RA01.06: TOTALLY MINIMALLY INVASIVE ESOPHAGECTOMY IN A PATIENT WITH PREVIOUS NISSEN FUNDOPLICATION: CAN INDOCYANINE GREEN BE A USEFUL TOOL?

Abstract Description Total esophagectomy may be technically demanding. Previous abdominal surgeries may increase the difficulty of the technique, especially when affecting the stomach as a gastric conduit is the preferred method for reconstruction. In this video, we demonstrate that the creation of the gastric conduit is feasible even with a previous Nissen fundoplication and that the use of indocyanine green (ICG) is useful to assess the vascularization of the gastric conduit. Methods A 70-year-old woman with medical history of high blood pressure, hysterectomy and hiatal hernia repair with laparoscopic Nissen fundoplication presented with symptoms of dysphagia and weight loss and was diagnosed of an adenocarcinoma of the esophagus (25 to 32 cm from the incisives) cT3N1. Neoadjuvant chemo-radiotherapy following CROSS scheme was administered. A total minimally invasive esophagectomy was performed in the prone position for the thoracic time. Concerns about the length of the gastric conduit due to the fundoplication were present during surgery. ICG was used to locate the right gastroepiploic arcade, asses the vascularization of the gastric conduit, specially in the gastric fundus, and after cervicotomy, to assess the vascularization of the gastric stump before performing the anastomosis. Results Surgical time was 360 minutes. Postoperative evolution was satisfactory except for hoarseness due to a possible right recurrent laryngeal nerve paralysis. She was discharged on the 11th postoperative day. Pathology confirmed an adenocarcinoma of the mid esophagus ypT1bN1 (1/15). Conclusions Totally minimally invasive esophagectomy in the prone position is feasible even in the case of previous upper gastrointestinal surgeries, such as Nissen fundoplication. The use of ICG is useful for the identification of the gastroepiploic arcade, assessment of the vascular supply to the gastric conduit and to the anastomosis, especially when a McKeown esophagectomy is performed. Disclosure All authors have declared no conflicts of interest.

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Thoracic duct identification with indocyanine green fluorescence during minimally invasive esophagectomy with patient in prone position

Diseases of the Esophagus ◽

10.1093/dote/doaa030 ◽

2020 ◽

Vol 33 (12) ◽

Cited By ~ 2

Author(s):

Massimo Vecchiato ◽

Antonio Martino ◽

Massimo Sponza ◽

Alessandro Uzzau ◽

Antonio Ziccarelli ◽

...

Keyword(s):

Minimally Invasive ◽

Indocyanine Green ◽

Prone Position ◽

Thoracic Duct ◽

Minimally Invasive Esophagectomy ◽

Standard Procedure ◽

Transthoracic Esophagectomy ◽

Green Fluorescence ◽

Indocyanine Green Fluorescence ◽

Invasive Esophagectomy

Abstract Chylothorax is a serious complication of transthoracic esophagectomy. Intraoperative thoracic duct (TD) identification represents a possible tool for preventing or repairing its lesions, and it is most of the time difficult, even during high-definition thoracoscopy. The aim of the study is to demonstrate the feasibility of using near-infrared fluorescence-guided thoracoscopy to identify TD anatomy and check its intraoperative lesions during minimally invasive esophagectomy. A 0.5 mg/kg solution of indocyanine green (ICG) was injected percutaneously in the inguinal nodes of 19 patients undergoing minimally invasive esophagectomy in a prone position, before thoracoscopy. TD anatomy and potential intraoperative lesions were checked with the KARL STORZ OPAL1® Technology. In all of the 19 patients where transthoracic esophagectomy was feasible, the TD was clearly identified after a mean of 52.7 minutes from injection time. The TD was cut for oncological radicality in two patients, and it was successfully ligated under the ICG guide. No postoperative chylothorax or adverse reactions from the ICG injection occurred. The TD identification with indocyanine green fluorescence during minimally invasive esophagectomy is a simple, effective, and non-time-demanding tool; it may become a standard procedure to prevent postoperative chylothorax.

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661 EFFICACY OF ROBOT ASSISTED MINIMALLY INVASIVE ESOPHAGECTOMY: PROPENSITY MATCHED ANALYSIS OF RAMIE IN COMPARISON WITH CONVENTIONAL MIE

Diseases of the Esophagus ◽

10.1093/dote/doab052.661 ◽

2021 ◽

Vol 34 (Supplement_1) ◽

Author(s):

Takeo Fujita ◽

Kazuma Sato ◽

Asako Ozaki ◽

Tomohiro Akutsu ◽

Hisashi Fujiwara ◽

...

