Predictive factors for postoperative tachyarrhythmia after thoracoscopic esophagectomy and the usefulness of landiolol hydrochloride for its treatment

Background

Tachyarrhythmia after esophagectomy is a severe complication that should not be underestimated because of its negative impact. The aims of this study were to clarify the cause and impact of postoperative tachyarrhythmia after thoracoscopic esophagectomy. Additionally, we analyzed the usefulness of landiolol administration for postoperative tachyarrhythmia.

Methods

We evaluated the predictive factors for tachyarrhythmia onset after surgery and its clinical impact in 127 patients who underwent thoracoscopic esophagectomy with extended lymphadenectomy. Moreover, we analyzed the efficacy of landiolol for postoperative tachyarrhythmia.

Results

Tachyarrhythmia developed in 38 of the 127 patients. Multivariate analysis showed that advanced age, heart disease, and hyperlipidemia were associated with postoperative tachyarrhythmia. Hyponatremia, hypoalbuminemia, and leukocytosis on postoperative day 3 were significantly associated with tachyarrhythmia onset. The incidence of all complications and respiratory complications, including pneumonia, was significantly higher in patients with than in those without tachyarrhythmia. The mortality rate in the tachyarrhythmia group tended to be higher than that in the nontachyarrhythmia group. Landiolol as a treatment for tachyarrhythmia immediately decreased heart rate and safely reduced subsequent respiratory complications.

Conclusion

In elderly patients with cardiac disease or hyperlipidemia, surgeons should be alert for the occurrence of tachyarrhythmia after esophagectomy. Postoperative tachyarrhythmia is a marker of morbidities with particular emphasis on respiratory complications. However, it can be adequately managed by landiolol, resulting in fewer respiratory complications. Landiolol might be a safe and convenient agent for managing postoperative tachyarrhythmia after thoracoscopic esophagectomy, resulting in lower mortality and morbidity rates.     

Comparison of outcomes of open and minimally invasive esophagectomy in 183 patients with cancer

Background and objectives

Only few randomized trials or comparative studies with large number of patients have been reported on the outcomes of thoracoscopic and laparoscopic esophagectomy (TLE) with cervical anastomosis and open 3-field esophagectomy (OE) for patients with esophageal cancer. The objective of this study is to compare the safety, feasibility, and short-term outcomes between TLE and OE (via right throax, abdomen, and left neck) for esophageal cancer.

Methods

Clinical and surgical data of patients with esophageal cancer who underwent either TLE or OE between February 2011 and December 2013 were retrospectively analyzed. Demographic characteristics, pathological data, operative procedures, and intraoperative and postoperative outcomes and survival in patients were compared between both groups.

Results

Of the 183 patients included in this retrospective analysis, 94 underwent TLE and 89 underwent OE. Demographics, pathologic data, inpatient mortality, and overall surgical morbidity in both cohorts were almost identical. A significant difference was observed in blood loss (182.6±78.3 vs. 261.4±87.2 mL, P<0.001), hospital stay (13.9±7.5 vs. 17.1±10.2 days, P=0.017), overall surgical morbidity (25.5% vs. 46.1%, P=0.004), and rate of pulmonary and cardiac complication (9.6% vs. 27.0%, P=0.002; 4.1% vs. 12.4%, P=0.046) between TLE and OE groups; however, no difference in survival period was observed between the groups.

Conclusions

The procedure of TLE for esophageal cancer possesses advantages in intraoperative and postoperative outcomes compared with OE. The TLE procedure results in similar or potentially better outcomes.     

Immediate extubation after esophagectomy with three-field lymphadenectomy enables early ambulation in patients with thoracic esophageal cancer

Background

We retrospectively compared the effects of immediate extubation (IE) in the operating room with those of overnight mechanical ventilation (MV) after radical transthoracic esophagectomy with 3-field lymphadenectomy in patients with thoracic esophageal cancer.

Methods

A total of 96 patients were evaluated. 48 patients were extubated in the operating room after surgery (IE group). The other 48 patients were extubated on the following morning (MV group). The propensity score-matching method was used to assemble a well-balanced cohort. Clinical and postoperative outcomes were investigated in each group. We also compared postoperative laboratory parameters between groups.

