Now that advanced minimally invasive surgical procedures are being performed more frequently, detailed results and outcomes must be reported to the surgical community to assess potential advantages and disadvantages. A number of open approaches are used to resect esophageal cancer. These operations are frequently associated with significant morbidity and a mortality rate reported from experienced centers in the range of 6–7%.1 In a report summarizing nationwide statistics, the mortality rates from esophagectomy ranged from 8% in high-volume centers to as high as 23% in low-volume centers.2 Given concerns over this high morbidity and mortality, patients with esophageal cancer may not even be referred for operation at all. Older patients and those with comorbid conditions may be referred for nonsurgical therapies; for example, photodynamic therapy is used in some centers to treat high-grade dysplasia. Photodynamic therapy, with its low mortality rate (which approaches 0%) is attractive to patients and referring physicians, even though its results have not been proven to equal those of surgical resection.3 Yet, because of the risk of incomplete ablation of Barrett's and the risk of missing an early stage occult cancer that could be potentially cured by resection, most surgeons continue to favor esophagectomy.4

Since the introduction of laparoscopic fundoplication in 1991,5 improvements in instrumentation and optics have allowed the development of minimally invasive approaches to esophageal diseases that have been traditionally managed by open operation. Such diseases include the treatment of achalasia,6 giant paraesophageal hernia,7 and other complex esophageal disorders.8-10 Minimally invasive esophagectomy (MIE) has the potential to lower the morbidity of open operation and allow quicker return to normal function. In addition if morbidity is lowered, a greater number of patients may be referred and benefit from MIE. We have previously reported on our initial experience of MIE in 77 patients.10 This report details our growing experience of MIE and describes outcomes in 223 patients.

Minimally Invasive Esophagectomy: Outcomes in 222 Patients

https://www.gastrojournal.org/article/S0016-5085(05)00606-2/pdf

American Gastroenterological Association Technical Review on the Role of the Gastroenterologist in the Management of Esophageal Carcinoma

There is an increasing burden upon diagnostic histopathologists to identify accurately factors of prognostic and therapeutic implication in gastrointestinal cancer. It is perhaps partly because of the use of rigid sequential staging systems, such as the Dukes' classification, that some factors, perhaps most notably involvement of surgical margins (especially in rectal cancer) and serosal involvement (particularly in oesophageal, colonic and rectal cancer), have been relatively neglected until more recently. This is surprising and concerning because both of these pathologically derived parameters strongly correlate with subsequent locoregional recurrence and, ultimately, with prognosis. Whilst the occurrence and significance of serosal involvement have been well recognized in gastric cancer for many years, relatively little attention has been paid to the phenomenon in oesophageal cancer and yet both pleural and peritoneal involvement may be comparatively commonly identified in oesophageal cancer. Serosal involvement and transperitoneal spread are also of considerable prognostic importance in primary appendiceal carcinoma. Only more recently has the significance of serosal involvement been appreciated in colonic and rectal cancer. In the colon, the phenomenon is now recognized to be one of the most important factors in predicting transperitoneal spread and overall prognosis. Furthermore, there is increasing interest in alternative novel strategies, including intraperitoneal chemotherapy and radical peritoneal surgery, as legitimate therapeutic options in many gastrointestinal cancers.

Serosal involvement in gastrointestinal cancer : its assessment and significance

Objective: The management of high-grade dysplasia (HGD) of the esophagus is controversial with some clinicians advocating nonoperative ablation or surveillance. Minimally invasive esophagectomy (MIE) allows re-section of the esophagus and may minimize morbidity. This report summarizes our experience with MIE for HGD. Methods: A retrospective review of 28 patients who underwent MIE for a pre-operative diagnosis of HGD. MIE initially involved a laparoscopic transhiatal approach ðn ¼ 1Þ, but subsequently evolved to laparoscopy with VATS mobilization ðn ¼ 27Þ of the esophagus. Results: From August 1996 to March 2001, 28 patients underwent MIE. There were 23 males and five females; median age was 61 (40‐78) years. Median hospital stay was 5 (3‐20) days and ICU stay was 1 (1‐20) day. One patient required conversion to laparotomy because of dense adhesions. There were ten other patients who had successful MIE despite prior laparotomy. Median operating time was 8 (5.8‐13) h. One death occurred from sepsis, pneumonia and multi-system organ failure. Complications occurred in 15 patients. In addition to the patient who died, five re-operations were required for: small bowel perforation ðn ¼ 1Þ, jejunostomy leak ðn ¼ 1Þ, pyloric dilation for gastric outlet obstruction ðn ¼ 1Þ, cholecystectomy ðn ¼ 1Þ, incision and drainage of an abdominal abscess ðn ¼ 1Þ. Final pathologies were HGD ðn ¼ 17Þ, in situ cancer ðn ¼ 6Þ and invasive cancer ðn ¼ 5Þ .A t a median follow-up of 13 (2‐41) months all hospital survivors are alive and free of disease. Conclusions: This report confirms the risk of occult cancer in patients with HGD (39% in this series) supporting the recommendation for esophagectomy. MIE can be performed with acceptable results and may minimize morbidity compared to previous reports of open esophagectomy for HGD. q 2002 Elsevier Science B.V. All rights reserved.

