Rationale for video-assisted radical esophagectomy

Identification of Preoperative Fat-Free Mass Index for the Prognosis of Curatively Resected Esophageal Cancer

BACKGROUND

The progressive, systemic depletion of muscle mass is a poor prognostic factor for various types of cancers. However, the assessment of body composition for patients with esophagectomy remains unclear. Therefore, we evaluated the significance of the fat-free mass index (FFMI) and estimated the appropriate cutoff value.

METHODS

We compiled clinicopathological characteristics of patients who underwent curative operation for esophageal cancer between October 2013 and March 2018 at Toranomon Hospital and reviewed them until December 2020. We analyzed the short- and long-term outcomes, compared to conventional nutritional factors, and calculated the area under the receiver operating characteristic (ROC) curve.

RESULTS

A total of 200 patients were eligible for inclusion. FFMI was ineffective in predicting postoperative complications, with no correlation with other nutritional biomarkers. Preoperative low FFMI led to poor overall survival (OS), and the lower cutoff values based on the time-dependent ROC analysis were 14.4 and 16.8 kg/m² in women and men, respectively. Multivariate analysis for OS revealed that low FFMI (p = 0.010, HR 2.437, 95% CI 1.234-4.815) and clinical stage (p = 0.010, HR 4.781, 95% CI 1.447-15.796) were independent prognostic factors. The 3-year survival rates were 68.9% in low FFMI and 88.6% in normal FFMI.

CONCLUSIONS

The low FFMI was not predictive of postoperative complications but an independent prognostic factor in esophageal cancer with curative resection, having no correlation with other biomarkers. Our cutoff FFMI values could be useful in selecting the target for muscle improvement programs.

Perioperative risk factors of psychological distress in patients undergoing treatment for esophageal cancer

Background

Esophageal cancer patients often feel depressed and are fearful of metastasis and death. The objective of this study was to clarify the characteristics of patients with psychological distress at all 5 time points compared with patients with no psychological distress especially from standpoints of personal coping styles and QOL.

Methods

In total, 102 of 152 consecutive patients who attended the outpatient clinic at Toranomon Hospital between April 2017 and April 2019 met eligibility criteria for inclusion in this study. Questionnaires designed to identify psychological distress (HADS-scores) and assess QOL (EORTC QLQ C-30/OES18) were administered at 5 time points from the time of the first outpatient consultation to 3 months after esophagectomy. The questionnaire of coping strategies (MAC-scales) was administered at only time 1 point.

Results

Based on the trends of HADS-scores, we defined two groups: “persistent high-HAD scores” and “persistent low-HADS scores.” There are strong relationships between psychological distress and coping strategy, and psychological distress and QOL. The possibility that there are relationships between stress coping strategies and some QOL status depending on some point of treatment.

Conclusions

The psychological distress during the treatment course of esophageal cancer is significantly associated with the coping strategies and QOL influenced by esophagectomy. This study can provide baseline information for identifying patients in need of psychological management and paves the way for larger clinical studies in the future.

Risk Factors for Postoperative Chylothorax After Radical Subtotal Esophagectomy

BACKGROUND

Chylothorax is one of the complications of esophagectomy for esophageal cancer. The treatment of this condition has been well discussed, but the risk factors for postoperative chylothorax remain unclear.

METHODS

A retrospective review of 294 patients who underwent esophagectomy for esophageal cancer was conducted. These were patients with squamous cell carcinoma or adenocarcinoma of the esophagus including Siewert type I tumor of the esophagogastric junction who underwent subtotal esophagectomy with two-field or three-field lymphadenectomy. Of these, 24 patients who were diagnosed with chylothorax as a postoperative complication were allocated to the chylothorax group and the other 270 patients were allocated to the nonchylothorax group.

RESULTS

Univariate analysis showed a significant difference in three factors: resection of thoracic duct, post-chemoradiotherapy, and high intraoperative fluid balance. Multivariate analysis revealed that post-chemoradiotherapy [hazard ratio (HR) = 3.430; 95% confidence interval (CI) 1.364-8.625] and high intraoperative fluid balance (HR = 1.569; 95% CI 1.2.7-2.039) were independent factors predicting chylothorax. In addition, resection of the thoracic duct may be a predictor of chylothorax after esophagectomy (HR = 3.389; 95% CI 0.941-12.201, p = 0.062). Receiver operating characteristic curve analysis of intraoperative fluid revealed that the sensitivity was 62.5%, specificity was 74.1%, and the cutoff value was 6.55 mL/kg/h.

CONCLUSIONS

This study revealed that post-chemoradiotherapy and high intraoperative fluid balance are predictors of chylothorax after esophagectomy. The elucidation of clinicopathological factors that can predict the incidence of chylothorax will help to establish more effective perioperative management for esophageal cancer patients.

Video-assisted thoracic surgery and jejunal reconstruction in a case of situs inversus totalis with esophageal cancer

A 78-year-old man with situs inversus totalis who had a previous history of distal gastrectomy for gastric cancer was referred to our hospital for treatment of esophageal cancer. He was diagnosed as cT2N0M0 and underwent video-assisted thoracic surgery and open completion gastrectomy with jejunal reconstruction via the ante-thoracic route. The postoperative period was uneventful except for transient palsy of the right recurrent laryngeal nerve. Based on a preoperative assessment of anatomical abnormality and an intraoperative adaptation to the mirror image of the standard procedure, video-assisted esophagectomy was considered safe and feasible. It can be recommended for patients with esophageal cancer complicated by situs inversus totalis. This is the first case report of a patient with situs inversus totalis who underwent video-assisted esophagectomy with jejunal reconstruction. Relevant literature is also discussed and reviewed.

