ObjectiveTo determine the influence of high BMI on postoperative complications in a cohort of squamous esophageal cancer patients. MethodsWe retrospectively analyzed the clinical data of 450 consecutive esophageal cancer patients who underwent esophagectomy in our hospital from September 2010 through November 2012 year. The patients were divided into three groups. Forty-five patients were classified as a low BMI group (BMI < 18.5 kg/m2), 304 patients were classified as a normal BMI group (18.5≤BMI < 25.0 kg/m2), and 101 patients as a high BMI group (BMI≥25.0 kg/m2). Patients' demographics, tumor characteristics, and postoperative complications were compared among the three groups. ResultsThe comorbidity of diabetes was higher in the high BMI group compared with the other two groups (P=0.025). Longer operative time, wound infection or delayed healing were more frequent in the high BMI group (P=0.010 and P=0.039, respectively). Pneumonia and length of hospital stay had a tendency to increase in the high BMI group (P=0.052 and P=0.081, respectively). However, the differences did not reach statistical significance. There was no statistical difference in pulmonary embolism, respiratory failure, anastomotic leakage, vocal code paresis, chylothorax, other organ damage, reoperation, arrhythmia, or in-hospital mortality among the three groups. ConclusionsHigh BMI has a negative impact on postoperative morbidity after esophagectomy. However, overweight is not a postoperative complications which should always be paid attention to.
Barrett’s esophagus is considered an important risk factor for the pathogenesis of esophageal adenocarcinoma. Treatment strategies for diseases from high-grade dysplasia （HGD） to adenocarcinoma are different. The recurrence rates of endoscopic treatment and anti-reflux surgery are comparatively higher. Abnormal lesions of the esophagus can be completely resected by esophagectomy for the treatment of HGD to adenocarcinoma, and treatment outcomes are confirmed.But appropriate surgical strategies and lymph node dissection scopes should be chosen according to different cancer staging.Lymph node metastasis is a major factor in determining prognosis.
Objective To determine if laparoscopic assisted Ivor-Lewis cervical stapled esophagogastrostomy via a minor subaxillary incising enables better perioperative and medium-term outcome than Ivor-Lewis cervical stapled esophagogastrostomy via thorax for middle esophageal carcinoma without intumescent lymphnode of neck. Methods The perioperative and medium-term outcome of a series of 55 patients underwent Ivor-Lewis cervical stapled esophagogas-trostomy via thorax between April 2010 and December 2012 were as a historic cohort (group A, 36 males, 19 females at age of 65±8 years). And 46 patients underwent laparoscopic assisted Ivor-Lewis cervical stapled esophagogastrostomy via a minor subaxillary incising between January 2013 and March 2015 were as a prospective cohort (group B, 31males, 15 females at age of 66±7 years). Perioperative indexes, lymphadenectomy, and result at end of one year following up were compared. Results Compared with group A, there was shorter thoracic operation time (t=5.94, P < 0.05), shorter time of restored anus exhaust (t=2.08, P < 0.05), less pulmonary complication (χ2=3.08, P < 0.05) and less total perioperative complications (χ2=4.30, P < 0.05), shorter postoperative hospital stay (t=3.20, P < 0.05) in the group B. While no statistically significant difference was found between the two group in postoperative morbidity of circulation or digestive and associated with surgical techniques (all P>0.05), lymph node metastasis rate of cervico-thoracic (include cervical paraesophageal) or mediastinum or abdominal cavity (χ2=0.03, 0.15, 0.08, all P>0.05), lymph node ratio (LNR) of cervical thoracic (include cervical paraesophageal) or mediastinum or abdominal cavity (χ2=0.01,0.71, 0.01, all P>0.05), recurrence rate of tumour (χ2=0.04, P>0.05), or survival rate (χ2=0.13, P>0.05) one year after the surgery. Conclusion Laparoscopic assisted Ivor-Lewis cervical stapled esophagogastrostomy via a minor subaxillary incising is a more rational surgery of cervicothoracic and cervical paraesophageal lymph nodes dissection via intrathoracic instead of cervical approach for middle esophageal carcinoma.
