Surgical approach for esophageal cancer / 中华胃肠外科杂志

Due to the anatomical specificity of esophagus, esophagectomy can be carried out using different approaches, such as left transthoracic, right transthoracic and transhiatal approaches. Each surgical approach is associated with a different prognosis due to the complex anatomy. The left transthoracic approach is no longer the primary choice due to its limitations in providing adequate exposure, lymph node dissection, and resection. The right transthoracic approach is capable of achieving a larger number of dissected lymph nodes and is currently considered the preferred procedure for radical resection. Although the transhiatal approach is less invasive, it could be challenging to perform in a limited operating space and has not been widely adopted in clinical practice. Minimally invasive esophagectomy offers a wider range of surgical options for treating esophageal cancer. This paper reviews different approaches to esophagectomy.

Hotspots and prospects of esophageal cancer research in China / 中华胃肠外科杂志

Esophageal cancer is a malignant tumor with a high incidence in China. At pesent, advanced esophageal cancer patients are still frequently encountered. The primary treatment for resectable advanced esophageal cancer is surgery-based multimodality therapy, including preoperative neoadjuvant therapy, such as chemotherapy, chemoradiotherapy or chemotherapy plus immunotherapy, followed by radical esophagectomy with thoraco-abdominal two-field or cervico-thoraco-abdominal three-field lymphadenectomy via minimally invasive approach or thoracotomy. In addition, adjuvant chemotherapy, radiotherapy, or chemoradiotherapy, or immunotherapy may also be administered if suggested by postoperative pathological results. Although the treatment outcome of esophageal cancer has improved significantly in China, many clinical issues remain controversial. In this article, we summarize the current hotspots and important issues of esophageal cancer in China, including prevention and early diagnosis, treatment selection for early esophageal cancer, surgical approach selection, lymphadenectomy method, preoperative neoadjuvant therapy, postoperative adjuvant therapy, and nutritional support treatment.

Clinical analysis of inflatable video-assisted mediastinoscopic transhiatal esophagectomy combined with laparoscopy / 中华外科杂志

Objective: To examine the safety and effectiveness of inflatable video-assisted mediastinoscopic transhiatal esophagectomy (IVMTE). Methods: Totally 269 patients admitted to the Anhui Provincial Hospital of Anhui Medical University who underwent IVMTE (IVMTE group, n=47) or thoracoscopy combined with minimally invasive Mckeown esophageal cancer resection (MIME group, n=222) from September 2017 to December 2021 were analyzed retrospectively. There were 31 males and 16 females in IVMTE group, aged (68.6±7.5) years (range: 54 to 87 years). There were 159 males and 63 females in MIME group, aged (66.8±8.8) years (range: 42 to 93 years). A 1∶1 match was performed on both groups by propensity score matching, with 38 cases in each group. The intraoperative conditions and postoperative complication rates of the two groups were compared by t test, Wilcoxon rank, χ2 test, or Fisher exact probability method. Results: Patients in IVMTE group had less intraoperative bleeding ((96.0±39.2) ml vs. (123.8±49.3) ml, t=-2.627, P=0.011), shorter operation time ((239.1±47.3) minutes vs. (264.2±57.2) minutes, t=-2.086, P=0.040), and less drainage 3 days after surgery (85(89) ml vs. 675(573) ml, Z=-7.575, P<0.01) compared with that of MIME group. There were no statistically significant differences between the two groups in terms of drainage tube-belt time, postoperative hospital stay, and lymph node dissection stations and numbers (all P>0.05). The incidence of Clavien-Dindo grade 1 to 2 pulmonary infection (7.9%(3/38) vs. 31.6%(12/38), χ²=6.728, P=0.009), total complications (21.1%(8/38) vs. 47.4%(18/38), χ²=5.846, P=0.016) and total lung complications (13.2%(5/38) vs. 42.1%(16/38), χ²=7.962, P=0.005) in the IVMTE group were significantly lower. Conclusion: Inflatable video-assisted mediastinoscopic transhiatal esophagectomy combined with laparoscopic esophagectomy is safe and feasible, which can reach the same range of oncology as thoracoscopic surgery.

Síndrome de Boerhaave: manejo diagnóstico y terapéutico en el Hospital Regional de Talca / Boerhaave Syndrome: diagnostic and therapeutic management at the Hospital Regional de Talca

Introduction: Boerhaave syndrome is a spontaneous rupture of the esophageal wall caused by a sudden increase in intraesophageal pressure. It represents an incidence of approximately 15% of all esophageal perforations, which do not exceed 3.1 per 1 million inhabitants per year. Objectives: To communicate the clinical presentation and management of patients with this syndrome, as well as to reveal the different options available in our service for its treatment. Methods: Search in the statistical data of the regional Hospital of Talca for patients with a diagnosis of Boerhaave syndrome. Five patients were found. Information was obtained from their clinical records and is presented as a clinical case report with a descriptive analysis of their management. Results: Of the 5 clinical cases presented, a classic clinical presentation can be observed, most of the patients presented with vomiting that later evolved with thoracic and/or epigastric pain, associated with imaging studies suggesting esophageal perforation. Management was surgical in 100% of the cases, applying different techniques described in the literature. Discussion and Conclusion: Boerhaave syndrome is a medical-surgical emergency that requires timely management. In spite of the variety of management and the consequences of each one of them, all the patients had an evolution that allowed them to preserve their lives until nowadays. Keeping a high index of suspicion and choosing the best management will have an impact on morbidity and mortality.

