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Aiolfi A, Bona D, Cali M, Manara M, Bonitta G, Alfieri R, Castoro C, Elshafei M, Markar SR, Bonavina L. Impact of Thoracic Duct Resection on Long-Term Survival After Esophagectomy: Individual Patient Data Meta-analysis. Ann Surg Oncol 2024:10.1245/s10434-024-15770-3. [PMID: 39031260 DOI: 10.1245/s10434-024-15770-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Accepted: 06/24/2024] [Indexed: 07/22/2024]
Abstract
BACKGROUND Radical esophagectomy, including thoracic duct resection (TDR), has been proposed to improve regional lymphadenectomy and possibly reduce the risk of locoregional recurrence. However, because of its impact on immunoregulation, some authors have expressed concerns about its possible detrimental effect on long-term survival. The purpose of this review was to assess the influence of TDR on long-term survival. PATIENTS AND METHODS PubMed, MEDLINE, Scopus, and Web of Science databases were searched through 15 March 2024. Overall survival (OS), cancer specific survival (CSS), and disease-free survival (DFS) were primary outcomes. Restricted mean survival time difference (RMSTD), risk ratio (RR), standardized mean difference (SMD), and 95% confidence intervals (CI) were used as pooled effect size measures. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) methodology was employed to evaluate the certainty of evidence. RESULTS The analysis included six studies with 5756 patients undergoing transthoracic esophagectomy. TDR was reported in 49.1%. Patients' ages ranged from 27 to 79 years and 86% were males. At 4-year follow-up, the multivariate meta-analysis showed similar results for the comparison noTDR versus TDR in term of OS [- 0.8 months, 95% confidence interval (CI) - 3.1, 1.3], CSS (0.1 months, 95% CI - 0.9, 1.2), and DFS (1.5 months, 95% CI - 2.6, 5.5). TDR was associated with a significantly higher number of harvested mediastinal lymph nodes (SMD 0.57, 95% CI 0.01-1.13) and higher risk of postoperative chylothorax (RR = 1.32; 95% CI 1.04-2.23). Anastomotic leak and pulmonary complications were comparable. CONCLUSIONS TDR seems not to improve long-term OS, CSS, and DFS regardless of tumor stage. Routine TDR should not be routinely recommended during esophagectomy.
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Affiliation(s)
- Alberto Aiolfi
- I.R.C.C.S Ospedale Galeazzi - Sant'Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Milan, Italy.
| | - Davide Bona
- I.R.C.C.S Ospedale Galeazzi - Sant'Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Milan, Italy
| | - Matteo Cali
- I.R.C.C.S Ospedale Galeazzi - Sant'Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Milan, Italy
| | - Michele Manara
- I.R.C.C.S Ospedale Galeazzi - Sant'Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Milan, Italy
| | - Gianluca Bonitta
- I.R.C.C.S Ospedale Galeazzi - Sant'Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Milan, Italy
| | - Rita Alfieri
- Upper Gastrointestinal Surgery Unit, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Carlo Castoro
- Upper Gastrointestinal Surgery Unit, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Moustafa Elshafei
- Department of Bariatric and Metabolic Medicine, Clinic Northwest, Frankfurt, Germany
| | - Sheraz R Markar
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Luigi Bonavina
- Department of Biomedical Sciences for Health, Division of General and Foregut Surgery, IRCCS Policlinico San Donato, University of Milan, Milan, Italy
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Somashekhar SP, Saldanha E, Kumar R, Monteiro A, Pillarisetti SR, Ashwin KR. A comparative study of indocyanine green instillation in inguinal node versus foot web space using da Vinci indocyanine green FireFly™ technology in identifying thoracic duct during robotic-assisted transthoracic oesophagectomy. J Minim Access Surg 2024; 20:271-277. [PMID: 38340077 DOI: 10.4103/jmas.jmas_2_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 10/09/2023] [Indexed: 02/12/2024] Open
Abstract
INTRODUCTION Chyle leak is a serious complication following oesophagectomy with incidence varies from 1% to 9%. Near infra-red fluorescence imaging of thoracic duct (TD) can provide real-time dynamic imaging during the surgery. In this study, we intend to compare indocyanine green (ICG) dye instillation through inguinal node with subcutaneous first web space instillation for visualisation of TD during robotic-assisted minimally invasive oesophagectomy (RAMIE) procedure. PATIENTS AND METHODS A prospective study of 50 patients underwent RAMIE with da Vinci X System. After general anaesthesia, patients were divided into inguinal node and foot first web space ICG instillation group. The former group had 1 ml of ICG dye instilled on bilateral inguinal nodes under ultrasound guidance and while the other group received 1 mL of ICG dye injected at bilateral foot first web space and then underwent surgery. TD was visualised using ICG FireFly™ fluorescence technology, first at the time of docking and subsequently for every 5 min until 60 min of instillation time and analysed. RESULTS Twenty-five patients were enrolled in each group. The mean docking time for thoracic phase was 13.76 ± 3.43 min. TD was visualised in 72% (18/25) of cases of first web space instillation group, whereas 100% in ultrasound guidance inguinal node instillation group. None of the patients had a chyle leak. CONCLUSION ICG FireFly™ fluorescence technology for the identification of TD during oesophageal mobilisation is safe and effective and provides real-time dynamic visualisation with high accuracy in ultrasound-guided bilateral inguinal node instillation group. It is an effective method for the surgeons planning to negotiate their initial learning curve in RAMIE procedures.
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Affiliation(s)
- S P Somashekhar
- Department of Surgical Oncology, Aster Hospitals, Bengaluru, Karnataka, India
| | - Elroy Saldanha
- Department of Surgical Oncology, Fr. Muller Medical College, Mangalore, Karnataka, India
| | - Rohit Kumar
- Department of Surgical Oncology, Aster Hospitals, Bengaluru, Karnataka, India
| | - Ashma Monteiro
- Department of Data Science, Prasanna School of Public Health, MAHE, Manipal, Karnataka, India
| | | | - K R Ashwin
- Department of Surgical Oncology, Aster Hospitals, Bengaluru, Karnataka, India
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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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Matsuda S, Takeuchi M, Kawakubo H, Takeuchi H, Kitagawa Y. Oncological and physiological impact of thoracic duct resection in esophageal cancer. Dis Esophagus 2023; 36:doad015. [PMID: 36950928 PMCID: PMC10543365 DOI: 10.1093/dote/doad015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 03/01/2023] [Accepted: 03/06/2023] [Indexed: 03/24/2023]
Abstract
Despite advances in multidisciplinary treatment, esophagectomy remains the main curative treatment for esophageal cancer. The advantages and disadvantages of thoracic duct (TD) resection have been controversial for decades. We have herein reviewed relevant published literature regarding 'thoracic duct,' 'esophageal cancer,' and 'esophagectomy' describing the anatomy and function of the TD, and incidence of thoracic duct lymph nodes (TDLN) and TDLN metastases, as well as the oncological and physiological effects of TD resection. The presence of lymph nodes around the TD, referred to as TDLN, has been reported previously. The delineation of TDLNs is clearly defined by a thin fascial structure covering the TD and the surrounding adipose tissue. Previous studies have examined the number of TDLNs and the percentage of patients with TDLN metastasis and revealed that each patient had approximately two TDLNs. The percentage of patients with TDLN metastasis was reported to be 6-15%. Several studies have been conducted to compare the survival after TD resection with that after TD preservation. However, no consensus has been reached because all studies were retrospective, precluding firm conclusions. Although the issue of whether the risk of postoperative complications is affected by TD resection is still unclear, resecting the TD has been shown to have a long-term impact on nutritional status after surgery. In summary, TDLNs are quite common and present in most patients, while metastasis in the TDLNs occurs in a minority. However, the oncological value of TD resection in esophageal cancer surgery remains controversial due to varying findings and methodological limitations of previous comparative studies. Considering the potential but unproven oncological benefits and possible physiological drawbacks of TD resection, including postoperative fluid retention and disadvantages in the long-term nutritional outcome, clinical stage, and nutritional status should be considered before deciding whether to perform TD resection or not.
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Affiliation(s)
- Satoru Matsuda
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Masashi Takeuchi
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Hirofumi Kawakubo
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Hiroya Takeuchi
- Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
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Oshikiri T, Numasaki H, Oguma J, Toh Y, Watanabe M, Muto M, Kakeji Y, Doki Y. Prognosis of Patients with Esophageal Carcinoma After Routine Thoracic Duct Resection: A Propensity-matched Analysis of 12,237 Patients Based on the Comprehensive Registry of Esophageal Cancer in Japan. Ann Surg 2023; 277:e1018-e1025. [PMID: 34913902 DOI: 10.1097/sla.0000000000005340] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To clarify whether routine thoracic duct (TD) resection improves the prognosis of patients with esophageal cancer after radical esophagectomy. SUMMARY OF BACKGROUND DATA Although TD resection can cause nutritional disadvantage and immune suppression, it has been performed for the resection of surrounding lymph nodes. METHODS We analyzed 12,237 patients from the Comprehensive Registry of Esophageal Cancer in Japan who underwent esophagectomy between 2007 and 2012. TD resection and preservation groups were compared in terms of prognosis, perioperative outcomes, and initial recurrent patterns using strict propensity score matching. Particularly, the year of esophagectomy and history of primary cancer of other organs were added as covariates. RESULTS After propensity score matching, 1638 c-Stage I-IV patients participated in each group. The 5 year overall survival and cause-specific survival rates were 57.5% and 65.6% in the TD-resected group and 55.2% and 63.4% in the TD-preserved group, respectively, without significant differences. The TD-resected group had significantly more retrieved mediastinal nodes (30 vs 21, P < 0.0001) and significantly fewer lymph node recurrence (376 vs 450, P = 0.0029) compared with the TD-preserved group. However, the total number of distant metastatic organs was significantly greater in TD-resected group than in the TD-preserved group (499 vs 421, P = 0.0024). CONCLUSIONS TD resection did not improve survival in patients with esoph-ageal cancer. Despite having retrieved more lymph nodes, TD resection caused distant metastases in more organs compared to TD preservation. Hence, prophylactic TD resection should not be recommended in patients with esophageal cancer.
