Modified Subxiphoid Thoracoscopic Thymectomy for Locally Invasive Thymoma.

BACKGROUND: We explored the feasibility and safety of modified subxiphoid thoracoscopic thymectomy for patients with locally invasive thymomas. METHODS: Subxiphoid thoracoscopic thymectomy was performed on select patients with locally invasive thymomas (Masaoka stage III) using an auxiliary sternal retractor to create a larger operative field. RESULTS: From June 2015 to March 2019, we performed modified subxiphoid thoracoscopic thymectomy on 48 patients with locally invasive thymomas: 39 patients had pericardium or lung infiltration and received a combination of a partial pericardium or lung wedge resection, and 9 patients had left innominate vein infiltration and underwent combined resection of the left innominate vein. Thoracoscopic thymectomy was performed from the subxiphoid pathway with an auxiliary sternal retractor in all 48 patients, and there were no conversions to median sternotomy. The median tumor size was 5 cm, and the maximal tumor size was 12 cm. The median blood loss was 50 mL. The median duration of chest tube placement was 3 days, and the median hospital stay was 4.5 days after surgery. All patients achieved a good recovery after surgery, and none had serious complications during the perioperative period. All patients underwent postoperative adjuvant radiotherapy and presented no local recurrence or distant metastasis until now. CONCLUSIONS: Modified subxiphoid thoracoscopic thymectomy with an auxiliary sternal retractor makes minimally invasive thymectomy easier and safer to perform and is an alternative approach for some patients with locally invasive thymomas.

Engineering surface oxygen defects on tungsten oxide to boost photocatalytic oxygen evolution from water splitting.

The engineering of surface oxygen vacancies (OVs) in WO3 was primitively done using a facile solvothermal method. The photocatalytic activities of the as-prepared samples were studied by evaluating their performances in the photocatalytic OER. The best sample (W-3) yielded 57.6 µmol of O2 in 6 h under the illumination of simulated sunlight.

The evolution of surgical approach for esophageal cancer.

Esophageal surgery for esophageal cancer has been performed for over a century now. Minimally invasive esophagectomy (MIE) was first described in 1992, and it is now a standard approach in many countries. However, MIE is technically difficult and requires a long learning curve. It takes >100 cases to train for MIE with gastric tube reconstruction with an intrathoracic anastomosis. A possible option to overcome several challenges of MIE might be the use of a robotic system. A robot-assisted MIE was first described in 2005, and long-term results have shown its feasibility and safety. Over the years, different approaches for esophagectomy have been established. Our review discusses these developments and recent literature on open, minimally invasive and robotic esophageal surgery.

Effect of Early Full-Calorie Nutrition Support Following Esophagectomy: A Randomized Controlled Trial.

BACKGROUND: Early use of enteral nutrition (EN) is indicated following surgical resection of esophageal cancer. However, early EN support does not always meet the optimal calorie or protein requirements, and the benefits of supplementary parenteral nutrition (PN) remain unclear. We aimed to evaluate the efficacy and safety of early supplementary PN following esophagectomy. MATERIALS AND METHODS: We enrolled 80 consecutive patients who underwent esophagectomy. Resting energy expenditure and body composition measurements were performed in all patients preoperatively and postoperatively. EN was administered after surgery, followed by randomization to either EN+PN or EN alone. The amount of PN administered was calculated to meet the full calorie requirement, as measured by indirect calorimetry, and 1.5 g protein/kg fat-free mass (FFM) per day was added as determined by body composition measurement. The clinical characteristics were compared between the 2 groups. RESULTS: Patients in the EN+PN group but not in the EN group preserved body weight (0.18 ± 3.38 kg vs -2.15 ± 3.19 kg, P < .05) and FFM (1.46 ± 2.97 kg vs -2.08 ± 4.16 kg) relative to preoperative measurements. Length of hospital stay, postoperative morbidity rates, and standard blood biochemistry profiles were similar. However, scores for physical functioning (71.5 ± 24.3 vs 60.4 ± 27.4, P < .05) and energy/fatigue (62.9 ± 19.5 vs 54.2 ± 23.5, P < .05) were higher in the EN+PN group 90 days following surgery. CONCLUSION: Early use of supplemental PN to meet full calorie requirements of patients who underwent esophagectomy led to better quality of life 3 months after surgery. Moreover, increased calorie and protein supplies were associated with preservation of body weight and FFM.

Long-Term Survival After Surgical Treatment of Thymic Carcinoma: A Retrospective Analysis from the Chinese Alliance for Research of Thymoma Database.

