Preoperative gastric conditioning in cervical gastroplasty

To determine if ischemic conditioning of the stomach improves the morbidity, mortality, and the anastomotic failure in gastroplasties with cervical anastomosis. Analysis of all patients with indication for cervical gastroplasty during the period of study. In all cases, ischemic conditioning was performed by selective embolization. Anastomotic failure, morbidity, and mortality rates were studied. Thirty‐nine consecutive patients were included. Angiography and selective embolization of the left gastric, right gastric, and splenic arteries were performed. Surgery was performed 2 weeks later. Four patients did not have a complete embolization; median hospital stay after conditioning was 1.24 ± 0.6 days. In two patients, surgery could not be completed. Of the 33 remaining, 29 had a posterior mediastinic gastroplasty and four through the anterior mediastinum. The most common morbidity was respiratory. Five patients had a reoperation and the mortality was 6%. One case of anastomotic leak was found (3%). The mean hospital stay was 17.5 days. Preoperative embolization is a technique with acceptable morbidity and a short hospital stay. In our experience it can reduce the incidence of the morbidity, mortality, and anastomotic leak in gastroplasties with cervical anastomosis. Prospective studies will be necessary to demonstrate the validity of this approach.     

Totally minimally invasive Ivor‐Lewis esophagectomy with single‐utility incision video‐assisted thoracoscopic surgery for treatment of mid‐lower esophageal cancer

The study aims to evaluate the safety and availability of totally minimally invasive Ivor‐Lewis esophagectomy (MIIE) with single‐utility incision video‐assisted thoracoscopic surgery. Forty‐one patients with mid‐lower thoracic esophageal cancer were prospectively treated with totally MIIE. Two stages of laparoscopic‐thoracoscopic procedures were performed. The first 29 patients were treated with four‐port video‐assisted thoracoscopic surgery (Group 1); the others were treated with single‐utility incision video‐assisted thoracoscopic surgery (Group 2). Short‐term clinicopathological outcomes were examined. All patients had negative tumor margins and were pathologically staged from T1N0M0 to T3N2M0. Among Group 1, there was one conversion to open surgery. The mean duration of surgery was 268.4 ± 37.8 minutes, and mean blood loss was 207.2 ± 74.1 mL without significant differences between groups. The average thoracic or abdominal lymph node yield was 12.6 ± 7.1 or 6 ± 5.8, respectively. The median postoperative hospital stay was 7 days. No mortalities occurred. Minor morbidity complicated by late‐stage gastroparesis occurred in two patients (4.9%) after discharge. Major morbidities, including intestinal obstruction and anastomotic leakage, occurred in three patients (7.3%) after discharge. Among Group 2, the average operative duration was 275.4 ± 31.2 minutes, and the mean blood loss was 220 ± 94.9 mL. One patient developed late‐stage anastomotic leakage. The average thoracic or abdominal lymph node yield was 14.7 ± 8.8 and 6.3 ± 5.7, respectively. No statistically significant differences were identified between Group 1 and Group 2. MIIE with single‐utility incision video‐assisted thoracoscopic surgery is feasible in patients with mid‐lower thoracic esophageal cancer without compromising the extent of surgical resection and perioperative outcomes.     

Application of a modified McKeown procedure (thoracoscopic esophageal mobilization three‐incision esophagectomy) in esophageal cancer surgery: Initial experience with 30 cases

Early efforts with minimally invasive esophagectomy (MIE) were hybrid approaches. No conclusive benefit was seen with this approach compared with the standard open procedure. Total MIE has demonstrated its advantages in single institution series. The drawbacks of total MIE include the steep learning curve and the high cost of the disposable instrumentation. We sought to determine the feasibility of modifying the surgical technique involved in the hybrid approach in an effort to decrease the cost of the surgery without compromising the outcome. From December 2007 to September 2008, the modified McKeown procedure (thoracoscopic esophageal mobilization three‐incision esophagectomy) was performed in 30 cases. The median operative time was 225 minutes (range, 195 ?290 minutes) and the median average time of VATS was 70 minutes (range, 50 ?130 minutes). Median lymph node retrieval was 25.6 ± 4.8 nodes (15.1 ± 3.4 intrathoracic) per patient. The median postoperative hospital stay was 17.1 ± 6.3 days. There was no in‐hospital (30 days) mortality. Postoperative complications occurred in 9 patients (30%), including 2 (6.7%) pneumonia, 1 (3.3%) chylothorax, 1 (3.3%) delayed gastric emptying ,1 (3.3%) vocal cord palsy, 2 (6.7%) neck anastomotic leaks, and 2 (6.7%) arrhythmias. This procedure is technically feasible and safe with lower mortality and mobility. The short‐term surgical outcomes are comparable with most of the total MIE reports. Performing the gastric mobilization and spontaneous neck anastomosis first greatly facilitate and simplifies the VATS maneuver.     

