Reverse-puncture anastomosis in minimally invasive Ivor-Lewis esophagectomy for lower esophageal carcinoma: A single-center retrospective study / 中国胸心血管外科临床杂志

@#Objective    To investigate the clinical efficacy of minimally invasive Ivor-Lewis esophagectomy (MIILE) with reverse-puncture anastomosis. Methods    Clinical data of the patients with lower esophageal carcinoma who underwent MIILE with reverse-puncture anastomosis in our department from May 2015 to December 2020 were collected. Modified MIILE consisted of several key steps: (1) pylorus fully dissociated; (2) making gastric tube under laparoscope; (3) dissection of esophagus and thoracic lymph nodes under artificial pneumothorax with single-lumen endotracheal tube intubation in semi-prone position; (4) left lung ventilation with bronchial blocker; (5) intrathoracic anastomosis with reverse-puncture anastomosis technique. Results     Finally 248 patients were collected, including 206 males and 42 females, with a mean age of 63.3±7.4 years. All 248 patients underwent MIILE with reverse-puncture anastomosis successfully. The mean operation time was 176±35 min and estimated blood loss was 110±70 mL. The mean number of lymph nodes harvested from each patient was 24±8. The rate of lymph node metastasis was 43.1% (107/248). The pulmonary complication rate was 13.7% (34/248), including 6 patients of acute respiratory distress syndrome. Among the 6 patients, 2 patients needed endotracheal intubation-assisted respiration. Postoperative hemorrhage was observed in 5 patients and 2 of them needed hemostasis under thoracoscopy. Thoracoscopic thoracic duct ligation was performed in 1 patient due to the type Ⅲ chylothorax. TypeⅡ anastomotic leakage was found in 3 patients and 1 of them died of acute respiratory distress syndrome. One patient of delayed broncho-gastric fistula was cured after secondary operation. Ten patients with type Ⅰ recurrent laryngeal nerve injury were cured after conservative treatment. All patients were followe up for at least 16 months. The median follow-up time was 44 months. The 3-year survival rate was 71.8%, and the 5-year survival rate was 57.8%. Conclusion    The optimized MIILE with reverse-puncture anastomosis for the treatment of lower esophageal cancer is safe and feasible, and the long-term survival is satisfactory.

Short-term efficacy of minimally invasive esophagectomy combined with three-field versus two-field lymphadenectomy for 257 patients / 中国胸心血管外科临床杂志

@#Objective To explore the safety of minimally invasive esophagectomy (MIE) with three-field lymphadenectomy (3-FL) for esophageal squamous cell carcinoma (ESCC) by comparing the short-term outcomes between the 3-FL and the two-field lymphadenectomy (2-FL) in MIE. Methods The clinical data of patients with ESCC who underwent minimally invasive McKeown esophagectomy in our hospital from July 2015 to March 2022 were collected retrospectively. Patients were divided into a 3-FL group and a 2-FL group according to lymph node dissection method. And the clinical outcomes and postoperative complications were compared between the two groups. Results A total of 257 patients with ESCC were included in this study. There were 211 males and 46 females with an average age of 62.2±8.1 years. There were 109 patients in the 3-FL group and 148 patients in the 2-FL group. The operation time of the 3-FL group was about 20 minutes longer than that of the 2-FL group (P<0.001). There was no statistical difference between the two groups in the intraoperatve blood loss (P=0.376). More lymph nodes (P<0.001) and also more positive lymph nodes (P=0.003) were obtained in the 3-FL group than in the 2-FL group, and there was a statistical difference in the pathological N stage between the two groups (P<0.001). But there was no statistical difference in the incidence of anastomotic leak (P=0.667), chyle leak (P=0.421), recurrent laryngeal nerve injury (P=0.081), pulmonary complications (P=0.601), pneumonia (P=0.061), cardiac complications (P=0.383), overall complications (P=0.147) or Clavien-Dindo grading (P=0.152) between the two groups. Conclusion MIE 3-FL can improve the efficiency of lymph node dissection and the accuracy of tumor lymph node staging, but it does not increase the postoperative complications, which is worthy of clinical application.

