traditionally , esophagectomy has been performed by 1 of 3 routes : a thoracoabdominal approach , a 3-stage procedure also including an anastomosis in the neck , or a transhiatal approach .
the transhiatal approach was initially described by denk in 1913 , but was later popularized by orringer .
however , all 3 methods have an acknowledged high intraoperative and postoperative morbidity , as well as mortality rates in published series of up to 23% .
minimally invasive surgery has revolutionized many areas of surgery , with laparoscopic cholecystectomy and fundoplication accepted as the gold standards in their areas .
but with the potential to reduce trauma , it is believed that by using these methods it should be possible to reduce the high morbidity and mortality associated with these procedures . also widely held concerns are associated with laparoscopic oncologic surgery , because of the possibility of missed lesions , inadequate staging , compromised margins , inadequate lymph node retrieval and tumor dissemination including port - site metastases .
particular to esophagectomy , concerns also exist that decreased tactile control may possibly increase the risk of injuring adjacent and vital structures in the chest , particularly for tumors above the tracheal bifurcation .
however , this procedure should not only be aimed at cancer surgery , it also has potential benefits and attractions for other areas of treatment including patients with high - grade dysplasia in barrett 's esophagus , patients whose esophageal strictures are resistant to other treatment , and patients with end - stage achalasia .
the literature shows little agreement for the best application of minimal access techniques to esophagectomy . the most popular method described in the literature is a thoracic esophagectomy coupled with gastric mobilization via laparotomy and a cervical anastomosis .
various other groups have used differing combinations of laparoscopic , thoracoscopic , and open techniques .
the use of hand - assist devices has also been noted . a large series of minimally invasive esophagectomies using primarily thoracoscopic mobilization has observed a 1.4% mortality rate in 222 consecutive patients .
what can be inferred from much of the work with the thoracoscope is that this requires the use of prolonged single - lung ventilation ( much in excess of the open methods ) and mediastinal trauma remains substantial .
this has done little to reduce the morbidity and mortality from this procedure in many series .
two groups in germany have also described the use of a novel mediastinoscope , though its use has not become widespread , and its use is limited to tumors that are not bulky .
the method that is used in our district general hospital is that of a laparoscopic transhiatal esophagectomy .
two groups have reported in the literature their results using this technique , with a long operating time , a high rate of vocal cord palsy , high leakage rates , and a mortality rate of up to 13% .
it would appear from these reports and from much of the other work that these methods offer little advantage over traditional methods .
the aim of this study was to compare the results of our experience in a small district general hospital with published data , the hypothesis being that surgery in such a setting is comparable to the results in larger centers .
the patient is placed supine on the table with an operative setup similar to that of a laparoscopic nissen fundoplication .
the port placement involves a 10-mm port in the epigastrium with 12-mm working ports on either side .
a 5-mm port is placed for retraction in the anterior axillary line below the left coastal margin , and a nathanson liver retractor is placed to aid exposure of the hiatus .
the technique is similar to that described by swanstrom ; however , we have not found it necessary to use 45-mm instruments .
the operation proceeds much as the open procedure with the mobilization of the stomach on the right gastroepiploic arcade .
the operation differs from the open procedure in that the transhiatal mobilization is carried to the level of the bronchial vessels under direct vision .
a gastric tube is created with an endo - gia staple gun , which is then oversewn with absorbable suture for delivery of the specimen to the neck .
this is a running suture and was introduced after case 6 . during this procedure ,
the dissection can normally be achieved using standard 30-mm instruments and one series of port placements . occasionally , because of the patients habitus modifications to these placements have to be entertained .
this is achieved through an incision along the anterior border of the sternomastoid , with division of the omohyoid muscle and exposure and mobilization of the esophagus away from the trachea and prevertebral fascia , avoiding the recurrent laryngeal nerve . the specimen is then delivered to the neck by a combination of gentle traction from above and gentle manipulation from below with the laparoscopic instruments . in the neck ,
the specimen undergoes resection , and anastomosis is performed using an endo gia stapling device .
occasionally , a left subcoastal incision is required to deliver a bulky specimen if there is difficulty in passing through the hiatal orifice .
the size of the wound is dependent to a certain extent on patient habitus and specimen size .
if such an incision was used then this was also used to place a jejunostomy for enteral feeding .
the patient is placed supine on the table with an operative setup similar to that of a laparoscopic nissen fundoplication .
the port placement involves a 10-mm port in the epigastrium with 12-mm working ports on either side .
a 5-mm port is placed for retraction in the anterior axillary line below the left coastal margin , and a nathanson liver retractor is placed to aid exposure of the hiatus .
the technique is similar to that described by swanstrom ; however , we have not found it necessary to use 45-mm instruments .
the operation proceeds much as the open procedure with the mobilization of the stomach on the right gastroepiploic arcade .