Results

The rate of ambulation on postoperative day (POD) 1 was significantly higher in the IE group compared with that in the MV group (50 vs 19%, respectively, p?=?0.003). Moreover, the rate of catecholamine use in the ICU was significantly lower in the IE group compared with that in the MV group (15 vs 65%, respectively, p?<?0.001). With regard to postoperative respiratory management, there were no significant differences between groups. The length of ICU stay after esophagectomy was significantly shorter in the IE group compared with that in the MV group (p?=?0.01), whereas the length of postoperative hospital stay was similar between groups (p?=?0.265). There were also no significant differences in the incidence of postoperative complications.

Conclusions

IE in the operating room is not only safe and feasible, even after transthoracic esophagectomy with radical 3-field lymphadenectomy, but also contributes to decrease in catecholamine use, to increase in ambulation on POD 1 and to shorten the ICU stay.

     

Re-evaluation of the role of thoracoscopic esophagectomy as a Japanese-style radical surgery

Purpose

To investigate the value of thoracoscopic surgery in radical esophagectomy with three-field lymphadenectomy.

Materials and method

The subjects were 329 consecutive patients who, without preoperative chemoradiotherapy, underwent R0 radical esophagectomy with three-field lymphadenectomy for thoracic squamous cell esophageal cancers during 1998–2013. Open thoracotomy was applied in 212 (O), and thoracoscopic surgery in 117 (V). Survivals according to TNM Stages and Efficacy index (EI) were analyzed.

Results

Hospital death rates of O/V were 1.9/0%. The survivals of V according to TNM Stages had significantly better prognosis in TNM6th cStage III and showed not worse prognosis in general. In the analysis using Cox proportional hazards model, “V or O” was a significant prognostic factor indicating better prognosis of V. More bilateral paratracheal lymph nodes along the recurrent laryngeal nerves tended to be classified as mediastinal instead of cervical in V. Efficacy index of mediastinal paratracheal nodes was higher in V than in O, while cervical lymphadenectomy maintained high EI.

Discussion and conclusion

Though our series have limitations of retrospective study and substantial bias, the feasibility and safety of thoracoscopic esophagectomy with three-field lymphadenectomy was shown. Higher paratracheal lymph nodes along the recurrent laryngeal nerves could be dissected from the mediastinal side in V group. Thoracoscopic esophagectomy, which is regarded as minimally invasive surgery in other countries, is being accepted in Japan mainly in the expectation of more thorough and meticulous lymphadenectomy. At the same time, the dissection range is continuously re-evaluated for safer surgery maintaining radicality.

     

Salvage lymphadenectomy without esophagectomy is an option for recurrent or residual lymph nodes after definitive chemoradiotherapy for esophageal cancer

Purposes

The aim of this study was to determine the prognostic factors in salvage surgery following definitive chemoradiotherapy (dCRT) for esophageal cancer.

Methods

We retrospectively reviewed twenty-five patients who underwent salvage surgery from 1986 to 2011 at Kurume University Hospital.

Results

Esophagectomy was adopted for 20 patients, while lymphadenectomy alone without esophagectomy was adopted for the other 5 patients. Univariate analysis found that age, response to initial treatment, presence of residual tumor, pT after salvage surgery, and severe complications were each significantly correlated with overall survival after salvage surgery. The type of surgery (esophagectomy vs lymphadenectomy) and presence of residual tumor (R) were each determined to be an independent prognostic factor by the multivariate analysis. Namely, the prognosis after R0 resection was better than that after R1/2 resection (HR 18.050, p < 0.0001), and the prognosis after salvage lymphadenectomy was better than that after salvage esophagectomy (HR 5.091, p = 0.0086).

Conclusions

Salvage lymphadenectomy without esophagectomy is suggested to be an option for patients having recurrent or residual lymph nodes without any other recurrence or residual tumor after dCRT for esophageal cancer.     

