Early oral feeding after esophagectomy accelerated gut function recovery by regulating brain-gut peptide secretion.

BACKGROUND: The impact of early oral feeding after esophagectomy on brain-gut peptide secretion and gut function recovery has not been well investigated. This study aimed to fill this research gap. METHODS: This study was based on a randomized clinical trial (ClinicalTrials.gov: NCT01998230). The patients in the early oral feeding group started oral food intake on postoperative day 1. In the late oral feeding group, nasogastric/nasoenteral feeding was applied from postoperative day 1 to 7, after which the patients began oral food intake. Serum brain-gut peptides were selected as the primary end points and tested before surgery and on postoperative days 1, 3, and 5. The time to first flatus and first defecation after surgery were evaluated. RESULTS: A total of 110 participants undergoing minimally invasive McKeown esophagectomy were prospectively included, with 63 patients in the early oral feeding group and 47 patients in the late oral feeding group. The distribution of clinicopathological characteristics was balanced between the 2 groups. Perioperative dynamic surveillance demonstrated higher serum concentrations of excitatory brain-gut peptides (gastrin P = .021, motilin P = .027, and substance-P P = .023) and lower serum concentrations of inhibitory brain-gut peptides (cholecystokinin P = .004 and somatostatin P = .019) in the early oral feeding group. Perioperative serum levels of brain-gut peptides correlated with postoperative early flatus and defecation. The multivariate analysis showed early oral feeding (versus late oral feeding) to be an independent predictive factor for early flatus and defecation (hazard ratio 2.40, P < .001; hazard ratio 2.73, P < .001, respectively). CONCLUSION: The early oral feeding program may accelerate the recovery of gut function by regulating brain-gut peptide secretion. Brain-gut peptides are possible treatment targets to improve early oral feeding benefits and promote personalized early oral feeding programs.

Nutritional assessment in esophageal fast-track surgery: comparisons of 4 objective malnutrition screening tools.

BACKGROUND: This cohort study aimed to compare the performance of the 2015 diagnostic criteria for malnutrition of the European Society of Clinical Nutrition and Metabolism (ESPEN), the Nutritional Risk Screening 2002 (NRS 2002), Malnutrition Universal Screening Tool (MUST), and Short-Form of Mini-Nutritional Assessment (MNA-SF) in detecting malnutrition risk and predicting postoperative complications and the failure of early oral feeding (EOF) programs in esophageal cancer patients. METHODS: The 4 tools were used to conduct malnutrition assessments before surgery. The patients were divided into the groups of severe malnutrition and mild/moderate malnutrition and the incidences of the endpoints were observed. Multivariable logistic regression and receiver operating characteristic (ROC) curve analyses were conducted. RESULTS: Two hundred and nineteen consecutive esophageal cancer patients were included in the study. The prevalence rates of severe malnutrition as determined by the ESPEN 2015 criteria, MUST, NRS 2002, and MNA-SF were 24.7%, 29.7%, 23.7%, and 16.0%, respectively. The moderate/severe malnutrition risk screened by the MUST had a high sensitivity (100.0%) with malnutrition identified by the ESPEN 2015 criteria. In total, 42 (19.2%) patients experienced major complications, and the incidence rate of EOF failure was 7.3%. The severe malnutrition identified by the ESPEN 2015 criteria, MUST, and NRS 2002 were comparable in predicting the incidence of postoperative pulmonary complications, anastomotic leakage, readmission to intensive care units (ICUs), and EOF failure, but the ESPEN 2015 criteria was better in predicting postoperative overall complications, major complications, and delayed hospital discharge. CONCLUSIONS: The ESPEN 2015 criteria specializes in identifying severe malnutrition and is better in predicting adverse surgical outcomes; however, the MUST and NRS 2002 are better superior in detecting early malnutrition and are also valuable in the perioperative management in esophageal surgery. It is recommended that the MUST be used as the malnutrition screening tool before the ESPEN 2015 criteria is applied.

Video-assisted mediastinoscopic and laparoscopic transhiatal esophagectomy for esophageal cancer.

