Anterior gastric wall anastomosis may lead to lower rate of delayed gastric emptying after minimally invasive Ivor Lewis esophagectomy: a retrospective cohort study.

INTRODUCTION: In minimally invasive esophagectomy, a circular stapled anastomosis is common, but no evidence exists investigating the role of the specific localization of the anastomosis. The aim of this study is to evaluate the impact of an esophagogastrostomy on the anterior or posterior wall of the gastric conduit on the postoperative outcomes. MATERIAL AND METHODS: All oncologic minimally invasive Ivor Lewis procedures, performed between 2017 and 2022, were included in this study. The cohort was divided in two groups: a) intrathoracic esophagogastrostomy on the anterior gastric wall of the conduit (ANT, n = 285, 65%) and b) on the posterior gastric wall (POST, n = 154, 35%). Clinicopathological parameters and short-term outcomes were compared between both groups by retrieving data from the prospective database. RESULTS: Overall, 439 patients were included, baseline characteristics were similar in both groups, there was a higher proportion of squamous cell carcinoma in ANT (22.8% vs. 16.2%, P = 0.043). A higher rate of robotic-assisted procedures was observed in ANT (71.2% vs. 49.4%). Anastomotic leakage rate was similar in both groups (ANT 10.4% vs. POST 9.8%, P = 0.851). Overall complication rate and Clavien-Dindo > 3 complication rates were higher in POST compared to ANT: 53.2% vs. 40% (P = 0.008) and 36.9% vs. 25.7% (P = 0.014), respectively. The rate of delayed gastric emptying (20.1% vs. 7.4%, P < 0.001) and nosocomial pneumonia (22.1% vs. 14.8%, P = 0.05) was significantly higher in POST. CONCLUSION: Patients undergoing minimally invasive Ivor Lewis esophagectomy with an intrathoracic circular stapled anastomosis may benefit from esophagogastrostomy on the anterior wall of the gastric conduit, in terms of lower rate of delayed gastric emptying.

[Anastomotic techniques in minimally invasive esophageal and gastric surgery]. / Anastomosentechniken in der minimal-invasiven Ösophagus- und Magenchirurgie.

In specialized centers minimally invasive surgery has become established as the standard of care for esophageal and gastric surgery. Offering equal oncological outcome, patients benefit with respect to lower postoperative pain and complication rates. The creation of the anastomosis during minimally invasive surgery remains a critical step and the complications are decisive for the immediate postoperative course. So far no clear consensus exists in the literature regarding the recommended techniques for placement of an anastomosis after resections in the upper gastrointestinal tract. This article summarizes and compares the various established anastomotic techniques used in minimally invasive esophageal and gastric surgery.

[Minimum case volume regulations in surgery from the perspective of the specialist society (DGCH) : Balancing act between science, politics, treatment reality and a range of other aspects]. / Mindestmengenregelungen in der Chirurgie aus Sicht der Fachgesellschaft (DGCH) : Spagat zwischen Wissenschaft, Politik, Versorgungsrealität und einer Reihe weiterer Aspekte.

The scientifically founded surgical specialist discussion regarding the legal requirements for minimum volume numbers for diverse organ systems and selected surgical procedures as the basis of quality assurance and optimization of treatment is not new. Comprehensive and also reliable data from national and international studies are available for colorectal surgery, pancreatic surgery, esophageal surgery, liver surgery and gastric surgery. Recently, the raising of the minimum volume for complex esophageal interventions by the Federal Joint Committee (G-BA) in Germany from 10 up to 26 procedures per hospital and year, reignited the debate on this topic as well as the debate on centralization in the healthcare system in general. This decision seems to be scientifically well-justified from the perspective of political bodies and realizable in the practical implementation; however, from the perspective of physicians routinely involved in the corresponding highly complex procedures, there is a very much broader basis for discussion, which is only partially covered by a report of the Institute for Quality and Efficiency in the Healthcare System (IQWiG) as the foundation of the decision of the G­BA. For the scientifically oriented surgical specialist society, in the first instance priority is given to the scientific evidence as the guiding principle. Nevertheless, aspects of the treatment reality cannot and should not be ignored. Therefore, the recommendations of the specialist society must be oriented not only to the quality of results but also to the realistic options for successful implementation in practice. Furthermore, questions of further education, the right of the patient to freedom of choice of the physician and preservation of the attractiveness of the occupational profile of surgeons are immanent topics for the surgical specialist society.

