Minimally invasive transhiatal esophagectomy: lessons learned.
BACKGROUND
Minimally invasive esophagectomy has the potential to minimize the morbidity of esophageal resection and is particularly suited to the transhiatal approach. This report details our experience with this technique and the lessons we have learned.


METHODS
A retrospective analysis of patients who underwent minimally invasive transhiatal esophagectomy was performed. Parameters assessed included patient demographics, tumor pathology, operative and postoperative course, and survival.


RESULTS
Eighteen patients underwent minimally invasive transhiatal esophagectomy [median age = 69 years (range = 36-79)]. Seventeen were operated on for cancer, including 13 adenocarcinomas and 4 squamous cell carcinomas (median histological stage = 2, range = 1-3), and 1 for high-grade dysplasia in Barrett's. One patient had neoadjuvant chemotherapy. Two patients underwent nonemergency conversion to open surgery. The median duration of operation was 300 min (range = 180-450). All anastomoses were end-to-side hand-sewn. No patients received a red cell transfusion. The 30-day mortality was zero. Complications developed in 15 patients, including 7 respiratory and 10 recurrent laryngeal nerve injuries. There were two anastomotic leaks. Six patients developed stenosis requiring dilatation. The median length of stay was 15 days (range = 10-39). The median number of nodes harvested was 10 (range = 2-26). At a median follow-up of 13 months (range = 4-42), 13 patients were alive.


CONCLUSIONS
Minimally invasive transhiatal esophagectomy is feasible in our unit, with acceptable mortality. The high rate of anastomotic stenosis has resulted in a change to a semimechanical, side-to-side isoperistaltic technique. The high rate of recurrent laryngeal nerve injuries has resulted in the avoidance of metal retractors at the tracheo-esophageal groove.
Sanders
Grant
G
Department of Gastrointestinal Surgery, St. Eloi Hospital, University Hospital of Montpellier, Montpellier, France.
Borie
Frederic
F
Husson
Emanuel
E
Blanc
Pierre Marie
PM
Di Mauro
Gianluca
G
Claus
Christiano
C
Millat
Bertrand
B
D000328:Adult; D000368:Aged; D000714:Anastomosis, Surgical; D001471:Barrett Esophagus / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D004938:Esophageal Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D016629:Esophagectomy / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007582:Jejunostomy / Q000379:methods; D010535:Laparoscopy / Q000379:methods; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000379:methods; D011028:Pneumoperitoneum, Artificial; D011182:Postoperative Care; D011183:Postoperative Complications / Q000401:mortality; D012189:Retrospective Studies; D018570:Risk Assessment; D015996:Survival Rate; D013906:Thoracoscopy / Q000379:methods*; D016896:Treatment Outcome