Original Article

Comparison of transhiatal esophagectomy using a mediastinoscope with transhiatal esophagectomy by the classic method

Asian Cardiovascular & Thoracic Annals 0(0) 1–5 ! The Author(s) 2020 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/0218492320963976 journals.sagepub.com/home/aan

Reza Rezaei1, Seyed Hossein Fattahi Masuom1 , Navid Soroush1 and Vahid Zehi2

Abstract Background: This study aimed to evaluate the results of transhiatal esophagectomy using a mediastinoscope in comparison with conventional transhiatal esophagectomy. Methods: Sixty-two esophageal cancer patients who were referred to our thoracic surgery clinic between April 2015 and March 2017, and met the inclusion criteria, were randomly divided into two groups of 31 each. In the first group, patients were operated on by conventional transhiatal esophagectomy. In the second group, only release of the thoracic esophagus through a neck incision (mediastinal esophagolysis) was performed using a mediastinoscope. The other surgical procedures were similar to those in the first group. Results: The mean age of the patients was almost the same in both groups (57.7 years in the first group versus 56.7 years in the second group). There was no significant difference in sex ratio. The mean volume of blood loss during the operation, mean operative time, and intensive care unit stay as well as cardiopulmonary complications and early postoperative complications were lower in the group that had esophagectomy using a mediastinoscope, and the number of resected mediastinal lymph nodes was greater. Conclusion: Based on the results of this study, it can be expected that use of a video mediastinoscope for esophagolysis of the thoracic esophagus in a transhiatal esophagectomy procedure is safe and it will reduce the morbidity and mortality in these patients. Keywords Adenocarcinoma, carcinoma, squamous cell, esophageal neoplasms, esophagectomy, lymph node excision, mediastinoscopy

Introduction Esophageal cancer is one of the most common malignancies in the world, and the sixth leading cause of death from cancer. With an annual involvement of 480,000 new cases, it was responsible for 440,000 deaths in 2015,1 and in Iran, it is very common, especially in northern areas.2 Despite advances in multiple treatment modalities for esophageal cancer, the mortality rate remains high, with a 5-year survival rate of approximately 17% and an average survival of 23 months, and mortality increases with advanced age due to comorbidities including cardiopulmonary disease.3,4 Because esophageal cancer surgery is one of the most complicated alimentary tract surgeries

and the tissue trauma and surgical complications are high, surgeons have used various minimally invasive procedures in recent decades to reduce these complications. One such method is use of a mediastinoscope to 1 Endoscopic and Minimally Invasive Surgery Research Center, Mashhad University of Medical Sciences, Mashhad, Iran 2 General Surgery, Torbat-e- Heydariyeh University of Medical Sciences, Torbat-e-Heydariyeh, Iran

Corresponding author: Seyed Hossein Fattahi Masuom, Endoscopic and Minimally Invasive Surgery Research Center, Mashhad University of Medical Sciences, Mashhad, Iran. Email: [email protected]

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release the thoracic esophagus from the mediastinal tissue in transhiatal esophagectomy surgery, mediastinoscopy-assisted esophagectomy (MAE) has reduced complications and mortality, especially in elderly patients with underlying cardiopulmonary diseases.5,6 So far, this method has not been used in our country for various reasons. The mediastinoscope is commonly used for biopsy of masses and lymph nodes in the mediastinum. In 1990, it was first used in esophageal cancer surgery for dissection and release of the thoracic esophagus during transhiatal esophagectomy, and due to the benefits of new mediastinoscopes and improvements in endoscopic technologies, its use is expanding.7 In this study, we examined the use of a mediastinoscope, a minimally invasive method, in transhiatal esophagectomy surgery in comparison with similar experiences in other parts of the world.

Patients and methods From April 2015 to March 2017, in our Department of Surgery, 62 patients underwent transhiatal esophagectomy with and without the use of a mediastinoscope by the same surgical team. Preoperative evaluations were performed uniformly in all patients, and those who were referred to the Thoracic Surgery Clinic and met the inclusion criteria, were randomly divided into two groups of 31 each. The inclusion criteria were patients aged 18 to 75 years with a diagnosis of distal or middle esophageal cancer and pathology of squamous cell carcinoma or adenocarcinoma, who were candidates for transhiatal esophagectomy based on preoperative evaluations and staging. In the first group (A), patients underwent routine transhiatal esophagectomy (blunt dissection of the thoracic esophagus) and in the second group (B), release of the thoracic esophagus was performed through a neck incision using a mediastinoscope; the other surgical procedures were similar to those in the first group. The mean age was similar in each group but in group A, the number of female patients was slightly higher, although there was no significant difference between the two groups. (Table 1)