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Outcomes of minimally invasive esophagectomy (MIE) for high-grade dysplasia of the esophagus.

Study design A retrospective review of a single surgeon consecutive series of video-assisted thoracoscopic anterior release and fusion Objectives To examine radiographic fusion rates and standard radiographic parameters of spinal deformity correction, as well as to identify possible complications of thoracoscopic anterior release and fusion in patients with a minimum of 2-year follow-up treated for spinal deformity Summary of background data Anterior release and fusion of the thoracic spine is indicated in the treatment of rigid scoliosis and kyphosis, the treatment or prevention of crankshaft growth, and in patients at increased risk for pseudarthrosis Although early postoperative outcomes of video-assisted thoracoscopic anterior release/fusion exist in the literature, few data are available with follow-up greater than 2 years Methods A retrospective chart and radiograph review of 112 consecutive cases of thoracoscopic anterior release/fusion with open posterior instrumentation/fusion was performed The diagnosis, indications, perioperative data, as well as early and delayed complications, were evaluated Deformity correction and intervertebral fusion rates were assessed at latest follow-up (> or =2 years) Results The diagnoses included 50 patients with neuromuscular deformity, 42 with idiopathic deformity, 10 congenital, and 10 miscellaneous etiologies The average operative time was 160 +/- 41 minutes to excise and bone graft an average of 7 +/- 2 discs, with an average blood loss of 285 +/- 303 cc The average hospital stay was 9 +/- 5 days Fourteen percent of the patients had perioperative respiratory complications that varied from atelectasis to chylothorax There were no long-term complications associated with the anterior surgery Scoliosis improved from 80 +/- 12 degrees to 36 +/- 17 degrees, and kyphosis from 88 +/- 15 degrees to 60 +/- 20 degrees at latest evaluation (P 50% filling of the disc space) was present radiographically in 75% of the disc spaces with moderate interobserver reliability of the grading system (kappa = 049) Conclusion Thoracoscopic anterior release and fusion of the thoracic spine is a safe and effective procedure when combined with posterior instrumentation and fusion The primary goal of increasing the flexibility of a rigid spine and achieving a solid arthrodesis occurred in the vast majority of cases

The success of thoracoscopic anterior fusion in a consecutive series of 112 pediatric spinal deformity cases.

Background We reviewed our experience using anterior thoracoscopic procedures in the correction of severe idiopathic scoliosis and kyphotic deformities to evaluate the feasibility and effectiveness of such procedures. Study design Twenty-four patients who underwent thoracoscopic surgical correction of the spine between March 1995 and December 2001 were retrospectively reviewed. A team consisting of one orthopaedic surgeon and one thoracic surgeon performed anterior thoracoscopic soft tissue release, disc excision, and bone grafting followed on the same day with posterior instrumentation and correction of deformity. Results There were 16 female and 8 male patients, with a median age of 16 years (range 11 to 47 years) with idiopathic scoliosis (20 patients) or kyphotic deformity (4 patients). The average time for the thoracoscopy was 125 minutes (range 60 to 175 minutes). Blood loss averaged 135 mL (range 20 to 350 mL), and a median number of five discs (range two to eight) were excised. The median ICU time was 2 days (range 1 to 8 days), and the median length of hospital stay was 6 days (range 4 to 11 days). One patient required conversion to an open procedure because of arterial bleeding from the cancellous bone (T5). Postoperative complications occurred in four patients (atelectasis, pneumothorax, pneumonia, and wound infection in one patient each). All patients had an uneventful hospital course after treatment. Conclusions Thoracoscopic anterior procedures can be used safely and effectively in the treatment of idiopathic scoliosis and kyphotic deformity. This minimally invasive approach might decrease procedure-related trauma, operative time, blood loss, and length of hospitalization and may also alleviate postthoracotomy pain.

Xiaolong Jiao

Papers

Thoracoscopic approach for spine deformities.

Thoracoscopic and laparoscopic staging for esophageal cancer.