Surgery For Thoracic Esophageal Cancer Research Articles

Bilateral video-assisted thoracic surgery for esophageal cancer with left inferior pulmonary vein invasion following chemoradiation therapy

BackgroundThe surgical strategy for thoracic esophageal cancer that invades the lungs is controversial. In particular, invasion of the pulmonary vein is often regarded unresectable. We successfully applied bilateral video-assisted thoracic surgery (VATS) in esophagectomy for esophageal cancer with left inferior pulmonary vein invasion following induction chemoradiotherapy (CRT), with a favorable response.Case presentationA 64-year-old woman was diagnosed with squamous cell carcinoma of the lower third of the esophagus. Computed tomography (CT) revealed that the tumor was suspected to be invading the main trunk of the left lower pulmonary vein and left lower lung. We initiated induction CRT comprising 5-fluorouracil, cisplatin, and concurrent radiotherapy at 50.4 Gy/28Fr. CT revealed shrinkage of the tumor, and the main trunk of the left inferior pulmonary vein was released from the tumor invasion. We considered the tumor to be completely resectable. VATS esophagectomy is usually performed using a right-sided approach. However, the right-sided approach is inappropriate for evaluating tumors around the left inferior pulmonary vein. We started with left-sided VATS to determine tumor resectability and dissected between the esophagus and the main trunk of the left inferior pulmonary vein. We only needed to perform partial resection of the left lower lobe. We then performed a right-sided VATS esophagectomy and lymphadenectomy with partial en bloc resection of the left lower lobe. Following this, we performed hand-assisted laparoscopic proximal gastrectomy and reconstruction using the gastric remnant. The postoperative course was uneventful. The patient was discharged on postoperative day 14. Histopathological examination of the surgical specimen revealed a complete pathological response without any remnant tumor or lymph node metastasis. There were no signs of recurrence or metastasis at the 1-year follow-up.ConclusionsCurative resection for thoracic esophageal cancer that invades the pulmonary vein could be possible via the bilateral VATS approach following induction CRT with a favorable response.

Learning curve for inflatable mediastinoscopic and laparoscopic-assisted esophagectomy.

To identify the morbidity that is associated with the learning curve of inflatable mediastinoscopic and laparoscopic-assisted esophagectomy (IMLE), and investigate the strategies to ride out the early period. Our study included a retrospective series of 108 consecutive patients undergoing IMLE by a single surgeon with advanced training in minimally invasive esophageal surgery in independent practice at high-volume tertiary center from July 2017 to November 2020. The cumulative sum (CUSUM) method was used to analyze the learning curve. Patients were stratified into two groups in chronological order, defining the surgeon's early (Group 1: the first 27 cases) and late experience (Group 2: the next 81 cases). Intraoperative characteristics and short-term surgical outcomes were compared between the two groups. A total of 108 patients were included. Three patients converted into thoracoscopic surgery. The number of patients with postoperative pulmonary infection was 16 (14.8%), and vocal cord palsy had occurred in 12 patients (11.1%). One patient died within 90days after surgery. CUSUM plots revealed decreasing total operative time, thoracic procedure time, abdominal procedure time, assistant-adjustment time after patients 27, 17, 26, and 35, respectively. IMLE is technically feasible, in terms of perioperative outcomes, for using as a radical surgery for thoracic esophageal cancer. For a surgeon experienced in minimally invasive esophageal surgery, experience of 27 cases is required to gain early proficiency of IMLE.

