Surgical technique
postoperative pain, purulent, bleeding
BLEEDING, CAVITY, DECUBITUS, PNEUMOTHORAX
To avoid the risk of learning-associated bias, only surgeons with sufficient proficiency will be allowed to perform the randomized interventions. Surgeons involved in the trial as the responsible surgeons must have a personal operative experience of at least 20 RAMIEs. The standard technique and surgical instruments may vary in several aspects. The technique of the Dresden Center was described elsewhere [The abdominal part can be performed either laparoscopically or robotically.Intraoperative abdominal drains can be placed through the trocar sites in both groups.The patients are then placed in a left lateral decubitus position.The thoracic part is performed robotically in all cases. A circular, end-to-side, oesophagogastrostomy after gastric tube pull-up is performed over muscle-sparing mini-thoracotomy to reduce postoperative pain.Randomization is performed intraoperatively after the completion of the oesophagogastrostomy.Two 24 Charrière (Ch) chest drains are inserted through trocar sites robotic arms 1 and 3 (R1 and R3) at the end of the procedure in the control group; one 24 Ch chest drain is inserted through trocar site robotic arm 3 (R3) in the intervention group. The chest drains are immediately connected to the vacuum suction device to remove the remaining postoperative air in the right pleural cavity.Muscles at the trocar sites will be sutured with resorbable material (e.g. Vicryl 2–0 or equivalent) in a single stitch technique.Chest drains will be secured with a non-resorbable suture anchored to the skin. This should prevent excessive travel of the drain in and out of the chest wall. The suture will be looped several times around the drainage to achieve airtight wound closure after the drainage has been removed by knotting the suture. The skin incision can be closed on each side of the chest tube, usually with additional sutures if necessary. Further skin incisions will be closed with resorbable sutures (3–0 or equivalent) or staplers.The patient is turned into a supine position for extubation or transferal to the intensive care unit.In the intervention group, abdominal drains (if inserted) and chest drains (if air leak is < 100 ml/min, not increasing over 2 min, pneumothorax < 2.5 cm and no signs of active bleeding are present) are removed after chest X-ray 3 h after the end of surgery.In the control group, abdominal drains are removed after 3 h, and the two chest drains remain in place (suction − 15 mmHg). These drains are removed during further postoperative days according to a standard algorithm (see below).According to the standard algorithm, a chest X-ray is performed on POD1 and POD 3. The first chest tube can be removed at POD 3 if the daily secretion is below 450 ml per 24 h and if there is no evidence of an air leak (< 100 ml/min), pneumothorax > 2.5 cm, chyle leak, purulent secretion or bleeding followed by chest X-ray for control. On POD 6, chest drain 2 is removed if the daily secretion is below 450 ml per 24 h, followed by radiographic control. Deviations because of clinical conditions or logistic delays are allowed.