INTRODUCTION:Sarcopenia, a key component of frailty in cancer patients, is associated with complicated procedures and worse survival after esophageal resection. The psoas muscle index (PMI) has been implicated as a possible sarcopenia imaging marker. This retrospective study aims to elucidate the effect of PMI and BMI in a cohort in Europe after totally minimally invasive esophagectomy for cancer. METHODS:The study included 318 consecutive adult patients (261 men and 57 women) who underwent minimally invasive esophagectomy for cancer between January 2016 and April 2021 in a German University Hospital. The PMI was measured at the third lumbar vertebra in the preoperative CT scan. The endpoints postoperative complication rates and survival rates were analysed and correlated with PMI and BMI according to gender. RESULTS:Male patients with low PMI (< 5.3 cm2/ m2) had a significantly higher rate of postoperative pulmonary and cardiac complications (p = 0.016, respectively p = 0.018). Low PMI and low BMI (<25 kg/m2) were associated with decreased survival rates in the univariate (p < 0.001) and multivariate analysis in male patients (p = 0.024, respectively 0.004). Having a low PMI (< 5.3 cm2/ m2) was significantly associated with worse overall survival in normal and underweight men (p < 0.001), but not in obese men with a BMI ≥ 25kg/m2 (p = 0.476). CONCLUSION:Preoperative PMI and BMI are valid risk factors regarding postoperative survival after minimal invasive esophagectomy for cancer especially in a male European cohort.

BACKGROUND:Studies have shown minimally invasive esophagectomy (MIE) to be a feasible surgical technique in treating esophageal carcinoma. Postoperative complications have been extensively reviewed, but literature focusing on intraoperative complications is limited. The main objective of this study was to report major intraoperative complications and 90-day mortality during MIE for cancer.METHODS:Data were collected retrospectively from 10 European esophageal surgery centers. All intention-to-treat, minimally invasive laparoscopic/thoracoscopic esophagectomies with gastric conduit reconstruction for esophageal and GE junction cancers operated on between 2003 and 2019 were reviewed. Major intraoperative complications were defined as loss of conduit, erroneous transection of vascular structures, significant injury to other organs including bowel, heart, liver or lung, splenectomy, or other major complications including intubation injuries, arrhythmia, pulmonary embolism, and myocardial infarction.RESULTS:Amongst 2862 MIE cases we identified 98 patients with 101 intraoperative complications. Vascular injuries were the most prevalent, 41 during laparoscopy and 19 during thoracoscopy, with injuries to 18 different vessels. There were 24 splenic vascular or capsular injuries, 11 requiring splenectomies. Four losses of conduit due to gastroepiploic artery injury and six bowel injuries were reported. Eight tracheobronchial lesions needed repair, and 11 patients had significant lung parenchyma injuries. There were 2 on-table deaths. Ninety-day mortality was 9.2%.CONCLUSIONS:This study offers an overview of the range of different intraoperative complications during minimally invasive esophagectomy. Mortality, especially from intrathoracic vascular injuries, appears significant.

Minimally invasive esophagectomy (MIE) for esophageal cancer is a complex procedure that reduces postoperative morbidity in comparison to open approach. In this study, thoracic cage width as a factor to predict surgical difficulty in MIE was evaluated. All patients of our institution receiving either total MIE or robotic-assisted MIE (RAMIE) with intrathoracic anastomosis between February 2016 and April 2021 for esophageal cancer were included in this study. Right unilateral thoracic cage width on the level of vena azygos crossing the esophagus was measured by the horizontal distance between the esophagus and parietal pleura on preoperative computer tomography. Patients’ data as well as operative and postoperative details were collected in a prospective database. Correlation between thoracic cage width with duration of the thoracic procedure and postoperative complication rates was analyzed. Overall, 313 patients were eligible for this study. Thoracic width on vena azygos level ranged from 85 to 149 mm with a mean of 116.5 mm. In univariate analysis, a small thoracic width significantly correlated with longer duration of the thoracic procedure (p = 0.014). In multivariate analysis, small thoracic width and neoadjuvant therapy were identified as independent factors for long duration of the thoracic procedure (p = 0.006). Regarding postoperative complications, thoracic cage width was a significant risk factor for occurrence of postoperative pneumonia in the multivariate analysis (p = 0.045). Dividing the cohort into two groups of patients with narrow (≤ 107 mm, 19.5

