Application of enhanced recovery after surgery in da Vinci robotic McKeown surgery for esophageal cancer: A retrospective cohort study / 中国胸心血管外科临床杂志

@#Objective     To investigate the application of enhanced recovery after surgery (ERAS) in da Vinci robotic McKeown surgery for esophageal cancer. Methods     Clinical data of patients admitted to the First Hospital of Lanzhou University and undergoing da Vinci robotic McKeown surgery for esophageal cancer from 2017 to 2021 were retrospectively analyzed. According to the treatment, they were divided into two groups, a conventional group and an ERAS group. Patients in the conventional group were treated with the conventional perioperative treatment mode of thoracic surgery, and patients in the ERAS group were treated with accelerated rehabilitation surgical treatment mode. Relevant hospitalization indicators and postoperative complication rates were compared between the two groups. Results     Finally 128 patients were collected, including 106 males and 22 females, with an average age of 61.91 years. There were 71 patients in the conventional group and 57 patients in the ERAS group. The postoperative pain index in the ERAS group was significantly lower than that in the conventional group (P<0.05), and the duration of postoperative analgesic pump used in the ERAS group was shorter than that in the conventional group (2.39±0.49 d vs. 3.13±0.63 d, P<0.001). There was no statistical difference in the incidence of postoperative related complications (gastroesophageal reflux, anastomotic stenosis, anastomotic fistula, arrhythmia, recurrent laryngeal nerve injury, chylothorax, anastomosis stomatitis or incisional infection) between the two groups (P>0.05), but the incidence of postoperative lung infection in the ERAS group was statistically lower (12.28% vs. 26.76%, P=0.043), and the volume of postoperative pleural effusion was statistically less compared with the conventional group (P<0.05). In the ERAS group, the surgery time (294.35±15.19 min vs. 322.79±59.09 min, P<0.001), postoperative exhaust time (1.44±0.39 d vs. 1.94±0.43 d, P<0.001), postoperative removal time of nasolasal tube (6.79±0.73 d vs. 8.21±0.86 d, P<0.001), hospital stay (19.88±3.36 d vs. 21.34±3.59 d, P=0.020), hospitalization costs (105 575.28±8 960.75 yuan vs. 137 894.64±19 518.60 yuan, P<0.001) were all lower or shorter than those of the conventional group. Postoperative activity was longer in the ERAS group than that in the conventional group (P<0.05), but there was no statistical difference in preoperative anesthesia time between the two groups (P=0.841). Conclusion     The application of ERAS in da Vinci robotic McKeown surgery for esophageal cancer can effectively alleviate the physiological and psychological burden of patients, reduce the occurrence of postoperative related complications, effectively shorten the total hospital stay, save hospitalization costs, and reduce the economic burden of patients and society. Therefore, it can be promoted and applied in the clinic.

Clinical observation on perioperative complications of minimally invasive Ivor-Lewis and minimally invasive McKeown esophagectomy / 中华肿瘤杂志

Objective: To compare and analyze the perioperative clinical effects of minimally invasive Ivor-Lewis esophagectomy (MIE-Ivor-Lewis) and minimally invasive McKeown esophagectomy (MIE-McKeown). Methods: A total of 147 patients who underwent endoscopic esophageal cancer surgery from April 2018 to August 2019 were selected, including 85 patients undergoing MIE-McKeown surgery and 62 patients undergoing MIE-Ivor-Lewis surgery. The measurement data were expressed as (x±s), the comparison of normally distributed measurement data was performed by independent sample t-test, and the comparison of count data was performed by χ(2) test or Fisher's exact test. Results: The operation time of McKeown (M) group and Ivor-Lewis (IL) group were (219.2±72.4) minutes and (225.8±65.3) minutes. The mediastinal lymph node dissection number of M and IL groups were 13.3±4.8 and 11.6±6.5, respectively. The number of left recurrent laryngeal nerve lymph node dissection were 3.5±1.2 and 3.1±1.4, respectively. The intraoperative blood loss were (178.3±41.3) ml and (163.2±64.1) ml, respectively. The number of patients reoperated for postoperative bleeding were 1 and 0, respectively. The number of patients with postoperative gastric bleeding were 0 and 1, respectively. The postoperative chest tube retention time were (2.8±1.3) days and (3.1±1.2) days, respectively. The number of patients with anastomotic leakage were 7 and 1, respectively. The number of patients with lung infection were 13 and 5, respectively, and with chylothorax were 2 and 1, respectively, without statistically significant difference (P>0.05). The number of patients with hoarseness were 11 and 3, respectively. The total incidence of complication were 41.2% (35/85) and 17.7% (11/62), and the postoperative hospital stay were (14.7±6.5) days and (12.3±2.3) days, with statistical difference (P<0.05). Conclusion: MIE-Ivor-Lewis and MIE-McKeown are safe and effective in treating esophageal cancer, but the complication of MIE-Ivor-Lewis is less than that of MIE-Mckeown, and the perioperative clinical effect of MIE-Ivor-Lewis is better than that of MIE-McKeown.

