Subcarinal Lymph Node Dissection Research Articles

Analysis of the Trends and Influencing Factors for Postoperative Cough in Patients with Esophageal Cancer Based on Patient-Reported Outcomes.

Cough is a common symptom that affects patients' recovery and quality of life after esophagectomy. This study sought to investigate trends in postoperative cough and the factors that influence cough. A total of 208 of 225 patients were enrolled in this study. The Mandarin Chinese version of the Leicester Cough Questionnaire was administered the day before surgery and at three time points (1 week, 1 month, and 3 months) after esophagectomy to assess patient-reported outcomes. All patients' LCQ-MC scores after surgery were lower than presurgery (P < 0.05), with the lowest score found 1 week after esophagectomy. Factors associated with a cough 1 week after surgery included clinical stage of cancer (OR 0.782, 95% CI 0.647-0.944, P = 0.011), anastomotic position (OR 1.241, 95% CI 1.069-1.441, P = 0.005), duration of surgery (OR 0.759, 95% CI 0.577-0.998, P = 0.049), and subcarinal lymph node dissection (OR 0.682, 95% CI 0.563-0.825, P < 0.001). Factors associated with a cough one month after surgery included clinical stage (OR 0.782, 95% CI 0.650-0.940, P = 0.009), anastomotic position (OR 1.293, 95% CI 1.113-1.503, P = 0.001), and maintaining a semi-reclining position (OR 1.440, 95% CI 1.175-1.766, P < 0.001). Factors associated with a cough 3 months after surgery were clinical stage (OR 0.741, 95% CI 0.591-0.928, P = 0.009) and anastomotic position (OR 1.220, 95% CI 1.037-1.435, P = 0.016). This study showed that the factors influencing postoperative cough differed over time following esophagectomy. These results may warrant prospective intervention to better manage patients undergoing surgery for esophageal cancer to prevent postoperative cough.

Establishment of a Predictive Model for Chronic Cough after Pulmonary Resection

Chronic cough after pulmonary resection is one of the most common complications, which seriously affects the quality of life of patients after surgery. Therefore, the aim of this study is to explore the risk factors of chronic cough after pulmonary resection and construct a prediction model. The clinical data and postoperative cough of 499 patients who underwent pneumonectomy or pulmonary resection in The First Affiliated Hospital of University of Science and Technology of China from January 2021 to June 2023 were retrospectively analyzed. The patients were randomly divided into training set (n=348) and validation set (n=151) according to the principle of 7:3 randomization. According to whether the patients in the training set had chronic cough after surgery, they were divided into cough group and non-cough group. The Mandarin Chinese version of Leicester cough questionnare (LCQ-MC) was used to assess the severity of cough and its impact on patients' quality of life before and after surgery. The visual analog scale (VAS) and the self-designed numerical rating scale (NRS) were used to evaluate the postoperative chronic cough. Univariate and multivariate Logistic regression analysis were used to analyze the independent risk factors and construct a model. Receiver operator characteristic (ROC) curve was used to evaluate the discrimination of the model, and calibration curve was used to evaluate the consistency of the model. The clinical application value of the model was evaluated by decision curve analysis (DCA). Multivariate Logistic analysis screened out that preoperative forced expiratory volume in the first second/forced vital capacity (FEV1/FVC), surgical procedure, upper mediastinal lymph node dissection, subcarinal lymph node dissection, and postoperative closed thoracic drainage time were independent risk factors for postoperative chronic cough. Based on the results of multivariate analysis, a Nomogram prediction model was constructed. The area under the ROC curve was 0.954 (95%CI: 0.930-0.978), and the cut-off value corresponding to the maximum Youden index was 0.171, with a sensitivity of 94.7% and a specificity of 86.6%. With a Bootstrap sample of 1000 times, the predicted risk of chronic cough after pulmonary resection by the calibration curve was highly consistent with the actual risk. DCA showed that when the preprobability of the prediction model probability was between 0.1 and 0.9, patients showed a positive net benefit. Chronic cough after pulmonary resection seriously affects the quality of life of patients. The visual presentation form of the Nomogram is helpful to accurately predict chronic cough after pulmonary resection and provide support for clinical decision-making.

Subcarinal lymph node dissection (station 7) using a traditional mediastinoscope with a 30-degree, 5 mm lens, connected to the video camera.

