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1.
Steven R. DeMeester 《Journal of gastrointestinal surgery》2010,14(1):94-100
Introduction
Adenocarcinoma of the esophagus is the fastest increasing cancer in the USA, and an increasing number of patients are identified with early-stage disease. The evaluation and treatment of these superficial cancers differs from local and regionally advanced lesions.Methods
This paper is a review of the current methods to diagnose, stage, and treat superficial esophageal adenocarcinoma.Results
Intramucosal adenocarcinoma can be effectively treated with endoscopic resection techniques and with less morbid surgical options including a vagal-sparing esophagectomy. However, submucosal lesions are associated with a significant risk for lymph node metastases and are best treated with esophagectomy and lymphadenectomy.Discussion
There has been a major shift in the treatment for Barrett’s high-grade dysplasia and superficial esophageal adenocarcinoma in the past 10 years. New therapies minimize the morbidity and mortality of traditional forms of esophagectomy and in some cases allow esophageal preservation. Individualization of therapy will allow maximization of successful outcome and quality of life with minimization of complications and recurrence of Barrett’s or cancer.2.
Background
The treatment of early-stage esophageal cancer and high-grade dysplasia of the esophagus has changed significantly in recent years. Many early tumors that were traditionally treated with esophagectomy can now be resected with endoscopic therapy alone. These new endoscopic modalities can offer similar survival outcomes without the associated morbidity of a major operation. However, a number of these cases may still require surgical intervention as the best treatment option.Methods
The current scientific literature, national and international guidelines were reviewed for recommendations regarding optimal treatment of early esophageal malignancy.Results
The primary advantage of surgery over endoscopic treatment lies in the reduced risk of recurrence as well as the ability to assess harvested lymph nodes for regional disease. We recommend that esophageal tumors that have invaded into the submucosa (T1b) or beyond should be treated with an esophagectomy. In addition, dysplastic lesions and cancers that demonstrate poorly differentiated pathology or lymphovascular or perineural invasion should be surgically resected. Finally, large tumors, multifocal lesions, tumors within a long segment of Barrett’s esophagus, tumors adjacent to a hiatal hernia, tumors that cannot be resected enbloc with endoscopic techniques should also be treated with an esophagectomy.Conclusions
When performed at high-volume centers in experienced hands, esophagectomy can have consistently good outcomes for high-grade dysplasia and early esophageal cancers, and should be considered as a treatment option.3.
Introduction
Minimally invasive esophagectomy has gained popularity over the past two decades. The procedural goal is to decrease the high overall morbidity of a traditional open esophageal resection. The entire spectrum of open esophagectomy techniques has been successfully replicated in a minimally invasive fashion.Discussion
Esophagectomy remains one of the most technically challenging operations, and developing the skills necessary for minimal invasive esophagectomy is associated with a steep learning curve. Minimally invasive approaches show most promise for benign disease and select early esophageal cancers, but their role in more advanced cancer remains controversial due to lack of long-term results.Conclusion
As minimally invasive esophagectomy matures, its true value in both benign and malignant disorders will become better defined.4.
Teus J. Weijs Jelle P. Ruurda Misha D. P. Luyer Grard A. P. Nieuwenhuijzen Sylvia van der Horst Ronald L. A. W. Bleys Richard van Hillegersberg 《Surgical endoscopy》2016,30(9):3816-3822
Background
Pulmonary vagus branches are transected as part of a transthoracic esophagectomy and lymphadenectomy for cancer. This may contribute to the development of postoperative pulmonary complications. Studies in which sparing of the pulmonary vagus nerve branches during thoracoscopic esophagectomy is investigated are lacking. Therefore, this study aimed to determine the feasibility and pitfalls of sparing pulmonary vagus nerve branches during thoracoscopic esophagectomy.Methods
In 10 human cadavers, a thoracoscopic esophagectomy was performed while sparing the pulmonary vagus nerve branches. The number of intact nerve branches, their distribution over the lung lobes and the number and location of the remaining lymph nodes in the relevant esophageal lymph node stations (7, 10R and 10L) were recorded during microscopic dissection.Results
A median of 9 (range 5–16) right pulmonary vagus nerve branches were spared, of which 4 (0–12) coursed to the right middle/inferior lung lobe. On the left side, 10 (3–12) vagus nerve branches were spared, of which 4 (2–10) coursed to the inferior lobe. In 8 cases, lymph nodes were left behind, at stations 10R and 10L while sparing the vagus nerve branches. Lymph nodes at station 7 were always removed.Conclusions
Sparing of pulmonary vagus nerve branches during thoracoscopic esophagectomy is feasible. Extra care should be given to the dissection of peribronchial lymph nodes, station 10R and 10L.5.