Complicaciones de la esofagectomía por cáncer de esófago / Complications of Esophagectomy for Esophageal Cancer

Introducción: La esofagectomía es uno de los procedimientos con más alta morbilidad posoperatoria en cirugía oncológica digestiva. Objetivo: Describir las complicaciones relacionadas con la esofagectomía subtotal programada según variables de interés. Métodos: Se realizó un estudio descriptivo y transversal en los Servicios de Cirugía General de los hospitales "Saturnino Lora" y "Juan Bruno Zayas" de Santiago de Cuba, desde 2010 hasta 2019. La población estuvo conformada por 81 pacientes, de la cual se reclutó una muestra aleatoria de 68 enfermos sometidos a esofagectomía subtotal programada por cáncer de esófago. Fueron investigadas las siguientes variables: presencia de complicaciones posoperatorias y tipo de técnica quirúrgica utilizada. Además, se clasificaron en grados según Dindo Clavien. Resultados: Todos los enfermos fueron operados por técnica abierta mediante esofagectomía subtotal programada, donde la resección mediante la técnica de Ivor-Lewis se realizó en el 69,2 por ciento. Para todas las técnicas quirúrgicas empleadas predominó la atelectasia (39,7 por ciento) como complicación posquirúrgica, y entre las infecciosas la neumonía en 30 enfermos (44,1 por ciento), mientras que para las complicaciones quirúrgicas no infecciosas el neumotórax fue mayormente incidente, para el 25,0 por ciento. El mayor número de complicaciones se ubicó en el grado II de Dindo Clavien. Conclusiones: La presencia de complicaciones posquirúrgicas de la enfermedad es notable, en correspondencia a lo reflejado por la literatura médica. Existió relación significativa entre la presencia del hábito de fumar, de enfermedad pulmonar obstructiva crónica y la de toracotomía con algunas de las complicaciones encontradas(AU)

Introduction: Esophagectomy is one of the procedures with the highest postoperative morbidity in digestive cancer surgery. Objective: To describe the complications related to scheduled subtotal esophagectomy according to variables of interest. Methods: A descriptive and cross-sectional study was carried out in the General Surgery Services at Saturnino Lora and Juan Bruno Zayas hospitals in Santiago de Cuba, from 2010 to 2019. The population consisted of 81 patients, out of which a random sample of 68 patients undergoing elective subtotal esophagectomy for esophageal cancer was selected. The variables investigated were presence of postoperative complications and type of surgical technique used. In addition, they were classified in grades according to Clavien-Dindo. Results: All the patients were operated by open technique by programmed subtotal esophagectomy, the resection by the Ivor-Lewis technique was performed in 69.2 percent. For all the surgical techniques used, atelectasis (39.7 percent) prevailed as a postsurgical complication, and among the infectious complications, pneumonia prevailed in 30 patients (44.1 percent), while for non-infectious surgical complications, pneumothorax was mostly incidental for 25.0 percent. The highest number of complications was in Clavien-Dindo grade II. Conclusions: The presence of post-surgical complications of the disease is notable, corresponding to what is reflected in the medical literature. There was significant relationship between the presence of smoking, chronic obstructive pulmonary disease and thoracotomy with some of the complications found(AU)

Comparación de vía mediastinal posterior versus vía retroesternal para el reemplazo de esófago con ascenso gástrico parcial. Motivo de un cambio de estrategia / Comparison of posterior mediastinal versus retrosternal route for esophageal replacement with partial gastric pull-up. Rationale for a change in strategy

Introducción: existen dos rutas para realizar el reemplazo de esófago (RE), la retroesternal (RRE) y la mediastinal posterior (RMP). El objetivo del estudio es comparar los pacientes que recibieron un ascenso gástrico parcial empleando estas dos rutas. Material y métodos: Se revisaron las historias clínicas de 51 pacientes con ascenso gástrico parcial, en 27 años en el Hospital Garrahan. Se utilizó la vía RRE en 25 casos y la RMP en 26. Fueron comparados los datos epidemiológicos de los grupos y las variables para valorar la dificultad del acto quirúrgico, evolución inmediata y alejada. El estudio es comparativo, retro-prospectivo y longitudinal. Resultados: las características generales de los pacientes fueron similares. Los que recibieron el ascenso gástrico por vía RMP presentaron una menor incidencia de dehiscencia (p=0,017), de enfermedad por reflujo gastroesofágico (ERGE) (p=0,001) y de dumping (p=0,0001). No hubo diferencias estadísticamente significativas entre los dos grupos al comparar la duración del procedimiento, días de internación total y en Unidad de Cuidados Intensivos (UCI), días de permanencia en asistencia respiratoria mecánica (ARM), inicio de alimentación oral y estenosis de la anastomosis. Se observó una tendencia clínicamente relevante, que no alcanzó significancia estadística en las complicaciones intraquirúrgicas y número de dilataciones postoperatorias. No hubo necrosis del ascenso. Fallecieron 2 pacientes. Conclusiones: considerando la menor incidencia de dehiscencia, ERGE y dumping reemplazados por RMP, elegimos a ésta como nuestra primera opción para el reemplazo esofágico en la infancia (AU)

Introduction: The two routes for esophageal replacement (ER) are retrosternal (RRE) and posterior mediastinal (PMR). The aim of the study was to compare patients who received a partial gastric pull-up using either of these two routes. Material and methods: The clinical records of 51 patients who underwent partial gastric pull-up over 27 years at the Garrahan Hospital were reviewed. The RRE route was used in 25 and the RMP in 26 cases. The epidemiological data of the groups and the variables to evaluate the complexity of the surgical procedure, and shortand long-term outcome were compared. A comparative, retroprospective, and longitudinal study was conducted. Results: the general characteristics of the patients were similar. Those who underwent gastric pull-up via PMR had a lower incidence of dehiscence (p=0.017), gastroesophageal reflux disease (GERD) (p=0.001), and dumping (p=0.0001). No statistically significant differences were found between the two groups when comparing the duration of the procedure, days of total hospital and intensive care unit (ICU) stay, days on mechanical ventilation (MV), initiation of oral feeding and stenosis of the anastomosis. A clinically relevant trend, which did not reach statistical significance, was observed in intraoperative complications and number of postoperative dilatations. There was no necrosis of the pull-up. Two patients died. Conclusions: considering the lower incidence of dehiscence, GERD, and dumping associated with PMR, this was our first choice for esophageal replacement in infancy (AU)