Robot‐assisted thoracoscopic esophagectomy with extensive mediastinal lymphadenectomy: experience with 114 consecutive patients with intrathoracic esophageal cancer

The study aims to report the operative outcomes of robot‐assisted thoracoscopic esophagectomy (RATE) with extensive mediastinal lymphadenectomy (ML) for intrathoracic esophageal cancer. We analyzed a prospective database of 114 consecutive patients who underwent RATE with lymph node dissection along recurrent laryngeal nerve (RLN) followed by cervical esophagogastrostomy. The study included 104 men with a mean age of 63.1 ± 0.8 years. Of these, 110 (96.5%) had squamous cell carcinoma, and the location of the tumor was upper esophagus in 7 (6.1%), middle in 62 (54.4%), and lower in 45 (39.5%). Preoperative concurrent chemoradiation was performed in 15 patients (13.2%). All but one patient underwent successful RATE, and R0 resection was achieved in 111 patients (97.4%). Extended ML and total ML were performed in 24 (21.1%) and 90 (78.9%) patients, respectively. Total operation time was 419.6 ± 7.9 minutes, and robot console time was 206.6 ± 5.2 minutes. The mean number of total, mediastinal, and RLN nodes was 43.5 ± 1.4, 24.5 ± 1.0, and 9.7 ± 0.7, respectively. The most common complication was RLN palsy (30, 26.3%), followed by anastomotic leakage (17, 14.9%) and pulmonary complications (11, 9.6%). Median hospital stay was 16 days, and 90‐day mortality was observed in three patients (2.5%). On multivariate analysis, preoperative concurrent chemoradiation was a risk factor for pulmonary complications (odds ratio 7.42, 95% confidence interval 1.91–28.8, P = 0.004). RATE with extensive ML could be performed safely with acceptable postoperative outcomes. Long‐term survival data should be followed in the future to verify the oncological outcome of the procedure.     

Vascular conditioning of the stomach before esophageal reconstruction by gastric interposition

Gastric interposition with intrathoracic or cervical esophagogastrostomy is currently the preferred operation for reconstruction after esophagectomy. Anastomotic leaks however result from poor vascular supply to the proximal stomach. They are responsible for significant morbidity and mortality. ‘Ischemic conditioning’ of the interposed stomach has been proposed as a technique where the ‘delay phenomenon’ aims at improving the microcirculation of the gastric conduit and preventing anastomotic leakage. Experimental observations and clinical studies have been conducted to document the immediate effects and results of this approach. The aim of this work is to review the principles, pathophysiology, experimental, and clinical evidence related to vascular conditioning of the stomach prior to esophagectomy with gastric interposition and esophagogastric anastomosis. MEDLINE and PubMed were searched to identify articles related to vascular conditioning of the stomach. Cross references were added and reviewed to complete the reference list. The anatomic basis of ischemic conditioning, the prevalence of ischemic events on the gastric conduit, the methodology to assess the microcirculation before and after gastric devascularization, animal experiments, and clinical studies reported on this approach were reviewed. Ten experimental works, eleven clinical observations, four reviews, and two editorial commentaries addressing ischemic conditioning of the stomach were identified and reviewed. Experimental observations document improved microcirculation to the proximal stomach following partial gastric devascularization. Clinical reports show the feasibility and relative safety of gastric ischemic conditioning. Preliminary observations suggest potential improvements to the gastric microcirculation resulting from gastric ischemic conditioning. This approach may help prevent complications at the esophagogastric anastomosis. The actual level of evidence however cannot promote its use outside of clinical research protocols.     