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.
Esophagectomy and extensive lymphadenectomy still remain effective treatment strategies for patients with resectable esophageal carcinoma (EC). However,traditional esophagectomy is performed via open approaches and associated with significant postoperative morbidity and mortality. In order to reduce morbidity and mortality after esophagectomy,various minimally invasive techniques have been introduced to esophagectomy by many medical centers,and minimally invasive esophagectomy (MIE) has been widely developed in thoracic surgery. MIE has been proven to be a safe and feasible approach for the treatment of EC. Compared with open esophagectomy,MIE can reduce surgical blood loss,achieve complete and standardized tumor resection and lymph node dissection,and obtain equivalent long-term survival results. However,there are still controversies in some aspects of MIE for the treatment of EC,and the superiority of MIE has not been fully demonstrated. In this review,we focus on five aspects of MIE for the treatment of EC,including MIE techniques,perioperative outcomes,completeness and standard of tumor resection,long-term survival results and current problems.
ObjectiveTo compare the short-and mid-term outcomes of patients with esophageal cancer after subtotal esophagectomy via thoracoscopy in lateral prone position, prone position, or left lateral position. MethodsThis randomized prospectively controlled study was conducted in 121 patients receiving subtotal esophagectomy via thoracoscopy between January 2010 and February 2013. The patients were randomly assigned into three groups to underwent esophagectomy in lateral prone position, prone position, or left lateral position, respectively. Forty-three patients (24 males, 19 females, 61.5±1.5 years) underwent surgery in lateral prone position, 39 patients (21 males, 18 females, 63.2±1.7 years) in prone position and other 39 patients (22 males, 17 females, 60.1±1.6 years) in left lateral position. Esophagogastric anastomosis was performed in the left neck. ResultsThe median operative time in the three groups was 232 (165-296) min, 230 (170-310) min, and 280 (190-380) min, respectively (P < 0.05). The median perioperative bleeding was 262 (185-330) ml, 275 (100-320) ml and 350 (120-560) ml, respectively (P > 0.05). The average number of harvested lymph nodes was 19.1 (9-26), 18.4 (11-23), 10.9 (6-21), respectively (P < 0.05). The postoperative medical complications occurred in 10, 9 and 11 patients in three groups, respectively, with no statistical difference. Twenty patients died in the lateral prone position group after a median follow-up period of 19.2 (6-31) months, 18 patients died in the prone position group after a median follow-up period of 20.7 (8-29) months, and 21 patients died in the left lateral position group after a median follow-up period of 18.5 (12-33) months. ConclusionThe results confirm the feasibility and safety of this minimally invasive esophagectomy via thoracoscopy in lateral prone position, prone position, or left lateral position for patients with esophageal carcinoma. A possible advantage of lateral prone technique is that in case of an emergency, precious time could be saved in changing the position of the patient.
Objective To classify the postoperative complications (POCs) in patients receiving esophagectomy and find risk factors of different grades of complications. Methods We retrospectively analyzed the clinical data of 298 patients with esophageal cancer who underwent esophagectomy from January 2012 to August 2015 in our hospital. According to the postoperative complications, they were divided into two groups: the complication group (n=113) and the non-complication group (n=185). In the complications group, there were 86 males and 27 females with an average age of 61.42±7.81 years. There were 150 males and 35 females with an average age of 60.39±7.76 years in the non-complication group. The POCs were classified by Clavien-Dindo system. All possible factors influencing the occurrence of grade Ⅱ-Ⅴ POCs were analyzed. Univariate and multivariate analyses were used for seeking independent risk factors of POCs. Results The incidence of grade Ⅱ POCs was 29.87% (89/298), 5.37% (16/298) for grade Ⅲ and 2.68% (8/298) for grade Ⅳ and Ⅴ. The most common POC was lung infection with the incidence of 13.76%. Univariate and multivariate analyses showed the operation duration and the number of lymph node dissection were the independent risk factors of grade Ⅱ-Ⅴ POCs. Conclusion Postoperative lung infection is the major complication in patients receiving esophagectomy. The operation duration and the number of lymph node dissection are the independent risk factors of grade Ⅱ-Ⅴ POCs.
