ObjectiveTo investigate the effect of the interval between neoadjuvant chemoradiotherapy (nCRT) and surgery on the clinical outcome of esophageal cancer.MethodsPubMed and EMbase databases from inception to March 2018 were retrieved by computer. A random-effect model was used for all meta-analyses irrespective of heterogeneity. The meta-analysis was performed by RevMan5.3 software. The primary outcomes were operative mortality, incidence of anastomotic leakage, and overall survival; secondary outcomes were pathologic complete remission rate, R0 resection rate, and positive resection margin rate.ResultsA total of 17 studies with 18 173 patients were included. Among them, 13 were original studies with 2 950 patients, and 4 were database-based studies with a total of 15 223 patients. The results showed a significant positive correlation between the interval and operative mortality (Spearman coefficient=0.360, P=0.027). Dose-response meta-analysis revealed that there was a relatively better time window for surgery after nCRT. Further analysis for primary outcomes at different time cut-offs found the following results: (1) when the time cut-off point within 30-70 days, the shorter interval was associated with a reduced operative mortality (7-8 weeks: RR=0.67, 95% CI 0.55-0.81, P<0.05; 30-46 days: RR=0.63, 95%CI 0.47-0.85, P<0.05; 60-70 days: RR=0.64, 95%CI 0.48-0.85, P<0.05); (2) when the time cut-off point within 30-46 days, the shorter interval correlated with a reduced incidence of anastomotic leakage (RR=0.39, 95%CI 0.21-0.72, P<0.05); when the time cut-off point within 7-8 weeks, the shorter interval could achieve a critical-level effect of reducing the incidence of anastomotic leakage (RR=0.73, 95%CI 0.52-1.03, P>0.05); (3) when the time cut-off point within 7-8 weeks, increased interval significantly was associated with the poor overall survival (HR=1.17, 95% CI 1.00-1.36, P<0.05). Secondary outcomes found that the shorter interval could significantly reduce the positive resection margin rate (RR=0.53, 95% CI 0.38-0.75, P<0.05) when time cut-off point within 56-60 days.ConclusionShortening the interval between nCRT and surgery can reduce the operative mortality, the incidence of anastomotic leakage, long-term mortality risk, and positive resection margin rate. It is recommended that surgery should be performed as soon as possible after the patient's physical recovery, preferably no more than 7-8 weeks, which supports the current study recommendation (within 3-8 weeks after nCRT).
Objective To investigate the feasibility, safety, and short-term efficacy of minimally invasive McKeown esophagectomy (MIME) in patients with locally advanced thoracic esophageal squamous cell carcinoma (TESCC) after neoadjuvant immunotherapy. Methods The clinical data of the patients with locally advanced TESCC in the First Affiliated Hospital of University of Science and Technology of China from July 2022 to March 2023 were restrospectively analyzed. They were divided into a neoadjuvant immunotherapy (NI) group and a non-neoadjuvant immunotherapy (NNI) group according to different preoperative neoadjuvant therapy. The perioperative clinical data and 3-month follow-up data were compared between the two groups. Results A total of 47 patients were collected, including 31 males and 16 females with a mean age of (67.57±7.64) years. There were 29 patients in the NI group and 18 patients in the NNI group. There were no statistical differences in baseline data, perioperative complications, short-term complications, surgical time, intraoperative bleeding, postoperative adjuvant therapy, metastasis/recurrence within 3 months, R0 resection rate, postoperative pathological staging decline, or College of American Pathologists (CAP) tumor regression grade between the two groups (P＞0.05). Conclusion Neoadjuvant immunotherapy combined with minimally invasive McKeown esophagectomy can be safely and effectively performed for patients with locally advanced TESCC without increasing operation time, intraoperative blood loss and perioperative complications.
