Impact of the extent of recurrent laryngeal nerve lymphadenectomy on thoracic esophageal squamous cell carcinoma: a real-world multicentre study.

OBJECTIVES: To determine the impact of recurrent laryngeal nerve (RLN) lymph node (LN) dissection on survival and postoperative complications in patients with oesophageal squamous cell carcinoma (ESCC). METHODS: Patients with cT1-4N0-3M0 thoracic ESCC who underwent oesophagectomy and two-field lymphadenectomy from three institutions were included. The entire cohort was divided into three groups that underwent the total two-field lymphadenectomy (T-2FL), standard two-field lymphadenectomy (S-2FL) or unilateral RLN-LN dissection plus S-2FL (U-2FL) based on the extent of RLN-LN dissection. Subgroup analyses were also performed and were stratified by treatment modality. RESULTS: Both the U-2FL and T-2FL groups had significantly superior outcomes compared with the S-2FL group (overall survival: U-2FL versus S-2FL: P = 0.002; T-2FL versus S-2FL: P < 0.001; recurrence-free survival: U-2FL versus S-2FL: P = 0.01; T-2FL versus S-2FL: P < 0.001). Moreover, no significant differences were observed between U-2FL and T-2FL regarding overall survival (P > 0.05) and recurrence-free survival (P > 0.05), irrespective of administration of neoadjuvant therapy plus oesophagectomy or upfront oesophagectomy. Additionally, the extent of RLN-LN dissection was not an independent predictor of stage migration (P = 0.14) but was for postoperative nodal upstaging (P = 0.02). Notably, S-2FL brought significantly lowered risk in postoperative complications, especially for RLN palsy, when compared with T-2FL (P = 0.002) but not U-2FL (P = 0.72). CONCLUSIONS: Adequacy of RLN-LN dissection is an important prognosticator for improved overall survival and recurrence-free survival in patients with thoracic ESCC. U-2FL may serve as an alternative to T-2FL in selected populations.

[Efficacy Analysis of High-flow Nasal Oxygen Therapy in Patients 
Accepting Single-port Video-assisted Thoracoscopic Lobectomy].

BACKGROUND: Patients who underwent lobectomy resection are prone to hypoxemia, and the vast majority present with type I respiratory failure. Thus, improvement of hypoxemia is one of the most important factors to facilitate postoperative recovery of patients. In this study, the superiority-inferiority of different oxygen inhalation methods were compared with high-flow nasal oxygen therapy (HFNO), noninvasive mechanical ventilation (NIMV) and nasal oxygen breath (NOB) in patients with hypoxemia after single-port video-assisted thoracoscopic (VATS) lobectomy, and the clinical efficacy of HFNO in these patients was further investigated. METHODS: A total of 180 patients from the Second Affiliated Hospital of Soochow University in China with hypoxemia who accepting single-port VATS lobectomy from June 2021 to March 2022 were randomly divided into three groups (n=60), which were treated with HFNO, NIMV and NOB, respectively. The results of arterial blood gas analysis, patient's comfort score and incidence of complications were observed before, 1 h, 6 h-12 h and after use. Statistical analyses were conducted using statistical program for social sciences 25.0 (SPSS 25.0), and P<0.05 was considered as statistical significance. RESULTS: For patients with hypoxemia after accepting single-port VATS lobectomy, HFNO was no less effective than NIMV (P=0.333), and both of whom could fast increase patients' partial pressure of oxygen/fraction of inspiration O2 (PaO2/FiO2) compared to NOB (P<0.001). Besides, HFNO shows a great advantage in comfort degree and stay length (P<0.001, P=0.004), and incidence of complications were slightly lower than other groups (P=0.232). But it is worthy to note that HFNO is still slightly less effective than NIMV in patients with postoperative hypoxemia accompanied by elevated partial pressure of carbon dioxide (PaCO2). CONCLUSIONS: For patients with hypoxemia who accepting single-port VATS lobectomy, HFNO can be used as the first choice. However, for patients with postoperative hypoxemia accompanied by elevated PaCO2, NIMV is still recommended to improve oxygenation.

Log odds of positive lymph nodes is a robust predictor of survival and benefits from postoperative radiotherapy in stage IIIA-N2 resected non-small cell lung cancer.

