DOI: https://doi.org/10.21203/rs.3.rs-1658389/v1
As a novel alternative to the conventional minimally invasive esophagectomy(MIE) to treat esophageal cancer, single-port laparoscopic retrograde three-step gastric mobilization (SLRM) for esophageal reconstruction during MIE to treat esophageal cancer was attempted in our department. The aim of the present study was to explore the preliminary clinical outcomes and feasibility of this innovative surgery.
From March 2020 to November 2021, patients undergoing SLRM combined with four-port thoracoscopic McKeown esophagectomy for their esophageal cancers were reviewed. Gastric mobilization with abdominal lymph node dissection was performed via single-port laparoscopic retrograde three-step gastric mobilization. The clinical characteristics and short-term outcomes were analyzed retrospectively.
A total of 120 patients underwent R0 resection without conversion to open surgery. The mean times needed for the thoracic part, abdominal part, and total operation were 43 ± 6 min, 60 ± 18 min, and 230 ± 20 min, respectively. The numbers of mediastinal and abdominal lymph nodes harvested were 13.2 ± 2.7 and 10.2 ± 2.5, respectively. Postoperative pneumonia was encountered in 10 patients (8.3%). Anastomotic leakage occurred in 3 case (2.5%). Temporary vocal cord paralysis was reported in 20 cases (16.6%). The mean length of hospital stay was 8.5 ± 4.6 days.
The SLRM is a technically feasible and safe treatment for patients with esophageal cancer. It can be considered as an alternative method for the patients, especially for the ones with obesity and gastric distension.
Surgery is the mainstay treatment for resectable esophageal cancer. While ensuring the same radical treatment outcomes, minimally invasive esophagectomy (MIE) could significantly limit surgical trauma, reduce the incidence of postoperative complications, and improve the postoperative quality of life[1]. At present, thoracoscopy combined with laparoscopic esophagectomy is routinely performed in most centers. However, the optimal operative position, number of trocars, and layout are still controversial[2, 3].
Single-port thoracic technology has been applied successfully during lung operations[4, 5] by reducing postoperative pain and improving aesthetics. However, few institutions have performed esophagectomy through single-port thoracoscopy, since esophageal mobilization and lymph node dissection is difficult through single-port thoracoscopy, and most esophagectomies have been performed in the thoracic part[6–8]. Yuan et al. [9]reported the preliminary comparisons between the single-port and four-port esophagectomy approaches. The average surgical time in the single-port group was 30–40 min longer than in the multi-port group. The report performing MIE with a single-incision approach using thoracoscopic and laparoscopic procedures simultaneously is even rarer10.In order to reduce the difficulty of surgery, they[11, 12]often make one more auxiliary port outside the abdominal cavity in the single-port laparoscopic procedure,.
Thus, since March 2020, our center has innovatively adopted a pure single-port without auxiliary port to complete abdominal procedure. For the reduction of incisions increases the difficulty of endoscopic operation, the protocol of gastric mobilization is rearranged and we call it retrograde three-step gastric mobilization. Herein, we report our preliminary experience performing SLRM for esophageal reconstruction during MIE to treat esophageal cancer and describe the procedure details. The results of this study will be helpful to local hospitals that are planning to adopt this procedure.
We retrospectively analyzed the patients with esophageal cancer who received single-port laparoscopy combined with thoracoscopic McKeown esophagectomy from March 2020 to November 2021. The study was approved by the local Ethics Committee (No.[2021]300). Preoperative esophagogastroduodenoscopy and pathological examinations confirmed the diagnosis of esophageal squamous cell carcinoma in these patients. All patients received computed tomography (CT) and ultrasound for staging studies. For patients with advanced disease (T3 + or N+), postoperative chemoradiation therapy was followed by surgery 4–6 weeks later. All procedures were performed by the same surgical team.
All the surgeries were performed under general anaesthesia and a single-lumen endotracheal tube with an enclosed bronchial blocker was inserted. The thoracic part was performed first .
The patient was placed in the left lateral prone position. The thoracic area of the operation was carried out under the left single-lung ventilation (details of the position and the port design are described in our previous report[13]). The esophagus was mobilized from the side of the spine upward to the thoracic inlet and downward to the diaphragmatic hiatus. Then, lymph nodes and soft tissues of the RLN were dissected With the esophagus and trachea being pressed anteriorly using a special trachea retractor, lymph node dissection was conducted along the left RLN up to the thoracic inlet. The remaining mediastinal lymph nodes in the tracheobronchial region and the upper, middle, and lower paraesophageal regions were dissected. Finally, the whole thoracic part of the esophagus was mobilized. A 22-French thoracic tube was inserted into the 6th costal cavity, and an Abel drainage tube was inserted into the 8th costal cavity and clamped.
