A New Risk Factor for Cervical Anastomotic Leakage-Role of The Relative Gastric Length in the Surgical Treatment of Esophageal Cancer.

BACKGROUND: Blood supply is especially weak near the gastric fundus. Making the anastomosis in this area would increase the risk of anastomotic leakage (AL). In cervical anastomosis, the gastric conduit needs to travel through the thorax. Therefore, the relative length between the stomach and the thorax is an essential factor in deciding if the poorly supplied area could be removed. This study was to explore if a small relative gastric length was a risk of cervical AL. If all other conditions are equal, could intrathoracic anastomosis be a better choice? METHODS: Patients who underwent esophagectomy with a preoperative barium swallow in West China Hospital between 2014 and 2017 were included. The length of the greater curvature and the thorax were obtained from the barium esophagogram. The ratio between the length of the greater curvature and the thorax was the relative gastric length calculated from the greater curvature (RGL-G). RESULTS: A total of 782 patients were enrolled in the final analysis. The cervical AL group had a significantly higher ratio of patients with an RGL-G less than 1.3 (26.7% vs. 8.9%, p = 0.003). The multivariate logistic regression proved that RGL-G less than 1.3 was a risk factor for cervical anastomotic leakage (p = 0.012). Correspondingly, RGL-G less than 1.3 was not a risk factor (6.3% vs. 14.3%, p = 0.289) in the intrathoracic anastomosis group. CONCLUSIONS: RGL-G less than 1.3 was a new risk factor for cervical AL, but it would not be a problem for intrathoracic anastomosis.

Safety profile of preoperative administration of low-molecular-weight heparin on minimally invasive lung cancer surgery: a randomized controlled trial.

BACKGROUND: Venous thromboembolism remains a common but preventable complication for cancerous lung surgical patients. Current guidelines recommend thromboprophylaxis for lung patients at high risk of thrombosis, while a consensus about specific administration time is not reached. This study was designed to investigate the safety profile of preoperative administration of low-molecular-weight-heparin (LMWH) for lung cancer patients. METHODS: From July 2017 to June 2018, patients prepared to undergo lung cancer surgery were randomly divided into the preoperative LMWH-administration group (PRL) for 4000 IU per day and the postoperative LMWH-administration group (POL) with same dosage, all the patients received thromboprophylaxis until discharge. Baseline characteristics including demographics and preoperative coagulation parameters were analyzed, while the endpoints included postoperative coagulation parameters, postoperative drainage data, hematologic data, intraoperative bleeding volume and reoperation rate. RESULTS: A total of 246 patients were collected in this RCT, 34 patients were excluded according to exclusion criterion, 101 patients were assigned to PRL group and 111 patients belonged to POL group for analysis finally. The baseline characteristic and preoperative coagulation parameters were all comparable except the PRL group cost more operation time (p = 0.008) and preoperative administration duration was significantly longer (p < 0.001). The endpoints including postoperative day 1 coagulation parameters, mean and total drainage volume, drainage duration, intraoperative bleeding volume and reoperation rate were all similar between the two groups. Moreover, coagulation parameters for postoperative day 3 between the two groups demonstrated no difference. CONCLUSION: Preoperative administration of low-molecular-weight-heparin demonstrated safety and feasibility for lung cancer patients intended to receive minimally invasive surgery. TRIAL REGISTRATION: ChiCTR2000040547 ( www.chictr.org.cn ), 2020/12/1, retrospectively registered.

[Three Dimensional Measurement of the Space Distance Between the Hilum and Clinical Stage T 1 Non-small Cell Lung Cancer and Its Relationship with Lymph Node Metastasis].

OBJECTIVE: The aim of this study was to develop a novel method to quantitatively define the tumor location of clinical stage T 1 (cT 1) non-small cell lung cancer (NSCLC) and to evaluate its impact on lymph node metastasis in a large cohort group. METHODS: We developed a novel method to transform the datum of 2D CT scans to 3D datum and to quantitatively measure the distance between the tumor and hilum through the Pythagorean theorem. Multiple logistic regression analysis was applied to identify the risk factors associated with lymph node metastasis. RESULTS: A total of 399 patients (166 male and 233 female) with cT 1 NSCLC were enrolled in this study. The mean age was (57.48±10.88) yr., the mean distance between tumor and hilum was (5.44±1.96) cm, and the mean tumor diameter was (1.77±0.65) cm. Patients were divided into lymph node positive group (N + group) and lymph node negative group (N － group). By multiple logistic regression analysis, we identified 4 risk variables associated with lymph node metastasis. Gender (odds ratio ( OR)=2.118， P=0.022), distance between tumor and hilum ( OR=0.843， P=0.040), differentiation (moderate vs. high， OR=15.547， P=0.008；poor vs. high， OR=70.749， P=0.000), and cancer embolus ( OR=24.769， P=0.004) were independent risk variables associated with lymph node metastasis. CONCLUSION: Distance between tumor and hilum was identified as an independent risk factor associated with lymph node metastasis in cT 1 NSCLC.

