Role of 3D in minimally invasive esophagectomy

Role of 3D in minimally invasive esophagectomy

Alexandros Charalabopoulos, Bruno Lorenzi, Ali Kordzadeh, Cheuk-Bong Tang, Sritharan Kadirkamanathan & Naga Venkatesh Jayanthi Langenbeck's Archives of Surgery ISSN 1435-2443 Langenbecks Arch Surg DOI 10.1007/s00423-017-1570-0

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Author's personal copy Langenbecks Arch Surg DOI 10.1007/s00423-017-1570-0

HOW-I-DO-IT ARTICLES

Role of 3D in minimally invasive esophagectomy Alexandros Charalabopoulos 1,2 & Bruno Lorenzi 1,2 & Ali Kordzadeh 1,2 & Cheuk-Bong Tang 1,2 & Sritharan Kadirkamanathan 1,2 & Naga Venkatesh Jayanthi 1,2

Received: 31 October 2016 / Accepted: 13 February 2017 # Springer-Verlag Berlin Heidelberg 2017

Abstract Purpose Two-stage minimally invasive esophagectomy (MIE) has gained popularity in the surgical treatment of esophageal cancer. MIE’s limitation is embedded in the construction of intrathoracic anastomosis. Various anastomotic techniques have been reported; however, the mechanical one remains the most commonly adopted. This pilot study aims to describe an efficient, safe, and reproducible way of performing a hand-sewn intrathoracic esophagogastric anastomosis in conjunction with short-term results using 2D and 3D thoracoscopic approaches. Methods A total of n = 13 patients (mean age 67.4) underwent MIE for distal esophageal or gastroesophageal junction adenocarcinoma between January and September 2016. Resection was performed in prone position, and the esophagogastric anastomosis was constructed in an end-toside manner in two layers with barbed knotless suture. A 2D thoracoscopic approach was used in n = 10 patients (77%) and a 3D approach in n = 3 (23%). Results n = 8 patients (61.5%) had neo-adjuvant chemotherapy and n = 5 (38.5%) had primary surgery. The mean operating time was 420 min, and the average length of stay was 10 days with no associated mortality. n = 1 (7.7%) developed a radiological leak that did not require an intervention.

* Alexandros Charalabopoulos [email protected]

1

Regional Oesophagogastric Cancer Centre, Department of Upper Gastrointestinal Surgery, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, Chelmsford CM1 7ET, Essex, UK

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Upper GI Unit, Department of General Surgery, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, Chelmsford CM1 7ET, Essex, UK

Thoracoscopic approach with the glasses-based 3D optical system using the angulating-tip 100° camera provided a far superior view for precise lymphadenectomy in combination to an efficient and safe construction of the anastomosis. Conclusion The barbed knotless suturing technique in MIE is an efficient and safe method of constructing the esophagogastric anastomosis with promising short-term outcomes. A 3D thoracoscopic approach appears to be superior in performing the anastomosis to that of a 2D technique. Keywords Minimally invasive esophagectomy . 2D esophagectomy . 3D esophagectomy . Hand-sewn intrathoracic anastomosis . Barbed sutures . Esophageal cancer

Introduction Surgical treatment of esophageal cancer remains a challenge worldwide, and even in specialized centers, it is associated with a high incidence of morbidity and mortality. An open transthoracic approach for the resection of esophageal cancer is still the most commonly adopted technique to date. However, a trend towards minimally invasive techniques has been on the rise [1]. From hybrid (laparoscopic abdomen/open chest, open abdomen/thoracoscopic chest) to totally minimally invasive procedures (totally laparoscopic and thoracoscopic), the main challenge and limitation in a thoracoscopic two-stage esophagectomy is the formation of intrathoracic anastomosis [2]. Main issues have always been vascularization of the anastomosis and the tension across it. Currently and perhaps even more importantly, with the minimally invasive esophagectomy (MIE) anastomosis, its technical difficulty and demand on the surgeon remain the rate-limiting step. In order to avoid such challenges but nevertheless embrace the minimal access approach with reduction of morbidity in mind, surgeons tend to