Subcarinal lymph node dissection (station 7) using a traditional mediastinoscope with a 30-degree, 5 mm lens, connected to the video camera.

MO62-4 Evaluation of the significance of subcarinal lymph node dissection in stage IB non-small cell lung cancer

MO62-4 Evaluation of the significance of subcarinal lymph node dissection in stage IB non-small cell lung cancer

Subcarinal lymph node dissection facilitated by applying suture passer in uniportal video-assisted thoracoscopic surgery.

With the advancement of surgical skills and instrumentation, uniportal video-assisted thoracoscopic surgery (UniVATS) has become a popular option for the treatment of early stage lung cancer surgery. However, performing subcarinal lymph node dissection remains technically challenging under UniVATS view. We introduce a novel technique that utilized a suture passer to improve the exposure of the subcarinal area and simplify lymph node dissection, which has the potential for widespread adoption in clinical practice. There were 13 lung cancer patients who underwent UniVATS lobectomy with mediastinal lymphadenectomy in our institution from July to August 2022. Clinical data of the patients were documented and reviewed. The study population consisted of nine females and four males, with an average age of 57.5 ± 9.1years. UniVATS lobectomy with mediastinal lymphadectomy was successfully performed in all patients without conversion to open surgery. The mean operation time was 90.7 ± 36.0min (53-178min), intraoperative blood loss was 73.1 ± 43.8mL (50-200mL), and postoperative hospital stay was 2.9 ± 0.3days (2-3days). No complications related to lymph node dissection, such as chylothorax, occurred. Our novel method of using a suture passer could simplify the procedure of subcarinal lymph node dissection during UniVATS in initial clinical practice. Further comparative studies are warranted in the future.

Evaluation of the significance of subcarinal lymph node dissection in stage IB non‑small cell lung cancer.

Lymph node dissection is used to treat early-stage lung cancer. The present study aimed to investigate if resecting the subcarinal lymph nodes affects prognosis of patients with stage IB non-small cell lung cancer (NSCLC). A total of 597 patients with stage IB NSCLC who underwent lung cancer surgery at Sun Yat-Sen University Cancer Center from January 1999 to December 2009 were included in the present study. The potential prognostic factors were evaluated using the Cox proportional hazard regression model. A total of 252 cases were obtained following propensity score matching (PSM). To compare overall survival (OS) and recurrence-free survival (RFS), Kaplan-Meier method and log-rank test were used. Among the 597 cases included, 185 did not undergo subcarinal lymph node resection, whereas 412 did. There were statistically significant differences between the two groups in terms of bronchial invasion, number of resected lymph node stations and resected lymph node numbers (P<0.05). Age, family history of cancer and the number of resected lymph nodes were prognostic factors for OS, whereas age and the number of resected lymph nodes were prognostic factors for RFS (P<0.05). Resection of subcarinal lymph nodes was not associated with OS and RFS. After PSM, survival analysis was recalculated using the Kaplan-Meier method and log-rank test; subcarinal lymph node resection was not statistically associated with OS and RFS. (P>0.05). For stage IB NSCLC, there was no statistically significant association between subcarinal lymph node resection and OS and RFS. Subcarinal lymph node resection in surgery of stage IB NSCLC may be considered optional.

Relevance of Subcarinal Lymph Node Dissection for Gastroesophageal Junction Adenocarcinoma

IntroductionReported rates of subcarinal lymph node (LN) metastases for esophageal carcinoma vary from 20% to 25% and the relevance of subcarinal lymph node dissection (LND) for gastroesophageal junction (GEJ) adenocarcinoma is poorly defined. This study aimed to evaluate rates of subcarinal LN metastasis in GEJ carcinoma and determine their prognostic significance. MethodsPatients with GEJ adenocarcinoma undergoing robotic minimally invasive esophagectomy from 2019 to 2021 were retrospectively assessed within a prospectively maintained database. Baseline characteristics and outcomes were examined with attention to subcarinal LND and LN metastases. ResultsAmong 53 consecutive patients, the median age was 62, 83.0% were male, and all had Siewert type I/II tumors (49.1% and 50.9%, respectively). Most patients (79.2%) received neoadjuvant therapy. Three patients had subcarinal LN metastases (5.7%) and all had Siewert type I tumors. Two had clinical evidence of LN metastases preoperatively and all three additionally had non-subcarinal nodal disease. A greater proportion of patients with subcarinal LN disease had more advanced (T3) tumors compared to patients without subcarinal metastases (100.0% versus 26.0%; P = 0.025). No patient with subcarinal nodal metastases remained disease free at 3 y after surgery. ConclusionsIn this consecutive series of patients with GEJ adenocarcinoma undergoing minimally invasive esophagectomy, subcarinal LN metastases were found only in patients with type I tumors and were noted in just 5.7% of patients, which is lower than historical controls. Subcarinal nodal disease was associated with more advanced primary tumors. Further study is warranted to determine the relevance of routine subcarinal LND, especially for type 2 tumors.