Patterns of treatment failure after minimally invasive esophagectomy among patients with thoracic esophageal carcinoma: implications for value of adjuvant therapy / 中华放射肿瘤学杂志

Objective:To investigate the overall recurrence rate and the pattern of treatment failure in thoracic esophageal cancer (TEC) patients after minimally invasive esophagectomy (MIE), and to evaluate the significance of adjuvant therapy after MIE.Methods:Clinical data of TEC patients who underwent MIE with or without neoadjuvant chemotherapy in the Fourth Hospital of Hebei Medical University between 2016 and 2018 were retrospectively analyzed. The pathology-based lymph node metastasis (LNM) rate, overall recurrence rate, and pattern of treatment failure following MIE were analyzed by SPSS 26.0 statistical software. Cox regression model was used to identify the high-risk factors for recurrent disease. Propensity score matching was performed to compare the survival of patients between the postoperative radiotherapy group and non-radiotherapy group.Results:A total of 443 eligible patients were enrolled in this study, and the pathology-based LNM rate in all groups was 42.0%. The overall recurrence rate was 34.8%. Regional lymphatic metastasis was the most frequent pattern of recurrence (24.2%), followed by distant metastasis (19.4%). Multivariate Cox regression analysis identified pT 3-4 stage and pN + stage as the independent risk factors for recurrence. At the same time, the total number of lymph nodes dissected ≥12 and the number of lymph nodes dissected ≥7 in the neck clavicle and upper mediastinum could reduce the risk of tumor recurrence. The 1-, 3-, and 5-year disease-free survival (DFS) rates in the postoperative radiotherapy group and non-radiotherapy group were 83.5%, 66.8%, 60.7%, and 79.2%, 61.6%, 57.2%, respectively ( χ2=0.13, P=0.715). The 1-, 3-, and 5-year overall survival (OS) rates in two groups were 92.0%, 72.0%, 67.5% and 84.0%, 68.0%, 55.4% , respectively ( χ2=0.43, P=0.513). Conclusions:Regional lymphatic and distant metastases are the main patterns of recurrence for TEC patients after MIE with or without neoadjuvant chemotherapy. pT 3-4 stage, pN + stage, insufficient total number of lymph node dissection and insufficient number of lymph nodes in neck supraclavicular and upper mediastinal dissection are high-risk factors for postoperative recurrence. The survival rate in the postoperative radiotherapy group tends to be higher than that in the non-radiotherapy group. Adjuvant therapy, including postoperative radiotherapy, may remain necessary.

Patterns of Failure After Minimally Invasive Esophagectomy and Evaluation of Value of Adjuvant Therapy for Esophageal Cancer / 肿瘤防治研究

The current recommendation for postoperative radiotherapy for esophageal cancer in China is mainly based on the data of incomplete two-field dissection of open left thoracotomy. At present, the type of surgery for esophageal cancer gradually transitions from open left thoracotomy to open right thoracotomy and from open esophagectomy to minimally invasive esophagectomy (MIE). Patients with early-stage esophageal cancer are selected as candidates for MIE. MIE is less invasive than open esophagectomy, and the right thoracic approach is conducive to more thorough lymph node dissection. However, few data and related studies are available on the patterns of failure after MIE in esophageal cancer, and guiding an adjuvant therapy is difficult. The feasibility of an adjuvant therapy for selective high-risk patients and the optimized treatment after MIE remains to be explored in clinical practice. In this regard, this article aims to review the safety of MIE, long-term survival outcomes, postoperative recurrence patterns, and recurrence rates of patients to discuss the value of postoperative adjuvant therapy and guide clinical treatment.

