A modified pleurodesis in treating postoperative chylothorax.

BACKGROUND: To introduce a modified pleurodesis as an effective treatment for refractory chylothorax and to develop a novel insight for its mechanism. METHODS: Patients who underwent thoracic surgery at West China Hospital or its affiliated hospitals between 2010 and 2015 and who subsequently experienced chylothorax that was not resolved by conventional treatment, received daily pleurodesis involving 100 mL 50% glucose and 20 mL 1% lidocaine. The chest tube was clamped after 7 days of pleurodesis, regardless of drainage amount. If no remarkable pulmonary atelectasis was detected within 2 days, the chest tube was removed. All patients were followed up with for at least 3 months after discharge from our hospital. RESULTS: Among the 34 patients, 10 did not experience an increase in the pleural fluid after the chest tube was clamped. Minor effusion increase occurred in 21 patients, while encapsulated effusion occurred in 3. In 23 patients among the latter 24 patients, pleural fluid was gradually absorbed and disappeared spontaneously. One patient suffered chylothorax recurrence after discharge but successfully recovered after the second round of modified pleurodesis. Several patients suffered from electrolyte imbalance, weakness, and dyspnea; all were cured by plasma infusion and other symptomatic treatments. CONCLUSIONS: Being safe and effective for patients with postoperative refractory chylothorax, our modified pleurodesis enhanced the process of chemical pleurodesis and could remove the chest tube right after the extensive adhesion formed instead requiring a wait for drainage decrease. This method can thus shorten the period of hospitalization and reduce fluid loss compared with traditional pleurodesis.

End-to-End Versus End-to-Side Hand-Sewn Anastomosis for Minimally Invasive McKeown Esophagectomy.

BACKGROUND: Standard anastomotic configuration for esophagogastric anastomosis is not conclusive. This study aimed to compare the short-term outcomes of end-to-end (ETE) cervical double-layer hand-sewn anastomoses with those of end-to-side (ETS) anastomoses for minimally invasive McKeown esophagectomy. METHODS: Between January 2016 and December 2017, the clinical data of 252 consecutive patients who underwent minimally invasive esophagectomy were reviewed retrospectively. The 252 patients comprised 130 patients in the ETS group and 122 patients in the ETE group. The same surgical procedures were applied in both groups, except for esophagogastric reconstruction. Short-term outcomes including leakage, stricture, reflux, operative features, and other surgical complications were analyzed for a comparison of the two configurations. RESULTS: The ETS and ETE groups did not differ significantly in terms of leakage rate (P = 0.34), anastomotic stricture rate (P = 0.70), or postoperative reflux (P = 0.66). However, the ETS group had a longer operation time (P = 0.011), a longer anastomosis time (P < 0.001), and a longer postoperative hospital stay (P = 0.009) than the ETE group, and the postoperative gastric dilation rates were lower in ETE group than in the ETS group (P = 0.025). The two groups did not differ significantly in terms of other postoperative complications. CONCLUSIONS: The major postoperative complications were comparable for the two anastomotic configurations. However, the patients with ETE anastomosis showed a favorable outcome in terms of a decreasing postoperative thoracic gastric dilation rate. End-to-end anastomosis also seemed to have slight advantages in terms of shorter operation and anastomosis times as well as a shorter postoperative hospital stay.

Modified Double-Layer Anastomosis for Minimally Invasive Esophagectomy: An Effective Way to Prevent Leakage and Stricture.