Combined laparoscopic-thoracoscopic esophagectomy and intrathoracic esophagogastric anastomsis

We retrospectively analyzed the clinical data of 112 patients who underwent esophagectomy for esophageal carcinoma and gastro-esophageal anastomosis in right thoracic cavity from October 2011 to June 2013. First, the gastric tube was created with the aid of linear stapling device by removing the stomach and dissecting lymph nodes under laparoscopy and making a 3-4 cm incision through the subxiphoid area in the upper abdomen. Second, the thoracic esophagus and lymph nodes were dissected during thoracoscopic procedure. Gastric tube was inserted into the chest cavity and placed in the posterior mediastinum. The thoracic gastro-esophageal anastomosis was stapled with a circular stapler. Combined laparoscopic-thoracoscopic esophagectomy and intrathoracic esophagogastric anastomosis is technically feasible and safe, with minimized trauma, less operative blood loss and quick recovery.KEYWORDS : Laparoscopic, thoracoscopic, esophagectomy, esophagogastric anastomosis, esophageal carcinoma     

A novel method for lymphadenectomy along the left laryngeal recurrent nerve during thoracoscopic esophagectomy for esophageal carcinoma

Background

Due to limited space in the left upper mediastinum, complete dissection of lymph nodes (LN) along left recurrent laryngeal nerve (RLN) is difficult. We herein present a novel method for lymphadenectomy along the left RLN during thoracoscopic esophagectomy in the semi-prone position for esophageal carcinoma. The method, suspension the esophagus and push aside trachea, allows en bloc lymphadenectomy along the left RLN from the below aortic arch to the thoracic inlet.

Methods

Between September 2014 and September 2015, a total of 110 consecutive patients with esophageal carcinoma were treated with thoraco-laparoscopic esophagectomy with cervical anastomosis in the semi-prone position. Outcomes between those who received surgery with the novel method and conventional surgery were compared.

Results

Fifty patients underwent the novel method and sixty received conventional surgery. The operative field around the left RLN was easier to explore with the novel method. The estimated blood loss was less (23.7±8.2 vs. 34.2±10.3 g, P=0.001), and the number of harvested LNs along the left RLN was greater (6.4±3.2 vs. 4.1±2.8 min, P=0.028) in the novel method group, while the duration of lymphadenectomy along left RLN was longer in the novel method group (28.2±3.9 vs. 20.3±2.8 min, P=0.005). The rate of hoarseness in the novel and conventional groups was 10% and 16.7%, respectively. No significant difference in postoperative morbidity related to the left RLN was noted between the groups.

Conclusions

The novel method during semi-prone esophagectomy for esophageal carcinoma is associated with better surgeon ergonomics and operative exposure.     

Improvement in short-term outcomes after esophagectomy with a multidisciplinary perioperative care team

Background

Esophagectomy for patients with esophageal cancer remains a high-risk surgery. We introduced a multidisciplinary perioperative management team in the Cancer Institute Hospital (PeriCan) to improve short-term outcomes after esophagectomy.

Methods

To clarify the effect of PeriCan, we compared short-term outcomes between patients who underwent esophagectomy 1 year before the introduction of PeriCan and those who underwent esophagectomy 1 year after the introduction.

Results

One hundred and thirteen patients who underwent esophagectomy between October 2012 and September 2013 were included in the “Before PeriCan” group, while 105 patients who underwent esophagectomy between October 2013 and September 2014 were included in the “PeriCan” group. The incidence of postoperative complications significantly decreased from 73 to 49 % (P = 0.0003) with the introduction of PeriCan. In particular, the incidence of postoperative pneumonia significantly decreased from 43 to 13 % (P < 0.0001). Before the introduction of PeriCan, almost 70 % of patients with recurrent laryngeal nerve palsy experienced postoperative pneumonia, but the incidence significantly decreased to 32 % after the introduction of PeriCan (P = 0.017). Although the operative approach differed between groups, significant reduction in pneumonia was observed both in patients who underwent open esophagectomy and in those who underwent minimally invasive esophagectomy.

Conclusion

The introduction of PeriCan significantly decreased the incidence of postoperative complications, especially pneumonia. Systematic and cooperative interaction among professionals as a perioperative team can minimize the risks associated with esophagectomy.

