Two-field Lymphadenectomy Research Articles

647. INDOCYANINE GREEN (ICG) IDENTIFICATION OF A CISTERNA CHYLI LEAK FOLLOWING RADICAL OESOPHAGO-GASTRECTOMY WITH 2-FIELD LYMPHADENECTOMY: DESCRIPTION OF A NEW TECHNIQUE

Abstract Background Chyle leak is a rare but feared complication post oesophago-gastrectomy, with far-reaching clinical and resource impacts including infection, re-admission and prolonged hospital stay, invasive procedures, and potentially missing the adjuvant therapy window. Low volume leaks can be managed medically via low-fat diet, nutritional support, and somatostatin analogues. Those of higher volume, or where medical management has failed, require radiological or surgical techniques. Where described, these techniques address leaks from a thoracic duct source and are therefore not applicable in patients having undergone oesophago-gastrectomy with radical two- or three- field lymphadenectomy, or where the suspected leak source is from abdominal lymphatics. Methods We report the case of a 78-year-old male diagnosed with cT4a N1 M0 oesophageal adenocarcinoma of the gastro-oesophageal junction. Following neoadjuvant chemotherapy, he underwent robotic-assisted two-phase oesophago-gastrectomy with two-field lymphadenectomy, in which the thoracic duct was identified and ligated. He returned one week post discharge with a left chylothorax. Drinage and medical management were unsuccessful, as were two radiological and one laparoscopic attempt at embolization of the leak. We describe a novel technique utilising indocyanine green (ICG) to identify and facilitate control of a cisterna chyli leak post-oesophago-gastrectomy with radical lymphadenectomy. Results Laparoscopy was performed and indocyanine green injected into the proximal jejunum submucosa, draining via mesenteric lymphatics to the cisterna chyli. Subsequent thoracoscopy revealed a prominent lymphatic channel around the left crus which was ligated. However, further leak was seen through the hiatus upon administration of high-fat jejunostomy feed. Re-laparoscopy revealed a leak from the cisterna chyli which was successfully ligated with ethibond sutures, leading to cessation of chyle leak and successful discharge of the patient, who subsequently received adjuvant therapy within the treatment window. Conclusion We describe a safe and effective novel technique for management of chyle leak from abdominal lymphatics or the cisterna chyli following oesophago-gastrectomy with radical two-field lymphadenectomy. https://drive.google.com/file/d/1nCNnowdJVPlV0GOleXVNVMshuU19kCb/view?usp=sharing

776. THREE-FIELD LYMPHADENECTOMY IN ESOPHAGEAL CANCER: EXPERIENCE OF A PORTUGUESE TERTIARY CENTER

Abstract Background The American Joint Committee for Cancer (AJCC) and the Japanese Esophagus Society (JES) differ in the N classification for esophageal cancer, with the former considering the presence of disease in the supraclavicular lymph nodes as M1, and the latter classifying it as loco-regional disease in thoracic esophageal tumors. Patients who would be excluded from a curative intent treatment strategy by the AJCC classification may be candidates for surgery with lymphadenectomy of nodal groups 101 and 104 (JES). Our goal is to understand the impact of three-field lymphadenectomy on morbidity, loco-regional control and overall survival in patients with esophageal cancer. Methods A retrospective cohort study was conducted using data from a prospective database from a single center, which included all consecutive patients undergoing esophagectomy for cancer with either two-field total thoracic lymphadenectomy or three-field lymphadenectomy, between January 2019 and December 2023. Three-field lymphadenectomy was performed for clinical supraclavicular and recurrent nerve nodal involvement and for proximal third tumors. We assessed the morbidity and mortality of both types of surgery, and loco-regional and distant recurrence and overall survival for both groups. Results Of the 279 esophagectomies for cancer, 137 were included for analysis. The median age was 65 years, with 84% males. 58,4% had squamous cell carcinoma and 41,6% adenocarcinoma. 34.3% of the patients had a 3-field lymphadenectomy, 27,7% of these for supraclavicular N+ and 34% for recurrent nerve N+. Conclusion In this large single-center cohort, patients with significant lymph node involvement, treated with esophagectomy and three-field lymphadenectomy, demonstrated comparable loco-regional control and overall survival to more favorable cases, with no statistically significant increase in morbidity and mortality.

