Abstract: Esophageal carcinoma is a common worldwide malignancy for which the major treatment method is surgery, and there are various kinds of surgical procedures: (1) esophagectomy via right thoracic, abdominal and cervical approaches; (2) esophagectomy via left thoracic approach with anastomosis upon or under aortic arch； (3) esophagectomy via left thoracic approach with cervical anastomosis； (4) Ivor-Lewis； (5) esophageal pull-out via abdominal and cervical approaches with cervical anastomosis； (6) esophagectomy aided by videoassisted thoracoscope； (7) esophagectomy with jejunum or colon substitution. In this review, the current surgical treatments for esophageal carcinoma, perioperative management and novel surgical technique applications are summarized. Besides, the future of esophageal surgery is predicted including minimally invasive surgery, the improving standard of lymph node dissection, neoadjuvant therapy application, postoperative life quality and prospective artificial esophagus. Meanwhile, the remaining problems are discussed.
Lymphatic metastasis of esophageal cancer is one of the main ways of esophageal cancer metastasis and it is as well one of the most important factors influencing the prognosis of esophageal cancer patients. Compared to intravenous administration of chemotherapy, local chemotherapy has the less toxicity and less systemic side effects. Nano carbon is a safe and effective carrier for intraoperative lymphatic chemotherapy. It plays an important role in tracing and targeting lymph node during the lymphatic chemotherapy. Lymphatic chemotherapy can induce tumor into necrosis and apoptosis. For esophageal cancer, lymphatic chemotherapy is also to be proved to improve the rate of lymph node dissection and the number of metastatic lymph nodes, decrease tumor size, improve the quality of life and survival rate. In conclusion, lymphatic chemotherapy can be considered an assistant therapy to eliminate the tumor cell in lymph nodes and micrometastatic foci. In this review, the metastatic characteristic of esophageal cancer, the significance, mechanism and application of lymphatic chemotherapy carried by nano carbon are summarized.
In this review, development and application of the minimally invasive esophagectomy(MIE) for esophageal cancer are discussed including the types of MIE procedures, short- and long- term outcome after MIE; as well the future of MIE is forecasted. Main procedures of MIE performed currently include esophagectomy via thoracoscopy and laparoscopy and cervical esophagogastrosty, Ivor-Lewis MIE via thoracoscopy and laparoscopy, and hiatal MIE. Ivor-Lewis MIE gradually becomes a standard surgical option for the cancer of distal esophagus or esophagogastric junction while the solution of intrathoracic anastomosis via thoracoscopy has achieved. Several methods of intrathoracic anastomosis are reported such as hand-sewn, circular stapler, side-to-side and triangular anastomosis. MIE could decrease operative blood loss, shorten hospital stay and ICU stay, reduce postoperative especially pulmonary complications, and harvest more lymph nodes compared to open esophagectomy. The long-term survival has been proved similar with that after open esophagectomy for esophageal cancer. MIE has developed rapidly in recent years with some aspects in future prospectively: individual MIE treatment and quality of life, fast track after surgery, and robot-assisted MIE, as well the endoscopic submucosal dissection for esophageal cancer is mentioned.
ObjectiveTo investigate the efficacy of uniportal video-assisted thoracoscopic surgery (VATS) anatomic basal segmentectomy.MethodsThe clinical data of 15 patients who underwent uniportal VATS anatomic basal segmentectomy between June 2020 and December 2020 were retrospectively reviewed. There were 4 males and 11 females with a median age of 53 (32-70) years. The incisions were placed in the fifth intercostal space across the mid-axillary line. All basal segmentectomies were performed through the interlobar fissure or inferior pulmonary ligament approach following the strategies of single-direction and stem-branch.ResultsAll patients underwent basal segmentectomy successfully with no conversion to multi-portal procedure or thoracotomy. The median operation time was 120 (90-160) min, median intraoperative blood loss was 20 (10-50) mL, median drainage time was 3 (2-5) d, and median postoperative hospital stay was 4 (4-10) d. The maximum diameter of the lesion in the resected basal segment was 1.2 (0.7-1.9) cm. The median resected lymph nodes were 7 (5-12). There was no evidence of nodal metastases. One patient suffered postoperative atelectasis and subsequent pneumonia. No perioperative death occurred.ConclusionUniportal VATS anatomic basal segmentectomy is feasible and safe. It can be performed in a simple manner following the strategy of single-direction.
