Perform Lymph Node Dissection Research Articles

Surgical strategy for incidental intrahepatic cholangiocarcinoma in terms of lymph node dissection

BackgroundAlthough many guidelines recommend performing lymph node dissection (LND) during surgery for intrahepatic cholangiocarcinoma (ICC), there is no evidence for patients with incidentally detected ICC who did not undergo LND. This study aimed to identify the role of LND in patients with incidental ICC. MethodsThe data from 284 patients who had undergone radical surgery for ICC from 2000 to 2020 were retrospectively reviewed. The enrolled patients were divided into 3 groups according to their T stage (T1 vs T2 vs T3 + 4). Moreover, the patients of each T group were divided into 3 groups according to their nodal status (N0 vs N1 vs Nx) and their survival outcomes were compared. ResultsSurvival outcomes of Nx group were statistically similar to that of N0 group in T1 stage (Nx vs N0: disease-free survival [DFS] [months], 129.0 [75.6–182.4] vs 125.0 [65.7–184.3], P = .948; overall survival [OS] [months], 175.0 [153.9–196.1] vs 173.0 [109.0–237.0], P = .443). In contrast, survival outcomes of Nx group in the other T stage (T2 and T3 + 4) were poorer than that of N0 group and were better than that of N1 group. In addition, in the Nx subgroup analysis according to T stage, T1 group showed significantly better survival outcomes than the other groups (T1 vs T2 vs T3 + 4: DFS [months], 129.0 [75.9–182.1] vs 16.0 [9.8–22.2] vs 13.0 [0.3–25.7], P < .001; OS [months], 175.0 [153.9–196.1] vs 53.0 [30.8–75.2] vs 37.0 [17.6–56.4], P < .001). ConclusionPatients with ICC incidentally diagnosed as having T2 or above T stage may consider additional LND.

A newly developed surgeon‐controlled suction device in robotic‐assisted thoracoscopic surgery

AbstractIntroductionAssistant surgeons usually clean the surgical field with a suction cannula in robotic‐assisted surgery. This manipulation requires skill and experience to avoid interfering with the operation of the console surgeon. Recently, we created a new suction device that a console surgeon can manipulate with the robotic arms.Materials and Surgical TechniqueA small metal suction tip with as a lumen and small side pores for suction and can be connected to a silicone tube connected to wall suction. The tip of the silicone tube can be grasped with robotic forceps and used for organ retraction as well as suction. The suction device has been used in eight lung lobectomy cases and four lung segmentectomy cases to date. There were no major difficulties related to the new suction device except for metal tip disconnection and blood clots clogging.DiscussionOur newly developed surgeon‐controlled suction device is inexpensive, easy to handle, and useful for suction, blunt dissection, and organ retraction in robotic‐assisted thoracoscopic surgery, especially when performing lymph node dissection.

Robotic Anterior Resection for Rectosigmoid Colon Cancer using Single Port Access.

Single-port laparoscopic surgery (SPLS) and a robotic surgical system have recently been included in contemporary colorectal surgical practice. 1-4 SPLS may result in better cosmetic outcomes, reduced postoperative incisional pain, fewer incisional hernias, minimal organ damage, and fewer wound complications. 2,5 However, SPLS for left-sided colorectal cancer is a challenging technique, even for experienced laparoscopic colorectal surgeons, owing to the difficulty of constructing instrument triangulation and using endo-staplers in the pelvic cavity from a single umbilical port with adequate distal margins. The Da Vinci Si Single-Site ® system (Intuitive Surgical, Sunnyvale, CA) was specifically developed to overcome SPLS limitations. Since the robotic instruments are crossed at the port site, but the software "reassigns" them to the surgeon's hand on the robotic console, the platform can easily create instrument triangulation while minimizing external robotic arm collisions. 6-8 Due to the lack of wrist articulation, the limited range of motion of the semi-rigid robotic instruments, and the limited choice of instruments, the Single-Site ® platform has not yet been widely utilized for colorectal diseases. A novel robotic technique, the da Vinci SP ® system (Intuitive Surgical, Sunnyvale, CA, USA), was designed for single-site surgery. This platform has a robotic arm with a high degree of freedom that is introduced directly into the peritoneal cavity through a single incision. The benefits of the single-port da Vinci robot platform include a holographic display of the instrument location, wristed articulation and flexible elbows, a console-controlled camera, and three-dimensional optics. This robotic system for single-port access can perform lymph node dissection around the inferior mesenteric artery using 4-arm wrist articulation while preserving the autonomic nerves during left-sided colorectal cancer surgery.

Questionnaire survey regarding current status of minimally invasive surgery for endometrial cancer in Japan: A cross-sectional survey for JSGOE members.