The university ethics committee approved the study, and all patients filled in an informed consent form before the operation. Preoperative measures and evaluations included barium swallow, computed tomography of the chest and abdomen, and examination for distant metastases; cardiac evaluation including electrocardiogram and, in the case of a history of respiratory disease, pulmonary function tests were performed. After completing the preoperative evaluations, patients in group A and group B underwent routine transhiatal esophagectomy surgery and MAE, respectively. The duration of surgery, volume of blood loss during the operation, and any amount of transfusion were recorded. The patients were examined for intraoperative complications including airway damage, major vascular injury, arrhythmia, and possible pneumothorax, and postoperative complications including stridor, recurrent laryngeal nerve injury, chylothorax, anastomosis leakage, and other possible complications, were recorded. The duration of intensive care unit (ICU) stay and hospitalization were also considered at the time of discharge. At follow-up after one week, one month, and 3 months, the following details were recorded: anastomosis stenosis and any late complications, the pathology report on the number of resected lymph nodes, tumor location and type of definite pathology, and mortality in the first 30 days after surgery. Finally, after completing each patient’s checklist and checking the number of patients, statistical data were collected and analyzed. In terms of surgical procedures, MAE is similar to the classic transhiatal esophagectomy except that dissection of the thoracic esophagus in the mediastinum, which is performed by hand and blunt dissection in the classic method, is performed with a mediastinoscope under direct observation. After a neck incision in the anterior border of the sternocleidomastoid muscle and cutting the omohyoid muscle, the carotid sheath is exposed and shifted laterally. The recurrent laryngeal nerve is exposed in the groove between the esophagus and the trachea. The esophagus, inside which the nasogastric tube is located, is exposed and raised by placing

Table 1. Characteristics of 62 patients undergoing transhiatal esophagectomy. Mediastinoscope-assisted Variable

Blunt esophagectomy

Esophagectomy

p value

Mean age (years) Body mass index (kg  m2) Male/female ratio Operative time (min) Mean blood loss (mL) Intensive care unit stay (h) Hospital stay (days)

57.7  10.91 18.53  1.37 2/3 188  9.22 135  24 40 10

56.7  11.58 19.0  1.74 3/2 173  15.86 90  18 25 10

0.713 0.331 0.143 0.005 0.0001 0.029

Rezaei et al. a Penrose drain around it. The first few centimeters of the anterior surface of the esophagus and trachea are dissected in a blunt manner, and then the tip of the mediastinoscope is carefully inserted in the groove between the trachea and the esophagus. The anterior surface of the esophagus is dissected using the special suction of the mediastinoscope, and electrocautery and micro-scissors are used when necessary. The posterior surface of the trachea, carina, and mediastinal lymph nodes are observed, and resection of the mediastinal lymph nodes is performed with special mediastinoscopy forceps. Blood vessels and the lymphatic system are coagulated and cut with a 5-mm LigaSure. The smaller blood vessels are coagulated and dissected with suction-electrocautery. The mediastinoscope is carefully inserted into the mediastinum as long as its length allows, and the anterior surface of the esophagus is dissected. The mediastinoscope enters the mediastinum from the posterior surface of the esophagus and the anterior surface of the vertebral bodies, and with soft tissue dissection of the mediastinum in this part, similar to the anterior surface, the esophagus is released at the posterior and then the lateral surface. Simultaneously, the abdominal surgery team releases the distal esophagus with blunt finger dissection through the diaphragm hiatus; viewing images of the mediastinum in the monitor helps in distal esophageal dissection. When the esophagus is completely released, the rest of the procedure is the same as in the classic method.

Results Nineteen patients in group A and 17 in group B received neoadjuvant treatment before surgery, and 12 patients in group A and 14 in group B were operated on without receiving neoadjuvant treatment, there was no significant difference between the two groups in this regard. Cancer pathology is listed in Table 2. There was significantly less blood loss during the operation in the mediastinoscopy group (Table 1). This was because in MAE, due to the possibility of direct vision, the feeding vessels of the esophagus and the soft tissues around it were visible in the mediastinum, and using cauterysuction and a LigaSure, they were ligated and cut homeostatically, which resulted in better hemostasis compared to manual manipulation. The mean operative time was shorter in the mediastinoscopy group due to the simultaneous mediastinoscopic stage from the neck incision and the abdominal stage, performed by the two surgical teams (Table 1). The mean ICU stay was significantly longer after the blunt esophagectomy procedure. The reason for this is that entry of the hand or fingers into the mediastinum causes mechanical pressure on the heart and lungs, resulting in temporary

3 Table 2. Pathology and location of the tumors in 62 patients. Mediastinoscope-assisted Variable Tumor location Middle Lower Tumor pathology Squamous cell carcinoma Adenocarcinoma No. of lymph nodes removed

