285 RIGHT COMPARED WITH LEFT THORACIC APPROACH ESOPHAGECTOMY FOR PATIENTS WITH MIDDLE ESOPHAGEAL SQUAMOUS CELL CARCINOMA

The open surgical approaches for esophageal cancer (EC) can be mainly divided into the right and left transthoracic approach in China. Although it shows an increasing number of right side approach, the optimal surgical technique remains unclear. This study attempt to compare the long-term survival between two approaches in a large cancer center with rich experience of both side transthoracic approach. Methods The patients who underwent right transthoracic approach esophagectomy (Right, McKeown) and left transthoracic approach esophagectomy (Left, Sweet or chest neck dual-incision) for esophageal squamous cell carcinoma (ESCC) during January 2015 to January 2018 were included. The overall survival (OS) rate and perioperative data between two groups were retrospectively analysed. Results We included 437 patients who underwent Right (n = 202) or Left (n = 235) approach for ESCC. There was a significantly longer median operative time (250 min vs. 190 min, P < 0.001) and longer median postoperative hospital stady days (17 days vs. 14 days, P < 0.001) in Right groups. The OS at 34-months was 69.83% and 67.32% in Right and Left groups, respectively; hazard ratio (HR) (95% CI): 1.121 (0.723–1.737), p = 0.611. Conclusion For middle thoracic ESCC without suspected lymph node metastasis in the upper mediastinum, the esophagectomy through left thoracic approach could achieve the same OS with right side, and better short-term outcomes.

Posterior Transdural Approach for a Calcified Thoracic Intradural Disc Herniation Using a 3-Dimensional Exoscope: 2-Dimensional Operative Video

This video depicts the removal of an intradural thoracic disc herniation through a purely transdural approach. Thoracic disc herniations are rare, and less than 5% are intradural. Though thoracic disc herniations are removed through a posterolateral or transthoracic corridor, there is literature to support a transdural approach for central herniations.1-3 Although the transdural approach has been selectively adopted for central soft herniations, calcified herniations have been regarded as less suitable.1,2 Intradural thoracic herniations have not been specifically addressed by a transdural approach in the limited literature, though it has been utilized in conjunction with a larger transthoracic approach.4 Our case features a 72-yr-old female presenting with worsening left leg weakness. Computed tomography (CT) identified a multilobulated ventral calcified mass at T11-12. Magnetic resonance imaging was not possible because of an incompatible pacemaker. Our impression was that this likely represented an intradural meningioma though a calcified intradural disc herniation was considered. Given the apparent intradural location, we opted for a transdural approach only via T11-12 laminectomy and a midline dural opening. Dentate ligament sectioning allowed a clear corridor to the now apparent disc material. Postoperative CT confirmed near complete resection, and the patient showed neurological improvement. Ultimately, the transdural approach alone led to complete discectomy while avoiding the morbidity of an invasive transthoracic approach and instrumented fusion. To our knowledge, this is the first video documenting a purely transdural approach for resection of an intradural disc herniation. The patient consented to the surgical procedure and to the use of intraoperative video for education purposes.

Importance of Circumferential Resection Margin in Management of Esophageal Cancer

Esophagectomy (R0) remains the gold standard for the management of esophageal cancer. But due to close vicinity of esophagus with the major structures like heart, aorta, vertebral column, tracheobronchial tree and lungs, a wider circumferential resection is generally not possible and a R1/ R2 resection might occur. Therefore, locoregional recurrence rates of esophageal cancer are reported to be as high as 52%. The Royal College of Pathologists (RCP) and The College of American Pathologists (CAP) define circumferential resection margin (CRM) differently. A mean overall CRM involvement was found to be 40.7% (RCP criteria) and 11.8% (CAP criteria). Twometa-analyses have shown poor survival in CRM positive cases. CRM positivity in T1/ T2 lesions should not occur unless there is a surgical fault. For T3 lesions, a higher rate of CRM positivity has been documented. Therefore, a wider CRM using transthoracic approach appears mandatory, especially for T3 lesions.

Robotic Transthoracic Repair of a Right-Sided Traumatic Diaphragmatic Rupture

Introduction Traumatic diaphragm rupture injury repairs are predominately performed through thoracotomy, laparotomy, or a combination of the two approaches. While open surgery is often necessary to follow the fundamentals of damage-control operations in unstable or polytrauma patients, minimally invasive surgery may be an alternative for those with a low injury burden to reduce the postoperative morbidities associated with open operations. Case Description We describe the first case of a right-sided diaphragm rupture from blunt trauma that was repaired by a robotic transthoracic approach in the index admission. Conclusion Minimally invasive repair of an acute traumatic diaphragm rupture is feasible in selected trauma patients.