BACKGROUND: Anastomotic leakage and stricture contribute to a large number of mortality and morbidity after esophagectomy. The aim of this work is to evaluate the outcome of modified double-layer hand-sewn esophagogastric anastomosis during minimally invasive esophagectomy for esophageal cancer. METHODS: The clinicopathological data of 176 consecutive esophageal cancer patients who underwent cervical esophagogastric anastomosis using modified double-layer hand-sewn technique after radical esophagectomy were retrospectively reviewed. Total minimally invasive approach, including thoracoscopic surgery for thoracic procedure and laparoscopic approach for abdominal procedure, was implemented during the radical Mckeown esophagectomy. Patients were followed up for the assessment of postoperative anastomotic complications including anastomotic leakage and stricture, being the primary outcome measures for this study. RESULTS: Anastomotic leakage occurred in 2 of 176 patients (1.1%); both of the patients experienced only minor leakage and were treated conservatively. There was no significant difference in leakage between patients with and without major comorbidity (p = 0.331). After a mean follow-up of 21.3 months, four patients (4/176, 2.3%) developed benign anastomotic strictures, including those 2 patients experienced postoperative leakage. Symptoms for stricture were improved by endoscopic dilatations in all 4 patients. Besides, there was one case (1/176, 0.6%) of gastric necrosis in this cohort, who was also successfully managed by conservative therapy with no operative mortality. CONCLUSION: This modified double-layer hand-sewn anastomosis is a highly safe and stable technique for esophagogastrostomy, which is an effective way to prevent both anastomotic leakage and stricture.

Comparison of survival outcomes between transthoracic and transabdominal surgical approaches in patients with Siewert-II/III esophagogastric junction adenocarcinoma: a single-institution retrospective cohort study.

OBJECTIVE: To compare the survival outcomes of transabdominal (TA) and transthoracic (TT) surgical approaches in patients with Siewert-II/III esophagogastric junction adenocarcinoma. METHODS: This retrospective study was conducted in patients with Siewert-II/III esophagogastric junction adenocarcinoma who underwent either TT or TA operations in the West China Hospital between January 2006 and December 2009. RESULTS: A total of 308 patients (109 in the TT and 199 in the TA groups) were included in this study with a follow-up rate of 87.3%. The median (P25, P75) number of harvested perigastric lymph nodes was 8 (5, 10) in the TT group and 23 (16, 34) in the TA group (P<0.001), and the number of positive perigastric lymph nodes was 2 (0, 5) in the TT group and 3 (1, 8) in the TA group (P<0.004). The 5-year overall survival (OS) rate was 36% in the TT group and 51% in the TA group (P=0.005). Subgroup analysis by Siewert classification showed that 5-year OS rates for patients with Siewert II tumors were 38% and 48% in TT and TA groups, respectively (P=0.134), whereas the 5-year OS rate for patients with Siewert III tumors was significantly lower in the TT group than that in the TA group (33% vs. 53%; P=0.010). Multivariate analysis indicated that N2 and N3 stages, R1/R2 resection and a TT surgical approach were prognostic factors for poor OS. CONCLUSIONS: Improved perigastric lymph node dissection may be the main reason for better survival outcomes observed with a TA gastrectomy approach than with TT gastrectomy for Siewert III tumor patients.

Anastomosis Between Thoracic Duct and Azygos Vein During Esophagectomy: A Novel Technique with 3-year Follow-up.

BACKGROUND: Ligation of thoracic duct is the standard procedure currently used to prevent postoperative chylothorax for patients undergoing esophagectomy when thoracic duct is surgically injured or invaded by tumor. However, preservation of lymphovenous circulation is particularly important for a subset of patients, including individuals with liver cirrhosis, ascites, nephrotic syndrome, sclerosing mesenteritis, or some cardiac conditions. METHODS: We have developed a new technique of restoring lymphovenous circulation for patients undergoing esophagectomy. Intrathoracic lymphovenous anastomosis was performed for an esophageal cancer patient by intravenous catheter assisted end-to-side "insertion" technique. RESULTS: The time taken for lymphovenous anastomosis was 35 min. No massive bleeding or other adverse events occurred during operation, and the patient had an uneventful postoperative course. Lipid metabolisms, assessed by pre- and postoperative plasma concentrations of cholesterol, triglycerides, high-density and low-density lipoprotein, were not affected after lymphovenous anastomosis. Lymphangiography also indicated lymphovenous anastomosis remained patent 3 years after operation. No long-term surgery-related adverse events were observed during 3-year follow-up. CONCLUSION: Lymphovenous anastomosis was successfully implemented for the patient with esophagectomy, selected patients might benefit from this novel technique.