Abstract Background and aim A combined trans-hiatal and transcervical approach to perform esophagectomy has been described in the literature for patients who are not candidates for a transthoracic approach. In this context, the technical limitations of conventional laparoscopy might be overcome by the application of robotic systems such as the DaVinci Xi. We aimed at describing the technical details and the feasibility of our technique for the robotic-assisted trans-cervical esophagectomy (RACE) and a preliminary case series. Methods In the abdominal phase the DaVinci Xi is docked using the standard 5-trocar configuration used for Ivor-Lewis esophagectomy. After gastric mobilization, tubulization and D2 lymphadenectomy, the dissection is advanced trans-hiatally until the tracheal carina. Infra-tracheal lymph-node dissection is normally feasible from the abdomen. A left cervical incision and neck lymph node dissection are performed, the esophagus is encircled. The robot is docked at the neck using a gel port with a 3-trocar configuration and an assistant-trocar for suction. The upper mediastinal preparation starts by dissecting the esophagus from the mediastinal pleura bilaterally, the pars membranacea anteriorly and the aortic arch proceeding caudally. Dissection of the left recurrent laryngeal nerve (l-RLN) lymph nodes can be achieved; care should be taken to avoid nerve injuries. Proceeding caudally, the tracheal dissection is advanced to the left bronchus. The azygos vein is encountered at the right tracheobronchial angle. Dissection of bronchial lymph nodes is performed bilaterally, the plane is connected to the previous abdominal plane. After retrieval of the specimen an end-to-side circular stapled anastomosis is performed at the neck. Results The procedure was completed in 4 patients with mid-esophageal squamous cell carcinoma who were not candidate for a trans-thoracic approach due to cardio-pulmonary comorbidities. Median hospital stay was 14 (9–18) days, median ICU stay was 4 (1–6) days. Left vocal cord palsy requiring rehabilitation therapy occurred in 2 patients (50%). No postoperative mortality was recorded. R0 resection was achieved in all patients with a median of 19 (15–22) retrieved lymph nodes. Conclusion RACE using the robotic system is feasible and provides an adequate surgical radicality. The procedure is safe, although the rate of RLN injury is higher.

Abstract Background and aim We evaluated causes and implications of conversion during minimally invasive (MI) esophagectomy and the feasibility of MI surgery in patients with ‘risk indications’ that would potentially prompt the referral to open surgery. Methods We analyzed 371 patients treated with esophagectomy for cancer, between January 2016 and April 2021. We identified three groups: (I) non-MI surgery group including patients with planned open/hybrid esophagectomy (n = 26); (II) the MI surgery group including patients with totally MI procedures, both thoracoscopic/laparoscopic and robotic esophagectomy (n = 335); (III) the MI converted group with patients who had unplanned conversion (n = 10). Pre- and postoperative data were compared. ‘Risk indications’ motivating open/hybrid surgery were evaluated to define two subgroups of high- and low-risk patients treated with MI surgery, and to compare the surgical outcomes between these 2 groups. Results Overall, 345 patients were approached via MI surgery: 335 had completed MI esophagectomy (RAMIE = 63.28%; MIE = 36.72%). The conversion-rate was 2.9% (n = 10): 6.1% in MIE, 0.9% in RAMIE (P = 0.008). Postoperative leakage was higher in converted patients compared to the non-MI and the totally MI groups (P < 0.001). Surgical radicality, readmission rate and mortality were comparable. Patients with and without ‘risk indication’ for open surgery showed a similar conversion rate and post-operative outcomes following MI esophagectomy. Conclusion Conversion does not significantly affect the oncological outcomes and short-term mortality after MI esophagectomy. A MI approach could be safely offered also to patients with ‘risk indications’ that would potentially lead the choice of an open surgery.

