Escolar Documentos
Profissional Documentos
Cultura Documentos
Original research
h i g h l i g h t s
This study evaluated a feasibility of laparoscopically assisted gastric pull-up (LAG) following thoracoscopic esophagectomy (TE).
LAG was compared with open laparotomy gastric pull-up (OLG) following TE.
No signicant difference was found between two groups in the technical and oncological outcomes.
LAG following TE was feasible in patient with thoracic esophageal cancer.
a r t i c l e i n f o
a b s t r a c t
Article history:
Received 6 November 2013
Received in revised form
23 March 2015
Accepted 9 April 2015
Available online 15 May 2015
Keywords:
Thoracoscopic surgery
Laparoscopic surgery
Esophageal cancer
1. Introduction
Surgical resection is the standard treatment for carcinoma of the
thoracic esophagus. However, the procedure is a complex; involves
the cervical, thoracic, and abdominal elds; and includes
thoracotomy or laparotomy or both. Accordingly, resection of carcinomas of the thoracic esophagus can be associated with signicant morbidity and mortality and a delay in return to preoperative
activity levels. Thoracolaparoscopic esophagectomy (TLE) is a type
of minimally invasive esophagectomy (MIE) for esophageal cancer
which comprises both thoracoscopic resection and laparoscopic
reconstruction. Such an MIE can produce less morbidity than open
operations and allows a quicker return to normal function [1]. We
have assessed the technical and oncological feasibility of
http://dx.doi.org/10.1016/j.ijsu.2015.04.040
1743-9191/ 2015 The Authors. Published by Elsevier Ltd on behalf of IJS Publishing Group Limited. This is an open access article under the CC BY-NC-SA license (http://
creativecommons.org/licenses/by-nc-sa/4.0/).
62
Fig. 1. Port placement and skin incisions. Filled circle, Filled circle: 5-mm port; lled
square: 12-mm port. Dotted line is additional minilaparotomy 3e4 cm in diameter.
63
Table 1
Clinical and pathological characteristics of TSEP with 3-eld lymph node dissection
according to method of gastric pull-up.
Number of Patients
Sex
male/female
Age, years
Median (range)
Location of tumors
Upper thorax
Middle thorax
Lower thorax
Clinical T status
cT1
cT2
cT3
Clinical N status
cN0
cN1
Clinical stage
I
IIA/IIB
III
Pathological T status
pT1
pT2
pT3
Pathological N status
pN0
pN1
Pathological stage
I
IIA/IIB
III
IVA
Total
OLG
LAG
64
33
31
56/8
28/5
28/3
66 (49e78)
65 (49e76)
66 (49e78)
7
23
34
7
14
12
0
9
22
45
6
13
30
1
2
15
5
11
60
4
31
2
29
2
43
16/3
2
29
2/1
1
14
14/2
1
46
7
11
28
4
18
3
10
45
19
27
6
18
13
37
6/12
6
3
24
2/6
0
1
13
4/6
6
2
P Value
0.71
0.45
0.01
0.001
1.0
0.002
0.002
0.035
0.05
64
Table 2
Surgical outcomes of TSEP with 3-eld lymph node dissection according to method of gastric pull-up.
Number of Patients
Conversion to open procedure
to thoracotomy
to laparotomy
Operation time (minutes)
Mean (range)
Total
Thoracic phase
Abdominal phase
Amount of blood loss (ml)
Mean (range)
Total
Thoracic phase
Abdominal phase
Number of dissected lymph nodes
Mean (range)
Total
Thoracic phase
Abdomen
Completeness of resection
R0
R1
Total
OLG
LAG
64
33
31
P Value
3
0
1
0
1.0
409 (297e569)
217 (123e325)
161 (90e248)
390 (297e480)
233 (147e325)
131 (90e235)
429 (308e569)
200 (123e256)
194 (145e248)
0.009
0.006
0.0001
396 (28e4225)
157 (5e4138)
238 (1e1131)
498 (28e4225)
250 (5e4138)
249 (40e618)
286 (50e1183)
59 (8e263)
227 (1e1131)
0.13
0.15
0.71
57 (20e88)
24 (6e44)
15 (5e31)
57 (26e88)
23 (7e39)
15 (5e31)
58 (20e85)
25 (6e44)
15 (5e29)
0.77
0.24
0.56
1.0
63
1
32
1
31
0
Table 3
Postoperative course and complications of TSEP with 3-eld lymph node dissection according to method of gastric pull-up.
