Prophylactic thoracic duct ligation is associated with poor prognosis and regional lymph node relapse in esophageal squamous cell carcinoma

Sex differences in survival following surgery for esophageal cancer: A systematic review and meta-analysis

The impact of sex on the prognosis of patients with esophageal cancer remains unclear. Evidence supports that sex- based disparities in esophageal cancer survival could be attributed to sex- specific risk exposures, such as age at diagnosis, race, socioeconomic status, smoking, drinking, and histological type. The aim of our study is to investigate the role of sex disparities in survival of patients who underwent surgery for esophageal cancer. A systematic review and meta-analysis of the existing literature in PubMed, EMBASE, and CENTRAL from December 1966 to February 2023, was held. Studies that reported sex-related differences in survival outcomes of patients who underwent esophagectomy for esophageal cancer were identified. A total of 314 studies were included in the quantitative analysis. Statistically significant results derived from 1-year and 2-year overall survival pooled analysis with Relative Risk (RR) 0.93 (95% Confidence Interval (CI): 0.90-0.97, I2 = 52.00) and 0.90 (95% CI: 0.85-0.95, I2 = 0.00), respectively (RR < 1 = favorable for men). In the postoperative complications analysis, statistically significant results concerned anastomotic leak and heart complications, RR: 1.08 (95% CI: 1.01-1.16) and 0.62 (95% CI: 0.52-0.75), respectively. Subgroup analysis was performed among studies with <200 and > 200 patients, histology types, study continent and publication year. Overall, sex tends to be an independent prognostic factor for esophageal carcinoma. However, unanimous results seem rather obscure when multivariable analysis and subgroup analysis occurred. More prospective studies and gender-specific protocols should be conducted to better understand the modifying role of sex in esophageal cancer prognosis.

Does Thoracic Duct Ligation at the Time of Esophagectomy Impact Long-Term Survival? An Individual Patient Data Meta-Analysis

Background: Thoracic duct ligation (TDL) during esophagectomy has been proposed to reduce the risk of postoperative chylothorax. Because of its role in immunoregulation, some authors argued that it had an unfavorable TDL effect on survival. The aim of this study was to analyze the effect of TDL on overall survival (OS). Methods: PubMed, MEDLINE, Scopus, and Web of Science were searched through December 2023. The primary outcome was 5-year OS. The restricted mean survival time difference (RMSTD), hazard ratios (HRs), and 95% confidence intervals (CI) were used as pooled effect size measures. The GRADE methodology was used to summarize the certainty of the evidence. Results: Five studies (3291 patients) were included. TDL was reported in 54% patients. The patients' age ranged from 49 to 69, 76% were males, and BMI ranged from 18 to 26. At the 5-year follow-up, the combined effect from the multivariate meta-analysis is -3.5 months (95% CI -6.1, -0.8) indicating that patients undergoing TDL lived 3.5 months less compared to those without TDL. TDL was associated with a significantly higher hazard for mortality at 12 months (HR 1.54, 95% CI 1.38-1.73), 24 months (HR 1.21, 95% CI 1.12-1.35), and 28 months (HR 1.14, 95% CI 1.02-1.28). TDL and noTDL seem comparable in terms of the postoperative risk for chylothorax (RR = 0.66; p = 0.35). Conclusions: In this study, concurrent TDL was associated with reduced 5-year OS after esophagectomy. This may suggest the need of a rigorous follow-up within the first two years of follow-up.

Carbon dioxide gas-induced pneumothorax versus one-lung ventilation in minimally invasive esophagectomy: a multicenter propensity score matching cohort study

BACKGROUND

Carbon dioxide gas-induced pneumoperitoneum might be the reason for the shorter postoperative survival of patients with malignant tumors. Whether CO 2 gas-induced pneumothorax has unfavorable impacts on the surgical and oncological outcomes of minimally invasive esophagectomy remains unclear.

METHODS

Between 2010 and 2016, a total of 998 patients with squamous cell carcinoma of the esophagus who received video-assisted surgery were registered from three large-volume medical centers. The overall survival (OS) and disease-free survival (DFS) were compared after using propensity score-matched and inverse probability-weighted methods. In addition, the tumor-relapse state was evaluated, and the relapse pattern was compared.

