The clinical application and advancement of robot-assisted McKeown minimally invasive esophagectomy for esophageal cancer

Robotic surgery systems,as emerging minimally invasive approaches,have been increasingly applied for the treatment of esophageal cancer because they provide a high-definition three-dimensional surgical view and mechanical rotating arms that surpass the limitations of human hands,greatly enhancing the accuracy and flexibility of surgical methods.Robot-assisted McKeown esophagectomy(RAME),a common type of robotic esophagectomy,has been gradually implemented with the aim of reducing postoperative complications,improving postoperative recovery and achieving better long-term survival.Multiple centers worldwide have reported and summarized their experiences with the RAME,and some have also discussed and analyzed its perioperative effects and survival prognosis compared with those of video-assisted minimally invasive esophagectomy.Compared to traditional surgery,the RAME has significant advantages in terms of lymph node dissection although there seems to be no difference in overall survival or disease-free survival.With the continuous advancement of technology and the development of robotic technology,further development and innovation are expected in the RAME field.This review elaborates on the prospects of the application and advancement of the RAME to provide a useful reference for clinical practice.

Cost burden following esophagectomy:A single centre observational study

BACKGROUND Cost analyses of patients undergoing esophagectomy is valuable for identifying modifiable expenditure drivers to target and curtail costs while improving the quality of care.We aimed to define the cost-complication relationship after esophagectomy and delineate the incremental contributions to costs.AIM To assess the relationship between the hospital costs and potential cost drivers post esophagectomy and investigate the relationship between the cost-driving variables(predicting variables)and hospital costs(dependent variable).METHODS In this retrospective single center study,the severity of complications was graded using the Clavien-Dindo(CD)classification system.Key esophagectomy complications were categorized and defined according to consensus guidelines.Raw costing data included the in-hospital costs of the index admission and any unplanned admission within 30 postoperative days.We used correlation analysis to assess the relationship between key clinical variables and hospital costs(in United States dollars)to identify cost drivers.A mediation model was used to investigate the relationship between these variables and hospital costs.RESULTS A total of 110 patients underwent primary esophageal resection.The median admission cost was $47822.7(interquartile range:35670.2-68214.0).The total effects on costs were $13593.9(95%CI:10187.1-17000.8,P<0.001)for each increase in CD severity grade,$4781(95%CI:3772.7-5789.3,P<0.001)for each increase in the number of complications,and $42552.2(95%CI:8309-76795.4,P=0.015)if a key esophagectomy complication developed.Key esophagectomy complications drove the costs directly by $11415.7(95%CI:992.5-21838.9,P=0.032).CONCLUSION The severity and number of complications,and the development of key esophagectomy complications significantly contributed to total hospital costs.Continuous institutional initiatives and strategies are needed to enhance patient outcomes and minimize costs.

Development and validation of a nomogram for predicting the probability of serious complication in esophageal cancer patients after esophagectomy

Background:Esophagectomy remains a procedure with one of the highest complication rates.This study aimed to develop and validate a model of nomogram for predicting the probability serious postoperative complications for the postoperative esophageal cancer(EC)patients.Methods:An observational study was conducted at Daping Hospital,China,encompassing 529 postoperative EC patients from December 2014 to November 2023.Weintegrated independent prognostic factors to craft a predictivemodel,specifically a nomogram,designed to forecast the risk of severe postoperative complications.Results:The incidence of serious complications for postoperative EC patients was 58.1%.A total of seven variables,including age,gender,bleeding volume during the operation(P=0.035),operating time(P=0.031),the Nutritional Risk Screening 2002(NRS 2002)score(P=0.027),the perioperative nutrition screen(PONS)score(P=0.018),and cystatin C levels(P<0.001),were applied to draw the nomogram of predicting serious complications after esophagectomy.The accuracy of predictive value for the model was quantified by Harrell’s C index at 0.690(95%confidence interval=0.596-0.785,P<0.001).Conclusion:We developed a nomogram system to demonstrate exceptional predictive capabilities for postoperative EC patients in forecasting the risk of serious complications.These results also emphasize the predictive value of the preoperative nutritional risk screening with NRS 2002 and PONS in EC patients undergoing esophagectomy.