Objective To explore the short-term surgical outcomes of the modified surgical procedure for uniportal thoracoscopic right middle lobectomy. Methods In this modified approach, the incision was created at sixth or seventh intercostal space inferior to the subscapular angle. The surgeon stood on the opposite side of the operating table. The surgery was performed by serial division of the anterior oblique fissure, the vein, bronchus, artery, and horizontal fissure following the single-direction strategy. As for patients with malignant lesions, hilar and mediastinal lymph node dissection was performed. Clinical characteristics and early surgical outcomes were collected and analyzed. Results Fifty two patients with a mean age of 48 years were included in this study. There were 20 males and 32 females at an average age of 48.0±10.5 years. No conversion or perioperative mortality was occurred. Mean surgical time was 68.1±16.8 min, mean blood loss was 16.5±4.9 mL, median chest tube duration was 2 (2-22) d and median postoperative hospital stay was 3 (3-24) d. There was no intraoperative or postoperative complication but one patient developed postoperative prolonged air leak (>5 d). Mean postoperative visual-analog scale (VAS) on postoperative day 1, day 2 and day 3 was 1.5±0.8, 1.7±0.4, 0.8±0.7, respectively. Conclusions Trans-posterior-approach uniportal thoracoscopic single-direction RML is a safe, feasible, and effective procedure, which provides an appropriate direction and angle for dissection and stapling, solving the challenge of conventional uniportal RML lobectomy.
Objective To investigate the value of contrast-enhanced ultrasonography in detection and diagnosis of small primary liver cancer. Methods SonoVue-enhanced ultrasonography were performed on 353 patients with 378 primary liver cancer, less than 3 cm in diameter. Enhancement patterns and enhancement phases of hepatic lesions on contrast-enhanced ultrasonography were analyzed and compared with the results of histopathology. Results In all hepatic tumors, 96.6% （365/378） lesions enhanced in the arterial phase. Among them, 317 (83.9%) tumors enhanced earlier than liver parenchyma and 48 (12.7%) tumors enhanced synchronously with liver parenchyma, and 342 (90.5%) tumors showed early wash-out in the portal and late phases. With regard to the enhancement pattern, 329 (87.0%) tumors presented whole-lesion enhancement, 35 (9.3%) to be mosaic enhancement and 14 (3.7%) to be rim-like enhancement. If taking the whole-lesion enhancement and mosaic enhancement in arterial phase as diagnotic standard for primary liver cancer on contrast-enhanced ultrasonography, the sensitivity was 92.9%(351/378), and if the earlier or synchronous enhancement of the tumor compared with liver parenchyma in arterial phase and the wash-out in portal phase were regarded as the stardand, the sensitivity was 87.3%(330/378). Conclusion Contrast-enhanced ultrasonography could display real-time enhancement patterns as well as the wash-out processes both in hepatic tumors and the liver parenchyma. It might be of clinical value in diagnosis of primary liver cancer based on the hemodynamics of hepatic tumors on contrast-enhanced ultrasonography.
Objective To compare the distribution of drug concentration in lymph nodes and blood between lymphatic chemotherapy and single drug chemotherapy and to study if nano carbon can enhance the number of lymph node dissection. Methods From June 2015 to February 2016, 80 patients with esophageal cancer in the Department of Thoracic Surgery, West China Hospital were enrolled and they were divided into two groups: a lymphatic chemotherapy with paclitaxel (LCP) group and a paclitaxel alone (PTX) group. There were 35 males and 5 females with an average age of 60.63±8.78 years in the LCP group, and 30 males and 10 females with an average age of 62.13±7.89 years in the the PTX group. We observed the incidence rate of complications after operation, the number of lymph node dissection and the rate of lymph node metastasis. The drug concentration in the blood and lymph nodes between the two groups was compared. Results The postoperative morbidity did not increase in the both groups, which did not have adverse drug reactions such as bone marrow suppression, gastrointestinal reaction and so on. The concentration of chemotherapy drug in lymph nodes in the LCP group was higher than that in the PTX group. The LCP group collected 771 lymph nodes, and the average number was 19.27±7.77 for each patient; the PTX group collected 658 lymph nodes, and the average number was 16.45±7.12 for each patient; but the difference between two groups was not statistically significant (P>0.05). Conclusion Nano carbon carriers can effectively improve the drug concentration in lymph nodes after the local injection of chemotherapy drugs. The use of nano carbon tracer in the operation to improve lymph node dissection may not have significance.