Purpose
To reveal the patterns of the mediastinal course of the bronchial arteries (BAs).Methods
The BAs were dissected to determine the positional relationships of their mediastinal courses with the tracheobronchus and the esophagus in 72 adult cadavers.Results
The mediastinal courses of the 227 BAs found in this study were classified into 4 types. There were 61 and 163 BAs passing the right side (Type I) and the left side (Type II reaching dorsal surface (n = 98), or Type III reaching ventral surface (n = 65) of the tracheobronchus) of the esophagus, respectively. Three BAs originated from the subclavian artery (Type IV). All Type I BAs were right BAs, whereas 91.8% of the Type II BAs were left BAs. However, 43.1 and 56.9% of the Type III BAs were the right and left BAs, respectively.Conclusion
The classification of the mediastinal course of the BAs determined by the spatial relationships to the tracheobronchus and the esophagus may be clinically useful, because each category of this classification can be determined during esophagectomy and indicates whether the BA is a right or left BA.6.
Hui-Ju Ho Hui-Shan Chen Wei-Heng Hung Po-Kuei Hsu Shiao-Chi Wu Heng-Chung Chen Bing-Yen Wang 《Annals of surgical oncology》2018,25(13):3820-3832
Background
Current esophageal treatment guidelines suggest that, when more than 15 lymph nodes are detected, dissection should be done as the minimum requirement for staging in esophageal squamous cell carcinoma (ESCC) patients undergoing esophagectomy without induction chemoradiotherapy (CRT). However, for neoadjuvant CRT, there is limited information. We sought to clarify the role of lymphadenectomy in ESCC patients with and without neoadjuvant CRT.Patients and Methods
Data on 3156 ESCC patients receiving esophagectomy with (group 1, n?=?1399) and without (group 2, n?=?1757) neoadjuvant CRT between 2008 and 2014 were collected from a national cancer registry in Taiwan. The impact of the resected lymph nodes on overall survival was assessed according to pathologic stages. A Cox regression model was used to identify prognostic factors for overall survival.Results
Five-year overall survival rates were 35.6% for the entire group, 30.32% for group 1, and 39.55% for group 2 (p?<?0.0001 for group 1 vs group 2). The best cutoff value was 21 lymph nodes in both group 1 and group 2. In group 1, the independent prognostic factors included age?≥?54 years, clinical N status, y-pathologic T, y-pathologic N, y-pathologic stage, grade, location, margin status, esophagectomy (thoracoscopic vs open), and number of total resected lymph nodes (≤?21 vs?>?21). For group 2, the independent prognostic factors were gender, clinical stage, pathologic T, pathologic N, tumor length, grade, and margin status.Conclusions
Extent of lymphadenectomy was associated with survival in patients with neoadjuvant CRT followed by esophagectomy. The optimum lymphadenectomy should be modulated by pathologic stage.7.
Purpose
Neoadjuvant chemotherapy (NAC) with cisplatin and fluorouracil is the recommended standard treatment for resectable locally advanced esophageal cancer (EC) in Japan. We investigated the effects of NAC on the safety and feasibility of thoracoscopic esophagectomy with total mediastinal lymphadenectomy for EC.Methods
This retrospective study analyzed data from 225 consecutive patients who underwent thoracoscopic esophagectomy with lymph node dissection between April 2007 and December 2015. Patients with clinical stage IB, IIA, IIB, IIIA, or IIIB EC, and no active concomitant malignancy were included. We compared intraoperative outcomes, and postoperative morbidity and mortality between patients who received NAC (n = 139; NAC group) and patients who did not (n = 86; non-NAC group).Results
Preoperative laboratory data revealed that anemia, thrombopenia, and renal dysfunction were more common in the NAC group than in the non-NAC group. There were no differences between the groups in operating times, blood loss, number of dissected lymph nodes, overall complication rates, or length of postoperative hospital stay.Conclusion
Based on our findings, thoracoscopic esophagectomy is safe and effective for locally advanced EC, even after NAC.8.
