Laparoscopic reconstruction in McKeown esophagectomy is a risk factor for postoperative diaphragmatic hernia

Diaphragmatic hernia is a very rare but high-risk complication after esophagectomy. Although there are many studies on the Ivor Lewis esophagectomy procedure for diaphragmatic hernia, there are fewer studies on the McKeown procedure. The present study aimed to estimate the incidence of diaphragmatic hernia after esophagectomy, describing its presentation and management with the McKeown procedure. We retrospectively evaluated the 622 patients who underwent radical esophagectomy between January 2002 and December 2020 at the Wakayama Medical University Hospital. Statistical analyses were performed to evaluate risk factors for diaphragmatic hernia. Emergency surgery for postoperative diaphragmatic hernia was performed in nine of 622 patients (1.45%). Of these nine patients, one developed prolapse of the small intestine into the mediastinum (11.1%). The other eight patients underwent posterior mediastinal route reconstructions (88.9%), one of whom developed prolapse of the gastric conduit, and seven of whom developed transverse colon via the diaphragmatic hiatus. Laparoscopic surgery was identified in multivariate analysis as the only independent risk factor for diaphragmatic hernia (odd's ratio [OR] = 9.802, p = 0.034). In all seven cases of transverse colon prolapse into the thoracic cavity, the prolapsed organ had herniated from the left anterior part of gastric conduit. Laparoscopic surgery for esophageal cancer is a risk factor for diaphragmatic hernia. The left anterior surface of gastric conduit and diaphragmatic hiatus should be fixed firmly without compromising blood flow to the gastric conduit.

Quercetin as an anticancer agent: Focus on esophageal cancer

Esophageal cancer (EC) is regarded as the sixth highest contributor to all cancer-related mortality, worldwide. In spite of advances in the treatment of EC, currently used methods remain ineffective. Quercetin, as a dietary antioxidant, is a plant flavonol from the flavonoid group of polyphenols, and can be found in numerous vegetables, fruits, and herbs. Quercetin can affect the processes of cancer-related diseases via cell proliferation inhibitory effects, potential apoptosis effects, and antioxidant properties. Of the various types of cancer, the use of quercetin has now become prominent in the treatment of EC. In this review, we discuss how quercetin may be an important supplement for the prevention, treatment, and management of EC, owing to its natural origin, and low-cost relative to synthetic cancer drugs. However, most findings cited in the current study are based on in vitro and in vivo studies, and thus, further human-based research is necessitated. PRACTICAL APPLICATIONS: In spite of advances in the treatment of esophageal cancer, currently used methods remain ineffective, therefore, an alternative or complementary therapy is required. Quercetin, as a dietary antioxidant, can affect the processes of cancer-related diseases via cell proliferation inhibitory effects, potential proapoptotic functions, and antioxidant properties. Quercetin may be an important supplement for the prevention, treatment, and management of EC, owing to its natural origin. The low cost of quercetin as supplement or dietary intake, relative to synthetic cancer drugs, is an advantage of the compound which should be considered.

Costs and benefits of different methods of esophagectomy for esophageal cancer

Background A minimally invasive approach to esophagectomy is being used increasingly, but concerns remain regarding the feasibility, safety, cost, and outcomes. We performed an analysis of the costs and benefits of minimally invasive, hybrid, and open esophagectomy approaches for esophageal cancer surgery. Methods The data of 83 consecutive patients who underwent a McKeown's esophagectomy at Prince of Songkla University Hospital between January 2008 and December 2014 were analyzed. Open esophagectomy was performed in 54 patients, minimally invasive esophagectomy in 13, and hybrid esophagectomy in 16. There were no differences in patient characteristics among the 3 groups Minimally invasive esophagectomy was undertaken via a thoracoscopic-laparoscopic approach, hybrid esophagectomy via a thoracoscopic-laparotomy approach, and open esophagectomy by a thoracotomy-laparotomy approach. Results Minimally invasive esophagectomy required a longer operative time than hybrid or open esophagectomy ( p = 0.02), but these patients reported less postoperative pain ( p = 0.01). There were no significant differences in blood loss, intensive care unit stay, hospital stay, or postoperative complications among the 3 groups. Minimally invasive esophagectomy incurred higher operative and surgical material costs than hybrid or open esophagectomy ( p = 0.01), but there were no significant differences in inpatient care and total hospital costs. Conclusion Minimally invasive esophagectomy resulted in the least postoperative pain but the greatest operative cost and longest operative time. Open esophagectomy was associated with the lowest operative cost and shortest operative time but the most postoperative pain. Hybrid esophagectomy had a shorter learning curve while sharing the advantages of minimally invasive esophagectomy.

