Reduction in the time of surgical procedures via a safe one-step disinfection modification to the minimally invasive McKeown esophagectomy

Introduction

Globally, esophageal cancer ranks as the eighth most common cancer and the sixth leading cause of cancer-related mortality (1). The two primary procedures are the McKeown and Ivor Lewis techniques (2-4). Post-surgical complication rates are lower in patients who undergo MIE as compared to those who undergo open surgery (5). The most prevalent complication following esophagectomy is pneumonia, while the incidence and severity of anastomotic fistula adversely affect the long-term survival of patients with esophageal cancer (6,7). Extended surgical durations in procedures such as lobectomy and hysterectomy have been demonstrated to be associated with a heightened likelihood of post-surgical complications (8,9). Therefore, it is essential to reduce the surgical time to lessen the risks of complications after general anesthesia. The McKeown esophagectomy for esophageal cancer is a complex procedure characterized by a lengthy surgical time, comprising a thoracic surgical, an abdominal free gastric procedure, and a cervical esophagogastric anastomosis. The need to adjust body position, resterilize, and spread sterile towels between the chest and abdominal surgery is time-consuming. Through clinical practice, we developed a one-step disinfection method for the McKeown esophagectomy that eliminates the process of re-disinfection and the reapplication of sterile towels after position adjustments, thereby reducing surgical time. In this study, we conducted a retrospective analysis of clinical data from 63 patients diagnosed with esophageal cancer who underwent MIE performed by the same surgeon. The aim was to assess the short-term safety and feasibility of a one-step disinfection McKeown esophagectomy procedure performed in the left semiprone position and rotated sequentially to the supine position. We present this article in accordance with the SUPER reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2024-2244/rc).

Preoperative preparations and requirements

The inclusion criteria for the study were as follows: (I) confirmed esophageal cancer via barium meal and endoscopic examination with biopsy; (II) absence of distant metastasis as verified by abdominal computed tomography imaging, brain magnetic resonance imaging, and bone scan; (III) pre-surgical clinical staging of esophageal cancer categorized as cT1–3, N0–3, or M0 according to in the eighth edition of the United States Joint Committee on Esophageal Cancer staging manual; (IV) the ability to tolerate surgery; and (V) minimally invasive McKeown esophagectomy. Meanwhile, the exclusion criteria were as follows: (I) a body mass index (BMI) of ≥30 kg/m²; (II) a history of other malignant tumors; and (III) severe underlying diseases that would preclude tolerance to surgery.

In this study, we retrospectively reported 63 patients with esophageal cancer who were admitted to The Second Affiliated Hospital of Shantou University Medical College between August 2021 and October 2024 and who underwent one-step disinfection in minimally invasive McKeown esophagectomy. Surgeries were conducted by the same surgical team, and information on the initial patient characteristics and outcome was collected. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study’s protocol received approval from the Ethics Committee at The Second Affiliated Hospital of Shantou University Medical College (No. 2024-116). Written consent was obtained from all patients (or their parents/guardians) for inclusion in this study.

Step-by-step description

One-step sanitization process

For the one-step sanitization process, a soft cushion is positioned beneath the patient’s chest, and a medium-sized (200 cm × 100 cm) sheet is placed in the middle of cushion and body, extending sufficiently on both the left and right sides to facilitate repositioning. Following the completion of single-lumen endotracheal intubation anesthesia, the patient is placed in a left lateral recumbent position. One sandbag is inserted under the anterior thoracic section of the sheet, and the right upper limb hangs by a bandage that is wrapped around the wrist. Soft pads are positioned between the legs to alleviate muscle tension, and a belt turns around the hip to maintain the body position. The sterile field covers both sides of neck, right upper limb, right axilla, chest, and an abdominal area extending from the left anterior axillary line to the posterior midline of the back. During the sterilization process, an assistant aids in exposing the left neck and the abdominal area near to the right anterior axillary line. The operator dons gloves to disinfect the area extending from the jaw down to the hips, ventrally to the right anterior axillary line, along the dorsal left scapular line, including the right axilla and right upper limb up to the wrist joint (Figure 1).