Robotic-assisted esophagectomy: A literature review and our experience at a tertiary care centre

Esophageal cancer is a common cancer with a high case-related mortality worldwide,and radical resection offers the best survival.Initial reports have suggested that esophagus is an ideal organ which could benefit with robotic assistance.However,it remains to be seen whether robotic technology translates into better surgical outcomes and survival for the patients with esophageal cancer.We searched PubMed,Scopus and Google Scholar for English language articles.The search terms included minimally invasive esophagectomy or MIE,robotic-assisted esophagectomy,hybrid esophagectomy,robot-assisted minimal invasive esophagectomy or RAMIE,esophageal cancer,esophageal carcinoma.We review the development of robotic-assisted esophagectomy to focus on the surgical techniques and oncological clearance,and present a brief summary of our experience in this approach.Controlled trials will be required to establish the benefit of robotic-assisted esophagectomy,however the current literature points towards the safety and feasibility of this approach.

Minimally invasive esophagectomy

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.

Strategies to reduce pulmonary complications after esophagectomy

Esophagectomy,the surgical removal of all or part of the esophagus,is a surgical procedure that is associated with high morbidity and mortality.Pulmonary complications are an especially important postoperative problem.Therefore,many perioperative strategies to prevent pulmonary complications after esophagectomy have been investigated and introduced in daily clinical practice.Here,we review these strategies,including improvement of patient performance and technical advances such as minimally invasive surgery that have been implemented in recent years.Furthermore,interventions such as methylprednisolone,neutrophil elastase inhibitor and epidural analgesia,which have been shown to reduce pulmonary complications,are discussed.Benefits of the commonly applied routine nasogastric decompression,delay of oral intake and prophylactic mechanical ventilation are unclear,and many of these strategies are also evaluated here.Finally,we will discuss recent insights and new developments aimed to improve pulmonary outcomes after esophagectomy.

Quality of life after three kinds of esophagectomy for cancer

AIM： TO evaluate quality of life （QOL） following Ivor Lewis, left transthoracic, and combined thoracoscopic/ laparoscopic esophagectomy in patients with esopha- geal cancer. METHODS： Ninety patients with esophageal cancer were assigned to Ivor Lewis （/7 = 30）, combined thora- coscopic/laparoscopic （n = 30）, and left transthoracic （n = 30） esophagectomy groups. The QOL-core 30 questionnaire and the supplemental QOL-esophageal module 18 questionnaire for patients with esophageal cancer, both developed by the European Organization for Research and Treatment of Cancer, were used to evaluate patients＇ QOL from 1 wk before to 24 wk after surgery. RESULTS： A total of 324 questionnaires were collect- ed from 90 patients, 36 postoperative questionnaires were not completed because patients could not be contacted for follow-up visits. QOL declined markedly in all patients at 1 wk postoperatively： preoperative and 1-wk postoperative global QOL scores in the Ivor Lewis, combined thoracoscopic/laparoscopic, and left transthoracic groups were 80.8 ± 9.3 vs 32.0 ± 16.1 （P 〈 0.001）, 81.1±9.0 vs 53.3 ± 11.5 （P 〈 0.001）, and 83.6 ± 11.2 vs 46.4 ± 11.3 （P 〈 0.001）, respectively. Thereafter, QOL recovered gradually in all patients. Patients who underwent Ivor Lewis esophagectomy showed the most pronounced decline in QOL; global scores were lower in this group than in the combined thoracoscopic/laparoscopic （P 〈 0.001） and left trans- thoracic （P 〈 0.001） groups at 1 wk postoperatively and was not restored to the preoperative level at 24 wk postoperatively. QOL declined least in patients under- going combined thoracoscopic/laparoscopic esopha- gectomy, and most indices had recovered to preopera- tive levels at 24 wk postoperatively. In the Ivor Lewis and combined thoracoscopic/laparoscopic groups, pain and physical function scores were 78.9 ± 18.5 vs 57.8 ± 19.9 （P 〈 0.001） and 59.3 ± 16.1 vs 70.2 ± 19.2 （P = 0.02）, respectively, at 1 wk postoperatively and 26.1 ± 28.6 vs 9.5 ± 15.6 （P = 0.007） and 88.4 ± 10.5 vs 95.8 ± 7.3 （P = 0.003）, respectively, at 24 wk postop- eratively. Scores in the left transthoracic esophagecto- my group fell between those of the other two groups. CONCLUSION： Compared with Ivor Lewis and left transthoracic esophagectomies, combined thoraco- scopic/laparoscopic esophagectomy enables higher postoperative QOL, making it a preferable surgical ap- proach for esophageal cancer.

