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Aiolfi A, Bona D, Calì M, Manara M, Rausa E, Bonitta G, Elshafei M, Markar SR, Bonavina L. Does Thoracic Duct Ligation at the Time of Esophagectomy Impact Long-Term Survival? An Individual Patient Data Meta-Analysis. J Clin Med 2024; 13:2849. [PMID: 38792391 PMCID: PMC11122204 DOI: 10.3390/jcm13102849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 05/01/2024] [Accepted: 05/08/2024] [Indexed: 05/26/2024] Open
Abstract
Background: Thoracic duct ligation (TDL) during esophagectomy has been proposed to reduce the risk of postoperative chylothorax. Because of its role in immunoregulation, some authors argued that it had an unfavorable TDL effect on survival. The aim of this study was to analyze the effect of TDL on overall survival (OS). Methods: PubMed, MEDLINE, Scopus, and Web of Science were searched through December 2023. The primary outcome was 5-year OS. The restricted mean survival time difference (RMSTD), hazard ratios (HRs), and 95% confidence intervals (CI) were used as pooled effect size measures. The GRADE methodology was used to summarize the certainty of the evidence. Results: Five studies (3291 patients) were included. TDL was reported in 54% patients. The patients' age ranged from 49 to 69, 76% were males, and BMI ranged from 18 to 26. At the 5-year follow-up, the combined effect from the multivariate meta-analysis is -3.5 months (95% CI -6.1, -0.8) indicating that patients undergoing TDL lived 3.5 months less compared to those without TDL. TDL was associated with a significantly higher hazard for mortality at 12 months (HR 1.54, 95% CI 1.38-1.73), 24 months (HR 1.21, 95% CI 1.12-1.35), and 28 months (HR 1.14, 95% CI 1.02-1.28). TDL and noTDL seem comparable in terms of the postoperative risk for chylothorax (RR = 0.66; p = 0.35). Conclusions: In this study, concurrent TDL was associated with reduced 5-year OS after esophagectomy. This may suggest the need of a rigorous follow-up within the first two years of follow-up.
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Affiliation(s)
- Alberto Aiolfi
- IRCCS Ospedale Galeazzi—Sant’Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, 20157 Milan, Italy; (D.B.)
| | - Davide Bona
- IRCCS Ospedale Galeazzi—Sant’Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, 20157 Milan, Italy; (D.B.)
| | - Matteo Calì
- IRCCS Ospedale Galeazzi—Sant’Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, 20157 Milan, Italy; (D.B.)
| | - Michele Manara
- IRCCS Ospedale Galeazzi—Sant’Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, 20157 Milan, Italy; (D.B.)
| | - Emanuele Rausa
- IRCCS Ospedale Galeazzi—Sant’Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, 20157 Milan, Italy; (D.B.)
| | - Gianluca Bonitta
- IRCCS Ospedale Galeazzi—Sant’Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, 20157 Milan, Italy; (D.B.)
