A safe and simple technique for nasogastric tube insertion in patients with thoracic esophageal cancer surgery

Background Risk factors for anastomotic leakage include local factors such as excessive tension across anastomosis and increased intraluminal pressure on the gastric conduit; therefore, we consider the placement of a nasogastric tube to be essential in reducing anastomotic leakage. In this study, we devised a safe and simple technique to place an NGT during an end-to-side, automatic circular-stapled esophagogastrostomy. Methods First, a 4-0 nylon thread is fixed in the narrow groove between the plastic and metal parts of the tip of the anvil head. After dissecting the esophagus, the tip of the NGT is guided out of the lumen of the cervical esophageal stump. The connecting nylon thread is applied to the anvil head with the tip of the NGT. The anvil head is inserted into the cervical esophageal stump, and a purse-string suture is performed on the esophageal stump to complete the anvil head placement. The main unit of the automated stapler is inserted through the tip of a reconstructed gastric conduit, and the stapler is subsequently fired and an end-to-side esophagogastrostomy is achieved. The main unit of the automated stapler is then pulled out from the gastric conduit, and the NGT comes out with the anvil head from the tip of the reconstructed gastric conduit. Subsequently, the nylon thread is cut. After creating an α-loop with the NGT outside of the lumen, the tip of the NGT is inserted into the gastric conduit along the lesser curvature toward the caudal side. Finally, the inlet of the automated stapler on the tip of the gastric conduit is closed with an automated linear stapler, and the esophagogastrostomy is completed. Results We utilized this technique in seven patients who underwent esophagectomy for esophageal cancer; smooth and safe placement of the NGT was accomplished in all cases. Conclusion Our technique of NGT placement is simple, safe, and feasible.

Complications After Lymph Node Dissection Along Bilateral Recurrent Laryngeal Nerves Through Right Thoracic Approach in the Patients With Thoracic Esophageal Cancer

Background: Extensive lymph nodes dissection can improve the accuracy of tumor staging and prognosis of the patients with thoracic esophageal cancer, palsy of recurrent laryngeal nerve (RLN) caused by the lymph node (LN) dissection along RLN chain also increase postoperative complications and may affect the prognosis. This study aimed to evaluate the associated postoperative complications after LN dissection along RLNs in the patients with thoracic esophageal squamous cell cancer (ESCC).Methods: 339 eligible patients with thoracic ESCC who underwent radical McKeown or Ivor-Lewis esophagectomy by open or VATS procedures through right thoracic approach with LN dissection along bilateral RLNs were included in this study. Univariate and multivariate logistic regression analysis were conducted to assess the correlation of RLN paralysis (RLNP) with other post-operative complications. Results: 39 of the 339 patients were diagnosed with RLNP (11.5%) postoperatively. The incidence of RLNP in three-field (3FL) LN dissection was significantly higher than that in the two-field (2FL) LN dissection ( 24.0% vs 8.0%, P＜0.001). Compared with the patients without RLNP, the patients with it had a significantly higher incidence of postoperative anastomotic leakage (P=0.029), pulmonary complications (P=0.001) and much longer hospital stay (P=0.001). Two patients died of respiratory failure within 30 days caused by RLNP and were treated by reintubation. Conclusion: RLNP after LN dissection along bilateral RLN in thoracic ESCC was associated with much higher morbidity such as pulmonary complications, anastomotic leakage, and much longer hospital stay. New technologies are required to reduce RLNP incidence and its associated complications.

Preoperative C-reactive protein to albumin ratio predicts anastomotic leakage after esophagectomy for thoracic esophageal cancer: a single-center retrospective cohort study

Background Postoperative anastomotic leakage (AL) is associated with not only prolonged hospital stay and increased medical costs, but also poor prognosis in esophageal cancer. Several studies have addressed the utility of various inflammation-based and/or nutritional markers as predictors for postoperative complications. However, none have been documented as specific predictors for AL in esophageal cancer. We aimed to identify predictors of AL after esophagectomy for thoracic esophageal cancer, focusing on preoperative inflammation-based and/or nutritional markers. Methods We retrospectively analyzed 295 patients who underwent radical esophagectomy for thoracic esophageal squamous cell carcinoma between June 2007 and July 2020. As inflammation-based and/or nutritional markers, Onodera prognostic nutritional index, C-reactive protein (CRP)-to-albumin ratio (CAR) and modified Glasgow prognostic score were investigated. Optimal cut-off values of inflammation-based and/or nutritional markers for AL were determined by receiver operating characteristic curves. Predictors for AL were analyzed by logistic regression modeling. Results AL was observed in 34 patients (11.5%). In univariate analyses, preoperative body mass index (≥ 22.1 kg/m2), serum albumin level (≤ 3.8 g/dL), serum CRP level (≥ 0.06 mg/dL), CAR (≥ 0.0139), operation time (> 565 min) and blood loss (≥ 480 mL) were identified as predictors of AL. Multivariate analyses revealed higher preoperative CAR (≥ 0.0139) as an independent predictor of AL (p = 0.048, odds ratio = 3.02, 95% confidence interval 1.01–9.06). Conclusion Preoperative CAR may provide a useful predictor of AL after esophagectomy for thoracic esophageal squamous cell carcinoma.

