Evaluation of the clinical effect of inflatable mediastinoscopy synchronous laparoscopic radical resection of esophageal cancer: a comparative study

Abstract

Objective

To explore the technical innovation and clinical application effect of inflatable mediastinoscopy synchronous laparoscopic radical resection of esophageal cancer.

Methods

The clinical data of 180 patients with esophageal cancer treated by the same surgical team from January 2018 to December 2019 were retrospectively analyzed. The patients were divided into the inflatable mediastinoscopy synchronous laparoscopic group (n = 93) and the McKeown group (n = 87) according to the surgical approach. Preoperative general baseline data, perioperative indices, postoperative indices, and short- and long-term survival rates were recorded and statistically analyzed for both groups.

Results

Compared to McKeown’s procedure, the inflatable mediastinoscopy synchronized laparoscopic esophagectomy was associated with relatively less operative time, blood loss, and hospital stay, specifically (94.46 ± 20.17) minutes, (36.76 ± 16.63)ml, and (13.63 ± 2.57) days, respectively. At the same time, the postoperative complication rate of the inflatable mediastinoscopy synchronized laparoscopic esophagectomy was low compared to the postoperative complication rate of McKeown's procedure.

Conclusion

Compared with the traditional McKeown procedure, the patients treated with inflatable mediastinoscopy synchronous laparoscopic radical resection of esophageal cancer have a lower incidence of thoracic complications, shorter operation time, less pain, and faster postoperative recovery so that it can be used as a new supplementary method for mainstream McKeown radical resection of esophageal cancer.

Introduction

Esophageal cancer is a common malignant tumor in the world, especially esophageal squamous cell carcinoma. It has a high incidence in China [1], and most of them have a poor prognosis [2]. At present, surgery is the main treatment of esophageal cancer, especially in the early and middle stages, which can achieve the purpose of radical cure [3]. Early surgical approaches were predominantly open, but with rapid improvements in minimally invasive techniques and advances in instrumentation and optics, minimally invasive esophagectomy (MIE) has become increasingly popular and has been performed in most academic centers over the past decade [4].Currently, the most commonly performed minimally invasive esophagectomy (MIE) is McKeown. While thoracoscopic transthoracic esophagectomy is the mainstream treatment for esophageal cancer, it has the disadvantages of high trauma, obvious postoperative pain, high incidence of postoperative respiratory complications caused by intraoperative single-lung ventilation, and high perioperative mortality [5, 6]. This kind of operation not only prolongs the postoperative hospital stay, increases the death rate in the hospital, hinders the rapid recovery after operation, but also affects the long-term survival rate of patients [7]. Based on this, a new method of Inflatable mediastinoscope combined with laparoscopic radical esophagectomy for esophageal cancer appeared in the clinic. The procedure is a non-transthoracic esophageal cancer resection. Compared with transthoracic surgery, non-transthoracic surgery effectively reduces postoperative pain and perioperative cardiopulmonary complications, thus expanding the surgical indications for patients who cannot undergo transthoracic surgery [8]. So, it has become the best choice for some elderly patients or patients with poor cardiopulmonary function. And it also provides surgical access to some patients who are unable to undergo the McKeown procedure, allowing more patients to be treated. However, the procedure requires the surgeon to perform separate mediastinal and abdominal surgeries, thus the operation length will be increased, the anesthesia time will be prolonged, and the patient's chance of intraoperative bleeding and intraoperative complications will be increased. Therefore, our team proposes inflatable mediastinoscopy synchronous laparoscopic radical resection of esophageal cancer on this basis. The procedure is performed by two groups of surgeons at the same time, one performing mediastinal surgery and one performing abdominal surgery. It has a lower incidence of thoracic complications, shorter operation time, less pain, and faster postoperative recovery.