Brian E. Louie 《Journal of gastrointestinal surgery》2010,14(1):115-120
Introduction
Esophagectomy is considered one of the most complicated, difficult to perform, and physiologically altering operations performed by surgeons.Discussion
Outcome, not only depends upon surgeon and hospital volume but also involves a “supporting cast” of health professionals, such as physical therapy and ICU. The complementary skill set of the surgeon may also influence esophagectomy outcomes.Conclusions
Young surgeons can perform esophagectomy with low mortality while their volume increases if they engage and involve all of the components in this paradigm.9.
Rationale
Reflux of gastric and duodenal contents in patients with gastroesophageal reflux disease (GERD) has been postulated as a major cause of complications, such as Barrett’s esophagus or malignant degeneration.Findings
We present a summary of experimental, clinical, and immunohistochemical studies that show that acid and bile reflux are increased in patients who suffer from GERD, are the key factor in the pathogenesis of Barrett’s esophagus, and are possibly related to the development of esophageal adenocarcinoma.10.
Naoya Yoshida Yoshifumi Baba Hironobu Shigaki Kazuto Harada Masaaki Iwatsuki Junji Kurashige Yasuo Sakamoto Yuji Miyamoto Takatsugu Ishimoto Keisuke Kosumi Ryuma Tokunaga Yu Imamura Satoshi Ida Yukiharu Hiyoshi Masayuki Watanabe Hideo Baba 《World journal of surgery》2016,40(8):1910-1917
Background
A nutritional indicator suitable for predicting complications after esophagectomy has not been confirmed. The nutritional screening tool CONUT is a potential candidate.Methods
We retrospectively analyzed 352 patients who underwent elective esophagectomy with lymphadenectomy for esophageal cancer between April 2005 and December 2014. Patients were divided into three groups according to the malnutrition degree in controlling nutritional status (CONUT): normal, light malnutrition, moderate or severe malnutrition.Results
The numbers of patients assigned to the normal, light malnutrition, and moderate or severe malnutrition groups were 205, 126, and 21, respectively. One hundred forty-seven (41.8 %) patients were considered malnourished. Patients with moderate or severe malnutrition had a significantly high incidence of any morbidity, severe morbidities, and surgical site infection. Hospital stay in patients with moderate or severe malnutrition was significantly longer. Logistic regression analysis suggested that moderate or severe malnutrition was an independent risk factor for any morbidity [hazard ratio (HR) 2.75, 95 % confidence interval (CI) 1.081–7.020; p = 0.034] and severe morbidities (HR 3.07, 95 % CI 1.002–9.432; p = 0.049).Conclusions
CONUT was a convenient and useful tool to assess nutritional status before esophagectomy. Patients with moderate or severe malnutrition according to CONUT are at high risk for postoperative complications.11.
12.
Giovanni Docimo Paolo Limongelli Giovanni Conzo Simona Gili Alfonso Bosco Antonia Rizzuto Vincenzo Amoroso Salvatore Marsico Nicola Leone Antonio Esposito Chiara Vitiello Landino Fei Domenico Parmeggiani Ludovico Docimo 《BMC surgery》2013,13(Z2):S8
Background
Axillary lymphadenectomy or sentinel biopsy is integral part of breast cancer treatment, yet seroma formation occurs in 15-85% of cases. Among methods employed to reduce seroma magnitude and duration, fibrin glue has been proposed in numerous studies with controversial results.Methods
Thirty patients over 60 years underwent quadrantectomy or mastectomy with level I/II axillary lymphadenectomy; a suction drain was fitted in all patients. Fibrin glue spray were applied to the axillary fossa in 15 patients; the other 15 patients were treated with harmonic scalpel.Results
Suction drainage was removed between post-operative Days 3 and 4. Seroma magnitude and duration were not significant in patients receiving fibrin glue compared with the harmonic scalpel group.Conclusions
Use of fibrin glue does not always prevent seroma formation, but can reduce seroma magnitude, duration and necessary evacuative punctures.13.
