Comparison of surgical approaches for thymic disorders: feasibility of VATS thymectomy and comparison with small incision and median sternotomy / 中华外科杂志

<p><b>OBJECTIVES</b>To evaluate the feasibility and safety of video-assisted thoracoscopic surgery (VATS), and to compare surgical results of VATS with standard median sternotomy (MS) and other minimal invasive approaches through various small incisions (SI).</p><p><b>METHODS</b>Totally 111 patients underwent surgery for thymic disorders (maximun diameter ≤ 5 cm, clinical stage I-II for thymic tumors) during March 2010 to June 2012 was retrospectively reviewed. There were 46 male and 65 female patients with a mean age of (51 ± 15) years.Resection via VATS was carried out in 47 patients, via SI in 26 patients, and via MS in 38 patients. Demographic characteristics, operation time, number and cause of conversion, blood loss during operation, duration and amount of chest tube drainage, transfusion, morbidity, and length of hospital stay (LHS) were compared between the three groups.</p><p><b>RESULTS</b>Of the 111 patients, 79 patients had thymic epithelia tumors (stage I 32 patients, stage II 39 patients, stage III 8 patients), 31 patients had benign cysts and 1 patient had tuberculosis.In the VATS group, there were 3 conversions among 38 patients through right-side approach, and 4 conversions among 9 patients through left-side approach. The causes for conversion included dense pleura adhesion, invasion of tumor into adjacent structures (pericardium, lung, or great vessels), and injury of the left inominate vein. There was no significant difference in operative time, blood loss or transfusion during operation, duration or amount of postoperative chest tube drainage among the 3 groups (P > 0.05). Average LHS was significantly shorter in the VATS group (5.7 ± 1.7) days than in the SI group (7.5 ± 2.2) days and the MS group (8.2 ± 1.9) days (F = 3.759, P = 0.002). Total thymectomy was performed in 74 patients, 25 patients (53.2%, 25/47) in VATS group, 11 patients (42.3%, 11/26) in SI group, and 38 patients (100%, 38/38) in MS group. The reset of the patients received tumor resection and partial thymectomy. Among all the subgroups, LHS was the shortest in VATS total thymectomy patients (5.0 ± 1.4) days (F = 5.844, P = 0.001). There was no perioperative mortality. The only major morbidity was a postoperative bleeding necessitating reintervention in SI group.</p><p><b>CONCLUSIONS</b>VATS for benign thymic lesions and early-stage thymic tumors is safe and feasible.It is associated with shorter hospital stay compared with other minimal invasive approaches or standard sternotomy.</p>

Recurrence pattern of histological node-negative squamous cell carcinoma of the thoracic esophagus after extended radical esophagectomy with lymphadenectomy / 中华外科杂志

<p><b>OBJECTIVE</b>To analyze the clinical and pathologic influencing factors of early recurrence in patients with histological node-negative (pN0 stage) esophageal squamous cell carcinoma after radical esophagectomy.</p><p><b>METHODS</b>A retrospective study on 112 consecutive pN0 stage esophageal squamous cell carcinoma patients who underwent esophagectomy with lymphadenectomy by the same surgical team from January 2004 to December 2010. There were 92 male and 20 female patients, aging from 36 to 80 years with a mean age of 60.3 years. The Cox proportional hazards model was used to determine the independent risk factors for recurrence within 3 years after the operation.</p><p><b>RESULTS</b>Recurrence was recognized in 45 patients (40.2%) within 3 years after operation. The median time to tumor recurrence was 17.4 months. Locoregional recurrence was found in 38 patients (33.9%), and hematogenous metastasis in 7 patients (6.3%). Recurrence closely correlated with tumor location, grade of differentiation, pT stage and pathologic stage (χ(2) = 6.380 to 18.837, P < 0.05). The Cox multivariate analysis showed that tumor location (RR = 1.092, P = 0.049) and pT3-4a stage (RR = 3.296, P = 0.017) were independent risk factors for postoperative locoregional recurrence.</p><p><b>CONCLUSIONS</b>The most common recurrence pattern of patients with pN0 esophageal squamous cell carcinoma would develop recurrence within 3 years after operation is locoregional recurrence. Upper/middle thoracic location and pT3-4a stage are independent risk factors for locoregional recurrence of pN0 esophageal squamous cell carcinoma after operation.</p>