Role of Lower Esophageal Squamous Cell Carcinoma Margin Location on Abdominal Lymph Node Metastasis Risk.

BACKGROUND: Different sites of esophageal cancer are accompanied by different regional lymph node metastasis (LNM) risks. We aimed to investigate the impact of a lower tumor margin on abdominal LNM risk. METHODS: We enrolled patients who underwent esophagectomy for esophageal squamous carcinoma (ESCC) from 2014 to 2017 in West China Hospital. Overall survival (OS) analysis was performed. We measured the distance between the lower tumor margin and esophagogastric junction (LED) with upper gastrointestinal contrast-enhanced X-ray (UGCXR). Multivariate logistic regression analysis and propensity score matching (PSM) were performed to explore the relationship between LED and the risk of abdominal LNM. Abdominal LNM risk in ESCC was stratified based on the location of the lower tumor margin. A model predicting abdominal LNM risk was constructed and presented with a nomogram. RESULTS: The included patients had an abdominal LNM rate of 48.29%. In multivariate logistic regression analysis, LED was identified as a risk factor for abdominal LNM. Subgroup analysis of middle ESCC showed that patients with an LED less than 10 cm had a significantly higher rate of abdominal LNM than those with an LED greater than 10 cm. The abdominal LNM rate in middle ESCC patients with an LED less than 10 cm was 32.2%, while it was 35.1% in lower ESCC patients whose lower tumor margin did not invade the esophagogastric junction (EGJ), which was comparable after PSM. CONCLUSIONS: LED could help surgeons evaluate the risk of abdominal LNM preoperatively and better guide dissection of abdominal lymph nodes according to risk level.

Is the routine placement of a feeding jejunostomy during esophagectomy worthwhile?-a systematic review and meta-analysis.

BACKGROUND: Malnutrition dramatically increases the risk of postoperative complications and delays patient recovery. Therefore, a feeding jejunostomy tube (FJT) is routinely placed during esophagectomy to maintain the postoperative nutrition supply. However, recently published studies have questioned the need of a FJT in every esophageal cancer patient. Because most patients can resume oral intake shortly after surgery, the nutrition-providing function of a FJT becomes much less critical. In contrast, FJT-related complications could be severe. METHODS: Relevant publications were found out by systemic searching of four medical databases (PubMed, EMBASE, Medline, and Cochrane Center Register of Controlled Trials). By reading the titles and the abstracts, potentially relevant studies were screened from the search results. The incidence of postoperative complications and FJT-related complications were calculated and compared to evaluate the efficacy of a FJT. RESULTS: Eighteen studies were included in the meta-analysis. The no-FJT group had a similar or even lower incidence of postoperative complications [anastomotic leakage (AL), pulmonary complications, and wound infections] compared with the FJT group. Ileus and FJT site infections were the most common FJT-related complications. The incidence of ileus was approximately 6% (95% CI: 3-12%), and over 63% of the patients with an ileus required re-operation to relieve the obstruction. The pooled mean rate of FJT site infections was 7% (95% CI: 6-9%). Approximately 7% of patients had dysfunction (obstruction or dislocation) of the jejunostomy tube (95% CI: 3-14%). CONCLUSIONS: The non-selective placement of a FJT during esophagectomy provides few benefits to the patients and may even increase the risk of postoperative complications. Therefore, an intraoperative FJT should be selectively prescribed, but not routinely in the surgical treatment of esophageal cancer.

From McKeown to Ivor Lewis, the learning curve for thoracic lymphadenectomy over the first 100 robotic esophagectomy cases: a retrospective study.