Robotic-assisted surgery for esophageal submucosal tumors: a single-center case series.

Esophageal submucosal tumors (SMTs) are rare heterogenous clinical entities. The surgical resection can be performed in different surgical approaches. However, the robotic surgical strategy is poorly documented in the treatment of SMTs. We present our series of operated esophageal SMTs approached via robotic-assisted surgery. Six patients with symptomatic esophageal submucosal tumors underwent robotic surgery within a 3-year period. The performed procedures were robotic-assisted enucleation, robotic esophagectomy (RAMIE) and reverse hybrid robotic esophagectomy. Patients' clinical data, intra/postoperative outcomes, and histopathological features were retrieved from the institution's prospective database. Five of six patients were scheduled for upfront surgery: four underwent robotic enucleation (three leiomyoma and one suspected GIST) and one underwent reverse hybrid robotic esophagectomy (suspected GIST). One patient, diagnosed with GIST, was treated with neoadjuvant Imatinib therapy, before undergoing a RAMIE. No major intra-operative complications were recorded. Median length of stay was 7 days (6-50), with a longer post-operative course in patients who underwent esophagectomy. Clavien-Dindo > 3a complications occurred in two patients, aspiration pneumonia and delayed gastric emptying. The final histopathological and immuno-histochemical diagnosis were leiomyoma, well-differentiated GIST, low-grade fibromyxoid sarcoma and Schwannoma. Robotic-assisted surgery seems to be a promising option for surgical treatment strategies of benign or borderline esophageal submucosal tumors.

[Complete response after neoadjuvant therapy for gastric cancer: implications for surgery]. / Komplette Response nach neoadjuvanter Therapie beim Magenkarzinom: Implikationen für die Chirurgie.

BACKGROUND: Perioperative or neoadjuvant therapy is the mainstay of treatment for locally advanced gastric cancer in Europe; however, data regarding possible modifications in the surgical strategy depending on the response to preoperative treatment are lacking. METHODS: This review was carried out based on a search of the relevant contemporary literature regarding neoadjuvant or perioperative treatment for gastric adenocarcinoma and the implications of tumor response for the subsequent surgical treatment. RESULTS: The most recent randomized trials showed a survival benefit after perioperative or neoadjuvant treatment for gastric cancer. Due to the variable response to the preoperatively administered part of the therapy, including complete response, it appears reasonable to develop an individualized surgical approach; however, scientific results supporting this approach are limited due to the variable quality of the surgical resection provided in these studies and the limited rate of complete response to preoperative treatment. Moreover, the reliability of clinical restaging after preoperative treatment is also limited. On the other hand, there is currently evidence that supports a re-evaluation of the necessary resection margins for partial gastrectomy in advanced gastric cancer with the help of intraoperative frozen sections and new reconstruction methods. CONCLUSION: The current evidence does not support the implementation of a complete organ-sparing strategy with active follow-up surveillance for gastric cancer.; however, stomach-preserving partial gastrectomy techniques could be applied for advanced disease more often in the future.

Robot-Assisted Minimally Invasive Esophagectomy with Intrathoracic Anastomosis (Ivor Lewis): Promising Results in 100 Consecutive Patients (the European Experience).