Optimal timing and route of nutritional support after esophagectomy: A review of the literature

Some controversy surrounds the postoperative feeding regimen utilized in patients who undergo esophagectomy.Variation in practices during the perioperative period exists including the type of nutrition started,the delivery route,and its timing.Adequate nutrition is essential for this patient population as these patients often present with weight loss and have altered eating patterns after surgery,which can affect their ability to regain or maintain weight.Methods of feeding after an esophagectomy include total parenteral nutrition,nasoduodenal/nasojejunal tube feeding,jejunostomy tube feeding,and oral feeding.Recent evidence suggests that early oral feeding is associated with shorter LOS,faster return of bowel function,and improved quality of life.Enhanced recovery pathways after surgery pathways after esophagectomy with a component of early oral feeding also seem to be safe,feasible,and cost-effective,albeit with limited data.However,data on anastomotic leaks is mixed,and some studies suggest that the incidence of leaks may be higher with early oral feeding.This risk of anastomotic leak with early feeding may be heavily modulated by surgical approach.No definitive data is currently available to definitively answer this question,and further studies should look at how these early feeding regimens vary by surgical technique.This review aims to discuss the existing literature on the optimal route and timing of feeding after esophagectomy.

Esophagectomy for locally advanced esophageal cancer, followed by chemoradiotherapy and adjuvant chemotherapy

AIM： To compare the efficacy and toxicity of a three-step combination therapy with post-operative radiation alone for locally advanced esophageal cancer.METHODS： Patients with T3-4 and N0-1 esophageal carcinoma from a number of institutions were non-randomly, prospectively enrolled in the study. All patients underwent single-stage curative en bloc esophagectomy. The patients were then assigned into one of two treatment groups based on treatment consisting of either post-operative concurrent chemoradiotherapy （CCRT） with weekly cisplatin 30 mg/m^2 followed by systemic adjuvant chemotherapy （four monthly cycles of cisplatin 20 mg/m^2 and 5-fluorouracil 1 000 mg/m^2 for five consecutive days）, or, post-operative radiation alone. The radiotherapy dose was 55-60 Gy for all patients. Primary end-point of this study was to assess the per-protocol patients＇ improvement of overall survival benefit. Secondary end-point was designed to evaluate both the per-protocol and intent-totreat patients＇ outcome of survival. RESULTS： A total of 60 patients （n=30 per group） were enrolled in this study. The two groups were generally comparable for demographic characteristics and hematological and non-hematological toxicities. The CCRT with weekly cisplatin was well tolerated, with significantly better overall survival （30.9 mo vs 20.7 mo; 95% CI, 27.5-36.4 vs 15.2-26.1） and 3-year survival （70.0% vs 33.7%; P=0.003）. Low histological grade of tumor （P〈0.001） was associated with favorable survival in these locally advanced patients. CONCLUSION： For locally advanced esophageal cancer, the combination of esophagectomy, post-operative CCRT with weekly cisplatin and systemic adjuvant chemotherapy is well tolerated and effective. A large-scale, prospective randomized trial of this regimen is in progress.