Clinical value of routine contrast esophagram in the diagnosis of anastomotic leakage for three-incision esophagectomy with cervical anastomosis / 中华外科杂志

Objective: To examine the clinical value of routine contrast esophagram (RCE) for the diagnosis of anastomotic leakage (AL) after three-incision esophagectomy with cervical anastomosis. Methods: Clinical data of 1 022 patients with esophageal cancer who underwent McKeown three-incision esophagectomy with cervical anastomosis from January 2015 to December 2019 at Department of Minimally Invasive Esophageal Surgery, Tianjin Medical University Cancer Hospital and Institute were analyzed retrospectively. There were 876 males and 146 females, aging(M(IQR)) 48(16) years (range: 36 to 84 years). There were 253 patients (24.8%) with neoadjuvant therapy, and 817 patients (79.9%) with minimally invasive esophagectomy. According to the diagnosis and treatment habits of the attending surgeons, 333 patients were included in the RCE group, and RCE was performed on the 7th day postoperative, while 689 patients were included in the non-RCE group, and RCE was performed when the patients had suspicious symptoms. Taking clinical symptoms, RCE, CT, endoscopy and other methods as reference to the diagnosis of AL, the sensitivity and specificity were used to analyze and evaluate the efficacy of RCE for the diagnosis of AL. The data were compared by U test or χ² test between groups. Results: The incidence rate of AL after three-incision esophagectomy was 7.34% (75/1 022), including 30 cases in the RCE group and 45 cases in the non-RCE group (9.0%(30/333) vs. 6.5%(45/689), χ²=2.027, P=0.155). The diagnostic time of AL was 9(5) days postoperative (range: 4 to 30 days). Among them, 23 cases showed cervical leakages, 50 cases showed intro-thoracic leakages, and 2 cases both cervical and intro-thoracic leakages. The diagnostic time of patients with intro-thoracic leakages was longer than that of cervical leakages (10(4) days vs. 6(3) days, Z=-2.517, P=0.012). Among the 333 patients in the RCE group, 16 cases of RCE indicated leakages including 11 cases of true positive and 5 cases determined to be false positive, while 317 cases indicated no abnormalities including 19 cases developed leakages. The sensitivity and specificity of RCE to detect AL were 36.7%(11/30) and 98.3%(298/333), respectively. The Youden-index was 0.35, and the diagnostic accuracy was 92.8%(309/333). The positive and negative predictive value were 11/16 and 94.0%(298/317), respectively. Conclusions: Routine contrast esophagram after three-incision esophagectomy with cervical anastomosis has low sensitivity and high specificity in the diagnosis of AL. The diagnostic time of AL is the 9th day after surgery. It is necessary to prolong the observation time clinically, and combine RCE with CT, endoscopy and other inspection methods for diagnosis.

Caracterización de pacientes operados por cáncer del esófago en Cuba / Characterization of Patients Operated on for Esophageal Cancer in Cuba

Introducción: El cáncer en Cuba constituye un grave problema de salud debido a sus altas tasas de incidencia y mortalidad. Representa la primera causa de años de vida potencialmente perdidos y en el esófago es poco frecuente, su comportamiento es más agresivo y la supervivencia es baja. Objetivo: Caracterizar los pacientes operados por cáncer de esófago en Cuba en el periodo de 1988 al 2020. Métodos: Se realizó una investigación observacional clínico epidemiológica multicéntrica, no randomizada, en el periodo de 1988 al 2020. El universo y la muestra quedaron constituido por 595 enfermos de 9 centros hospitalarios. Algunas variables estudiadas incluyeron sexo, edad, variedad histológica, intervención quirúrgica realizada y presencia de comorbilidades asociadas. Resultados: Predominó el sexo masculino (66,1 por ciento), la edad promedio fue 62,8 años. La hipoproteinemia estuvo presente en el 46,1 por ciento. El 43,2 por ciento fueron fumadores y el 35,8 por ciento ingería bebidas alcohólicas. El epidermoide fue la variedad histológica más frecuente (64,6 por ciento). Las técnicas quirúrgicas más utilizadas fueron la de Ivor Lewis (68,4 por ciento) y la transhiatal (63,6 por ciento). Predominó la anastomosis en un plano, término-lateral, de localización torácica para el epidermoide (68,4 por ciento) y la cervical para el adenocarcinoma (71,4 por ciento), realizada de forma manual en cara posterior. Conclusiones: El cáncer de esófago predominó en hombres mayores de 55 años fumadores y con hipoproteinemia. Las técnicas quirúrgicas más utilizadas fueron la de Ivor Lewis y la transhiatal(AU)

Introduction: Cancer in Cuba is a serious health concern due to its high incidence and mortality rates. It represents the first cause of years of life potentially lost and. Esophageal cancer is rare, but its behavior is more aggressive and its survival rate is low. Objective: To characterize patients operated on for esophageal cancer in Cuba in the period from 1988 to 2020. Methods: A nonrandomized, multicenter, clinical-epidemiological and observational research was carried out in the period from 1988 to 2020. The universe and the sample consisted of 595 patients from nine hospital institutions. Some of the variables studied included sex, age, histological variety, surgical intervention performed, and presence of associated comorbidities. Results: There was a predominance of the male sex (66.1 percent). The average age was 62.8 years. Hypoproteinemia was present in 46.1 percent. 43.2 percent of patients were smokers and 35.8 percent drank alcoholic beverages. Epidermoid was the most frequent histological variety (64.6 percent). The most widely used surgical techniques were Ivor Lewis (68.4 percent) and transhiatal (63.6 percent) esophagectomies. There was a predominance of one-plane, termino-lateral anastomosis of thoracic location for epidermoid cases (68.4 percent) and the cervical one for adenocarcinoma cases (71.4 percent), performed manually on the posterior face. Conclusion: Esophageal cancer prevailed in men over 55 years of age, smokers and with hypoproteinemia. The most used surgical techniques were Ivor Lewis and transhiatal esophagectomies(AU)