The prognostic importance of pathologically involved celiac node metastases in node‐positive patients with carcinoma of the distal esophagus or gastroesophageal junction: a surgical series from the Mayo Clinic

The management of esophageal cancer with involvement of celiac lymph nodes is controversial. The purpose of this retrospective study was to evaluate the clinical importance of metastases to celiac lymph nodes in patients with carcinoma of the distal esophagus or gastroesophageal junction (GEJ) who undergo surgical treatment with curative intent. We reviewed the medical records of 310 patients who underwent definitive esophagectomy at the Mayo Clinic, Rochester, Minnesota, between 1976 and 1999 for carcinoma of the distal esophagus or GEJ. The disease location was distal esophagus in 163 and GEJ in 147. Fifty‐two patients (17%) were found to have celiac node involvement. The survival of these patients was compared with that of 97 N0 patients and 161 N1 patients without celiac node involvement. Squamous cell carcinoma and adenocarcinomas were found in 24% and 76%, respectively. Ivor Lewis esophagectomy was the most common surgical procedure (76%), followed by transhiatal resection (14%) and modified Ivor Lewis procedure (5%). The median number of nodes resected was 15 (range, 2–45). The median survival of the entire group was 18.8 months. The median survival was 48 months (range, 1.6 months–22 years) for N0 patients and 15.9 months (range, 0.03 months–14.4 years) for N1 patients without celiac node disease (P < 0.001). The median survival was 11.7 months (range, 2.2 months–15.7 years) for celiac node–positive patients, and this difference was statistically significant when compared with survival in N0 patients (P= 0.001) but not when compared with that in N1 patients without celiac node disease (P= 0.57). Survival at 3 and 5 years was 61% and 45% for N0 patients, 21% and 9% for N1 patients without celiac node disease, and 18% and 11% for patients with celiac node disease, respectively. At 10 years, 7% of patients with celiac node involvement in their resected specimen were alive. By multivariate analysis, patients with 4 or more positive lymph nodes had the worst prognosis (risk ratio [RR], 2.63; 95% confidence interval [CI], 1.98–3.48), regardless of their location. We concluded that celiac node metastases were not an adverse prognostic indicator in patients with celiac node involvement compared with N1 patients without celiac node disease. Overall, the number of positive nodes, not their location, correlated best with survival. Although median survival was poor, a small number of patients with resected celiac node disease had long‐term survival. Patients with undetected celiac node disease at the time of surgical resection who were subsequently found to have celiac node involvement appeared to have a prognosis similar to that of patients with stage III disease. Therefore, treatment with curative intent should be considered for fit patients with celiac node disease.     

Anastomotic strictures and delayed gastric emptying after esophagectomy: incidence,risk factors and management

The aim of this study was to report the incidence, risk factors, and management of gastric conduit dysfunction after esophagectomy in 177 patients over a 3‐year period in a single center. Patients with anastomotic strictures or delayed gastric emptying (DGE) were identified from a prospective database. Anastomotic strictures occurred in 48 patients (27%). Eighty‐three percent of early anastomotic strictures (<1 year) were benign, and all late strictures (>1 year) were malignant. Dilatation was effective in 98% of benign and 64% of malignant strictures. DGE occurred in 21 patients (12%), and was associated with both anastomotic leak (P = 0.001) and anastomotic stricture (P = 0.001). 4/8 patients with late DGE (>3 months postesophagectomy) were tumor‐related. Pyloric dilatation was effective in 92% of early and 63% of late DGE. Pyloric stents were inserted in 3 patients with tumor‐related DGE. After esophagectomy, early anastomotic strictures (within 1 year) and early delayed gastric emptying (within 3 months) are usually benign and respond to dilatation. However, patients presenting later with tumor‐related obstruction are unlikely to respond to anastomotic or pyloric dilatation and should be stented.     

