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Year : 2018  |  Volume : 14  |  Issue : 8  |  Page : 167-172

Short-term outcomes after transition from Sweet to thoracoscopic esophagectomy: Our experience and cost analysis

Department of Thoracic Surgery, The Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing, Jiangsu, China

Date of Web Publication26-Mar-2018

Correspondence Address:
Jian Wang
Department of Thoracic Surgery, The Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing, Jiangsu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0973-1482.161931

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 > Abstract 

Objective: Thoracoscopic esophagectomy (TSE), as a minimally invasive technique, has obtained wide acceptance for treating esophageal cancer. In this study, we report our experience of the transfer from open sweet esophagectomy (OSE) to TSE and compare cost associated with the two approaches for esophageal cancer.
Patients and Methods: Data were taken through a retrospective review of operative outcomes, complications and cost of 91 patients who underwent OSE or TSE for esophageal cancer from January 2012 to June 2014.
Results: Among 91 patients, 48 patients underwent TSE, and 43 patients underwent OSE. Patients dealt with TSE had significantly less blood loss (152 ml vs. 204 ml, P = 0.004), shorter chest drainage time (3.3 days vs. 4.5 days, P < 0.001), less patients admitted to the Intensive Care Unit after surgery (6.3% vs. 30.2%, P = 0.003), and lower incidence of respiratory complications (16.7% vs. 37.2%, P = 0.026). However, the operative time was statistically longer in TSE group (276.0 min vs. 207.4 min, P < 0.001). The total cost (¥61,817 vs. ¥48,712, P < 0.001) and the day of surgery cost (¥29,701 vs. ¥19,446, P < 0.001) were significantly higher in the TSE group.
Conclusion: This study shows that TSE is a safe and acceptable alternative to OSE. TSE will be more competitive if its cost can be reduced.

Keywords: Cost analysis, esophagectomy, short-term outcomes

How to cite this article:
Yao F, Yao J, Hang FR, Cao S, Qian JL, Wang J. Short-term outcomes after transition from Sweet to thoracoscopic esophagectomy: Our experience and cost analysis. J Can Res Ther 2018;14, Suppl S1:167-72

How to cite this URL:
Yao F, Yao J, Hang FR, Cao S, Qian JL, Wang J. Short-term outcomes after transition from Sweet to thoracoscopic esophagectomy: Our experience and cost analysis. J Can Res Ther [serial online] 2018 [cited 2021 Nov 30];14:167-72. Available from: https://www.cancerjournal.net/text.asp?2018/14/8/167/161931

 > Introduction Top

Esophageal cancer, one of the most common tumors, is the fifth leading cause of cancer-related death in men, and the eighth in women.[1] Transthoracic esophagectomy with lymphadenectomy remains a mainstay treatment for resectable thoracic esophageal cancer although it is an operation associated with high morbidity and mortality rates.[2],[3] Luketich et al. first used thoracoscopy to perform the esophageal mobilization with cervical anastomosis in 1998.[4] Recently, minimal invasive esophagectomy has become recommended by a growing number of experienced surgeons.[5]

Thoracoscopic esophagectomy (TSE) was introduced to our department in 2012 as an alternative to open sweet esophagectomy (OSE) (left thoracic esophagectomy), with the hope of reducing the pain and quicker functional recovery. Here, the study reports the clinical experience of the transition period from OSE to TSE. Moreover, the cost related to the two surgical approaches performed during the transition period was analyzed, to better understand of the financial implications of the two approaches.

 > Patients and Methods Top

The data analyzed in the present study were collected retrospectively from patients with esophageal cancer, who had undergone TSE or OSE from January 2012 to June 2014. All patients were definitely diagnosed with esophageal cancer by preoperative ultrasound endoscopy, barium meal, and enhanced computed tomography (positron emission tomography, if possible). All operations were performed by the surgeon having completed more than 200 cases of esophagectomy. The patients were collated into two groups. One group (TSE group) was dealt with TSE, whereas another group (OSE group) with OSE. An informed consent was obtained from all the patients. This study was approved by the Ethics Committee of the Hospital.