| | - Moustafa Elshafei
- Department of Bariatric and Metabolic Medicine, Clinic Northwest, 60488 Frankfurt, Germany;
| | - Sheraz R. Markar
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford OX1 2JD, UK;
| | - Luigi Bonavina
- IRCCS Policlinico San Donato, Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, University of Milan, 20097 Milan, Italy;
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Donohoe CL. Editorial: Role of thoracic duct ligation in esophagectomy. Dis Esophagus 2023; 36:doad047. [PMID: 37465850 DOI: 10.1093/dote/doad047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 06/23/2023] [Indexed: 07/20/2023]
Affiliation(s)
- C L Donohoe
- Department of Surgery, Trinity St James Cancer Institute, St James' Hospital, Dublin, Ireland
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Liu B, Li X, Yu MJ, Xie JB, Liao GL, Qiu ML. Application of single-port laparoscopic retrograde gastric mobilization during McKeown esophagectomy for esophageal cancer. Ann Thorac Med 2023; 18:39-44. [PMID: 36968329 PMCID: PMC10034825 DOI: 10.4103/atm.atm_205_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 11/05/2022] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND As a novel alternative to the conventional minimally invasive esophagectomy (MIE) to treat esophageal cancer, single-port laparoscopic retrograde three-step gastric mobilization (SLRM) for esophageal reconstruction during MIE to treat esophageal cancer was attempted in our department. The aim of the present study was to explore the preliminary clinical outcomes and feasibility of this innovative surgery. METHODS From March 2020 to November 2021, patients undergoing SLRM combined with four-port thoracoscopic McKeown esophagectomy for their esophageal cancers were reviewed. Gastric mobilization with abdominal lymph node dissection was performed through SLRM. The clinical characteristics and short-term outcomes were analyzed retrospectively. RESULTS A total of 120 patients underwent R0 resection without conversion to open surgery. The mean times needed for the thoracic part, abdominal part, and total operation were 43 ± 6 min, 60 ± 18 min, and 230 ± 20 min, respectively. The numbers of mediastinal and abdominal lymph nodes harvested were 13.2 ± 2.7 and 10.2 ± 2.5, respectively. Postoperative pneumonia was encountered in 10 (8.3%) patients. Anastomotic leakage occurred in 3 (2.5%) cases. Temporary vocal cord paralysis was reported in 20 (16.6%) cases. The mean length of hospital stay was 8.5 ± 4.6 days. CONCLUSIONS The SLRM is a technically feasible and safe treatment for patients with esophageal cancer. It can be considered an alternative method for patients, especially for the ones with obesity and gastric distension.
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Affiliation(s)
- Bo Liu
- Department of Thoracic Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, Fujian, China
| | - Xu Li
- Department of Thoracic Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, Fujian, China
| | - Min-Jie Yu
- Department of Thoracic Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, Fujian, China
| | - Jin-Bao Xie
- Department of Thoracic Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, Fujian, China
| | - Guo-Liang Liao
- Department of Thoracic Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, Fujian, China
| | - Ming-Lian Qiu
- Department of Thoracic Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, Fujian, China
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Ongoing Controversies in Esophageal Cancer I. Thorac Surg Clin 2022; 32:541-551. [DOI: 10.1016/j.thorsurg.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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dos Santos CL, dos Santos LL, Tavares G, Tristão LS, Orlandini MF, Serafim MCA, Datrino LN, Bernardo WM, Tustumi F. Prophylactic thoracic duct obliteration and resection during esophagectomy: What is the impact on perioperative risks and long‐term survival? A systematic review and meta‐analysis. J Surg Oncol 2022; 126:90-98. [DOI: 10.1002/jso.26827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 02/06/2022] [Accepted: 02/08/2022] [Indexed: 01/27/2023]
Affiliation(s)
- Clara L. dos Santos
- Department of Evidence‐based Medicine Centro Universitário Lusíada Santos SP Brazil
| | - Laura L. dos Santos
- Department of Gastroenterology Universidade de São Paulo Sao Paulo SP Brazil
| | - Guilherme Tavares