3D腹腔镜直肠癌根治术28例治疗体会

目的探讨3D高清腹腔镜在直肠癌根治术中的临床应用价值。 方法对我院2015年11月至2016年2月行3D腹腔镜直肠癌根治术28例患者的临床资料进行回顾性分析,其中Dixon手术18例、Miles手术10例。 结果28例均顺利进行3D腹腔镜下直肠癌根治手术,无中转及死亡病例,平均手术时间为（150±21）min,平均出血量为（52±23）ml,肠蠕动恢复时间为（2.1±1.8）d,恢复流质饮食时间为（2.0±0.6）d,平均清扫淋巴结（16.3±2.8）个,平均住院时间为（8.9±3.5）d,无术后出血、吻合口漏、狭窄、输尿管损伤或者肠梗阻的发生。 结论3D高清腹腔镜能实现精细化操作,使用3D腹腔镜行直肠癌根治手术更方便,手术质量更高,并发症更少,取得良好的近期疗效。     

Thoracoscopic purse string technique for minimally invasive Ivor Lewis esophagectomy

Objective

Thoracolaparoscopic esophagectomy with chest anastomosis (TLE-chest) is increasingly performed for middle and lower esophageal cancer; however, gastroesophageal anastomosis for this surgery remains both challenging and inefficient. To address this issue, we previously reported our MIE technique with Ivor-Lewis anastomosis. Here we present the video to introduce our TLE-chest operation procedures.

Methods

TLE-chest with a combined thoracoscopic and laparoscopic technique was performed by one group of surgeons. From October 2011 to September 2013, 80 esophageal cancer patients were treated with TLE-chest using this improved anastomotic technique.

Results

The surgery was successful for all patients, although the anastomosis in one patient required intraoperative manual repair. No patients required open conversion. In this video, dissociation of stomach, and dissection of lymph nodes, creation of gastric tube and staple line embedding, jejunostomy were carried out by laparoscopic surgery. Dissection of esophageal cancer and mediastinal lymph nodes were done through rib 3 or 4 by a 3-4 cm video-assisted right anterior minithoracotomy, then esophago-gastric anastomosis was performed in right thoracic cavity This video shows the R0 resection of T3N0M0 esophageal cancer. Totally, 36 lymph nodes were dissected, including 21 mediastinal lymph nodes and 15 abdominal lymph nodes. The patient recovered well and was discharged on day 8 after the surgery, with good short term outcomes.

Conclusions

A safe, cost effective purse string stapled anastomotic technique has been presented for TLE-chest in our video. It is consistent with the oncology principles.     

Appropriate routes of reconstruction following transthoracic esophagectomy

BACKGROUND/AIMS: The effectiveness of reconstructive methods after esophagectomy remains controversial. METHODOLOGY: A total of 211 patients who underwent transthoracic esophagectomy and esophagogastric anastomosis using the gastric conduit were enrolled in this study. A retromediastinal approach was used in 79 patients and a retrosternal approach in 132. The surgical outcomes were compared between the two groups. RESULTS: In the retrosternal group, anastomotic leakage (26.5%), stenosis of the anastomosis (13.6%), and respiratory complications (18.2%) were frequently observed. Five patients died of aspiration pneumonia probably due to stenosis of the anastomotic site in the retrosternal group. In the retromediastinal group, two patients died from bleeding of a peptic ulcer in the gastric conduit. Partial resection of the manubrium significantly reduced the incidence of leakage in the retrosternal group (4/29 vs. 31/68, p=0.0305). Retrosternal approach and stage were independent prognostic factors for overall survival whereas only stage was an independent prognostic factor for disease-specific survival. CONCLUSIONS: Retrosternal reconstruction is suggested as the unwillingly adopted method of choice after palliative esophagectomy (R2) for the following radiotherapy. Partial resection of the bony structures can be used to prevent postoperative morbidity in this operative procedure. Retromediastinal reconstruction is the possible method of choice in patients receiving curative esophagectomy.     

