Minimally Invasive Esophagectomy Utilizing a Stapled Side-to-Side Anastomosis is Safe in the Western Patient Population.

BACKGROUND: There has been an increased utilization of minimally invasive esophagectomy (MIE) in an effort to reduce morbidity, decrease length of stay, and improve quality of life. However, there are limited large series of patients undergoing MIE from the United States and no standardized approach. We reviewed our experience with MIE utilizing a stapled side-to-side anastomosis during a 7.5-year period. STUDY DESIGN: A retrospective review of prospectively maintained databases for patients undergoing planned esophagectomy were reviewed from 2007 to 2015. Esophagogastric anastomoses were performed via a 6-cm linear stapled side-to-side method. Demographics, comorbidities, surgical approach, pathology data, and postoperative morbidities were recorded and reviewed. RESULTS: A MIE was attempted in 303 of 315 (96 %) patients, and a total minimally invasive approach was completed in 293 of 315 (93 %) patients. Location of anastomosis was predominantly in the neck, with 244 patients (77.5 %) undergoing a total minimally invasive McKeown approach (n = 231). A total, minimally invasive Ivor-Lewis was completed in 60 patients (19.1 %). Anastomotic leak was identified in 24 patients (7.6 %). Rates of anastomotic leak were 4.4 % for Ivor-Lewis and 8.5 % for McKeown resection. Median length of stay was 8 days, and in-hospital mortality occurred in only three patients (n = 1 %). Ninety-day follow-up demonstrated a 4.1 % stricture rate requiring dilatation. CONCLUSIONS: In the Western patient population, MIE utilizing a 6-cm stapled side-to-side anastomosis is associated with low rates of anastomotic leak, stricture, and mortality.

Discordant HER2 expression and response to neoadjuvant chemoradiotherapy in esophagogastric adenocarcinoma.

BACKGROUND: Targeting human epidermal growth factor receptor 2 (HER2) with trastuzumab in metastatic esophagogastric adenocarcinoma (EGA) improves survival. The impact of HER2 inhibition in combination with chemoradiotherapy (CRT) in early stage EGA is under investigation. This study analyzed the pattern of HER2 overexpression in matched-pair tumor samples of patients who underwent neoadjuvant CRT followed by surgery. METHODS: All patients with EGA who underwent standard neoadjuvant CRT followed by esophagectomy at the University of Florida were included. Demographics, risk factors, tumor features, and outcome data were analyzed. Descriptive statistics, Chi-square exact test, uni- and multivariate analyses, and Kaplan Meier method were used. HER2 expression determined by immunohistochemical (IHC) was scored as negative (0, 1+), indeterminate (2+) or positive (3+). RESULTS: Among 49 sequential patients (41 M/8 F) with matched-pair tumor samples, 9/49 patients (18%) had pathologic complete response (pCR), 10/49 had near pCR or not enough tumor (NET) to examine in the post- treatment samples. Patients with initial HER2 negativity demonstrated conversion to HER2 positivity after neoadjuvant CRT (7/30 cases; 23%). Baseline HER2 overexpression was more common in lower stage/node negative patients (67% in stages I, IIA vs. 33% in stages IIB, III) and did not correlate with treatment response or survival. CONCLUSIONS: Although limited by a relatively small sample size, our study failed to demonstrate that baseline HER2 protein over-expression in EGA predicts response to standard CRT. However, our data suggested that HER2 was up regulated by CRT resulting in unreliable concordance between pre-treatment (pre-tx) and post-treatment (post-tx) samples. Pre-therapy HER2 expression may not reliably reflect the HER2 status of persistent or recurrent disease.

Prospective Comprehensive Swallowing Evaluation of Minimally Invasive Esophagectomies with Cervical Anastomosis: Silent Versus Vocal Aspiration.

