Nicole van der Wielen

Surgical anatomy of the supracarinal esophagus based on a minimally invasive approach : vascular and nervous anatomy and technical steps to resection and lymphadenectomy

BackgroundDuring esophageal dissection and lymphadenectomy of the upper mediastinum by thoracoscopy in prone position, we observed a complex anatomy in which we had to resect the esophagus, dissect vessels and nerves, and take down some of these in order to perform a complete lymphadenectomy. In order to improve the quality of the dissection and standardization of the procedure, we describe the surgical anatomy and steps involved in this procedure.MethodsWe retrospectively evaluated twenty consecutive and unedited videos of thoracoscopic esophageal resections. We recorded the vascular anatomy of the supracarinal esophagus, lymph node stations and the steps taken in this procedure. The resulting concept was validated in a prospective study including five patients.ResultsSeventy percent of patients in the retrospective study had one right bronchial artery (RBA) and two left bronchial arteries (LBA). The RBA was divided at both sides of the esophagus in 18 patients, with preservation of one LBA or at least one esophageal branch in all cases. Both recurrent laryngeal nerves were identified in 18 patients. All patients in the prospective study had one RBA and two LBA, and in four patients the RBA was divided at both sides of the esophagus and preserved one of the LBA. Lymphadenectomy was performed of stations 4R, 4L, 2R and 2L, with a median of 11 resected lymph nodes. Both recurrent laryngeal nerves were identified in four patients. In three patients, only the left recurrent nerve could be identified. Two patients showed palsy of the left recurrent laryngeal nerve, and one showed neuropraxia of the left vocal cord.ConclusionsKnowledge of the surgical anatomy of the upper mediastinum and its anatomical variations is important for standardization of an adequate esophageal resection and paratracheal lymphadenectomy with preservation of any vascularization of the trachea, bronchi and the recurrent laryngeal nerves.

The role of tissue adhesives in esophageal surgery, a systematic review of literature

BACKGROUND Anastomotic leakage following esophageal surgery is a major contributor to mortality. According to the national database leakage occurs in 20% of esophagectomies carried out in the Netherlands. Therefore anastomotic leakage has been the topic of many studies. However, studies discussing application of tissue adhesives for either prevention or management of anastomotic leakage are limited. This article systematically reviewed all available literature on the potential use of tissue adhesives in esophageal surgery. METHODS Medline, Embase and Cochrane were searched to identify studies that used tissue adhesives as anastomotic sealants to prevent esophageal anastomotic leakage or used tissue adhesives to treat esophageal anastomotic leakage. Two authors independently selected nineteen out of 3107 articles. RESULTS Eight articles, of which five were experimental and three clinical, discussed prevention of anastomotic leakage. Eleven articles, of which one was experimental and ten clinical, discussed treatment of anastomotic leakage. Most articles reported positive results, however overall quality was low due to a high degree of bias and lack of homogeneity. CONCLUSION This study shows mainly positive results for the use of tissue adhesives for the esophageal anastomosis both in prevention of leakage as treating anastomotic leakage. However, the quality of current literature is poor.

Major abdominal surgery in octogenarians: should high age affect surgical decision-making?

BACKGROUND Over the last decades longevity has increased significantly, with more octogenarians undergoing surgery. Here, we assess surgical outcomes after major abdominal surgery in octogenarians. METHODS Observational cohort of 874 patients undergoing major abdominal elective surgery between January 2009 and March 2014. Seventy-six octogenarians were propensity matched to 76 younger patients, corrected for sex, body mass index, American Society of Anesthesiologists classification, comorbidity, indication, and type of surgery. RESULTS Minor complications were more prevalent in octogenarians (P = .01) and consisted mainly of respiratory complications; progressing to respiratory insufficiency requiring intubation in 28.6%. Preoperative weight loss (odds ratio 3 [1.1 to 8.3]) and upper gastrointestinal surgery (odds ratio 11 [2 to 60]) were associated with minor complications. CONCLUSIONS Octogenarians are at increased risk of minor complications after major abdominal surgery. Major complication rates were similar, indicating the importance of preoperative assessment and standardized surgical techniques. Taking into account preoperative morbidities and type of surgery and techniques. Implementation of quality control algorithms may further improve outcomes in octogenarians.

Short-term outcomes in minimally invasive versus open gastrectomy: the differences between East and West. A systematic review of the literature

ObjectiveMinimally invasive surgical techniques for gastric cancer are gaining more interest worldwide. Several Asian studies have proven the benefits of minimally invasive techniques over the open techniques. Nevertheless, implementation of this technique in Western countries is gradual. The aim of this systematic review is to give insight in the differences in outcomes and patient characteristics in Asian countries in comparison to Western countries.MethodologyAn extensive systematic search was conducted using the Medline, Embase, and Cochrane databases. Analysis of the outcomes was performed regarding operative results, postoperative recovery, complications, mortality, lymph node yield, radicality of the resected specimen, and survival. A total of 12 Asian and 8 Western studies were included.ResultsMinimally invasive gastrectomy shows faster postoperative recovery, fewer complications, and similar outcomes regarding mortality in both the Eastern and Western studies. However, patient characteristics such as age and BMI differ between these populations. Comparison of overall outcomes in minimally invasive and open procedures between East and West showed differences in complications, mortality, and number of resected lymph nodes in favor of the Asian population.ConclusionImproved outcomes are observed following minimally invasive gastrectomy in comparison to open procedures in both Western and Asian studies. There are differences in patient characteristics between the Western and Asian populations. Overall outcomes seem to be in favor of the Asian population. These differences may fade with centralization of care for gastric cancer patients in the West and increasing surgical experience.