Caracterización de la fuga anastomótica en operados por cáncer del esófago en Cuba / Characterization of Anastomotic Leak in Patients Operated on for Esophageal Cancer in Cuba

Introducción: La fuga anastomótica es la principal complicación de la cirugía del esófago, con altos índices de incidencia y mortalidad. Objetivo: Identificar los factores involucrados en la aparición de la fuga anastomótica en pacientes operados de cáncer de esófago en Cuba en el periodo de 1988 al 2020. Métodos: Se realizó una investigación observacional clínico epidemiológica multicéntrica, no randomizada, en el periodo de 1988 al 2020. El universo y la muestra quedaron constituidos por 2844 y 595 enfermos de 9 centros hospitalarios. Algunas variables estudiadas incluyeron sexo, edad, variedad histológica, intervención quirúrgica realizada, comorbilidades y su interrelación con la fuga anastomótica. Resultados: La fuga anastomótica predominó en el grupo de mayores de 55 años (17,8 por ciento), en el sexo femenino 65 (10,9 por ciento), en los no fumadores 79 (13,3 por ciento) y en los que no ingerían bebidas alcohólicas con 100 pacientes (16,8 por ciento). En enfermos con niveles de albúmina normales 98 (16,5 por ciento), con proteínas bajas 94 (15,7por ciento) y cifras normales de hemoglobina 105 (17,6 por ciento). En la variedad histológica adenocarcinoma 65 (10,9 por ciento), la técnica quirúrgica transhiatal 69 (11,6 por ciento), realizada de forma manual 123 (20,7 por ciento), de localización cervical 111 (18,6 por ciento), en cara anterior 57 (9,6 por ciento), en un plano 78 (13,1 por ciento), en la variante término-lateral 120 (20,2 por ciento). Conclusiones: La fuga anastomótica predominó en mujeres mayores de 50 años, con adenocarcinoma, operadas con técnicas transhiatales, manuales, en un plano, termino-laterales, en cara anterior y con hipoproteinemia(AU)

Introduction: Anastomotic leak is the main complication of esophageal surgery, with high incidence and mortality rates. Objective: To identify the factors involved in the appearance of anastomotic leak in patients operated on for esophageal cancer in Cuba in the period from 1988 to 2020. Methods: A nonrandomized, multicenter, clinical-epidemiological and observational investigation was carried out in the period from 1988 to 2020. The universe and the sample consisted of 2844 and 595 patients from nine hospital centers. Some of the variables studied included sex, age, histological variety, surgical intervention performed, comorbidities, and their interrelation with anastomotic leak. Results: Anastomotic leak prevailed in the group aged over 55 years (17.8 percent), in the female sex (65; 10.9 percent)), in nonsmokers (79; 13.3 percent)) and in those who did not ingest alcoholic beverages (100, 16.8; as well as in patients with normal albumin levels (98; 16.5), with low proteins (94; 15.7 percent) and with normal levels of hemoglobin (105; 17.6 percent). In the histological variety of adenocarcinoma (65; 10.9 percent), there was a predominance of the transhiatal surgical technique (69; 11.6 percent), performed manually (123; 20.7 percent), of cervical location (111; 18.6 percent), in the anterior face (57; 9.6 percent), in one plane (78; 13.1 percent), and in the termino-lateral variant (120; 20.2 percent). Conclusions: Anastomotic leak prevailed in women aged over 50 years, with adenocarcinoma, operated on through transhiatal techniques, manually, in one plane, using the termino-lateral variant, in the anterior face and with hypoproteinemia(AU)

Esofagectomía minimamente invasiva / Minimally invasive esophagectomy

INTRODUCTION: Minimally invasive esophagectomy aims to reduce complications compared to open esophagectomy. In this report of the first patient undergoing this procedure at Hospital Pasteur, we highlight the importance of multidisciplinary management, and the main anesthesiological objectives. OBJECTIVE: To present the case report highlighting the anesthetic management, together with the bibliographic review carried out in order to update the anesthetic action protocols, with the main objective of reducing the appearance of perioperative complications. MATERIAL AND METHOD: Bibliographic search in PubMed bibliographic databases. Initially, 67 articles were obtained, selecting 20 considered relevant by the authors. CLINICAL CASE: It was a 46-year-old patient coordinated for esophagectomy for squamous neoplasm. Rapid sequence induction, selective endobronchial intubation and anesthetic maintenance with Isoflurane and epidural analgesia were performed. The hydroelectric replacement was restricti- ve. The surgical technique was performed in 3 stages: thoracic time by thoracoscopy; a second laparoscopic abdominal stage and a third stage for left cervicotomy. Extubation was carried out in the operating room with transfer to the ICU where she remained for 6 days to manage analgesia and due to the presence of a mild infectious complication, with good subsequent evolution. CONCLUSION: The use of perioperative multidisciplinary management protocols has fundamental importance as a strategy aimed at reducing morbidity and mortality. Advances in surgical technique added to anesthetic management constitute strategies that aim to reduce perioperative complications.