Blunt esophagectomy

Esophagectomy

12 19

15 16

27 4 8

31 0 12

dysfunction. In patients with esophageal cancer, who are often elderly, this causes cardiac and pulmonary disorders and requires hospitalization in the ICU in the postoperative period. However, the length of hospital stay was similar in both groups (Table 1). In the blunt mediastinal dissection procedure, it is more likely that the mediastinal pleura will open and create a pneumothorax. In group A, due to opening of the mediastinal pleura, 6 patients needed to have bilateral chest tubes and 25 needed a right-side chest tube, but in group B, esophagolysis of the thoracic esophagus was performed with mediastinoscopy and only 2 patients needed bilateral chest tubes and 24 patients had rightside chest tubes inserted; in 5 patients, because the mediastinal pleura was intact, there was no need to insert a chest tube (Table 3). The mean number of lymph nodes removed in the mediastinoscopy group (12) was greater than in the blunt esophagectomy group (8), which was significantly different (p ¼ 0.0001), and that was the result of direct observation of the mediastinal lymph nodes during mediastinoscopy (Table 2).

Discussion Esophageal cancer surgery is a difficult and complex procedure that is associated with multiple postoperative complications. With improvements in technology, surgeons have tried to use minimally invasive methods including mediastinoscopy to reduce morbidity and mortality. Bumm and colleagues8 first reported the technique of MAE. They compared 61 patients who underwent blunt transhiatal esophagectomy with 47 who underwent MAE; the rates of pneumonia, cardiac complications, and recurrent laryngeal nerve injury were lower in the mediastinoscopy group. In a study in Munich, Germany in 1992, two groups of esophageal cancer patients who underwent surgery were compared. The first group consisted of 30 patients who underwent blunt transhiatal esophagectomy (classic

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Table 3. Mediastinal pleura opening in 62 patients. Mediastinoscope-assisted Variable

Blunt esophagectomy

Esophagectomy

Unilateral pneumothorax Bilateral pneumothorax No pneumothorax

25 6 0

24 2 5

procedure) and the second group included 30 who underwent MAE. The mean age of the patients was 60 years, the pathology was often adenocarcinoma, and the clinical stage of their disease was mainly stages IIa and Ia. The two groups were compared in terms of complications during and after surgery. Bleeding during and after surgery, leakage of the neck anastomosis, pneumonia, recurrent laryngeal nerve palsy, and mortality were less in the MAE group at the end of 30 days after surgery. In another study published in 1997, esophageal cancer patients who were candidates for surgery were divided into two groups of 37 and 48 who underwent MAE and classic esophagectomy, respectively. The results indicated that mediastinoscopy reduced the duration of surgery and cardiopulmonary complications.9 In a similar study in 2004, 42 esophageal cancer patients underwent MAE and the results showed less bleeding during surgery, shorter duration of surgery, and the possibility of greater lymph node resection.10 Wang and colleagues11 operated on 112 T2 stage esophageal cancer patients, using Ivor Lewis esophagectomy (81 patients) and mediastinoscopeassisted esophagectomy (31 patients). The duration of surgery and intraoperative blood loss in the MAE method were less than in the Ivor Lewis method, but patient survival did not depend on the surgical method and the involvement of the lymph nodes was more effective. In transhiatal esophagectomy, during blunt dissection of the mediastinum by hand, sometimes due to pressure on the heart and inability of the heart to fill with blood, the patient has a temporary drop in blood pressure. In these cases, mediastinal dissection should be discontinued, and after the patient’s blood pressure improves, dissection can be continued. Furthermore, blunt dissection by hand and heart stimulation can cause arrhythmia. Among our study patients in the blunt dissection group, two cases of supraventricular arrhythmias occurred during surgery, which improved on administration of antiarrhythmic drugs. In our study on 62 patients undergoing esophagectomy, chylothorax occurred in one patient in the blunt esophagectomy group, and part of the thoracic duct