Predictors of the difficulty of transcervical subcarinal lymph node dissection for esophageal cancer

BackgroundTransmediastinal radical esophagectomy (TME) is a new minimally invasive approach without thoracotomy. However, the transcervical dissection of subcarinal lymph nodes (SCLN) is challenging. The shape or narrowness of the mediastinal space, particularly around the aortic arch to the tracheal bifurcation, may increase the difficulty of this procedure. The present study aimed to clarify predictors of the difficulty of transcervical SCLN dissection.MethodsPatients who underwent TME between 2016 and 2019 were included (n = 126). Four indicators, the cervical angle, carina distance, aorta distance, and sternum distance, were defined as indicators of mediastinal narrowness by 3D-CT. The relationships between the difficulty of transcervical SCLN dissection and clinicopathological features, including the above indicators, were investigated.ResultsIn a univariate analysis, the cervical angle (p = 0.023), aorta distance (p = 0.002), and middle thoracic tumor (p = 0.040) correlated with difficulty. The median cervical angle and aorta distance were 15° and 33 mm in difficult cases and 19° and 43 mm in easy cases, respectively. In a multivariate analysis, the short aorta distance (odds ratio: 7.96, p = 0.002) and middle thoracic tumor (odds ratio: 3.35, p = 0.042) were independent predictive factors.ConclusionsThe cervical angle, aorta distance, and middle thoracic tumor may predict the difficulty of transcervical SCLN dissection. In difficult cases, a transhiatal approach should be combined for complete SCLN dissection.

Value of subcarinal lymph node dissection in esophageal cancer surgery: A case-control study.

We investigated the value of subcarinal lymph node dissection in esophageal cancer surgery. Altogether, 240 patients with esophageal cancer admitted to our department between June 2012 and January 2016 were prospectively assigned to an experimental group (subcarinal lymph node dissection group, n = 120 cases) and a control group (uncleaned group, n = 120 cases). The number of subcarinal lymph nodes and the rate of subcarinal lymph node metastasis were determined, and the factors influencing subcarinal lymph node metastasis were analyzed using logistic regression in the experimental group. The operation time, postoperative complications, intraoperative blood loss, postoperative hospital stay, total postoperative hospital cost, and 5-year survival rate were compared between the 2 groups. In the experimental group, an average of 6.03 subcarinal lymph nodes were dissected, and the lymph node metastasis rate was 18.33%. The subcarinal lymph node metastasis rate in the experimental group was related to the size of the subcarinal lymph nodes, depth of tumor invasion, and tumor location. The 5-year survival rate was higher in the experimental group than in the control group (44.2% vs 30.0%, χ2 = 6.407, P = .04). The subcarinal lymph node metastasis rate in patients with esophageal cancer is high. Patients with mid-thoracic esophageal cancers that infiltrate beyond the esophageal muscle layer with subcarinal lymph node size > 1.0 cm should undergo lymph node resection, despite increased operation time, incidence of postoperative pulmonary infection, hospitalization time, and total postoperative cost; lymph node resection may improve the 5-year survival rate.

