Propensity-Matched Analysis Comparing Survival After Hybrid Thoracoscopic-Laparotomy Esophagectomy and Complete Thoracoscopic-Laparoscopic Esophagectomy.

BACKGROUND: Hybrid thoracoscopic-laparotomy esophagectomy (hTE) and complete thoracoscopic-laparoscopic esophagectomy (cTLE) are the two most frequently used minimally invasive esophagectomy (MIE) procedures and are broadly utilized for esophageal cancer. We evaluated differences in short- and long-term outcomes between hTE and cTLE in patients with esophageal squamous cell carcinoma (ESCC). METHODS: Patients who underwent MIE for ESCC between September 2009 and February 2016 were included in this retrospective study. Propensity score matching (PSM) was utilized to contrast the postoperative results of hTE and cTLE according to the obtained and analyzed pertinent patient features and postoperative variables. Univariate and multivariate Cox proportional hazard regression analysis was used on possible predictors of survival. RESULTS: Eighty-six well-balanced pairs of patients were available for outcome comparison after PSM. Compared to Group 1 (hTE), the patients in Group 2 (cTLE) had significantly shorter operative times and less intraoperative blood loss, but a higher number of retrieved nodes (p = 0.000, p = 0.003, and p = 0.000, respectively). The incidence of postoperative complications was 40.7% (70/172) and did not significantly differ between the two groups. The patients in Group 2 exhibited higher disease-free survival and disease-specific survival (DSS) than those in Group 1 (p = 0.048 and p = 0.041, respectively). Univariate and multivariate Cox proportional hazard regression analyses showed that pT stage, pN stage, differentiation grade, and the surgical procedure had significant HRs, which suggested that cTLE is associated with better DSS. CONCLUSIONS: cTLE possibly shows better postoperative and oncologic outcomes than hTE.

Intraoperative conversion does not affect the oncological outcomes of minimally invasive esophagectomy for treatment of esophageal cancer.

BACKGROUND: The aim of this study is to summarize the causes and implications of intraoperative conversion from minimally invasive esophagectomy (MIE) to open thoracotomy, and to evaluate the effect on long-term survival. METHODS: There were 293 thoracoscopic esophagectomies for esophageal squamous cell carcinoma (ESCC) of the thoracic esophagus performed by the authors from September 2009 to August 2015. Totally, 257 patients were enrolled in this study. These patients were divided into two groups (those underwent complete MIE and those converted to open thoracotomy) and then compared. A standardized preoperative evaluation, as well as a postoperative method of following at a regular frequency were adopted for all of these patients. The clinicopathologic characteristics and the perioperative variables were retrospectively analyzed. Univariate and multivariate analyses were performed to identify prognostic factors. And the Kaplan-Meier method was used to compare survival differences. RESULTS: There were 231 patients (89.9%) underwent successful thoracoscopic esophagectomy (Group 1), and 26 cases (10.1%) required conversion to open procedure (Group 2). The majority of conversion (73.1%, 19/26) occurred in the initial 100 cases. No significant difference in background or clinicopathologic factors between the two groups was observed, but patients in Group 2 had significantly longer operative time and more operative blood loss. Among the 26 patients of Group 2, there were nine cases that need emergent conversion for various reasons. And the most common cause for emergent conversion was intraoperative bleeding. Univariate and multivariate analyses all demonstrated that intraoperative conversion did not significantly influence the overall or recurrence-free survival of these patients. CONCLUSIONS: Univariate analysis and multivariate Cox proportional hazard regression analysis indicated that intraoperative conversion did not significantly influence the OS and RFS rate of these patients. Our results demonstrated that the intraoperative conversion did not affect the long-term survival of patients underwent MIE for ESCC.

The effect of postoperative complications on survival of patients after minimally invasive esophagectomy for esophageal cancer.