     

Results of the introduction of a minimally invasive esophagectomy program in a tertiary referral center

Background

Esophagectomy is accompanied by a high postoperative complication rate. Minimally invasive esophageal surgery appears to be a promising technique that might be associated with a lower pulmonary morbidity rate. The objective of this study was to describe the implementation of minimally invasive esophageal surgery in a tertiary referral center and to compare the results of our first series of minimally invasive esophagectomies (MIE) to conventional open esophagectomies.

Methods

MIE was implemented after several procedures had been proctored by a surgeon with extensive experience with MIE. Preoperative characteristics and the postoperative course of patients who underwent a transthoracic esophagectomy were prospectively registered. Morbidity and overall hospital stay were compared between minimally invasive and open resections performed in the same period.

Results

A total of 90 consecutive esophageal cancer patients underwent a transthoracic resection, 41 patients by means of a minimally invasive approach. Preoperative characteristics were comparable for both groups. The duration of surgery was longer in the MIE group (6.0 vs. 5.2 hours, P<0.001) and median blood loss was lower [100 vs. 500 mL (P<0.001)]. There was only a trend towards a shorter hospital stay in the MIE group (11 vs. 13 days, P=0.072), pulmonary complications occurred in 20% of patients in the MIE group vs. 31% in the open group (P=0.229). The overall complication rate was 51% in the MIE group vs. 63% in the open group, P=0.249.

Conclusions

Implementation of MIE in our center was successful and it appears to be a safe technique for patients with potentially curable esophageal carcinoma.KEY WORDS : Esophageal cancer, surgical technical, complications, thoracoscopy     

Columnar metaplasia in the remnant esophagus is a long-term indicator for pneumonia after radical esophagectomy

Background

This study investigated the long-term risk factors for pneumonia after esophageal reconstruction using a gastric tube via the posterior mediastinal route following esophagectomy for esophageal cancer. The influence of columnar metaplasia in the remnant esophagus was specifically assessed.

Methods

Among 225 patients who underwent esophagectomy between January 2004 and December 2010, the subjects were 54 patients who could be followed up for more than 5 years. Routine oncologic follow-up consisted of CT scanning of the abdomen and chest every 4–6 months and annual endoscopy. Data on the occurrence of pneumonia were collected by retrospective review of chest CT scans. Risk factors for pneumonia investigated by univariate and multivariate analyses included the age, gender, diameter of the stapler, length of the intrathoracic remnant esophagus, anastomotic stricture, and presence of columnar metaplasia in the remnant esophagus.

Results

The median age was 62.4 years (interquartile range: 55.8–68.0 years). Forty-three patients were men. Pneumonia was detected in 39 patients (72.2%). The incidence of columnar metaplasia in the remnant esophagus increases with time. Anastomotic stricture was significantly related to the absence of columnar metaplasia on endoscopy in the first year after esophagectomy (p = 0.013). Univariate analysis showed that the frequency of pneumonia was significantly related to the intrathoracic remnant esophagus length ≥4.4 cm (p = 0.014), age over 65 years (p = 0.014), and the presence of columnar metaplasia in the remnant esophagus in the fifth year after esophagectomy (p = 0.005). Among them, age over 65 years and the presence of columnar metaplasia in the remnant esophagus in the fifth year after esophagectomy were found to be independent indicators of the postoperative pneumonia by multivariate analysis.

Conclusion

Pneumonia occurred in 72.2% (39/54) of patients after esophagectomy for esophageal cancer. The presence of columnar metaplasia after esophagectomy is an indicator for pneumonia over the long term.

     

Hand grip strength as a predictor of postoperative complications in esophageal cancer patients undergoing esophagectomy

Background

Radical esophagectomy remains the primary treatment option for resectable esophageal cancer. However, it sometimes induces postoperative complications due to its invasive nature. Recently, the impact of loss of muscle mass on postoperative complications and survival among cancer patients has been highlighted. This study aimed to identify the impact of low hand grip strength (HGS) on postoperative complications after esophagectomy.

Methods

A total of 188 patients (male: 166, female: 22) who underwent radical esophagectomy with gastric tube reconstruction between 2008 and 2014 were included. The correlation between HGS and age was analyzed using Pearson’s correlation coefficient. Due to the small patient numbers, only male patients were stratified into two groups according to age (<70 years: non-elderly group, ≥70 years: elderly group). Receiver operating characteristic curve analysis was performed for each group using postoperative complication occurrence as the endpoint to determine an optimal HGS cutoff value.