Percutaneous endoscopic gastrostomy versus percutaneous radiological gastrostomy for swallowing disturbances.

BACKGROUND: Gastrostomy has been established as the standard procedure for administering long-term enteral nutrition in individuals with swallowing disturbances. Percutaneous gastrostomy is a less-invasive approach than open surgical gastrostomy, and can be accomplished via endoscopy (percutaneous endoscopic gastrostomy or PEG) or sonographic or fluoroscopic guidance (percutaneous radiological gastrostomy or PRG). Both techniques have different limitations, advantages, and contraindications. In order to determine the optimal technique for long-term nutritional supplementation many studies have been conducted to compare the outcomes of these two techniques; however, it remains unclear as to which method is superior to the other with respect to both efficacy and safety. OBJECTIVES: To compare the safety and efficacy of PEG and PRG in the treatment of individuals with swallowing disturbances. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, January 2016); MEDLINE (1946 to 22 January 2016); EMBASE (1980 to 22 January 2016); the reference lists of identified articles; databases of ongoing trials, including the Chinese Cochrane Centre Controlled Trials Register; and PubMed. We applied no language restrictions. SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing PEG with PRG in individuals with swallowing disturbances, regardless of the underlying disease. DATA COLLECTION AND ANALYSIS: Two authors independently evaluated the search results and assessed the quality of the studies. Data analyses could not be performed as no RCTs were identified for inclusion in this review. MAIN RESULTS: We identified no RCTs comparing PEG and PRG for percutaneous gastrostomy in individuals with swallowing disturbances. The large body of evidence in this field comes from retrospective and non-randomised controlled studies and case series. Based on this evidence, both PEG and PRG can be safely performed in selected individuals, although both are associated with major and minor complications. A definitive RCT has yet to be conducted to identify the preferred percutaneous gastrostomy technique. AUTHORS' CONCLUSIONS: Both PEG and PRG are effective for long-term enteral nutritional support in selected individuals, though current evidence is insufficient to recommend one technique over the other. Choice of technique should be based on indications and contraindications, operator experience and the facilities available. Large-scale RCTs are required to compare the two techniques and to determine the optimal approach for percutaneous gastrostomy.

Changes of Esophagogastric Junctional Adenocarcinoma and Gastroesophageal Reflux Disease Among Surgical Patients During 1988-2012: A Single-institution, High-volume Experience in China.

OBJECTIVE: To evaluate the changes of esophagogastric junctional adenocarcinoma (EGJA) and gastroesophageal reflux disease (GERD) among surgical patients from 1988 to 2012 in a Chinese high-volume hospital. BACKGROUND: The incidence of EGJA in Western countries has rapidly increased in recent decades. However, recent data from China remain sparse. METHODS: A retrospective analysis was performed on the basis of 5053 patients who underwent surgery for gastric and distal esophageal adenocarcinoma. Total of 1723 patients with EGJA who underwent surgery were included. Changes of the prevalence of GERD and the clinicopathological features and surgical treatment of EGJA were longitudinally analyzed by a 5-year interval. RESULTS: The proportion of EGJA was increased from 22.3% in period 1 (1988-1992) to 35.7% in period 5 (2008-2012) (P < 0.001). The proportion of Siewert type III (35.9% vs 47.0%) (P < 0.001) and type I (8.7% vs 15.8%) (P = 0.002) tumors of EGJA was also increased during the past 25 years. The prevalence of GERD had increased gradually from 6.5% in period 1 to 10.9% in period 5 for the 3 subgroups without significant difference (P = 0.459). There was an upward tendency with significant difference between the proportion of EGJA and the prevalence of GERD (r = 0.946, P = 0.000). Instead of type II and type III tumors, there was a positive correlation with change in GERD for type I tumors (r = 0.438, P = 0.029). Total gastrectomy was more preferred among patients with EGJA in period 5 than in period 1 (42.0% vs 19.6%) (P < 0.001). CONCLUSIONS: An increasing trend of EGJA is observed during the past 25 years in West China Hospital. The prevalence of GERD among EGJA had showed a gradually increased trend. However, the causality between GERD and EGJA still needs to be researched further. Total gastrectomy is becoming more preferred procedure in patients with EGJA.