the operation differs from the open procedure in that the transhiatal mobilization is carried to the level of the bronchial vessels under direct vision .
a gastric tube is created with an endo - gia staple gun , which is then oversewn with absorbable suture for delivery of the specimen to the neck .
this is a running suture and was introduced after case 6 . during this procedure ,
the dissection can normally be achieved using standard 30-mm instruments and one series of port placements . occasionally , because of the patients habitus modifications to these placements have to be entertained .
this is achieved through an incision along the anterior border of the sternomastoid , with division of the omohyoid muscle and exposure and mobilization of the esophagus away from the trachea and prevertebral fascia , avoiding the recurrent laryngeal nerve . the specimen is then delivered to the neck by a combination of gentle traction from above and gentle manipulation from below with the laparoscopic instruments . in the neck ,
the specimen undergoes resection , and anastomosis is performed using an endo gia stapling device .
occasionally , a left subcoastal incision is required to deliver a bulky specimen if there is difficulty in passing through the hiatal orifice .
the size of the wound is dependent to a certain extent on patient habitus and specimen size .
if such an incision was used then this was also used to place a jejunostomy for enteral feeding .
twenty - nine patients were referred for consideration of laparoscopic transhiatal esophagectomy after radiological assessment as being possibly suitable for resection . however , 9 patients were found at diagnostic laparoscopy to have advanced disease and therefore were discharged the same day . of the 20 patients operated on , 17 underwent a laparoscopic transhiatal resection with cervical anastomosis .
one had a laparoscopic transhiatal resection of a tumor , which histologically was a gastrointestinal stromal tumor .
all statistical figures given ( unless specified otherwise ) are the median followed by the inter - quartile ranges .
the patients ' ages ranged from 34 to 78 with a median age of 63 .
pathologies included 2 squamous cell carcinomas , 1 gastrointestinal stromal tumor , 6 high - grade dysplasias ( 2 contained early invasive carcinoma ) , and 11 adenocarcinomas .
the median time of the procedure was 415 minutes ( range , 320 to 480 ) ( figure 1 ) ; this is the total operative time taken including any surgical breaks .
it should be noted that from patient 7 the oversewing of the gastric tube added some 40 minutes to 60 minutes to the time of the procedure .
the total blood loss as recorded by the nursing staff was 300 ml ( range , 200 to 350 ) .
the total operative time ( including breaks ) listed as length of operation and the total blood loss as recorded in the notes for patients listed in order of their procedure .
the figures on the y - axis are minutes for time and ml of blood for blood loss .
this was in relation to the identification and transection of the left gastric artery ( patient 10 ) .
initially , thoracoscopy was attempted ; however , because of previous tuberculosis apical adhesions were present , and the lung would not deflate , precluding access and an endoscopic procedure ( patient 12 ) .
this patient also then had a prolonged stay in the critical care complex but was discharged from the unit ; unfortunately , on day 33 the patient suffered an extensive cerebrovascular accident and died on day 34 .
the incision was small and of a size sufficient to deliver the specimen from the abdominal cavity .
the reasons for nondelivery of the specimen varied , but included bulky tumors and in one case a single band of attachment in the mediastinum , which could not be identified .
this was either via a nasogastric tube placed at the time of surgery or via a jejunal tube that was tunneled at the time of surgery .
this enteral feeding continued until full oral feeding was possible and thus lasted for a median of 8 days ( range , 7 to 14 ) .
a contrast swallow was performed at a median of 7 days ( range , 6 to 8) .
three of these studies showed leaks ( 15% ) at the level of the anastomosis : 2 of these were on the initial study , 1 was demonstrated on a repeat study .
this patient also experienced an upper gastrointestinal bleed ( patient 15 ) ( see postoperative complications ) .
the leaks were managed conservatively with enteral feeding continued via the nasogastic or jejunal route .
figure 2 displays the length of postoperative ventilation and days spent in the intensive care unit .
one laparotomy for omental bleeding was necessary on the first postoperative day ( patient 14 ) .
one patient developed bilateral pleural effusions that clinically produced dyspnea . these required drainage , but settled rapidly with this intervention .
the total time spent on the ventilator and on the itu stay and time spent on the ventilator as measured in days with the sequence of patients listed on the x - axis .
these all settled rapidly on conservative management , none requiring intervention . one postoperative death ( patient 12 ) occurred .
this was a patient converted to an open procedure , and he died of a cerebrovascular accident on day 34 postoperatively .
one patient had a sudden and massive hemetemesis from a duodenal ulcer that led to a cardiorespiratory arrest ( patient 15 ) .
this was successfully managed medically with no requirement for further surgery , and the patient was discharged home on day 65 postoperatively , with no long - term adverse sequeale .
the median length of in - patient hospital stay was 17 days ( range , 10 to 28 ) .
all patient specimens when examined showed clear resection margins both proximally and distally as well as circumferentially .