Minimally invasive surgery (MIS) has been introduced as an alternative to more radical surgical procedures. The Japan Society of Gynecologic and Obstetric Endoscopy and Minimally Invasive Therapy conducted a cross-sectional questionnaire survey to ascertain the status of MIS for endometrial cancer. The survey was conducted between May 10 and June 30, 2022. The questionnaire included information on personal attributes, academic affiliations, qualifications, hysterectomies, and intraoperative procedures performed. The total number of questionnaire respondents was 436 (9.2% of the membership). The hysterectomy methods and percentage performed were as follows: simple total hysterectomy (equivalent to benign surgery), 3%; simple total hysterectomy with care to avoid shaving the cervix, 31%; extended total hysterectomy, 48%; and modified radical hysterectomy, 15%. An analysis of hysterectomies performed using MIS for endometrial cancer by qualified gynecologists of endoscopy or board-certified gynecologic oncologists showed a tendency not to choose simple total hysterectomy compared to the gynecologists who did not hold certification (p = 0.019, p = 0.045, and p = 0.010, respectively). Additionally, 67% of respondents did not use uterine manipulators, and 59% of the respondents did not perform lymph node dissection following the guidelines for treating endometrial cancer in Japan. This study provided the current status of MIS for endometrial cancer in Japan. The hysterectomy method, use of uterine manipulators, and criteria for omitting lymph node dissection were generally in agreement with the guidelines. Currently, an extra-fascial simple hysterectomy, including at least not shaving the cervix, was a major method for early invasive endometrial cancer using MIS.

ХИРУРГИЧЕСКИЕ АСПЕКТЫ ЛЕЧЕНИЯ МЕЛАНОМЫ КОЖИ (обзор литературы)

The article deals with the problems of surgical treatment of skin melanoma. Modern surgical treatment of skin melanoma includes various surgical interventions: wide excision of primary skin melanoma, amputation of the finger or disarticulation of the phalanx of the finger, resection of the auricle with its reconstruction, and other operations.&#x0D; The paper discusses the importance of assessing the state of regional lymph nodes in skin melanoma to decide whether to perform lymph node dissection. In addition to adequate excision of primary skin melanoma, to ensure the radicalness of surgical treatment, according to indications, lymph node dissection is performed in case of met astatic lesions of regional lymph nodes.&#x0D; A modern approach to detecting latent metastases involves performing a biopsy of sentinel lymph nodes. The information obtained is extremely important not only in assessing the damage to regional lymph nodes, determin ing the stage of the disease, but also in choosing the tactics of treatment and predicting the course of the tumor.&#x0D; Significant in the work is the conclusion that regional lymph node dissection is performed only in case of met astatic lesions of regional lymph nodes, confirmed morphologically. Accordingly, the best option is to perform regional lymph node dissection simultaneously with excision of primary skin melanoma. Prophylactic lymph node dissection for skin melanoma is not recommended. In conclusion, the latest trends in the surgical treatment of skin melanoma are indicated: an adequate reduction in the indentation and volume of operations when removing primary melanomas, an increase in the role of sentinel lymph node biopsy, the need for morphological verification of lymph node involvement in justifying lymph node dissection, and an increase in the number of metastasectomy.

Development and External Validation of a Machine Learning Model for Prediction of Lymph Node Metastasis in Patients with Prostate Cancer

BackgroundPelvic lymph node dissection (PLND) is the gold standard for diagnosis of lymph node involvement (LNI) in patients with prostate cancer. The Roach formula, Memorial Sloan Kettering Cancer Center (MSKCC) calculator, and Briganti 2012 nomogram are elegant and simple traditional tools used to estimate the risk of LNI and select patients for PLND. ObjectiveTo determine whether machine learning (ML) can improve patient selection and outperform currently available tools for predicting LNI using similar readily available clinicopathologic variables. Design, setting, and participantsRetrospective data for patients treated with surgery and PLND between 1990 and 2020 in two academic institutions were used. Outcome measurements and statistical analysisWe trained three models (two logistic regression models and one gradient-boosted trees–based model [XGBoost]) on data provided from one institution (n = 20267) with age, prostate-specific antigen (PSA) levels, clinical T stage, percentage positive cores, and Gleason scores as inputs. We externally validated these models using data from another institution (n = 1322) and compared their performance to that of the traditional models using the area under the receiver operating characteristic curve (AUC), calibration, and decision curve analysis (DCA). Results and limitationsLNI was present in 2563 patients (11.9%) overall, and in 119 patients (9%) in the validation data set. XGBoost had the best performance among all the models. On external validation, its AUC outperformed that of the Roach formula by 0.08 (95% confidence interval [CI] 0.042–0.12), the MSKCC nomogram by 0.05 (95% CI 0.016–0.070), and the Briganti nomogram by 0.03 (95% CI 0.0092–0.051; all p < 0.05). It also had better calibration and clinical utility in terms of net benefit on DCA across relevant clinical thresholds. The main limitation of the study is its retrospective design. ConclusionsTaking all measures of performance together, ML using standard clinicopathologic variables outperforms traditional tools in predicting LNI. Patient summaryDetermining the risk of cancer spread to the lymph nodes in patients with prostate cancer allows surgeons to perform lymph node dissection only in patients who need it and avoid the side effects of the procedure in those who do not. In this study, we used machine learning to develop a new calculator to predict the risk of lymph node involvement that outperformed traditional tools currently used by oncologists.