[Comparison of mucosal reflux damage in remnant esophagus after esophagectomy and gastric interposition between Chinese and Canadian population].

OBJECTIVE: To compare the difference of mucosal damage in the remnant esophagus with similar postoperative reflux after esophagectomy and gastric interposition between Chinese and Canadian population. METHODS: A prospective 1 to 1 paired study based on the same surgical approach was performed in Medical Centre of University of Montreal and West China Hospital of Sichuan University during the period from September 2010 to October 2013. The patients were followed up and evaluated by reflux symptom scoring, endoscopic assessment of mucosal damage, pathologic examination of biopsies and proliferation index test of esophageal epithelium. RESULTS: Eighteen Han Chinese and 18 Caucasian Canadian patients with esophagectomy and gastric interposition were included in this study, with a follow-up period of 45 (28-67) months. There were no significant differences between the two groups in the incidence of postoperative reflux symptom, reflux symptom scoring, histological reflux esophagitis, erosion or stricture of remnant esophagus (all P>0.05). However, the incidence of mucosal metaplasia [44.4% (8/18) versus 11.1% (2/18), P=0.026], quantitative MUSE scoring [1.5 (1.0-2.0) versus 1.0 (0-2.0), P=0.042] and proliferation index [0.40 (0.30-0.45) versus 0.35 (0.30-0.50), P=0.038] of esophageal epithelium were significantly higher in Canadian patients than those in Chinese patients. CONCLUSION: Under similar reflux situation, esophageal mucosa of Canadian population is more sensitive to the gastroesophageal reflux damage compared with Chinese population, resulting in more severe reflux damage of remnant esophagus in Canadian patients.

[Expressions of Notch signaling-associated proteins in esophageal squamous cell carcinoma].

OBJECTIVE: To investigate the expressions and the role of Notch signaling-associated proteins in esophageal squamous cell carcinoma (ESCC). METHODS: Fifty patients with ESCC were included in this study. The expressions of Notch signaling-associated protein (4 receptors: Notch1, Notch2, Notch3, Notch4; 5 ligands: Dll1, Dll3, Dll4, Jagged1, Jagged2) in cancer foci and adjacent normal tissues (5 cm distance to cancer) were examined by immunohistochemitry. Correlations of these proteins with cancer cell proliferation(Ki-67 index) and clinicopathologic features were investigated. RESULTS: Higher levels of Notch1 and Notch2 were measured in cancer foci compared with adjacent tissues (all P<0.05). There were no differences in the expressions of Notch3, Dll1 and Dll3 (all P>0.05). Notch4, Dll4 and Jagged2 were not detected in both cancer foci and adjacent tissues. Notch1 expression was negatively correlated with lymph node metastasis and TNM staging (all P<0.01). Jagged 1 expression was positively correlated with TNM staging (P<0.01). Ki-67 index was obviously higher in cancer foci, while it was negatively correlated with Notch1 and Notch3 (all P<0.01) and positively correlated with Dll1 and Jagged 1 (all P<0.01). CONCLUSION: Notch signaling path may act as tumor suppressive gene in the pathogenesis of esophageal squamous cell cancer, in which Notch1 protein plays an important role.

Comparison of injury epidemiology between the Wenchuan and Lushan earthquakes in Sichuan, China.

OBJECTIVE: We aimed to compare injury characteristics and the timing of admissions and surgeries in the Wenchuan earthquake in 2008 and the Lushan earthquake in 2013. METHODS: We retrospectively compared the admission and operating times and injury profiles of patients admitted to our medical center during both earthquakes. We also explored the relationship between seismic intensity and injury type. RESULTS: The time from earthquake onset to the peak in patient admissions and surgeries differed between the 2 earthquakes. In the Wenchuan earthquake, injuries due to being struck by objects or being buried were more frequent than other types of injuries, and more patients suffered injuries of the extremities than thoracic injuries or brain trauma. In the Lushan earthquake, falls were the most common injury, and more patients suffered thoracic trauma or brain injuries. The types of injury seemed to vary with seismic intensity, whereas the anatomical location of the injury did not. CONCLUSIONS: Greater seismic intensity of an earthquake is associated with longer delay between the event and the peak in patient admissions and surgeries, higher frequencies of injuries due to being struck or buried, and lower frequencies of injuries due to falls and injuries to the chest and brain. These insights may prove useful for planning rescue interventions in trauma centers near the epicenter.