431. THORACOSCOPIC ESOPHAGEAL CANCER SURGERY IN THE LEFT LATERAL POSITION WITH EMPHASIS ON SAFETY AND RADICAL CURE

Abstract Compared with thoracoscopic esophagectomy in the prone position (PP), the conventional thoracoscopic esophagectomy in the left lateral position (LL) with artificial pneumothorax is slightly more difficult for dissection of the middle and lower mediastinum, but is superior to PP because the operation can be performed with good visual field in the upper mediastinum. The purpose of this study was to clarify the safety and curative potential of this technique. We retrospectively reviewed 246 cases of thoracic esophageal cancer surgery from April 2012 to December 2018. Thoracoscopic surgery (group V) was performed in 154 patients and open right thoracotomy (group O) in 92 patients. When this procedure was judged to be feasible, it was started thoracoscopically, and when it was judged to be unfeasible, a small thoracotomy of about 10–15 cm was added to allow one hand to enter. Thoracoscopy not only reduces the invasiveness of the procedure, but also allows us to share the anatomy, and improves the maneuverability of esophageal transfer and ensures safety in emergency situations. Postoperative complications with Clavien-Dindo classification II or higher were 40% in group O and 51% in group V. In group V, anastomotic leak was 15 (9.7%), vocal cord paralysis 34 (22%), pneumonia 17 (11%), SSI 16 (10%). The mean postoperative hospital stay was 20 days. 8 (8.7%) patients in the O group had anastomotic leak, 10 (11%) had vocal cord paralysis, 8 (8.7%) had pneumonia, 12 (7.8%) had SSI. The mean postoperative hospital stay was 28 days. Of 27 salvage procedures, 14 (52%) were performed thoracoscopically. Thoracoscopic surgery was completed in 10 cases and combined thoracotomy in 4 cases. Short-term outcomes of thoracoscopic surgery show an increase in vocal cord paralysis compared to open surgery. The procedure does not improve infectious complications. This technique has the advantage of easy conversion to open thoracotomy, including in emergency situations, and is more advantageous in advanced cancer, and can be a curative and safe treatment for highly advanced cancer.

A case of refractory pneumothorax and contralateral atelectasis after thoracoscopic subtotal esophagectomy treated with independent lung ventilation

BackgroundIndependent lung ventilation (ILV) allows separate positive end-expiratory pressures (PEEP) and inspiratory pressures for each lung. However, only a few articles have reported ILV management for lungs affected by different pathologies.Case presentationA 56-year-old man underwent video-assisted thoracic surgery for esophageal cancer. The right lung was injured during surgery, causing a bronchopleural fistula and necessitating chest drainage. On the third day in the intensive care unit, the patient’s oxygenation worsened during pressure support with continuous positive airway pressure ventilation. ILV was initiated for right-sided severe pneumothorax and left-sided atelectasis and pneumonia. ILV was continued for 2 days, and the patient’s trachea was successfully extubated the following day.ConclusionApplying high-level PEEP to the one lung and minimizing the airway pressure on the other lung could be achieved using ILV, which might contribute to successful tracheal extubation.

胸部食道癌術後の嚥下障害に対するチーム医療

胸部食道癌術後の嚥下障害に対するチーム医療

Analyses on Lymph Nodes Metastases Pattern and Factors Related to Survival after Thoracic Esophageal Cancer Surgery: A Systematic Literature Review

Analyses on Lymph Nodes Metastases Pattern and Factors Related to Survival after Thoracic Esophageal Cancer Surgery: A Systematic Literature Review

An enhanced recovery programs after thoracic esophageal cancer surgery for patients over 75 years old

Rationale: Data on enhanced recovery programs after thoracic esophageal cancer surgery for patients over 75 years old are sparse. The aim of this study was to evaluate the impact of an enhanced recovery after surgery (ERAS) program in patients with elderly patients who underwent a transthoracic esophagectomy.