BACKGROUND: Thymic carcinoma is a type of rare and highly malignant tumor that originates from the thymic epithelium. Treatment and prognosis of thymic carcinoma remain controversial. We retrospectively analyzed survival data from a large-sample multicenter database in China. METHODS: The Chinese Alliance for Research of Thymoma constructed a retrospective database of patients with thymic epithelial tumors, which enrolled 1930 patients from January 1996 to August 2013, including 329 with thymic carcinomas. In this study, we analyzed clinical, pathologic, and treatment information, measured long-term survival rates, and identified relevant prognostic factors. RESULTS: Of 329 patients, R0 resection was performed in 211 (57.7 %), R1 in 34 (9.2 %), and R2 in 84 (22.5 %).The 3-, 5-, and 10-year survival rates were 78.3, 67.1, and 47.9 %, respectively. In univariate analysis, early Masaoka-Koga stage, R0 resection, and postoperative radiotherapy were associated with better overall survival.Early Masaoka-Koga stage and postoperative radiotherapy were also associated with disease-free survival. In multivariate analyses, R0 resection, Masaoka-Koga stage, and postoperative radiotherapy were significant prognostic factors of survival. CONCLUSIONS: Complete resection is the preferred primary treatment for thymic carcinoma. R0 resection, early Masaoka-Koga stage, and postoperative radiotherapy are significant predictors of improved survival.

Clinical significance of cyclophilin a expression in esophageal squamous cell carcinoma.

OBJECTIVE: To explore the expression of cyclophilin A (CypA) in esophageal tissues and its clinical significance. METHOD: Expression of CypA was detected in 236 esophageal cancer tissues and 236 normal tissues by using an immunohistochemical method, and the relationship between CypA expression and clinical outcomes was observed. RESULTS: There were 166 patients with high expression of CypA (70.23%) and a higher expression in 69.3% of males and 73.3% in females. The CypA expression was irrelevant to age, tumor location, lymph node metastasis, and tumor differentiation degree. The Kaplan-Meier survival curve analysis showed that the expression of CypA was associated with the prognosis of patients with esophageal squamous cell carcinoma. CONCLUSION: The poor prognosis of esophageal cancer patients was associated with high expression of CypA.

Video-assisted mediastinoscopic resection compared with video-assisted thoracoscopic surgery in patients with esophageal cancer.

OBJECTIVE: The purpose of this study was to explore the indications of radical vedio-assisted mediastinoscopic resection for esophageal cancer. METHODS: The data of 109 patients with T1 esophageal cancer who underwent video-assisted mediastinoscopic resection (VAMS group) in Third Affiliated Hospital of Soochow University Hospital from December 2005 to December 2011 were collected in the study for comparison with the 58 patients with T1 esophageal cancer who underwent video-assisted thoracoscopic surgery (VATS group) in Zhongshan Hospital, Fudan University. The perioperative safety and survival were compared between the two groups. RESULTS: All operations were successful in both groups. One perioperative death was noted in the VATS group. The incidences of post-operative complications were not significantly different between these two groups, whereas the VAMS group was favorable in terms of operative time (P<0.001) and blood loss (P<0.001), and a significantly larger number of chest lymph nodes were dissected in the VATS group compared with the VAMS group (P<0.001). Long-term follow-up showed that the overall survival was not significantly different between these two groups (P=0.876). CONCLUSIONS: T1N0M0 esophageal cancer can be as the indication of VAMS radical resection. VAMS radical resection can be considered as the preferred option for patients with poor pulmonary and cardiac function or a history of pleural disease.

[Evaluation of safety of video-assisted thoracoscopic esophagectomy for esophageal carcinoma].

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

[Feasibility and safety of radical mediastinal lymphadenectomy in thoracoscopic esophagectomy for esophageal cancer].

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

Minimally invasive esophagectomy for esophageal squamous cell carcinoma: a case-control study of thoracoscope versus mediastinoscope assistance.