BACKGROUND: Minimally invasive esophagectomy (MIE) has been shown to be a feasible technique for the treatment of esophageal cancer; however, its postoperative morbidity remains high. This retrospective study aimed to evaluate the effect of postoperative complications on long-term outcomes in patients who have undergone MIE for esophageal squamous cell carcinoma (ESCC). METHODS: This retrospective study enrolled patients who had undergone MIE for ESCC between September 2009 and November 2014; all procedures were performed by a single surgical team. Relevant patient characteristics and postoperative variables were collected and evaluated. The disease-free survival (DFS) and disease-specific survival (DSS) were determined by the Kaplan-Meier method, and compared by log-rank tests. Possible predictors of survival were subjected to univariate analysis and multivariate Cox proportional hazard regression analysis. RESULTS: In all, data on 214 patients with ESCC were analyzed, including 170 men and 44 women. All study subjects had undergone thoracoscopic or thoracoscopic-laparoscopic esophagectomy and cervical esophagogastric anastomosis. One hundred and thirty patients (60.7%) had postoperative complications (Grades 1-4). The overall DFS and DSS rates were 80.0 and 88.9% at 1 year, 48.6 and 54.2% at 3 years, and 43.2 and 43.5% at 5 years, respectively. Univariate analysis and multivariate Cox proportional hazard regression analysis showed that T stage, N stage, and tumor grade were independent prognostic factors for long-term survival; however, postoperative complications had no significant effect on the DFS or DSS of this patient cohort (log-rank test, p = 0.354 and 0.160, respectively). CONCLUSIONS: Postoperative complications have no significant effect on long-term survival in patients who have undergone MIE for ESCC.

Do alterations in plasma albumin and prealbumin after minimally invasive esophagectomy for squamous cell carcinoma influence the incidence of cervical anastomotic leak?

BACKGROUND: Anastomotic leak (AL) remains a challenging and bothersome complication of minimally invasive esophagectomy (MIE). In this retrospective study, we measured the perioperative albumin (ALB) and prealbumin (PA) of patients who underwent MIE, and investigated the relationship between the occurrence of AL and the altering levels of ALB/PA. PATIENTS AND METHODS: Sixty patients underwent video-assisted thoracoscopic-laparoscopic esophagectomy between September 2013 and August 2014. The preoperative and postoperative levels of ALB and PA were detected, and the baseline of altering levels for ALB and PA were established. According to the decreasing values of postoperative ALB, patients were divided into Group A1 (decreased value of ALB over the average level) and Group A2 (decreased value of ALB not reach the average level). Similarly, patients were also divided into Group P1 and Group P2 according to the average decreasing values of postoperative PA. The incidence of AL and non-anastomotic-relative complications between different groups were calculated and analyzed. RESULTS: One postoperative death occurred (1/60, 1.7 %). Eighteen complications were observed (18/60, 30 %), including seven cases of cervical AL (7/60, 11.7 %). There was no significant difference in background or clinicopathologic factors between different groups. The levels of ALB and PA descended significantly after MIE (p = 0.0000, p = 0.0000, respectively). No correlation between deficient levels of ALB and PA was observed (p = 0.1874, r = 0.0298). There was a significant higher AL incidence in Group P1 than in Group P2 (p = 0.0322). However, the incidence of AL did not exhibit significant difference between Group A1 and Group A2 (p = 0.9252). CONCLUSIONS: MIE appears to be a procedure of obvious influence on the nutrient metabolism of patients. The results demonstrated that patients with severely deficient level of PA had higher risk of AL after MIE.

Should stage T2 esophageal squamous cell carcinoma be subclassified?

BACKGROUND: In patients with esophageal squamous cell carcinoma (ESCC), pathologic examination allows T2 tumors to be further subclassified according to whether the circular or longitudinal muscle layers are invaded. Therefore, we aimed to investigate whether subclassifying the T2 stages can aid in determining the prognosis for patients with ESCC. METHODS: The clinical and pathologic characteristics of 85 ESCC patients with T2 tumors who underwent thoracoscopic esophagectomy between 2008 and 2013 were retrospectively analyzed. Univariate and multivariate analyses were performed to identify prognostic factors. The Kaplan-Meier method was used to compare survival differences with respect to each prognostic factor. RESULTS: Thirty-nine patients had tumors invading the circular muscle layer and were designated as having T2a disease. The remaining 46 patients had T2b disease, with tumors invading the longitudinal muscle layer. The overall 1-, 3-, and 5-year survival rates were 96.1, 53.8, and 36.4 %, respectively, with a median survival of 39.0 months. Univariate analysis indicated that sex, smoking history, grade, location, and tumor length did not significantly influence on survival. Only T stage (P = 0.017) and N stage (P = 0.003) were associated with survival. The results of multivariate Cox proportional hazard regression analysis showed that T stage (P = 0.045) and N stage (P = 0.003) were independent prognostic factors. CONCLUSIONS: N stage and subclassified T stage are independent prognostic factors in patients with T2 tumors. Therefore, we concluded that T2 tumors can be subclassified further into T2a and T2b stages, and patients with different T2 stages may have different prognoses.