Clinical data were collected from the database. Preoperative chemoradiotherapy was not used in any case. The pathologic characteristics, including tumor invasion, node metastasis, and stage, were classified according to the American Joint Committee on Cancer Staging Manual, the Seventh Edition.[6] R0 defined as >1 mm from a resection margin.[7] Postoperative complications included respiratory complications (included pneumonia, pleural effusion, atelectasis, pulmonary embolism, and respiratory failure), arrhythmia (defined as persistent arrhythmia requiring medical treatment), chylothorax (defined as the appearance of milky fluid from thoracic drains after surgery), anastomotic leaks, wound infections, and vocal-cord palsy. Operative mortality was defined as death from any cause within the first 30 postoperative days (PODs).



All patients were intubated with double-lumen endotracheal tubes and received single-lung ventilation.

Thoracoscopic esophagectomy

Thoracic phase

The patient was placed in the left lateral decubitus position, leaning forward at a 30° angle. The “four ports” approach was adopted: (1) At the midaxillary line in the seventh intercostal space (10 mm, camera port); (2) at the posterior axillary line in the ninth intercostal space (10 mm); (3) at the scapular line in the seventh intercostal space (5 mm); (4) at the fourth intercostal space in the anterior axillary line (5 mm). All the trocars were gas proof for establishing the artificial pneumothorax (6–8 mmHg). The esophagus was mobilized with the paraesophageal lymph nodes in an en bloc maneuver. The azygos vein was clamped with Hem-o-Lok (Weck Surgical, Teleflex, ME, USA) and transected. Lymph nodes from the different mediastinal stations were completely dissected. A 28-Fr chest tube was placed through camera port. Thoracic duct ligation was not routinely conducted.

Abdominal phase

After completing the thoracoscopic procedure, the patient was rotated to a supine position, the neck extended. Open laparotomy (8–10 cm) was performed for stomach mobilization and abdominal lymph node dissection. The stomach was mobilized along the greater and lesser curvatures. The short gastric vessels and left gastroepiploic vessels were transected by ultrasonic shear coagulation (Ethicon Endo-Surgery, Cincinnati, OH, USA). The left gastric artery was divided at its origin with Hem-o-Lok. During the procedure of gastric mobilization, lymph nodes along the coeliac and gastric vessels were dissected. A 3–4 cm width gastric conduit was created with linear staplers (Frankenman Corporation, Suzhou, China). Finally, a jejunostomy was conducted at 30 cm from the ligament of Treitz. Pyloroplasty was not performed routinely.

Cervical phase

In this phase, esophagus was exposed through a left anterior sternomastoid incision, and the conduit was sutured to the mobilized esophagus for tunneling to the neck where an end-to-side esophagogastric anastomosis was performed.[8] All patients were applied with a circular stapler anastomosis method (Frankenman Corporation, Suzhou, China). Cervical lymphadenectomy was not systematically undertaken. A nasogastric tube was routinely placed.

Open sweet esophagectomy

The patient was placed in the right lateral decubitus position. A left posterolateral thoracotomy was performed through the fifth or sixth intercostal space. The esophagus was mobilized at least 5 cm above the lesion. The diaphragm was incised to expose the abdominal cavity. The stomach was mobilized along the greater and lesser curvatures. The origin of left gastric artery was transected. During the procedure, abdominal lymph nodes were dissected. After having formed the gastric conduit (about 5 cm in width), the patient received an intrathoracic circular stapler anastomosis (Frankenman Corporation, Suzhou, China) above aortic arch. The patient, whose lesion location was at the upper third, received the left thoracic esophagectomy, combined with a left cervical incision.[9] A nasojejunal feeding tube was guided into the jejunum. A nasogastric drainage tube was positioned within the conduit. Pyloroplasty and thoracic duct ligation were not performed routinely. A 28-Fr chest tube was placed through the midaxillary line in the eighth intercostal space.

Postoperative management

Patients in both groups received similar postoperative care. On POD 1, patients were encouraged to move out of bed, and enteral nutrition was given though jejunostomy or nasojejunal feeding tube. Contrast swallow was performed on POD 6. Oral feeding was started on POD 7. Patients were eventually discharged home when oral intake was adequate for their nutritional needs.