Results

Postoperative complications occurred in 60.9% of the elderly group and 47.4% of the non-elderly group. When the cutoff values were set at 30.5 and 37 kg for the elderly and non-elderly group, respectively, low HGS was an independent predictive factor of postoperative complications on multivariate analysis only in the elderly group (p = 0.008). In the elderly group, the incidence of postoperative pneumonia was 39.5% among patients with low HGS vs. 3.8% among patients with high HGS.

Conclusion

Preoperative HGS is an independent predictive factor of postoperative complications, especially postoperative pneumonia, for elderly male patients with esophageal cancer treated with radical esophagectomy.

     

Decreased preoperative plasma substance P concentration is likely associated with postoperative silent aspiration after esophagectomy

Background

Postoperative pneumonia is the most common complication after esophagectomy and is closely associated with swallowing dysfunction and silent aspiration. Silent aspiration in the elderly is associated with decreased secretion of substance P (SP), which controls the swallowing and cough reflexes. The majority of patients with esophageal cancer are elderly. We hypothesized that surgical stress would decrease SP secretion, thereby increasing the risk of postoperative aspiration after esophagectomy, and prospectively investigated.

Methods

Thirty patients with esophageal cancer scheduled to undergo esophagectomy were enrolled in the study. Plasma and salivary SP concentrations and cough reflex sensitivity were measured before surgery and on postoperative days 2 and 7 to examine the association with postoperative aspiration.

Results

Postoperative silent aspiration was observed in 6 patients, 4 of whom developed pneumonia. Plasma SP concentration did not change significantly during the perioperative period. Salivary SP concentration and cough reflex sensitivity could not be measured in nearly one-third of patients because of postoperative dry mouth and unwillingness of patients to undergo measurement, respectively; thus, these perioperative changes could not be assessed. Preoperative plasma and salivary SP concentrations had a significant association with postoperative aspiration on univariate analysis and multivariate logistic regression analysis using variables selected by stepwise forward selection identified preoperative plasma SP concentration as the only significant risk factor for postoperative aspiration (p = 0.023).

Conclusion

Definitive results supporting our hypothesis could not be obtained. However, multivariate analysis suggested that decreased preoperative plasma SP concentration is likely associated with postoperative silent aspiration after esophagectomy.     

Estimation of physiologic ability and surgical stress (E-PASS) can assess short-term outcome after esophagectomy for esophageal cancer

Background

Postoperative morbidity after esophagectomy for esophageal cancer is still frequent. Tools for prediction of postoperative complications have been sought, with the estimation of physiologic ability and surgical stress (E-PASS) scoring system being one of the candidates. The aim of this study was to determine the usefulness of the E-PASS system for risk assessment of esophagectomy.

Methods

The clinical courses of 308 patients who underwent elective subtotal esophagectomy with lymph node dissection for esophageal cancer were analyzed. The incidence and severity of complication and influence of preoperative therapy were investigated using the E-PASS system.

Results

The incidence of any complication was as high as 42.2 %. The frequency of severe and critical complications was 13.0 and 6.8 %, respectively. The E-PASS system could estimate the incidence and severity of complications. Patients with a comprehensive risk score (CRS) >0.9 had a significantly higher probability of incidence of severe or critical complications. The incidence of complication and the CRS increased linearly according to preoperative treatment in the following order: no preoperative treatment < neoadjuvant chemotherapy < neoadjuvant chemoradiotherapy < definitive chemoradiotherapy. These were significantly higher after salvage esophagectomy.

Conclusion

The E-PASS scoring system was useful for risk assessment after esophagectomy. Patients with a CRS >0.9 and patients undergoing salvage esophagectomy should be treated carefully after surgery. Among two scoring systems of which the CRS consisted, the surgical stress score strongly correlated with postoperative complications after esophagectomy, but the preoperative risk score did not.     

