Torben Glatz

Intraoperative crystalloid overload leads to substantial inflammatory infiltration of intestinal anastomoses—a histomorphological analysis

BACKGROUND It has been shown that crystalloid fluid-overload promotes anastomotic instability. As physiologic anastomotic healing requires the sequential infiltration of different cells, we hypothesized this to be altered by liberal fluid regimes and performed a histomorphological analysis. METHODS 36 Wistar rats were randomized into 4 groups (n=8-10 rats/group) and treated with either liberal (+) or restrictive (-) perioperative crystalline (Jonosteril = Cry) or colloidal fluid (Voluven = Col). Anastomotic samples were obtained on postoperative day 4, routinely stained and histophathologically reviewed. Anastomotic healing was assessed using a semiquantitative score, assessing inflammatory cells, anastomotic repair and collagenase activity. RESULTS Overall, the crystalloid overload group (Cry (+)) showed the worst healing score (P < 0.01). A substantial increase of lymphocytes and macrophages was found in this group compared to the other three (P < 0.01). Both groups that received colloidal fluid (Col (+) and Col (-)) as well as the group that received restricted crystalloid fluid resuscitation (Cry (-)) had better intestinal healing. Collagenase activity was significantly higher in the Cry (+) group. CONCLUSION Intraoperative infusion of high-volume crystalloid fluid leads to a pathological anastomotic inflammatory response with a marked infiltration of leukocytes and macrophages resulting in accelerated collagenolysis.

First-line endoscopic treatment with over-the-scope clips significantly improves the primary failure and rebleeding rates in high-risk gastrointestinal bleeding: A single-center experience with 100 cases

AIM To evaluate rebleeding, primary failure (PF) and mortality of patients in whom over-the-scope clips (OTSCs) were used as first-line and second-line endoscopic treatment (FLET, SLET) of upper and lower gastrointestinal bleeding (UGIB, LGIB). METHODS A retrospective analysis of a prospectively collected database identified all patients with UGIB and LGIB in a tertiary endoscopic referral center of the University of Freiburg, Germany, from 04-2012 to 05-2016 (n = 93) who underwent FLET and SLET with OTSCs. The complete Rockall risk scores were calculated from patients with UGIB. The scores were categorized as < or ≥ 7 and were compared with the original Rockall data. Differences between FLET and SLET were calculated. Univariate and multivariate analysis were performed to evaluate the factors that influenced rebleeding after OTSC placement. RESULTS Primary hemostasis and clinical success of bleeding lesions (without rebleeding) was achieved in 88/100 (88%) and 78/100 (78%), respectively. PF was significantly lower when OTSCs were applied as FLET compared to SLET (4.9% vs 23%, P = 0.008). In multivariate analysis, patients who had OTSC placement as SLET had a significantly higher rebleeding risk compared to those who had FLET (OR 5.3; P = 0.008). Patients with Rockall risk scores ≥ 7 had a significantly higher in-hospital mortality compared to those with scores < 7 (35% vs 10%, P = 0.034). No significant differences were observed in patients with scores < or ≥ 7 in rebleeding and rebleeding-associated mortality. CONCLUSION Our data show for the first time that FLET with OTSC might be the best predictor to successfully prevent rebleeding of gastrointestinal bleeding compared to SLET. The type of treatment determines the success of primary hemostasis or primary failure.

Laparoskopisch-thorakotomische Ösophagusresektion mit intrathorakaler Ösophagogastrostomie als Hybridverfahren

INTRODUCTION In the past decades various techniques of esophagectomy for the curative treatment of esophageal cancer have been described. Especially minimally invasive techniques of esophagectomy have been used increasingly in the last decade. Technical issues and results of hybrid laparoscopic-thoracotomic en bloc esophagectomy with intrathoracic esophagogastric anastomosis (HMIE) are presented and discussed in the article. PATIENTS AND METHODS Between May 2013 and April 2014 a total of 23 patients underwent esophagectomy for esophageal cancer at the University of Freiburg Medical Center. Of these patients 10 were treated by HMIE and the other 13 patients had open esophagectomy (OE). RESULTS A detailed description of the operative technique of HMIE is given in a step-by-step fashion. Margin negative resection was achieved in all patients after HMIE and OE and the median lymph node yield of lymphadenectomy in HMIE and OE (29 vs. 27) was nearly the same. The medium duration of the operation (347 min vs. 412 min) and median length of stay on the intensive care unit (6 days vs. 9 days) and hospital (13 days vs. 17 days) were decreased in HMIE patients compared to OE, respectively. Overall postoperative morbidity (40 % vs. 69 %) and especially pulmonary morbidity (10 % vs. 46 %) were also favorable in HMIE. No anastomotic leakage and postoperative in-hospital mortality occurred after HMIE. CONCLUSION The HMIE procedure combines the advantages of minimally invasive operative approaches on especially postoperative pulmonary morbidity after esophagectomy with the high safety of anastomosis and reconstruction achieved in OE. Further advantages are shorter duration of operation and shorter length of hospital stay in HMIE.

