Prevention and treatment of postoperative complications of esophageal cancer / 中华胃肠外科杂志

Surgery is the primary treatment for esophageal cancer, but the postoperative complication rate remains high. Therefore, it is important to prevent and manage postoperative complications to improve prognosis. Common perioperative complications of esophageal cancer include anastomotic leakage, gastrointestinal tracheal fistula, chylothorax, and recurrent laryngeal nerve injury. Respiratory and circulatory system complications, such as pulmonary infection, are also quite common. These surgery-related complications are independent risk factors for cardiopulmonary complications. Complications, such as long-term anastomotic stenosis, gastroesophageal reflux, and malnutrition are also common after esophageal cancer surgery. By effectively reducing postoperative complications, the morbidity and mortality of patients can be reduced, and their quality of life can be improved.

Advantages and disadvantages of transthoracic approach for adenocarcinoma of the esophagogastric junction / 中华胃肠外科杂志

Adenocarcinoma of the esophaogastric junction (AEG) has anatomical characteristics of spanning two organs and anatomical sites. Thoracic surgery and gastrointestinal surgery aim at the safe resection margin of esophagus, the scope of lower mediastinal lymph node dissection and whether transthoracic surgery will increase complications. However, there are great differences and controversies in the surgical approach, surgical method, lymph node dissection and extent of resection of AEG. For Siewert II AEG via abdominal mediastinal approach, due to the limitation of exposure and the difficulty of operation, it is difficult to acquire a satisfactory proximal resection margin, and very difficult to dissect the inferior mediastinal lymph nodes. The transthoracic approach can provide adequate exposure, reduce the difficulty of operation, obtain satisfactory resection margin of esophagus and allow lower mediastinal lymph node dissection, which may bring better prognosis. Although transthoracic approach may increase the incidence of pulmonary infection, the standard development of thoracoscopic technology will overcome the disadvantage of transthoracic approach for Siewert II AEG.

Evaluation of safety of video-assisted thoracoscopic esophagectomy for esophageal carcinoma / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To explore the safety of video-assisted thoracoscopic esophagectomy for esophageal carcinoma.</p><p><b>METHODS</b>From January 2005 to March 2012, 260 patients with esophageal carcinoma received thoracoscopic esophagectomy (TE group), while 322 patients underwent conventional open esophagectomy (OE group). Operative procedures, perioperative complications, reoperation, readmission to intensive care unit (ICU), and perioperative mortality were compared between the two groups.</p><p><b>RESULTS</b>Compared with OE group, TE group possessed less thoracic operative time [(105±30) min vs. (112±41) min, P=0.000], less blood loss [(95±48) ml vs. (107±44) ml, P=0.002], shorter postoperative hospital stay [(14.3±7.5) d vs. (16.9±9.5) d, P=0.000] and more lymph node harvest from thorax [(13.5±5.0) vs. (11.6±4.7), P=0.000]. The total perioperative complication rate was lower in TE group than that of OE group (34.6% vs. 45.0%, P=0.011), as well as perioperative mortality (0.8% vs. 3.4%, P=0.032). Lower rate of readmission to ICU (5.4% vs. 10.6%, P=0.024) was found in the TE group as compared to the OE group, while the reoperation rate was comparable (1.5% vs. 2.5%, P=0.425).</p><p><b>CONCLUSION</b>Thoracoscopic esophagectomy is advantageous than open procedure in terms of surgical safety.</p>

Feasibility and safety of radical mediastinal lymphadenectomy in thoracoscopic esophagectomy for esophageal cancer / 中华肿瘤杂志