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perform a total MIE (laparoscopic abdomen-thoracoscopic chest) with formation of the anastomosis in the neck (threestage MIE) [3]. Despite technically less challenging to perform, three-stage MIE is associated with higher incidence of complications, mainly anastomotic leak and recurrent laryngeal nerve palsy [4]. Recently, two-stage MIE has gained popularity in the surgical treatment of esophageal cancer. Various techniques for the formation of the intrathoracic anastomosis have been reported. These include mainly stapled anastomosis with either the use of a linear or a circular stapler [5]. In most studies describing the use of the linear stapler, the intrathoracic esophagogastric anastomosis tends to be a side-to-side one, whereas in studies describing the use of a circular stapler, the anastomosis tends to be an end-to-side one [6, 7]. For the latter, the trans-oral anvil system (OrVil) and the transthoracic anvil system with formation of esophageal purse string have been described [8]. However, the authors believe that there is a more efficient, safer, and reproducible alternative to the aforementioned techniques. Therefore, the objective of this study is to describe an easy and reproducible way of performing a safe hand-sewn anastomosis using barbed knotless sutures, in a two-stage (Ivor-Lewis) MIE. In addition, we aim to investigate and report our initial experience with this technique in a standard two-stage MIE with two field lymph node dissections in a prone position, in association with short-term results and initial experience using 2D and 3D thoracoscopic approaches.

Materials and methods A prospective consecutive cohort pilot study of n = 13 with a mean age of 67.4 years (IQR, 53–78 years) that underwent two-stage MIE with hand-sewn intrathoracic anastomosis using barbed sutures in Mid Essex Hospital Services NHS Trust from January to September 2016 was performed. The primary end point of the study was to assess the efficacy and safety of 2D and 3D constructed, hand-sewn intrathoracic anastomosis. Short-term outcomes, as measured by anastomotic leak rate, length of hospital stay, and 30-day and inhospital mortality rate, were also studied. All patients enrolled in the study were surgically treated in our high-volume, tertiary center by three surgical teams. Preoperative staging and investigations included esophagogastroduodenoscopy (EGD); computed tomography (CT) of the chest, abdomen, and pelvis; PET-CT; staging laparoscopy; endoscopic ultrasound (EUS); and cardiopulmonary exercise testing (CPET) in all patients. All operations were performed in a prone position with a double-lumen endotracheal tube (during both the abdominal and chest phases) with intravenous and inhalation anesthesia. The esophagogastric anastomosis was constructed in an endto-side way in two layers with an outer seromuscular and an inner full-thickness layer. The suture material used was a 3/0

barbed suture on a round bodied needle without the need of knotting (V-Loc™—Medronic or Filbloc—Assut). A 2D thoracoscopic (Olympus 30° endoeye) approach was used in n = 10 (77%) cases, and a 3D optical imaging system using the Endoeye Flex 3D videoscope with a 100° angulating-tip scope (Olympus 3D Imaging System) was deployed in n = 3 individuals (23%). Patient and port positioning During the abdominal laparoscopic phase, the patient was placed in a supine position with split legs. The operating surgeon positioned in between the legs, the first assistant on the patient’s left, and the camera holder on the patient’s right. Two 5-mm port incisions (one epigastric—for a Nathanson’s liver retractor and one left flank at the anterior axillary line—for the first assistant) and three 10-mm ports (one subumbilical— camera port, one in the right mid-clavicular line—operating port, and one in the left mid-clavicular line—operating port) were placed under direct vision. During the thoracic videoscopic phase, the patient was placed in a fully prone position (swimmer’s position) with the operating table broken at the mid-chest level. The operating surgeon and the assistant were standing on the right side of the patient. Three 10-mm ports were placed (one posterior to the angle of the scapula at the fifth intercostal space—camera port, one at the posterior edge of the scapula at third intercostal space—operating port, and one at eighth intercostal space posterior to the scapular line—operating port) under direct vision (Fig. 1). At the end of the procedure, the 10-mm port site at the eighth intercostal space was converted to a 3-cm mini-thoracotomy for specimen extraction.