744. LEFT THORACOABDOMINAL ESOPHAGECTOMY: ITS VALIDITY IN MODERN ESOPHAGEAL SURGERY

Abstract Background The optimal surgical approach for the treatment of esophageal and gastroesophageal junction tumors remains elusive. An open left thoracoabdominal approach may prove particularly useful in certain clinical scenarios, mainly because of its versatility and excellent exposure provided. The aim of this study is to present our experience and evaluate the early outcomes related to an open left thoracoabdominal esophagectomy (LTE). Methods A retrospective cohort study of prospectively collected data was conducted from two institutions performing esophageal surgery. Patients with distal esophageal or junctional tumors who underwent an open LTE between November 2018 and December 2023 were included. Primary outcomes were 30-day and in-hospital mortality, postoperative complications, and surrogates of oncological efficacy, including resection margin status and lymph node yield. Complications were recorded using the definitions provided by the Esophagectomy Complications Consensus Group and scored according to the Clavien-Dindo classification. Circumferential resection margin status was based on the definition used by the College of American Pathologists. Results During the study period 22 patients underwent an open LTE with a standard two-field lymphadenectomy. Eight patients (36%) suffered from postoperative complications, with pulmonary complications being the most common (7 patients; 32%). Severe complications (Clavien-Dindo ≥3) occurred in 3 patients. One patient experienced a clinical anastomotic leak. None of the patients required a reoperation or a step-up to a higher level of care. The 30-day and in-hospital mortality were zero. On histological examination, 6 patients (27%) had tumor cells at the surgical margin, most commonly the circumferential resection margin. A mean number of 27 lymph nodes were retrieved. Conclusion This small series demonstrates the applicability of an open left thoracoabdominal approach in everyday surgical practice for the treatment of distal esophageal and gastroesophageal junction tumors. Our results imply that open LTE can be implemented in select patients with acceptable morbidity and oncological efficacy.

489. EVALUATION OF THE ONCOLOGICAL QUALITY OF MINIMALLY INVASIVE TRANSCERVICAL OESOPHAGECTOMY (MICE) USING A CADAVERIC MODEL

Abstract Background Nodal involvement is a well-known factor of poor prognosis for esophageal cancer, but the extent of the lymph node dissection, or the number of the dissected lymph nodes, remains controversial questions. Western guidelines (ESMO and NCCN) suggest accomplishing esophagectomy with en-bloc two-field lymphadenectomy. Minimally Invasive transCervical oEsophagectomy (MICE) is a novel technique for the minimally invasive treatment of esophageal cancer. In the literature, the radicality of this procedure still remains unknown, as evidenced by studies conducted in Eastern countries. This descriptive study explores feasibility of MICE in Western countries using a cadaveric model. Methods A cadaver study was conducted in a real operating room setting, with bilateral lung ventilation induced to replicate a real-life situation. Mediastinal dissection was carried out via single port left transcervical mediastinoscopy. Subsequently, a right thoracoscopy in prone position was performed to access the clearance of the fatty tissue at the anatomical boundaries of the lymph node stations. The finalization of the dissection of the lower mediastinum via transhiatal approach was not performed because it was not in the aim of the study. The extent and the radicality of the dissection were evaluated by an independent external expert. Results Results indicated effectiveness of MICE in dissecting lymph nodes around the lower and middle esophagus, as well as at the subcarinal station. At the upper esophagus level, harvesting was complete on the left side but some residual tissue was found on the right-side at the right recurrent laryngeal nerve and on the right pleura, this result was attributed to technical difficulty. Conclusion The findings suggest that MICE is adequate in accomplish a complete dissection of lymph nodes around the mediastinal esophagus, including a complete subcarinal dissection, adhering to Western lymphadenectomy standards. Further descriptive study on cadaver will help to understand if a more extensive lymphadenectomy is achievable.

Short-term outcomes of three- and two-field lymphadenectomy with minimally invasive esophagectomy for esophageal cancer: a propensity score-matching analysis.