Keyword(s):

Minimally Invasive ◽

Minimally Invasive Esophagectomy ◽

Recurrent Laryngeal Nerve Paralysis ◽

Surgical Results ◽

Matched Cohort ◽

Robot Assisted ◽

Nerve Paralysis ◽

Invasive Esophagectomy ◽

Significant Difference ◽

The Difference

Abstract Robot assisted minimally invasive esophagectomy (RAMIE) has been reported to be potential advantages in previous reports. Here we demonstrate the difference between these two minimally invasive procedures and investigated the surgical results of RAMIE in comparison with MIE using propensity matched-cohort. Methods We investigated 154 cases of thoracic esophagectomy conducted between 2020/1 to 2021/1. Among these cases, we analyzed 30 cases of RAMIE in comparison with 30 cases of matched-cohort which conducted conventional thoracoscopic esophagectomy (MIE) in the prone. Then we evaluated the surgical results between two groups. Results There were no differences in age (69.2 vs 69.1 yo), gender (M:F = 24:6 vs 24:6), cStage (Stage I,II,III,IV:6,3,14,7 vs 8,3,14,5), and preoperative chemotherapy (70% vs 66.7%) between RAMIE and matched-cohort MIE. There was statistically significant difference in total time of thoracic phase (233.1 vs 173.3 min; p < 0.01). There were no significant differences in postoperative events in RAMIE vs MIE (Clavien-Dindo Grade 1≧; Recurrent laryngeal nerve paralysis (RLNP) (16.7 vs 20.0%; p = 0.19). However, after the learning curve archived, seldom cases were diagnosed postoperative RLNP in RAMIE cases in comparison with MIE (p = 0.06). Conclusion We demonstrated the formalization of our procedure and surgical results of RAMIE. There were no significant differences in postoperative events between two groups. However RLNP was lower after the learning peak. Incidence of RLNP could be reduced in RAMIE.

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384 SHORT-TERM OUTCOMES OF INTRA-THORACIC ESOPHAGO-GASTRIC ANASTOMOSES UNDER MINIMALLY INVASIVE ESOPHAGECTOMY VIA A PRONE POSITION

Diseases of the Esophagus ◽

10.1093/dote/doab052.384 ◽

2021 ◽

Vol 34 (Supplement_1) ◽

Author(s):

Shinji Mine ◽

Masayuki Watanabe ◽

Atushi Kanamori ◽

Yu Imamura ◽

Akihiko Okamura ◽

...

Keyword(s):

Minimally Invasive ◽

Anastomotic Stricture ◽

Minimally Invasive Esophagectomy ◽

Anterior Wall ◽

Gastric Conduit ◽

Linear Stapler ◽

Short Term ◽

Invasive Esophagectomy ◽

Operative Complications ◽

Gastric Anastomosis

Abstract Although minimally invasive esophagectomy (MIE) has been performed for esophageal cancer worldwide, intra-thoracic anastomosis under prone positions is still challenging. In this retrospective study, we reviewed our short-term results of this anastomotic technique in our institution. Methods From November 2016 to December 2019, we performed 319 esophagectomies. Of these patients, 28 patients (9%) underwent intra-thoracic esophago-gastric anastomosis under MIE. Procedures The left side of an esophageal stump which had been closed using a linear stapler was opened for anastomosis. Then, the anterior wall of a gastric conduit, around 5 cm below the tip, was opened for anastomosis. Linear staplers were inserted in both esophageal stump and gastric conduit and side-to-side anastomosis was performed. The opening for insertion was closed using a hand-sewn anastomosis in 2 layers. Results Five patients (18%) suffered anastomotic leakage with Clavien-Dindo 2 and 3a, and all of them recovered by conservative treatments. Two patients (2/19, 11%) showed anastomotic stricture which improved by several endoscopic dilatations. Six patients (6/19, 32%) showed the reflux esophagitis of Grade C. Conclusion Although we have not experienced severe or critical post-operative complications, the short-term results of intra-thoracic anastomosis under MIE were not sufficient. Additional progresses in techniques are required.