Figure 1 Anterior view of the patient position and range of disinfection in the one-step modification.

The right upper limb is placed into a sterile sheet wrap, with the coverage extending at least from the hand to the elbow, after which it is wrapped and secured with a sterile bandage. The surgical area is then taped, and a perforated large sheet is laid down. The right upper limb rests on the frame in order to facilitate the placement of the patient into the left lateral position (Figure 2).

Figure 2 Sheet and post-laminating position.

Minimally invasive McKeown esophagectomy

For minimally invasive McKeown esophagectomy, the operating table is tilted ventrally at a 45° angle to acquire a semiprone position at the beginning of the thoracoscopic surgical procedure. An artificial pneumothorax pressure of 8 mmHg is applied, and four thoracoscopic ports are established in routine fashion: a 12-mm trocar is inserted in the fourth intercostal space along the anterior axillary line, a 5-mm trocar is placed in the sixth intercostal space along the posterior axillary line, a 10-mm trocar is positioned in the sixth intercostal space along the anterior axillary line, and another 10-mm trocar is inserted in the eighth intercostal space along the midaxillary line. Subsequently, the procedures of freeing and cutting the esophagus, along with lymph node dissection, are performed. Lymph nodes removed include those from the paratracheal, paraesophageal, subaortic arch, anterior mediastinum, subcarinal, inferior pulmonary ligament, parabronchial, and paradiaphragmatic regions. Upon completion of the thoracoscopic surgery, the patient’s right hand is positioned naturally above the right chest wall, and the operating table is returned back to a horizontal plane. An assistant loosens the hip restraining belt and then tugs the sheet beneath the patient toward the direction of the ventral side. Simultaneously, the anesthetist elevates the head. The patient us then rotated into the supine position (Figures 3,4).

Figure 3 Change in body position from the left lateral position to the supine position.

Figure 4 From the supine position, the patient’s neck, chest, and abdomen remain sterile in preparation for the laparoscopic stage.

A puncture point is established 1 cm below the umbilicus, and carbon dioxide is injected through the umbilical orifice to create a pneumoperitoneum at a pressure of 12–14 cmH₂O. The laparoscopic surgery involves five port incisions: a 10-mm incision is made 1 cm beneath the umbilicus to act as the laparoscopic access point, a 12-mm incision is made 3 cm right of the umbilicus to serve as the primary access port, a 5-mm incision is made beneath the right costal margin, and another 5-mm incision is made 3 cm to the left of the umbilicus. Moreover, an additional 10-mm incision is made beneath the xiphoid, contributing to the secondary port. The stomach is mobilized, and the dissection of abdominal lymph nodes proceeds in line with the standard laparoscopic technique, which encompasses the common hepatic artery along the posterior pancreatic hiatus, the left gastric artery, and lymph node groups 17, 18, and 20 originating from the celiac trunk. Following this, a subxiphoid longitudinal incision measuring 4 cm is made, overlapping with the initial auxiliary port, to aid in the formation of a tube stomach. A circular anastomosis was subsequently established at the neck.

Postoperative considerations and tasks

In this study, based on the anesthetist’s assessment, most patients were transferred to the general ward following the surgery, while a small number required admission to the intensive care unit for ventilatory support. These patients were subsequently returned to the general ward after a period of stable vital sign monitoring. Post-surgical total parenteral nutrition was initiated, and a nutritional solution was administered via a gastrointestinal tube following anal insufflation. On the seventh post-surgical day, upper gastrointestinal barium swallow was conducted to confirm the absence of fistulae, after which an oral liquid diet was introduced.

Tips and pearls

A total of 63 patients, with a median age of 65 years (range, 49 to 80 years), successfully underwent McKeown MIE from August 2021 to October 2024, as described above. Among these patients, 33 (52.4%) were male and 30 (47.6%) were female. The distribution of esophageal tumors was as follows: 2 (3.2%) patients had tumors located in the upper esophagus, 41 (65.1%) in the middle esophagus, and 20 (31.7%) in the lower esophagus. Squamous carcinoma was resected in 58 patients (92.1%), while adenocarcinoma was present in 5 patients (7.9%).

