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Sabatelle RC, Colson YL, Sachdeva U, Grinstaff MW. Drug Delivery Opportunities in Esophageal Cancer: Current Treatments and Future Prospects. Mol Pharm 2024; 21:3103-3120. [PMID: 38888089 DOI: 10.1021/acs.molpharmaceut.4c00246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2024]
Abstract
With one of the highest mortality rates of all malignancies, the 5-year survival rate for esophageal cancer is under 20%. Depending on the stage and extent of the disease, the current standard of care treatment paradigm includes chemotherapy or chemoradiotherapy followed by surgical esophagogastrectomy, with consideration for adjuvant immunotherapy for residual disease. This regimen has high morbidity, due to anatomic changes inherent in surgery, the acuity of surgical complications, and off-target effects of systemic chemotherapy and immunotherapy. We begin with a review of current treatments, then discuss new and emerging targets for therapies and advanced drug delivery systems. Recent and ongoing preclinical and early clinical studies are evaluating traditional tumor targets (e.g., human epidermal growth factor receptor 2), as well as promising new targets such as Yes-associated protein 1 or mammalian target of rapamycin to develop new treatments for this disease. Due the function and location of the esophagus, opportunities also exist to pair these treatments with a drug delivery strategy to increase tumor targeting, bioavailability, and intratumor concentrations, with the two most common delivery platforms being stents and nanoparticles. Finally, early results with antibody drug conjugates and chimeric antigenic receptor T cells show promise as upcoming therapies. This review discusses these innovations in therapeutics and drug delivery in the context of their successes and failures, with the goal of identifying those solutions that demonstrate the most promise to shift the paradigm in treating this deadly disease.
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Affiliation(s)
- Robert C Sabatelle
- Departments of Biomedical Engineering and Chemistry, Boston University, Boston, Massachusetts 02215, United States
| | - Yolonda L Colson
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts 02114, United States
| | - Uma Sachdeva
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts 02114, United States
| | - Mark W Grinstaff
- Departments of Biomedical Engineering and Chemistry, Boston University, Boston, Massachusetts 02215, United States
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Liu J, Zeng X, Zhou X, Xu Y, Ding Z, Hu Y, Yuan Y, Chen L, Wang J, Lu Y, Liu Y. Longer interval between neoadjuvant chemoradiotherapy and surgery is associated with improved pathological response, but does not accurately estimate survival in patients with resectable esophageal cancer. Oncol Lett 2023; 25:155. [PMID: 36936022 PMCID: PMC10018328 DOI: 10.3892/ol.2023.13741] [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: 03/25/2022] [Accepted: 12/12/2022] [Indexed: 03/06/2023] Open
Abstract
Neoadjuvant chemoradiotherapy (nCRT) has been shown to reduce tumor burden and achieve tumor regression in patients with esophageal cancer (ESC). However, the most beneficial time interval between the administration of nCRT and surgery remains unclear. Therefore, the aim of the present study was to explore the association of the duration of time between nCRT and surgery with the prognosis of patients with ESC. Patients with ESC who received nCRT following surgical resection (n=161) were reviewed and divided into the prolonged time interval group (time interval ≥66 days) and the short time interval group (time interval <66 days), according to the median value. Subsequent analysis revealed that the prolonged time interval group achieved a higher pathological complete response (pCR) rate compared with the short time interval group (49.4 vs. 26.3%; P=0.003). Furthermore, multivariate logistic regression analysis showed that it was possible to independently estimate a higher pCR rate based on a prolonged time interval (odds ratio, 2.131; P=0.042). However, no association between a prolonged time interval and disease-free survival (DFS) was detected using Kaplan-Meier curves (P=0.252) or multivariate Cox regression (P=0.607) analyses. Similarly, no association was identified between a prolonged time interval and overall survival (OS; P=0.946) based on Kaplan-Meier curve analysis, and subsequent multivariate Cox regression analyses showed that the time interval also failed to independently estimate OS (P=0.581). Moreover, female sex (P=0.001) and a radiation dose ≥40 Gy (P=0.039) served as independent factors associated with a higher pCR rate, and the pCR rate was an independent predictor of favorable DFS (P=0.002) and OS (P=0.015) rates. In conclusion, the present study revealed that a prolonged time interval from nCRT to surgery was associated with a higher pCR rate, but it failed to estimate the survival profile of patients with ESC.