Daniela Treitl Steven N. Hochwald Philip Q. Bao Joshua M. Unger Kfir Ben-David 《Journal of gastrointestinal surgery》2016,20(8):1523-1529
Introduction
An optimal method has yet to be established for laparoscopic total gastrectomy with intracorporeal anastomosis.Methods
We aim to describe a simple technique for intracorporeal anastomoses. Technique of laparoscopic total gastrectomy with side-to-side stapled intracorporeal esophagojejunostomy anastomosis and Roux-en-Y jejunojejunostomy is performed on patients with gastric malignancy in an academic community tertiary care center.Results
The anastomotic technique of laparoscopic total gastrectomy with side-to-side stapled esophagojejunostomy is described.Conclusion
Laparoscopic total gastrectomy with D2 lymphadenectomy and side-to-side esophagojejunostomy is safe to perform and has the advantage of a wide lumen with low chance for stricture. A laparoscopic total gastrectomy with stapled side-to-side esophagojejunostomy is feasible and safe in advanced gastric cancer.14.
Kojiro Eto Naoya Yoshida Masaaki Iwatsuki Junji Kurashige Satoshi Ida Takatsugu Ishimoto Yoshifumi Baba Yasuo Sakamoto Yuji Miyamoto Masayuki Watanabe Hideo Baba 《World journal of surgery》2016,40(5):1145-1151
Background
Recently, a simple and easy complication prediction system, the Surgical Apgar Sore (SAS) calculated by three intraoperative parameters (estimated blood loss, lowest mean arterial pressure, and lowest heart rate), has been proposed for general surgery. This study aimed to determine if the SAS could accurately predict perioperative morbidity in patients undergoing esophagectomy for esophageal cancer.Methods
We investigated 399 patients who underwent esophagectomy at the Kumamoto University Hospital between April 2007 and March 2015. Clinical data, including intraoperative parameters, were collected retrospectively. Patients had postoperative morbidities classified as Clavien–Dindo grade III or more. Univariate and multivariate analyses were performed to elucidate factors that affected the development of complications.Results
The mean age of the study population was 65.7 years, 357 patients (89.5 %) were male. The frequency of any morbidity was 32.3 %. Univariate analyses showed that the SAS as well as preoperative chemotherapy, volume of bleeding, and reconstruction of organs were associated with morbidities. Multivariate analysis showed that a SAS < 5 was found to be an independent risk factor for morbidities.Conclusion
The SAS is considered to be useful for predicting the development of postoperative morbidities after esophagectomy for esophageal cancer.15.
Background
The appearance and incidence of gastroesophageal reflux after sleeve gastrectomy is not yet resolved, and there is an important controversy in the literature. No publications regarding the appearance of Barrett’s esophagus after sleeve gastrectomy are present in the current literature.Purpose
The purpose of this paper was to report the incidence of Barrett’s esophagus in patients submitted to sleeve.Material and Methods
Two hundred thirty-one patients are included in this study who were submitted to sleeve gastrectomy for morbid obesity. None had Barrett’s esophagus. Postoperative upper endoscopy control was routinely performed 1 month after surgery and 1 year after the operation, all completed the follow-up in the first year, 188 in the second year, 123 in the third year, 108 in the fifth year, and 66 patients over 5 years after surgery.Results
Among 231 patients operated on and followed clinically, reflux symptoms were detected in 57 (23.2 %). Erosive esophagitis was found in 38 patients (15.5 %), and histological examination confirmed Barrett’s esophagus in 3/231 cases (1.2 %) with presence of intestinal metaplasia.Conclusion
Bariatric surgeons should be aware of the association of gastroesophageal reflux (GER) disease and obesity. Appropriate bariatric surgery should be indicated in order to prevent the occurrence of esophagitis and Barrett’s esophagus.16.
Jerome Melon Fay Chao Weng Chan Anna Rosamilia 《International urogynecology journal》2018,29(4):599-600
Aim
Vesico-uterine fistulas (VUFs) are rare in modern gynecological practice. We aim to demonstrate with a video the surgical techniques involved in laparoscopic repair of a vesico-uterine fistula (Youssef’s syndrome).Methods
A 37-year-old woman, para 2 and otherwise healthy, was referred to the Urogynaecology Unit 4 months following a vaginal birth after a previous cesarean, with ongoing pink-colored vaginal watery discharge. Cystoscopy and hysteroscopy confirmed the findings of a well-granulated fistulous tract connecting the base of the bladder and anterior uterine wall just above the level of the internal os. She underwent an uncomplicated laparoscopic repair of VUF.Results
She has remained asymptomatic with resumption of normal menses and no clinical evidence of fistula recurrence at 6-week and 6-month post-operative reviews.Conclusion
This video demonstrates the surgical techniques involved in the laparoscopic repair of a VUF, a rare case in modern gynecological practice where there are few surgical videos demonstrating techniques.17.