CYP1A2 rs762551 polymorphism contributes to risk of lung cancer: a meta-analysis.

Previous studies proposed that CYP1A2 rs762551 polymorphism might be associated with risk of lung cancer by influencing the function of CYP1A2. However, previous studies on the association between CYP1A2 rs762551 polymorphism and risk of lung cancer reported inconsistent findings. We performed a meta-analysis of the published case-control studies to assess the association between CYP1A2 rs762551 polymorphism and risk of lung cancer. PubMed and Embase were searched to identify relevant studies on the association between CYP1A2 rs762551 polymorphism and risk of lung cancer, and seven studies with a total of 3,320 subjects were finally included into the meta-analysis. The pooled odds ratio (OR) and 95 % confidence interval (95%CI) was calculated to evaluate the association. Meta-analysis of total studies showed that CYP1A2 rs762551 polymorphism contributed to risk of lung cancer under all four genetic models (C versus A: OR = 1.26, 95%CI 1.13 to 1.40, P < 0.001; CC versus AA: OR = 1.61, 95%CI 1.28 to 2.04, P < 0.001; CC versus AA/AC: OR = 1.52, 95%CI 1.11 to 2.09, P = 0.009; CC/AC versus AA: OR = 1.28, 95%CI 1.10 to 1.48, P = 0.001). Subgroup analysis based on ethnicity further suggested that CYP1A2 rs762551 polymorphism was associated with risk of lung cancer in Caucasians. These results from the meta-analysis suggest that CYP1A2 rs762551 polymorphism contributes to risk of lung cancer.

Overexpression of Sox3 is associated with diminished prognosis in esophageal squamous cell carcinoma.

BACKGROUND: Esophageal squamous cell carcinoma (ESCC) is a lethal malignancy lacking valid prognostic biomarkers. As a member of the High Mobility Group domain-containing DNA-binding proteins, Sox3 has been reported to induce oncogenic transformation of chicken embryo fibroblasts. However, the expression and prognostic value of Sox3 in ESCC remain unclear. METHODS: A total of 30 pairs of ESCC with a corresponding non-neoplastic esophageal epithelium (NE) specimen were investigated for Sox3 expression using RT-PCR and western blot analysis. Tissue microarrays containing 118 ESCC and 30 NE samples were detected for Sox3 expression using immunohistochemical staining. The relationship of Sox3 staining with various clinicopathological characteristics and survival of patients was statistically analyzed. RESULTS: Sox3 expression in ESCC was 3.1- and 2.7-fold higher than in NE at mRNA (P < 0.001) and protein level (P < 0.001), respectively. Positive staining of Sox3 was observed in 77.1 % of the ESCC and 16.7 % of the NE samples (P < 0.001). High expression of Sox3 was significantly correlated with the regional lymph nodes metastasis (RLNM) (P = 0.022) and advanced TNM stage (P = 0.011). Moreover, high expression of Sox3 was significantly associated with poor overall survival (P < 0.001) and recurrence-free survival (P < 0.001) in ESCC patients. Both Sox3 expression (P < 0.001) and RLNM (P = 0.002) were independent prognostic factors for patients with ESCC. CONCLUSIONS: Sox3 might play a positive role in tumor development and could serve as an independent predictor of poor prognosis for ESCC.

Lateral position could provide more excellent hemodynamic parameters during video-assisted thoracoscopic esophagectomy for cancer.