BACKGROUND: Lymphadenectomy is an essential but challenging part of the surgical treatment for esophageal cancer. However, the previously reported learning curve for robotic esophagectomy primarily focused on only one surgical approach (McKeown or Ivor Lewis). However, both approaches must be mastered by a mature robotic surgical team to deal with different clinical conditions and satisfy patients' needs. This study aimed to show how an experienced esophageal surgical team became proficient in both McKeown and Ivor Lewis robotic esophagectomy. METHODS: A retrospective review of the first 100 cases of robot-assisted minimally invasive esophagectomy (RAMIE) by a single surgical team was performed. The cumulative sum (CUSUM) analysis was used to distinguish the change point during the learning course. A subgroup analysis was performed according to a surgical approach (McKeown or Ivor Lewis) to determine the effect of experience from one surgical approach on learning the other RAMIE technique. RESULTS: According to the tendency of the CUSUM plot, the learning curve was divided into four phases. The subgroup analysis indicated the decline of the CUSUM plot in the 3rd phase originated from the start of the Ivor Lewis approach. The attending surgeon took 23 cases to achieve a significant improvement in the number of harvested thoracic lymph nodes using the McKeown approach. Regardless of the acquired experience of McKeown RAMIE, it took another 18 cases for the surgical team to achieve significant improvement in harvesting thoracic lymph nodes using the Ivor Lewis approach. CONCLUSIONS: Twenty-three cases were needed for an experienced surgical team to improve thoracic lymphadenectomy results using McKeown RAMIE. There was another learning phase during the transition from McKeown to Ivor Lewis esophagectomy. Importantly, the acquired experience from performing McKeown RAMIE could shorten how long it takes to learn Ivor Lewis RAMIE.

Pretreatment-assisted robot intrathoracic layered anastomosis: our exploration in Ivor-Lewis esophagectomy.

BACKGROUND: Minimal invasive Ivor-Lewis esophagectomy (MIIVE) with intrathoracic esophago-gastric anastomosis (EGA) is still under exploration and the preferred technique for intrathoracic anastomosis has not been established. METHODS: We retrospectively reviewed 43 consecutive patients who underwent MIIVE using the series technique called pretreatment-assisted robot intrathoracic layered anastomosis (PRILA), performed by a single surgeon between September 2018 and December 2020. The operative outcomes were analyzed. RESULTS: The mean total operation time had been reduced from 446.38±54.775 minutes (range, 354-552) in the first year to 347.70±60.420 minutes (range, 249-450) later. There were no conversions to thoracotomy. All the patients achieved R0 resection. No patient suffered from anastomotic leakage. There was no 30-day mortality. The median length of postoperative stay was 10.0 days. CONCLUSIONS: PRILA further visualizes and streamlines the process of minimal invasive intrathoracic EGA, thus ensuring the precise anastomosis. It could be considered as a feasible alternative for intrathoracic EGA in MIILE.

Is immunonutrition superior to standard enteral nutrition in reducing postoperative complications in patients undergoing esophagectomy? A meta-analysis of randomized controlled trials.

PURPOSE: Perioperative enteral nutrition supports are recommended in esophagus cancer patients. Immunonutrition contains immuno-enhancing nutrients in addition to standard formula. These new nutrients are thought to be efficacious in reducing inflammatory response and improving postoperative immune response and they have been proved to be better than standard enteral nutrition in reducing postoperative complications in gastric cancer. However, if it would lead to a better clinical outcome in patients undergoing esophagectomy remains controversial. METHODS: A systematic literature search was performed in the online database of PubMed, Medline, EMBASE and Cochrane Library. The relevant studies were screened out of the results by reading titles and abstracts. Then, we read the full-texts to finally confirm the studies included in this meta-analysis. RESULTS: Six randomized controlled trials having enrolled 638 patients were included in the final analysis. The pooled analysis didn't show statistically significant difference between immunonutrition group and standard nutrition group in reducing postoperative complications. CONCLUSIONS: The postoperative complications are comparable between immunonutrition and the standard enteral nutrition in patients undergoing esophagectomy, but its value in severe malnutrition patients is undetermined, whereas the high tolerance and other advantages brought by the immunonutrition should not be overlooked and need to be further proved.

Role of nodal skip metastasis in patients with mid-thoracic oesophageal squamous cell carcinoma: a propensity score matching study.

