subaxillary major port. While, 30 underwent ILE [Table 1]. All the patients were Han with a mean age of 60 years (52–74). The indication of surgery was esophageal cancer and squamous cell carcinoma defined by pathologist before operation. None of the patients had neoadjuvant
a
b
Figure 1: The anvil is placed through the half cut of esophagus (a) and then the string is tensed (b)
Table 1: Patient demographics and preoperative characteristics N Age, mean±SD, year Male, n (%) History of smoking, n (%) Hypertension, n (%) Diabetes mellitus, n (%) Coronary artery disease, n (%) Chest surgery history, n (%) COPD, n (%) Pathologic stage, n (%) Stage 0 Stage I Stage II Stage III Neoadjuvant therapy, n (%)
MIE
ILE
P
33 57.85±8.14 29 (87.879) 28 (84.848) 9 (27.273) 3 (9.091) 3 (9.091) 1 (3.030) 7 (21.212)
30 60.03±6.03 28 (93.33) 23 (76.667) 9 (30) 3 (10) 3 (10) 1 (3.333) 7 (23.333)
0.222 0.465 0.413 0.812 0.903 0.903 0.946 0.841
0 (0) 11 (33.333) 19 (57.576) 3 (9.091)
0 (0) 9 (30) 18 (60) 3 (10)
0 (0)
0 (0)
0.777
MIE=Minimally invasive esophagectomy; ILE=Ivor Lewis esophagectomy; SD=Standard deviation; COPD=Chronic obstructive pulmonary disease
Indian Journal of Cancer | Volume 51 | Special Issue 1-2014
Zhao, et al.: MIE via two ports provides equivalent perioperative outcomes
Table 2: The operative data
c
d
Figure 2: A port is made around cardia to allow the stapler insert into stomach (c), and transthoracic anastomoses are done (d)
chemotherapy and radiation. There were no conversions to open thoracotomy or laparotomy for MIE. Patients who underwent MIE had less blood loss than the ILE group. Intrathoracic operative time and anastomosis time were longer for patients who underwent MIE compared with those undergoing ILE respectively (P < 0.001). Median lymph node harvest was higher in the MIE group compared with the ILE group (P = 0.001) [Table 2]. The overall hospital stay did not differ between the 2 groups. The pain degree in both groups were evaluated in the postoperative period. The MIE group had apparently advantage in pain degree score. One patient in the MIE group had postoperative pneumonia while 6 in the ILE group. Clinical staging was not statistically different between the two groups. There were no in-hospital mortalities in MIE group, and the MIE group had lower morbidity and mortality rates than the ILE group [Table 3]. Discussion Minimally invasive esophagectomy has become increasingly prevalent with numerous reports after its first description in 1992, and the experience for minimally invasive approach to esophageal resection was growing in the past decades.[12,14] And for many investigations, the safety of this kind of technique has been proved. In some series, the in hospital and oncologic outcomes are both equivalent to that of the open operation. [15-17] This operation could be taken in different ways, as laparoscopic-thoracoscopic ILE, laparoscopic transhiatal and laparoscopic-thoracoscopic 3-hole (McKeown).[16,18] The Ivor Lewis technique was commonly adopted in our center. The major advantages of this technique are tensionfree anastomosis between the remnant esophagus and the gastric conduit. The MIE has evolved considerably as it allows for improved visualization of mediastinal structures, decreased frequency of recurrent laryngeal nerve injuries. However, there are technical challenges of transthoracic anvil placement.[19] Transoral anvil placement in Ivor Lewis technique is one of the major procedures in some centers. But the head of the patient should be repositioned, and the endotracheal tube may need to be deflated to achieve passage into the stump.[20] We chose a 25-mm stapler for utility of placement through the subaxillary major port. And the stump of esophagus was not cut out of the entire circumference before the placement. The stapler used in our study was in a normal length which was adequate for anastomosis through the major port located at the 4th intercostal space. Indian Journal of Cancer | Volume 51 | Special Issue 1-2014
MIE
ILE
P
Operating time Abdomen portion, median, min Chest portion, median, min Anastomosis, median, min Estimated blood loss, median, ml Intraoperative transfusions, n (%) Lymph nodes harvested, median Positive lymph nodes, median
45 56 45 270 1 (3.03) 12 4
47 60.5 38 275 2 (6.67) 10 5
0.201 0.001 0.000 0.961 0.602 0.001 0.387
R0 resection, n (%)
33 (100)
30 (100)
0.294
MIE=Minimally invasive esophagectomy; ILE=Ivor Lewis esophagectomy
Table 3: Perioperative parameters and complications ICU length of stay, median, day Hospital length of stay, median, day Mortality, n (%) Atrial fibrillation, n (%) Respiratory failure or ARDS, n (%) Pneumonia, n (%) Chylothorax, n (%) Anastomotic leak, n (%) Pulmonary embolus, n (%)
MIE
ILE
P
0.000 13 0 (0) 2 (6.06) 0 (0) 1 (3.03) 0 (0) 0 (0)
0.000 13 0 (0) 3 (10) 1 (3.3) 6 (20) 1 (3.3) 1 (3.3)
0.577 0.768 1.000 1.000 1.000 0.034 0.294 0.294
0 (0)
0 (0)
1.000
All cardiac and pulmonary complications were calculated as the number of patients that experienced any type of cardiac or pulmonary complication divided by the total number of patients. MIE=Minimally invasive esophagectomy; ILE=Ivor Lewis esophagectomy; ARDS=Acute respiratory distress syndrome; ICU=Intensive care unit
The morbidity of this kind of procedure was acceptable and similar to or better than most published series of open esophagectomy. [21-24] In our series, MIE and ILE, patients who underwent MIE represents a trend to have a fast recovery with a shorten median hospital stay and a lower complication rates. Several recent reports of MIE have demonstrated the trend to decrease the rates of pulmonary complications, and our report supports the finding. [14,16,21,22,25,26] A MIE may lead to fewer early perioperative complications, when compared with an ILE. As fewer reports of complications with MIE method because of the relative novelty of this technique, we need more evidence to support the advantage. Conclusion The staplers for esophagogastric anastomosis in MIE could be used in viable ways. The anastomosis using the transthoracic stapler through the subaxillary port in MIE with comparable morbidity and oncologic data with that of open. Two ports minimal invasive surgery could be utilized in esophagectomy with acceptable safety and feasibility. References 1. Connors RC, Reuben BC, Neumayer LA, Bull DA. Comparing outcomes after transthoracic and transhiatal esophagectomy: A 5-year prospective cohort of 17,395 patients. J Am Coll Surg 2007;205:735-40. 2. Mardin WA, Palmes D, Bruewer M. Current concepts in the management of leakages after esophagectomy. Thorac Cancer 2012;3:117-24. 3. Safranek PM, Cubitt J, Booth MI, Dehn TC. Review of open and minimal access approaches to oesophagectomy for cancer. Br J Surg 2010;97:1845-53. 4. Atkins BZ, Shah AS, Hutcheson KA, Mangum JH, Pappas TN, Harpole DH Jr, e27
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How to cite this article: Zhao Y, Jiao W, Zhao J, Wang X, Luo Y, Wang Y. Anastomosis in minimally invasive Ivor lewis esophagectomy via two ports provides equivalent perioperative outcomes to open. Indian J Cancer 2014;51:25-8 Source of Support: Nil. Conflict of Interest: None declared.
Indian Journal of Cancer | Volume 51 | Special Issue 1-2014
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