- Department of Evidence‐based Medicine Centro Universitário Lusíada Santos SP Brazil
| | - Luca S. Tristão
- Department of Evidence‐based Medicine Centro Universitário Lusíada Santos SP Brazil
| | - Marina F. Orlandini
- Department of Evidence‐based Medicine Centro Universitário Lusíada Santos SP Brazil
| | - Maria C. A. Serafim
- Department of Evidence‐based Medicine Centro Universitário Lusíada Santos SP Brazil
| | - Letícia N. Datrino
- Department of Evidence‐based Medicine Centro Universitário Lusíada Santos SP Brazil
| | - Wanderley M. Bernardo
- Department of Evidence‐based Medicine Centro Universitário Lusíada Santos SP Brazil
- Department of Gastroenterology Universidade de São Paulo Sao Paulo SP Brazil
| | - Francisco Tustumi
- Department of Evidence‐based Medicine Centro Universitário Lusíada Santos SP Brazil
- Department of Gastroenterology Universidade de São Paulo Sao Paulo SP Brazil
- Department of Surgery Hospital Israelita Albert Einstein Sao Paulo SP Brazil
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Zheng XD, Li SC, Lu C, Zhang WM, Hou JB, Shi KF, Zhang P. Safety and efficacy of minimally invasive McKeown esophagectomy in 1023 consecutive esophageal cancer patients: a single-center experience. J Cardiothorac Surg 2022; 17:36. [PMID: 35292067 PMCID: PMC8922768 DOI: 10.1186/s13019-022-01781-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 03/06/2022] [Indexed: 12/24/2022] Open
Abstract
Objective By analyzing the perioperative, postoperative complications and long-term overall survival time, we summarized the 8-year experience of minimally invasive McKeown esophagectomy for esophageal cancer in a single medical center. Methods This retrospective follow-up study included 1023 consecutive patients with esophageal cancer who underwent MIE-McKeown between Mar 2013 and Oct 2020. Relevant variables were collected and evaluated. Overall survival (OS) and disease-free survival (DFS) were analyzed by Kaplan–Meier method. Results For 1023 esophageal cancer undergoing MIE-McKeown, the main intraoperative complications were bleeding (3.0%, 31/1023) and tracheal injury (1.7%, 17/1023). There was no death occurred during operation. The conversion rate of thoracoscopy to thoracotomy was 2.2% (22/1023), and laparoscopy to laparotomy was 0.3% (3/1023). The postoperative morbidity of complications was 36.2% (370/1023), of which anastomotic leakage 7.7% (79/1023), pulmonary complication 13.4% (137/1023), chylothorax 2.3% (24/1023), and recurrent laryngeal nerve injury 8.8% (90/1023). The radical resection rate (R0) was 96.0% (982/1023), 30-day mortality was 0.3% (3/1023). For 1000 cases with squamous cell carcinoma, the estimated 3-year and 5-year overall survival was 37.2% and 17.8% respectively. In addition, neoadjuvant chemotherapy offered 3-year disease-free survival rate advantage in advanced stage patients (for stage IV: 7.2% vs. 1.8%). Conclusions This retrospective single center study demonstrates that MIE-McKeown procedure is feasible and safe with low perioperative and postoperative complications’ morbidity, and acceptable long-term oncologic results.
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Affiliation(s)
- Xiao-Dong Zheng
- Department of Cardiothoracic Surgery, Tianjin Medical University General Hospital, AnShan Road No. 154, Heping District, Tianjin, 30052, China
| | - Shi-Cong Li
- Department of Cardiothoracic Surgery, Tianjin Medical University General Hospital, AnShan Road No. 154, Heping District, Tianjin, 30052, China
| | - Chao Lu
- Department of Cardiothoracic Surgery, Tianjin Medical University General Hospital, AnShan Road No. 154, Heping District, Tianjin, 30052, China
| | - Wei-Ming Zhang
- Department of Thoracic Surgery, Anyang Tumor Hospital, The Fourth Affiliated Hospital of Henan University of Science and Technology, HuanBin North Road, No. 1, Anyang, 455000, Henan, China
| | - Jian-Bin Hou
- Department of Thoracic Surgery, Anyang Tumor Hospital, The Fourth Affiliated Hospital of Henan University of Science and Technology, HuanBin North Road, No. 1, Anyang, 455000, Henan, China
| | - Ke-Feng Shi
- Department of Thoracic Surgery, Anyang Tumor Hospital, The Fourth Affiliated Hospital of Henan University of Science and Technology, HuanBin North Road, No. 1, Anyang, 455000, Henan, China
| | - Peng Zhang
- Department of Cardiothoracic Surgery, Tianjin Medical University General Hospital, AnShan Road No. 154, Heping District, Tianjin, 30052, China.