Cost analysis and statistics

The cost analysis was based on data provided by hospital's financial department. As many patients had completed part or all of the preoperative examinations before admission, the cost we analyzed only included the expenditure from the day of surgery to discharge, mainly consisting of the day of surgery cost and the postoperative cost (including Intensive Care Unit [ICU] cost).

The differences between the groups were assessed with the Statistical Package for Social Sciences (20.0 Mac, SPSS, Chicago, IL, USA). Mean and standard deviation were computed for the continuous covariates, and frequency distributions were computed for nominal covariates. Patient characteristics, perioperative results, surgical performance, and cost were analyzed using independent-samples t-test, the Chi-square test, or Mann–Whitney U-test. A two-sided statistical test was computed, with a value of P < 0.05 considered as statistically significant.

 > Results Top

Baseline demographics

In this study, 48 cases were analyzed in the TSE group and 43 in the OSE group. The demographic and clinical characteristics except the tumor location of the two groups were similar [Table 1]. The tumor location in the TSE group was higher than that in the OSE group.
Table 1: Baseline characteristics

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Operative outcomes

Operative outcomes are summarized in [Table 2]. There were no intraoperative conversions in TSE group. Compared with the OSE group, operative time was longer (P < 0.001), and the blood loss and chest drainage time were significantly less in the TSE group (P < 0.05). Although the length of stay in the ICU in each group was similar (P = 0.353), more patients were admitted to ICU after surgery in the OSE group (P = 0.003). The length of stay in the hospital after surgery in the OSE group was longer, but the difference was not significant (P = 0.078). The operative mortality (30 days) was similar between the two groups (P = 1.000). Only one patient (2.1%) died from pulmonary embolism 5 days after the operation in the TSE group. There was no significant difference in the number of lymph nodes harvested between both groups (P = 0.056). We surveyed a scatter plot for the learning period, the number of lymph nodes harvested increased substantially with increasing experience in the TSE group [Figure 1].
Table 2: Operative outcomes

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Figure 1: Lymph nodes harvested for thoracoscopic esophagectomy cases

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Complications between two groups are shown in [Table 3]. There were no intraoperative complications in the OSE group, but intraoperative complications occurred in four patients in the TSE group, including the bronchus injury (one patient, 2.1%) and the thoracic duct injury (three patients, 6.3%). Compared with OSE group, more respiratory complications were observed in the TSE group (16.7% vs. 37.2%, P= 0.026). Three vocal-cord paralysis patients (6.3%) were observed in the TSE group. There was one case of chylothorax after surgery in each group (P = 1.000). Both patients were treated conservatively and resolved. Four anastomotic leaks (8.3%) were observed in TSE group and managed with cervical drainage and resolved. Atrial fibrillation and wound infection after surgery were similar between the two groups (P = 0.233, P= 0.899). There were no reoperations in both groups.
Table 3: Complications

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Cost analysis

The cost analysis associated with the two different approaches is shown in [Table 4]. The total cost in the TSE group was higher (¥61,817 vs. ¥48,712, P < 0.001). When the total hospital cost was broken down into two components, the postoperative cost was similar between two groups (P = 0.121) and the day of surgery cost was significantly higher in the TSE group (P < 0.001).
Table 4: Cost data

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 > Discussion Top

Esophagectomy with lymphadenectomy remains the mainstay therapy for esophageal cancer. However, the best surgical approach is still a controversy. Before the introduction of thoracoscopic approach, OSE was the most preferable in our department. Compared with other approaches, it has several advantages. OSE can be completed with one single incision. Meanwhile, it offers adequate exposure of the stomach and excellent access to the gastric arteries through the opening in the left hemidiaphragm.[3] For the lesion located in the upper third esophagus, OSE can be combined with a cervical incision to acquire enough resection margin.[10] However, as a complete dissection of the regional lymph nodes is critical for long-term survival, inadequate lymph lymphadenectomy is thought to be one main disadvantage of OSE.[11] Meanwhile, open esophagectomy is frequently associated with significant morbidity and mortality.[12] Because of these reasons, TSE has been gradually introduced in our department. In this study, we report the initial experience in practicing this approach. It shows that TSE can be safely performed without compromising patient safety, surgical outcomes, and survival.