Omentoplasty for oesophagogastrostomy after oesophagectomy.

BACKGROUND: Oesophagectomy followed by oesophagogastrostomy is the preferred treatment for early-stage oesophageal cancer. It carries the risk of anastomotic leakage after oesophagogastric anastomosis, which causes considerable morbidity and mortality and is one of the most dangerous complications. Omentoplasty has been recommended by some researchers to prevent anastomotic leaks associated with oesophagogastrostomy. However, the value of omentoplasty for oesophagogastrostomy after oesophagectomy has not been systematically reviewed. OBJECTIVES: To assess the effects of omentoplasty for oesophagogastrostomy after oesophagectomy in patients with oesophageal cancer. SEARCH METHODS: A comprehensive search to identify eligible studies for inclusion was conducted using the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PubMed and other reliable resources. SELECTION CRITERIA: Randomised controlled trials comparing omentoplasty versus no omentoplasty for oesophagogastrostomy after oesophagectomy in patients with oesophageal cancer were eligible for inclusion. DATA COLLECTION AND ANALYSIS: Two review authors (Yong Yuan and Xiaoxi Zeng) independently assessed the quality of included studies and extracted data; disagreements were resolved through arbitration by another review author. Results of dichotomous outcomes were expressed as risk ratios (RRs) with 95% confidence intervals (CIs), and continuous outcomes were expressed as mean differences (MDs) with 95% CIs. Meta-analysis was performed when available data were sufficiently similar. Subgroup analysis was carried out on the basis of different approaches to surgery. MAIN RESULTS: Three randomised controlled trials (633 participants) were included in this updated review. No significant differences in hospital mortality were noted between the study group (with omentoplasty) and the control group (without omentoplasty) (RR 1.28, 95% CI 0.49 to 3.39). None of the included studies reported differences in long-term survival between the two groups. The incidence of postoperative anastomotic leakage was significantly less among study participants treated with omentoplasty than among those treated without (RR 0.25, 95% CI 0.11 to 0.55), but the additional benefit was seen in the subgroup analysis only for participants undergoing a transhiatal oesophagogastrectomy (THE) procedure (RR 0.23, 95% CI 0.07 to 0.79); transthoracic oesophagogastrectomy (TTE) (RR 0.19, 95% CI 0.03 to 1.03); or three-field oesophagectomy (RR 0.33, 95% CI 0.09 to 1.19 ). Omentoplasty did not significantly improve other surgery-related complications, such as anastomotic stricture (RR 0.91, 95% CI 0.33 to 2.57). However, participants treated with omentoplasty could reduce the duration of hospitalisation compared with that seen in the control group (MD -2.13, 95% CI -3.57 to -0.69). AUTHORS' CONCLUSIONS: Omentoplasty may provide additional benefit in decreasing the incidence of anastomotic leakage after oesophagectomy and oesophagogastrostomy for patients with oesophageal cancer without increasing or decreasing other complications, especially among those treated with THE. It also has the potential to reduce the duration of hospital stay after operation. Further randomised controlled trials are needed to investigate the influences of omentoplasty on the incidence of anastomotic leakage and anastomotic stricture, long-term survival, duration of hospital stay and quality of life after oesophagectomy and oesophagogastrostomy when different surgical approaches are used.

Tissue-engineered ribs for chest wall reconstruction: a case with 12-year follow-up.