INTRODUCCIÓN: La esofagectomía minimamente invasiva tiene como objetivo disminuir las complicaciones en comparación con la esofagectomía abierta. En este reporte del primer paciente sometido a este procedimiento en el Hospital Pasteur destacamos la importancia del manejo multidisciplinario, y los principales objetivos anestesiológicos. OBJETIVO: Presentar el reporte de caso destacando el manejo anestésico, junto con la revisión bibliográfica realizada en vistas a la actualización de protocolos de actuación anestésica, con objetivo principal de disminuir la aparición de complicaciones perioperatorias. MATERIAL Y MÉTODO: Búsqueda bibliográfica en las bases bibliográficas PubMed. Inicialmente se obtuvieron 67 artículos, seleccionando 20 considerados relevantes por los autores. CASO CLÍNICO: Se trató de una paciente de 46 años coordinada para esofagectomía por neoplasma epidermoide. Se realizó inducción en secuencia rápida, intubación endobronquial selectiva y mantenimiento anestésico con Isofluorano y analgesia peridural. La reposición hidroelectrolítica fue restrictiva. La técnica quirúrgica se realizó en 3 tiempos: tiempo torácico por toracoscopía; un segundo tiempo abdominal laparoscópico y un tercer tiempo para cervicotomía izquierda. La extubación se realizó en sala de operaciones con traslado a CTI donde permaneció por 6 días para manejo de la analgesia y por presencia de complicación infecciosa leve, con buena evolución posterior. CONCLUSIÓN: Resulta de fundamental importancia el uso de protocolos de manejo multidisciplinario perioperatorio como estrategia destinada a disminuir la morbimortalidad. Los avances en cuanto a la técnica quirúrgica sumado al manejo anestésico constituyen estrategias que apuntan a disminuir las complicaciones perioperatorias.

Type 2 myocardial infarction resulted from the left thoracic stomach

Abstract The universal definition of myocardial infarction (MI) provides five subtypes of acute myocardial infarction (AMI). We present an interesting case of a type 2 myocardial infarction caused by the dilation of the left thoracic stomach.

Lymphoparietal index in esophageal cancer is stronger than tnm staging in long-term survival prognosis in a latin-american country / índice linfoparietal no câncer esofágico é mais forte do que tnm no prognóstico de sobrevivência em longo prazo em um país latinoamericano

ABSTRACT Background: The identification of prognostic factors of esophageal cancer has allowed to predict the evolution of patients. Aim: Assess different prognostic factors of long-term survival of esophageal cancer and evaluate a new prognostic factor of long-term survival called lymphoparietal index (N+/T). Method: Prospective study of the Universidad de Chile Clinical Hospital, between January 2004 and December 2013. Included all esophageal cancer surgeries with curative intent and cervical anastomosis. Exclusion criteria included: stage 4 cancers, R1 resections, palliative procedures and emergency surgeries. Results: Fifty-eight patients were included, 62.1% were men, the average age was 63.3 years. A total of 48.3% were squamous, 88% were advanced cancers, the average lymph node harvest was 17.1. Post-operative surgical morbidity was 75%, with a 17.2% of reoperations and 3.4% of mortality. The average overall survival was 41.3 months, the 3-year survival was 31%. Multivariate analysis of the prognostic factors showed that significant variables were anterior mediastinal ascent (p=0.01, OR: 6.7 [1.43-31.6]), anastomotic fistula (p=0.03, OR: 0.21 [0.05-0.87]), N classification (p=0.02, OR: 3.8 [1.16-12.73]), TNM stage (p=0.04, OR: 2.8 [1.01-9.26]), and lymphoparietal index (p=0.04, RR: 3.9 [1.01-15.17]. The ROC curves of lymphoparietal index, N classification and TNM stage have areas under the curve of 0.71, 0.63 and 0.64 respectively, with significant statistical difference (p=0.01). Conclusion: The independent prognostic factors of long-term survival in esophageal cancer are anterior mediastinal ascent, anastomotic fistula, N classification, TNM stage and lymphoparietal index. In esophageal cancer the new lymphoparietal index is stronger than TNM stage in long-term survival prognosis.

RESUMO Racional: A identificação de fatores prognósticos do câncer de esôfago permitiu prever a evolução dos pacientes. Objetivo: Avaliar diferentes fatores prognósticos da sobrevida em longo prazo do câncer de esôfago e avaliar um novo fator prognóstico da sobrevida em longo prazo chamado índice linfoparietal (N+/T). Método: Estudo prospectivo do Hospital Clínico da Universidade do Chile, entre janeiro de 2004 e dezembro de 2013. Incluiu todas as operações de câncer de esôfago com intenção curativa e anastomose cervical. Os critérios de exclusão incluíram: câncer em estágio 4, ressecções R1, procedimentos paliativos e operações de emergência. Resultados: Cinquenta e oito pacientes foram incluídos, 62,1% eram homens, a idade média foi de 63,3 anos. Um total de 48,3% eram escamosos, 88% eram cânceres avançados, a colheita média de linfonodos foi de 17,1. A morbidade cirúrgica pós-operatória foi de 75%, com 17,2% de reoperações e 3,4% de mortalidade. A sobrevida global média foi de 41,3 meses, a sobrevida em três anos foi de 31%. A análise multivariada dos fatores prognósticos mostrou que variáveis significativas foram elevação pelo mediastinal anterior (p=0,01, OR: 6,7 [1,43-31,6]), fístula anastomótica (p=0,03, OR: 0,21 [0,05-0,87]), classificação N (p=0,02, OR: 3,8 [1,16-12,73]), estágio TNM (p=0,04, OR: 2,8 [1,01-9,26]) e índice linfoparietal (p=0,04, RR: 3,9 [1,01-15,17]. As curvas ROC do índice linfoparietal, classificação N e estádio TNM apresentam áreas abaixo da curva de 0,71, 0,63 e 0,64, respectivamente, com diferença estatística significativa (p=0,01). Conclusão: Os fatores prognósticos independentes de sobrevida em longo prazo no câncer de esôfago são a elevação mediastinal anterior, fístula anastomótica, classificação N, estágio TNM e índice linfoparietal. No câncer de esôfago, o novo índice linfoparietal é mais forte que o estágio TNM no prognóstico de sobrevida em longo prazo.