Risk factors of recurrence and metastasis in pN1 stage squamous cell carcinoma of the thoracic esophagus after radical esophagectomy with lymphadenectomy / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To analyze the clinical and pathologic risk factors of early recurrence in patients with pathological N1 (pN1) stage esophageal squamous cell carcinoma after radical esophagectomy.</p><p><b>METHODS</b>A retrospective study was carried out on 95 consecutive pN1 stage esophageal squamous cell carcinoma patients undergoing esophagectomy with lymphadenectomy by the same surgical team from January 2004 to December 2010 was performed. The Cox proportional hazards model was used to determine the independent risk factors for recurrence and metastasis within 3 years after the operation.</p><p><b>RESULTS</b>Recurrence was identified in 52 patients (54.7%) within 3 years after operation. Local recurrence was found in 42 patients (44.2%), and distant metastasis in 10 patients (10.5%). The Cox multivariate analysis showed that pT3-4a stage (RR=3.604, P=0.027), positive lymph node metastasis in two stations (RR=4.834, P=0.009) or two fields (RR=5.689, P=0.003), and postoperative adjuvant chemotherapy (RR=1.594, P=0.048) were independent risk factors for postoperative recurrence.</p><p><b>CONCLUSIONS</b>Postoperative adjuvant chemotherapy can decrease the probability of postoperative recurrence and metastasis of pN1 esophageal squamous cell carcinoma. As for patients who are identified as multi-station or multi-field lymph node metastasis, preoperative induced therapy maybe further improve treatment outcomes.</p>

Comparison of outcomes after surgery between adenocarcinoma of the esophagogastric junction and lower thoracic esophageal squamous cell cancer / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To compare the differences in biological behavior and clinical features between adenocarcinoma of the esophagogastric junction (AEG) and lower thoracic esophageal squamous cell cancer (LESC), and to explore reasonable procedures for each cancer.</p><p><b>METHODS</b>Clinical data of 111 patients with AEG and 126 patients with LESC who underwent surgery from January 2004 to April 2012 were retrospectively reviewed. Data pertaining to resection rate, lymph node metastasis, and postoperative complication rate were analyzed.</p><p><b>RESULTS</b>The resection rate was 94.6% for AEG and 97.6% for LESC, and the difference was not statistically significant (P<0.05). The rate of lymph node metastasis in the mediastinum in patients with AEG was significantly lower [6.3%(7/111) vs. 32.5%(41/126), P<0.01], while the rate of lymph node metastasis in the abdomen was significantly higher [57.7%(64/111) vs. 34.1%(43/126), P<0.01]. The rate of lymph node metastasis in mediastinum of AEG was 12.5%(4/32) for Siewert I and 4.7%(3/64) for Siewert II, and there was no lymph node metastasis in Siewert III (n=15). For AEG patients who underwent trans-abdominal surgery, the rate of positive lymph node in the middle and lower mediastinum was significantly lower than trans-thoracic surgery [0/22 vs. 7.9% (7/89), P<0.05]. LESC via right thorax with two-field or three-field lymph node dissection was associated with a significantly higher rate of positive lymph node metastasis in the upper mediastinum than that of single incision via left thorax [17.9%(12/67) vs. 0/59, P<0.01]. The postoperative complication rates were 23.4%(26/111) and 27.0%(34/126) respectively, and the difference was not statistically significant(P>0.05).</p><p><b>CONCLUSIONS</b>AEG and LESC show different lymph node metastasis pattern and should be operated differently. Lymphadenectomy in mid-lower mediastinum should be emphasized in Siewert I and Siewert II type cancers.</p>