A safe and simple technique for nasogastric tube insertion in patients with thoracic esophageal cancer surgery

BackgroundRisk factors for anastomotic leakage include local factors such as excessive tension across anastomosis and increased intraluminal pressure on the gastric conduit; therefore, we consider the placement of a nasogastric tube to be essential in reducing anastomotic leakage. In this study, we devised a safe and simple technique to place an NGT during an end-to-side, automatic circular-stapled esophagogastrostomy.MethodsFirst, a 4-0 nylon thread is fixed in the narrow groove between the plastic and metal parts of the tip of the anvil head. After dissecting the esophagus, the tip of the NGT is guided out of the lumen of the cervical esophageal stump. The connecting nylon thread is applied to the anvil head with the tip of the NGT. The anvil head is inserted into the cervical esophageal stump, and a purse-string suture is performed on the esophageal stump to complete the anvil head placement. The main unit of the automated stapler is inserted through the tip of a reconstructed gastric conduit, and the stapler is subsequently fired and an end-to-side esophagogastrostomy is achieved. The main unit of the automated stapler is then pulled out from the gastric conduit, and the NGT comes out with the anvil head from the tip of the reconstructed gastric conduit. Subsequently, the nylon thread is cut. After creating an α-loop with the NGT outside of the lumen, the tip of the NGT is inserted into the gastric conduit along the lesser curvature toward the caudal side. Finally, the inlet of the automated stapler on the tip of the gastric conduit is closed with an automated linear stapler, and the esophagogastrostomy is completed.ResultsWe utilized this technique in seven patients who underwent esophagectomy for esophageal cancer; smooth and safe placement of the NGT was accomplished in all cases.ConclusionOur technique of NGT placement is simple, safe, and feasible.

Effectiveness and safety of a newly introduced multidisciplinary perioperative enhanced recovery after surgery protocol for thoracic esophageal cancer surgery.

Data are sparse regarding the multidisciplinary perioperative enhanced recovery after surgery protocol (E-P) for thoracic esophageal cancer surgery that was newly used at another institution. Therefore, this study aimed to retrospectively evaluate the effectiveness and safety of the protocol. We enrolled 101 patients who underwent transthoracic esophagectomy for E-P at the Shizuoka Cancer Center Hospital (SCC). The outcomes obtained at the SCC were compared with the outcomes of 140 patients treated with E-P at the Saitama Medical University International Medical Center (SMU). At the SMU, we compared the results before and after the introduction of E-P. The rates of morbidity, pulmonary complications, and postoperative pneumonia were 44%, 31%, and 6.9% at the SCC and 44%, 27%, and 6.5% at the SMU (P = 0.91, 0.55, and 0.88, respectively). The mean time to walk was 1.1 and 1.5days at the SCC and SMU, respectively (P < 0.001). The median length of hospital stay was longer at the SMU than at the SCC (24.0 versus 20.8days; P = 0.004). In the comparative study before and after the introduction of E-P, the rate of postoperative pneumonia was 16% in the conventional management group and 6.5% in the E-P group (P = 0.02). Postoperative pneumonia was reduced before and after introduction of E-P. As similar short-term postoperative outcomes were promising (except for the time to walk and postoperative hospital stay), the same E-P that was safely performed at the SMU can be implemented as a standard practice.

Near-infrared fluorescence imaging-guided lymphatic mapping in thoracic esophageal cancer surgery

Identifying the lymphatic drainage pathway is important for accurate lymph node (LN) dissection in esophageal cancer (EC). This study aimed to assess lymphatic drainage mapping in thoracic EC using near-infrared fluorescent (NIRF) imaging with indocyanine green (ICG) and identify its feasibility for intraoperative LN drainage visualization and dissection. From November 2019 to August 2020, esophagectomy was performed using intraoperative NIRF navigation with ICG injected into the esophageal submucosa by endoscopy. All LNs were divided into four groups according to the NIRF status and presence of metastasis: NIRF+LN+, NIRF+LN-, NIRF-LN+, and NIRF-LN-. Regional LNs were detected in all 84 enrolled patients with thoracic EC. A total of 2164 LNs were removed, and the mean number of dissected LNs was 25.68 ± 12.00. NIRF+ LNs were observed in all patients and distributed at 19 LN stations, which formed lymphatic drainage maps. The top five LN stations of NIRF+ probability in upper thoracic EC were No. 7, 106ecR, 107, 1, and 106recL; in middle thoracic EC, they were No. 107, 7, 110, 1, and 105; and in lower thoracic EC, they were No. 107, 7, 110, 106recR, and 1. There were no cases of ICG-related adverse events or chylothorax. The 30-day mortality rate was 0%. Major complications included anastomotic fistula (7.14%), pneumonia (4.76%), pleural effusion (13.10%), atelectasis (3.75%), hoarseness (8.33%), and arrhythmia (4.76%). Regional LN mapping of thoracic EC was performed using ICG/NIRF imaging, which showed different preferred LN drainage stations in various anatomical locations of the thoracic esophagus. ICG/NIRF imaging is feasible for intraoperative LN drainage visualization and dissection. The clinical trial registration number is NCT04173676 ( http://www. gov/ ).