Whether patients can benefit from three-field lymphadenectomy (3-FL) in minimally invasive esophagectomy (MIE) remains unclear. This study retrospectively compared short-term outcomes between 3-FL and two-field lymphadenectomy (2-FL) in MIE for patients with esophageal cancer (EC) and aimed to evaluate the clinical significance of 3-FL. There were 284 patients enrolled in the study (124 patients with 3-FL and 160 patients with 2-FL). The cases were matched based on their propensity scores using a matching ratio of 1:1, the nearest neighbor matching protocol, and a caliper of 0.02. Patients were propensity-score matched for sex, cancer location, Age-adjusted Charlson Comorbidity Index (ACCI), and neoadjuvant treatment. The short-term outcomes were postoperative complications, operation characteristics, pathology results and postoperative hospital stay. There were no significant differences in intraoperative hemorrhage, postoperative hospital stay, or postoperative complications between the 2-FL and 3-FL groups. The operation time of the two groups was significantly different (227.1±46.2 vs. 248.5±45.9 min, P=0.001); the operation time of the 3-FL group was about 20 minutes longer than that of the 2-FL group. The number of lymphatic nodes (LNs) obtained in the 3-FL group was significantly higher than that in the 2-FL group (31.3±12.9 vs. 54.6±18.0, P<0.001). Pathological N stage was also significantly different (P=0.002); the 3-FL group was more advanced than the 2-FL group. Compared to 2-FL MIE, 3-FL MIE does not increase postoperative complications, can obtain more LNs, and improves the accuracy of tumor LN staging.

Mapping of lymph node metastasis from esophageal squamous cell carcinoma after neoadjuvant treatment: a prospective analysis from a high-volume institution in China.

The study aimed to describe the prevalence of lymph node metastases per lymph node station for esophageal squamous cell carcinoma (ESCC) after neoadjuvant treatment. Clinicopathological variables of ESCC patients were retrieved from the prospective database of the Surgical Esophageal Cancer Patient Registry in West China Hospital, Sichuan University. A two-field lymphadenectomy was routinely performed, and an extensive three-field lymphadenectomy was performed if cervical lymph node metastasis was suspected. According to AJCC/UICC 8, lymph node stations were investigated separately. The number of patients with metastatic lymph nodes divided by those who underwent lymph node dissection at that station was used to define the percentage of patients with lymph node metastases. Data are also separately analyzed according to the pathological response of the primary tumor, neoadjuvant treatment regimens, pretreatment tumor length, and tumor location. Between January 2019 and March 2023, 623 patients who underwent neoadjuvant therapy followed by transthoracic esophagectomy were enrolled. Lymph node metastases were found in 212 patients (34.0%) and most frequently seen in lymph nodes along the right recurrent nerve (10.1%, 58/575), paracardial station (11.4%, 67/587), and lymph nodes along the left gastric artery (10.9%, 65/597). For patients with pretreatment tumor length of >4cm and non-pathological complete response of the primary tumor, the metastatic rate of the right lower cervical paratracheal lymph nodes is 10.9% (10/92) and 10.6% (11/104), respectively. For patients with an upper thoracic tumor, metastatic lymph nodes were most frequently seen along the right recurrent nerve (14.2%, 8/56). For patients with a middle thoracic tumor, metastatic lymph nodes were most commonly seen in the right lower cervical paratracheal lymph nodes (10.3%, 8/78), paracardial lymph nodes (10.2%, 29/285), and lymph nodes along the left gastric artery (10.4%, 30/289). For patients with a lower thoracic tumor, metastatic lymph nodes were most frequently seen in the paracardial station (14.2%, 35/247) and lymph nodes along the left gastric artery (13.1%, 33/252). The study precisely determined the distribution of lymph node metastases in ESCC after neoadjuvant treatment, which may help to optimize the extent of lymphadenectomy in the surgical management of ESCC patients after neoadjuvant therapy.

430. MAPPING OF LYMPH NODE METASTASIS FROM ESCC AFTER NEOADJUVANT TREATMENT: A PROSPECTIVE ANALYSIS FROM A HIGH-VOLUME INSTITUTION IN CHINA