BACKGROUND: The significance of postoperative adjuvant radiotherapy (PORT) on the survival of resected IIIA-N2 non-small cell lung cancer (NSCLC) remains controversial. Here, we aimed to determine the predictive value of the three nodal classifications which might aid in PORT decision-making. METHODS: A total of 4797 patients with stage IIIA-N2 resected NSCLC were identified in the Surveillance, Epidemiology and End Results (SEER) database and were grouped by whether PORT was administered. Survival analysis was used to identify the patient groups who can benefit from PORT. Multivariate analysis was performed to confirm the independent risk factors for lung cancer-specific survival (LCSS) and overall survival (OS). A validation cohort of 1184 patients from three medical centers in China were also included. RESULTS: PORT was not associated with better LCSS and OS in the entire cohort after propensity score matching (PSM). However, in the subgroups of positive lymph nodes 4 (PLN4), lymph node ratio 4 (LNR4), and log odds of positive lymph nodes 4 (LODDS4), PORT exhibited its role in improving LCSS (p < 0.05). Although the three nodal classifications were all identified as independent predictors of LCSS and OS, LODDS classification had the best discriminatory ability and prognostic accuracy for stage IIIA-N2 patients. Similar results were also obtained in the validation cohort. CONCLUSIONS: The LODDS classification not only exhibited the best prognostic performance in predicting LCSS and OS in stage IIIA-N2 disease, but also could help tailor individualized PORT.

HBO1 induces histone acetylation and is important for non-small cell lung cancer cell growth.

We examined the expression and the potential biological function of HBO1 in non-small cell lung cancer (NSCLC). TCGA and Oncomine databases showed that HBO1 transcripts were elevated in NSCLC. Furthermore, in local NSCLC tumor tissues HBO1 expression was higher than that in matched adjacent lung tissues. In primary and immortalized NSCLC cells, HBO1 shRNA robustly inhibited cell viability, proliferation and migration. Moreover, HBO1 knockout by CRISPR/Cas9 induced significant anti-tumor activity in NSCLC cells. Conversely, ectopic HBO1 overexpression in primary NSCLC cells increased proliferation and migration. H3-H4 histone acetylation and expression of several potential oncogenic genes (CCR2, MYLK, VEGFR2 and OCIAD2) were significantly decreased in NSCLC cells with HBO1 silencing or knockout. They were however increased after HBO1 overexpression. Intratumoral injection of HBO1 shRNA-expressing adeno-associated virus hindered the growth of A549 cell xenografts and primary NSCLC cell xenografts in nude mice. H3-H4 histone acetylation as well as expression of HBO1 and HBO1-dependent genes were decreased in HBO1-silenced NSCLC xenograft tissues. An HBO1 inhibitor WM-3835 potently inhibited NSCLC cell growth. Together, HBO1 overexpression promotes NSCLC cell growth.

Learning curve for uniportal video-assisted thoracoscopic anatomical segmentectomy.

BACKGROUND: Anatomical segmentectomy by uniportal video-assisted thoracoscopic surgery (U-VATS) is a delicate surgical procedure. Hitherto, only few studies have assessed the learning curves of anatomical segmentectomy by U-VATS, with varying data available. The present study aimed to investigate the learning curve and clinical advantages for U-VATS segmentectomy. METHODS: The medical records of patients who underwent U-VATS or non-U-VATS segmentectomy between August 2017 and May 2020 were retrospectively reviewed. Cumulative sum (CUSUM) analysis was employed to illustrate the learning curve of U-VATS segmentectomy. Perioperative parameters were used to determine the structural intervals of the learning curve, and to compare U-VATS and non-U-VATS segmentectomy. RESULTS: In total, 122 patients receiving U-VATS segmentectomy and 98 patients receiving non-VATS segmentectomy were included. Of these, 116 patients underwent successful U-VATS segmentectomy, while the other six patients underwent conversions. The structural intervals of 20-29 cases and 58-63 cases were determined as the threshold according to the CUSUM analyses. The learning process of U-VATS segmentectomy was therefore divided into three phases. Interestingly, the perioperative parameters differed significantly between Phases 1 and 3, including operative time (Op-T), postoperative hospital stays (Po-Hst), postoperative thoracic drainage (Po-D), and operative failure (Po-F) rates (P<0.05). Moreover, U-VATS segmentectomy in Phase 3 was associated with significantly shorter Po-Hst and Op-T, less Po-D, and reduced postoperative pain compared with non-U-VATS (P<0.05). CONCLUSIONS: U-VATS segmentectomy is an ideal alternative to non-U-VATS segmentectomy. Surgeons can preliminarily complete U-VATS anatomical segmentectomy after performing 20-29 cases, and can master the surgical techniques after completing 58-63 cases.