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Bao T, Li KK, Liu B, Zhao XL, Wang YJ, Guo W. Learning Curve and Associated Prognosis of Minimally Invasive McKeown Esophagectomy. Ann Thorac Surg 2022; 114:933-939. [PMID: 35202595 DOI: 10.1016/j.athoracsur.2022.01.045] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 12/21/2021] [Accepted: 01/25/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND The implementation of McKeown minimally invasive esophagectomy (MIE) is associated with a steep learning curves. However, there is no consensus on the number of cases required before effective and safe McKeown MIE can be achieved. METHODS Data of consecutive patients with esophageal carcinoma undergoing esophagectomy by a single surgeon in the Department of Thoracic Surgery at Daping Hospital from September 2009 to June 2019 were collected. Cumulative sum learning curve was plotted based on the learning associated parameters. Propensity score matching (PSM) was used to reduce selection bias from confounding factors. Kaplan-Meier was used to assess the survival differences. RESULTS The learning curve was divided into the ascending period (case 1-197), the plateau period (198-314), and the descending period (315-onward). After 197 cases, significant improvements in operative time (300 vs. 210minutes; P<.001), retrieved lymph nodes (17 vs. 20; P=.004), length of stay (18 vs. 13; P=.001), major postoperative complications (38.6 vs. 32.5%; P<.001), vocal cord palsy (6.1 vs. 0.9%; P=.04), and pulmonary complications (31.5 vs. 17.1%; P=.005) were observed. In addition, after 314 cases, a significant decrease in blood loss (200 vs. 100milliliters; P<.001), anastomotic leak (24.8 vs. 14.8%; P=.02), and chylothorax (4.3 vs. 0%; P=.001) was observed.After PSM, the overall and disease-free survival rates were significantly improved during the experienced period (P=.02 and .03, respectively). CONCLUSIONS The initial learning phase of McKeown MIE consisted of 197 procedures in 51 months. Moreover, the surgeon's experience did have a direct impact on the long-term outcomes for patients with esophageal carcinoma. (250).
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Affiliation(s)
- Tao Bao
- Department of Thoracic Surgery, Daping Hospital, Army Medical University, Chongqing, China
| | - Kun-Kun Li
- Department of Thoracic Surgery, Daping Hospital, Army Medical University, Chongqing, China
| | - Bi Liu
- Department of Thoracic Surgery, Daping Hospital, Army Medical University, Chongqing, China
| | - Xiao-Long Zhao
- Department of Thoracic Surgery, Daping Hospital, Army Medical University, Chongqing, China
| | - Ying-Jian Wang
- Department of Thoracic Surgery, Daping Hospital, Army Medical University, Chongqing, China
| | - Wei Guo
- Department of Thoracic Surgery, Daping Hospital, Army Medical University, Chongqing, China.
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Adjuvant chemotherapy for node-positive esophageal squamous cell carcinoma improves survival. Ann Thorac Surg 2021; 114:1205-1213. [PMID: 34626616 DOI: 10.1016/j.athoracsur.2021.08.068] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 07/16/2021] [Accepted: 08/30/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the survival benefits of adjuvant chemotherapy in patients with positive lymph nodes after esophagectomy for esophageal squamous cell carcinoma. METHODS Patients who underwent esophagectomy for esophageal cancer in the Affiliated Cancer Hospital of Zhengzhou University (Henan Cancer Hospital) from 2013 to 2017 were selected for this retrospective cohort study. Patients with positive lymph nodes were grouped into the surgery alone group and adjuvant chemotherapy group. Propensity score matching (1:1) was used to minimize baseline differences. RESULTS Among the 5118 patients who underwent esophagectomy, 792 patients were enrolled in the study. After matching, 253 (of 476) patients (adjuvant chemotherapy group) and 253 (of 316) patients (surgery alone group) were included. The median overall survival was significantly prolonged in the adjuvant chemotherapy group (54.0 months, 95% CI, 41.1-66.9 months) compared with the surgery alone group (28.0 months, 95% CI, 22.4-33.6 months) (P <0.001). A significant difference was also observed in median disease-free survival between the two groups (adjuvant chemotherapy group, 33.0 months, 95% CI, 20.8-45.2 months compared with the surgery alone group, 22.0 months, 95% CI, 17.0-27.0 months; P = 0.007). In a multivariable analysis, receiving adjuvant chemotherapy (P <0.001) was significantly associated with a reduced risk of death and dissection of more than six lymph node stations (P = 0.05) was marginally associated with a reduced risk of death. CONCLUSIONS Postoperative adjuvant chemotherapy improves the overall survival and disease-free survival of patients with resected esophageal squamous cell carcinoma with positive lymph nodes.