One patient required conversion from thoracoscopic to open thoracic surgery due to severe adhesions. None of the surgical frozen sections revealed positive proximal margins, and all patients underwent neck round anastomosis. Importantly, there were no surgical deaths.

The median total surgical time for the one-step disinfection group was 261 minutes (range, 241–289 minutes), with a median surgical bleeding of 145 mL (range, 95–200 mL), and a median of 24 lymph nodes collected (range, 12–35). Anastomotic leaks occurred in 3 (4.8%) patients, while pneumonia was observed in 7 (11.1%) patients. Additionally, anastomotic stenosis was noted in 1 (1.6%) patient. Furthermore, 5 (7.9%) patients experienced arrhythmia, 3 (4.8%) patients had unilateral recurrent laryngeal nerve paralysis, and 9 (14.3%) patients required prolonged ventilation (more than 48 hours). Finally, 1 (1.6%) patient developed an incisional infection. The median length of stay was 18 days (range, 13–28 days).

Discussion

The safety and immediate benefits of the MIE McKeown technique have been clearly demonstrated (10,11). Typically, McKeown esophagectomy is conducted while the patient is in the left lateral position during the thoracoscopic phase and in a supine posture during the laparoscopic phase. This transition requires resterilization and sterile toweling, a process that prolongs the surgical time (12).

In our center, we use gravity and positive pneumothorax to induce lung collapse. The 45° tilted modified semiprone position effectively prevents the collapsed lungs from the obstructing posterior mediastinal manipulation, thereby minimizing the risk of injury caused by the mechanical pulling of the lungs to enhance the field of view. At the conclusion of the thoracic surgery, the tilted bed is returned to a horizontal position, transitioning the modified semiprone position to a lateral position. An assistant outside the operating table then pulls the sheet underneath the body to convert the lateral position to a flat position, which eliminates the need for resterilization and toweling, ultimately saving time (13,14).

The surgical time may influence the prognosis of patients undergoing MIE (15). Minimally invasive McKeown esophagectomy with a one-stage approach is distinct from the traditional two-stage method. This technique enhances surgical continuity and has the potential to reduce the overall surgical time while improving the surgeon’s comfort during the procedure. Furthermore, the one-stage disinfection modification to the McKeown position demonstrates post-surgical complication rates and discharge times noninferior to those observed with the traditional two-stage disinfection surgical approach. The introduction of 3D imaging technology, robotic systems, and various cutting-edge minimally invasive surgical methods for esophageal cancer has improved accuracy, expertise, and visualization capabilities. Nonetheless, implementing robotic assistance frequently leads to increased surgery durations. The single-stage minimally invasive McKeown esophagectomy could present favorable opportunities for other forms of minimally invasive surgery (16-18).

It should be noted, however, that we employed a retrospective review. Furthermore, all participants received treatment at a single institution, which could restrict the applicability of our results to other healthcare facilities. Moreover, the sample size was limited, and the relatively brief study duration complicated our efforts to collect extensive data on long-term survival and recurrence rates. As a result, additional prospective and multicenter clinical investigations are necessary to address these issues.

Conclusions

The one-step disinfection modification contributes to reduced surgical time without compromising safety. This advancement is anticipated to be the next evolution in McKeown esophagectomy, given its potential for improved patient prognosis, along with its simplicity, safety, and reliability.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The authors have completed the SUPER reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2024-2244/rc

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2024-2244/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2024-2244/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are responsible for all aspects of the work in ensuring that any issues related to the accuracy or completeness of any part of the work are thoroughly investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study’s protocol received approval from the Ethics Committee at The Second Affiliated Hospital of Shantou University Medical College (No. 2024-116). Written consent was obtained from all patients (or their parents/guardians) for inclusion in this study.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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(English Language Editor: J. Gray)