INTRODUCTION: Pneumonia and tracheal aspiration remain problematic following esophagectomy. We hypothesized that the incidence of postesophagectomy pneumonia occurs in part because of swallowing dysfunction and more importantly silent tracheobronchial aspiration. Therefore, we instituted a routine prospective formal swallowing evaluation to determine if the aspiration rate and its associated morbidity can be decreased by early identification of patients with silent or vocal aspiration. METHODS: Patients undergoing minimally invasive McKeown esophagectomy and receiving neoadjuvant chemoradiotherapy (NACR) were prospectively enrolled between December 2013 to January 2015. A standardized cineradiography observation utilizing the Rosenbek penetration-aspiration (RPA) scale was used to rule out anastomotic leak and/or aspiration. RESULTS: Of 27 patients evaluated, twelve patients were noted to have silent (n = 8) or vocal (cough n = 4) aspiration of thin liquid (n = 8) or nectar-thick consistency (n = 4) on their initial study. Three patients were noted to have an anastomotic leak and vocal aspiration on their initial study. Eight of the nine patients who aspirated but did not have an anastomotic leak on their initial study had a repeat RPA study prior to discharge showing improvement from the initial study. Six patients (22 %) had vocal cord paresis and clinical hoarseness, but only two patients who had clinical diagnosis of pneumonia were noted to have vocal cord paresis and silent aspiration. CONCLUSIONS: Swallowing dysfunction remains a common problem after minimally invasive esophagectomy (MIE) with cervical anastomosis and can be readily identified. Silent aspiration likely contributes to pneumonia after MIE.

Gastroesophageal Reflux Management with the LINX® System for Gastroesophageal Reflux Disease Following Laparoscopic Sleeve Gastrectomy.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) has gained significant popularity in the USA, and consequently resulted in patients experiencing new-onset gastroesophageal reflux disease (GERD) following this bariatric procedure. Patients with GERD refractory to medical therapy present a more challenging situation limiting the surgical options to further treat the de novo GERD symptoms since the gastric fundus to perform a fundoplication is no longer an option. OBJECTIVES: The aim of this study is to determine if the LINX® magnetic sphincter augmentation system is a safe and effective option for patients with new gastroesophageal reflux disease following laparoscopic sleeve gastrectomy. SETTINGS: This study was conducted at the University Medical Center. METHODS: This is a retrospective review of seven consecutive patients who had a laparoscopic LINX® magnetic sphincter device placement for patients with refractory gastroesophageal reflux disease after laparoscopic sleeve gastrectomy between July 2014 and April 2015. RESULTS: All patients were noted to have self-reported greatly improved gastroesophageal reflux symptoms 2-4 weeks after their procedure. They were all noted to have statistically significant improved severity and frequency of their reflux, regurgitation, epigastric pain, sensation of fullness, dysphagia, and cough symptoms in their postoperative GERD symptoms compared with their preoperative evaluation. CONCLUSION: This is the first reported pilot case series, illustrating that the LINX® device is a safe and effective option in patients with de novo refractory gastroesophageal reflux disease after a laparoscopic sleeve gastrectomy despite appropriate weight loss.

Thoracoscopic and Laparoscopic Enucleation of Esophageal Leiomyomas.

Although infrequent, esophageal leiomyomas are the most common benign intramural tumors of the esophagus. As malignant potential is not a concern in these lesions, they represent ideal candidates for an organ-preserving approach. Due to their well-circumscribed growth, a minimally invasive approach should be pursued in almost all patients. We present our recent techniques and results associated with totally minimally invasive thoracoscopic and laparoscopic approaches to resection of esophageal leiomyomas. These approaches require technical expertise but can be accomplished with a short learning curve.

Laparoscopic hernia repair with adductor tenotomy for athletic pubalgia: an established procedure for an obscure entity.