Surgical treatment and prognosis analysis of thoracic esophageal squamous cell carcinoma: a report of 2 766 cases / 中华消化外科杂志

Objective:To investigate the surgical treatment and prognosis of thoracic esophageal squamous cell carcinoma (ESCC).Methods:The retrospective cohort study was conducted. The clinicopathological data of 2 766 patients with thoracic ESCC who were admitted to Sichuan Cancer Hospital & Institute from January 2010 to December 2017 were collected. There were 2 256 males and 510 females, aged (62±8)years. All patients underwent surgical treatment. Observation indicators: (1) treatment; (2) postoperative complications; (3) postoperative survival. Measurement data with normal distribution were represented as Mean± SD. Measurement data with skewed distribution were represented as M( Q1, Q3). Count data were described as absolute numbers or percentages. The Kaplan-Meier method was used to draw survival curve and calculate survival rate, and the Log-Rank test was used for survival analysis. Result:(1) Treatment. Fifty-two of the 2 766 patients underwent neoadjuvant therapy. There were 1 444 patients undergoing open surgery, including 44 cases conversion to thoracotomy, and there were 1 322 patients undergoing minimally invasive esophagectomy. There were 1 991, 729 and 46 cases with McKeown, Ivor-Lewis and Sweet esophagectomy, respectively. One thousand two hundred and seventy-one of the 2 766 patients underwent postoperative adjuvant therapy. The number of lymph node metastases, the number of lymph node dissected, rate of R 0 resection, operation time of 2 766 patients were 2.1(0,3.0), 22±12, 94.722%(2 620/2 766), (237±66)minutes. (2) Postoperative complications. The overall incidence of postoperative complications was 25.850%(715/2 766). The top two postoperative complications were pneumonia and anastomotic fistula, with incidence rates of 8.604%(238/2766) and 7.484%(207/2766), respectively. One patient may have more than two kinds of postoperative complications. (3) Postoperative survival. The 1-, 3-and 5-year overall survival rates of 2 766 patients were 86.2%, 57.5% and 46.8%, respectively. Further analysis indicated that the 5-year overall survival rates of 510 female patients and 2 256 male patients were 62.0% and 43.3%, respectively, showing a significant difference between them ( χ2=48.94, P<0.05). The 5-year overall survival rates of 693 cases with upper thoracic ESCC, 1 479 cases with middle thoracic ESCC and 594 cases with lower thoracic ESCC were 49.5%, 46.7% and 44.1%, respectively, showing no significant difference among them ( χ2=3.21, P>0.05). The 5-year overall survival rates of 68 cases with stage 0 thoracic ESCC, 259 cases with stage Ⅰ esophageal ESCC, 885 cases with stage Ⅱ thoracic ESCC, 1 222 cases with stage Ⅲ thoracic ESCC, and 332 cases with stage Ⅳ thoracic ESCC were 95.6%, 76.4%, 61.4%, 35.6%, and 14.5%, respectively, showing a significant difference among them ( χ2=500.40, P<0.05). The 5-year overall survival rates of 1 444 patients undergoing open esophagectomy and 1 322 patients undergoing minimally invasive esophagectomy were 42.5% and 51.8%, respectively, showing a significant difference between them ( χ2=31.29, P<0.05). The 5-year overall survival rates of 1 991 cases undergoing McKeown esophagectomy, 729 cases undergoing Ivor-Lewis esophagectomy, and 46 cases undergoing Sweet esophagectomy were 49.5%, 41.2%, and 32.3%, respectively, showing a significant difference among them ( χ2=19.19, P<0.05). Conclusions:Compared with open esophagectomy, minimally invasive esophagectomy brings survival benefits to patients with thoracic esophageal ESCC. Among different esophagectomy methods, the McKeown esophagectomy has also brought survival benefits to patients with esophageal ESCC compared to the Ivor-Lewis esophagectomy and the Sweet esophagectomy.

Conversion to thoracotomy during minimally invasive esophagectomy: Retrospective analysis in a single center / 中国胸心血管外科临床杂志