ObjectiveTo investigate the predictive value of prognostic nutritional index (PNI) in complications after thoracoscopy-assisted radical resection of esophageal cancer.MethodsWe collected the clinical data of patients who underwent thoracoscopy-assisted esophagectomy in the First Affiliated Hospital of Xinjiang Medical University from January 2015 to June 2020. The predictive value of PNI for postoperative complications was evaluated by establishing receiver operating characteristic (ROC) curve and the optimal cut-off point was determined. The patients were divided into a high PNI group and a low PNI group according to the cut-off point. The differences of baseline data and perioperative complications-related indicators between the two groups were compared and analyzed. Univariate and multivariate analyses were used to investigate the influence of PNI and other related indexes on postoperative complications.ResultsA total of 116 patients were enrolled in this study, including 75 males and 41 females, aged 65 (58-69) years. The area under ROC curve was 0.647, and the optimal cut-off point was 51.9. According to the cut-off point, there were 45 patients in the high PNI group and 71 patients in the low PNI group. The overall complication rate (χ2=10.437, P=0.001) and the incidence of postoperative pulmonary infection (χ2=10.811, P=0.001) were statistically different between the two groups. The results of univariate analysis showed that the duration of ventilator use (Z=–3.136, P=0.002), serum albumin value (t=2.961, P=0.004), and PNI value (χ2=10.437, P=0.001) were the possible risk factors for postoperative complications after thoracoscopy-assisted esophagectomy. The results of multivariate analysis suggested that the duration of ventilator use (OR=1.015, P=0.002) and the history of drinking (OR=5.231, P=0.013) were independent risk factors for postoperative complications, and high PNI was the protective factor for postoperative complications (OR=0.243, P=0.047).ConclusionPNI index has a certain value in predicting postoperative complications, which can quantify the preoperative nutritional and immune status of patients. Drinking history and duration of ventilator use are independent risk factors for postoperative complications of thoracoscopy-assisted esophagectomy, and high PNI is a protective factor for postoperative complications.
ObjectiveTo present the initial clinical experience of robot-assisted thoracoscopic esophagectomy for patients with esophageal cancer and to analyze the short-term outcomes of these patients.MethodsBetween February 2016 and December 2017, 148 patients with esophageal carcinoma underwent robotic esophagectomy and two-fields lymph node dissection. There were 126 males and 22 females at average age of 62.0±8.0 years. Demographic data, intraoperative characteristics and short-term surgical outcomes were collected and analyzed.Results106 patients underwent McKeown esophagectomy and 42 patients underwent Ivor-Lewis esophagectomy. The mean operation time was 336.0±76.0 min, the mean intraoperative blood loss was 130.0±89.0 ml, the mean number of lymph nodes removed was 21.0±8.0 and the mean length of postoperative hospital-stay was 12.0±7.2 days. Postoperative complications included anastomotic fistula (n=8, 5.4%), pulmonary infection (n=13, 8.7%), hoarseness (n=23, 15.5%), tracheoesophageal fistula (n=1, 0.7%), chylothorax (n=4, 2.7%) and incision infection (n=2, 1.4%). There was no intra-operational massive hemorrhage or in-hospital mortality.ConclusionBoth robot-assisted McKeown and Ivor-Lewis esophagectomy are safe and feasible with good early outcomes.