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Affiliation(s)
- Jiaqi Liu
- Department of Thoracic Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, P.R. China
| | - Xiaoxiao Zeng
- Department of Thoracic Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, P.R. China
- Department of Oncology, The People's Hospital of Jianyang City, Jianyang, Sichuan 641400, P.R. China
| | - Xiaojuan Zhou
- Department of Thoracic Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, P.R. China
| | - Yong Xu
- Department of Thoracic Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, P.R. China
| | - Zhenyu Ding
- Department of Biotherapy, Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, P.R. China
| | - Yang Hu
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, P.R. China
| | - Yong Yuan
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, P.R. China
| | - Longqi Chen
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, P.R. China
| | - Jin Wang
- Department of Thoracic Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, P.R. China
| | - You Lu
- Department of Thoracic Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, P.R. China
| | - Yongmei Liu
- Department of Thoracic Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, P.R. China
- Correspondence to: Dr Yongmei Liu, Department of Thoracic Oncology, Cancer Center, West China Hospital, Sichuan University, 37 Guoxue Alley, Chengdu, Sichuan 610041, P.R. China, E-mail:
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Outcomes of Minimally Invasive and Robot-Assisted Esophagectomy for Esophageal Cancer. Cancers (Basel) 2022; 14:cancers14153667. [PMID: 35954331 PMCID: PMC9367610 DOI: 10.3390/cancers14153667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 07/26/2022] [Accepted: 07/26/2022] [Indexed: 12/10/2022] Open
Abstract
Simple Summary This is an invited review for the special edition, “Minimally Invasive Surgery for Cancer: Indications and Outcomes.” Indications to perform minimally invasive techniques for esophagectomy rather than the classic open technique do not exist. This review outlines the current research by comparing outcomes among minimally invasive esophagectomy, robot-assisted esophagectomy, and open esophagectomy. After determining the benefits of each technique in terms of each outcome, the discussion focuses on how surgeons may use the presented information to determine which approach is most appropriate. We hope this study provides a comprehensive review of the current state of the literature regarding minimally invasive esophagectomy, as well as a guide for surgeons who treat patients with esophageal cancer. Abstract With the evolution of minimally invasive esophagectomy (MIE) and robot-assisted minimally invasive esophagectomy (RAMIE), questions remain regarding the benefits and indications of these methods. Given that set indications do not exist, this article aims first to review the reported outcomes of MIE, RAMIE, and open esophagectomy. Then, considerations based on the reported outcomes are discussed to guide surgeons in selecting the best approach. MIE and RAMIE offer the potential to improve outcomes for esophagectomy patients; however, surgeon experience as well as individual patient factors play important roles when deciding upon the surgical approach.
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Ahmadinejad M, Hashemi M, Tabatabai A. A Comparative Study between the Postoperative Complications of Stripping Esophagectomy and Classic (Orringer's Technique) Esophagectomy. Surg J (N Y) 2022; 8:e34-e40. [PMID: 35128051 PMCID: PMC8807099 DOI: 10.1055/s-0041-1736666] [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: 01/04/2020] [Accepted: 08/19/2021] [Indexed: 10/25/2022] Open
Abstract
Recent studies have suggested that morbidity and mortality rate of transhiatal esophagectomy is comparable to that of thoracotomy, calling the need for the modifications in the surgical procedures. Our methodology includes stripping of esophagus by nasogastric tube to reduce the manipulation of thoracic cavity and associated complications. We also present the comparison between the stripping and classic (Orringer's technique) esophagectomy. Patients presenting esophageal carcinoma from 2015 to 2017 were the target of this study. Patients undergoing esophagectomy were randomized to have classic or stripping esophagectomy. Operating time, manipulation time, blood losses during the surgery, duration of hospitalization, volume intake, hypotension time, arrhythmia, and transfusion were the recorded parameters. Complications, such as anastomotic leak, cardiac effects, and morbidity, were also studied. Seventy patients were referred for transhiatal esophagectomy for esophageal carcinoma at the Al Zahra Hospital. Mean ages of patients in the stripping and Orringer group were 64.00 ± 10.57 and 57.42 ± 12.20 years, respectively. Manipulation time, operating time, blood loss during the surgery, and transfusion were statistically significant variables between the two groups. Although volume intake and duration of hospitalization were not significantly different parameters, however, betterment in the outcomes was evident. Substantial decrease in overall complications via stripping method was obtained, hence can be suggested as an effective alternative, to remove the need of thoracotomy, for transhiatal esophagectomy.
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Affiliation(s)
- Mojtaba Ahmadinejad
- Department of General Surgery, Faculty of Medicine, Úlborz University of Medical Sciences, Karaj, Iran
| | - Mozaffar Hashemi
- Department of General Surgery, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Abbas Tabatabai
- Department of General Surgery, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
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Park BJ, Kim DJ. Robot-Assisted Thoracoscopic Esophagectomy with Total Mediastinal Lymphadenectomy: A Guide to a Systematic Approach Using the Concept of Fascial Plane Dissection. J Chest Surg 2021; 54:294-301. [PMID: 34353970 PMCID: PMC8350464 DOI: 10.5090/jcs.21.065] [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: 06/14/2021] [Accepted: 07/02/2021] [Indexed: 12/02/2022] Open
Abstract
Recent case series and meta-analyses have suggested that robot-assisted minimally invasive esophagectomy (RAMIE) could be a useful alternative to video-assisted thoracic surgery esophagectomy. The advantages of RAMIE are a 3-dimensional view, 7 degrees of freedom, and tremor filtering, which enable more meticulous lymph node dissection with a lower incidence of complications. However, in radical esophagectomy, understanding the concepts of the fascia and compartment is crucial for successful and reliable dissection. The first RAMIE in Korea was performed by our team in July 2006, and since then, we have developed related techniques to achieve better short- and long-term outcomes. The key step in RAMIE for esophageal squamous cell carcinoma is dissection of the upper mediastinum due to the difficulty of lymph node dissection and the high incidence of nodal metastasis in the area. Herein, we describe the technique of fascial plane dissection with esophageal suspension during RAMIE.