@#Objective     To explore the causes of conversion to thoracotomy in patients with minimally invasive esophagectomy (MIE) in a surgical team, and to obtain a deeper understanding of the timing of conversion in MIE. Methods     The clinical data of patients who underwent MIE between September 9, 2011 and February 12, 2022 by a single surgical team in the Department of Thoracic Surgery of the Fourth Hospital of Hebei Medical University were retrospectively analyzed. The main influencing factors and perioperative mortality of patients who converted to thoracotomy in this group were analyzed. Results     In the cohort of 791 consecutive patients with MIE, there were 520 males and 271 females, including 29 patients of multiple esophageal cancer, 156 patients of upper thoracic cancer, 524 patients of middle thoracic cancer, and 82 patients of lower thoracic cancer. And 46 patients were converted to thoracotomy for different causes. The main causes for thoracotomy were advanced stage tumor (26 patients), anesthesia-related factors (5 patients), extensive thoracic adhesions (6 patients), and accidental injury of important structures (8 patients). There was a statistical difference in the distribution of tumor locations between patients who converted to thoracotomy and the MIE patients (P<0.05). The proportion of multiple and upper thoracic cancer in patients who converted to thoracotomy was higher than that in the MIE patients, while the proportion of lower thoracic cancer was lower than that in the MIE patients. The perioperative mortality of the thoracotomy patients was not significantly different from that of the MIE patients (P=1.000). Conclusion     In MIE, advanced-stage tumor, anesthesia-related factors,extensive thoracic adhesions, and accidental injury of important structures are the main causes of conversion to thoracotomy. The rate varies at different tumor locations. Intraoperative conversion to thoracotomy does not affect the perioperative mortality of MIE.

Progress of comprehensive surgical treatment for esophageal cancer / 中华消化外科杂志

Esophageal cancer is one of the common malignant tumors in the worldwide and has regional characteristics in China. At present, the treatment of esophageal cancer is still a comprehensive diagnosis and treatment mode based on surgery. With the application of minimally invasive technique in surgery of esophageal cancer, the concept of surgical diagnosis and treatment for esophageal cancer is constantly updating. The application of robotic surgical system in esophageal surgery promotes the surgical quality of lymph node dissection and improves the technique of intraluminal anastomosis under total endoscopy. For locally advanced esophageal cancer, a diagnosis and treatment mode based on neoadjuvant therapy has been gradually accepted by most of doctors around China. Combined with the latest researches at home and abroad, the authors investigate the development of surgical techniques, the renewal of surgical concept and the changes on diagnosis and treatment, summarize the new advances in comprehensive surgical treatment for esophageal cancer, in order to provide the theoretical guidance for the standardized treatment of esophageal cancer.

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.

Application of single-direction gastric mobilization under 3D-laparoscopy in minimally invasive esophagectomy for the treatment of esophageal cancer / 中国胸心血管外科临床杂志

@#Objective    To evaluate the safety, feasibility and short-term outcomes of single-direction gastric mobilization under 3D-laparoscopy in minimally invasive esophagectomy for the treatment of esophageal cancer. Methods    From February 2018 to December 2019, 118 consecutive patients who underwent minimally invasive McKeown esophagectomy for esophageal squamous cell carcinoma in our hospital were included. There were 94 males and 24 females with an average age of 53.7 (41–77) years. They were divided into two groups based on the methods of gastric mobilization: a traditional dissociation (TD) group (n=55) and a single-direction mobilization (MD) group (n=63). The clinical data of the two groups were compared. Results    Enbloc resection and a negative resection margin were obtained in all patients. There was no postoperative mortality or incision complication. The rate of postoperative complications was 22.9%. There was no significant difference in the spleen injury, gastric injury, conversion to open surgery, abdominal reoperation as well as cervical anastomotic leakage between the two groups (P>0.05). It took significantly less time in the MD group compared with the TD group (P<0.05). There was an obvious statistical difference in the incidence of gastric mobilization related complications between the MD group (1.6%, 1/63) and TD group (12.7%, 7/55, P<0.05). Conclusion    Application of single-direction gastric mobilization under 3D-laparoscopy in minimally invasive esophagectomy for the treatment of esophageal cancer is safe and easy to perform with a satisfactory short-term outcome.