The requirement of mitochondrial RNA polymerase for non-small cell lung cancer cell growth.

POLRMT (RNA polymerase mitochondrial) is responsible for the transcription of mitochondrial genome encoding key components of oxidative phosphorylation. This process is important for cancer cell growth. The current study tested expression and potential functions of POLRMT in non-small cell lung cancer (NSCLC). TCGA cohorts and the results from the local lung cancer tissues showed that POLRMT is overexpressed in human lung cancer tissues. In both primary human NSCLC cells and A549 cells, POLRMT silencing (by targeted lentiviral shRNAs) or knockout (through CRSIPR/Cas9 gene editing method) potently inhibited cell viability, proliferation, migration, and invasion, and induced apoptosis activation. On the contrast, ectopic overexpression of POLRMT using a lentiviral construct accelerated cell proliferation and migration in NSCLC cells. The mtDNA contents, mRNA levels of mitochondrial transcripts, and subunits of respiratory chain complexes, as well as S6 phosphorylation, were decreased in POLRMT-silenced or -knockout NSCLC cells, but increased after ectopic POLRMT overexpression. In vivo, intratumoral injection of POLRMT shRNA adeno-associated virus (AAV) potently inhibited NSCLC xenograft growth in severe combined immune deficiency mice. The mtDNA contents, mRNA levels of mitochondria respiratory chain complex subunits, and S6 phosphorylation were decreased in POLRMT shRNA AAV-injected NSCLC xenograft tissues. These results show that POLRMT is a novel and important oncogene required for NSCLC cell growth in vitro and in vivo.

Cytosolic protein delivery via metabolic glycoengineering and bioorthogonal click reactions.

Cytosolic protein delivery holds great potential for the development of protein-based biotechnologies and therapeutics. Currently, cytosolic protein delivery is mainly achieved with the assistance of various carriers. Herein, we present a universal and effective strategy for carrier-free cytosolic protein delivery via metabolic glycoengineering and bioorthogonal click reactions. Ac4ManNAz (AAM), an azido-modified N-acetylmannosamine analogue, was first employed to label tumor cell surfaces with abundant azido groups via glycometabolism. Then, proteins including RNase A, cytochrome C (Cyt C), and bovine serum albumin (BSA) were covalently modified with dibenzocyclooctyne (DBCO). Based on the highly efficient bioorthogonal click reactions between DBCO and azido, DBCO-modified proteins could be efficiently internalized by azido-labeled cancer cells. RNase A-DBCO could largely maintain its enzymatic activity and, thus, led to notable anti-tumor efficacy in HeLa and B16F10 cells in vitro and in B16F10 xenograft tumors in vivo. This study therefore provides a simple and powerful approach for carrier-free protein delivery and would have broad applicability in anti-tumor protein therapy.

M2 macrophage-derived exosomal long non-coding RNA AGAP2-AS1 enhances radiotherapy immunity in lung cancer by reducing microRNA-296 and elevating NOTCH2.

Long noncoding RNAs (lncRNAs) and microRNAs (miRNAs) play vital roles in human diseases. We aimed to identify the effect of the lncRNA AGAP2 antisense RNA 1 (AGAP2-AS1)/miR-296/notch homolog protein 2 (NOTCH2) axis on the progression and radioresistance of lung cancer. Expression of AGAP2-AS1, miR-296, and NOTCH2 in lung cancer cells and tissues from radiosensitive and radioresistant patients was determined, and the predictive role of AGAP2-AS1 in the prognosis of patients was identified. THP-1 cells were induced and exosomes were extracted, and the lung cancer cells were respectively treated with silenced AGAP2-AS1, exosomes, and exosomes upregulating AGAP2-AS1 or downregulating miR-296. The cells were radiated under different doses, and the biological processes of cells were assessed. Moreover, the natural killing cell-mediated cytotoxicity on lung cancer cells was determined. The relationships between AGAP2-AS1 and miR-296, and between miR-296 and NOTCH2 were verified. AGAP2-AS1 and NOTCH2 increased while miR-296 decreased in radioresistant patients and lung cancer cells. The malignant behaviors of radioresistant cells were promoted compared with the parent cells. Inhibited AGAP2-AS1, macrophage-derived exosomes, and exosomes overexpressing AGAP2-AS1 or inhibiting miR-296 facilitated the malignant phenotypes of radioresistant lung cancer cells. Furthermore, AGAP2-AS1 negatively regulated miR-296, and NOTCH2 was targeted by miR-296. M2 macrophage-derived exosomal AGAP2-AS1 enhances radiotherapy immunity in lung cancer by reducing miR-296 and elevating NOTCH2. This study may be helpful for the investigation of radiotherapy of lung cancer.

