title: Transcervical videoscopic esophageal dissection during two-field minimally invasive esophagectomy: early patient experience.
abstract: BACKGROUND
  Transhiatal (two-field) esophagectomy reduces cardiopulmonary complications by avoiding thoracic access, but requires blind mediastinal dissection. The authors developed a minimally invasive esophagectomy (MIE) technique applying single-incision laparoscopy technology to better visualize the thoracic esophageal dissection. This is performed using laparoscopy and simultaneous transcervical videoscopic esophageal dissection (TVED). Our aim is to demonstrate feasibility of two-field MIE with TVED and improve recovery in high-risk patients.
  
  
  METHODS
  We performed a retrospective cohort study of eight patients who underwent two-field MIE with TVED over 10 months. The majority were male (N = 6) with mean age of 63 ± 12 years. Mean body mass index (BMI) was 30.2 ± 5.1 kg/m(2). Indications for operation were: high-grade dysplasia (N = 2), adenocarcinoma (N = 6) with one receiving neoadjuvant chemoradiation. Using the Charlson comorbidity index, three patients were low risk and five were high risk. TVED was performed with a modified single-incision access device across the left neck. The mediastinal esophagus was dissected distally and circumferentially with simultaneous transabdominal laparoscopy for gastric conduit creation and distal esophageal dissection.
  
  
  RESULTS
  Mean operative time was 292 min (range 194-375 min). Three obese patients required temporary abdominal desufflation to avoid extrinsic mediastinal compression. Mean estimated blood loss was 119 mL (range 25-400 mL). A median of 23 lymph nodes (range 13-29) was harvested. Median intensive care unit (ICU) stay was 1 day (range 1-5 days), and median overall stay was 7 days (range 5-16 days). The three low-risk patients had no major complications. Three of five high-risk patients had major complications, including two cervical anastomotic leaks. Major complications were seen in three of four obese patients (BMI >30 kg/m(2)). There were no mortalities.
  
  
  CONCLUSIONS
  The TVED approach may avoid the morbidity of transthoracic esophageal dissection by improving esophageal visualization. Complications with TVED appear to correlate with obesity and comorbidities. Although TVED appears feasible, a larger experience is required.
authors.affiliation: Department of Surgery, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL 322246, USA.
authors.forename: Michael
authors.initials: M
authors.lastname: Parker
authors.forename: Steven P
authors.initials: SP
authors.lastname: Bowers
authors.forename: Ross F
authors.initials: RF
authors.lastname: Goldberg
authors.forename: Jason M
authors.initials: JM
authors.lastname: Pfluke
authors.forename: John A
authors.initials: JA
authors.lastname: Stauffer
authors.forename: Horacio J
authors.initials: HJ
authors.lastname: Asbun
authors.forename: C
authors.initials: C
authors.lastname: Daniel Smith
mesh_terms: D000230:Adenocarcinoma / Q000601:surgery*; D000368:Aged; D004938:Esophageal Neoplasms / Q000601:surgery*; D016629:Esophagectomy / Q000379:methods*; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D020535:Video-Assisted Surgery / Q000379:methods*