BACKGROUND: Thoracoscopic esophagectomy is a feasible technique that has been shown to be safe for the treatment of esophageal cancer. There continues to be controversy about the optimal position during thoracoscopic esophagectomy. In this study, we compared the intraoperative hemodynamic parameters, clinical pathological characteristics, as well as postoperative complications in patients who underwent thoracoscopic esophagectomy in the prone position (PP) or left-lateral decubitus position (LDP). METHODS: Between January 2011 and June 2011, 23 patients underwent thoracoscopic esophagectomies for cancer of the esophagus in LDP (group A). Since February 2011, we have performed thoracoscopic esophagectomies for cancer of the esophagus in PP for 21 patients (group B). The demographics and clinicopathologic factors, as well as the intraoperative hemodynamic parameters, of the two groups were analyzed. RESULTS: No postoperative death occurred in these 44 patients. Overall morbidity was similar in the two groups. No significant difference in the length of operation or number of retrieved mediastinal nodes between the two groups was observed, but the intraoperative blood loss in group A was significantly higher than in group B (P = 0.0228). There was no significant difference of the intraoperative mean arterial pressure, central venous pressure, heart rate, and stroke volume variation between the two groups and various positions. In group A, the cardiac output (CO), cardiac index (CI), as well as stroke volume index (SVI) did not exhibit significant difference after altering patients' position from LDP to SP. However, patients who underwent thorascopic esophagectomy in PP had lower CO, CI, and SVI than in LDP during the thoracoscopic stage. CONCLUSIONS: Compared with the PP, the LDP could provide more excellent hemodynamic parameters during thoracoscopic esophagectomy. However, the various hemodynamic statuses did not exert significant influence on the occurrence of postoperative complications.

One surgeon's learning curve for video-assisted thoracoscopic esophagectomy for esophageal cancer with the patient in lateral position: how many cases are needed to reach competence?

BACKGROUND: Minimally invasive esophagectomy is a feasible technique shown to be safe and oncologically adequate for the treatment of esophageal cancer. This study aimed to describe one surgeon's learning curve for video-assisted thoracoscopic esophagectomy with the patient in lateral position. METHODS: From May 2010 to June 2012, 89 thoracoscopic esophagectomies for esophageal cancer were performed by one surgeon. The patients were divided into three groups. Group A included the first 30 cases. Group B comprised cases 31 to 60, and group C included the final 29 cases. The demographic characteristics and the intra- and postoperative variables were collected retrospectively and analyzed. RESULTS: One postoperative death occurred. Eight patients required conversion. No significant difference in background or clinicopathologic factors among the three groups was observed. Compared with group A, a significant decrease in intrathoracic operative time (107.7 ± 16.2 min; P = 0.0000), total operative time (326.3 ± 40.7 min; P = 0.0002), and blood loss (290.8 ± 114.3 ml; P = 0.0129) was observed in group B, whereas more retrieved nodes were harvested (20.1 ± 9.5; P = 0.0002). The last 29 patients (group C) involved significantly less intrathoracic operative time (82.8 ± 18.4 min; P = 0.0386), total operative time (294.7 ± 37.4 min; P = 0.0009), and blood loss (234.7 ± 87.8 ml; P = 0.0125) as well as a shorter postoperative hospital stay (12.4 ± 3.7 days; P = 0.0125) compared with group B. A significant decline in the overall morbidity from group A to group C (P = 0.0005) also was observed. CONCLUSIONS: The results of this study suggest that at least 30 cases were needed to reach the plateau of thoracoscopic esophagectomy. After more than 60 cases of thoracoscopic esophagectomies had been managed, lower morbidity could be obtained.

Prevention of postoperative chylothorax with thoracic duct ligation during video-assisted thoracoscopic esophagectomy for cancer.

BACKGROUND: Minimally invasive esophagectomy (MIE) is a feasible technique that has been shown to be safe for the treatment of esophageal cancer. Chylothorax remains a challenging and potentially life-threatening postoperative complication of MIE. In this retrospective series, we evaluated the results of preventive intraoperative thoracic duct ligation in patients who underwent video-assisted thoracoscopic esophagectomy for cancer. METHODS: From May 2009 to June 2010, 70 video-assisted thoracoscopic esophagectomies for cancer of the esophagus (group A) were performed without prophylactic thoracic duct ligation. Since June 2010, 65 patients (group B) with esophageal cancer underwent video-assisted thoracoscopic esophagectomy with routine ligation of the thoracic duct during the operation. RESULTS: No intraoperative or postoperative complications directly related to thoracic duct ligation were recorded. Postoperative chylothorax occurred in seven patients in group A and in one patient in group B (P = 0.0375). CONCLUSIONS: The results of this study suggest that thoracic duct ligation during video-assisted thoracoscopic esophagectomy for cancer is an effective and safe method for prevention of postoperative chylothorax.