Pelvic and inguinal single-site approach: PISA technique. New minimally invasive technique for lymph node dissection in penile cancer

ObjectivesTo describe our initial experience with a new minimally invasive inguinal and pelvic single-access laparoscopic approach, for performing lymph node dissection (LND) in penile cancer: the Pelvic and Inguinal Single Access (PISA) technique. Material and methods10 patients with different penile squamous cell carcinoma stages (cN0 and ≥pT1G3 or cN1/cN2) were operated by means of the PISA technique, between 2015–2018. Intraoperative frozen section analysis was carried out routinely and if ≥2 inguinal nodes (pN2) or extracapsular nodal extension (pN3) are detected, ipsilateral pelvic LND was performed sequentially as a single-stage procedure and using the same surgical incisions. Variables: 30-day PCs, estimated blood loss (EBL), transfusion rate, operative time, time to drainage removal, and length of hospital stay (LOS). Medians and ranges of values for selected variables were reported as descriptive statistics. ResultsInguinal LND was bilateral in all cases, and pelvic LND was required in 40%. Total operative time was 120–170 min and median EBL was 66 (30–100) cc. No blood transfusion was required. No intraoperative complications were noted, and postoperative complications rate was 40% (10% major complications-symptomatic inguinal lymphocele). Median LOS was 5.8 (3–10) days. Median time to inguinal drain removal was 4.7 days. Mean number of lymph nodes removed by inguinal LND: 10.25 (8–14). Limited volume retrospective experience from a referral center with short follow-up. Outcomes reported may not be reproducible by surgeons with less experience and skills. ConclusionsPISA is a novel, minimally invasive single-site surgical approach to one stage bilateral inguinal/pelvic LNDs for penile cancer showing a low rate of major complications.

Técnica PISA: nueva técnica mínimamente invasiva de acceso único para la linfadenectomía pélvica e inguinal en el cáncer de pene

ObjectivesTo describe our initial experience with a new minimally invasive inguinal and pelvic single-access laparoscopic approach, for performing lymph node dissection (LND) in penile cancer: the Pelvic and Inguinal Single Access (PISA) technique. Material and Methods10 patients with different penile squamous cell carcinoma stages (cN0 and ≥pT1G3 or cN1/cN2) were operated by means of the PISA technique, between 2015-2018. Intraoperative frozen section analysis was carried out routinely and if ≥2 inguinal nodes (pN2) or extracapsular nodal extension (pN3) are detected, ipsilateral pelvic LND was performed sequentially as a single-stage procedure and using the same surgical incisions. Variables: 30-day postoperative complicactions, estimated blood loss (EBL), transfusion rate, operative time, time to drainage removal, and length of hospital stay (LOS). Medians and ranges of values for selected variables were reported as descriptive statistics. ResultsInguinal LND was bilateral in all cases, and pelvic LND was required in 40%. Total operative time was 120-170minutes and median EBL was 66 (30-100) cc. No blood transfusion was required. No intraoperative complications were noted, and postoperative complications rate was 40% (10% major complications- symptomatic inguinal lymphocele). Median LOS was 5.8 (3-10) days. Median time to inguinal drain removal was 4.7 days. Mean number of lymph nodes removed by inguinal LND: 10.25(8-14). Limited volume retrospective experience from a referral center with short follow-up. Outcomes reported may not be reproducible by surgeons with less experience and skills. ConclusionsPISA is a novel, minimally invasive single-site surgical approach to one stage bilateral inguinal/pelvic LNDs for penile cancer showing a low rate of major complications.

The accuracy and clinical impact of intraoperative frozen section in determining the extent of surgical intervention in patients with early stage endometrial cancer

The aim of this study was to compare intraoperative frozen section (FS) with the final pathology (FP), and determine its clinical impact in clinically apparent early stage endometrial cancer (EC) at the American University of Beirut Medical Center (AUBMC). Data for patients 18 years or older, with clinically apparent early stage, grade 1 or 2, endometrioid EC, who underwent hysterectomy ± lymph node dissection (LND) at AUBMC between January 1st 1996 and June 30th 2016 were retrospectively reviewed. 70 patients were included. The overall concordance between FS and FP was 92.3% for histological subtype, 77% for tumour grade, 82% for Myometrial invasion (MI) and 100% for tumour size. At a median follow up of 30 months, 8 recurrences (11.4%) were noted, with a 5-year PFS and OS of 76 and 84% respectively, with a trend towards lower recurrence and improved survival in patients who underwent FS or LND. Impact statement What is already known on this subject? Hysterectomy and bilateral salpingo-oophorectomy is the standard surgery for stage I endometrial cancer (EC). Intraoperative frozen section (FS) facilitates the decision on performing lymph node dissection (LND). However, its accuracy and clinical impact have been questioned. What do the results of this study add? Our objective is to compare FS with the final pathology (FP), and determine its clinical impact in clinically apparent early stage EC at the American University of Beirut Medical Center (AUBMC). There is a lack of standardisation regarding FS use and reporting at AUBMC. What are the implications of these findings for clinical practice and/or further research? The strong correlation between FS and FP can serve as a tool to guide decision to perform LND in patients with apparent early stage disease, where use of sentinel LN biopsy technique is not available.

