Improved Functional Results After Minimally Invasive Esophagectomy: Intrathoracic Versus Cervical Anastomosis

Abstract Background Anastomotic leakage, fibrous stricture and gastroesophageal reflux are three major complications of gastroesophageal anastomosis, particularly in cervical anastomosis. Our aim was to evaluate the safety and efficacy of a novel cervical anastomosis technique (NA) by comparing it to the traditional side-to-side anastomosis (SS), and the end-to-side anastomosis using a circular stapler (CS) in terms of postoperative leakage, stricture and reflux. Methods A total of 390 patients with thoracic esophageal cancer underwent a minimally invasive esophagectomy with cervical anastomosis (192 with NA, 34 with SS and 164 with CS) in our institute from January 2013 and May 2016. The new anastomotic technique was improved from a type of side-to-side anastomosis technique which was reported by Collard et al. The difference of our new technique is that the part of the anastomotic stump was pushed into the tubular stomach. It let the end part of esophagus was embedded in the gastric tube while the end portion of the stomach was also reversed into the gastric tube (figure 1, 2, 3). The major postoperative complications including postoperative leakage, stricture and reflux were compared using three armed controlled study. Results With regard to the incidence of anastomotic leakage and reflux, the patients who underwent Jiang's anastomosis had a significantly lower rate than those in the SS group and CS group (Leaks: 1.0% vs. 8.8% and 8.5%, P = 0.025, 0.001; Reflux: 5.7% vs. 23.5% and 18.3%, P = 0.003, 0.001). The incidence of dysphagia was 10.4% with an occurrence rate of 1.5% for anastomotic strictures in the NA group. It was significant lower than that in the CS group (41.5% vs. 18.9%, P < 0.05) but not significantly different from that in SS group (11.8% vs. 2.9%). Conclusion The novel anastomotic technique remarkably reduced the incidence of gastroesophageal-anastomotic leakage, stricture and reflux and was a safe and effective technique for minimally invasive esophagectomy. Disclosure All authors have declared no conflicts of interest.

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P113 ESOPHAGECTOMY-SPECIFIC OBJECTIVE STRUCTURED ASSESSMENT OF TECHNICAL SKILL (E-OSATS): CONSENSUS ON ESSENTIAL IVOR-LEWIS AND MCKEOWN STEPS TROUGH DELPHI METHODOLOGY

Diseases of the Esophagus ◽

10.1093/dote/doz092.113 ◽

2019 ◽

Vol 32 (Supplement_2) ◽

Author(s):

Yassin Eddahchouri ◽

Workum Frans van ◽

Bastiaan Klarenbeek ◽

den Wildenberg Frits van ◽

Berge Henegouwen Mark van ◽

...

Keyword(s):

Minimally Invasive ◽

Learning Curve ◽

Assessment Tool ◽

Minimally Invasive Esophagectomy ◽

Round Table ◽

Cervical Anastomosis ◽

International Consensus ◽

Ivor Lewis ◽

Invasive Esophagectomy ◽

Specific Objective

Abstract Aim The objective of this study was to determine expert consensus on essential steps in MIE to develop an ‘Esophagectomy-specific Objective Structured Assessment of Technical Skills’ tool (E-OSATS). Background & Methods Minimally invasive esophagectomy (MIE) is a complex and technically demanding procedure. Studies have shown that MIE has a long learning curve which is associated with increased morbidity and mortality. To master MIE training of procedural steps is crucial. Yet, no consensus regarding the essential steps nor a structured way of assessment of MIE are available. Essential steps were defined for both Ivor-Lewis (IL) and McKeown (MCK) approach, based on expert opinion and peer-reviewed literature. In round table discussions experts finalized the list, and an online Delphi questionnaire was sent to an international expert panel (7 European countries) of minimally invasive upper GI surgeons. Based on replies and comments steps were adjusted and rephrased and sent in iterative fashion until consensus was achieved. Results Two Delphi rounds were conducted, and response rates were 74% (23 out of 31 experts) for the first and 81% (27 out of 33 experts) for the second round. Consensus was achieved on 94 and 98 steps for the IL and MCK approach respectively. Cronbach’s alpha in the first round was 0,77 (IL) and 0,77 (MCK), and in the second round 0,91 (IL) and 0,87 (MCK). Conclusion International consensus on essential surgical steps for MIE with both intrathoracic- and cervical anastomosis was achieved. Validation of the assessment tool allows for specific and structured feedback and will potentially shorten the learning curve and decrease learning associated morbidity consequently.

