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Hsu PK, Chien LI, Chuang LC, Lee YY, Huang CS, Hsu HS, Wu YC, Hsu WH. Modified En Bloc Esophagectomy for Squamous Cell Carcinoma After Neoadjuvant Chemoradiotherapy. Ann Thorac Surg 2023; 115:862-869. [PMID: 36669675 DOI: 10.1016/j.athoracsur.2023.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 01/04/2023] [Accepted: 01/09/2023] [Indexed: 01/19/2023]
Abstract
BACKGROUND The optimal type of esophagectomy and extent of lymphadenectomy for patients after neoadjuvant chemoradiotherapy (nCRT) for esophageal squamous cell carcinoma remain controversial. We hypothesized that a more radical resection is associated with better survival. METHODS Data of patients who received nCRT followed by resection for esophageal squamous cell carcinoma between 2012 and 2021 were analyzed. Modified en bloc esophagectomy (mEBE) involves total mediastinal lymphadenectomy and resection of all periesophageal node-bearing tissues. Perioperative outcomes and survival rates of mEBE were compared with those of conventional esophagectomy (CE). RESULTS A total of 238 patients were included. Compared with CE, mEBE was associated with a longer operative time, higher total number of resected lymph nodes, fewer complications, and less anastomotic leakage; length of stay was similar between the 2 groups. There was no difference in overall survival rates between patients with ypT0 N0 stage in the mEBE and CE groups; however, in patients with non-ypT0 N0 stage in the mEBE and CE groups, the 3-year overall survival rates were 58.5% and 28.5%, respectively (P < .001). On disease-free survival analysis, no difference was observed in patients with ypT0 N0 stage, whereas patients with non-ypT0 N0 stage after nCRT had significantly better disease-free survival after mEBE compared with CE (49.7% vs 27.2%; P = .017). CONCLUSIONS Survival after mEBE was significantly better than that after CE. The mEBE did not increase postoperative hospital stay and complication rates.
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Affiliation(s)
- Po-Kuei Hsu
- Division of Thoracic Surgery, Department of Surgery, Taipei Veterans General Hospital and School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
| | - Ling-I Chien
- Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Lin-Chi Chuang
- Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yi-Ying Lee
- Division of Thoracic Surgery, Department of Surgery, Taipei Veterans General Hospital and School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chien-Sheng Huang
- Division of Thoracic Surgery, Department of Surgery, Taipei Veterans General Hospital and School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Han-Shui Hsu
- Division of Thoracic Surgery, Department of Surgery, Taipei Veterans General Hospital and School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yu-Chung Wu
- Division of Thoracic Surgery, Department of Surgery, Taipei Medical University Hospital, Taipei, Taiwan; Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Wen-Hu Hsu
- Division of Thoracic Surgery, Department of Surgery, Taipei Veterans General Hospital and School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
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Kim HE, Yang YH, Park BJ, Park SY, Min IK, Kim DJ. Skeletonizing En Bloc Esophagectomy Revisited: Oncologic Outcome in Association with the Presence of Thoracic Duct Lymph Nodes. Ann Surg Oncol 2022; 29:4909-4917. [PMID: 35438467 DOI: 10.1245/s10434-022-11496-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 02/08/2022] [Indexed: 12/19/2022]
Abstract
BACKGROUND Skeletonizing en bloc esophagectomy (SEBE) involves the removal of the esophagus en bloc with locoregional soft tissues and lymph nodes, including the thoracic duct (TD); however, its oncologic benefits remain unclear. We evaluated the impact of SEBE on oncologic outcomes in patients with esophageal squamous cell carcinoma. METHODS Patients undergoing McKeown esophagectomy without neoadjuvant therapy between 2013 and 2019 were evaluated. Outcomes after SEBE were compared with those after conventional esophagectomy (CE) using propensity score-matched analysis. RESULTS Overall, 232 patients were identified, including 133 patients with SEBE and 99 patients with CE. Lymph node metastasis along the TD was identified in 7.5% (10/133) of the SEBE group, and the incidence was closely related with the tumor invasion depth (2.2% in pT1 and 19.0% in pT2-3). Based on the propensity score, 180 patients (90 pairs) were analyzed. Tumor recurrence was identified in 24.4% and 12.2% of CE and SEBE cases, respectively (p = 0.036). The observed difference was due to the higher incidence of locoregional recurrence in CE (10.5% vs. 2.2%; p = 0.024), while the incidence of systemic recurrence was similar (18.6% vs. 12.2%; p = 0.240). The 5-year disease-free survival rate was 83.6% and 62.4% in the SEBE and CE groups, respectively (p = 0.022). Multivariate analysis revealed that SEBE could significantly reduce the risk of recurrence or death in patients with pT2-3 tumors (hazard ratio 0.173, 95% confidence interval 0.048-0.628; p = 0.008). CONCLUSIONS SEBE could identify and eradicate lymphatic metastasis along the TD and positively impact disease-free survival, particularly in patients with pT2-3 tumors.
