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.
Abstract： Objective To investigate the indications， surgical techniques and postoperative complication management of transhiatal esophagectomy without thoracotomy for patients with esophageal cancer. Methods We retrospectively analyzed the clinical records of 105 patients with esophageal cancer who underwent transhiatal esophagectomy without thoracotomy in the First Affiliated Hospital of Nanjing Medical University between July 2002 and July 2010， including 28 patients who received video-assisted mediastinoscopy. There were 59 male patients and 46 female patients with their average age of 63 （48-81） years. There were 51 patients with upper thoracic esophageal cancer， 18 patients with middle thoracic esophageal cancer and 36 patients with lower thoracic esophageal cancer. Surgical outcomes and safety were evaluated. Results Mean operation time was 153 （140-210） minutes， mean intraoperative blood loss was 150 （100 to 250） ml， and mean hospital stay was 15 （10-35） days. There was no in-hospital death or residual tumor cells in esophagus stumps. Twenty-seven patients had postoperative complications， including 3 patients with anastomotic leakage at neck， 4 patients with recurrent laryngeal nerve injury， 5 patients with pleural effusion， 2 patients with pneumothorax， 3 patients with pneumonia， 3 patients with arrhythmia， 1 patient with chylothorax， 2 patients with incision infection， 2 patients with delayed gastric emptying， and 2 patients with anastomotic stenosis， who were all cured after treatment. Ninety-seven patients were followed up from 16 months to 5 years， and 8 patients were lost during follow-up. During follow-up， there were 94 patients who had lived for 1 year， 67 patients who had lived for 3 years， and 34 patients who had lived for 5 years postoperatively， and some patients needed further follow-up. Conclusion Transhiatal esophagectomy without thoracotomy is a minimally traumatic procedure and can provide fast postoperative recovery. It is especially suitable for patients with stageⅡor earlier esophageal cancer who can’t tolerate or aren’t suitable for transthoracic esophagectomy.
Abstract: Objective To evaluate the feasibility and safety of combined laparoscopic and thoracoscopic esophagectomy and intrathoracic esophagogastric anastomosis for the treatment of esophageal cancer. Methods We retrospectively analyzed clinical data of 40 patients with esophageal cancer who underwent esophagectomy in Beijing Chaoyang Hospital of Capital Medical University from March 2010 to March 2012. All the 40 patients were divided into 2 groups according to their different surgical approach， including 22 patients who underwent combined laparoscopic and thoracoscopic esophagectomy and intrathoracic esophagogastric anastomosis （minimally invasive surgery group） and 18 patients who underwent Ivor Lewis esophagectomy （open surgery group）. Operation time， intra-operative blood loss， lymph node dissection， postoperative morbidity， hospital stay and cost were compared between the two groups. Results The hospitalcost of minimally invasive surgery group was significantly higher than that of open surgery group ［（78 181.5±8 958.8） yuan vs. （61 717.2±35 159.4） yuan， Z=4.078，P=0.000］ . There was no statistical difference in operation time ［（292.0±74.8） min vs. （256.1±41.0） min， t=1.838，P=0.074］， intra-operative blood loss ［（447.7±597.0） ml vs. （305.6±125.9） ml， Z=0.401，P=0.688］， total number of dissected lymph nodes （230 vs. 215， t=1.714，P=0.095）， postoperative morbidity ［22.7% （5/22） vs. 33.3% （6/18）， χ2=0.559，P=0.498］， time to resume oral intake ［（8.5±3.5） d vs. （11.1±9.6） d，t=1.202，P=0.237］， and postoperative hospital stay ［（11.6±5.7） d vs. （13.3±9.4） d， t=0.680， P=0.501）］ between the two groups. The minimally invasive surgery group was further divided into two subgroups according to operation date， including 10 patients in the early stage subgroup and 12 patients in the later stage subgroup. The operation time of the later stage subgroup was significantly shorter than that of the early stage subgroup ［（262.9±64.9） min vs. （327.5±73.0） min， t=2.197， P=0.040］， but not statistically different from that of the open surgery group ［（262.9±64.9） min vs. （256.1 ±41.0） min， t=0.353， P=0.727］. Intra-operative blood loss of the later stage subgroup was significantly reduced compared with those of the early stage subgroup ［（220.8±149.9） ml vs. （720.0±808.0） ml， Z=3.279， P=0.001)］ and the open surgery group ［（220.8±149.9）ml vs. （305.6±125.9） ml， Z=2.089， P=0.037）］. Conclusion Combined laparoscopic and thoracoscopic esophagectomy and intrathoracic esophagogastric anastomosis is a safe and effective surgical procedure for the treatment of esophageal cancer.