Abstract Objective The aim of the study was to describe the prevalence of lymph node metastases per lymph node station for esophageal squamous cell carcinoma (ESCC) after neoadjuvant treatment. Methods Clinicopathological variables of ESCC patients were retrieved from the prospective database of the Surgical Esophageal Cancer Patient Registry in West China Hospital, Sichuan University. Two-field lymphadenectomy was routinely performed and an extensive three-field lymphadenectomy was performed if cervical lymph nodes metastasis were suspected. Lymph node stations according to AJCC 8 were separately investigated. Percentage of patients with lymph node metastases was defined as number of patients with metastatic lymph nodes/number of patients with lymph node dissection of this station. Data is also separately analyzed according to pathological response of the primary tumor, pretreatment tumor length and tumor location. Results Between January 2019 and March 2023, 623 patients who underwent neoadjuvant therapy followed by transthoracic esophagectomy were enrolled (Table 1–1). Lymph node metastases were found in 215 patients (34.5%) and most frequently seen in lymph nodes along the right recurrent nerve (10.1%, 58/575), paracardial station (11.4%, 67/587) and lymph nodes along the left gastric artery (10.9%, 65/597). For patients with pretreatment tumor length &amp;gt; 4 cm and non-PCR of primary tumor, the metastatic rate of right lower cervical paratracheal lymph nodes is 10.9% (10/92) and 10.6% (11/104), respectively (Table 1–2). For patients with an upper thoracic tumor, metastatic lymph nodes were most frequently seen along the right recurrent nerve (14.2%, 8/56). For patients with a middle thoracic tumor, metastatic lymph nodes were most frequently seen in the right lower cervical paratracheal lymph nodes (10.3%, 8/78), paracardial lymph nodes (10.2%, 29/285) and lymph nodes along the left gastric artery (10.4%, 30/289). For patients with a lower thoracic tumor, metastatic lymph nodes were most frequently seen in paracardial station (14.2%, 35/247) and lymph nodes along the left gastric artery (13.1%, 33/252) (Table 1–3). Conclusion The study accurately identified the distribution of lymph node metastases from ESCC after neoadjuvant treatment, which may contribute to guide the optimal extent of lymphadenectomy in the surgical treatment of ESCC patients after neoadjuvant treatment.

145. PRECISE PATTERN OF LYMPHATIC SPREAD OF ESOPHAGEAL SQUAMOUS CELL CARCINOMA RESULTS OF 1074 PATIENTS WITH N1 DISEASE

Abstract Objective The precise pattern of lymphatic spread in esophageal cancer remains unclear. The present study aimed to determine the pattern of lymphatic metastasis in its early stages. Methods The data were reviewed of 1074 patients who underwent curative esophagectomy for thoracic esophageal squamous cell carcinoma and metastasis in 1–2 lymph nodes between January 2015 and December 2021. The frequencies of lymph node metastasis were analyzed by the anatomic sites and regions involved. Results Of the 1074 patients, the median number of resected lymph nodes was 27 (interquartile range, 20–35). There were 668 patients (62.2%) with one positive lymph node and 406 patients (37.8%) with two positive lymph nodes. Paracardial lymph nodes were the most frequently involved nodes (35.2%), followed by the right thoracic recurrent nerve nodes (24.0%) and middle thoracic paraesophageal nodes (14.7%). The majority of lymph node metastases occurred in the longitudinal direction to the perigastric (35.2%) and bilateral recurrent nerve regions (33.0%) and in the transverse direction to the paraesophageal region (27.7%). Deep tumor depth (P = 0.047), poor tumor differentiation (P = 0.038), and lymphovascular invasion (P = 0.023) were associated with lymph node metastasis. Conclusion Perigastric nodes, bilateral recurrent nerve nodes, and paraesophageal lymph nodes were the most common early lymph node metastasis regions. Esophageal squamous cell carcinoma involves more longitudinal than transverse lymph node metastases. Two-field lymphadenectomy should include the radical lymph nodes dissection both in the upper mediastinum and in the upper abdomen.

Patterns and Influence of Lymph Nodal Metastases After Neoadjuvant Chemotherapy and Surgery for Thoracic Esophageal Squamous Cell Carcinoma.

The purpose of this retrospective study was to define the pattern of lymph nodal metastases in patients with esophageal squamous cell carcinoma (ESCC) after neoadjuvant chemotherapy (NCT) followed by esophagectomy and to evaluate its influenceonprognosis. A total of 398 patients with clinical stage T3N0 or T1-3N+ ESCC who underwent NCT and radical esophagectomy with two-field lymphadenectomy were included. The distribution and frequency of metastases were counted separately for each lymph node station. The ypN stage, number of positive lymph node stations and lymph node stations with a metastasis rate greater than 5% were analyzed by using univariate Cox regression, followed by separate multivariable Cox regression analyses after adjusting for various clinical factors. Lymph node metastases were most frequently observed in the right upper paratracheal (16.8%) and left gastric artery (13.1%) stations. Multivariable models controlling for clinical factors showed that ypN stage remained a significant independent predictor of survival (N1 vs. N0: hazard ratio [HR], 2.30, 95% confidence interval [CI] 1.38-3.83, P < 0.001; N2 vs. N0: HR, 3.76, 95% CI 2.21-6.38, P < 0.001; N3 vs. N0: HR, 7.14, 95% CI 3.78-13.48, P < 0.001). The model from the multivariable analysis with the highest c-index score, indicating superior discriminatory preference, was ypN stage (c-index, 0.72). The pattern and influence of lymph node metastases after NCT will provide guidance on the extent of lymphadenectomy. Common positive lymph node stations for thoracic ESCC after NCT include the paratracheal, subcarinal, paraesophageal, paracardial, and left gastric artery stations.