Comparative study of perioperative complications and lymphadenectomy between minimally invasive esophagectomy and open procedure / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To analyze the differences in perioperative morbidity and lymph node dissection between minimally invasive esophageal carcinoma resection and open procedure.</p><p><b>METHODS</b>From January to December 2011, 72 patients with esophageal cancer underwent surgery. Thirty-four patients underwent video-assisted esophagectomy, and 38 underwent open procedure. In the minimally invasive group, there were 7 thoraco-laparoscopic cases, 16 thoracoscopic cases, and 11 laparoscopic cases.</p><p><b>RESULTS</b>The early cases (T1-T2) were more common in the minimally invasive group than that in the open group [79.4%(27/34) vs. 55.3%(21/38), P<0.05]. The complication rate was 41.2%(11/34) in the open group and 42.1%(16/38) in the minimally invasive group, and the difference was not statistically significant (P>0.05). However, the functional complication in minimally invasive group was significantly lower than that in open group [2.9%(1/34) vs. 28.9%(11/38), P<0.01], while technical complications (anastomotic leak and recurrent laryngeal nerve injury) were significantly more common( 38.2% vs. 10.5%, P<0.05). Lymph node group number in minimally invasive group was comparable with the open group (9.1 vs. 11.2, P>0.05), but the number of node in minimally invasive group was significantly lower (13.5±5.9 vs. 17.8±5.2, P<0.05). When stratified by time period, early 17 cases were associated with similar technical complication rate with the late 17 cases (P>0.05), while thoracic lymph node group number, number of node, and positive node were improved in the late phase (all P>0.05).</p><p><b>CONCLUSIONS</b>Minimally invasive esophagectomy reduces functional morbidity, while technical complication including anastomotic leak and recurrent laryngeal nerve injury may be increased. Endoscopic lymph node dissection may be comparable to open surgery.</p>

Comparison of surgical outcomes after different surgical approach for middle or lower thoracic esophageal squamous cancer / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To compare outcomes of left and right thoracic incision for middle and lower thoracic esophageal squamous cancer, and to determine reasonable surgical approach for thoracic esophageal squamous carcinoma.</p><p><b>METHODS</b>One hundred and twenty patients with middle or lower thoracic esophageal squamous cancer who received esophagectomy plus lymphadenectomy between January 2004 and December 2007 were divided into two groups including left(n=60) and right thoracic(n=60) approach. Clinical data were analyzed including the results of surgical resection, lymphadenectomy, postoperative complication, recurrence, and survival.</p><p><b>RESULTS</b>The rate of surgical resection was 91.7%(55/60) in the left approach group and 95%(57/60) in the right approach group. There was no significant difference(P>0.05). But the average number of lymph nodes resected (4.60 vs. 8.32) and metastatic lymph nodes(0.57 vs. 1.33) were both significantly higher in the right approach group(P<0.01). There was no statistical difference in postoperative complications[26.7%(16/60) vs. 31.7%(19/60), P>0.05] between the two groups. However, the incidence of local recurrence was lower[43.3%(26/60) vs. 23.3%(14/60), P<0.05] in the right approach group than that in left-approach group. There was no significant difference in distant metastasis(P>0.05).</p><p><b>CONCLUSIONS</b>The resection rate is comparable between left and right approach for thoracic esophageal cancer. However, it is easier to perform systemic lymphadenectomy via right thoracic approach and therefore the local recurrence is reduced and long-term survival improved.</p>