Inflatable mediastinoscope synchronized laparoscopic radical esophageal cancer surgery is a further innovation based on the existing surgery for the treatment of esophageal cancer. In 2015 and 2016, Prof. Fujiwara developed new surgical approaches for mediastinal lymph node clearance using a single-port mediastinoscope through a neck incision [9] and lower mediastinal lymph nodes (including subglottic lymph nodes), respectively, under laparoscopy [10]. On this basis, Prof. Qingdong Cao advanced the surgical method to the “single-port inflatable mediastinoscopy combined with laparoscopy for the radical treatment of esophageal cancer” [8]. Based on accumulating the experience of mediastinoscopy combined with laparoscopic radical resection of esophageal cancer, the thoracic surgery team of Huaihe Hospital of Henan University began to propose a single-center study of inflatable mediastinoscopic simultaneous laparoscopic radical resection of esophageal cancer in October 2018. The main purpose of this study is to compare two surgical procedures, the inflatable mediastinoscopy synchronous laparoscopic procedure and the McKeown procedure, to investigate the clinical effect of the Inflatable mediastinoscopy synchronous laparoscopic procedure, so that more patients with esophageal cancer can benefit from it.

Methods and materials

General information

The clinical data of 180 patients with esophageal cancer treated by the same surgical team from January 2018 to December 2019 were retrospectively analyzed. The patients were divided into the inflatable mediastinoscopy synchronous laparoscopic group (n = 93) and the McKeown group (n = 87) according to the surgical approach. The criteria for inclusion in this study were as follows: (1) all enrolled patients were diagnosed with esophageal squamous cell carcinoma by preoperative gastroscopy and pathology; (2) All patients underwent either minimally invasive McKeown esophagectomy or inflatable mediastinoscopy synchronized laparoscopic esophagectomy procedures, which were completed; (3) Preoperative examination suggests that there are no enlarged lymph nodes in the neck and distant metastasis of the tumor, and the tumor stage is T1 - 2 N0 - 1M0 or T3 N1M0 (IIIa); (4) No history of thoracic and/or abdominal surgery; and (5) Patient’s clinical data complete. The exclusion criteria for the patients in this study are as follows: (1) patients had tumors adjacent to the lower part of the cardia and esophagus or gastroesophageal junction, which could be operated through a single left thoracic approach; (2) Conversion to open surgery during surgery; and (3) Distant metastases during surgery. This study was approved by the Ethics Committee of Henan University, under the permission number HUSOM2023 - 348. All patients provided their informed consent by signing the necessary documentation. According to the above criteria, a total of 180 eligible esophageal cancer patients were enrolled in this study. All the enrolled patients completed the surgery.

Surgical method

Preoperative preparation

Neoadjuvant therapy: According to the basic preoperative conditions of patients to decide whether to carry out preoperative neoadjuvant therapy, preoperative neoadjuvant chemotherapy intervention for patients can promote the tumor lesion volume reduction or tumor stage downgrade, laying the foundation for surgical resection treatment. The main neoadjuvant treatment is the TP program. TP regimen: paclitaxel (albumin-bound) 200 mg/m [2] IV on day 1, carboplatin injection 0.3–0.4 g/m² IV on days 1–3. 4 weeks for 1 course of chemotherapy and 1–2 courses of chemotherapy. Review 4 weeks after neoadjuvant chemotherapy and surgery for those with significant or stable chemotherapy efficacy.

Gastrointestinal preparation: The night before the operation, at 23:00, consume 100 ml of olive oil or 1000 ml of plain milk. A gastric tube was left in place preoperatively for gastrointestinal decompression to avoid gastric distension due to the induction of anesthesia, which could affect the surgical outcome. A cleansing enema was also administered.