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Affiliation(s)
- Taro Oshikiri
- Division of Gastrointestinal Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, Hyogo, Japan
| | - Hodaka Numasaki
- Department of Medical Physics and Engineering, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Junya Oguma
- Division of Esophageal Surgery, National cancer center Hospital, Tokyo, Japan
| | - Yasushi Toh
- Department of Gastroenterological Surgery, National Hospital Organization Kyushu Cancer Center, Fukuoka, Japan
| | - Masayuki Watanabe
- Department of Gastroenterological Surgery, cancer institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Manabu Muto
- Department of Therapeutic Oncology, Kyoto University Graduate School of Medicine, Kyoto, Japan; and
| | - Yoshihiro Kakeji
- Division of Gastrointestinal Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, Hyogo, Japan
| | - Yuichiro Doki
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
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Li C, Li B, Yang Y, Li Z. Short-term clinical effects of robot-assisted esophagectomy with thoracic duct resection. J Gastrointest Oncol 2023; 14:11-21. [PMID: 36915429 PMCID: PMC10007922 DOI: 10.21037/jgo-22-985] [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: 10/09/2022] [Accepted: 12/21/2022] [Indexed: 02/24/2023] Open
Abstract
Background Whether extended robot-assisted esophagectomy with thoracic duct resection (RAE-TDR) has a favorable effect on esophageal cancer patients is not yet known. This study sought to analyze the safety and efficiency of RAE-TDR. Methods From January 2019 to July 2020, 73 thoracic duct (TD)-resected and 127 TD-preserved consecutive patients who received standard RAE McKeown surgery were enrolled in this study. The perioperative-related indicators of recurrence-free survival (RFS) and overall survival (OS) at 1-year were compared between the 2 groups. Results In relation to morbidity, the Clavien-Dindo (CD) classifications for grades greater than or equal to II-III were similar between the 2 groups (P>0.05). The number of retrieved total lymph nodes (LNs) and mediastinal nodes were significantly higher in the TD-resected group than in the TD-preserved group (total lymph nodes: 29.0±11.1 vs. 25.1±8.5, P=0.006; mediastinal nodes: 19.5±8.0 vs. 16.1±5.5, P=0.002). Additionally, more metastatic TD-related LNs were harvested in cT3-4 patients (2.3±3.7 vs. 1.7±2.8; P=0.21). The rates of LN recurrence and local recurrence were similar between the 2 groups (LN recurrence: 6.8% vs. 7.1%, P>0.99; local recurrence: 1.4% vs. 2.4%, P>0.99). The OS and RFS at 1-year were equivalent regardless of the TD procedure at each stage (P>0.05). However, the rate of hematogenous metastasis in the TD-resected group was significantly elevated (17.8% vs. 7.9%; P=0.034). Conclusions RAE-TDR may help to improve total and metastatic LN harvest, especially in patients with advanced esophageal squamous cell carcinoma (ESCC) without increasing the intra- and post-operative adverse events. However, RAE-TDR did not lead to a decrease in the local recurrence rate within the short-term follow-up period. Whether the increase in distant metastasis rate in the TD-resected group was associated with relevant immune system damage is unclear. Thus, nonselective RAE-TDR is not routinely recommended.
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Affiliation(s)
- Chunguang Li
- Department of Thoracic Surgery, Section of Esophageal Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Bin Li
- Department of Thoracic Surgery, Section of Esophageal Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yang Yang
- Department of Thoracic Surgery, Section of Esophageal Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Zhigang Li
- Department of Thoracic Surgery, Section of Esophageal Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
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Ozawa H, Kawakubo H, Nishimura E, Matsuda S, Takemura R, Irino T, Fukuda K, Nakamura R, Wada N, Kitagawa Y. Comparison of hand-sewn and circular stapled esophagogastric anastomoses in the neck after esophagectomy for thoracic esophageal cancer: a propensity score-matched analysis. Dis Esophagus 2023; 36:6758196. [PMID: 36222073 DOI: 10.1093/dote/doac066] [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: 03/24/2022] [Revised: 08/25/2022] [Accepted: 08/26/2022] [Indexed: 12/11/2022]
Abstract
Esophagectomy is a highly invasive surgical procedure; however, anastomotic leakage is one of the major surgical complications that should be prevented. Institutions have their own inherited or specialized anastomosis methods. The superior anastomosis procedure remains unknown despite the many studies to determine the optimal method. The present study enrolled 341 patients who underwent esophagectomy at Keio University Hospital, Tokyo, Japan, between January 2009 and January 2019. The anastomosis method was changed from circular stapled anastomosis to hand-sewn anastomosis in February 2014 to reduce the risk of anastomotic leakage. We retrospectively compared short-term results (anastomotic leakage and stricture) between hand-sewn and circular stapled anastomoses. Analysis of heterogeneity after propensity score matching between the 107 patients in the hand-sewn anastomosis group and 107 patients in the circular stapled anastomosis group revealed almost equal distributions. The incidence rate of anastomotic leakage was significantly lower in the hand-sewn anastomosis group than in the circular stapled anastomosis group (9 vs. 20%, hazard ratio: 2.521; 95% confidence interval: 1.112-5.716; P = 0.027). No significant difference was found in the incidence of anastomotic stricture (16 vs. 18%, P = 0.844). Furthermore, no significant difference was found in the incidence of anastomotic leakage in any of the tumor locations between the two anastomosis procedures. For esophagogastric anastomosis in the neck after esophagectomy, hand-sewn anastomosis is superior to circular stapled anastomosis with regard to reducing the risk of anastomotic leakage.
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Affiliation(s)
- Hiroki Ozawa
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Hirofumi Kawakubo
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Erica Nishimura
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Satoru Matsuda
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Ryo Takemura
- Keio University Hospital, Clinical and Translational Research Center, Tokyo, Japan
| | - Tomoyuki Irino
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Kazumasa Fukuda
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Rieko Nakamura
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Norihito Wada
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
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Kanaji S. Significance of Thoracic Duct Resection During Esophagectomy for Esophageal Squamous Cell Carcinoma. Ann Surg Oncol 2023; 30:2582-2583. [PMID: 36689032 DOI: 10.1245/s10434-022-13060-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 12/26/2022] [Indexed: 01/24/2023]
Affiliation(s)
- Shingo Kanaji
- Division of Gastrointestinal Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, Kobe-City, Hyogo, Japan.
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Oshikiri T, Numasaki H, Oguma J, Toh Y, Watanabe M, Muto M, Kakeji Y, Doki Y. Is Thoracic Duct Resection Necessary for Esophageal Squamous Cell Carcinoma Patients Treated with Neoadjuvant Chemoradiotherapy? A Propensity-Matched Analysis Based on the Comprehensive Registry of Esophageal Cancer in Japan. Ann Surg Oncol 2022; 30:2691-2698. [PMID: 36529778 DOI: 10.1245/s10434-022-12891-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 10/17/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND The thoracic duct (TD) plays an important role in nutrition and immunity but is often resected with the esophagus when dissecting surrounding lymph nodes in patients with esophageal squamous cell carcinoma (ESCC). We examined whether indiscriminate TD resection improved the prognosis of patients with ESCC treated with neoadjuvant chemoradiotherapy (NACRT) followed by esophagectomy. METHODS A total of 440 patients treated with NACRT followed by esophagectomy between 2007 and 2012 were analyzed using data from the Comprehensive Registry of Esophageal Cancer in Japan. The propensity score-matched TD resection and TD preservation groups were compared in terms of short- and long-term outcomes. RESULTS After matching, there were 85 patients in both groups. No significant differences were found between groups in either overall survival or cause-specific survival rates at 5 years: 44.2% and 49.0% in the TD resection group, and 39.8% and 47.2% in the TD preservation group, respectively. Furthermore, the number of retrieved mediastinal lymph nodes was significantly greater in the TD resection group than in the TD preservation group (26 vs. 15, p < 0.0001). In contrast, TD resection was associated with metastasis to a significantly greater number of distant organs than TD preservation (49 vs. 32, p = 0.049). CONCLUSIONS TD resection did not contribute to improved survival in patients with ESCC but did lead to metastases in more organs than TD preservation. Consequently, indiscriminate TD resection might be avoided in patients with ESCC treated with NACRT followed by esophagectomy.
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Affiliation(s)
- Taro Oshikiri
- Division of Gastrointestinal Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, Kobe, Japan.
| | - Hodaka Numasaki
- Department of Medical Physics and Engineering, Osaka University Graduate School of Medicine, Suita, Japan
| | - Junya Oguma
- Division of Esophageal Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Yasushi Toh
- Department of Gastroenterological Surgery, National Hospital Organization Kyushu Cancer Center, Fukuoka, Japan
| | - Masayuki Watanabe
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Manabu Muto
- Department of Therapeutic Oncology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yoshihiro Kakeji
- Division of Gastrointestinal Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, Kobe, Japan
| | - Yuichiro Doki
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
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10
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Muir D, Antonowicz S, Whiting J, Low D, Maynard N. Implementation of the Esophagectomy Complication Consensus Group definitions: the benefits of speaking the same language. Dis Esophagus 2022; 35:6603615. [PMID: 35673848 DOI: 10.1093/dote/doac022] [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: 01/16/2022] [Revised: 03/17/2022] [Indexed: 12/24/2022]
Abstract
In 2015 the Esophagectomy Complication Consensus Group (ECCG) reported consensus definitions for complications after esophagectomy. This aimed to reduce variation in complication reporting, attributed to heterogeneous definitions. This systematic review aimed to describe the implementation of this definition set, including the effect on complication frequency and variation. A systematic literature review was performed, identifying all observational and randomized studies reporting complication frequencies after esophagectomy since the ECCG publication. Recruitment periods before and subsequent to the index ECCG publication date were included. Coefficients of variance were calculated to assess outcome heterogeneity. Of 144 studies which met inclusion criteria, 70 (48.6%) used ECCG definitions. The median number of separately reported complication types was five per study; only one study reported all ECCG complications. The coefficients of variance of the reported frequencies of eight of the 10 most common complications were reduced in studies which used the ECCG definitions compared with those that did not (P = 0.036). Among ECCG studies, the frequencies of postoperative pneumothorax, reintubation, and pulmonary emboli were significantly reduced in 2020-2021, compared with 2015-2019 (P = 0.006, 0.034, and 0.037 respectively). The ECCG definition set has reduced variation in esophagectomy morbidity reporting. This adds greater confidence to the observed gradual improvement in outcomes with time, and its ongoing use and wider dissemination should be encouraged. However, only a handful of outcomes are widely reported, and only rarely is it used in its entirety.
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Affiliation(s)
- Duncan Muir
- Department of Upper GI Surgery, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Stefan Antonowicz
- Department of Upper GI Surgery, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Jack Whiting
- Department of Upper GI Surgery, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Donald Low
- Department of Thoracic Surgery and Thoracic Oncology, Virginia Mason Medical Center, Seattle, WA, USA
| | - Nick Maynard
- Department of Upper GI Surgery, Oxford University Hospitals NHS Trust, Oxford, UK
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Hsu PK, Lee YY, Chuang LC, Wu YC. Lymph Node Dissection for Esophageal Squamous Cell Carcinoma. Thorac Surg Clin 2022; 32:497-510. [DOI: 10.1016/j.thorsurg.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Intra-Nodal Indocyanine Green Injection to Delineate Thoracic Duct During Minimally Invasive Esophagectomy. J Gastrointest Surg 2022; 26:1559-1565. [PMID: 35501550 DOI: 10.1007/s11605-022-05341-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 04/16/2022] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Post-operative chylothorax is a dreaded complication after esophagectomy; hence real-time identification of the thoracic duct (TD) may aid in avoiding its injury or promptly tackling injury when it occurs. We utilized intra-nodal injection of Indocyanine green (ICG) dye to delineate TD anatomy while performing esophagectomy for esophageal carcinoma. METHOD Two ml of 1 mg/ml solution of ICG was injected into the inguinal lymph nodes under ultrasound guidance. TD was checked with the laparoscopic Karl Storz IMAGE1 STM or Robotic da Vinci Xi system. The thoracic esophagus, periesophageal tissue, and lymph nodes were dissected. The TD was visualized throughout the dissection using OverlayTM technology & Firefly mode™ and checked at the end to rule out any dye leak. TD was clipped if any dye leakage or TD injury (TDI) was noted using Near Infra-Red Spectroscopy. RESULTS Twenty one patients with M:F 13:8 underwent minimally invasive esophagectomy (MIE) [thoracoscopic assisted (n = 15) and robotic-assisted (n = 6)]. TD was visualized in all the cases after a median (IQR) time of 35 (30, 35) min. The median (IQR) duration of the thoracic phase was 150 (120,165) min. TDI occurred in 1 case, identified intra-operatively, and TD was successfully clipped. There were no post-operative chylothorax or adverse reactions from the ICG injection. CONCLUSION Intra-nodal ICG injection before MIE helps to identify the TD in real-time and is a valuable intra-operative aid to prevent or successfully manage a TD injury. It may help to prevent the dreaded complication of post-operative chylothorax after esophagectomy.