Comparison of short-term outcomes and three yearsurvival between total minimally invasive McKeown and dual-incision esophagectomy

Background

The aim of this study was to compare the short‐term outcomes and three‐year survival between dual‐incision esophagectomy (DIE) and total minimally invasive McKeown esophagectomy (MIME) for esophageal cancer patients with negative upper mediastinal lymph nodes requiring esophagectomy and neck anastomosis.

Methods

One hundred and fifty patients underwent DIE, while 361 patients received total MIME. Perioperative outcomes and three‐year survival were compared in unmatched and propensity score matched data between two groups.

Results

Both unmatched and matched analysis demonstrated that there were no significant differences in the number of lymph nodes harvested, or major or minor complication rates between the DIE and MIME groups. Compared with patients who underwent DIE, patients who underwent total MIME had longer operation duration (310 minutes vs. 345 minutes; P = 0.002). However, there was significantly less intraoperative blood loss in the total MIME compared with the DIE group (191 mL vs. 287 mL, respectively; P < 0.001). Kaplan‐Meier analysis demonstrated a trend that patients who underwent MIME had longer overall (79.5% vs. 64.1%; P = 0.063) and disease‐free three‐year survival (65.3% vs. 82.8%; P = 0.058) compared with patients who underwent DIE.

Conclusions

Both total MIME and DIE are feasible for the surgical treatment of esophageal cancer patients with negative upper mediastinal lymph nodes requiring esophagectomy and neck anastomosis. However, MIME was associated with better overall and disease‐free three‐year survival compared with DIE.

Minimally invasive oesophagectomy versus open esophagectomy for resectable esophageal cancer: a meta-analysis

Background

Open esophagectomy (OE) is associated with significant morbidity and mortality. Minimally invasive oesophagectomy (MIO) reduces complications in resectable esophageal cancer. The aim of this study is to explore the superiority of MIO in reducing complications and in-hospital mortality than OE.

Methods

MEDLINE, Embase, Science Citation Index, Wanfang, and Wiley Online Library were thoroughly searched. Odds ratio (OR)/weighted mean difference (WMD) with a 95% confidence interval (CI) was used to assess the strength of association.

Results

Fifty-seven studies containing 15,790 cases of resectable esophageal cancer were included. MIO had less intraoperative blood loss, short hospital stay, and high operative time (P < 0.05) than OE. MIO also had reduced incidence of total complications; (OR = 0.700, 95% CI = 0.626 ~ 0.781, P_V < 0.05), pulmonary complications (OR = 0.527, 95% CI = 0431 ~ 0.645, P_V < 0.05), cardiovascular complications (OR = 0.770, 95% CI = 0.681 ~ 0.872, P_V < 0.05), and surgical technology related (STR) complications (OR = 0.639, 95% CI = 0.522 ~ 0.781, P_V < 0.05), as well as lower in-hospital mortality (OR = 0.668, 95% CI = 0.539 ~ 0.827, P_V < 0.05). However, the number of harvested lymph nodes, intensive care unit (ICU) stay, gastrointestinal complications, anastomotic leak (AL), and recurrent laryngeal nerve palsy (RLNP) had no significant difference.

Conclusions

MIO is superior to OE in terms of perioperative complications and in-hospital mortality.

Does minimally invasive oesophagectomy provide a benefit in hospital length of stay when compared with open oesophagectomy?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was: 'in patients undergoing oesophagectomy, does a minimally invasive approach convey a benefit in hospital length of stay (LOS), when compared to an open approach?' A total of 647 papers were identified, using an a priori defined search strategy; 24 papers represented the best evidence to answer the clinical question. The authors, journal, date, country of publication, patient group, study type, relevant outcomes and key results are tabulated. Of the studies identified, data from two randomized controlled trials were available. The first randomized study compared the use of open thoracotomy and laparotomy versus thoracoscopy and laparoscopy. Those undergoing minimally invasive oesophagectomy (MIO) left hospital on average 3 days earlier than those treated with the open oesophagectomy (OO) technique (P = 0.044). The other randomized trial, which compared thoracotomy with thoracoscopy and laparoscopy, demonstrated a reduction of 1.8 days in the LOS when employing the MIO technique (P < 0.001). With the addition of the remaining 22 non-randomized studies, comprising 3 prospective and 19 retrospective cohort studies, which are heterogeneous with regard to their design, study populations and outcomes; data are available representing 3173 MIO and 25 691 OO procedures. In total, 13 studies (including the randomized trials) demonstrate a significant reduction in hospital LOS associated with MIO; 10 suggest no significant difference between techniques; and only 1 suggests a significantly greater length of stay associated with MIO. The only two randomized trials comparing MIO and OO demonstrated a reduction in length of stay in the MIO group, without compromising survival or increasing complication rates. All bar one of the non-randomized studies demonstrated either a significant reduction in length of stay with MIO or no difference. The benefit in reduced length of stay was not at the cost of worsened survival or increased complications, and conversion rates in all studies were low.