Use of efficient purse-string stapling technique for esophagogastric anastomosis in minimally invasive Ivor Lewis esophagectomy

Minimally invasive esophagectomy (MIE) is increasingly accepted in the treatment of locoregional or advanced esophageal cancer. Laparoscopic-thoracoscopic Ivor-Lewis esophagectomy has been proved to be effective in treating middle and distal esophageal cancer, however, intrathoracic esophagogastric anastomosis is technically complex. When using circular stapler for making intrathoracic anastomosis in MIE, both transoral and transthoracic methods are frequently used for delivering the anvil into the esophageal stump. Herein, we report a new method to construct a thoracoscopic esophagogastric anastomosis by using a circular stapler: efficient purse-string stapling technique (EST). This technique is easy to handle and especially good to be used in patients with distal esophageal cancer or expanded esophageal cavity.KEYWORDS : Minimally invasive esophagectomy (MIE), Ivor Lewis esophagectomy, esophageal cancer, esophagogastric anastomosis, efficient purse-string stapling technique (EST)     

Is there room for improvement in esophageal cancer surgery? Results of a prospective protocol for individualization of surgical treatment

Background

Despite improvements in multimodality approach , overall survival of esophageal cancer (EC) is still very low. Because of the rarity of the disease and the lack of large prospective studies, several controversies exist regarding the optimal type of surgery and the use of adjuvant and neoadjuvant therapy. Traditionally, the debate for the extent lymphadenectomy is between transhiatal esophagectomy with 1-field lymphadenectomy (THE-1FL) and transthoracic esophagectomy with 2-field lymphadenectomy (TTE-2FL). The purpose of this study is to evaluate the effect of optimal patient selection for submission to each procedure, on overall survival.

Methods

Patients with EC were prospectively enrolled in a database and a protocol of individualized surgical treatment of EC (PISTEC) was applied to patients with resectable disease. PISTEC is based on patient’s physical status and disease stage, with intent to select the appropriate surgical procedure for each patient.

Results

From 01/2006 to 12/2011, 61 patients with EC were individualized according to the PISTEC. Of them, 52.4 % were submitted to THE-1FL and 31.1 % to TTE-2FL. The 30-day mortality rate was 4.9 %. The 5-year overall survival rate was 54.9 % and recurrence was observed in 27.5 % of patients. The estimated 5-year overall survival of patients with stages 0, I, II, III and IV was 100, 100, 92.9, 45 and 0 %, respectively.

Conclusion

The algorithm proposed by the PISTEC aims at balancing perioperative risks with oncological benefit. When type of surgery is individualized, the outcomes regarding survival are favorable. This effect could probably be enhanced with the concurrent application of neoadjuvant treatment.     

Minimally invasive radical esophagectomy for esophageal cancer

Background Thoracoabdominal esophagectomy with three-field lymphadenectomy is considered one of the best treatments for thoracic esophageal carcinoma because the disease is aggressive and lymph node metastasis is common. However, the efficacy of the procedure remains unclear, and it is associated with high postoperative mortality and morbidity. Methods Seventy patients with esophageal carcinoma underwent thoracoscopic and laparoscopic esophagectomy with three-field lymphadenectomy. We retrospectively reviewed our procedure and the short-term surgical outcome of both thoracoscopic and laparoscopic esophagectomy. Results In 70 patients, duration of the thoracoscopic and total procedure was 229 ± 50 min and 581 ± 82 min, respectively. For all procedures, estimated blood loss was 447 ± 227 g. Overall mortality was 1%. Postoperative major complications occurred in 18 patients (26%), and respiratory complications occurred in 11 patients (16%). Conclusion Radical esophagectomy via thoracoscopy and laparoscopy is technically safe and feasible. We consider that the superior visualization and magnified view provided by thoracoscopy and the smaller surgical wounds in thorax and abdomen will prove advantageous to the postoperative clinical course and surgical outcome in spite of the longer operation time.     

