Evolution of a minimally invasive oesophagectomy program - effective complication management is key.

Introduction: Despite improvements in patient selection, operative technique, and postoperative care, oesophagectomy remains one of the most morbid oncologic resection types. Introduction of minimally invasive practice has been shown to have a greater marginal benefit for oesophagectomy than most of the other types of procedures. Aim: To evaluate early surgical outcomes through the adoption of totally minimally invasive oesophagectomy and accumulating experience in perioperative management. Material and methods: All patients with mid and distal oesophageal carcinoma who underwent oesophagectomy and gastric conduit construction between June 2004 and December 2021 were recorded prospectively. Demographic information, neoadjuvant treatment, operative data, and perioperative mortality/morbidity were evaluated. Patients were classified depending on the timeline and predominant surgical approach: Group 1 (2004-2011, open surgery), Group 2 (2011-2015, adoption period of minimally invasive surgery), and Group 3 (2015-2021, routine minimally invasive surgery). Results: In total, 167 patients were identified (Group 1, n = 48; Group 2, n = 44; Group 3, n = 75). Group 3 was significantly older (59.5 ±11.6 vs. 54.1 ±10.6 years and 56.2 ±10.8 years; p = 0.031).The likelihood of successful completion of a totally minimally invasive esophagectomy was increased as well as the preference for intrathoracic anastomosis (p < 0.0001 for both). The major morbidity rate was stable across the groups, but 90-day mortality significantly decreased for the most recent cohort. Conclusions: Accumulating experience led to enhanced success in completion of minimally invasive oesophagectomy, and intrathoracic anastomosis was increasingly the preferred modality. Surgical mortality decreased over time despite the older patients and comparable perioperative morbidity including anastomotic leaks. Improvement in the management of complications is an apparent contributor to good perioperative outcomes as well as technical development.

Uniportal video-assisted thoracoscopic surgery esophagectomy outcomes in 40 consecutive patients.

OBJECTIVES: Minimally invasive esophagectomy has improved over time becoming faster and less invasive. We have changed our technical approach from multiportal to uniportal video-assisted thoracoscopic surgery (VATS) esophagectomy over the years. In this study, we analysed our results with uniportal VATS esophagectomy technique. METHODS: This study was a retrospective analysis of 40 consecutive patients with the intent to perform uniportal VATS esophagectomy for esophageal cancer between July 2017 and August 2021. Demographic criteria, comorbidities, neoadjuvant therapy, intraoperative data, complications, length of stay, pathological data, 30- and 90-day mortality and 2-year survival data were recorded. RESULTS: Forty patients (21 female) were operated (median age 62.9 [53.5-70.25]). Eighteen patients (45%) received neoadjuvant chemoradiation. The chest part of all cases was started with uniportal VATS and 31 (77.5%) was completed uniportally (34 Ivor Lewis, 6 McKeown). The median thoracic operation time in minimally invasive Ivor Lewis esophagectomy was 90 min (77.5-100). The median time for uniportal side-to-side anastomosis was 12 min (11-16). Five (12.5%) patients had leak, and 4 were intrathoracic. Twenty-eight (70%) patients had squamous cell carcinoma, 11 adenocarcinoma and 1 squamous cell carcinoma with sarcomatoid differentiation. Thirty-seven (92.5%) patients had R0 resection. The mean number of lymph nodes dissected was 24 ± 9.5. Thirty- and ninety-day mortality was 2.5% (n = 1). The mean follow-up was 44 ± 2.8 months. Two-year survival was 80%. CONCLUSIONS: Uniportal VATS esophagectomy is a safe, fast and feasible alternative to other minimally invasive and open approaches. Comparable results to contemporary series are observed in perioperative and oncologic outcomes.

Consensus on technical procedures for simulation-based training in thoracic surgery: an international needs assessment.