Background
Routine contrast esophagram has been shown to be increasingly limited in diagnosing anastomotic leaks after esophagectomy.Methods
Patients undergoing esophagectomy from 2013 to 2014 at Huai’an First Peoples’ Hospital were identified. We retrospectively analyzed patients who underwent routine contrast esophagram on postoperative day 7 (range 6–10) to preclude anastomotic leaks after esophagectomy.Results
In 846 patients who underwent esophagectomy, a cervical anastomosis was performed in 286 patients and an intrathoracic anastomosis in 560 patients. There were 57 (6.73%) cases with anastomotic leaks, including cervical leaks in 36 and intrathoracic leaks in 21 patients. In the cervical anastomotic leak patients, 13 were diagnosed by early local clinical symptoms and 23 underwent routine contrast esophagram. There were 7 (30.4%) true-positive, 11 (47.8%) false-negative, and five (21.8%) equivocal cases. In the intrathoracic anastomotic leak patients, four (19%) were diagnosed by clinical symptoms, 16 (76.2%) were true positives, and one (4.8%) was a false negative. Aspiration occurred in five patients with cervical anastomoses and in eight patients with intrathoracic anastomoses; aspiration pneumonitis did not occur in these cases.Conclusions
Gastrografin and barium are safe contrast agents to use in post-esophagectomy contrast esophagram. Because of the low sensitivity in detecting cervical anastomotic leaks, routine contrast esophagram is not advised. For patients with intrathoracic anastomoses, it is still an effective method for detecting anastomotic leaks.18.
Introduction
Laparoscopic and robotic surgery of the pancreas has only recently emerged as viable treatment options for benign and malignant disease. This review seeks to evaluate the current body of evidence on these approaches to pancreaticoduodenectomy and distal pancreatectomy.Methods
A systematic review of large published series was performed utilizing the PubMed search engine.Results
Based on these reports, both the laparoscopic and robotic techniques for these complex procedures appear to be safe and effective, if performed by high volume experienced pancreatic surgeons. The advantages of each approach are highlighted, emphasizing the data available on the learning curve and potential dissemination.Conclusions
Both minimally invasive approaches to pancreatic resection are safe and feasible.19.
Masashi Takeuchi Hirofumi Kawakubo Shuhei Mayanagi Kayo Yoshida Kazumasa Fukuda Rieko Nakamura Koichi Suda Norihito Wada Hiroya Takeuchi Yuko Kitagawa 《Journal of gastrointestinal surgery》2018,22(11):1881-1889
Background or Purpose
As we previously indicated, postoperative pneumonia has a negative impact on the overall survival after planned esophagectomy. However, the impact of postoperative pneumonia after salvage esophagectomy on long-term oncologic outcomes still remains unclear. This study aimed to indicate the association between postoperative pneumonia and long-term outcomes of definitive chemoradiotherapy followed by salvage esophagectomy. Furthermore, we determined a prediction model for overall survival (OS) and disease-free survival (DFS) using a survival classification and regression tree (CART).Methods
Ninety-three patients who underwent CRT followed by esophagectomy for thoracic esophageal cancer were identified for this study. Forty-nine patients and 44 patients were included in the salvage and neoadjuvant groups, respectively. We investigated the association between postoperative pneumonia and long-term oncologic outcomes following salvage esophagectomy.Results
Patients from the salvage group tended to have a lower OS compared to neoadjuvant group (median survival: salvage, 24 months vs neoadjuvant, 43 months, p?=?0.117). Multivariate analyses revealed that postoperative pneumonia adversely affected both OS (p?<?0.001) and DFS (p?=?0.044) after salvage esophagectomy. We generated the prediction model for OS and DFS in the salvage group using survival CART. Postoperative pneumonia was the most important parameter for predicting the OS.Discussion
The present study demonstrates the long-term outcomes and risk factors for mortality of salvage esophagectomy. To improve OS after salvage surgery, the development of a means of decreasing pulmonary complications is needed.20.
Vaitl T. Grifka J. Bolm-Audorff U. Eberth F. Gantz S. Liebers F. Schiltenwolf M. Spahn G. 《Trauma und Berufskrankheit》2012,14(4):437-438