Efficacy of jejunostomy combined with Ivor-Lewis or McKeown operation in the treatment of middle and lower esophageal cancer: A retrospective cohort study / 中国胸心血管外科临床杂志

@#Objective    To investigate the effect of jejunostomy combined with Ivor-Lewis or McKeown operation on the treatment of middle and lower esophageal cancer. Methods    The clinical data of 127 patients with middle and lower esophageal cancer admitted to our hospital from June 2018 to October 2019 were retrospectively analyzed, including 89 males and 38 females, aged 62.82±8.65 years. The patients were divided into an Ivor-Lewis group (IL group, 72 patients) and a McKeown group (MK group, 55 patients) according to surgical methods. Patients in the IL group received jejunostomy combined with Ivor-Lewis operation, and patients in the MK group received jejunostomy combined with McKeown operation. The operation time, postoperative bedside electrical impedance tomography (EIT) parameters, postoperative inflammatory factor levels, postoperative complications and rehabilitation of the two groups were compared. Results    The operation time (262.65±49.78 min vs. 303.04±60.13 min), postoperative eating time (10.54±2.22 d vs. 11.47±2.49 d) and postoperative hospital stay (14.78±2.47 d vs.15.72±2.36 d) in the IL group were significantly shorter than those in the MK group (P<0.05). The blood loss (156.13±52.43 mL vs. 158.87±48.47 mL) and the number of lymph node dissection (29.47±8.88 vs. 30.17±9.80) in the IL group were less than those in the MK group, but the differences were not statistically significant (P>0.05). The repeated measurement analysis of variance showed that the time point could significantly affect tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), and IL-8 levels (Ftime point=520.543, 272.379, 147.688, all P<0.05), but the surgical methods and the interactive effect of time point and surgical methods did not affect the levels of TNF-α, IL-6 and IL-8 (P>0.05). Postoperative bedside EIT image parameters were statistically different on the postoperative 1 d, 3 d, 5 d and 7 d between the two groups (P<0.05). Compared with the MK group, the incidences of recurrent laryngeal nerve injury, arrhythmia, pulmonary infection and atelectasis, anastomotic leakage, gastric wall necrosis and stump fistula, secondary thoracotomy and abdominal hemostasis, and intestinal obstruction were lower, but the differences were not statistically different (P>0.05). The recurrence rate of patients in the IL group within 6 months was lower than that in the MK group, but the difference was not statistically significant (8.33% vs. 9.09%, P>0.05). Conclusion    Jejunostomy combined with Ivor-Lewis or McKeown surgery have equivalent effects on patients with middle and lower esophageal cancer.

Minimally invasive esophagectomy via Sweet approach in combination with cervical mediastinoscopy is a valuable approach for surgical treatment of esophageal cancer / 中南大学学报(医学版)

OBJECTIVES@#To compare the short-, mid-, and long-term outcomes in patients with esophageal cancer between minimally invasive esophagectomy via Sweet approach in combination with cervical mediastinoscopy (MIE-SM) and minimally invasive esophagectomy via McKeown approach (MIE-MC), and to evaluate the value of MIE-SM in the surgical treatment of esophageal cancer.@*METHODS@#A prospective, nonrandomized study was adopted. A total of 65 esophageal cancer patients after MIE-SM and MIE-MC from June 2014 to May 2016 were included. Among them, 33 patients underwent MIE-SM and 32 patients underwent MIE-MC. Short-term outcomes (including the duration of surgery, intraoperative blood loss volume, ICU stay time, postoperative complications, postoperative hospital stay, reoperation, open surgery, number of dissected lymph nodes, and 30-day mortality), mid-term outcomes, [including Quality of Life Core Questionnaire (QLQ-C30) and the esophageal site-specific module (QLQ-OES18)], long-term outcomes [including overall survival and disease-free survival] were compared between the 2 groups.@*RESULTS@#Radical resection (R0) were achieved in all patients. There were no significant differences in the duration of surgery, intraoperative blood loss volume, ICU stay time, postoperative complications, and postoperative hospital stay between the 2 groups (all @*CONCLUSIONS@#MIE-SM appears to be a safe surgical approach, which may get better quality of life, suffer less pain, and can achieve the same therapeutic effect as MIE-MC. Therefore, MIE-SM should be considered as a valuable approach for the treatment of middle and lower esophageal cancer.