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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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Daroudi R, Nahvijou A, Arab M, Faramarzi A, Kalaghchi B, Sari AA, Javan-Noughabi J. A cost-effectiveness modeling study of treatment interventions for stage I to III esophageal squamous cell carcinoma. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2022; 20:16. [PMID: 35366919 PMCID: PMC8976992 DOI: 10.1186/s12962-022-00352-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 03/21/2022] [Indexed: 11/10/2022] Open
Abstract
Background Esophageal cancer causes considerable costs for health systems. Appropriate treatment options for patients with esophageal squamous cell carcinoma (ESCC) can reduce medical costs and provide more improved outcomes for health systems and patients. This study evaluates the cost-effectiveness of treatment interventions for patients with ESCC according to the Iranian health system. Material and methods A five-state Markov model with a 15-year time horizon was performed to evaluate the cost-effectiveness of treatment interventions based on stage for ESCC patients. Costs ($US 2021) and outcomes were calculated from the Iranian health system, with a discount rate of 3%. One-way sensitivity analyses were performed to assess the potential effects of uncertain variables on the model results. Results In stage I, the Endoscopic Mucosal Resection (EMR) treatment yielded the lowest total costs and highest total QALY for a total of $1473 per QALY, making it the dominant strategy compared with esophagectomy and EMR followed by ablation. In stages II and III, chemoradiotherapy (CRT) followed by surgery dominated esophagectomy. CRT followed by surgery was also cost-effective with an incremental cost-effectiveness ratio (ICER) of $2172.8 per QALY compared to CRT. Conclusion From the Iranian health system’s perspective, EMR was the dominant strategy versus esophagectomy and EMR followed by ablation for ESCC patients in stage I. The CRT followed by surgery was a cost-effective intervention compared to CRT and esophagectomy in stages II and III. Supplementary Information The online version contains supplementary material available at 10.1186/s12962-022-00352-5.
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15
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Effectiveness of lymphadenectomy along the thoracic duct for radical esophagectomy. Esophagus 2022; 19:85-94. [PMID: 34333712 DOI: 10.1007/s10388-021-00868-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 07/29/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND There has been much debate on whether to perform TD resection in radical esophagectomy for esophageal cancer from the perspectives of metastatic rate, effect on postoperative hemodynamics, and other factors. The objective of this study was to determine whether TDLN dissection contributes to improved prognosis. METHODS This study involved 1211 patients who underwent D2/D3 dissection with TD resection for thoracic esophageal cancer between 1984 and 2020. The lymph nodes along the TD were defined as TDLNs and the remaining No. 112 nodes as non-TDLNs. The metastatic rate in TDLNs and non-TDLNs and their outcomes were compared with those of other thoracic lymph nodes. Correlation with the invasion depth of the main lesion was also analyzed (T0-2 545 patients, T3-4 666 patients). RESULTS The metastatic rates in TDLNs/non-TDLNs in all patients were 7.3%/7.5%, respectively, while those in T0-2 were 2.2%/3.9%, and those in T3-4 were 11.5%/10.6%, with both having higher rates in advanced cases. The efficacy index (EI) for lymphadenectomy in T3-4 was 2.94 for TDLNs and 3.44 for non-TDLNs, with no significant difference. The metastatic rate in TDLNs by tumor site was as follows: Ut/Mt/Lt = 1.1/2.4/2.4% (T0-2) and 7.7/14.5/8.4% (T3-4), being especially high (~ 15%) in patients with advanced cases in Mt region. The EI was comparable or higher for TDLNs compared with other group-2 (Mt/Lt) and group-3 (Ut) regional lymph nodes, regardless of site. CONCLUSIONS The significance of TD resection was low in T0-2 due to the low metastatic rate but became evident in cases with invasion depth of T3-4. TDLN resection was at least as effective as dissection of other group-2 or -3 lymph nodes, including No. 112 nodes.
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Barnes TG, MacGregor T, Sgromo B, Maynard ND, Gillies RS. Near infra-red fluorescence identification of the thoracic duct to prevent chyle leaks during oesophagectomy. Surg Endosc 2021; 36:5319-5325. [PMID: 34905086 PMCID: PMC9160097 DOI: 10.1007/s00464-021-08912-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 11/21/2021] [Indexed: 11/25/2022]
Abstract
Background Chyle leaks following oesophagectomy are a frustrating complication of surgery with considerable morbidity. The use of near infra-red (NIR) fluorescence in surgery is an emerging technology and the use of fluorescence to identify the thoracic duct has been demonstrated in animal work and early human case reports. This study evaluated the use mesenteric and enteral administration of indocyanine green (ICG) in humans to identify the thoracic duct during oesophagectomy.
Methods Patients undergoing oesophagectomy were recruited to the study. Administration of ICG via an enteral route or mesenteric injection was evaluated. Fluorescence was assessed using a NIR fluorescence enabled laparoscope system with a visual scoring system and signal to background ratios. Visualisation of the thoracic duct under white light and NIR fluorescence was compared as well as any identification of active chyle leak. Patients were followed up post-operatively for adverse events and chyle leak.
Results 20 patients received ICG and were included in the study. The enteral route failed to fluoresce the thoracic duct. Mesenteric injection (17 patients) identified the thoracic duct under fluorescence prior to white light in 70% of patients with a mean signal to background ratio of 5.35. In 6 participants, a possible active chyle leak was identified under fluorescence with 4 showing active chyle leak from what was identified as the thoracic duct. Conclusion This study demonstrates that ICG administration via mesenteric injection can highlight the thoracic duct during oesophagectomy and may be a potential technology to reduce chyle leak following surgery. Clinical trial registration Clinical trials.gov (NCT03292757).
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Affiliation(s)
- Thomas G Barnes
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK.
- Department of Oesophagogastric Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
| | - Thomas MacGregor
- Department of Oesophagogastric Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Bruno Sgromo
- Department of Oesophagogastric Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Nicholas D Maynard
- Department of Oesophagogastric Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Richard S Gillies
- Department of Oesophagogastric Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Higuchi T, Ozawa S, Koyanagi K, Oguma J, Ninomiya Y, Yatabe K, Yamamoto M, Nomura T, Niwa T. Clinical impacts of magnetic resonance thoracic ductography on preventing postoperative chylothorax after thoracoscopic esophagectomy for esophageal cancer. Esophagus 2021; 18:753-763. [PMID: 33770289 DOI: 10.1007/s10388-021-00832-2] [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: 11/11/2020] [Accepted: 03/20/2021] [Indexed: 02/03/2023]
Abstract
PURPOSE The study aimed to determine whether magnetic resonance thoracic ductography (MRTD) is useful for preventing injury to the thoracic duct (TD) during thoracoscopic esophagectomy and for reducing the incidence of postoperative chylothorax. MATERIALS AND METHOD A total of 389 patients underwent thoracoscopic esophagectomy between September 2009 and February 2019 in Tokai University Hospital. Of them, we evaluated 228 patients who underwent preoperative MRTD (MRTD group) using Adachi's classification and our novel classification (Tokai classification). Then, the clinicopathological factors of the MRTD group (n = 228) were compared with those of the non-MRTD group (n = 161), and comparative analyses were conducted after propensity score matching (PSM). RESULTS The TD could be visualized by MRTD in 228 patients. The MRTD findings were divided into 9 classifications including normal findings and abnormal TD findings (Adachi classification vs Tokai classification; 5.3% vs 16.2%). After PSM, both groups consisted of 128 patients. The rate of postoperative chylothorax after thoracoscopic esophagectomy was significantly lower in the MRTD group (0.8%) than in the non-MRTD group (6.3%) (p = 0.036). In the multivariate analysis for risk factors for chylothorax, the independent prognostic factors were preoperative therapy and the presence of MRTD. CONCLUSIONS This study revealed that MRTD was useful for preventing of chylothorax after thoracoscopic esophagectomy for esophageal cancer.
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Affiliation(s)
- Tadashi Higuchi
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Soji Ozawa
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan.
| | - Kazuo Koyanagi
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Junya Oguma
- Division of Esophageal Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Yamato Ninomiya
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Kentaro Yatabe
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Miho Yamamoto
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Takakiyo Nomura
- Department of Radiology, Tokai University School of Medicine, Kanagawa, Japan
| | - Tetsu Niwa
- Department of Radiology, Tokai University School of Medicine, Kanagawa, Japan
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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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Fujisawa K, Ohkura Y, Ueno M, Yago A, Shimoyama H, Udagawa H. Nutritional Outcomes of Thoracic Duct Resection for Radical Esophagectomy by Assessing Body Composition Changes in One Year: A Single-Center Retrospective Study. Ann Surg Oncol 2021; 28:8414-8425. [PMID: 34085142 DOI: 10.1245/s10434-021-10222-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 05/12/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Thoracic duct (TD) resection is performed when the tumor or a metastatic lymph node directly invades the TD, and is sometimes indicated for radical lymphadenectomy during esophagectomy in esophageal cancer patients. However, the effect of TD resection on nutritional status has not been established. PATIENTS AND METHODS In total, 174 consecutive patients from October 2015 to March 2019 who underwent radical esophagectomy for esophageal cancer in Toranomon Hospital were classified into thoracic duct preserved group (n = 51) and TD-resected (TD-R) group (n = 123). We compared laboratory data, body composition data from bioelectrical impedance analysis measured preoperatively and at 1 and 12 months after surgery, and postoperative complications between the two groups. RESULTS Clinical stage was significantly more advanced in the TD-R group. Total body weight, body mass index, and fat mass continuously decreased in the two groups over 12 months after surgery, and the decreases were statistically greater in the TD-R group at 12 months after surgery. Skeletal muscle mass and fat-free mass decreased over 1 month after surgery and stayed in a reduced state until 12 months after surgery without statistically significant differences between the two groups. TD resection did not increase incidence of postoperative complications (Clavien-Dindo classification ≥ grade III), but TD resection increased incidence of chylothorax. CONCLUSIONS Our results suggest that loss of body fat mass, which was a main contributor to body weight loss, was accelerated in the TD-R group, but TD resection does not deteriorate loss of muscle mass at 12 months after surgery.
