BACKGROUND The studies of laparoscopic-assisted transhiatal gastrectomy(LTG) in patients with Siewert type Ⅱ adenocarcinoma of the esophagogastric junction(AEG) are scarce.AIM To compare the surgical efficiency of LT...BACKGROUND The studies of laparoscopic-assisted transhiatal gastrectomy(LTG) in patients with Siewert type Ⅱ adenocarcinoma of the esophagogastric junction(AEG) are scarce.AIM To compare the surgical efficiency of LTG with the open transhiatal gastrectomy(OTG) for patients with Siewert type Ⅱ AEG.METHODS We retrospectively evaluated a total of 578 patients with Siewert type Ⅱ AEG who have undergone LTG or OTG at the First Medical Center of the Chinese People’s Liberation Army General Hospital from January 2014 to December 2019. The short-term and long-term outcomes were compared between the LTG(n = 382) and OTG(n = 196) groups.RESULTS Compared with the OTG group, the LTG group had a longer operative time but less blood loss, shorter length of abdominal incision and an increased number of harvested lymph nodes(P < 0.05). Patients in the LTG group were able to eat liquid food, ambulate, expel flatus and discharge sooner than the OTG group(P < 0.05). No significant differences were found in postoperative complications and R0 resection. The 3-year overall survival and disease-free survival performed better in the LTG group compared with that in the OTG group(88.2% vs 79.2%, P = 0.011;79.7% vs 73.0%, P = 0.002, respectively). In the stratified analysis, both overall survival and disease-free survival were better in the LTG group than those in the OTG group for stage Ⅱ/Ⅲ patients(P < 0.05) but not for stage I patients.CONCLUSION For patients with Siewert type Ⅱ AEG, LTG is associated with better short-term outcomes and similar oncology safety. In addition, patients with advanced stage AEG may benefit more from LTG in the long-term outcomes.展开更多
Esophageal cancer continues to represent a formidable challenge for both patients and clinicians. Relative 5-year survival rates for patients have improved over the past three decades, probably linked to a combination...Esophageal cancer continues to represent a formidable challenge for both patients and clinicians. Relative 5-year survival rates for patients have improved over the past three decades, probably linked to a combination of improved surgical outcomes, progress in systemic chemotherapy and radiotherapy, and the increasing acceptance of multimodality treatment. Surgical treatment remains a fundamental component of the treatment of localized esophageal adenocarcinoma. Multiple approaches have been described for esophagectomy, which can be thematically grouped under two major categories: either transthoracic or transhiatal. The main controversy rests on whether a more extended resection through thoracotomy provides superior oncological outcomes as opposed to resection with relatively limited morbidity and mortality through a transhiatal approach. After numerous trials have addressed these issues, neither approach has consistently proven to be superior to the other one, and both can provide excellent short-term results in the hands of experienced surgeons. Moreover, the available literature suggests that experience of the surgeonand hospital in the surgical management of esophageal cancer is an important factor for operative morbidity and mortality rates, which could supersede the type of approach selected. Oncological outcomes appear to be similar after both procedures.展开更多
Objective: To explore the change and feasibility of surgical techniques of laparoscopic transhiatal(TH)-lower mediastinal lymph node dissection(LMLND) for adenocarcinoma of the esophagogastric junction(AEG)according t...Objective: To explore the change and feasibility of surgical techniques of laparoscopic transhiatal(TH)-lower mediastinal lymph node dissection(LMLND) for adenocarcinoma of the esophagogastric junction(AEG)according to Idea, Development, Exploration, Assessment, and Long-term follow-up(IDEAL) 2a standards.Methods: Patients diagnosed with AEG who underwent laparoscopic TH-LMLND were prospectively included from April 14, 2020, to March 26, 2021. Clinical and pathological information as well as surgical outcomes were quantitatively analyzed. Semistructured interviews with the surgeon after each operation were qualitatively analyzed.Results: Thirty-five patients were included. There were no cases of transition to open surgery, but three cases involved combination with transthoracic surgery. In qualitative analysis, 108 items under three main themes were detected: explosion, dissection, and reconstruction. Revised instruction was subsequently designed according to the change in surgical technique and the cognitive process behind it. Three patients had anastomotic leaks postoperatively, with one classified as Clavien-Dindo Ⅲa.Conclusions: The surgical technique of laparoscopic TH-LMLND is stable and feasible;further IDEAL 2b research is warranted.展开更多