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Bazancir LA, Jensen RJ, Frevert SC, Ryom P, Achiam MP. Embolization of the thoracic duct in patients with iatrogenic chylothorax. Dis Esophagus 2021; 34:6129921. [PMID: 33550366 DOI: 10.1093/dote/doab001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 10/14/2020] [Accepted: 12/29/2020] [Indexed: 12/11/2022]
Abstract
Chylothorax is leakage of lymphatic fluid accumulating in the pleural cavity due to the thoracic duct's (TD) trauma or obstructions. It generally occurs as a traumatic complication after general thoracic surgery procedures (0.4%), especially after esophagectomy (4.7-8.6%). Traditionally, surgical intervention is performed if conservative management fails, but reports of high mortality (2.1%) and morbidity (38%) have led to the development of a minimally invasive percutaneous treatment method; TD embolization (TDE). The records of all patients treated for chylothorax with TDE from April 2015 to June 2019 were reviewed. Only patients with iatrogenic chylothorax were included. The outcomes measures are defined as a technical and a clinical success. A technical success, is defined as the ability to perform the embolization procedure, thereby injecting embolizing material Histoacryl with or without coils. A clinical success is defined as a complete cessation of lymphatic leakage into the pleural cavity without surgical intervention and, therefore, a cured patient. Lymphography was performed in all patients, and visualization of cisterna chyli was achieved in 14/17 patients (82.4%). Of the 17 patients included, 15 patients were successfully embolized and cured of chylothorax (88.2%). Successfully embolized patients had a median discharge time of 7 days. Most patients reported postprocedural pain, which was dealt with using conventional pain medication. TDE seems like a safe percutaneous treatment technique with a high clinical success rate in iatrogenic chylothorax patients which can be readily implemented if the clinical experience is available..
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Affiliation(s)
- Laser Arif Bazancir
- Department of Surgical Gastroenterology, Copenhagen University, Copenhagen, Denmark
| | - Ruben Juhl Jensen
- Department of Diagnostic Radiology, Copenhagen University, Copenhagen, Denmark
| | | | - Philip Ryom
- Department of Cardiothoracic Surgery, Copenhagen University, Copenhagen, Denmark
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Takhellambam L, Yadav TD, Kumar H, Gupta V, Tandup C, Gorsi U, Sharma V, Mandhavdhare H, Samra T, Singh H. Prophylactic ligation of the opacified thoracic duct in minimally invasive esophagectomy - feasibility and safety. Langenbecks Arch Surg 2021; 406:2515-2520. [PMID: 34410481 DOI: 10.1007/s00423-021-02300-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 08/09/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Chyle leak is a rare but morbid complication of esophagectomy. We assessed the feasibility of visualization and prophylactic ligation of the opacified thoracic duct (TD) after administration of 50 ml of olive oil. METHODS This prospective single center study considered all patients with carcinoma of the middle and lower thirds of the thoracic esophagus including the gastroesophageal junction (GEJ), managed from January 2018 to December 2019, for inclusion. All patients underwent McKeown minimally invasive esophagectomy. After anesthesia and endotracheal intubation, 50 ml of olive oil was administered through a nasogastric (NG) tube. During thoracoscopic esophageal mobilization, the opacified thoracic duct was identified and ligated using Weck Hem-o-lok clips immediately above the diaphragmatic hiatus. Postoperatively, the nature, volume, and triglyceride levels of the fluid from the chest drain were recorded. RESULTS Forty-three patients with carcinoma of the esophagus were assessed for inclusion and eventually, 33 were enrolled. The median age of the study population was 55 years, and there were 20 males. The tumor site was the lower esophagus in 24 (72.7%) patients. The most common histolopathological finding was squamous cell carcinoma (97%). The opacified thoracic duct could be identified and ligated in 31 (93.9%) patients. The median duration from the administration of olive oil to the ligation of the thoracic duct was 100 min. The median chest drain output and triglyceride levels on postoperative day (POD) one were 250 ml and 48 mg% respectively. No patient developed postoperative chylothorax. CONCLUSION Opacification and visualization of the thoracic duct during thoracoscopy can be aided by administering olive oil. Ligation of this opacified duct is feasible and safe.