We hereby report on a case in which a huge chest wall defect generated by resection of a massive aggressive tumor (desmoplastic fibroma) was repaired with osteogenic-induced mesenchymal stem cells embedded in a bone-derived biomaterial. In this case, there were three challenges to overcome: reconstruction of the soft tissue, repair of the skeletal defect of the thoracic wall and repair of the defect in the pleural cavity. The defects of soft tissue and pleural cavity were reconstructed, respectively, with an ipsilateral abdominal flap and a diaphragm muscular flap. The huge defect in the chest wall was successfully repaired with the tissue-engineered ribs, which was confirmed by long-term follow-up with computerized tomography and histological and immunohistochemical evaluations. In view of its effectiveness and safety, tissue-engineered bones may have a broad application for the repair of large skeletal defects and bone regeneration.

Retrospective cohort analysis of chest injury characteristics and concurrent injuries in patients admitted to hospital in the Wenchuan and Lushan earthquakes in Sichuan, China.

BACKGROUND: The aim of this study was to compare retrospectively the characteristics of chest injuries and frequencies of other, concurrent injuries in patients after earthquakes of different seismic intensity. METHODS: We compared the cause, type, and body location of chest injuries as well as the frequencies of other, concurrent injuries in patients admitted to our hospital after the Wenchuan and Lushan earthquakes in Sichuan, China. We explored possible relationships between seismic intensity and the causes and types of injuries, and we assessed the ability of the Injury Severity Score, New Injury Severity Score, and Chest Injury Index to predict respiratory failure in chest injury patients. RESULTS: The incidence of chest injuries was 9.9% in the stronger Wenchuan earthquake and 22.2% in the less intensive Lushan earthquake. The most frequent cause of chest injuries in both earthquakes was being accidentally struck. Injuries due to falls were less prevalent in the stronger Wenchuan earthquake, while injuries due to burial were more prevalent. The distribution of types of chest injury did not vary significantly between the two earthquakes, with rib fractures and pulmonary contusions the most frequent types. Spinal and head injuries concurrent with chest injuries were more prevalent in the less violent Lushan earthquake. All three trauma scoring systems showed poor ability to predict respiratory failure in patients with earthquake-related chest injuries. CONCLUSIONS: Previous studies may have underestimated the incidence of chest injury in violent earthquakes. The distributions of types of chest injury did not differ between these two earthquakes of different seismic intensity. Earthquake severity and interval between rescue and treatment may influence the prevalence and types of injuries that co-occur with the chest injury. Trauma evaluation scores on their own are inadequate predictors of respiratory failure in patients with earthquake-related chest injuries.

Management of thoracic esophageal perforation.

BACKGROUND: The aim of this study was to characterize an optimal strategy in managing thoracic esophageal perforation, focusing on the differential diagnosis and treatment of patients with contained versus noncontained perforations and on the importance of the time interval between injury and repair and how that affects the outcome of a primary repair. METHODS: A retrospective study was conducted. A strict definition of contained or noncontained perforation was based on a combination of esophagography, chest CT scan, and endoscopy as well as monitoring systemic symptoms. Management options for our cohort included conservative therapy, primary repair and debridement, esophagectomy, and mesh-covered stents. Patients were stratified into two groups according to the time interval after injury: ≤ 48-h group and >48-h group. RESULTS: Between January 1997 and January 2013, a total of 66 consecutive patients (47 males and 19 females, mean age = 49.1 ± 16.2 years) were treated for thoracic esophageal perforation. Perforation was confirmed by esophagography in 51 patients and by endoscopy in 15 patients. Eighteen patients were assigned to the contained perforation group. All these patients were successfully cured without surgery. The noncontained group included 48 patients; its mortality rate was 7.7 % (3/39) with surgery and 55.6 % (5/9) with stent placement. Compared with the contained group, the noncontained group had a significantly longer length of stay (LOS) (16 ± 3.2 vs. 26.3 ± 18.7 days; p < 0.05) and a higher mortality rate (0 vs. 22.9 %, p < 0.05). In the two time-interval groups, patient characteristics, including age, gender, and comorbidities, etiologic cause, length and location of the perforation, and the incidence of using tissue buttress were similar (p > 0.05). The incidence of postoperative leak was significantly higher in >48-h group (0 in ≤ 48-h group vs. 37.5 % in >48-h group; p < 0.01). In addition, the >48-h group had a significantly longer LOS (18.0 ± 9.1 days in ≤ 48-h group vs. 31.5 ± 18.6 days in >48-h group; p < 0.01). The two deaths occurred in the >48-h group (0 in ≤ 48-h group vs. 12.5 % in >48-h group; p > 0.05) due to postoperative leaks. CONCLUSIONS: Contained or noncontained perforation should be rigorously differentiated. Then, for a contained perforation, conservative therapy coupled with repeated imaging is reasonable treatment. For a noncontained perforation, a primary repair can be safely performed within 48 h after injury. After that, a primary repair is still reasonable but is associated with an increased risk of postoperative leaks.