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Affiliation(s)
- Byung Jo Park
- Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Dae Joon Kim
- Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Korea
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Chen C, Ma Z, Shang X, Duan X, Yue J, Jiang H. Risk factors for lymph node metastasis of the left recurrent laryngeal nerve in patients with esophageal squamous cell carcinoma. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:476. [PMID: 33850873 PMCID: PMC8039656 DOI: 10.21037/atm-21-377] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background The factors for left recurrent laryngeal nerve (RLN) lymph node (LN) metastasis have important guiding significance for whether the left RLN LNs should be dissected in patients with esophageal squamous cell carcinoma (ESCC), but few studies are currently available. To analyze the risk factors of LN metastasis of the left RLN area and to assess which LNs should be dissected in ESCC. Methods This was a retrospective study of patients who underwent McKeown minimally invasive esophagectomy (MIE) (no neoadjuvant therapy) at Tianjin Medical University Cancer Institute and Hospital (from January 2016 to December 2019). The detection of left RLN LNs using enhanced computed tomography (CT) was compared with the pathological examination. Results Of the total 94 participants, 43 had LN metastasis. The metastatic LNs were mainly located next to left (18.1%) and right (14.9%) RLN, and the left gastric artery (13.8%). Tumor size, LN size, tumor invasion (T stage), N stage, and tumor node metastasis (TNM) stage were associated with left RLN LNs metastasis, while LN size was the only independently associated factor [odds ratio (OR) =1.569, 95% confidence interval (CI): 0.259–1.956, P=0.0012]. The area under receiver operating characteristic (ROC) curve (AUC) reached 0.877, with 64% sensitivity and 75% specificity using a cutoff of 5.5 mm LN size. Conclusions The size of left RLN LN is independently associated with metastasis. Left RLN LNs >5.5 mm at CT examination are more likely to be positive and should probably be dissected.
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Affiliation(s)
- Chuangui Chen
- Department of Minimally Invasive Esophagus Surgery, Key Laboratory of Prevention and Therapy, National Clinical Research Center of Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Zhao Ma
- Department of Minimally Invasive Esophagus Surgery, Key Laboratory of Prevention and Therapy, National Clinical Research Center of Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Xiaobin Shang
- Department of Minimally Invasive Esophagus Surgery, Key Laboratory of Prevention and Therapy, National Clinical Research Center of Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Xiaofeng Duan
- Department of Minimally Invasive Esophagus Surgery, Key Laboratory of Prevention and Therapy, National Clinical Research Center of Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Jie Yue
- Department of Minimally Invasive Esophagus Surgery, Key Laboratory of Prevention and Therapy, National Clinical Research Center of Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Hongjing Jiang
- Department of Minimally Invasive Esophagus Surgery, Key Laboratory of Prevention and Therapy, National Clinical Research Center of Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
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Baram A, Sherzad H. Trans-thoracic versus trans-hiatal resection for oesophageal carcinoma: a retrospective comparative study of a single-centre case series. THE CARDIOTHORACIC SURGEON 2020; 28:25. [PMID: 38624644 PMCID: PMC7686938 DOI: 10.1186/s43057-020-00035-y] [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: 07/20/2020] [Accepted: 11/10/2020] [Indexed: 12/24/2022] Open
Abstract
Background Oesophageal carcinoma (EC) is the eighth most common cancer. Surgery is the cornerstone of management for resectable EC. Trans-thoracic oesophagectomy (TTE) and trans-hiatal oesophagectomy (THE) are the two most widely practised procedures. Most of the related controversies are centred on both early and late post-operative complications and mortality (in terms of overall survival and cancer-free survival).This was a single-centre, retrospective, comparative study analysing the outcomes of two EC resection methods. All 87 patients underwent surgery by the same surgical team over 13 years. Consequently, 87 oesophagectomies with curative intent were performed and divided into the TTE group (group A = 47) and the THE group (group B = 40). Results The mean patient age was 65.60 ± 6.30 years in the TTE group and 63.48 ± 9.34 years in the THE group. No significant difference was found in operative time, blood loss or duration of stay in the intensive care unit. The duration of hospital stay was significantly different between the THE and TTE groups (17.25 ± 5.92 vs. 12.93 ± 3.44, respectively; P ≤ 0.001). In-hospital mortality was higher in the TTE group (9/47, 19.14%) than in the THE group (5/40, 12.5%) (P = 0.400). The mean survival rate from our series showed the superiority of group A (TTE) (65.56 months) over group B (THE) (45.01 months), with P = 0.146. Conclusion No high level of evidence suggests the superiority of one surgical procedure over another. The THE procedure is less time-consuming concerning care and follow-up, and most patients were more satisfied and experienced less pain than with the TTE procedure. Both THE and TTE have comparable post-operative anastomotic complications, and they have no significant long-term survival differences.