Learning curve to lymph node resection in minimally invasive esophagectomy for cancer

OBJECTIVE

Minimally invasive esophagectomy (MIE) is a safe alternative to open approaches, yet the impact of the minimally invasive approach on oncologic efficacy is unclear. The objectives of the current study were to compare lymph node yields and surgical margins during a single-surgeon series to examine the learning curve to oncologic aspects of MIE.

METHODS

A retrospective review of a prospectively maintained institutional database was performed. The sequential MIE experience for esophageal cancer was subcategorized into terciles (first 25 MIEs as early, next 24 as middle, and most recent 24 as later).

RESULTS

Seventy-three patients underwent MIE for cancer between 2008 and 2013. Complete resections (R0) were performed in 71 cases (93%), and there were no significant differences in the number of complete resections with negative margins during the MIE experience (P = 0.54). The number of lymph nodes harvested during MIE increased significantly with progressive experience, with a mean of 22, 29, and 28 nodes recovered in the early, middle, and late subgroups, respectively (P = 0.038). On multivariate analysis, only increasing surgeon experience (1.4-fold increase in nodal yield for the latter two thirds relative to the first third, P = 0.0011) and histology of high-grade dysplasia (0.54-fold decrease in nodal yield relative to adenocarcinoma or squamous cell carcinoma, P = 0.025) were significant predictors of lymph node yield.

CONCLUSIONS

The ability to execute a complete lymphadenectomy during MIE is affected by surgeon experience and improves over time, plateauing after the first 25 cases.

A single-center experience of endoscopic submucosal dissection performed in a Western setting

BACKGROUND

Compared with the piecemeal resection associated with endoscopic mucosal resection, endoscopic submucosal dissection (ESD) enables en bloc resection of larger lesions, allows for more accurate histological assessments, and has reduced recurrence rates. ESD is not widely performed in Western countries given increased technical difficulty, high complication rates, and long procedure times.

AIMS

To evaluate the safety and efficacy of ESD in a single center in the USA.

METHODS

A retrospective study on a prospectively collected database identified cases in which a single operator (IW) performed ESD at a tertiary referral center. Twenty cases were identified, nine in the upper digestive tract (four esophagus and five stomach) and 11 in the lower digestive tract (nine rectal and two sigmoid colon). Data regarding lesion location, pathology, method of ESD (composition/volume of lifting injection and resection method), post-procedure complications, and margin involvement were collected.

RESULTS

En bloc resection was obtained in 14/20 patients (70 %). The average procedure time was 202 min in the esophagus, 148 min in the stomach, and 106 min for lower lesions. A major complication (perforation) occurred in 1/20 cases (5 %). Complete resection was obtained in 14/20 (70 %). R0 resection was obtained in 16/20 (80 %) cases.

CONCLUSIONS

The complication, en bloc resection, and complete resection rates of this study are similar to those found in large studies on ESD performed in Eastern settings. ESD is safe and efficacious for en bloc resections of pre-malignant and early-invasive lesions, and should be offered to patients with suitable lesions in Western settings.

Outcomes in the management of esophageal cancer

Esophageal cancer rates have continued to rise in the Western World. Esophageal cancer will be responsible for an estimated 15,450 deaths in the United States in 2014 alone. Esophageal resection with or without preoperative therapy remains the mainstay of treatment. Advances in surgical technique and perioperative care have improved short-term outcomes considerably by decreasing operative mortality. Despite these advances though, esophagectomy remains a procedure associated with considerable morbidity from a wide range of complications. Prompt recognition and treatment of complications can lower overall morbidity and mortality. Unfortunately, long-term outcomes remain poor as the vast majority of patients present with loco-regionally advanced or metastatic disease. Surgery by itself provides poor loco-regional control and fails to address micrometastatic disease. Neoadjuvant chemotherapy or chemoradiation provides a modest survival advantage compared to surgical resection alone. Future gains in understanding the molecular biology of esophageal cancer will hopefully lead to improved therapeutics and resultant outcomes.