Advancing Gastroscope From Intraluminal to Extraluminal Dissection: Primary Experience of Laparo-gastroscopic Esophagectomy

Abstract

Transhiatal esophagectomy facilitates esophageal resection without the need for thoracotomy. However, this procedure carries the risks of blind and blunt dissection within the mediastinum. More recently, video-assisted or mediastinoscopic transhiatal esophagectomy was introduced to mobilize the esophagus under direct visualization. Even though, the procedure is technically demanding and animal studies have shown that the CO 2 pneumomediastinum may be associated with hemodynamic instability. By further developing already established techniques, we pioneered the transhiatal esophageal mobilization by using hybrid gastroscope (Fig. 1 ). Laparo-gastroscopic esophagectomy, which integrates gastroscope and laparoscope for esophageal mobilization, was successfully implemented on an esophageal cancer patient with a history of lung cancer surgery. The operative duration was 240 minutes with an estimated blood loss of 110 mL. The patient experienced an uneventful recovery and was discharged on postoperative day 9. Further studies will be required to confirm the surgical and oncological efficacy of this innovation.

Transcervical versus transthoracic minimally invasive esophagectomy: a randomized and controlled trial protocol

“…The procedure was further refined to allow adequate lymph node dissection (5). Based on the previous modifications, we developed extraluminal gastroscopic esophageal mobilization through a cervical incision, in which a single gastroscope is used instead of multiple thoracoscopic instruments within the mediastinum, and without artificial pneumomediastinum (7). The results of our primary study have led to the question if transcervical LGE has comparable efficacy to conventional transthoracic MIE.…”

“…Recently our team reported a further modification of transcervical minimally invasive esophagectomy (MIE) in which extraluminal gastroscopic esophageal mobilization is performed instead of mediastinoscopic esophagectomy (7). The safety and efficacy have also been proven by our serial successful cases.…”

“…Patients assigned to arm A will receive radical laparogastroscopic esophagectomy (LGE), and patients assigned to arm B will receive radical laparo-thoracoscopic esophagectomy (LTE). Details of LGE and LTE have been reported previously (7,8). The procedural steps of LTE and LGE are shown in Figure 1 and Figure 2, respectively.…”

Skills in Flexible Endoscopy Are a Valuable Tool for GI Surgeons

“…In Shen et al, the authors present a case of a hybrid laparo-endoscopic approach to transhiatal esophagectomy 4 . Building off techniques from submucosal dissection and tunneling (ie, the use of CO 2 insufflation, blue dye/saline, and water jet systems for visualization of dissection planes), the authors describe gastroscopic dissection of the cervical and upper thoracic esophagus with the goal of minimizing total CO 2 insufflation of the mediastinum and manipulation of mediastinal organs.…”

“…In Shen et al, the authors present a case of a hybrid laparo-endoscopic approach to transhiatal esophagectomy. 4 Building off techniques from submucosal dissection and tunneling (ie, the use of CO 2 insufflation, blue dye/saline, and water jet systems for visualization of dissection planes), the authors describe gastroscopic dissection of the cervical and upper thoracic esophagus with the goal of minimizing total CO 2 insufflation of the mediastinum and manipulation of mediastinal organs. As an initial proof of concept on the feasibility of such an approach, this report provides food for thought in considering the procedure was accomplished within a reasonable length of time and with a technical success for the patient (ie, no postoperative complications as well as disease-free survival at 1 year).…”