Pancreatic cancer: Circulating Tumor Cells and Primary Tumors show Heterogeneous KRAS Mutations

Pancreatic ductal adenocarcinoma (PDAC) is a devastating disease. Circulating tumor cells (CTC) in the blood are hypothesized as the means of systemic tumor spread. Blood obtained from healthy donors and patients with PDAC was therefore subject to size-based CTC-isolation. We additionally compared Kirsten rat sarcoma viral oncogene homolog (KRAS) mutations in pancreatic CTC and corresponding tumors, and evaluated their significance as prognostic markers. Samples from 68 individuals (58 PDAC patients, 10 healthy donors) were analyzed; CTCs were present in patients with UICC stage IA-IV tumors and none of the controls (p < 0.001). Patients with >3 CTC/ml had a trend for worse median overall survival (OS) than patients with 0.3–3 CTC/ml (P = 0.12). Surprisingly, CTCs harbored various KRAS mutations in codon 12 and 13. Patients with a KRASG12V mutation in their CTC (n = 14) had a trend to better median OS (24.5 months) compared to patients with other (10 months), or no detectable KRAS mutations (8 months; P = 0.04). KRAS mutations in CTC and corresponding tumor were discordant in 11 of 26 “tumor-CTC-pairs” (42%), while 15 (58%) had a matching mutation; survival was similar in both groups (P = 0.36). Genetic characterization, including mutations such as KRAS, may prove useful for prognosis and understanding of tumor biology.