Effectiveness and safety of a newly introduced multidisciplinary perioperative enhanced recovery after surgery protocol for thoracic esophageal cancer surgery

Effectiveness and safety of a newly introduced multidisciplinary perioperative enhanced recovery after surgery protocol for thoracic esophageal cancer surgery

Thoracoscopic esophagectomy with left recurrent laryngeal nerve monitoring for thoracic esophageal cancer in a patient with a right aortic arch: a case report

BackgroundSurgery for cases of thoracic esophageal cancer with a right aortic arch is rare, and the anatomic abnormalities in such patients necessitate a different surgical approach. Since the position of the recurrent laryngeal nerve often differs from the usual in these cases, the lymph node dissection around the recurrent laryngeal nerve, which is an important step in surgery for thoracic esophageal cancer, requires careful attention. There are some reports on the usefulness of intraoperative recurrent laryngeal nerve monitoring during esophageal cancer surgery. Herein, we report a case of successful thoracoscopic esophagectomy for esophageal cancer in a patient with a right aortic arch using intraoperative recurrent laryngeal nerve monitoring.Case presentationA 70-year-old man was diagnosed as having esophageal cancer (Ut, type 0-IIc, T1b/MtLt, type 0-IIc, T1b, N2, M0, cStage II) and was treated by neoadjuvant chemoradiotherapy followed by radical surgery. Preoperative CT examination revealed a right aortic arch, and based on the findings of 3D-CT, we classified the right aortic arch as type IIIB1 (Edwards classification), which is the most frequent type of right aortic arch. We performed thoracoscopic esophagectomy via a left thoracic approach with the patient placed in the prone position, cervical esophagogastric conduit reconstruction via the retrosternal route, and three-field lymph node dissection. Although Kommerell’s diverticulum could be easily confirmed, the descending aorta took a meandering course, making it difficult for the esophagus to be mobilized and detached and therefore also to identify the ductus arteriosus and left recurrent laryngeal nerve. Intraoperative recurrent laryngeal nerve monitoring using NIM-RESPONSE® 3.0 (Medtronic Japan, Tokyo, Japan) allowed the position of the left recurrent laryngeal nerve to be accurately determined, and upper mediastinal lymph node dissection and mobilization of the upper thoracic esophagus were performed safely. Postoperatively, the patient showed no evidence of recurrent laryngeal nerve palsy, but needed conservative treatment for anastomotic leakage. The patient was discharged 46 days after the surgery.ConclusionIt was suggested that intraoperative recurrent laryngeal nerve monitoring is useful in esophageal cancer with a right aortic arch undergoing surgery, in whom anatomic abnormalities of the recurrent laryngeal nerve can be expected.

Clinical significance and prognosis of supraclavicular lymph node metastasis in patients with thoracic esophageal cancer.