was exposed in several patients in the mediastinoscopy group, which was well preserved by leaf dissection around it. One case of severe exposure of the thoracic duct was treated by ligation with titanium clips. In group A (blunt esophagectomy) and group B (MAE), 4 and 2 cases of recurrent laryngeal nerve palsy occurred, respectively, which was due to observation of the nerve and avoidance of approaching it. In the blunt esophagectomy and mediastinoscopy groups, 1 and 2 cases of cervical fistula occurred, respectively, which improved with conservative treatment. Stenosis of the neck anastomosis occurred in 3 cases in the blunt esophagectomy group and in 2 in the mediastinoscopy group. One of the intraoperative complications was a case of inferior pulmonary vein rupture in the mediastinoscopic group, due to a large tumor in the middle esophagus with adhesion to the vein. During the attempt to isolate the tumor, the vein ruptured and extensive bleeding occurred. After the vein was repaired and the patient was transferred to the ICU, he died due to bleeding and heart complications. In the blunt esophagectomy group, we had one death due to myocardial infarction on day 2 after surgery, but no fatal complication occurred during surgery. In terms of pulmonary complications, one case of lung collapse and 2 cases of pneumonia in the blunt esophagectomy group, and 1 case of pulmonary embolism in the mediastinoscopic group occurred in the postoperative period, which were treated conservatively. In the blunt esophagectomy group, there were two cases of supraventricular arrhythmias during dissection of the mediastinal esophagus, which were controlled with antiarrhythmic drugs during surgery, but in the mediastinoscopy group, no cardiac complications were observed during the operation. The results of our study show that the duration of surgery, volume of blood loss during the operation, average length of stay in the ICU, and postoperative complications in the MAE group were lower than in the blunt transhiatal esophagectomy group, and the number of lymph nodes removed was higher. One of the advantages of the video mediastinoscopy is the ability to see mediastinal structures with live images, which allows release of the mediastinal esophagus to be performed precisely, and esophageal release from surrounding tissues without damaging important mediastinal structures. Although in our study, one patients who did not receive neoadjuvant treatment, due to severe tumor adhesion to the inferior pulmonary vein of the lung the surgical team’s attempt to release it with mediastinoscopy, the vein ruptured, but with more experience and caution, this is less likely. The main limitation of mediastinoscopy is access to the lower esophagus, hence, it is not possible to release the distal esophagus from the neck due to its length, but

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this weak point can be eliminated by using laparoscopy to perform gastrolysis and gastroplasty in the abdominal phase of surgery. In general, according to the results of this and similar studies, it can be concluded that the use of mediastinoscopy for esophagolysis in esophageal cancer resection surgery is a safe and effective method that reduces morbidity and mortality. The use of mediastinoscopy alone in transhiatal esophagectomy has limitations, including the fact that it is not possible to release the distal esophagus, and this limitation can be overcome by combining mediastinoscopy with laparoscopy, but it requires two surgeons to perform both mediastinoscopy and abdominal surgery at the same time, whereas it is possible to perform blunt transhiatal esophagectomy with one surgeon. Declaration of conflicting interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD Seyed Hossein Fattahi Masuom 0001-6218-7526

https://orcid.org/0000-

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2. Huang J, Bashir M, Iannettoni M, et al. Carcinoma of the esophagus. In: Shields T, Locicero J, Reed C, Feins R, editors. General Thoracic Surgery. 7th ed. Philadelphia: Wolters Kluwer, 2009: 1984–2015. 3. Ebright M and Krasna M. Overview of esophageal and proximal stomach malignancy. In: Sugarbaker D, Bueno R, Colson Y, Jaklitsch M, Krasna M, Mentzer S, et al., editors. Adult Chest Surgery. 2nd ed. New York: Mc Graw Hill Education, 2015: 86–98. 4. Mimatsu K, Oida T, Kawasaki A, et al. Mediastinoscopy-assisted esophagectomy is useful technique for poor surgical-risk patients with thoracic esophageal cancer. Surg Laparosc Endosc Percutan Tech 2009; 19: e17–e20. 5. Koide N, Hiraguri M, Nishio A, et al. Three elderly patients with lower esophageal cancer successfully treated by transhiatal esophagectomy assisted by mediastinoscopy. Surg Laparosc Endosc Percutan Tech 2000; 10: 391–395. 6. Wu B, Xue L, Qiu M, et al. Video-assisted mediastinoscopic transhiatal esophagectomy combined with laparoscopy for esophageal cancer. J Cardiothorac Surg 2010; 5: 132. 7. Bumm R, Feussner H, Bartels H, et al. Radical transhiatal esophagectomy with two-field lymphadenectomy and end dissection for distal esophageal adenocarcinoma. World J Surg 1997; 21: 822–831. 8. Bumm R, H€ olscher AH, Feussner H, Tachibana M, Bartels H and Siewert JR. Endodissection of the thoracic esophagus. Technique and clinical results in transhiatal esophagectomy. Ann Surg 1993; 218: 97–104. 9. Buess G, Kaiser J, Manncke K, Walter DH, Bessell JR and Becker HD. Endoscopic microsurgical dissection of the esophagus (EMDE). Int Surg 1997; 82: 109–12. 10. Tangoku A, Yoshino S, Abe T, et al. Mediastinoscopeassisted transhiatal esophagectomy for esophageal cancer. Surg Endosc 2004; 18: 383–389. 11. Wang J, Wei N, Lu Y, Zhang X and Jiang N. Mediastinoscopy-assisted esophagectomy for T2 middle and lower thoracic esophageal squamous cell carcinoma patients. World J Surg Oncol 2018; 16: 58.

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Original Article Comparison of transhiatal esophagectomy using a mediastinoscope with transhiatal esophagectomy by the classic method Asian Cardiova...
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