Impact of the Extent of Recurrent Laryngeal Nerve Lymphadenectomy on Thoracic Esophageal Squamous Cell Carcinoma: A Real-World Multicenter Study.

To determine the impact of recurrent laryngeal nerve lymph node (RLN-LN) dissection on survival and postoperative complications in patients with oesophageal squamous cell carcinoma (ESCC). Patients with cT1-4N0-3M0 thoracic ESCC who underwent oesophagectomy and two-field lymphadenectomy from three institutions were included. The entire cohort was divided into three groups that underwent the total two-field lymphadenectomy (T-2FL), standard two-field lymphadenectomy (S-2FL), or unilateral RLN-LN dissection plus S-2FL (U-2FL) based on the extent of RLN-LN dissection. Subgroup analyses were also performed and were stratified by treatment modality. Both the U-2FL and T-2FL groups had significantly superior outcomes compared with the S-2FL group (overall survival: U-2FL vs S-2FL: P = 0.002; T-2FL vs S-2FL: P < 0.001; recurrence-free survival: U-2FL vs S-2FL: P = 0.01; T-2FL vs S-2FL: P < 0.001). Moreover, no significant differences were observed between U-2FL and T-2FL regarding overall survival (P > 0.05) and recurrence-free survival (P > 0.05), irrespective of administration of neoadjuvant therapy plus oesophagectomy or upfront oesophagectomy. Additionally, the extent of RLN-LN dissection was not an independent predictor of stage migration (P = 0.14), but was for postoperative nodal upstaging (P = 0.02). Notably, S-2FL brought significantly lowered risk in postoperative complications, especially for RLN palsy, when compared with T-2FL (P = 0.002) but not U-2FL (P = 0.72). Adequacy of RLN-LN dissection is an important prognosticator for improved overall survival and recurrence-free survival in patients with thoracic ESCC. U-2FL may serve as an alternative to T-2FL in selected populations.

Impact of two‑field or three‑field lymphadenectomy on overall survival in middle and lower thoracic esophageal squamous cell carcinoma: A single‑center retrospective analysis.

Squamous cell carcinoma is the main subtype of esophageal cancer in East Asia. The effect of the number of lymph nodes (LNs) removed to treat middle and lower thoracic esophageal squamous cell carcinoma (ESCC) in China remains controversial. Therefore, the present study aimed to investigate the impact of the number of LNs removed during lymphadenectomy on the survival of patients with middle and lower thoracic ESCC. Data were obtained from the Sichuan Cancer Hospital and Institute Esophageal Cancer Case Management Database from January 2010 to April 2020. Either three-field systematic lymphadenectomy (3F group) or two-field systematic lymphadenectomy (2F group) was performed for ESCC cases with or without suspicious tumor-positive cervical LNs, respectively. Subgroups were designed for further analysis based on the quartile number of resected LNs. After 50.7 months of median follow-up, 1,659 patients who underwent esophagectomy were enrolled. The median overall survival (OS) of the 2F and 3F groups was 50.0 months and 58.5 months, respectively. The OS rates at 1, 3 and 5 years were 86, 57 and 47%, respectively, in the 2F group, and 83, 52 and 47%, respectively, in the 3F group (P=0.732). The average OS of the 3F B and D groups was 57.7 months and 30.2 months, respectively (P=0.006). In the 2F group, the OS between subgroups was not significantly different. In conclusion, resection of >15 LNs during two-field dissection in patients with ESCC undergoing esophagectomy did not affect their survival outcomes. In three-field lymphadenectomy, the extent of LNs removed could lead to different survival outcomes.