Number of Patients
Deaths
Morbidity: number of cases (%)
Pneumonia
Recurrent laryngeal nerve palsy
Anastomotic leakage
Surgical site infection
Chylothorax
Postoperative hospital stay, days
Mean (range)
OLG: open laparotomy gastric pull-up.
LAG: laparoscopic assisted gastric pull-up.
Total
OLG
LAG
64
0
22 (34)
0
9 (14)
10 (16)
5 (9)
3 (5)
33
0
12 (36)
0
6 (18)
4 (12)
5 (15)
1 (3)
31
0
10 (32)
0
3 (10)
6 (19)
0
2 (6)
20 (10e76)
19 (13e51)
20 (10e76)
P Value
0.80
0.48
0.50
0.05
0.61
0.76
65
Table 4
Restoration rate of respiratory function between before and after operation according to method of gastric pull-up.
Before
VC (L)
%VC
FVC (L)
FEV1.0 (L)
FEV1.0%
3.3
97.5
3.2
2.4
77.0
OLG after
0.7
17.4
0.7
0.6
6.1
2.4
71.0
2.3
1.8
75.0
0.7
15.6
0.6
0.5
15.4
Restoration rate
72.3
73.2
73.1
72.1
97.3
14.0
14.5
14.5
14.2
8.3
Before
3.5
110.9
3.5
2.7
75.3
LAG after
0.6
17.2
0.6
0.4
9.0
2.6
81.3
2.6
2.0
77.0
0.6
16.1
0.6
0.5
13.2
Restoration rate
74.7
73.5
73.3
72.4
131.5
11.0
10.4
10.4
14.0
172.0
P Value
0.51
0.93
0.93
0.94
0.37
Table 5
Pattern of rst failure of TSEP with 3-eld lymph node dissection according to
method of gastric pull-up.
Number of Patients
Median follow-up time, days
Pattern of recurrence: n
Locoreginal
Thorax
Abdomen
Distant
Both
Total
OLG
LAG
64
601
7
2
2
0
4
1
33
784
3
2
2
0
0
1
31
412
4
0
0
0
4
0
P Value
0.70
the abdominal phase is of particular importance for the perioperative outcome and oncological completeness of resection.
In the present study, we have demonstrated the technical and
oncological feasibility of LAG in comparison with conventional
open abdominal procedures for esophageal cancer. We found no
signicant differences between LAG and OLG in the mean number
of dissected abdominal lymph nodes, volume of blood loss, incidence of postoperative complications, mean postoperative hospital
stay, restoration rate of respiratory function, or rate of complete
resection or locoregional control, but the mean duration of
abdominal procedure was signicantly longer for LAG than for OLG.
Pulmonary function is suppressed after abdominal surgery
because of diaphragmatic dysfunction and postoperative pain.
Several randomized trials have demonstrated that FVC and FEV1.0
value are suppressed less after laparoscopic cholecystectomy than
after open procedures [24e26]. However, Kitano et al. have reported that the suppression of FVC differs signicantly between
laparoscopically assisted distal gastrectomy and open distal gastrectomy but that the suppression of FEV1.0 does not [27]. Moreover, Stage et al. have found no signicant difference in pulmonary
function between a laparoscopic colectomy and open colectomy
[28]. Whether laparoscopic surgery or open surgery causes greater
suppression of pulmonary function remains controversial. Therefore, a study with a large number of cases is necessary to investigate
the effects of laparoscopic surgery and open surgery on pulmonary
function.