Fifty five years old male with gastrointestinal stromal tumor: a case report

Esophageal Gastrointestinal Stromal Tumors (GISTs) were extremely rare, with an incidence of 0,2% of GIST cases. Majority of esophageal GISTs were classified as high-risk category (70.83%), thus, it was required more aggressive approaches, e.g. radical surgery, chemotherapy and radiotherapy. This was a case of a 55-year-old male patient who was referred to surgery department complained of atypical chest pain and swallowing difficulty. Based on thorax X-Ray, it was suspected mediastinal mass. In addition, based on chest CT scan, it was suspected a mass at distal esophagus with multiple nodular lesions in liver dd/fatty liver. X-ray Oesophagus Maag Duodenum (OMD): Esophageal mass at 1/3 middle-distal part. Upper endoscopy diagnosis showed a fragile circularly spreading tumor mass which it was easily bleeds. Biopsy also showed a mild esophageal dysplasia with non-specific inflammation and necrotic tissue which was difficult to assess. This patient underwent McKeown esophagectomy. Moreover, pathology report showed diagnosis of a malignant tumor which fitted with criteria of malignant GIST, with both ends tumor-free. Finally, the patient was administered for imatinib as adjuvant therapy 1x400mg daily. This report illustrated complexity in diagnosing and treating esophageal GIST. The tumor size and mitotic rate of tumor were associated with poor survival.

Advances and prospects in the application of robotic surgery system in the treatment of esophageal cancer / 中国胸心血管外科临床杂志

@#At present, the application of the robot assisted surgery system in the surgical treatment of esophageal cancer is gradually emerging, and it is more and more widely used and recognized in the field of surgery. According to the domestic and foreign literatures, the robot has many advantages, and robotic assisted esophageal cancer surgery has been proved to be safe and effective, and its short-term efficacy is significantly better than thoracotomy. Other studies have shown that in long-term follow-up, the effect is comparable to video-assisted thoracoscopic surgery. In this paper, the author are systematically reviewed the development history of the robot assisted surgery system, the effect of robotic assisted esophagectomy on safety, surgical method, short-term efficacy and long-term prognosis. The traditional open surgery and thoracoscopic laparoscopic esophagectomy has been carried on the detailed comparison to provide some advice and theoretical basis for esophageal cancer surgery robot system.

Clinical analysis of minimally invasive McKeown esophagectomy in a single center by a single medical group / 浙江大学学报（英文版）（B辑：生物医学和生物技术）

OBJECTIVE@#McKeown esophagectomy followed by cervical and abdominal procedures has been commonly used for invasive esophageal carcinoma. This minimally-invasive operative procedure in the lateral prone position has been considered to be the most appropriate method. We describe our experiences in minimally invasive McKeown esophagectomy (MIME) for esophageal cancer.@*METHODS@#Between March 2016 and February 2018, a total of 82 patients underwent MIME by a single group in our department (a single center). All procedure, operation, oncology, and complication data were reviewed.@*RESULTS@#All MIME procedures were completed successfully, with no conversions to open surgery. The median operative time was 260 min, and median blood loss was 100 ml. The average number of total harvested lymph nodes was 20.1 in the chest and 13.5 in the abdomen. There were no deaths within 30 postoperative days. Twenty cases (24.4%) developed postoperative complications, including anastomotic leak in 4 (4.9%), single lateral recurrent nerve palsy in 4 (4.9%), bilateral recurrent nerve palsy in 1 (1.2%), pulmonary problems in 3 (3.7%), chyle leak in 1 (1.2%), and other complications in 7 (including pleural effusions in 4, incomplete ileus in 2, and neck incision infection in 1; 8.54%). Average postoperative hospitalization time was 12 d. Blood loss, operation time, morbidity rate, and the number of harvested lymph nodes were analyzed by evaluating learning curves in different periods. Significant differences were found in operative time (P=0.006), postoperative hospitalization days (P=0.015), total harvested lymph nodes (P=0.003), harvested thoracic lymph nodes (P=0.006), and harvested abdominal lymph nodes (P=0.022) among different periods.@*CONCLUSIONS@#Surgical outcomes following MIME for esophageal cancer are safe and acceptable. The MIME procedure for stages I and II could be performed proficiently and reached an experience plateau after approximately 25 cases.