OBJECTIVES: To identify and prioritize technical procedures for simulation-based training to be integrated into the thoracic surgical curriculum. METHODS: A 3-round Delphi survey was conducted from February 2022 to June 2022 among 34 key opinion leaders in thoracic surgery from 14 countries worldwide. The 1st round was a brainstorming phase to identify technical procedures that a newly qualified thoracic surgeon should be able to perform. All the suggested procedures were categorized, qualitatively analysed and sent to the 2nd round. The second round investigated: the frequency of the identified procedure at each institution, the number of thoracic surgeons that should be able to perform these procedures, the degree of risk to the patient if the procedure is performed by a non-competent thoracic surgeon and the feasibility of simulation-based education. In the 3rd round, elimination and re-ranking of the procedures from the 2nd round were performed. RESULTS: Response rates in the 3 iterative rounds were 80% (28 out of 34), 89% (25 out of 28) and 100% (25 out of 25) in the 1st, 2nd and 3rd round, respectively. Seventeen technical procedures were included for simulation-based training in the final prioritized list. The top 5 procedures were Video-Assisted Thoracoscopic Surgery (VATS) lobectomy, VATS segmentectomy, VATS mediastinal lymph node dissection, diagnostic flexible bronchoscopy and robotic-assisted thoracic surgery port placement, robotic-assisted thoracic surgery docking and undocking. CONCLUSIONS: The prioritized list of procedures represents a consensus of key thoracic surgeons worldwide. These procedures are suitable for simulation-based training and should be integrated in the thoracic surgical curriculum.

Online Survey Evaluation of Three Years of European Society of Thoracic Surgeons Educational Webinars as Part of The E-learning Platform.

BACKGROUND: E-learning has become an important tool in surgical education in the last decade. The European Society of Thoracic Surgeons launched its e-learning platform in 2013 and started its educational webinars series in 2018. The aim of this paper is to discuss the introduction, evolution and impact of the educational webinars within this e-learning platform. METHODS: Twenty-four English spoken webinars discussing different subdomains in general thoracic surgery (21 expert talks, 2 pro-con debates and 1 multidisciplinary case discussion) were analyzed. An online questionnaire on timing, quality and technical aspects of the webinars was sent to 3012 registrants. RESULTS: The webinars reached 3128 unique registrants from 76 countries worldwide. The mean number of registrants was 355 with 171 live attendees (48%) and 155 replay watchers (36%). Hundred and twenty-six attendees (13.1% of people who registered for at least 4 webinars) completed the questionnaire. Timing and duration of the webinars were rated "very good" to "excellent" in 78%, and the quality of the webinar content and the expertise of the webinar presenters were rated "very good" to "excellent" in 88% and 90%, respectively. The impact on knowledge and clinical practice was scored with a weighted average of 7.27 out of 10 and 6.79 out of 10, respectively. CONCLUSIONS: The ESTS educational webinars were effective in delivering up-to-date knowledge to almost half of the countries around the globe. The impact of these events on knowledge and clinical practice were rated high. New e-learning tools should be added to the surgical educational curriculum.

Macroscopic complete resection is not associated with improved survival in patients with malignant pleural mesothelioma.

OBJECTIVE: Macroscopic complete resection (MCR) is the recommended surgical strategy in malignant pleural mesothelioma. Our objective was to analyze whether MCR influences survival in malignant pleural mesothelioma. METHODS: Between 2002 and 2016, 154 patients underwent pleurectomy decortication (n = 90), extrapleural pneumonectomy (n = 42), or exploratory/diagnostic procedures (n = 22) in a single institution. Patient data were recorded in a prospective database. Patients who underwent surgical resection (n = 132) were analyzed according to MCR as a whole group and after propensity score matching based on gender, age, histology, clinical T and N status, adjuvant chemotherapy, and trimodality treatment. Kaplan-Meier survival and univariate and multivariate analyses were performed. RESULTS: Median age was 56 years (range, 26 to 80 years) and 62 were women. One hundred ten had epithelioid histology. MCR was achieved in 75 patients (49%). In-hospital mortality was seen in 7 patients (4.5%). Preoperative chemotherapy was applied in 32 patients. One hundred thirty-three patients underwent adjuvant treatment (45 had chemoradiation). Mean follow-up was 21 ± 19 months. Overall median survival, 2-year, and 5-year survivals were 18.1 months, 36%, and 16%, respectively. There was no difference in median survival between patients who underwent MCR (21.4 months) and who did not (16.3 months) (P = .6). Following propensity score matching (23 patients in each group), median survivals were similar (13.3 vs 14.2 months; P = .63). CONCLUSIONS: MCR was not associated with improved survival in malignant pleural mesothelioma. We need to clearly define MCR and identify subgroups of patients who would benefit from this principle because minimal versus extensive and location of gross residual disease may have different influences on survival.

