OPERATIVE OUTCOMES IN THORACOSCOPIC-ESOPHAGECTOMY WITH TWO-LUNG VENTILATION IN PRONE POSITION

Objective: To study the post-operative outcomes of two-lung ventilation in patients undergoing prone position thoracoscopicesophagectomy. Study Design: Prospective comparative study. Place and Duration of Study: Department of Thoracic Surgery, Combined Military Hospital, Rawalpindi Pakistan, from Jan to Dec 2019. Methodology: A total of 60 patients operated for both groups of thoraco-esophagectomy in which 34 patients for TLV (two-lung ventilation) and 26 patients for One-lung ventilation were studied. Patients position was prone for Two-lung ventilation in Thoracoscopic-esophagectomy. Post-op blood loss, Hospital stay, duration of anesthesia and operative morbidity was calculated. Results: A total of 60 patients underwent two-lung ventilation in prone position out of which patient of thoracoscopicesophagectomy were 34, while 26 underwent One-lung ventilation in semi-decubitus position thoracoscopic-esophagectomy. All of them were successfully performed without conversion to open thoracotomy. In the study with preparation span for anesthesia induction, mean time of mobilization of thoracic esophagus, mean blood loss during the thoracic mobilization phase, the mean Intensive care unit stay and total hospital stay in two-lung ventilation was less than one-lung ventilation (p<0.05). Conclusion: The present study summarized the clinical outcomes of two-lung ventilation for thoracoscopic-esophagectomy operated patients. This study data showed that Two-lung ventilation intubation in prone position is better approach during the Thoracoscopic-esophagectomy.

Semi-Prone Thoracoscopic Esophagectomy for Esophageal Carcinoma with Aberrant Right Subclavian Artery and Non-Recurrent Inferior Laryngeal Nerve: A Case Report

Background Aberrant right subclavian artery (ARSA) accompanied by non-recurrent inferior laryngeal nerve (NRILN) is a rare anomaly. In cases of thoracic esophageal carcinoma associated with ARSA and NRILN, surgeons must take extra care not to injury these vessels and nerves. We believe semi-prone thoracoscopic esophagectomy to be a surgical approach that can safely deal with such an anomaly. Case presentation: A 70-year-old man complained of feelings of chest constriction. Endoscopic examination revealed an esophageal tumor and computed tomography showed an ARSA. we performed semi-prone thoracoscopic esophagectomy for case with ARSA and NRILN. We identified these anomalies during esophagectomy, and we could complete surgery without injury these vessels and nerves. The patient had an uneventful recovery and discharged 22 days after surgery. Conclusions Semi-prone thoracoscopic esophagectomy for esophageal carcinoma can be performed safely with a wide operative field, and is an excellent procedure for dissecting esophageal carcinoma in patients with ARSA and NRILN.

Carcinosarcoma of the Thoracic Esophagus That Presented as Focal Ulcerative Lesion

Esophageal carcinosarcoma is a rare malignant tumor composed of both carcinomatous and sarcomatous elements. We report a case of esophageal carcinosarcoma in a 56-year-old woman with dysphagia. Esophageal ulcerative tumors were detected by endoscopy and resected by thoracoscopic esophagectomy. Carcinosarcoma was confirmed by the presence of both carcinomatous and sarcomatous tumor components. On immunohistochemistry, the sarcomatous area was positive for keratin staining, while the sarcomatous area was positive for vimentin staining. The tumor reportedly had a better prognosis than SCC of the esophagus, especially in terms of survival rate. The patient’s disease was classified as ypT3N0M0, ypStage II. No definitive diagnosis was made preoperatively. We report this case along with a review of the literature.