Anastomotic leak is a devastating complication of esophagectomy leading to high morbidity and mortality rates.[13],[14] Some studies found that cervical anastomosis was associated with a significantly increased risk of anastomotic leak that seen with intrathoracic anastomosis.[15],[16],[17] Blood supply to the anastomosis may be the potential drive of this differential. Compared with intrathoracic anastomosis, there is longer distance and higher tension from supply artery to anastomosis in cervical anastomosis.[18] Moreover, the stomach is usually stuck in the outlet of the thoracic cavity during the procedure of cervical anastomosis, which affects the blood supply and increases the anastomotic tension.[19] The above can compromise the vascular integrity of the peripheries surrounding the gastric conduit, resulting in a greater incidence of leak. In order to reduce the incidence of the cervical anastomotic leak, many techniques have been developed such as cervical end-to-side esophagogastric triangular anastomosis and Doppler examination to evaluate blood supply.[20],[21] Even associated with a higher leak rate, the cervical anastomosis is still adopted as an ordinary approach in our department. Because compared with the cervical anastomotic leak, an intrathoracic anastomotic leak always leads to severe mediastinitis or bronchial fistula and leave the patient in a dangerous situation. On the other hand, when a leak occurs to a cervical anastomosis, the incision in the neck can be open to allow an easier drainage. As is shown in this study, in the TSE group, there were 4 (8.3%) patients suffering from anastomotic leaks. All of the patients were treated conservatively and resolved. During the care of patients with the anastomotic leak, we found that decompression with a nasogastric tube beneath the anastomotic leak site could greatly shorten the healing time. The healing time of the first two patients with anastomotic leak was 14 days and 11 days, respectively. After a second insertion of nasogastric tube, the healing time for the other two patients with anastomotic leak was reduced to 4 days and 6 days, respectively. Two factors may contribute to the reduction of time. First, the nasogastric tube reduced the pressure generated by the interior of gastric conduit, especially when the patient coughed. Second, the gastric juice and saliva that may prolong the healing time of anastomotic leak were cleared away by nasogastric tube. Based on this finding, new nasogastric tube management strategy was applied. Before this, the nasogastric tube was removed on POD 5, the day before contrast swallow. And now, the nasogastric tube is removed on POD 6 if no anastomotic leak is identified by contrast swallow. The change can also avoid a second insertion of the nasogastric tube.

Postoperative chylothorax is a 4% risk complication of esophagectomy and significantly associated with adverse outcomes.[18] Losing huge amounts of chyle can lead to malnutrition, immunosuppression, and infection.[22] In this study, each group had a case of chylothorax after surgery. Both patients were treated conservatively and resolved. Shen et al. introduced a method that taking in 500 mL of whole milk orally 6 h before surgery could significantly facilitate visualization of the thoracic duct and reduce intraoperative thoracic duct injury.[23] In our department, the same method was applied, except prolonging the time to 10 h before surgery to facilitate patient's sleep. In this study, intraoperative thoracic duct injury occurred in three patients with TSE, which were easily identified because of bright white chylous fluid flowing out [Figure 2]. No massive chylothorax occurred after thoracic duct ligation (Hem-o-Lok). Interestingly, lesions of all three patients were located in the middle third esophagus, where the thoracic duct crossed from right to left side of vertebra. This finding is consistent with Rao et al., who identify lesions in the mid-to-upper esophagus as a risk for postoperative chylothorax.[24] Increased risk for postoperative chylothorax in patients with middle third esophagus lesion is warranted.
Figure 2: Identification of the thoracic duct injury during thoracoscopic esophagectomy. (A) Thoracic duct injury; (B) chylous fluid in bright white