Zinc induces cell cycle arrest and apoptosis by upregulation of WIG-1 in esophageal squamous cancer cell line EC109.

Zinc deficiency was implicated in the etiologies of human esophageal squamous cell carcinoma (ESCC). Wild-type p53-induced gene 1 (WIG-1), a kind of zinc finger protein, was cloned from the human 3q26.3 region and encoded a putative polypeptide of 289 amino acids. Our previous studies have demonstrated that the expression of WIG-1 was downregulated in ESCC tissues. Herein, we investigated the effect of zinc on cell proliferation, apoptosis, as well as expression of WIG-1 in EC109 cells. Meanwhile, an RNAi vector of WIG-1 was transfected into EC109 cells and the effect of zinc on WIG-1 expression was investigated. We found that zinc could suppress cell proliferation and induce G0/G1 cell cycle arrest and apoptosis of EC109, and this efficacy might result from the expression altering of several apoptosis-related genes, such as Bax, p21 ( WAF ), and cyclin D1. In particular, upregulation of WIG-1 was observed after zinc supplementation, indicating that WIG-1 might be involved in the zinc-induced cell cycle arrest and apoptosis of EC109 cells by regulating the expression of Bax, p21 ( WAF ), and cyclin D1.

Optimization of sympathectomy to treat palmar hyperhidrosis: the systematic review and meta-analysis of studies published during the past decade.

OBJECTIVE: The systemic review and meta-analysis of the studies published during the past 10 years was designed to optimize the surgical procedures of video-assisted thoracoscopic sympathectomy (VTS) to treat palmar hyperhidrosis (PH). METHODS: Citations from 2000 to 2010 were included regarding the following aspects: selection of ganglia level for VTS, comparison of different techniques for VTS, evaluating clinical efficacy of intraoperative intrapleural analgesia, and postoperative intrapleural drainage. Major clinical outcomes are defined as: cases with postoperative resolution of symptoms, total cases with postoperative compensatory hyperhidrosis (CH), cases with severe or moderate CH, satisfied cases, evaluation of postoperative pain, and postoperative pneumothorax. RESULTS: Systemic review indicates that T3 and T3-4 sympathectomy had the "best" clinical efficacy. Meta-analysis suggests that efficacious rates of PH are nearly similar compared with multiple and single ganglia sympathectomy (100 vs. 95.6%). However, single-ganglia sympathectomy can render a lower risk of total CH compared with multiple-ganglia block. Risk of moderate/severe CH has a similar trend. Additionally, single-ganglia sympathectomy is more potent to satisfy patients postoperatively. One randomized, controlled trial (RCT) that compared different techniques for VTS indicated that the overall success rate of the operation was 95% and the differences were not statistically significant. Two RCTs indicated that there were significant differences between trial group (intraoperative intercostal nerve blocks using bupivacaine) and control group regarding the attenuation of postoperative pain. One RCT suggested that there was no significant difference with or without pleural drainage regarding the incidence of postoperative residual pneumothorax. CONCLUSIONS: T3 sympathectomy is supposed to be recommended for the treatment of PH regardless of using various techniques. Intraoperative intrapleural analgesia using bupivacaine or bupivacaine plus epinephrine is effective to prevent postoperative pain. Pleural drainage after VTS should be abandoned.

Retrospective analysis for thirty-nine patients with solitary fibrous tumor of pleura and review of the literature.

BACKGROUND: Solitary fibrous tumor of the pleura (SFTP) is an uncommon neoplasm arising from mesenchymal cells. The aim of this study is to summarize the experience and the outcome of the surgical treatment for 39 cases of SFTP. METHODS: From January 2004 to December 2008, 39 patients underwent surgical resection of SFTP in our department. All patients had clinical follow-up by the same team of surgeons. The mean follow-up was 40.3 months. RESULTS: A local removal of the neoplasm was accomplished by video-assisted thoracic surgery (VATS) in 9 patients (group A) and by thoracotomy in 30 patients (group B) respectively. Comparing with group B, operations in group A took significantly less operative time, blood loss and spent less time in the intensive care unit and hospital. All specimens were positive for CD34 and Bcl-2. One patient developed recurrence, and the remaining 38 patients are alive and disease free at the end of follow-up. CONCLUSIONS: Malignant SFTP still had the potential recurrence. VATS represents the more acceptable choice for the selected patients with SFTP.