OBJECTIVES: Nodal skip metastasis (NSM) is a common phenomenon in mid-thoracic oesophageal squamous cell carcinoma (MT-OSCC); however, the prognostic implications of NSM in patients with MT-OSCC remain unclear. METHODS: This retrospective study enrolled 300 patients with MT-OSCC who underwent radical oesophagectomy and who had pathologically confirmed lymph node metastasis from January 2014 to December 2016. The patients were divided into 2 groups according to the presence or absence of NSM. Propensity score matching was applied to minimize patient selection bias. The impact of NSM on overall survival (OS) was assessed by Kaplan-Meier and multiple Cox proportional hazards analyses. The median follow-up time was 57 months. RESULTS: The NSM rate in the entire cohort was 22.0% (66/300). Pathological N (pN) stage (P < 0.001) and sex (P = 0.001) were identified as significant independent risk factors for NSM. NSM was more frequent in pN1 compared with pN2 patients (87.9% vs 12.1%, P < 0.001) and no NSM was found in pN3. NSM(+) patients had better prognoses than NSM(-) patients (Kaplan-Meier; 3-year OS, 62.1% vs 34.1%, P < 0.001). Propensity score matching produced 51 matched pairs, and the 3-year OS was still better in the NSM(+) compared with the NSM(-) group (66.7% vs 40.0%, P = 0.025). Multivariable Cox analysis confirmed NSM(+) as an independent factor favouring OS in patients with MT-OSCC. CONCLUSIONS: NSM usually occurs at pN1 stage in patients with MT-OSCC, and is associated with a favourable prognosis.

Predictors for the clinical benefit of anti-PD-1/PD-L1 therapy in advanced gastroesophageal cancer: a meta-analysis of clinical trials.

BACKGROUND: The overall objective response rate (ORR) of published clinical trials in advanced gastroesophageal cancer patients who received anti-program-death-1 (anti-PD-1) or program-death-legend-1 (anti-PD-L1) therapy was only 10%. This ratio is far away from satisfying. It is necessary to identify patients who are more likely to benefit from the treatment. This study aimed to identify the factors with which the patients would have a higher response rate to anti-PD-1/anti-PD-L1 therapy. METHODS: The study was carried out according to the Cochrane handbook for systemic reviews of intervention. The comparisons were conducted according to the patients' characteristics to distinguish the factors with which the patients would have a higher response rate and better survival from the therapy. RESULTS: One thousand and nine hundred ninety-eight patients with advanced gastroesophageal cancer receiving anti-PD-1 or anti-PD-L-1 therapy were enrolled totally. Both the anti-PD-1 and anti-PD-L-1 therapy were significantly more efficacy in patients with high expression of PD-L1. Adenocarcinoma patients with high microsatellite instability (MSI-H) were more likely to benefit from anti-PD-1 therapy. Patients with a better Eastern Cooperative Oncology Group (ECOG) performance status had a significantly higher ORR and disease control rate (DCR). The treatment also had a better performance in improving the overall survival (OS) and progression-free survival (PFS) in patients with high expression of PD-L1. CONCLUSIONS: The expression level of PD-L1, MSI, and ECOG performance status could be the predictors of achieving clinical benefit from anti-PD-1/anti-PD-L1 therapy in advanced gastroesophageal cancer.

The efficacy of ischemic conditioning in the prevention of gastroesophageal anastomotic complications: a meta-analysis.

BACKGROUND: The blood supply to the gastric conduit is thought to be the most crucial factor affecting the healing of the gastroesophageal anastomosis. By selective ligation or embolization of gastric vessels, ischemic conditioning (IC) could promote the hypertrophy and neovascularization of the remaining gastric vessels. So that it could help the stomach adapt to the decline of blood supply before esophagectomy. However, the safety and efficacy of the technique still needs to be proved. Several new studies on this topic have been published recently. We conduct this meta-analysis to update the evidence on this topic. METHODS: A logistic searching strategy was designed to find out related publications on four medical databases (PubMed, EMBASE, Medline, and Cochrane Central Register of controlled trials). The included studies were confirmed by reading the title, abstract, or full text. Based on these included studies, the comparison of postoperative outcomes between patients who received IC and those did not was made. After that, the safety and efficacy of IC were assessed. RESULTS: Fourteen studies were enrolled in the meta-analysis. The pooled analysis showed IC reduced the incidence of anastomotic leakage significantly. And both the embolization and laparoscopic ligation approach were effective. The subgroup analysis indicated the interval between IC and esophagectomy should be over two weeks before the IC worked. The IC also could decrease the anastomotic stricture rate dominantly. What's more, the IC didn't increase the mortality. CONCLUSIONS: This meta-analysis proved that ischemic conditioning is a safe intervention that could reduce anastomotic complications effectively. Future randomized controlled clinical trials are needed to provide high-level evidence on this topic.