A 2-wk conservative treatment regimen preceding thoracic duct ligation is effective and safe for treating post-esophagectomy chylothorax.

BACKGROUND: Chylothorax is a pathologic condition defined by an accumulation of lymphatic fluid, the chyle, in the thorax. Postoperative chylothorax is a potentially lethal complication, with a reported mortality rate of 15.4%-25%. PATIENTS AND METHODS: Esophageal cancer patients hospitalized for elective radical esophagectomy by thoracotomy (n = 10,574) were consecutively enrolled between January 1996 and December 2011. Patients (n = 306) who experienced post-esophagectomy chylothorax were assigned to a 48-h (group A, n = 186) or to a 2-wk (group B, n = 120) conservative treatment regimen. For patients with a daily chylothorax output >1000 mL, thoracic duct ligation (TDL) was performed by thoracotomy. Measured outcomes included frequency of TDL, overall and treatment-specific morbidity and mortality rates, and the rate of chylothorax recurrence. RESULTS: A total of 171 patients (171 of 306 [55.9%]) underwent TDL. A larger proportion of patients in group A required TDL compared with group B (72.6% versus 30.0%, P < 0.001). Group A had a significantly higher rate of overall morbidity compared with group B (31.7% versus 19.2%, P = 0.02). Moreover, the overall mortality rate was significantly higher in group A (14.0% versus 4.2%, P = 0.006). Chylothorax recurred in nine patients (9 of 306 [2.9%]), and there was no difference between the two groups (3.2% versus 2.5%, P = 1.000). CONCLUSIONS: The 2-wk regimen reduced the requirement for TDL and the overall morbidity and mortality rates compared with the 48-h regimen. Importantly, this regimen does not increase the risk of chylothorax recurrence.

Surgical treatment of Zenker's diverticulum.

BACKGROUND: Different surgical techniques have been indicated for the management of Zenker's diverticulum (ZD), including diverticulectomy, diverticulopexy, and diverticular inversion, with or without myotomy, and myotomy alone. More recently, minimally invasive techniques (such as the transoral endoscopic approach) have become increasingly reliable for this disorder. We therefore conducted this systematic review in order to gain a profound understanding of the current trend and evidence in surgical management of ZD. METHODS: Medline and PubMed were searched to identify studies on surgical intervention of ZD published in English between January 1990 and March 2011. RESULTS: We identified 6,915 patients from 93 studies evaluating the effect of the surgical intervention for ZD. No randomized controlled trials comparing one technique with another were identified. CONCLUSION: Diverticulectomy with myotomy has become the mainstream treatment option for ZD. In certain selected patients, endoscopic diverticulotomy may offer some advantages over open surgery, such as less trauma and a lower complication rate. It is important to individualize optimal therapy for each patient. More randomized controlled trials with long-term follow-up results are required to draw a valid conclusion on the best surgical intervention modality for ZD.

Omentoplasty for esophagogastrostomy after esophagectomy.