BACKGROUND: Mediastinoscopy was originally applied for lymph node biopsy and mediastinal tumor resection. Improved video imaging with spreadable working channels enabled mediastinoscopy for inspection and tissue biopsy in the superior mediastinum but it is rarely used in minimally invasive esophageal cancer surgery. In this prospective trial, the practicability and security of spreadable video-assisted mediastinoscopic combined with laparoscopic transhiatal esophagectomy (VAME) with video-assisted thoracoscopic esophagectomy (VATE) were compared. METHODS: A total of 200 eligible patients with esophageal squamous cell carcinoma were randomly divided into VAME or VATE groups. Early postoperative outcomes and lymph node dissection between the two groups were compared. RESULTS: The operation time was significantly shorter (164.3 ± 47.0 min vs. 265.4 ± 47.2 min, P < 0.001), the number of dissected lymph nodes was less (15.8 ± 4.5 vs. 20.3 ± 6.5, P < 0.001), and the intraoperative blood loss was also significantly reduced (94.7 ± 56.7 mL vs. 184.4 ± 65.2 mL, P < 0.001) in the VAME compared to the VATE group, respectively. The incidence of pneumonia was lower (7% vs. 29%; P < 0.001) and the length of hospital stay was shorter in the VAME group compared to the VATE group (18.0 ± 7.6 days vs. 23.2 ± 7.2, P < 0.001, respectively). The chyle leak incidence appeared to be lower in the VAME group but statistical significance was not reached (1% vs. 4%; P = 0.369). There were no differences in the incidence of anastomotic leakages and recurrent laryngeal nerve paralysis between the groups. No 30-day mortality occurred in any of the cases. CONCLUSION: VAME appears to be a practicable and secure method for esophagectomy but needs further proof of concept. CLINICAL REGISTRATION NUMBER: Registered at Chinese Clinical Trial Registry, ChiCTR1900022797.

MiR-27b suppresses epithelial-mesenchymal transition and chemoresistance in lung cancer by targeting Snail1.

HEADING AIMS: MicroRNA-27b (miR-27b) has been shown to play a role in the progression of many different forms of cancer, but its specific relevance in the context of non-small cell lung cancer (NSCLC) remains uncertain. As such, this study sought to explore the role of miR-27b in NSCLC and the mechanisms whereby it functions. MATERIALS AND METHODS: We quantified miR-27b and target gene expression via quantitative real-time PCR (RT-qPCR).We then used functional including proliferation assays, migration assay, flow cytometry, and western blotting to explore the mechanisms whereby miR-27b functions in vitro and in vivo. We additionally confirmed miR-27b target genes via luciferase reporter assay. KEY FINDINGS: We observed a marked decrease in miR-27b expression in NSCLC patient samples relative to paracancerous control tissues. We further found that altering miR-27b expression levels in vitro affected NSCLC tumor cell migration, proliferation, and ability to undergo epithelial-mesenchymal transition. Through the use of target prediction algorithms we identified Snail to be a miR-27b target protein that was suppressed when this miRNA was highlight expressed. Lastly, we found miR-27b expression to increase NSCLC cell sensitivity to cisplatin through its ability to target Snail. SIGNIFICANCE: Our results clearly demonstrate that miR-27b can suppress NSCLC tumor development and progression, highlighting this miR-27b/Snail1 axis as putative target for the therapeutic treatment of NSCLC.

Effectiveness and safety of bovine pericardium patch repair for cervical anastomotic leakage after oesophagectomy for cancer.

BACKGROUND: The objective of this study is to evaluate the effectiveness and safety of bovine pericardium patch (BPP) repair for cervical anastomotic leakage after esophageal squamous cancer. METHODS: Intractable cervical anastomotic leakage developed in 7 patients of esophageal squamous cell carcinoma undergoing cervical anastomosis. These patients received the BPP repair. The necrotic tissue around the cervical anastomosis was removed during the operation, and the defect was repaired with BPP according to the size of the leakage. RESULTS: The operative duration was 60-90 min (median, 75 min). There were no signs of recurrent anastomotic leakage in each patient undergoing BPP repair. Oral intake was initiated 5-8 days (median, 6 days) after the BPP repair operation without any discomfort. CONCLUSIONS: The BPP repair is a safe and effective processing scheme for patients with cervical anastomotic fistula after resection of esophageal squamous cell carcinoma. This method may be recommended for appropriate patients with intractable cervical anastomotic fistula.