ObjectiveTo explore the application value of machine learning models in predicting postoperative survival of patients with thoracic squamous esophageal cancer. MethodsThe clinical data of 369 patients with thoracic esophageal squamous carcinoma who underwent radical esophageal cancer surgery at the Department of Thoracic Surgery of Northern Jiangsu People's Hospital from January 2014 to September 2015 were retrospectively analyzed. There were 279 (75.6%) males and 90 (24.4%) females aged 41-78 years. The patients were randomly divided into a training set (259 patients) and a test set (110 patients) with a ratio of 7 : 3. Variable screening was performed by selecting the best subset of features. Six machine learning models were constructed on this basis and validated in an independent test set. The performance of the models' predictions was evaluated by area under the curve (AUC), accuracy and logarithmic loss, and the fit of the models was reflected by calibration curves. The best model was selected as the final model. Risk stratification was performed using X-tile, and survival analysis was performed using the Kaplan-Meier method with log-rank test. ResultsThe 5-year postoperative survival rate of the patients was 67.5%. All clinicopathological characteristics of patients between the two groups in the training and test sets were not statistically different (P>0.05). A total of seven variables, including hypertension, history of smoking, history of alcohol consumption, degree of tissue differentiation, pN stage, vascular invasion and nerve invasion, were included for modelling. The AUC values for each model in the independent test set were: decision tree (AUC=0.796), support vector machine (AUC=0.829), random forest (AUC=0.831), logistic regression (AUC=0.838), gradient boosting machine (AUC=0.846), and XGBoost (AUC=0.853). The XGBoost model was finally selected as the best model, and risk stratification was performed on the training and test sets. Patients in the training and test sets were divided into a low risk group, an intermediate risk group and a high risk group, respectively. In both data sets, the differences in surgical prognosis among three groups were statistically significant (P<0.001). ConclusionMachine learning models have high value in predicting postoperative prognosis of thoracic squamous esophageal cancer. The XGBoost model outperforms common machine learning methods in predicting 5-year survival of patients with thoracic squamous esophageal cancer, and it has high utility and reliability.
With the widespread application of minimally invasive esophagectomy, inflatable video-assisted mediastinoscopic transhiatal esophagectomy (IVMTE) has gradually become one of the alternative surgical methods for transthoracic esophagectomy due to less trama, fewer perioperative complications and better short-term efficacy. However, there is no uniform standard for surgical methods and lymph node dissection in medical centers that perform IVMTE, which affects the standardization and further promotion of IVMTE. Therefore, on the basis of fully consulting domestic and foreign literature, our team proposed an expert consensus focusing on IVMTE, in order to standardize the clinical practice, guarantee the quality of treatment and promote the development of IMVTE.
Objective To investigate the short-term postoperative pain between robot-assisted and thoracolaparoscopic McKeown esophagectomy for esophageal carcinoma. Methods We prospectively analyzed clinical data of 77 patients with esophageal carcinoma in our hospital between September 2016 and February 2017. The patients were allocated into two groups including a robot group and a thoracolaparoscopic group. The patients underwent robot assisted McKeown esophagectomy in the robot group and thoracolaparoscopic McKeown esophagectomy in the thoracolaparoscopic group. There were 38 patients with 30 males and 8 females at average age of 60.80±6.20 years in the thoracolaparoscopic group, and 39 patients with 35 males and 4 females at average age of 60.90±7.20 years in the robot group. Results There was no statistical difference between the two groups in terms of the postoperative usage of analgesic drugs. The patients in the robot group experienced less postoperative pain on postoperative day 1, 3, 5, 6 and 7 than the patients in the thoracolaparoscopic group. The mean value of visual analogue scale (VAS) on postoperative day 1, 3, 5, 6 and 7 for the robot group and the thoracolaparoscopic group was 3.20±1.10 versus 2.70±0.90 (P=0.002), 2.75±0.96 versus 2.40±0.98 (P=0.030), 2.68±1.08 versus 2.02±0.8 (P=0.005); 2.49±0.99 versus 1.81±0.88 (P=0.003), 2.27±0.83 versus 1.51±0.61 (P<0.001), respectively. Conclusion Compared with the thoracolaparoscopic group, patients receiving robot assisted McKeown esophagectomy experience less postoperative short-term pain. However, the long-term postoperative pain for these patients needs to be further studied.