Abstract Background The ideal extent of lymphadenectomy (LAD) in esophageal oncological surgery is debated. There is no evidence for improved survival after standardized paratracheal lymph node resection performing oncological esophagectomy. Lymph nodes from the lower paratracheal station are not standardly resected during 2-field Ivor-Lewis esophagectomy for esophageal cancer. The objective of this study was to evaluate the impact of lower paratracheal lymph node (LPL) resection on perioperative outcome during esophagectomy for cancer and analyze its relevance. Methods Retrospectively, we identified 200 consecutive patients operated in our center for esophageal cancer from January 2017 – December 2019. Patients with and without lower paratracheal LAD were compared regarding demographic data, tumor characteristics, operative details, postoperative complications, tumor recurrence and overall survival. Results 103 out of 200 patients received lower paratracheal lymph node resection. On average, five lymph nodes were resected in the paratracheal region and cancer infiltration was found in two patients. Those two patients suffered from neuroendocrine carcinoma and melanoma respectively. Cases with lower paratracheal lymph node yield had significantly less overall complicated procedures (p = 0.026). Regarding overall survival and recurrence rate no significant difference could be detected between both groups (p = 0.168 and 0.371 respectively). Conclusion The resection of lower paratracheal lymph nodes during esophagectomy remains debatable for distal squamous cell carcinoma or adenocarcinoma of the esophagus. Tumor infiltration was only found in rare cancer entities. Since resection can be performed safely, we recommend LPL resection on demand.

Abstract Objective To evaluate the impact of lower paratracheal lymph node resection on oncological radicality and complication rate during esophagectomy for cancer. Backround The ideal extend of lymphadenectomy (LAD) in esophageal surgery is debated. Until today, there has been no proof for improved survival after standardized paratracheal lymph node resection performing oncological esophagectomy. Methods Lymph nodes from the lower paratracheal station are not standardly resected during 2-field Ivor-Lewis esophagectomy for esophageal cancer. Retrospectively, we identified 200 patients operated in our center for esophageal cancer from January 2017—December 2019. Histopathologically, 143 patients suffered from adenocarcinoma, 53 patients from squamous cell carcinoma, two patients from neuroendocrine carcinoma, and one from melanoma of the esophagus. Patients with and without lower paratracheal LAD were compared to patients regarding demographic data, tumor characteristics, operative details, postoperative complications, tumor recurrence and overall survival. Results 103 of 200 patients received lower paratracheal lymph node resection. On average, six lymph nodes were resected in the paratracheal region with histopathological cancer positivity in two patients. Those two patients suffered from neuroendocrine carcinoma and melanoma, none of the AC or SCC patients were positive. There was no significant difference between both groups regarding age, gender, BMI, or comorbidity. Harvesting of lower paratracheal lymph nodes was associated with less postoperative overall complications (p-value 0,029). Regarding overall survival and recurrence rate no difference could be detected between both groups (p-value 0,168, respectively 0,371). Conclusion The resection of lower paratracheal lymph nodes during esophagectomy seems not mandatory for distal squamous cell carcinoma or adenocarcinoma of the esophagus. It may be necessary in NEC, Melanoma of the esophagus or on demand if suspicious LN are detected in the CT scan. No increase of morbidity was caused by paratracheal dissection.

Background For patients undergoing an Ivor Lewis esophagectomy with a circular stapled anastomosis, the optimal diameter of the used circular stapler to restore continuity is unknown. The aim of this study was to compare the 25 mm stapled versus the 28 mm stapled esophagogastric anastomosis after Ivor Lewis esophagectomy, focusing on anastomotic insufficiency and postoperative anastomotic strictures. Methods Between February 2008 and June 2019, 349 consecutive patients underwent Ivor Lewis esophagectomy with gastric conduit reconstruction and circular stapled anastomosis. Patient characteristics and postoperative results, such as anastomotic insufficiency rates, postoperative anastomotic stricture rates, time to anastomotic stricture rate, and the number of dilatations, were recorded in a prospective database and analyzed. Results In 222 patients (64%), the 25 mm circular stapler was used and in 127 patients (36%) the 28 mm circular stapler was used. There were no differences in baseline characteristics. Anastomotic insufficiency rates were comparable between the 25 mm (12%) and the 28 mm groups (11%) ( p = 0.751). There were no differences between postoperative anastomotic strictures in the 25 mm (14%) and the 28 mm groups (14%) ( p = 0.863). Within patients with postoperative anastomotic strictures, a median number of 2 dilatations were observed in each group ( p = 0.573) without differences in the time to first diagnosis ( p = 0.412). Conclusion There were no differences in anastomotic insufficiency and postoperative anastomotic stricture rates between the 25 mm and the 28 mm circular stapled esophagogastric anastomosis after Ivor Lewis esophagectomy. Both the 25 mm and 28 mm stapler can be safely used to create a circular stapled esophagogastric anastomosis to restore continuity after esophagectomy.

