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. 2024 Jul 21;16(7):e65053.
doi: 10.7759/cureus.65053. eCollection 2024 Jul.

Long-Term Outcomes of Carbon Dioxide Insufflation in Thoracoscopic Esophagectomy After Neoadjuvant Chemotherapy for Esophageal Squamous Cell Carcinoma: A Retrospective Cohort Study

Koji Otsuka  1 , Satoru Goto  1 , Tomotake Ariyoshi  1 , Takeshi Yamashita  1 , Akira Saito  1 , Masahiro Kohmoto  1 , Rei Kato  1 , Kentaro Motegi  1 , Nobuyuki Yajima  2   3   4 , Masahiko Murakami  1
Affiliations

Long-Term Outcomes of Carbon Dioxide Insufflation in Thoracoscopic Esophagectomy After Neoadjuvant Chemotherapy for Esophageal Squamous Cell Carcinoma: A Retrospective Cohort Study

Koji Otsuka et al. Cureus. .

Abstract

Background: Thoracoscopic esophagectomy (TE) with carbon dioxide (CO2) insufflation is increasingly performed for esophageal cancer; however, there is limited evidence of the long-term outcomes of CO2 insufflation on postoperative survival.

Objectives: We investigated the long-term outcomes of TE with or without CO2 insufflation.

Methods: We enrolled 182 patients who underwent TE for esophageal cancer between January 2003 and October 2013 and categorized them into two groups: with and without CO2 insufflation. The primary endpoint was five-year overall survival (5y-OS). Secondary endpoints included long-term outcomes, such as five-year relapse-free survival (5y-RFS) and five-year cancer-specific survival (5y-CSS), and short-term outcomes, such as surgical and non-surgical complications and reoperation within 30 days.

Results: Follow-up until death or the five-year postoperative period was 98.9% (median follow-up duration was six years in survivors). After adjusting for age, sex, and yield pathologic tumor, node, and metastasis (TNM) stage, we found no significant differences in 5y-OS (HR 1.12, 95% CI 0.66-1.91), 5y-RFS (HR 1.12, 95% CI 0.67-1.83), or 5y-CSS rates (HR 1.00, 95% CI 0.57-1.75). For short-term outcomes, significant intergroup differences in operation time (p=0.02), blood loss (p<0.001), postoperative length of stay (p<0.001), and incidence of atelectasis (p=0.004) were observed. The results of the sensitivity analysis were similar to the main results.

Conclusions: In thoracoscopic procedures, CO2 insufflation significantly improved short-term outcomes, and it appears that the recurrence risk of esophageal cancer may not impact the long-term prognosis. While the influence of CO2 insufflation in thoracoscopic esophageal surgery remains unclear, our study suggests that the long-term prognosis is not compromised in other thoracic surgeries.

Keywords: carbon dioxide insufflation; esophageal cancer surgery; long-term prognosis; overall survival (os); thoracoscopic esophagectomy.

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Conflict of interest statement

Human subjects: Consent was obtained or waived by all participants in this study. Institutional Review Board of Showa University School of Medicine issued approval 2256. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

Figures

Figure 1
Figure 1. Port placement and thoracic view
(a) Wound retractors are inserted in the no CO2 insufflation procedure. (b) The diaphragm (black triangle) disrupted the lower mediastinal view. (c) The left recurrent laryngeal nerve (black arrow) and cardiac blanch of the sympathetic nerve (white arrow) can be seen in the bloody view. (d) Three 5-mm and two 12-mm ports are inserted. AirSeal ports are inserted in a slightly ventral position in the third intercostal space at the anterior axillary line. (e) The picture is the same case with a. The diaphragm was pressed down after CO2 insufflation. (f) We can get a good view of the left recurrent laryngeal nerve (black arrow) and the cardiac branch of the sympathetic nerve (white arrow). Bleeding was decreased by CO2 insufflation pressure and helped with the view during the mediastinal lymph node dissection. OpLt: operator’s left-hand port, OpRt: operator’s right-hand port, AsRt: operator’s right-hand port, AsLt: operator’s left-hand port, Scp: scopist port
Figure 2
Figure 2. Patient selection flowchart
Of the 454 patients who underwent TE for esophageal cancer, we excluded 265 patients. Finally, 182 patients were registered and assigned to the intrathoracic CO2 insufflation or non-CO2 insufflation groups. TE: thoracoscopic esophagectomy, CO2: carbon dioxide
Figure 3
Figure 3. Kaplan–Meier estimates of long-term outcomes
Kaplan-Meier estimates of long-term outcomes. (A) Kaplan-Meier curves for the 5y-OS with or without CO2 insufflation. There is no significant intergroup difference in the analysis using the log-rank test (p=0.37). (B) Kaplan-Meier curves for above 5y-RFS with or without CO2 insufflation show no significant differences between groups using the log-rank test (p=0.40). (C) Kaplan-Meier curves for 5y-CSS with or without CO2 insufflation show no significant intergroup difference using the log-rank test (p=0.30). CO2: carbon dioxide, 5y-OS: five-year overall survival, 5y-RFS: five-year relapse-free survival, 5y-CSS: five-year cancer-specific survival
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