The first clinical experience of using the new Senhance remote-controlled robotic system in general surgery in Russia

Evaluation of own initial experience of using Senhance robotic surgical system in the work of the general surgery department. A prospective collection of data on the surgical treatment of patients with various pathologies using the Senhance robotic system was carried out, followed by its analysis in relation to the duration of the operation, the incidence of intraoperative complications and the need for conversion, as well as the volume of blood loss and early postoperative complications. Now, only perioperative, and early postoperative data are available for analysis. While accumulating our own experience with the Senhance system, we concluded that, since the transition from robotic to manual laparoscopic surgery and vice versa does not require changing of access points and is performed quickly, it is practically expedient to perform some stages of the operation manually, and others using surgical robot. For example, with the help of manual laparoscopy, it is more ergonomic to perform wide tractions and movements of organs and tissues. At the same time, robotic surgery has undeniable advantages when performing lymph node dissection, performing manual sutures, including anastomoses, which does not lead to an increase in the duration of the intervention. Presented experience of using the Senhance system has shown that it meets the declared indicators of convenience, efficiency and safety of operations in general surgery.

Risk Factors for Recurrence in Patients with Pathological Lymph Node-Positive Prostate Cancer after Extended Lymph Node Dissection in Laparoscopic and Robotic-Assisted Radical Prostatectomy

From April 2007 to April 2018, we performed lymph node dissection in 305 cases of laparoscopic radical prostatectomy and 202 cases of robot-assisted radical prostatectomy at our hospital, and there were 68 cases with positive lymph node metastasis (pN1). Of these 68 cases, we examined retrospectively 62 cases in which extended lymph node dissection (ELND) was performed. The median number of removed lymph nodes was 25 (interquartile range [IQR] ; 18-34) and the median number of metastatic lymph nodes was 1 (IQR ; 1-3). Postoperative prostate-specific antigen (PSA) recurrence was observed in 40 of the 62 patients. The median time to PSA recurrence was 24 months. After univariate analysis, PSA at initial diagnosis (iPSA) of 10 ng/ml or more, pathological Gleason score (pGS) of 8 or more, total number of lymph node metastases of 2 or more, and positive surgical margin (RM＋) were found to be riskfactors of PSA recurrence. In multivariate analysis, iPSA of 10 ng/ml or more, pGS of 8 or more and RM＋ were independent riskfactors of PSA recurrence (p＜0.05). In the cases without riskfactors such as iPSA≥10, pGS≥8, and RM＋, immediate postoperative adjuvant therapy may be avoided even with pN1.

Is lymph node dissection mandatory among early stage endometrial cancer patients? A retrospective study

BackgroundWhether routine lymph node dissection for early endometrial cancer is beneficial to survival is still controversial. However, surgeons usually perform lymph node dissection on all patients with early endometrial cancer. This study aimed to prove that the risk of lymph node metastasis, as defined by our standard, is very low in such patients and may change the current surgical practice.Methods36 consecutive patients who had staged surgery for endometrial cancer were collected. All eligible patients meet the following very low risk criteria for lymph node metastasis, including: (1) preoperative diagnosis of endometrial cancer (preoperative pathological diagnosis), (2) tumors confined to the uterine cavity and not beyond the uterine body, (3) PET-MRI lymph node metastasis test is negative. PET-MRI and pathological examination were used to assess the extent and size of the tumor, the degree of muscular invasion, and lymph node metastasis.ResultsThe median age at diagnosis was 52 years (range 35–72 years). The median tumor size on PET-MRI was 2.82 cm (range 0.66–6.37 cm). Six patients underwent robotic surgery, 20 underwent laparoscopic surgery, 8 underwent Laparoscopic-assisted vaginal hysterectomy, and 2 underwent vaginal hysterectomy. 23% (63.9%) patients had high-grade (i.e. 2 and 3) tumors. Among the 36 patients who underwent lymph node sampling, the median number of lymph nodes retrieved was 32 (range 9–57 nodules). No patient (0%) was diagnosed with lymph node metastasis. According to the policy of each institution, 8 patients (22.2%) received adjuvant therapy, and half of them also received chemotherapy (4 patients; 50%).ConclusionsNone of the patients who met the criteria had a pathological assessment of lymph node metastasis. Omitting lymph node dissection may be reasonable for patients who meet our criteria.