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Affiliation(s)
- Aram Baram
- Department of Surgery, School of Medicine, Faculty of Medical Sciences, University of Sulaimani, François Mitterrand Street, Sulaymaniyah, 46001 Iraq
- Department of Thoracic and Cardiovascular Surgery, Sulaimani Teaching Hospital, Al Sulaymaniyah, Kurdistan Region 46001 Iraq
| | - Hiwa Sherzad
- Kurdistan Board for Medical Specialization/Cardiothoracic and Vascular Surgery, Sulaimani DOH, Al Sulaymaniyah, Kurdistan Region Iraq
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Lindenmann J, Fink-Neuboeck N, Porubsky C, Fediuk M, Anegg U, Kornprat P, Smolle M, Maier A, Smolle J, Smolle-Juettner FM. A nomogram illustrating the probability of anastomotic leakage following cervical esophagogastrostomy. Surg Endosc 2020; 35:6123-6131. [PMID: 33106886 PMCID: PMC8523496 DOI: 10.1007/s00464-020-08107-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 10/16/2020] [Indexed: 01/18/2023]
Abstract
BACKGROUND Early diagnosis of anastomotic dehiscence following cervical esophagogastrostomy may become difficult. Estimation of an individual probability could help to establish preventive and diagnostic measures. The predictive impact of epidemiological, surgery-related data and laboratory parameters on the development of anastomotic dehiscence was investigated in the immediate perioperative period. METHODS Retrospective study in 412 patients with cervical esophagogastrostomy following esophagectomy. Epidemiological data, risk factors, underlying disease, pre-treatment- and surgery-related data, C-reactive protein and albumin levels pre-and post-operatively were evaluated. We applied univariable and multivariable logistic regression analysis and developed a nomogram for individual risk assessment. RESULTS There were 345 male, 67 female patients, mean aged 61.5 years; 284 had orthotopic, 128 retrosternal gastric pull-up; 331 patients had carcinoma, 81 non-malignant disease. Mean duration of operation was 184 min; 235 patients had manual, 113 mechanical and 64 semi-mechanical suturing; 76 patients (18.5%) developed anastomotic dehiscence clinically evident at mean 11.4 days after surgery. In univariable testing young age, retrosternal conduit transposition, manual suturing, high body mass index, high ASA and high postoperative levels of C-reactive protein were predictors for anastomotic leakage. These six parameters which had yielded a p < 0.1 in the univariable analysis, were entered into a multivariable analysis and a nomogram allowing the determination of the patient's individual risk was created. CONCLUSION By using the nomogram as a supportive measure in the perioperative management, the patient's individual probability of developing an anastomotic leak could be quantified which may help to take preventive measures improving the outcome.
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Affiliation(s)
- Joerg Lindenmann
- Division of Thoracic Surgery and Hyperbaric Surgery, Department of Surgery, Medical University of Graz, Auenbruggerplatz 29/3, 8036, Graz, Austria.
| | - Nicole Fink-Neuboeck
- Division of Thoracic Surgery and Hyperbaric Surgery, Department of Surgery, Medical University of Graz, Auenbruggerplatz 29/3, 8036, Graz, Austria
| | - Christian Porubsky
- Division of Thoracic Surgery and Hyperbaric Surgery, Department of Surgery, Medical University of Graz, Auenbruggerplatz 29/3, 8036, Graz, Austria
| | - Melanie Fediuk
- Division of Thoracic Surgery and Hyperbaric Surgery, Department of Surgery, Medical University of Graz, Auenbruggerplatz 29/3, 8036, Graz, Austria
| | - Udo Anegg
- Division of Thoracic Surgery and Hyperbaric Surgery, Department of Surgery, Medical University of Graz, Auenbruggerplatz 29/3, 8036, Graz, Austria
| | - Peter Kornprat
- Department of General Surgery, Medical University of Graz, Graz, Austria
| | - Maria Smolle
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria
| | - Alfred Maier
- Division of Thoracic Surgery and Hyperbaric Surgery, Department of Surgery, Medical University of Graz, Auenbruggerplatz 29/3, 8036, Graz, Austria
| | - Josef Smolle
- Institute of Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Freyja Maria Smolle-Juettner
- Division of Thoracic Surgery and Hyperbaric Surgery, Department of Surgery, Medical University of Graz, Auenbruggerplatz 29/3, 8036, Graz, Austria
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Lindenmann J, Fediuk M, Fink-Neuboeck N, Porubsky C, Pichler M, Brcic L, Anegg U, Balic M, Dandachi N, Maier A, Smolle M, Smolle J, Smolle-Juettner FM. Hazard Curves for Tumor Recurrence and Tumor-Related Death Following Esophagectomy for Esophageal Cancer. Cancers (Basel) 2020; 12:cancers12082066. [PMID: 32726927 PMCID: PMC7466063 DOI: 10.3390/cancers12082066] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 07/17/2020] [Accepted: 07/25/2020] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND The knowledge of both patterns and risk of relapse following resection for esophageal cancer is crucial for establishing appropriate surveillance schedules. The aim of this study was to evaluate the pattern of hazards for tumor recurrence and tumor-related death in the postoperative long-term follow-up after esophagectomy. METHODS Retrospective single-center analysis of 362 patients, with resected esophageal cancer. Multivariate Cox proportional hazard model was used. RESULTS A total of 192 (53%) had postoperative tumor recurrence. The relapse patterns of adenocarcinoma and squamous-cell carcinoma showed that each had a single peak, 12 months after surgery. After induction there was one peak at 5 months, the non-induced patients peaked 11 months, postoperatively. At 18 months, the recurrence hazard declined sharply in all cases. The hazard curves for tumor-related death were bimodal for adenocarcinoma, with two peaks at 6 and 22 months and one single peak for squamous-cell carcinoma at 18 months after surgery, showing pronounced decline later on. CONCLUSION In curatively resected esophageal cancer, both tumor recurrence hazard and hazard for tumor-related death showed distinct, partly bimodal patterns. It could be justified to intensify the surveillance during the first two postoperative years by initiating a close-meshed follow-up to detect and treat tumor recurrence, as early as possible.