Preoperative dilated esophagus is associated with a high risk of intrathoracic anastomotic leakage for patients with esophageal cancer.

BACKGROUND: The association between the preoperative condition of the esophagus and anastomotic leakage has seldom been studied. We observed a dominant dilation of the esophagus under barium esophagography in some esophageal cancer patients. In consideration of the larger circular stapler are applied in colorectal surgery, we wonder if larger circular stapler should be applied in these patients to fit the larger esophagus. The larger size of the circular stapler also could decrease the incidence of anastomosis stricture. Thus, we made this study to explore if patients with a dilated esophagus were facing a higher risk of anastomotic leakage when applying the 25 mm circular stapler. METHODS: A retrospective review of patients undergoing gastroesophageal intrathoracic anastomosis using a 25 mm circular stapler was performed. Patients with endoscopy or barium esophagography confirmed anastomotic leakage was assigned to leakage group (LG) while the left was enrolled in no leakage group (NLG). The measurement of the diameter of the esophagus was carried out at the level of 5 centimeters away from the upper margin of the tumor on esophagography. RESULTS: LG had a greater intraluminal mucosal phase diameter (IMPD) than NLG (P=0.010). The ROC curve indicated 1.79 cm as the cutoff value for IMPD. Patients with IMPD greater than 1.79 cm had a statistically significant higher rate of leakage. In the multivariate logistic regression analysis, dilated IMPD was proven to be a risk factor of 25 mm-circular-stapler anastomotic leakage. CONCLUSIONS: Patients with an IMPD over 1.79 mm are facing a higher risk of intrathoracic anastomosis leakage when applying the 25 mm circular stapler. Larger circular stapler or hand-sewn would be the better choice for these patients.

Predictive Value of Excision Repair Cross-Complementation Group 1 in the Response to Platinum-Based Chemotherapy in Esophageal Cancer: A Meta-Analysis.

INTRODUCTION: Platinum is widely used in the treatment of esophageal cancer. In clinical practice, it is significant to distinguish patients who respond to platinum from those who do not. Excision repair cross-complementation group 1 (ERCC1) is thought to be the key in the resistance to platinum. However, whether it is related to the platinum-based chemotherapy response on real esophageal cancer patients is controversial. We conducted this meta-analysis to explore the association between ERCC1 polymorphisms, its expression levels and platinum-based chemotherapy response, and identify the most sensitive genotypes. METHODS: The study was carried out according to the Cochrane handbook for systemic reviews of intervention. The study protocol has been registered on PROSPERO. RESULTS: Three studies were included in the analysis of C8092A polymorphisms, 5 in the C118T, and another 6 in ERCC1 expression levels. In C118T polymorphisms, compared to wild genotype, patients with mutant genotypes had a significantly higher response rate. As for C8092A polymorphisms, the mutant genotypes also presented a better response than the wild genotype. The pooled analysis indicated a significantly higher response rate in patients with a low expression of ERCC1. CONCLUSIONS: ERCC1 is a valuable biomarker for platinum-based chemotherapy in esophageal cancer. Patients with ERCC1 mutations or low-level ERCC1 expression are more sensitive to platinum-based chemotherapy.

Fixed in the neck or pushed back into the thorax?-Impact of cervical anastomosis position on anastomosis healing.

BACKGROUND: Cervical anastomotic leakage remains a great challenge for thoracic surgeons in the surgical treatment of esophageal cancer. Among the factors affecting cervical anastomosis healing, the surgical technique is the key controllable element. This study aimed to identify the risk factors of cervical anastomotic leakage after McKeown esophagectomy, especially those controllable surgical factors. METHODS: A retrospective review of patients who underwent McKeown esophagectomy in the past eight years in West China Hospital was performed. Patients with cervical anastomotic leakage were assigned to leakage group (LG) while the left was enrolled in the none-leakage group (NLG). Multivariate logistic regression analysis was used to identify independent risk factors of anastomotic leakage. RESULTS: A total of 518 patients were enrolled in the final analysis. In the baseline comparison, the difference in fixation of anastomosis in the neck, anastomosis mode, diabetes, and hypertension between the LG and NLG reached statistically significant. Moreover, the statistical difference of cervical fixation, anastomosis mode, and hypertension remained significant in the multivariate logistic regression analysis. CONCLUSIONS: The cervical anastomosis fixation, anastomosis mode, and hypertension are independent risk factors of gastroesophageal cervical anastomotic leakage.