Systematic review of health-related quality of life after esophagectomy for esophageal cancer

This study is aimed to assess the long-term healthrelated quality of life （HRQL） of patients after esophagectomy for esophageal cancer in comparison with established norms, and to evaluate changes in HRQL during the different stages of follow-up after esophageal resection. A systematic review was performed by searching medical databases （Medline, Embase and the Cochrane Library） for potentially relevant studies that appeared between January 1975 and March 2011. Studies were included if they addressed the question of HRQL after esophageal resection for esophageal cancer. Two researchers independently performed the study selection, data extraction and analysis processes. Twenty-one observational studies were included with a total of 1282 （12-355） patients. Five studies were performed with short form-36 （SF-36） and 16 with European Organization for Research and Treatment of Cancer （EORTC） QLQ c30 （14 of them also utilized the disease-specific OESI8 or its previous version OES24）.The analysis of long-term generic HRQL with SF-36 showed pooled scores for physical, role and social function after esophagectomy similar to United States norms, but lower pooled scores for physical function, vitality and general health perception. The analysis of HRQL conducted using the Global EORTC C30 global scale during a 6-mo follow-up showed that global scale and physical function were better at the baseline. The symptom scales indicated worsened fatigue, dyspnea and diarrhea 6 mo after esophagectomy. In contrast, however, emotional function had significantly improved after 6 mo. In conclusion, short- and long-term HRQL is deeply affected after esophagectomy for cancer. The impairment of physical function may be a long-term consequence of esophagectomy involving either the respiratory system or the alimentary tract. The short- and long-term improvement in the emotional function of patients who have undergone successful operations may be attributed to the impression that they have survived a near-death experience.

Incidence and treatment of mediastinal leakage after esophagectomy:Insights from the multicenter study on mediastinal leaks

BACKGROUND Mediastinal leakage(ML) is one of the most feared complications of esophagectomy. A standard strategy for its diagnosis and treatment has beendifficult to establish because of the great variability in their incidence and mortality rates reported in the existing series.AIM To assess the incidence, predictive factors, treatment, and associated mortality rate of mediastinal leakage using the standardized definition of mediastinal leaks recently proposed by the Esophagectomy Complications Consensus Group(ECCG).METHODS Seven Italian surgical centers(five high-volume, two low-volume) affiliated with the Italian Society for the Study of Esophageal Diseases designed and implemented a retrospective study including all esophagectomies(n = 501) with intrathoracic esophagogastric anastomosis performed from 2014 to 2017.Anastomotic MLs were defined according to the classification recently proposed by the ECCG.RESULTS Fifty-nine cases of ML were recorded, yielding an overall incidence of 11.8%(95%CI: 9.1%-14.9%). The surgical approach significantly influenced the occurrence of ML: the proportion of leakage was 10.5% and 9% after open and hybrid esophagectomy(HE), respectively, and doubled(20%) after totally minimally invasive esophagectomy(TMIE)(P = 0.016). No other predictive factors were found. The 30-and 90-d overall mortality rates were 1.4% and 3.2%,respectively; the 30-and 90-d leak-related mortality rates were 5.1% and 10.2%,respectively; the 90-d mortality rates for TMIE and HE were 5.9% and 1.8%,respectively. Endoscopy was the first-line treatment in 49% of ML cases, with the need for retreatment in 17.2% of cases. Surgery was needed in 44.1% of ML cases.Endoscopic treatment had the lowest mortality rate(6.9%). Removal of the gastric tube with stoma formation was necessary in 8(13.6%) cases.CONCLUSION The incidence of ML after esophagectomy was high mainly in the TMIE group.However, the general and specific(leak-related) mortality rates were low. Early treatment(surgical or endoscopic) of severe leaks is mandatory to limit related mortality.