Chirurgische Therapie des Ösophaguskarzinoms

ZusammenfassungHintergrundDie Therapie des Ösophaguskarzinoms wurde in den letzten 25 Jahren durch die Zunahme der Inzidenz von Adenokarzinomen, durch Modifikationen der chirurgischen Technik und die Einführung multimodaler Therapieschemata beeinflusst.FragestellungIn der vorliegenden Arbeit werden die Entwicklung dieser Faktoren und ihr Einfluss auf Kurz- und Langzeitergebnisse nach Ösophagusresektion anhand der in der eigenen Klinik in den letzten 25 Jahren behandelten Patienten analysiert.Patienten und MethodenDie Analyse umfasst 366 Patienten mit der Diagnose Ösophaguskarzinom, die zwischen 1988 und 2012 am Universitätsklinikum Freiburg ösophagusreseziert wurden. Die Therapiezeiträume wurden in vier Gruppen unterteilt (1988–1994; 1995–2001; 2001–2006; 2007–2012) und verglichen.ErgebnisseIm Untersuchungszeitraum ist ein deutlich zunehmender Anteil von Adenokarzinomen nachweisbar (21 %, 37 %, 61 %, 64 %, p < 0,001). Das initial häufig angewandte transhiatale Operationsverfahren und die zervikale Anastomose wurden zunehmend verlassen und durch das thorakoabdominale Verfahren mit intrathorakaler Rekonstruktion ersetzt (2007–2012: 98 %). Mehr Patienten erhielten eine neoadjuvante Therapie (13 %; 85 %; 72 %; 84 %; p < 0,001). Die Gesamtzahl perioperativer Komplikationen (70 %, 88 %, 73 %, 56 %; p < 0,001) und die perioperative Mortalität (16 %; 18 %; 8 %; 2,5 %; p < 0,001) sanken im Verlauf signifikant ab, während das 5-Jahres-Überleben (12 %; 34 %; 42 %; 62 %; p < 0,001) anstieg. Ein niedriges T-Stadium (p = 0,002), N0-Status (p < 0,001) und der Histotyp Adenokarzinom (p = 0,011) konnten als unabhängige Prädiktoren für ein längeres Überleben identifiziert werden.ZusammenfassungIm Zeitraum von 1988 bis 2012 können unabhängig voneinander eine signifikante Verbesserung des Langzeitüberlebens und eine deutliche Reduktion der perioperativen Sterblichkeit nach Ösophagusresektion beobachtet werden. Diese Therapieerfolge gehen mit einem vermehrten Einsatz multimodaler Therapieverfahren und des thorakoabdominellen Operationsverfahrens sowie dem histoepidemiologischen Wandel einher.AbstractBackgroundAn increasing incidence of adenocarcinoma, a modified surgical strategy and the increasing use of multimodal therapeutic protocols have had a major impact on the surgical treatment of esophageal cancer during the last 3 decades.ObjectivesThis study analyzed the development of these factors and their impact on the short and long-term prognosis of esophageal cancer over the last 25 years.Patients and methodsThe study included 366 patients with esophageal cancer treated by esophagectomy at the University Hospital in Freiburg from 1988 to 2012. The study period was split into four time periods for further comparisons, i.e. 1988–1994, 1995–2001, 2001–2006 and 2007–2012.ResultsWithin the time periods analyzed a marked increase in adenocarcinoma was found (time periods1988–1994, 1995–2001, 2001–2006 and 2007–2012: 21 %, 37 %, 61 % and 64 %, respectively, p < 0.001). The initially commonly used transhiatal approach and reconstruction with cervical anastomosis was gradually replaced by the thoracoabdominal procedure with intrathoracic reconstruction (i.e. Ivor Lewis esophagectomy, 2007–2012: 98 %). During the study period increasingly more patients received multimodal therapy (13 %, 85 %, 72 % and 84 %, p < 0.001), the overall rate of perioperative complications (70 %, 88 %, 73 % and 56 %, p < 0.001) and perioperative mortality (16 %, 18 %, 8 % and 2.5 %, p < 0.001) were significantly reduced, while the overall 5-year survival (12 %, 34 %, 41 % and 62 %, p < 0.001) improved. An early tumor stage (p = 0.002), N0 status (p < 0.001) and histological type of adenocarcinoma (p = 0.011) were identified as independent predictors of improved survival.ConclusionDuring the period from 1988 to 2012 a significant improvement of long-term survival as well as a marked reduction of perioperative mortality after esophagectomy were observed. The improved outcome was associated with an increased use of multimodal therapeutic protocols, the preferred use of thoracoabdominal esophagectomy and epidemiological changes in histology over the study period.BACKGROUND An increasing incidence of adenocarcinoma, a modified surgical strategy and the increasing use of multimodal therapeutic protocols have had a major impact on the surgical treatment of esophageal cancer during the last 3 decades. OBJECTIVES This study analyzed the development of these factors and their impact on the short and long-term prognosis of esophageal cancer over the last 25 years. PATIENTS AND METHODS The study included 366 patients with esophageal cancer treated by esophagectomy at the University Hospital in Freiburg from 1988 to 2012. The study period was split into four time periods for further comparisons, i.e. 1988-1994, 1995-2001, 2001-2006 and 2007-2012. RESULTS Within the time periods analyzed a marked increase in adenocarcinoma was found (time periods1988-1994, 1995-2001, 2001-2006 and 2007-2012: 21%, 37%, 61% and 64%, respectively, p<0.001). The initially commonly used transhiatal approach and reconstruction with cervical anastomosis was gradually replaced by the thoracoabdominal procedure with intrathoracic reconstruction (i.e. Ivor Lewis esophagectomy, 2007-2012: 98 %). During the study period increasingly more patients received multimodal therapy (13%, 85%, 72% and 84%, p<0.001), the overall rate of perioperative complications (70%, 88%, 73% and 56%, p<0.001) and perioperative mortality (16%, 18%, 8% and 2.5%, p<0.001) were significantly reduced, while the overall 5-year survival (12%, 34%, 41% and 62%, p<0.001) improved. An early tumor stage (p=0.002), N0 status (p<0.001) and histological type of adenocarcinoma (p=0.011) were identified as independent predictors of improved survival. CONCLUSION During the period from 1988 to 2012 a significant improvement of long-term survival as well as a marked reduction of perioperative mortality after esophagectomy were observed. The improved outcome was associated with an increased use of multimodal therapeutic protocols, the preferred use of thoracoabdominal esophagectomy and epidemiological changes in histology over the study period.