<p><b>OBJECTIVE</b>To explore the feasibility and safety of radical mediastinal lymphadenectomy in thoracoscopic esophagectomy for esophageal cancer.</p><p><b>METHODS</b>We retrospectively analyzed the clinical data of a cohort of 147 patients with esophageal cancer who underwent thoracoscopic esophagectomy. Seventy-one patients received traditional lymphadenectomy for the periesophageal and subcarinal lymph nodes (traditional dissection group), while 76 patients received radical lymph node dissection for the bilateral recurrent laryngeal nerve lymphatic chains as well as the periesophageal and subcarinal nodes (radical dissection group). The number of retrieved lymph nodes, incidence of node metastasis, the operation time, estimated blood loss, complications, morbidity and mortality were compared between the two groups.</p><p><b>RESULTS</b>Thoracoscopic esophagectomy was completed in all patients with no conversion to thoracotomy. There were no significant differences of operational time and blood loss between the two groups [(89 ± 32) min versus (99 ± 32) min, P = 0.064; (152 ± 108) ml versus (107 ± 82) ml, P = 0.261]. In all patients, the total and average number of retrieved mediastinal nodes were 1644 and 11.2 ± 5.9/case, and the incidence of metastatic lymph nodes was 24.5%. The total and average number of retrieved mediastinal nodes were 999 and 13.6 ± 6.4/case in the radical dissection group, significantly higher than that in the traditional dissection group (645 and 9.1 ± 4.4/case) (P < 0.001). The average number of retrieved nodes and node metastasis rate in the radical dissection group were significantly higher than in the traditional dissection group (13.1 ± 6.4 versus 9.1 ± 4.4, P < 0.001; 35.5% versus 12.7%, P < 0.05). In the total group of 147 cases, the metastasis rates of periesophageal, subcarinal nodes and nodes along the recurrent laryngeal nerve lymphatic chains were 19.7%, 3.4% and 17.1%, respectively. There was thoracic lymph node metastasis in 27 cases with a metastasis rate of 35.5% in the radical dissection group, significantly higher than that in 9 cases and 12.7% in the traditional dissection group (P > 0.001). In the 1644 retrieved thoracic lymph nodes, there were 90 positive metastatic lymph nodes (metastasis ratio 5.5%). Among the 1644 lymph nodes, the metastasis ratio of periesophageal lymph nodes was 6.5%, subcarinal lymph modes 2.4% and the recurrent laryngeal nerve chain lymph nodes 7.5%. Among the 147 cases, complications occurred in 60 cases, with an overall morbidity rate of 40.8%. There were no significant differences of the incidence rates of overall complications, pulmonary complications and recurrent laryngeal nerve injury between the two groups (P > 0.05).</p><p><b>CONCLUSION</b>Thoracoscopic esophagectomy with radical mediastinal lymphadenectomy is technically Safe and feasible.</p>

Comparison of thoracoscopic esophagectomy in decubitus position with prone position / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To compare the safety and efficacy between two different surgical approaches for thoracoscopic esophagectomy including left lateral decubitus position and prone position.</p><p><b>METHODS</b>From January 2008 to December 2009, 88 patients who underwent thoracoscopic esophagectomy were enrolled in this study. Among them, 52 patients were placed in decubitus position and 36 patients were placed in prone position.</p><p><b>RESULTS</b>No conversion to thoracotomy occurred in either group. The operative time was shorter in the prone group than that in the decubitus group (70 ± 20 min vs. 82 ± 17 min, P<0.01). Blood loss during operation was less in the prone group(100 ± 52 ml vs. 139 ± 54 ml, P<0.01). More lymph nodes were harvested from chest in the prone group(12.2 ± 6.2 vs. 8.6 ± 4.3, P<0.01). There was no significant difference between the two groups in morbidity.</p><p><b>CONCLUSION</b>Thoracoscopic esophagectomy in prone position is associated with better exposure of surgical filed, shorter operative time, less blood loss, and more extensive lymph node dissection as compared to decubitus position.</p>