Surgical procedure

Under general anesthesia, the patient was placed in the supine position with the head elevated by 30° and the legs separated by 45°. Single-lumen intubation was performed, and positive pressure ventilation was applied to both lungs. Pulse, blood pressure, and oxygen saturation were monitored during the operation. The neck and abdominal surgical site were sterilized with iodophor. Two sets of high-definition machines were placed on the right side of the bed and the distal end of the bed. The instrument nurses were also divided into two groups, specifically positioned at the cephalosome and abdominal portions. The two groups of surgeons were divided into a cervical mediastinal laparoscopy group and an abdominal laparoscopy group for simultaneous surgical operations. The inflatable mediastinoscopy group mainly dissects, frees, and resects the esophagus in the mediastinum by means of an inflatable mediastinoscope, and completes a total mesenteric resection of the esophagus as well as lymph node dissection. The laparoscopic team mainly performed lymph node dissection in the stomach and abdominal region and continued to dissect and free the abdominal segment of the esophagus, the lower mediastinum, and the lower esophagus to meet the inflatable mediastinoscopic team at the level of the bulge, and to make a tubular stomach horizontally along the greater curvature of the stomach.

Position and layout of operation

The operating room temperature was controlled at 22–24℃, and the patient was placed in the"human"position, with the head raised to 30° and maintained in the dorsal elevated position. The arms were positioned alongside the upper body, the extension tube for the deep vein puncture of the neck was located at the feet and the legs were split at 45º. The instrumentation nurses in both groups place the surgical instruments in place and within reach of the surgeon in charge. The mediastinoscopy team's support hand stood on the right side of the patient's head after placing the instrument in a sterile wrap, the attending surgeon stood on the same side as the instrument nurse, and the anesthesiologist stood on the right side of the patient's head. The laparoscopic team stands as follows: the lead surgeon stands on the perineal side of the patient, the instrumentation nurse stands on the left side of the patient's body, to the left of the lead surgeon, the mirror support handstands on the left side of the patient's abdomen, and the assistant stands on the patient's right side (Fig. 1A–D).

Fig. 1

Schematic diagram of surgical stations

Inflatable mediastinoscopy synchronized laparoscopic esophagectomy

Mediastinal operation group: A 3-cm transverse incision was made 1 cm above the left clavicle along the dermatome, and the internal jugular artery and vein were freed along the anterior border of the sternocleidomastoid muscle, and the cervical segmental esophagus was exposed from the intra-arterial posterior aspect, and an artificial mediastinal emphysema was established after freeing the cervical segmental esophagus (8–10 mmHg CO₂). A 5-mm 30° endoscope and LigaSure (model: LF1537) were inserted through the protective sleeve of the multichannel incision, and the cervical esophagus was dissected downward along the cervical esophagus with the assistance of a retractor (model: SCL0601) (Fig. 2A). The sequence was left margin, posterior margin, superior margin, and right margin of the esophagus. Remove the paraesophageal lymph nodes, taking care to protect the thoracic duct and tracheo-membranous structures (Fig. 2B), and free the esophagus as far down as possible below the level of the rump or the inferior pulmonary vein. Locate the left recurrent laryngeal nerve, determine the course of the nerve, and clear the lymph nodes adjacent to the left recurrent laryngeal nerve (Fig. 2C). The multichannel protective sleeve is removed, and the trachea is retracted to the right from the neck incision, exposing the right edge of the trachea, locating the right recurrent laryngeal nerve, and removing the right paraglottic lymph nodes (Fig. 2D). The esophagus was dissected at the neck incision, and the short end of the cephalad esophagus was placed into the anastomotic head and secured with a posterior suture.

Fig. 2

Operative diagram of mediastinoscopy group

Laparoscopic operation group (synchronized with mediastinoscopic surgery): After establishing an artificial pneumoperitoneum (10–12 mmHg CO₂), abdominal lymph node dissection was accomplished through periumbilical and right subcostal marginal multiple-hole approaches (Fig. 3A–C), and the perigastric ligament was freed and ligated to cut off the right gastric vessel and gastric coronary vessels, preserving the left gastric vascular arch. After penetrating the thoracic cavity through the esophageal hiatus, the stomach and most of the esophagus were removed from the abdomen through a subxiphoid incision, the esophagus was resected, and a 3- to 4-cm tube stomach was created with plasma muscular layer reinforcement (Fig. 3D). The tube stomach was lifted to the neck via the esophageal bed, and the fundus–esophagus end-side anastomosis was completed using an anastomosis with double-layer reinforcement, and a gastric tube and jejunal nutritional tube were finally placed, and after complete hemostasis, the cervico-abdominal area was sutured layer by layer and drains were placed.