Neoadjuvant chemoradiotherapy plus tislelizumab followed by surgery for esophageal carcinoma (CRISEC study): the protocol of a prospective, single-arm, phase II trial

BackgroundThe failure rate after neoadjuvant chemoradiotherapy followed by surgery is approximately 34.6%–48% for resectable esophageal carcinoma. Pathologic complete response after neoadjuvant chemoradiotherapy is an important factor in predicting lower recurrence and better survival. Whether the sequential addition of immunotherapy to neoadjuvant chemoradiotherapy will be beneficial to improving the pathologic complete response rate is unknown.MethodsPatients with pathologically confirmed thoracic esophageal squamous cell carcinoma and at clinical T1-2N1-3M0 or T3-4aN0-3M0 (stage II–IVA) according to the eighth edition of American Joint Committee on Cancer staging will be allocated to receive neoadjuvant radiotherapy (41.4 Gy with 23 fractions to planning target volume) with concurrent chemotherapy (albumin-bound paclitaxel, 100 mg/m2, once weekly for five weeks; carboplatin, area under the curve of 2 mg/mL/min, once weekly for five weeks) plus tislelizumab monotherapy sequentially (200 mg every three weeks for three cycles, beginning from the first to the 14th day after the end of radiotherapy). Then, subtotal esophagectomy with two-field lymphadenectomy, including the whole mediastinum and abdomen, will be performed. The primary endpoint for this study is the pathologic complete response rate after neoadjuvant chemoradiotherapy plus tislelizumab.DiscussionThe optimal timing of the combination of immunotherapy and neoadjuvant chemoradiotherapy in esophageal carcinoma is not determined. The results of this phase II trial will be helpful to clarify the safety and efficacy of the sequential addition of tislelizumab after neoadjuvant chemoradiotherapy for locally advanced resectable esophageal carcinoma.Trial registrationThis study was approved on January 26, 2021 and retrospectively registered with ClinicalTrials.gov (NCT04776590) on March 1, 2021.

Neoadjuvant Chemotherapy Compared with Surgery for Oesophageal Carcinoma: A Retrospective Study and Missing Evidence.

Background: Negative evidence for the use of neoadjuvant chemotherapy (NAC) to treat oesophageal squamous cell carcinoma (ESCC) has been reported in Western countries in the past century. However, in China, most ESCC patients underwent paclitaxel and platinum-based NAC without evidence from local RCTs. Empiricism or a lack of evidence does not necessarily mean that the evidence is negative. However, there was no way to compensate for the missing evidence. The only way to obtain evidence is by conducting a retrospective study using propensity score matching (PSM) to compare the effects of NAC and primary surgery on overall survival (OS) and disease-free survival (DFS) among ESCC patients in China, which is the country with the highest prevalence of ESCC patients. Methods: From January 1, 2015, to December 31, 2018, a total of 5443 patients with oesophageal cancer/oesophagogastric junction carcinoma who underwent oesophagectomy were retrospectively identified at Henan Cancer Hospital. After PSM, 826 patients were selected for the retrospective study and divided into the NAC and primary surgery groups. The median follow-up period was 54.08 months. Toxicity and tumour responses to NAC, intraoperative and postoperative outcomes, recurrence, DFS and OS were analysed. Results: The postoperative complication rates were not significantly different between the two groups. The 5-year DFS rates were 57.48% (95% CI, 52.05% to 62.53%) for the NAC group and 49.93% (95% CI, 44.56% to 55.05%) for the primary surgery group (P=0.0129). The 5-year OS rates were 62.95% (95% CI, 57.63% to 67.79%) for the NAC group and 56.29% (95% CI, 50.99% to 61.25%) for the primary surgery group (P=0.0397). Conclusion: Compared with primary surgery, NAC with paclitaxel and platinum-based chemotherapy and two-field extensive mediastinal lymphadenectomy might be associated with long-term survival benefits among ESCC patients.

The safety of neoadjuvant chemotherapy combined with non-tube nofasting fast-track surgery for esophageal carcinoma.