Objective To evaluate the characteristics and reasons of complications in the patients with thoracoscopic esophagectomy. Methods We retrospectively analyzed the clinical data of 165 patients with thoracoscopic esophagectomy in our hospital from January 2013 through January 2015. There were 102 males and 63 females at average age of 67.9±8.3 years. Results The operation time was 275.3±50.2 min. The intraoperative blood loss was 230.0±110.5 ml. The number of lymph node dissection was 18.1±6.5. The volume of drainage in thoracic cavity was 750±550 ml on the third day after operation. Thoracoscopic esophagectomy surgeries were successful except that 13 patients (7.8%) converted to open operation including 6 patients (4.2%) with severe pleural adhesion, 2 patients (1.2%) with hemorrhage, 2 patients (1.2%) with arrhythmia, and 3 patients (1.8%) with abnormal oxygenation. There were 17 patients (10.8%) were with intraoperative complications including 2 patients (1.2%) with arrhythmia, 3 patients (1.8%) with abnormal oxygenation, 7 patients (4.2%) with hemorrhage caused by vascular injury, 4 patients (2.4%) with thoracic duct injury, 1 patient (0.6%) with recurrent laryngeal nerve injury. Moreover, 46 patients (27.8%) experienced postoperative complications including 23 patients (13.9%) with pulmonary infection, 6 patients (3.6%) with hoarseness, 4 patients (2.4%) with anastomotic leakage, 3 patients (1.8%) with incision infection, 2 patients (1.2%) with tracheoesophageal fistula, and 2 patients (1.2%) with pneumothorax. Unexpectedly, five patients underwent re-operation due to chylothorax (n=3, 1.8%) and hemorrhage (n=2, 1.2%). One patient (0.06%) died of acute pulmonary embolism. Conclusion Serious adhesion in abdominal cavity, abnormal of lung and heart. And bleeding are the main reasons caused transferring open thoracic surgery operation in patients with thoracoscopic esophagectomy. Lung infection, hoarseness, and anastomotic leakage of neck are the most common postoperative complications. And acute pulmonary embolism is the main cause of postoperative death. Proper precautions to decrease the morbidity of complication are necessary.
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 compare the outcome of tubular stomach and cervical esophagus laminated anastomosis and mechanical anastomosis. Methods A total of 128 patients with middle and upper esophageal cancer in our hospital from January 2013 to January 2016 were randomly divided into two groups, 64 patients in each group and all patients underwent esophagectomy. In the group A, there were 46 males and 18 females with age of 40–75 years, treated with tubular stomach and cervical esophagus layered anastomosis. There were 51 males and 13 females with age of 43–71 years in the group B receiving mechanical anastomosis. We observed the short-term and long-term efficacy as well as complications. Results In the group A, there was cervical anastomotic fistula in 1 patient, anastomotic stenosis in 2 patients and reflux esophagitis in 12 patients. In the group B, 1 patient suffered chylothorax, 8 patients cervical anastomotic fistula, 4 patients anastomotic stenosis and 14 patients reflux esophagitis. Conclusion Layered anastomosis can effectively reduce the incidence of anastomotic fistula and stenosis. Tubular stomach can effectively prevent and reduce the reflux esophagitis, and the high long-term quality of life will be achieved after the operation.
ObjectiveTo compare the short-term outcomes between Ivor Lewis esophagectomy and McKeown esophagectomy under thoracoscopy and laparoscopy for thoracic middle-lower esophageal carcinoma and to investigate the optimal approach.MethodsThe relevant literatures (from database foundation to March 2016) comparing minimally invasive Ivor Lewis esophagectomy and minimally invasive McKeown esophagectomy were searched through PubMed, EMbase, The Cochrane Library, CBM, CNKI, Wanfang Data and VIP. RevMan 5.3 software was used for data analysis.ResultsA total of 870 patients in 5 studies were reviewed and data were pooled for analysis. The score of Newcastle Ottawa for the literatures was 7-8 points. The results showed that compared with the McKeown group, Ivor Lewis group had shorter operation time (WMD=–34.67, 95% CI –53.70 to –15.65, P=0.000 4), less recurrent laryngeal nerve injuries (OR=0.23, 95% CI 0.12 to 0.44, P<0.000 01), anastomotic leakage (OR=0.24, 95% CI 0.14 to 0.41, P<0.000 01), anastomotic stenosis (OR=0.30, 95% CI 0.16 to 0.55, P=0.000 01), and pulmonary complications ( OR=0.25, 95% CI 0.15 to 0.43, P<0.000 01). There was no significant difference between the two groups in intraoperative blood loss, postoperative stay, hospitalization cost and chylothorax incidence. The McKeown group was associated with much more lymph nodes dissection (WMD=–1.16, 95% CI –2.00 to –0.31,P=0.007) than the Ivor Lewis group.ConclusionCompared with McKeown esophagectomy combined with thoracoscopy and laparoscopy, Ivor Lewis esophagectomy combined with thoracoscopy and laparoscopy has some advantages for thoracic middle-lower esophageal carcinoma, but a greater number of lymph nodes are dissected in McKeown procedure.
Objective To analyze the clinical characteristics of patients treated with esophagectomy following endoscopic submucosal dissection (ESD) for early stage esophageal cancer or precancerosis and the reasons for esophagectomy. Methods We retrospectively analyzed the clinical data of 57 patients who were treated with esophagectomy following ESD in West China Hospital and Shanxian Hygeia Hospital from January 2012 through October 2016. There were 42 males and 15 females at age of 65.4 (52–77) years. There were 15 patients of upper thoracic lesions, the middle thoracic lesions in 34 patients, and the lower thoracic lesions in 8 patients. Results The reasons for esophagectomy included 3 patients with residual tumor, 8 patients with local recurrence, 37 patients with esophageal stricture, and 9 patients with dysphagia, although the diameter was larger than 1.0 cm. The pathology after esophagectomy revealed that tumor was found in 16 patients, including 3 patients with residual tumor and 8 with recurrent tumor confirmed before esophagectomy, and 5 patients with new-found recurrent tumor. Conclusion In the treatment of early stage esophageal cancer or precancerosis, the major reasons for esophagectomy following ESD include esophageal stricture, abnormal esophageal dynamics, local residual or recurrence.
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.
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.