A previous study has demonstrated the safety and oncological
feasibility of throacoscopic MIE but did not assess the technical and
oncological feasibility of LAG compared with conventional open
abdominal procedures for esophageal cancer [2]. The present
report is, to our knowledge, the rst to demonstrate the technical
and oncological feasibility of alimentary tract reconstruction with
LAG following TSEP and extended lymph-node dissection for
esophageal cancer. The safety and oncological effectiveness of
reconstruction with LAG following TSEP are comparable to those of
reconstruction with OLG. For these reasons, we believe TLE consisting of TSEP followed by LAG has the potential to become a
standard surgical treatment and the ultimate minimally invasive
surgery for esophageal cancer.
This study demonstrates that the quality and safety of surgery
and the oncological effectiveness of LAG for esophageal cancer. We
conclude that TLE, consisting of TSEP followed by LAG with
extended lymph node dissection, is a feasible surgical technique for
thoracic esophageal carcinoma.
Conict of interest
None.
References
[1] J.D. Luketich, M. Alvelo-Rivera, P.O. Buenaventura, N.A. Christie,
J.S. McCaughan, V.R. Litle, et al., Minimally invasive esophagectomy: outcomes
in 222 patients, Ann. Surg. 238 (2003) 486e494 discussion 94e5.
66
[2] H. Daiko, M. Nishimura, A pilot study of the technical and oncologic feasibility
of thoracoscopic esophagectomy with extended lymph node dissection in the
prone position for clinical stage I thoracic esophageal carcinoma, Surg. Endosc.
26 (2012) 673e680.
[3] H. Akiyama, M. Tsurumaru, H. Udagawa, Y. Kajiyama, Radical lymph node
dissection for cancer of the thoracic esophagus, Ann. Surg. 220 (1994)
364e372 discussion 72e3.
[4] J.D. Urschel, Esophagogastric anastomotic leaks: the importance of gastric
ischemia and therapeutic applications of gastric conditioning, J. Invest. Surg.
11 (1998) 245e250.
[5] C. Mariette, G. Piessen, J.P. Triboulet, Therapeutic strategies in oesophageal
carcinoma: role of surgery and other modalities, Lancet Oncol. 8 (2007)
545e553.
[6] N. Ni Choileain, H.P. Redmond, Cell response to surgery, Arch. Surg. 141 (2006)
1132e1140.
[7] M.B. Orringer, B. Marshall, M.D. Iannettoni, Transhiatal esophagectomy: clinical experience and renements, Ann. Surg. 230 (1999) 392e400 discussion
00e3.
[8] R. Rindani, C.J. Martin, M.R. Cox, Transhiatal versus Ivor-Lewis oesophagectomy: is there a difference? Aust. N. Z. J. Surg. 69 (1999) 187e194.
[9] U. Zingg, A. McQuinn, D. DiValentino, A.J. Esterman, J.R. Bessell,
S.K. Thompson, et al., Minimally invasive versus open esophagectomy for
patients with esophageal cancer, Ann. Thorac. Surg. 87 (2009) 911e919.
[10] T.H. Pham, K.A. Perry, J.P. Dolan, P. Schipper, M. Sukumar, B.C. Sheppard, et al.,
Comparison of perioperative outcomes after combined thoracoscopiclaparoscopic esophagectomy and open Ivor-Lewis esophagectomy, Am. J.
Surg. 199 (2010) 594e598.
[11] S. Law, M. Fok, K.M. Chu, J. Wong, Thoracoscopic esophagectomy for esophageal cancer, Surgery 122 (1997) 8e14.
[12] S. Taguchi, H. Osugi, M. Higashino, T. Tokuhara, N. Takada, M. Takemura, et al.,
Comparison of three-eld esophagectomy for esophageal cancer incorporating open or thoracoscopic thoracotomy, Surg. Endosc. 17 (2003)
1445e1450.
[13] T. Shiraishi, K. Kawahara, T. Shirakusa, S. Yamamoto, T. Maekawa, Risk analysis in resection of thoracic esophageal cancer in the era of endoscopic surgery, Ann. Thorac. Surg. 81 (2006) 1083e1089.
[14] T. Fabian, J.T. Martin, A.A. McKelvey, J.A. Federico, Minimally invasive
esophagectomy: a teaching hospital's rst year experience, Dis. Esophagus 21
(2008) 220e225.