Robot‐assisted transhiatal esophagectomy: a 3‐year single‐center experience

Minimally invasive esophagectomy has emerged as an important procedure for disease management in esophageal cancer (EC) with clear margin status, less morbidity, and shorter hospital stays compared with open procedures. The experience with transhiatal approach robotic esophagectomy (RE) for dissection of thoracic esophagus and associated morbidity is described here. Between March 2007 and November 2010, 40 patients with resectable esophageal indications underwent transhiatal RE at the institute. Clinical data for all patients were collected prospectively. Of 40 patients undergoing RE, one patient had an extensive benign stricture, one had high‐grade dysplasia, and 38 had EC. Five patients were converted from robotic to open. Median operative time and estimated blood loss were 311 minutes and 97.2 mL, respectively. Median intensive care unit stay was 1 day (range, 0–16), and median length of hospital stay was 9 days (range, 6–36). Postoperative complications frequently observed were anastomotic stricture (n= 27), recurrent laryngeal nerve paresis (n= 14), anastomotic leak (n= 10), pneumonia (n= 8), and pleural effusion (n= 18). Incidence rates of laryngeal nerve paresis (35%) and leak rate (25%) were somewhat higher in comparison with that reported in literature. However, all vocal cord injuries were temporary, and all leaks healed following opening of the cervical incision and drainage. None of the patients died in the hospital, and 30‐day mortality was 2.5% (1/40). Median number of lymph nodes removed was 20 (range, 3–38). In 33 patients with known lymph node locations, median of four (range, 0–12) nodes was obtained from the mediastinum, and median of 15 (range, 1–26) was obtained from the abdomen. R0 resection was achieved in 94.7% of patients. At the end of the follow‐up period, 25 patients were alive, 13 were deceased, and 2 patients were lost to follow‐up. For patients with EC, median disease‐free survival was 20 months (range, 3–45). Transhiatal RE, by experience, is a feasible albeit evolving oncologic operation with low hospital mortality. The benefits include minimally invasive mediastinal dissection without thoracotomy or thoracoscopy. A reasonable operative time with minimal blood loss and postoperative morbidity can be achieved, in spite of the technically demanding nature of the procedure. Broader use of this technology in a setting of high‐volume comprehensive surgical programs will almost certainly reduce the complication rates. Robotic tanshiatal esophagectomy with the elimination of a thoracic approach should be considered an option for the appropriate patient population in a comprehensive esophageal program.     

Totally laparoscopic resection with natural orifice specimen extraction (NOSE) has more advantages comparing with laparoscopic-assisted resection for selected patients with sigmoid colon or rectal cancer

Purpose

The purposes of this study were to compare the short-term outcomes of natural orifice specimen extraction (NOSE) and laparoscopic-assisted resection for sigmoid colon cancer or rectal cancer and to appraise whether totally laparoscopic resection with NOSE had more advantages compared with conventional laparoscopic-assisted resection.

Methods

Sixty-five patients who underwent totally laparoscopic resection with NOSE were assigned to NOSE group, and 132 patients who underwent laparoscopic-assisted resection were assigned to laparoscopic-assisted (LA) group. Data of all 197 cases were reviewed. Short-term outcomes (including operative outcomes, gastrointestinal recovery, hospital stay, and complication) of the two groups were compared.

Results

Mean numbers of lymph nodes harvested were 17.0?±?8.3 and 18.9?±?11.6 in NOSE group and LA group, respectively, (P?=?0.248); mean operative times were 111.6?±?25.4 min and 115.3?±?23.0 min in the two groups (P?=?0.384); and the mean blood losses in these two groups were 70.2?±?66.1 ml and 126.3?±?58.6 ml, respectively, (P?P?P?=?0.002) in NOSE group and LA group, respectively. Hospital stay in NOSE group were 9.0?±?1.9 and 9.9?±?2.0 days in LA group. Incidences of peri-operative complications were 6.2 and 17.2 % in the two groups, respectively (P?=?0.031).

Conclusions

Without compromising oncologic outcome, totally laparoscopic resection with NOSE had more advantages including less blood loss, less pain, faster recovery of intestinal function and shorter hospital stay compared with laparoscopic-assisted resection for selected patients with sigmoid colon cancer or rectal cancer.     