The modified minimally invasive esophagectomy using the concept of "single-direction" thoracoscopic technique / 中国胸心血管外科临床杂志

@#Objective    To explore the safety and feasibility of the modified and improved thoracoscopic surgery for esophageal cancer using the concept of "single-direction" thoracoscopic technique. Methods    The clinical data of 65 patients undergoing this modified minimally invasive esophagectomy based on "single-direction" thoracoscopic system between June 2018 and April 2019 were retrospectively analyzed, including 54 males and 11 females aged 62.5±7.8 years. Results    The thoracoscopic operation time was 133.4±28.6 min, and intraoperative blood loss was 61.9±29.2 mL. No intraoperative blood transfusion was needed. One patient was transferred to open thoracotomy (due to severe pleural adhesion atresia). Major complications included anastomotic leak, pneumonia, chylothorax, incisional infection, recurrent laryngeal nerve paralysis and gastric emptying disorders, which were recovered by conservative treatment. No postoperative death occurred. The median number of lymph nodes and lymph node station harvested was 19 and 10, respectively. The median postoperative hospital stay was 10 days. The volume of chest drainage was 1 117.3±543.4 mL. Conclusion    The minimally invasive operation mode of esophageal cancer based on "single-direction" thoracoscopic system is safe and feasible, and has good field vision and smooth and simplified procedure.

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.

Eventos adversos durante la esofagectomía mininvasiva en posición prona y su relación con la curva de aprendizaje / Adverse events during minimally invasive esophagectomy in prone position associated with the learning curve

Antecedentes: desde la introducción de la funduplicatura laparoscópica en 1991 para tratar la enfermedad por reflujo gastroesofágico, se han desarrollado diferentes procedimientos mininvasivos hasta llegar en la actualidad a las esofagectomías totalmente toracoscópicas y laparoscópicas. Objetivo: analizar los eventos adversos durante la esofagectomía mininvasiva en posición prona durante la curva de aprendizaje. Material y métodos: en el período comprendido entre noviembre de 2011 y junio de 2017 fueron intervenidos quirúrgicamente en el Hospital Interzonal General de Agudos San Martín (HIGA) y el Instituto de Diagnóstico de La Plata 36 pacientes mediante esofagectomía mininvasiva (EMI) en posición prona (PP). Resultados: durante el tiempo abdominal se produjo una lesión de vasos coronarios. En el tiempo torácico se registraron dos lesiones pulmonares, una lesión del cayado de vena ácigos y una sección del conducto torácico; además hubo un caso de daño al nervio recurrente y una lesión del bronquio fuente izquierdo durante la linfadenectomía. Al analizar el total de las complicaciones se observó que la mayoría de ellas se presentaron en los primeros 20 casos, mientras que en los 16 siguientes solo se registró una lesión pulmonar (p=0,10). Conclusión: como conclusión podemos decir que la EMI en PP, como ya es sabido, es un procedimiento factible y seguro pero ‒dada su complejidad‒ puede provocar lesiones intraoperatorias graves. Aunque los resultados de nuestra serie no arrojaron diferencias de significancia estadística, la cantidad de eventos adversos durante las operaciones realizadas por el mismo equipo disminuyó sensiblemente en la medida en que se adquirió el entrenamiento suficiente.

Background: Since the initial description of laparoscopic fundoplication in 1991 for the treatment of gastroesophageal reflux disease, different minimally invasive procedures have been developed until nowadays, when esophagectomy is performed using combined thoracoscopy and laparoscopy. Objective: The aim of our study is to analyze the adverse events of minimally invasive esophagectomy in prone position during the learning curve. Material and methods: Between November 2011 and June 2017, 36 patients underwent minimally invasive esophagectomy in prone position in the Hospital Interzonal General de Agudos (HIGA) San Martín and the Instituto de Diagnóstico de La Plata. Results: During the abdominal stage one patient presented coronary vessel injury. The complications occurring in the thoracic stage included lung injury (n =2), azygos arch injury (n = 1), thoracic duct dissection (n = 1), laryngeal recurrent nerve lesion (n = 1) and main stem bronchus injury (n = 1) during lymph node resection. Most of these complications occurred in the first 20 patients, while in the remaining 16 cases only lung injury occurred (p = 0.10) Conclusion: Minimally invasive esophagectomy in prone position is a feasible and safe procedure that can cause serious intraoperative complications due to its complexity. Although the results of our series did not show statistically significant differences, the number of adverse events during surgeries performed by the same team showed an important reduction associated with better training.

