Mediastinal Envelope Closure in Total Minimally Invasive Ivor Lewis Esophagectomy

This video is part of CTSNet’s 2023 Innovation Video Competition. Watch all entries into the competition, including the winning videos.

Anastomotic leaks of the esophagogastric conduit in minimally invasive esophagectomies (MIE) are associated with increased length of hospital stay, formation of anastomotic strictures, and increased morbidity and mortality rates. The authors’ study has shown that complete closure of the mediastinal envelope over the anastomotic site is associated with decreased rates of postoperative complications, including anastomotic leaks. The method also provides an enhanced recovery and diet regimen for patients, allowing patients to resume oral feeding on postoperative day one without use of a jejunostomy tube. 

The Surgery

To begin, the hiatus was dissected in the laparoscopic phase to define the gastroesophageal junction and the stomach was fully mobilized. The gastric conduit was created using tubularization along the lesser curve of the stomach.

In the thoracoscopic phase, the mediastinal envelope was dissected. Care was taken to preserve the envelope edge for mediastinal envelope closure later. The esophagus was circumferentially dissected for full mobilization and then divided. Next, the gastric conduit was pulled up into the mediastinum and the esophagogastric anastomosis was formed. The stomach was fully tubularized and the final specimen was removed through a wound protector. The mediastinal envelope was closed from the level of the azygous vein to the hiatus using interrupted sutures. A nasograstric (NG) tube, 28 French chest tube, and 24 French Blake drain were placed.

Conclusion

Closure of the mediastinal envelope reinforces the anastomotic site and prevents outpouching of the gastric conduit. This minimizes tension on the anastomosis and improves conduit emptying. The authors’ results have shown that closure has been associated with decreased rates of anastomotic leaks, postoperative pyloric dilation, and delayed gastric emptying. It is also associated with shorter length of stay and decreased rates of hospital readmission in 90 days.

Closure of the mediastinal envelope also provides benefits in postoperative recovery and diet. Patients can undergo early removal of their NG tube and resume oral feeding on postoperative day one. This quick transition to oral feeding is possible because closure of the mediastinal envelope creates a narrow mechanical feeding pathway that facilitates gastric emptying, allowing patients to resume oral feeding on postoperative day one without use of a jejunostomy tube. Patients can advance to a full liquid diet on postoperative day five and are also given Boost Glucose Control Max supplemental drink to nutritionally support them during recovery. The patient in this video followed this enhanced recovery protocol and is doing well postoperatively.

References

1. Ashiku SK, Patel AR, Horton BH, Velotta J, Ely S, Avins AL. A refined procedure for esophageal resection using a full minimally invasive approach. J Cardiothorac Surg. 2022;17(1):29. Published 2022 Mar 4. doi:10.1186/s13019-022-01765-2. PMID: 35246177
2. Banks KC, Alcasid NJ, Susai C, Velotta JB. Standardized Operative Approach for Total Minimally Invasive Ivor Lewis Esophagectomy in Hostile Abdomen. March 2023. doi:10.25373/ctsnet.22220854.v1
3. Banks KC, Barnes KE, Wile RK, Hung YY, Santos J, Hsu DS, Choe G, Elmadhun NY, Ashiku SK, Patel AR, Velotta JB. Outcomes of Anastomotic Evaluation Using Indocyanine Green Fluorescence During Minimally Invasive Esophagectomy. Am Surg. 2022 Nov 3:31348221138084. doi: 10.1177/00031348221138084. Epub ahead of print. PMID: 36327490.
4. Ely S, Alabaster A, Dominguez DA, Maxim C, Ashiku SK, Patel AR, Velotta JB. Effect of Thoracic Surgery Regionalization on 1- and 3-Year Survival After Cancer Esophagectomy. Ann Surg. 2023 Feb 1;277(2):e305-e312. doi: 10.1097/SLA.0000000000005076. Epub 2023 Jan 10. PMID: 34261883.
5. Ely S, Alabaster A, Ashiku SK, Patel A, Velotta JB. Regionalization of thoracic surgery improves short-term cancer esophagectomy outcomes. J Thorac Dis. 2019 May;11(5):1867-1878. doi: 10.21037/jtd.2019.05.30. PMID: 31285879; PMCID: PMC6588736.

Disclaimer

The information and views presented on CTSNet.org represent the views of the authors and contributors of the material and not of CTSNet. Please review our full disclaimer page here.