Surgical treatment of relapsed megaesophagus / Tratamento cirúrgico do megaesôfago recidivado

ABSTRACT Objective: to analyze the surgical treatment of patients with recurrent megaesophagus followed at the esophageal-stomach-duodenal outpatient clinic of the Hospital de Clínicas - UNICAMP. Methods: a retrospective study, from 2011 to 2017, with 26 patients with Chagas or idiopathic megaesophagus, surgically treated, and who recurred with dysphagia. Clinical, endoscopic and radiographic aspects were assessed and correlated with the performed surgical procedures. Results: 50% had dysphagia for liquids, 69% regurgitation, 65.3% heartburn, 69.2% weight loss and 69.2% had Chagas disease. In addition, 38.4% had megaesophagus stage 1 and 2 and 61.5% stage 3 and 4. Regarding the reoperations, 53% of them underwent Heller-Pinotti surgery by laparoscopy, Serra-Dória in 30.7% and esophageal mucosectomy in 7.9%. In 72% of the reoperations there were no postoperative complications, and 80% of the patients had a good outcome, with reduction or elimination of dysphagia. Among the reoperated patients undergoing the laparoscopic Heller-Pinotti technique, three reported little improvement of dysphagia in the postoperative period and among those who underwent Serra-Dória surgery, 100% had no dysphagia. It was observed that, when the time between the first procedure and the reoperation was longer, the better the surgical result was, with statistical significant decreased dysphagia (p=0.0013, p<0.05). Conclusions: there was a preference to perform laparoscopic re-miotomy and, as a second option, Serra-Dória surgery, for patients with recurrent megaesophagus. Esophagectomy or esophageal mucosectomy were reserved for more severe patients.

RESUMO Objetivo: analisar o tratamento cirúrgico dos pacientes com megaesôfago recidivado acompanhados no ambulatório de cirurgia de esôfago-estômago-duodeno do Hospital de Clínicas da UNICAMP. Métodos: estudo restrospectivo no período de 2011 a 2017, com 26 pacientes portadores de megaesôfago chagásico ou idiopático, tratados cirurgicamente e que evoluíram com recidiva da disfagia. Foram avaliados aspectos clínicos, endoscópicos e radiográficos, sendo correlacionados com os procedimentos cirúrgicos realizados. Resultados: 50% apresentava disfagia para líquidos, 69% regurgitação, 65,3% pirose, 69,2% perda de peso e 69,2% era chagásico. Além disso, 38,4% apresentavam megaesôfago estágio 1 e 2 e 61,5% estágio 3 e 4. Quanto às reoperações, em 53% foi realizada a cirurgia de Heller-Pinotti videolaparoscópica, seguida de Serra-Dória em 30,7% e mucosectomia esofágica em 7,9%. Em 72% das reoperações não houve complicações pós-operatórias e 80% tiveram evolução satisfatória com redução ou ausência da disfagia. Dentre os pacientes reoperados pela técnica de Heller-Pinotti videolaparoscópica, três referiram pouca melhora da disfagia no pós-operatório. Dentre os pacientes submetidos à cirurgia de Serra-Dória, 100% tiveram evolução satisfatória da disfagia. Foi observado nos pacientes com o tempo entre a primeira cirurgia e a reoperação mais longo, um melhor resultado cirúrgico com diminuição da disfagia, com relevância estatística (p=0,0013, p<0,05). Conclusão: houve preferência nas reoperações de megaesôfago pela realização de re-miotomia por videolaparoscopia e, como segunda opção, a cirurgia de Serra-Dória. A esofagectomia ou mucosectomia esofágica foram reservadas para os casos mais avançados.

Erector spinae plane block as a multiple catheter technique for open esophagectomy: a case report / Bloqueio do plano do eretor da espinha com técnica de múltiplos cateteres para esofagectomia aberta: relato de caso

Abstract Background and objective: Erector spinae plane block is a valid technique to provide simultaneously analgesia for combined thoracic and abdominal surgery. Case report: A patient underwent open esophagectomy followed by reconstructive esophagogastroplasty but refused thoracic epidural analgesia; a multi-modal analgesia with a multiple erector spinae plane block was then planned. Three erector spinae plane catheters (T5 and T10 on the right side and T9 on the left side) for continuous analgesia were placed before surgery. During the first 48 h pain was never reported in the thoracic area but the patient reported multiple times to feel a pain well localized in epigastrium, but never localized in any other abdominal quadrant. Discussion: Erector spinae plane block is a valid technique to provide analgesia simultaneously for combined thoracic and abdominal surgery and could be a valid alternative strategy if the use of epidural analgesia is contraindicated.

Resumo Justificativa e objetivo: O bloqueio do plano do eretor da espinha é uma técnica válida para fornecer analgesia em cirurgias combinadas, torácica e abdominal, de modo simultâneo. Relato de caso: Um paciente foi submetido à esofagectomia aberta seguida de esofagogastroplastia reconstrutiva, mas recusou analgesia peridural torácica; uma analgesia multimodal com o bloqueio dos múltiplos segmentos do eretor da espinha foi então planejada. Três cateteres foram colocados no plano do eretor da espinha (T5 e T10 no lado direito e T9 no lado esquerdo) para analgesia contínua antes da cirurgia. Durante as primeiras 48 horas, não houve queixa de dor na área torácica, mas várias vezes o paciente relatou sentir uma dor bem localizada no epigástrio, mas nunca localizada em qualquer outro quadrante abdominal. Discussão: O bloqueio do plano do eretor da espinha é uma técnica válida para fornecer analgesia de modo simultâneo em cirurgias combinadas - torácica e abdominal - e pode ser uma estratégia opcional também válida nos casos em que o uso de analgesia peridural for contraindicado.