Impact of number and extent of lymph node metastasis on prognosis of thoracic esophageal cancer / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To evaluate the influence of the number, station and field of metastatic lymph node on the prognosis of thoracic esophageal cancer and to investigate an ideal nodal staging method.</p><p><b>METHODS</b>Clinicopathological and follow-up data of the 204 patients who underwent thoracic esophagectomy from June 2001 to December 2009 were analyzed retrospectively and all the patients were re-staged according to the 7th edition of the AJCC TNM staging system. Log-rank test was applied to perform survival analysis according to lymph node metastasis staging(number, station, and field), Cox proportional hazard model was used to screen risk factors.</p><p><b>RESULTS</b>The follow-up rate was 93.1%(190/204). The median follow up time was 37.0(0-104) months. The overall and cancer-specific 5-year survival rates were 35.0% and 38.8%. When grouped according to the number of metastatic lymph node(0, 1-2, 3-6, ≥ 7), the 5-year survival rates of pN0, pN1, pN2 and pN3 were 47.8, 31.8%, 11.5% and 0 respectively(P=0.000). When grouped according to the number of stations of metastatic lymph node[N(0s), N(1s)(1 station LN metastasis), N(≥ 2s)(≥ 2 stations LN metastasis)], the 5-year survival rates of N(0s), N(1s), N(≥ 2s) were 47.8%, 31.5% and 11.3% respectively(P=0.000). When grouped according to the number of fields of metastatic lymph node, the 5-year survival rates of N0, 1 field, 2 fields and 3 fields involvement were 47.8%, 34.2%, 12.1% and 0 respectively(P=0.000). Cox regression showed that the number of stations [P=0.043, RR(95% CI)=1.540(1.013-2.342)], and the number of fields[P=0.010, RR(95%CI)=2.187(1.210-3.951)] of metastatic lymph node were the independent risk factors for survival.</p><p><b>CONCLUSIONS</b>The extent of metastatic lymph node is an independent risk factor for the prognosis of esophageal cancer patients. Revision of the current N-classification of TNM staging system according to the number of stations of metastatic lymph node may be more reasonable.</p>

Clinical implications of the new TNM staging system for thoracic esophageal squamous cell carcinoma / 中华肿瘤杂志

<p><b>OBJECTIVE</b>To evaluate THE clinical significance of the 2009 UICC staging system for thoracic esophageal squamous cell carcinoma.</p><p><b>METHODS</b>Two hundred and nine patients with thoracic esophageal squamous cell carcinoma undergone selective cervico-thoraco-abdominal lymphadenectomy were reviewed retrospectively and restaged according to the new 2009 UICC staging system. The relationship between individual stages and survival were analyzed accordingly.</p><p><b>RESULTS</b>The five-year overall and cause-specific survivals were 35.0% and 38.8%, respectively. Depth of invasion (T, P = 0.004), number of metastatic lymph nodes (N, P < 0.001), distant lymph node metastasis (M, P = 0.003), complete resection (R, P = 0.005) were significantly related to postoperative survival. On the other hand, location of primary tumor (L, P = 0.743) and histological grade (G, P = 0.653) were not significantly related to long-term prognosis. Upon stratification, the 5-year survival for T4a (32.0%) was significantly better than that of T4b (0, P < 0.001), but was similar to that of T3 (28.4%, P = 0.288). Patients without nodal involvement (47.8%, P < 0.001) and those with single station nodal disease (37.5%, P < 0.001) had significantly better survival than patients having 2 or more stations of lymph node metastasis (11.3%). Also patients without nodal involvement and those with metastasis confined to a single field (34.2%) had significantly better survival than patients having nodal diseases in 2 fields (12.1%) and 3 fields (0, P < 0.001). The 5-year survival for cervical metastasis after complete resection was 20.0%. Upon multivariate analysis, depth of tumor invasion (P = 0.001, RR = 1.635), numbers of metastatic nodal stations (P = 0.043, RR = 1.540) and fields (P = 0.010, RR = 2.187) were revealed as independent risk factors for long-term survival.</p><p><b>CONCLUSIONS</b>The new UICC staging system effectively predicts long-term prognosis for thoracic esophageal squamous cell carcinoma. Depth of tumor invasion and extent of lymph node involvement are two most important prognostic factors. To improve surgical outcomes, much effort is needed to increase the accuracy of preoperative staging and to include effective induction therapies into a multidisciplinary setting.</p>

Optimized perioperative management helps improve the results of thoracotomy in elderly patients / 中华外科杂志

