Open versus hybrid versus totally minimally invasive Ivor Lewis esophagectomy: Systematic review and meta-analysis.

BACKGROUND: Hybrid and minimally invasive approaches have emerged as less invasive alternatives to open Ivor Lewis esophagectomy. The aim of this study was to compare surgical outcomes between open (OE), hybrid (HE), and totally minimally invasive esophagectomy (TMIE). METHODS: A systematic literature search was performed to analyze outcomes after OE, HE, and TMIE with intrathoracic anastomosis. Main outcomes included anastomotic leak rate, overall morbidity, and 30-day mortality. A meta-analysis of proportions was used to assess the effect of each approach on different outcomes. RESULTS: A total of 130 studies comprising 16,053 patients were included for analysis; 8081 (50.3%) underwent OE, 1524 (9.5%) HE, and 6448 (40.2%) TMIE. The risk of anastomotic leak was lower after OE (odds ratio [OR], 0.71; 95% CI, 0.62-0.81; P < .0001). Overall morbidity rate was 45% (95% CI, 38%-52%) after OE, 40% (95% CI, 25%-59%) after HE, and 37% (95% CI, 32%-43%) after TMIE. Risk estimation showed higher odds of postoperative mortality after OE (OR, 2.22; 95% CI, 1.76-2.81; P < .0001) and HE (OR, 1.93; 95% CI, 1.32-2.81; P < .001), compared with TMIE. Median length of hospital stay (LOS) was 14.1 (range, 8-28), 12.5 (range, 8-18), and 11.9 (range, 7-30) days after OE, HE and TMIE, respectively (P = .003). CONCLUSIONS: HE and TMIE are associated with lower rates of overall morbidity, reduced postoperative mortality, and shorter LOS, compared with OE. TMIE is associated with lower mortality rates and shorter LOS than HE. Further efforts are needed to widely embrace TMIE in a safe manner.

Surgical outcomes after totally minimally invasive Ivor Lewis esophagectomy. A systematic review and meta-analysis.

BACKGROUND: A transthoracic esophagectomy is associated with high rates of morbidity. Minimally invasive esophagectomy has emerged to decrease such morbidity. The aim of this study was to accurately determine surgical outcomes after totally minimally invasive Ivor-Lewis Esophagectomy (TMIE). METHODS: A systematic literature search was performed to identify original articles analyzing patients who underwent TMIE. Main outcomes included overall morbidity, major morbidity, pneumonia, arrhythmia, anastomotic leak, chyle leak, and mortality. A meta-analysis was conducted to estimate the overall weighted proportion and its 95% confidence interval (CI) for each analyzed outcome. RESULTS: A total of 5619 patients were included for analysis; 4781 (85.1%) underwent a laparoscopic/thoracoscopic esophagectomy and 838 (14.9%) a robotic-assisted esophagectomy. Mean age of patients was 63.5 (55-67) years and 75.8% were male. Overall morbidity and major morbidity rates were 39% (95% CI, 33%-45%) and 20% (95% CI, 13%-28%), respectively. Postoperative pneumonia and arrhythmia rates were 10% (95% CI, 8%-13%) and 12% (95% CI, 8%-17%), respectively. Anastomotic leak rate across studies was 8% (95% CI, 6%-10%). Chyle leak rate was 3% (95% CI, 2%-5%). Mortality rate was 2% (95% CI, 2%-2%). Median ICU stay and length of hospital stay were 2 (1-4) and 11.2 (7-20) days, respectively. CONCLUSIONS: Totally minimally invasive Ivor-Lewis esophagectomy is a challenging procedure with high morbidity rates. Strategies to enhance postoperative outcomes after this operation are still needed.

Indocyanine green (ICG) fluorescence imaging for prevention of anastomotic leak in totally minimally invasive Ivor Lewis esophagectomy: a systematic review and meta-analysis.

BACKGROUND: Indocyanine green (ICG) fluorescence imaging is an emerging technology that might help decreasing anastomotic leakage (AL) rates. The aim of this study was to determine the usefulness of ICG fluorescence imaging for the prevention of AL after minimally invasive esophagectomy with intrathoracic anastomosis. METHODS: A systematic literature review of the MEDLINE and Cochrane databases was performed to identify all articles on totally minimally invasive Ivor Lewis esophagectomy. Studies were then divided into two groups based on the use or not of ICG for perfusion assessment. Primary outcome was anastomotic leak. Secondary outcomes included operative time, ICG-related adverse reactions, and mortality rate. A meta-analysis was conducted to estimate the overall weighted proportion and its 95% confidence interval (CI) for main outcomes. RESULTS: A total of 3,171 patients were included for analysis: 381 (12%) with intraoperative ICG fluorescence imaging and 2,790 (88%) without ICG. Mean patients' age and proportion of males were similar between groups. Mean operative time was also similar between both groups (ICG: 354.8 vs. No-ICG: 354.1 minutes, P = 0.52). Mean ICG dose was 12 mg (5-21 mg). No ICG-related adverse reactions were reported. AL rate was 9% (95% CI, 5-17%) and 9% (95% CI, 7-12%) in the ICG and No-ICG groups, respectively. The risk of AL was similar between groups (odds ratio 0.85, 95% CI 0.53-1.28, P = 0.45). Mortality was 3% (95% CI, 1-9%) in patients with ICG and 2% (95% CI, 2-3%) in those without ICG. Median length of hospital stay was also similar between groups (ICG: 13.6 vs. No-ICG: 11.2 days, P = 0.29). CONCLUSION: The use of ICG fluorescence imaging for perfusion assessment does not seem to reduce AL rates in patients undergoing minimally invasive esophagectomy with intrathoracic anastomosis.