Barrett's esophagus(BE) is a precursor of esophageal adenocarcinoma and is associated with gastroesophageal reflux disease, which is often preceded by a hiatal hernia. We describe a case of esophageal adenocarcino...Barrett's esophagus(BE) is a precursor of esophageal adenocarcinoma and is associated with gastroesophageal reflux disease, which is often preceded by a hiatal hernia. We describe a case of esophageal adenocarcinoma arising in long-segment BE(LSBE) associated with a hiatal hernia that was successfully treated with a laparoscopic transhiatal approach(LTHA) without thoracotomy. The patient was a 42-year-old male who had previously undergone laryngectomy and tracheal separation to avoid repeated aspiration pneumonitis. An ulcerative lesion was found in a hiatal hernia by endoscopy and superficial esophageal cancer was also detected in the lower thoracic esophagus. The histopathological diagnosis of biopsy samples from both lesions was adenocarcinoma. There were difficulties with the thoracic approach because the patient had severe kyphosis and muscular contractures from cerebral palsy. Therefore, we performed subtotal esophagectomy by LTHA without thoracotomy. Using hand-assisted laparoscopic surgery, the esophageal hiatus was divided and carbon dioxide was introduced into the mediastinum. A hernial sac was identified on the cranial side of the right crus of the diaphragm and carefully separated from the surrounding tissues. Abruption of the thoracic esophagus was performed up to the level of thearch of the azygos vein via LTHA. A cervical incision was made in the left side of the permanent tracheal stoma, the cervical esophagus was divided, and gastric tube reconstruction was performed via a posterior mediastinal route. The operative time was 175 min, and there was 61 m L of intra-operative bleeding. A histopathological examination revealed superficial adenocarcinoma in LSBE. Our surgical procedure provided a good surgical view and can be safely applied to patients with a hiatal hernia and kyphosis.展开更多
AIM:To compare the efficacy and safety of the transthoracic and transhiatal approaches for cancer of the esophagogastric junction.METHODS:An electronic and manual search of the literature was conducted in PubMed,EmBas...AIM:To compare the efficacy and safety of the transthoracic and transhiatal approaches for cancer of the esophagogastric junction.METHODS:An electronic and manual search of the literature was conducted in PubMed,EmBase and the Cochrane Library for articles published between March1998 and January 2013.The pooled data included the following parameters:duration of surgical time,blood loss,dissected lymph nodes,hospital stay time,anastomotic leakage,pulmonary complications,cardiovascular complications,30-d hospital mortality,and long-term survival.Sensitivity analysis was performed by excluding single studies.RESULTS:Eight studies including 1155 patients with cancer of the esophagogastric junction,with 639 patients in the transthoracic group and 516 in the transhiatal group,were pooled for this study.There were no significant differences between two groups concerning surgical time,blood loss,anastomotic leakage,or cardiovascular complications.Dissected lymph nodes also showed no significant differences between two groups in randomized controlled trials(RCTs)and nonRCTs.However,we did observe a shorter hospital stay(WMD=1.92,95%CI:1.63-2.22,P<0.00001),lower30-d hospital mortality(OR=3.21,95%CI:1.13-9.12,P=0.03),and decreased pulmonary complications(OR=2.95,95%CI:1.95-4.45,P<0.00001)in the transhiatal group.For overall survival,a potential survival benefit was achieved for typeⅢtumors with the transhiatal approach.CONCLUSION:The transhiatal approach for cancers of the esophagogastric junction,especially typesⅢ,should be recommended,and its long-term outcome benefits should be further evaluated.展开更多