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Affiliation(s)
- Lunkhomba Takhellambam
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Thakur Deen Yadav
- Department of Surgical Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Hemanth Kumar
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vikas Gupta
- Department of Surgical Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Cherring Tandup
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ujjwal Gorsi
- Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Vishal Sharma
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Harshal Mandhavdhare
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Tanvir Samra
- Department of Anaesthesiology and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Harjeet Singh
- Department of Surgical Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
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Chen YT, Wang CT, Chiu CH, Chao YK. Salvage surgery, chylothorax and pneumonia are the main drivers of unplanned readmissions after oesophagectomy for cancer. Eur J Cardiothorac Surg 2021; 59:1021-1029. [PMID: 33367507 DOI: 10.1093/ejcts/ezaa451] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 10/28/2020] [Accepted: 11/15/2020] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES Unplanned readmissions after surgery can be cumbersome to patients and costly on healthcare resources. The aim of this single-centre study was to identify the independent risk factors for unplanned readmissions in patients who had undergone oesophagectomy for cancer. METHODS We retrospectively reviewed the clinical records of 526 consecutive patients with oesophageal cancer who received transthoracic oesophagectomy and were discharged home between 2006 and 2017. Risk factors for unplanned readmission within the first 30 days from discharge were identified by multivariable competing risk analysis. RESULTS The mean age of the study patients was 55.14 years and 93.7% were men. Squamous cell carcinoma was identified in 94.1% of the participants, and 68.0% received chemoradiotherapy. There were 299 (56.8%) patients who experienced at least 1 postoperative complication. Fifty-five patients (10.5%) experienced an unplanned readmission. The postoperative 90-day mortality rate among patients who experienced an unplanned readmission was significantly higher than that of cases who did not (9.1% vs 0.2%, respectively, P < 0.001). Multivariable analysis identified chylothorax [hazard ratio (HR): 3.86, 95% confidence interval (CI): 1.89-7.91, P < 0.001], pneumonia (HR: 1.98, 95% CI 1.03-3.82, P = 0.042) and salvage surgery (HR: 2.27, 95% CI: 1.10-4.69, P = 0.027) as independent risk factors for unplanned readmissions. CONCLUSIONS Salvage surgery, postoperative chylothorax and pneumonia are the main drivers of 30-day unplanned readmissions in patients who had undergone oesophagectomy for cancer. Patients who required unplanned readmissions showed increased early mortality rates.
