Risk factors for anastomotic leakage after surgical resections for esophageal cancer

3,3'-Diindolylmethane inhibits the proliferation of esophageal squamous cell carcinoma cells via downregulation of STIM1

3,3'-Diindolylmethane (DIM) is a natural phytochemical derived from cruciferous plants that has inhibitory effects on a wide range of tumor cells; however, its relevant effects on esophageal cancer cells have been poorly studied. Therefore, in the present study, a pharmacology network approach was used to predict the possible core targets of DIM acting on esophageal cancer. Subsequently, using in vitro experiments, TE-1 human esophageal cancer cells were treated with different concentrations of DIM (0, 40, 60 and 80 µM) for 24 h. Changes in cell activity were detected by Cell Counting Kit-8 assay, and changes in the expression levels of stromal interaction molecule 1 (STIM1) and apoptosis-related proteins, B-cell lymphoma-2 (Bcl-2) and Bax, were assessed by western blotting, followed by the upregulation of STIM1 by thapsigargin (Tg). Network pharmacology analysis showed that there were 39 potential core targets of DIM in esophageal cancer. The results of the in vitro experiments showed that DIM could inhibit the viability of esophageal cancer cells, downregulate the expression of STIM1 and Bcl-2 proteins and upregulate the expression of Bax protein, all in a concentration-dependent manner. The results also demonstrated that toxic carotenoids were agonist against STIM1 protein and upregulated STIM1 and Bax protein expression. After agonizing STIM1 protein expression using Tg, DIM was able to counteract the expression trend of STIM1, Bcl-2 and Bax protein in TE-1 cells. In summary, DIM induced apoptosis and inhibited the viability of esophageal cancer cells by downregulating the expression of STIM1 protein; therefore, the natural phytochemical, DIM, may be a potential substance for the early prevention and treatment of esophageal cancer cells.

Assessment of safety during hospitalization for patients undergoing Surgery after neoadjuvant therapy for moderately advanced Esophageal cancer

PURPOSE

To study the safety of patients with moderately advanced esophageal cancer during their hospital stay after undergoing surgery.

METHODS

The clinical and pathological data of 66 patients with locally advanced esophageal cancer discharged from the Department of Thoracic Surgery of Jiangsu University Hospital from January 2017 to October 2022 were selected, of whom 32 underwent direct surgery (control group) and 34 underwent neoadjuvant therapy followed by surgery (experimental group), to retrospectively analyze whether there were differences in surgical outcomes, complication rates, biochemical and infection indicators between the two groups.

RESULTS

The number of lymph node dissections, lymph node dissection rate, and hemoglobin value on the first day after the operation in the experimental group were smaller than those in the control group, and the difference was statistically significant (P < 0.05). The thoracic drainage volume of the experimental group was more than that of the control group, and the difference was statistically significant (P < 0.05). The incidence of pulmonary complications in the experimental group was higher than that in the control group, especially pulmonary infection, and the difference was statistically significant (P < 0.05). Compared with the control group, the experimental group was more prone to anastomotic leakage, and the difference was statistically significant (P < 0.05).

CONCLUSION

Neoadjuvant therapy combined with surgery for patients with advanced esophageal cancer is generally safe during hospitalization.

Single-stage transoral incisionless fundoplication and laparoscopic sleeve gastrectomy for the management of GERD and obesity

INTRODUCTION AND IMPORTANCE

Gastro-esophageal reflux disease (GERD) is frequently associated with obesity. Excess body weight, particularly central adiposity, with a concomitantly raised intra-abdominal pressure, leads to a reduced lower esophageal sphincter (LES) pressure and GERD. The lax LES essentially causes acid reflux in the lower esophagus.

CASE PRESENTATION

We report a 44-year-old woman who presented to our surgical clinic with heartburn and acid reflux, associated with difficulty in weight management. The patient had a BMI of 35 kg/m². The upper GI endoscopy showed a small hiatal hernia, with lax LES and grade A esophagitis. She was initially started on daily proton pump inhibitors (PPIs). All available management plans were discussed with the patient, and she did not prefer to continue with life-long PPIs. At the same time, the patient was also concerned about her weight and requested for a plausible weight management solution.

