RICCARDO ROSATI MINIMALLY INVASIVE IVOR-LEWIS ESOPHAGECTOMY

Good morning, everyone. Thank you for the opportunity to present the clinical case of this morning,

a minimally invasive hyaluronic acid oesophagectomy.

This is a 58-year-old female patient with 25.3 BMI,

no past cigarette smoking, no alcohol consumption,

and a weight loss of 20 kilos in seven months with a nutrition risk screening of three.

Her past clinical history included an hypothyroidism in therapy and a right quadrantectomy in 2000 with a negative follow-up.

The patient complained of a history of long-term typical symptoms of GERD never treated with PPI.

The patient presented with a progressive worsening dysphagia associated with a weight loss of 20 kilos since May 2020.

As a first staging examination, the patient underwent an upper GI endoscopy which documented

a vegetating and narrowing lesion 29 cm from incisors. Pathology revealed centering cells

adenocarcinoma. A CT scan confirmed a bulky tumor of the lower thoracic esophagus with

some small perilisional nodes involving the distal esophagus, the cardia and the

part of the gastric fundus for a total extension of eight centimeters. After a

multidisciplinary meeting the patient underwent a staging laparoscopy with no

evidence of peritoneal disease, jejunostomy tube placement and the port-a-cat

positioning. Peritoneal washing was negative for malignant cells. Neoadjuvant

chemo-radiotherapy was done according to cross regimen from August to September 2020 with a

complete regression of dysphagia and the weight gain of six kilos. As a restaging examination,

the patient underwent an upper GI endoscopy which documented the presence of a vegetating

and ulcerated tissue 30 centimeters from incisor with an extension of eight centimeters

meters and a luminal narrowing. Irregular mucosa of the greater curvature of the stomach was also

detected. A CT scan confirmed the persistence of some small lymph nodes and a suspicious nodular

lesion in the right paravertebral region at the level of the right inferior pulmonary vein.

It was also shown a reduction of esophageal wall thickening.

A PET-TC showed a mild metabolic activity at the distal esophagus and at the right lower pulmonary lobe close to the bronchus.

After a careful multidisciplinary team re-evaluation, a minimally invasive overused esophagectomy was indicated.

I forgot to introduce you to Fabio, Fabio Capitani, who is the real indispensable person in this operating room, one of the most valiant collaborators I have ever had.

I thank him, he has a small defect, being an Inter fan, but apart from that.

So, I put the first trocar in place immediately above the umbilical, the patient had a small umbilical hernia.

I ask the director to tell me if I have to speak in English or if I go on in Italian.

Let's put an external image. Give me one more second.

We have it on the other monitor. Does this microphone work?

Without any audio feedback in the room from external commentators,

external my meeting will be with the professor opocher ordinary of

surgery of the university of milan director of the operating unit of

general surgery of the san paolo hospital not only my great friend and

schoolmate since we both come from the school of professor pezzuoli

thank you enrico for being here also this time thanks for the invitation then

So, let's do the point where we put the...

Okay, then,

optics above the umbilical,

trocar of the left hand of the operator,

which is a 512,

on the transverse umbilical,

on the right side,

trocar of the right hand of the operator,

under the right rib,

and trocar under the xyphoid

for the hepatic divarication.

so it seems to me that the trocard 5 of the right hand is very high compared to what

is normally done yes exactly it is very high because I keep it like this to arrive with a good

angle of incidence on the vascular and pathosplenic axis and therefore to have a lymph of

my anectomy a little easier. So the intervention begins with a

Cocker maneuver that will not be very extensive because the forecast is precisely to

do an Ivor Lewis and not to go to the neck is obviously more extensive if

if we think of going to the cervical region with the anastomosis.

Could you already comment on what cases you would think you would have to go to the neck instead of doing an Ivor Lewis?

So, I think that adenocarcinoma, which is the histological form that we see more frequently,

has an indication to an Ivor Lewis and not to go to the neck.

There was an abuse, in my opinion, of McKeown's technique, therefore of an anastomosis to the neck,

simply because it is easier than an intra-thoracic anastomosis, the bipolar one.

So I believe that cancer, adenocarcinoma and subcutaneous cell squamous

should be treated with an Ivor Lewis.

the cancer from the skull upwards needs instead of a mcqueen with a lymphadenectomy also

of the upper mediastinal compartment for a few years now I always do a pyloromyotomy

The pyloromyotomy is quite easily identified, you can see the cut here, and I do this to improve the drainage of the gastric tubule.

The pyloromyotomy, if possible, is extramucosa, even if it is completely thick, nothing happens,

and about one centimeter longitudinal with a transverse pyloroplastic.

transversal plastic bottle bottle we have tried a little but it needs little or nothing in my opinion

so or nothing in laparoscopy so there are no alternatives or nothing or make a plastic pylor

please give me the dots and with this with this from when you do the plastic pylor

how many times have you seen problems with the emptying or how many times have you seen them compared to before?

Well, there are few problems with the emptying of the tubule. Normally when there are, here you can see the

mucosa a little bit open, but nothing happens. When there are problems there are mostly

for a kneeling of the tubule to the hiatal passage

compared to a bad emptying.

When we did nothing we had a discreet incidence of dilatations

rather than, in some cases, we also did a G-poem,

then a gastric poem I must say with from when we do it

the bad emptying of the tube practically never we are using a

4k column of the latest generation of the stores that has a very function

very interesting function that you will then see of indocyanine green the column is the ruby name to me

well known because my wife is called ruby the reason why I told the stores that I will never buy

this column joke and yes because if not exactly I do not know where this name comes from

It's like having a diamond in the living room, it costs like a diamond, this is the reality of things.