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Affiliation(s)
- Kentoku Fujisawa
- Department of Gastroenterological Surgery, Toranomon Hospital, Okinaka Memorial Institute for Medical Research, Tokyo, Japan.
| | - Yu Ohkura
- Department of Gastroenterological Surgery, Toranomon Hospital, Okinaka Memorial Institute for Medical Research, Tokyo, Japan
| | - Masaki Ueno
- Department of Gastroenterological Surgery, Toranomon Hospital, Okinaka Memorial Institute for Medical Research, Tokyo, Japan
| | - Akikazu Yago
- Department of Gastroenterological Surgery, Toranomon Hospital, Okinaka Memorial Institute for Medical Research, Tokyo, Japan
| | - Hayato Shimoyama
- Department of Gastroenterological Surgery, Toranomon Hospital, Okinaka Memorial Institute for Medical Research, Tokyo, Japan
| | - Harushi Udagawa
- Department of Gastroenterological Surgery, Toranomon Hospital, Okinaka Memorial Institute for Medical Research, Tokyo, Japan
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Matsuda S, Kawakubo H, Takeuchi H, Mayanagi S, Irino T, Fukuda K, Nakamura R, Wada N, Kitagawa Y. Prognostic impact of thoracic duct lymph node metastasis in esophageal squamous cell carcinoma. Ann Gastroenterol Surg 2021; 5:321-330. [PMID: 34095722 PMCID: PMC8164460 DOI: 10.1002/ags3.12432] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 12/27/2020] [Accepted: 12/29/2020] [Indexed: 12/24/2022] Open
Abstract
AIM We have previously reported the existence of lymph nodes surrounding the thoracic duct ( TDLN) and transthoracic esophagectomy (TTE) with thoracic duct (TD) resection increased the number of lymph nodes (LNs) retrieved. The current study aims to evaluate the prognostic impact of TDLN metastasis in esophageal cancer patients subdivided by its location and comparing the patients' survival with those with extra-regional LN metastasis. METHODS Patients who underwent TTE with TD resection for esophageal squamous cell carcinoma (ESCC) were reviewed. Patients were classified into those with or without TDLN metastasis, and clinicopathological factors were compared between groups. TDLN was further divided into TDLN-Ut/Mt/Lt based on the location in the mediastinum. The relapse-free survival (RFS) and overall survival (OS) were compared between groups. RESULTS Of 232 patients, TDLN metastasis was observed in 17 (7%). RFS and OS were significantly worse in the TDLN metastasis group. TDLN metastasis was shown to be an independent prognostic factor for RFS and OS in the multivariate analysis. The negative prognostic impact of TDLN metastasis was evident in TDLN-Mt/Lt. The RFS and OS of patients with TDLN metastasis were almost identical to those with positive LN metastasis in extra-regional LNs. CONCLUSION TDLN metastasis was proven to be a strong prognostic indicator. Although the TDLN has been included in the classification of regional LN in the current staging systems, it could be independently classified from the current regional LNs. Given that neoadjuvant therapy has been a standard, we might need to introduce adjuvant therapy when TDLN metastasis is observed.
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Affiliation(s)
- Satoru Matsuda
- Department of SurgeryKeio University School of MedicineTokyoJapan
| | | | - Hiroya Takeuchi
- Department of SurgeryHamamatsu University School of MedicineHamamatsuJapan
| | - Shuhei Mayanagi
- Department of SurgeryKeio University School of MedicineTokyoJapan
| | - Tomoyuki Irino
- Department of SurgeryKeio University School of MedicineTokyoJapan
| | - Kazumasa Fukuda
- Department of SurgeryKeio University School of MedicineTokyoJapan
| | - Rieko Nakamura
- Department of SurgeryKeio University School of MedicineTokyoJapan
| | - Norihito Wada
- Department of SurgeryKeio University School of MedicineTokyoJapan
| | - Yuko Kitagawa
- Department of SurgeryKeio University School of MedicineTokyoJapan
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21
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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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22
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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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Ozawa H, Kawakubo H, Takeuchi M, Ishibashi Y, Matsuda S, Mayanagi S, Takemura R, Irino T, Fukuda K, Nakamura R, Wada N, Kitagawa Y. Prognostic Significance of the Number and Extent of Metastatic Lymph Nodes in Patients with Esophageal Cancer: Comparison of the Union for International Cancer Control 8th Edition and Japan Esophageal Society Japanese Classification of Esophageal Cancer 11th Edition Classifications for Esophageal Cancer. Ann Surg Oncol 2021; 28:6355-6363. [PMID: 33748898 DOI: 10.1245/s10434-020-09545-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 12/14/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND The tumor, node, metastasis staging system of the Union for International Cancer Control (UICC) has been used worldwide for esophageal cancer, and, in Japan, the Japan Esophageal Society Japanese Classification of Esophageal Cancer (JES) has also been used; however, there is a big difference between the two classifications with regard to node staging. We hypothesized that these two node staging systems may lead to different outcome predictions in terms of tumor location. METHODS This study enrolled 409 patients who underwent esophagectomy at Keio University Hospital, Tokyo, Japan, between January 2005 and December 2017. We included those who underwent R0 or R1 resection or esophagectomy with additional organ excision, and excluded those who underwent salvage surgery. Thereafter, we investigated how the number or spread of metastatic lymph nodes affected the prognosis. RESULTS For all 409 patients, the 5-year overall survival rate was 64.1% and the 5-year recurrence-free survival rate was 58.4%. The concordance indices were 0.756 for UICC 8th edition pathological node staging and 0.732 for JES 11th edition pathological node staging (p = 0.06). Based on tumor location, the difference in the concordance indices between these two classifications was greatest for lower thoracic esophageal tumors (p = 0.02). CONCLUSIONS For all patients, the UICC 8th edition node staging system tended to reflect survival more precisely than that of the JES 11th edition. For lower thoracic esophageal tumors in particular, the former node staging system could be more useful.
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Affiliation(s)
- Hiroki Ozawa
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Hirofumi Kawakubo
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan.
| | - Masashi Takeuchi
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yoshiki Ishibashi
- Department of Preventive Medicine and Public Health, Keio University School of Medicine, Tokyo, Japan
| | - Satoru Matsuda
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Shuhei Mayanagi
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Ryo Takemura
- Clinical and Translational Research Center, Keio University Hospital, Tokyo, Japan
| | - Tomoyuki Irino
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Kazumasa Fukuda
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Rieko Nakamura
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Norihito Wada
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
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The presence of metastatic thoracic duct lymph nodes in Western esophageal cancer patients. Ann Thorac Surg 2021; 113:429-435. [PMID: 33676903 DOI: 10.1016/j.athoracsur.2021.02.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 02/04/2021] [Accepted: 02/22/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND The thoracic lymphadenectomy during an esophagectomy for esophageal cancer includes resection of the thoracic duct (TD) compartment containing the thoracic duct lymph nodes (TDLN). However, the role of TD compartment resection is still a topic of debate since metastatic TDLNs have only been demonstrated in squamous cell carcinomas in Eastern esophageal cancer patients. Therefore, the aim of this study was to assess the presence and metastatic involvement of TDLNs in a Western population, in which adenocarcinoma is the predominant type of esophageal cancer. METHODS From July 2017 to May 2020 all consecutive patients undergoing an open or robot-assisted transthoracic esophagectomy with concurrent lymphadenectomy and resection of the TD compartment in the University Medical Center Utrecht, The Netherlands and the Città della Salute e della Scienza University Hospital in Turin, Italy were included. The TD compartment was resected en bloc and was separated in the operation room by the operating surgeon after which it was macro- and microscopically assessed for (metastatic) TDLNs by the pathologist. RESULTS A total of 117 patients with an adenocarcinoma (73%) or squamous cell carcinoma (27%) of the esophagus were included. In 61 (52%) patients TDLNs were found, containing metastasis in 9 (15%) patients. No major complications related to TD compartment resection were observed. CONCLUSIONS This is the first study to demonstrate the presence of metastatic TDLNs in adenocarcinomas of the esophagus. This result provides a valid argument to routinely extend the thoracic lymphadenectomy with resection of the TD compartment during an esophagectomy for esophageal cancer.
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The perioperative presepsin as an accurate diagnostic marker of postoperative infectious complications after esophagectomy: a prospective cohort study. Esophagus 2020; 17:399-407. [PMID: 32303873 DOI: 10.1007/s10388-020-00736-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2019] [Accepted: 03/28/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Presepsin is suggested to be an accurate sepsis diagnostic biomarker, playing an important role in distinguishing infection from no-infection status. However, to date, there is no study determining presepsin's role in diagnosing post-esophagectomy infectious complications. METHODS Thirty patients who underwent esophagectomy for esophageal carcinoma were included in this prospective observational study. We investigated preoperative presepsin levels' changes and evaluated the relationship between infectious complications and presepsin levels. Moreover, we analyzed the classification and regression tree (CART) to determine presepsin's optimal cutoff values for discriminating infectious complications. RESULTS For 10 patients with infectious complications, median presepsin levels were 168, 337, 303, 271, 314, 978, and 752 pg/ml, pre- and immediately post-surgery, and 1, 2, 3, 5, 7 days post-surgery, respectively. Presepsin levels were significantly higher in the infectious complication group exclusively from preoperation to POD 7 (p = 0.048). Furthermore, area under the curve's value of presepsin on POD 5 and 7 was higher than the other three biomarkers included for discriminating infectious complications (i.e., procalcitonin, leukocyte, and C-reacted protein). We set an optimal cutoff value for presepsin calculated by CART. Specifically, on POD 5, the cutoff was 888 pg/ml with a sensitivity of 60% and a specificity of 90%, and on POD 7, the cutoff was 668 pg/ml with a sensitivity of 60% and a specificity of 85%. CONCLUSIONS Presepsin levels on POD 5 and 7 after esophagectomy are a valuable indicator of infectious complication's detection vs. leukocyte, C-reacted protein, and procalcitonin.
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26
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Liu L, Gong L, Zhang M, Wu W. The effect of prophylactic thoracic duct ligation during esophagectomy on the incidence of chylothorax and survival of the patients: an updated review. Postgrad Med 2020; 133:265-271. [PMID: 32729759 DOI: 10.1080/00325481.2020.1803666] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND The role of thoracic duct ligation (TDL) during esophagectomy remains controversial. This review aimed to elucidate the effect of TDL on chylothorax and survival of the patients after esophagectomy for cancer. METHODS We searched articles from PubMed, Web of Science, Scopus, Cochrane, and Google Scholar till May 2020 according to the PRISMA guidelines using the terms of [Oesophagectomy OR esophagectomy] AND [chylothorax] AND [thoracic duct ligation]. Only those compared the incidence of chylothorax in patients who ligated or resected the thoracic duct (ligation group) or preserved the thoracic duct (preservation group) were selected. RESULTS First, 15 studies including one randomized controlled trial were collected for meta-analysis regarding post-esophagectomy chylothorax. Of these, 3658 patients underwent TDL and 4638 cases preserved the thoracic duct. Both groups showed similar chylothorax rate (odd ratios 0.73 in favor of ligation group; 95% confidence interval [CI] 0.50-1.07, p = 0.11). Second, four studies providing survival information were included for another meta-analysis, and the patients in preservation group demonstrated better 5-year overall survival compared to those in ligation group (odds ratio 1.25; 95% CI 1.08-1.44, p = 0.002). CONCLUSIONS The present review provided updated evidence opposing prophylactic TDL during esophagectomy for lowering chylothorax. Considering the harmful effect of TDL on survival of the patients, further well-designed trials should be considered in selected cases under strict supervision.
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Affiliation(s)
- Lei Liu
- Department of Gastroenterology of Yichang Central People's Hospital, Institute of Digestive Disease, China Three Gorges University, Yichang, People's Republic of China
| | - Longbo Gong
- Department of Surgery, Xuzhou Central Hospital, Southeast University School of Medicine, Xuzhou, People's Republic of China
| | - Miao Zhang
- Department of Surgery, Xuzhou Central Hospital, Southeast University School of Medicine, Xuzhou, People's Republic of China
| | - Wenbin Wu
- Department of Surgery, Xuzhou Central Hospital, Southeast University School of Medicine, Xuzhou, People's Republic of China
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27
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Malibary N, Manfredelli S, Almuttawa A, Delhorme JB, Romain B, Brigand C, Rohr S. Evaluating the Surgeon's Experience as a Risk Factor for Post-Esophagectomy Chylothorax on a Four-Year Cohort. Cureus 2020; 12:e8696. [PMID: 32699693 PMCID: PMC7370582 DOI: 10.7759/cureus.8696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background: Chylothorax (CHT) is a known post-operative complication after esophageal surgery with vaguely defined risk factors. Methods: This is a retrospective chart review of 70 consecutive patients with operable cancer over a period of four years (January 2013 to December 2016). Ivor Lewis and McKeown interventions were performed. Thoracic duct is identified and ligated routinely. Factors related to the patient, the tumor, and the operating surgeon were analyzed. Results: Incidence of CHT was 10%. Surgeons with less than five years of esophageal surgery experience had the most CHT, 71% (p=0.001). No association was found between tumor location, type, body mass index (BMI), neoadjuvant therapy, response to neoadjuvant therapy or male sex, and CHT. The odds of developing CHT were 17 times higher in patients operated by a junior surgeon (odds ratio, OR=17.67, confidence interval, CI 2.68-116.34, p=0.003). Four patients (5.7%) had anastomotic leaks, none of them had CHT. Senior surgeons had less operative time and harvested more lymph nodes (p=0.0002 and p=0.1086 respectively). Conclusion: Surgeon’s experience might be considered a major risk factor to develop CHT. This finding needs to be confirmed by a larger multicentric series taking into consideration the human factor.