[Surgical treatment of esophageal cancer : Evolution of management and prognosis over the last 3 decades].

ZusammenfassungHintergrundDie Therapie des Ösophaguskarzinoms wurde in den letzten 25 Jahren durch die Zunahme der Inzidenz von Adenokarzinomen, durch Modifikationen der chirurgischen Technik und die Einführung multimodaler Therapieschemata beeinflusst.FragestellungIn der vorliegenden Arbeit werden die Entwicklung dieser Faktoren und ihr Einfluss auf Kurz- und Langzeitergebnisse nach Ösophagusresektion anhand der in der eigenen Klinik in den letzten 25 Jahren behandelten Patienten analysiert.Patienten und MethodenDie Analyse umfasst 366 Patienten mit der Diagnose Ösophaguskarzinom, die zwischen 1988 und 2012 am Universitätsklinikum Freiburg ösophagusreseziert wurden. Die Therapiezeiträume wurden in vier Gruppen unterteilt (1988–1994; 1995–2001; 2001–2006; 2007–2012) und verglichen.ErgebnisseIm Untersuchungszeitraum ist ein deutlich zunehmender Anteil von Adenokarzinomen nachweisbar (21 %, 37 %, 61 %, 64 %, p < 0,001). Das initial häufig angewandte transhiatale Operationsverfahren und die zervikale Anastomose wurden zunehmend verlassen und durch das thorakoabdominale Verfahren mit intrathorakaler Rekonstruktion ersetzt (2007–2012: 98 %). Mehr Patienten erhielten eine neoadjuvante Therapie (13 %; 85 %; 72 %; 84 %; p < 0,001). Die Gesamtzahl perioperativer Komplikationen (70 %, 88 %, 73 %, 56 %; p < 0,001) und die perioperative Mortalität (16 %; 18 %; 8 %; 2,5 %; p < 0,001) sanken im Verlauf signifikant ab, während das 5-Jahres-Überleben (12 %; 34 %; 42 %; 62 %; p < 0,001) anstieg. Ein niedriges T-Stadium (p = 0,002), N0-Status (p < 0,001) und der Histotyp Adenokarzinom (p = 0,011) konnten als unabhängige Prädiktoren für ein längeres Überleben identifiziert werden.ZusammenfassungIm Zeitraum von 1988 bis 2012 können unabhängig voneinander eine signifikante Verbesserung des Langzeitüberlebens und eine deutliche Reduktion der perioperativen Sterblichkeit nach Ösophagusresektion beobachtet werden. Diese Therapieerfolge gehen mit einem vermehrten Einsatz multimodaler Therapieverfahren und des thorakoabdominellen Operationsverfahrens sowie dem histoepidemiologischen Wandel einher.AbstractBackgroundAn increasing incidence of adenocarcinoma, a modified surgical strategy and the increasing use of multimodal therapeutic protocols have had a major impact on the surgical treatment of esophageal cancer during the last 3 decades.ObjectivesThis study analyzed the development of these factors and their impact on the short and long-term prognosis of esophageal cancer over the last 25 years.Patients and methodsThe study included 366 patients with esophageal cancer treated by esophagectomy at the University Hospital in Freiburg from 1988 to 2012. The study period was split into four time periods for further comparisons, i.e. 1988–1994, 1995–2001, 2001–2006 and 2007–2012.ResultsWithin the time periods analyzed a marked increase in adenocarcinoma was found (time periods1988–1994, 1995–2001, 2001–2006 and 2007–2012: 21 %, 37 %, 61 % and 64 %, respectively, p < 0.001). The initially commonly used transhiatal approach and reconstruction with cervical anastomosis was gradually replaced by the thoracoabdominal procedure with intrathoracic reconstruction (i.e. Ivor Lewis esophagectomy, 2007–2012: 98 %). During the study period increasingly more patients received multimodal therapy (13 %, 85 %, 72 % and 84 %, p < 0.001), the overall rate of perioperative complications (70 %, 88 %, 73 % and 56 %, p < 0.001) and perioperative mortality (16 %, 18 %, 8 % and 2.5 %, p < 0.001) were significantly reduced, while the overall 5-year survival (12 %, 34 %, 41 % and 62 %, p < 0.001) improved. An early tumor stage (p = 0.002), N0 status (p < 0.001) and histological type of adenocarcinoma (p = 0.011) were identified as independent predictors of improved survival.ConclusionDuring the period from 1988 to 2012 a significant improvement of long-term survival as well as a marked reduction of perioperative mortality after esophagectomy were observed. The improved outcome was associated with an increased use of multimodal therapeutic protocols, the preferred use of thoracoabdominal esophagectomy and epidemiological changes in histology over the study period.BACKGROUND An increasing incidence of adenocarcinoma, a modified surgical strategy and the increasing use of multimodal therapeutic protocols have had a major impact on the surgical treatment of esophageal cancer during the last 3 decades. OBJECTIVES This study analyzed the development of these factors and their impact on the short and long-term prognosis of esophageal cancer over the last 25 years. PATIENTS AND METHODS The study included 366 patients with esophageal cancer treated by esophagectomy at the University Hospital in Freiburg from 1988 to 2012. The study period was split into four time periods for further comparisons, i.e. 1988-1994, 1995-2001, 2001-2006 and 2007-2012. RESULTS Within the time periods analyzed a marked increase in adenocarcinoma was found (time periods1988-1994, 1995-2001, 2001-2006 and 2007-2012: 21%, 37%, 61% and 64%, respectively, p<0.001). The initially commonly used transhiatal approach and reconstruction with cervical anastomosis was gradually replaced by the thoracoabdominal procedure with intrathoracic reconstruction (i.e. Ivor Lewis esophagectomy, 2007-2012: 98 %). During the study period increasingly more patients received multimodal therapy (13%, 85%, 72% and 84%, p<0.001), the overall rate of perioperative complications (70%, 88%, 73% and 56%, p<0.001) and perioperative mortality (16%, 18%, 8% and 2.5%, p<0.001) were significantly reduced, while the overall 5-year survival (12%, 34%, 41% and 62%, p<0.001) improved. An early tumor stage (p=0.002), N0 status (p<0.001) and histological type of adenocarcinoma (p=0.011) were identified as independent predictors of improved survival. CONCLUSION During the period from 1988 to 2012 a significant improvement of long-term survival as well as a marked reduction of perioperative mortality after esophagectomy were observed. The improved outcome was associated with an increased use of multimodal therapeutic protocols, the preferred use of thoracoabdominal esophagectomy and epidemiological changes in histology over the study period.

