Treatment of Siewert type II adenocarcinoma of the esophagogastric junction: the perspectives from thoracic surgery / 中华胃肠外科杂志

A greater controversy remains in clinical diagnosis and treatment of Siewert type II adenocarcinoma of esophagogastric junction (AEG), compared with Siewert type I and III AEG. In 2018, the first edition of Chinese Expert Consensus on the Surgical Treatment for Adenocarcinoma of Esophagogastric Junction was published in the Chinese Journal of Gastrointestinal Surgery. In the past few years, the advance in minimally invasive thoracoscopic surgery has been proven to reduce thoracic trauma in Siewert type II AEG. Meanwhile, distal thoracic esophagectomy can achieve more complete resection, and upper abdomen-right thoracic approach can ensure the mediastinal lymph node dissection and improve long-term survival. The concept and practice of endoscopic surgery and the comprehensive treatment also give new supplements to the treatment regimen of Siewert type II AEG. More clinical researches should be conducted to address the surgical residual safety and lymph node dissection issues.

Meta-analysis on reconstructions of posterior mediastinal route and anterior mediastinal route after esophagectomy / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To evaluate the efficacy and safety of posterior mediastinal route (PR) as compared with anterior mediastinal route (AR) after esophagectomy.</p><p><b>METHODS</b>A systematic literature retrieval was carried out to obtain studies of randomized controlled trials (RCT) comparing PR with AR after esophagectomy before June 2012. Study selection, data collections and methodological quality assessments of retrieved studies were independently performed by two individual reviewers and meta-analysis was conducted using the RevMan 5.0 software.</p><p><b>RESULTS</b>Six RCTs involving 376 patients (PR:197 cases, AR:179 cases) met the selection criteria. Meta-analysis showed that operative mortality (RR=0.49, 95%CI:0.18-1.36), anastomotic leaks (RR=0.95, 95%CI:0.44-2.07), cardiac morbidity (RR=0.51, 95%CI:0.25-1.04), pulmonary morbidity (RR=0.69, 95%CI:0.41-1.15), anastomotic strictures (RR=0.88, 95%CI:0.62-1.25), dysphagia (RR=1.26, 95%CI:0.75-2.11), 6-month body weight after esophagectomy were not significantly different between these two routes of reconstruction (all P>0.05).</p><p><b>CONCLUSION</b>AR should be the choice of reconstruction in view of its potential advantages in the prevention of tumor recurrence within the gastric conduit and avoidance of conduit irradiation when undergoing postoperative radiotherapy. However, further studies are needed to confirm the difference of long-term efficacy between the two routes.</p>

Subcarinal lymph node metastasis and strategy of lymphadenectomy in thoracic esophageal carcinoma / 中华肿瘤杂志

<p><b>OBJECTIVE</b>To assess the metastatic frequency of subcarinal lymph nodes of thoracic esophageal carcinoma and its influencing factors, in order to determine the adequate range of lymph node dissection during esophagectomy.</p><p><b>METHODS</b>The clinical data from a cohort of 782 patients with thoracic esophageal carcinoma who underwent esophagectomy with lymphadenectomy were analyzed retrospectively with respect to the impact of subcarinal lymph nodes dissection or no dissection on the incidence of postoperative complications.</p><p><b>RESULTS</b>The metastasis rate of subcarinal lymph nodes was 17.5%. The metastasis rates in the upper, middle and lower esophageal carcinomas were 8.3%, 19.1% and 16.2%, respectively (P > 0.05). For T1, T2, T3 and T4, they were 0, 4%, 22.2% and 34%, respectively (P < 0.05). The overall incidence of postoperative complications with and without subcarinal lymph nodes dissection was 19.0% versus 14.6% (P > 0.05), and the incidence of pulmonary complications was 10.3% versus 7.3% (P > 0.05).</p><p><b>CONCLUSIONS</b>Thoracic esophageal carcinomas have a high metastasis rate of subcrinal lymph nodes, and subcarinal lymph nodes dissection is not associated with increasing perioperative complications. Therefore, for the thoracic esophageal carcinoma, no matter the tumor site, esophageal cancer length or size, once the tumor invades the outer membrane, routine subcarinal lymph node dissection should be done.</p>