308. RIGHT TOP PULMONARY VEIN IS A VENOUS ANOMALY OF WHICH SURGEONS SHOULD BE AWARE IN SUBCARINAL DISSECTION FOR RADICAL ESOPHAGECTOMY

Abstract A right top pulmonary vein (RTPV) that crosses behind the right bronchus, is a variation of the superior posterior pulmonary vein in the right upper lobe. Damage of this vessel can lead to intraoperative bleeding, congestion of the posterior segment of the right upper lobe, and cardiac tamponade. Subcarinal lymph node dissection is mandatory in radical esophagectomy for esophageal cancer, and the RTPV is an anomalous vessel of which surgeons should be aware. A 70-year-old man underwent thoracoscopic esophagectomy for esophageal cancer (T3N1M0). An anomaly of the superior posterior pulmonary vein in the right lobe was recognized on preoperative computed tomography imaging. With simulation and intraoperative navigation using three-dimensional imaging (SYNAPSE VINCENT, Fuji Photo Film Co., Ltd, Tokyo, Japan) of the same view as that observed during the operation, radical subcarinal dissection could be performed with preservation of the RTPV. Only 5 case reports have described the association of RTPV in esophagectomy. In review of the literature, the incidence of RTPV ranged from 0.28 to 9.3%, and its mean vascular diameter ranged from 7.0 mm to 2.2 mm, with the right superior pulmonary vein being a common inflow site. Our case in which the RTPV ran dorsal to the right main bronchus is very rare. In radical subcarinal dissection of esophagectomy in cases with RTPV, it is important to recognize the posterior pericardial plane and release the ventral fixation of these lymph nodes to free space for the back side. Based on our review of the relevant literature, an RTPV larger than 4.5 mm should be noted in order to prevent injury and ligation should be avoided. The preoperative recognition of this abnormal vessel using 3D imaging was very useful for radical SCLN dissection during thoracoscopic esophagectomy.

274. AUTOMATED SURGICAL STEP RECOGNITION FOR ROBOT-ASSISTED MINIMALLY INVASIVE ESOPHAGECTOMY USING ARTIFICIAL INTELLIGENCE

Abstract More robot-assisted minimally invasive esophagectomy (RAMIE) procedures have been performed owing to three-dimensional field of view, image stabilization, and flexible joint function, however, both the surgeon, and surgical team require proficiency. Therefore, assessing the surgical learning curve and determining the surgical difficulty are essential for reducing complications. This study aimed to establish an artificial intelligence (AI)-based automated surgical phase recognition system for RAMIE by analyzing robotic surgical videos and evaluate the learning curve. This study enrolled 31 patients who underwent RAMIE. We annotated the videos into the following nine surgical phases, namely preparation, lower mediastinal dissection, upper mediastinal dissection, azygos vein division, subcarinal lymph node dissection (LND), right recurrent laryngeal nerve (RLN) LND, left RLN LND, esophageal transection, and post-dissection to completion of surgery to train the AI for automated phase recognition. We divided all patients into two groups, namely early period (20 patients) and late period (11 patients), after which the relationship between the surgical phase duration and learning curve was assessed. Frames were extracted from each video at a rate of one frame per second (fps), with an average of 14517 ± 4770 frames per video, which were used to train and test the AI model. Four-fold cross validation was applied to evaluate the performance of the present model. The AI had an accuracy of 84%. The preparation (p = 0.012), post-dissection to completion of surgery (p = 0.003), and ‘no step’ (p &amp;lt; 0.001) phases predicted by the AI were significant shorter in the late period than in the early period. We established an automated surgical phase recognition system for RAMIE using deep learning. Specific phase durations were significantly associated with surgeons’ learning curve, and similar tendencies were observed on phase durations predicated by the AI. Our AI-based system can be useful for not only education or OR efficiency but also evaluating surgical skill.

239. EVALUATION OF SUBCARINAL LYMPH NODE DISSECTION AND METASTASIS IN TRANSMEDIASTINAL RADICAL ESOPHAGECTOMY

Abstract The aim of the present study was to evaluate subcarinal lymph node dissection in transmediastinal radical esophagectomy and subcarinal lymph node metastasis in patients with esophageal cancer and to identify predictive factors for subcarinal lymph node metastasis. Three hundred and twenty-three patients with primary esophageal cancer who underwent transmediastinal or transthoracic esophagectomy with radical two- or three-field lymph node dissection were retrospectively investigated. The clinicopathological characteristics of patients with subcarinal lymph node metastasis were analyzed in detail. The median number of dissected subcarinal lymph nodes in transmediastinal and transthoracic esophagectomy groups was 6 and 7, respectively, and there was no significant difference between the two groups (p = 0.12). Of all patients, 26 (8.0%) were pathologically diagnosed as positive for subcarinal lymph node metastasis. By univariate analysis, subcarinal lymph node metastasis was found in larger (≥ 30 mm) and deeper (T3/T4a) primary lesions (p = 0.02 and 0.02, respectively), but it was not found in patients (n = 49) with the primary lesion located in the upper thoracic esophagus. Subcarinal lymph nodes can be dissected in transmediastinal esophagectomy, almost equivalent to transthoracic esophagectomy. The tumor size, depth, and location may be predictive factors for subcarinal lymph node metastasis.