Robotic esophagectomy with total mediastinal lymphadenectomy using four robotic arms alone in esophageal and esophagogastric cancer (RETML-4): a prospective feasibility study.

Robotic-assisted esophagectomy is still in the implementation phase. Robotic surgical systems refine visualization via robotically-enhanced surgical anatomy (RESA), and the stable articulated robotic arms provide precise movements. This prospective feasibility study was conducted to evaluate robotic esophagectomy with total mediastinal lymphadenectomy using four robotic arms exclusively (RETML-4). The inclusion criterion was clinical stage I-IIIB esophageal cancer with stable general condition. Patients were positioned hemi-prone with single-lung ventilation, and the operation table was tilted until the patient was prone. The first, second, third, and fourth robotic ports were inserted into the ninth intercostal space (ICS) on the angulus inferior scapulae line, seventh ICS on the posterior axillary line, and the fifth and third ICS on the mid-axillary line, respectively. RETML-4 was performed by precise sharp dissection in wide stable operation fields, with countertraction created by a tip-up fenestrated grasper with gauze. Esophagectomy was performed separately for the middle to lower, and upper esophagus. After mobilizing the middle to lower esophagus and performing lymph node dissection, the upper esophagus was mobilized, with bilateral lymph node dissection along the recurrent laryngeal nerves. The assistant surgeon was involved only during removing gauze and collecting harvested lymph nodes in the thorax. RETML-4 was performed in all ten patients enrolled in 2018. The median postoperative hospital stay was 15days, and the complication rate was 60%. Nine cases achieved R0 resection. Recurrence occurred in two cases. RETML-4 is feasible, and may facilitate minimally invasive esophagectomy by providing precise instrument movements and RESA.

Analysis of Prognostic Factors in Complicated Colorectal Cancer Operated in Emergency.

Introduction: In 2018, the colon cancer was the 5th type of neoplasia regarding the cancer mortality and the rectal cancer was the 10th. The survival of patients with colorectal cancer operated in emergency still remains unsatisfactory, the death being due to local recurrences and to metastases. The aim of this study is to evaluate some correlations of overall survival with clinic and paraclinic features, tumor or treatment characteristics in order to identify prognostic factors, for cases with colorectal tumors that underwent emergency surgery. Material and Methods: We performed a retrospective analysis on 431 patients with colorectal cancer operated in emergency between 2008-2017, excluding 40 patients with postoperative deaths, with a follow-up period of at least one year. There were correlations of some clinic and paraclinic features, tumor or treatment characteristics with the overall survival. Results: In the univariate statistical survival analysis, a statistically significant association was obtained with: the age 61 years (p_value = 0.000049), abdominal surgical history (p_value = 0.031725), heart disease (p_value = 0.000007), atrial fibrillation (p_value = 0.007496), preoperative diagnosis (p_value = 0.034352), cachexia (p_value = 0.000000), oliguria (p_value = 0.000000), anemia (p_value = 0.000006) hydro-electrolytic disorders (p_value = 0.000001), tumor localization (p_value = 0.000030), invasion into other organs (p_value = 0.000000), appearance of "frozen pelvis" (p_value = 0.000000), peritoneal carcinomatosis (p_value = 0.000000), liver metastases (p_value = 0.000000), type of surgery (p_value = 0.000000), lymph node dissection (p_value = 0.000001), liver biopsy (p_value = 0.043483), stoma reversal (p_value = 0.000000 ), serial interventions (p_value = 0.000000), pTNM (p_value = 0.000000), tumor grading (p_value = 0.007069). The Cox multivariate regression analysis revealed that: the age 61 years - HR = 1,026, 95% CI (1,012, 1,039) (p value = 0.000139), cachexia - HR = 1,358, 95% CI (1,046, 1,764) (p value = 0.021617), peritoneal carcinomatosis - HR = 2.346, 95% CI (1.163, 4.732) (p_value = 0.017253), disease stage - HR = 36.745, 95% CI (14.778, 91.366) (p_ value = 0.000000), intervention type - HR = 0.187, 95% CI (0.045, 0.779) (p_ value = 0.021281) and serial interventions - HR = 0.282, 95% CI (0.144.0.551) (p_ value = 000213) are independent prognostic factors. Conclusions: The prognostic factors for patients with colorectal cancers operated in emergency are: the age 61, the presence of abdominal surgical history and associated cardiac conditions, especially atrial fibrillation, diagnosis of diastatic perforation imminence, cachexia, oliguria, hydro-electrolytic disorders at admission, rectal tumors, tumor invasion in other organs, the appearance of "frozen pelvis", the presence of liver metastases or peritoneal carcinomatosis, undifferentiated tumors, stage IV, practicing an internal derivation or not performing lymph node dissection. The age over 61, cachexia, as well as peritoneal carcinomatosis, stage III or IV are independent risk factors the Hartmann procedure and the serial interventions are independent protective factors.