Minimally invasive techniques in thymic surgery: a worldwide perspective.

Minimally invasive surgical techniques are important in surgical management of thymic pathologies. Traditional access techniques are being replaced with minimally invasive techniques using multiportal or uniportal approach. Adoption of minimally invasive techniques for thymic malignancies has been slow due to long term recurrence concerns. Recent studies show that minimally invasive video-assisted thoracoscopic surgery (VATS) or robotic approach to early stage thymic malignancies are associated with less intraoperative bleeding, lower rate of respiratory complications, shorter chest tube duration and shorter hospital stay. Oncologic outcomes are at least equivalent to open approach. Minimally invasive approach for benign pathologies is widely applied. There are significant variations in VATS approaches for thymus, showing a multinational interest in the issue of minimizing trauma during thymectomy. Use of robotic technology is also popular, as the retrosternal area is a narrow anatomic space to manipulate conventional instruments. The evolution of minimally invasive surgery for thymus has been possible with contribution from centers all around the world. In the current practice, various approaches are being adopted and every surgeon should prefer a technique depending on surgical preference and experience.

Turkey National Mesothelioma Surveillance and Environmental Asbestos Exposure Control Program.

Malignant mesothelioma (MM) is an important health problem due to ongoing asbestos exposure. Environmental asbestos exposure leads to a high risk of MM in Turkey. The Turkish Mesothelioma Working Group and the Turkish Public Health Institute designed and performed the Turkey National Mesothelioma Surveillance and Environmental Asbestos Exposure Control Program (TUNMES-EAECP). The aim of this study was to analyze the results of the TUNMES-EAECP. Patients diagnosed with MM (code C45.0-C45.9) between 2008 and 2012 were identified. The "from case to the field" method was used to determine the villages with current or previous asbestos exposure. Special public health teams took soil samples from these villages, which were then examined using an X-ray diffractometer. Direct Standardized Average Annual Mesothelioma Incidence Rate (AMIR) and relative risk (RR) of MM were calculated. Finally, a projection on the incidence of MM between 2013 and 2033 was made. The number of confirmed MM cases was 5617 with a male to female ratio of 1.36. Mean age was 61.7 ± 13.4 (20-96) years. The median survival was eight (95% CI 7.6-8.4) months. Asbestos exposure continues in 379 villages, with 158,068 people still living in high risk areas. The standardized AMIR was 2.33/100,000 per year. The risk of MM was higher in males, in both sexes over the age of 40, in asbestos-containing provinces, and in those where the TUNMES was organized. Among the population with continuing asbestos exposure in rural areas, the number of MM cases between 2013 and 2033 was estimated as 2511. As such, the incidence of MM in Turkey is as high as in industrialized countries. Asbestos exposure in rural areas continues to be a serious problem in Turkey, which obviates the necessity for effective preventive measures.

No Adverse Outcomes of Video-Assisted Thoracoscopic Surgery Resection of cT2 Non-Small Cell Lung Cancer during the Learning Curve Period.

