Objective To evaluate the security and outcomes of thoracolaparoscopic esophagectomy (TLE) versus open approach (OA) for thoracic esophageal squamous cell carcinoma. Methods From June 2014 to June 2015, 125 patients with thoracic esophageal squamous cell carcinoma underwent esophagectomy through McKeown approach, including TLE (a TLE group, 107 patients, 77 males and 30 females) and OA (an OA group, 18 patients, 13 males and 5 females). The data of operation and postoperative complications of the two groups were analyzed retrospectively. Results There was no statistical difference in the duration of operation and ICU stay and resected lymph nodes around laryngeal recurrent nerve between the TLE group and the OA group (333.58±72.84 min vs. 369.17±91.24 min, P=0.067; 2.84±1.44 d vs. 6.44±13.46 d, P=0.272; 4.71±3.87 vs. 3.89±3.97, P=0.408) . There was a statistical difference in blood loss, total resected lymph nodes and resected lymph nodes groups between TLE group and OA group (222.62±139.77 ml vs. 427.78±276.65, P=0.006; 19.62±9.61 vs. 14.61±8.07, P=0.038; 3.70±0.99 vs. 3.11±1.13, P=0.024). The rate of postoperative complications was 32.7% in the TLE group and 38.9% in the OA group (P=0.608). There was a statistical difference (P=0.011) in incidence of pulmonary infection (2.8% in the TLE group and 16.7% in the OA group). Incidences of complications, such as anastomotic leakage, cardiac complications, left-side hydrothorax, right-side pneumothorax, voice hoarse and incision infection, showed no statistical difference between two groups. Conclusion For patients with thoracic esophageal squamous cell carcinoma, TLE possesses advantages of more harvested lymph nodes, less blood loss and less pulmonary infection comparing with open approach, and is complied with the principles of security and oncological radicality of surgery.
ObjectiveTo investigate the clinical efficacy of minimally invasive Ivor-Lewis esophagectomy (MIILE) with reverse-puncture anastomosis. MethodsClinical data of the patients with lower esophageal carcinoma who underwent MIILE with reverse-puncture anastomosis in our department from May 2015 to December 2020 were collected. Modified MIILE consisted of several key steps: (1) pylorus fully dissociated; (2) making gastric tube under laparoscope; (3) dissection of esophagus and thoracic lymph nodes under artificial pneumothorax with single-lumen endotracheal tube intubation in semi-prone position; (4) left lung ventilation with bronchial blocker; (5) intrathoracic anastomosis with reverse-puncture anastomosis technique. Results Finally 248 patients were collected, including 206 males and 42 females, with a mean age of 63.3±7.4 years. All 248 patients underwent MIILE with reverse-puncture anastomosis successfully. The mean operation time was 176±35 min and estimated blood loss was 110±70 mL. The mean number of lymph nodes harvested from each patient was 24±8. The rate of lymph node metastasis was 43.1% (107/248). The pulmonary complication rate was 13.7% (34/248), including 6 patients of acute respiratory distress syndrome. Among the 6 patients, 2 patients needed endotracheal intubation-assisted respiration. Postoperative hemorrhage was observed in 5 patients and 2 of them needed hemostasis under thoracoscopy. Thoracoscopic thoracic duct ligation was performed in 1 patient due to the type Ⅲ chylothorax. TypeⅡ anastomotic leakage was found in 3 patients and 1 of them died of acute respiratory distress syndrome. One patient of delayed broncho-gastric fistula was cured after secondary operation. Ten patients with type Ⅰ recurrent laryngeal nerve injury were cured after conservative treatment. All patients were followed up for at least 16 months. The median follow-up time was 44 months. The 3-year survival rate was 71.8%, and the 5-year survival rate was 57.8%. ConclusionThe optimized MIILE with reverse-puncture anastomosis for the treatment of lower esophageal cancer is safe and feasible, and the long-term survival is satisfactory.