Extracapsular lymph node involvement is a robust survival predictor in esophageal cancer patients: A pooled analysis.

BACKGROUND: Although extracapsular lymph node involvement (EC-LNI) has been proposed to be incorporated into the staging system of esophageal cancer, the prognostic value of EC-LNI remains controversial with conflicting data available, especially in the era of neoadjuvant therapy. METHODS: An electronic literature search was undertaken using four public databases. Studies investigating the effects of EC-LNI on survival were included. In addition to analysis of the entire cohort, subset analyses were also performed to assess the impact of EC-LNI on patients receiving different treatment modalities. RESULTS: A total of 20 studies were included in this meta-analysis. Pooling 13 studies on overall survival (OS), we observed that presence of EC-LNI was associated with significantly worse OS (HR = 2.09, 95%CI: 1.63-2.68; p < 0.01). Nine studies describing disease-free survival (DFS) included, the pooled data revealed that presence of EC-LNI was associated with significantly worse DFS (HR = 1.89, 95%CI: 1.63-2.20; p < 0.001). Subset analyses of patients receiving neoadjuvant therapy demonstrated a survival disadvantage of EC-LNI on OS (HR = 1.928, 95%CI: 1.196-3.107; p = 0.007) and DFS (HR = 1.985, 95%CI: 1.585-2.487; p < 0.001). Similar result was also seen in patients receiving primary surgery (OS: HR = 2.219, 95%CI: 1.720-2.864; p < 0.001; DFS: HR = 1.659, 95%CI: 1.285-2.141; p < 0.001). CONCLUSION: EC-LNI is a strong prognostic predictor of inferior survival in patients with esophageal cancer irrespective of treatment modality. The currently pooled evidence indicates that EC-LNI has great potential to be incorporated into the future staging system.

Simultaneous Vascular Reconstruction and Cervical Anastomosis in McKeown Esophagectomy.

A stomach was considered ineligible to be an ideal conduit conventionally if its right gastroepiploic artery (RGEA) were injured. However, both sufficient blood flow and good venous return are crucial to the success of reconstruction. And there lacks robust evidence regarding the surgical techniques of reconstructing RGEA and right gastroepiploic vein (RGEV) and performing cervical anastomosis with gastric conduit simultaneously. Herein, we summarized the key surgical techniques for simultaneous vascular reconstruction and gastric conduit anastomosis in McKeown esophagectomy.

AMPK activation by ASP4132 inhibits non-small cell lung cancer cell growth.

Activation of adenosine monophosphate-activated protein kinase (AMPK) is able to produce significant anti-non-small cell lung cancer (NSCLC) cell activity. ASP4132 is an orally active and highly effective AMPK activator. The current study tested its activity against NSCLC cells. In primary NSCLC cells and established cell lines (A549 and NCI-H1944) ASP4132 potently inhibited cell growth, proliferation and cell cycle progression as well as cell migration and invasion. Robust apoptosis activation was detected in ASP4132-treated NSCLC cells. Furthermore, ASP4132 treatment in NSCLC cells induced programmed necrosis, causing mitochondrial p53-cyclophilin D (CyPD)-adenine nucleotide translocase 1 (ANT1) association, mitochondrial depolarization and medium lactate dehydrogenase release. In NSCLC cells ASP4132 activated AMPK signaling, induced AMPKα1-ACC phosphorylation and increased AMPK activity. Furthermore, AMPK downstream events, including mTORC1 inhibition, receptor tyrosine kinases (PDGFRα and EGFR) degradation, Akt inhibition and autophagy induction, were detected in ASP4132-treated NSCLC cells. Importantly, AMPK inactivation by AMPKα1 shRNA, knockout (using CRISPR/Cas9 strategy) or dominant negative mutation (T172A) almost reversed ASP4132-induced anti-NSCLC cell activity. Conversely, a constitutively active AMPKα1 (T172D) mimicked and abolished ASP4132-induced actions in NSCLC cells. In vivo, oral administration of a single dose of ASP4132 largely inhibited NSCLC xenograft growth in SCID mice. AMPK activation, mTORC1 inhibition and EGFR-PDGFRα degradation as well as Akt inhibition and autophagy induction were detected in ASP4132-treated NSCLC xenograft tumor tissues. Together, activation of AMPK by ASP4132 potently inhibits NSCLC cell growth in vitro and in vivo.

