Novel technique for lymphadenectomy along left recurrent laryngeal nerve during thoracoscopic esophagectomy.

BACKGROUND: In esophageal squamous carcinoma, lymphadenectomy along the left recurrent laryngeal nerve (RLN) is recommended owing to its highly metastatic potential. However, this procedure is difficult due to limited working space in the left upper mediastinum, and increases postoperative complications. AIM: To present a novel method for lymphadenectomy along the left RLN during thoracoscopic esophagectomy in the semi-prone position. METHODS: The fundamental concept of this novel method is to exfoliate a bilateral pedicled nerve flap, which is a two-dimensional membrane, which includes the left RLN, lymph nodes (LNs) along the left RLN, and tracheoesophageal vessels, by suspending the esophagus to the dorsal side and pushing the trachea to the ventral side (named "bilateral exposure method"). Then, the hollow-out method is performed to transform the two-dimensional membrane to a three-dimensional structure, in which the left RLN and tracheoesophageal vessels are easily distinguished and preserved during lymphadenectomy along the left RLN. This novel method was retrospectively evaluated in 116 consecutive patients with esophageal squamous carcinoma from August 2016 to February 2018. RESULTS: There were 58 patients in each group. No significant difference was found between the two groups in terms of age, gender, postoperative pneumonia, anastomotic fistula, and postoperative hospitalization. However, the number of dissected LNs along the left RLN in this novel method was significantly higher than that in the conventional method (4.17 ± 0.359 vs 2.93 ± 0.463, P = 0.0447). Moreover, the operative time and the rate of postoperative hoarseness in the novel method were significantly lower than those in the conventional method (306.0 ± 6.774 vs 335.2 ± 7.750, P = 0.0054; 4/58 vs 12/58, P = 0.0312). CONCLUSION: This novel method for lymphadenectomy along the left RLN during thoracoscopic esophagectomy in the semi-prone position is much safer and more effective.

Population structure of a global agricultural invasive pest, Bactrocera dorsalis (Diptera: Tephritidae).

Bactrocera dorsalis, the Oriental fruit fly, is one of the world's most destructive agricultural insect pests and a major impediment to international fresh commodity trade. The genetic structuring of the species across its entire geographic range has never been undertaken, because under a former taxonomy B. dorsalis was divided into four distinct taxonomic entities, each with their own, largely non-overlapping, distributions. Based on the extensive sampling of six a priori groups from 63 locations, genetic and geometric morphometric datasets were generated to detect macrogeographic population structure, and to determine prior and current invasion pathways of this species. Weak population structure and high genetic diversity were detected among Asian populations. Invasive populations in Africa and Hawaii are inferred to be the result of separate, single invasions from South Asia, while South Asia is also the likely source of other Asian populations. The current northward invasion of B. dorsalis into Central China is the result of multiple, repeated dispersal events, most likely related to fruit trade. Results are discussed in the context of global quarantine, trade, and management of this pest. The recent expansion of the fly into temperate China, with very few associated genetic changes, clearly demonstrates the threat posed by this pest to ecologically similar areas in Europe and North America.

Transumbilical thoracic sympathectomy: a single-centre experience of 148 cases with up to 4 years of follow-up†.