BACKGROUND: Video-assisted thoracoscopic surgery (VATS) anatomic lung resections are gradually becoming the standard surgical approach in early-stage non-small cell lung cancer (NSCLC). The technique is being applied in cases of larger tumors depending on the experience of the surgical team. The objective of this study was to compare early surgical and survival outcomes in patients undergoing anatomic pulmonary resections using VATS and thoracotomy techniques for clinical T2 NSCLC during the adaptation period of the surgical team to the VATS approach. METHODS: The data of all patients who underwent anatomic pulmonary resection for NSCLC using VATS and open techniques since April 2012 were recorded to create a prospective lung cancer database. Clinical T2 NSCLC patients who underwent VATS anatomic lung resection were identified and compared with cT2 patients who underwent open resection. RESULTS: Between April 2012 and August 2014, 269 anatomical resections for NSCLC were performed (80 VATS and 189 thoracotomy). Thirty-four VATS patients who had clinical T2 disease were identified and stage-matched to thoracotomy patients. The average tumor diameter was comparable (34.2±11.1×29.8±10.1 mm vs. 32.3±9.8×32.5±12.2 mm, p=0.4). Major complications were higher in the thoracotomy group (n=0 vs. n=5, p=0.053). There was no 30-day mortality, and the 2-year survival rate was 91% for VATS and 82% for thoracotomy patients (p=0.4). CONCLUSION: VATS anatomic resections in clinical T2 NSCLC tumors are safe and have perioperative and pathologic outcomes similar to those of thoracotomy, while remaining within the learning curve.

Extrapleural pneumonectomy (EPP) vs. pleurectomy decortication (P/D).

Surgical techniques for treatment of malignant pleural mesothelioma (MPM) have improved over the decades. The main surgical principle was accepted as macroscopic complete resection. This principle was achieved with extrapleural pneumonectomy (EPP) and extended pleurectomy/decortication (P/D). Mortality and morbidity are higher following EPP with supraventricular arrhythmias, pulmonary embolism, bronchopleural fistula and pulmonary failure being the most common, while prolonged air leak is frequent following P/D. Completion of multimodality treatment was also shown to be a prognostic factor. Many different neoadjuvant and adjuvant protocols were applied with limited effect on prognosis. While locoregional recurrence is more common following P/D, EPP patients typically recur in contralateral hemithorax and abdomen. Hemithoracic radiation following EPP was the only effective technique shown to decrease locoregional recurrence. However, neither surgical technique (EPP vs. P/D), nor types of multimodality treatment protocols were found to be prognostic in MPM. Epithelioid histology, metastasis to extrapleural lymph nodes and completion of multimodality treatment were prognostic in most of the series. In conclusion, based on the current evidence, the choice of a less morbid and mortal procedure (P/D) seems to be the logical choice in the treatment of MPM.

Radiation field size and dose determine oncologic outcome in esophageal cancer.

BACKGROUND: Locoregional recurrence is a major problem in esophageal cancer patients treated with definitive concomitant chemoradiotherapy. Approximately half of the patients fail locoregionally. We analyzed the impact of enlarged radiation field size and higher radiation dose incorporated to chemoradiotherapy on oncologic outcome. METHODS: Seventy-four consecutive patients with histologically proven nonmetastatic squamous or adenocarcinoma of the esophagus were included in this retrospective analysis. All patients were locally advanced cT3-T4 and/or cN0-1. Treatment consisted of either definitive concomitant chemoradiotherapy (Def-CRT) (n = 49, 66 %) or preoperative concomitant chemoradiotherapy (Pre-CRT) followed by surgical resection (n = 25, 34 %). Patients were treated with longer radiation fields. Clinical target volume (CTV) was obtained by giving 8-10 cm margins to the craniocaudal borders of gross tumor volume (GTV) instead of 4-5 cm globally accepted margins, and some patients in Def-CRT group received radiation doses higher than 50 Gy. RESULTS: Isolated locoregional recurrences were observed in 9 out of 49 patients (18 %) in the Def-CRT group and in 1 out of 25 patients (3.8 %) in the Pre-CRT group (p = 0.15). The 5-year survival rate was 59 % in the Def-CRT group and 50 % in the Pre-CRT group (p = 0.72). Radiation dose was important in the Def-CRT group. Patients treated with >50 Gy (11 out of 49 patients) had better survival with respect to patients treated with 50 Gy (38 out of 49 patients). Five-year survivals were 91 and 50 %, respectively (p = 0.013). CONCLUSIONS: Radiation treatment planning by enlarged radiation fields in esophageal cancer decreases locoregional recurrences considerably with respect to the results reported in the literature by standard radiation fields (18 vs >50 %). Radiation dose is as important as radiation field size; patients in the Def-CRT group treated with ≥50 Gy had better survival in comparison to patients treated with 50 Gy.