OBJECTIVE: Minimally invasive esophagectomy (MIE) has been widely applied for esophageal carcinoma treatment. Thoracoscope-assisted transthoracic esophagectomy (TATTE) and mediastinoscope-assisted transhiatal esophagectomy (MATHE) are two kinds of MIE. The objective of this study is to compare these two methods with respect to surgical safety and survival. METHODS: Single-institution experience with MATHE and TATTE was analyzed to assess morbidity, adequacy of tumor clearance, and survival. A pair-matched case-control study was performed to compare 54 patients who underwent either MATHE or TATTE between July 2000 and December 2009. Patients were matched by age, sex, comorbidity, forced expiratory volume in 1 s (FEV1), tumor location, and stage. RESULTS: Statistically significant differences between the MATHE group and the TATTE group were: shorter operative time for MATHE (194.4 min) versus TATTE (228.1 min), less blood loss during operation in the TATTE group (142.6 ml) versus the MATHE group (214.6 ml), and more lymph nodes retrieved in the TATTE group (19.1 nodes) versus the MATHE group (11.4 nodes). There was no difference in survival between the groups. CONCLUSIONS: MATHE and TATTE are both technically feasible. TATTE can provide better visibility. TATTE has less blood loss compared with MATHE. More adequate tumor clearance in terms of lymph node dissection can be achieved with TATTE.

[Comparison of thoracoscopic esophagectomy in decubitus position with prone position].

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

Identification of galectin-7 as a potential biomarker for esophageal squamous cell carcinoma by proteomic analysis.

BACKGROUND: Esophageal squamous cell carcinoma (ESCC) is one of the most common malignancies. Early diagnosis is critical for guiding the therapeutic management of ESCC. It is imperative to find more effective biomarkers of ESCC. METHODS: To identify novel biomarkers for esophageal squamous cell carcinoma (ESCC), specimens from 10 patients with ESCC were subjected to a comparative proteomic analysis. The proteomic patterns of ESCC samples and normal esophageal epithelial tissues (NEETs) were compared using two-dimensional gel electrophoresis. And differentially expressed proteins were identified using MALDI-TOF-MS/MS. For further identification of protein in selected spot, western blotting and immunohistochemistry were employed. RESULTS: Twelve proteins were up-regulated and fifteen proteins were down-regulated in the ESCC samples compared with the NEET samples. Up-regulation of galectin-7 was further confirmed by western blotting and immunohistochemistry. Furthermore, immunohistochemical staining of galectin-7 was performed on a tissue microarray containing ESCC samples (n = 50) and NEET samples (n = 10). The expression levels of galectin-7 were markedly higher in the ESCC samples than in the NEET samples (P = 0.012). In addition, tissue microarray analysis also showed that the expression level of galectin-7 was related to the differentiation of ESCC. CONCLUSIONS: The present proteomics analysis revealed that galectin-7 was highly expressed in ESCC tissues. The alteration in the expression of galectin-7 was confirmed using a tissue microarray. These findings suggest that galectin-7 could be used as a potential biomarker for ESCC.

[Comparison of retrosternal and posterior mediastinal gastric tube reconstruction after three-phase esophagectomy].

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

[Video-assisted thoracoscopic esophagectomy in esophageal carcinoma].

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

[The value of multislice spiral computed tomography in demonstrating the relationship between bronchus and peripheral lung cancer].

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

Full-length phrenic nerve transfer by means of video-assisted thoracic surgery in treating brachial plexus avulsion injury.

Phrenic nerve transfer has been widely used in treating brachial plexus avulsion injury. However, the present method crosses the thoracic part of the phrenic nerve, and nerve graft is needed, resulting in a long period of regeneration and partly irreversible muscle atrophy. We present our early experience of using video-assisted thoracic surgery to harvest a full length of phrenic nerve for transfer. Fifteen patients (mean age, 28 years) were treated. The thoracic part of the phrenic nerve was freed by means of video-assisted thoracic surgery and taken out of the thoracic cavity, and a full-length phrenic nerve was transferred to the musculocutaneous nerve to recover elbow flexion. The patients were followed. Another 29 patients with long-term follow-up who underwent traditional cervical phrenic nerve to musculocutaneous nerve transfer in our institute between 1994 and 1997 were selected. The period of newborn potential appearing in the biceps and the period for biceps to achieve M3 between two groups were compared. The operation was safe and no complications occurred. The additional length of phrenic nerve was 12.3 +/- 4.5 cm. Eleven patients received sufficient follow-up. Eight patients achieved biceps recovery to M3 (elbow flexion against gravity), and mean time was 198.8 +/- 36.0 days, much earlier than that of the traditional method (p < 0.01). Pulmonary function recovered to the preoperative level 9 months after operation. This new method is safe and minimally invasive. The result of full-length phrenic nerve transfer is much better than that of the traditional method. It obviously shortens the time required for nerve reinnervation, and offers a promising method for patients who have had a long interval from injury to operation and for forearm muscle reconstruction by phrenic nerve transferred to the median nerve or combined with free-muscle transfer.