No abstract

Oesophageal cancer surgery is a complex procedure with high morbidity and mortality rate. High volume centres, complete multidisciplinary support and clear clinical guidelines are required to obtain adequate results. One of the objectives of multimodal rehabilitation programs in this field is to reduce surgical aggression. Initial experience with the tubeless oesophagectomy technique is described. Methods Description of the technique and perioperative management of tubeless oesophagectomy. We performed a 3-stage esophagectomy with a minimally invasive approach, without NGT placement or any type of drainage. The procedure includes the so-called phantom jejunostomy, which require of fixing the first jejunal loop to the parietal peritoneum in order to position a percutaneous catheter if necessary. All patients were extubated at the end of the surgery, remaining in the ICU with high-flow glasses for the first 24–48 hours. Also in the first 2 days, the urinary catheter and the epidural catheter were removed, sitting and fluid tolerance began. Results Beteween June–November 2020 6 patients were operated on. Median age was 60 years (range: 52–70), 83.3% were squamous cell carcinoma located in the middle oesophagus, 4 patients received neoadjuvant CROSS treatment. No intraoperative complications reported and a median stay of 7 days (range: 6–28). There was no anastomotic leak, nor need to place a jejunostomy, nor need to place a nasogastric tube and neither reoperation. A thoracic tube was necessary for chylothorax and another for pneumothorax (in a patient with acute respiratory distress). There was no mortality at 30 and 90 days after the procedure. Conclusion Tubeless oesophagectomy is a feasible concept that can improve postoperative recovery in selected cases, reducing pain associated with drains and tubes, facilitating early mobilization and correct performance of respiratory physiotherapy exercises. Improving functional recovery and quality of life during the postoperative period. Studies with a greater number of cases and well designed are necessary to strongly evaluate this type of procedure.

The extent of lymphadenectomy in oesophageal cancer surgery is currently controversial, although current evidence shows that survival is directly related to the number of lymph nodes removed during surgery. Methods Descriptive study of patients with oesophageal cancer who underwent oesophagectomy with extended and total mediastinal lymphadenectomy using a minimally invasive approach (right prone thoracoscopy, laparoscopy and left cervicotomy) in our hospital for 2 years (2019 and 2020). Extended lymphadenectomy was indicated in patients with adenocarcinoma of the distal oesophagus, while total lymphadenectomy was indicated in patients with squamous tumours and adenocarcinoma of the middle oesophagus. The characteristics of the series studied and the results obtained in the 90 days postoperatively are described. Results 26 patients, mean age 65 ± 7.8 years, were operated. 21 with total mediastinal lymphadenectomy and 5 with extended lymphadenectomy. 80.7% received neoadjuvant treatment (CROSS scheme). The mean number of lymph nodes removed was 33.6 ± 14.3, with a 50% probability of being affected. As much in the lymphadenectomy of the right (106R) as in the left (106 L) recurrent groups, it was more frequently affected in the distal oesophagus adenocarcinomas. Postoperative morbidity was not negligible, with anastomotic leak rate of 7.7% (thoracic location) and 23.1% (cervical location) the majority mild, 23.1% of recurrent injury and 11.5% of chylothorax. Mortality at 90 days was 15.38%. Conclusion Based on our results, extended and total lymphadenectomy increases as much the global number of lymph nodes removed as the lymph nodes cancer-positive. In addition, it supports the performance of wide lymphadenectomies also in adenocarcinomas of the distal oesophagus. We cannot forget the greater radicalism is taxed with significant morbidity. We should remember the limitation of this study is the low number of cases, the extent of lymphadenectomy continues to be a matter of controversy.

Aim To present a video of a complete bilateral recurrent laryngeal nerve lymphadenectomy performed during minimally invasive esophagectomy using thoracoscopic video-assisted surgery in the prone position. Background and Methods Surgical treatment for esophageal cancer needs detailed lymphadenectomy. Indeed, the number of surgically dissected lymph nodes is important for staging accuracy and also determines patient’s prognosis, including those along the recurrent laryngeal nerve. However, recurrent laryngeal nerve dissection remains difficult and increases the appearance of postoperative complications. This is a video of a bilateral recurrent laryngeal nerve lymphadenectomy during thoracoscopic esophagectomy performed in the prone position in a female patient with esophageal cancer. Results A 75 year-old female was diagnosed with recurrent squamous cell middle third esophageal carcinoma. The patient had first been diagnosed eleven years ago, receiving chemoradiotherapy as a radical treatment. The patient achieved a complete response after treatment, which remained for eleven years. Eleven years later, during routine follow-up, tumor recurrence was identified in the middle third of the esophagus. After presentation in a Multidisciplinary Group the patient underwent minimally invasive McKeown esophagectomy. First, a video-assisted thoracoscopic surgery was performed in the prone position to mobilize the thoracic esophagus and complete a detailed mediastinal lymph node dissection, including infra-carinal lymph nodes, bilateral bronchial lymph nodes and also bilateral recurrent laryngeal nerve lymph nodes. Afterwards, the abdominal esophagus and lymph node dissection is performed using a laparoscopic approach, and also a left cervicotomy in the supine position. An assistance laparotomy was made to externalize the specimen and make the gastric conduit. A manual end-to end esophago-gastric anastomosis was executed and finally, a feeding jejunostomy tube was placed. The patient presented a benign postoperative course, introducing enteral nutrition and oral intake developing no complications, such as dysphonia, nor dysphagia and was discharged on the 8th postoperative day. The postoperative barium swallow radiography showed no leaks nor other complications and pathology report confirmed tumor free resection margins. Conclusion Detailed mediastinal lymph node dissection and exhaustive bilateral recurrent laryngeal nerve lymphadenectomy can be safely performed by minimally invasive surgery, as is shown in the video. The technique shown is feasible, achieves a complete lymph-node dissection and avoids postoperative complications such as dysphonia and recurrent laryngeal nerve palsy.

Anastomotic leakage in oesophageal cancer surgery is one of the most serious complications and occurs mainly at the cervical level between 10–30% according to series. The use of immunofluorescence could help to select a better vascularized area in which to perform the anastomosis more safely. We present the initial experience (between July and December 2020) of our group. Methods Prospective and descriptive study of patients with oesophageal neoplasia who underwent a 3 stage oesophagectomy with cervical anastomosis using immunofluorescence with indocyanine green (dose: 7,5 mg) for quick evaluation of vascularization in the theoretical anastomosis zone in gastric plasty. Intravenous injection of the indocyanine green dilution was performed intraoperatively in a peripheral line, once the plasty was positioned in place to perform the anastomosis. The route of ascent was transmediastinal in all cases. 9 patients with a mean age of 61 ± 7.6 years were included in the study. Results The mean heart rate was 83 ± 16 bpm, the mean systolic blood pressure was 111 ± 17 mmHg. The time and mean speed it took for the fluorescence to reach the marked area to perform the anastomosis was 30 ± 28 seconds and 1.83 cm/sec; and at the apex of the plasty it was 93 ± 79 seconds and 0.75 cm/sec. In all patients in whom the anastomosis was performed in the area where ICG arrived between 30 and 90 seconds, there was no leakage. In two patients, due to anatomical needs, the anastomosis was performed in areas where ICG took more than 100 seconds and in the postoperative period leaked. Conclusion Immunofluorescence is a technique that allows an immediate visual image to evaluate the vascularization of the gastric plasty during an esophagectomy. It allows characterizing the adequate vascularization of the future anastomotic area, being able to help decide the best place to carry out the anastomosis. Studies with a larger number of cases are needed to be able to define the range in which to establish the anastomosis or change the surgical strategy.