Video-assisted thoracoscopic surgery and open chest surgery in esophageal cancer treatment: present and future

Impact of the introduction of an enhanced recovery pathway in esophageal cancer surgery: a cohort study and propensity score matching analysis

Enhanced recovery pathways (ERP) have the potential to improve clinical outcomes. Aim of this study was to determine the impact of ERP on perioperative results as compared with traditional care (TC) after esophagectomy. In this study, two cohorts were compared. Cohort 1 represented 296 patients to whom TC was provided. Cohort 2 consisted of 200 unselected ERP patients. Primary endpoints were postoperative complications. Secondary endpoints were the length of stay and 30-day readmission rates. To confirm the possible impact of ERP, a propensity matched analysis (1:1) was conducted. A significant decrease in complications was found in ERP patients, especially for pneumonia and respiratory failure requiring reintubation (39% in TC and 14% in ERP; P<0.0001 and 17% vs. 12%; P<0.0001, respectively) and postoperative blood transfusion (26.7%-11%; P<0.0001). Furthermore, median length of stay was also significantly shorter: 13 days (interquartile range [IQR] 10-23) in TC compared with 10 days (IQR 8-14) in ERP patients (P<0.0001). The 30-day readmission rate (5.4% in TC and 9% in ERP; P=0.121) and in-hospital mortality rate (4.4% in TC and 2.5% in ERP; P=0.270) were not significantly affected. A propensity score matching confirmed a significant impact on pneumonia (P=0.0001), anastomotic leak (P=0.047), several infectious complications (P=0.01-0.034), blood transfusion (P=0.001), Comprehensive Complications Index (P=0.01), and length of stay (P=0.0001). We conclude that ERP for esophagectomy is associated with significantly fewer postoperative complications and blood transfusions, which results in a significant decrease of length of stay without affecting readmission and mortality rates.

Surgical treatment of the severe thoracic gastrocutaneous fistula by pedicled muscle flap filling and thoracoplasty after oesophagectomy for oesophageal squamous cell carcinoma: A case report

BACKGROUND

Thoracic anastomotic fistula (TAF) is a severe postoperative complication of oesophagectomy, and its occurrence coupled with a thoracic gastrocutaneous fistula (TGCF) and tracheostenosis is very unusual and may lead to a fatal consequence.

CASE PRESENTATION

We describe a case of an old female diagnosed with mid-oesophageal carcinoma, who presented with a TAF after oesophagectomy, which was healed by an effective treatment, while a severe TGCF and tracheostenosis appeared one month postoperation. The complications were detected by gastroscopy, barium oesophagogram and thoracic computed tomography (CT). Through surgical treatments, including pedicled muscle flap filling and thoracoplasty, and a correlated corrective procedure, the patient completely recovered and was discharged six months after the admission.

CONCLUSION

Treatment by pedicled muscle flap filling and thoracoplasty after oesophagectomy for oesophageal squamous cell carcinoma can be a curative alternative for the severe thoracic gastrocutaneous fistula.

Initial experience with uniportal video-assisted thoracic surgery esophagectomy

Background

Multiportal thoracoscopic approach is already a well standardized procedure for minimally invasive esophagectomy (MIE); conversely very few reports have been published about uniportal video-assisted thoracic surgery (VATS) technique till now. We present our preliminary experience with uniportal VATS esophagectomy, evaluating short-term outcomes as perioperative mortality, complications, oncological radicality, postoperative pain and cosmetic results.

Methods

From December 2016 to November 2017, the prospectively collected clinical data of 12 patients, who underwent uniportal VATS esophagectomy and reconstruction with a stomach conduit, according to McKeown technique, were reviewed and outcomes evaluated.

Results

The mean age of population was 60.67±8.61 years. Ten (83.3%) patients were males. The main histological type was a squamous cell carcinoma in six patients (50%). No patient had a local recurrence. After 4.33±3.31 months 10 patients (83.3%) were alive with no evidence of disease; 2 (16.7%) patients died of other causes. Two (16.7%) patients developed an anastomotic leak (treated conservatively) and one (8.3%) patient a chylothorax (which required a surgical treatment). The mean operative time of uniportal VATS esophagectomy was 104.67±20.66 min. Mean number of thoracic nodes removed was 10.44±3.94. Post-operative hospitalization was 15.73±14.29 days (median of 9 days). The mean level of pain was 1.92±0.90 in first postoperative day with a duration of 2.25±1.54 days. Cosmetic result was 2.42±0.79 on a 3-point scale.