OBJECTIVES: Thoracic sympathectomy is considered as the most effective method to treat palmar hyperhidrosis (PH). Here, we report our experience of transumbilical thoracic sympathectomy with an ultrathin flexible endoscope for PH in a series of 148 patients with up to 4 years of follow-up. METHODS: A prospective database was used in this retrospective analysis of 148 patients (61 males, 87 females, with a mean age of 21.3 years) with PH who were operated on by the same surgeon in a single institution from April 2010 to March 2014. All procedures were performed under general anaesthesia involving intubation with a double-lumen endotracheal tube. Demographic, postoperative and long-term data of patients were recorded and statistical analyses were performed. All patients were followed up at least 6 months post procedure through clinic visits or telephone/e-mail interviews. RESULTS: The procedure was performed successfully in 148 of the 150 patients. Two patients had to be converted to conventional thoracoscopic procedure because of severe pleural adhesions. The mean operating time was 43 min (ranging from 39 to 107 min) and the mean postoperative length of stay was 1 day (range 1-4 days). All patients were interviewed 6-48 months after surgery and no diaphragmatic hernia or syndrome was observed. The rate of resolution of PH and axillary hyperhidrosis was 98 and 74.6%, respectively. Compensatory sweating was reported in 22.3% of patients. Almost all of the patients were satisfied with the surgical results and the cosmetic outcome of the incision. CONCLUSIONS: This preliminary human experience suggested that transumbilical thoracic sympathectomy was a safe and efficacious alternative to the conventional approach. This technique avoided the chronic pain and chest wall paraesthesia that are associated with the chest incision. In addition, this novel procedure afforded maximum cosmetic benefits.

String esophageal capsule endoscopy with real-time viewing improves visualization of the distal esophageal Z-line: a prospective, comparative study.

OBJECTIVE: Esophageal capsule endoscopy (ECE) is relatively limited because of poor visualization of the distal esophagus. This study aimed to investigate whether string esophageal capsule endoscopy with real-time viewing (SECE+RTV) could improve the Z-line viewing of the distal esophagus as compared with conventional ECE. METHODS: Thirty healthy volunteers, aged 20-45 years, were recruited and underwent SECE+RTV and ECE sequentially. The main outcome measures included grade of air-bubble and saliva interference, success rate of Z-line viewing (frequency of visualizing at least three quadrants), and frame number of images captured on the Z-line. RESULTS: SECE+RTV showed a significantly greater percentage of no or mild air-bubble/saliva interference at the gastroesophageal junction [SECE+RTV vs. ECE, 90.0% (27/30) vs. 10.0% (3/30), P<0.001]. SECE+RTV had a significantly greater frame number of images captured on the Z-line (154.4±6.3 vs. 46±5.1, P<0.001). Moreover, SECE+RTV had significantly greater percentages of at least two quadrants [100.0% (30/30) vs. 80.0% (24/30), P<0.001] and at least three quadrants [90.0% (27/30) vs. 36.7% (11/30), P<0.001] of Z-line visualization. CONCLUSION: Compared with ECE, SECE+RTV provides a better view of the distal esophagus in healthy individuals.

One-year follow-up period after transumbilical thoracic sympathectomy for hyperhidrosis: outcomes and consequences.

OBJECTIVES: Thoracic sympathectomy is considered the most effective method to treat palmar hyperhidrosis. We developed a novel approach for thoracic sympathectomy in patients with palmar hyperhidrosis through the umbilicus, using an ultrathin gastroscope. The aim of this study was to evaluate the continuing efficacy and patient satisfaction of this innovative surgery. METHODS: All procedures were performed under general anesthesia and the patients were intubated with a dual-lumen endotracheal tube. After a 5-mm umbilical incision, the muscular parts of the diaphragmatic dome were incised with a needle-knife and the nasal gastroscope was advanced into the thoracic cavity. The sympathetic chain was identified at the desired thoracic level and ablated with hot biopsy forceps. All patients were followed up for at least 1 year after the procedure through clinic visits or telephone/e-mail interviews. RESULTS: From April 2010 to August 2011, a total of 35 patients underwent a transumbilical thoracic sympathectomy. Fifty-seven percent were male patients, with a mean age of 21.2 years (range, 16-33 years). The success rate after 12 months was 97.1% (34 of 35) for isolated palmar hyperhidrosis and 72.2% (13 of 18) for axillary hyperhidrosis. Compensatory sweating was reported in 28.6% of patients at the 1-year follow-up evaluation. There was no mortality, no diaphragmatic hernia, and no Horner syndrome was observed. Quality of life related to hyperhidrosis improved substantially in 27 (77.1%) patients, and improved in 4 (11.4%) patients at 12 months after surgery. A total of 94.3% of patients were satisfied with the excellent cosmetic results of the surgical incision. CONCLUSIONS: Transumbilical thoracic sympathectomy is an efficacious alternative to the conventional approach. This technique avoided the chronic pain and chest wall paresthesia associated with the chest incision. In addition, this novel procedure afforded maximum cosmetic benefits.