Our non-tube no fasting (early oral feeding and no nasogastric tube) fast-track surgery (FTS) was safe and effective to combine with neoadjuvant chemotherapy for McKeown minimally invasive esophagectomy. In addition, the two groups were similar in terms of the recovery time, hospital discharge day, and early resumption of oral feeding.ObjectivesTo evaluate the safety of early oral feeding (EOF) combined with neoadjuvant chemotherapy (NAC) of esophagectomy.Summary Background DataOur non-tube no fasting (early oral feeding and no nasogastric tube) fast-track surgery (FTS) was safe and effective for primary surgery esophageal cancer patients.MethodsWe retrospectively evaluated consecutive patients who underwent non-tube no fasting and McKeown minimally invasive (MIE). They were divided into two groups: one received NAC, and the other received primary surgery. Complications after the operation, postoperative CRG complications, operative time, operative bleeding, and length of stay were evaluated.ResultsBetween 01/2014 and 12/2017, there hundred and eighty two consecutive patients underwent MIE with total two-field lymphadenectomy under the non-tube no fasting fast-track surgery program. A total of 137 patients received NAC, and 245 accepted primary surgery. Propensity score matching was used to compare NAC patients with 62 matched patients from each group. The NAC group had a similar number of total complications as the primary surgery group (32.26% in the primary surgery group vs. 25.81% in the NAC group; p=0.429) and had the same median postoperative hospitalization duration (8 days, p=0.723).ConclusionsAfter McKeown MIE, the patients receiving NAC combined with “non-tube no fasting” FTS had a similar incidence of postoperative complications outcomes as those without NAC. In addition, the two groups were similar in terms of the recovery time, hospital discharge day, and early resumption of oral feeding.

Long-Term Survival After Transhiatal Versus Transthoracic Esophagectomy: A Population-Based Nationwide Study in Finland

BackgroundNo population-based studies comparing long-term survival after transhiatal esophagectomy (THE) and transthoracic esophagectomy (TTE) exist. This study aimed to compare the 5-year survival of esophageal cancer patients undergoing THE or TTE in a population-based nationwide setting.MethodsThis study included all curatively intended THE and TTE for esophageal cancer in Finland during 1987–2016, with follow-up evaluation until 31 December 2019. Cox proportional hazard models provided hazard ratios (HRs) with 95% confidence intervals (CIs) of 5-year and 90-day mortality. The results were adjusted for age, sex, year of operation, comorbidities, histology, neoadjuvant treatment, and pathologic stage.ResultsA total of 1338 patients underwent THE (n = 323) or TTE (n = 1015). The observed 5-year survival rate was 39.3% after THE and 45.0% after TTE (p = 0.072). In adjusted model 1, THE was not associated with greater 5-year mortality (HR 0.99; 95% CI 0.82–1.20) than TTE. In adjusted model 2, including T stage instead of pathologic stage, the 5-year mortality hazard rates after THE (HR 0.87, 95% CI 0.72–1.05) and TTE were comparable. The 90-day mortality rate for THE was higher than for TTE (adjusted HR 0.72; 95% CI 0.45–1.14). In subgroup analyses, no differences between THE and TTE were observed in Siewert II gastroesophageal junction cancers, esophageal cancers, or pN0 tumors, nor in the comparison of THE and TTE with two-field lymphadenectomy. The sensitivity analysis, including patients with missing patient records, who underwent surgery during 1996–2016 mirrored the main analysis.ConclusionsThis Finnish population-based nationwide study suggests no difference in 5-year or 90-day mortality after THE and TTE for esophageal cancer.

Double purse-string suture technique for circular-stapled anastomosis during robotic Ivor Lewis esophagectomy.

BackgroundWith the advantage of the robotic suturing capacity, the purse-string suture is technically simple and convenient. This study aimed to present our technical aspects and initial results of robotic Ivor Lewis esophagectomy using two purse-string sutures for circular-stapled anastomosis.MethodsAfter stomach mobilization, gastric conduit formation, esophagus mobilization and two-field lymphadenectomy, the first robotic hand-sewn purse-string suture was applied to the esophageal muscular layer with an adequate margin above the tumor. A longitudinal incision in the anterior wall of the esophagus was made and the circular stapler anvil was inserted. The esophagus was transected by scissors 1 cm caudal to the first purse-string suture and the purse-string tied to secure the anvil. Then the second robotic hand-sewn purse-string suture was applied to the whole-layer of the proximal end of the esophagus and tied. Finally, the anvil was connected to the body of the stapler and fired.ResultsThe clinical data of ten patients who underwent robotic Ivor Lewis esophagectomy with an intrathoracic circular-stapled end-to-side anastomosis from February 2022 to April 2022 were collected. There were seven male and three female patients and had a mean age of 63.2 ± 7.6 years. Tissue donuts were complete in all cases and all operations were successfully performed without conversions. The mean overall operative time was 358.2 ± 40.3 min. The mean estimated blood loss was 83.2 ± 15.6 ml. The median length of hospital stay was 11.5 ± 4.1 days. All the patients had an uneventful postoperative period.ConclusionTwo purse-string sutures are necessary to obtain a tight seal of the esophageal tissue around the anvil to avoid potential anastomotic leak and are an essential process for the safety of circular-stapled anastomosis during robotic Ivor Lewis esophagectomy.