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Affiliation(s)
- Nadim Malibary
- Surgery, King Abdulaziz University, Jeddah, SAU.,Visceral and General Surgery, Hautepierre Hospital, Strasbourg, FRA
| | | | | | | | - Benoit Romain
- Visceral and Digestive Surgery, Hautepierre University Hospital, Strasbourg, FRA
| | - Cecile Brigand
- Visceral and Digestive Surgery, Hautepierre University Hospital, Strasbourg, FRA
| | - Serge Rohr
- Visceral and Digestive Surgery, Hautepierre University Hospital, Strasbourg, FRA
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Matsuda S, Kawakubo H, Takeuchi H, Hayashi M, Mayanagi S, Takemura R, Irino T, Fukuda K, Nakamura R, Wada N, Kitagawa Y. Minimally invasive oesophagectomy with extended lymph node dissection and thoracic duct resection for early-stage oesophageal squamous cell carcinoma. Br J Surg 2020; 107:705-711. [PMID: 32077101 DOI: 10.1002/bjs.11487] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Revised: 10/05/2019] [Accepted: 12/02/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Oesophageal squamous cell carcinoma is an aggressive disease owing to early and widespread lymph node metastases. Multimodal therapy and radical surgery may improve prognosis. Few studies have investigated the efficacy of radical lymph node and thoracic duct resection. METHODS Patients with oesophageal squamous cell carcinoma who underwent transthoracic minimally invasive oesophagectomy (TMIE) for cancer at Keio University Hospital between January 2004 and December 2016 were selected. Between 2004 and 2008, TMIE was performed in the lateral decubitus position without thoracic duct resection (standard TMIE). From 2009 onwards, TMIE with extended lymph node and thoracic duct resection was introduced (extended TMIE). Demographics, co-morbidity, number of retrieved lymph nodes, pathology, postoperative complications and recurrence-free survival (RFS) were compared between groups. RESULTS Forty-four patients underwent standard TMIE and 191 extended TMIE. There were no significant differences in clinical and pathological tumour stage or postoperative complications. The extended-TMIE group had more lymph nodes removed at nodal stations 106recL and 112. Among patients with cT1 N0 disease, RFS was better in the extended-TMIE group (P < 0·001), whereas there was no difference in RFS between groups in patients with advanced disease. CONCLUSION Extended TMIE including thoracic duct resection increased the number of lymph nodes retrieved and was associated with improved survival in patients with cT1 N0 oesophageal squamous cell carcinoma.
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Affiliation(s)
- S Matsuda
- Department of Surgery, Keio University School of Medicine, Keio University Hospital, Tokyo, Japan
| | - H Kawakubo
- Department of Surgery, Keio University School of Medicine, Keio University Hospital, Tokyo, Japan
| | - H Takeuchi
- Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - M Hayashi
- Department of Surgery, Keio University School of Medicine, Keio University Hospital, Tokyo, Japan
| | - S Mayanagi
- Department of Surgery, Keio University School of Medicine, Keio University Hospital, Tokyo, Japan
| | - R Takemura
- Biostatistics Unit, Clinical and Translational Research Centre, Keio University Hospital, Tokyo, Japan
| | - T Irino
- Department of Surgery, Keio University School of Medicine, Keio University Hospital, Tokyo, Japan
| | - K Fukuda
- Department of Surgery, Keio University School of Medicine, Keio University Hospital, Tokyo, Japan
| | - R Nakamura
- Department of Surgery, Keio University School of Medicine, Keio University Hospital, Tokyo, Japan
| | - N Wada
- Department of Surgery, Keio University School of Medicine, Keio University Hospital, Tokyo, Japan
| | - Y Kitagawa
- Department of Surgery, Keio University School of Medicine, Keio University Hospital, Tokyo, Japan
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Ishida T, Kanamori J, Daiko H. Lymphangiography and focal pleurodesis treatment of chylothorax with an aberrant thoracic duct following oesophagectomy: a case report. Surg Case Rep 2019; 5:195. [PMID: 31828443 PMCID: PMC6906276 DOI: 10.1186/s40792-019-0709-3] [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: 05/28/2019] [Accepted: 09/27/2019] [Indexed: 12/02/2022] Open
Abstract
Background Management of postoperative chylothorax usually consists of nutritional regimens, pharmacological therapies such as octreotide, and surgical therapies such as ligation of thoracic duct, but a clear consensus is yet to be reached. Further, the variation of the thoracic duct makes chylothorax difficult to treat. This report describes a rare case of chylothorax with an aberrant thoracic duct that was successfully treated using focal pleurodesis through interventional radiology (IVR). Case presentation The patient was a 52-year-old man with chylothorax after a thoracoscopic oesophagectomy for oesophageal cancer. With conventional therapy, such as thoracostomy tube, octreotide or fibrogammin, a decrease in the amount of chyle was not achieved. Therefore, we performed lymphangiography and pleurodesis through IVR. The patient appeared to have an aberrant thoracic duct, as revealed by magnetic resonance imaging (MRI); however, after focal pleurodesis, the leak of chyle was diminished, and the patient was discharged 66 days after admission. Conclusions Chylothorax remains a difficult complication. Focal pleurodesis through IVR can be one of the options to treat chylothorax.
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Affiliation(s)
- Tomoyuki Ishida
- Department of Esophageal Surgery, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Jun Kanamori
- Department of Esophageal Surgery, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Hiroyuki Daiko
- Department of Esophageal Surgery, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan.
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Oshikiri T, Kakeji Y. ASO Author Reflections: Is It Truly Necessary to Resect the Thoracic Duct in Esophagectomy for Esophageal Cancer? Ann Surg Oncol 2019; 26:814. [PMID: 31659648 DOI: 10.1245/s10434-019-07995-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Indexed: 11/18/2022]
Affiliation(s)
- Taro Oshikiri
- Division of Gastrointestinal Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, Kobe, Hyogo, Japan.
| | - Yoshihiro Kakeji
- Division of Gastrointestinal Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, Kobe, Hyogo, Japan
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Anand S, Kalayarasan R, Chandrasekar S, Gnanasekaran S, Pottakkat B. Minimally Invasive Esophagectomy with Thoracic Duct Resection Post Neoadjuvant Chemoradiotherapy for Carcinoma Esophagus-Impact on Lymph Node Yield and Hemodynamic Parameters. J Gastrointest Cancer 2019; 50:230-235. [PMID: 29344808 DOI: 10.1007/s12029-018-0051-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Neoadjuvant therapy followed by surgery is the current recommended treatment for locally advanced esophageal carcinoma. Thoracic duct (TD) resection was indicated for radical mediastinal lymphadenectomy. However, TD resection can cause hemodynamic disturbances. The presence of metastasis in TD has not been previously studied. METHODS Twenty-two patients who underwent minimally invasive esophagectomy with D2 lymphadenectomy after neoadjuvant chemoradiotherapy for esophageal squamous cell carcinoma were analyzed. Ten patients had their TD resected from thoracic inlet till the esophageal hiatus. Multiple histopathological sections of the TD were examined for evidence of tumor spread. Intraoperative and immediate (48 h) postoperative hemodynamic parameters, lymph node yield, and postoperative morbidity were compared between TD-resected and TD-preserved groups. RESULTS The median postoperative day 1 fluid requirement (3310 mL vs. 2875 mL, P = 0.059) and the median postoperative day 2 pulse rate were higher in the TD-resected group (111/min vs. 95/min, P = 0.043). There was no significant difference in the intraoperative fluid infusion, blood loss, urine output, mean blood pressure, pulse rate, postoperative urine output, and mean blood pressure between two groups. Median (range) mediastinal lymph node count was similar in TD-resected and TD-preserved groups [15(11-32) vs. 14(9-31), P = 0.283]. Pathological examination of TD did not reveal tumor cells in any of the patients. There was no significant difference in the postoperative morbidity between two groups except for cervical anastomotic dehiscence (P = 0.007). CONCLUSIONS Minimally invasive esophagectomy with TD resection causes minor hemodynamic changes in the immediate postoperative period, without adversely affecting the postoperative outcome. In the setting of neoadjuvant chemoradiotherapy, TD resection does not increase lymph node yield.
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Affiliation(s)
- Santosh Anand
- Department of Surgical Gastroenterology, JIPMER, Room no 551, Fourth floor, Superspeciality block, Puducherry, 605006, India
| | - Raja Kalayarasan
- Department of Surgical Gastroenterology, JIPMER, Room no 551, Fourth floor, Superspeciality block, Puducherry, 605006, India.
| | - Sandip Chandrasekar
- Department of Surgical Gastroenterology, JIPMER, Room no 551, Fourth floor, Superspeciality block, Puducherry, 605006, India
| | - Senthil Gnanasekaran
- Department of Surgical Gastroenterology, JIPMER, Room no 551, Fourth floor, Superspeciality block, Puducherry, 605006, India
| | - Biju Pottakkat
- Department of Surgical Gastroenterology, JIPMER, Room no 551, Fourth floor, Superspeciality block, Puducherry, 605006, India
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32
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Takeuchi M, Kawakubo H, Mayanagi S, Yoshida K, Irino T, Fukuda K, Nakamura R, Wada N, Takeuchi H, Kitagawa Y. The Benefits of Docetaxel Plus Cisplatin and 5-Fluorouracil Induction Therapy in Conversion to Curative Treatment for Locally Advanced Esophageal Squamous Cell Carcinoma. World J Surg 2019; 43:2006-2015. [PMID: 30972432 DOI: 10.1007/s00268-019-05000-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Definitive chemoradiotherapy (CRT), used for treatment of patients with an initial diagnosis of unresectable locally advanced esophageal cancer, has led to unsatisfactory long-term prognosis. Moreover, CRT can lead to esophageal fistula, perforation, and strictures. Therefore, strong induction chemotherapeutic treatments are necessary to reduce the tumor volume for subsequent radical esophagectomy. This study aimed to determine the oncological utility of docetaxel plus cisplatin and 5-fluorouracil (DCF) and the technical feasibility of subsequent esophagectomy for locally advanced esophageal cancer. METHODS Eighty-seven patients with clinical borderline unresectable T3 and T4 esophageal squamous cell carcinoma without distant metastases were included in this study. There were 44 patients in primary DCF group and 43 patients in definitive CRT group, and perioperative and long-term oncological outcomes were compared between the two groups. RESULTS Twenty-two patients (50%) achieved R0 resection in the DCF group. Albeit not significant, the rate of curative treatment was higher in the DCF group than the definitive CRT group (p = 0.099). The overall survival (OS) and progression-free survival (PFS) were better with DCF than with definitive CRT (median OS, 29 vs. 17 months, p = 0.206; median PFS, 10 vs. 6 months, p = 0.020). Specifically, the OS of patients with a Charlson score of less than 3 among the DCF-treated patients tended to be better than those among the definitive CRT-treated patients. CONCLUSION DCF and subsequent esophagectomy achieved R0 resection in 50% of the patients and was associated with better long-term oncological outcomes in patients with initially unresectable esophageal cancer if their systemic status is acceptable.