After the patient was placed in the supine position, a 3–4 cm vertical incision(Fig. 1c) was made in the middle between the umbilicus and the xiphoid process. Next, a single-port incision protector (Hangzhou Kangji Medical Devices Co, Ltd, disposable casing puncture, kit BA, Hangzhou, China) was placed, through which two or three surgical instruments and a standard 10-mm 30°laparoscope were inserted. laparoscope was at the 6 o’clock position, chief ports were at the 9 and 12 o’clock positions, respectively. The assistant port was introduced at the 3 o’clock position (Fig. 1a.b). CO2 was insufflated at 13 mmHg. To expose the surgical field by the gravity retractions from the body weight, the patient's position was changed frequently from the Trendelenburg to the reverse Trendelenburg position and by tilting from the right to the left side. The lymph nodes were dissected, and the stomach was mobilized during the single-port laparoscopic retrograde three-step gastric mobilization(SLRM) (Fig. 2)which is shown in the Supplemental Video (Video).
In brief, firstly, the hepatogastric ligament was dissected to the esophageal hiatus. The left liver lobe was retracted by a modified combined suture technique using 2–0 polypropylene stitches on a straight needle (Prolene®; Ethicon, Somerville, NJ, USA) and 5-mm hemoclips (Weck®; Teleflex, Morrisville, NC, USA) with a self-retaining fixing stitch passed through the diaphragmatic hiatus and tightened extracorporeally (Fig. 3a). The lymph nodes at lesser curvature, left gastric artery, celiac trifurcation, and the hiatus were dissected during mobilization of the stomach. The left gastric vessels were then dissected (Fig. 3b). Secondly, the esophageal hiatus and the abdominal esophagus were dissociated (Fig. 3c, d). The cardia was cutoff using a 60 mm linear stapler (EndoGIA 60 mm–3.5 mm, Covidien, Mansfield, MA, USA). Finally, the cardia was pulled down by the assistant. The gastric fundus and greater curvature were mobilized by dividing the short gastric vessels and gastrosplenic ligament, preserving the right gastric and gastroepiploic artery(Fig. 3e, f). The mobilization continued toward the left colon. The pylorus and duodenum were released. The lymph nodes at the greater curvature were dissected. During this step, a part of the pedicled omentum from the mid-to upper third of the greater curvature was kept intact in order to wrap around the esophagogastric anastomosis (Fig. 4a). After the stomach was pulled out through the abdominal incision, a 3–4-cm-diameter gastric conduit was constructed using 60-mm linear staplers. The gastric conduit was pulled in a plastic protective sleeve and put back into the abdominal cavity (Fig. 4b).
A approximate 4-cm incision was made along the anterior border of the left sternocleidomastoid muscle. The gastric conduit was pulled up to the left neck through the posterior mediastinum. During this process, the gastric conduit was protected by a plastic bag, and the pulling was facilitated by laparoscopic manipulations.
A side-to-side anastomosis of esophagogastric anastomosis was performed by the linear stapler. After being reinforced by interrupted 5–0 silk sutures, the anastomotic area was encircled by the pedicled fat (Fig. 4c,d), and a closed suction drain was placed in the anastomotic region. 12-French and 14-French nasogastric tubes were inserted into the gastric conduit for decompression and duodenum for nutrition, respectively. An abdominal drain tube was not placed.
The continuous data were were by the mean and standard deviation. All the analyses were performed using SPSS software, version 21.0 (SPSS, Inc., Chicago, IL, USA).
A total of 120 patients (88 males and 32 females) were included in the present study. The median age was 64 ± 2.3 years. The clinical characteristics of the patients are shown in Table 1. None of them required conversion to thoracotomy or laparotomy. There was no additional port placement. No death occurred during surgical and the hospital stays. One patient suffered from abdominal wall bleeding due to an accidental intraoperative puncture by a straight needle. The bleeding was stopped after electrocoagulation. The perioperative outcomes and surgical complications are shown in Table 2. The numbers of mediastinal and abdominal lymph nodes harvested were 13.2 ± 2.7 and 10.2 ± 2.5, respectively. The mean time for the entire procedure was 230 ± 20 min, including the thoracic part (60 ± 18 min) and abdominal part (43 ± 6 min). The mean entire blood loss was 65 ± 16 ml, including abdominal blood loss of 15 ± 5 ml. The timing to start to ambulate was on the second to third day after the surgery. The thoracic and cervical drainage tubes were removed on an average of 2 days after the operation. The thoracic Abel drainage tube was removed about 5 days after the operation. Postoperative pneumonia occurred in 10 patients (8.3%), which was successfully treated by antibiotics. Anastomotic leakages were reported in 3 patients (2.5%), which were recovered by fully draining the neck incision and wet dressing. Temporary vocal cord paralysis occurred in 20 patients (16.6%), which recovered within 6 weeks. No anastomotic stenosis was recorded in this study. All the patients were discharged after they tolerated the semifluid diet. The mean postoperative hospital stay was 8.5 ± 4.6 days.