<p><b>OBJECTIVES</b>To optimize perioperative respiratory and circulatory management so as to improve the surgical results of thoracotomy in elderly patients.</p><p><b>METHODS</b>Respiratory and circulatory status was prospectively monitored and postoperative complications were documented in 58 elderly patients aged over 65 years underwent thoracotomy. The results were compared with those from 56 young patients aged under 65 years in the same time period. Based on the study results, the original perioperative management model was modified and prospectively studied in the following 179 elderly patients. Again the results were compared with 477 younger patients concomitantly treated.</p><p><b>RESULTS</b>Through optimized perioperative management, the in-hospital mortality (4.9% vs. 1.1%, P = 0.033) and overall morbidity (58.6% vs. 21.8%, P < 0.01) were significantly decreased. This was most significant in the decrease of functional complications (51.7% vs. 14.5%, P < 0.01), especially the cardiovascular (22.4% vs. 7.3%, P = 0.001) and respiratory complications (20.7% vs. 7.3%, P = 0.004). There was no difference in technical complications between the two time periods. Comparing with the original model, the optimized perioperative management strategy resulted in significant decrease in acute lung injury (17.2% vs. 6.7%, P = 0.016), respiratory failure (6.9% vs. 1.7%, P = 0.041), as well as cardiac arrhythmia (20.7% vs. 7.3%, P = 0.004) in the early postoperative period.</p><p><b>CONCLUSIONS</b>Optimization of perioperative management through careful preoperative functional evaluation, intraoperative protective ventilation, postoperative close monitoring of water balance, and timely intervention, may help improve surgical results in the elderly.</p>

VEGF-C mRNA expression and its relationship with clinicopathological parameters in esophageal squamous cell carcinoma / 中华肿瘤杂志

<p><b>OBJECTIVE</b>To detect the expression of VEGF-C mRNA and to investigate its relationship with clinicopathological parameters in esophageal squamous cell carcinoma (ESCC).</p><p><b>METHODS</b>Real-time quantitative reverse transcriptase-PCR was used to measure the level of VEGF-C mRNA in the tumor tissue and corresponding normal mucosa in ESCC patients.</p><p><b>RESULTS</b>The VEGF-C mRNA expression in tumor tissue was significantly higher than that in the corresponding normal mucosa (6.30 vs. 2.81, P = 0.02), and also significantly higher in the patients with lymph node metastasis than that in those without lymph node metastasis (10.11 vs. 4.15, P = 0.04). Among the patients with metastatic lymph nodes, VEGF-C mRNA expression was 62.19 in the patients with > or = 4 metastatic lymph nodes versus 6.30 in those with < 4 (P = 0.01), and 18.98 in the patients with > or = 3 metastatic lymph node stations versus 4.92 in those with < 3 (P = 0.04). In terms of stage, VEGF-C mRNA expression was significantly higher in the stage II b + III + IV than that in the stage I + II a (9.99 vs. 3.80, P = 0.03). Logistic binary regression analysis showed that VEGF-C mRNA was an independent risk factor for lymph node metastasis in ESCC (P = 0.01). In survival analysis, 2-year survival rate was not related with VEGF-C mRNA expression (P = 0.46). It was showed by COX regression model that the number of metastatic lymph node stations was the only independent risk factor for survival (P < 0.01).</p><p><b>CONCLUSION</b>The expression of VEGF-C mRNA play an important role in lymph node metastasis of human ESCC.</p>