Prevention of early delayed gastric emptying after high-level esophagogastrostomy by "pyloric digital fracture".

OBJECTIVE: This study was designed to evaluate the clinical efficacy of pyloric digital fracture for the prevention of early delayed gastric emptying (DGE) after high-level esophagogastrostomy. METHODS: From January 2004 to March 2009, we sequentially enrolled 78 patients after esophagogastrostomy: 48 patients with pyloric digital fracture (DF group) and 30 patients without any drainage procedure (non-DF group). Intraoperative manometric study was performed in 48 patients of the DF group. Postoperative evaluation was performed, including symptomatic questionnaire, radiographic study, and gastric scintigraphy. RESULTS: Intraoperative manometric study revealed that basal pyloric pressure and peak pressure of pylorus in phase III of the migrating motor complex increased significantly after gastric conduit was made and anastomosed, but decreased appreciably following digital fracture. Compared with the peak pressure of IPPW before digital fracture (88.52 ± 19.88 mmHg), it appreciably decreased following digital fracture (40.45 ± 13.52 mmHg). Occurrences of IPPW (in 10 min) and duration time of each occurrence (s) had similar trends for before and after digital fracture (11.5 ± 4.5 vs. 5.0 ± 3.5 and 7.0 ± 2.0 vs. 3.0 ± 1.0, respectively). Postoperative evaluation demonstrated that early DGE occurred in four patients in the non-DF group (13.3%), and there was no DGE patient in the DF group. There was significant difference regarding gastric scores between the DF group and the non-DF group (10.5 ± 3.4 vs. 16.7 ± 3.8, t = 2.8271, P < 0.05). Gastric scintigraphy revealed that either semi-emptying-time or percent of retention at 4 h of the DF group was significantly lower than that of the non-DF group. CONCLUSION: Pyloric digital fracture can prevent early DGE after high-level esophagogastrostomy efficaciously and conveniently.

Erratum: P130cas is required for TGF-ß1-mediated epithelial-mesenchymal transition in lung cancer.

[This corrects the article DOI: 10.3892/ol.2014.2123.].

Upregulation of ZNRD1 enhances cisplatin resistance in human esophageal cancer cells by regulation of ERCC1 and Bcl-2.

BACKGROUND/AIMS: The precise mechanism of the zinc ribbon domain-containing-1 (ZNRD1) gene on cisplatin resistance remains unclear. The aim of this study is to identify the gene expression profile and explore the role of these genes in ZNRD1-induced cisplatin resistance in esophageal cancer cells. METHODS: An expression vector with ZNRD1 was transfected into the EC109 cells, and then cDNA microarray analysis was performed to identify the gene expression profile. The sensitivity of transfected EC109 cells to cisplatin was evaluated using the MTT assay. RT-PCR and Western blots were performed to validate the differential expression of genes identified by cDNA microarray analysis. RESULTS: We identified 16 genes with significantly different expression levels between the transfected and control cells. The tolerance of EC109 cells to cisplatin was significantly enhanced by the upregulation of ZNRD1. Furthermore, the expression of excision repair cross-complementing-1 (ERCC1) and B-cell lymphoma-2 (Bcl-2) was significantly upregulated. CONCLUSION: The ZNRD1 gene might be involved in the cisplatin resistance of EC109 cells by regulating the expression of ERCC1 and Bcl-2.

Restoring the metabolic disturbance of zinc: may not only contribute to the prevention of esophageal squamous cell cancer.

The relationship between zinc deficiency (ZD) and esophageal squamous cell cancer (ESCC) is well-established. Zinc supplement has long been considered as potential strategy for prevention of ESCC. However, the effect of zinc replenishment on prevention of ESCC is still in controversy and no convincing evidence to support these proposals has become known. We hypothesized that zinc deficiency might be the major initiator for dysfunction of numerous genes and subsequent carcinogenesis of esophagus, and replenishment of zinc might improve the prognosis of patients with ESCC.

[Thymectomy for myasthenia gravis by video-assisted thoracoscopic surgery through right anterior-lateral approach].