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Affiliation(s)
- Joerg Lindenmann
- Division of Thoracic and Hyperbaric Surgery, Department of Surgery, Medical University of Graz, 8036 Graz, Austria; (M.F.); (N.F.-N.); (C.P.); (U.A.); (A.M.); (F.M.S.-J.)
- Correspondence: ; Tel.: +43-316-385-13302; Fax: +43-316-385-14679
| | - Melanie Fediuk
- Division of Thoracic and Hyperbaric Surgery, Department of Surgery, Medical University of Graz, 8036 Graz, Austria; (M.F.); (N.F.-N.); (C.P.); (U.A.); (A.M.); (F.M.S.-J.)
| | - Nicole Fink-Neuboeck
- Division of Thoracic and Hyperbaric Surgery, Department of Surgery, Medical University of Graz, 8036 Graz, Austria; (M.F.); (N.F.-N.); (C.P.); (U.A.); (A.M.); (F.M.S.-J.)
| | - Christian Porubsky
- Division of Thoracic and Hyperbaric Surgery, Department of Surgery, Medical University of Graz, 8036 Graz, Austria; (M.F.); (N.F.-N.); (C.P.); (U.A.); (A.M.); (F.M.S.-J.)
| | - Martin Pichler
- Division of Cancer Medicine, Department of Experimental Therapeutics, The University of Texas MD Anderson Cancer Center, UTHealth, Texas A&M College of Medicine, Houston, TX 77030, USA;
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria; (M.B.); (N.D.)
| | - Luka Brcic
- Diagnostic and Research Institute of Pathology, Medical University of Graz, 8036 Graz, Austria;
| | - Udo Anegg
- Division of Thoracic and Hyperbaric Surgery, Department of Surgery, Medical University of Graz, 8036 Graz, Austria; (M.F.); (N.F.-N.); (C.P.); (U.A.); (A.M.); (F.M.S.-J.)
| | - Marija Balic
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria; (M.B.); (N.D.)
| | - Nadia Dandachi
- Division of Oncology, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria; (M.B.); (N.D.)
| | - Alfred Maier
- Division of Thoracic and Hyperbaric Surgery, Department of Surgery, Medical University of Graz, 8036 Graz, Austria; (M.F.); (N.F.-N.); (C.P.); (U.A.); (A.M.); (F.M.S.-J.)
| | - Maria Smolle
- Department of Orthopaedics and Trauma, Medical University of Graz, 8036 Graz, Austria;
| | - Josef Smolle
- Institute of Medical Informatics, Statistics and Documentation, Medical University of Graz, 8036 Graz, Austria;
| | - Freyja Maria Smolle-Juettner
- Division of Thoracic and Hyperbaric Surgery, Department of Surgery, Medical University of Graz, 8036 Graz, Austria; (M.F.); (N.F.-N.); (C.P.); (U.A.); (A.M.); (F.M.S.-J.)
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Tian J, Mei X, Guo M, Xiong R, Sun X. Effectiveness of jejunostomy for enteral nutrition during complete thoracoscopic and laparoscopic Ivor-Lewis esophagectomy in thoracic segment esophageal carcinoma. J Cardiothorac Surg 2020; 15:142. [PMID: 32552786 PMCID: PMC7298823 DOI: 10.1186/s13019-020-01162-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 05/18/2020] [Indexed: 02/07/2023] Open
Abstract
Background Although jejunostomy is widely used in complete thoracoscopic and laparoscopic minimally invasive Ivor-Lewis esophagectomy, its clinical effectiveness remains undefined. This study aimed to assess the therapeutic and side effects of jejunostomy in patients undergoing Ivor-Lewis esophagectomy for thoracic segment esophageal carcinoma. Methods A total of 1400 patients with esophageal carcinoma who underwent minimally invasive esophagectomy in the Thoracic Surgery of our hospital from 2015 to 2018 were retrospectively evaluated. Of these, 356 and 1044 were treated with nasojejunal feeding tubes (Nasojejunal group) and by jejunostomy (Jejunostomy group), respectively. Clinicopathologic factors, postoperative complications and tubule-related complications between the two groups were compared. Results Both groups were well-balanced for clinicopathological data, except tumor location, which was significantly different (P < 0.001). Operation time (208.8 ± 53.5 min vs. 218.1 ± 43.2 min) was shorter in the Jejunostomy group compared with the Nasojejunal group, while intraoperative (26.6 ± 10.4 min vs 18.4 ± 9.1 min) and postoperative (38.6 ± 6.9 min vs 18.5 ± 7.6 min) indwelling times of nutrition tubes were prolonged (all P < 0.05). Postoperative pulmonary infection (17.0% vs 22.2%), incision infection (0.2% vs 1.1%), nutrient tube slippage (0.2% vs 5.1%) and nutrient reflux 1 (0.1% vs 5.6%) rates were reduced in the Jejunostomy group compared with the Nasojejunal group (P < 0.05). Meanwhile, ileus rates perioperatively (1.7% vs 0.3%) and at 3 postoperative months (1.7% vs 0.3%) were both higher in the Jejunostomy group compared with the Nasojejunal group. Conclusions Jejunostomy is a reliable enteral nutrition method in Ivor-Lewis esophagectomy for thoracic segment esophageal carcinoma.