Two- versus three-field lymphadenectomy for esophageal cancer. A systematic review and meta-analysis of early and late results.

This study aims to estimate whether prophylactic cervical lymphadenectomy for esophageal cancer influences the short- and long-term results through a systematic literature review and meta-analysis. Twenty-eight articles were selected in this systematic review, encompassing 9180 patients. Prophylactic neck lymphadenectomy for esophageal cancer should be performed with caution, as it is associated with worse short-term results compared to traditional two-field lymphadenectomy and does not improve long-term survival.

Is Prophylactic Cervical Drainage Effective in Patients Undergoing McKeown Esophagectomy Reconstructed Through the Retrosternal Route with Two-Field Lymphadenectomy?

McKeown esophagectomy with two-field lymphadenectomy is the treatment of choice for oncologic esophagectomy. A cervical drain is placed in cases after modern two-field lymph node dissection (M2FD) to provide information on anastomotic leakage. However, the necessity of prophylactic cervical drainage during surgery remains unknown. This study aimed to clarify the clinical significance of cervical drainage in patients who underwent McKeown esophagectomy with M2FD. A total of 293 patients underwent McKeown surgery with two-field lymphadenectomy at our institute between January 2013 and December 2019. We compared the day of drain removal, amount of drainage volume, and the appearance of drainage fluid between patients with and without anastomotic leakage. McKeown esophagectomy reconstructed through the retrosternal route is 203 patients (69.3%) of all. Nineteen patients (6.5%) experienced anastomotic leakage. The amount of cervical drain discharge was comparable between patients with and without anastomotic leakage. In addition, no purulent or salivary discharge was observed in patients with anastomotic leakage. There was no difference in the median day of drain removal between the groups. The initial clinical findings for the diagnosis of anastomotic leakage were surgical site infection in 10 (52.6%), fever in 5 (26.3%), prolonged inflammation in a blood test in 3 (15.8%), and bloody discharge from the chest tube in 1 (5.3%). There was no mortality due to any cause. A prophylactic cervical drain may not be mandatory in patients with esophageal cancer undergoing McKeown esophagectomy reconstructed through the retrosternal route with two-field lymphadenectomy.

Editorial acerca de “Esofagectomía con linfadenectomía guiada por fluorescencia con verde de indocianina en cáncer de esófago“

Esophageal cancer is one of the gastrointestinal cancers with the greatest incidence over the past years and is the eighth most common cancer worldwide, affecting more than 450 000 people per year1. Its treatment and prognosis depend on tumor stage, location, histological type, nutritional status and presence of comorbidities2. Although there have been significant advances in the field of oncology in recent years, esophagectomy with lymph node clearance remains the main curative treatment. Total esophagectomy with two-field or three-field lymphadenectomy plays a very important role in the locoregional control of the disease. In recent years, the technological advances and the development of minimally invasive surgical techniques have significantly reduced morbidity and mortality.

A case of choroidal metastasis from postoperative esophagogastric junctional adenocarcinoma treated with local radiotherapy and systemic chemotherapy with ramucirumab

An 80-year-old male was presented with metamorphopsia of the left eye. Two years ago, the patient was diagnosed with an esophagogastric junction (EGJ) adenocarcinoma with Barrett's esophagus. The patient subsequently underwent esophagectomy with esophagogastrostomy followed by two-field lymphadenectomy. The pathological stage of the tumor was pT1bN0M0, pStage I, tub1-2, ly1, and v0. The human epidermal growth factor receptor type 2 score was 1 plus. The patient experienced an uncomplicated recovery after being discharged from the hospital with no recurrences for the next 28 months. However, follow-up computed tomography performed at the time of the complaint of metamorphopsia of the left eye revealed systemic metastasis. An ophthalmologic evaluation showed an elevated lesion on the left fundus. Finally, brain magnetic resonance imaging indicated choroidal metastases from an EGJ adenocarcinoma. When the left eye was treated with radiotherapy combined with S-1 and oxaliplatin, complete response for choroidal metastasis and partial response for systemic metastasis were achieved. Due to early diagnosis and treatment, the patient's eyesight was salvaged. Furthermore, the availability and contribution of ramucirumab, an angiogenesis inhibitor used as a second line of treatment for advanced gastric cancer, to choroidal metastasis following irradiation-controlled hemorrhagic tumor was explored.