Chin-down-plus-larynx-tightening maneuver improves choking cough after esophageal cancer surgery.

BACKGROUND: Esophageal cancer patients can benefit from dissection of the recurrent laryngeal nerve (RLN) lymph node (LN); however, this procedure increases the risk of RLN injury. After nerve injury, many complications can occur, including choking cough, which can affect patients' quality of life. This study examined the effectiveness of the chin-down-plus-larynx-tightening maneuver for improving choking cough after radical thoracic esophageal cancer surgery. METHODS: Sixty-two patients with resectable thoracic esophageal cancer presented with choking cough, hoarseness or vocal cord paralysis after radical operations. Twenty-two patients who choked on water were guided to swallow 1 mL of warm water using a chin-down-plus-larynx-tightening maneuver. Choking cough relief results and their relationships with clinical factors were analyzed. RESULTS: No correlation was found between the occurrence of post-operative choking cough and gender, age, surgical method, hoarseness, vocal cord fixation type, vocal cord fixation, or glottal closure. Multivariate regression analysis revealed no independent risk factors associated with choking cough. Choking cough was completely relieved in 17 of 22 (77.3%) patients. Fifteen of 19 (78.9%) patients with choking cough and hoarseness, and 2 of 3 patients with only choking cough reported complete relief when they tried the new maneuver. The chin-down-plus-larynx-tightening maneuver was more effective for males than for females. CONCLUSIONS: The chin-down-plus-larynx-tightening maneuver significantly relieved choking cough; thus, this maneuver can aid in managing choking cough after radical thoracic esophageal cancer surgery.

Chewing 50 times per bite could help to resume oral feeding on the first postoperative day following minimally invasive oesophagectomy.

OBJECTIVES: In our previous study, early oral feeding following McKeown minimally invasive oesophagectomy (MIE) has been shown to be a safe and a feasible approach for early recovery of intestinal function and an improvement of quality of life. This study investigates the effect of 'chewing 50 times per bite' on early oral feeding following MIE. METHODS: Between May 2016 and December 2016, we retrospectively analysed 95 cases of oesophageal carcinoma in patients who underwent MIE in our department. All patients received instructions for a 'chewing 50 times per bite' method for solid food intake on postoperative day (POD) 1. The primary end-points were the incidence of pneumonia and anastomotic leakage rate. In addition, postoperative nutritional status was studied. RESULTS: Overall, 95 patients willingly started oral nutrition on POD 1. The rates of anastomotic leakage and pneumonia incidence were 2.1% and 7.4%, respectively. The caloric intake means on POD 1, POD 3 and POD 5 were 1388 ± 184, 1549 ± 206 and 1522 ± 203 respectively, which were 78%, 88% and 77% of the mean caloric requirements, respectively. There were no significant differences in protein index values between the preoperative measurements and the hospital discharge measurements. CONCLUSIONS: The '50 chewing times per bite' solid food intake method on POD 1 in patients with MIE was shown to be feasible and safe, because the application of this method helps to convert solid food into liquid nutrition. More importantly, we demonstrated that it is possible for patients to be able to eat at will on Day 1 following MIE.

Application of bronchoscope for the placement of nasoenteric feeding tube in patients with esophagectomy: a novel technique.

BACKGROUND: Currently the available techniques for the placement of nasoenteric feeding tube (NET), utilizing transnasal gastroscope are fast and tolerable, which is known as the most popular method. However, lots of hospitals don't have this endoscopic system. Bronchoscope, which is the basic respiratory endoscope, not only has the advantages of transnasal endoscopy, but also is popular in common hospitals. We used oxygen instillation as air supply plant of the bronchoscope, which broke its application limitation in digestive tract. The aim of this study is to evaluate the feasibility and availability of the method of placing NET with the bronchoscope in patients with esophagectomy. METHODS: From January 2013 to January 2016, a total of 48 patients with esophagectomy who underwent NET placement with the bronchoscope were included in our study. Information concerning age, gender, as well as background disease of the patients was collected. The success rate, procedure duration, and complications were recorded for each patient. RESULTS: The technique success rate reached 100%, procedure time ranged from 150 to 750 s, with an average time of 257 s. All patients tolerated well under local anesthesia, no complication of epistaxis or perforation occurred. CONCLUSIONS: The new technique of placing NET with the bronchoscope is fast, safe, effective, and well tolerated for patients with esophagectomy.