Would you recommend adding another trocar? Because I see you a little ...

So, in theory, another trocar, especially in certain phases, can be useful,

sometimes we put it and it is a 5 trocar that we put lower but practically on the left side

in reality this patient had a gastrostomy so in that seat then you will see we have

removed the gastrointestinal catheter at the beginning because he had it for practically three months

after that we will reposition it, so it would go, excuse me, here it would go a little

in conflict this trocar, now let's see above all it can be useful in the phases of

lymphadenectomy if we see each other well maybe we don't use it if instead it is useful we will put it

However, I usually start with four trocari in all.

You said that you put the points, let's go back to a problem of the neoadjuvant.

I saw that he did the cross scheme, which is what you always do in these cases?

We have two regimes for neoadjuvant.

So if neoplasia is a rather bulky neoplasia, especially developed in mediastinic sites,

then we do a chemioradio and by doing a chemioradio we use the CROSS scheme,

which is a scheme of paclitaxel and carboplatin weekly for five weeks

with an intermediate dosage of radiotherapy around 41.4 gray give me a moment to

breathe and then the bipolar and this is precisely what we use if there is a

give me a moment the bipo if there is a fairly voluminous neoplasia if it is

is mostly mediastinic. If there is a prevalence of adenopathy, then

we prefer to use only chemo and by doing only chemo in general we use the

FLOT scheme which is just as... give me a moment,

What are you doing now? You start immediately from there.

Yes, I identify Corvo's leg, so basically the angular region and just below the

angular region, at the point where I will start my gastric tubulation, I open the small

a small increase, an invitation maybe with an anklets and then…

That you like so much?

I really like the anklets, yes.

Yes, the anklets are very precise.

Yes, yes. And then with an energy device.

What do we have today here in the room?

So, today I have the energy devices,

if I'm not mistaken I call them all ciccio,

well because so the chick is the chick today we have a device of the plaid which is the

voyant which is a device with a fairly comfortable shape that you see has a tip

tip like Maryland, let's say, and it has an automatic regulation of the energy of radiofrequency

delivered and it makes an excellent haemostasis and little smoke.

So you see, I opened the small menthol, I try to preserve the vascularization that comes

from the pyloric vases. So you're a little far away. Yes, I'm not really on the wall because

in my opinion these also contribute a little to give a good vascularization of the tubule.

And then you can show me where the peduncle is so they can see each other. The pyloric peduncle is here.

so you have to be careful with the gastric. Yes, and then we go close to the

liver margin. Erika, no. We are close to station 12, there, that you have

practically burst. Yes, now then we go to remove it. We go to remove it. I do

first the whole round of the small increase, then I go down. There you can already see the

Pancreas. Yes, pancreas. Here, give me a moment, here you see the

pyloric vessels, they are here, do you see them? Yes, of course, which we must carefully hold.

Well, in short, it is not fundamental, there are those who tie them, sometimes to make a tube that

that comes to the neck must be tied on purpose, but if you can keep them it is always a

contribution to vascularization. Can you increase the anti-trend a bit please? Thank you.

What I missed a moment ago indicated increased lymph nodes in volume at the

abdominal level or not? No. Here you can see that I have opened from above the peritoneal space

between the head of the pancreas, the gastro-duodenal artery which is below. You can already see some lymph nodes.

They are lymph nodes of the common hepatic system. Which can be seen below. Yes, you can see the common hepatic system

to its confluence. See if you can show me a little better, Paolo,

with your own hepatic and we start towards the lymph nodes of station 12a

which was the one you rightly indicated before. Here it is, that is probably

the left hepatic artery, the one you see. In fact in these

maneuvers the nail seems practically irreplaceable.

Well, I really like to use it, yes, but I have to say that these energies are also quite...

But the energy does not induce a perfect dissection like that one, to tell the truth.

Yes, but it helps you a little in these micro-bloodstains to keep the field perhaps a little cleaner.

clean. Here is the artery that you can see well below. The Koreans suggested to use the energy

for a better lymphatic stasis, that is, lymphatic hemostasis. The problem is if the energy gives

of pseudo-aneurysms being so close to the vases. Yes, but look, I don't know if you have

seen this energy in particular, it has such advanced software that the application time is

so it doesn't significantly increase the temperature and the lateral spreading, let's say.

Increase the anti-trend a little more, please.

very well, sometimes I underpass it with a vessel loop.

the medial edge of the door. And do you always do this? Yes, in adenocarcinomas

always. And so also when you do the lymphadenectomy of the stomach? Yes, of course.

little more to the left, to my left, just, just, thank you. You

You have practically taken over the place of the poor anesthesiologist.

Yes, but he is of good character, so he doesn't say anything.

Here you see the door, the right edge of the door, give me a moment the bipo and those are done.

Now let's open this peritoneal reflection a little, along the pancreatic capsule.

Fabio, can you give me a hand to better put the pedals on my feet, please?

Thank you. Here, this is fine.

Very good, thank you.

Here, maybe there was a lymph node there.

That redness there. We haven't seen the gastric on the left yet.

We haven't seen it yet. Here behind there is also a bit of pancreas that goes up there.

Here, the vein is here. Now let's see, normally I put a clip both on the vein and on the artery,

even if certainly for vases of this caliber any device is more than enough

the habit is hard to ... you have to be careful when you give it to me because you always remove the cable from me ... here is that pancreatic

cornea we have detached it ... you give me a moment the cheek ... there probably there is nothing

pilastro. This then allows us to get a little better on the left gastric artery.