BACKGROUND: Robot-assisted minimally invasive esophagectomy (RAMIE) with intrathoracic anastomosis is gaining popularity as a treatment for esophageal cancer. The aim of this study was to describe postoperative complications and short-term oncologic outcomes for RAMIE procedures using the da Vinci Xi robotic system 4-arm technique. METHODS: Data of 100 consecutive patients with esophageal or gastro-esophageal junction carcinoma undergoing modified Ivor Lewis esophagectomy were prospectively collected. All operations were performed by the same surgeon using an identical intrathoracic anastomotic reconstruction technique with the same perioperative management. Intraoperative and postoperative complications were graded according to Esophagectomy Complications Consensus Group (ECCG) definitions. RESULTS: Mean duration was 416 min (±80); 70% of patients had an uncomplicated postoperative recovery. Pulmonary complications were observed in 17% of patients. Anastomotic leakage was observed in 8% of patients. Median ICU stay was 1 day and median overall postoperative hospital stay was 11 days. The 30-day mortality was 1%; 90-day mortality was 3%. A R0 resection was reached in 92% of patients with a median number of 29 dissected lymph nodes. All patients had at least 7 months of follow-up with a median follow-up of 17 months. Median overall survival was not reached yet. CONCLUSION: RAMIE with intrathoracic anastomosis (Ivor Lewis) for esophageal or gastro-esophageal junction cancer was technically feasible and safe. Postoperative complications and short-term oncologic results were comparable to the highest international standards nowadays.

Technical details of the abdominal part during full robotic-assisted minimally invasive esophagectomy.

The full robotic-assisted minimally invasive esophagectomy (RAMIE) is an upcoming approach in the treatment of esophageal and junctional cancer. Potential benefits are seen in angulated precise maneuvers in the abdominal part as well as in the thoracic part, but due to the novelty of this approach the optimal setting of the trocars, the instruments and the operating setting is still under debate. Hereafter, we present a technical description of the 'Mainz technique' of the abdominal part of RAMIE carried out as Ivor Lewis procedure. Postoperative complication rate and duration of the abdominal part of 100 consecutive patients from University Medical Center in Mainz are illustrated. In addition, the abdominal phase of the full RAMIE is discussed in general.

C-reactive Protein Levels After Esophagectomy Are Associated With Increased Surgical Trauma and Complications.

BACKGROUND: With the introduction of minimally invasive esophagectomy, postoperative complications rates have decreased. Daily laboratory tests are used to screen patients for postoperative complications. The course of inflammatory indicators after esophagectomy after different surgical approaches has not been described yet. The aim of the study was to describe the postoperative C-reactive protein (CRP) and leukocyte levels after different surgical approaches for esophagectomy and relate it to postoperative complications. METHODS: Between 2010 and 2018, 217 consecutive patients underwent thoracoabdominal esophagectomy with gastric conduit reconstruction. Blood tests to assess CRP and leukocytes were performed daily in all patients. Differences between treatment groups were analyzed with a linear mixed model. All postoperative complications were recorded in a prospective database. Prognostic factors were analyzed using multivariate logistic regression modeling. RESULTS: The study evaluated 4 different esophagectomy techniques: open (n = 57), hybrid (n = 53), totally minimally invasive (n = 52), and robot-assisted minimally invasive (n = 55). The increase of inflammatory indicators was significantly higher after open esophagectomy on the first 2 postoperative days compared with the 3 minimally invasive procedures (P < .001). Postoperative CRP values exceeding 200 mg/L on the second postoperative day and open esophagectomy were independently associated with postoperative complications. CONCLUSIONS: Open esophagectomy results in significantly higher CRP and leukocyte values compared with hybrid, minimally invasive, and robot-assisted minimally invasive esophagectomy. Open esophagectomy and a CRP increase on the second postoperative day above 200 mg/L are independent positive predictors for postoperative complications in multivariate analysis.

The da Vinci Xi Robotic Four-Arm Approach for Robotic-Assisted Minimally Invasive Esophagectomy.

Robotic surgery is gaining importance in complex thoracoscopic surgery, such as robotic-assisted minimally invasive esophagectomy (RAMIE). The RAMIE procedure was designed using the first generation of the robotic system. The latest da Vinci Xi system has substantially increased the dexterity, especially designed for multiquadrant surgery. The original three-arm RAMIE approach was modified including the robotic four-arm use for the thoracoscopic and laparoscopic part of the operation. This extended approach (four-arm RAMIE approach) provides more flexibility and raises the independence of the surgeon.