Efficacy comparison of transcervical video-assisted mediastinoscopic lymphadenectomy combined with left transthoracic esophagectomy versus right transthoracic esophagectomy for esophageal cancer treatment

Prognostic prediction model for patients with pathological T1N0 stage esophageal squamous cell carcinoma undergone esophagectomy

Background

There is a shortage of reliable predictive models to provide valuable prognostic information for early esophageal squamous cell carcinoma (ESCC) without lymph node metastasis (LNM). We aimed to develop and validate a nomogram using the prognostic factors in T1N0 ESCC patients.

Methods

Patients with pathological T1N0 ESCC who underwent esophagectomy between 2014 and 2021 at three institutes were reviewed. The prognostic factors were evaluated by Cox proportional hazards model and a nomogram was developed. Patients were divided into high- and low-risk groups based on cut-off value of total points in the nomogram. Overall survival (OS) was estimated by the Kaplan-Meier method and compared using the log-rank test.

Results

A total of 275 patients were included and split into training (n=180) and external validation (n=95) cohorts. In the training cohort, multivariable analysis showed that the surgical approach, T1 substage, and carcinoembryonic antigen (CEA) level were independent prognostic factors. The developed nomogram had relatively high performance, with the area under the receiver operating characteristic (ROC) curve (AUC) of 0.783, 0.711 and 0.612 for 1-, 3-, and 5-year OS, respectively. The calibration curves showed that the predicted probability was in good agreement with the actual probability. Forty-seven was determined as cut-off value of total points. High-risk group (n=148) showed a significant poor OS than low-risk group (n=127) (P<0.001).

Conclusions

Left surgical approach, stage T1b, and higher CEA were associated with poorer prognosis in T1N0 ESCC patients. The nomogram demonstrated a good performance to predict the individual survival.

Safety and Feasibility of Mediastinoscopy-assisted Esophagectomy: A Meta-analysis

BACKGROUND

The objective of the current study was to investigate the safety and feasibility of mediastinoscopy-assisted esophagectomy (MAE).

METHODS

A meta-analysis was conducted between MAE and traditional transthoracic esophagectomy (TTE). For a comparative analysis of MAE and TTE, we searched PubMed, the Cochrane Library, Embase, and Web of Science databases. We identified the relevant literature and extracted the relevant data. Finally, RevMan 5.3 software was applied to conduct a meta-analysis of the data.

RESULTS

A total of 1256 people were enrolled in 16 studies, comprising 575 patients with MAE and 681 with TTE. The findings revealed that the pulmonary complications, cardiac complications, and postoperative hospital stay in the MAE group were significantly better than those in the TTE group. No significant differences were found between the 2 groups in postoperative chylothorax, anastomotic fistula, and postoperative mortality. But the incidence of recurrent laryngeal nerve injury in the MAE group was higher than that in the TTE group (odds ratio=1.64, 95% CI, 1.15 to 2.35, P =0.006). The MAE group had less lymph node dissection than the TTE group (mean difference=-4.62, 95% CI, -5.97 to 3.45, P <0.00001).

CONCLUSIONS

This meta-analysis presented that MAE was safe and feasible, reduced postoperative pulmonary and cardiac complications, and shortened hospital stay, but lymph node dissection was less, recurrent laryngeal nerve injury was higher, and the impact of long-term survival prognosis required more randomized controlled trials.

Left versus right approach for middle and lower esophageal squamous cell carcinoma: A propensity score-matched study

Background

Despite superior short-term outcomes, there is considerable debate about the oncological efficacy of the left approach esophagectomy for middle and lower squamous esophageal carcinoma (ESCC). A propensity score-matched retrospective study was conducted to evaluate the left approach's short- and long-term effects.

Methods

We recorded data from patients with ESCC who underwent curative resection via the left or right approach between January 2010 and December 2015. Propensity score matching (PSM) was performed, and maximally selected rank statistics (MSRS) were utilized to determine the appropriate number of lymph nodes to resect during esophagectomy.

Results

One hundred and forty-eight ESCC patients underwent esophagectomy via the right approach, and 108 underwent the left approach esophagectomy. After PSM, the left approach esophagectomy showed statistically significant superiority in operative time and time to oral intake, and there was a trend toward a shorter length of hospital stay. Fewer cervical, upper thoracic, and recurrent laryngeal nerve lymph nodes were harvested via the left approach than the right approach; the total number of lymph nodes harvested via the left and right approaches was similar. Similar long-term survival outcomes were achieved. MSRS suggested that at least 25 lymph nodes are needed to be resected during esophagectomy to improve survival in N0 patients.

Conclusions

The left approach esophagectomy might facilitate postoperative recovery in patients with middle and lower ESCC. With adequate lymphadenectomy, the left approach esophagectomy might achieve similar long-term outcomes for middle and lower ESCC patients.

Unresected small lymph node assessment predicts prognosis for patients with pT3N0M0 thoracic esophageal squamous cell carcinoma

Background

The role of unresected small lymph nodes (LNs) which may contain metastases for thoracic esophageal squamous cell carcinoma (TESCC) has not been addressed. The aim of the study was to investigate the role of unresected small LNs assessment using computed tomography (CT) in prognostic estimates of pT3N0M0 TESCC patients.