I don't go into the mediastinum now because I don't want to do a pneumothorax to the patient

so as not to create problems with the anesthetist.

There you can see the gastric.

And here is the splenic.

Do you see it?

Immediately below there is the splenic.

Now we divide it.

And here too we put a clip.

Yes, yes. Give me a moment, I would like to... first the vacuum cleaner, or rather the bipolar one,

vacuum cleaner, then bipolar, I would like to clean it a little better down there.

Emolock never? I see normal clips closed.

Almost. In the chest I put the Emolock on the bottom and on the azigos. Bipo,

that has eaten a piece of artery. No, it's not an artery, I think it's

tissue, but I want to clean it to put it better. Let's see not to remove it

vacuum cleaner a second here you see that the cleanliness of the tripod is good

pull it down a moment let's show it again that here you can see very well it is a nice

stretch also of the splenic artery and now we continue a little along the splenic and we go

lungo il pilastro sinistro qua l'arteria splenica fa un kinking vedete che torna

indietro bisogna stare attenti perché di non portarla via è molto frequente che

ritorni mediale per cui uno se usa un ciccio qualsiasi in maniera un po

incongrua fa un danno vascolare e poi devi farla splenectomia stiamo

gaining a little space here behind and this is the lymphadenectomy of the 11 p proximal stations

and d because we will practically arrive at the splenic lilo there we are behind the stomach if

should now see the decursion of the diaphragmatic pillar on the left.

Here, it is not risky to go into the milza. Yes, you have to be careful and take small steps.

Here you see this is the left pillar, then we do this dissection later. So

practically you go first back than in front, contrary to what is usually done

because here you are already behind for the lymphadenectomy that I do as the first act and it is

convenient to go a little further from here. Now we focus on gastrolysis,

so the assistant will attach the angulus and bring it to us medially and already from this maneuver

the right gastro-epiploic arch, you see?

That we must keep tassatively?

Absolutely yes, if we have not finished any surgical velleity to do an Evo-Lewis.

because from there towards the gastric fund there is space,

There is a space, while towards the Duodeno it is a more virtual space, which is better to look for after you are certain of this.

the safety distance not only for this section but also for a possible hemostasis with the

bipolar where some of these blood vessels. Do you pay attention to how much

tissue can prevent a correct descent into the chest or not? So I always try to be a

a little bit abundant because I like to do a little sharpness with the residual increase

around the anastomosis and then I have a technique to raise the tubule using a

a gauze that you will then see when we are in the thoracic part so as not to make tractions

so yes not too much but a little more than what could be normal yes here now

she no longer needs us there so we let her go and we put her under here you are there

Could you please suck a little bit of the nasal swab?

Thank you.

There's a bit of liquid in the bottom.

The patients follow an ERAS protocol,

so they've been charged with carbohydrates

two hours earlier, at 6 in the morning,

last night and this morning.

so there is a bit of excess liquid in the stomach here you see here I am a bit

wide compared to the arched one but this fabric can then make it comfortable in the chest a

gentile rispetto al mio standard, forse perché sono indiretto.

Non hai ancora detto niente. No, ma sta pensando di essere perfetta.

Oggi sei convinta di essere perfetta.

Ecco, fra quello che avevamo... Siamo arrivati in fondo, fra quello che avevamo

done below and what we have done from above here we are at the

esophageal brake membrane of leimer bertelli vacuum cleaner a second

now let's expose all the left pillar well

up to here here there is the success of his radiotherapy and where the tumor

What do we have to be careful about when these patients do radiotherapy?

Everything.

Is it much more difficult, do you notice it?

No, the big difficulties we found for neoplasia are very close to the airway,

so normally the cell foam no no no no closed like this good now we go down

down and the important thing apart obviously the saving of the right gastroepiploic is to clean

up to the duodenum so as to have completely the good mobility of the tube and you can see the

the gastroduodenal or not? Yes, from the back to see the gastroduodenal and from the front to see the duodenum.

Look where your pilauroplastica is, let's show it to understand. No, no, it's here.

No, that was the coagulated one I gave on the other one that was bleeding a little.

Here are the vases, do you see them?

No, no, no, because you would risk dilating the gastroepiploic.

In Eivor Lluis 6 and 4 remain. If the patient has adenopathy on the A6 or on the A4, we do an esophageal gastrectomy with an intra-thoracic digunoplasty, or for the via di Pinotti or with a thoracotomy.

miotomia adesso te la faccio vedere eccola lì mi dai un attimo l'uncino completiamo questa

gastrico la prima mi dai una 45 viola e le altre delle 60 viola ecco il vantaggio per esempio di

utilizzare le lineari io normalmente utilizzo le lineari eticon oggi utilizziamo lineari

metronic ottime anche queste che hanno il vantaggio rispetto alla eticon che può

indifferently use a 45 or 60 caliber suture loader and the advantages of using

electric sutures is that the fabrics are much more stable here

Here you wanted to see the duodenal gastro here, I would say we can settle for it, it seems to me a dissection more than enough.

Here you can inject the green.

So what do we look at the green? Because it seems to me that you don't just look at the color, of course, but also at the times.

Exactly. Paolo, who is helping me now, has devised and coordinated a very nice study called AGE that correlates the data...

So you see that the advantage of this instrumentation is that it allows us to see the ICG and therefore the fluorescence even with a normal vision, so we are here, here it appears, you see, you have seen that it has also arrived from the pyloric, you see that here it is preserved up to the tip of the tube,

so very good great let's try to re-insert the digiunostomia give me no no no give me

just this without trying to give me just this as I told you we had slipped it because it is

Hold it for a moment.