Learning curve of non-tube and early oral feeding after McKeown minimally invasive esophagectomy / 中国胸心血管外科临床杂志

@#Objective    To investigate the learning curve of non-tube and early oral feeding procedure following McKeown minimally invasive esophagectomy (MIE). Methods    We analyzed the clinical data of 38 patients (26 males, 12 females, aged 42–79 years) with esophageal cancer who received non-tube and early oral feeding procedure after surgery at the Affiliated Tumor Hospital, Zhengzhou University from November 2017 to August 2018. They suffered upper thoracic esophageal cancer (n=4), middle thoracic esophageal cancer (n=22) or lower thoracic esophageal cancer (n=12). Results    McKeown MIE was successfully performed on 38 patients. Oral feeding began 1.7 (1-4) days after surgery in the 38 patients with non-tube. Pneumonia/atelectasis occurred in 5 patients (13.1%), respiratory failure in 1 patient (2.6%), arrhythmia in 3 patients (7.9%), hoarseness in 5 patients (13.1%), anastomotic fistula in 1 patient (2.6%), cervical incision infection in 1 patient (2.6%), pneumomediastinum and infection in 1 patient (2.6%) and gastric emptying disorder in 2 patients (5.2%). No death was observed. After 26 patients with McKeown MIE were treated with enhanced recovery after surgery procedure, the operation time and complications could reach a relatively stable state and entered a plateau phase of learning curve. Conclusion    Non-tube and early oral feeding procedure following MIE is technically safe and feasible. It can shorten hospital stay, relieve the discomfort of placement of nasogastric and nutrition tube and may reduce the incidence of complications. The learning curve of non-tube and early oral feeding procedure following MIE is  about 26 cases.

Postoperative administration of flurbiprofen helps rapid rehabilitation of the patient following minimally invasive esophagectomy / 医学研究生学报

Objective Pain is an important factor affecting rapid rehabilitation of the patient after minimally invasive esophagectomy (MIE), and few studies are reported on the analgesic effect of intravenous administration of flurbiprofen (FBP) following MIE. This study was to investigate the role of FBP analgesia in rapid rehabilitation of the patients after MIE. Methods Sixty-four patients with esophageal cancer underwent MIE in the General Hospital of Eastern Theater Command from October 2015 to October 2016. Thirty-two of them received analgesia with a patient-controlled analgesia (PCA) pump (the control group) and the other 32 with FBP plus a PCA pump (the FBP group) postoperatively. We measured the concentrations of serum interleukin 6 (IL-6) and procalcitonin (PCT) at 12, 24, 48 and 72 hours after surgery, recorded the visual analog scale (VAS) pain scores at rest, and compared the parameters obtained between the two groups of patients. Results Compared with the control group, the FBP group showed significantly decreased concentrations of serum IL-6 ([156.53 ± 13.46] vs [120.19±13.52] μg/L, P < 0.05) and PCT ([1.99 ± 0.12] vs [1.89 ± 0.18] μg/L, P < 0.05) at 12 hours after MIE, even more significantly at 24, 48 and 72 hours (P < 0.05). And the VAS scores were markedly lower in the FBP than in the control group at all the four time points (P < 0.05). Conclusion Postoperative intravenous administration of flurbiprofen can significantly reduce inflammatory reaction, relieve pain and contribute to rapid rehabilitation after minimally invasive esophagectomy.

Short-term efficacy of purse-string Ivor-Lewis approach in minimally invasive esophagectomy for middle and lower esophageal cancer: A case control study / 中国胸心血管外科临床杂志

