Video-assisted McKeown esophagectomy for esophageal cancer: 18-year experience in a single institution (2016)

Objective
To summarize the 18-year experience in video-assisted McKeown esophagectomy for esophageal cancer.


Methods
The clinical data of 639patients with esophageal cancer undergoing McKeown esophagectomy between August 1997 and June 2015 in Department of Thoracic Surgery, Taizhou Hospital affiliated to Wenzhou Medical University were retrospectively analyzed. Among these 639 patients, 622(97.34%) completed the surgery with video-assisted procedures. A total of 7.98% of esophageal tumors located in the upper segment, 63.54% in the middle segment, and 28.48% in the lower segment.Preoperative neoadjuvant chemoradiotherapy was done in 8.92% of patients. For TNM staging, stage 0 accounted for 10.33%, stage Ⅰ29.26%, stage Ⅱ 42.10%, stage Ⅲ15.02% and stage Ⅳ 3.29%. Pathological examinations demonstrated that there were 92.02% of squamous cancer and 7.98% of adenocarcinoma and other histological types.Surgery were completed by thoracoscopy and laparotomy(44.60%), thoracoscopy and laparoscopy(47.26%), thoracotomy and laparoscopy(5.48%), and conversion to thoracotomy or laparotomy (2.66%).


Results
The time of esophagus freeing and pleural lymph node dissection under thoracoscope was (78.6±36.9)min, and the time of stomach freeing and abdominal lymph node dissection under laparoscope was (55.4±19.5) min. The volumes of blood loss in thoracoscopic surgery and laparoscopic surgery were (99.5±79.2) ml and (40.5±23.4) ml respectively. The mean total number of lymph node dissection was(24.1±12.4) per case, and the number of thoracic lymph node dissection was (14.9±8.1) per case, abdominal lymph node dissection (9.1±5.5) per case, and neck lymph node dissection (1.5±1.3) per case. There was no death during operation. There were 4 cases of intraoperative bleeding due to the azygos vein or spleen injury, 4 cases of accidental tracheal injury caused by cautery hook or ultrasound knife, 13 cases of thoracic duct injury of non-focal cause, 11 cases of atrial fibrillation and 4 cases of esophageal resection margin-positive R1 resection. The major complications in the early postoperative period which occurred in more than 10 cases were lung infection(11.42%), neck anastomosis leak(7.04%), arrhythmia(4.85%), pleural effusion catheterization(3.29%), recurrent laryngeal nerve injury(3.13%) and chylothorax(2.03%). Six cases(0.94%) died early after operation. Among them, 3 died of postoperative respiratory failure, 1 severe pulmonary infection after tracheoesophageal fistula, 1 recurrent hyperglycemia complicated with neck anastomotic fistula uncured and multiple organ failure, and the other aorta rupture and bleeding caused by chest gastric fistula or necrosis. Three hundred and seven patients (48.04%) received postoperative radiotherapy and chemotherapy. The follow-up rate was 90.8%, and the mean follow-up time was (44.5 ± 33.1) months.The 1, 2, 3, and 5-year overall survival rates were 83.9%, 69.7%, 57.1%and 45.5%, respectively.


Conclusions
Video-assisted McKeown esophagectomy for esophageal cancer is feasible and effective in tumor R0 resection and short-term and long-term effects.


Key words: 
Esophageal neoplasms; Thoracoscopy; Laparoscopy; Minimally-invasive surgery