Surgical anatomy of the omental bursa and the stomach based on a minimally invasive approach: different approaches and technical steps to resection and lymphadenectomy

BACKGROUND It is imperative for surgeons to have a proper knowledge of the omental bursa in order to perform an adequate dissection during minimally invasive surgery (MIS) of the upper gastrointestinal (GI) tract. This study aimed to describe (1) the various approaches which can be used to enter the bursa and to perform a complete lymphadenectomy, (2) the boundaries and anatomical landmarks of the omental bursa as seen during MIS, and (3) whether a bursectomy should be performed for oncological reasons in upper GI cancer. METHODS In this observational study, videos of 20 patients undergoing different MIS procedures were reviewed, and the findings were verified prospectively in 5 patients undergoing a total gastrectomy and in a transversely sectioned cadaver. A systematic literature review (PubMed) was performed on the additive value of bursectomy during gastrectomy for cancer. RESULTS The omental bursa can be surgically entered through the hepatogastric ligament, gastrocolic ligament, gastrosplenic ligament or through the transverse mesocolon. Anatomical boundaries of the omental bursa could be clearly identified, and new anatomical landmarks were described (gastro-omental folds). The cranial part of the omental bursa consists of two compartments (splenic recess and superior recess), separated by the gastropancreatic fold, communicating at the level of the pancreas, and extending distally as the inferior recess. There is no clear evidence regarding beneficial effect of a bursectomy in upper GI oncology. CONCLUSIONS The description of the omental bursa in this study may help surgeons perform a more adequate oncological dissection during MIS. Bursectomy should not be routinely performed during oncological resections.

Systematic Review of Exocrine Pancreatic Insufficiency after Gastrectomy for Cancer

Background: Survival rates after a total gastrectomy with adequate lymphadenectomy are improving, leading to a shift in outcomes of interest from survival to postoperative outcomes and symptoms. In this systematic review, we investigate gastrointestinal symptoms that occur after a gastrectomy in relation to exocrine pancreatic insufficiency and the effect of pancreatic exocrine enzyme supplementation on these symptoms. Methods: Online databases PubMed, Embase, and Cochrane Library were systematically searched in accordance with the PRISMA guidelines. Studies that researched gastrointestinal symptoms, exocrine pancreatic function, and enzyme supplementation were identified and assessed. Results: The search resulted in a total of 1,023 articles after exclusion of duplicates. After performing a thorough assessment, 4 studies were included for systematic review. Exocrine pancreatic insufficiency was investigated by 2 studies; the results showed a significant decrease of total exocrine pancreatic function of up to 76%. The other 2 studies investigated the effect of pancreatic enzyme supplementation and found minor improvement in fecal consistency and a decrease in high-degree steatorrhea. No differences in individual symptom scores were reported. Conclusion: Gastrointestinal symptoms such as steatorrhea, bloating, and dumping syndrome may be related to exocrine pancreatic function, initiated by total gastrectomy. Treatment with pancreatic enzymes had a minor positive effect on patients. It should be noted that these studies were of a small sample size and low quality. New and larger RCTs are necessary to either prove or disprove the benefit of pancreatic enzyme replacement therapy in the treatment of the gastrointestinal symptoms after total gastrectomy.

Mastering minimally invasive esophagectomy requires a mentor; experience of a personal mentorship

Since the first laparoscopic procedure, there has been an steady increase in advanced minimally invasive surgery. These procedures include oncological colorectal, hepatobiliary and upper gastrointestinal surgery. Implementation of these procedures requires different and new skills for the surgeons who wish to perform these procedures. To accomplish this surgical teaching program, a mentorship seems the most ideal method to teach the apprentice surgeon these specific skills. At the VU medical center a teaching program for a minimally-invasive esophagectomy for esophageal cancer started in 2009. At first it started in different centers in the Netherlands and later on we also started mentoring other institutes throughout Europe, Latin America and India. In this article we describe our experience and the outcomes of this mentorship in advanced minimally invasive surgery.

Mastering Major Minimally Surgery

New teaching programs in Minimally Invasive Surgery (MIS) require mentoring. We see that once a new MIS procedure has been validated by evidence, we can expect many surgical teams wanting to adopt the new procedure. The issue is how doing this according to best standards of practice is best learned. Commonly, the teaching programs in MIS may range from the institutionalized programs involved in the residency period to the quick one-or-two-days courses organized by Surgical Departments or companies targeting (young) surgeons desirous but still unable to operate by the new MIS approaches. While these opportunities offer interesting displays of new MIS, yet effective teaching programs in MIS developments are very variable and ad hoc.

Open or Minimally Invasive Esophagectomy After Neoadjuvant Therapy

In 1991, Dallemagne introduced the right thoracoscopic approach in lateral position for esophageal cancer with total lung block, thereby mimicking the conventional approach [1]. Initial reports showed a high conversion rate to thoracotomy and a high respiratory morbidity rate. Searching for reduction of the conversion rate and the respiratory infection rate, Cuschieri et al. redesigned the thoracoscopic approach in prone decubitus position so that a total collapse of the lung was no longer necessary for dissecting the esophagus and thereby possibly reducing the rate of respiratory infections [2].

Open or Minimally Invasive Gastrectomy

Gastric cancer has been amongst the most commonly diagnosed malignancies worldwide since 1975 with the highest incidence in Eastern Asia (13.3%) followed by Central and Eastern Europe (6.7%) [1]. Japan was the first country to start with the implementation of a screening program for gastric cancer in 1983 to facilitate early detection of the disease [2]. Consequently, other countries with a high prevalence of gastric cancer also implemented a screening program, such as Korea and China [3]. This resulted in a high incidence of early gastric cancer. Despite the early detection of this disease, the overall mortality is still amongst the highest in the world [1].