@#Objective    To compare the short-term efficacy of Ivor-Lewis via hand-sewn purse-string approach and purse-string forceps approach in minimally invasive esophagectomy for middle and lower esophageal cancer, and to discuss the safety and feasibility of hand-sewn purse-string anastomosis technique for minimally invasive Ivor-Lewis esophagectomy (MIILE). Methods     The clinical data of 151 patients undergoing thoracoscopic and laparoscopic esophageal cancer surgery from January 2014 to January 2017 in our hospital were retrospectively analyzed. According to the different methods of purse string making, the patients were divided into a purse-string forceps group including 49 males and 16 females with a mean age of 67.98±7.07 years ranging from 51 to 80 years treated with forceps to make purse-string and a handcraft group including 61 males and 25 females with a mean age of 67.76±8.18 years ranging from 52 to 83 years using hand-sewn way. The perioperative data of two two groups were compared. Results    The purse-string making time and postoperative total volume of chest drainage were less in the handcraft group than those in the purse-string forceps group (P<0.05). There was no significant difference between the two groups in hemorrhage during operation, the operation duration or postoperative hospital stay (P>0.05). There was also no statistical difference between the two groups in the rate of anastomotic or gastric tube fistula, anastomotic stenosis, pulmonary infection or incision infection (P>0.05). Conclusion    In minimally invasive esophagectomy for middle-lower section, MIILE by hand-sewn purse-string is as safe as purse-string forceps, with no more complications, needing no professional equipments, and easy to learn, master and promote.

Development and future of the minimally invasive esophagectomy for esophageal cancer / 中国胸心血管外科临床杂志

@#In this review, development and application of the minimally invasive esophagectomy(MIE) for esophageal cancer are discussed including the types of MIE procedures, short- and long- term outcome after MIE; as well the future of MIE is forecasted. Main procedures of MIE performed currently include esophagectomy via thoracoscopy and laparoscopy and cervical esophagogastrosty, Ivor-Lewis MIE via thoracoscopy and laparoscopy, and hiatal MIE. Ivor-Lewis MIE gradually becomes a standard surgical option for the cancer of distal esophagus or esophagogastric junction while the solution of intrathoracic anastomosis via thoracoscopy has achieved. Several methods of intrathoracic anastomosis are reported such as hand-sewn, circular stapler, side-to-side and triangular anastomosis. MIE could decrease operative blood loss, shorten hospital stay and ICU stay, reduce postoperative especially pulmonary complications, and harvest more lymph nodes compared to open esophagectomy. The long-term survival has been proved similar with that after open esophagectomy for esophageal cancer. MIE has developed rapidly in recent years with some aspects in future prospectively: individual MIE treatment and quality of life, fast track after surgery, and robot-assisted MIE, as well the endoscopic submucosal dissection for esophageal cancer is mentioned.

Feasibility of neoadjuvant therapy followed by minimally invasive esophagectomy for locally advanced esophageal cancer: A case control study / 中国胸心血管外科临床杂志

@#bjective    To evaluate the safety and efficacy of neoadjuvant therapy followed by minimally invasive esophagectomy (MIE) for locally advanced esophageal cancer. Methods    We retrospectively analyzed clinical data of 56 consecutive patients with locally advanced esophageal cancer treated by neoadjuvant therapy followed by surgery in our hospital between January 2015 and December 2016. There were 51 males and 5 females. The patients were divided into 2 groups. Neoadjuvant therapy followed by open surgery esophagectomy group was as an OE group with 25 patients aged 61 (50-73) years. And neoadjuvant therapy followed by MIE was as a MIE group with 31 patients aged 60 (55-79) years. Results    The pathologic complete response (pCR) rate of 28 patients with neoadjuvant concurrent chemoradiotherapy was significantly higher than that of 28 patients with neoadjuvant chemotherapy (21.4% vs. 10.7%, P<0.05). The operation time, intraoperative blood loss, R2 rate and the number of lymph nodes dissection in the MIE group were obviously better than those of the OE group with statistical differences (P<0.05). However, there was no significant difference in the number of resected lymph nodes along the bilateral recurrent laryngeal nerves and lymph node metastasis rate (P>0.05) between the two groups. The incidence of postoperative respiratory complications in the MIE group was lower than that of the OE group (P=0.041). There was no significant difference between the two groups in the incidence of other complications, re-operation, re-entry to ICU, median length of stay or perioperative deaths (P>0.05). There was only one patient with neoadjuvant concurrent chemoradiotherapy in the OE group died due to gastric fluid asphyxia caused by  trachea-esophageal fistula. Conclusion    Neoadjuvant therapy followed by MIE for locally advanced esophageal cancer is safe and feasible. The oncological outcomes seem comparable regardless of OE.