Re-evaluation of the role of thoracoscopic esophagectomy as a Japanese-style radical surgery

PURPOSE

To investigate the value of thoracoscopic surgery in radical esophagectomy with three-field lymphadenectomy.

MATERIALS AND METHOD

The subjects were 329 consecutive patients who, without preoperative chemoradiotherapy, underwent R0 radical esophagectomy with three-field lymphadenectomy for thoracic squamous cell esophageal cancers during 1998-2013. Open thoracotomy was applied in 212 (O), and thoracoscopic surgery in 117 (V). Survivals according to TNM Stages and Efficacy index (EI) were analyzed.

RESULTS

Hospital death rates of O/V were 1.9/0%. The survivals of V according to TNM Stages had significantly better prognosis in TNM6th cStage III and showed not worse prognosis in general. In the analysis using Cox proportional hazards model, "V or O" was a significant prognostic factor indicating better prognosis of V. More bilateral paratracheal lymph nodes along the recurrent laryngeal nerves tended to be classified as mediastinal instead of cervical in V. Efficacy index of mediastinal paratracheal nodes was higher in V than in O, while cervical lymphadenectomy maintained high EI.

DISCUSSION AND CONCLUSION

Though our series have limitations of retrospective study and substantial bias, the feasibility and safety of thoracoscopic esophagectomy with three-field lymphadenectomy was shown. Higher paratracheal lymph nodes along the recurrent laryngeal nerves could be dissected from the mediastinal side in V group. Thoracoscopic esophagectomy, which is regarded as minimally invasive surgery in other countries, is being accepted in Japan mainly in the expectation of more thorough and meticulous lymphadenectomy. At the same time, the dissection range is continuously re-evaluated for safer surgery maintaining radicality.

Hyperglycemia 3 days after esophageal cancer surgery is associated with an increased risk of postoperative infection

PURPOSE

Postoperative hyperglycemia is associated with infectious complications after various types of surgery. Our objective was to determine whether postoperative blood glucose levels up to 1 week after highly invasive esophageal cancer surgery are associated with the incidence of postoperative infections (POIs).

METHODS

We conducted a retrospective chart review of 109 consecutive thoracic esophageal squamous cell cancer patients who underwent invasive esophagectomy with thoracotomy and laparotomy. The incidence of postoperative POIs and risk factors for POIs, including postoperative blood glucose levels, were evaluated.

RESULTS

Of the 109 patients, 37 (34.0 %) developed POIs. Clinically, 73.0 % of the POIs became evident on or after postoperative day 4 (median, 5.25 days; interquartile range, 3.00-9.25 days). On and after postoperative day 3, chronological changes in blood glucose levels were significantly different between two groups of patients with or without POIs, as indicated by repeated measures ANOVA (P = 0.006). Multivariate logistic regression analysis results showed that an increased blood glucose concentration on postoperative day 3 was a significant risk factor for POIs.

CONCLUSIONS

Our findings suggested that postoperative hyperglycemia on postoperative day 3 was a predictive factor of POIs after highly invasive esophageal cancer surgery.

Combined thoracoscopic and laparoscopic minimally invasive esophagectomy

With the improvement in thoracoscopic and laparoscopic surgery, thoracoscopic and laparoscopic esophagectomy (TLE), a minimally invasive approach, has attracted increasing attention as an alternative to open three-field esophagectomy. From June 2012 to October 2013, 90 patients underwent laparoscopic and thoracoscopic resection of esophageal carcinoma in our department. The VATS esophagectomy technique described here is the approach currently employed in the department of thoracic surgery at Sichuan Provincial People's Hospital of China.

A method of gastric conduit elevation via the posterior mediastinal pathway in thoracoscopic subtotal esophagectomy

Background

Despite efforts to improve surgical techniques, serious complications still sometimes occur. Use of a physiological posterior mediastinal pathway has increased given advances such as automated anastomotic devices and a reduction in the incidence of anastomotic sufficiency. Until now the gastric conduit created has been protected by an echo probe cover and, sown to the ventral side of polyester tape placed through the abdomen to the neck, and then blindly elevated to the neck. We report on a new method of gastric conduit elevation.

Methods

Two 60-cm lengths polyester tape are ligated at both ends to form a loop. An echo probe cover of 10 cm in diameter and 50 cm in length is prepared and the tip cut off, forming a cylinder. The knots in the previously looped polyester tape are inserted into the echo probe cover. The looped polyester tape and echo probe cover is ligated with silk approximately 5 cm in front of the knots on both sides.

After dissection is carried out according to practice, the previously crafted polyester tape is inserted into the chest cavity. One end of polyester tape is fixed to the distal esophageal stump with the clips, with the opposite end fixed to the proximal esophageal stump. The echo probe cover that connects the proximal esophagus and distal esophagus is monitored for the presence of creases along the long axis to ensure there are no twists in the echo probe cover.

We carry out a laparoscopic-assisted perigastric lymph node dissection, make a small skin incision, and guide part of the thoracic esophagus and stomach outside the body.

Either one of the two lengths of polyester tape is connected to the gastric conduit. By pulling up this length of polyester tape from the neck, the gastric conduit can pass through the echo probe cover and be elevated to the neck.

Results

No perioperative complications such as bleeding or difficulty of the gastric conduit elevation were recognized with this method.

Conclusions

This method is considered to serve as a useful technique for gastric conduit elevation.