INTRODUCTION: Athletic pubalgia is a syndrome of chronic lower abdomen and groin pain that occurs in athletes. It is the direct result of stress and microtears of the rectus abdominis inserting on the pubis from the antagonizing adductor longus muscles, and weakness of the posterior transversalis fascia and bulging of the inguinal floor. METHODS: Under IRB approval, we conducted a retrospective review of our prospectively competitive athlete patients with athletic pubalgia from 2007 to 2013. RESULTS: A cohort of 54 patients was examined. Mean age was 22.4 years. Most patients were football players (n = 23), triathlon (n = 11), track and field (n = 6), soccer players (n = 5), baseball players (n = 4), swimmers (n = 3), golfer (n = 1), and tennis player (n = 1). Fifty one were males and three were females. All patients failed medical therapy with physiotherapy prior to surgery. 76 % of patients had an MRI performed with 26 % having a right rectus abdominis stripping injury with concomitant strain at the adductor longus musculotendinous junction. 7 % of patients had mild nonspecific edema in the distal bilateral rectus abdominis muscles without evidence of a tear. Twenty patients had no findings on their preoperative MRI, and only one patient was noted to have an inguinal hernia on MRI. All patients underwent laparoscopic totally extraperitoneal inguinal hernia repair with synthetic mesh and ipsilateral adductor longus tenotomy. All patients were able to return to full sports-related activity in 24 days (range 21-28 days). One patient experienced urinary retention and another sustained an adductor brevis hematoma 3 months after completion of rehabilitation and surgical intervention. Mean follow up was 18 months. CONCLUSION: Athletic pubalgia is a disease with a multifactorial etiology that can be treated surgically by a laparoscopic totally extraperitoneal hernia repair with synthetic mesh accompanied with an ipsilateral adductor longus tenotomy allowing patients to return to sports-related activity early with minimal complications.

Esophageal perforation management using a multidisciplinary minimally invasive treatment algorithm.

BACKGROUND: The surgical management of esophageal perforation (EP) often results in mortality and significant morbidity. Recent less invasive approaches to EP management include endoscopic luminal stenting and minimally invasive surgical therapies. We wished to establish therapeutic efficacy of minimally invasive therapies in a consecutive series of patients. STUDY DESIGN: An IRB-approved retrospective review of all acute EPs between 2007 and 2013 at a single institution was performed. Patient demographic, clinical outcomes data, and hospital charges were collected. RESULTS: We reviewed 76 consecutive patients with acute EP presenting to our tertiary care center. Median age was 64 ± 16 years (range 25 to 87 years), with 50 men and 26 women. Ninety percent of EPs were in the distal esophagus, with 67% of iatrogenic perforations occurring within 4 cm of the gastroesophageal junction. All patients were treated within 24 hours of initial presentation with a removable covered esophageal stent. Leak occlusion was confirmed within 48 hours of esophageal stent placement in 68 patients. Median lengths of ICU and hospital stay were 3 and 10 days, respectively (range 1 to 86 days). One-third of the patients were noted to have prolonged intubation (>7 days) and pneumonia that required a tracheostomy. One in-hospital (1.3%) mortality occurred within 30 days. Median total hospital charges for EP were $85,945. CONCLUSIONS: Endoscopically placed removable esophageal stents with minimally invasive repair of the perforation and feeding access is an effective treatment method for patients with EP. This multidisciplinary method enabled us to care for severely ill patients while minimizing morbidity and mortality and avoiding open esophageal surgery.

Minimally invasive esophagectomy is safe in patients with previous gastric bypass.

BACKGROUND: The prevalence of morbid obesity in the United States has been steadily increasing, and there is an established relationship between obesity and the risk of developing certain cancers. Patients who have undergone prior gastric bypass (GB) and present with newly diagnosed esophageal cancer represent a new and challenging cohort for surgical resection of their disease. We present our case series of consecutive patients with previous GB who underwent minimally invasive esophagectomy (MIE). METHODS: Retrospective review of consecutive patients with a history of GB who underwent a MIE for esophageal cancer between July 2010 and August 2012. RESULTS: Five patients were identified with a mean age of 57 years. Mean follow-up was 9.1 months. Four patients had undergone laparoscopic GB, and 1 patient had an open GB. Two patients received neoadjuvant chemoradiation therapy for locally advanced disease. Minimally invasive procedures were thoracoscopic/laparoscopic esophagectomy with cervical anastomosis in 4 patients and colonic interposition in 1 patient. Mean operative time was 6 hours and 52 minutes. Median length of stay was 7 days. There was no mortality. Postoperative complications occurred in 3 patients and included pneumonia/respiratory failure, recurrent laryngeal nerve injury, and pyloric stenosis. All patients are alive and disease free at last follow-up. CONCLUSIONS: Minimally invasive esophagectomy after prior GB is well tolerated, is technically feasible, and has acceptable oncologic and perioperative outcomes. We conclude that precise endoscopic evaluation before bariatric surgery in patients with gastroesophageal reflux disease is essential, as is the necessity for continuing postsurgical surveillance in patients with known Barrett's esophagitis and for early evaluation in patients who develop new symptoms of gastroesophageal reflux disease after bariatric surgery.