Let's try without.

Do you put it at the same point?

Yes, yes.

I try to go back. Try to inject a little.

Give me the needle.

The one that goes away is the one on the right?

Yes. Try.

No. Out.

Give me the needle to inject some water.

Try. Yes, yes.

Break it.

or you can hold it as you prefer. It's bending a bit. Yes, yes, now I'll give it to him. Wait a minute, go.

Or we can also leave it like this, you know. In the meantime we are well inside. But it's inside, so let's see.

yes yes ok here it is see why it is ruby it would be emeraldine like the mineral water of porto

much more complex because one studied it who had a gigantic hand and who took care of it

of the poor Italian surgeons who have small hands but the advantage that it rotates by itself

excuse me I did all this work for nothing you did not look behind and the problem if a bit of

these nothing happens but they make you make a line no they make you make a line of suture less

to gradually remove the probe, if you're a little confused with the vision.

As you can see, the first stroke is a little oblique.

two or three times. No, no, pull it back, don't move it forward, pull it back, pull it

pull back 10 cm, pull back 10 cm, ok, now stay still, now it's a 60,

in the case of Metronic the purple is practically the one that is used almost

always, yes, because having the three lines of graph, check that it is free, having the three lines

of grafts at a different height is perhaps the best compromise between the

hemostasis on the side, let's say, closer to the blade and the hold on the other two.

Let's make a comment instead on the size of the tubule, since maybe someone has a problem.

but I make a tube around 3-4 cm in diameter.

A tube that is too big probably has some discharge defects,

a tube that is too narrow has some vascularization defects.

Here, check it.

Give me another 45 now.

What?

Maybe you have to earn something.

is missing so as to give us an idea there is the junction now I give a further hit here so you

One of the problems, let's say, in the follow-up of these patients is the incidence of herniations, sometimes even massive.

Of the tubule?

Not so much of the tubule as of the colon or of the small intestine,

that normally are in half of the cases let's say scarcely symptomatic but that can

become real emergencies with a colic occlusion of the colon migrated especially the transverse

in the left hamstring. For this reason we have started to do a kind of

colopessi, trying to anchor the increase at the level of the left half of the transverse

to the left side wall to see, to try to prevent this complication that was described, we had it,

perhaps we were the first to describe it with Uberto Fumagalli in 2005, we had done a work

published on disease of the esophagus and lately I have seen that a review has come out

and it insists on 11 percent of ivor lewis so not little not little then the idea is that this

can serve as a bit of prevention and how many have you done so but now maybe it's not even

even a year we do it paolo a year we will have we do about 100

ivor lewis a year so more or less we will have made a hundred a little less

than 100 now when we get to 100 we make a small one a small review of the

experience. Ok, now we dedicate ourselves to the alloy part.

Excuse me, let me see one thing, give me a little dot of Maxon. All the dots that

were put in open, at the crosses, the sutures. I practically don't put them anymore.

And what kind of problems do you have with pistols on the tubular?

Well, not so much. In my opinion, I have had two in the last five years.

At the level of the suture?

Yes. Well, I must say that there were certainly many more in open surgery, where the manual gia was used, which had two lines instead of three points.

I would say that with these absolutely very performing sutures if there is a vascular problem

and if it is a vascular problem it involves not only the suture of the tubule but also the anastomosis

So one of the sciences in general is intra-thoracic.

Yes, yes, also because practically when you do the pull-up of the tubule, the entire suture line remains in the chest.

Ok, give me your nipple too.

So now we focus on the urethra and the mediastinal esophagus.

I now you will see I always open the pleura widely generally I try to open

only the right often in reality it happens to you to open both does nothing and then I no longer put

the thoracic drainage here you can feel the neoplasia at this level I no longer put the

thoracic drainage but I put a transient drainage like a jackson pratt that I conduct on this

because we had noticed that the greatest annoyance the patients the greatest pain referred to it at the level

of the very thoracic drainage so there is also to say that if there is a descent on the

The classic thoracic drainage does not bring out anything.

Also because almost all the descents are on the mediastinal side and the drainage is on the lateral side.

Yes, he didn't do much with the radiotherapy. I feel a nice hard here, hold it like this.

here you have seen the open right pleura here we are on the parahortic mediastinum

now that I have opened the right pleura if you find some hemodynamic problem or

pressure but for a short time the right pillar do not cut it anymore

No, because I'm afraid that this is also one of the things that facilitates migration.

Go to the other side.

And the tube passes on the same?

Yes, yes. You will see later when we pull it up with the gauze, it does not strain.

If you open it, do you close it? The pericardium? Yes, here in general it

practically never opens, it happens to open it every now and then in the chest when you do the lymphadenectomy

of the 107 and 109 stations, so of the subcutaneous ones.

The tumour is just a nice bump.

We are participating in an international study coordinated by the Dutch,

which is the Tiger Study, which proposes to evaluate the entity of lymphadenectomy in esophagectomies.

It is a very ambitious study that provides for a roll-out of 5,000 cases.

At the moment, about 600 have been rolled out, and we are the second center in terms of the number of cases,

after Amsterdam, which is the center coordinator, which has proposed 120-130 at the moment, we have inserted 89.

What does it include?

To evaluate the entity of the mediastinic lymphadenectomy and to see,

basically for the various types of neoplasia the lymph node involvement entity

then correlating it to the type of surgery done and to the type of possible neoadjuvant treatment

performed. We normally perform a rather extensive lymphadenectomy in the abdomen,

you have seen it, in the chest you will see it, basically in an adenocarcinoma we remove all the

lymph nodes of the lower mediastinum and a selective lymphadenectomy of the upper mediastinum,

above saving substantially only the recurrent ones that we take away instead

in which percentage these adenocarcinomas are

neodymium in your experience? Ah, many, 70%. So now it's almost the rule. This is the famous

Yes, that's right, it's a Jackson Pratt, which we now insert all the way in here.