P152 CLINICAL PREDICTIVE MODEL OF LYMPH NODE METASTASIS AT RIGHT RECURRENT LARYNGEAL NERVE ZONE IN ESOPHAGEAL SQUAMOUS CELL CARCINOMA

Abstract Aim The aim of this study is to establish a clinical predictive standard for lymph node metastasis at this location by retrospectively comparing the traditional imaging findings of RRLN lymph nodes in esophageal squamous cell carcinoma with postoperative pathology. Background The right recurrent laryngeal nerve (RRLN) is the zone most prone to lymph node metastasis of esophageal squamous cell carcinoma. Although the survival benefit is large after surgical dissection, however, the postoperative mortality rate is significantly increased if the nerve is injured. How to selectively perform lymph node dissection at this location has always been a clinical problem that needs to be addressed. In the past, clinical evaluations mostly used lymph node short diameter ≥1cm as the diagnostic criteria for metastasis, which significantly underestimated the actual clinical situation. Methods 308 patients with thoracic esophageal squamous cell carcinoma who underwent surgical treatment in Shanghai Chest Hospital from Jan 2018 to Dec 2018 were retrospectively analyzed. According to imaging 1mm layer thickness enhanced CT as a tool, the RRLN lymph node short diameter (ctNd) size was measured. All patients were divided into four groups: (A) CT images without RRLN lymph node, (B) CT images with RRLN lymph node was 0&lt;ctNd&lt;5mm, (C) CT images with RRLN lymph node was 5mm≤ctNd&lt;10mm, (D) CT images with RRLN lymph node was ctNd≥10mm. The RRLN lymph node metastasis of each group was analyzed, and the influencing factors were analyzed to establish a predictive model. Results Among all patients, 87.6% of the patients had lymph nodes detected in the RRLN surgical specimens. The sampling rate was 14.5% (121/832), the RRLN lymph node metastasis rate was 19.48%, and the total lymph node metastasis rate was 48.7%. RRLN lymph nodes (57.1%) (A-132, B-43, C-125, D-9) were seen in the preoperative CT scan of 176 patients. The postoperative pathological RRLN lymph node metastasis rate was 9.1%, 18.6%, 27.2% and 66.7%, respectively (P=0.01). Multivariate analysis showed that ctNd, tumor location and N stage were risk factors for RRLN lymph node metastasis (P&lt;0.05). The risk of upper esophageal cancer metastasis was higher than middle segment esophageal cancer (28.2% vs 18.6%, P&lt;0.05). The higher the risk of right laryngeal lymph node metastasis was detected in the later N stage (cN0-13.2%, cN1-21.5%, cN2-46.7%, P&lt;0.05). The 6.5mm short diameter of RRLN lymph nodes on CT scan is the critical value of metastasis at this position (sensitivity 50%, specificity 83.5%), and the higher the risk of metastasis was seen in the larger the short diameter (P&lt;0.05). Conclusion More than 6.5mm short diameter in the CT scan image should be the clinical predictor of lymph node metastasis of the right recurrent laryngeal nerve. The higher risk of metastasis was seen in the greater short diameter. Upper esophageal cancer and multiple lymph node metastasis increase the risk of RRLN lymph node metastasis. Key words esophageal cancer, lymph node metastasis, recurrent laryngeal nerve, computed tomography