Abstract Aim The aim of this study was to describe postoperative complications and short-term oncologic outcomes for RAMIE4 with intrathoracic anastomosis for esophageal cancer within our case series of 100 consecutive patients. Background & Methods Robot assisted minimally-invasive esophagectomy (RAMIE) with intrathoracic anastomosis is gaining popularity as a treatment for esophageal cancer. In this study, we present the results of 100 RAMIE procedures using the da Vinci Xi robotic system (RAMIE4). The aim of this study was to describe postoperative complications and short-term oncologic outcomes for RAMIE4 within our case series of 100 consecutive patients. Between January 2017 and February 2019, data of 100 consecutive patients with esophageal carcinoma undergoing modified Ivor-Lewis esophagectomy were prospectively collected. All operations were performed by the same surgeon using an identical intrathoracic anastomotic reconstruction technique with the same perioperative management and pain control regimen. Intra-operatively and post operatively complications were graded according to definitions stated by the Esophagectomy Complications Consensus Group (ECCG). Results Mean duration of the surgical procedure was 416 min (± 80). In total, 70 patients (70%) had an uncomplicated operative procedure and postoperative recovery. Pulmonary complications were most common and were observed in 17 patients (17 %). Anastomotic leakage was observed in 8 patients (8%). Median ICU stay was 1 day and median overall postoperative hospital stay was 11 days. 30 day mortality was 1%. A R0 resection was reached in 92% of patients with a median number of 29 dissected lymph nodes. Conclusion RAMIE4 with intrathoracic anastomosis for esophageal cancer or cancer located in the esophagus was technically feasible and safe. Postoperative complications and short term oncologic results were comparable to the highest international standards nowadays. These results could only be obtained due to a structured RAMIE training pathway. The superiority of RAMIE compared to conventional minimally invasive esophagus is currently investigated in multiple randomized controlled trials. Results of these trials will define the role for RAMIE for patients with esophageal cancer in the future.

The aim of this study is to evaluate the results of esophageal balloon dilatation (BD) for strictures after esophageal atresia (EA) surgery. Flexible endoscopic BD was done under fluoroscopic and manometric control. The balloon placed in the stricture was inflated by contrast. The target pressure and the diameter were decided in compliance with the manufacturer's directions as well as fluoroscopic guidance. The balloon was kept inflated for 3 minutes. Prospectively collected data over 10 years were retrospectively evaluated. Cure was defined as no need for dilatation during the last 12 months. A total of 79 patients with variable diagnoses underwent 481 BD. Forty (51%) had strictures which developed after EA surgery. They underwent 175 (36%) BD (P < 0.05). There were 21 males and 19 females. The atresia was distal fistula type in 31 (77.5%) patients and isolated EA in nine (22.5%). The BD was done for primary esophago-esophageal anastomosis site in 37 patients. The remaining three patients with long gap EA had undergone previous replacement surgery and the BD was done for the proximal esophago-colonic anastomosis. The median age at the time of the first BD was 14 months with 17 (43%) patients below the age of 1 year. The maximal inflation diameter varied between 5–20 mm. Esophageal BD catheters were used in all except two occasions where 5 mm ureteral balloons were used. The median number of BD was four (n = 1–15). Thirty-four (85%) patients underwent more than one BD. A transmural perforation was encountered in one occasion (0.6%) and the patient eventually underwent esophageal replacement surgery with an uneventful outcome. There was no mortality. Fundoplication was done in nine patients. Thirty-three patients (82.5%) were regarded as ‘cure’. Esophageal BD is employed for strictures caused by a variety of reasons. Patients with EA comprise a substantial number of cases needing BD and have strictures less resistant to dilatation. The technique employed in this study is advantageous because it enables direct endoscopic visualization of the stricture and both gradual and controlled increase of the dilatation pressure. BD is safe and efficient yet there is a risk of esophageal perforation as in the other dilatation techniques.