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PS01.246: ESOPHAGECTOMY-SPECIFIC OBJECTIVE STRUCTURED ASSESSMENT OF TECHNICAL SKILL (E-OSATS): CONSENSUS ON ESSENTIAL STEPS THROUGH DELPHI METHODOLOGY

Diseases of the Esophagus ◽

10.1093/dote/doy089.ps01.246 ◽

2018 ◽

Vol 31 (Supplement_1) ◽

pp. 119-119

Author(s):

Yassin Eddahchouri ◽

Suzanne Gisbertz ◽

Mark I Van Berge Henegouwen ◽

Bastiaan Klarenbeek ◽

Camiel Rosman

Keyword(s):

Minimally Invasive ◽

Conflicts Of Interest ◽

Minimally Invasive Esophagectomy ◽

Round Table ◽

Round Table Discussion ◽

Cervical Anastomosis ◽

Invasive Esophagectomy ◽

Delphi Round ◽

Specific Objective ◽

International Experts

Abstract Background Minimally invasive esophagectomy (MIE) is a technically demanding procedure, but without consensus regarding essential steps and assessment of surgical technique. The objective of this study was to determine expert consensus on essential steps in MIE as a first step in the development of an ‘esophagectomy-specific objective structured assessment of technical skills’ tool (E-OSATS). Methods Essential steps were defined for both MIE with intrathoracic- and cervical anastomosis, based on local expert opinion, peer-reviewed literature and surgical textbooks. In round table discussion disparities between experts were resolved, and an online Delphi questionnaire was sent to an international expert panel of minimally invasive upper GI surgeons. Based on replies and comments steps were adjusted and resent in iterative fashion. Results A total of 137 and 138 essential steps were identified for the MIE with intrathoracic- and cervical anastomosis respectively. After the first Delphi round 24 out of 36 (67%) invited international experts replied, and consensus was reached in 99 out of 137 (72%) and 95 out of 138 steps for both procedures respectively. Conclusion A Delphi method seems feasible in determining essential steps as a first step in the development of an E-OSATS for both MIE with intrathoracic- and cervical anastomosis. The second Delphi round is currently pending. Disclosure All authors have declared no conflicts of interest.

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PS01.244: MINIMALLY INVASIVE ESOPHAGECTOMY FOR ESOPHAGEAL CANCER WITH THE PATIENT IN PRONE POSITION: EXPERIENCE OF 156 CONSECUTIVE CASES IN A SINGLE CENTER

Diseases of the Esophagus ◽

10.1093/dote/doy089.ps01.244 ◽

2018 ◽

Vol 31 (Supplement_1) ◽

pp. 119-119

Author(s):

Antonio Ziccarelli ◽

Massimo Vecchiato ◽

Chiara Lirusso ◽

Alessandro Rosignoli ◽

Roberto Silvestro ◽

...

Keyword(s):

Squamous Cell Carcinoma ◽

Mortality Rate ◽

Minimally Invasive ◽

Hospital Stay ◽

Cell Carcinoma ◽

Prone Position ◽

Minimally Invasive Esophagectomy ◽

Cervical Anastomosis ◽

Invasive Esophagectomy ◽

The Mean

Abstract Background Minimally invasive esophagectomy is performed with increasing frequency and proves to be a safe and effective surgical alternative to the open technique. Minimally invasive esophagectomy using thoracoscopic esophageal mobilization with the patient in prone position seems to offer some advantages with regard to surgeon ergonomics and clinical outcome. Methods Between July 2005 and December 2017, 156 patients underwent minimally invasive esophagectomy in the prone position at the authors' institutionin. Was performed 132 three field McKeown MIE (84,6%) with circular stapled cervical anastomosis and 24 two field Ivor Lewis MIE (15,4%) with circular stapled intrathoracic anastomosis; For four patients (2,6%) the colon was used for cervical anastomosis, and two patients (1,3%) had previously undergone left pneumonectomy because of lung cancer. The preoperative indication was squamous cell carcinoma for 100 patients (64,1%) and adenocarcinoma for 53 patients (33,9%). In three cases (1,9%), the histology of the specimen showed a squamous cell carcinoma with neuroendocrine differentiation. Neoadjuvant treatment was administered to 79 patients (50,6%) Results In 152 patients (97,4%) was performed esophagectomy using minimally invasive thoracic mobilization of the esophagus with the patient in prone position. In four cases (2,6%) an early thoracotomic conversion was necessary due to the presence of lung adhesions such that made it impossible to establish the pneumothorax. The mean operative time was 255 min (range: 130–420 min). The median intensive care unit stay was 2 days (range: 0–77 day), and the median postoperative hospital stay was 15 days (range: 8–79 day). The mean number of procured lymph nodes was 16 (range: 0–56 Ln). The perioperative pulmonary morbidity rate was 22,4%, and the perioperative mortality rate was 2.6%. An anastomotic leakage occurred in 13 patients (8,3%). Conclusion Minimally invasive esophagectomy is safe and technically feasible. It entails a lower mortality rate and a shorter hospital stay than those reported in most open series. Thoracoscopy with the patient in prone position offers results comparable with those obtained using other minimally invasive techniques.This technique shows considerable advantages such as improved surgeon ergonomics, increased operative field exposure, and satisfactory respiratory results. Disclosure All authors have declared no conflicts of interest.

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