Novel technique for lymphadenectomy along left recurrent laryngeal nerve during thoracoscopic esophagectomy

BACKGROUND In esophageal squamous carcinoma,lymphadenectomy along the left recurrent laryngeal nerve(RLN)is recommended owing to its highly metastatic potential.However,this procedure is difficult due to limited working space in the left upper mediastinum,and increases postoperative complications.AIM To present a novel method for lymphadenectomy along the left RLN during thoracoscopic esophagectomy in the semi-prone position.METHODS The fundamental concept of this novel method is to exfoliate a bilateral pedicled nerve flap,which is a two-dimensional membrane,which includes the left RLN,lymph nodes(LNs)along the left RLN,and tracheoesophageal vessels,by suspending the esophagus to the dorsal side and pushing the trachea to the ventral side(named“bilateral exposure method”).Then,the hollow-out method is performed to transform the two-dimensional membrane to a three-dimensional structure,in which the left RLN and tracheoesophageal vessels are easily distinguished and preserved during lymphadenectomy along the left RLN.This novel method was retrospectively evaluated in 116 consecutive patients with esophageal squamous carcinoma from August 2016 to February 2018.RESULTS There were 58 patients in each group.No significant difference was found between the two groups in terms of age,gender,postoperative pneumonia,anastomotic fistula,and postoperative hospitalization.However,the number of dissected LNs along the left RLN in this novel method was significantly higher than that in the conventional method(4.17±0.359 vs 2.93±0.463,P=0.0447).Moreover,the operative time and the rate of postoperative hoarseness in the novel method were significantly lower than those in the conventional method(306.0±6.774 vs 335.2±7.750,P=0.0054;4/58 vs 12/58,P=0.0312).CONCLUSION This novel method for lymphadenectomy along the left RLN during thoracoscopic esophagectomy in the semi-prone position is much safer and more effective.

Efficacy of hybrid minimally invasive esophagectomy vs open esophagectomy for esophageal cancer: A meta-analysis

BACKGROUND The first line treatment regimen for esophageal cancer is still surgical resection and the choice of surgical scheme depends on surgeon.Now the efficacy comparison of hybrid minimally invasive esophagectomy(HMIE)and open esophagectomy(OE)is still controversial.AIM To compare the perioperative and postoperative outcomes of HMIE and OE in patients with esophageal cancer.METHODS PubMed,EMBASE,and Cochrane Library databases were searched for related articles.The odds ratio(OR)or standard mean difference(SMD)with a 95%confidence interval(CI)was used to evaluate the effectiveness of HMIE and OE.RESULTS Seventeen studies including a total of 2397 patients were selected.HMIE was significantly associated with less blood loss(SMD=-0.43,95%CI:-0.66,-0.20;P=0.0002)and lower incidence of pulmonary complications(OR=0.72,95%CI:0.57,0.90;P=0.004).No significant differences were seen in the lymph node yield(SMD=0.11,95%CI:-0.08,0.30;P=0.26),operation time(SMD=0.24,95%CI:-0.14,0.61;P=0.22),total complications rate(OR=0.68,95%CI:0.46,0.99;P=0.05),cardiac complication rate(OR=0.91,95%CI:0.62,1.34;P=0.64),anastomotic leak rate(OR=0.95,95%CI:0.67,1.35;P=0.78),duration of intensive care unit stay(SMD=-0.01,95%CI:-0.21,0.19;P=0.93),duration of hospital stay(SMD=-0.13,95%CI:-0.28,0.01;P=0.08),and total mortality rates(OR=0.70,95%CI:0.47,1.06;P=0.09)between the two treatment groups.CONCLUSION Compared with the OE,HMIE shows less blood loss and pulmonary complications.However,further studies are necessary to evaluate the long-term oncologic outcomes of HMIE.

Two-step method for creating a gastric tube during laparoscopic-thoracoscopic Ivor-Lewis esophagectomy

AIM To introduce a two-step method for creating a gastric tube during laparoscopic-thoracoscopic Ivor-Lewis esophagectomy and assess its clinical application.METHODS One hundred and twenty-two patients with middle or lower esophageal cancer who underwent laparoscopicthoracoscopic Ivor-Lewis esophagectomy at Liaoning Cancer Hospital and Institute from March 2014 to March 2016 were included in this study,and divided into two groups based on the procedure used for creating a gastric tube. One group used a two-step method for creating a gastric tube,and the other group used the conventional method. The two groups were compared regarding the operating time,surgical complications,and number of stapler cartridges used.RESULTS The mean operating time was significantly shorter in the two-step method group than in the conventional method group [238(179-293) min vs 272(189-347) min,P < 0.01]. No postoperative death occurred in either group. There was no significant difference in the rate of complications [14(21.9%) vs 13(22.4%),P= 0.55] or mean number of stapler cartridges used [5(4-6) vs 5.2(5-6),P = 0.007] between the two groups.CONCLUSION The two-step method for creating a gastric tube during laparoscopic-thoracoscopic Ivor-Lewis esophagectomy has the advantages of simple operation,minimal damage to the tubular stomach,and reduced use of stapler cartridges.