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Affiliation(s)
- Jieyong Tian
- Department of Thoracic Surgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230036, Anhui, China.
| | - Xinyu Mei
- Department of Thoracic Surgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230036, Anhui, China
| | - Mingfa Guo
- Department of Thoracic Surgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230036, Anhui, China
| | - Ran Xiong
- Department of Thoracic Surgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230036, Anhui, China
| | - Xiangxiang Sun
- Department of Thoracic Surgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230036, Anhui, China
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11
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Chen LL, Mead E, Dhawan V, Halpern NA. A Patient in Respiratory Distress After Esophagectomy. Chest 2019; 154:e157-e160. [PMID: 30526981 DOI: 10.1016/j.chest.2018.07.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 07/21/2018] [Accepted: 07/24/2018] [Indexed: 11/24/2022] Open
Affiliation(s)
- Leon L Chen
- Critical Care Medicine Service, Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY; Rory Meyers College of Nursing, New York University, New York, NY.
| | - Elena Mead
- Critical Care Medicine Service, Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Vikram Dhawan
- Critical Care Medicine Service, Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Neil A Halpern
- Critical Care Medicine Service, Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
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12
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Yu J, Ouyang W, Li C, Shen J, Xu Y, Zhang J, Xie C. Mapping patterns of metastatic lymph nodes for postoperative radiotherapy in thoracic esophageal squamous cell carcinoma: a recommendation for clinical target volume definition. BMC Cancer 2019; 19:927. [PMID: 31533656 PMCID: PMC6749673 DOI: 10.1186/s12885-019-6065-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 08/19/2019] [Indexed: 12/28/2022] Open
Abstract
Background The clinical target volume (CTV) for postoperative radiotherapy for thoracic esophageal squamous cell carcinoma (TESCC) needs to be defined. The study aim was to map metastatic lymph nodes (LNMs) in a computed tomography (CT)-based atlas and delineate the postoperative radiotherapy target area. Methods Sixty-nine TESCC patients with first recurrent regional LNMs after esophagectomy were included. The LNM epicenters were registered onto corresponding anatomic axial CT images of a standard patient in the treatment position, with reference to the surrounding vascular and bony structures. The LNM sites were based on lymph node map of esophageal cancer, AJCC 8th. The lymph metastasis risk for different segments of thoracic esophagus was assessed. Results One hundred and seventy-nine LNMs were mapped onto standard axial CT images. The upper-middle mediastinum region (station 1 to 8 M) contained 97% of metastases in the upper segment of thoracic esophagus, 90% in the middle segment, and 66% in the lower one. Advanced pathological stage (≥IIIB) might be a predictive factor for upper abdominal region (UAR) relapse in lower TESCC. Lower cervical para-tracheal LNMs were within a 4.3-cm bilaterally expanded area from the midline of the body and a 2.2-cm expanded area from the anterior of vertebral body, from the superior border of the C7, to the inferior border of the first thoracic vertebra. Conclusion A modified target from the upper border of C7 to the lower border of caudal margin of the inferior pulmonary vein level could cover the high-risk area of TESCC underwent postoperative radiotherapy. UAR seems to be an elective irradiation target for lower TESCC at pathological IIIB stage and higher. Electronic supplementary material The online version of this article (10.1186/s12885-019-6065-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jing Yu
- Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, People's Republic of China, 430071.,Hubei Key Laboratory of Tumor Biological Behaviors, Zhongnan Hospital of Wuhan University, Wuhan, 430071, Hubei, China.,Hubei Cancer Clinical Study Center, Zhongnan Hospital of Wuhan University, Wuhan, 430071, Hubei, China
| | - Wen Ouyang
- Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, People's Republic of China, 430071.,Hubei Key Laboratory of Tumor Biological Behaviors, Zhongnan Hospital of Wuhan University, Wuhan, 430071, Hubei, China.,Hubei Cancer Clinical Study Center, Zhongnan Hospital of Wuhan University, Wuhan, 430071, Hubei, China
| | - Chunyang Li
- Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, People's Republic of China, 430071.,Hubei Key Laboratory of Tumor Biological Behaviors, Zhongnan Hospital of Wuhan University, Wuhan, 430071, Hubei, China.,Hubei Cancer Clinical Study Center, Zhongnan Hospital of Wuhan University, Wuhan, 430071, Hubei, China
| | - Jiuling Shen
- Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, People's Republic of China, 430071.,Hubei Key Laboratory of Tumor Biological Behaviors, Zhongnan Hospital of Wuhan University, Wuhan, 430071, Hubei, China.,Hubei Cancer Clinical Study Center, Zhongnan Hospital of Wuhan University, Wuhan, 430071, Hubei, China
| | - Yu Xu
- Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, People's Republic of China, 430071.,Hubei Key Laboratory of Tumor Biological Behaviors, Zhongnan Hospital of Wuhan University, Wuhan, 430071, Hubei, China.,Hubei Cancer Clinical Study Center, Zhongnan Hospital of Wuhan University, Wuhan, 430071, Hubei, China
| | - Junhong Zhang
- Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, People's Republic of China, 430071. .,Hubei Key Laboratory of Tumor Biological Behaviors, Zhongnan Hospital of Wuhan University, Wuhan, 430071, Hubei, China. .,Hubei Cancer Clinical Study Center, Zhongnan Hospital of Wuhan University, Wuhan, 430071, Hubei, China.
| | - Conghua Xie
- Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, People's Republic of China, 430071. .,Hubei Key Laboratory of Tumor Biological Behaviors, Zhongnan Hospital of Wuhan University, Wuhan, 430071, Hubei, China. .,Hubei Cancer Clinical Study Center, Zhongnan Hospital of Wuhan University, Wuhan, 430071, Hubei, China.