Comparison of retrosternal and posterior mediastinal gastric tube reconstruction after three-phase esophagectomy / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To compare the outcome between retrosternal and posterior mediastinal gastric tube reconstruction after three-phase esophagectomy.</p><p><b>METHODS</b>A total of 107 patients who underwent three-phase esophagectomy between July 2005 and May 2009 were enrolled in this study.</p><p><b>RESULTS</b>There were 78 men and 29 women. Median age was 62.1 years. The tumor located at upper segment in 20 cases, middle segment in 69 cases and lower segment in 18 cases. There were 55 patients in the posterior mediastinal group and 52 in the retrosternal group. There were no significant differences between two groups in operation time, intraoperative blood loss, duration of chest tube. Hospital stay of retrosternal group was longer as compared to posterior mediastinal group. No death occurred in both groups. Anastomotic leakage occurred more frequently in retrosternal group than that in posterior mediastinal group (26.9% vs 5.5%). Postoperative pneumonia, atelectasis and arrhythmia were not significantly different between two groups.</p><p><b>CONCLUSIONS</b>After three-phase esophagectomy, both retrosternal and posterior mediastinal gastric tube reconstruction can be performed easily and safely. Morbidity of anastomotic leakage is higher in retrosternal reconstruction. Individualized gastric tube reconstruction should be considered.</p>

Video-assisted thoracoscopic esophagectomy in esophageal carcinoma / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To evaluate the efficacy and safety of video-assisted thoracoscopic (VATS) esophagectomy in the treatment of esophageal cancer.</p><p><b>METHODS</b>From June 2004 to October 2007, video-assisted thoracoscopic esophagectomy was performed in 36 patients, including 29 men and 7 women with median age of 58.9 years old. The cancer located at upper segment in 5 cases, middle 25 cases and lower 6 cases. VATS approach was used to mobilize the intrathoracic esophagus and stomach was mobilized by open approach. Esophagogastric anastomosis was performed in the left neck.</p><p><b>RESULTS</b>The mean operative time was 250 minutes (190-330 min) and average time of VATS was 70 minutes. The mean hospital stay was 8.7 days. Mean lymph node harvest was 14.3 nodes. Post-operative complications occurred in 11 patients(30.6%), but no perioperative death occurred.</p><p><b>CONCLUSION</b>Video-assisted thoracoscopic esophagectomy is technically feasible and safe with lower morbidity and shorter hospital stay as compared to open procedure, and may replace the open esophagectomy in selected patients.</p>

The value of multislice spiral computed tomography in demonstrating the relationship between bronchus and peripheral lung cancer / 中华肿瘤杂志

<p><b>OBJECTIVE</b>To investigate the value of multislice spiral computed tomography (MSCT) in demonstrating the relationship between bronchus and peripheral lung cancer.</p><p><b>METHODS</b>We prospectively performed volumetric targeted scans of 0.5 mm collimation with MSCT and reconstructed images of multiplanar reconstruction (MPR), curved multiplanar reformations (CMPR) and surface shaded display (SSD) in 53 peripheral lung cancers. The results were compared with macroscopic and microscopic specimens.</p><p><b>RESULTS</b>(1) The third- to seventh-order branches of the bronchi were clearly shown in all patients by the designed protocol. CT demonstrated the tumor-bronchus relationship in 29 (96.7%) adenocarcinomas and 13 (76.5%) squamous-cell carcinomas. Statistic analysis showed that there was no significant difference between the two groups (chi(2) = 2.8, P > 0.05). (2) The tumor-bronchus relationship was identified as four types with MSCT. Type I: bronchus was obstructed abruptly by the tumor, type II: bronchus penetrated into the tumor with tapered narrowing and interruption, type III: bronchus lumen shown within tumor was patent and intact, type IV: bronchus ran at the periphery of the tumor with intact or narrowed lumen. (3) Type I was shown in 31 of 53 (58.5%) tumors with squamous-cell carcinoma slightly more common than adenocarcinoma. Type II and type III were seen equally in 8 of 53 (15.1%) tumors which occurred only in adenocarcinomas. Type IV was seen in 15 of 53 (28.3%) tumors with adenocarcinoma being slightly more frequent than squamous cell carcinoma. (4) The tumor at the fourth-order bronchus was more common in squamous cell carcinoma, whereas that at the fixth-order bronchus was more likely in adenocarcinoma.</p><p><b>CONCLUSION</b>Volumetric targeted scan of ultra-thin section with MSCT and followed by MPR, CMPR and SSD reconstruction can greatly improve the manifestation of the bronchioles and accurately demonstrate the patterns of tumor-bronchus relationship, thereby reflecting pathologic changes to some extent.</p>