Objective To evaluate the advantages about video-assisted thoracoscopic surgery (VATS) lobectomy with optimized management of surgical instruments package. Methods A total of 200 patients with lung cancer were enrolled, which included 78 males and 122 females, aged 24-83 years at median age of 56.8 years. All of them were divided into 2 groups including a routine group (n=100) and an optimized management of surgical instruments group (n=100). The total operation time, bleeding, instrument weights, utilization rate of instruments, counted and cleaning time in 2 groups were recorded and analyzed. Results The average operation time and average lost blood of the routine group was 117.62±42.52 min and 53.14±50.69 ml, respectively, and the one of the optimized instruments group was 120.48±40.62 min, 56.10±49.87 ml, respectively, with no significant difference between the two groups (P=0.112, P=0.231, respectively). The utilization rate of instruments in the routine group (58.02%±2.39%) was significantly lower than that of the optimized instruments group (94.00%±1.48%, P=0.014). The counted time, the loading and unloading time and the cleaning time of instruments in the routine group was 112.00±26.00 s, 70.00±15.00 s, 1 010.00±130.00 s, respectively, much longer than the time of the optimized instruments group, which was 65.00±23.00 s, 20.00±4.00 s, 665.00±69.00 s, respectively. There was a statistical difference between the two groups (P=0.028, P=0.011, P=0.039, respectively). The value of instruments in the routine group (177 574.00±14 438.00 yuan) was apparently higher than that of the optimized instruments group(132 027.00±10 311.00 yuan), with a statistical difference (P=0.032). Conclusion It is demonstrated that optimized management of surgical instruments package in VATS lobectomy can greatly improve the utilization rate of instruments and work efficiency, with no effects on the operation time and amount of bleeding in lobectomy.
ObjectiveTo analyze the operation outcomes and learning curve of uniportal video-assisted thoracoscopic surgery (VATS).MethodsAll consecutive patients who underwent uniportal VATS between November 2018 and December 2020 in Shangjin Branch of West China Hospital of Sichuan University were retrospectively enrolled, including 62 males and 86 females with a mean age of 50.1±13.4 years. Operations included lobectomy, segmentectomy, wedge resection, mediastinal mass resection and hemopneumothorax. Accordingly, patients' clinical features in different phases were collected and compared to determine the outcome difference and learning curve for uniportal VATS.ResultsMedian postoperative hospital stay was 5 days, and the overall complication rate was 8.1% (12/148). There was no 30-day death after surgery or readmissions. Median postoperative pain score was 3. Over time, the operation time, incision length and blood loss were optimized in the uniportal VATS lobectomy, the incision length and blood loss increased in the uniportal VATS segmentectomy, and the postoperative hospital stay decreased in the uniportal VATS wedge resection.ConclusionUniportal VATS is safe and feasible for both standard and complex pulmonary resections. While, no remarkable learning curve for uniportal VATS lobectomy is observed for experienced surgeon.
ObjectiveTo explore the safety and feasibility of the modified and improved thoracoscopic surgery for esophageal cancer using the concept of "single-direction" thoracoscopic technique.MethodsThe clinical data of 65 patients undergoing this modified minimally invasive esophagectomy based on "single-direction" thoracoscopic system between June 2018 and April 2019 were retrospectively analyzed, including 54 males and 11 females aged 62.5±7.8 years.ResultsThe thoracoscopic operation time was 133.4±28.6 min, and intraoperative blood loss was 61.9±29.2 mL. No intraoperative blood transfusion was needed. One patient was transferred to open thoracotomy (due to severe pleural adhesion atresia). Major complications included anastomotic leak, pneumonia, chylothorax, incisional infection, recurrent laryngeal nerve paralysis and gastric emptying disorders, which were recovered by conservative treatment. No postoperative death occurred. The median number of lymph nodes and lymph node station harvested was 19 and 10, respectively. The median postoperative hospital stay was 10 days. The volume of chest drainage was 1 117.3±543.4 mL.ConclusionThe minimally invasive operation mode of esophageal cancer based on "single-direction" thoracoscopic system is safe and feasible, and has good field vision and smooth and simplified procedure.