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.
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.
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 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.
ObjectiveTo systematically evaluate the efficacy of tubular stomach and whole stomach reconstruction in the treatment of esophageal cancer.MethodsWe searched PubMed, Web of Science, The Cochrane Library, EMbase, CNKI, Wanfang Data, VIP and CBM databases to collect the randomized controlled trial (RCT) studies on the efficacy comparison between tubular stomach and total gastric reconstruction of esophagus in esophagectomy from their date of inception to May 2019. Then meta-analysis was performed by using RevMan 5.3 software.ResultsA total of Twenty-nine RCTs were included, and 3 012 patients were involved. The results of meta-analysis showed that the postoperative complications such as anastomotic fistula [RR=0.64, 95%CI (0.50, 0.83), P=0.000 6], anastomotic stenosis [RR=0.65, 95%CI (0.50, 0.86), P=0.002], thoracic gastric syndrome [RR=0.19, 95%CI (0.13, 0.27), P<0.001], reflux esophagitis [RR=0.23, 95%CI (0.19, 0.30), P<0.001], gastric emptying disorder [RR=0.39, 95%CI (0.27, 0.57), P<0.001] and pulmonary infection [RR=0.44, 95%CI (0.31, 0.62), P<0.001] were significantly reduced, and the postoperative quality of life score and satisfaction were higher at 6 months and 1 year in the tubular stomach group (P<0.05). In terms of intraoperative blood loss and postoperative hospital stay, they were better in the tubular stomach group than those in the whole stomach group (P<0.05). However, there was no statistically significant difference between the two groups in operation time, postoperative gastrointestinal decompression time, postoperative closed drainage time, postoperative 1-year, 2-year and 3-year survival rate, postoperative quality of life score at 3 weeks and 3 months, and postoperative life satisfaction at 3 weeks.ConclusionThe tubular stomach is more advantageous than the whole stomach in the reconstruction of esophagus after esophagectomy.
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.
Abstract: Objective To explore the protection of pulmonary function by shortening the thoracic opening time inesophagectomy of esophageal carcinoma. Methods A retrospective review of the postoperative pulmonary function of 54 patients with upper esophageal cancer undergoing esophagectomy with triple incisions in Tongji Hospital from January 2007 to April 2010 was conducted. The patients were divided into two groups. Twentyeight patients including 25 males and 3 females aged at 58.9±8.2 years were in in the classic procedure group, accepting classical esophagectomy with triple incision approach. Among them, there were 26 patients with squamous carcinoma and 2 with adenocarcinoma. Twentysix patients including 22 males and 4 females aged at 54.7±9.4 years were in the improved procedure group, accepting improved esophagectomy with triple incision approach. Among them, 25 patients had squamous carcinoma and 1 had adenocarcinoma. We analyzed the difference of the thoracic opening time, onelung ventilation time during the operation, arterial oxygen pressure (PaO2), arterial carbon dioxide differential pressure(PaCO2), pulse oximeter saturation (SpO2), postoperative mechanical ventilation time, intensive care unit (ICU) stay time, postoperative oxygen support days, postoperative inhospital days, and the incidence of pulmonary infection and respiratory failure between the two groups. Results There was a statistical difference between the two groups in thoracic opening time (4.7±1.2 hours versus 2.6±0.8 hours, t=7.51, Plt;0.05) and onelung ventilation time (3.7±15 hours versus 23±0.8 hours, t=4.23, Plt;0.05). The PaO2 and SpO2 on the 1st day and the 3rd day after operation were significantly lower than those before operation in both the classic procedure group (on the 1st day after [CM(159mm]operation, PaO2: F=516.03, Plt;0.05; SpO2: F=129.63, Plt;0.05; on the 3rdday after operation, PaO2: F=213.99, Plt;005; SpO2: F=61.84, Plt;0.05) and the improved procedure group (on the 1st day after operation, PaO2: F=423.56, Plt;0.05; SpO2: F=184.24, Plt;0.05; on the 3st day after operation, PaO2: F=136.78, Plt;0.05). On the 1st day after operation, PaO2 and SpO2 in the improved procedure group were significantly higher than those in the classic procedure group (F=36.20, Plt;0.05; F=93.42, Plt;0.05), while PaCO2 in the improved procedure group was significantly lower than that in the classic procedure group (F=155.49, Plt;0.05). On the 3rd day after operation, PaO2 in the improved procedure group was significantly higher than that in the classic procedure group (F=29.23, Plt;0.05). The postoperative mechanical ventilation time and ICU stay time in the improved procedure group were significantly shorter than those in the classic procedure group (t=3.81, P=0.00; t=4.65, Plt;0.05). Conclusion Improved esophagectomy of carcinoma with triple incision approach can significantly shorten the thoracic opening time and onelung ventilation time during operation, which plays a good role in protecting pulmonary function and lowering the incidence of pulmonary complications.
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.
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.
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.