High Intrathoracic Anastomosis with Thoracoscopy Is Safe and Feasible for Treatment of Esophageal Squamous Cell Carcinoma

Abstract

BackgroundMinimally invasive esophagectomy (MIE) has the potential to reduce the morbidity and mortality of esophageal cancer surgery. Esophageal squamous cell carcinoma (ESCC) has a high incidence of earlier lymphatic spread and is usually located more proximal to the incisor than esophageal adenocarcinoma; consequently, the anastomosis should be made more proximal in the thorax or in the neck. We adopted the proximal intrathoracic anastomotic technique using thoracoscopy for mid-to-lower ESCC.MethodsFrom October 2010 to August 2014, fifty-eight consecutive patients underwent MIE for ESCC. After laparoscopic gastric tubing, thoracoscopic esophageal resection and reconstruction were performed using a 28-mm circular stapler following radical mediastinal lymph node dissection. We tried to make an anastomosis at the apex of the chest. Postoperative outcomes, including overall survival and recurrence, were assessed.ResultsThe mean patient age was 64.3±9 years. The mean operative time was 371.8±51.6 minutes, and the duration of the thorax procedure was 254.8±38.3 minutes. The mean number of lymph nodes dissected was 31±11.7. The mean intensive care unit (ICU) stay and hospital stay were 3.5±8.2 hours and 13.6±7.4 days, respectively. The level of anastomosis was 22.3±1.8cm from the incisor. One patient died of uncontrolled sepsis due to necrosis of the gastric graft. Two patients developed small contained leakage. Nine patients exhibited distant metastasis during the follow-up period.ConclusionThoracoscopic intrathoracic anastomosis at the proximal esophagus is feasible and safe.

Using the Hand-Sewn Purse-String Stapled Anastomotic Technique for Minimally Invasive Ivor Lewis Esophagectomy

“…These results are consistent with several previous studies with MIILE, which range from 0 to 9.4%. [8][9][10][11][12][13][14][15][16] All patients were managed conservatively without any serious consequences. The following four reasons may have contributed to our successful outcomes for leakages after MIILE: (1) the hand-sewn purse-string technique effectively prevents esophageal mucosal retraction; (2) protection of the gastric blood supply during laparoscopic stomach mobilization; (3) no anastomotic tension in the intrathoracic anastomosis; and (4) the gastric volume decreases after using the gastric conduit, reducing contaminants when leakage occurs.…”

“…However, the first step is very difficult under thoracoscopy. 7 Although surgeons have adopted different methods to complete it in limited cases, [8][9][10][11][12][13][14][15][16] they are technically demanding and still not widely accepted. To resolve this problem, we have adopted a hand-sewn purse-string stapled anastomotic technique for MIILE.…”

Recent Advances in Minimally Invasive Esophagectomy

“…Also, the intrathoracic anastomosis was associated with better functional results with a lower incidence of dysphagia and recurrent nerve injury (45). Nowadays, several centers have stopped using the triple approach (including open or hybrid surgery) and they propose an intrathoracic anastomosis in the upper mediastinum by two-stage Ivory Lewis's laparoscopic and thoracoscopic approach to avoid cervical approach, while respecting oncological safety margins performing frozen sections histopathological examinations intraoperatively (46).…”

Minimally invasive Ivor Lewis esophagectomy for esophageal cancer

“…Frozen sectioning was checked proximal margins. The gastric tube was placed in the posterior mediastinum, and the whole length incised pleura closed with interrupted sutures for the prevention of gastric elongation or bulging into the pleural cavity (7). Finally, a single chest tube placed.…”