Role of intercostal trocars on laparoscopic liver resection for tumors in segments 7 and 8

Performing laparoscopic liver resection for lesions located in segment 7 and 8 is technically difficult, as the operative field is far from the conventional trocar site, and the liver impedes free motion of the laparoscopic instrument. Inserting the port through the intercostal space (ICS) may facilitate liver resection for these lesions. From January 2012 to July 2013, five patients (four men and one woman) underwent laparoscopic S7 or 8 segmentectomy for liver metastasis and hepatocellular carcinoma (HCC). Ports were inserted at the 7th and 9th ICS, respectively, in addition to conventional abdominal ports. The mean age was 58 ± 10 (45–74) years; operation time, 197 ± 68 (110–300) minutes; blood loss, 161 ± 138 (40–320) ml; and length of hospital stay, 7 ± 3 (4–12) days. Pathologic findings revealed three, one, and one case(s) of colon cancer metastasis, breast cancer metastasis, and HCC, respectively. The mean tumor size and tumor‐free margin were 2.2 ± 1.1 cm and 5.8 ± 1.9 mm, respectively. There were no postoperative complications. Laparoscopic liver resection using intercostal trocars could be a useful method for tumors located in segments 7 and 8 of the liver in selected patients.     

Should we continue to drain the pylorus in patients undergoing an esophagectomy?

A systematic review of the literature was performed to assess the necessity of a pyloric drainage procedure during an esophagectomy with gastric conduit reconstruction. Earlier data recommend performing a pyloric drainage procedure for all esophagectomies; however, recent studies have questioned this. A thorough literature search (January 2001–November 2011) was performed using the terms esophagectomy, pyloroplasty, pyloromyotomy, botulinum toxin, and pyloric drainage. Only studies that compared patient outcome after undergoing an esophagectomy with a pyloric drainage procedure with those undergoing an esophagectomy without a pyloric drainage procedure were selected. Only four studies, comprising 668 patients in total, were identified that compared patient outcome after undergoing an esophagectomy with or without a pyloric drainage procedure, and two additional meta‐analyses were identified and selected for discussion. All studies were retrospective, and because of the heterogeneity of studies, patient demographics, reporting, and statistical analysis of patient outcome, pooling of data and meta‐analysis could not be performed. Careful analysis demonstrated that pyloric drainage procedure was associated with a non‐significant trend for delayed gastric emptying and biliary reflux, while not affecting the incidence of dumping. No correlation was determined between a pyloric drainage procedure and anastomotic leaks, postoperative pulmonary complications, length of hospital stay, and overall perioperative morbidity. While there are risks associated with a pyloric drainage procedure and data exist supporting its omission during an esophagectomy, no good conclusion can be drawn from the current literature. Larger multi‐institutional, prospective studies are required to definitively answer this question.     

Left thoracoabdominal esophagectomy: results from a single specialist center

The left thoracoabdominal approach to esophagectomy is not widely performed, despite offering excellent exposure to tumors of the esophagogastric junction. Criticisms of the approach have focused on historically high rates of mortality, complications, and positive resection margins. Our aim was to determine whether left thoracoabdominal esophagectomy could combine a radical oncological resection with acceptably low mortality and morbidity. A retrospective cohort study of all left thoracoabdominal esophagectomies was performed at a single specialist center over an 11‐year period. Primary outcomes were in‐hospital mortality, complications, resection margin involvement, and lymph node yield; secondary outcomes were 1‐year and 5‐year survival. Two hundred eleven esophagectomies were performed. In‐hospital mortality was 5.7% (12/211). One hundred one subjects (47.9%) had an uncomplicated recovery; 110 subjects (52.1%) developed at least one complication. There were 15 clinically significant anastomotic leaks (7.1%). Twenty‐four subjects (11.4%) required emergency reoperation, the most common indication being anastomotic leakage. Complete tumor excision (R0 resection) was achieved in 151 of 211 cases (71.6%); median lymph node yield was 24. One‐year and 5‐year survival rates were 70% (147/211) and 21% (24/116), respectively. Left thoracoabdominal esophagectomy can combine a radical oncological resection with acceptably low mortality and morbidity.     

The impact of pyloric drainage on clinical outcome following esophagectomy: a systematic review