Adoption of pleurectomy and decortication for malignant mesothelioma leads to similar survival as extrapleural pneumonectomy.

OBJECTIVE: We changed our surgical approach to malignant pleural mesothelioma (MPM) in August 2011 and adopted pleurectomy and decortication (PD) instead of extrapleural pneumonectomy (EPP). In this study, we analyzed our perioperative and survival results during the 2 periods. METHODS: All patients who underwent surgical intervention for MPM during 2003-2014 were included. Data were retrospectively analyzed from a prospective database. Before August 2011, patients underwent evaluation for EPP and adjuvant chemoradiation (group 1). After August 2011, patients were evaluated for PD and adjuvant chemotherapy and/or radiation (group 2). Demographic characteristics, surgical technique, histology, side, completeness of resection, and types of treatments were recorded. Statistics was performed using Student t test, χ(2) tests, uni- and multivariate regression, and Kaplan-Meier survival analysis. RESULTS: The same surgical team operated on 130 patients. Median age was 55.7 years (range, 26-80 years) and 76 were men. EPP and extended PD was performed in 72 patients. Ninety-day mortality was 10%. Median survival was 17.8 months with a 5-year survival rate of 14%. Uni- and multivariate analyses showed that epithelioid histology, stage N0, and trimodality treatment were associated with better survival (P = .039, P = .012, and P < .001, respectively). Demographic variables and overall survival (15.6 vs 19.6 months, respectively) were similar between the groups, whereas nonepithelioid histology, use of preoperative chemotherapy, and incomplete resections were more frequent in group 2 (P < .001, P < .001, and P = .006, respectively). Follow-up was shorter in group 2 (22.5 ± 20.6 vs 16.4 ± 10.9 months; P < .001). CONCLUSIONS: Adoption of PD as the main surgical approach is not associated with survival disadvantage in the surgical treatment of MPM.

Feasibility and Complications in Concomitant Lung Resection With Minimally Invasive Repair of Pectus Excavatum.

Minimally invasive repair of pectus excavatum (MIRPE) is the procedure of choice in experienced centers and can be offered in combination with other thoracic procedures. Between 2001 and 2013, 3 cases involving MIRPE and lung surgery were done in our clinic. While postoperative course of 2 procedures (MIRPE and video-assisted thoracoscopic surgery [VATS] segmentectomy and MIRPE and VATS bullectomy) were uncomplicated, the MIRPE and VATS lung biopsy patient developed major complications arising from prolonged air leak and was ultimately managed with an Eloesser flap. In carefully selected cases, simultaneous lung surgery and MIRPE can be done safely but problems of lung reexpansion, long-term drainage, and infection should be kept in mind.

Preoperative chemoradiation therapy decreases the number of lymph nodes resected during esophagectomy.

BACKGROUND: This study aimed to analyze the effect of preoperative chemoradiation on the adequacy of lymph node dissection. METHODS: Patients with esophageal cancer treated with esophagectomy by the same surgeon between 2004 and 2011 were reviewed. Specimens were examined by the same pathologist. Patients were grouped into two depending on the type of treatment received. RESULTS: Forty-seven patients with curative esophagectomy were included in the study. Twenty patients had preoperative chemoradiation followed by surgery and 27 had surgery alone. Open and hybrid esophagectomy approaches were used. The average number of lymph nodes dissected was 16 ± 10 (1-39). There was a significant decrease in the number of lymph nodes examined in patients with preoperative chemoradiotherapy in comparison to surgery alone (p = 0.001). Median length of stay was 12 days. R0 resection rate was 96%. The median survival was 36.3 months, with a 42% 5-year survival. Seven patients (25%) had complete pathologic response following chemoradiation. No significant difference was recorded in terms of disease recurrence (p = 0.3). While morbidity was higher in the preoperative therapy group with 30 day mortality of 10%, type of surgical approach does not seem to influence the number of lymph nodes dissected (p = 0.7). CONCLUSIONS: Preoperative chemoradiation decreases the number of harvested lymph nodes following esophagectomy regardless of the surgical technique used. The optimum number of lymph nodes currently recommended to be dissected for accurate nodal staging and survival needs revision in this group of patients.