Bronchial bleeding caused by recurrent pneumonia after radical esophagectomy for esophageal cancer

We herein report a case of bronchial bleeding afterradical esophagectomy that was treated with lobectomy.A 65-year-old male who underwent subtotal esophagectomy with three-field lymph node dissection for esophageal carcinoma was referred to our hospital because of sudden hemoptysis.After the esophagectomy,bilateral vocal cord paralysis was observed,and the patient suffered from repeated episodes of aspiration pneumonia.Bronchoscopy revealed hemosputum in the right middle lobe bronchus,and contrast-enhanced computed tomography showed tortuous arteries arising from the right inferior phrenic artery and left subclavian artery toward the right middle lobe bronchus.Although bronchial arterial embolization was performed twice to control the recurrent hemoptysis,the procedures were unsuccessful.Right middle lobectomy was therefore performed via video-assisted thoracic surgery.Engorged bronchial arterys with medial hypertrophy and overgrowth of the small branches were noted near the bronchus in the resected specimen.The patient recovered uneventfully and was discharged on postoperative day 14.

Aspiration pneumonia during general anesthesia induction after esophagectomy: A case report

BACKGROUND Esophageal cancer is a common malignant tumor of the digestive system.At present,surgery is the most important treatment strategy.After esophagectomy and gastric esophagoplasty,the patients are prone to regurgitation.However,these patients currently do not receive much attention,especially from anesthesiologists.CASE SUMMARY A 55-year-old woman was scheduled for right lower lung lobectomy.The patient had undergone radical surgery for esophageal cancer under general anesthesia 6 mo prior.Although the patient had fasted for>17 h,unexpected aspiration still occurred during induction of general anesthesia.Throughout the operation,oxygen saturation was 98%-100%,but the airway pressure was high(35 cmH2O at double lung ventilation).The patient was sent to the intensive care unit after surgery.Bedside chest radiography was performed,which showed exudative lesions in both lungs compared with the preoperative image.After surgery,antibiotics were given to prevent lung infection.On day 2 in the intensive care unit,the patient was extubated and discharged on postoperative day 7 without complications related to aspiration pneumonia.CONCLUSION After esophagectomy,patients are prone to regurgitation.We recommend nasogastric tube placement followed by rapid sequence induction or conscious intubation.

Esophageal intramural pseudodiverticulosis of the residual esophagus after esophagectomy for esophageal cancer

A 91-year-old man was referred to our hospital with intermittent dysphagia. He had undergone esophagectomy for esophageal cancer(T3N2M0 Stage Ⅲ) 11 years earlier. Endoscopic examination revealed an anastomotic stricture; signs of inflammation,including redness,erosion,edema,bleeding,friability,and exudate with white plaques; and multiple depressions in the residual esophagus. Radiographical examination revealed numerous fine,gastrografinfilled projections and an anastomotic stricture. Biopsy specimens from the area of the anastomotic stricture revealed inflammatory changes without signs of malignancy. Candida glabrata was detected with a culture test of the biopsy specimens. The stricture was diagnosed as a benign stricture that was caused by esophageal intramural pseudodiverticulosis. Accordingly,endoscopic balloon dilatation was performed and antifungal therapy was started in the hospital. Seven weeks later,endoscopic examination revealed improvement in the mucosal inflammation; only the pseudodiverticulosis remained. Consequently,the patient was discharged. At the latest follow-up,the patient was symptomfree and the pseudodiverticulosis remained in the residual esophagus without any signs of stricture or inflammation.