AB002. Lymph node dissection under minimal invasive surgery

: A minimal invasive approach for lung cancer has become standard of care in many major thoracic centres around the world. In our institution at the Department of Thoracic Surgery at the University Hospital of Copenhagen, 90% of all lung cancer operations are performed with a minimal invasive approach. However implementation was slow in the beginning of the minimal invasive era. Thoracic surgeons were concerned about two major issues preventing implementation. Firstly, how to control major bleeding from the pulmonary artery? Secondly, the oncological efficacy of a minimal invasive approach was a concern. Many thoracic surgeons doubted that a systematic lymph node dissection under minimal invasive surgery could be performed with the same quality as in open surgery. Like in any other surgical approach, there is a considerable learning curve for learning the skills to perform a minimal invasive lobectomy. It is my experience from proctoring many thoracic surgeons around the world in video-assisted thoracoscopic surgery (VATS) lobectomy, that first step is to learn the techniques of performing the lobectomies. Then the technique of performing lymph node dissection has a separate learning curve to overcome. The key recommendation is to perform an “en bloc” resection with all lymphatic tissue and fatty tissue in one station. Keeping the capsule of the lymph intact decreases the risk of tumour cell spreading. Removing the lymph nodes this way makes it easier and more reliable for the pathologist to count the number of lymph nodes removed. The lymph node dissection is usually performed using monopolar electro coagulation (electro cautery hook) or using bipolar advanced energy devices such as Ligasure or Harmonic scalpel. The electro cautery hook is less costly and easy to use. However, there is a risk for injuring the pulmonary artery during dissection and the there is a considerable risk of lateral thermal spread up to 1 cm for the target area. This should be taken into consideration when dissecting near the recurrent nerve in the aorta-pulmonary window. Using advanced energy on the other hand is more expensive, however bipolar advanced energy devices can be used in close proximity to vascular structures and nerves with minimal risk of injury. Limiting bleeding by sealing minor vessels improves the overview of the dissection and thereby makes the dissection easier and safer. On the right side the lymph node dissection in the superior mediastinum is performed as an “en bloc” resection of the lymph nodes in station 2R and 4R. The dissection begins inferior to the azygos vein along the pulmonary artery lifting the azygos vein up. The azygos vein can be divided, but in most cases this is not necessary. The smaller vessels from the superior vena cava (SVC) are sealed. Dissection continues along the SVC, the pericardium and trachea. Pleura over this area are divided and the dissection is continued to the top area near the subclavian artery. In the angle between the subclavian artery and trachea dissection should be performed carefully to avoid injuring the recurrent nerve. The specimen with lymph nodes and fatty tissue is removed via the utility port, which should be protected with a port protector to avoid seeding of tumour cells. The subcarinal area (station 7) is approached superior to the inferior vein. Dissection is continued until the left main bronchus is seen and 2 cm of the left main bronchus should be cleared for lymph nodes along with bronchus intermedius. Oesophagus can be retracted with the suction to open the space and facilitate dissection. It is recommended to divide the inferior ligament, when removing the paraoesophageal lymph nodes (station 8) and the lymph nodes in the lymph nodes in the inferior ligament (station 9). On the left side, lymph node dissection in the aorta-pulmonary window (stations 5 and 6) is initiated along the superior part of the aortic arch, identifying the vagal nerve. The recurrent nerve can easily be localized, when following the vagal nerve to the inferior part of the aortic arch. Once the recurrent nerve is identified, the risk of injury and traction is less. The majority of injuries to recurrent nerve during lymph node dissection is due to traction and causes neuropraxia. Fortunately this type of injury is temporary, however patients are often hoarse for several months. After the recurrent nerve is localized, dissection continues along the phrenic nerve and pleura are opened. The dissection continues along the main pulmonary artery and all the lymph nodes and fatty tissue can be removed via the utility port and a port protector like the right side. The lymph nodes in stations 7, 8 and 9 can removed similar to removal on the right side, however the dissection is deeper in the subcarinal area on the left side and retraction with 2 or more instruments facilitates the dissection.

Hospital readmissions after limited vs. extended lymph node dissection during open and robot-assisted radical prostatectomy

PurposeDifferences exist concerning when and how to perform lymph node dissection (LND) during radical prostatectomy due to lack of high-grade evidence to its safety and efficacy. We aimed to compare readmission rates between limited and extended LND during open radical prostatectomy (ORP) and robot-assisted radical prostatectomy (RARP). Materials and methodsWe conducted a prospective trial of 3,706 eligible patients comparing ORP vs. RARP (LAPPRO). Six hundred and twenty-seven underwent concomitant LND. Data were retrieved for readmissions within 90 days from surgery from the Swedish Patient Registry. Causes for readmissions were classified according to the modified Clavien-Dindo classification system. We estimated risks for readmission stratified by type of LND and surgical approach. ResultsWe recorded 107 readmissions in 90 patients. The overall readmission rate was 14% (90/627). In the open group, extended LND had a higher, but not statistically significant readmission rate of 18% compared to 11% after limited LND (95%CI 0.87–3.01). In the robot-assisted group, readmissions after extended LND did not differ from limited LND (15% vs. 18%, 95%CI 0.49–1.61). RARP with limited LND showed a higher risk for any (RR 1.98, 95%CI [1.02–3.81]) as well as Clavien-Dindo grade 1 to 2 readmissions (RR 2.49, 95%CI [1.10–5.63]) compared to open approach with limited LND. Robot-assisted extended LND reduced the risk for Clavien-Dindo grade 3 to 5 complications leading to readmissions compared to the open approach by 59% (RR 0.41, 95%CI [0.19-0.87]). ConclusionsThe risk for hospital readmission was similar when performing limited or extended LND during a radical prostatectomy. Robot-assisted technique for performing extended LND may decrease the risk for severe complications.