CLINICAL DISCUSSION

The patient was planned for a single-stage Transoral Incisionless Fundoplication (TIF) and laparoscopic sleeve gastrectomy for her GERD and obesity, respectively. TIF was performed by two experienced endoscopists, one controlling the EsophyX device and the other ensuring continuous direct visualization of the field of work with the endoscope. Following the procedure, laparoscopic sleeve gastrectomy was performed during the same session. The patient had an uneventful recovery.

CONCLUSION

Eight months after surgery, the patient reported resolution of her GERD symptoms and a weight loss of 20 kg.

Albumin and Derived Neutrophil-to-Lymphocyte Ratio is a Novel Prognostic Factor for Patients with Esophageal Squamous Cell Carcinoma

BACKGROUND

Multidisciplinary treatment combining neoadjuvant treatment (NAT) and surgery has slightly improved the prognosis of patients with esophageal squamous cell carcinoma (ESCC). Although various biomarkers targeting nutrition and inflammation are associated with cancer prognosis, most studies have focused on conditions prior to NAT. Developing real-time and sensitive biomarkers that monitor changes in systemic conditions during NAT is important. We established a novel nutritional and inflammatory index, represented as the albumin to derived neutrophil-to-lymphocyte ratio (Alb-dNLR), and calculated the change in Alb-dNLR (ΔAlb-dNLR) during neoadjuvant chemotherapy (nCT). In this study, we aimed to evaluate whether ΔAlb-dNLR is associated with prognosis in patients with ESCC.

METHODS

We investigated 172 patients who underwent nCT before esophagectomy between April 2010 and March 2018. The dNLR was calculated as the ratio of neutrophil count to (white blood cell count - neutrophil count), Alb-dNLR was calculated by dividing the serum albumin level by the dNLR, and ΔAlb-dNLR was evaluated by dividing the post-Alb-dNLR by the pre-Alb-dNLR. Patients were divided into 'high' and 'low' groups according to the ΔAlb-dNLR.

RESULTS

Thirty-nine patients (22.7%) had a low ΔAlb-dNLR (≤ 0.8), and the 5-year overall survival (OS) rates in patients with low and high ΔAlb-dNLR were 38.1% and 53.6%, respectively (p = 0.0072). Multivariate analyses demonstrated that estimated blood loss (p = 0.044), pathological T stage (p = 0.0005), pathological N stage (p = 0.017), and ΔAlb-dNLR (p = 0.005) were independent prognostic factors for OS.

CONCLUSIONS

ΔAlb-dNLR is a useful prognostic factor for OS in patients with ESCC receiving nCT.

Risk Factors for Failure of Direct Oral Feeding Following a Totally Minimally Invasive Esophagectomy

Recently, it has been shown that directly starting oral feeding (DOF) from postoperative day one (POD1) after a totally minimally invasive Ivor-Lewis esophagectomy (MIE-IL) can further improve postoperative outcomes. However, in some patients, tube feeding by a preemptively placed jejunostomy is necessary. This single-center cohort study investigated risk factors associated with failure of DOF in patients that underwent a MIE-IL between October 2015 and April 2021. A total of 165 patients underwent a MIE-IL, in which DOF was implemented in the enhanced recovery after surgery program. Of these, 70.3% (n = 116) successfully followed the nutritional protocol. In patients in which tube feeding was needed (29.7%; n = 49), female sex (compared to male) (OR 3.5 (95% CI 1.5–8.1)) and higher ASA scores (III + IV versus II) (OR 2.2 (95% CI 1.0–4.8)) were independently associated with failure of DOF for any cause. In case of failure, this was either due to a postoperative complication (n = 31, 18.8%) or insufficient caloric intake on POD5 (n = 18, 10.9%). In the subgroup of patients with complications, higher ASA scores (OR 2.8 (95% CI 1.2–6.8)) and histological subtypes (squamous-cell carcinoma versus adenocarcinoma and undifferentiated) (OR 5.2 (95% CI 1.8–15.1)) were identified as independent risk factors. In the subgroup of patients with insufficient caloric intake, female sex was identified as a risk factor (OR 5.8 (95% CI 2.0–16.8)). Jejunostomy-related complications occurred in 17 patients (10.3%). In patients with preoperative risk factors, preemptively placing a jejunostomy may be considered to ensure that nutritional goals are met.