|
Characteristics |
Results |
|---|---|
|
Age, years (mean ± SD) |
64 ± 2.3 |
|
Sex, n (male/female) |
88/32 |
|
Smoking, n (yes/no) |
67/53 |
|
Hypertension, n |
32 |
|
Diabetes, n |
26 |
|
Adjuvant therapy, n |
|
|
• Chemoradiotherapy/no treatment |
59/61 |
|
Location of the tumor, n |
|
|
• Upper/middle/lower |
16/68/36 |
|
Preoperative clinical stage, n |
|
|
• cT1N0-1M0 |
26 |
|
• cT2N0-1M0 |
37 |
|
• cT3N0-1M0 |
57 |
| SLRM: Single-port laparoscopic retrograde three-step gastric mobilization; SD: Standard deviation | |
|
Outcome measurements |
Results |
|---|---|
|
Operating time ,min, mean ± SD |
|
|
• Total time |
230 ± 20 |
|
• Chest |
60 ± 18 |
|
• Abdominal |
43 ± 6 |
|
Blood loss ml, mean ± SD |
65 ± 16 |
|
Abdominal blood loss, ml, mean ± SD |
15 ± 5 |
|
Harvested lymph nodes, n, mean ± SD |
|
|
• Chest |
13.2 ± 2.7 |
|
• Abdominal |
10.2 ± 2.5 |
|
Postoperative hospital stay ,days, mean ± SD |
8.5 ± 4.6 |
|
The most common complications, n (%) |
|
|
• Pneumonia |
10 (8.3%) |
|
• Temporary vocal cord paralysis |
20 (16.6%) |
|
• Anastomotic leakage |
3 (2.5%) |
| SLRM: Single-port laparoscopic retrograde three-step gastric mobilization | |
Detailed outcomes were reviewed in these patients at a mean follow-up duration of 13 months (range, 3–20) by hospital visits or telephone. No tumor recurrence occurred, and none of the patients had dysphagia. None of the patients died during the follow-up period.
Since Cuschieri et al. [14] first reported thoracoscopic esophagectomy in 1992, laparo-thoracoscopic esophagectomy has been routinely performed to treat patients with esophageal cancer[15]. However, because of the narrow operating space, lacking of triangular vision of traditional endoscopy, difficult cooperation between the master and assistant, studies[16–18] on the single-port laparoscopic esophagectomy are still extremely limited. And the surgical approach of SLRM has hardly been mentioned before. In the present study, we sought to evaluate the effectiveness and feasiblity of the novel procedure and shared our experience.
In 2020, the SLRM was developed in our center. All the patients underwent the McKeown procedure. This study focuses on the abdominal step, operative advantages and perioperative complications. The procedure can be summarized into three steps: 1) retraction, which includes liver lobe retraction, the lesser curvature mobilization, left gastric vessel dissection, and lymph node dissection; 2) dissection, which involves the dissection of the cardioesophageal junction. In patients with a tumor at the lower location, we should cut off the lower esophagus in the thoracic cavity; and 3) mobilization, which includes mobilization of the gastric fundus and the hilum of the spleen, along with lymph node dissection of the greater curvature.
The SLRM has the following obvious advantages. Firstly, compared with the traditional five-port laparoscope, the single-port laparoscope reduced the number of abdominal incision to one. The nerve and muscle compressions caused by the instrument operation were also limited to a 3-cm-incision, which suggests less trauma, less postoperative stress and pain, and better cosmetic effects.
Secondly, we optimized the surgical procedure. Conventional laparoscopic gastric mobilization starts from the greater curvature. The space is limited by the upper diaphragm. The risk of bleeding from the spleen is high, especially in patients with obesity or bloat. But, the SLRM mobilized the gastric tissue reversely from the lesser curvature to the gastric fundus and the greater curvature. The omental adipose tissue on the greater curvature can be avoided, and the operation is not affected even if bloating and the gastrosplenic ligament is exposed clearly. The operation of the upper pole of the spleen, such as cutting off the gastrosplenic ligaments and short gastric vessels, is unimpeded.