RESULTS

A total of 422 and 576 minimally invasive esophagectomies with intraoperative one-lung ventilation and CO 2 -induced pneumothorax were enrolled, respectively. The 5-year OS and DFS were similar between the CO 2 -induced pneumothorax (64.2% and 64.7%) and one-lung ventilation (65.3% and 62.4%) groups following propensity matching. The inverse probability weighting revealed similarly equal survival results in the two groups. The 5-year relapse rates were 35.1% and 30.6% in the one-lung ventilation and CO 2 -induced pneumothorax groups, respectively. Moreover, the relapse patterns were not significantly different between the two groups.

CONCLUSION

The results of this study suggested that the use of intraoperative one-lung ventilation and CO 2 -induced pneumothorax have similar oncological outcomes; therefore, the two methods are both viable options in esophagectomy.

Pre-operative oil ingestion reduces the probability of thoracic duct trunk ligation during esophagectomy

Chylothorax is an important complication after esophagectomy. Ligation of the injured thoracic duct is the main method to prevent chylothorax after esophagectomy, but may be associated with adverse effects. Whether ligation of the injured tributary alone, keeping the main trunk intact, may suffice to prevent post-operative chylothorax is not well known. Since March 2017, 40 mL of olive oil was administered to patients posted for esophagectomy. We compared patients admitted between March 2017 and December 2019 with patients admitted between July 2014 and February 2017, who had not received pre-operative oil. The outcome measures were the need for thoracic duct main trunk or tributary ligation, development of chylothorax and missed ligation. There were 371 patients in the oil ingestion group and 308 patients in the standard control group. Chylothorax in the oil ingestion group was significantly lower than that in the standard control group (1.3% vs. 4.5%, P = 0.012). Chyle leak from thoracic duct tributaries was diagnosed in a significantly higher percentage (5.7% vs. 0.0%, P < 0.001) and missed ligation of the injured thoracic duct was significantly lower (0.3% vs. 3.9%, P = 0.002) in the oil ingestion group compared with the standard control group. The incidence of post-operative chylothorax was not statistically different (6.3% vs. 10.0%, P = 1.000) between the tributary and the trunk ligation group. Pre-operative oil ingestion can help visualize the thoracic duct trunk and its tributaries during esophagectomy. Thus, non-selected thoracic duct trunk ligation and missed ligation during esophagectomy can be reduced. Precise ligation of the injured tributary while the main trunk is intact can also prevent post-operative chylothorax.

The effect of prophylactic thoracic duct ligation during esophagectomy on the incidence of chylothorax and survival of the patients: an updated review

BACKGROUND

The role of thoracic duct ligation (TDL) during esophagectomy remains controversial. This review aimed to elucidate the effect of TDL on chylothorax and survival of the patients after esophagectomy for cancer.

METHODS

We searched articles from PubMed, Web of Science, Scopus, Cochrane, and Google Scholar till May 2020 according to the PRISMA guidelines using the terms of [Oesophagectomy OR esophagectomy] AND [chylothorax] AND [thoracic duct ligation]. Only those compared the incidence of chylothorax in patients who ligated or resected the thoracic duct (ligation group) or preserved the thoracic duct (preservation group) were selected.

RESULTS

First, 15 studies including one randomized controlled trial were collected for meta-analysis regarding post-esophagectomy chylothorax. Of these, 3658 patients underwent TDL and 4638 cases preserved the thoracic duct. Both groups showed similar chylothorax rate (odd ratios 0.73 in favor of ligation group; 95% confidence interval [CI] 0.50-1.07, p = 0.11). Second, four studies providing survival information were included for another meta-analysis, and the patients in preservation group demonstrated better 5-year overall survival compared to those in ligation group (odds ratio 1.25; 95% CI 1.08-1.44, p = 0.002).

CONCLUSIONS

The present review provided updated evidence opposing prophylactic TDL during esophagectomy for lowering chylothorax. Considering the harmful effect of TDL on survival of the patients, further well-designed trials should be considered in selected cases under strict supervision.