Objective To systematically evaluate the efficacy and safety of thoraco-laparoscopy combined with Ivor Lewis surgery versus thoraco-laparoscopy combined with McKeown surgery in the treatment of esophageal carcinoma. MethodsPubMed, EMbase, The Cochrane Library, Web of Science, Wanfang database, VIP database and CNKI were searched by computer for the relevant literature comparing the efficacy and safety of Ivor Lewis surgery and McKeown surgery in the treatment of esophageal carcinoma from inception to January 2022. The Newcastle-Ottawa Scale (NOS) was used to evaluate the quality of cohort studies, and the Cochrane risk of bias tool was used to evaluate the methodological quality of randomized controlled studies. Review Manager 5.4 software was utilized to perform a meta-analysis of the literature. ResultsA total of 33 articles were included, which consisted of 26 retrospective cohort studies, 3 prospective cohort studies and 4 randomized controlled trials. There were 11 518 patients in total, including 5 454 patients receiving Ivor Lewis surgery and 6064 patients receiving McKeown surgery. NOS score was≥7 points. Meta-analysis showed that, in comparison to the McKeown surgery, the Ivor Lewis surgery had shorter operative time (MD=–19.61, 95%CI –30.20 to –9.02, P<0.001), shorter postoperative hospital stay (MD=–1.15, 95%CI –1.43 to –0.87, P<0.001), lower mortality rate during hospitalization or 30 days postoperatively (OR=0.37, 95%CI 0.20 to 0.71, P=0.003), and lower incidence of total postoperative complications (OR=0.36, 95%CI 0.27 to 0.49, P<0.001). The McKeown surgery had an advantage in terms of the number of lymph nodes dissected (MD=–1.25, 95%CI –2.03 to –0.47, P=0.002), postoperative extubation time (MD=0.78, 95%CI 0.37 to 1.19, P<0.001) and 6-month postoperative recurrence rate (OR=1.83, 95%CI 1.41 to 2.39, P<0.001). The differences between the two surgeries were not statistically significant in terms of intraoperative bleeding, postoperative 1 year-, 3 year- and 5 year-overall survival (OS), and impaired gastric emptying (P>0.05). ConclusionCompared with McKeown surgery, Ivor Lewis surgery has shorter operative time, shorter postoperative hospital stay, lower mortality rate during hospitalization or 30 days postoperatively and lower incidence of total postoperative complications. However, in terms of the number of lymph nodes dissected, postoperative extubation time and 6-month postoperative recurrence rate, McKeown surgery has advantages. Both surgeries have comparable results in terms of intraoperative bleeding, postoperative 1 year-, 3 year- and 5 year-OS, and impaired gastric emptying.
Objective To explore the causes of conversion to thoracotomy in patients with minimally invasive esophagectomy (MIE) in a surgical team, and to obtain a deeper understanding of the timing of conversion in MIE. Methods The clinical data of patients who underwent MIE between September 9, 2011 and February 12, 2022 by a single surgical team in the Department of Thoracic Surgery of the Fourth Hospital of Hebei Medical University were retrospectively analyzed. The main influencing factors and perioperative mortality of patients who converted to thoracotomy in this group were analyzed. Results In the cohort of 791 consecutive patients with MIE, there were 520 males and 271 females, including 29 patients of multiple esophageal cancer, 156 patients of upper thoracic cancer, 524 patients of middle thoracic cancer, and 82 patients of lower thoracic cancer. And 46 patients were converted to thoracotomy for different causes. The main causes for thoracotomy were advanced stage tumor (26 patients), anesthesia-related factors (5 patients), extensive thoracic adhesions (6 patients), and accidental injury of important structures (8 patients). There was a statistical difference in the distribution of tumor locations between patients who converted to thoracotomy and the MIE patients (P<0.05). The proportion of multiple and upper thoracic cancer in patients who converted to thoracotomy was higher than that in the MIE patients, while the proportion of lower thoracic cancer was lower than that in the MIE patients. The perioperative mortality of the thoracotomy patients was not significantly different from that of the MIE patients (P=1.000). Conclusion In MIE, advanced-stage tumor, anesthesia-related factors, extensive thoracic adhesions, and accidental injury of important structures are the main causes of conversion to thoracotomy. The rate varies at different tumor locations. Intraoperative conversion to thoracotomy does not affect the perioperative mortality of MIE.