Comparison of endoscopic and open McKeown esophagectomy / 肿瘤研究与临床

Objective To evaluate the feasibility of endooscopic minimally invasive McKeown esophagectomy in the treatment of esophageal carcinoma. Methods From June 2012 to August 2015, the data of 180 patients with esophageal carcinoma was retrospectively analyzed. The patients were divided into endoscopy McKeown esophagectomy group (EME group) and open McKeown esophagectomy group (OME group), each group had 90 patients. The clinical pathological data, perioperative data and postoperative complications between the two groups were analyzed. Results The operation time in EME group was longer than that in OME group [(289 ± 30) min vs. (252 ± 28) min, t= 8.063, P 0.05). Conclusions Endoscopic minimally invasive McKeown esophagectomy has the same effect as open surgery, and trauma is small. Therefore, for the patients who are suitable for the minimally invasive surgery, it can be preferred.

Comparison of short-term outcomes between minimally invasive McKeown esophagectomy and Ivor-Lewis esophagectomy for esophageal cancer / 中南大学学报(医学版)

Objective:To summarize the outcomes of 74 patients with minimally invasive McKeown esophagectomy (MIE-McKeown),and to discuss the short-term outcomes by comparing with IvorLewis esophagectomy (ILE) procedure.Methods:A total of 74 patients with esophageal carcinoma underwent MIE-McKeown in Xiangya Hospital from November 2014 to July 2016 were retrospectively reviewed,and 85 patients underwent ILE procedure were selected as a control group.Perioperative and short-term outcomes were analyzed.Results:Compared with the ILE group,patients underwent MIE-McKeown had less blood loss,less pulmonary infection,longer resection length and more harvested lymph nodes (P＜0.05),but they had more anastomotic leakage and stricture rate,longer operation time and hospital stay as well (P＜0.05).The total rate of lymph node metastatic in all patients was 52.8％,and the rate of cervical lymph node metastases was 9.5％ in the MIE-McKeown group.Multiple carcinomas were found in 16 cases,and 7 were proximally located.The distance from the distal margin of the second lesion to the center of the main lesion was 20-85 (50.7±23.0) mm,while the distance in 9 second carcinomas distally located was 30-90 (57.8±20.5) mm.Conclusion:Compared with Ivor-Lewis esophagectomy procedure,MIE-McKeown procedure has a more complete lesion dissection and more harvested lymph nodes with smaller incisions,better short-term outcomes and more safety.It is an appropriate procedure for esophagectomy.However,it should be optimized for its high rate of anastomotic leakage and stricture.

Application of root seeking method and suspension method in lymph nodes dissection of recurrent laryngeal nerve during minimally invasive McKeown surgery of thoracic esophageal cancer / 中华消化外科杂志