Objective： To analyze the results and introduce the experiences of transhiatal esophagectomy in combined with different synthetic therapy. Methods： Seventy-one patients with esophageal carcinoma, median age was 62, ...Objective： To analyze the results and introduce the experiences of transhiatal esophagectomy in combined with different synthetic therapy. Methods： Seventy-one patients with esophageal carcinoma, median age was 62, 40 of stage Ⅰ, 26 of Ⅱa, 4 of stage Ⅱb, 1 of stage Ⅳ, were treated with transhiatal esophagectomy. 9 and 17 patients were treated with preoperative radiotherapy （4000 cGy） and postoperative adjuvant radiotherapy （6000 cGy） respectively; 5 patients were treated with preoperative chemotherapy. Results： The postoperative 1, 3 and 5 years survival rates were 100%, 91.43%, and 86.21% for stage Ⅰ; 92%, 83.33%, and 57.14% for stage Ⅱa; 75%, 50%, and 50% for stage Ⅱb; 100%, 0, and 0 for stag Ⅳ and 95.71%, 86.89%, and 71.70% as a whole, respectively. The incidence of complications was 12.68%. Conclusion： Transhiatal esophagectomy combined with chemotherapy or radiotherapy may be beneficial to patients with esophageal carcinoma at stage Ⅱa or earlier who can＇t tolerate or need not be treated by transthoracic esophagectomy.展开更多
Esophageal resection is associated with a high morbidity and mortality rate. Minimally invasive esophagectomy (MIE) might theoretically decrease this rate. We reviewed the current literature on MIE, with a focus on th...Esophageal resection is associated with a high morbidity and mortality rate. Minimally invasive esophagectomy (MIE) might theoretically decrease this rate. We reviewed the current literature on MIE, with a focus on the available techniques, outcomes and comparison with open surgery. This review shows that the available literature on MIE is still crowded with heterogeneous studies with different techniques. There are no controlled and randomized trials, and the few retrospective comparative cohort studies are limited by small numbers of patients and biased by historical controls of open surgery. Based on the available literature, there is no evidence that MIE brings clear benef its compared to conventional esophagectomy. Increasing experience and the report of larger series might change this scenario.展开更多
AIM： To prospectively present our initial experience with totally laparoscopic transhiatal esophagogastrectomies for benign diseases of the cardia and distal esophagus. METHODS： Laparoscopic gastric mobilization and...AIM： To prospectively present our initial experience with totally laparoscopic transhiatal esophagogastrectomies for benign diseases of the cardia and distal esophagus. METHODS： Laparoscopic gastric mobilization and tubularization combined with transhiatal esophageal dissection and intrathoradc esophagogastric anastomosis accomplished by a circular stapler was done in 3 patients. There were 2 females and 1 male patient with a mean age of 73 ± 5 years. RESULTS： Two patients were operated on due to benign stromal tumor of the cardia and one patient had severe oesophageal peptic stenosis. Mean blood loss was 47 ± 15 mL and mean operating time was 130 ± 10 rain. There were no cases that required conversion to laparotomy. All patients were extubated immediately after surgery. Soft diet intake and ambulation times were 5.1 ± 0.4 d and 2.6 ±0.6 d, respectively. There were no intraoperative and postoperative complications and there were no perioperative deaths. The average length of hospital stay was 9.3 ± 3 d. All procedures were curative and all resected margins were tumor free. The mean number of retrieved lymph nodes was 18 ±8. CONCLUSION： Laparoscopic transhiatal esophagogastrectomy for benign lesions has good effects and proves feasible and safe.展开更多