Fig. 1 Patient and port positioning during thoracoscopic stage in a prone position

Author's personal copy Langenbecks Arch Surg Fig. 2 Gastric mobilization and extent of abdominal lymphadenectomy

Laparoscopic gastric mobilization Routine mobilization of the stomach via division of the gastrocolic and gastrosplenic ligaments 3–4 cm outside the gastroepiploic arcade was performed with the use of an energy device (Thunderbeat—Olympus or LigaSure—Covidien or Harmonic scalpel—Ethicon). The lesser omentum was divided close to the liver and the hiatus mobilized, by removing part of the crura bilaterally, pericardial fat, para-aortic fat, and bilateral pleura. D2 lymphadenectomy with excision of left gastric, celiac, splenic, and common hepatic nodes was performed as part of the standard procedure (Fig. 2). An umbilical tape was placed around the distal esophagus to aid dissection during the thoracic part of the procedure. The gastric conduit was formed starting at the lesser curve, on the antrum, at the level of the vascular arcade where the left and right gastric branches meet. The iDrive™ ultra powered stapling system with Tri-Staple™ technology (Medronic) with purple cartridges was used for the formation of a 4–5-cm-wide, 28–32cm-long gastric conduit. The last 2 cm of the conduit at the gastric fundus remained uncut, to facilitate conduit relocation Fig. 3 Esophageal mobilization and extent of thoracic lymphadenectomy

into the right hemithorax during the thoracic phase of the procedure. A trans-abdominal left thoracic 20-Fr Robinson’s drain was placed at the end of the abdominal stage. Feeding jejunostomy was not routinely placed.

Thoracoscopic esophageal mobilization Routine esophageal mobilization with en block lymphadenectomy of peri-esophageal, para-aortic, and subcarinal nodes was performed (Fig. 3). The LigaSure™ Maryland jaw 37cm laparoscopic sealer and divider (Medronic) were used for the chest dissection. The esophagus was mobilized up to 2 cm above the level of the azygos vein. The vein was ligated using the Hem-o-lok® Polymer Locking Ligation System (Teleflex) and divided with scissors. Esophageal division using the iDrive™ stapler was performed just above the level of the azygos vein with removal of surrounding esophageal tissue for the distal 1 cm. The gastric conduit was then brought to the chest, and complete division was performed using the iDrive stapler.

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Fig. 4 Posterior, outer seromuscular layer of esophagogastric anastomosis

barbed sutures (either a V-Loc™—Medronic or a Filbloc— Assut) were used for this anastomotic layer, starting at the middle of the posterior layer and running opposite to each other to reach each Bside^ of the posterior aspect of the anastomosis. At that stage, a nasogastric tube was placed across the anastomosis under direct vision, in essence Bstenting^ the posterior anastomotic wall and allowing better visualization of the anterior anastomotic wall, which was about to be formed (Fig. 6). The same sutures were then reversed to provide a Bforehand stitch,^ and the anterior, inner anastomotic full-thickness layer was then completed. At the middle of the anterior inner layer, the two sutures were stabilized with a green Hem-o-lok® clip (Fig. 7). An anterior, outer seromuscular esophagogastric layer using another 3/0 barbed stitch in a running fashion (Lembert suture) was finally added to the anastomosis (Fig. 8). A methylene blue leak test via the nasogastric tube with occlusion of the gastric conduit at the level of the hiatus was performed in all cases.