I pass this in the chest, in the anterior mediastinum, in front of the lung,

so that it doesn't break my ribs during the thoracic phase.

it is sufficient to put it inside up to this whole plate here, hold it like this, hold it

still and I pull it out of the trocar that I used for my right hand and this basically

does not bother the patient. And let's say it does its job on the lung. Yes, yes, then

So, in patients who have many pleural adhesions, in which you have to do a lysis fixed to the drainage,

a lysis on the pleura, then sometimes we also put a small one on the right, but basically for the air,

because if not we can have too many air losses and then it happens that you have to put it in the

operating room but if the patient does not have large pleuric adhesions it is not needed and it is more than

enough. Today the Storz is a great success, we use the tap, we use the lake of Bersì

to close things, then magic of magic we will also use their tool for the

tobacco bag. It is practically all sponsored by Storz. And they don't even invite us to dinner because

Because the restaurants are closed.

Can you give me a pair of tweezers, please?

Give me a pair of tweezers, please, and touch me.

A little bit.

Ok.

Ok.

Now I would suggest, or rather, I would suggest to those who are watching us on the internet

to stay connected because I'll show you how we reposition the patient.

Stop the gas, please.

It's not like the French who go to eat now.

No, it's not like the French.

In fact, there is a real team work.

Each one has its own task and in this way the patient's repositioning is really fast.

Ok, now a very wide field for the camera, can we have it?

Yes.

The camera is above.

No.

To contaminate.

Hold the

I have the drainage that has been cut in half.

No.

Is that all?

Where?

Here?

Yes.

Go, go.

wide shot? Let's do a very wide field shot, please. Let's lower the bed.

Where is the external vision?

There, the one you see there.

No, no, which one?

The one you see there.

No, it doesn't look good like this.

Ah, yes.

Ok, fine.

ok at 3

traditional thoracotomy and then using the functionalities of movement of the bed

we will transform it into a semi-prone decubit which is very useful for the thoracoscopy

Where is the...

I'll go, I'll go.

Now, from the lateral decubitus, which is this...

No, you have to move your arm forward, as if you were swimming.

As far forward as possible.

ok now the head is tied not yet then we tie the head fabio

give him a hand in the head sorry but this is not good so

it is a little further back with this

here you see you see no you don't go there you have to come from here where it was before from here you have to

see it from here, from there you can't see a tube, from here, far away, because this way you can see the

laterality that it has taken. You're done there, that's it, ok. You can see it well, eh? You can see it from this one here now,

not from that one, but you can understand that the patient is in ... let's see this, you can understand that the

malata ecco è in semiprono abbassalo un po ecco perfetto adesso si vede così anche

il tuo amico masoni e contento perché anche chiamato professore

This time I don't have anything to say.

Yes, later we'll show it.

Yes, here, to the right goes ICG and non-ICG.

So let's mark where you put the trocar.

Yes, this is the scapula.

I'll put the lens here, my left hand here, my right hand here,

and the help trocker here, which is the one where I'll do the mini thoracotomy.

Can you... Yes, that's fine. Yes, yes, that's fine, that's fine, wherever you want.

The light is not on? Yes, now we'll do it again, but first we'll clean it.

Are you doing it? No, I'll do it. Okay, fine.

I put it here.

Okay, so it's been about 20 minutes since...

More or less, yes. Okay, let's take a look.

very well pneumo 8 high flow exclude me the lung please give me the optical please

very well we are there no adhesion fortunately give me to inject me to inject for

pleasure this is a 5 this is a 12 to 12 I put 3 12 that of the optical this that

which is the one from which the instrument for the tobacco bag will also enter, the clipper and then

I put it here because here is the one that I then enlarge to make the mini-thoracic and instead I put

E' sporca l'ottica, la puliamo?

the intercostal vessels that can be seen well, the upper cava vein, the

phrenic nerve here, the vagus nerve on the right here, the suclavia artery there behind the aortic arch

that is not yet visible. So let's start with the isolation of the arch of the azygos.

Fabio, give a hand to Paolo, because otherwise he's in a crisis.

Paolo, you're very close.

No, I'll hit you physically.

Sorry, thank you.

You're wrong.

If I may, since these maneuvers have a fairly limited interest,

Mi piacerebbe scambiare due chiacchiere con te, Enrico, sul discorso della centralizzazione

e dei volumi, nel senso, io credo che non sia un problema tecnico, cioè non è che

in high volume centers the surgeon if he is better than low volume centers yes maybe it will be

a problem to put a little less because he is more used to doing them etc. the problem is

the management of complications in the sense this is a surgery that as everyone knows has many

There are many complications that range from the most trivial complications and also of limited severity to the most severe complications,

perhaps infectious, pulmonary, a high incidence of pneumonia, etc.

to the most fearsome complications, which are the anastomotic decency and the lesion of the airway.

So, I think that whoever approaches this surgery must either be able to manage his

complications or have close relationships with a high-volume center, so where the

the complication arises, the management is a bit collegial, in the sense that you give each other a hand,

you share the type of treatment to be done and you face together the eventual complication.