Methods

Between January 2009 and December 2017, 294 patients who underwent esophagectomy with R0 resection at Sichuan Cancer Hospital were retrospectively examined, and the last follow-up time was July 2018. Patients were classified into CT-suspect and CT-negative groups according to the shortest diameter and the shape (axial ratio) of the unresected small LNs on preoperative CT. The Kaplan–Meier method was used to compare survival differences in prognostic factors. Univariate and multivariate analyses were performed to identify prognostic factors for survival and recurrence.

Results

Eighty-four patients (28.6%) were classified as CT-suspect group according to the diagnostic criteria; survival analysis suggested that CT-suspect group of patients had a relatively poorer prognosis (P<0.05). Cox regression analysis indicated that unresected small LNs status, tumor grade, and postoperative adjuvant therapy were independent prognostic factors for patients with pT3N0M0 TESCC (P<0.05). Further analysis shown the rates of total recurrence (TR) and locoregional recurrence (LR) in the CT-suspect group were significantly higher than that in the CT-negative group (TR, P<0.001; LR, P<0.001). Among the LRs, the rate of supraclavicular lymph node recurrence in the CT-suspect group was significantly higher than that in the CT-negative group (P<0.001).

Conclusions

Unresected small lymph node assessment is critically important and predict prognosis for pT3N0M0 TESCC patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12957-021-02412-1.

Radical minimally invasive esophagectomy for esophageal cancer via transcervical and transhiatal approaches: a narrative review

Objective

Minimally invasive esophagectomy (MIE) has been widely applied for the treatment of esophageal carcinoma. It is much less invasive, as it avoids employing a transthoracic procedure.

Background

MIE via transcervical and transhiatal approaches has been adopted in our center. In this approach, with the assistance of single-port techniques or robotic-assisted surgical systems, the esophagus is mobilized under visualization, which is followed by the removal of esophageal and mediastinal lymph nodes.

Methods

Increasing the surgical space by mediastinal insufflation or by elevation of the sternum with a hook may improve intraoperative identification of tissues and facilitate intraoperative mobilizations. The procedure can be performed simultaneously via both cervical and abdominal approaches without the need for intraoperative turning of the patient, which shortens the operative time. Also, there is no need for thoracotomy or single-lung ventilation, which avoids disturbance to the respiratory and circulation systems.

Conclusions

Suitable instruments, especially state-of-the-art energy instruments, facilitate surgical separation and hemostasis. This surgical procedure has become increasingly sophisticated over the past decade, and its modular operation has been widely recognized. The feasible place of the neck-esophageal hiatus rendezvous is on the left main bronchus around the subcarinal region. Here we describe the technical features, key steps, and necessary precautions of this minimally invasive surgery for esophageal carcinoma.

Combined single-port transmediastinal and laparoscopic access with CO2 insufflation for esophageal resection: a case report on a canine model

In order to be familiar with the dissection of the esophagus through a single transmediastinal access. Combined single-port transmediastinal and laparoscopic access with CO₂ insufflation for esophageal resection were performed in experimental dogs. The esophagus was separated by single-hole mediastinoscopy, the stomach was separated by laparoscopy, and left neck anastomosis of tubular gastroesophagus was performed on the experimental dogs. Combined single-port transmediastinal and laparoscopic access with the CO₂ insufflation is an alternative approach for esophagectomy with certain advantages compared to transthoracic approach. Animal models can help the surgeon get familiar with a certain procedure before transmediastinal esophagectomy on a human.

Influencing factors of postoperative early delayed gastric emptying after minimally invasive Ivor-Lewis esophagectomy

BACKGROUND

The main clinical treatment for esophageal cancer is surgery. Since traditional open esophageal cancer resection has the disadvantages of large trauma, long recovery period, and high postoperative complication rate, its clinical application is gradually reduced. The current report of minimally invasive Ivor-Lewis esophagectomy (MIILE) is increasing. However, researchers found that patients with MIILE had a higher incidence of early delayed gastric emptying (DGE).

AIM

To investigate the influencing factors of postoperative early DGE after MIILE.

METHODS

A total of 156 patients diagnosed with esophageal cancer at Deyang People's Hospital were enrolled. According to the criteria of DGE, patients were assigned to a DGE group (n = 49) and a control group (n = 107). The differences between the DGE group and the control group were compared. Multivariate logistic regression analysis was used to further determine the influencing factors of postoperative early DGE. The receiver operating characteristic (ROC) curve was used to assess potential factors in predicting postoperative early DGE.

RESULTS

Age, intraoperative blood loss, chest drainage time, portion of anxiety score ≥ 45 points, analgesia pump use, postoperative to enteral nutrition interval, and postoperative fluid volume in the DGE group were higher than those in the control group. Perioperative albumin level in the DGE group was lower than that in the control group (P < 0.05). Age, anxiety score, perioperative albumin level, and postoperative fluid volume were independent factors influencing postoperative early DGE, and the differences were statistically significant (P < 0.05). The ROC curve analysis revealed that the area under the curve (AUC) for anxiety score was 0.720. The optimum cut-off value was 39, and the sensitivity and specificity were 80.37% and 65.31%, respectively. The AUC for postoperative fluid volume were 0.774. The optimal cut-off value was 1191.86 mL, and the sensitivity and specificity were 65.3% and 77.6%, respectively. The AUC for perioperative albumin level was 0.758. The optimum cut-off value was 26.75 g/L, and the sensitivity and specificity were 97.2% and 46.9%, respectively.

CONCLUSION

Advanced age, postoperative anxiety, perioperative albumin level, and postoperative fluid volume can increase the incidence of postoperative early DGE.