Role of everolimus in the treatment of advanced neuroendocrine tumor: a meta-analysis of randomized trials.

PURPOSE: There are two fundamentally groups of neuroendocrine neoplasms: neuroendocrine tumors (NETs) and neuroendocrine carcinomas (NECs). Target therapy plays a quite important role in the treatment of NETs. However, whether everolimus (mTOR inhibitor) could improve the overall survival (OS) of NETs is contradictory and the efficacy of the agent in NETs from specific organ is lacking analysis. This meta-analysis enrolled the relevant published trials to see the results in a large sample size and further analyzed the efficacy of everolimus according to the tumor origin. METHODS: A systemic search was performed on four major medical databases and related studies were screened out of the result. All the works were done by two reviewers independently and then checked with each other. RESULTS: Finally, 5 articles and 4 conference abstracts from 3 trials were included. All of the trials indicated a statistically significant difference of progression free survival (PFS) in patients receiving everolimus. And the statistic difference remained significant when it came to the NETs from specific organ (overall HR=0.42, 95%CI 0.35, 0.51). As for OS, all the three trials showed no statistically significant difference between the experimental group (patients receiving everolimus) and control group (patients receiving placebo) and the pooled analysis also indicated no significant difference (HR=0.95, 95%CI 0.71,1.25, p=0.695). CONCLUSION: Everolimus is effective in improving the PFS of NETs and the statistical difference remained significant when it came to the NETs from specific organs.

Preoperative prognostic nutritional index shows no significant prognostic value for short-term outcomes of anastomosis-leakage patients after cancerous esophagectomy.

BACKGROUND: The relationship between preoperative nutritional and immunological status and long-term outcome after cancerous esophagectomy has been investigated widely. Growing evidence also demonstrated preoperative nutritional and immunological status also affects short-term outcome after surgery for esophageal cancer. However, the relationship between preoperative nutritional and immunological status and short-term outcome of anastomosis-leakage patients after cancerous esophagectomy was scarce. The aim of this study was to evaluate the association between preoperative prognostic nutritional index (PNI) and short-term outcome of anastomosis-leakage patients after surgery. METHODS: In this study, we retrospectively enrolled 90 patients who were confirmed to be esophageal cancer by preoperative biopsy or postoperative pathological review and also suffered postoperative anastomotic leakage from January 2014 to June 2017 at the Department of Thoracic Surgery, West China Hospital. Then we evaluated the association between PNI and short-term surgical outcome. The endpoints included postoperative mortality, postoperative hospital duration, postoperative intensive care unit (ICU) duration, hospitalization cost. RESULTS: The cut-off value of PNI was set at 49.83 in our study, patients with a preoperative PNI ≥49.83 were divided into high-PNI group, while those with a preoperative PNI <49.83 were classified into low-PNI group. For the postoperative anastomosis-leakage patients in the two groups, baseline characteristics were all comparable, and analysis revealed no significantly statistical difference between the two groups regarding mortality, postoperative hospital duration and postoperative ICU duration. Though mean hospital-duration cost (144,791.08±87,312.87 vs. 127,364.25±69,233.16) was more in the low-PNI group, there was still no significant difference demonstrated (P=0.297). There was no significant difference revealed between the subgroups of non-death patients from the two original groups concerning the endpoints, while the hospital-duration cost of the high-PNI group tended to be lower than low-PNI group (125,262.80±71,304.12 vs. 136,421.60±77,052.49, P=0.503). CONCLUSIONS: Although in-hospital cost of high-PNI group tended to be lower than low-PNI group, preoperative PNI showed no significant prognostic value for short-outcomes of anastomosis-leakage patients after cancerous esophagectomy. More prospective studies were badly needed to provide more evidence in the future.

Tumor location is an independent prognostic factor of esophageal adenocarcinoma based on the eighth edition of TNM staging system in Chinese patients.