I find a little bit out of line what is perhaps done in many cases that,

but since I saw it, it's fine, it happens to me two a year or three a year then I do it

because I don't know I think this is not correct it is not as I said it is not a problem neither

of technique nor of surgeon but it is to understand which is the patient who is turning towards a complication

immediately manage the complication from the diagnostic point of view,

So having an H24 radiology, an H24 endoscopy, a group of endoscopists who know what to do, how to do it, when to do it.

let's not forget that for the majority of endoscopists and for a good part of

surgeons the fact that there is a fresh anastomosis is a contraindication to perform an

endoscopy when the endoscopy is one of the first acts to do. What do you think Enrico?

I absolutely agree with this, I find myself absolutely in line. I think that this situation that you say is the result of the Italian system that never manages to put precise rules.

What is done, what actually happens is always left to chance, in the sense that, for example, in Milan, this situation of centralization seems to me, for example, since we are now operating an esophagus,

de facto è avvenuta ma senza che questa cosa sia stata codificata in maniera centrale come

invece dovrebbe essere e come invece viene fatta in tanti altri parti del mondo, questo è sicuro.

Né governata dalle nostre strutture sanitarie.

Esattamente. Allora questa cosa per cui in tutti gli ospedali, piccoli e grandi,

beautiful and ugly, if one wants to do anything, it will end, but in fact it cannot end because it ends

on its own, because there are no more sick people or because the sick have understood that to do certain

interventions they have to go to certain places. The reality is that it should end because there

should be a governance that establishes that things have to go this way.

think that the other day there was a very interesting webinar on digestive anastomosis

organized by franco corcione where a series of surgeons participated and domenico dugo

reported that, according to GENAS data, in the last period there was a gastric surgery.

50% of gastrectomy interventions in Italy are done in hospitals with less than four cases a year,

and I find this chilling and we are talking about stomach, esophagus the same, in short, it is not good at all.

Yes, but I think this is valid for the pancreas, it is valid for the rectum, it is valid for the vast majority of pathologies.

The problem is that when one goes to do the primary in any hospital, even smaller,

you feel absolutely authorized, if you are able to do it, to do any type of intervention.

where, rightly, perhaps in hospitals, where one can come from a school, where in fact

perhaps he is very capable of doing certain types of interventions, but which in fact, as you said, are not

equipped to be able to have all the, let's say, services that are needed for the management of

complications. This is absolutely true. Do you also use green to see the lymphatic duct or not?

So, there is a very nice work done by Roberto Petri in which they inject the green on the inguinal lymph nodes and you can see it from God.

In reality, we have never done it and lately...

Excuse me, Paolo, I'm coming here with this.

Lately, can you clean my anus?

Just in function of that Tiger study I was referring to before,

we are actually doing an M-Block transplant, which also includes the thoracic duct.

So, yes, seeing it is a great chromatic suggestion, but from the moment we go to dissect it and transport it into the block...

And what is the philosophy of removing the thoracic duct?

Well, the philosophy is to make a dissection on the aortic plane and in theory it should...

I don't think it's a useful premise in theory it should export a

when doctor thoracic down here you see yes yes yes well it's because the eye

trained at least trained I have to tell the truth that now you can see well

otic for a moment. I saw that you don't use the gauze very much, bring inside the gauze. Sometimes yes,

now you will see maybe in the lymphadenectomy I do it, vacuum cleaner for a moment and beep,

Davis Skinner e Nasser Al-Torki avevano definito l'esofagectomia en bloc. Loro in realtà

asportavano anche la pleura controlaterale, cosa che a meno di casi veramente particolari

Here, more or less at the height of the arch of the azigus, the dot crosses again, so here we will interrupt it again with another clipping.

chest kilo I say in theory because never say never in our profession you see that the

we resume the initial positions. I will usually perform the anastomosis more or

less at the level, for a case like this. Immediately above the arch? Yes, immediately above the arch.

The anastomosis in the Ivor Lewis must never be too low for the results

even functional results. I happened to see Ivor Lewis made by, or so-called Ivor Lewis made by

someone who perhaps was not so competent, who even did not bind the gastric vases on the left,

so I wonder how he could think of making a gastric tube rise. Anyway, the world is beautiful

because it has changed then the right vagus nerve is not a cell squamous so I'm not going to

isolate myself in the right recurrent that is there and here behind it passes around the

suclavia and goes up but these lymph nodes which are the lymph nodes of station 106

tracheobronchial trachea. You usually go on the vagus, as you see do now along the edge of the

airway. This is practically the edge of the main bronchial right. Maybe you have to clean

the cheek a little because I see that it is doing a less effective hemostasis. Give me the bipolar a

a moment and then when you are close to the airway you are particularly careful with the

device or not? Yes, I try to use them from the protected side which in theory heats up less

but when you give me the vacuum cleaner you give it to me with the gauze that Professor Hopper said before

But this in particular is a device that heats up zero.

Here, back there is the ascending aorta.

Yes, you can see it well.

Can you clean it up for me for a second?

Thank you.

The incidence of lymph node metastases in these stations is around 10% for Sivert1 and Sivert2.

Yes, it is not very high, but those who say that Sivert2, for example, must be operated only by the abdomen,

In my opinion, beyond the positive tranches, it also risks leaving behind a certain number of lymph node metastases.

We put these separately, right?

Yes, they are stations that it is a bit difficult to be able to take away in a block,

but in general I also remove the lymph nodes, even the subcutaneous ones, separately.

Ok, a sachet.

106 TBR.

Give me a second to bipolar, so we can see the hemostasis.

And then?

I mean, not for the brown ones.

Hold it, pull it.

Put it together, I don't think it's anything.

Bipo.

Let me breathe for a moment.

Look, there's a lymph node here just behind the vagus.

Yes, maybe you're right.

This instead that I give you now is the lymph node of the main bronchial right.