Fig. 3

Operative diagram of the laparoscopic group

McKeown group

The patient was placed in the left lateral position and tilted forward by 30° to perform one-lung ventilation, and the esophagus was freed and the tumor was resected through the main operation hole in the anterior axillary line of the fourth rib of the right chest and the auxiliary holes in the intercostal space, and the bilateral pararectal lymph nodes, subluxation lymph nodes, and lymph nodes adjacent to the right and left laryngeal retractor nerves were routinely cleared. After the chest drain was placed, the patient was transferred to the lying position, and the abdominal surgery was performed, similar to the laparoscopic operation mentioned above, to free the perigastric region, make a tubular stomach, and remove lymph nodes at the cardia and the lesser curvature of the stomach (Fig. 4 A, B); the esophagus was retracted through the left cervical sternocleidomastoid muscle internal incision, and the posterior wall of the stomach was anastomosed mechanically to the esophagus (Fig. 4C, D). A nutritional tube was left in place after inspection of the anastomosis, and the cervico-abdominal incision was closed in layers and a drain was placed.

Fig. 4

Surgical operation diagram of McKeown procedure

Surgical method

Based on the concept of rapid rehabilitation, patients were encouraged to get out of bed at an early stage, and all patients were treated with a nasal feeding tube for nutritional support, as well as anti-inflammatory, rehydration and other symptomatic treatments after surgery. All patients were fasted for 2–3 weeks after surgery, discharged from the hospital with nasal feeding tubes, and the tubes were removed after 2 weeks of review.

Statistical analysis

SPSS27.0 statistical software was used to analyze the data. The measurement data were expressed as mean ± standard deviation (x ± s), and the count data were expressed as the number of cases and percentage (%). The t-test was employed to assess the differences in measurement data between the two groups, while the χ2 test was used to compare the count data. P < 0.05 was considered statistically significant.

Results

Comparison of general information between the two groups of patients

Comparing the general information of the two groups of patients, the differences in all indicators are not statistically significant (P > 0.05) and are comparable. The data are shown in Table 1.

Table 1 180 cases of esophageal cancer patients general clinical data comparison

Comparison of perioperative indicators between the two groups of patients

The operation time, intraoperative bleeding, 24-h postoperative thoracic drainage, 3-day postoperative total drainage, and postoperative hospitalization time of the inflatable mediastinal synchronous laparoscopic group were significantly shorter than those of the minimally invasive McKeown group (P < 0.05). The comparison of the number of paralaryngeal nerve lymph nodes and paraesophageal lymph nodes, the total number of lymph nodes discharged, the first time to get out of bed after the operation, and hospitalization costs in the patients of the 2 groups, the difference was not statistically significant (P > 0.05). For details, see Table 2.

Table 2 Comparison of perioperative indicators between two groups of esophageal cancer patients

Comparison of postoperative complications between the two groups of patients

There were no perioperative deaths in either group. There were a total of 16 complications in inflatable mediastinal synchronous laparoscopic group, the total incidence was 17.25%. The minimally invasive McKeown group had a total of 29 complications, with a total incidence rate of 33.35%. Compared with the two groups, the overall postoperative complication rate was lower in the inflatable mediastinal synchronous laparoscopic group than in the McKeown group, and the difference was statistically significant (P < 0.05). However, the incidence of individual complications was not statistically different between the two groups (P > 0.05). For details, see Table 3.

Table 3 Comparison of postoperative complications between two groups of esophageal cancer patients

Comparison of postoperative short-term and long-term survival rates between the two groups of patients

There were no statistically significant differences observed in the overall survival rates between the two groups at 30 days, 3 months, 6 months, 1 year, and 3 years post-surgery (P > 0.05). There was a statistically significant difference in the 5-year overall survival rate between the two groups (P < 0.05); see Table 4.