Photodynamic therapy versus endoscopic submucosal dissection for management of patients with early esophageal neoplasia: a retrospective study.

BACKGROUND: Photodynamic therapy (PDT) and endoscopic submucosal dissection (ESD) have been proposed as a treatment for early esophageal neoplasia. The objective of this study is to compare between the clinical outcome after ESD and PDT to reach the best management for early esophageal neoplasia. METHODS: All patients undergoing ESD or PDT for early esophageal neoplasia between 2014 and 2015 were eligible for the study. A retrospective analysis for comparison between the results of ESD and PDT was done. RESULTS: 36 patients underwent ESD and Thirty PDT. No significant difference was found between the two groups regarding the demographic or pathologic data. Also, there was no significant difference regarding the length of hospital stay, presence of hydrothorax, fever, and pain. Operative time was significantly longer in ESD than in PDT (72 vs. 8 minutes, P<0.001). In addition, bleeding was significantly lower in ESD than PDT (12 vs. 2, P<0.05). There was a significant difference regarding stricture and cost which were less in ESD (6 vs. 15, P<0.05). However, perforation was much more in ESD (6 vs. 0, P<0.05). There was no significant difference between the two groups regarding the disease free survival (DFS), but it was observed that patients who underwent PDT had more favorable 2-year DFS rates than patients received ESD. CONCLUSIONS: The PDT may be comparable to the ESD. With the exception of esophageal stenosis, PDT could reduce many complications and have longer DFS in comparison with ESD. PDT is feasible for patients with early esophageal neoplasia confined to the mucosal layer without regional lymph nodal or distant metastasis.

Accuracy and influence factors of preoperative clinical staging for T2 esophageal cancer by endoscopic ultrasound / 中国胸心血管外科临床杂志

@#Objective    To evaluate the accuracy and investigate the influence factors of preoperative T staging by endoscopic ultrasonography (EUS) in patients with postoperative pathological stage of T2 esophageal carcinoma (EC). Methods    A total of 206 patients with EC underwent EUS and curative operation in Henan Tumor Hospital from March 2015 to January 2016 were enrolled, among whom 81 patients were identified with pathological stage of T2 EC followed by esophageal resection without induction therapy. There were 59 males and 22 females, with a mean age of 63.9 years and meadian age of 63.0 years. We reviewed the medical records of the 81 patients and compared EUS findings with histopathologic results according to clinicopathologic factors. Results    The overall accuracy of EUS for evaluating staging of T2 EC was 61.7% (50/81), while 38.3% (31/81) were overstaged by EUS. Accuracy differed between the accurate staging group and over staging group (P=0.023). There was no significant difference in sex, age, tumor location and shape, histologic type, tumor differentiation or lymph node metastasis between two groups. Conclusion    EUS is highly overstaged in the diagnosis of postoperative pathological stage of T2 EC. Higher postoperative pathological TNM stage appears to be a factor of EUS overstaging in patients with postoperative pathological stage of T2 EC.

Relationship between expression of PD-L1 and PD-L2 on esophageal squamous cell carcinoma and the antitumor effects of CD8⁺ T cells.

The programmed death-1 (PD-1)/programmed death-ligands (PD-Ls) signal pathway has been implicated as a potential immune escape mechanism in several human cancers. However, the studies of PD­1/PD­Ls pathway in esophageal squamous cell carcinoma (ECSS) are not yet sufficient. The current study investigated the expression of PD­L1, PD­L2 and PD­1 in ESCC tissues. The correlations between the expression of these proteins and clinical histopathological parameters were analyzed. Then the stable transfected Ec109 cell lines overexpressing PD­L1/PD­L2 were established by plasmid transfection successfully. Ec109 and CD8+ T cells were co­cultured to analyze the effects of PD­1/PD­Ls signal pathway on the function of CD8+ T cells including proliferation, apoptosis and interferon­Î³ production. We found that PD­L1-positive patients had significantly poorer prognosis than the negative patients, while their prognosis was not related to PD­L2 expression. The count of PD­1+ TILs (tumor­infiltrating lymphocytes) was negatively correlated with both PD­L1 and PD­L2 expression. In functional studies, we found that PD­1/PD­Ls signal pathway was able to downregulate the function of CD8+ T lymphocyte and its function could be restored by blocking the signal pathway. This indicates that PD­1/PD­Ls may prevent effective antitumor immunity, which provides important evidence to delineate the cellular immune deficiency mechanism in ESCC. Therefore, PD-1/PD-Ls are predicted to become novel targets for ESCC immunotherapy.