Internet-based perioperative exercise program in patients with Barrett’s carcinoma scheduled for esophagectomy [iPEP - study] a prospective randomized-controlled trial

BackgroundPatients undergoing surgery for esophageal cancer have a high risk for postoperative deterioration of lung function and pulmonary complications. This is partly due to one-lung ventilation during thoracotomy. This often accounts for prolonged stay on intensive care units, delayed postoperative reconvalescence and reduced quality of life. Socioeconomic disadvantages can result from these problems. Physical preconditioning has become a crucial leverage to optimize fitness and lung function in patients scheduled for esophagectomy, in particular during the time period of neoadjuvant therapy.Methods/Study designWe designed a prospective multicenter randomized-controlled trial. The objective is to evaluate the impact of an internet-based exercise program on postoperative respiratory parameters and pneumonia rates in patients with Barrett’s carcinoma scheduled for esophagectomy. Patients are randomly assigned to either execute internet-based perioperative exercise program (iPEP), including daily endurance, resistance and ventilation training or treatment as usual (TAU). During neoadjuvant therapy and recovery, patients in the intervention group receive an individually designed intensive exercise program based on functional measurements at baseline. Personal feedback of the supervisor with customized training programs is provided in weekly intervals.DiscussionThis study will evaluate if an intensive individually adapted training program via online supervision during neoadjuvant therapy will improve cardiorespiratory fitness and reduce pulmonary complications following esophagectomy for Barrett’s cancer.Trial registrationNCT02478996, registered 26 May 2015.