What is it, Paolo, 105?

No, 109 are the ones below.

109?

of the count given the vague that goes down here I am the vague I try to keep it until it has given

the bronchial branches. The French called it, you who are a French student, they called the

vagus the pneumogastric. Nice times, especially because we were young. Here, there is a branch.

Then I would say that the part here is the one that remains for the lung. I see, for example,

For example, the school of Leroux was very high.

Now here I can saw it because it goes only to the esophagus and also down here.

I keep it up to here.

Here you see here, I go straight to the esophagus, then the infonodes of the hull I take away separately.

Here we are at the arch of the Adrigo.

More or less, yes. Now we release it a few centimeters up.

Can you give me another Emolock, the one I put to the face?

Can you pull the probe back a bit?

See, I'm trying to be very delicate, but it's fragile here.

A bit of muscle.

For the moment, stop, then we'll check.

Here we are, we have to be careful because we are in the left recurrent zone that after having turned here around the arc

comes up parallel to the esophagus, I think here more or less, here I would say.

Do you never put a lace? Sometimes yes.

Here it is, the recurrent here, that little white there.

Give me the umbilical cord, please.

as soon as I have tied this piece, I ask you to retract it.

here there is a lymph node for esophageal this is 108 105 I would say 108 and lower under the

There is where we do the anastomosis? More or less, yes.

You are very tall, in fact. Yes, but you know, the neoplasia was not very low, it was all in the chest,

so we are quite safe. Pinch, remove the lymph node.

at the edge of the hole is quite close and you give the chick and now you will see that behind it

the pleura appears on the left, you can already see the lung a little transparent

below. If you open it a little, nothing happens, at most it makes a little pleuric

movement on the left in the operating room and it is drained. Can you see the lung over there?

Yes, you can see it well. We do not have smoke aspiration, let's see, let's clean the

because it's foggy in Valpadena.

There's a little hole there, have you seen it?

In the pleura.

There too.

This is the site of the radiotherapy of the neoplasia,

so even if it comes and goes, I'm happy.

Back.

Upwards.

Erika, please.

Here we are joining a little to the dissection made from below, now there is really little left,

those are the lymph nodes that I leave down and then I take them separately.

And now that you are participating in this study, there are many more lymph nodes at the mediastinal level than before?

I have always done a fairly extensive lymphadenectomy and let's say that my average of

exported lymph nodes has always been between 50 and 60 now in more than one case we have had

more than 100 lymph nodes because for example those of station 112 which are those practically

razo to the garden or you clean the garden like this or you don't take them then when we tied the

the thoracic dot with the mass binding without drying it so well there are then we have an

exceptional pathologist dr luca albarello who from the moment when at the beginning when I

arrived I told him remember that professor sievert said that a good pathologist can be seen

from the number of lymph nodes under three millimeters that counts then everything counts for me and he is

really an exceptional person we are very lucky here because we have a fantastic

collaboration with here you have seen the drainage back there yes of course here it comes up there is

There's still a little bit here.

Here, the last one.

Well, it's free.

Now I'm going to move to Paolo's place

and we're going to remove the lymph nodes of the skull,

which are the last station we're missing

to then start the reconstructive part.

Maybe a little more here.

Yes, or let it go.

lengthen the pedal over there? Yes, practically in inversion. Yes, give it to me here, give it to me here,

Pinsa e ciccio. La testa.

E' il raso del bronco di sinistra.

Sì. Aspiratore un attimo.

Lipolare.

Puliamo.

Ciccio.

107, 109, R e L.

Questo è un 109 R.

Sì.

Dammi il sacchetto.

Pinsa.

Tieni. Aspiratore un attimo.

Ecco, mi sembra che la pulizia...

What is the incidence of respiratory complications?

3-4%.

And the solution?

Re-intervention, thoracotomy, intercostal muscle embolism, suture of bronchial or tracheal lesion

and plastic with embolism.

In general they are secondary to a fistula, a non-recognized fistula, maybe with the subclinic,

with the patient who was well and suddenly on the sixth day he has acute dyspnea,

a pneumothorax, give me the bag of tobacco and then at that point you have to wait,

Wait, let's see, pull that trocar back, come on, pull it back.

Can you try to free the Sondino, please?

Hold it, without retracting it, just try, turn it a little, no.

Here, this is a very delicate maneuver, because from the opposite side, where the needle comes out...

You put it directly in the groove.

Exactly. Then you have to hold it with the right hand, the needle, pull it out a little, bend it and then step by step with the left hand without ever letting go of the right hand.

This is the same as a thread that is normally used for bags?

It's the same, yes.

And making it shorter would not be necessary?

What?

The thread.

Well, yes, it has to go into the chest, it has to make a vein, another one, then you cut it later, so here you have to see well that it takes the first two, yes, then once it has taken it, you are in place.

The same, fastened, this one is going to protect the bow a little, folded and then pulled forward like this.

Scissors, scissors, here it is convenient not to go straight, but leave a couple of millimeters of wall.

A small cuff, because if it is too big then it breaks the balls with the sewing machine.

if instead it is too small when it clings to put the head inside it is not good we generally

do not make an extemporaneous on the strip we do it on the scales to decide maybe those

who are at the limit between the volumes and neck you do it at the beginning and decide

Here we stop the gas, we turn on the chalitica for a second, now before pulling the tube up, because then the tube inside the chest holds space and breaks the boxes a little, we do the mini thoracotomy and put the head inside.

I'll manage it myself. The 10 mm clamp for a moment. I try to use the

caliper as large as possible. Here is a 28 mm. So let's widen this a little up and a little down.