OBJECTIVE: To evaluate the feasibility and curative effect of thymectomy for myasthenia gravis (MG) by video-assisted thoracoscopic surgery (VATS) through right anterior-lateral approach. METHODS: Fifty-six patients of MG were treated with thoracoscopic thymectomy and mediastinal fat dissection through right anterior-lateral approach from August 2001 to October 2007. The feasibility, safety, complication and remission for MG were retrospectively analyzed. RESULTS: Fifty-five operations were completed by VATS. The mean operative time and blood loss were (96.2 +/- 52.1) min and (68.7 +/- 21.4) ml, respectively. The brachiocephalic vein injury by the electric coagulator occurred in two cases and one of them performed thoracotomy for homeostasis, the other performed ligation. The postoperative pathology showed hyperplasia in 38 cases, atrophy in 5 cases, thymoma in 12 cases and cyst of thymus in 1 case. And the operative complication included one myasthenia crisis (1.8%) at the third day and one death (1.8%) at the eighth day because of postoperative hemorrhage. The average length of stay was (7.9 +/- 2.9) d. All cases were followed up from one to seventy months. Eight (14.3%) of complete remission, 39 cases (69.6%) of partial remission and 7 cases (12.5%) of no change were found. The total effective rate was 83.9%. CONCLUSIONS: Thoracoscopic thymectomy through right anterior lateral approach is technically feasible, safe and minimally invasive. It has a high remission rate for MG.

Prevention of stricture with intraluminal stenting through laparotomy after corrosive esophageal burns.

OBJECTIVE: We sought to present our experience in preventing esophageal stricture formation using modified intraluminal stenting in patients with caustic burns. METHODS: Between April 1976 and June 2005, 33 of 162 patients with corrosive esophageal burns were included in this study. Endoscopy was performed to define the degree of injury in all the patients but one. Among the 33 patients, 31 underwent modified esophageal intraluminal stenting through laparotomy 2-3 weeks after ingestion of corrosive agent and the remaining 2 patients underwent immediately after experiencing esophageal perforation. RESULTS: There was no death in this series. A 1-year-old child had aspiratory pneumonia because of poor compliance. The stent was removed without requiring anesthesia after it had been in situ for 4-6 months in the 33 patients. All the patients had a normal intake of food after removal of the stents, and stricture was not found on barium swallow. However, five patients had esophageal stenosis from 2 to 3 months during follow-up. One of them responded to esophageal bougienage, the remaining four patients required esophageal reconstruction and had a normal diet postoperatively. Twenty-four-hour pH monitoring in five patients showed that there was no gastroesophageal reflux. CONCLUSION: The modified esophageal intraluminal stent is able to prevent the formation of caustic esophageal stricture.

Management of corrosive esophageal burns in 149 cases.

OBJECTIVES: We sought to present our experience in the management of esophageal burns. METHODS: From April 1976 through October 2003, 149 patients with corrosive esophageal burns were included in this study. Treatment modalities consisted of modified intraluminal stenting in 28, colon interposition in 71, gastric transposition in 25, repair of cervical stricture with platysma myocutaneous flap in 17, and miscellaneous operations in 12 patients. Eleven of these patients underwent the above procedures twice at our institute. The remaining 7 patients were treated with conservative therapy. RESULTS: Twenty-three patients recovered from intraluminal stenting, and 5 experienced stricture after stent removal. One of the 5 patients with failed stents responded to bougienage, and the remaining 4 patients required esophageal reconstruction later. Of the 71 colon interpositions, 5 patients died postoperatively, and complications consisted of proximal anastomotic fistula in 17, anastomotic stenosis in 6, and abdominal incision dehiscence in 2 patients. Postoperative complications in the 25 patients with gastric transpositions comprised anastomotic stricture in 2 patients and empyema in 1 patient. There was a cervical leak in 1 of the 17 patients undergoing the repair of cervical esophageal or anastomotic stricture with a platysma myocutaneous flap. One of the patients in the group undergoing 12 miscellaneous procedures died 8 months after surgical intervention. All the survivors currently eat regular diets. CONCLUSIONS: Intraluminal stenting can prevent the formation of caustic esophageal stricture. The location of the cicatricial esophagus dictates whether to perform concomitant esophagectomy during esophageal reconstruction. Platysma myocutaneous flap repair is an excellent method for the treatment of severe cervical esophageal or anastomotic stricture.