Transhiatal esophagectomy is not associated with poor quality lymphadenectomy / Esofagectomia trans-hiatal não está associada com linfadenectomia de baixa qualidade

ABSTRACT Background: Esophageal cancer neoadjuvant therapy followed by surgery increases the likelihood of treatment success. Aim: To evaluate variables that can influence the number of retrieved lymph nodes, the number of retrieved metastatic lymph nodes and lymphnodal recurrence in esophagectomy after neoadjuvant chemoradiotherapy. Methods: Patients of a single institute were evaluated after completion of trimodal therapy. Univariate and multivariate analyses were performed to evaluate variables that can influence in the number of retrieved lymph nodes and retrieved metastatic lymph nodes. Results: One hundred and forty-nine patients were included. Thoracoscopy access was considered an independent factor for the number of lymph nodes retrieved, but was neither related to the number of positive lymph nodes retrieved nor to lymphnodal recurrence. Pathological complete response on the primary tumor and male were independent variables associated with the number of positive lymph node retrieved. Pathological complete response on the primary tumor site did not statistically influence the likelihood of a lower number of lymph nodes retrieved. Conclusion: Patients submitted to esophagectomy after neoadjuvant chemoradiotherapy, thoracoscopic access is more accurate for pathological staging, even in a complete pathological response. With a proper patient selection, transhiatal surgery may preserve the quality of lymphadenectomy of the positive lymph nodes.

RESUMO Racional: No câncer esofágico a terapia neoadjuvante seguida de procedimento cirúrgico aumenta a probabilidade de sucesso do tratamento. Objetivo: Avaliar variáveis que podem influenciar o número de linfonodos recuperados, o número de linfonodos metastáticos recuperados e a recorrência linfonodal na esofagectomia após quimiorradioterapia neoadjuvante. Métodos: Os pacientes incluídos foram aqueles que terminaram terapia trimodal. Análises univariadas e multivariadas foram realizadas para avaliar as variáveis que pudessem influenciar no número de linfonodos recuperados e nos metastáticos recuperados. Resultados: Cento e quarenta e nove pacientes foram incluídos. O acesso por toracoscopia foi considerado fator independente para o número de linfonodos recuperados, mas não teve relação com o número de linfonodos positivos recuperados, nem com recorrência linfonodal. Resposta patológica completa no tumor primário e homens foram variáveis independentes associadas ao número de linfonodos positivos recuperados. A resposta patológica completa do tumor primário não acarretou em número menor de linfonodos recuperados. Conclusão: Em pacientes submetidos à esofagectomia após quimiorradioterapia neoadjuvante o acesso toracoscópico é mais preciso para estadiamento patológico, mesmo em resposta patológica completa. Com seleção adequada a esofagectomia trans-hiatal pode preservar a qualidade da linfadenectomia dos linfonodos positivos.

Primera experiencia de cirugía laparoscópica en cáncer del tracto digestivo superior / First experience of minimally invasive surgery in the upper digestive tract

Introducción: El cáncer del tracto digestivo superior es responsable de gran parte de las muertes a nivel mundial y es ampliamente asociada a los hábitos en el estilo de vida así como factores genéticos. Los abordajes mínimamente invasivos para su tratamiento son aun controversiales con curvas de aprendizaje empinadas, tiempos quirúrgicos prolongados pero con evidentes ventajas en sangrado, manejo del dolor, retorno a actividades y menores complicaciones relacionadas con la incisión. Objetivo: Describir nuestra primera experiencia en el tratamiento quirúrgico mínimamente invasivo en el Instituto Nacional de Cancerología del cáncer de tracto digestivo superior. Materiales y métodos: Revisión prospectiva de una base datos retrospectiva. Análisis descriptivo de pacientes en quienes se realizaron procedimientos mínimamente invasivos en el Instituto Nacional de Cancerología de Bogotá, Colombia, para el tratamiento del cáncer de tracto digestivo superior. Resultados: En 44 pacientes se realizo cirugía mínimamente invasiva para el tratamiento del cáncer del tracto digestivo superior. En 16 pacientes (36,4%) se realizó resección en cuña gástrica, en 13 pacientes (29,6%) gastrectomía total, en 9 pacientes (24,4%) gastrectomía subtotal y en 6 pacientes (13,6%) esofagectomía. No se presentaron complicaciones durante la cirugía, en 8 pacientes se presentaron complicaciones posoperatorias (18,2%). La estancia hospitalaria tuvo una mediana de 7,5 días. Conclusiones: La cirugía mínimamente invasiva para el tratamiento del cáncer del tracto digestivo superior en una técnica segura, factible, con tiempos quirúrgicos aceptables y sangrados mínimos en pacientes con y sin comorbilidades.

Background: Upper gastrointestinal cancer is responsible of important numbers deaths worldwide and is widely associated with lifestyle and genetic factors. Minimally invasive surgery treatment is still controversial wit difficult learning curves, longer operative times but clear advantages in bleeding, postoperative pain, return to activities and less complications associated with de incision. Objective: Describe our first experience in minimally invasive surgery of the upper alimentary tract for cancer at the Instituto Nacional de Cancerología. Materials and methods: Retrospective review of a prospectively set database. We describe the outcomes of patients in whom minimally invasive procedures, for the treatment of cancer of the upper alimentary tract was performed, at the InstitutoNacional de Cancerología in Bogotá, Colombia. Results: In 44 patients video assisted procedures were performed. In 16 of the 44 patients (36,4%) was wedged gastric resection, in 13 patients (29,6%) total gastrectomy, in 9 patients (24,4%) subtotal gastrectomy and in 6 patients (13,6%) and esophagectomy was performed. No intraoperative complications were present. Eight patients had any postoperative complication (18,2%). The average hospital stay was 7,5 days. Conclusions: Minimally invasive surgery for treatment of the upper gastrointestinal cancer is a safety and factible procedure with acceptable operative times and minimally bleeding in patients with or without co morbidities.