BACKGROUND Thoracoscopic esophagectomy is related to an extended lymphadenectomy,and a high number of retrieved lymph nodes,compared to the transhiatal approach;however,its association with an improvement in overall s...BACKGROUND Thoracoscopic esophagectomy is related to an extended lymphadenectomy,and a high number of retrieved lymph nodes,compared to the transhiatal approach;however,its association with an improvement in overall survival(OS)is debatable.AIM To compare thoracoscopic esophagectomy with transhiatal esophagectomy in patients with adenocarcinoma of the esophagogastric junction(AEGJ)in terms of survival,number of lymph nodes,and complications.METHODS In total,147 patients with AEGJ were selected retrospectively from 2002 to 2019,and divided into Group A for thoracoscopic esophagectomy,and group B for transhiatal esophagectomy.OS,disease-free survival,postoperative complications,and number of nodes,were similarly evaluated.RESULTS One hundred and thirty(88%)were male;the mean age was 64 years.Group A had a mean age of 61.1 years and group B 65.7 years(P=0.009).Concerning the extent of lymphadenectomy,group A showed a higher number of retrieved lymph nodes(mean of 31.89±8.2 vs 20.73±7;P<0.001),with more perioperative complications,such as hoarseness,surgical site infections,and respiratory complications.Although both groups had similar OS rates,subgroup analysis showed better survival of transthoracic esophagectomy in patients with earlier diseases.CONCLUSION Both methods are safe,having similar morbidity and mortality rates.Transthoracic thoracoscopic esophagectomy allows a more extensive resection of the lymph nodes and may have better oncological outcomes during earlier stages of the disease.Prospective studies are warranted to better evaluate these findings.展开更多
文摘BACKGROUND The studies of laparoscopic-assisted transhiatal gastrectomy(LTG) in patients with Siewert type Ⅱ adenocarcinoma of the esophagogastric junction(AEG) are scarce.AIM To compare the surgical efficiency of LTG with the open transhiatal gastrectomy(OTG) for patients with Siewert type Ⅱ AEG.METHODS We retrospectively evaluated a total of 578 patients with Siewert type Ⅱ AEG who have undergone LTG or OTG at the First Medical Center of the Chinese People’s Liberation Army General Hospital from January 2014 to December 2019. The short-term and long-term outcomes were compared between the LTG(n = 382) and OTG(n = 196) groups.RESULTS Compared with the OTG group, the LTG group had a longer operative time but less blood loss, shorter length of abdominal incision and an increased number of harvested lymph nodes(P < 0.05). Patients in the LTG group were able to eat liquid food, ambulate, expel flatus and discharge sooner than the OTG group(P < 0.05). No significant differences were found in postoperative complications and R0 resection. The 3-year overall survival and disease-free survival performed better in the LTG group compared with that in the OTG group(88.2% vs 79.2%, P = 0.011;79.7% vs 73.0%, P = 0.002, respectively). In the stratified analysis, both overall survival and disease-free survival were better in the LTG group than those in the OTG group for stage Ⅱ/Ⅲ patients(P < 0.05) but not for stage I patients.CONCLUSION For patients with Siewert type Ⅱ AEG, LTG is associated with better short-term outcomes and similar oncology safety. In addition, patients with advanced stage AEG may benefit more from LTG in the long-term outcomes.
文摘Esophageal cancer continues to represent a formidable challenge for both patients and clinicians. Relative 5-year survival rates for patients have improved over the past three decades, probably linked to a combination of improved surgical outcomes, progress in systemic chemotherapy and radiotherapy, and the increasing acceptance of multimodality treatment. Surgical treatment remains a fundamental component of the treatment of localized esophageal adenocarcinoma. Multiple approaches have been described for esophagectomy, which can be thematically grouped under two major categories: either transthoracic or transhiatal. The main controversy rests on whether a more extended resection through thoracotomy provides superior oncological outcomes as opposed to resection with relatively limited morbidity and mortality through a transhiatal approach. After numerous trials have addressed these issues, neither approach has consistently proven to be superior to the other one, and both can provide excellent short-term results in the hands of experienced surgeons. Moreover, the available literature suggests that experience of the surgeonand hospital in the surgical management of esophageal cancer is an important factor for operative morbidity and mortality rates, which could supersede the type of approach selected. Oncological outcomes appear to be similar after both procedures.
基金supportedbyBeijing Municipal Administration of Hospitals(No.DFL20181103)Beijing Hospitals Authority Innovation Studio of Young Staff Funding Support(No.202123).
