Page 11 - World Journal of Laparoscopic Surgery

Laparoscopic vs Open Transhiatal Esophagectomy
nearest to the neck. The 5 mm ports were placed in subxiphoid for 400 cc and 33 (91.7%) patients had no drainage. The two groups
liver retractor, right subcostal region in midclavicular line, for the showed no significant difference in term of the drainage volume
left hand of the surgeon, and left subcostal anterior axillary line (p = 0.087).
for the assistant. Then the left lobe of the liver was retracted and Regarding mortality and morbidity, no intraoperative death,
dissection began by dividing the phrenoesophageal ligament. and no major bleeding occurred; packed cell transfusion was also
The esophagus was dissected from the adjacent crura. The not required.
abdominal esophagus was handled with a surgical tape encircling The mean operative time was 75 ± 16 minutes in the open
it for different maneuvers for dissection of the mediastinal part of group and 125 ± 25 minutes in the laparoscopic group (p < 0.05).
the esophagus. Then the esophagus was dissected up as high as Two laparoscopic procedures were converted to open, i.e., one
possible to the neck, under the direct vision of the scope. Thereafter, patient due to tumor invasion to aorta and one due to invasion to
gastro lysis was performed by preserving the right gastric and right carina. In another case, the lack of vision and inability to dissect the
gastroepiploic arcades using a 10 × 35 ligature. Kocher maneuver esophagus led to open surgery. Hospital staying was 8 ± 1.7 days
and pyloroplasty were not performed. After dissecting the left in open group and 7 ± 1.9 days in laparoscopic group (p > 0.05).
gastric artery lymph nodes, the gastroesophageal junction was
stapled and divided to make a conduit. Then a suture was tied dIscussIon
between the conduit and the esophagus to pull the stomach
up through the neck. An oblique incision was made parallel and According to the literature, minimally invasive esophagectomy
anterior to the left sternocleidomastoid muscle and the cervical (MIE) is usually a combination of laparoscopy, thoracoscopy,
1–3
esophagus was explored, dissected, and brought to the incision. In laparotomy or thoracotomy, with or without cervical anastomosis.
1
this step, care was taken to avoid recurrent laryngeal nerve injury. In the study by Luketich et al. which was performed on more than
The stomach was brought up to the neck via esophagus traction 1,000 MIEs, two groups were compared in terms of laparoscopic–
and the suture between them was cut and a hand-sewn single- thoracoscopic MIE (Ivor Lewis MIE) and thoracoscopy–laparoscopy
layer end-to-side esophagogastric anastomosis was performed. No neck anastomosis (McKeown MIE or neck MIE). In the view of the
nasogastric tube was used. Then the anastomosis was drawn back complications and mortality, the total 30-day in-hospital mortality
to the neck and the incision was closed with simple nylon sutures. in both the groups was 1.68%. In our study, a 10% mortality rate
No feeding jejunostomy was used. If required, the chest tube was was observed in hospital, with no out-hospital mortality in the
inserted at the end of the operation. All patients were transferred 30-day period after surgery. Their study indicated no difference
to the intensive care unit. in mortality in two MIE groups, but in our study the mortality was
The open procedure was performed in the same manner but statistically higher in the laparoscopic group. This can be partially
via midline laparotomy. attributed to the learning curve issues with minimally invasive
approaches and poor patient selection. We should mention that
Statistical Analysis their technique is completely different. In another study by Meng
2
The data concerning the type of operation, type of conduit, pylorus et al., open transhiatal esophagectomy was compared to MIE using
drainage procedures, intraoperative complications, chest tube thoracoscopic combined with minilaparotomy in 183 patients. Total
insertion, and amount and type of drained fluid, postoperative mortality was five patients, which was lower than ours. Postoperative
complications, operative time, and need for reoperation were complications including anastomosis leakage (8 vs 2 in ours) and
recorded. Then the data were analyzed using SPSS version 16 with recurrent laryngeal nerve injury (8 vs 2 in ours) were similar in both
Fisher’s exact test and Peterson’s Chi-square test. p value < 0.05 groups. They reported chylothorax in 7 (3%) patients, but in our
was set as statistically significant. study it occurred in 5 (7%) patients. But these complications were
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the same in both groups in their study. Another study compared
the results of open vs laparoscopic transhiatal esophagectomy. The
results only difference in laparoscopic technique was abdominal phase of
Totally, 93 patients were enrolled in the study. Of the 93 patients, the operation which was performed in epigastrium with a 7-cm
57 had open procedure and 36 had laparoscopic esophagectomy. minilaparotomy. Just like our study, no pyloroplasty was performed
The mean age was 60 ± 11 and male to female (M:F) ratio was in the laparoscopic group; but unlike our study, only 36 patients had
1.5:2 in open group and the mean age was 57 ± 15 and M:F ratio neoadjuvant chemoradiotherapy. They had 9 (18%) conversions
was 1.4:2 in laparoscopic group without significant difference. to open surgery, but we had 2 conversions. Similar to our study,
Mortality occurred in 3 (5.3%) patients in the open group and laparoscopic group had longer operative time (300 minutes). No
7 (19.4%) patients in the laparoscopic group (p = 0.037). Four (7%) mortality was reported in MIE group, but one was reported in
patients had chylothorax in the open group and 1 (2.8%) patient the in open group. In our study, three patients who underwent
in laparoscopic group (p = 0.354). Other morbidities happened open surgery died and seven patients in the laparoscopy group.
in both groups but without statistically significant difference, This difference may be due to patient selection or tumor location.
consisting of one recurrent laryngeal nerve palsy in open group Compared with our study, they had more morbidity, recurrent
and two case of neck fistula in laparoscopic group. Fifteen (26.3%) laryngeal nerve palsy (8 vs 1 in our study) and neck fistula (7 vs 2 in
patients had chest tube in open group and 8 (22.2%) patients in our study), but they reported less chylothorax (3 vs 5 in our study).
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laparoscopic group (p = 0.425). Three categories of chest tube In another study by Rodham et al., patients were studied in view
drainage were considered, namely, more than 400 cc, less than of hospital stays. They reviewed 24 studies and concluded that
400 cc, and no drainage. In the open group, 10 patients had more patients underwent MIE by any method had lower hospital stay
than 400 cc (17.5%), 4 patients had less than 400 cc (7%), and 43 had (mean of 3 days). In our study, the two groups showed no statistically
no drainage. In the laparoscopic group, 3 patients had more than significant difference in terms of hospital stay.

World Journal of Laparoscopic Surgery, Volume 12 Issue 2 (May–August 2019) 57