Causes and management of intraoperative complications in robot-assisted anatomical pulmonary resection for lung cancer.

BackgroundTo perform safe robot-assisted anatomical lung resections, the details of intraoperative complications need to be shared among thoracic surgeons. However, only limited data are available.MethodsThis retrospective, single-institutional study evaluated 134 patients who underwent robot-assisted anatomical lung resection. We examined the causes, management, and outcomes of all intraoperative complications.ResultsOf the 134 eligible patients, 118 (88%) underwent lobectomy and 16 (12%) underwent segmentectomy. Intraoperative complications occurred in 17 (12.7%) patients. These complications included pulmonary artery (PA) injuries in seven patients, pulmonary vein (PV) injuries in three, azygos vein (AV) injury in one, superior vena cava (SVC) injury in one, bronchial injuries in three, and lung injuries in four. Most PA injuries were at a distal side and controlled by pressure, fibrin sealant, or stapling of the proximal side. In the three PV injuries, right upper PV was sandwiched by robotic instruments, V6 was punctured by the tip of the Maryland bipolar forceps, and the distal side of V2t was injured during tunneling of a minor interlobar fissure. These were controlled the same way as the PA injuries. The AV injury occurred during hilar lymph node (LN) dissection and was controlled by suturing. The SVC injury was caused by interference of the robotic forceps and the suction tube outside the field of view during upper mediastinal LN dissection. The injury was controlled by continuous pressure while layering polyglycolic acid sheets and fibrin glue. In the three bronchial injuries, B10 was injured during subcarinal LN dissection, right main bronchus was injured during upper bronchus dissection and the stapling failure of the bronchus occurred by strong traction. They were all repaired by suturing. All lung parenchymal injuries were caused by manipulation of robotic instruments outside the field of view. The lung injuries were repaired by suturing with pledgets. No cases were converted to thoracotomy. The 30-day mortality rate was 0.7%. The cause of mortality was pneumonia.ConclusionsIn robot-assisted anatomical pulmonary resection for lung cancer, most major intraoperative complications can be safely managed robotically without conversion to thoracotomy.

Automated Surgical-Phase Recognition for Robot-Assisted Minimally Invasive Esophagectomy Using Artificial Intelligence.

Although a number of robot-assisted minimally invasive esophagectomy (RAMIE) procedures have been performed due to three-dimensional field of view, image stabilization, and flexible joint function, both the surgeons and surgical teams require proficiency. This study aimed to establish an artificial intelligence (AI)-based automated surgical-phase recognition system for RAMIE by analyzing robotic surgical videos. This study enrolled 31 patients who underwent RAMIE. The videos were annotated into the following nine surgical phases: preparation, lower mediastinal dissection, upper mediastinal dissection, azygos vein division, subcarinal lymph node dissection (LND), right recurrent laryngeal nerve (RLN) LND, left RLN LND, esophageal transection, and post-dissection to completion of surgery to train the AI for automated phase recognition. An additional phase ("no step") was used to indicate video sequences upon removal of the camera from the thoracic cavity. All the patients were divided into two groups, namely, early period (20 patients) and late period (11 patients), after which the relationship between the surgical-phase duration and the surgical periods was assessed. Fourfold cross validation was applied to evaluate the performance of the current model. The AI had an accuracy of 84%. The preparation (p = 0.012), post-dissection to completion of surgery (p = 0.003), and "no step" (p < 0.001) phases predicted by the AI were significantly shorter in the late period than in the early period. A highly accurate automated surgical-phase recognition system for RAMIE was established using deep learning. Specific phase durations were significantly associated with the surgical period at the authors' institution.