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Affiliation(s)
- Masashi Takeuchi
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Hirofumi Kawakubo
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.
| | - Shuhei Mayanagi
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Kayo Yoshida
- Department of Radiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Tomoyuki Irino
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Kazumasa Fukuda
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Rieko Nakamura
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Norihito Wada
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Hiroya Takeuchi
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, Shizuoka, 431-3192, Japan
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
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Oshikiri T, Takiguchi G, Miura S, Goto H, Otsubo D, Hasegawa H, Yamamoto M, Kanaji S, Yamashita K, Matsuda T, Fujino Y, Tominaga M, Nakamura T, Suzuki S, Kakeji Y. Thoracic Duct Resection During Esophagectomy Does Not Contribute to Improved Prognosis in Esophageal Squamous Cell Carcinoma: A Propensity Score Matched-Cohort Study. Ann Surg Oncol 2019; 26:4053-4061. [PMID: 31313045 DOI: 10.1245/s10434-019-07627-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Indexed: 02/06/2023]
Abstract
PURPOSE Esophagectomy with extended lymphadenectomy remains the mainstay of treatment for localized esophageal squamous cell carcinoma (ESCC). Thoracic duct (TD) resection has been recommended as part of extended lymphadenectomy, although its merits are unclear. The aim of this two-institutional, matched-cohort study is to clarify whether TD resection improves prognosis in esophagectomy for ESCC. PATIENTS AND METHODS In this two-institutional, matched-cohort study of 399 patients with ESCC who underwent McKeown esophagectomy between 2010 and 2014, the primary outcomes were overall survival (OS), disease-free survival (DFS), and cause-specific survival (CSS). Secondary outcomes were perioperative results and recurrence patterns. RESULTS Based on a propensity score, 122 TD-resected or 122 TD-preserved patients in all stages were selected (median follow-up 4.5 years). The 5-year OS, DFS, and CSS rates in the TD-resected versus TD-preserved groups were 49% versus 60%, 53% versus 57%, and 58% versus 70%, respectively, without any significant differences. Operative time for the thoracic procedure was significantly longer and the number of retrieved mediastinal nodes was significantly higher in the TD-resected group (P = 0.009 and 0.005, respectively). The rates of chylothorax and left recurrent laryngeal nerve (RLN) palsy were significantly higher in the TD-resected group (P = 0.041 and 0.018, respectively). There were no significant differences in rates of local or distant metastases between the two groups. CONCLUSIONS TD resection does not contribute to improve OS, DFS, or CSS in ESCC but increases incidence of chylothorax and left RLN palsy. Prophylactic TD resection should be avoided in esophagectomy for ESCC.
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Affiliation(s)
- Taro Oshikiri
- Division of Gastrointestinal Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, Kobe, Hyogo, Japan.
| | - Gosuke Takiguchi
- Division of Gastrointestinal Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, Kobe, Hyogo, Japan
| | - Susumu Miura
- Division of Gastrointestinal Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, Kobe, Hyogo, Japan
| | - Hironobu Goto
- Department of Gastroenterological Surgery, Hyogo Cancer Center, Akashi, Hyogo, Japan
| | - Dai Otsubo
- Department of Gastroenterological Surgery, Hyogo Cancer Center, Akashi, Hyogo, Japan
| | - Hiroshi Hasegawa
- Division of Gastrointestinal Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, Kobe, Hyogo, Japan
| | - Masashi Yamamoto
- Division of Gastrointestinal Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, Kobe, Hyogo, Japan
| | - Shingo Kanaji
- Division of Gastrointestinal Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, Kobe, Hyogo, Japan
| | - Kimihiro Yamashita
- Division of Gastrointestinal Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, Kobe, Hyogo, Japan
| | - Takeru Matsuda
- Division of Minimally Invasive Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, Kobe, Hyogo, Japan
| | - Yasuhiro Fujino
- Department of Gastroenterological Surgery, Hyogo Cancer Center, Akashi, Hyogo, Japan
| | - Masahiro Tominaga
- Department of Gastroenterological Surgery, Hyogo Cancer Center, Akashi, Hyogo, Japan
| | - Tetsu Nakamura
- Division of Gastrointestinal Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, Kobe, Hyogo, Japan
| | - Satoshi Suzuki
- Division of Community Medicine and Medical Network, Department of Social Community Medicine and Health Science, Graduate School of Medicine, Kobe University, Kobe, Hyogo, Japan
| | - Yoshihiro Kakeji
- Division of Gastrointestinal Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, Kobe, Hyogo, Japan
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Aoyama J, Kawakubo H, Mayanagi S, Fukuda K, Irino T, Nakamura R, Wada N, Suzuki T, Kameyama K, Kitagawa Y. Discrepancy Between the Clinical and Final Pathological Findings of Lymph Node Metastasis in Superficial Esophageal Cancer. Ann Surg Oncol 2019; 26:2874-2881. [PMID: 31209674 DOI: 10.1245/s10434-019-07498-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND Recent advances in endoscopic examinations have resulted in the detection of a larger number of early esophageal cancers; however, there have been many cases with clinically negative but pathologically positive lymph node metastasis (LNM). In this study, we aimed to evaluate the discrepancy between the clinical and pathological diagnoses of LNM in patients with cT1a-MM/cT1b N0M0 esophageal cancer, and assess LNM size in these patients to clarify the presence of LNM that cannot be detected with current modalities. METHODS This study included 50 patients who underwent surgery for cT1a-MM/cT1b N0M0 thoracic esophageal squamous cell carcinoma between January 2012 and November 2016 at our institution. The maximum size of involved LNs and metastatic nests were measured, and the distribution of LNM was investigated. RESULTS Of the 50 patients, 13 (26%) had LNM on pathological examination. Lymphatic invasion was significantly more frequent in the LNM-positive group than in the LNM-negative group (p = 0.005). The median sizes of 28 involved LNs and metastatic nests were 3 and 1.6 mm, respectively. Of these LNs, 20 (71%) were classified as micrometastases (≤ 2 mm). The involved nodes were distributed across three fields. CONCLUSIONS There was a discrepancy between the clinical and final pathological findings of LNM in patients with cT1a-MM/cT1b N0M0 esophageal cancer. The detection of involved nodes with current modalities in these patients was difficult because of the small size of LNM. Therefore, continued strong consideration for extended LN dissection is necessary in these patients to ensure appropriate diagnosis and treatment.
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Affiliation(s)
- Junya Aoyama
- Department of Surgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Hirofumi Kawakubo
- Department of Surgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan.
| | - Shuhei Mayanagi
- Department of Surgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Kazumasa Fukuda
- Department of Surgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Tomoyuki Irino
- Department of Surgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Rieko Nakamura
- Department of Surgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Norihito Wada
- Department of Surgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Tatsuya Suzuki
- Department of Radiology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Kaori Kameyama
- Department of Pathology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
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Affiliation(s)
- Sufeng Chen
- Departments of Thoracic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200333, China.,Department of Oncology, Shanghai Medical College of Fudan University, Shanghai 200333, China
| | - Yue Zhao
- Departments of Thoracic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200333, China.,Department of Oncology, Shanghai Medical College of Fudan University, Shanghai 200333, China
| | - Haiquan Chen
- Departments of Thoracic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200333, China.,Department of Oncology, Shanghai Medical College of Fudan University, Shanghai 200333, China
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Takeuchi M, Kawakubo H, Mayanagi S, Irino T, Fukuda K, Nakamura R, Wada N, Takeuchi H, Kitagawa Y. Influence of Neoadjuvant Therapy on Poor Long-Term Outcomes of Postoperative Complications in Patients with Esophageal Squamous Cell Carcinoma: A Retrospective Cohort Study. Ann Surg Oncol 2019; 26:2081-2089. [PMID: 30937664 DOI: 10.1245/s10434-019-07312-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Postoperative complications have a negative impact on overall survival after esophagectomy because systemic inflammation may induce residual cancer cell growth. A solution that could suppress micrometastasis is neoadjuvant therapy; however, to date, no study has shown that neoadjuvant therapy suppresses proliferation of cancer cells due to postoperative complications after esophagectomy. The aim of this study is to investigate the influence of neoadjuvant therapy on poor long-term outcomes of postoperative complications in patients with esophageal carcinoma. PATIENTS AND METHODS In total, 431 patients who underwent esophagectomy for esophageal squamous cell carcinoma were included in this study. We investigated the relationship between complications, such as pneumonia, and long-term oncologic outcomes with and without neoadjuvant therapy. RESULTS Among the patients, the 3-year overall survival (OS) rate was 69.5% and the disease-free survival (DFS) rate was 59.0%. The patients were categorized into two groups: the neoadjuvant therapy (+) group (n = 217) and neoadjuvant therapy (-) group (n = 214). Among patients not undergoing neoadjuvant therapy, patients with pneumonia or pyothorax had significantly poorer OS and DFS than patients without these complications. However, among patients undergoing neoadjuvant therapy, there were no significant differences in long-term outcomes, regardless of presence of complications. On multivariate analysis, pneumonia (p = 0.003), pyothorax (p < 0.001), and chylothorax (p = 0.002) were identified as predictors of death in the neoadjuvant therapy (-) group. CONCLUSION The negative impact of postoperative complications on long-term prognoses can be reduced by performing neoadjuvant therapy in patients with esophageal carcinoma.
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Affiliation(s)
- Masashi Takeuchi
- Department of Surgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Hirofumi Kawakubo
- Department of Surgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan.
| | - Shuhei Mayanagi
- Department of Surgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Tomoyuki Irino
- Department of Surgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Kazumasa Fukuda
- Department of Surgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Rieko Nakamura
- Department of Surgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Norihito Wada
- Department of Surgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Hiroya Takeuchi
- Department of Surgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan.,Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
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Yoshida N, Nagai Y, Baba Y, Miyamoto Y, Iwagami S, Iwatsuki M, Hiyoshi Y, Eto K, Ishimoto T, Kiyozumi Y, Nomoto D, Akiyama T, Imamura Y, Watanabe M, Baba H. Effect of Resection of the Thoracic Duct and Surrounding Lymph Nodes on Short- and Long-Term and Nutritional Outcomes After Esophagectomy for Esophageal Cancer. Ann Surg Oncol 2019; 26:1893-1900. [PMID: 30863941 DOI: 10.1245/s10434-019-07304-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND The effect of resection of the thoracic duct (TD) along with surrounding lymph nodes (LN) on short- and long-term outcomes of esophagectomy in esophageal cancer patients is not well defined. METHODS A total of 537 consecutive patients suffering from esophageal cancer who underwent three-incision esophagectomy between April 2005 and August 2018 were eligible for short-term outcome analysis. Among them, 487 patients who underwent surgery before August 2017 were eligible for analysis of long-term outcomes. Moreover, 164 patients who underwent esophagectomy after August 2012 and had no recurrence at 1-year postoperative follow-up were prospectively investigated for postoperative nutritional status. RESULTS A total of 145 patients (27.0%) underwent TD resection with surrounding LN. Since the clinical stage was significantly more advanced in the removal group, preoperative treatment was more frequently performed in them. The operative time was significantly longer in the removal group. Intraoperative bleeding was higher in the removal group. Morbidity of Clavien-Dindo classification (CDc) ≥ II and pulmonary morbidities were frequently observed in the removal group. Multivariate analysis suggested that TD resection was an independent risk factor for pulmonary morbidities. Moreover, it may be associated with the incidence of CDc ≥ II morbidity. Greater numbers of LN were dissected in the thorax of patients in the removal group. However, overall survival was equivalent irrespective of the TD procedure in each stage. Nutritional status at 1-year follow-up was equivalent between the groups. CONCLUSIONS On the basis of the present results, routine removal of the TD during esophagectomy is not recommended.