Pre-therapy laparoscopic feeding jejunostomy is safe and effective in patients undergoing minimally invasive esophagectomy for cancer.

OBJECTIVE: Laparoscopic feeding jejunostomy is a safe and effective means of providing enteral nutrition in the preoperative phase to esophageal cancer patients. DESIGN: This research is a retrospective case series. SETTING: This study was conducted in a university tertiary care center. PATIENTS: Between August 2007 and April 2012, 153 laparoscopic feeding jejunostomies were performed in patients 10 weeks prior to their definitive minimally invasive esophagectomy. MAIN OUTCOME MEASURES: The outcome is measured based on the technique, safety, and feasibility of a laparoscopic feeding jejunostomy in the preoperative phase of esophageal cancer patients. RESULTS: One hundred fifty-three patients underwent a laparoscopic feeding jejunostomy approximately 1 and 10 week(s) prior to the start of their neoadjuvant therapy and definitive minimally invasive esophagectomy, respectively. Median age was 63 years. Of the patients, 75 % were males and 25 % were females. One hundred twenty-seven patients had gastroesophageal junction adenocarcinoma and 26 had squamous cell carcinoma. All patients completed their neoadjuvant chemoradiation therapy. The median operative time was 65 min. We had no intraoperative complications, perforation, postoperative bowel necrosis, bowel torsion, herniation, intraperitoneal leak, or mortality as a result of the laparoscopic feeding jejunostomy. Four patients were noted to have superficial skin infection around the tube, and 11 patients required a tube exchange for dislodgment, clogging, and leaking around the tube. All patients progressed to their definitive surgical esophageal resection. CONCLUSION: A laparoscopic feeding jejunostomy is technically feasible, safe, and can provide appropriate enteral nutrition in the preoperative phase of esophageal cancer patients.

Decreasing morbidity and mortality in 100 consecutive minimally invasive esophagectomies.

INTRODUCTION: Esophagectomy is a complex invasive procedure that requires exploration of multiple body cavities for removal and subsequent restoration of gastrointestinal continuity. In many institutions, esophagectomy morbidity and mortality rates remain high despite improvement of intensive care treatment. We reviewed our minimally invasive esophagectomy (MIE) experience of a consecutive series of 100 patients to analyze trends in morbidity and mortality as we transitioned from open to MIE. METHODS: A total of 105 consecutive patients who underwent operative exploration for esophagectomy from August 2007 to January 2011 were reviewed. The preoperative evaluation, operative technique, and postoperative care of these cases were evaluated and analyzed for 100 patients who have had a MIE and compared with 32 open esophagectomies 2 years prior. RESULTS: During the time frame of the study, 105 patients underwent an exploration for attempted esophagectomy. Resection was completed in 100 patients and was done for malignant disease in 95 patients and benign disease in 5 patients. There was one in hospital mortality due to a pulmonary embolism. There was no significant difference in postoperative complications consisting of transient left recurrent nerve injury (7 vs. 12.5%) or pneumonia (9 vs. 15.6%) in those who underwent MIE compared with open resection. However, wound infections were significantly less in patients who underwent MIE compared with open esophagectomy (1 vs. 12.5%, respectively, p = 0.01). Anastomotic leak (4 vs. 12.5%, p = 0.05) also was lower in those who underwent MIE. Median length of stay (LOS) was significantly less in patients who underwent MIE compared with open esophagectomy (7.5 vs. 14 days, p < 0.05). Finally, there was a trend toward improvement in median LOS in the 30 patients who underwent MIE during the most recent time period compared with the initial 17 patients who underwent MIE (7.5 vs. 10 days, p = 0.05) CONCLUSIONS: Our results support the continued safe use of esophagectomy for selected esophageal diseases, including malignancy. Morbidity, especially wound infection, anastomotic leak, and length of stay is decreasing with the incorporation of minimally invasive techniques.