Management and outcome of esophageal stenting for spontaneous esophageal perforations

Treatment of spontaneous esophageal perforation (SEP) consists of different conservative, surgical and endoscopic treatment modalities. In this study, we evaluated the clinical efficacy and the outcome of covered self-expanding stent (CSES) treatment of SEP. All patients with SEP treated by CSES at our institution between 2005 and 2014 were included in this prospective single-center study. The data were collected from a prospective database based on clinical, endoscopic and operative reports. Follow-up data were procured by contacting the patients or their family doctors. The patient data were analyzed concerning course of treatment, leakage sealing rate, complications, and mortality. Patients with iatrogenic or malignant perforations were excluded. In total, 16 patients underwent endoscopic CSES placement for SEP between 2005 and 2014. Sealing of the leakage was immediately successful in 50% (8 patients). A second stent was placed in 5 patients, but did not achieve sealing of the perforation in any case, requiring a switch in treatment to a surgical procedure (n=4) or drainage of the persisting leakage (n=4). In-hospital mortality was 13%. Only delayed treatment was identified as a risk factor for inferior outcome. Patients with successful CSES treatment had a shorter ICU- and hospital stay and had a reduced risk of developing esophageal stenosis (RR: 0.4) or persisting dysphagia despite treatment (RR: 0.33). Endoscopic treatment of SEP is beneficial to the patient if immediately successful, but in our experience, failure rates are higher than described in the literature. Secondary placement of CSES was not successful when initial stent treatment failed, while both surgical intervention and drainage of the perforation showed good results in sealing the leakage.

Is There a Rationale for Structural Quality Assurance in Esophageal Surgery

Background: Advances regarding perioperative mortality rates and oncological outcomes after esophagectomy have been reported extensively by specialized high-volume centers in Europe and the USA over the last decade. However, recent database analyses reveal that the perioperative mortality of esophagectomy remains high in these countries, indicating a discrepancy between surgical quality in baseline hospitals and specialized centers. Methods: This article provides an overview over the existing literature on the correlation between structural quality, procedural volume, and surgical outcome in e- sophageal surgery. Results: Structural, procedural and outcome measures can be used to assess the quality of surgical treatment and perioperative management. Surgical procedures on the esophagus for both benign and malignant diseases are rare and typically associated with high perioperative morbidity and mortality. Usually, direct outcome measures do not provide enough statistical power to actually identify differences in surgical quality between hospitals, making structural quality measures the only feasible parameter to compare the quality of e- sophageal surgery among different centers. Several analyses from different countries have shown a strong correlation between hospital volume and postoperative mortality. Data from countries in which esophageal surgery has been centralized indicate beneficial effects of a centralized health care system on postoperative mortality after esophagectomy. Additionally, only high-volume centers generally provide optimal preoperative and postoperative management and comprehensive access to modern multimodal treatment. In Germany, esophageal surgery is still decentralized, but hospitals performing complex esophageal procedures have to fulfill minimum caseload requirements of 10 cases per year. In practice, these requirements are not met by the majority of hospitals and a detrimental effect on the achieved surgical outcomes can be noted. Conclusion: Therefore, we conclude that structural quality assurance is crucial to further reduce postoperative morbidity after esophageal surgery and to improve long-term results.

Hybrid laparoscopic thoracotomic esophagectomy with intrathoracic esophagogastric anastomosis

INTRODUCTION In the past decades various techniques of esophagectomy for the curative treatment of esophageal cancer have been described. Especially minimally invasive techniques of esophagectomy have been used increasingly in the last decade. Technical issues and results of hybrid laparoscopic-thoracotomic en bloc esophagectomy with intrathoracic esophagogastric anastomosis (HMIE) are presented and discussed in the article. PATIENTS AND METHODS Between May 2013 and April 2014 a total of 23 patients underwent esophagectomy for esophageal cancer at the University of Freiburg Medical Center. Of these patients 10 were treated by HMIE and the other 13 patients had open esophagectomy (OE). RESULTS A detailed description of the operative technique of HMIE is given in a step-by-step fashion. Margin negative resection was achieved in all patients after HMIE and OE and the median lymph node yield of lymphadenectomy in HMIE and OE (29 vs. 27) was nearly the same. The medium duration of the operation (347 min vs. 412 min) and median length of stay on the intensive care unit (6 days vs. 9 days) and hospital (13 days vs. 17 days) were decreased in HMIE patients compared to OE, respectively. Overall postoperative morbidity (40 % vs. 69 %) and especially pulmonary morbidity (10 % vs. 46 %) were also favorable in HMIE. No anastomotic leakage and postoperative in-hospital mortality occurred after HMIE. CONCLUSION The HMIE procedure combines the advantages of minimally invasive operative approaches on especially postoperative pulmonary morbidity after esophagectomy with the high safety of anastomosis and reconstruction achieved in OE. Further advantages are shorter duration of operation and shorter length of hospital stay in HMIE.