ObjectiveTo study the gastric function of vagus-preserved patients after esophagectomy, and to evaluate the significance of keeping vagus and the value of gastric tube with vagal-sparing esophagectomy. MethodsWe retrospectively analyzed clinical data of 15 patients in West China Hospital between June 2012 and January 2014. They were divided into two groups. There were 8 patients with 6 males and 2 females with average age of 57 years ranging from 44 to 77 years, in a gastric pull-up group with vagal-sparing esophagectomy. There were 7 patients with 6 males and 1 female at average age of 60 years ranging from 50 to 70 years in a gastric tube group with vagal-sparing esophagectomy. We chose 8 patients with 7 males and 1 female at average age of 62 years ranging from 47 to 69 years as a control group with a classical esophagectomy and a gastric pull-up. Then we evaluated the function of the vagal nerves and gastric reservoir after vagal-sparing esophagectomy. ResultsAll 23 surgeries were successfully performed. In subjective symptom, diarrhea was rare in the vagal-sparing esophagectomy patients and statistically more common in patients with a standard esophagectomy. Dumping and early satisfaction situation were similar among 3 groups. The 60 minutes gastric emptying rate was much better in the vagal-sparing group than that in the control group. And the esophageal manometry of the vagal-sparing group was statistically hihger than that in the control group. The gastroscope showed that the incidence of reflux esophagitis in the vagal-sparing group was statistically lower than that of the control group. There was no statistic difference in weight in the vagus-preserved group before and after the surgery while the weight decreased statistically in the control group. ConclusionsFor both esophageal replacement and gastric tube, preserving the vagus can reduce the functional dyspepsia after esophagectomy.
Esophageal cancer is a common gastrointestinal cancer，and the incidence in China is the highest in the world. Esophagectomy represents the gold standard for patients with resectable esophageal cancer，but postoperative morbidity and mortality rates remain high. In recent years，there have been many reports on the pathogenesis of morbidity and mortality after esophagectomy without reaching any concrete conclusion. This review focuses on the pathogenesis，prophylaxis and therapeuticsof pulmonary infection after esophageal cancer resection．
ObjectiveTo investigate the impact of thoracic duct ligation (TDL) on metabolism and postoperative complications during esophagectomy in patients with type-2 diabetes mellitus (T2DM).MethodsWe conducted a retrospective clinical data analysis of 230 esophageal carcinoma patients with T2DM who underwent esophagectomy in our hospital from January 2003 to December 2018. Patients were divided into a TDL+ group (n=112), including 78 males and 34 females aged 63.47±7.23 years, and a TDL– group (n=118), including 84 males and 34 females aged 64.38±7.57 years. We compared the blood glucose, liver function parameters and lipid metabolic parameters at different time points before and after surgery. In addition, we compared the postoperative major complications between the two groups. Propensity score-matched (PSM) was used to control the observed confounders.ResultsCompared with the TDL– group, patients in TDL+ group had higher blood glucose level (P<0.05, except the fourth postoperative day). The total protein and albumin levels on the first and fourth postoperative days in the TDL+ group were lower than those in the TDL– group (P<0.05). The alanine transaminase (P=0.027) and aspartate transaminase (P=0.007) levels on the fourth postoperative day in the TDL+ group were higher than those in the TDL– group. More pulmonary complications (P=0.014) and anastomotic leaks (P=0.047) were found in the TDL+ group.ConclusionGiven that TDL may aggravate metabolic disorders, increase anastomotic leaks and the pulmonary complications, it is cautious to perform TDL, and prophylactic TDL should not be performed routinely for patients with T2DM.