Conclusions

Uniportal VATS esophagectomy seems to be a safe, feasible and effective alternative to multiportal VATS in terms of operative time, postoperative mortality, hospital stay and oncological outcomes. Less postoperative pain and better cosmetic results seem to be some advantages in favor of Uniportal VATS, however further studies with longer follow-up are claimed.

ypT0N+: the unusual patient with pathological complete tumor response but with residual lymph node disease after neoadjuvant chemoradiation for esophageal cancer, what's up?

Background

Little is known about the prognostic significance of residual nodal disease in otherwise complete pathologic responders (ypT0N+) after neoadjuvant chemoradiation (nCRT) for esophageal cancer (EC). The purpose is to analyze the long-term outcomes of EC patients with ypT0N+ following nCRT and esophagectomy.

Methods

From a single institution database, 466 consecutive EC patients undergoing esophagectomy after nCRT were collected (1996-2016). ypT0N+ responders were compared to pathological complete responders (ypT0N0) and to pathological non-complete responders (ypT+N0 and ypT+N+).

Results

There were 149 ypT0N0, 31 ypT0N+, 141 ypT+N0 and 145 ypT+N+. Median overall survival (OS) was worse in ypT0N+ (21.7 months) and ypT+N+ (16.8 months) compared to ypT0N0 (55.2 months) and ypT+N0 (42.0 months). Stratification by histology revealed a significant difference in prevalence of ypT0: 62.5% in 184 squamous cell carcinomas (SCC) compared to 23.0% in 282 adenocarcinomas (ADC) (P<0.0001) but not in ypT0N+ (15% vs. 22% respectively, P=0.25). In ADC, locoregional recurrence in ypT0N+ (43%) was comparable to ypT+N+ (31%) and more common compared to ypT0N0 (7%) and ypT+N0 (10%), reflected in median OS rates of 20.6, 17.5, 53.0 and 36.6 months respectively. Median OS in ADC is significantly determined by number of positive lymph nodes, being 21.7 months for pN1 and 2.7 months for pN2/3 (P=0.005) in ypT0N+ and 33.7 months for pN1 and 16.2 months for pN2/3 (P=0.031) in ypT+N+. In SCC, locoregional recurrences were found in 17% of ypT0N+, 33% of ypT+N+, 11% of ypT0N0 and 22% in ypT+N0 and median OS was 26.6, 15.6, 55.2 and 43.8 months respectively. In SCC ypN+ number of affected lymph nodes showed no difference on OS.

Conclusions

ypT0N+ in EC patients following nCRT has a poor prognosis and behaves similar to ypT+N+. However, stratification by histology shows that this is especially true in ADC but seems determined by the number of involved lymph nodes.

[Effects of minimally invasive versus open esophagectomy on circulating tumor cells in patients with esophageal cancer]

OBJECTIVE

To investigate the effects of minimally invasive esophagectomy (MIE) and open esophagectomy (OE) on the level of circulating tumor cells (CTCs) in patients with esophageal cancer (EC).

METHODS

A total of 73 patients with EC undergoing MIE (n=38) or OE (n=35) in our department between October, 2015 and October, 2017 were enrolled, with 10 patients with benign esophagus disease and 10 healthy volunteers as controls. The levels of CTCs in the peripheral blood of the participants were detected using CanPatrolTM technique and analyzed for their association with the operation methods and perioperative complications.

RESULTS

CTCs were detected in 60.3% (44/73) of the EC patients but in none of the control subjects. CTC level after the surgery was significantly higher than that during the surgery, and CTC level during the surgery was significantly higher than that before surgery (P<0.001). The preoperative and intra-operative CTC levels were not significantly different between MIE and OE groups (P>0.05), but the postoperative CTC level was significantly lower in MIE group than in OE group, and postoperative increment of CTC level (from the preoperative level) was significantly lower in MIE group than in OE group (P<0.001). The total incidence of postoperative complications was significantly lower in MIE group than in OE group (28.9% vs 54.3%, P=0.023), and in both groups, CTC levels in patients with complications were significantly higher than those in patients without complications (P=0.001 and P=0.005 in MIE and OE groups, respectively).

CONCLUSION

MIE may help to reduce the number of peripheral blood CTCs early after the operation, and dynamic monitoring CTCs level assists in evaluation of the prognosis of EC patients. CTC level may serve as an indicator for monitoring the prognosis of EC.