Perioperative outcomes of esophagectomy preceded by the laparoscopic transhiatal approach for esophageal cancer

Abstract

This study was designed to determine the efficacy of esophagectomy preceded by the laparoscopic transhiatal approach (LTHA) with regard to the perioperative outcomes of esophageal cancer. The esophageal hiatus was opened by hand-assisted laparoscopic surgery, and carbon dioxide was introduced into the mediastinum. Dissection of the distal esophagus was performed up to the level of the tracheal bifurcation. En bloc dissection of the posterior mediastinal lymph nodes was performed using LTHA. Next, cervical lymphadenectomy, reconstruction via a retrosternal route with a gastric tube and anastomosis from a cervical approach were performed. Finally, a small thoracotomy (around 10 cm in size) was made to extract the thoracic esophagus and allow upper mediastinal lymphadenectomy to be performed. The treatment outcomes of 27 esophageal cancer patients who underwent LTHA-preceding esophagectomy were compared with those of 33 patients who underwent the transthoracic approach preceding esophagectomy without LTHA (thoracotomy; around 20 cm in size). The intrathoracic operative time and operative bleeding were significantly decreased by LTHA. The total operative time did not differ between the two groups, suggesting that the abdominal procedure was longer in the LTHA group. The number of resected lymph nodes did not differ between the two groups. Postoperative respiratory complications occurred in 18.5% of patients treated with LTHA and 30.3% of those treated without it. The increase in the number of peripheral white blood cells and the duration of thoracic drainage were significantly decreased by this method. Our surgical procedure provides a good surgical view of the posterior mediastinum, markedly shortens the intrathoracic operative time, and decreases the operative bleeding without increasing major postoperative complications.

Middle and lower esophagectomy preceded by hand-assisted laparoscopic transhiatal approach for distal esophageal cancer

“…Furthermore, our results demonstrated that the total intraoperative blood loss was significantly decreased and the duration of thoracic drainage was significantly shortened using LTHA. We consider that one of the reasons is that this method enables dissection of the appropriate layer under a magnified videoscopic view and, therefore, damage to the microvessels and lymphatic ducts is avoided (8,9). In our experience, there were no problems associated with applying a 10-mmHg pneumomediastinum pressure for intraoperative respiratory care.…”

“…The scopist stood near the patient's groin. Carbon dioxide was introduced into the intra-abdominal space and the pneumoperitoneum pressure was controlled at 10 mmHg (8)(9)(10)(11).…”

“…In our previous study, we demonstrated the efficacy of LTHA preceding subtotal esophagectomy with gastric tube reconstruction via a retrosternal route, with regard to perioperative outcomes (8). In this study, we aimed to analyze the perioperative treatment outcomes of patients with distal esophageal cancer who underwent middle and lower esophagectomy preceded by hand-assisted LTHA and gastric tube reconstruction via the posterior mediastinal route (anastomosis in the thoracic cavity).…”

“…In addition, a good surgical view of the lower mediastinum is obtained and the quality of the mediastinal surgery may be improved. By December, 2012, a total of 121 patients with esophageal tumors had undergone LTHA during a variety of esophageal surgical procedures, including subtotal esophagectomy, middle and lower esophagectomy and tumor resection (8)(9)(10)(11).…”

“…We first performed an esophagectomy preceded by the laparoscopic transhiatal approach (LTHA) for patients with esophageal cancer in 2009 (8)(9)(10). With this method, carbon dioxide is introduced into the mediastinum from the abdominal side of the diaphragm and middle and lower mediastinal operations may be performed via a transhiatal approach.…”