190 THE USEFULNESS OF A BILATERAL TRANS-CERVICAL PNEUMOMEDIASTINAL APPROACH FOR MEDIASTINOSCOPIC RADICAL ESOPHAGECTOMY

Several authors have reported on the left trans-cervical and transhiatal approaches under pneumomediastinum and right cervical open surgery for mediastinoscopic esophagectomy. However, with these approaches, sufficient dissection of the right upper mediastinal paraesophageal lymph nodes, right recurrent nerve lymph nodes and the subaortic arch to the left tracheobronchial lymph nodes is thought to be difficult. We herein report the usefulness of the ‘bilateral’ trans-cervical pneumomediastinal approach. Methods Ten patients with thoracic esophageal cancer were treated using this approach. Under pneumomediastinum via a right neck incision, the right cervical and upper mediastinal paraesophageal lymph nodes were dissected. The left recurrent nerve lymph nodes were dissected using a left trans-cervical pneumomediastinal approach. The subaortic arch to the left tracheobronchial lymph nodes was dissected with a combined right and left trans-cervical crossover approach. After this approach, thoracoscopic observation was then performed in the left decubitus position, and if the lymph nodes were not sufficiently dissected, the remnant lymph nodes were retrieved thoracoscopically. Results The average total number of dissected lymph nodes among the right cervical and upper mediastinal paraesophageal lymph nodes identified with a right cervical open/right trans-cervical mediastinoscopic/right thoracoscopic approach was 3.2/4.0/0.6, respectively. The average total number of dissected lymph nodes among the subaortic arch to the left tracheobronchial lymph nodes with a right trans-cervical mediastinoscopic/right thoracoscopic approach was 1.5/0.6, respectively. These findings indicate that, without the right trans-cervical pneumomediastinal approach, roughly four of the right cervical and upper mediastinal paraesophageal lymph nodes and one or two of the subaortic arch to the left tracheobronchial lymph nodes could not have been retrieved. Conclusion A bilateral trans-cervical pneumomediastinal approach is useful for achieving sufficient upper mediastinal lymph node dissection and esophagectomy.

142 A RANDOMIZED TRIAL: THREE-FILED LYMPHADENECTOMY COMPARED WITH TWO-FIELD LYMPHADENECTOMY FOR MIDDLE AND LOWER THORACIC ESOPHAGEAL CANCER

Esophagectomy combined with radical lymphadenectomy is widely accepted, but the role of three-field lymphadenectomy (3-FLD) remains unclear. Methods We performed an open-label, randomized, controlled trial involving patients with resectable cancer of the middle or lower third of the esophagus. Patients were randomly assigned to undergo esophagectomy with either 3-FLD (cervical-thoracic-abdominal lymphadenectomy) or two-field lymphadenectomy (thoracic-abdominal lymphadenectomy, 2-FLD) at a 1:1 ratio. The primary endpoint was overall survival (OS). Analysis were done according to the intent-to-treat principle. Results Postoperative complications were similar in the two arms. More lymph nodes were resected in 3-field arm (Median, 37 vs. 24 [2-FLD], P < 0.001), 43 (21.5%) patients had cervical LNM. More pN3 patients were identified in the 3-FLD arm (10.5%, 21/200 vs. 5.0%, 10/200 [2-FLD], P = 0.040). The cumulative probability of disease-free survival (DFS) was comparable between the two arms (HR, 1.021, 95%CI, 0.735–1.417, P = 0.903), as well as the OS (HR, 1.026, 95%CI, 0.694–1.515, P = 0.899). The cumulative 5-year DFS was 52% in the 3-FLD arm, as compared with 53% in the 2-FLD arm; 5-year OS rates were 64% and 62%. Conclusion Three-field lymphadenectomy offered more accurate nodal staging without increasing the surgical complications. Comparing with radical 2-FLD, there was no improvement in OS or DFS after 3-FLD for patients with middle and lower thoracic esophageal cancer. .