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13
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Abstract
Over the last few decades, minimally invasive approaches have gained in popularity for the surgical treatment of esophageal cancer, with the hopes of reducing the morbidity and mortality of this formidable procedure. The traditional McKeown approach includes thoracic esophageal dissection, abdominal mobilization of the gastric conduit and a cervical anastomosis. It presents several advantages over the Ivor Lewis approach: it is suitable for proximal tumors, allows a 3-field lymph node dissection, and avoids the morbidity associated with an intra-thoracic anastomotic leak. Here, we discuss the technical aspects of robotic-assisted minimally invasive McKeown esophagectomy (McKeown RAMIE).
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Affiliation(s)
- Shrey Patel
- Department of Thoracic Medicine and Surgery, Temple University Hospital, Philadelphia, PA, USA
| | - Roman Petrov
- Department of Thoracic Medicine and Surgery, Temple University Hospital, Philadelphia, PA, USA.,Department of Surgical Oncology, Section of Thoracic Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Abbas Abbas
- Department of Thoracic Medicine and Surgery, Temple University Hospital, Philadelphia, PA, USA.,Department of Surgical Oncology, Section of Thoracic Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Charles Bakhos
- Department of Thoracic Medicine and Surgery, Temple University Hospital, Philadelphia, PA, USA.,Department of Surgical Oncology, Section of Thoracic Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
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14
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Mu JW, Gao SG, Xue Q, Mao YS, Wang DL, Zhao J, Gao YS, Huang JF, He J. Comparison of short-term outcomes and three yearsurvival between total minimally invasive McKeown and dual-incision esophagectomy. Thorac Cancer 2017; 8:80-87. [PMID: 28052566 PMCID: PMC5334296 DOI: 10.1111/1759-7714.12404] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Revised: 10/03/2016] [Accepted: 10/07/2016] [Indexed: 12/30/2022] Open
Abstract
Background The aim of this study was to compare the short‐term outcomes and three‐year survival between dual‐incision esophagectomy (DIE) and total minimally invasive McKeown esophagectomy (MIME) for esophageal cancer patients with negative upper mediastinal lymph nodes requiring esophagectomy and neck anastomosis. Methods One hundred and fifty patients underwent DIE, while 361 patients received total MIME. Perioperative outcomes and three‐year survival were compared in unmatched and propensity score matched data between two groups. Results Both unmatched and matched analysis demonstrated that there were no significant differences in the number of lymph nodes harvested, or major or minor complication rates between the DIE and MIME groups. Compared with patients who underwent DIE, patients who underwent total MIME had longer operation duration (310 minutes vs. 345 minutes; P = 0.002). However, there was significantly less intraoperative blood loss in the total MIME compared with the DIE group (191 mL vs. 287 mL, respectively; P < 0.001). Kaplan‐Meier analysis demonstrated a trend that patients who underwent MIME had longer overall (79.5% vs. 64.1%; P = 0.063) and disease‐free three‐year survival (65.3% vs. 82.8%; P = 0.058) compared with patients who underwent DIE. Conclusions Both total MIME and DIE are feasible for the surgical treatment of esophageal cancer patients with negative upper mediastinal lymph nodes requiring esophagectomy and neck anastomosis. However, MIME was associated with better overall and disease‐free three‐year survival compared with DIE.