Association between number of lymphadenectomy and postoperative complication in surgery for esophageal carcinoma / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the association between the number of lymph nodes retrieval and the incidence of postoperative complications in patients with esophageal carcinoma.</p><p><b>METHOD</b>From January 2008 to December 2009, 794 patients with esophageal carcinoma underwent esophagectomy and lymphadenectomy in the Department of Thoracic Surgery at the West China Hospital of Sichuan University. The clinical data, surgeons, the extent of lymphadenectomy and its association with operative morbidity were retrospectively analyzed.</p><p><b>RESULTS</b>There was no operative death. A total of 84 patients with complication(10.6%) were documented. There were 11,770 lymph nodes harvested in total with an average of 14.8. Multivariate logistic regression showed that gender, number of metastatic lymph nodes, level of anastomosis, and surgeons' experience were risk factors associated with postoperative complications (all P<0.05), while the number and group of lymph node resection were not(all P>0.05).</p><p><b>CONCLUSION</b>Within a rational range of lymphadenectomy(<50) following esophagectomy, the postoperative complications are significantly associated with the gender, extent of regional lymph nodes metastasis, site of anastomosis and the expertise of the surgeons, but not associated with the number and group of lymph nodes resection.</p>

Esophagogastrostomy by side-to-side anastomosis in prevention of anastomotic stricture: a randomized clinical trial / 中华外科杂志

<p><b>OBJECTIVE</b>To compare a side-to-side esophagogastric anastomosis with conventional hand-sewn or stapled esophagogastrostomy for prevention of anastomotic stricture by randomized clinical trial.</p><p><b>METHODS</b>Between November 2007 and September 2008, 160 patients with esophageal carcinoma or gastric cardia cancer were consecutively admitted and underwent surgical treatment. After excluding 5 patients (2 refused to participate in and 3 did not meet inclusion criteria), the remaining 155 patients were completely randomized to receive either a side-to-side esophagogastric anastomosis (SS group), or the conventional hand-sewn (HS group), or a circular stapled (CS group) anastomosis, after the removal of esophageal tumor. The primary outcome measured the incidence of anastomotic stricture at 3 months after the operation (defined as the diameter of the anastomotic orifice <or= 0.8 cm on esophagogram), analyzed by intention-to-treat.</p><p><b>RESULTS</b>There was 1 operative death (in HS group) and 1 simple exploration (in SS group). The anastomotic leakage was observed in 4 patients (2 cervical and 1 intrathoracic leaks in HS group, and 1 intrathoracic leak in CS group). The follow-up rate was 96.1% (1 patient in SS group, 3 in HS group, and 2 in CS group were lost). Finally 45 patients in SS group, 52 in HS group, and 47 in CS group were included in the analysis. The 3 groups were preoperative similar. The anastomotic stricture rate was 0% (0/45) in SS group, 9.6% (5/52) in HS group, and 19.1% (9/47) in CS group, respectively (Fisher exact probability test, P = 0.005). The reflux/regurgitation score among 3 groups was similar (chi(2) = 1.681, P = 0.432).</p><p><b>CONCLUSION</b>The side-to-side esophagogastric anastomosis could prevent stricture formation, without increasing gastroesophageal reflux.</p>

Long-term result of total versus partial fundoplication following esophagomyotomy for primary esophageal motor disorders / 中华外科杂志

<p><b>OBJECTIVE</b>To compare the long-term results of total and partial fundoplication on esophagus myotomy.</p><p><b>METHODS</b>From January 1978 to October 1998, 64 patients with achalasia or diffuse esophageal spasm underwent esophagomyotomy and antireflux operation via left thoracotomy. Twenty-one patients underwent Nissen total fundoplication (Nissen group) and 43 patients underwent Belsey Marker IV partial fundoplication (Belsey group). Clinical, radiologic, radionuclide transit, manometric, 24-hour pH monitoring and endoscopic assessments were performed before and after the operation.</p><p><b>RESULTS</b>There was no operative death and major complications for either group. At over 6 years follow-up and compared to Belsey group, patients in Nissen group revealed a higher frequency of dysphagia (P = 0.025) and more radionuclide material retention (P = 0.044). Both operative procedures reduced the lower esophageal sphincter pressure gradient. However, in Nissen group, the esophageal diameter observed on radiology was significantly increased from 3.9 cm preoperatively to 5.5 cm postoperatively (P = 0.012), while it kept the same for Belsey group (from 5.4 to 5.3 cm, P = 0.695). Reoperation in order to relieve the recurrent dysphagia and esophageal obstruction was performed on 8 patients in Nissen group and 1 in Belsey group (P < 0.01).</p><p><b>CONCLUSION</b>When treating achalasia or diffuse esophageal spasm by esophageal myotomy and an antireflux operation, a total fundoplication is not appropriate, whereas a partial fundoplication provides proper antireflux effect without significant esophageal emptying difficulty.</p>