BACKGROUND: Whether tumor location has any impact on the survival of esophageal adenocarcinoma patients remains unclear. Therefore, we aimed to investigate the prognostic value of tumor location for esophageal adenocarcinoma based on the eighth edition of tumor-node-metastasis (TNM) staging system in Chinese patients for the first time. METHODS: We conducted a retrospective analysis of patients undergoing esophagectomy for esophageal adenocarcinoma in our department. We analyzed the data about demography, comorbidity, pathologic findings, surgical approach, adjuvant therapy, and survival time. Tumor location was categorized into two groups: adenocarcinomas at the esophagogastric junction (EGJ) and adenocarcinomas at other sites of the esophagus. Both univariate and multivariate analyses were applied. And propensity-score matched (PSM) analysis was also conducted for comparison. RESULTS: A total of 107 patients from January 2009 to December 2015 were involved in the analysis. The median follow-up time was 60.0 months and the median survival time of all those patients was 41.0 months. In the univariate analysis, adenocarcinomas in the EGJ (P=0.047), early pT stage (P=0.030), and moderate/well differentiation (P=0.022) were significantly correlated with better survival. Moreover, in the multivariate analysis, tumor site [hazard ratio (HR) =0.536; 95% confidence interval (CI) =0.300-0.958], pT stage (HR =0.298; 95% CI =0.124-0.717), and tumor differentiation (HR =0.437; 95% CI =0.238-0.802) were significant independent prognostic factors for overall survival of these esophageal adenocarcinoma patients. After the adjustment by PSM, patients with adenocarcinomas at the EGJ still yielded significantly longer survival than these with adenocarcinomas at other sites of the esophagus (P=0.039). CONCLUSIONS: Tumor location was an independent prognostic factor for esophageal adenocarcinoma based on the eighth edition of TNM staging system in Chinese patients. Therefore, different surgical therapeutic modalities may be applied for esophageal adenocarcinoma with different tumor locations.

Ergonomic thoracic port design for video-assisted thoracoscopic minimally invasive esophagectomy and lymphadenectomy: a preliminary pilot study.

BACKGROUND: Video-assisted minimally invasive esophagectomy (MIE) has been widely applied in clinical practice. However, the optimal port design for thoracoscopic esophagectomy and lymphadenectomy has not been well established. Here we introduced our novel ergonomic thoracic port design as well as our novel procedures of lymphadenectomy via tissue interactive retraction and compared its effects with that of conventional port design in this pilot study. METHODS: Patients undergoing McKeown MIE from January 2018 to December 2018 in one surgical team were randomly assigned into the ergonomic port design group and conventional port design group. Data of baseline characteristics, perioperative outcomes, and ergonomic assessment were collected and compared between the two groups. RESULTS: A total of 70 patients undergoing curative McKeown MIE were randomly assigned and there were 35 patients in each group. The baseline characteristics between the two groups were comparable and well-matched. Moreover, there was no significant difference of number of total dissected lymph nodes, positive lymph nodes and total dissected mediastinal lymph nodes between the two groups. As for perioperative outcomes, there was also no significant difference of in-operating time and blood loss in the thoracic part between the two groups. However, there were significantly less times of forced pause of the surgeon by fatigue during thoracic part in the ergonomic group compared to conventional group (mean time: 1.1 vs. 7.4, respectively; P<0.001) and the symptom score referable to the musculoskeletal system by the surgeon was significantly lower in the ergonomic group than in the conventional group (2.3 vs. 7.6; P<0.001). Postoperatively, there was no significant difference of hospital stay duration and rate of complication and 30-day mortality between the two groups. CONCLUSIONS: Our novel thoracoscopic port design and procedures of lymphadenectomy was proved to be feasible and ergonomic, which could be easily mastered by most of the thoracic surgeons.

Preoperative thromboprophylactic administration of low-molecular-weight-heparin significantly decreased the risk of intraoperative bleeding compared with heparin in patients undergoing video-assisted lobectomy for lung cancer.