[15] R. Parameswaran, D. Veeramootoo, R. Krishnadas, M. Cooper, R. Berrisford,
S. Wajed, Comparative experience of open and minimally invasive esophagogastric resection, World J. Surg. 33 (2009) 1868e1875.
[16] B.M. Smithers, D.C. Gotley, I. Martin, J.M. Thomas, Comparison of the outcomes between open and minimally invasive esophagectomy, Ann. Surg. 245
(2007) 232e240.
[17] Y. Kinjo, N. Kurita, F. Nakamura, H. Okabe, E. Tanaka, Y. Kataoka, et al.,
Effectiveness of combined thoracoscopic-laparoscopic esophagectomy: comparison of postoperative complications and midterm oncological outcomes in
patients with esophageal cancer, Surg. Endosc. 26 (2012) 381e390.
[18] N.T. Nguyen, P. Roberts, D.M. Follette, R. Rivers, B.M. Wolfe, Thoracoscopic and
laparoscopic esophagectomy for benign and malignant disease: lessons
learned from 46 consecutive procedures, J. Am. Coll. Surg. 197 (2003)
902e913.
[19] S. Sihag, C.D. Wright, J.C. Wain, H.A. Gaissert, M. Lanuti, J.S. Allan, et al.,
Comparison of perioperative outcomes following open versus minimally
invasive Ivor Lewis oesophagectomy at a single, high-volume centre, Eur. J.
Cardiothorac. Surg. 42 (2012) 430e437.
[20] H. Tsujimoto, R. Takahata, S. Nomura, Y. Yaguchi, I. Kumano, Y. Matsumoto, et
al., Video-assisted thoracoscopic surgery for esophageal cancer attenuates
postoperative systemic responses and pulmonary complications, Surgery 151
(2012) 667e673.
[21] A. Cuschieri, Thoracoscopic subtotal oesophagectomy, Endosc. Surg. Allied
Technol. 2 (1994) 21e25.
[22] C. Palanivelu, A. Prakash, R. Senthilkumar, P. Senthilnathan, R. Parthasarathi,
P.S. Rajan, et al., Minimally invasive esophagectomy: thoracoscopic mobilization of the esophagus and mediastinal lymphadenectomy in prone positioneexperience of 130 patients, J. Am. Coll. Surg. 203 (2006) 7e16.
[23] H. Noshiro, H. Iwasaki, K. Kobayashi, A. Uchiyama, Y. Miyasaka, T. Masatsugu,
et al., Lymphadenectomy along the left recurrent laryngeal nerve by a minimally invasive esophagectomy in the prone position for thoracic esophageal
cancer, Surg. Endosc. 24 (2010) 2965e2973.
[24] P.R. Schauer, J. Luna, A.A. Ghiatas, M.E. Glen, J.M. Warren, K.R. Sirinek, Pulmonary function after laparoscopic cholecystectomy, Surgery 114 (1993)
389e397 discussion 97e9.
[25] A.J. McMahon, J.N. Baxter, G. Kenny, P.J. O'Dwyer, Ventilatory and blood gas
changes during laparoscopic and open cholecystectomy, Br. J. Surg. 80 (1993)
1252e1254.
[26] R.C. Frazee, J.W. Roberts, G.C. Okeson, R.E. Symmonds, S.K. Snyder,
J.C. Hendricks, et al., Open versus laparoscopic cholecystectomy. A comparison
of postoperative pulmonary function, Ann. Surg. 213 (1991) 651e653 discussion 53e4.
[27] S. Kitano, N. Shiraishi, K. Fujii, K. Yasuda, M. Inomata, Y. Adachi, A randomized
controlled trial comparing open vs laparoscopy-assisted distal gastrectomy
for the treatment of early gastric cancer: an interim report, Surgery 131
(2002) S306eS311.
[28] J.G. Stage, S. Schulze, P. Moller, H. Overgaard, M. Andersen, V.B. RebsdorfPedersen, et al., Prospective randomized study of laparoscopic versus open
colonic resection for adenocarcinoma, Br. J. Surg. 84 (1997) 391e396.