Minimally invasive approaches for histological diagnosis of anterior mediastinal masses / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Anterior mediastinal masses include a wide variety of diseases from benign lesions to extremely malignant tumors. Management strategies are highly diverse and depend strongly on the histological diagnosis as well as the extent of the disease. We reported a prospective study comparing the usefulness of core needle biopsy and mini-mediastinotomy under local anesthesia for histological diagnosis in anterior mediastinal masses.</p><p><b>METHODS</b>A total of 40 patients with masses of unknown histology and located either at or near the anterior mediastinum received biopsy prior to treatment. The diagnostic methods were core needle biopsy in 28 patients and biopsy through mini-mediastinotomy under local anesthesia in 15 patients (including 3 patients for whom core needle biopsy failed to yield a definite diagnosis).</p><p><b>RESULTS</b>Histological diagnosis was achieved in 18 of the 28 patients receiving core needle biopsy. Of them, all 4 patients with pleural fibromas and 9 of the 12 patients (75%) with pulmonary mass were diagnosed definitively. In the remaining 12 patients with mediastinal mass, histological diagnosis was achieved in only 5 patients (41.7%). In contrast, biopsy through a mini-mediastinotomy failed in only 3 patients. In the remaining 12 patients with huge mediastinal masses, who underwent mini-mediastinotomy, a definitive histological diagnosis was reached by pathological and/or immunohistochemical study (diagnostic yield 85.7% in 12 of 14 cases of mediastinal mass, P = 0.038 vs core needle biopsy). For the 9 patients with thymic epithelial tumors, the diagnostic yield was 40% (2 in 5 cases) for core needle biopsy and 83.3% (5 in 6 cases) for mini-mediastinotomy. There was no morbidity in patients receiving mini-mediastinotomy. In the 30 patients with biopsy-proven histological diagnosis, the results contributed to therapeutic decision making in 25 cases (83.3%).</p><p><b>CONCLUSIONS</b>Core needle biopsy is effective in the diagnosis of pulmonary and pleural diseases. Yet its diagnostic yield in mediastinal mass is rather low. Superior to core needle biopsy, biopsy through a mini-mediastinotomy under local anesthesia is highly effective in the histological diagnosis of anterior mediastinal mass, and has a satisfactory diagnostic yield. The method is safe, minimally invasive, cost-effective, and useful in therapeutic decision making for anterior mediastinal masses.</p>

Selective three-field lymphadenectomy for thoracic esophageal squamous carcinoma / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the lymph node metastasis and the rational lymphadenectomy in thoracic esophageal carcinoma.</p><p><b>METHODS</b>Eighty-seven patients with thoracic esophageal squamous carcinoma received esophagectomy plus two-field or three-field lymphadenectomy based on cervical ultrasonography.</p><p><b>RESULTS</b>Thirty-five patients (40.2% ) with enlarged cervical nodes revealed by cervical ultrasonography received cervical lymphadenectomy. The proportion of cervical lymphadenectomy was 66.7% (16/24) in upper thoracic esophageal carcinomas, significantly higher than 30.2% (19/63) in middle and lower esophageal carcinomas (P=0.002). Regional and cervical lymph node metastasis were found in 48(55.2% ) and 17(19.5% ) patients respectively. The regional lymph node metastatic rates were 37.5% (9/24), 62.3% (33/53) and 60.0% (6/10) respectively in the patients with upper, middle, and lower thoracic esophageal carcinoma. The cervical lymph node metastatic rates in the patients with or without regional lymph node metastasis were 31.3% (15/48) and 5.1% (2/39) respectively(P=0.002). The rates of upper, mid, lower mediastinal and upper abdominal lymph node metastasis were 25.3%, 23.0%, 5.7%, and 24.1% respectively. Cervical lymph node metastasis was significantly correlated with upper and mid mediastinal metastasis (both P< 0.01), but not with lower mediastinal and upper abdominal lymph node metastasis. The overall postoperative morbidity rate was significantly higher in three field lymphadenectomy group than that in two field group(60.0% vs. 34.6%, P=0.020).</p><p><b>CONCLUSION</b>Selective 3-field lymphadenectomy based on cervical ultrasonography should be performed in thoracic esophageal carcinoma, especially with upper and mid mediastinal lymph node metastasis.</p>