Table 4 Comparison of the short-term and long-term survival rates between the two groups

Discussion

Esophageal cancer is one of the malignant tumors diagnosed and treated by thoracic surgery [11]. However, surgical treatment of esophageal cancer is invasive and carries a high intraoperative risk due to the deep anatomical location of esophageal cancer and its proximity to vital structures such as the aorta and trachea [12]. With the advancement of technology, the procedure has been gradually improved. Inflatable mediastinoscopy synchronous laparoscopic radical resection of esophageal cancer surgery mainly involves making an incision in the neck and tunneling down the esophagus to free the esophagus. This procedure is less invasive, less uncomfortable for patients and is performed through the mediastinum, because the procedure is performed by two groups of surgeons at the same time, the length of surgery is shortened, and it has the advantages of absence of pain due to trauma to the thorax, fewer postoperative complications, and rapid recovery.

Compared with the McKeown procedure, the main advantages of inflatable mediastinoscopy synchronous laparoscopic radical resection of esophageal cancer are: ① it does not enter the pleural cavity, which can avoid the compression of lung tissues by artificial pneumothorax and the pushing of surgical instruments in conventional thoracoscopic surgery, and it has less impact on cardiopulmonary function [13], and it is a good choice for some patients who are elderly or have poor cardiopulmonary function. ② Synchronization of mediastinoscopy and laparoscopy significantly shortens the total operation time (usually completed within about 2 h). At the same time, the 2 groups of operators and 2 groups of instrument nurses synchronized the approach and operation, and the upper and lower intersections, which not only reduced the anesthesia time and intraoperative bleeding, but also reduced the waiting time for the patient's position change and re-sterilization of the toweling during the operation, and thus greatly shortened the overall duration of the operation. ③ Because there is no chest incision and no damage to the blood vessels in the chest, the amount of surgical bleeding is small, and the prolonged operation time due to repeated hemostasis is also effectively reduced. ④ Intraoperative preservation of the singular vein and bronchial artery avoids liver injury in patients with combined hepatic insufficiency and reduces the incidence of postoperative cough. ⑤ Simultaneous mediastinoscopic and laparoscopic surgery allows the two groups of operators to help each other according to the patient's specific situation, giving more options in favor of the patient than one group of operators. ⑥ It is applicable to patients with some chest wall lesions that are difficult to enter the chest via the intercostal space, etc., thus expanding the clinical surgical indications for the current clinical mainstream McKeown procedure for radical esophageal cancer surgery.

It also has a wider range of surgical indications compared to the McKeown procedure. It mainly includes: ① early stage esophageal cancer (stage 0 and I). ② Stage II or III esophageal cancer in which the length of the upper esophageal cancer lesion is less than 3.0 cm, the length of the middle esophageal cancer lesion is less than 5.0 cm, and the length of the lower esophageal cancer lesion is less than 7.0 cm, and the tumor does not have any obvious external invasion. ③ Some patients with stage III esophageal cancer with preoperative external invasion who are in good general condition after preoperative induction radiotherapy. However, there are corresponding contraindications to this procedure, which mainly include: ① the cancer has a large invasion range or obvious external invasion, and may even invade adjacent vital organs that cannot be resected. ② Esophageal cancer with perforation sign or distant metastasis. ③ Those with serious heart, lung, liver and kidney insufficiency who cannot bear the operation; and those with a high degree of malignant stasis.

In conclusion, Inflatable mediastinoscopy synchronous laparoscopic radical resection of esophageal cancer surgery, as a new procedure, not only shortens the operative time and reduces intraoperative bleeding compared with McKeown's procedure, but also reduces the occurrence of thoracic complications by performing lymph node dissection in the mediastinal tunnel that enters from the neck. Therefore, it can be used as a new complementary procedure to the current mainstream McKeown procedure. However, as a new technology, there are still many problems that need to be clearly solved, and our team will actively try to improve and solve them, with the aim of creating surgical opportunities for more esophageal cancer patients and actively promoting its application in the clinic.