ObjectiveTo compare the clinical efficacy of cone-shaped gastric tube combined with cervical end-to-end stratified manual anastomosis and conventional tubular stomach combined with neck end-to-end mechanical side-to-side anastomosis in thoracoscopic and laparoscopic esophagectomy for esophageal cancer. MethodsThe clinical data of consecutive patients treated by thoracoscopic and laparoscopic esophagectomy for esophageal cancer in the Department of Cardiothoracic Surgery of the First People's Hospital of Neijiang from January 1, 2018 to March 25, 2021 were analyzed. The patients were divided into a cone-shaped gastric tube manual group (treated with cone-shaped gastric tube combined with cervical end-to-end stratified manual anastomosis) and a conventional tubular stomach mechanical group (treated with conventional tubular stomach+end-to-end mechanical side-to-side anastomosis). The anastomotic time, intraoperative blood loss, number of lymph node dissection, anastomotic fistula, anastomotic stenosis, anastomotic cost, sternogastric dilatation, gastroesophageal reflux symptoms, and postoperative complications were compared and analyzed between the two groups. ResultsA total of 161 patients were enrolled, including 112 males and 49 females aged 40-82 years. There were 80 patients in the cone-shaped gastric tube manual group, and 81 patients in the conventional tubular stomach mechanical group. There was no statistical difference in the intraoperative blood loss, number of lymph nodes dissected, hoarseness, pulmonary infection, arrhythmia, respiratory failure or chylothorax between the two groups (P>0.05). The anastomosis time of the cone-shaped gastric tube manual group was longer than that of the conventional tubular stomach mechanical group (28.35±3.20 min vs. 14.30±1.26 min, P<0.001), but the anastomotic cost and incidence of thoracogastric dilatation in the cone-shaped gastric tube manual group were significantly lower than those of the conventional tubular stomach mechanical group [948.48±70.55 yuan vs. 4 978.76±650.29 yuan, P<0.001; 3 (3.8%) vs. 14 (17.3%), P=0.005]. The incidences of anastomotic fistula and anastomotic stenosis in the cone-shaped gastric tube manual group were lower than those in the conventional tubular gastric mechanical group, but the differences were not statistically significant (P>0.05). The gastroesophageal reflux scores in the cone-shaped gastric tube manual group were lower than those in the conventional tubular gastric mechanical group at 1 month, 3 months, 6 months and 1 year after the operation (P<0.05). Logistic regression analysis showed that digestive tract reconstruction method was the influencing factor for postoperative thoracogastric dilation, which was reduced in the cone-shaped gastric tube manual group. ConclusionCone-shaped gastric tube combined with cervical end-to-end stratified manual anastomosis can significantly reduce the incidence of thoracogastric dilatation after thoracoscopic and laparoscopic esophagectomy for esophageal cancer and save hospitalization costs, with mild gastroesophageal reflux symptoms, and it still has certain advantages in reducing postoperative anastomotic fistula and anastomotic stenosis, which is worthy of clinical promotion.
Abstract： Objective To investigate the clinical application of tubular stomach in cervical esophageal reconstruction after esophagectomy for esophageal cancer. Methods A total of 850 patients with esophageal cancer who underwent esophagectomy through cervico-thoraco-abdominal（3-field）approach between January 2007 and January 2009 in North Jiangsu Hospital were allocated into the tubular stomach group（group A, n=425） and the whole stomach group （group B, n=425）by operation order. Group A included 287 male and 138 female patients with their average age of 58.2±11.5 years. Among them, 27 patients had upper esophageal cancer, 346 patients had middle esophageal cancer and 52 patients had lower esophageal cancer. Group B included 298 male and 127 female patients with their average age of 58.5±12.8 years. Among them, 33 patients had upper esophageal cancer, 338 patients had middle esophageal cancer, and 54 patients had lower esophageal cancer. Operation time, postoperative length of hospital stay and the incidence of anastomotic leakage, anastomotic stricture, intra-thoracic stomach syndrome and reflux esophagitis of the two groups were compared. Results All the patients recovered uneventfully with no in-hospital death. There was no statistical difference in operation time （175.0±12.8 min vs.171.0±10.5 min，t=1.702，P＞ 0.05）and postoperative length of hospital stay （16.0±8.5 d vs.16.3±8.8 d，t=1.773，P＞ 0.05） between the two groups. During follow-up of six months, the rates of anastomotic leakage（χ2=5.550，P＜ 0.05）, intra-thoracic stomach syndrome （χ2=10.500，P＜ 0.05）and reflux esophagitis（χ2=9.150，P＜ 0.05） of group A were significantly lower than those of group B. There was no significant difference in the incidence of anastomotic stricture （χ2=0.120，P＞ 0.05） between the two groups. Conclusion Tubular stomach is better than whole stomach for cervical esophageal reconstruction after esophagectomy for esophageal cancer since it is more physiologically and anatomically complied. It can decrease the incidence of anastomotic leakage, intra-thoracic stomach syndrome, reflux esophagitis and improve the postoperative quality of life.