Right top pulmonary vein is a venous anomaly of which surgeons should be aware in subcarinal dissection for thoracoscopic esophagectomy: a case report and literature review

BackgroundA right top pulmonary vein (RTPV) that crosses behind the right main or intermediate bronchus is a variation of the superior posterior pulmonary vein in the right upper lobe. Damage or ligation of this abnormal vessel can lead to massive intraoperative bleeding and serious complications, such as congestion of the posterior segment of the right upper lobe and cardiac tamponade. Subcarinal lymph node dissection is mandatory in radical thoracoscopic esophagectomy for esophageal cancer, and the RTPV is an anomalous vessel of which thoracic surgeons should be aware.Case presentationA 70-year-old man underwent thoracoscopic esophagectomy for esophageal cancer (T3N1M0). An anomaly of the superior posterior pulmonary vein in the right lobe was recognized on preoperative computed tomography imaging. With simulation and intraoperative navigation using three-dimensional imaging of the same view as that observed during the operation, radical subcarinal dissection could be performed with preservation of the RTPV.ConclusionIn our review of the relevant literature, the incidence of RTPV ranged from 0.28 to 9.3%, and its mean vascular diameter was 7.0 mm at the maximum and 2.2 ± 0.72 mm at the minimum, with the right superior pulmonary vein being a relatively common inflow site. Our case in which the RTPV ran dorsal to the right main bronchus is very rare. In radical subcarinal dissection of thoracoscopic esophagectomy, it is important to recognize the posterior pericardial plane and release the ventral fixation of these lymph nodes to free space for the back side. This is also true in the case of RTPV, which should be noted to avoid injury. In cases involving an RTPV larger than 4.5 mm, ligation should be avoided, and preoperative recognition of the exact run of this abnormal vessel using three-dimensional imaging can be very useful.

Adenoid Cystic Carcinoma Bronchus - A Case Report

Primary adenoid cystic carcinoma of lung is an unusual thoracic neoplasm, which is considered as a slow-growing low-grade malignancy. Usually, it is diagnosed at a higher clinical stage and is difficult to resect due to its central location. A 48-year-old female presented with history of breathlessness. On chest Xray and CT-Thorax showed well defined soft tissue lesion in left main bronchus. She underwent left pneumonectomy and subcarinal node dissection. Histopathological examination was consistent with Adenoid Cystic Carcinoma Bronchus.

Subcarinal Lymph Node Dissection in Solo Robot-assisted Thoracic Surgery

The surgical instruments used in robot-assisted thoracic surgery are flexible to enable the surgeon to approach the surgical field from any direction. However even in robot-assisted thoracic surgery subcarinal lymph node dissection requires a precise technique suitable for a small area surrounded by important organs. We present a method of subcarinal node dissection with solo robot-assisted thoracic surgery using a bronchial traction method and a metal basket suction device, the Dobon (Senko Medical Instrument Mfg, Tokyo, Japan).

Evaluation of subcarinal lymph node dissection and metastasis in transmediastinal radical esophagectomy

BackgroundThe aim of the present study was to evaluate subcarinal lymph node dissection in transmediastinal radical esophagectomy and subcarinal lymph node metastasis in patients with esophageal cancer.MethodsThree hundred and twenty-three patients with primary esophageal cancer who underwent transmediastinal or transthoracic esophagectomy with radical two- or three-field lymph node dissection were retrospectively investigated. The clinicopathological characteristics of patients with subcarinal lymph node metastasis were analyzed in detail.ResultsThe median of dissected subcarinal lymph nodes in transmediastinal and transthoracic esophagectomy groups was 6 and 7, respectively, and there was no significant difference between the two groups (p = 0.12). Of all patients, 26 (8.0%) were pathologically diagnosed as positive for subcarinal lymph node metastasis, whereas only 7 (26.9%) of those with metastasis were preoperatively diagnosed as positive. In addition, all patients with subcarinal lymph node metastasis had other non-subcarinal lymph node metastasis. By univariate analysis, subcarinal lymph node metastasis was found in larger (≥ 30 mm) and deeper (T3/T4a) primary lesions (p = 0.02 and 0.02, respectively), but it was not found in 49 patients with the primary lesion located in the upper thoracic esophagus.ConclusionsSubcarinal lymph nodes can be dissected in transmediastinal esophagectomy, almost equivalent to transthoracic esophagectomy. The tumor size, depth, and location may be predictive factors for subcarinal lymph node metastasis.

Pattern of subcarinal lymph node metastasis and dissection strategy for thoracic esophageal cancer.