Analysis of lymph node metastasis in the thoracic esophageal squamous cell carcinoma / 中华肿瘤杂志

<p><b>OBJECTIVE</b>To assess the metastatic frequency in different groups of lymph nodes and its influencing factors of the thoracic esophageal squamous cell carcinoma (ESCC) in order to determine the extent of lymphadenectomy during esophagectomy.</p><p><b>METHODS</b>The clinical data of 730 patients with ESCC who underwent esophagectomy and lymphadenectomy were analyzed retrospectively.</p><p><b>RESULTS</b>Of 730 patients, 166 had metastasis to the para-esophageal lymph nodes (22.7%), 90 to the left gastric artery lymph nodes (12.3%), 67 to the lymph nodes around gastric cardia, and 15 to the subcrinal lymph nodes (2.1%). Univariate analysis showed that metastasis to the subcrinal lymph node was positively correlated with the length and differentiation of tumor (P < 0.05), but it was not correlated with any the above parameters when analyzed by multivariate analysis. The metastasis to the para-esophageal lymph node was positively correlated with the length, invasion depth and differentiation of tumor by univariate and multivariate analysis (P < 0.05). The metastasis to the lymph nodes around gastric cardia and metastasis to left gastric artery lymph nodes were positively correlated with the position and invasion depth of tumor by univariate and multivariate analysis (P < 0.05).</p><p><b>CONCLUSION</b>Lymph nodes of the para-esophagus, gastric cardia and left gastric artery usually have high frequency to harber mestastasis, therefore, it was suggested that the lymph nodes in these groups should be dissected during esophagectormy with two-field lymphadenectomy for thoracic esophageal squamous cell carcinoma. Whereas for those patients with the lesion < 3 cm in length or with tumor invasion confined within the esophageal wall or with a lesion located at the upper or lower third of the thoracic esophagus, the subcrinal lymph nodes may not be necessarily dissected.</p>

Influence of number of removed lymph nodes on the TNM staging and survival in advanced esophageal carcinoma / 中华肿瘤杂志

<p><b>OBJECTIVE</b>To evaluate the impact of total number of removed regional lymph nodes (LN) during esophagectomy on TNM staging and long-term survival.</p><p><b>METHODS</b>Between 1984 and 1989, a total of 1098 patients with advanced squamous cell carcinoma of the thoracic esophagus were surgically treated, and the data were retrospectively analyzed. The survival was analyzed by Kaplan-Meier method. Multivariate and univariate analysis were performed using Cox proportional hazard model and Log-rank test respectively in order to compare the survival difference and the impact of <6 or > or =6 removed LN on TNM staging and survival.</p><p><b>RESULTS</b>The shortest follow-up time was 10 years with a follow-up rate of 91.4%. Of these 1098 patients, 378 patients were found to have regional LN metastases with a LN metastasis rate of 34.4%. Totally, 4157 LN were removed and tumor spreading into the lymph node was documented in 800 with a lymph node metastasis degree of 19.2%. The mean number of removed LN in each esophgectomy was 3.8. According to the number of total removed LN, patients were divided into group A (removed LN <6, N=825) and group B (removed LN > or =6, N=273). The survival of group A was worse than that of group B. The depth of tumor invasion, degree of lymph node metastasis, tumor location, and tumor residual status were the most important prognostic factors. Even though the lymphatic metastasis rate in group A was significantly lower than that in group B (30.3% vs. 46.9% P < 0.001), the LN metastasis degree was higher in group A than that in group B (21.2% vs. 17.5% P = 0.002) due to less number of removed LN in group A than in group B. With the stratification analysis according to the number of involved lymph nodes, for patients without LN spreading, the survival in group A was significantly worse than that in group B (P = 0.003), but in the patients with only one or > or =2 positive nodes, the survival was similar (P = 0.919 and 0.182, respectively). When stratified patients according to TNM stage, for stage IIa patients (T2N0M0, T3N0M0), the survival in group A was significantly worse than that in group B (P = 0.006), while such difference did not exist in patients with stage IIb or stage lIII(P = 0.302 and 0.108, respectively).</p><p><b>CONCLUSION</b>A large series of retrospective study on advanced squamous cell carcinoma of the thoracic esophagus demonstrates that the number of metastatic LN is an important prognostic factor, therefore, it should be considered when refining UICC-TNM classification for esophageal cancer. If the total number of LN removed during each esophagectomy is less than 6, the occult positive regional LN might be missed, resulting in an inaccurate N classification and incorrect staging. Removal of > or = LN for each esophageal cancer patient during esophagectomy recommended by UICC is rational and should be complied with.</p>