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Affiliation(s)
- Yu-Ting Chen
- Department of Thoracic Surgery, Chang Gung Memorial Hospital-Linko, Chang Gung University, Taoyuan, Taiwan
| | - Chen-Ti Wang
- Department of Thoracic Surgery, Chang Gung Memorial Hospital-Linko, Chang Gung University, Taoyuan, Taiwan
| | - Chien-Hung Chiu
- Department of Thoracic Surgery, Chang Gung Memorial Hospital-Linko, Chang Gung University, Taoyuan, Taiwan
| | - Yin-Kai Chao
- Department of Thoracic Surgery, Chang Gung Memorial Hospital-Linko, Chang Gung University, Taoyuan, Taiwan
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12
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Bao T, Zhao XL, Li KK, Wang YJ, Guo W. Effect of surgical start time on short- and long-term outcomes after minimally invasive esophagectomy: a propensity-score matching analysis. Dis Esophagus 2021; 34:5917701. [PMID: 33015706 DOI: 10.1093/dote/doaa108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 08/12/2020] [Accepted: 09/10/2020] [Indexed: 12/11/2022]
Abstract
There is growing focus on the relationship between surgical start time and postoperative outcomes. However, the extent to which the operation start time affects the surgical and oncological outcomes of patients undergoing esophagectomy has not previously been studied. The purpose of this retrospective study was to investigate the potential effect of surgical start time on the short- and long-term outcomes for patients who underwent thoracoscopic-laparoscopic McKeown esophagectomy. From September 2009 to June 2019, a total of 700 consecutive patients suffering from esophageal cancer underwent thoracoscopic-laparoscopic McKeown esophagectomy in the Department of Thoracic Surgery at Daping Hospital. Among these patients, 166 esophagectomies were performed on the same day and were classified as the first- or second-start group. Patients in the first-start group were more likely to be older than those in the second-start group: (64.73 vs. 61.28, P = 0.002). In addition, patients with diabetes mellitus were more likely to be first-start cases (8.4 vs. 1.2%). After propensity score matching (52 matched patients in first-start cases and 52 matched patients in second-start cases), these findings were no longer statistically significant. There was no difference in the incidence rate of peri- or postoperative adverse events between the first- and second-start groups. The disease-specific survival rates and disease-free survival rates were comparable between the two groups (P = 0.236 and 0.292, respectively). On the basis of the present results, a later start time does not negatively affect the short- or long-term outcomes of patients undergoing minimally invasive McKeown esophagectomy.
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Affiliation(s)
- Tao Bao
- Department of Thoracic Surgery, Daping Hospital, Army Medical University, Chongqing, China
| | - Xiao-Long Zhao
- Department of Thoracic Surgery, Daping Hospital, Army Medical University, Chongqing, China
| | - Kun-Kun Li
- Department of Thoracic Surgery, Daping Hospital, Army Medical University, Chongqing, China
| | - Ying-Jian Wang
- Department of Thoracic Surgery, Daping Hospital, Army Medical University, Chongqing, China
| | - Wei Guo
- Department of Thoracic Surgery, Daping Hospital, Army Medical University, Chongqing, China
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Tanaka K, Yamasaki M, Sugimura K, Shiraishi O, Motoori M, Hamakawa T, Takeno A, Yamashita K, Makino T, Kimura Y, Miyata H, Hirao M, Eguchi H, Yasuda T, Yano M, Doki Y. Thoracic Duct Resection Has a Favorable Impact on Prognosis by Preventing Hematogenous Spread of Esophageal Cancer Cells: A Multi-institutional Analysis of 2269 Patients. Ann Surg Oncol 2021; 28:4402-4410. [PMID: 33861403 DOI: 10.1245/s10434-021-09962-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 02/19/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND The impact of thoracic duct (TD) resection on prognosis is controversial. This study aimed to examine the impact of TD resection. METHODS In this six-institution, matched-cohort study, 2269 consecutive patients with esophageal squamous cell carcinoma who underwent esophagectomy between 2000 and 2017 were enrolled for analysis of long-term outcomes, including overall survival (OS), disease-free survival (DFS), cause-specific survival (CSS), and recurrence patterns. RESULTS Based on a propensity score, 642 TD-resected and 642 TD-preserved patients with all stages of disease were selected. At 5 years, the TD-resected group had an OS of 57.7%, a DFS of 50.9%, and a CSS of 62.2%. These rates were significantly higher than the corresponding rates of 48.7% (p = 0.0078), 41.0% (p = 0.0297), and 55.3% (p = 0.0473) in the TD-preserved group. The OS in the TD-preserved and TD-resected groups was similar for the patients with cStage 1 or 2 (p = 0.6265), but it was significantly higher in the TD-resected group for the patients with cStage 3 or 4 (p = 0.0052). The incidence of total recurrence did not differ between the two groups. However, the incidence of hematogenous recurrence in the TD-resected group (19.0%) was significantly lower than in the TD-preserved group (26.2%) (p = 0.0021). For cT4a tumors, the incidence of local recurrence in the TD-resected group (2.4%) was significantly lower than in the TD-preserved group (18.4%) (p = 0.0183). CONCLUSIONS Performance of TD resection may help to improve prognosis, especially for patients with advanced esophageal squamous cell carcinoma, by reducing hematogenous and local recurrence. Prospective trials are needed to determine whether prophylactic TD resection has a positive impact on the prognosis of patients with esophageal cancer.