Indicações da cirurgia de Ivor Lewis modificada / Indications of modified Ivor Lewis esophagectomy

A técnica de Ivor Lewis modificada, utilizada para a ressecção do câncer de esôfago, consiste na combinação de toracotomia direita e laparotomia, seguida de anastomose esofagogástrica intratorácica. Apesar de ser o tratamento de eleição em muitos serviços, não há critérios rigorosos para sua indicação. Neste relato de caso o paciente apresenta antecedente de carcinoma espinocelular invadindo pele e mandíbula tratado com radioterapia e cirurgia. Durante o seguimento se diagnosticou neoplasia esofágica, que foi tratada por cirurgia de Ivor Lewis modificada, seguida de complicações leves e boa evolução. A técnica de Ivor Lewis modificada é uma opção adequada para o tratamento da neoplasia esofágica, sendo sua melhor indicação nos casos em que há radioterapia cervical prévia, já que esta torna a cervicotomia um procedimento de alto risco para lesões vasculares e/ou de vias aéreas. Entretanto, a decisão da técnica a ser utilizada para a ressecção do câncer de esôfago ficará a cargo do cirurgião.

Caracterización del cáncer de esófago en pacientes operados. Hospital "Dr. Carlos J. Finlay" / Characterization of the esophagus cancer in operated patients. "Dr. Carlos J. Finlay" Hospital

Introducción: el cáncer de esófago es una de las neoplasias más agresivas del tracto digestivo. La cirugía es el método fundamental de tratamiento, con una alta frecuencia de complicaciones. Objetivo: caracterizar el cáncer de esófago en pacientes intervenidos quirúrgicamente. Método: se realizó un estudio descriptivo, longitudinal y con carácter prospectivo, en el Hospital "Dr. Carlos J. Finlay", entre enero de 2002 y diciembre de 2012. Universo de 62 pacientes. Se incluyeron pacientes con cáncer de esófago sometidos a resección. Las variables cualitativas se describieron estadísticamente mediante cifras frecuenciales y porcentuales. Resultados: el 82.3% perteneció al sexo masculino. El tercio inferior del esófago fue el más afectado en 42.2%. La variedad histológica que predominó fue el adenocarcioma en 59.7%. La mayoría de los pacientes se diagnosticaron en estadio IIb (41.9 %). La técnica quirúrgica más empleada fue la de Ivor Lewis (58.1%) y la sutura que más se realizó fue la mecánica. La estenosis de la anastomosis fue la complicación más frecuente en 12.9% y apareció solo cuando se realizó la sutura manual de la anastomosis. El tipo de sutura más utilizada fue la manual en 17.4%. La sobrevida postoperatoria fue de 17.7% a los 5 años. Conclusiones: predominaron los pacientes mayores de 60 años y pertenecientes al sexo masculino. La localización más frecuente fue en tercio inferior, con predominio del adenocarcinoma. La mayoría fueron diagnosticados en estadio IIb. La estenosis posquirúrgica fue la complicación más frecuente. La sobrevida postoperatoria fue aceptable.

Introduction: the esophagus cancer is one of the most aggressive neoplasias in the digestive tract. The surgery is the fundamental method of treatment, with a high frequency of complications. Objective: to characterize the esophagus cancer in patients intervened surgically. Method: it was done a descriptive, longitudinal study and of prospective character, in the "Dr. Carlos J. Finlay", between January of 2002 and December of 2012. The universe of the study was 62 patients. It was included patients with resection of esophagus cancer and in which the author of this paper participated on the operation. The qualitative variables were described statistically by means of frequencies and percentages. Results: 82.3% belonged to the masculine sex. The inferior third of the esophagus was the more affected in 42.2%. The histological variety that prevailed was the adenocarcioma in 59.7%. Most of the patients were diagnosed in IIb stage (41.9%). The surgical technique more carried out was Ivor Lewis (58.1%) and the type of suture was the mechanical. The stenosis of the anastomosis was the most frequent complication in 12.9% and it was appear only in cases with manual suture of the anastomosis. The type suture more used was the manual in the 17. 4%. The postoperative overlife was 17.7% at five years. Conclusions: most of patients were older than 60 years and men. The most frequent localization was in inferior third, with prevalence of the adenocarcinoma. Most was diagnosed in IIB stage. The postsurgical stenosis was the most frequent complication. The postoperative overlife was acceptable.