BACKGROUND: Esophagectomy followed by esophagogastrostomy is the preferred treatment for early-stage esophageal cancer. It carries the risk of anastomotic leakage after esophagogastric anastomosis, which is one of the most dangerous complications and causes considerable morbidity and mortality. Omentoplasty was recommended in some studies to preventing anastomotic leaks associated with esophagogastrostomy. However, the value of omentoplasty for esophagogastrostomy after esophagectomy has not been systematically reviewed. OBJECTIVES: To assess the effects of omentoplasty for esophagogastrostomy after esophagectomy in esophageal cancer patients. SEARCH METHODS: A comprehensive search strategy was carried out to identify eligible studies for inclusion in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PubMed and other reliable resources. SELECTION CRITERIA: Randomized controlled trials comparing omentoplasty with no omentoplasty for esophagogastrostomy after esophagectomy in esophageal cancer patients were eligible for inclusion. DATA COLLECTION AND ANALYSIS: Two review authors (Yong Yuan and Xiaoxi Zeng) independently assessed the quality of included studies and extracted data, with disagreements resolved by arbitration by another review author. Results of dichotomous outcomes were expressed as risk ratios (RR) with 95% confidence intervals (CI), while continuous outcomes were expressed as mean differences (MD) with 95% CI. Meta-analysis was performed where the data available were sufficiently similar. Subgroup analysis was carried out based on different operation approaches. MAIN RESULTS: Two randomized controlled trials (449 participants) were included in the review. There was no significant difference for hospital mortality between the study (with omentoplasty) and the control group (without omentoplasty) (RR 1.00; 95% CI 0.25 to 3.92). Neither of the included studies reported the difference of long-term survival between two groups. The incidence of postoperative anastomotic leakage was significantly lower in patients treated with omentoplasty than those without (RR 0.22; 95% CI 0.08 to 0.58); but the additional benefit only showed in patients receiving a transhiatal esophagogastrectomy (THE) procedure in subgroup analysis (THE: RR 0.23; 95% CI 0.07 to 0.79; transthoracic esophagogastrectomy (TTE): RR 0.19; 95% CI 0.03 to 1.03). Omentoplasty did not significantly improve other surgical-related complications, anastomotic strictures (RR 0.73; 95% CI 0.21 to 2.58) and duration of hospitalization (MD -2.70; 95% CI -6.01 to 0.61). AUTHORS' CONCLUSIONS: Omentoplasty may provide an additional benefit to decrease the incidence of anastomotic leakage after esophagectomy and esophagogastrostomy for esophageal cancer patients without increasing or decreasing other complications, especially for those patients treated with THE. Further randomized controlled trials are still needed to investigate the influences of omentoplasty in different operation procedures of esophagectomy and esophagogastrostomy on the incidence of anastomotic leakage, anastomotic stricture, long-term survival rate and quality of life after esophagectomy and esophagogastrostomy.

Early recurrence and death after esophagectomy in patients with esophageal squamous cell carcinoma.

BACKGROUND: The aim of this retrospective study is to analyze recurrence and death within 1 year after esophagectomy in patients with esophageal carcinoma. METHODS: The records of 533 consecutive patients with esophageal squamous cell carcinoma who underwent surgery from January 2002 to January 2005 were reviewed. Patients who died of recurrence within 1 year after operation (group A) were compared with patients who survived more than 5 years without any recurrence (group B). Their clinicopathologic characteristics were evaluated by univariate and multivariate analyses. RESULTS: The overall 1-year and 5-year survival rates for the entire cohort were 76.1% and 32.3%, respectively, with the follow-up rate of 93.4%. Of the 119 patients who died within 1 year after the esophagectomy, local recurrence or distant metastasis or both were documented in 62 patients (52.1%). The radicality of resection, size of tumor, radicality of resection, grade of differentiation, depth of invasion, status of lymph node metastasis, number of lymph node metastases, and marginal status were shown by univariate analysis to be the significant prognostic factors. By multivariate analysis, they were also the independent prognostic factors, except for the size of tumor and the radicality of resection. CONCLUSIONS: More than half of early death in esophageal squamous cell carcinoma patients after esophagectomy were still tumor recurrence related, especially hematogeneous spreading. The grade of differentiation, depth of invasion, lymph node metastasis, number of lymph node metastases, and marginal status are valuable prognostic factors in predicting early death.