Intrathoracic anastomosis Once the gastric conduit was brought in the right chest, it was aligned with the esophagus and inspected along its length to avoid possible rotation. The esophageal staple line was sutured to the posterior (looking at the patient’s left side) gastric conduit wall with a 3/0 barbed suture (either a V-Loc™— Medronic or a Filbloc—Assut) in an end-to-side esophagogastric manner, forming the posterior, outer seromuscular layer of the anastomosis (Fig. 4). An anterior esophagotomy using hook scissors, just above the staple line, and a longitudinal posterior gastrotomy (midway between the greater curve and the gastric staple line) of equal to the esophagostomy size were created, with subsequent approximation of the two forming the posterior, inner, full-thickness layer of the esophagogastric anastomosis (Fig. 5). Two 3/0

Fig. 5 Posterior, inner fullthickness layer of esophagogastric anastomosis

Results Nine individuals (n = 9, 69%) were treated for adenocarcinoma of the distal esophagus and four patients (n = 4, 31%) for adenocarcinoma of the gastroesophageal junction. There were n = 12 (92%) male and n = 1 female patients. The presenting complain was progressive dysphagia in n = 9 (69%) patients and upper gastrointestinal bleeding in n = 2 (15%) patients. Two individuals (n = 2, 15%) had lesions detected in surveillance endoscopy for Barrett’s esophagus. Clinical TNM staging was T2N0M0 in n = 4 (31%), T3N0M0 in n = 3 (23%), and T3N1M0 in n = 6 cases (46%). The mean lesion length was 40 mm (IQR, 20–70 mm). A total of n = 8 patients (61.5%) had neo-adjuvant chemotherapy comprising

Author's personal copy Langenbecks Arch Surg Fig. 6 Nasogastric tube across anastomosis, Bstenting^ posterior anastomotic wall

epirubicin, oxaliplatin, and capecitabine (EOX), and n = 5 patients (38.5%) went straight to surgery without any neoadjuvant treatment (of these, n = 4 were preoperatively staged as T2N0 and no neo-adjuvant treatment was offered and n = 1 was deemed not fit for neo-adjuvant treatment). The mean operating time was 420 min (IQR, 291–649 min). For all minimally invasive esophagectomies performed, no open conversions were made. No intraoperative complications, including positive anastomotic leak tests, or chyle leak, were noted. No grade III or above Clavien-Dindo surgical complications were noted postoperatively. One patient developed left-sided pneumothorax immediately postoperatively in intensive care unit that necessitated chest drain insertion. No further complications were noted in that particular patient, and he was discharged at postoperative day 9. One patient (7.7%) developed a radiological anastomotic leak with no interventional management needed. He remained on the ward with parenteral nutrition for 3 weeks until radiological resolution of the leak on a gastrografin swallow. He was subsequently discharged home at day 28 on a soft diet. One patient was readmitted

6 months after the operation with pneumonia and severe sepsis and eventually died in the hospital during that admission. Of the 13 cases studied, 12 resections were R0 and 1 resection was R1 with positive circumferential resection (CRM) margins of less than 1 mm. The mean lymph node harvest was 29 (range 13–49). Histological staging was found to be highgrade dysplasia (HGD) in 2 cases and invasive adenocarcinoma in 11 cases. Of the adenocarcinoma cases, one case was T1N1, two cases were T2N0, one case was T3N0, two cases were T3N1, two cases were T3N2, and three cases were T3N3. Between the 3D and 2D performed cases, there were no differences in terms of short-term outcomes as outlined earlier. Without any objective measures, but subjectively from the operating surgeon perspective, all three surgeons felt that formation of the intrathoracic hand-sewn anastomosis as well as lymphadenectomy was superior with the 3D platform, mainly due to depth perception and enhanced optical system that accompany the 3D system, allowing thus greater precision. The average length of stay was 10 days (range 8– 12 days), excluding the patient with the anastomotic leak. The 30-day and in-hospital mortality rate was 0%. The patients were followed up for 1–11 months, with no disease recurrence reported.