Anastomosis esofagogástrica látero-lateral con engrapadora lineal en la operación de Ivor Lewis / Side-to-side esophagogastric anastomosis with linear stapler in Ivor Lewis operation

Las lesiones tumorales del esófago tienen un creciente impacto sobre la población cubana, pero su tratamiento quirúrgico es riesgoso, en particular por los fallos anastomóticos. Objetivo: proponer una modificación a la esófago-gastrectomía de Ivor Lewis mediante una anastomosis látero-lateral con engrapadora. Métodos: se realizaron 19 esófago-gastrectomías de Ivor Lewis con la modificación propuesta de la técnica anastomótica entre enero de 2004 y diciembre de 2010. Resultados: de los pacientes operados, dos presentaron tumores en tercio medio, once en tercio distal, y seis en la unión esófago-gástrica o estómago alto invadiendo el esófago distal. No ocurrieron muertes quirúrgicas. Las complicaciones mayores fueron: tromboembolismo pulmonar de ramas finas, fibrilación auricular, neumonía, atelectasia . En ningún caso ocurrió dehiscencia o estenosis de la anastomosis. La estadía hospitalaria promedio fue de 11 días (mínimo 8, máximo 17). Conclusiones: la anastomosis esófago-gástrica látero-lateral por engrapadora lineal permite reducir la incidencia de dehiscencia y estenosis, lo que evita complicaciones en la intervención quirúrgica esofágica...

"Esophageal tumoral lesions have a growing impact on the Cuban population. However, their surgical treatment is risky, particularly due to the occurrence of anastomotic failures. Objective: propose a modification of Ivor Lewis esophagogastrectomy by means of a side-to-side anastomosis with stapler. Methods: nineteen Ivor Lewis esophagogastrectomies were performed with the proposed modification of the anastomotic technique between January 2004 and December 2010. Results: of the patients operated on, two had tumors in the middle third, eleven in the distal third, and six in the esophagogastric junction or the upper stomach invading the distal esophagus. No surgical deaths occurred. The following were major complications: pulmonary thromboembolism of fine branch, atrial fibrillation, pneumonia and atelectasis. No case presented anastomotic dehiscence or stenosis. Average hospital stay was 11 days (minimum 8, maximum 17). Conclusions: side-to-side esophagogastric anastomosis with linear stapler reduces the incidence of dehiscence and stenosis, preventing the occurrence of complications in esophageal surgery...

Dos décadas de trabajo con la técnica de Ivor Lewis en la cirugía del cáncer del esófago / Twenty years of application of Ivor Lewis' technique in esophageal cancer surgery

Objetivos: describir los resultados históricos obtenidos por un mismo grupo de trabajo en el tratamiento multidisciplinario del carcinoma esofágico, destacando el tratamiento quirúrgico y sus complicaciones. Métodos: se realizó un estudio observacional descriptivo del tipo de serie de casos durante el periodo 1987-2010, que incluyó los pacientes intervenidos quirúrgicamente por esta enfermedad. Fueron investigadas aquellas variables consideradas de interés, como la localización de la lesión, su estadio, el tratamiento quirúrgico empleado, las complicaciones y la supervivencia. Resultados: durante el período estudiado fueron tratados 132 pacientes, de ellos el 64,4 por ciento eran hombres y el 59 por ciento se incluían en el grupo de edad de 60-69 años. El carcinoma epidermoide fue más frecuente que el adenocarcinoma (54,5 vs. 41 por ciento), y la principal localización fue el tercio medio (42,4 por ciento). La morbilidad fue de un 28,8 por ciento, y las principales complicaciones posoperatorias fueron las infecciones respiratorias y el tromboembolismo pulmonar. La mortalidad operatoria fue de un 12,9 por ciento, y la supervivencia a los 5 años de un 2 por ciento. Conclusiones: el tratamiento multidisciplinario constituye uno de los principales logros en el tratamiento de esta enfermedad. Sin embargo, aun cuando se han obtenido resultados superiores relacionados con la morbilidad y mortalidad quirúrgica respecto a décadas atrás, la supervivencia, a largo plazo, sigue siendo decepcionante. No obstante, la cirugía sigue siendo el único tratamiento con intención curativa. Queda por nosotros mejorarla y perfeccionarla(AU)

Objectives: to describe the historical results achieved by a working team in the multidisciplinary treatment of esophageal carcinoma by underlining the surgical treatment and its complications. Methods: a case series-type descriptive and observational study was carried out in the 1987-2010 period, in which the patients operated on from this disease were included. Some variables of interest such as location of lesion, staging, type of surgery, complications and survival rate were researched on. Results: one hundred and thirty two patients were treated, 64.4 percent were males and 59 percent were in the 60-69 y group. The epidermoid carcinoma was more common than the adenocarcinoma (54.5 vs. 41 percent) and the main location of carcinoma was the middle third (42.4 percent). Morbidity was 28.8 percent and the main postoperative complications were respiratory infection and pulmonary thromboembolism. The operative mortality was 12.9 percent and the survival rate at 5 years was 2 percent. Conclusions: the multidisciplinary treatment is one of the fundamental achievements in treating this disease. However, even when higher results has been attained with respect to surgical morbidity and mortality rates of previous decades, the long-term survival rate is still discouraging. Nevertheless, surgery continues to be the only treatment with curing intentions. It is up to us to upgrade it(AU)