Endoscopic resection versus esophagectomy for patients with small-sized T1N0 esophageal cancer: A propensity-matched study.

OBJECTIVES: Endoscopic resection (ER) has been rapidly adopted in the treatment of early-stage esophageal cancer. We aimed to compare the outcomes of ER with esophagectomy for patients with small-sized (≤2 cm) stage T1a and T1b esophageal cancer in a population-based cohort. METHODS: We queried the Surveillance, Epidemiology, and End Results database for patients with T1N0M0 esophageal cancer who underwent ER or esophagectomy and generated a balanced cohort with 217 matched pairs using propensity score matching (PSM). Kaplan-Meier method and multivariable Cox regression analysis were employed to investigate the matched cohort. Subgroup analyses of T stage were also performed. RESULTS: We identified 702 patients; 309 (44.0 %) underwent ER, and 393 (56.0 %) underwent esophagectomy. In the unmatched cohort, patients who underwent ER were older, more likely to have a T1a stage, and less likely to receive lymph node sampling. In the entire matched cohort, multivariate analysis found esophagectomy were associated with better overall survival (OS) (HR: 0.62, 95 % CI: 0.40-0.96, p = 0.032) than ER, but no significant difference in esophageal cancer-specific survival (ECSS) (HR: 1.37, 95 % CI: 0.64-2.96, p = 0.420) between the two procedures. The results were similar for subgroup analyses of stage T1b patients. However, ER and esophagectomy were associated with similar OS (HR: 0.74, 95 % CI: 0.41-1.36; p = 0.334) and ECSS (HR: 3.69, 95 % CI: 0.95-14.39; p = 0.060) in patients with stage T1a disease. CONCLUSIONS: In patients with stage T1 esophageal cancer, ER was similar to esophagectomy in terms of oncologic outcomes. More prospective studies should be implemented to determine the optimal treatment for T1b esophageal cancer patients with risk factors.

Comparison of Ivor Lewis and Sweet esophagectomy for middle and lower esophageal squamous cell carcinoma: A systematic review and pooled analysis.

BACKGROUND: Lack of robust evidence highlights the important need to address the controversy on the clinical safety and effectiveness between Ivor Lewis versus Sweet procedure for middle and lower esophageal squamous cell carcinoma (ESCC). METHODS: Search results were filtered according to certain criteria and were analyzed in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. FINDINGS: The inter-study heterogeneity was high. Ivor Lewis procedure might be associated with longer operation time (p < 0.01) and higher lymph node yield (p < 0.01) compared with Sweet procedure. There was no significant difference in the length of hospital stay and postoperative complications with similar reoperation rate between the two procedures (p > 0.05). As the combined analysis of survival data revealed, there was no statistical difference in the oncologic efficacy of them (p = 0.97). INTERPRETATION: The present study based on retrospective data with high heterogeneity indicated that Ivor Lewis esophagectomy might be associated with increased lymph node yield but longer operation time than Sweet. Prospective studies are warranted to compare the long-term survival of Ivor Lewis esophagectomy versus Sweet for middle and lower ESCC.

Long non-coding RNA CASC8 polymorphisms are associated with the risk of esophageal cancer in a Chinese population.