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Affiliation(s)
- Naoya Yoshida
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan.,Division of Translational Research and Advanced Treatment Against Gastrointestinal Cancer, Kumamoto University, Kumamoto, Japan
| | - Yohei Nagai
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Yoshifumi Baba
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Yuji Miyamoto
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Shiro Iwagami
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Masaaki Iwatsuki
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Yukiharu Hiyoshi
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Kojiro Eto
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Takatsugu Ishimoto
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan.,Division of Translational Research and Advanced Treatment Against Gastrointestinal Cancer, Kumamoto University, Kumamoto, Japan
| | - Yuki Kiyozumi
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Daichi Nomoto
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Takahiko Akiyama
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Yu Imamura
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Koto-ku, Tokyo, Japan
| | - Masayuki Watanabe
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Koto-ku, Tokyo, Japan
| | - Hideo Baba
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan.
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Takeuchi M, Kawakubo H, Mayanagi S, Yoshida K, Fukuda K, Nakamura R, Suda K, Wada N, Takeuchi H, Kitagawa Y. Postoperative Pneumonia is Associated with Long-Term Oncologic Outcomes of Definitive Chemoradiotherapy Followed by Salvage Esophagectomy for Esophageal Cancer. J Gastrointest Surg 2018; 22:1881-1889. [PMID: 29980971 DOI: 10.1007/s11605-018-3857-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Accepted: 06/19/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND OR PURPOSE As we previously indicated, postoperative pneumonia has a negative impact on the overall survival after planned esophagectomy. However, the impact of postoperative pneumonia after salvage esophagectomy on long-term oncologic outcomes still remains unclear. This study aimed to indicate the association between postoperative pneumonia and long-term outcomes of definitive chemoradiotherapy followed by salvage esophagectomy. Furthermore, we determined a prediction model for overall survival (OS) and disease-free survival (DFS) using a survival classification and regression tree (CART). METHODS Ninety-three patients who underwent CRT followed by esophagectomy for thoracic esophageal cancer were identified for this study. Forty-nine patients and 44 patients were included in the salvage and neoadjuvant groups, respectively. We investigated the association between postoperative pneumonia and long-term oncologic outcomes following salvage esophagectomy. RESULTS Patients from the salvage group tended to have a lower OS compared to neoadjuvant group (median survival: salvage, 24 months vs neoadjuvant, 43 months, p = 0.117). Multivariate analyses revealed that postoperative pneumonia adversely affected both OS (p < 0.001) and DFS (p = 0.044) after salvage esophagectomy. We generated the prediction model for OS and DFS in the salvage group using survival CART. Postoperative pneumonia was the most important parameter for predicting the OS. DISCUSSION The present study demonstrates the long-term outcomes and risk factors for mortality of salvage esophagectomy. To improve OS after salvage surgery, the development of a means of decreasing pulmonary complications is needed.
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Affiliation(s)
- Masashi Takeuchi
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Hirofumi Kawakubo
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.
| | - Shuhei Mayanagi
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Kayo Yoshida
- Department of Radiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Kazumasa Fukuda
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Rieko Nakamura
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Koichi Suda
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Norihito Wada
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Hiroya Takeuchi
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.,Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, Shizuoka, 431-3192, Japan
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
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Technical feasibility and oncologic safety of diagnostic endoscopic resection for superficial esophageal cancer. Gastrointest Endosc 2018; 88:456-465. [PMID: 29750982 DOI: 10.1016/j.gie.2018.04.2361] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Accepted: 04/26/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Active use of endoscopic resection (ER) for cM3-SM2 esophageal cancer may enable sufficient extent of esophageal resection and help determine the need for lymph node dissection based on histopathologic findings. However, ER preceding esophagectomy may have an adverse impact on outcomes. This study was designed to determine the technical feasibility and oncologic safety of diagnostic ER. METHODS A single-institution retrospective cohort study was performed between July 2008 and June 2014. During this period, 135 consecutive patients with clinical T1a-M3N0M0, T1b-SM1N0M0, and T1b-SM2N0M0 primary esophageal cancer were referred to our division. Eight patients who underwent chemoradiotherapy as primary treatment were excluded because of inadequate pathologic findings. Based on oncologic and physical factors, we categorized the remaining 127 patients into 2 groups: primary esophagectomy (n = 54) and primary ER (n = 73). RESULTS In all 127 patients, the 3-year overall survival (OS) and disease-free survival (DFS) rates were 95.7% and 87.6%, respectively. No adverse event requiring surgical intervention was observed after ER. Diagnostic ER had no negative impact on surgical outcomes, DFS, and OS after esophagectomy. Fourteen patients (19.2%) of those who received primary ER underwent curative resection, whereas 11 (20.4%) who had pT1a disease, no lymphovascular invasion, and no pathologic lymph node metastasis underwent primary esophagectomy. CONCLUSIONS Diagnostic ER for cM3-SM2 esophageal cancer with or without subsequent esophagectomy was feasible and safe, not only from a surgical perspective but also an oncologic perspective. Approximately 20% of cM3-SM2N0M0 patients can potentially avoid undergoing additional treatment including esophagectomy using diagnostic ER.
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40
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Schurink B, Defize IL, Mazza E, Ruurda JP, Brosens LAA, Roeling TAP, Bleys RLAW, van Hillegersberg R. Two-Field Lymphadenectomy During Esophagectomy: The Presence of Thoracic Duct Lymph Nodes. Ann Thorac Surg 2018; 106:435-439. [PMID: 29580778 DOI: 10.1016/j.athoracsur.2018.02.047] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 01/30/2018] [Accepted: 02/12/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND Resection of the thoracic duct is part of the formal en bloc mediastinal esophagolymphadenectomy for cancer, although with the adaptation of minimally invasive techniques, some centers started to leave the thoracic duct compartment in situ. However, previous studies reported thoracic duct lymph nodes in this compartment that may contain metastasis. The aim of this study was to assess the presence and number of lymph nodes in the fatty tissue surrounding the thoracic duct. METHODS A right-sided thoracoscopic esophagectomy was performed on seven fresh-frozen human cadavers (male, n = 3; female, n = 4). The esophagus and lymph node stations 7, 8, and 9 were resected en bloc, followed by resection of the thoracic duct compartment consisting of the fatty tissue covering the aorta, the thoracic duct and thoracic duct lymph nodes. Lymph nodes were visualized by a hematoxylin and eosin stain and counted macroscopically and microscopically. RESULTS Thoracic duct lymph nodes were found in 6 of 7 cadavers (86%), with a median number of 1 (range, 0 to 6). Nodes were predominantly located in the area of the azygos vein. A median of 4 subcarinal nodes (range, 1 to 8) and 2 periesophageal nodes (range, 1 to 4) were present. CONCLUSIONS This study shows that thoracic duct lymph nodes are located within the fatty tissue surrounding the thoracic duct. Resection of this compartment during an esophagectomy for cancer increases lymph node yield.
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Affiliation(s)
- Bernadette Schurink
- Department of Anatomy, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands; Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Ingmar L Defize
- Department of Anatomy, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands; Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Elena Mazza
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Jelle P Ruurda
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Lodewijk A A Brosens
- Department of Pathology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Tom A P Roeling
- Department of Anatomy, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Ronald L A W Bleys
- Department of Anatomy, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Richard van Hillegersberg
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
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Defize IL, Schurink B, Weijs TJ, Roeling TAP, Ruurda JP, van Hillegersberg R, Bleys RLAW. The anatomy of the thoracic duct at the level of the diaphragm: A cadaver study. Ann Anat 2018; 217:47-53. [PMID: 29510243 DOI: 10.1016/j.aanat.2018.02.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 01/11/2018] [Accepted: 02/01/2018] [Indexed: 01/30/2023]
Abstract
BACKGROUND Injury and subsequent leakage of unrecognized thoracic duct tributaries during transthoracic esophagectomy may lead to chylothorax. Therefore, we hypothesized that thoracic duct anatomy at the diaphragm is more complex than currently recognized and aimed to provide a detailed description of the anatomy of the thoracic duct at the diaphragm. BASIC PROCEDURES The thoracic duct and its tributaries were dissected in 7 (2 male and 5 female) embalmed human cadavers. The level of origin of the thoracic duct and the points where tributaries entered the thoracic duct were measured using landmarks easily identified during surgery: the aortic and esophageal hiatus and the arch of the azygos vein. MAIN FINDINGS The thoracic duct was formed in the thoracic cavity by the union of multiple abdominal tributaries in 6 cadavers. In 3 cadavers partially duplicated systems were present that communicated with interductal branches. The thoracic duct was formed by a median of 3 (IQR: 3-5) abdominal tributaries merging 8.3cm (IQR: 7.3-9.3cm) above the aortic hiatus, 1.8cm (IQR: -0.4 to 2.4cm) above the esophageal hiatus, and 12.3cm (IQR: 14.0 to -11.0cm) below the arch of the azygos vein. CONCLUSION This study challenges the paradigm that abdominal lymphatics join in the abdomen to pass the diaphragm as a single thoracic duct. In this study, this occurred in 1/7 cadavers. Although small, the results of this series suggest that the formation of the thoracic duct above the diaphragm is more common than previously thought. This knowledge may be vital to prevent and treat post-operative chyle leakage.
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Affiliation(s)
- Ingmar L Defize
- Department of Anatomy, University Medical Center Utrecht, Universiteitsweg 100, P.O. Box 85060, 3508 AB Utrecht, The Netherlands; Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, P.O. Box 85500, 3508 GA Utrecht, The Netherlands
| | - Bernadette Schurink
- Department of Anatomy, University Medical Center Utrecht, Universiteitsweg 100, P.O. Box 85060, 3508 AB Utrecht, The Netherlands; Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, P.O. Box 85500, 3508 GA Utrecht, The Netherlands.
| | - Teus J Weijs
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, P.O. Box 85500, 3508 GA Utrecht, The Netherlands
| | - Tom A P Roeling
- Department of Anatomy, University Medical Center Utrecht, Universiteitsweg 100, P.O. Box 85060, 3508 AB Utrecht, The Netherlands
| | - Jelle P Ruurda
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, P.O. Box 85500, 3508 GA Utrecht, The Netherlands
| | - Richard van Hillegersberg
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, P.O. Box 85500, 3508 GA Utrecht, The Netherlands
| | - Ronald L A W Bleys
- Department of Anatomy, University Medical Center Utrecht, Universiteitsweg 100, P.O. Box 85060, 3508 AB Utrecht, The Netherlands.