Delayed emptying of the gastric conduit following esophagectomy can be associated with an increased incidence of complications including aspiration pneumonia and anastomotic leak. The aim of this systematic review is to evaluate the current modalities of pyloric drainage following esophagectomy and their impact on anastomotic integrity and postoperative morbidity. Medline, Web of Science, Cochrane library, trial registries, and conference proceedings were searched. Five pyloric management strategies following esophagectomy were evaluated: no intervention, botulinum toxin (botox) injection, finger fracture, pyloroplasty, and pyloromyotomy. Outcomes evaluated were hospital mortality, anastomotic leak, pulmonary complications, delayed gastric emptying, and the late complication of bile reflux. Twenty‐five publications comprising 3172 patients were analyzed. Pooled analysis of six comparative studies published after 2000 revealed pyloric drainage to be associated with a nonsignificant trend toward a reduced incidence of anastomotic leak, pulmonary complications, and delayed gastric emptying. Overall, the current level of evidence regarding the merits of individual pyloric drainage strategies remains very poor. There is significant heterogeneity in the definitions of clinical outcomes, in particular delayed gastric emptying, which has prevented meaningful assessment and formulation of consensus regarding the management of the pylorus during esophagectomy. Pyloric drainage procedures showed a non‐significant trend toward fewer anastomotic leaks, pulmonary complications, and reduced gastric stasis when employed following esophagectomy. However, the ideal technique remains unproven suggesting that further collaborative investigations are needed to determine the intervention that will maximize the potential benefits, if any, of pyloric intervention.     

Clinical study on the D4 lymph nodes excision in advanced gastric cancer

AIM To study the safety and the traumatic degree of D4 approach by retrospective analysis of the para-operative data from the para-aortic lymph nodes excision in comparison with those from standard radicalresection in advanced gastric cancer (AGC).METHODS Several para-operative data including the resectability, the mortality, the complicatedmorbidity, the amount of transfused blood, and the hospitalized days relating to the operation were analyzedstatistically between D4(n = 30) and D2 lymph nodes excision (n = 34) groups. The data expressed as means±SD was analyzed statistically by Student t test. Percentage of the data was analyzed by x2 test statistically.It was taken as significant difference if P value was less than 0.05.RESULTS The percentage of palliated resection in D4 group was significantly lower than that in D2 group(16.67% vs 47.06%, P<0.05). This D4 radical resection would indeed prolong the drainage time (7.35±0.98 days vs 14.78±2.16 days, P < 0.01). The amount of transfused blood during operation (774.32±112.09mL) and the operative consuming time in D4 group (7.14±0.39h) increased significantly toocompared with those in D2 group (538.67±59.87mL, P < 0.05; 4.12±0.18h, P < 0.05), suggesting that thedraumatic degree of D4 operation was severer than that of D2 operation. But the mortality, the morbidity ofcomplication and the hospitalized time after D4 operation did not increase significantly, indicating that D4lymph nodes excision as a choice of the surgical treatment of AGC was safe and feasible.CONCLUSION D4 lymph nodes excision for AGC is safe, reasonable and feasible.     

Hand‐assisted laparoscopic transhiatal esophagectomy with a systematic procedure for en bloc infracarinal lymph node dissection

Laparoscopic transhiatal esophagectomy is a minimally invasive approach for esophageal cancer. However, a transhiatal procedure has not yet been established for en bloc mediastinal dissection. The purpose of this study was to present our novel procedure, hand‐assisted laparoscopic transhiatal esophagectomy, with a systematic procedure for en bloc mediastinal dissection. The perioperative outcomes of patients who underwent this procedure were retrospectively analyzed. Transhiatal subtotal mobilization of the thoracic esophagus with en bloc lymph node dissection distally from the carina was performed according to a standardized procedure using a hand‐assisted laparoscopic technique, in which the operator used a long sealing device under appropriate expansion of the operative field by hand assistance and long retractors. The thoracoscopic procedure was performed for upper mediastinal dissection following esophageal resection and retrosternal stomach roll reconstruction, and was avoided based on the nodal status and operative risk. A total of 57 patients underwent surgery between January 2012 and June 2013, and the transthoracic procedure was performed on 34 of these patients. In groups with and without the transthoracic procedure, total operation times were 370 and 216 minutes, blood losses were 238 and 139 mL, and the numbers of retrieved nodes were 39 and 24, respectively. R0 resection rates were similar between the groups. The incidence of recurrent laryngeal nerve palsy was significantly higher in the group with the transthoracic procedure, whereas no significant differences were observed in that of pneumonia between these groups. The hand‐assisted laparoscopic transhiatal method, which is characterized by a systematic procedure for en bloc mediastinal dissection supported by hand and long device use, was safe and feasible for minimally invasive esophagectomy.