Although most studies proved that thoracic esophageal cancer surgery with supraclavicular lymph nodes (SCLNs) metastasis could benefit, less than 30% of the 5-year survival rate remained controversy on its surgical treatment. In this study, we aimed to analyze the prognosis of SCLNs on the different segments of thoracic esophageal cancer, which will supply a reference for the treatment of this disease. Retrospectively collected the clinical data of 163 patients with thoracic esophageal squamous cancer (ESCC) and compared the effects of SCLNs on prognosis in different segments. Patients with SCLNs metastasis had a worse prognosis than the negative group (P<0.001). In the upper thoracic group, there was no significant difference in OS between SCLNs positive group and negative group (P=0.077); however, in the middle and lower thoracic group, SCLNs positive group had a worse prognosis than the negative group (P<0.001) and lymph nodes positive in other sites (except for SCLNs) (P=0.039). Multivariate analysis found that SCLNs metastasis was an independent risk factor affecting the prognosis of ESCC in the middle and lower thoracic segments (P=0.007). For patients with upper thoracic ESCC, SCLNs appear to be regional nodes. For the middle and lower thoracic ESCC, SCLNs should be defined as distant metastasis, and neoadjuvant therapy first may be an available therapy.

A Study of the Changes in Laryngeal Elevation Distance and Dysphagia after Thoracic Esophageal Cancer Surgery

A Study of the Changes in Laryngeal Elevation Distance and Dysphagia after Thoracic Esophageal Cancer Surgery

Frailty In Thoracic Surgery for Esophageal Cancer

Frailty In Thoracic Surgery for Esophageal Cancer

Impact of certification status of the institute and surgeon on short-term outcomes after surgery for thoracic esophageal cancer: evaluation using data on 16,752 patients from the National Clinical Database in Japan

BackgroundIn 2009, the Japan Esophageal Society (JES) established a system for certification of qualified surgeons as “Board Certified Esophageal Surgeons” (BCESs) or institutes as “Authorized Institutes for Board Certified Esophageal Surgeons” (AIBCESs). We examined the short-term outcomes after esophagectomy, taking into consideration the certifications statuses of the institutes and surgeons.MethodsThis study investigated patients who underwent esophagectomy for thoracic esophageal cancer and who were registered in the Japanese National Clinical Database (NCD) between 2015 and 2017. Using hierarchical multivariable logistic regression analysis adjusted for patient-level risk factors, we determined whether the institute’s or surgeon’s certification status had greater influence on surgery-related mortality or postoperative complications.ResultsEnrolled were 16,752 patients operated on at 854 institutes by 1879 surgeons. There were significant differences in the backgrounds and incidences of postoperative complications and surgery-related mortality rates between the 11,162 patients treated at AIBCESs and the 5590 treated at Non–AIBCESs (surgery-related mortality rates: 1.6% vs 2.8%). There were also differences between the 6854 patients operated on by a BCES and the 9898 treated by a Non-BCES (1.7% vs 2.2%). Hierarchical logistic regression analysis revealed that surgery-related mortality was significantly lower among patients treated at AIBCESs. The institute’s certification had greater influence on short-term surgical outcomes than the operating surgeon’s certification.ConclusionsThe certification system for surgeons and institutes established by the JES appears to be appropriate, as indicated by the improved surgery-related mortality rate. It also appears that the JES certification system contributes to a more appropriate medical delivery system for thoracic esophageal cancer in Japan.

Chin-down-plus-larynx-tightening maneuver improves choking cough after esophageal cancer surgery.

Esophageal cancer patients can benefit from dissection of the recurrent laryngeal nerve (RLN) lymph node (LN); however, this procedure increases the risk of RLN injury. After nerve injury, many complications can occur, including choking cough, which can affect patients' quality of life. This study examined the effectiveness of the chin-down-plus-larynx-tightening maneuver for improving choking cough after radical thoracic esophageal cancer surgery. Sixty-two patients with resectable thoracic esophageal cancer presented with choking cough, hoarseness or vocal cord paralysis after radical operations. Twenty-two patients who choked on water were guided to swallow 1 mL of warm water using a chin-down-plus-larynx-tightening maneuver. Choking cough relief results and their relationships with clinical factors were analyzed. No correlation was found between the occurrence of post-operative choking cough and gender, age, surgical method, hoarseness, vocal cord fixation type, vocal cord fixation, or glottal closure. Multivariate regression analysis revealed no independent risk factors associated with choking cough. Choking cough was completely relieved in 17 of 22 (77.3%) patients. Fifteen of 19 (78.9%) patients with choking cough and hoarseness, and 2 of 3 patients with only choking cough reported complete relief when they tried the new maneuver. The chin-down-plus-larynx-tightening maneuver was more effective for males than for females. The chin-down-plus-larynx-tightening maneuver significantly relieved choking cough; thus, this maneuver can aid in managing choking cough after radical thoracic esophageal cancer surgery.