Laparoscopic and thoracoscopic esophagectomy with intrathoracic anastomosis for middle or lower esophageal carcinoma

Thoracoscopic mobilization of esophagus and laparoscopic mobilization of stomach with cervical anastomosis is employed widely in minimally invasive esophagectomy (MIE) for esophageal carcinoma. However, it is associated with high incidence of complications, including recurrent laryngeal nerve injury and anastomotic leak. This paper summarizes the key techniques in total laparoscopic and thoracoscopic esophagectomy with intrathoracic anastomosis for MIE in 62 patients of middle or lower esophageal cancer between March 2012 and August 2013. Total laparoscopic and thoracoscopic esophagectomy with intrathoracic anastomosis was performed to treat the middle or lower esophageal cancer. Laparoscopic and thoracoscopic Ivor-Lewis esophagectomy was performed using a circular stapler (Johnson and Johnson) intrathoracically to staple esophagogastric anastomosis and reconstruct the digestive tract. In addition, we performed tension-relieving anastomotic suture and embedded with pedicled omental flap. Compared with the trans-orally inserted anvil (OrVil) approach, the technique reported here is safe, feasible and user-friendly. Total thoracoscopic intrathoracic anastomosis can be performed with a circular stapler (Johnson and Johnson).     

Surgical treatment for esophageal cancer patients with myelodysplastic syndrome

Background

Myelodysplastic syndrome (MDS) is a clinical condition with pancytopenia, dysfunction of neutrophils and poor prognosis caused by dysplasia of the bone marrow. MDS patients tend to have other malignant diseases, and the treatment is complicated because of high morbidity and mortality. Moreover, esophageal cancer is one of the most aggressive cancers, and its surgical treatment has high morbidity.

Methods

Among 450 patients with esophageal cancer who underwent surgical treatment, 4 (0.8 %) had MDS. We describe esophageal cancer patients with MDS who underwent radical surgical treatment and estimate the perioperative management and postoperative outcome.

Results

Two patients underwent transhiatal resection involving lower esophagectomy and proximal gastrectomy, and two other patients underwent thoracoscopic thoracoabdominal resection. Important critical points for the surgical treatment of esophageal cancer patients with MDS were as follows: hematological examination for patients with cytopenia, surgical indication for patients with WHO classification of RA or RARS and IPSS of low or intermediate-1 risk, planning transfusions for patients with thrombocytopenia, expecting postoperative complications such as pneumonia or bleeding, and careful follow-up for the early detection of relapse of disease.

Conclusion

With careful management, we were able to treat esophageal cancer patients with MDS surgically.     

Combined thoracoscopic and laparoscopic esophagectomy: experience,technique and cautions

We described a 59-year-old female, who came to our institute with the diagnosis of esophageal squamous cell carcinoma. The preoperative clinical diagnosis was stage II esophageal squamous cell carcinoma. The three-stage minimally invasive esophagectomy (MIE), combined thoracoscopic-laparoscopic esophagectomy with cervical anastomosis, was performed in this case. The lateral-prone decubitus position and Harmonic scalpel facilitate the operation.KEYWORDS : Minimally invasive esophagectomy (MIE), thoracoscopic, laparoscopic     

Utilization of partition analysis to evaluate the incidence on deep vein thrombosis following esophagectomy

Background

We performed a retrospective observational study to examine the involvement of suspicious factors and causes of deep vein thrombosis using cases of esophagectomy that were done to treat esophageal carcinoma.

Methods

The 144 patients received esophagectomy in Okayama University Hospital from January 2005 to June 2007. All patients had an enhanced CT or an ultrasound examination after their operations. The incidence of deep vein thrombosis was then determined. For cases that found deep vein thrombosis, the anticoagulant treatment was strengthened. When the thrombosis was already so large to be seen in the inferior vena cava, the IVC filter was left to prevent a pulmonary embolism. Using JMP5.0.1 statistical analysis software, we analyzed the relationship between various clinical factors and the incidence of deep vein thrombosis.

Results

Using JMP5.0.1, factors causing deep vein thrombosis were analyzed and partitioning was done. The most significant risk factor causing deep vein thrombosis is leaving the central venous catheter inserted into the inguinal femoral area. Logistic analysis also showed that only the catheter if inserted from the inguinal femoral area, was significantly related to cause deep vein thrombosis (p < 0.0055). No other factor was a significant risk to cause deep vein thrombosis.

Conclusions

We analyzed the relationship between suspicious factors and the causes of deep vein thrombosis in cases of esophagectomy. The most relevant factors were inserting the central venous catheter from the inguinal femoral route. This evidence can be applied to both pre-operative and postoperative management to prevent deep vein thrombosis.