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Affiliation(s)
- Ju-Wei Mu
- Department of Thoracic Surgical Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shu-Geng Gao
- Department of Thoracic Surgical Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qi Xue
- Department of Thoracic Surgical Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - You-Sheng Mao
- Department of Thoracic Surgical Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Da-Li Wang
- Department of Thoracic Surgical Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jun Zhao
- Department of Thoracic Surgical Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yu-Shun Gao
- Department of Thoracic Surgical Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jin-Feng Huang
- Department of Thoracic Surgical Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jie He
- Department of Thoracic Surgical Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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15
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Javidfar J, Speicher PJ, Hartwig MG, D'Amico TA, Berry MF. Impact of Positive Margins on Survival in Patients Undergoing Esophagogastrectomy for Esophageal Cancer. Ann Thorac Surg 2015; 101:1060-7. [PMID: 26576752 DOI: 10.1016/j.athoracsur.2015.09.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Revised: 09/04/2015] [Accepted: 09/08/2015] [Indexed: 01/03/2023]
Abstract
BACKGROUND Multimodality treatment that includes esophagogastrectomy may represent the best option for curing accurately staged patients with esophageal cancer. We analyzed the impact of incomplete resection on outcomes after esophagogastrectomy for esophageal cancer. METHODS The incidence of positive margins for patients who underwent esophagogastrectomy without induction therapy for pathologic T1-3N0-1M0 esophageal cancer of the mid and lower esophagus from 2003 to 2006 in the National Cancer Database was analyzed with multivariate logistic regression. The impact of positive margins on survival was assessed using Kaplan-Meier and Cox proportional hazards analysis. RESULTS Positive margins occurred in 342 of 3,125 patients (10.9%) who met study criteria. Increasing clinical T status was an independent predictor of positive margins in multivariate analysis, but the chance of positive margins decreased with larger facility case volumes. The presence of clinical nodal disease was not predictive of an incomplete resection. The 5-year survival of patients with positive margins (13.8%, 95% confidence interval [CI]: 10.5% to 18.1%) was significantly worse than that for patients with negative margins (46.3%, 95% CI: 44.4% to 48.3%, p < 0.001). Both microscopic residual disease (hazard ratio 1.37, 95% CI: 1.16 to 1.60, p < 0.001) and gross residual disease (hazard ratio 1.98, 95% CI: 1.62 to 2.42, p < 0.001) predicted worse survival in multivariate analysis of the entire cohort. Receiving adjuvant chemoradiation therapy slightly improved 5-year survival of patients with positive margins (16.9%, 95% CI: 11.3% to 23.6%, versus 13.5%, 95% CI: 9% to 20.3%, p < 0.001). CONCLUSIONS Positive margins are associated with poor survival, and adjuvant therapy only marginally improved prognosis. Future studies are needed to better evaluate whether induction therapy can lower the incidence of positive margins.
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Affiliation(s)
- Jeffrey Javidfar
- Division of Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Paul J Speicher
- Division of Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Matthew G Hartwig
- Division of Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Thomas A D'Amico
- Division of Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Mark F Berry
- Department of Cardiothoracic Surgery, Stanford University Medical Center, Stanford, California.
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16
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Huang HT, Wang F, Shen L, Xia CQ, Lu CX, Zhong CJ. Comparison of thoracolaparoscopic esophagectomy with cervical anastomosis with McKeown esophagectomy for middle esophageal cancer. World J Surg Oncol 2015; 13:310. [PMID: 26542373 PMCID: PMC4635614 DOI: 10.1186/s12957-015-0727-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 11/02/2015] [Indexed: 01/01/2023] Open
Abstract
Background In China, the middle esophageal squamous cell cancer is the most common tumor type, and Mckeown esophagectomy (ME) is preferably adopted by thoracic surgeon. But, the surgical trauma of ME is great. Thoracolaparoscopic esophagectomy (TE) was developed to decrease the operative stress; however, the safety and efficacy were not defined. In this study, clinical outcomes were compared between patients who received ME and TE. Methods The data of 113 patients who suffered from middle-thoracic esophageal cancer during the same period were collected. Sixty-two patients received ME (ME group), and 51 patients received TE (TE group). Patients’ demographics and short-term clinicopathologic outcomes were comparable between the two groups. Survival rate was estimated using the Kaplan–Meier method, and comparisons between groups were performed with log–rank test. Results Patients in TE group had lower body mass index (BMI). Preoperative tumor stage in TE group was much earlier. Both overall and thoracic operation time were longer in TE group. The blood loss during operation and postoperative day (POD) 1 was less in TE group, which contributed to the less blood transfusion. In TE group, postoperative incidence of pulmonary complications and atrial fibrillation (p = 0.035 and p = 0.033) was lower; the inflammatory response and incision pain were significantly alleviated; the ICU and in-hospital stay was shorter as well because of less surgical trauma. No statistically significant difference was found between two groups in terms of overall survival or disease-free survival. Conclusions The efficacy and safety of TE were supported by the selected patients in this cohort study. Although it is lack of randomness in this research, some advantages of TE were gratifying such as lower postoperative complications and similar survival with ME. A multicenter prospective randomized study is now required.
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Affiliation(s)
- Hai-Tao Huang
- Department of Thoracic and Cardiovascular Surgery, Nantong First People's Hospital, the Second Affiliated Hospital of Nantong University, No.6 North Hai'er Xiang Road, Nantong, 226001, People's Republic of China.
| | - Fei Wang
- Department of Thoracic and Cardiovascular Surgery, Nantong First People's Hospital, the Second Affiliated Hospital of Nantong University, No.6 North Hai'er Xiang Road, Nantong, 226001, People's Republic of China.
| | - Liang Shen
- Department of Thoracic and Cardiovascular Surgery, Nantong First People's Hospital, the Second Affiliated Hospital of Nantong University, No.6 North Hai'er Xiang Road, Nantong, 226001, People's Republic of China.
| | - Chun-Qiu Xia
- Department of Thoracic and Cardiovascular Surgery, Nantong First People's Hospital, the Second Affiliated Hospital of Nantong University, No.6 North Hai'er Xiang Road, Nantong, 226001, People's Republic of China.
| | - Chen-Xi Lu
- Department of Thoracic and Cardiovascular Surgery, Nantong First People's Hospital, the Second Affiliated Hospital of Nantong University, No.6 North Hai'er Xiang Road, Nantong, 226001, People's Republic of China.
| | - Chong-Jun Zhong
- Department of Thoracic and Cardiovascular Surgery, Nantong First People's Hospital, the Second Affiliated Hospital of Nantong University, No.6 North Hai'er Xiang Road, Nantong, 226001, People's Republic of China.
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