Objective To introduce a simple preoperative risk score for esophageal cancer (PRSEC) and its relationship with the prognosis of patients who underwent resection of esophageal carcinoma. Methods We retrospectively analyzed the clinical data of 498 patients receiving resection of esophageal carcinoma between 2005 and 2015 in our hospital. They were divided into three groups (PRSEC1, PRSEC2 and PRSEC3 groups) according to the results of PRSEC (revised cardiac risk index, model for end-stage liver disease score and pulmonary function test). Their overall survival (OS) and disease-free survival (DFS) were measured to find the relationship between the PRSEC and prognosis of patients. Results The mortality, morbidity, DFS and OS were correlative with the PRSEC. Therefore the PRSEC can be used to predict the short-term outcome. The patients with score 2 or 3 had higher risk of mortality and morbidity than those with score 1. In addition, the DFS and OS of patients with higher score were shorter (P<0.001). Conclusion The PRSEC is easy and efficient and can predict the morbidity, mortality, and long-term outcomes for the patients with resection of esophageal carcinoma.
Objective To explore the feasibility of single mediastinal drainage tube in treatment of esophageal carcinoma after thoracoscopic combined with laparoscopic surgery. Methods There were 90 esophagus cancer patients treated by surgery in our hospital between June 2015 and October 2016. The patients were allocated into two groups including a single-drainage tube group and a two-drainage tube group. There were 45 patients with 24 males and 21 females at age of 48-78 years in the two-drainage tube group and 45 patients with 23 males and 22 females at age of 45-84 years in the single-drainage tube group.The clinical effect of the two groups was compared. Results There was no statistical difference in gender and age, bleeding amount and surgical duration in operation, thoracic drainage amount, incidence of atelectasis, pneumothorax, and encapsulated effusion between the two groups(P<0.05). Discussion Single-drainage tube group displays less postoperative pain, faster recovery, and more convenient clinical care without complication.
ObjectivesTo compare the clinical efficacy of different surgical thoracic duct management on prevention of postoperative chylothorax and its impact on the outcome of the patients. MethodsWe searched the electronic databases including PubMed, The Cochrane Library (Issue 4, 2016), Web of Science, CBM, CNKI, VIP and WanFang Data to collect randomized controlled trials (RCTs), cohort studies and case-control studies related to the comparison of different surgical thoracic duct management during esophagectomy on prevention of postoperative chylothorax from inception to May 2016. Two reviewers independently screened literature, extracted data and assessed the risk of bias of included studies. Then RevMan 5.2 software was used for meta-analysis. ResultsTwenty-three trials were included, involving four RCTs, four cohort studies and 15 case-control studies. The results of meta-analysis indicated:(1) Prophylactic thoracic duct ligation group had lower incidence of postoperative chylothorax compared with non thoracoic duct ligation group (RCT:OR=0.20, 95%CI 0.09 to 0.47, P=0.000 02; Co/CC:OR=0.20, 95%CI 0.14 to 0.28, P<0.000 01); (2) There were no significant differences between the two groups in the respect of mortality, morbidity and the 2-year, 3-year, 5-year survival rates (all P values >0.05); (3) Prophylactic thoracic duct ligation could reduce the reoperation rate of chylothorax complicating esophageal cancer patients (RCT:OR=0.17, 95%CI 0.10 to 0.28, P<0.000 01; Co/CC:OR=0.18, 95%CI to 0.11 to 0.32, P<0.000 01), and increase the cure rate of expectant treatment on them (OR=0.25, 95%CI 0.11 to 0.56, P=0.000 8); (4) En bloc thoracic duct ligation group had a lower incidence of postoperative chylothorax compared with single thoracic duct ligation group (OR=3.67, 95%CI 1.43 to 9.43, P=0.007). ConclusionProphylactic thoracic duct ligation during esophagectomy could effectively reduce the incidence of postoperative chylothorax and is good for reducing the reoperation rate of chylothorax complicating esophageal cancer patients. En bloc thoracic duct ligation has a better efficacy on prevention of postoperative chylothorax compared with single thoracic duct ligation.