BACKGROUND: Esophageal cancer (EC) is an important disease that threatens public health and safety. Although there are numerous treatment options for esophageal cancer including surgery, radiation therapy, and chemotherapy, these treatments have limited effects. Its morbidity and mortality vary widely among countries and regions. Esophageal cancer is classified into squamous cell carcinoma (ESCC) and esopheageal adenocarcinoma (EADC). Here, we examined the genetic susceptibility to ESCC in relation to functional single nucleotide polymorphisms (SNPs) in the long non-coding RNA (lncRNA) CASC8. METHODS: To detect the susceptibility to ESCC in relation to functional polymorphisms in CASC8, a hypothesis-driven study was performed to identify CASC8 SNPs in 949 patients with ESCC and 1369 control subjects. RESULTS: The CASC8 rs1562430 GG genotype was significantly associated with increased ESCC risk in men, patients younger than 63 years, non-smokers, and nondrinkers. CONCLUSIONS: CASC8 rs1562430 A > G may cause susceptibility to ESCC and CASC8 SNPs may play a vital role in ESCC risk, thereby serving as a potential biomarker for diagnosing ESCC. A larger sample size and multifactor information are needed to confirm these results.

Does the lymph node yield affect survival in patients with esophageal cancer receiving neoadjuvant therapy plus esophagectomy? A systematic review and updated meta-analysis.

BACKGROUND: Conflicting data have been reported on the prognostic impact of the extent of lymphadenectomy during esophagectomy for esophageal cancer (EC) after neoadjuvant therapy, especially after neoadjuvant chemoradiotherapy (nCRT). METHODS: A comprehensive online search was performed to explore the association between increased lymph node yield (LNY) and survival of patients with EC, in which the overall survival (OS) was set as the primary outcome. In addition to analysis of the entire cohort, subgroup analyses of different induction therapy and different populations were also performed. FINDINGS: A total of 19528 patients from twelve studies were included in our study. The pooled data revealed that more lymph node harvested was associated with better OS (HR = 0·87; 95% CI: 0·79-0·95, p < 0·001). Notably, a higher LNY was associated with better OS if the threshold was less than 18. However, more thorough lymphadenectomy might not bring additional survival benefits when it came to a cutoff value more than 18. The subgroup analysis further revealed that a higher LNY after nCRT was associated favorable survival. In terms of subset analysis of different populations, increased LNY was associated with longer OS in Western populations but not in Eastern. INTERPRETATION: Increased LNY during esophagectomy after neoadjuvant therapy, especially after nCRT, might be associated with improved OS. More studies are warranted to assess the survival benefits of a higher LNY receiving neoadjuvant therapy plus esophagectomy, especially in Eastern populations. FUNDING: Supported by the projects from Suzhou Key Laboratory of Thoracic Oncology (SZS201907), Suzhou Key Discipline for Medicine (SZXK201803), the Science and Technology Research Foundation of Suzhou Municipality (SYS2018063, SYS2018064), Municipal Program of People's Livelihood Science and Technology in Suzhou (SS2019061) and Major Project for Social Development, Jiangsu Provincial Department of Science and Technology (SBE2020750085).

Strategy for initial en bloc resection of a giant mediastinal solitary fibrous tumor: Judicious usage of cardiopulmonary bypass.

A solitary fibrous tumor (SFT) is a rare mediastinal neoplasm associated with a high recurrence rate. Total excision on initial surgery is an established indicator of a positive outcome. Here, we report the case of a 52-year-old man who was admitted to our hospital with symptoms of cough, chest pain, and dyspnea for two months. Chest computed tomography (CT) scan revealed a middle mediastinal mass which infiltrated adjacent vital structures, and surgery was performed with the assistance of cardiopulmonary bypass (CPB) and median sternotomy. The mass was completely removed and histopathology confirmed the presence of a mesenchymal tumor. The patient had an uneventful recovery without any perioperative symptoms, hoarseness, or dysfunction of the diaphragm. Sixty-nine months after surgery, a CT scan confirmed that the patient remained disease-free without necessitating the introduction of chemotherapy or radiotherapy. Here, to the best of our knowledge, we report the first case of a giant invasive mediastinal SFT that was completely resected during initial surgery under CPB with a remarkable outcome.

Is the result of modified Allen's test still accurate after endoscopic thoracic sympathectomy?