Thirdly, when the gastric conduit is constructed and placed back to the abdominal cavity, it is easier to re-establish the pneumoperitoneum with the single-port operation. The gastric conduit can be pulled up through the mediastinum under laparoscopic surveillance. In contrast, the re-establishment of traditional laparoscopic pneumoperitoneum is slightly troublesome.
Meanwhile, we have several considerations to share about this novel technique. 1) Our approach benefits from the use of a multichannel single-port incision protector which contains four moderately sized ports and they are flexible and interchangeable. The base is locked in the abdominal wall. The upper part can be disassembled and assembled freely. 2) The skilled implementation of single-port abdominal surgery also requires a period of training and experience. After the surgical procedure was standardized, the laparoscopic time was reduced to 40min, while the time is about 60min in the multi-port laparoscopic procedure[13]. 3) Some surgical techniques are worth special attention. The first one is the site of incision. The most appropriate location for a 3-cm-long incision is in the middle between the umbilicus and the xiphoid process. If the incision location is too low, the vision well be remote, and the operating instruments can interfere with each other frequently. If the incision location is too high, retracting the liver lobe well be difficult, which can obstruct the surgical field. The second important technique is the retraction process of the left liver lobe. Lakdawala et al. [19] routinely used a grasping forceps to elevate the left lobe. Huang et al. [20] recommended inserting needles into the edge of the liver for retraction. We used a 2–0 prolene needle and thread to enter from the left margin of the costal arch, then removed the needle through the abdominal wall on the left of the falciform ligament. The left liver lobe was then retracted and fixed at the hiatus, which offered a better exposure to the lesser curvature and the cardia. 4) The other important part is the skill of the laparoscope holder. The laparoscope should be placed at the lower pole of the incision and pressed down as far as possible. Other surgical instruments should be kept parallel and leveled up without crossing. A small field of vision aperture can enlarge the overall field of vision and reduce the limitation of a narrow surgical space.
In our series, the average number of harvested abdominal lymph nodes was about 10.2, which is similar to previous meta-analyses[21, 22]. In terms of intraoperative complications, only one patient with abdominal wall bled from an accidental puncture by the needle. For postoperative complications, the reports of McKeown MIE from Japan indicate that The median incidences of pneumonia, anastomotic leakage, and recurrent laryngeal nerve palsy were 12.0%, 7.2%, and 19.8%, respectively[23]and our result were 8.3%, 2.5%, and 16.8%, respectively, which were lower.
We note that this is just our personal opinion, and currently there is no sufficient data compare SLRM with traditional laparoscopic surgery; therefore, a single-center randomized controlled study about the comparison is being conducted at our institution and has been registered at Clinical Trials Registry (NO. ChiCTR 2100043730). We look forward to further results.
The preliminary results demonstrate that the SLRM is a technically feasible and safe procedure with the optimal operating process and a single incision. The SLRM can be considered as an alternative method for the patients with esophageal cancer, especially the ones with obesity and gastric distension. However, it is still in the exploratory stage and requires more investigation.
SLTE = Single-port laparoscopic retrograde three-step gastric mobilization
TS = T-shape stapling; MIE = minimally invasive esophagectomy
CT = computed tomography; RLN = recurrent laryngeal nerve
Author contributions
Bo Liu is responsible for the acquisition, drafting, analysis, and interpretation of data and drafting of the manuscript; Xu Li is responsible for the study conception and design; Min-Jie Yu, is responsible for acquisition, analysis, and interpretation of data; Jin-Bao Xie is responsible for acquisition, analysis; Zhi Feng, is responsible for acquisition; Ming-Lian Qiu is responsible for drafting and critical revision of the manuscript.. All authors read and approved the final manuscript.
Acknowledgements
None.
Funding
This study was funded by the Natural Science Foundation of Fujian Province, China(Grant numbers 2020J01953 ), Scientific Research Project from the Education Department of Fujian Province, China (Grant numbers JAT190212 )
Conflict of interest
Ming-Lian Qiu, Bo Liu, Xu Li, Min-Jie Yu, Jin-Bao Xie and Zhi Feng declare that they have no conflict of interest.
Ethical approval
The study was approved by the Ethics Committee of Fujian Medical University (No.[2021]300). All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1964 and later versions.