Thoracolaparoscopic versus open approach for thoracic esophageal squamous cell carcinoma: A case control study / 中国胸心血管外科临床杂志

@#Objective    To evaluate the security and outcomes of thoracolaparoscopic esophagectomy (TLE) versus open approach (OA) for thoracic esophageal squamous cell carcinoma. Methods    From June 2014 to June 2015, 125 patients with thoracic esophageal squamous cell carcinoma underwent esophagectomy through McKeown approach, including TLE (a TLE group, 107 patients, 77 males and 30 females) and OA (an OA group, 18 patients, 13 males and 5 females). The data of operation and postoperative complications of the two groups were analyzed retrospectively. Results    There was no statistical difference in the duration of operation and ICU stay and resected lymph nodes around laryngeal recurrent nerve between the TLE group and the OA group (333.58±72.84 min vs. 369.17±91.24 min, P=0.067; 2.84±1.44 d vs. 6.44±13.46 d, P=0.272; 4.71±3.87 vs. 3.89±3.97, P=0.408) . There was a statistical difference in blood loss, total resected lymph nodes and resected lymph nodes groups between TLE group and OA group (222.62±139.77 ml vs. 427.78±276.65, P=0.006; 19.62±9.61 vs. 14.61±8.07, P=0.038; 3.70±0.99 vs. 3.11±1.13, P=0.024). The rate of postoperative complications was 32.7% in the TLE group and 38.9% in the OA group (P=0.608). There was a statistical difference (P=0.011) in incidence of pulmonary infection (2.8% in the TLE group and 16.7% in the OA group). Incidences of complications, such as anastomotic leakage, cardiac complications, left-side hydrothorax, right-side pneumothorax, voice hoarse and incision infection, showed no statistical difference between two groups. Conclusion    For patients with thoracic esophageal squamous cell carcinoma, TLE possesses advantages of more harvested lymph nodes, less blood loss and less pulmonary infection comparing with open approach, and is complied with the principles of security and oncological radicality of surgery.

Current status and advances of uniportal video-assisted thoracoscopic esophagectomy / 中华消化外科杂志

Esophagectomy is one of the most complex interventions in thoracic surgery.Traditional open esophagectomy requires large incision and is associated with many complications.Video-assisted thoracoscopic surgery (VATS) contributes to less complications and hospital stay,and uniportal VATS has more minimal advantages over multi-portal VATS.Due to the technical complexity of esophagectomy,uniportal VATS is highly difficult.Surgeons from Taiwan reported uniportal VATS esophagectomy for the first time in 2015,and this uniportal technique was also reported by surgeons from other institutions.Nowadays,uniportal VATS esophagectomy is still in its initial stage,skills are immature,and long-term,large sample,controlled studies are demanded.Here,authors reviewed the development,skills,short-term outcomes,current practice in West China Hospital,the advantages and challenges for unipotrtal VATS esophagectomy.

Minimally invasive esophagectomy: practice of the standard of Chinese lymph node dissection / 中华胸心血管外科杂志

Objective To explore the application of the standard of Chinese lymph node dissection in minimally invasive esophagectomy.Methods Methods Between April 2014 to September 2015,63 patients with esophageal carcinoma received minimally invasive esophagectomy by the same group of surgeons.Wedescribed in detail the methods of thoracic esophagus mobilization and lymph node dissection in the peri-esophageal space.We analyzed the surgical effect,postoperative complications and follow-up results.Resnits The average operation time was(280.48 ± 44.28) mins,the median intraoperative blood loss was 100 ml,the mean number of lymph nodes was 22.25-± 11.18;the incidence of postoperative pulmonary infection in 28.57％,hoarseness was 17.46％,anastomotic leakage was 12.70％,postoperative 1 year survival rate was 84.1％,3 year survival rate of 61.1％.Conclusion Mobilization of thoracic esophagus based on peri-esophageal space and dissection lymph nodes guided by the Chinese standard of grouping lymph node would achieve good clinical effects.