Thoracoscopic esophagectomy with three-field lymphadenectomy for thoracic esophageal cancer in a patient with a double aortic arch: a report of a case

BackgroundWe encountered an esophageal cancer patient with a double aortic arch (DAA) who underwent radical thoracoscopic esophagectomy with three-field lymph node dissection. A DAA generally makes it difficult to perform upper mediastinal lymph node dissection via both sides of the thoracic cavity. Furthermore, most patients with a DAA have a superior right aortic arch and right-sided descending aorta, which hampers radical esophagectomy with a typical right thoracic approach. We herein report our operative strategy of thoracoscopic esophagectomy via the left side of the thoracic cavity with a preceding cervical procedure.Case presentationA 64-year-old man was diagnosed with esophageal squamous cell carcinoma in the upper esophagus at clinical Stage IIB (cT1bN1M0) according to the UICC-TNM classification 7th edition. First, we planned the preceding cervical procedure to complete upper mediastinal lymph node dissection, as the DAA prevented a bilateral thoracic approach to the upper mediastinum. We then planned the left thoracoscopic procedure to perform lymph node dissection below the left aortic arch, as the patient in our case had a right side-dominant DAA and right-sided descending aorta, as is common in such patients. We identified the bilateral recurrent laryngeal nerves during upper mediastinal lymph node dissection in the preceding cervical procedure and ultimately successfully resected the patient’s esophageal cancer.ConclusionThe cervical procedure preceding the left-thoracoscopic approach is reasonable for achieving radical esophagectomy for thoracic esophageal cancer in patients with a DAA.

International and Multi-institutional Assessment of Factors Associated With Performance and Quality of Lymph Node Dissection During Radical Nephrectomy

ObjectiveTo determine factors associated with performance and quality of lymph node dissection during radical nephrectomy. Materials and MethodsUsing an International Data Registry, we performed multilevel logistic regression to determine the association of surgical approach (open surgery vs minimally invasive surgery), institutional experience (low, moderate, and high tertiles), and institutional preference (minimally invasive surgery, balanced, and open surgery tertiles) with the performance of lymph node dissection in subgroups by clinical stage and nodal status. ResultsAmong 1,742 patients undergoing radical nephrectomy, 312 (18%) underwent lymph node dissection, which was associated with stage (28% for ≥cT2 vs 9.3% for cT1), and nodal status (68% for ≥cN1 vs 13% for cN0). Open surgery was significantly associated with performing lymph node dissection in all subgroups. Institutional experience and institutional preference had no association with performing lymph node dissection in the ≥cN1 group. The number of nodes removed was greater for open surgery (mean 5.9) vs minimally invasive surgery (mean 3.4); this held true even when stratified by stage and nodal status. ConclusionIn this large dataset, open surgical radical nephrectomy is associated with more frequent performance and higher quality of lymph node dissection, which may owe to selection bias but also could reflect technical concerns. In the patient population in whom lymph node dissection is recommended (≥cN1), this is not explained by institutional experience or preference. Lymph node dissection may be under-utilized for ≥cN1 disease and over-utilized for cN0 disease, at least according to practice guidelines.

Three-Year Recurrence-Free Survival in Patients With a Very Low Risk of Endometrial Cancer Who Did Not Undergo Lymph Node Dissection (Tree Retro): A Korean Multicenter Study.

Randomized studies have not demonstrated a survival benefit of routine lymph node dissection in early-stage endometrial cancer. Many surgeons nevertheless perform lymph node dissection in all patients with early-stage endometrial cancer. This study aimed to ascertain the survival outcomes of very low-risk endometrial cancer patients (by the Korean Gynecologic Oncology Group [KGOG] criteria) who did not undergo lymph node dissection. Medical records of 156 consecutive patients who underwent surgical staging without lymph node dissection were collected from 10 institutions. All patients fulfilled the KGOG criteria: (1) endometrioid corpus cancer diagnosed by preoperative endometrial biopsy, (2) serum cancer antigen-125 level ≤35 IU/mL, (3) <50% myometrial invasion with no extension beyond the uterine corpus by magnetic resonance imaging (MRI), and (4) no lymph nodes with a short diameter ≥1.0 cm by MRI or computed tomography. Sampling of <5 nodes was allowed at a surgeon's discretion. We evaluated the 3-year recurrence-free survival (RFS) and 5-year overall survival (OS) using the Kaplan-Meier method. The median patient age was 52 years (range, 24-86 years). The median follow-up was 59 months (range, 0-189 months). The 3-year RFS and 5-year OS were 98.6% (95% confidence interval [CI], 96.8%-100.0%) and 98.6% (95% CI, 96.7%-100.0%), respectively. No disease-related mortality occurred. The final pathology report revealed ≥50% myometrial invasion in 29 patients (18.6%) and extension beyond the uterine corpus in 2 patients (1.3%). One patient (0.6%) was diagnosed with lymph node metastasis after lymph node sampling. Eighteen patients (11.5%) received adjuvant therapy after the final pathologic results indicated high risk. Very low-risk patients who did not undergo lymph node dissection had acceptable survival outcomes. Omitting lymph node dissection may be reasonable in patients satisfying the KGOG criteria.