Embryonic NOTES thoracic sympathectomy for palmar hyperhidrosis: results of a novel technique and comparison with the conventional VATS procedure.

BACKGROUND: To avoid the disadvantages of chronic pain and chest wall paresthesia associated with video-assisted thoracic surgery (VATS) procedures, we developed a novel surgical technique for performing sympathectomy by embryonic natural orifice transumbilical endoscopic surgery (E-NOTES) with a flexible endoscope. In this study, we compared the outcomes of E-NOTES with conventional VATS thoracic sympathectomy on palmar hyperhidrosis. METHODS: From January 2010 to April 2011, a total of 66 patients with severe palmar hyperhidrosis were treated with thoracic sympathectomy in our department. Thirty-four transumbilical thoracic sympathectomies were performed via a 5-mm umbilicus incision with ultrathin gastroscope, then compared with 32 conventional needlescopic thoracic sympathectomies. Retrospective statistical analysis of a prospectively collected group of patients was performed. RESULTS: There was no significant difference with regard to gender, mean age, body mass index, and length of hospital stay between the two groups. The operative time for E-NOTES thoracic sympathectomy was longer than that of VATS thoracic sympathectomy (56.4 ± 10.8 vs. 40.3 ± 6.5 min, p < 0.01). No mortality, diaphragmatic hernia, or Horner syndrome was observed in either group. Postoperative questionnaires were returned by all treated patients with a mean time from operation to follow-up of 1.4 ± 0.3 years. All 66 patients receiving sympathectomy reported successful treatment of their palmar hyperhidrosis. Compensatory hyperhidrosis was noticed in 7 (20.1 %) and 6 (18.8 %) patients in the E-NOTES and VATS groups, respectively (p > 0.05). Postoperative pain and paresthesia were significantly reduced in the E-NOTES group at each time interval, and the aesthetic effect of the incision was superior in the E-NOTES group. CONCLUSIONS: Transumbilical-diaphragmatic thoracic sympathectomy is a safe and efficacious alternative to the conventional approach. This novel procedure can further reduce postoperative pain and chest wall paresthesia as well as afford maximum cosmetic benefits by hiding the surgical incision in the umbilicus.

Transumbilical thoracic sympathectomy with an ultrathin flexible endoscope in a series of 38 patients.

BACKGROUND: The newest trend in the field of thoracic surgery, thoracic natural orifice transluminal endoscopic surgery (NOTES), is still in the early stages of development and limited to animal experiments. Transumbilical endoscopic surgery could work as a viable intermediate step before pure NOTES. We describe our experiences performing transumbilical-diaphragmatic thoracic sympathectomy with an ultrathin flexible endoscope for palmar and axillary hyperhidrosis in human patients. METHODS: From April 2010 to January 2012, a total of 38 patients underwent transumbilical-diaphragmatic thoracic sympathectomy. Through the incision in the umbilicus, a newly developed long trocar was inserted into the abdominal cavity. An ultrathin endoscope was introduced through the long trocar and then passed through the rigid incision made in the left and right diaphragm and into the thoracic cavity. The ganglion was ablated at the desired thoracic level. RESULTS: Sympathectomy was performed successfully in all patients. Mean operation time was 68 ± 16 (range, 48-107) minutes. There was no mortality and no conversion to open surgery during the operation of any patient. At a median follow-up of 11 (range, 4-12) months after surgery, no diaphragmatic hernia was observed. The rate of palmar hyperhidrosis and axillary hyperhidrosis resolution was 100 and 75 %, respectively. CONCLUSIONS: Transumbilical endoscopic thoracic sympathectomy is technically feasible and safe, which has the possible advantages of pure NOTES and can be performed in routine clinical practice.