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Intrathoracic Esophagogastric Anastomosis Using a Linear Stapler Following Minimally Invasive Esophagectomy in the Prone Position

Journal of Gastrointestinal Surgery ◽

10.1007/s11605-012-2009-0 ◽

2012 ◽

Vol 17 (2) ◽

pp. 397-402 ◽

Cited By ~ 13

Author(s):

Hiroshi Okabe ◽

Eiji Tanaka ◽

Shigeru Tsunoda ◽

Kazutaka Obama ◽

Yoshiharu Sakai

Keyword(s):

Minimally Invasive ◽

Prone Position ◽

Minimally Invasive Esophagectomy ◽

Esophagogastric Anastomosis ◽

Linear Stapler ◽

Invasive Esophagectomy

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Minimally invasive esophagectomy: Preservation of arch of Azygos vein in prone position

Journal of Minimal Access Surgery ◽

10.4103/jmas.jmas_267_20 ◽

2021 ◽

Vol 0 (0) ◽

pp. 0

Author(s):

Madhabananda Kar ◽

Mohammed Imaduddin ◽

DillipK Muduly ◽

Mahesh Sultania ◽

Tim Houghton ◽

...

Keyword(s):

Minimally Invasive ◽

Prone Position ◽

Minimally Invasive Esophagectomy ◽

Azygos Vein ◽

Invasive Esophagectomy

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Management of gastric conduit retention following hybrid and minimally invasive esophagectomy for esophageal cancer: Two retrospective case series

International Journal of Surgery Case Reports ◽

10.1016/j.ijscr.2017.11.040 ◽

2017 ◽

Vol 41 ◽

pp. 505-510 ◽

Cited By ~ 2

Author(s):

Ingvild Farnes ◽

Egil Johnson ◽

Hans-Olaf Johannessen

Keyword(s):

Esophageal Cancer ◽

Minimally Invasive ◽

Minimally Invasive Esophagectomy ◽

Case Series ◽

Gastric Conduit ◽

Retrospective Case ◽

Invasive Esophagectomy ◽

Retrospective Case Series

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Classification and early recognition of gastric conduit failure after minimally invasive esophagectomy

Surgical Endoscopy ◽

10.1007/s00464-008-0233-1 ◽

2008 ◽

Vol 23 (9) ◽

pp. 2110-2116 ◽

Cited By ~ 27

Author(s):

Darmarajah Veeramootoo ◽

Rajeev Parameswaran ◽

Rakesh Krishnadas ◽

Peter Froeschle ◽

Martin Cooper ◽

...

Keyword(s):

Minimally Invasive ◽

Early Recognition ◽

Minimally Invasive Esophagectomy ◽

Gastric Conduit ◽

Invasive Esophagectomy

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Extracorporeal Gastric Stapling Reduces the Incidence of Gastric Conduit Failure after Minimally Invasive Esophagectomy

The American Surgeon ◽

10.1177/000313481007600825 ◽

2010 ◽

Vol 76 (8) ◽

pp. 823-828 ◽

Cited By ~ 6

Author(s):

Gregory D. Crenshaw ◽

Suven S. Shankar ◽

Russell E. Brown ◽

Abbas E. Abbas ◽

John S. Bolton

Keyword(s):

Minimally Invasive ◽

Anastomotic Leak ◽

Operative Mortality ◽

Minimally Invasive Esophagectomy ◽

Gastric Conduit ◽

Short Term ◽

Simple Modification ◽

Invasive Esophagectomy ◽

Clinic Foundation ◽

Significant Difference

Esophageal cancer resection is associated with significant morbidity and mortality. To date, no standardized technique exists. In this study, we analyze our short-term results in 92 minimally invasive resections performed over the past 10 years in an attempt to identify technical factors, which contribute to improved short-term outcomes. A retrospective review of 92 minimally invasive esophagectomies was performed at the Ochsner Clinic Foundation from 1999 through 2009. Data collected included preoperative stage, whether or not preoperative chemoradiation was used, technique of minimally-invasive resection, technique of esophagogastric anastomosis, margin status, anastomotic leak, conduit necrosis, gastric conduit failure of any type, and operative mortality. Gastric stapling was done either laparoscopically (intracorporeal) or through a minilaparotomy (extracorporeal). Ninety-two patients met criteria for this study. There was a significant difference in the incidence of positive gastric margins ( P = 0.04), anastomotic leak ( P = 0.045), conduit necrosis ( P = 0.03), and any gastric conduit failure ( P = 0.02) favoring the extracorporeal group. The overall short-term morbidity and operative mortality with minimally invasive esophagectomy is comparable to the results obtained with open techniques. A relatively simple modification of the operative technique—performing extracorporeal stapling of the gastric conduit—led to a significant reduction in the incidence of gastric conduit failures when compared with the intracorporeal stapling technique.

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