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Affiliation(s)
- Koji Tanaka
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita City, Osaka, Japan.
| | - Makoto Yamasaki
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita City, Osaka, Japan
| | - Keijiro Sugimura
- Department of Digestive Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Osamu Shiraishi
- Department of Surgery, Kindai University Faculty of Medicine, Osaka, Japan
| | - Masaaki Motoori
- Department of Surgery, Osaka General Medical Center, Osaka, Japan
| | - Takuya Hamakawa
- Department of Surgery, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Atsushi Takeno
- Department of Surgery, Kansai Rosai Hospital, Amagasaki, Hyogo, Japan
| | - Kotaro Yamashita
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita City, Osaka, Japan
| | - Tomoki Makino
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita City, Osaka, Japan
| | - Yutaka Kimura
- Department of Surgery, Kindai University Faculty of Medicine, Osaka, Japan
| | - Hiroshi Miyata
- Department of Digestive Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Motohiro Hirao
- Department of Surgery, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Hidetoshi Eguchi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita City, Osaka, Japan
| | - Takushi Yasuda
- Department of Surgery, Kindai University Faculty of Medicine, Osaka, Japan
| | - Masahiko Yano
- Department of Digestive Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Yuichiro Doki
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita City, Osaka, Japan
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Hu H, Chen H. Unlocking Better Survival for Esophageal Cancer Patients: Is Thoracic Duct Resection the Key? Ann Surg Oncol 2021; 28:4086-4087. [PMID: 33821342 DOI: 10.1245/s10434-021-09968-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 03/25/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Haichuan Hu
- Department of Medicine Harvard Medical School, Massachusetts General Hospital Cancer Center, Boston, MA, USA.
| | - Haiquan Chen
- Departments of Thoracic Surgery and State Key Laboratory of Genetic Engineering, Fudan University Shanghai Cancer Center, Shanghai, People's Republic of China.
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Gilyard SN, Khaja MS, Goswami AK, Kokabi N, Saad WE, Majdalany BS. Traumatic Chylothorax: Approach and Outcomes. Semin Intervent Radiol 2020; 37:263-268. [PMID: 32773951 DOI: 10.1055/s-0040-1713443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Traumatic chylothorax occurs more often now than in historic reports. In part, this is due to the increased ability to perform more advanced and aggressive thoracic resections and cardiovascular surgeries as well as the improved mortality of cancer patients. If untreated, chylothorax can result in significant morbidity and mortality, particularly in patients with underlying malignancy. Thoracic duct embolization for chylothorax was the first successful lymphatic intervention and has been performed for over 20 years. An overview of the clinical and technical approach to thoracic duct embolization for traumatic chylothorax is presented in addition to a review of outcomes.
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Affiliation(s)
- Shenise N Gilyard
- Division of Vascular and Interventional Radiology, Department of Radiology and Imaging Sciences, Emory University Hospital, Atlanta, Georgia
| | - Minhaj S Khaja
- Division of Vascular and Interventional Radiology, Radiology and Medical Imaging, University of Virginia, Charlottesville, Virginia
| | - Abhishek K Goswami
- Division of Vascular and Interventional Radiology, Department of Radiology and Imaging Sciences, Emory University Hospital, Atlanta, Georgia
| | - Nima Kokabi
- Division of Vascular and Interventional Radiology, Department of Radiology and Imaging Sciences, Emory University Hospital, Atlanta, Georgia
| | - Wael E Saad
- Division of Vascular and Interventional Radiology, Department of Radiology, National Institutes of Health, Bethesda, Maryland
| | - Bill S Majdalany
- Division of Vascular and Interventional Radiology, Department of Radiology and Imaging Sciences, Emory University Hospital, Atlanta, Georgia
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