BackgroundThis study aimed to assess the role of subcarinal lymph nodes in lymph node metastasis in thoracic esophageal squamous cell carcinoma (ESCC) and to investigate the adequate range of lymph node dissection during esophagectomy.MethodsThis study included 782 thoracic ESCC patients who underwent esophagectomy between July 2008 and December 2010. The metastatic rate of subcarinal lymph nodes and their influencing factors were investigated. The outcome of subcarinal lymph node dissection was assessed using the efficacy index (the incidence of metastasis to a lymph node station (%) multiplied by the 5-year survival rate (%) of patients with metastasis to that lymph node station and divided by 100). Additionally, postoperative complications were compared between the subcarinal lymph node resection and reservation groups.ResultsThe metastatic rates of subcarinal lymph nodes in the upper, middle, and lower thoracic ESCC were 8.3% (4/48), 19.1% (79/414), and 16.2% (23/142), respectively (χ2=3.669, P>0.05) and in T1, T2, T3, and T4 tumors were 0% (0/71), 4% (4/100), 22.2% (85/383), and 34% (17/50), respectively (χ2=42.859, P<0.05). Tumor invasion and size were significantly correlated with metastasis. For upper thoracic ESCC with positive subcarinal lymph nodes, metastasis tendency was mainly to the lower mediastinum. In middle third esophageal cancer, after subcarinal lymph nodes were involved, metastasis to the lower mediastinal lymph nodes increased by nearly 50%, and bidirectional metastasis increased by nearly three times compared with that before involvement. For lower third cancer with positive subcarinal lymph nodes, metastasis tendency was mainly to the upper mediastinum. The postoperative complication rates in the resection and reservation groups were as follows: overall, 19% and 14.6%, respectively (P>0.05), and pulmonary, 10.3% and 7.3%, respectively (P>0.05). The efficacy indexes of lymph node dissection at the upper, middle, and lower third esophagus were 0%, 7.6%, and 27.5%, respectively.ConclusionsDissection of subcarinal lymph nodes, which does not increase postoperative complications, should be performed routinely in lower thoracic ESCC after submucosal invasion of tumor; meanwhile, tumors larger than 3cm should also result in subcarinal lymph node dissection in patients with a tumor located in the upper esophagus and T1-T2 ESCC.

Predictive factors of cough after uniportal video-assisted thoracoscopic pulmonary resection.

BackgroundCough is one of the shared complications after lung surgery. In this study, a prospective analysis was conducted for exploring the risk factors of persistent cough after uniportal video-assisted thoracoscopic pulmonary resection.MethodsOne hundred thirty-five patients with pulmonary nodules who underwent surgical treatment in the same surgical group from November 2019 to January 2020 were enrolled in this prospective study. The severity of cough and its impact on patients’ quality of life before and after surgery were assessed by the Mandarin Chinese version of the Leicester cough questionnaire (LCQ-MC), and postoperative cough was tested by the cough visual analog scale (VAS) and cough symptom score (CSS). Risk factors of cough after pulmonary resection (CAP) were determined by univariate and multivariate logistic regression analysis.ResultsThe incidence of postoperative cough was 24.4% (33 of 135 patients). Univariate analysis showed that gender (female), the surgical site (upper right), the resection (lobectomy), subcarinal lymph node dissection, postoperative acid reflux, length of hospitalization contributed to the development of CAP resection. Multivariate logistic regression analysis showed that the resection (lobectomy) (OR 3.590, 95% CI: 0.637–20.300, P=0.017), subcarinal lymph node dissection (OR 4.420, 95% CI: 1.342–14.554, P=0.001), postoperative acid reflux (OR 13.55, 95% CI: 3.186–57.633, P<0.001) and duration of anesthesia (over 153 minutes, OR 0.987, 95% CI: 0.978–0.997, P=0.011) were independent risk factors for postoperative cough.ConclusionsThe application of uniportal video-assisted thoracoscopic techniques to several types of lung surgery are conducive to enhanced recovery after surgery (ERAS). Postoperative cough is related to an ocean of factors, the resection (lobectomy), subcarinal lymph node dissection, postoperative acid reflux, and duration of anesthesia (over 153 minutes) are independent high-risk factors for CAP resection.Trial registrationThis study was registered on ClinicalTrials.gov (NCT04204148).