文摘Objective: To explore the change and feasibility of surgical techniques of laparoscopic transhiatal(TH)-lower mediastinal lymph node dissection(LMLND) for adenocarcinoma of the esophagogastric junction(AEG)according to Idea, Development, Exploration, Assessment, and Long-term follow-up(IDEAL) 2a standards.Methods: Patients diagnosed with AEG who underwent laparoscopic TH-LMLND were prospectively included from April 14, 2020, to March 26, 2021. Clinical and pathological information as well as surgical outcomes were quantitatively analyzed. Semistructured interviews with the surgeon after each operation were qualitatively analyzed.Results: Thirty-five patients were included. There were no cases of transition to open surgery, but three cases involved combination with transthoracic surgery. In qualitative analysis, 108 items under three main themes were detected: explosion, dissection, and reconstruction. Revised instruction was subsequently designed according to the change in surgical technique and the cognitive process behind it. Three patients had anastomotic leaks postoperatively, with one classified as Clavien-Dindo Ⅲa.Conclusions: The surgical technique of laparoscopic TH-LMLND is stable and feasible;further IDEAL 2b research is warranted.
文摘Barrett's esophagus(BE) is a precursor of esophageal adenocarcinoma and is associated with gastroesophageal reflux disease, which is often preceded by a hiatal hernia. We describe a case of esophageal adenocarcinoma arising in long-segment BE(LSBE) associated with a hiatal hernia that was successfully treated with a laparoscopic transhiatal approach(LTHA) without thoracotomy. The patient was a 42-year-old male who had previously undergone laryngectomy and tracheal separation to avoid repeated aspiration pneumonitis. An ulcerative lesion was found in a hiatal hernia by endoscopy and superficial esophageal cancer was also detected in the lower thoracic esophagus. The histopathological diagnosis of biopsy samples from both lesions was adenocarcinoma. There were difficulties with the thoracic approach because the patient had severe kyphosis and muscular contractures from cerebral palsy. Therefore, we performed subtotal esophagectomy by LTHA without thoracotomy. Using hand-assisted laparoscopic surgery, the esophageal hiatus was divided and carbon dioxide was introduced into the mediastinum. A hernial sac was identified on the cranial side of the right crus of the diaphragm and carefully separated from the surrounding tissues. Abruption of the thoracic esophagus was performed up to the level of thearch of the azygos vein via LTHA. A cervical incision was made in the left side of the permanent tracheal stoma, the cervical esophagus was divided, and gastric tube reconstruction was performed via a posterior mediastinal route. The operative time was 175 min, and there was 61 m L of intra-operative bleeding. A histopathological examination revealed superficial adenocarcinoma in LSBE. Our surgical procedure provided a good surgical view and can be safely applied to patients with a hiatal hernia and kyphosis.
基金Supported by National Natural Science Foundation of China,No.81172373
文摘AIM:To compare the efficacy and safety of the transthoracic and transhiatal approaches for cancer of the esophagogastric junction.METHODS:An electronic and manual search of the literature was conducted in PubMed,EmBase and the Cochrane Library for articles published between March1998 and January 2013.The pooled data included the following parameters:duration of surgical time,blood loss,dissected lymph nodes,hospital stay time,anastomotic leakage,pulmonary complications,cardiovascular complications,30-d hospital mortality,and long-term survival.Sensitivity analysis was performed by excluding single studies.RESULTS:Eight studies including 1155 patients with cancer of the esophagogastric junction,with 639 patients in the transthoracic group and 516 in the transhiatal group,were pooled for this study.There were no significant differences between two groups concerning surgical time,blood loss,anastomotic leakage,or cardiovascular complications.Dissected lymph nodes also showed no significant differences between two groups in randomized controlled trials(RCTs)and nonRCTs.However,we did observe a shorter hospital stay(WMD=1.92,95%CI:1.63-2.22,P<0.00001),lower30-d hospital mortality(OR=3.21,95%CI:1.13-9.12,P=0.03),and decreased pulmonary complications(OR=2.95,95%CI:1.95-4.45,P<0.00001)in the transhiatal group.For overall survival,a potential survival benefit was achieved for typeⅢtumors with the transhiatal approach.CONCLUSION:The transhiatal approach for cancers of the esophagogastric junction,especially typesⅢ,should be recommended,and its long-term outcome benefits should be further evaluated.