Discussion

Fig. 7 Anterior, inner full-thickness layer of esophagogastric anastomosis

Since the first description of MIE in 1992, the approach has gained immense interest in the surgical treatment of especially lower esophageal and/or gastroesophageal junction cancers [5, 9]. A plethora of studies in the English literature describe various techniques of constructing the intrathoracic esophagogastric anastomosis [10, 11]. Since it is universally accepted that the particular anastomosis remains challenging to perform, with life-threatening consequences, most surgeons have tried to simplify its formation. Initially, in order to overcome the problem, most centers were performing minimally

Author's personal copy Langenbecks Arch Surg Fig. 8 Anterior, outer seromuscular layer of esophagogastric anastomosis

invasive esophagectomies with an anastomosis in the neck [12]. This way performing the anastomosis felt safer, but a three-stage esophagectomy with neck anastomosis carries its own risks, like increased rate of recurrent laryngeal nerve palsy, anastomotic leakage, and anastomotic strictures [12]. Surgeons have then slowly moved on to two-stage esophagectomy, mainly performing a mechanical intrathoracic anastomosis with the use of various stapling devices. Use of circular staples inserted via the mouth (OrVil) or chest cavity, as well as use of linear staplers, has been extensively reported [4, 6, 13]. Hand-sewn intrathoracic anastomosis has also been occasionally described but has not gained popularity due to its technical difficulty and high demand [5]. In our institution during the last 3 years, we have experienced higher anastomotic leak rates with the linear stapler to what expected and thus decided to study the results and short-term outcomes of a hand-sewn intrathoracic anastomosis with this pilot study. To the best of our knowledge, this is the first study published in the English literature to assess the efficacy and safety of an intrathoracic hand-sewn esophagogastric anastomosis using barbed knotless sutures in minimally invasive twostage Ivor-Lewis esophagectomy utilizing a 2D or a 3D thoracoscopic approach. Although at present, there is no study showing a long-term oncological or survival advantage of minimally invasive versus open esophagectomy in the treatment of esophageal cancer, it has been reported that short-term outcomes like length of hospital stay, postoperative pain, intraoperative blood loss, and postoperative recovery are superior in MIE [14]. The advanced technology and optics of endoscopic surgery mean better estimation of tissue planes, access to restricted spaces, and hence more precise dissection with less tissue trauma [15]. In our study, all three surgeons felt that the thoracoscopic view during MIE was enhanced

with the glasses-based 3D optical system using the 100° angulating-tip camera in comparison to the 2D optical system with the use of a 30° camera. Ultraprecise lymphadenectomy and easier construction of the anastomosis were made feasible, mainly due to depth perception with the 3D camera, thus potentially implying an improvement in clinical outcomes and postoperative remote patient outcomes. The main limitation of this study is its small number of cases and thus the inability to make safe conclusions regarding the efficacy and safety of the anastomosis, as well as the superiority of the 3D over the 2D optical system. On the basis of this study, a randomized controlled trial will be designed and performed within the next few years.

Conclusion Minimally invasive Ivor-Lewis esophagectomy for the treatment of especially lower esophageal and gastroesophageal junction cancer is gaining worldwide popularity and acceptance. Construction of the intrathoracic anastomosis has been the rate-limiting step of the procedure. A hand-sewn esophagogastric anastomosis in a two-stage Ivor-Lewis procedure is considered technically demanding and has hence being underutilized. Herein, we describe a hand-sewn intrathoracic anastomosis using barbed knotless sutures. It has proven to be a safe, reproducible, and relatively easy way of constructing the esophagogastric anastomosis with promising short-term outcomes. Although the 3D thoracoscopic approach, mainly due to depth perception and detailed optics, is promising and appears to be superior compared to the 2D in performing the anastomosis and additionally the lymphadenectomy, further evaluation with randomized controlled

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trials should be performed before extrapolating such a conclusion.

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Authors’ contributions Alexandros Charalabopoulos: study conception and design, acquisition of data, analysis and interpretation of data, and drafting of manuscript; Bruno Lorenzi: acquisition of data and analysis and interpretation of data; Ali Kordzadeh: analysis and interpretation of data; Cheuk-Bong Tang: analysis and interpretation of data; Sritharan Kadirkamanathan: critical revision of manuscript; and Naga Venkatesh Jayanthi: acquisition of data and critical revision of manuscript.

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Compliance with ethical standards 8. Conflict of interest The authors declare that they have no conflict of interest. Ethical approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

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Informed consent Informed consent was obtained from all individual participants included in the study. 11.

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