a median number of 5 ( range , 2 to 6 ) lymph nodes were found by histological examination ; however , this was a retrospective study , and the completeness of the examination for these ca n't be commented upon .
four of the patients were found to have evidence of metastatic spread to the nodes at the time of pathological staging . on follow - up , most patients have required anastomotic dilatation .
all have settled with anastomotic dilatation performed with sedation in an outpatient endoscopy unit setting .
three deaths occurred on follow - up ( at a mean 11 months after surgery ) from recurrent disease .
all of these have been in patients who were node positive at the time of surgery .
the patients ' ages ranged from 34 to 78 with a median age of 63 .
pathologies included 2 squamous cell carcinomas , 1 gastrointestinal stromal tumor , 6 high - grade dysplasias ( 2 contained early invasive carcinoma ) , and 11 adenocarcinomas .
the median time of the procedure was 415 minutes ( range , 320 to 480 ) ( figure 1 ) ; this is the total operative time taken including any surgical breaks .
it should be noted that from patient 7 the oversewing of the gastric tube added some 40 minutes to 60 minutes to the time of the procedure .
the total blood loss as recorded by the nursing staff was 300 ml ( range , 200 to 350 ) .
the total operative time ( including breaks ) listed as length of operation and the total blood loss as recorded in the notes for patients listed in order of their procedure .
the figures on the y - axis are minutes for time and ml of blood for blood loss .
this was in relation to the identification and transection of the left gastric artery ( patient 10 ) .
initially , thoracoscopy was attempted ; however , because of previous tuberculosis apical adhesions were present , and the lung would not deflate , precluding access and an endoscopic procedure ( patient 12 ) .
this patient also then had a prolonged stay in the critical care complex but was discharged from the unit ; unfortunately , on day 33 the patient suffered an extensive cerebrovascular accident and died on day 34 .
the incision was small and of a size sufficient to deliver the specimen from the abdominal cavity .
the reasons for nondelivery of the specimen varied , but included bulky tumors and in one case a single band of attachment in the mediastinum , which could not be identified .
this was either via a nasogastric tube placed at the time of surgery or via a jejunal tube that was tunneled at the time of surgery .
this enteral feeding continued until full oral feeding was possible and thus lasted for a median of 8 days ( range , 7 to 14 ) .
a contrast swallow was performed at a median of 7 days ( range , 6 to 8) .
three of these studies showed leaks ( 15% ) at the level of the anastomosis : 2 of these were on the initial study , 1 was demonstrated on a repeat study .
this patient also experienced an upper gastrointestinal bleed ( patient 15 ) ( see postoperative complications ) .
the leaks were managed conservatively with enteral feeding continued via the nasogastic or jejunal route .
figure 2 displays the length of postoperative ventilation and days spent in the intensive care unit .
one laparotomy for omental bleeding was necessary on the first postoperative day ( patient 14 ) .
one patient developed bilateral pleural effusions that clinically produced dyspnea . these required drainage , but settled rapidly with this intervention .
the total time spent on the ventilator and on the itu stay and time spent on the ventilator as measured in days with the sequence of patients listed on the x - axis .
these all settled rapidly on conservative management , none requiring intervention . one postoperative death ( patient 12 ) occurred .
this was a patient converted to an open procedure , and he died of a cerebrovascular accident on day 34 postoperatively .
one patient had a sudden and massive hemetemesis from a duodenal ulcer that led to a cardiorespiratory arrest ( patient 15 ) .
this was successfully managed medically with no requirement for further surgery , and the patient was discharged home on day 65 postoperatively , with no long - term adverse sequeale .
the median length of in - patient hospital stay was 17 days ( range , 10 to 28 ) .
all patient specimens when examined showed clear resection margins both proximally and distally as well as circumferentially .
a median number of 5 ( range , 2 to 6 ) lymph nodes were found by histological examination ; however , this was a retrospective study , and the completeness of the examination for these ca n't be commented upon .
four of the patients were found to have evidence of metastatic spread to the nodes at the time of pathological staging .
all have settled with anastomotic dilatation performed with sedation in an outpatient endoscopy unit setting .
three deaths occurred on follow - up ( at a mean 11 months after surgery ) from recurrent disease .
all of these have been in patients who were node positive at the time of surgery .
over a thousand patients have been reported in the literature as having undergone a laparoscopic or laparoscopically assisted esophagectomy .
the results regarding morbidity and mortality are mixed and vary between the centers and methodologies .
the results achieved in our series are certainly comparable for mortality and morbidity with those seen in previous series for transhiatal esophagectomy 
 ( table 1 ) .
a comparisonbetween current series and previous reported series of total laparoscopic transhiatal esophagectomy total operative time including any breaks taken by the surgeon .
the advantages that magnified dissection especially of the gastroesophageal junction and above must not be underestimated .