Causes and prevention of anastomotic leakage after esophagectomy and reconstruction through different routes for esophageal cancer / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To compare the anastomotic leakage rates after esophagectomy and reconstruction through different routes for esophageal cancer and analyze the causes for higher anastomotic leakage rate after esophagectomy, systemic lymph node dissection and reconstruction through retrosternal route and its prevention.</p><p><b>METHODS</b>Data of 1105 cases of esophagectomy were reviewed retrospectively. Patients in group A (n=229) underwent esophagectomy through left thoracotomy and intrathoracic anastomosis, patients in group B (n=716), esophagectomy through right anterio-lateral thoracotomy and cervical reconstruction through posterior mediastinal route, patients in group C (n=160) esophagectomy, systemic lymph node dissection and cervical anastomosis through the retrosternal route.</p><p><b>RESULTS</b>The leakage rate was significantly higher (19.4%) in group C than that in group B (11.9%, P< 0.05) and much significantly higher than that in group A (2.2%, P< 0.01). In group C, there was no significant difference in leakage rate between the patients with hand-sewn or mechanical anastomosis (22.2% vs.11.6%, P=0.133), between the patients who had whole stomach or tube-typed gastric reconstruction (25% vs.15.6%, P=0.146). The leakage rate was significantly decreased from 23.3% to 9.1% after prolonged nasal-gastric drainage for seven days (P< 0.05).</p><p><b>CONCLUSION</b>The high anastomotic leakage rate after retrosternal reconstruction is mainly due to compression of the stomach in the anterior mediastinum. Prolonged nasogastric drainage is an effective way to decrease the leakage rate after systemic lymphadenectomy.</p>

Surgical treatment of apical chest tumor in 27 patients / 中华外科杂志

<p><b>OBJECTIVE</b>To explore the "hemi-clamshell" approach to the resection of the apical chest tumors, and to evaluate its advantages of operative safety and completeness.</p><p><b>METHODS</b>We conducted a retrospective review of the records of 27 patients undergoing resection of the primary apical chest tumors from January 1995 to January 2001. Tumor type included NSCLC, sarcoma, neurofibromatosis, esophageal carcinoma. Data collected included clinical presentation, tumor type and involvement, type of resection, complication, and survival.</p><p><b>RESULTS</b>A clinical operation for gross-total resection of tumors and invaded structures was performed on six patients by means of a successful anterior approach. Among other 21 patients on whom a clinical operation was performed by posterior approach, only 13 patients obtained gross-total resection. There were significant difference between the two groups (P < 0.01). The mean duration for follow-up was 29 months, and the overall median survival was 21 months. Median survival in patients undergoing gross-total resection was 29 months, and this is significantly better than in incomplete resection group (P < 0.01).</p><p><b>CONCLUSIONS</b>The anterior "hemi-clamshell" approach is a successful technique for the exposure and resection of these tumors and invaded structures. Release of symptoms and long-term survival is acceptable if complete resection can be performed.</p>

Ultrasound surveillance of cervical lymph node metastasis in thoracic esophageal carcinoma / 中华外科杂志

<p><b>OBJECTIVE</b>To improve the accuracy of preoperative evaluation of cervical lymph node metastasis in thoracic esophageal squamous carcinoma.</p><p><b>METHODS</b>Forty-two patients with thoracic esophageal squamous carcinoma underwent neck ultrasonography. Enlarged lymph nodes with their long axis greater than 10 mm and a short-to-long axis ratio greater than 0.5 were considered as metastatic.</p><p><b>RESULTS</b>Preoperative neck ultrasonography revealed the enlarged lymph nodes in 16 patients, but only in 5 (31%) cases the nodes were palpable. Among them 9 were classified as metastatic (cM(1-LN)), including 4 patients with palpable nodes. In 5 cM(1-LN) patients surgical intervention was canceled and the remaining 37 patients underwent trans-thoracic esophagectomy. Cervical node metastasis (pM(1-LN)) was confirmed pathologically in 6 surgical patients, 4 with tumors invading the adventitia (pT3) and the other 2 into the surrounding structure (pT(4)) (pT(1), pT(2) vs. pT(3), pT(4), P = 0.020). All 6 pM(1-LN) patients had concomitant mediastinal node metastasis and 4 of them had upper abdominal node metastasis. Statistically significant relationship was detected between cervical and abdominal nodal status (r = 0.536, P = 0.007). In comparison with the results of pathological examination and treatment response, the accuracy and sensitivity were 81% and 95% (P = 0.043), 36% and 82% (P = 0.081), respectively, for palpation and ultrasonography. Five out of 39 (13%) patients had their therapy changed due to ultrasonographic findings.</p><p><b>CONCLUSIONS</b>Neck ultrasonography for cervical lymphadenopathy is of high sensitivity and accuracy, which plays an important role in the preoperative evaluation and therapeutic decision-making.</p>