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Li X, Wang W, Zhou Y, Yang D, Wu J, Zhang B, Wu Z, Tang J. Efficacy comparison of transcervical video-assisted mediastinoscopic lymphadenectomy combined with left transthoracic esophagectomy versus right transthoracic esophagectomy for esophageal cancer treatment. World J Surg Oncol 2018; 16:25. [PMID: 29426329 PMCID: PMC5807757 DOI: 10.1186/s12957-017-1268-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2017] [Accepted: 11/07/2017] [Indexed: 02/07/2023] Open
Abstract
Background This study aimed to propose a new surgical strategy, i.e., the transcervical video-assisted mediastinoscopic lymphadenectomy (VAMLA) with esophagectomy via the left transthoracic approach for patients with esophageal cancer (EC), and to compare the outcomes with those of esophagectomy via the right thoracic approach. Methods From December 2014 to March 2016, 49 cases were enrolled in this non-randomized concurrent control study. Twenty-eight patients with EC who underwent transcervical VAMLA with esophagectomy via the left transthoracic approach were assigned into the study group, while 21 EC patients undergoing esophagectomy via the right transthoracic approach during the same period were enrolled into the control group. Operative outcomes including operative time, the numbers of removed lymph nodes, intraoperative blood loss, the length of hospital stay, and postoperative complications in both groups were evaluated and compared. Results There were no significant differences in the baseline profiles between the two groups, and all patients in the two groups successfully underwent the surgery. There was a significant difference between transcervical VAMLA with esophagectomy via the left thoracic approach and esophagectomy via the right thoracic approach with regard to the number of all dissected lymph nodes [(29.0 ± 8.7) vs. (17.8 ± 8.1), p < 0.05], dissected superior mediastinal lymph nodes [(11.2 ± 5.0) vs. (3.7 ± 2.9), p < 0.05], and dissected in the recurrent laryngeal nerve lymph nodes [(5.6 ± 3.5) vs. (2.3 ± 2.1), p < 0.05]. No significant differences were observed in the operative time, intraoperative blood loss, length of postoperative hospital stay, number of dissected abdominal lymph nodes, postoperative pulmonary complications (pneumonia and atelectasis), anastomotic fistula, chylothorax, and vocal cord paralysis (p > 0.05). Conclusion Transcervical VAMLA combined with esophagectomy via the left thoracic approach appears technically feasible and safe and shows advantages in the number of dissected superior mediastinal lymph nodes, suggesting that it may serve as a new treatment option for patients with esophageal carcinoma.
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Affiliation(s)
- Xu Li
- Department of Thoracic Surgery, The Second Xiangya Hospital of Central South University, Changsha, Hunan, 410011, China
| | - Wenxiang Wang
- The Second Department of Thoracic Surgery, Hunan Cancer Hospital and The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, No.283 Tongzipo Street, Yuelu District, Changsha, Hunan, 410013, China.
| | - Yong Zhou
- The Second Department of Thoracic Surgery, Hunan Cancer Hospital and The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, No.283 Tongzipo Street, Yuelu District, Changsha, Hunan, 410013, China
| | - Desong Yang
- The Second Department of Thoracic Surgery, Hunan Cancer Hospital and The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, No.283 Tongzipo Street, Yuelu District, Changsha, Hunan, 410013, China
| | - Jie Wu
- The Second Department of Thoracic Surgery, Hunan Cancer Hospital and The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, No.283 Tongzipo Street, Yuelu District, Changsha, Hunan, 410013, China
| | - Baihua Zhang
- The Second Department of Thoracic Surgery, Hunan Cancer Hospital and The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, No.283 Tongzipo Street, Yuelu District, Changsha, Hunan, 410013, China
| | - Zhining Wu
- The Second Department of Thoracic Surgery, Hunan Cancer Hospital and The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, No.283 Tongzipo Street, Yuelu District, Changsha, Hunan, 410013, China
| | - Jinming Tang
- The Second Department of Thoracic Surgery, Hunan Cancer Hospital and The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, No.283 Tongzipo Street, Yuelu District, Changsha, Hunan, 410013, China
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Shoji Y, Takeuchi H, Fukuda K, Nakamura R, Wada N, Kawakubo H, Kitagawa Y. Air Bubble Sign: A New Screening Method for Anastomotic Leakage After Esophagectomy for Esophageal Cancer. Ann Surg Oncol 2018; 25:1061-1068. [PMID: 29318416 DOI: 10.1245/s10434-017-6327-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Contrast esophagography often is performed to screen for anastomotic leakage (AL) after esophagectomy. However, its sensitivity remains low. Adverse events also have been reported. This report describes a new screening method to detect AL on computed tomography (CT) after esophagectomy. METHODS From January 2012 to December 2015, 185 patients with esophageal cancer underwent surgical resection at the authors' institution. The study comparatively reviewed patient characteristics, surgical outcomes, and findings from postoperative CT images and contrast esophagrams of 142 patients who underwent esophagectomy followed by primary gastric conduit reconstruction through a posterior mediastinum route. RESULTS In this study, 24 patients (15.5%) had AL (leakage-positive group), and 120 patients (84.5%) did not (leakage-negative group). Both groups had comparable backgrounds. The number of air bubbles around the anastomotic site and the mediastinal space on postoperative CT images were significantly greater in the leakage-positive group than in the leakage-negative group. The cutoff value for the number of air bubbles required for a positive diagnosis of AL ("air bubble sign") was calculated to be 3 by receiver operating characteristic curve. Compared with contrast esophagography, the air bubble sign on CT demonstrated a significantly higher sensitivity (86.4 vs. 50.0%) and an equivalent specificity (95.8 vs. 100.0%). Contrast esophagography altered the postoperative management of only five patients (3.5%). CONCLUSIONS A positive air bubble sign on CT is an objective and noninvasive screening method for AL after esophagectomy for esophageal cancer and may replace contrast esophagography as a screening test for AL.
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Affiliation(s)
- Yoshiaki Shoji
- Department of Surgery, School of Medicine, Keio University, Tokyo, Japan
| | - Hiroya Takeuchi
- Department of Surgery, School of Medicine, Keio University, Tokyo, Japan. .,Department of Surgery, Hamamatsu University School of Medicine, Shizuoka, Japan.
| | - Kazumasa Fukuda
- Department of Surgery, School of Medicine, Keio University, Tokyo, Japan
| | - Rieko Nakamura
- Department of Surgery, School of Medicine, Keio University, Tokyo, Japan
| | - Norihito Wada
- Department of Surgery, School of Medicine, Keio University, Tokyo, Japan
| | - Hirofumi Kawakubo
- Department of Surgery, School of Medicine, Keio University, Tokyo, Japan
| | - Yuko Kitagawa
- Department of Surgery, School of Medicine, Keio University, Tokyo, Japan
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Effectiveness of etilefrine regimen for chylothorax after esophagectomy with thoracic duct resection. Esophagus 2018; 15:33-38. [PMID: 29308064 PMCID: PMC5742336 DOI: 10.1007/s10388-017-0592-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2017] [Accepted: 09/06/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND Management of postoperative chylothorax generally involves nutritional regimens as well as pharmacological and surgical therapies, but a clear consensus has yet to be reached. METHODS Retrospective review of 371 patients who underwent esophagectomy for esophageal cancer was performed. They were patients with squamous cell carcinoma or adenocarcinoma of the esophagus including Siewert type I/II tumor of the esophagogastric junction who underwent subtotal esophagectomy. Of these patients, 19 patients who were diagnosed with chylothorax as a postoperative complication were enrolled in this study. RESULTS Conservative treatment achieved cure in 16 patients among 19 patients. The duration of chylothorax tended to be longer in the no-etilefrine group (n = 5) than in the etilefrine group (n = 11) (27.8 vs. 11.6 days; p = 0.078). The 14 patients among 19 patients resected the thoracic duct. Etilefrine was used in 12 of these 14 patients. Among these 12 patients, 3 required surgical treatment and the remaining 9 patients were cured with conservative treatment. The duration of chylothorax was shorter in the conservative treatment group than in the surgical treatment group (11.9 vs. 36.3 days; p = 0.052). In addition, with the use of etilefrine as adjuvant therapy, cure was achieved in 9 patients (75%) without surgical intervention. CONCLUSIONS The findings of this study suggest that when used concurrently with conventional treatments, etilefrine facilitates early chest tube removal. In addition, post-thoracic duct resection chylothorax, which frequently requires surgical treatment because of the general less effectiveness of conservative treatments, showed high successful rate (75%) to etilefrine treatment.
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Takeuchi M, Takeuchi H, Kawakubo H, Booka E, Mayanagi S, Fukuda K, Nakamura R, Suda K, Wada N, Kitagawa Y. Perioperative Risk Calculator Predicts Long-Term Oncologic Outcome for Patients with Esophageal Carcinoma. Ann Surg Oncol 2017; 25:837-843. [PMID: 29282603 DOI: 10.1245/s10434-017-6311-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Indexed: 01/16/2023]
Abstract
BACKGROUND Few risk models have been provided to predict long-term prognosis after esophagectomy. This study investigated the reliability of a risk calculator as well as classification and regression trees analysis for predicting long-term prognosis after esophagectomy for esophageal cancer. METHODS The study enrolled 438 patients who underwent esophagectomy at Keio University Hospital, Tokyo, Japan, between July 2000 and June 2016. Patients who underwent R0 or R1 resection or esophagectomy with combined resection of other organs were included. The authors investigated the usefulness of a risk model for 30-day mortality and operative mortality described in their previous report for predicting long-term prognosis after esophagectomy. RESULTS The 438 patients (377 men and 61 women) in this study had a 5-year overall survival (OS) rate of 62.8% and a disease-free survival rate of 54.3%. The OS was higher for the patients with 30-day mortality risk model values lower than 0.675% than for those with values higher than 0.675% (p < 0.001). The cutoff values for prediction were shown to be significant risk factors in the multivariate analysis. The risk calculator was validated by comparing the cutoff values with Harrell's C-index values of clinical stage. For overall risk, the C-index of operative mortality was 0.697, and the C-index of cStage was 0.671. CONCLUSIONS The risk calculator was useful for predicting recurrence and death after esophagectomy. Furthermore, because the C-index of the risk model for operative mortality was higher than for clinical tumor-node-metastasis stage, this risk-scoring system may be more useful clinically.
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Affiliation(s)
- Masashi Takeuchi
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Hiroya Takeuchi
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan. .,Department of Surgery, Hamamatsu University School of Medicine, Shizuoka, Japan.
| | - Hirofumi Kawakubo
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Eisuke Booka
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Shuhei Mayanagi
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Kazumasa Fukuda
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Rieko Nakamura
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Koichi Suda
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Norihito Wada
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
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Matsuda S, Takeuchi H, Kawakubo H, Kitagawa Y. Three-field lymph node dissection in esophageal cancer surgery. J Thorac Dis 2017; 9:S731-S740. [PMID: 28815069 PMCID: PMC5538994 DOI: 10.21037/jtd.2017.03.171] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Accepted: 03/17/2017] [Indexed: 12/15/2022]
Abstract
Although multidisciplinary treatment has improved the prognosis of esophageal cancer, it is commonly associated with one of the worse prognoses. Since lymph node (LN) metastases can primarily occur from the cervical to the abdominal field, a strategy for extended LN dissection has been established. The three field LN dissection (3FD) during a transthoracic esophagectomy which is defined as a procedure for cervico-thoraco-abdominal LN dissection, was established in the 1980s' in Japan, and is currently widely accepted throughout the world. To date, various comparative trials between 3FD and two field LN dissections (2FD) have been reported and show that a transthoracic esophagectomy with 3FD is superior to 2FD for prognosis. However, in 3FD, postoperative complications, such as recurrent laryngeal nerve palsy and postoperative gastrointestinal dysfunction can be induced. Furthermore, there are few prospective trials that have compared between 2FD and 3FD. Therefore, to determine the ideal range of LN dissection, various factors (e.g., location of the primary tumor, disease progression, tumor histology, and perioperative treatment) must be considered. Recently, the efficacy of intense perioperative treatment for esophageal cancer has been reported, and the significance of minimally invasive surgical procedures are being verified. The ideal combination of perioperative treatment and feasible surgery must be established to improve the oncological outcome of esophageal cancer patients further.
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Affiliation(s)
- Satoru Matsuda
- Department of Surgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Hiroya Takeuchi
- Department of Surgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
- Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Hirofumi Kawakubo
- Department of Surgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
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Abstract
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