this is especially so when one considers the open transhiatal approach with dissection of the mediastinum achieved by blunt dissection by the surgeons ' hand .
also the pressure of the pneumoperitoneum aids the dissection of the esophagus and ensures a wide dissection .
the laparoscopic approach also holds the advantage in those cases that are inoperable especially where radiological evidence has been equivocal .
these patients are discharged the following day by avoiding a full - blown staging laparotomy .
the definition of a learning curve for laparoscopic esophagectomy has been attempted by a single surgeon . however , a number of considerations exist .
what are surgeons ' previous laparoscopic and open esophagectomy experiences ? what is a good parameter to measure the learning curve ?
indeed time is a poor indicator of quality , and there will be variation in the patient and possibly there will be evolution of the technique . in this series , failure of the gastric tube
was found on delivery to the neck ; ie , this was a failure of the stapling device .
this resulted in the modification of the technique to include an oversew of the staple line , adding some appreciable time to the length of the procedure for patient 7 . in terms of pathology
, it would appear that satisfactory margins of clearance have been obtained in those patients with a cancer .
a transhiatal approach also has the advantage of ensuring in those patients with high - grade dysplasia in a barrett 's esophagus that as much of the esophageal mucosa is removed as possible , in theory lowering the risk of malignant change .
the method would also appear to provide adequate staging of lymphatic spread with a median of 5 nodes removed .
however , because this was a retrospective study , the completeness of the pathologist 's examination of the specimen for nodes can not be addressed . within the confines of this paper
, we will not discuss either the advantages or disadvantages of extended lymphadenectomy for esophageal cancer because this is beyond the scope of this work , but if lymph node involvement is present then systemic disease is obviously present .
a recent large , randomized , controlled trial examining open transhiatal and transthoracic surgery failed to show a significant difference in survival between the 2 methods . compared with time reported in other results , the time to discharge is slow ; however , further work must be undertaken at ensuring an earlier discharge of the patient including the possibility of earlier introduction of oral intake . as a part of this contrast
, swallows are now being performed on day 2 so that fluids could potentially be introduced at an earlier stage .
the earlier the return to oral nutrition in a group where dysphagia and consequent malignant malnourishment have had a profound effect should not be underestimated .
this early study however will not exclude a delayed leak , but this possibility must be explored .
long - term follow - up must continue because this study considered only the early morbidity and mortality .
this will be essential if this procedure is to be considered from an oncological success .
comparison with open data should also occur because this article reports the experience of a single surgeon , allowing for a reasonable comparison between open and laparoscopic techniques .
what has not been considered in this study is patient acceptability , preference , and return to normal function compared with these things in open traditional surgery .
empirically , with earlier mobilization , lower analgesic requirements , and earlier return to oral feeding , one would expect minimal access techniques to have advantages and enhanced patient satisfaction .
we conclude that laparoscopic transhiatal resection of the esophagus in this series was both safe and feasible in a district general hospital with results similar to those in centers of excellence
. the technique should be more widely offered to patient as an acceptable and safe option .
 objective : esophagectomy is an operation with high morbidity and mortality . its adoption as a minimally invasive operation worldwide has been slow , but the potential benefits of reducing the trauma of surgery need to be considered . 
 our 30-month experience with transhiatal esophagectomy in a district general hospital is presented herein.methods:patients were considered for surgery after radiological staging had excluded inoperable disease . 
 laparoscopic staging was initially performed . 
 patients with tumors of the esophagus and high - grade dysplasia in a barrett 's esophagus were included.results:twenty-nine patients were referred for consideration for resectional surgery . 
 nine underwent outpatient laparoscopy only . 
 twenty patients ( age range , 34 to 78 , 15 males:5 females ) underwent resectional surgery . 
 seventeen transhiatal resections were completed , 2 were converted to open procedures , and 1 transhiatal resection of a benign tumor was performed . 
 median time of surgery was 415 minutes ( range , 320 to 480 ) and blood loss was 300 ml ( range , 200 to 350 ) . 
 the median length of postoperative ventilation and critical care stay were 1 ( range , 1 to 4 ) and 4 ( range , 2 to 8) days . 
 median duration of hospitalization was 17 days ( range , 10 to 28 ) . 
 thirty - day mortality was 0 ; 1 patient who was converted to an open procedure died after a cerebrovascular event on day 34.conclusion:a zero mortality rate for laparoscopic resection and a low - morbidity rate compare well with morbidity and mortality in reported series using this method and open surgery . 
 laparoscopic transhiatal esophagectomy is an advanced , complex procedure that can be performed safely in a district general hospital setting . 
INTRODUCTION
METHODS
The Operation
Data Collection
RESULTS
Demographics
Intraoperative Complications
Nutrition
Postoperative Complications
Histology
Follow-up
DISCUSSION
CONCLUSION