Insulin receptor substrate-1 and Golgi phosphoprotein 3 are downstream targets of miR­126 in esophageal squamous cell carcinoma.

Esophageal squamous cell carcinoma (ESCC) is a common histologic subtype in China. It has been suggested that abnormal expression of microRNAs (miRNAs) is associated with carcinogenesis. We investigated miR-126 expression and its potential targets in ESCC. The expression of miR-126 was detected in cancerous and paired paracancer tissues from 102 patients with ESCC. Target analysis of miR-126 was predicted using online tools. The effect of miR-126 expression on target proteins was assessed using miR-126 mimics or miR-126 inhibitors in ESCC cell lines. In addition, the impact of miR-126 on cell proliferation, apoptosis, migration and invasion was detected in ESCC cell lines. The expression of miR-126 was significantly lower in ESCC tissues, which was associated with tumor differentiation, lymph node metastasis, tumor in-depth and TNM stage. Insulin receptor substrate-1 (IRS-1) and Golgi phosphoprotein 3 (GOLPH3) were overexpressed in ESCC. Overexpression of IRS-1 was associated with cell differentiation, whereas GOLPH3 was related to lymph node metastasis, tumor invasion in-depth and TNM stage in ESCC patients. miR-126 mimics downregulated the expression of IRS-1 and GOLPH3 protein and suppressed the proliferation, migration and invasion of ESCC cells, whereas miR-126 inhibitors led to the opposite results. miR-126 suppressed the proliferation, migration and invasion of ESCC cells, and acted as a tumor suppressor in the carcinogenesis of ESCC. IRS-1 and GOLPH3 are downstream targets of miR-126 at the post-transcriptional level in ESCC.

The application of single-lumen endotracheal tube anaesthesia with artificial pneumothorax in thoracolaparoscopic oesophagectomy.

Double-lumen endotracheal tube (DLET) anaesthesia is the commonly used method in minimally invasive oesophagectomy (MIE). However, DLET intubation does have its disadvantages. Firstly, the placement of the DLET needs a skilled anaesthetist with familiarity of the technique and subsequent ability to perform a fibre-optic bronchoscopy for confirmation. Secondly, DLET intubation and one-lung ventilation are associated with numerous complications, including hoarseness, tracheobronchial injury and vocal injury. In this report, a retrospective analysis was performed on 42 consecutive patients who underwent MIE using single-lumen endotracheal tube (SLET) anaesthesia with CO2 artificial pneumothorax compared with 81 patients who underwent the same procedure with DLET intubation. Our findings showed that SLET intubation with artificial pneumothorax by CO2 insufflation is a feasible and safe method for MIE procedures.

[Clinical application of endobronchial ultrasound-guided transbronchial needle 
aspiration biopsy for the diagnosis of superior vena cava obstruction syndrome].

BACKGROUND AND OBJECTIVE: Mediastinal lymphoma or right upper lung cancer is a common cause of superior vena cava obstruction syndrome (SVCOS). Endobronchial ultrasound-guided needle aspiration (EBUS-TBNA) biopsy is applied for the diagnosis of mediastinal mass disease. The aim of this study is to explore the safety and feasibility of EBUS-TBNA biopsy under general anesthesia for the clinical diagnosis of SVCOS. METHODS: Twenty-five cases of SVCOS received EBUS-TBNA under general anesthesia between June 2012 and June 2013. The group consisted of 16 male and 9 female patients aged 33 years to 76 years, with a median age of 62.5. RESULTS: Twenty-four cases were confirmed to be of malignant pathology, and one case failed to yield a clear pathological diagnosis. No patient experienced any complications related to the operation, such as heavy bleeding and pneumothorax. CONCLUSIONS: For patients presenting with SVCOS, EBUS-TBNA under general anesthesia is a safe and reliable inspection method of high diagnostic yield. This method can be used for routine examination when other means cannot obtain clear pathological diagnosis.