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Tracheobronchial injury is rare but potentially life-threatening complication of TSE, often leading to conversion to open surgery. There was one case of left main bronchus membrane injury in TSE group, caused by ultrasonic shear coagulation [Figure 3]. We successfully repaired the damaged bronchus membrane with 3-0 Vicryl suture (Ethicon, Inc., Somerville, NJ) under thoracoscopy. During the repair procedure, two strategies were complied. First, to facilitate the accuracy of exposure and suturing, mechanical ventilation was stopped. Second, double-lumen endotracheal tube was pulled out into the trachea, preventing the main bronchus membrane from being sutured with the endotracheal tube balloon.
Figure 3: Identification of the bronchus injury during thoracoscopic esophagectomy. (A) Bronchus injury; (B) left main bronchus membrane

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With two options for esophageal cancer, acquiring knowledge about the cost of each approach is more conducive to the promotion of the target one. As shown in the cost analysis, the TSE's total cost of surgery is higher than that of OSE, a finding shared by Dhamija et al.[25] and Dhamija et al. showed that the overuse of ICU was a potential factor for rising surgery cost.[25] To find the potential reason for the cost differential in our department, a sub analysis of the day of surgery and postoperative cost suggested that the day of surgery cost may contribute to the total cost differential. Other groups also reported the finding that the day of surgery cost was considerably higher in the minimally invasive esophagectmy cohort than the open cohort.[7],[25],[26] The cost difference between TSE and OSE in this study may be explained by several factors. First, the higher day of surgery cost was related to the longer operative time, which increased the cost of nursing, anesthesia service, and postanesthetic care. Also, the TSE group represented the initial experience with this technique might also contribute to the cost differential as well. Finally, during TSE procedure, disposable instruments such as staplers, clip applier, and vessel sealing device also raised the cost.[27]

The cost analysis provides possibilities to reduce the total cost of TSE. According to the cost analysis, reducing the cost associated with the operative time may be a good choice. We believe that the operative time will be shortened with the accumulation of experience. If a reduction in operative time cannot diminish the cost differential, the other option is cutting down postoperative cost. As the TSE technique shows less tissue trauma and a better recovery, we initiate a program to shorten postoperative hospital stay by giving diet advice through telephone. We believe that these measures will increase the practical utility of TSE.

There are a number of limitations to this study. First, it is retrospective in nature and subject to bias and confounding. Second, the study was conducted in the transition period, and the TSE group was our initial experience. It is possible that the early TSE patients were highly selected. Third, the TSE is a hybrid approach, with laparotomy for creation of the gastric tube. Though no conclusive benefit is seen for laparoscopic gastric mobilization compared with laparotomy, many advantages of the total minimally invasive esophagectomy (thoracoscopy and laparoscopy) have been reported.[28] In our department, total minimally invasive esophagectomy has been introduced to selected patients. However, in hospitals without the experience for minimally invasive surgery, we still advocate the TSE as a transitional choice, especially for those medical centers with few visits.

 > Conclusion Top

This study has demonstrated that TSE technique was associated with less blood loss, shorter chest drainage time, less patients admitted to the ICU after surgery, and lower incidence of respiratory complications during the transition phase from OSE to TSE, and that TSE is a safe and acceptable alternative to OSE. Although TSE is expensive, there is a possibility to make it accessible to more patients.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

 > References Top

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Luketich JD, Pennathur A, Awais O, Levy RM, Keeley S, Shende M, et al. Outcomes after minimally invasive esophagectomy: Review of over 1000 patients. Ann Surg 2012;256:95-103.  Back to cited text no. 5
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Biere SS, Maas KW, Cuesta MA, van der Peet DL. Cervical or thoracic anastomosis after esophagectomy for cancer: A systematic review and meta-analysis. Dig Surg 2011;28:29-35.  Back to cited text no. 15
Klink CD, Binnebösel M, Otto J, Boehm G, von Trotha KT, Hilgers RD, et al. Intrathoracic versus cervical anastomosis after resection of esophageal cancer: A matched pair analysis of 72 patients in a single center study. World J Surg Oncol 2012;10:159.  Back to cited text no. 16
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Shah RD, Luketich JD, Schuchert MJ, Christie NA, Pennathur A, Landreneau RJ, et al. Postesophagectomy chylothorax: Incidence, risk factors, and outcomes. Ann Thorac Surg 2012;93:897-903.  Back to cited text no. 18
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  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2], [Table 3], [Table 4]


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