文摘Objective： To analyze the results and introduce the experiences of transhiatal esophagectomy in combined with different synthetic therapy. Methods： Seventy-one patients with esophageal carcinoma, median age was 62, 40 of stage Ⅰ, 26 of Ⅱa, 4 of stage Ⅱb, 1 of stage Ⅳ, were treated with transhiatal esophagectomy. 9 and 17 patients were treated with preoperative radiotherapy （4000 cGy） and postoperative adjuvant radiotherapy （6000 cGy） respectively; 5 patients were treated with preoperative chemotherapy. Results： The postoperative 1, 3 and 5 years survival rates were 100%, 91.43%, and 86.21% for stage Ⅰ; 92%, 83.33%, and 57.14% for stage Ⅱa; 75%, 50%, and 50% for stage Ⅱb; 100%, 0, and 0 for stag Ⅳ and 95.71%, 86.89%, and 71.70% as a whole, respectively. The incidence of complications was 12.68%. Conclusion： Transhiatal esophagectomy combined with chemotherapy or radiotherapy may be beneficial to patients with esophageal carcinoma at stage Ⅱa or earlier who can＇t tolerate or need not be treated by transthoracic esophagectomy.
文摘Esophageal resection is associated with a high morbidity and mortality rate. Minimally invasive esophagectomy (MIE) might theoretically decrease this rate. We reviewed the current literature on MIE, with a focus on the available techniques, outcomes and comparison with open surgery. This review shows that the available literature on MIE is still crowded with heterogeneous studies with different techniques. There are no controlled and randomized trials, and the few retrospective comparative cohort studies are limited by small numbers of patients and biased by historical controls of open surgery. Based on the available literature, there is no evidence that MIE brings clear benef its compared to conventional esophagectomy. Increasing experience and the report of larger series might change this scenario.
文摘AIM： To prospectively present our initial experience with totally laparoscopic transhiatal esophagogastrectomies for benign diseases of the cardia and distal esophagus. METHODS： Laparoscopic gastric mobilization and tubularization combined with transhiatal esophageal dissection and intrathoradc esophagogastric anastomosis accomplished by a circular stapler was done in 3 patients. There were 2 females and 1 male patient with a mean age of 73 ± 5 years. RESULTS： Two patients were operated on due to benign stromal tumor of the cardia and one patient had severe oesophageal peptic stenosis. Mean blood loss was 47 ± 15 mL and mean operating time was 130 ± 10 rain. There were no cases that required conversion to laparotomy. All patients were extubated immediately after surgery. Soft diet intake and ambulation times were 5.1 ± 0.4 d and 2.6 ±0.6 d, respectively. There were no intraoperative and postoperative complications and there were no perioperative deaths. The average length of hospital stay was 9.3 ± 3 d. All procedures were curative and all resected margins were tumor free. The mean number of retrieved lymph nodes was 18 ±8. CONCLUSION： Laparoscopic transhiatal esophagogastrectomy for benign lesions has good effects and proves feasible and safe.
文摘BACKGROUND Thoracoscopic esophagectomy is related to an extended lymphadenectomy,and a high number of retrieved lymph nodes,compared to the transhiatal approach;however,its association with an improvement in overall survival(OS)is debatable.AIM To compare thoracoscopic esophagectomy with transhiatal esophagectomy in patients with adenocarcinoma of the esophagogastric junction(AEGJ)in terms of survival,number of lymph nodes,and complications.METHODS In total,147 patients with AEGJ were selected retrospectively from 2002 to 2019,and divided into Group A for thoracoscopic esophagectomy,and group B for transhiatal esophagectomy.OS,disease-free survival,postoperative complications,and number of nodes,were similarly evaluated.RESULTS One hundred and thirty(88%)were male;the mean age was 64 years.Group A had a mean age of 61.1 years and group B 65.7 years(P=0.009).Concerning the extent of lymphadenectomy,group A showed a higher number of retrieved lymph nodes(mean of 31.89±8.2 vs 20.73±7;P<0.001),with more perioperative complications,such as hoarseness,surgical site infections,and respiratory complications.Although both groups had similar OS rates,subgroup analysis showed better survival of transthoracic esophagectomy in patients with earlier diseases.CONCLUSION Both methods are safe,having similar morbidity and mortality rates.Transthoracic thoracoscopic esophagectomy allows a more extensive resection of the lymph nodes and may have better oncological outcomes during earlier stages of the disease.Prospective studies are warranted to better evaluate these findings.