BACKGROUND: The radial artery (RA) is increasingly being used for coronary artery bypass grafting (CABG). Endoscopic thoracic sympathectomy (ETS) has been shown to block innervation of sympathetic nerves of upper limbs, which reduces sweating of hands and dilates blood vessels. The modified Allen's test (MAT) is one of the commonest methods of assessing collateral arm flow prior to RA harvest, though it has limitations. However, the reliability of MAT after ETS remains unclear. We therefore investigated the effects of ETS on the results of MAT. METHODS: A retrospective cohort study was conducted on 164 consecutive Chinese patients with palmar hyperhidrosis who underwent ETS between January 2016 and January 2019. The medical records were reviewed concerning the ultrasound examination and MAT results of their RAs and ulnar arteries (UAs) in both forearms before and after ETS. RESULTS: The performance of ETS significantly increased the diameter of the right RA from 2.731±0.122 to 3.102±0.114 mm in men and from 2.347±0.074 to 2.915±0.162 mm in women. Similar effects of ETS were observed in expanding the diameters of the left RA and the UA. Meanwhile, there was no significant effect of ETS on systolic blood pressure (BP) and heart rate (HR). Overall, retesting of patients following ETS with a preoperative positive MAT result revealed a transition to a negative result. CONCLUSIONS: ETS was effective in dilating RA in both men and women, which could lead to a false negative preoperative MAT result. Patients should be questioned about their history of ETS if their RAs are to be harvested for CABG. More studies are warranted to evaluate the safety of RA as a coronary artery graft after ETS.

Postoperative short-term outcomes of minimally invasive versus open esophagectomy for patients with esophageal cancer: An updated systematic review and meta-analysis.

BACKGROUND: We performed a systematic review and meta-analysis to synthesize the available evidence regarding short-term outcomes between minimally invasive esophagectomy (MIE) and open esophagectomy (OE). METHODS: Studies were identified by searching databases including PubMed, EMBASE, Web of Science and Cochrane Library up to March 2019 without language restrictions. Results of these searches were filtered according to a set of eligibility criteria and analyzed in line with PRISMA guidelines. RESULTS: There were 33 studies included with a total of 13 269 patients in our review, out of which 4948 cases were of MIE and 8321 cases were of OE. The pooled results suggested that MIE had a better outcome regarding all-cause respiratory complications (RCs) (OR = 0.56, 95% CI = 0.41-0.78, P = <0.001), in-hospital duration (SMD = -0.51; 95% CI = -0.78-0.24; P = <0.001), and blood loss (SMD = -1.44; 95% CI = -1.95-0.93; P = <0.001). OE was associated with shorter duration of operation time, while no statistically significant differences were observed regarding other outcomes. Additionally, subgroup analyses were performed for a number of different postoperative events. CONCLUSIONS: Our study indicated that MIE had more favorable outcomes than OE from the perspective of short-term outcomes. Further large-scale, multicenter randomized control trials are needed to explore the long-term survival outcomes after MIE versus OE.

Significance of TIM-3 Expression in Resected Esophageal Squamous Cell Carcinoma.

BACKGROUND: T-cell immunoglobulin and mucin-domain containing-3 (TIM-3) is a promising checkpoint. However, its features and prognostic value remain undetermined in esophageal squamous cell carcinoma (ESCC). This study evaluated the prognostic value of TIM-3 expression and its relationship with programmed cell death 1 (PD-1) and CD8+ tumor-infiltrating lymphocytes (TILs) in patients with surgically resected ESCC. METHODS: Expression levels of TIM-3, PD-1, and CD8+ TILs in ESCC were determined by immunohistochemistry. The association between clinicopathologic features or clinical outcomes and TIM-3 expression was analyzed. RESULTS: A total of 183 patients with ESCC who had undergone esophagectomy without implementation of neoadjuvant therapy at the Second Affiliated Hospital of Soochow University in Suzhou, China from January 2009 to December 2014 were included. PD-1 positivity (P = .032) and high CD8+ TIL density (P = .035) significantly correlated with positive TIM-3 expression. TIM-3 positivity was an independent risk factor for recurrence-free survival (RFS) (P < .001) and overall survival (OS) (P < .001). Subgroup analysis revealed that the TIM-3+PD-1+CD8 low group had the worst RFS and OS, whereas the TIM-3-PD-1-CD8 high group had the best RFS and OS (RFS: log-rank test P < .001; OS: log-rank test P < .001). CONCLUSIONS: Positive TIM-3 expression was associated with PD-1 positivity and high CD8+ TIL density and was an independent risk factor for RFS and OS in ESCC. Furthermore, the combination of TIM-3 and PD-1 expression or CD8+ TIL density could further stratify patients into different groups with distinct prognosis.