So now and then you don't use the gas anymore? No, but I don't even need it anymore, I would say.

Okay, what are you going to use?

Oh, okay, we'll be back in a minute.

Alexis, mini finocchietto.

I'll come back up.

We can turn off the chalice.

Let's clean the optics.

I don't think it's clean.

Head clip for me.

And five clip.

Okay.

Take this one, Paolo.

you got out with this trocar you show me you go inside stop give me the mandarin

you can hold this paolo behind I have the pure ok your edge wait I didn't take it

well ok this is another easy game sorry let go of it for a moment go inside and

a little bit because there is the bag a little pulled and it breaks the browns ok very well no wait

that I take them both ok then after you give me a second a wait leave it like this a

problem and two short zeros you don't put the loop anymore yes yes I put it but I want to redo the bag

No, not to redo it, but to put a little more. There is the exit point of the eagles, you see that now I...

o ancora la garza dentro vero dietro pinza dov'è un attimo me ne dai una pulita ok paolo

do the lever and traction with this instead of on the visor you see what I was telling you because

so you don't do trauma you hold paolo you look that in a little while I ask you again the green you hold

both of us let's clean the optics that makes shit on the web the quality of the optics on the web they heard

everyone who does shit. Yes, but it's the quality of the optics. You know, we are forced to have these

storts. Let's see down. Ok, here, very delicately, you can see the loyato well, the slats, very

delicately, we pull a little bit of that fat, delicately, delicately, because it is the fat that

Paolo, let's go back here. No, you only have one, let go. Here, you see that I get where I want to go.

Hold the gauze, okay? Then I can also adjust the fat from the outside, but I would say that we have it.

then do the green too, you press once alone, this is what was left

coming, now keep the right button pressed along, go to mono, ok, this is an

yellow inside, there, yes, in short, many tracks, however, it's fine, ok, ok, go to normal,

wait, ok, now press 1, ok, perfect, let go too,

Let's take the gauze off. The external camera, please, pointed here.

Ah, there it is. Can you see it? Is it right, the external camera pointed here?

This is always the magic moment not to turn it around, though.

No, you don't turn it around. If you do things in a way, as our beloved teacher used to say, you don't turn it around.

Ciccio to me, the tumor is felt, it is palpated, it is well represented, you have seen that we have always

pulled it up in a sense. Here now you are practically releasing the large curve. Yes, a little bit.

We will do the anastomosis at this level, so now I will dry it here, then I will do the further

troppo togli un pezzettino è un po troppo perché se per caso poi mi va in

Now these new sutures have three lines of grafts, let me see, okay, okay, clip it, throw it in, no, no, yes, I'll take it off, give me the head, let's turn off the chalitica, please, come under, Paolo, a little further back, let me see the tubule.

here the tube is straight when the suture line looks towards me, clings to Paolo and clings to me

and therefore the fat on the opposite side, the fat is there, behind, let me see here now

Stiamo centrando la suturatrice. Mettimela dietro qua.

Rondella gastrica e rondella esofagea, tutte e due belle, complete, cicciute.

Mandiamo l'esofagea. Vieni di qua, Paolo.

Pinza a me, pinza all'Erika.

Erika, ce l'ha già?

No, no, no, no, no. Scusa.

Erika, non crollare proprio l'ultimo.

How far away are you from the esophagus?

Here, I think this is a technique in which, in the end, you say exactly

I did exactly everything that I did in the open in the video, nothing has changed, I have not done any

pass the probe slowly, you see that the tubulation line is all ours,

go, vacuum cleaner, yes push it down slowly, without forcing it, yes I see you, go, go, go, go,

another five centimeters, let's do blue and methylene water, suspension dots, put

Do you put some suspension points?

I put a point that takes this pleura flap, the fat chick that I put there.

Can you give it to me?

Let's do the blue first.

Behind, behind, behind.

Go ahead.

Here you see that my stomach is swollen.

Okay.

Ok, you can inhale. Give me your little toe. Fabio, can you pull on the patient's legs?

And now let's do that maneuver I told you about at the beginning,

which is the one that actually allowed us to halve the fistula incidence,

that is, the positioning of the paravertebral catheter for post-operative analgesia

instead of the epidural.

Can you count the cost, please?

We normally position it in the fifth space.

Are they here or are they ten days ago?

and where but it is that I cannot speak because if not you should put a needle at the tip of the

I should put the paravertebral needle that I do not have and therefore I am using a

peridural needle because I do not make comments. Good morning, take that tweezers off.

Now the catheter is in the right place. Give me the scalpel first.

Yes, yes, just a little bit, but it's okay, it must be within three centimeters from the vertebra.

Here you go, okay.

The Jackson, are you going to look at it?

Now I'm going to take it and put it in its front, in its right place.

Can you please give me a pair of pliers, a vacuum cleaner?

If you want to start vacuuming the excluse lung,

Secondo me il punto cardine, oltre alla tua capacità naturalmente, ma solo il fatto che

you have, in my opinion, I like this thing to die, standardized the things.

I have already seen many of them made by you, I must say the truth is that they are always the same,

this in my opinion is the key to having good results.

Teamwork is the fact that you always do everything the same without inventing anything.

I thank all those who were connected via web, I greet you, it seems to me that it was an

interesting intervention conducted without problems, I thank Professor Palazzini for the invitation,

thank you for the technical collaboration Storz Metronic Applied and thank you to Image Communication

who has always followed us in our video broadcasts and of course thank you again to all

the staff in the room, the anesthetist, the instrumentalist, Dr. Peca and all the others.

Arrivederci a tutti.