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Page 4 of 10 de Pascale et al. Mini-invasive Surg 2019;3:18 I http://dx.doi.org/10.20517/2574-1225.2019.04

is performed, and right paratracheal nodes are routinely removed. The esophagogastric anastomosis is
performed at the apex of the right chest using a 28-mm stapler. The gastrostomy is closed with a linear
stapler. A large 360° omental wrap is performed, and the pleural cavity is drained with 32 Ch drain .

Thoracoscopy
The patient is placed in the semi-prone position and the forearm flexed to improve abduction of the scapula.
The chest is stabilized on the operative table using beanbag and side supports to allow rotation in a more
lateral decubitus position. This is helpful to aid mediastinal exposure in patients with a protruding spine or to
expedite the switch to thoracotomy if necessary. Artificial capnothorax with a pressure of 8 mmHg is induced
after first 12-mm trocar is placed below the inferior angle of the scapula. Three additional trocars are inserted:
two 12-mm trocars in the eighth intercostal space and the middle of the vertebral border of the scapula, and
a 5-mm trocar in the superior angle of the scapula. The arch of the azygos vein is divided using Hem-o-lock
clips. Incision of the mediastinal pleura is performed on both sides of the esophagus, and the dissection
preferably starts between the vagal trunk and the right main bronchus. This allows en-bloc lymphadenectomy
of the carina with nerve preservation in most circumstances. The esophagus is then mobilized up to the level
of the diaphragm and the inferior pulmonary ligament is divided. The thoracic duct is identified and ligated.
After an esophagotomy on the stapled side and a gastrotomy on the small gastric curvature are performed,
some stitches are used to fix the mucosa to the other layers of the esophageal wall, avoiding submucosal
slippage following the technique described by Irino . Gastrolysis is completed. A side-to-side anastomosis is
[8]
then performed with a 30-mm linear stapler. The enterotomies are closed with a self-gripping barbed suture.
A large 360° omental wrap is performed and the pleural cavity is drained.

Immediately after surgery, patients recovered in the Intensive Care Unit (ICU) until the first postoperative
day.

The complications were described according to the taxonomy recently proposed by the Esophagectomy
Complications Consensus Group .
[9]

Statistical analysis
The Mann-Whitney U test was used to compare continuous variables not normally distributed (presented as
median and range). Normality of the distribution of variables was determined using the D’Agostino-Pearson
test. Chi-square or Fisher’s exact test, when appropriate, were used to compare categorical variables. Two-
tailed P values are reported universally, and the significance threshold was designated at a P value of 0.05.
Statistical analysis was performed with statistical software for biomedical research (MedCalc Software for
Windows).

RESULTS
From January 2017 to July 2018 we performed 53 esophagectomies in patients affected by esophageal or EGJ
cancers. Ten patients were submitted to the McKeown procedure, 1 patient was treated with a transhiatal
esophagectomy and 3 patients with squamous cancer of the cervical esophagus underwent a pharyngo-
laryngo-esophagectomy. Thirty-nine patients underwent an IL procedure: 13 TMIIL, 14 HIL, and 12 OIL.

Patients submitted to TMIIL and HIL were compared according to the stage 2b IDEAL recommendation.
The general characteristics of the two groups are reported in Table 1. No difference was reported between
the 2 groups in terms of ASA (American Society of Anesthesiologists) Classification: 9 patients in the TMIIL
group and 13 patients in the HIL group were treated with a neoadjuvant or perioperative therapy; in the
TMIIL group, 6 patients received chemoradiotherapy and 3 patients received preoperative chemotherapy,
while in the HIL group 10 patients received neoadjuvant chemoradiotherapy and 3 patients received
preoperative chemotherapy.