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Affiliation(s)
- Ha Eun Kim
- Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Yonsei-ro 50, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Young Ho Yang
- Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Yonsei-ro 50, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Byung Jo Park
- Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Yonsei-ro 50, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Seong Yong Park
- Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Yonsei-ro 50, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - In Kyung Min
- Biostatistics Collaboration Unit, Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Dae Joon Kim
- Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Yonsei-ro 50, Seodaemun-gu, Seoul, 03722, Republic of Korea.
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Lin J, He J, Chen S, Lin J, Han Z, Chen M, Yu S, Gao L, Peng K, Shen Z, Zhang P, Kang M. Outcomes of minimally invasive total mesoesophageal excision: a propensity score-matched analysis. Surg Endosc 2021; 36:3234-3245. [PMID: 34845550 DOI: 10.1007/s00464-021-08634-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 07/05/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND This study aimed to investigate the safety and efficacy of minimally invasive total mesoesophageal excision (TME) for esophageal cancer. METHODS We retrospectively collected data from patients with esophageal cancer who underwent esophagectomy at our center between January 2011 and June 2017. Among 611 eligible patients, 302 underwent minimally invasive total mesoesophageal excision (the TME group) and 309 underwent non-total mesoesophageal excision (the NME group). Outcomes were compared after 1-to-1 propensity score matching, and subgroup analyses were performed for cases involving pT1-2 or pT3-4a disease. RESULTS The propensity score matching produced 249 pairs of patients. The TME group had a shorter operative time (P < 0.001), lower intraoperative bleeding (P < 0.001), and a shorter postoperative hospital stay (P < 0.001). There were no significant differences between the two groups in the number of removed lymph nodes, 30-day mortality, or postoperative complications. In addition, both groups had similar 3-year rates of overall survival (OS) and disease-free survival (DFS). However, the 3-year recurrence rate in the esophageal bed was significantly lower in the TME group (P = 0.033). Furthermore, among patients with pT3-4a disease, the TME group had better 3-year rates of OS, DFS, and recurrence. CONCLUSION Minimally invasive total mesoesophageal excision appears to be a safe technique that can reduce tumor recurrence in the esophageal bed. Furthermore, this technique provided survival benefits for patients with pT3-4a disease.
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Affiliation(s)
- Jihong Lin
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, No. 29, Xinquan Road, Fuzhou City, 350001, Fujian Province, China
| | - Junjie He
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, No. 29, Xinquan Road, Fuzhou City, 350001, Fujian Province, China
| | - Shuchen Chen
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, No. 29, Xinquan Road, Fuzhou City, 350001, Fujian Province, China
| | - Jiangbo Lin
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, No. 29, Xinquan Road, Fuzhou City, 350001, Fujian Province, China
| | - Ziyang Han
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, No. 29, Xinquan Road, Fuzhou City, 350001, Fujian Province, China
| | - Mingduan Chen
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, No. 29, Xinquan Road, Fuzhou City, 350001, Fujian Province, China
| | - Shaobin Yu
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, No. 29, Xinquan Road, Fuzhou City, 350001, Fujian Province, China
| | - Lei Gao
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, No. 29, Xinquan Road, Fuzhou City, 350001, Fujian Province, China
| | - Kaiming Peng
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, No. 29, Xinquan Road, Fuzhou City, 350001, Fujian Province, China
| | - Zhimin Shen
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, No. 29, Xinquan Road, Fuzhou City, 350001, Fujian Province, China
| | - Peipei Zhang
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, No. 29, Xinquan Road, Fuzhou City, 350001, Fujian Province, China
| | - Mingqiang Kang
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, No. 29, Xinquan Road, Fuzhou City, 350001, Fujian Province, China.
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Fluorescence Guided Thoracic Duct Dissection in Robotic En-bloc Esophagectomy. Ann Thorac Surg 2021; 113:e465-e467. [PMID: 34560041 DOI: 10.1016/j.athoracsur.2021.08.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 08/11/2021] [Indexed: 11/24/2022]
Abstract
En-bloc resection of the thoracic duct compartment enhances adequate lymph node removal and may improve oncological outcomes in esophagectomy for esophageal malignancies. However, it also increases the risk of postoperative chylothorax with a reported incidence of 5-20%. We describe a technique that facilitates intraoperative identification of the thoracic duct as well as proximal and distal ligation during robot-assisted esophagectomy by lymphangiography guided injection of indocyanine green in de right groin in left lateral positioning. This approach can be swiftly applied at any time during any thoracoscopic procedure in lateral position when visualization of the thoracic duct anatomy is needed.
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