BACKGROUND: Due to the threat from venous thromboembolism (VTE) after major thoracic surgery, especially for cancers, guidelines recommend either heparin sodium (unfractionated heparin) or low-molecular-weight-heparin (LMWH) for those patients at high risk of deep vein thrombosis (DVT). However, risk of bleeding remains a major concern for pre-operative administration of anti-coagulation agents. Therefore, this study aimed to compare the bleeding risk of preoperative administration of LMWH and heparin in patients undergoing video-assisted thoracic surgery (VATS) lobectomy for lung cancer. METHODS: A retrospective, single-center study was designed. A total of 130 patients diagnosed with lung cancer were included from August 2016 to January 2018. These patients were divided into two groups. The preoperative administration of heparin group (PH group) had received heparin 5,000 IU, BID (twice a day) both pre- and post-operatively. And the LMWH group (PL group) had received LMWH 4,000 IU, QD (once a day) both pre- and post-operatively. These anticoagulants would not be ceased until patient was discharged or 24-hour postoperative chest drainage volume exceeded 500 mL. Both preoperative and postoperative coagulation parameters including platelet count (PLT), hemoglobin value (HGB), international normalized ratio (INR), prothrombin time (PT), activated partial thromboplastin time (APTT), fibrinogen (FIB), thrombin time (TT), postoperative drainage parameters and intraoperative bleeding volume were compared. RESULTS: A total of 62 patients were collected in PH group, while 68 patients comprised PL group. Preoperative coagulation parameters, hematologic data and demographic data were comparable. Preoperative duration of two agents (P=0.414), operation time (P=0.155), postoperative HGB (P=0.943), PLT (P=0.244), INR (P=0.469), PT (P=0.651), TT (P=0.407), FIB (P=0.151), drainage duration (P=0.800), duration of heparin and LMWH (P=0.778) were all comparable between the two groups. Compared with PL group, intraoperative bleeding volume (105.11 and 50.26, P<0.001) and postoperative mean drainage volume (251.52 and 216.90 mL, P=0.025) of PH group were significant more. Postoperative APTT (30.17 vs. 28.20 seconds, P=0.022) was significantly longer in PH group. CONCLUSIONS: Compared with preoperative administration of heparin, preoperative thromboprophylactic administration of LMWH significantly decreased the risk of intraoperative bleeding in VATS lobectomy.

Novel biologic factors correlated to visceral pleural invasion in early-stage non-small cell lung cancer less than 3 cm.

BACKGROUND: Visceral pleural invasion (VPI) in early-stage non-small cell lung cancer (NSCLC) is traditionally believed as the result of too much close distance between cancerous lesion and the visceral pleura, but whether there are any other biologic factors correlated to VPI beyond our instinctive thoughts remains unclear. Therefore, we conducted this study to investigate potential factors correlated to VPI comprehensively. METHODS: Both clinical and pathological characteristics of patients undergoing surgery for NSCLC with a size of ≤3 cm were retrospectively analysed. RESULTS: A total of 403 patients were included for analysis. Patients with VPI had older age than those without (61.1 vs. 56.1 years; P<0.001). The mean size of NSCLCs with VPI was larger than those without (2.1 vs. 1.6 cm; P<0.001). Moreover, NSCLCs with VPI were located closer to visceral pleura (0.8 vs. 1.3 cm; P<0.001) and showed larger rates of pleural indentation (86.8% vs. 45.6%; P<0.001) and spiculation (59.7% vs. 34.7%; P<0.001) than those without. Pathologically, NSCLCs with VPI tended more likely to be adenocarcinomas (96.9% vs. 92.7%; P=0.097), and was more likely to be poorly differentiated (38.0% vs. 15.3%; P<0.001), to have cancer embolus (6.2% vs. 0.7%; P=0.001) and lymph node metastasis (29.5% vs. 10.2%; P<0.001) than those without. Besides shorter distance to visceral pleura [odds ratio (OR)=2.169, 95% CI: 1.221-3.855; P=0.008], older age [OR =2.119, 95% confidence interval (CI): 1.255-3.503; P=0.005], pleural indentation (OR =3.679, 95% CI: 1.888-7.169; P<0.001), adenocarcinoma (OR =4.741, 95% CI: 1.383-16.255; P=0.013), and poor tumor differentiation (OR =11.816, 95% CI: 4.470-31.234; P<0.001) were also found to be closely correlated to VPI in early-stage NSCLC. CONCLUSIONS: Besides shorter distance to visceral pleura and pleural indentation, elderly, adenocarcinoma, and poor tumor differentiation were novel biologic factors correlated to VPI in early-stage NSCLC, which may explain why VPI was an unfavorable prognostic factor for early-stage NSCLC.