An Investigation of Factors Related to Food Intake Ability and Swallowing Difficulty After Surgery for Thoracic Esophageal Cancer

Swallowing difficulty is among the major complications that can occur after surgery for thoracic esophageal cancer. Recurrent laryngeal nerve paralysis (RLNP) has been considered the most significant cause of a postoperative swallowing difficulty, but association between the two has not been adequately explained. We investigated the relation between postoperative RLNP and swallowing difficulty by means of video fluoroscopy. Our study included 32 patients who underwent subtotal esophagectomy for thoracic esophageal cancer at St. Marianna University School of Medicine between April 2014 and March 2017. We evaluated patients’ age and sex, disease stage, preoperative presence of a swallowing difficulty, nutritional status, extent and duration of surgery, blood loss volume, and postoperative presence of RLNP and/or hoarseness. Patients were divided into two groups according to whether oral food intake was possible when video fluoroscopy was performed on postoperative day (POD) 7, and we analyzed the associated factors. Postoperative RLNP occurred in 21 patients (65.6%); hoarseness occurred in 19 (59.4%). Eleven patients (34.4%) suffered swallowing difficulty that prevented food intake. No significant association was found between postoperative swallowing difficulty and postoperative RLNP or hoarseness, but a significant relation was found between the prognostic nutritional index and intraoperative lymph node dissection. Multivariable analysis revealed a significant relation between postoperative swallowing difficulty and only one factor: cervical lymph node dissection (P = 0.0075). There appears to be no relation between RLNP pursuant to esophageal cancer surgery and swallowing difficulty that prevents oral food intake.

Relation between Decrease in Geniohyoid Muscle Mass and Dysphagia after Surgery for Thoracic Esophageal Cancer

Relation between Decrease in Geniohyoid Muscle Mass and Dysphagia after Surgery for Thoracic Esophageal Cancer

PS02.222: CLINICAL CHARACTERISTICS AND MANAGEMENT OF GASTRIC TUBE CANCER AFTER ESOPHAGECTOMY

Abstract Background Gastric cancer is the second most common malignancy, overlapping with thoracic esophageal cancer (TEC). Among them, metachronous gastric tube cancers after TEC surgery have been increasing. The aims of this study were to examine the clinicopathological factors and treatment outcomes of gastric tube cancer (GTC) after TEC surgery. Methods Thirty-three GTCs in 30 cases after TEC treated between 1997 and 2016 were investigated retrospectively. Results Most cases were males. The median interval from TEC surgery to GTC occurrence was 68.1 months (6–190 months). Almost 2/3 lesions occurred in the lower third of the gastric tube (21/33); 29 lesions (in 26 cases) were superficial cancers, and 4 lesions were advanced cancers. Twenty-two lesions of superficial cancer were differentiated type, and the remaining seven lesions were undifferentiated type. Treatment for superficial cancer had previously been performed with partial gastric tube resection (10 lesions), and the number of cases undergoing endoscopic submucosal dissection (ESD) had increased recently (19 lesions). Most cases with superficial cancer survived without relapse. Four lesions of advanced cancer were found after a relatively long interval following TEC surgery. Most lesions of advanced cancer were scirrhous, undifferentiated type, and they died due to GTC. Conclusion GTCs may occur late in the postoperative course following TEC surgery. If they are discovered at an early stage, these lesions can be cured with ESD. Long-term periodic endoscopic examinations after TEC surgery are important. Disclosure All authors have declared no conflicts of interest.