ObjectiveTo investigate the feasibility, safety, and effectivity of the application of systematic lymph node dissection (SLND) in inflatable video-assisted mediastinoscopic transhiatal esophagectomy (IVMTE). MethodsThe clinical data of the patients who underwent IVMTE for esophageal cancer in the First Affiliated Hospital of University of Science and Technology of China From January to October 2024 were restrospectively analyzed. They were divided into a SLND group and an elective lymph node dissection (ELND) group according to intraoperative lymph node resection. clinical characteristics and perioperative outcomes were compared between the two groups. Results A total of 66 patients were enrolled, including 51 males and 15 females, with a mean age of (70.13 ± 8.49) years. There were 12 patients in the selective lymph node dissection (SLND) group and 54 patients in the extended lymph node dissection (ELND) group. There were no statistical differences between the two groups in terms of age, sex, cT stage, tumor location, differentiation grade, pT stage, pN stage, and preoperative comorbidities (P>0.05). statistical differences were observed between the two groups in terms of receiving preoperative neoadjuvant therapy and pTNM staging (P<0.05). There were no statistical differences between the two groups in postoperative complications, operative time, intraoperative blood loss, postoperative hospital stay, and left recurrent laryngeal nerve paratracheal lymph node dissection (P>0.05). The SLND group had a higher average number of lymph nodes dissected, number of stations, number of mediastinal lymph nodes, and number of mediastinal stations than the ELND group. statistical differences were observed between the two groups in the dissection of paraesophageal, right recurrent laryngeal nerve, subcarinal, and diaphragmatic lymph nodes (P<0.05). There were no statistical differences between the two groups in mediastinal lymph node metastasis and cervical lymph node metastasis (P>0.05). The SLND group had more abdominal lymph node metastasis than the ELND group, and the difference was statistically significant (P=0.034). Univariate and multivariate logistic regression analysis showed that cervical lymph node dissection was a risk factor for postoperative complications (P=0.023). Conclusion SLND is safe and effective in IVMTE. Compared with the ELND group, it increased the number of lymph nodes and stations dissected in the mediastinum, and improved the accuracy of postoperative staging. Meanwhile, it did not prolong operative time or hospital stay, nor did it increase the risk of postoperative complications or non-surgical complications.
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.
ObjectiveTo investigate the safety and effectiveness of near-infrared fluorescence imaging of the thoracic duct (NFITD) using indocyanine green (ICG) during inflatable video-assisted mediastinoscopic transhiatal esophagectomy (IVMTE) for esophageal cancer. MethodsA retrospective analysis was conducted on patients with esophageal cancer who underwent IVMTE at the Department of Thoracic Surgery, the First Affiliated Hospital of University of Science and Technology of China, from January 2024 to October 2024. Patients were divided into two groups based on whether they underwent NFITD: an ICG NFITD group (ITD group) and a non-ICG NFITD group (NITD group). Propensity score matching was used to balance confounding factors, and perioperative data and short-term follow-up results (within 6 months) of the two groups were compared. ResultsA total of 66 patients were included, of which 51 were males and 15 were females, with an average age of (70.9±7.2) years. In the comparison of general information between the two groups, the proportion of patients in the ITD group with preoperative chronic obstructive pulmonary disease was higher than that in the NITD group (P=0.044), and the proportion of patients with preoperative bronchiectasis was lower than that in the NITD group (P=0.035). After propensity score matching at a 1:1 ratio, a total of 15 pairs of patients were successfully matched. There was no statistically significant difference between the two groups in terms of intraoperative blood loss, postoperative hospital stay, complications, maximum tumor diameter, pT stage, pN stage, and pTNM stage (P>0.05). The 6-month postoperative follow-up results showed no statistically significant difference between the two groups in terms of anastomotic stricture, hoarseness, gastric paralysis, anastomotic leakage, and postoperative adjuvant treatment (P>0.05). ConclusionThe application of NFITD in IVMTE is safe and effective, with a thoracic duct visualization rate of 100.0%. Compared with NITD, ITD prolonged the operation time but increased the number and stations of lymph node dissection without increasing perioperative and short-term postoperative complications (within 6 months), making it worthy of further clinical promotion.