535 EVALUATION OF THORACOSCOPIC ESOPHAGECTOMY FOR ESOPHAGEAL CANCER FROM 650 CASES IN A SINGLE INSTITUTE

Minimally invasive surgery (MIS) for esophageal cancer has been wide-spreading in worldwide since the first report in 1992. In Japan, we firstly introduced thoracoscopic esophagectomy as a MIS for esophageal cancer in 1994 and performed more than 650 cases over the last two decades. The aim of the present study is to evaluate an oncological feasibility and less invasiveness of this operation from short and long term results. Methods Thoracoscopic esophagectomy was performed in almost all resectable thoracic esophageal cancer patient, briefly indication for this operation is cT1-T3 tumors and lymph node involvement within the regional lesion. We performed thoracoscopic esophagectomy with one lung ventilation in left lateral decubitus position (Group L) up to 2011. From 2012, prone thoracoscopic esophagectomy with bilateral ventilation and artificial pneumothorax (Group P) has been undergone. We analyzed the long-term outcome in all patients who received thoracoscopic esophagectomy with or without neoadjuvant treatment. Furthermore, we evaluated the less invasiveness from the results of short-term outcome and operation-related morbidity between Group L and Group P. Results The 5-year survival rates in no treatment before surgery cases were 61.9% overall, and 86.9%, 71.5%, 68.1%, 40.9%, 37.4% for pathological stages I, IIA, IIB, III and IVa, respectively (TNM classification 6th edition). 30 days mortality in this series was 0.6%. 5-year survival in cStage II and III with neoadjuvant chemotherapy was 65.7%. 3-year survival in salvage esophagectomy after failure of definitive chemoradiotherapy with R0 resection was 43.0%. Total amount of blood loss, rate of postoperative pulmonary complications and the postoperative inflammatory response were significantly lower in Group P than in Group L. Conclusion Thoracoscopic esophagectomy is safety and oncologically feasible. From the view point of less invasiveness benefits, prone esophagectomy has advantages than lateral decubitus procedure and this operation is recommended in almost all patients with a resectable esophageal cancer.

221 THORACOSCOPIC ESOPHAGECTOMY WITH OR WITHOUT SMALL THORACOTOMY FOR ADVANCED THORACIC ESOPHAGEAL CARCINOMA IN THE LEFT LATERAL DECUBITUS POSITION

Standardized thoracoscopic esophagectomy for thoracic esophageal carcinoma in the left lateral decubitus position under artificial pneumothorax is slightly more difficult to dissect the middle and lower mediastinum than in prone position, but it is possible to operate the upper mediastinum with good visual field. In salvage surgery after definitive chemoradiotherapy, it is difficult to complete the operation only by throscopic surgery, and it is thought that sometimes small thoracotomy can be performed safely and reliably. Methods If this procedure is considered feasible, start with thoracoscopic surgery. If it is decided that the procedure cannot be completed, add a small thoracotomy of about 10–15 cm to allow one hand. Thoracoscopy not only reduced invasiveness, shared detailed anatomy, but also improved operability by taping the esophagus and ensured emergency safety. Results This standardized procedure is applied to salvage surgery after definitive chemoradiotherapy from January 2016 to March 2019. Thoracoscopic surgery was performed in 14 of the 27 cases (52%). Thoracoscopic surgery was completed in 10 cases and small thoracotomy was used in 4 cases. There are no serious complications such as bleeding. Conclusion Starting surgery with a thoracoscopy and adding small thoracotomy as appropriate can share the advantages of thoracotomy and throcoscopic surgery. This technique has the advantage that it can be easily converted to thoracotomy even in an emergency, and is considered to be superior to advanced cancer. Video https://www.dropbox.com/sh/47jcqu3palpsfvg/AAC4PvReWDP_WPBkJufxWU3da?dl=0.

436 PRONE THORACOSCOPIC ESOPHAGECTOMY FOR PATIENTS WITH LOW PULMONARY FUNCTION

Thoracoscopic esophagectomy in the prone position (TEP) for esophageal cancer is reported to have superiority in preserving postoperative respiratory function and reducing postoperative respiratory complications. In Japan, the majority of patients with esophageal cancer are smokers and have obstructive ventilation disorders. But, the feasibirity and safety of TEP for patients with low respiratory function is unclear. Objectives To clarify the feasibirity and safety of TEP for esophageal cancer patients with obstructive respiratory function. Methods The 95 patients with obstructive respiratory disorder who underwent TEP and gastric tube reconstruction via posterior mediastinal route for esophageal cancer from January 2016 to April 2019 were divided into the two groups, low respiratory function (LRF) group and the control group. Short-term outcomes were compared between two groups. Results The control group was 73 cases, and the LRF group was 22 cases. Propensity score matching using age, gender, cT, and cN as covariates was used to identify matched patients (22 per group) in both groups. There were no differences in operation time of overall and intrathoracic part, or blood loss in each group. In the postoperative complications, pneumonia (13.6% vs. 9.1%), recurrent laryngeal palsy (18.2% vs. 22.7%), anastomotic leakage (13.6% vs. 13.6%) and hospital stay (36.3 days vs 27.5 days) were no differences in both groups. Conclusion TEP can be feasible and safe for the patients with obstructive ventilation disorder and low respiratory function.