| Part I: The Value of Lymphadenectomy in EsophagectomyObjective: There is no report on the effect of lymph node dissection in the Chinese grouping of esophageal cancer lymph nodes.This retrospective study aims to assess the efficacy of lymphadenectomy in different regions for esophageal squamous cell carcinoma in different primary locations according to the lymph node grouping by Chinese expert consensus.Methods: The medical records of patients with esophageal squamous cell carcinoma from March 2011 to December 2017 in our hospital were retrospectively analyzed.According to the pathological report,the lymph nodes were regrouped according to the Chinese lymph nodes grouping standard of esophageal cancer.The metastasis rate of each group of lymph nodes,the metastatic patients’ 5-year survival rate and efficacy index(EI)were calculated.Results: The upper esophageal cancer mainly metastasized to the lymph nodes of C201-203 group.The middle and lower segment tumors mainly metastasized to the lymph nodes of C205-207 group.The lower part of the tumor has a higher rate of metastasis to the abdominal lymph nodes.According to the metastasis rate,the mediastinal lymph nodes were divided into three regions: the upper mediastinum(C201-204),the middle mediastinum(C205-206),and the lower mediastinum(C207-209).The EIs of lymph nodes of C201-203 and 205~207 groups were higher.For patients with C201-207 group metastasis,the 5-year survival rates ranged from 13.39% to 21.60%.For patients with positive lymph nodes in each region,tumors at different primary locations had no significant difference in long-term survival.C205 lymph node had low EI in the upper segment tumors and higher in the middle and lower segment tumors.Conclusion: The effect of lymph node dissection in each area varies with the location of the tumor.No matter where the tumor is,it is necessary to dissect the upper mediastinal lymph nodes,especially the lymph nodes adjacent to the left and right recurrent laryngeal nerves.The division of lymph node regions in esophageal cancer deserves further study.Part II: Intubation Method Affects Lymphadenectomy along Left Recurrent Laryngeal NerveObjective: Lymph nodes dissection along left recurrent laryngeal nerve(RLN)is challenging in esophagectomy for esophageal cancer,and double-lumen endotracheal tube(DLT)impedes the exposure of this area.The aim of this study was to determine whether bronchial blockers(BB)could be a better choice for this procedure.Methods: The clinical characteristics of patients who received Mc Keown esophagectomy with radical lymph node dissection in Wuhan Tongji Hospital between August 2017 and July 2019 were retrospectively analyzed.The 1:1 propensity score match analysis was performed to compare the short-term effectiveness,the numbers of lymph nodes dissected,patterns of recurrence and survival between the two groups.Results: A total of 294 patients(192 and 102 in the DLT and BB group,respectively)were enrolled in the study.After matching,204 patients(102 pairs)who underwent one-lung ventilation with DLT or BB displayed no significant variance in baseline characteristics.The BB group had higher number of lymph nodes resected along left RLN(1.8±2.3 vs.2.5±2.5,P=0.001).For patients with metastatic Left RLN lymph nodes,the BB group had longer medium survival time(15 vs.32 months,P=0.045),and tended to have longer medium recurrence-free survival time(6 vs.15 months,P=0.079),and lower rate of upper mediastinal and cervical lymph nodes recurrence(30.00% vs.66.67%,P=0.198).The postoperative complications were similar in both groups.Conclusions: Compared with DLT,using BB in esophagectomy may allow more radical lymphadenectomy along left RLN.Part III: The Role of Anastomotic Oversewing Technique in Preventing Anastomotic LeakageObjectives: Esophagogastric anastomosis is a core part of esophagectomy,and anastomotic leakage is among its main concerns.We used the oversewing technique to reinforce the anastomosis created with a circular stapler.This study investigated the use of oversewing to reduce the incidence of anastomotic leakage without increasing morbidity.Methods: This study enrolled 1,734 patients who underwent Esophagectomy for oesophageal cancer between April 2012 and December 2019.Using propensity scorematched analysis,the clinical results of post-operative complications were compared between anastomotic-oversewn and-unsewn Esophagectomy.Results: Of the 1,734 patients,661 were included in the anastomotic-unsewn group and 661 in the anastomotic-oversewn group after propensity score matching.The clinical characteristics did not differ between the two groups,but the frequency of anastomotic leakage was significantly higher in the anastomotic-unsewn group than in the anastomoticoversewn group(10.3% vs.4.7%,P <0.001).Multivariable logistic analysis showed oversewn anastomosis and smoking history as the independent factors associated with anastomotic leakage(odds ratios,0.399 and 2.383;P <0.001 and P = 0.012,respectively).On sub-group analysis,the relative risk for anastomotic leakage was significantly higher with unsewn than with oversewn anastomosis in patients <65 years old;those with American Association of Anesthesiologists score II;those who had middle segment oesophageal cancer and those who have undergone the Mc Keown approach and cervical anastomosis.Conclusion: Anastomosis oversewing technique may be a practical method to reduce anastomotic leakage,especially in younger patients and those who have undergone the Mc Keown approach and cervical anastomosis.Part IV: Surgical Starting Time Affects the Therapeutic Outcomes Of EsophagectomyObjectives: The increase in the incidence of esophageal cancers combined with fewer surgeons working at large centers will increase the likelihood of surgery for esophageal cancers being performed during later hours.This study aimed to compare esophagectomies’ operative outcomes for esophageal cancer performed at different surgical starting times.Methods: This was a single-center,retrospective study.Risk-adjusted cumulative sum curve analysis and Cox regression analysis were used to identify the potential change-point of surgical starting times.The participants were then divided into 2 groups according to the change-point time.Propensity score matching was used to control confounding factors between the 2 groups.We compared the short-and long-term outcomes in both groups.Results: A total of 702 patients who underwent potentially radical esophagectomy from 7 May 2014 to 31 December 2017 in our institute were included.The 3-year all-cause mortality showed a significant change-point at 16:42,with an increment from 56.5% to 76.9%(P = 0.043).The change-point of anastomotic leakage was 15:00,and the incidence before and after the time was 6.9% vs 16.7%(P=0.001).The change-point of the number of lymph nodes dissected was 15:26,and the number of lymph nodes dissected on both sides was statistically different(18[IQR 13-24] vs 15[IQR 10-22],P=0.003).Esophagectomy that commenced between 17:00-18:59 was associated with significantly lower overall survival([OS] multivariate hazard ratio [HR]: 2.47;95% confidence interval [CI]: 1.25 to 4.90;P = 0.010)and disease-free survival([DFS] multivariate HR: 2.14;95% CI: 1.08 to 4.21;P = 0.028).The participants were allocated to the during-hours(DH)group and the after-hours(AH)group according to the change-point of 17:00.A total of 84 participants in the DH group were matched to 33 participants in the AH group.The median operative time was shorter in the AH group(309 vs.239 minutes,P = 0.014);the AH group had a greater incidence of respiratory complications(22.63% vs.45.45%,P = 0.023)and 90-day mortality(0 vs.9.09%,P = 0.021).The 5-year OS(P = 0.042)and DFS(P = 0.030)rates were significantly higher in the DH group.Conclusions: Esophagectomy that starts later in the day may have worse outcomes.It is recommended to cancel selective esophagectomies due to commence after 17:00. |
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