Preservation of the vagus nerves in subtotal esophagectomy without thoracotomy

Abstract Purpose: To evaluate the outcome of transhiatal esophagectomy without thoracotomy and with preservation of the vagal trunks for the treatment of advanced megaesophagus. Methods: Between March 2006 and September 2017, it was performed 136 transhiatal esophagectomies without thoracotomy by laparoscopy, with preservation of the vagus nerves. All patients were evaluated pre and postoperatively for respiratory and nutritional aspects Post operatively, some surgical aspects were evaluated like radiology and endoscopy of the digestive tract. Results: Follow-up for 7 months to 12 years by clinical, radiologic, endoscopic and pH monitoring revealed satisfactory and encouraging outcomes of the procedure. Conclusion: The laparoscopic transhiatal esophagectomy is a feasible and safe technique with good postoperative outcomes.

Combination of preoperative pulmonary and nutritional preparation for esophagectomy

Abstract Purpose: To compare pulmonary and nutritional parameters before and after inspiratory muscle training (IMT) and enteral feeding support in patients with esophageal disease undergoing preoperative outpatient follow-up. Methods: Thirty patients with a mean age of 55.83 years, 16 men and 14 women, were included. Pulmonary assessment consisted of the measurement of MIP, MEP, and spirometry. Anthropometric measurements and laboratory tests were performed for nutritional assessment. After preoperative evaluation, inspiratory muscle training and enteral nutrition support were started. A p<0.05 was considered statistically significant. Results: After an outpatient follow-up period of 4 weeks, a significant increase in MIP (-62.20 ± 25.78 to -81.53 ± 23.09), MEP (73.4 ± 31.95 to 90.33 ± 28.39), and FVC (94.86 ± 16.77 to 98.56 ± 17.44) was observed. Regarding the anthropometric variables, a significant increase was also observed in BMI (20.18 ± 5.04 to 20.40 ± 4.69), arm circumference (23.38 ± 3.28 to 25.08 ± 4.55), arm muscle circumference (21.48 ± 3.00 to 22.07 ± 3.36), and triceps skinfold thickness (5.62 ± 2.68 to 8.33 ± 6.59). Conclusion: Pulmonary and nutritional preparation can improve respiratory muscle strength, FVC and anthropometric parameters. However, further studies are needed to confirm the effectiveness of this preoperative preparation.

Minimally invasive laparoscopic esophagectomy vs. transhiatal open esophagectomy in achalasia: a randomized study / Esofagectomia minimamente invasiva laparoscópica vs. esofagectomia trans-hiatal aberta no megaesôfago avançado: estudo randomizado

ABSTRACT Background: Open and laparoscopic trans-hiatal esophagectomy has been successfully performed in the treatment of megaesophagus. However, there are no randomized studies to differentiate them in their results. Aim: To compare the results of minimally invasive laparoscopic esophagectomy (EMIL) vs. open trans-hiatal esophagectomy (ETHA) in advanced megaesophagus. Method: A total of 30 patients were randomized, 15 of them in each group - EMIL and ETHA. The studied variables were dysphagia score before and after the operation at 24-months follow-up; pain score in the immediate postoperative period and at hospital discharge; complications of the procedure, comparing each group. Were also studied: surgical time in minutes, transfusion of blood products, length of hospital stay, mortality and follow-up time. Results: ETHA group comprised eight men and seven women; in the EMIL group, four women and 11 men. The median age in the ETHA group was 47.2 (29-68) years, and in the EMIL group of 44.13 (20-67) years. Mean follow-up time was 33 months, with one death in each group, both by fatal aspiration. There was no statistically significant difference between the EMIL vs. ETHA scores for dysphagia, pain and in-hospital complications. The same was true for surgical time, transfusion of blood products and hospital stay. Conclusion: There was no difference between EMIL and ETHA in all the studied variables, thus allowing them to be considered equivalent.

RESUMO Racional: A esofagectomia trans-hiatal aberta e laparoscópica têm sido realizadas com êxito no tratamento do megaesôfago. Porém, não há estudos randomizados para diferenciá-las em seus resultados. Objetivo: Comparar os resultados da esofagectomia minimamente invasiva laparoscópica (EMIL) vs. esofagectomia trans-hiatal aberta (ETHA) no megaesôfago avançado. Método: Foram randomizados 30 pacientes, sendo alocados 15 em cada grupo - EMIL e ETHA. As variáveis estudadas foram escore de disfagia antes e após a operação no seguimento de 24 meses; escore de dor no pós-operatório imediato e na alta hospitalar; complicações do procedimento, comparando cada grupo. Foram também estudados: tempo cirúrgico em minutos, transfusão de hemoderivados, tempo de permanência hospitalar, mortalidade e tempo de seguimento. Resultados: Foram no grupo ETHA, oito homens e sete mulheres; no grupo EMIL, quatro mulheres e 11 homens. Faixa etária mediana no grupo ETHA foi de 47,2 (29-68) anos, e no grupo EMIL de 44,13 (20-67) anos. Tempo de seguimento médio foi de 33 meses, com um óbito em cada grupo, ambos por aspiração fatal. Não houve diferença estatística significativa, entre os grupos EMIL vs. ETHA quanto aos escores de disfagia, dor e complicações intra-hospitalares. O mesmo se verificou, quanto ao tempo cirúrgico, transfusão de hemoderivados e estadia hospitalar. Conclusão: Não houve diferença entre a EMIL e a ETHA em todas as variáveis estudadas, permitindo assim considerá-las equivalentes.