Commentary: Minimally invasive surgery: More than meets the eyeMinimally invasive surgery, starting with laparoscopy and thoracoscopy and evolving into robotics, has transformed patients' surgical experience. Large open incisions are no longer a prerequisite. With smaller incisions that do not require rib spreading in the chest, patients experience pain and consequently are more mobile and recover faster. Less invasive methods do not mean poorer-quality surgery, however. In most cases, postoperative outcomes are improved, and surgical options can be extended to more frail populations with less invasive surgery.
Commentary: We are in the same minimally invasive boat, and we have to row in the same directionDespite the superiority of robotic-assisted thoracic surgery (RATS) over video-assisted thoracic surgery (VATS) for mediastinal masses, in this issue of the Journal, Alushani and colleagues1 confirm the broad availability of VATS in most of the developing world, owing to the higher costs and inconsistent accessibility of RATS.
Thoracoscopic resection of esophageal duplication causing tracheobronchomalacia in a 5-year-old patientTracheobronchomalacia is the most common congenital anomaly of the upper airways in children.1 It is defined as a dynamic expiratory collapse of the posterior tracheal wall, which can be partial or total. Tracheomalacia is most often of congenital origin, explained by weakness of the cartilage ring or caused by extrinsic compression.1 We present a child with a delayed diagnosis of tracheobronchial compression by a mediastinal mass, which in terms of diagnosis and surgical strategy has been challenging and educational.
Commentary: Repairing the candy caneAnastomotic complications after Roux-en-Y esophagojejunostomy are relatively common, occurring in nearly 6% of all patients,1 but they may be as high as 10% in reoperative cases.2 The incidence of late complications, including strictures and other functional syndromes, is not well established. One of those late complications is the “candy cane” syndrome. Patients experience abdominal pain, nausea, and emesis and have a dilated blind afferent loop at the esophagojejunal anastomosis. The anastomosis is often herniated into the chest.
Commentary: Treatment of “candy cane” syndrome: Not necessarily a straight pathHerniation of a Roux-en-Y gastro- or esophagojejunostomy can present as “candy cane” syndrome, named for the radiographic appearance of the dilated afferent Roux limb. Risk factors include excessive length of the blind limb,1 which may preferentially collect food as the path of least resistance. Presentation ranges from nonspecific abdominal discomfort to acute pain with nausea and vomiting. Although rare and infrequently described, most cases are repaired transabdominally. The length of redundant bowel varies as much as 3 to 22 cm, and resection often results in prompt resolution of symptoms.
Thoracoscopic revision of a herniated Roux-en-Y esophagojejunostomy for treatment of “candy cane” syndromeAnastomotic complications following Roux-en-Y end-to-side esophagojejunostomy are reported in 5.7%,1 with transthoracic herniation in 0.08% to 3.8%.2,3 Patients can present with a dilated, redundant jejunal limb referred to as “hockey stick” or “candy cane,” creating a functional obstruction at the level of the anastomosis, known as “candy cane” syndrome.4 To our knowledge, this is the first report of a thoracoscopic anastomotic revision of a herniated Roux-en-Y end-to-side esophagojejunostomy for treatment of candy cane syndrome.