Clinicopathologic characteristics of esophagectomy for esophageal carcinoma in elderly patients

AIM： To evaluate the risk of esophagectomy for carcinoma of the esophagus in the elderly （70 years or more） compared with younger patients （〈70 years） and to determine whether the short-term outcomes of esophagectomy in the elderly have improved in recent years. METHODS： Preoperative risks, postoperative morbidity and mortality in 60 elderly patients （≥70 years） with esophagectomy for carcinoma of the esophagus were compared with the findings in 1 782 younger patients （〈70 years） with esophagectomy between 3anuary 1990 and December 2004. Changes in perioperative outcome and short-time survival in elderly patients between 1990 to 1997 and 1998 to 2004 were separately analyzed. RESULTS： Preoperatively, there were significantly more patients with hypertension, pulmonary dysfunction, cardiac disease, and diabetes mellitus in the elderly patients as compared with the younger patients. No significant difference was found regarding the operation time, blood loss, organs in reconstruction and anastomotic site between the two groups, but elderly patients were more often to receive blood transfusion than younger patients. Significantly more transhiatal and fewer transthoracic esophagectomies were performed in the elderly patients as compared with the younger patients. Resection was considered curative in 71.66% （43/60） elderly and 64.92% （1 157/1 782） younger patients, which was not statistically significant （P〉0.05）. There were no significant differences in the prevalence of surgical complications between the two groups. Postoperative cardiopulmonary medical complications were encountered more frequently in elderly patients. The hospital mortality rate was 3.3% （2/60） for elderly patients and 1.1% （19/1 782） for younger patients without a significant difference. When the study period was divided into a former （1990 to 1997） and a recent （1997 to 2004） period,operation time, blood loss, and percentage of patients receiving blood transfusion of the elderly patients significantly improved from the former period to the recent period. The hospital mortality rate of the elderly patients dropped from the former period （5.9%） to the recent period （2.3%）, but it was not statistically significant. CONCLUSION： Preoperative medical risk factors and postoperative cardiopulmonary complications after esophagectomy are more common in the elderly, but operative mortality is comparable to that of younger patients. These encouraging results and improvements in postoperative mortality and morbidity of the elderly patients in recent period are attributed to better surgical techniques and more intensive perioperative care in the elderly.

Phlegmonous gastritis after esophagectomy:A case report

Phlegmonous gastritis is an unusual infection of the gastric wall,which is extremely rare and associated with a poor prognosis.Here,we report the case of a 65-year-old male patient with a history of splenectomy,who had phlegmonous gastritis after esophagectomy.Computed tomography revealed a remarkably distended thoracic stomach,and the gastric wall was locally thickened.Gastric mucosa was red and white in color and significantly edematous on gastroscopy.He was successfully treated with a combination of antibiotics and povidone-iodide intraluminal lavage.In addition to this case,the clinical presentations,imaging examinations as well as treatments of phlegmonous gastritis are discussed.

Conduit necrosis following esophagectomy: An up-to-date literature review

Esophageal conduit ischaemia and necrosis is an uncommon but devastating complication of esophagectomy and remains one of the most challenging issues in surgical practice. The incidence, time interval to develop symptoms, and clinical presentation are highly variable with no predictable pattern. Evidence comes from case reports and case series rather than randomized controlled trials.We describe the issues surrounding conduit necrosis affecting the stomach,jejunum and colon as an esophageal replacement and the advantages,disadvantages and challenges of each type of reconstruction. Diagnosis is challenging for the most experienced surgeon. Upper gastrointestinal endoscopy and computed tomography thorax with both oral and intravenous contrast is the gold standard. Management, either conservative or interventional is also a difficult decision. Management options include conservative treatment and more aggressive treatments such as stent insertion, surgical debridement and repair of the esophagus using jejunum, colon or a musculocutaneous flap. In spite of recent advances in surgical techniques, there is no reliable strategy to manage esophageal conduit necrosis. Our review covers the pathophysiology and clinical significance of esophageal necrosis while highlighting current techniques of prevention, diagnosis and treatment of this life-threatening condition.