Objective To investigate the application value of root seeking method and suspension method in lymph nodes dissection of recurrent laryngeal nerve (RLN) during minimally invasive McKeown surgery of thoracic esophageal cancer.Methods The retrospective cohort study was conducted.The clinical data of 120 patients with thoracic esophageal cancer who were admitted to the First Affiliated Hospital of Zhengzhou University from March 2015 to May 2016 were collected.Sixty patients using root seeking method and suspension method in lymph nodes dissection of RLN were allocated into the study group,and 60 using unexposed lymph nodes dissection of RLN were allocated into the control group.All the patients underwent minimally invasive McKeown surgeries.Observation indicators:(1) intraoperative situations;(2) postoperative situations;(3) follow-up.Follow-up using outpatient examination and telephone interview was performed to detect the postoperative tumor recurrence or metastasis and injury of RLN up to January 2017.Measurement data with normal distribution were represented as-x±s.Comparisons between groups were evaluated with the independent-sample t test.Count data were analyzed using the chi-square test.Results (1) Intraoperative situations:patients between groups underwent successful minimally invasive McKeown surgery,without conversion to open surgery.The operation time and volume of intraoperative blood loss were respectively (250± 19)minutes,(484±80)mL in the study group and (248±22) minutes,(493±60)mL in the control group,with no statistically significant difference between groups (t =0.532,-0.697,P＞0.05).The number of lymph nodes dissection,successful dissection rate and metastasis rate in the left RLN and metastasis rate in the right RLN were respectively 5.0±4.1,86.7％ (52/60),23.3％ (14/60),16.7％ (10/60) in the study group and 1.0±0.9,60.0％ (36/60),1.7％ (1/60),5.0％ (3/60) in the control group,with statistically significant differences between groups (t =5.170,x2=10.909,12.876,4.227,P＜0.05).The number of lymph nodes dissection,successful dissection rate and metastasis degree in the right RLN and metastasis degree in the left RLN were respectively 3.5±3.6,93.3％(56/60),8.55％(20/234),7.69％ (20/260) in the study group and 1.5± 1.0,83.3％ (50/60),4.00％ (4/100),1.72％ (1/58) in the control group,with no statistically significant difference between groups (t=1.075,x2 =2.911,2.172,1.856,P＞0.05).(2) Postoperative situations:time to initial anal exsufflation,time of initial defecation and time for initial fluid diet intake were respectively (2.0±0.6)days,(3.1 ± 0.6)days,(7.2± 0.3)days in the study group and (2.2±0.8) days,(3.2±0.5) days,(6.9±0.5) days in the control group,with no statistically significant difference between groups (t=2.618,-0.991,3.985,P＞0.05).Comparisons of injury degree of RLN:5 and 1 patients in the study and control groups had mild injury,respectively,showing no statistically significant difference between groups (x2=1.581,P＞0.05);1 and 8 patients in the study and control groups had respectively moderate injury,showing a statistically significant difference between groups (x2 =4.323,P＜0.05);there was no severe injury between groups.Duration of hospital stay in the study and control groups were respectively (14.8±2.5)days and (14.5±2.8) days,showing no statistically significant difference between groups (t =0.619,P＞ 0.05).(3)Follow-up:120 patients were followed up for 4-22 months,with a median time of 13 months.During the follow-up,3 and 2 patients in the study and control groups had cervical lymph node metastases and received postoperative assisted chemotherapy and local radiotherapy of neck,without death between groups.There was no hoarseness in 6 patients with mild injury of RLN during the follow-up;voices in 9 patients with moderate injury of RLN were improved at 1-2 months postoperatively,and no bucking symptom was detected after fluid diet intake.Conclusion The root seeking method and suspension method in lymph nodes dissection of RLN is safe and effective during minimally invasive McKeown surgery of thoracic esophageal cancer,especially conducive to lymph nodes exposure and dissection of the left RLN,and reduce the incidence of moderate injury of RLN.

Feasibility and safety of McKeown-type minimally invasive esophagectomy in para-recurrent laryngeal nerve lymphadenectomy / 天津医药

Objective To explore the feasibility and safety of Mckeown-type minimally invasive esophagectomy in para-recurrent laryngeal nerve lymphadenectomy. Methods A total of 163 cases underwent minimally invasive McKeown resection for esophageal carcinoma in the Affiliated Tumor Hospital of Xinjiang Medical University were retrospectively analyzed. Patients were divided into routine treatment group (n=63), right recurrent nerve lymph node dissection group (right group, n=53) and bilateral recurrent laryngeal nerve lymph node dissection group (bilateral group, n=47) according to the operation modes. The postoperative pathology, operation time, intraoperative bleeding volume, postoperative hospitalization time, number of lymph nodes and pneumonia, anastomotic fistula, laryngeal nerve injury and other complications were compared between three groups of patients. Pathological conditions were consisted of the location of tumor, the degree of differentiation, T stage and pathological stage. Postoperative complications were followed up for 6 months. Results There were no significant differences in tumor location, pathological differentiation degree, T stage and pathologic stage between three groups. The amount of bleeding was more in the routine group than that of the right group and the bilateral group (P<0.05). There was no significant difference in the amount of bleeding between the right group and the bilateral group. The total lymph nodes and thoracic lymph nodes were increased in order in routine group, the right group and the bilateral group, and there was significant difference between three groups(P<0.05). There were no significant differences in other operation data and complications between three groups. Conclusion McKeown-type minimally invasive esophagectomy shows good feasibility and safety for para-recurrent laryngeal nerve lymphadenectomy .