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Robotic-assisted totally transhiatal lymphadenectomy in the middle mediastinum for esophageal cancer.

ABSTRACT: Robotic-assisted esophagectomy has been introduced as a minimally invasive esophagectomy; however, transhiatal esophagectomy with extended lymphadenectomy in the middle retromediastinal field has never been reported so far. We have developed a totally transhiatal robotic manipulation which enables middle retromediastinal lymph dissection. With this method, transthoracic approach, which is associated with risk of lung injury and loss of ventilatory function, can be avoided in radical esophageal cancer surgery. The robotic arms and camera entered the mediastinum passing the hiatus, and the dissection was performed along the medial aspect of the mediastinal pleura, the pericardia, and the aorta. The devices were able to reach the middle mediastinum, and lymph nodes on the bilateral main bronchi and the carina were retrieved by robotic manipulation. We present here our first experience of laparoscopic transhiatal lymphadenectomy of the middle mediastinal field, including a video, which could not have been possible without robotic-assisted surgery.

SUBMITTER: Mori K

PROVIDER: S-EPMC3835922 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:Patients with upper third esophageal cancer or esophageal cancer with upper mediastinal paratracheal lymph node metastases are often precluded from surgery because of technical difficulties. With the aid of robotic surgery, an excellent overview and reach of the thoracic inlet can be accomplished. In this way, patients with upper mediastinal esophageal cancer are eligible for esophageal resection with curative intent. The aim of this study was to review the results of a consecutive series of patients who underwent robot-assisted minimally invasive esophagectomy (RAMIE) for tumors of the upper 1/3 of the esophagus or positive lymph nodes in the upper mediastinum.Between 2007-2016, 31 patients who underwent RAMIE in the UMC Utrecht for proximal esophageal cancer or proximal thoracic lymphadenopathy were identified from a prospective surgical database. Perioperative characteristics and oncologic outcomes were collected.The majority of patients had a squamous cell carcinoma. Clinical tumor stage was cT3 or higher in 25 (81%) of patients. Clinically positive lymph nodes (cN1-3) were observed in 29 (94%) patients. Neoadjuvant treatment was administered in 27 (87%) patients. Median duration of the surgical procedure was 435 min (range 299-874 min). Pulmonary complications were most frequent and occurred in 13 (42%) patients. Median intensive care (ICU stay) was 1 day (range 1-65 days) and median overall postoperative hospital stay was 15 days (range 10-118 days). In hospital mortality was 10%. Causes of mortality were tracheo-neo-esophageal fistula, sepsis after abdominal wall drainage due to leakage of the jejunal fistula resulting in respiratory and kidney failure, after which refraining further treatment resulting in death, and irreversible ARDS in a patient with COPD Gold III needing extracorporeal life support. Radical resection was achieved in 30 (97%) of the patients. Median number of retrieved lymph nodes was 22 (range 9-57). Median time of follow up was 18 months (range 3-81 months). Median disease-free survival was 13 months (range 0-81 months) and median overall survival was 16 months (range 0-81 months). Tumor recurrence occurred in 15 patients (48%) and was locoregional only in 3 patients, systemic only in 5 patients and combined locoregional and systemic in 7 patients.Robot assisted thoraco-laparoscopic esophagectomy with curative intent in patients with upper mediastinal esophageal cancer is feasible, but associated with increased in hospital mortality. Short-term oncologic results are encouraging.

Project description:BackgroundAlthough considered complex and challenging, esophagectomy remains the best potentially curable treatment option for resectable esophageal and esophagogastric junction (AEG) carcinomas. The optimal surgical approach and technique as well as the extent of lymphadenectomy, particularly regarding quality of life and short- and long-term outcomes, are still a matter of debate. To lower perioperative morbidity, we combined the advantages of a one-cavity approach with extended lymph node dissection (usually achieved by only a two-cavity approach) and developed a modified single-cavity transhiatal approach for esophagectomy.MethodsThe aim of this study was to evaluate the outcome of an extended transhiatal esophageal resection with radical bilateral mediastinal en bloc lymphadenectomy (eTHE). A prospective database of 166 patients with resectable cancers of the esophagus (including adenocarcinomas of the AEG types I and II) were analyzed. Patients were treated between 2001 and 2017 with eTHE at a tertiary care university center. Relevant patient characteristics and outcome parameters were collected and analyzed. The primary endpoint was 5-year overall survival. Secondary outcomes included short-term morbidity, mortality, radicalness of en bloc resection and oncologic efficacy.ResultsThe overall survival rates at 1, 3 and 5 years were 84, 70, and 61.0%, respectively. The in-hospital mortality rate after eTHE was 1.2%. Complications with a Clavien-Dindo score of III/IV occurred in 31 cases (18.6%). A total of 25 patients (15.1%) had a major pulmonary complication. The median hospital stay was 17 days (interquartile range (IQR) 12). Most patients (n = 144; 86.7%) received neoadjuvant treatment. The median number of lymph nodes resected was 25 (IQR 17). The R0 resection rate was 97%.ConclusionIn patients with esophageal cancer, eTHE without thoracotomy resulted in excellent long-term survival, an above average number of resected lymph nodes and an acceptable postoperative morbidity and mortality.

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Robotic-assisted totally transhiatal lymphadenectomy in the middle mediastinum for esophageal cancer.

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